Emergency Care Readiness Programme
One answer. One pathway. It does not change when the diagnosis changes. Assessment structure from the Resuscitation Council UK ABCDE approach; resuscitation and peri-arrest pathways follow the AHA 2025 Guidelines, as on Day 1.
Before anything elseA 58-year-old man is carried into the treatment room. He is grey, sweating and breathing fast. Nobody knows what is wrong with him. What do you do first?
You do not need a diagnosis to start saving a life.
Lab tests, a full history and a working diagnosis all ask this patient to wait while you become certain. There is one pathway that does not.
Triage + NEWS2 — who cannot wait, and how we prove it. 35–45 minutes, then a formal handover.
The sick patient · ABCDE · shock · five cases including drowning · trauma · escalation.
By the end of the session you can run this pathway on a patient you have never seen before, without being told the diagnosis.
One suggested shape for four hours. It is a suggestion, not part of the teaching — the content below stands on its own whatever order you deliver it in. The two simulations at the end are the part that changes behaviour, so everything before them runs to time.
Do not read objectives. Put the patient on the screen and take three answers out loud before you press Reveal. The wrong answers are the useful ones — they are what people actually do under pressure.
That this morning teaches one pathway, not eight diseases. Say it plainly: “If you remember nothing else, remember the strip at the top of every screen.”
Spending ten minutes on the agenda. Ninety seconds maximum, then hand to the nurse.
“Think of the last patient here who deteriorated. How long between the first abnormal observation and the first phone call?”
One triage system, one physiological support tool — prioritise safely and recognise deterioration early.
How long can this patient
safely wait?
It does not ask what is wrong with them. That is a different question, and it cannot be answered in two minutes.
Oman uses ONSET — the Oman National System for Emergency Triage, a Ministry of Health policy first issued in 2019. It is a five-level scale derived from the Emergency Severity Index and modified for the Omani health system. ONSET remains referenced in Oman Ministry of Health emergency guidance published in 2025.
Before anything else, settle what is what. Most triage confusion in this building is not about thresholds — it is staff treating three different things as three competing systems, and not knowing which one they are supposed to be using.
Not five colours to memorise. Four questions, asked in sequence. Q1 and Q2 are stop questions — a yes at either ends the triage and starts the response. If both are no, you continue to Q3 and Q4.
A RED FLAG DOES NOT MEAN TRIAGE FASTER.
IT MEANS STOP TRIAGING.
Move the patient, call for help, and begin ABCDE. You do not finish a triage form on a patient who is dying in front of you. The form waits. The patient does not.
ONSET is the logic. Al Shifa is where the decision gets recorded. Two screens, depending on where the patient walked in. Most of these fields are not paperwork — they are the decision, written down.
These are our own screens. Every patient and staff identifier has been permanently removed from the image itself before publication — not hidden behind an overlay.
It is on the Al Shifa triage screen, and it is not decoration. But it is an input, not a system.
Triage Support — a phone-sized tool that walks the ONSET questions, scores NEWS2 and tells you what it found. Built for 02:00, when the question is “is this the one I call the doctor for?” Open the tool →
It names the features that are present. It does not assign an ONSET level and it does not tell you how many minutes you have — those come from approved policy, not from a training tool.
Up-triage when uncertain. Between two levels, choose the higher. The cost of over-triage is a nurse's time. The cost of under-triage is a patient found collapsed in a corridor.
Never triage by capacity. The category describes the patient, not how busy we are. Capacity problems require escalation; they do not justify assigning a lower acuity.
Category definitions, target waiting times and workflow follow the current Oman MOH / Lima approved ONSET policy. Waiting times are deliberately not printed here.
One number, on its ownRespiratory rate 32. Everything else looks acceptable.
How worried are you?
Very. And you should already be moving.
Respiratory rate is often an early and sensitive marker of deterioration. Count it properly and trend it. A rate of ≥25 or ≤8 scores 3 on NEWS2 by itself. One extreme physiological parameter can be enough to trigger urgent clinical review — the local escalation pathway defines who is called and how.
A written “18” that nobody counted is worse than no number at all, because it provides false reassurance.
A normal blood pressure
never rules out a critically ill patient.
Watch the trend, not a memorised list.
One patient, one common pattern. Watch the two lines against each other — that is the whole teaching point. It is a pattern, not a rule.
Six physiological measurements plus supplemental oxygen. It does not replace judgement, triage or ABCDE. What it does is give you a number that travels down a phone line.
One parameter scoring 3 — a respiratory rate of 26, for example — needs an urgent clinician review even when the total is only 3.
A score of 4 that was 1 an hour ago is more worrying than a stable 5. Look at the last set, not just this one.
Clinical concern overrides a reassuring score. If you are worried and the number is 2 — escalate anyway, and say why.
Who is called, by what method and within what timeframe follows the Lima Health Centre / Oman MOH escalation policy.
NEWS2 is validated in adults ≥16 years — not in pregnancy or in children, which have their own tools (Days 3 and 4). Scoring system: Royal College of Physicians, National Early Warning Score (NEWS) 2, reproduced unaltered.
anyone says they look worse · the observations change, especially a rising respiratory rate · new pain, confusion, breathlessness or vomiting · the wait exceeds the local interval · or you have a feeling something is wrong and cannot yet say why.
A level-2 patient with nobody named to review them has not been triaged — they have been labelled. Assign the category, and a person, and a time.
Five patients arrive together. Tap them in the order you would assess them, then reveal the reasoning.
“My job at the front desk is not to know what is wrong with you. My job is to know how long you can safely wait. Those are two completely different questions, and only one of them can be answered in two minutes.”
Eleven short steps, then the handover. You own the whole opening — triage and NEWS2 together, uninterrupted, and then you hand the room to the doctor and sit down. You do not come back later.
We are a primary health centre with a resuscitation bay, a small team and a transfer route that takes real time — by road, and sometimes by boat. That makes early triage more important here than in a large hospital: our level-1 and level-2 patients need the transfer conversation started at the moment of triage, not after the review.
On ONSET — do not quote waiting-time targets from memory or from another hospital. Say: “the target times are in our approved local policy and that is the version we follow.” An invented number quoted here would be repeated for years.
Take answers before revealing. Then have everyone count their neighbour's respiratory rate for a full minute. It feels long — that is the point, and it is why the number gets invented.
Do not read the scoring table aloud. Use the calculator live with a real recent patient's numbers from memory and let the room watch the score assemble itself. Use the “Load: septic patient” button if you want a fast example.
Do not reveal first. Pairs, ninety seconds, then take the order from two different pairs and let them disagree in public. The disagreement is the lesson. The useful argument is between the septic patient and the chest pain — both are level 2, and in a centre with two staff the honest answer is that both are started together.
Under-triage of the elderly, the very young and patients who cannot express themselves — including patients who do not share our language. Bias and stigma are documented causes of triage error, particularly in sepsis and in patients labelled “anxious”. If you cannot get a clear story, that raises risk; it does not lower it.
“Where exactly would a level-2 patient sit in this building, and who is responsible for looking at them again in fifteen minutes?”
You have identified the patient who cannot wait.
End of the nurse-led block. The rest of the morning is led from here.
Before any number, any test, any diagnosis — the end-of-the-bed judgement of an experienced clinician is a real clinical finding. Trust it, then confirm it.
Ten seconds, from the end of the trolleyWhat are you actually looking at?
And one sentence: “Hello, are you all right?” A clear reply means a patent airway, breathing, and a brain that is being perfused. Three letters answered in one sentence.
Stop. Activate Code Blue and go to the AHA BLS pathway taught on Day 1. Agonal gasping is not breathing.
Something is wrong — before the numbers collapse.
Early. A named person, a named method, and confirmation that they went. Late escalation reduces the time available for stabilisation and safe transfer.
And you do not leave a letter until what you found there is treated.
Two ideas only: the end-of-bed impression is a real finding, and the first sentence you speak is an assessment tool, not politeness.
Ask who, at Lima, on a night shift, is “the appropriate help”. Make them name a person and a method. If the answer is vague, that is a gap worth recording in the register.
Respiratory rate is the most frequently invented number in healthcare — a written “18” that nobody counted is worse than no number at all, because it gives false reassurance.
Everyone assesses; nobody calls. Assign it out loud: “You — call Dr X now, and come back and tell me you did it.”
“At 02:00, who do you call, how, and how long until they arrive?”
Five letters. The same four actions inside every one of them.
The same patient runs through all five. The monitor beside the letters is his — watch it change.
ABCDE IS A LOOP.
Treat → reassess → start again if the patient changes. Performed once on arrival and never repeated, it finds the deterioration at minute forty instead of minute twenty.
This is printed on the pocket card in the Day 2 print pack. One per person, top pocket.
This is where the educational weight of the day belongs — more time here than on any individual disease. Move through the letter tabs and say the four steps out loud each time until the room starts saying them with you. That is the entire teaching method.
Two sounds, two locations, two treatments. Stridor at the neck without a stethoscope; wheeze over the chest with one. Pitfall: nebulising salbutamol at a patient with stridor and a swelling tongue — that patient needs adrenaline. Second pitfall: the patient who was noisy and has gone quiet has usually obstructed, not improved.
Count the rate; treat oxygen as a drug with a target. Pitfall: “saturations are 96%” quoted as reassurance while the patient is on 15 litres breathing 34 times a minute.
Perfusion is the assessment; fluid is cause-specific. Demonstrate a sternal capillary refill and count out loud. Pitfalls: a normal blood pressure used to close the conversation, and the unmeasured “fluids running” that nobody reassesses.
One habit — glucose in every altered conscious level — prevents the most avoidable error in the framework. Confirm which hypoglycaemia preparation is stocked here and who may give it, so the teaching matches the cupboard.
Exposure finds the diagnosis. In a small community where staff and patients know each other, say explicitly how you manage dignity in our treatment room — curtain, named chaperone.
Slow down here. Say the sentence, pause, and let it sit. This is the memory anchor of the morning.
“After you give a treatment, what makes you go back and look again — a rule, or a feeling?”
Findings appear only when you assess for them. A life-threatening abnormality must be treated before you can move on — the walkthrough will not let you leave it.
Do not touch the screen yourself — nominate a nurse to choose the actions and make the room vote first. Read the vital signs aloud each time they change; the point is that the numbers respond to what you do.
When the walkthrough refuses to advance, do not apologise for it. That refusal is the single most important teaching moment of the morning: you cannot leave an untreated life threat behind you.
Rushing to name the diagnosis. If someone shouts “it's asthma” in the first thirty seconds, accept it — then ask what they are going to do, and in what order.
“What changed on the monitor after that treatment — and what would you do if nothing had changed?”
Not a blood-pressure number. A clinical diagnosis, made at the bedside, that exists long before the pressure falls.
Worth stopping onCan a shocked patient still have a normal blood pressure?
YES — compensated shock exists.
Young, previously well patients hold their systolic pressure by clamping down and speeding up — until they cannot. What gives them away first: tachycardia · a narrowing pulse pressure · cool mottled peripheries · capillary refill over 2 seconds · a rising respiratory rate · agitation, then drowsiness.
And in early distributive shock the skin may be warm. A warm patient is not a well patient.
Empty needs volume. Distribution failure needs volume, the cause treated, and often vasopressors at the receiving hospital. Pump failure and obstruction are harmed by an unconsidered fluid bolus: in pump failure fluids may worsen pulmonary oedema, so give only when indicated and reassess after every aliquot; in obstruction fluids do not treat the cause — definitive treatment requires relief of the obstruction.
No single physical sign proves a mechanism, and more than one can be present at once. The signs raise or lower probability; the history, the ABCDE assessment and the response to treatment decide.
One sentence, four boxes, one question. Eight minutes, no longer. The mechanism matters only because it decides the fluid.
All four present at Lima. Two of them get worse with the fluid we instinctively reach for.
Waiting for hypotension — and teaching signs as if they were diagnostic.
“Which of the four have you personally seen in this building in the last year?”
Five patients. Six identical questions each. None of them starts with the diagnosis. By the last one the sequence should feel automatic — that is the point of the repetition.
Case 1 is the ABCDE walkthrough patient from Chapter 03. It is kept here so the set is complete for reference and self-study, but it is not run live — teaching the same patient twice costs eight minutes and adds nothing. Run cases 2, 3, 4 and 5 live, eight minutes each. Case 5 — drowning — is a Lima local priority and is not optional here.
Run cases 2, 3, 4 and 5 live — eight minutes each, by the clock. Case 1 is the same patient as the Chapter 03 walkthrough and is not taught again; point at it and move on. The Timekeeper announces the last two minutes. Take an answer from the room at “What do you do NOW?” before you advance the step.
Severity is judged on speech, rate, accessory muscles, pulse, saturation and air entry — not on the patient's own estimate. Confirm out loud what we stock: inhaler, spacer, nebuliser, ipratropium, oral prednisolone. Pitfall: being reassured by a quiet chest; giving one nebuliser and walking away.
Clinical diagnosis on rapid onset plus A, B or C compromise. Skin changes are common but not required, and their absence is a classic reason for delay. Walk to the emergency drug box during the session and confirm where the ampoules are and who may draw one up. Pitfalls: antihistamine first; standing the patient up.
Suspected infection plus deteriorating physiology is enough to act — no test must return first. Our job is recognise → resuscitate → give what our protocol allows → reassess → transfer. Pitfall: waiting for hypotension, and treating 30 mL/kg as one uncontrolled bolus.
Start the timer first. Confirm which benzodiazepine, strength and route we hold and who may give it. Pitfalls: objects in the mouth, restraint, forgetting glucose, losing track of time.
This used to be its own chapter. It is now Case 5, run on the same six questions as the others, because that is the message of the whole day: the patient changes, the approach does not. Keep the live teaching to the six questions and the one memory point — CPR with breaths first, AED second. The rest is in the collapsed “Why drowning is different” panel; open it only if asked.
Point them at the case library below and move on. It exists so the main teaching narrative is not interrupted.
“Which of these five is most likely to walk through our door this week?”
The only change in the whole frameworkArterial blood is pumping from a thigh wound onto the road. The airway is noisy.
Which do you deal with first?
<C> = catastrophic haemorrhage.
Control catastrophic external haemorrhage immediately. Uncontrolled bleeding is the leading cause of preventable death in major trauma. With a team present, airway assessment proceeds in parallel — one pair of hands goes to the bleeding while another opens the airway. Alone, control the catastrophic bleeding first, then move to A.
Same systematic thinking. A different first priority when catastrophic bleeding is present.
A — assess and treat as taught. Consider spinal protection where mechanism or findings indicate, but never at the cost of an open airway; jaw thrust is preferred where cervical injury is possible.
B — look for the major chest threats. If tension pneumothorax is suspected with severe respiratory compromise or haemodynamic instability, urgent skilled treatment is required. Untrained staff must not attempt invasive decompression — call the person who can.
C — haemorrhage, perfusion, pulse and pressure. IV/IO access where appropriate. Avoid indiscriminate large-volume crystalloid in active haemorrhage. Move towards definitive haemorrhage control and transfer.
D — GCS, pupils, lateralising neurology, glucose. A falling GCS in trauma is a transfer accelerator, not an observation to repeat later.
E — expose enough to find the injuries, including the back, then cover: prevent heat loss, which worsens bleeding. Maintain dignity throughout.
Remember where blood hides from pressure: chest · abdomen · pelvis and retroperitoneum · long bones · the floor. Those patients need a surgeon, and the only treatment we can give is a fast, well-prepared transfer.
Tranexamic acid, where it is given at all, is time-critical — within 3 hours of injury, and only within staff scope of practice. For a centre with long road and sea transfers this is the one trauma clock that matters, so know before the day whether we hold it and who may give it.
Framework: NICE major trauma guidance for <C>ABCDE. If the patient arrests, transition to the
AHA 2025 cardiac arrest pathway.
One change only. Do not rebuild the framework — that is the message: the system you just learned still works, with a single insertion at the front. Keep this whole chapter under ten minutes. It is not an ATLS lecture.
Find out in the room whether we hold tourniquets and a pelvic binder, and who has ever applied one. Direct pressure is available to everyone and is under-used. Run the clock visibly on the challenge — sixty seconds is uncomfortable, and it should be.
Working through A while the patient bleeds out from a limb. And filling a bleeding patient with crystalloid instead of moving them.
“Road traffic collision on the coast road at midnight — what are our first three actions, and who does each one? Say the names.”
This room holds nurses, doctors, midwives and support staff. The clinical standard in this lecture is the same for all of you. What differs is which part of it each person performs — and that is a written, local answer, not a matter of confidence on the day.
What is wrong · what you found · what you did · the response · what you need.
Keep this short and keep it here, at the end — it must not interrupt the ABCDE teaching. SBAR is not bureaucracy; it ensures the person on the phone hears the severity in the first ten seconds.
Make one participant read their generated handover aloud as if on the phone. Then ask a second person whether they would leave what they are doing and come.
Burying the recommendation. Say what you need explicitly, and do not end the call without agreement on what happens next and by when.
“What stops you from saying ‘I need you now’ to a senior colleague — and what would make it easier?”
You know the framework.
NOW USE IT
without the labels.
“This 34-year-old was brought in by a relative. She is struggling to breathe. That is all you know.”
No diagnosis. No confirmation if asked. 8–10 minutes, then a four-step debrief.
“This 67-year-old man was found confused at home this morning. His daughter says he has been unwell for two days.”
Physiology first, label last. A different named leader from Simulation A.
Scored live by a facilitator who is not running the scenario. No patient-identifiable data. The three sub-scores matter more than the total: a team that scores well on ABCDE and poorly on reassessment and escalation has a specific, fixable problem — and that is exactly the kind of finding the programme's corrective-action register exists for. Full facilitator scripts are in the Day 2 print pack and runbook.
1 · Never state the diagnosis, and never confirm it if asked. 2 · Do not interrupt mid-scenario — if they fall, let them fall; the debrief is where it is fixed. 3 · The numbers respond to their actions, consistently: better if they act, worse if they delay. 4 · Name the leader before you start, and change the leader for the second scenario. 5 · Score live — retrospective scoring drifts towards kindness. 6 · Freeze at the transfer decision, not at “recovery”. 7 · If an arrest happens, they move to the AHA 2025 pathway from Day 1 — that is intentional. 8 · Scores are never read out to the group; debrief on behaviour, and the numbers go to the programme record.
Feelings (30 s, one sentence each, no discussion) → Description (60 s, the recorder reads the timeline) → Analysis (120 s — ask about the decision, not the person: “what made you choose that at that moment?”) → Summary (30 s, one thing to do differently. One, not three).
“What told you this was serious before the numbers did?” · “When did you call for help, and could you have called earlier?” · “What did you reassess after the first treatment?” · “When was the transfer decision made?”
“You were wrong when you…”. Replace with “At that moment, what was clear in front of you?” The first closes people; the second opens them.
Clinically useful cases that are not part of the main teaching narrative — kept here for microlearning, simulation, self-practice and future sessions. Every one of them runs on the same six questions.
Not an ECG course. One principle: treat the patient, then the rhythm.
These cases were in the earlier version of the day and are clinically sound — but eight diseases competing for attention is what stops people remembering the framework. They are preserved, not deleted, and moved out of the main flow.
Do not open it during the lecture unless the room asks a specific question you can answer in ninety seconds. Use it afterwards: one case per staff meeting, one case per drill, one case per WhatsApp microlearning post.
ACS is the highest-value addition for this centre, because time and transfer distance decide the outcome and the ECG is the intervention.
Anyone in the room who trained on an earlier ACLS course learned narrow regular 50–100 J, atrial fibrillation 120–200 J, atrial flutter 50–100 J. AHA 2025 supersedes all three. The teaching card deliberately prints only the current figures — two sets of joules for the same rhythm on one card is exactly the kind of thing that gets misread at the defibrillator. Name the old numbers here, in the room, so that staff recognise them as retired rather than meeting them on a card and having to work out which set is current. Then close on the AHA line that matters most: follow your specific device’s recommended energy level.
The peri-arrest pathway now points to the library card for the atropine, pacing and infusion detail rather than repeating it. If the room asks for the doses, open Symptomatic bradycardia above — that is the single maintained copy.
The cardioversion joules and the adenosine doses now live only on Tachyarrhythmia with a pulse in the case library. The peri-arrest pathway card points to them. These are the numbers most likely to be misread under pressure, so there is exactly one maintained copy of each. The never adenosine for an irregular or polymorphic wide-complex rhythm warning is deliberately left in both places — a safety rule with no number in it is worth repeating.
RECOGNISE BEFORE COLLAPSE.
LIMA PULSE · Day 2 · Lima Primary Health Centre
The same twenty items before the teaching and after it. The gap between the two is the only evidence that today changed anything.
Twenty single-best-answer items across triage, ABCDE, NEWS2, shock, the five core cases including drowning, peri-arrest rhythms and trauma. PRE mode hides the answers. POST mode shows the score, the domain breakdown, the pre-to-post delta and a short explanation for every item. Everything runs in the browser; the result file is downloaded and given to the trainer.
Precedence: Oman MOH guidance → device and manufacturer instructions → the guideline sources below → the treating clinician's judgement for the patient in front of them.
AHA 2025 is the LIMA PULSE resuscitation and peri-arrest framework. Resuscitation Council UK is used only as an educational source for the ABCDE assessment structure. AHA and ERC/RCUK cardiac-arrest and peri-arrest algorithms are never mixed. If a patient arrests in any scenario, we move to the AHA 2025 pathway taught on Day 1.
Lima holds no hospital-style local protocol document. Where earlier versions of this lecture deferred a number to “local protocol”, it now states the guideline position and names the source. That makes this a clinical reference — it is not a prescribing authorisation, it creates no nurse-initiated administration authority, and the treating clinician remains responsible for the decision in front of them.