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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.