((If suction is not performed within 2 minutes of arrival, the patient begins to vomit — facilitator describes gurgling worsening and SpO2 dropping to 78% — trainee must immediately laterally position patient and suction oropharynx.))

((If oxygen is not applied within 3 minutes, SpO2 remains at 82% and GCS drops to 7 — trainee must apply NRB mask at 15L/min and consider BVM-assisted ventilation.))

((If hypothermia is not identified and active warming not initiated by 5 minutes, facilitator reports patient develops muscle rigidity and heart rate drops to 44 bpm — trainee must remove wet clothing, wrap in Ready-Heat blanket over sheet, and raise concern for moderate hypothermia and associated arrhythmia risk.))

((If the contaminated water aspiration risk is not noted in handover or documented, facilitator prompts: 'The receiving facility asks — what type of water did the patient aspirate?' — trainee should be able to state open lake, potentially contaminated, untreated water, relevant to delayed pulmonary and infectious complications.))

((If BVM ventilation is not commenced despite RR of 8 and SpO2 remaining below 90% on high-flow oxygen, facilitator states patient becomes increasingly cyanosed — trainee must initiate assisted ventilations via BVM at appropriate rate, not exceeding 10 breaths per minute, ensuring minimal chest rise only.))

This patient is suffering from near-drowning (immersion injury) with aspiration of contaminated lake water causing severe hypoxia and respiratory compromise, complicated by moderate hypothermia secondary to prolonged submersion in cool water.

• Ensure scene safety — confirm patient has been removed from water and is on a dry, firm surface away from lake edge.
• Don appropriate PPE — note potential exposure to contaminated water (blood/body fluid and waterborne pathogen risk).
• Perform Primary Survey — C-spine consideration low given witnessed atraumatic submersion with no mechanism for spinal injury, but use clinical judgement.
• Open airway — use jaw thrust or triple airway manoeuvre; insert appropriately sized OPA to maintain patent airway.
• Suction oropharynx using Yankauer/Ducanto catheter — clear frothy secretions and water visible in oropharynx, suction for maximum 5 seconds at a time.
• Laterally position patient to facilitate drainage of secretions if airway management allows — or maintain supine with head turned if spinal concern.
• Apply high-flow oxygen via Non-Rebreather Mask at 10–15 L/min — target SpO2 94–98%.
• Assess adequacy of breathing — RR 8, shallow and irregular with SpO2 82% indicates inadequate spontaneous ventilation; commence BVM-assisted ventilations to supplement respiratory effort, timed with spontaneous breaths, at no more than 10 breaths/min.
• Obtain full Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, BGL, temperature (tympanic — note may underestimate core temperature in hypothermia).
• Identify hypothermia — tympanic temperature 32.1°C indicates moderate hypothermia; note absence of shivering is an ominous sign at this temperature.
• Remove all wet clothing immediately to stop ongoing heat loss.
• Apply Ready-Heat blanket over dry sheet to begin passive and active rewarming — do NOT apply directly to skin.
• Handle patient gently — avoid sudden movement or jarring which may precipitate ventricular arrhythmia in moderate hypothermia.
• Reassess GCS and SpO2 every 5 minutes — record full observations every 5 minutes given time-critical status.
• Monitor for cardiac arrest — defibrillator and CPR equipment to be at hand given hypothermia and hypoxia arrhythmia risk.
• Note contaminated water aspiration for IMISTAMBO handover — open lake water, untreated, potentially contaminated, risk of delayed pneumonia and waterborne infection.
• Reassure wife (Sarah Reid) on scene and obtain further history including allergies and medications.
• Prepare for Priority 1 transport — pre-notify receiving ED with IMISTAMBO including: near-drowning, approximately 8–10 minutes submersion, aspiration of contaminated lake water, moderate hypothermia 32.1°C, GCS 9, SpO2 82% on RA improving to 94% on NRB, assisted ventilations commenced.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Immersion · Hypothermia · Bag Valve Mask Ventilation · Suction · Oropharyngeal Airway · Oxygen Delivery · Lateral Position · Ready Heat Blanket · Primary Survey