((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?'))

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.

• Ensure scene safety and don appropriate PPE. Perform hand hygiene.
• Perform Primary Survey — identify airway patent, breathing compromised (elevated RR, wheeze, low SpO2), circulation compromised (tachycardia, hypotension, mottling), disability compromised (GCS 12, confusion).
• 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.
• Apply SpO2 monitoring immediately and recognise SpO2 86% on RA as critically low.
• 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.
• 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.
• 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).
• Formally identify this patient as RED FLAG SEPSIS — multiple organ dysfunction indicators present. Do not delay for further investigation.
• Position patient in position of comfort — semi-recumbent if tolerated and BP permits.
• Activate Priority 1 transport immediately — minimise on-scene time. This is a time-critical patient.
• 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.
• Contact Clinical Support Paramedic (CSP) in State Operations Centre (SOC) for early advice given complexity — COPD with sepsis, oxygen management, and immunocompromised status.
• Continue monitoring — repeat full observations every 5 minutes given time-critical status. Document all vital sign trends.
• Keep patient warm — blanket in ambulance/cool FAP environment.
• Document Red Flag Sepsis on ePCR and communicate explicitly at clinical handover to receiving hospital staff.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• 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