Home-ventilated child with night alarms — structured clinical encounter

Candidate instructions

You have 10 minutes at the bedside (simulated). Stabilise, reason aloud, and outline the next 24 hours and discharge-safety plan for this technology-dependent child with medical complexity. [1]

Scripted findings (released on request)

• Mother: “His usual SpO2 at night is about 94%. He smiles at me in the morning. Tonight he is floppy and the vent keeps alarming.” [20]
• Tracheostomy in situ; secretions thick; suction yields plugs; SpO2 rises from 84% to 94% after airway clearance. [13]
• Gastrostomy intact; last feed 4 hours ago; nine regular medicines on the list, three recent PRN sedatives added at another hospital. [17]
• No emergency care plan in the record; family carries a paper sheet with vent settings in mum’s bag. [1]
• Regional hospital; PICU retrieval available in 90 minutes if needed. [13]

Expected performance

Immediate

1. Call for help; ABCDE with technology; treat likely tube/secretion obstruction; oxygen; do not delay for labs. [13]
2. Use caregiver baseline knowledge as clinical data. [1]
3. State problem representation: CMC + technology dependence; acute airway/device threat improving after suction; possible infection/aspiration trigger still open. [1]

Assessment and plan

4. Examine devices, chest, perfusion, interaction versus baseline; glucose if indicated; consider gas/cultures if infection likely after stabilisation. [13]
5. Medication reconciliation — flag polypharmacy and unindicated sedatives. [17]
6. Escalate/retrieve if recurrent desaturation, rising support, or local capability exceeded. [13]

Systems

7. Create/update emergency care plan from the paper settings + hospital record. [1]
8. Structured handoff to ward/retrieval (baseline, devices, trajectory, outstanding tasks). [16]
9. Discharge only when training, supplies, power/oxygen, 24/7 contact and follow-up are real — do not assume continuous home nursing. [19]
10. Avoid diagnostic overshadowing and “always like this” reasoning. [1]

Examiner global anchors

• Pass: Device-aware ABCDE, CMC framing, emergency plan, polypharmacy and caregiver partnership, capability-matched disposition. [1]
• Borderline: Stabilises airway but no systems plan or baseline framing. [1]
• Fail: Ignores tracheostomy/ventilator, dismisses mother, discharges without equipment/training, or treats PMCA-like labels as bedside severity. [1]