Scenario — Red Flag Sepsis misidentified as heat exhaustion — COPD patient at music festival

advanced Medical · Adult · 35yr · female

Patient Information

Dispatch	You are called to the FAP at Southbound Music Festival, Busselton. A 35YO female (Maya Hennessy) has been brought in by friends after being found confused and sweating heavily near the main stage. Friends initially told staff she was 'just overheated from dancing.'
Patient	Maya Hennessy — 35yr (65kg)
Incident History	Pt brought to FAP by friends who say she has been 'not herself' for the past hour. Friends initially attributed her confusion and sweating to heat. Pt has been at the festival for two days. Friends report she had a productive cough for the past three days prior to the event and was 'already not feeling great' when they arrived. Pt is a known COPD patient.
Emergency Contact	Daniel Hennessy (Husband) — 0412 774 938

Initial Rapid Assessment

Response	Voice
Airway	Patent. No foreign body or obstruction. Mild audible wheeze noted on exhalation. No stridor.
Breathing	Rapid and laboured. Increased work of breathing with accessory muscle use. Audible wheeze bilaterally. RR 28/min. SpO2 88% on room air.
Circulation	Radial pulse rapid and weak. Skin pale, diaphoretic, mottled to lower extremities. CRT 4 seconds. No active external bleeding.
Disability	GCS 13 (E3V4M6). Confused — not orientated to time or place. Orientated to person only. PEARL 4mm bilaterally, sluggish.
Exposure	No rash or urticaria. No obvious trauma. Temperature 38.8°C tympanic. Abdomen non-tender on palpation. No peripheral oedema. Wearing festival wristband and medical alert bracelet indicating COPD.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	28	128	88/56	4s	13	4 4 SL	38.8	4.2 mmol/L	3
10 mins	91% (O2 NRB 10L/min)	Moderate	30	135	84/50	4s	11	4 4 SL	38.8	4.0 mmol/L	3

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from Red Flag Sepsis secondary to suspected community-acquired pneumonia, in the context of underlying COPD, presenting with organ dysfunction evidenced by altered mental state, hypotension, tachycardia, tachypnoea, and hypoxia. The initial presentation was misidentified as heat exhaustion by bystanders, creating a delay in recognition.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee accepts the 'heat exhaustion' history without further assessment and initiates cooling: patient's GCS drops to 11 and SpO2 falls to 86% on room air — prompt with 'The patient does not appear to be improving with cooling measures and her breathing is getting worse.')
! (If the trainee applies high-flow oxygen via NRB without recognising COPD and titrating to 88–92% SpO2: facilitator prompts 'You note the patient's medical alert bracelet indicates COPD — does this change your oxygen management?')
! (If the trainee fails to obtain a full history including medications and past medical history and misses COPD: patient remains on NRB with SpO2 climbing to 97% — prompt 'Is there any reason to be cautious about uncontrolled oxygen therapy in this patient?')
! (If the trainee does not identify Red Flag Sepsis criteria and fails to pre-notify ambulance: after 5 minutes prompt 'Her blood pressure is 88 systolic, heart rate 135, RR 28, GCS 13, and temperature 38.8°C — does this patient meet any sepsis criteria you are aware of?')
! (If the trainee does not perform a BGL: facilitator prompts 'Her conscious state is altered — is there any additional assessment you would perform?')
! (If the trainee attempts to administer salbutamol MDI without first addressing the airway and oxygen: prompt 'What is her SpO2 and what is your priority at this moment?')

Treatment Objectives

1. Don appropriate PPE and ensure scene safety at FAP.
2. Perform Primary Survey — identify Voice response, laboured breathing, weak rapid pulse, GCS 13.
3. Immediately DETECT and CORRECT: SpO2 88% on RA — apply oxygen therapy. Recognise COPD history from medical alert bracelet and titrate oxygen via nasal cannula or simple face mask targeting SpO2 88–92%. Do NOT apply NRB at maximum flow without titration — risk of CO2 retention in COPD patient.
4. If SpO2 cannot be maintained at 88–92% on low-flow oxygen, escalate to simple face mask at 5–8 L/min and reassess. If still inadequate, apply NRB at 10L/min and reassess continuously — targeting lowest effective FiO2.
5. Position patient semi-recumbent (position of comfort) — do not lay flat given respiratory distress.
6. Perform Vital Sign Survey: GCS 13, SpO2 88% RA, RR 28, BP 88/56, HR 128, Temp 38.8°C, CRT 4s, BGL 4.2 mmol/L.
7. Perform Blood Glucose Level test — BGL 4.2 mmol/L, normoglycaemic.
8. Identify Red Flag Sepsis criteria present: altered mental state (GCS 13, confused, not orientated to time/place), systolic BP ≤90 mmHg (88 mmHg), HR ≥130 (128 — approaching threshold, confirmed Red Flag with GCS + BP), RR ≥25 (28), temperature ≥38°C (38.8°C), requires O2 to maintain SpO2 ≥88%.
9. Recognise this patient meets RED FLAG SEPSIS criteria — do NOT continue to manage as heat exhaustion.
10. Immediately activate ambulance via State Operations Centre — Priority 1 transport.
11. Pre-notify receiving Emergency Department: 35YO female, known COPD, Red Flag Sepsis suspected — altered GCS, BP 88 systolic, HR 128, RR 28, SpO2 88% RA, Temp 38.8°C. Penicillin allergy documented.
12. Administer Salbutamol (Ventolin) via MDI and spacer 4–12 puffs (400–1200 microg) for bronchospasm component — titrate to response. Note: do NOT use nebuliser — outside EHS scope.
13. Consider administering Ondansetron 4mg oral wafer if nausea develops.
14. Perform continuous reassessment every 5 minutes given time-critical status — document all observations.
15. Communicate AMBER/RED Flag Sepsis clearly to ambulance crew at handover using IMISTAMBO format. Document Red Flag Sepsis on patient care record.
16. Minimise on-scene time — prepare patient for Priority 1 transport without delay.
17. Scenario ends on arrival of ambulance and IMISTAMBO handover.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen Delivery · Salbutamol Sulphate · Blood Glucose Monitor · Primary Survey · Pulse Oximetry · Ondansetron

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Signs/Symptoms	Confusion, profuse sweating, shortness of breath, productive cough present for 3 days, generalised weakness. Friends report she has been 'not making sense' for the past hour.
Allergies	Penicillin — rash.
Medications	Salbutamol MDI (Ventolin) PRN, Tiotropium inhaler daily. No other regular medications. Denies any PDE5 inhibitors.
Pertinent History	Known COPD diagnosed 4 years ago. Smoker — 10 cigarettes/day. No recent hospitalisation. No known immunosuppression. No recent surgery or invasive procedures.
Last Oral Intake	Small amount of food and water approximately 4 hours ago. Friends report she has barely eaten or drunk anything today.
Events Leading	Pt attended festival with friends. She had been feeling unwell with a cough for 3 days but came anyway. Over the past 2 days she reportedly became more fatigued and short of breath. Friends found her near the main stage confused, sweating, and unable to walk steadily.
Treatment Prior	Friends gave her water and had her sit in the shade for 30 minutes thinking it was heat exhaustion. No improvement noted. No medications self-administered today.

Onset	Gradual deterioration over past 3 days with acute worsening in the last 1–2 hours. Friends believed symptoms were heat-related on arrival at FAP.
Pain	Pt reports mild chest tightness 3/10. Pleuritic in character — worsens on deep breath.
Quality	Tightness and difficulty breathing. Cough productive of yellow-green sputum.
Radiates	Nil radiation.
Severity	3/10 chest pain. Pt reports feeling 'really terrible' overall.