Scenario — Sudden onset facial droop and arm weakness at AFL game

intermediate Neurological · Adult · 35yr · male

Patient Information

Dispatch	You are called to the northern grandstand concourse at Optus Stadium. A 35-year-old male has been found slumped on a bench by a friend. Bystanders report he suddenly couldn't speak properly and his face 'looked funny'.
Patient	Brendan Holt — 35yr (80kg)
Incident History	Pt was watching the AFL match with friends when he suddenly complained of a bad headache, then within minutes became unable to speak clearly and his right arm felt heavy and weak. Friend called for EHS immediately.
Emergency Contact	Kylie Holt (Wife) — 0412 774 883

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Patient able to attempt vocalisation but speech is slurred and difficult to understand.
Breathing	Adequate rate and depth. Nil increased work of breathing. Nil accessory muscle use.
Circulation	Radial pulse present, regular, normal rate and strength. Skin warm, dry, normal colour. Nil external bleeding.
Disability	GCS 13 (E4V3M6). Alert but confused and dysphastic. Not oriented to time. Right facial droop noted. Right arm weakness on command — unable to raise arm above shoulder level. Left arm and both legs appear normal strength.
Exposure	Nil rashes, nil trauma, nil medical alert jewellery visible. Dressed in AFL jersey and shorts.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	16	88	158/94	<2s	13	4 4 ++	36.8	5.6 mmol/L	7
10 mins	96% (RA)	Nil	17	90	162/96	<2s	12	4 4 ++	36.8	5.6 mmol/L	7

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected acute stroke (cerebrovascular accident) with features of left hemisphere involvement — right-sided facial droop, right arm weakness (hemiparesis), and expressive dysphasia, with sudden-onset severe headache raising concern for possible haemorrhagic aetiology.

Facilitator Triggers — if trainees miss a critical step

! (If BGL is not tested within the first 3 minutes of assessment, prompt the trainee: 'Your partner asks — have you checked his sugar?')
! (If time of symptom onset is not established, patient's friend taps the officer on the shoulder and says 'It happened about 25 minutes ago — I checked my watch when it started')
! (If the trainee does not note the right-sided facial droop and arm weakness during the initial rapid assessment, patient attempts to lift his right arm and it falls back to his lap — have friend say 'He keeps dropping his arm like that')
! (If oxygen is applied unnecessarily to a patient with SpO2 97% on room air, remind trainee of oxygen titration principles — oxygen is only indicated if SpO2 falls below 94%)
! (If the trainee does not establish time of onset within 5 minutes, GCS drops one point to 12 and trainee must reassess urgency)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE — standard precautions
2. Perform Primary Survey: airway patent, breathing adequate, circulation intact, disability assessed including GCS
3. Note right-sided facial droop, expressive dysphasia, and right arm weakness during disability assessment
4. Perform Blood Glucose Level test — result 5.6 mmol/L (rules out hypoglycaemia as cause of neurological deficit)
5. Establish and document exact time of symptom onset — 'approximately 25 minutes ago' — this is critical for stroke bypass eligibility
6. Perform Vital Sign Survey: BP 158/94, HR 88, RR 16, SpO2 97% (RA), Temp 36.8°C, GCS 13
7. Do NOT administer oxygen — SpO2 97% on room air is above the 94% threshold; oxygen is not indicated
8. Position patient comfortably — seated or semi-recumbent; do NOT lay flat as BP is elevated
9. Perform Secondary and CNS Survey: assess facial symmetry, upper and lower limb strength bilaterally, pupil response, and speech
10. Reassure patient continuously — patient is alert and will be frightened; use simple clear language
11. Contact State Operations Centre (SOC) immediately — this is a time-critical neurological emergency requiring Priority 1 transport and ambulance upgrade
12. Gather and document IMISTAMBO handover information: time of onset, BGL, neurological deficits, vital signs, medications and allergies
13. Do NOT administer any medications — no EHS-authorised medication is indicated in this presentation; aspirin is contraindicated until haemorrhagic stroke is excluded
14. Do NOT perform FAST or RACE assessment — these are Intermediate Care and above tools and are outside EHS Primary Care scope; document clinical findings that will support handover
15. Monitor patient persistently — record full observations every 10 minutes; note any deterioration in GCS or new neurological deficits
16. Scenario ends on arrival of ambulance and IMISTAMBO handover
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Stroke (Cerebrovascular Accident) · Unconsciousness · Hypoglycaemia · Primary Survey · Glasgow Coma Scale (GCS) · Blood Glucose Monitor · Oxygen Delivery

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Signs/Symptoms	Sudden severe headache, slurred speech, right-sided facial droop, right arm weakness and heaviness. Denies vision changes. Denies chest pain or shortness of breath.
Allergies	Nil known drug allergies.
Medications	Nil regular medications.
Pertinent History	No known history of hypertension, diabetes, heart disease, or previous stroke or TIA. Non-smoker. Occasional alcohol. No recreational drug use reported by friend.
Last Oral Intake	Had a meat pie and two beers approximately 90 minutes ago.
Events Leading	Pt was seated watching the AFL match. Stood up briefly during a goal celebration, sat back down, then immediately complained of sudden severe headache and right-sided weakness. No fall, no head strike, no trauma.
Treatment Prior	Nil. Friend sat him down on the bench and called for help immediately.

Onset	Acute onset approximately 25 minutes ago during the match. Friend reports patient was completely normal immediately prior.
Pain	Severe sudden-onset headache — occipital, described as 'worst headache of his life'.
Quality	Headache described as a sudden explosive pressure. Right arm described as feeling 'dead and heavy'.
Radiates	Headache does not radiate. Arm weakness localised to right upper limb.
Severity	Headache 7/10. Arm weakness prevents elevation above shoulder level.