Scenario — Acute Decompensated Heart Failure at AFL Match

intermediate Cardiac · Elderly · 75yr · male

Patient Information

Dispatch	You are called to a 75YO male (Barry Neville) who is seated in the grandstand at Optus Stadium, reporting he cannot catch his breath and feels unwell. Security has brought him to the FAP.
Patient	Barry Neville — 75yr (75kg)
Incident History	Pt was watching the AFL match when he felt increasingly breathless over the past 30 minutes. He says he could not get comfortable in his seat and feels like he is 'drowning'. His wife states he slept sitting up in a recliner last night as he could not lie flat.
Emergency Contact	Margaret Neville (Wife) — 0412 883 547

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil foreign body or obstruction. Speaking in short broken sentences.
Breathing	Laboured — DETECT & CORRECT. SpO2 88% on room air. RR 26 per minute. Audible crackles at bilateral lung bases. Use of accessory muscles noted. Unable to complete full sentences.
Circulation	Pulse rapid and irregular. Skin pale and diaphoretic. Bilateral pitting oedema to mid-shin. Nail beds cyanosed peripherally.
Disability	GCS 14 (E4V4M6). Alert but anxious and mildly confused. Oriented to person and place but unsure of time.
Exposure	Bilateral lower limb pitting oedema. No visible bleeding. Jugular venous distension noted bilaterally when sat upright. No rashes or injuries.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Severe	26	112	158/98	3s	14	4 4 ++	36.8	6.8 mmol/L	3
10 mins	94% (O2 NRB 15L/min)	Moderate	20	104	152/92	2s	15	4 4 ++	36.8	6.8 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from acute decompensated congestive cardiac failure (right and left heart failure) with hypoxia and respiratory distress, likely precipitated by dietary indiscretion (salt and alcohol intake) at the event.

Facilitator Triggers — if trainees miss a critical step

! (If trainee attempts to lay patient flat — patient becomes markedly more distressed, SpO2 drops to 84%, and patient says 'I can't breathe lying down'. Prompt: 'What position is safest for this patient?')
! (If oxygen is not applied within 3 minutes — patient's GCS drops to 13, SpO2 falls to 85%, patient becomes increasingly agitated and attempts to remove himself from the chair. Prompt: 'The patient is rejecting treatment — why might that be?')
! (If trainee attempts to administer GTN — facilitator states: 'You reach for the GTN spray. What do you need to consider before administering this medication in this patient?' Expected response: GTN is contraindicated / not indicated in CCF as it can worsen symptoms by reducing preload; GTN is also outside EHS scope for this indication.)
! (If trainee does not reassess vital signs at 10 minutes — patient's wife becomes distressed and states 'He looks worse, are you doing anything?' Prompt trainee to repeat observations and document trending.)
! (If BGL is not checked — patient becomes increasingly drowsy at 8 minutes. Facilitator states: 'Patient's wife mentions he is a diabetic.' Prompt trainee to perform BGL.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE. Perform hand hygiene.
2. Perform Primary Survey — identify respiratory distress and hypoxia as immediate life threats.
3. Position patient sitting upright or semi-recumbent with legs dependent (hanging down) — DO NOT lay patient flat.
4. Do NOT walk the patient — limit all exertion.
5. Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 litres per minute — titrate to target SpO2 94–98%.
6. Perform Vital Signs Survey — GCS, BGL, SpO2, RR, BP, HR, CRT, temperature.
7. Check blood glucose level — patient is a known diabetic. BGL 6.8 mmol/L — no hypoglycaemia management required.
8. Obtain IMISTAMBO history — signs/symptoms, onset, medications (including frusemide, carvedilol, ramipril), allergies (penicillin), pertinent history (known CCF, NSTEMI, hypertension, T2DM).
9. Do NOT administer GTN — GTN is contraindicated in CCF as it reduces preload and may exacerbate symptoms. GTN is also outside EHS scope for this indication.
10. Do NOT administer aspirin — chest heaviness in context of known CCF and no clinical suspicion of ACS; do not administer aspirin without clear ACS suspicion and discussion.
11. Monitor patient continuously — record full observations every 10 minutes (or 5 minutes if condition is time critical).
12. Continuously reassure patient and wife. Explain all interventions clearly.
13. Recognise patient as time critical — arrange Priority 1 transport and pre-notify receiving facility (hospital emergency department).
14. Maintain patient in upright position during transport.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Congestive Cardiac Failure · Oxygen Delivery · Primary Survey · Blood Glucose Monitor · Blood Pressure · Pulse & Respirations · Pulse Oximetry · Glasgow Coma Scale (GCS)

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Signs/Symptoms	Progressive shortness of breath over 30 minutes. Worse lying flat. Bilateral leg swelling over past week. Productive cough with frothy white sputum. Mild chest heaviness rated 3/10.
Allergies	Penicillin — rash. No known allergy to aspirin or NSAIDs.
Medications	Frusemide 40mg daily, Carvedilol 12.5mg BD, Ramipril 5mg daily, Atorvastatin 40mg nocte. Wife confirms patient took all medications this morning.
Pertinent History	Known congestive cardiac failure diagnosed 4 years ago. Previous NSTEMI 6 years ago. Hypertension, Type 2 Diabetes (diet controlled). No recent hospital admissions. Wife notes he has been eating salty food at the match and had two beers.
Last Oral Intake	Pie and two beers approximately 1 hour ago at the event.
Events Leading	Patient was seated in the grandstand watching the AFL match. He became progressively more breathless and was unable to get comfortable. Security staff assisted him to the FAP after he was found hunched forward in his seat.
Treatment Prior	Nil self-treatment. Wife encouraged him to sit upright.

Onset	Gradual onset over 30 minutes at the event; underlying symptoms worsening over past 3–4 days including increasing leg swelling and difficulty lying flat.
Pain	Mild chest heaviness / pressure 3/10. Non-radiating. Not the primary complaint — breathlessness is dominant.
Quality	Chest heaviness, described as 'tight'. Breathlessness described as 'like drowning'.
Radiates	Nil radiation.
Severity	Breathlessness 8/10. Chest heaviness 3/10.