Scenario — COPD Exacerbation in elderly female at community fair

intermediate Respiratory · Elderly · 75yr · female

Patient Information

Dispatch	You are called to the FAP at the Fremantle Community Fair for a 75YO female (Margaret Doyle) who is having trouble breathing. Bystanders say she has been struggling for the past 10 minutes.
Patient	Margaret Doyle — 75yr (60kg)
Incident History	Pt was browsing the market stalls when she became increasingly short of breath. A stall holder helped her to the FAP. Pt is visibly distressed and using accessory muscles to breathe.
Emergency Contact	Susan Doyle (Daughter) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Able to speak in short phrases only.
Breathing	Increased work of breathing. Audible expiratory wheeze. Use of accessory muscles. RR elevated. SpO2 low on room air.
Circulation	Radial pulse present — rapid and regular. Skin warm, mild peripheral cyanosis noted to fingertips. No active bleeding.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious.
Exposure	No rashes or visible injuries. Barrel-shaped chest noted. Pursed-lip breathing observed.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	84% (RA)	Moderate	26	108	148/88	<2s	15	3 3 ++	37.1	–	3
10 mins	90% (O2 NC 2L/min)	Mild	20	96	144/86	<2s	15	3 3 ++	37.1	–	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD).

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is applied at high flow — e.g. NRB 15L/min — without titration, patient's SpO2 rises above 92% and she becomes progressively drowsy over 5 minutes, GCS drops to 13. Facilitator prompts: 'She seems to be getting sleepier — her breathing is slowing down.')
! (If no oxygen is applied within 3 minutes of assessment, patient's SpO2 drops to 80% on room air and respiratory distress escalates to severe — accessory muscle use increases and she is unable to complete sentences.)
! (If trainee attempts to administer Salbutamol via MDI without a spacer, facilitator prompts: 'She is struggling to coordinate her breathing with the inhaler — what else do you have available?')
! (If trainee fails to ask about home oxygen or COPD history, the patient volunteers: 'I use oxygen at night, love — I've got the lung disease.')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE. Perform hand hygiene.
2. Conduct Primary Survey — confirm patent airway, assess breathing (audible wheeze, elevated RR, accessory muscle use), assess circulation, assess GCS.
3. Position patient upright or in position of comfort — do NOT lay patient flat.
4. Apply pulse oximetry (SpO2 monitoring) and obtain initial observations including RR, HR, BP, temp.
5. Administer oxygen via nasal cannula at 1–2 L/min — titrate carefully to target SpO2 of 88–92% (COPD target). Do NOT apply non-rebreather mask without careful monitoring. Adjust flow rate up or down to maintain target range.
6. Obtain IMISTAMBO history — confirm known COPD, current medications (including own Salbutamol MDI use prior to arrival), allergies, last oral intake.
7. Recognise that Salbutamol administration for COPD bronchospasm is Intermediate Care scope — EHS Primary Care scope does NOT include Salbutamol administration. Assist patient to use her own Salbutamol MDI via spacer if she is able to self-administer and clinically indicates benefit.
8. Reassess SpO2, RR, and respiratory distress every 5 minutes — maintain continuous monitoring.
9. Record full observations every 10 minutes (or 5 minutes if patient appears time critical).
10. Recognise time-critical indicators: SpO2 unable to be maintained at 88–92%, increasing GCS deterioration, severe respiratory distress, or inability to speak — escalate to Priority 1 transport with pre-notification of receiving facility.
11. Provide continuous reassurance to patient — anxiety worsens breathlessness.
12. Arrange transport to hospital. Request ambulance via State Operations Centre if not already dispatched.
13. Scenario ends on arrival of ambulance and IMISTAMBO handover.
14. Attention to hand hygiene will be given throughout the scenario.

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

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Signs/Symptoms	Increasing shortness of breath, expiratory wheeze, tight chest. Productive cough with increased yellow sputum over the past three days.
Allergies	Penicillin — rash
Medications	Tiotropium inhaler (once daily), Salbutamol MDI (as needed), Perindopril 5mg daily, Atorvastatin 40mg daily.
Pertinent History	Known COPD diagnosed 8 years ago — on home oxygen at 1L/min overnight. Ex-smoker, 40 pack-year history. Hypertension. No previous intubations. Last GP review 2 months ago.
Last Oral Intake	Cup of tea and toast approximately 2 hours ago.
Events Leading	Patient was walking around the outdoor market stalls in the warm weather. Became progressively more breathless and distressed over 10 minutes.
Treatment Prior	Used her own Salbutamol MDI twice before arriving at the FAP — minimal relief.

Onset	Progressive worsening over the past three days, acute deterioration in the last 10–15 minutes at the fair.
Pain	Mild chest tightness 3/10. No sharp or pleuritic pain.
Quality	Difficulty breathing, wheezy, feels like she cannot get air out fully.
Radiates	Nil
Severity	3/10 chest tightness