Scenario — Sudden onset facial droop and arm weakness in elderly male

intermediate Neurological · Elderly · 75yr · male

Patient Information

Dispatch	You are called to a 75YO male (Raymond Kowalski) at the ANZAC Day community fair who has been found slumped in his chair by event volunteers. Bystanders report he was speaking strangely and couldn't lift his right arm.
Patient	Raymond Kowalski — 75yr (75kg)
Incident History	Pt was seated watching a live performance when a volunteer noticed he had stopped responding normally. Pt is conscious but confused, with visible facial asymmetry and inability to move his right arm. Symptom onset reported approximately 35 minutes ago.
Emergency Contact	Margaret Kowalski (Wife) — 0412 883 647

Initial Rapid Assessment

Response	Voice
Airway	Patent. No obstructions. No stridor. Mild pooling of saliva at left corner of mouth.
Breathing	Spontaneous and unlaboured. Slight reduction in respiratory depth noted. No accessory muscle use.
Circulation	Radial pulse present — regular, moderate strength. Skin warm and pink centrally. No external bleeding.
Disability	GCS 12 (E3V4M5). Disoriented to time and events. Right-sided facial droop noted. Right arm weakness on assessment — unable to hold arm extended. Speech slurred and difficult to understand.
Exposure	No rashes, wounds, or injuries visible. No medical alert bracelet. Seated in chair at event grounds.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	95% (RA)	Nil	16	88	168/94	<2s	12	4 4 ++	36.8	6.2 mmol/L	2
10 mins	97% (O2 simple face mask 6L/min)	Nil	15	86	164/90	<2s	12	4 4 ++	36.8	6.2 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from an acute ischaemic stroke with right-sided hemiparesis and dysphasia, with symptom onset within the treatment window (35 minutes — well within 9 hours).

Facilitator Triggers — if trainees miss a critical step

! (If BGL is not checked within the first 5 minutes, prompt the trainee: the patient's wife asks 'He's diabetic — should you check his sugar?')
! (If oxygen is not administered within 3 minutes and SpO2 remains at 95%, have the patient become increasingly drowsy — GCS drops to 11 with more laboured breathing)
! (If the trainee fails to note symptom onset time and document it, the wife states: 'This started when the clock on the stage said 1:15pm — I remember because I looked up at it' — emphasise to trainee that exact time of onset is critical for stroke pathway decisions)
! (If the trainee attempts to give the patient food or fluid orally without checking swallowing ability, facilitator prompts: 'The patient begins to cough and splutter as you bring the cup to his lips — stop and reassess')
! (If warfarin is not identified during medication history, facilitator prompts: 'The wife pulls out a medication card from his wallet — what do you notice?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE before approaching patient.
2. Perform Primary Survey — confirm patent airway, spontaneous breathing, circulation present, and GCS 12.
3. Note symptom onset time accurately — 35 minutes ago, well within 9-hour stroke bypass window.
4. Perform BGL — result 6.2 mmol/L, ruling out hypoglycaemia as cause of altered conscious state.
5. Administer oxygen via simple face mask at 5–8 L/min to maintain SpO2 94–98%.
6. Position patient sitting upright or semi-recumbent — do not lay flat unless airway at risk.
7. Do NOT give food or fluids orally — dysphasia and reduced GCS create aspiration risk.
8. Complete Vital Sign Survey — document BP 168/94, HR 88, RR 16, GCS 12, SpO2 95% RA, Temp 36.8°C.
9. Obtain SAMPLER history — identify warfarin use, previous TIA, atrial fibrillation, hypertension, and diabetes.
10. Document exact time of symptom onset and time of EHS arrival — critical for receiving hospital stroke pathway activation.
11. Request Priority 1 ambulance immediately — stroke is a time-critical, life-threatening condition.
12. Pre-notify receiving facility (ambulance crew will do this, but EHS officer should relay all available information including symptom onset time and medication history at handover).
13. Monitor and record full observations every 10 minutes — watch for airway compromise, reduced GCS, vomiting, or seizure activity.
14. Reassure patient and wife continuously — patient may be distressed by inability to communicate effectively.
15. Prepare for potential deterioration — have suction and BVM ready at FAP.
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 · Oxygen Delivery · Primary Survey · Blood Glucose Monitor

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Signs/Symptoms	Right-sided facial droop, right arm weakness and inability to raise arm, slurred speech, confusion, mild headache.
Allergies	Nil known.
Medications	Warfarin (for atrial fibrillation), Ramipril (for hypertension), Atorvastatin.
Pertinent History	Known atrial fibrillation, hypertension, type 2 diabetes (well-controlled). Non-smoker. Previous TIA approximately 3 years ago — fully resolved.
Last Oral Intake	Lunch approximately 1.5 hours ago — sandwich and water.
Events Leading	Pt was seated at community fair watching ANZAC Day entertainment. Volunteer noticed he appeared confused and could not raise his right arm when spoken to.
Treatment Prior	Nil. Event volunteer sat him upright and called for EHS.

Onset	Approximately 35 minutes ago while seated watching a performance. Wife states he was completely normal this morning.
Pain	Mild headache — described as dull pressure across the forehead.
Quality	Sudden onset neurological symptoms with no preceding warning or injury.
Radiates	Nil
Severity	2/10 headache. Functional deficit rated as highly distressing by patient.