‘They’re not themselves’ — seriously ill child structured encounter

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses first-impression recognition, immediate stabilisation, communication, reassessment, escalation and safe transfer of information. [1] [18]

Candidate instructions

You are the paediatric registrar called to an acute assessment room. Assess Aisha from the doorway and say your Paediatric Assessment Triangle (PAT) findings aloud. Lead a focused, age-adapted ABCDE assessment and treat each problem as you find it. Speak directly to Aisha and her mother. Use Aisha’s usual communication methods and arrange professional language support. Reassess after each action. Call senior, critical-care or retrieval support early. Address safeguarding alongside urgent care. Finish with a structured handover and disposition plan. Do not perform painful or distressing manoeuvres on the actor. Say what you would assess or do instead. [1] [12] [15] [16] [17] [20] [21]

Room setup and observable starting state

The encounter. Aisha is 8 and has cerebral palsy with an expressive communication disability. She usually communicates through eye-gaze yes/no and a picture board. She is seated with support beside her mother. Her mother begins in English: “They’re not themselves.” She then asks to use Arabic for detailed discussion. A professional interpreter can join immediately. [15] [16] [17]

What is visible before touch. Aisha is unusually still and looks only briefly towards her mother. Her tone is lower than shown on her personal-baseline card. She has nasal flaring and intercostal recession. She looks pale, with mottling at the knees. These are abnormalities in Appearance, Work of Breathing and Circulation to Skin. The candidate should describe these signs, not diagnose from the doorway. They should say all three PAT domains are abnormal, call for help and start ABCDE immediately. The three domains come from the American Academy of Pediatrics PEPP framework. PAT is a rapid first look. It is not a score, diagnosis, full examination or disposition rule. [1] [2]

Simulation safety. Aisha remains seated and uses her board and eye gaze. She never hyperventilates, breath-holds, is forcibly positioned or undergoes physical examination. Cards or the assessor supply recession, breathing sounds, monitor readings and examination findings. Portray disability through Aisha’s documented baseline and communication method, never by caricature. The caregiver and interpreter do not obstruct urgent care. [16] [17]

Actor cues

Child actor

• When the candidate uses Aisha’s name, simple words and enough time, look towards them. Select “scared” and “hard to breathe” on the picture board.
• Use the agreed eye-gaze signal for yes/no. Do not invent speech or another impairment.
• If the candidate explains before touch and offers a simple choice, engage briefly. If ignored, look towards the caregiver. Do not act out worsening physical distress.
• Do not answer a leading safeguarding question. The assessor says, “Please ask only clinically necessary, non-leading questions.” [16] [20]

Caregiver actor

• Begin with “They’re not themselves.” If asked what has changed, answer through the professional interpreter: “Aisha usually looks straight at me, laughs and reaches for her board. Today she is quiet, breathing harder, drinking very little and passing much less urine.”
• If asked about baseline, give the personal-baseline card. Aisha has no home oxygen. She usually has lively eye-gaze communication and independent head control when supported. She does not usually have mottling. Offer Aisha’s emergency plan.
• If detailed discussion continues in English, say: “I understand some English, but I need Arabic for this.” Do not give detailed consent or safeguarding history until the professional interpreter is used.
• If asked about the new upper-arm bruises, say: “I noticed them after school transport yesterday. I do not know exactly what happened. Please make sure she is safe.” Do not accuse anyone or add history.
• If the candidate acknowledges the concern and explains the plan, stay beside Aisha and help her communicate. If the candidate dismisses the concern because of disability, repeat once: “This is not normal for her.” [15] [16] [17] [20]

Interpreter actor

Interpret in the first person. Interpret everything said without adding clinical information. Ask for shorter segments when needed. Do not answer for Aisha or her mother. The candidate should speak to them, not to you. [17]

Assessor cues and clinical data

Give each finding only when the candidate reaches that ABCDE step or asks for it. Do not require repeated handling or cause distress. Interpret rates and observations using Aisha’s exact age, measurement conditions, baseline, trend and active local chart. The Royal Children’s Hospital Melbourne acceptable ranges are one example for unwell children. They are not universal normal values or escalation thresholds. [5] [16]

The Resuscitation Council UK 2025 Paediatric Life Support guidance supports immediate ABCDE, treating threats as found, calling help and reassessing after treatment. This encounter gives no universal oxygen target, fluid rule, medicine dose or complete disease algorithm. The candidate should follow the active local pathway. They should use age- and weight-appropriate equipment and judge the response. Altered interaction and poor intake require a prompt glucose check. If glucose were dangerously low, correct it and recheck through the active pathway without delaying care. This boundary follows the Royal Children’s Hospital Melbourne hypoglycaemia guideline. [12] [23]

Reassessment cue within the same encounter

Once the candidate has called help, started ABCDE support and stated the response they expect, say: “The monitor signal is reliable. Aisha’s visible effort is now less, but air entry is poorer. She no longer selects on the picture board, and peripheral pulses remain weak.” This is not a second case or a new diagnosis. Less effort does not mean recovery here. The candidate should recognise possible fatigue, failing breathing and unresolved poor perfusion. They should repeat PAT and ABCDE, increase support and call PICU or retrieval early. [11] [12] [21]

If asked what the hospital can provide, say: “This hospital can provide initial paediatric stabilisation and continuous monitoring. It cannot provide sustained invasive ventilation or vasoactive support. Retrieval will not arrive immediately.” The candidate should agree a monitored backup plan with the senior clinician and retrieval team. This must name the next sign of failure and who will act while transfer is pending. The encounter does not imply a universal transport trigger, escort or mode. [21]

Expected candidate sequence

1. Look before touching. Approach calmly and introduce yourself. Keep Aisha with her mother. Describe the PAT findings and say all three domains are abnormal. Add: “PAT tells me what looks wrong now. It does not diagnose the cause.” Call the paediatric emergency response, senior clinician and appropriate airway or critical-care support immediately. [1] [2]
2. Communicate while care begins. Speak directly to Aisha: “Hello Aisha, I am Dr ____. I can see breathing is hard. I will explain each step. Your mum can stay.” Confirm her eye-gaze yes signal and picture board. Ask her mother what is different and what worries her most. Connect the professional Arabic interpreter without delaying stabilisation. Speak in short, first-person segments. [15] [16] [17]
3. Lead a focused ABCDE. Check whether the airway is open and likely to remain open. Support breathing through the active pathway. Check air entry, work, fatigue and whether the oximeter reading is reliable. Assess pulses, skin, documented capillary refill, blood pressure, urine output and trend together. Compare interaction and tone with Aisha’s baseline, check glucose and expose only as needed. Keep her warm, preserve dignity and protect possible evidence. Treat each problem when found. Allocate tasks and confirm they are completed. [7] [11] [12] [16] [23]
4. Name the immediate problem and keep causes open. State that Aisha has respiratory failure with circulatory compromise. Continue to consider airway, lower-respiratory, parenchymal, cardiac, infectious, metabolic, toxic, traumatic and device-related causes. Order tests after stabilisation only when they find a reversible cause, change immediate treatment or determine destination. [12] [23]
5. Reassess the actual response. Repeat the affected PAT and ABCDE findings after every action. Less effort with poorer air entry and interaction means failure unless the other findings also improve. State the response you expected and what happened. Record adverse effects, unresolved problems and the next escalation action. [12] [18]
6. Call PICU and retrieval early. Tell the senior clinician, PICU and retrieval service that Aisha may need support unavailable here. State current monitoring, access, equipment and staffing. Ask for advice and destination. Agree what to do if retrieval is delayed. Prepare Aisha with suitable staff, monitoring and equipment, and keep her family informed. [21]
7. Address safeguarding alongside stabilisation. Aisha’s breathing, circulation and immediate safety come first. Ask another team member to document the bruises and her mother’s exact words. Ask only necessary, non-leading questions. Do not conduct a forensic interview during respiratory compromise. Do not use a family member as interpreter. Preserve evidence when safe and activate the current local safeguarding pathway. The named operational source is NICE child abuse and neglect guidance. Reporting thresholds and agencies remain jurisdiction-specific. [17] [20]
8. Complete handover and transfer planning. Include Aisha’s age and measured or estimated weight status. Give her baseline, communication method, caregiver concern, PAT, current ABCDE findings and trend. Include timed actions and responses, tests, differential, access, devices, safeguarding information and interpreter need. State local limits, the requested destination and the next action if she worsens. Ask the receiver to read back the plan and confirm who owns each action. [15] [16] [17] [18] [21]

Keep the caregiver’s concern in every escalation, even if one score or observation seems reassuring. In Australia, the Australian Commission on Safety and Quality in Health Care Recognising and Responding to Acute Deterioration Standard requires locally agreed escalation criteria, individual monitoring and family escalation routes. It does not require one universal paediatric score. [15]

MedVellum formative marking domains

This educational rubric has 10 domains scored 0–3, giving a MedVellum formative total of 30. Score 0 for omitted or unsafe, 1 for named but incomplete, 2 for clear and safe, and 3 for integrated, prioritised and reassessed. This is not an official board mark or pass standard. Feedback should identify the first unsafe step, not only the total. [1] [18]

Critical fails

Any item below overrides a reassuring formative total because it creates immediate avoidable risk. [1] [12] [18]

• Does not call for help or start ABCDE despite all three PAT domains being abnormal.
• Uses PAT as a diagnosis, score or replacement for ABCDE. Allows blood pressure or one monitor reading to rule out serious illness.
• Calls quieter breathing a recovery despite worse air entry and interaction. Does not reassess or escalate.
• Delays professional interpretation for detailed discussion. Uses a family member for safeguarding interpretation or speaks only about Aisha, not to her.
• Dismisses caregiver concern or baseline information because Aisha has disability.
• Lets a detailed or leading safeguarding interview delay stabilisation. Ignores the bruises or immediate safety, or makes an unsupported accusation.
• Waits for all local options to fail before calling the senior clinician, PICU or retrieval team.
• Suggests discharge or unmonitored transfer while ABCDE problems remain unresolved. [1] [7] [12] [15] [16] [17] [20] [21]

Examiner prompts

Use as few neutral prompts as possible. A prompted behaviour can receive no more than 2/3 in the affected MedVellum formative domain. This is an educational feedback convention, not an official examination rule. The cited evidence supports the clinical behaviours, not this scoring convention. [1] [18]

1. “What do you notice before you touch Aisha?”
2. “Talk me through her PAT. What does it tell you, and what does it not tell you?”
3. “Aisha’s mother says, ‘They’re not themselves.’ What do you need to ask?”
4. “Aisha uses a picture board. A professional Arabic interpreter is available now. How will you communicate?”
5. “Talk me through your focused ABCDE. What response are you looking for?”
6. “Aisha’s visible effort is less, but her air entry and interaction are worse. What does that mean?”
7. “This hospital cannot provide sustained invasive ventilation or vasoactive support. What will you do now?”
8. “You find new bruises during exposure. How will you act without delaying stabilisation?”
9. “Please hand over Aisha. Include her destination and your plan while retrieval is delayed.” [1] [12] [15] [16] [17] [18] [20] [21]

Model performance

“From the doorway, Aisha is less interactive and has lower tone than usual. She has nasal flaring, recession, pallor and mottling. Appearance, Work of Breathing and Circulation to Skin are all abnormal. This is the PAT pattern of cardiopulmonary failure. PAT is a snapshot of how she looks now, not a diagnosis. I need the paediatric emergency response, senior paediatrician and airway team now. I will start ABCDE while help arrives.” [1] [2]

“Hello Aisha, I am Dr ____. I can see that breathing is hard. I will explain before I touch you. Please show me your yes signal. Keep your picture board with you. Mum, I hear that Aisha is not herself. What has changed most, and what worries you most? I will connect the professional Arabic interpreter now. Urgent care will continue while we talk.” [15] [16] [17]

“Her airway is open now, but I may not be able to maintain it if she becomes less responsive. I will support her breathing through the active paediatric pathway. I will check air entry, work, fatigue and whether the saturation reading is reliable. For circulation, I will assess pulses, skin, documented capillary refill, blood pressure, urine output and trend together. I will compare her interaction and tone with baseline. I will check pupils and glucose. I will expose only as needed. I will look for rash, injury and device problems while keeping her warm and preserving dignity. I will treat each problem as I find it. After every action, I will reassess from A.” [7] [11] [12] [16] [23]

“Less visible effort is not improvement here. Her air entry and interaction are worse, and her pulses remain weak. I am concerned that she is tiring and her breathing is failing. I will repeat PAT and ABCDE now. I will increase respiratory support through the local pathway. I will call PICU and retrieval because she may need support this hospital cannot provide. We need continuous monitoring, named action owners and a clear plan if transfer is delayed.” [12] [18] [21]

“The new bruises need objective documentation and immediate safety action. Stabilisation comes first. I will ask another clinician to use the professional interpreter for necessary, non-leading questions. We will record any spontaneous words exactly. We will not make accusations or conduct a detailed forensic interview now. I will activate the current local safeguarding pathway. I will explain to Aisha and her mother what we must share and why.” [17] [20]

“Aisha is 8, and her measured weight is pending. She usually communicates with lively eye gaze and her picture board. She normally has supported head control and no home oxygen. Her mother reports reduced interaction, intake and urine. All three PAT domains were abnormal. Her airway is open now. Her breathing is becoming less effective, with poorer air entry and a reliable low saturation reading. Her pulses are weak, her hands are cool and her urine output is reduced. Her interaction remains below baseline. Her glucose is not in the dangerous-low range on the active pathway. I have called the senior clinician, airway team, PICU and retrieval. I have started local ABCDE support, but her response is inadequate. We have documented the upper-arm bruises. The safeguarding pathway is being activated with a professional interpreter. She is not safe for discharge. She needs monitored transfer to the service agreed with PICU or retrieval. Until transfer, I remain responsible and each team member has a named role. We have agreed what will trigger the next action. I will ask Aisha and her mother to alert us immediately to any change in breathing, colour, response, seizure or device function. I will check understanding through the interpreter. I will hand over pending results and who owns each safety action.” [15] [16] [17] [18] [19] [20] [21]

Disposition and safety-net standard for this encounter

Aisha remains under continuous observation. She transfers to the service agreed with PICU or retrieval. A brief improvement does not make discharge safe. While waiting, her mother receives a specific bedside route to summon help. The team states the next sign of failure, the action, the owner and the plan if retrieval is delayed. Every receiving team inherits responsibility for pending results. Handover includes Aisha’s baseline, communication needs, safeguarding status and specific warning changes. “Tell us if you are worried” is not enough. Check understanding directly with Aisha at her level. Check her mother’s understanding through the professional interpreter. [15] [16] [17] [18] [19] [20] [21]