((If the trainee does not move the patient indoors or to a sheltered warm environment within the first 2 minutes, the patient begins to shiver more violently and GCS drops to 10 — prompt: 'The wind picks up and Margaret becomes increasingly difficult to rouse.'))

((If oxygen is not applied within 3 minutes, SpO2 drops to 90% on room air and respiratory rate decreases to 8 — prompt: 'Margaret's breathing appears to be getting slower and shallower.'))

((If wet or inadequate clothing is not removed and patient is not actively passively re-warmed with blankets, the 10-minute temperature does not improve and remains at 32.4°C — prompt: 'Despite being inside, Margaret still feels very cold to touch.'))

((If BGL is not checked, facilitator prompts: 'You notice Margaret is becoming increasingly drowsy — what other assessment would you perform?'))

((If the trainee attempts to walk the patient or has her stand and mobilise to the FAP, prompt: 'Margaret becomes very unsteady on her feet and nearly falls — what are your concerns about moving her this way?'))

((If the trainee does not consider the beta-blocker (Metoprolol) as a reason why the bradycardia may not resolve easily, facilitator prompts: 'You note the pulse has improved slightly but remains bradycardic at 56 — is there anything in Margaret's history that may be contributing?'))

This patient is suffering from moderate hypothermia (core temperature 32.4°C) presenting with bradycardia, altered conscious state, reduced respiratory rate, and peripheral shutdown following prolonged cold exposure at a community fair.

• Ensure scene safety and don appropriate PPE.
• Perform Primary Survey — confirm airway patent, breathing present but shallow and slow, pulse weak and bradycardic.
• Move patient immediately from cold outdoor environment into warm sheltered area (FAP tent or ambulance if available) — avoid sudden or rough movement to reduce risk of triggering ventricular arrhythmia.
• Position patient recumbent (supine or semi-recumbent in position of comfort) — do NOT walk the patient.
• Apply oxygen via non-rebreather mask at 10–15 L/min targeting SpO2 94–98% as per Oxygen CPG.
• Perform Vital Sign Survey — obtain full observations including tympanic temperature, BGL, BP, HR, RR, SpO2, GCS, pupils.
• Record tympanic temperature (note: may underestimate true core temperature in hypothermia — interpret with clinical context).
• Perform BGL — result 4.8 mmol/L, no hypoglycaemia treatment required.
• Remove wet and cold clothing — replace with dry blankets.
• Apply passive re-warming: wrap patient in blankets, use Ready-Heat blanket if available (do NOT apply directly to skin — place sheet beneath first), utilise vehicle/FAP heater.
• Do NOT provide warm oral fluids at this time as GCS is 11 and pt cannot safely ingest fluids — reassess once GCS improves to 15.
• Reassess GCS, temperature, and vital signs at 10 minutes — if GCS improves to 15 and pt can swallow safely, offer warm fluids orally.
• Monitor continuously for deterioration: watch for reduced RR, dropping GCS, increasing bradycardia, or onset of arrhythmia (without cardiac monitor, rely on pulse palpation and clinical signs).
• Arrange Priority 1 transport to nearest ED — hypothermia with GCS 11 and bradycardia is time critical.
• Pre-notify receiving facility of patient's condition, temperature, GCS, and haemodynamic status.
• Complete IMISTAMBO handover to incoming ambulance crew.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Hypothermia · Oxygen Delivery · Blood Glucose Monitor · Tympanic Thermometer · Primary Survey · Ready Heat Blanket · Glasgow Coma Scale (GCS)