Scenario — Sepsis in elderly female — delayed recognition at community fair

advanced Medical · Elderly · 75yr · female

Patient Information

Dispatch	You are called to the FAP at the Midland Community Fair for a 75YO female who has been brought in by her daughter. Patient is reported to be confused and unwell — initially thought to be heat exhaustion by event staff.
Patient	Margaret Holloway — 75yr (60kg)
Incident History	Pt was attending the fair with her daughter when she became increasingly confused and lethargic over the past hour. Event staff gave her water and moved her into the shade, assuming heat exhaustion. Daughter reports pt has been unwell for 2-3 days with a productive cough and fever, and 'just isn't herself today'.
Emergency Contact	Susan Holloway (Daughter) — 0412 883 741

Initial Rapid Assessment

Response	Voice
Airway	Patent. Nil airway obstruction. Audible coarse secretions noted on deeper breaths. No stridor.
Breathing	Increased work of breathing. Accessory muscle use visible. RR elevated. Audible wheeze bilaterally on auscultation. SpO2 86% on room air.
Circulation	Rapid, weak radial pulse. Skin warm, flushed, diaphoretic. CRT 3 seconds. Mottling noted to bilateral lower legs.
Disability	GCS 12 (E3V4M5). Disoriented to time and place. Unable to state where she is. Responds to voice but confused.
Exposure	No visible trauma. No rash. Temp 38.6°C tympanic. Bilateral ankle oedema noted — daughter states this is chronic.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	86% (RA)	Moderate	27	132	88/58	3s	12	3 3 ++	38.6	3.8 mmol/L	3
10 mins	91% (O2 NRB 10L/min)	Mild	23	124	92/60	3s	13	3 3 ++	38.6	3.8 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from Red Flag Sepsis (likely respiratory source — community-acquired pneumonia) with concurrent acute exacerbation of COPD, presenting with haemodynamic compromise, altered mental status, hypoxia, tachycardia, tachypnoea, and hypotension in an immunocompromised elderly patient on long-term corticosteroids.

Facilitator Triggers — if trainees miss a critical step

! (If trainees accept the initial heat exhaustion diagnosis without further assessment — patient's GCS drops to 10 and respirations increase to 32/min. Daughter becomes distressed and states 'she's getting worse, this is not just heat'.)
! (If oxygen is not applied within 3 minutes of arrival — SpO2 drops to 83% on RA and patient becomes more agitated and less responsive. Note: target SpO2 for this COPD patient is 88–92%, NOT 94–98%. If high-flow NRB is applied and maintained without titration, facilitator prompts trainee: 'SpO2 is now 94% — is this the correct target for this patient?')
! (If trainees fail to obtain a full medication history — facilitator reveals the Prednisolone and long-term steroid use only if directly asked, then prompts: 'What does long-term corticosteroid use mean for this patient's immune function and sepsis risk?')
! (If Red Flag Sepsis is not recognised and pre-notification is not called — patient deteriorates at 10 minutes: GCS drops to 11, BP drops to 82/50, HR increases to 140. Facilitator states: 'You have been on scene for 10 minutes. What is your escalation plan?')
! (If trainees attempt to administer high-flow oxygen via NRB without recognising COPD — facilitator prompts: 'You note the patient has known COPD. What is the appropriate oxygen target and delivery device for this patient?')
! (If trainees do not minimise on-scene time — facilitator states at 8 minutes: 'You are at a community fair FAP. What resources are available to you and what should your priority be right now?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE. Perform hand hygiene.
2. Perform Primary Survey — identify airway patent, breathing compromised (elevated RR, wheeze, low SpO2), circulation compromised (tachycardia, hypotension, mottling), disability compromised (GCS 12, confusion).
3. Do NOT accept the initial heat exhaustion diagnosis — recognise that a 2-3 day history of productive cough, fever, confusion, tachycardia, tachypnoea and hypotension in an immunocompromised elderly patient does NOT fit simple heat exhaustion.
4. Apply SpO2 monitoring immediately and recognise SpO2 86% on RA as critically low.
5. Apply oxygen therapy — titrate carefully to target SpO2 88–92% given known COPD. Commence with nasal cannula at 1-4 L/min or simple face mask at 5-8 L/min. Escalate to NRB 10-15 L/min only if target saturations cannot be maintained, then titrate down. Do NOT maintain SpO2 above 92% in this COPD patient.
6. Obtain full IMISTAMBO-style history — specifically eliciting: 2-3 day illness, productive cough, fever, known COPD, long-term corticosteroids (immunosuppression), prior recent UTI, current medications.
7. Perform Vital Sign Survey — identify ALL Red Flag Sepsis criteria present: altered mental state (GCS 12, disoriented), systolic BP ≤90 mmHg (88/58), heart rate ≥130/min (132), respiratory rate ≥25/min (27), SpO2 requiring O2 to maintain ≥88%, temperature ≥38°C (38.6°C).
8. Formally identify this patient as RED FLAG SEPSIS — multiple organ dysfunction indicators present. Do not delay for further investigation.
9. Position patient in position of comfort — semi-recumbent if tolerated and BP permits.
10. Activate Priority 1 transport immediately — minimise on-scene time. This is a time-critical patient.
11. Call pre-notification to receiving ED immediately — communicate Red Flag Sepsis, patient age, COPD, immunosuppression (corticosteroids), vital signs including GCS 12 and BP 88/58.
12. Contact Clinical Support Paramedic (CSP) in State Operations Centre (SOC) for early advice given complexity — COPD with sepsis, oxygen management, and immunocompromised status.
13. Continue monitoring — repeat full observations every 5 minutes given time-critical status. Document all vital sign trends.
14. Keep patient warm — blanket in ambulance/cool FAP environment.
15. Document Red Flag Sepsis on ePCR and communicate explicitly at clinical handover to receiving hospital staff.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Primary Survey · Pulse Oximetry · Oxygen Delivery

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Signs/Symptoms	Confusion, lethargy, productive cough (yellow-green sputum), fever for 2-3 days, shortness of breath, generalised weakness.
Allergies	Penicillin — causes rash.
Medications	Salbutamol MDI (PRN), Tiotropium inhaler (daily), Prednisolone 5mg (long-term low dose), Frusemide 40mg (daily). Daughter produces a medication list.
Pertinent History	Known COPD — on home oxygen PRN (daughter states not currently using it at the event). Long-term low-dose oral corticosteroids. Type 2 diabetes (diet-controlled). Lives independently. Daughter reports pt had a UTI 3 weeks ago treated with trimethoprim.
Last Oral Intake	Small amount of water at the fair approximately 30 minutes ago. Minimal food intake today due to nausea.
Events Leading	Pt was walking around the community fair with her daughter. Became progressively more confused and weak. Sat down and was unable to get up without assistance. Brought to FAP by daughter and event staff.
Treatment Prior	Event staff gave 500ml water orally and moved patient to shade. No medications administered by bystanders.

Onset	Acutely worsening over the past hour at the event; background deterioration over 2-3 days.
Pain	Chest discomfort 3/10 associated with coughing. Nil pleuritic chest pain at rest.
Quality	Dull chest discomfort on coughing. Generalised weakness and fatigue.
Radiates	Nil radiation.
Severity	3/10 chest discomfort on cough. Daughter rates overall deterioration as severe.