((If trainee attempts to lay patient flat — patient becomes markedly more distressed, SpO2 drops to 84%, and patient says 'I can't breathe lying down'. Prompt: 'What position is safest for this patient?'))

((If oxygen is not applied within 3 minutes — patient's GCS drops to 13, SpO2 falls to 85%, patient becomes increasingly agitated and attempts to remove himself from the chair. Prompt: 'The patient is rejecting treatment — why might that be?'))

((If trainee attempts to administer GTN — facilitator states: 'You reach for the GTN spray. What do you need to consider before administering this medication in this patient?' Expected response: GTN is contraindicated / not indicated in CCF as it can worsen symptoms by reducing preload; GTN is also outside EHS scope for this indication.))

((If trainee does not reassess vital signs at 10 minutes — patient's wife becomes distressed and states 'He looks worse, are you doing anything?' Prompt trainee to repeat observations and document trending.))

((If BGL is not checked — patient becomes increasingly drowsy at 8 minutes. Facilitator states: 'Patient's wife mentions he is a diabetic.' Prompt trainee to perform BGL.))

This patient is suffering from acute decompensated congestive cardiac failure (right and left heart failure) with hypoxia and respiratory distress, likely precipitated by dietary indiscretion (salt and alcohol intake) at the event.

• Ensure scene safety and don appropriate PPE. Perform hand hygiene.
• Perform Primary Survey — identify respiratory distress and hypoxia as immediate life threats.
• Position patient sitting upright or semi-recumbent with legs dependent (hanging down) — DO NOT lay patient flat.
• Do NOT walk the patient — limit all exertion.
• Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 litres per minute — titrate to target SpO2 94–98%.
• Perform Vital Signs Survey — GCS, BGL, SpO2, RR, BP, HR, CRT, temperature.
• Check blood glucose level — patient is a known diabetic. BGL 6.8 mmol/L — no hypoglycaemia management required.
• Obtain IMISTAMBO history — signs/symptoms, onset, medications (including frusemide, carvedilol, ramipril), allergies (penicillin), pertinent history (known CCF, NSTEMI, hypertension, T2DM).
• Do NOT administer GTN — GTN is contraindicated in CCF as it reduces preload and may exacerbate symptoms. GTN is also outside EHS scope for this indication.
• Do NOT administer aspirin — chest heaviness in context of known CCF and no clinical suspicion of ACS; do not administer aspirin without clear ACS suspicion and discussion.
• Monitor patient continuously — record full observations every 10 minutes (or 5 minutes if condition is time critical).
• Continuously reassure patient and wife. Explain all interventions clearly.
• Recognise patient as time critical — arrange Priority 1 transport and pre-notify receiving facility (hospital emergency department).
• Maintain patient in upright position during transport.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Congestive Cardiac Failure · Oxygen Delivery · Primary Survey · Blood Glucose Monitor · Blood Pressure · Pulse & Respirations · Pulse Oximetry · Glasgow Coma Scale (GCS)