Bring intensive care to the child — rural retrieval of a deteriorating child

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, the stay-and-stabilise retrieval principle, a pre-transport stabilisation checklist, management of the physics of altitude vibration and cold, the choice of mode and escort, communication, a rehearsed contingency, and a structured handover. [1] [4]

Candidate instructions

You are the paediatric registrar leading retrieval coordination in a rural hospital. Assess the child and say aloud what you see. Call the retrieval service in parallel with resuscitation. Apply the stay-and-stabilise principle and complete a pre-transport checklist before the trolley moves. Speak directly to the parent. Rehearse the contingency for deterioration en route. Finish with a structured handover and disposition plan. Say what you would assess or do; do not perform painful or distressing manoeuvres on the actor. [1] [12]

Room setup and observable starting state

The encounter. Arlo is four and is in the rural emergency department, three hours by road from the paediatric intensive care unit. He was admitted overnight with pneumonia and has deteriorated this morning. He is grunting, retracting and pale, the oxygen saturation is 88 per cent on high-flow oxygen, the heart rate is 165, the capillary refill is 4 seconds, and he is drowsy and responds to voice. These are abnormalities in appearance, breathing, circulation and consciousness. The candidate should describe these signs objectively, declare concern, call retrieval in parallel, and begin resuscitation. [2] [4]

Simulation safety. Arlo remains on the bed and is never forcibly positioned or made to hyperventilate. Cards or the assessor supply vital signs, monitor readings and examination findings. The parent does not obstruct urgent care. [4]

Actor cues

Parent actor

• Begin with "He was breathing so fast this morning, I knew something was wrong." If asked what has changed, answer: "He's usually running around. Now he won't wake up properly and he's gone grey and cold." [2]

Child actor

• Respond briefly to voice early in the encounter; become drowsier and harder to rouse if the assessor's cue card indicates deterioration, and grunt with any disturbance. [2]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward stay-and-stabilise behaviour and parallel activation; penalise sending the child unstable. [1]

Referral and principle

The candidate should call the retrieval service and the paediatric intensive care unit in parallel with resuscitation. Expected strong behaviour: state the stay-and-stabilise principle, agree the destination and the bed, and keep telehealth support open while resuscitating. [12] [1]

Airway and breathing

Respiratory rate 50, oxygen saturation 88 per cent on high-flow oxygen, reduced air entry bilaterally with crackles, working hard. Expected strong behaviour: recognise respiratory failure, intubate by rapid sequence with capnographic confirmation, fix the tube firmly, check the cuff pressure, set the ventilator, and confirm oxygen reserve for the journey plus a margin. [4] [8]

Circulation

Heart rate 165, weak central pulses, capillary refill 4 seconds, blood pressure low-normal, cool mottled limbs, venous lactate 4 and rising. Expected strong behaviour: diagnose septic shock, establish two reliable access sites, start a vasoactive infusion on a dedicated line, crossmatch blood, and continue aliquots to a sustained perfusion trend rather than a single blood pressure. [4] [2]

Disability and metabolic

Responds to voice but cannot sustain interaction; no seizure; bedside glucose normal; temperature 35.8 degrees Celsius. Expected strong behaviour: record the Glasgow Coma Scale and pupils, treat any seizure, confirm glucose, and warm the child actively because a cold cabin will worsen shock and coagulopathy. [2] [8]

Stabilisation event — the pre-transport checklist

The candidate should run a pre-transport checklist before departure. Expected strong behaviour: confirm airway secure and cuff pressure checked, ventilation effective with oxygen reserve, pneumothorax drained if present, shock treated, reliable access, vasoactive drugs on a dedicated line, glucose checked, seizures controlled, child warm, lines and tubes secured, monitoring continuous, and oxygen and battery reserve for the journey plus a margin. [1] [4]

Physics event — the flight

The retrieval team arrives; the plan is a rotary-wing flight with a cabin altitude around 7000 feet. Expected strong behaviour: state that gas expands by Boyle's law by up to about a third at cabin altitude, drain any pneumothorax and decompress the bowel and stomach before flight, check and adjust the cuff pressure with a plan to recheck in flight, trust continuous monitored data because vibration and noise degrade assessment, and keep the child warm throughout. [4] [8]

Mode, escort and contingency

The candidate should justify the mode and escort and rehearse the contingency. Expected strong behaviour: choose rotary-wing for a medium-distance time-critical transfer, escort with a specialist paediatric retrieval team that can manage foreseeable deterioration, and rehearse who does what if the child obstructs, desaturates, becomes hypotensive, seizes or loses a line. [1] [2]

Marking domains

Debrief prompts

• At what moment did you decide the child was stable enough to move, and what single question framed that decision?
• Which adverse event did you most worry about in flight, and what pre-emptive action did you take?
• How did you match the escort's skills to the child's foreseeable deterioration?
• What would you change in your system after this retrieval to prevent the next one being this close? [1] [6]