((If trainees accept the patient's claim that she is fine and agree to let her return to the mosh pit — facilitator stops the scenario. Facilitator note: a patient with active concussion indicators (amnesia, headache, dizziness, confusion) must NOT be returned to physical activity. 'I feel fine now' is not a concussion clearance. The patient is cognitively impaired and cannot self-assess reliably.))

((If trainees do not identify the retrograde amnesia — prompt: 'She says she is fine — ask her to tell you about the last few minutes before the impact.' Expected: patient cannot recall the 5 minutes before the hit. Friends confirm this. Retrograde amnesia is one of the most reliable indicators of significant concussion.))

((If trainees do not ask friends for a witness account of the post-impact period — prompt: 'What did you see happen immediately after she was hit?' Friends describe 30 seconds of confusion and 'blank stare' — this is a critical collateral history finding.))

((If trainees do not assess for red flags requiring escalation — prompt at 15 minutes: 'What specific findings would make you call for CSP?' Expected: worsening headache, repeated vomiting, GCS decline, seizure, pupil asymmetry, focal deficit. If the patient vomits once during the scenario — this is a single episode. If she vomits a second time, escalate to CSP.))

((If trainees note the patient is sober — reinforce: 'She has not had alcohol today — the confusion and amnesia are not attributable to intoxication.' This removes a common dismissal.)

Concussion (mild traumatic brain injury) — direct head impact with brief post-traumatic confusion and retrograde amnesia. GCS remains 15, which can falsely reassure trainees. The key concussion indicators in this scenario are: post-traumatic confusion (immediately after impact per witnesses), retrograde amnesia for 5 minutes before impact, headache, dizziness, nausea, and cognitive fogginess. Patient MUST NOT return to the mosh pit or any physical activity today — 'return to play' after concussion requires medical clearance and a graded return protocol, which is beyond EHS scope to initiate. The patient must be observed, and if any of the following develop, CSP must be called immediately: GCS drops below 15, repeated vomiting, worsening headache, new focal neurological deficit, unequal pupils, seizure, or increasing confusion. This scenario should also familiarise trainees with the concept that 'no loss of consciousness' does NOT mean no concussion.

• Ensure scene safety — move patient to a quiet area away from the crowd and loud music; the sensory environment will worsen her symptoms.
• Don appropriate PPE.
• Perform Primary Survey — GCS 15, no life-threatening injury. Confirm no cervical spine tenderness (mechanism is a lateral temporal impact, not axial load — low spinal risk but still ask about neck pain).
• Obtain full history — confirm mechanism (direct head impact), witness account (30 seconds post-impact confusion), absence of LOC, nature of amnesia (retrograde — cannot recall 5 minutes before impact).
• Confirm sobriety — patient has not consumed alcohol. Symptoms are from the head impact, not intoxication.
• Perform neurological assessment — GCS components individually, pupils (equal and reactive), orientation to time/place/person (impaired — cannot state the time or recall the last performers she saw), balance assessment (unsteady), upper and lower limb gross motor and sensation (intact).
• Identify concussion indicators present: post-traumatic confusion, retrograde amnesia, headache, dizziness, nausea, sensitivity to noise/light, cognitive fogginess.
• Complete Vital Sign Survey — all parameters normal.
• Advise patient clearly and specifically — do NOT return to the mosh pit or any physical activity today. 'Return to play' after concussion requires medical clearance. Returning too early risks second-impact syndrome, which can be fatal.
• If patient insists on returning — explain this is not a choice EHS can support and contact the patient's responsible friend or family member to assist.
• Observation: observe patient for a minimum of 30 minutes. Monitor for worsening headache, repeated vomiting, GCS decline, new focal deficit, or seizure.
• Escalation criteria — call CSP immediately if any of the following develop: GCS drops below 15, repeated vomiting (×2 or more), progressively worsening headache, unequal or non-reactive pupils, seizure, new motor or sensory deficit, increasing confusion beyond baseline.
• Advise patient on discharge: she must not be left alone tonight, must not drive, must not consume alcohol, must not return to strenuous activity, and should seek medical review if headache worsens, she vomits again, develops vision changes, or feels increasingly confused.
• Encourage the patient to have a responsible adult (sister or friend) stay with her overnight.
• Document all findings including the retrograde amnesia duration, witness account of post-impact confusion, and all neurological assessment results.
• Scenario ends after observation period with appropriate discharge advice and a responsible adult nominated to stay with her.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Head Injury · Primary Survey · Secondary & CNS Survey · Pulse & Respirations · Blood Pressure