((If the trainee does not perform a thorough pain assessment including onset, quality, radiation, and severity within the first 3 minutes — the patient becomes increasingly distressed and begins to vomit, prompting the need for ondansetron consideration.))

((If methoxyflurane is not offered within 5 minutes of assessment — the patient rates pain at 10/10 and asks repeatedly 'Can you give me anything for this pain?'))

((If allergies are not asked prior to any medication administration — the facilitator prompts: 'What do you need to check before you give him anything?'))

((If the trainee attempts to position the patient supine and tells him to stay still — the patient states 'I can't lie down, it makes it worse' — the trainee should allow position of comfort and not force supine positioning for this presentation.))

((If the trainee does not ask about prior medical history — the patient does not volunteer the kidney stone history; trainee must ask specifically about similar episodes.))

This patient is suffering from a suspected renal colic episode, consistent with his prior history of kidney stones, presenting with classic severe colicky left flank pain radiating to the groin, diaphoresis, tachycardia, and an inability to find a comfortable position.

• Ensure scene safety and don appropriate PPE.
• Perform Primary Survey — confirm patent airway, adequate breathing, intact circulation, GCS 15, no immediate life threats.
• Perform Vital Sign Survey — obtain HR, BP, RR, SpO2, temperature, and pain score. Document baseline observations.
• Perform thorough pain assessment using SOCRATES or equivalent: site, onset, character, radiation, associated symptoms, timing, exacerbating/relieving factors, severity (9/10).
• Take history including IMISTAMBO components: allergies (NKDA), medications (nil), pertinent history (prior kidney stones), last oral intake (90 mins ago), events leading.
• Allow patient position of comfort — do NOT force supine positioning. Patient is most comfortable ambulating or in a position of their choosing.
• Administer Methoxyflurane (Penthrox) 3 mL via Penthrox inhaler device (with charcoal filter attached) — for severe pain (9/10). Instruct patient to self-administer by forming a seal around the mouthpiece and breathing in and out through the inhaler. Onset of pain relief expected after 6–10 inhalations.
• If nausea develops or worsens: Administer Ondansetron 4 mg oral wafer — for nausea/active vomiting. Allow to dissolve on tongue. A second 4 mg oral wafer dose may be given after 15 minutes if patient remains symptomatic (maximum 8 mg within 8-hour period).
• Alternatively for nausea if oral route not tolerated: Administer Ondansetron 4 mg IM injection — repeat once after 15 minutes if still symptomatic, no further doses within 8 hours of second dose.
• Reassess pain score and vital signs at 10 minutes post-intervention. Document findings.
• Perform Secondary Survey — systematic head-to-toe assessment including abdominal palpation across all four quadrants for tenderness, rigidity, or guarding. Note: renal colic typically produces flank tenderness without significant peritonism.
• Consider Paracetamol 1000 mg (2 x 500 mg tablets) oral — for mild to moderate pain as component of multimodal analgesia if pain reduces to manageable level and patient can safely ingest. Do NOT give if patient has taken any paracetamol-containing product in the last 4 hours.
• Arrange transport to hospital via ambulance for definitive assessment and imaging (urinalysis, CT KUB). Pre-notify receiving facility if patient condition is time critical.
• Monitor patient continuously — record full observations every 10 minutes. Reassess pain score pre- and post-intervention.
• Secure used Penthrox inhaler and vial in supplied plastic bag for disposal.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Methoxyflurane · Ondansetron · Paracetamol · Pain Assessment · Primary Survey · Secondary & CNS Survey · Penthrox Inhaler Administration · Blood Pressure · Pulse & Respirations · Pulse Oximetry