☎️ “2-year-old, blue lips and reduced conscious level but still breathing.”

HR 90 bpm, RR 5 bpm, Sats 84% in air, CRT <2 seconds, Temp 37.4°C, BP 90/67 mmHg, GCS E2, V2, M4 = 8/15, AVPU P (responsive to pain).

It was a cold winters morning and a sluggish start to another shift in the Paediatric ED, so we pull the BUZZER ALARM in cubicle 10. Time for an in situ sim to warm everybody up!

The Scenario

The staff rush in: two doctors & two nurses. The team snaps into action, one doctor begins an ABC assessment, another assumes team leadership, the nurses are applying monitoring and one speaks with what turns out to be the babysitter.

Such situations are very disorientating. This is (1) an unexpected emergency, (2) in an unexpected clinical area and (3) with staff who have barely warmed up into their shift. It is easy to feel a degree of brain fog (speaking personally). However, for the benefit of this simulated patient, the mist quickly cleared…

The team quickly recognise they are dealing with a 2-year-old male with a decreased conscious level. They apply oxygen and provide bag mask ventilation effectively. The cyanosis abates and the chest rises nicely. Then, in a moment of clairvoyance, the leader considers this could be a poisoning. A child who has no signs of illness, no signs of injury and no prior history. A child who is cardiovascularly stable but with slow shallow breathing and pinpoint pupils.

Of course, rather than being clairvoyant, my esteemed colleague had a gut feeling. On speaking to the babysitter she breaks down in tears saying she is a methadone user and thinks the toddler might have gotten to her pills when she was distracted.

The team takes off the trolley brake and rushes this toddler to the high-dependency bay. Here, with ABC stabilised (albeit temporarily with effective bag mask ventilation and now also a Guedel airway), help is called for and intravenous access is sought. Bloods are sent. Naloxone is prescribed. But after 15 minutes their time is up…

The Debrief

After apologising to the team for their rude awakening and providing promises of coffee – we debrief. Learning points discussed and later considered are as follows…

How to maintain performance when you’re not at your physical best?

1) Recognise your fatigue

Tired? Thirsty? Hungry? Not at your best? Simply recognising this is an essential first step.

2) Maximise your resources

Call for help: easily said, always known, but not always done. “A problem shared is a problem halved.”

Use teamwork: with or without additional help you and your team work better together. Be efficient with role allocation. Be specific with task requests. Be concise with communication.