SIMULATION EVENTS TABLE:

Minute (state)	Participant action/trigger	Patient status (simulator response) & operator prompts	Monitor display (vital signs)
0:00 (Baseline)	SP nurse brings the team into the patient’s room in the emergency department.	Participants should begin by placing the patient on a monitor, obtaining history from patient, obtaining a point-of-care glucose, and performing a physical exam. If asked to go to CT before a neurologic physical exam has been performed, the CT scanner is currently busy with trauma patients.	A: T 99.8°F HR 60 BP 116/86 RR 12 O2 sat 96% room air (RA)
6:00	Team should recognize the bilateral ptosis, mydriasis, and dysarthria. IV placed, labs obtained. Labs, EKG should be ordered.	CT will be available to the learners once a neurologic exam has been performed. If the team recognizes botulism and orders antitoxin by minute 6, vitals remain unchanged from vitals (B). If the team does not order the antitoxin by minute 6, bradycardia worsens and patient develops dyspnea/hypoxia (C). The patient can also say, “Hey, I can’t shrug my shoulders,” and give a weak/minimal shrug to demonstrate descending muscle weakness. If team doesn’t order a CT scan, nursing will remind them that a stroke alert was called and ask them if they still want to go to the CT scanner. If neurology is called before CT head is interpreted by the team, the nurse will tell the participants that the neurologist is busy and therefore unavailable for consultation at this time. If neurology is called after CT head is interpreted by the team, neurology will remark that the patient does not sound like a tPA candidate and leave the conversation abruptly	B: T 99.8°F HR 48 BP 116/86 RR 12 O2 sat 94% RA
8:00 (Case Completion)	Team should recognize worsening dyspnea and hypoxia. Should order neurologic respiratory parameters and order the antitoxin	If team orders respiratory parameters and antitoxin, vitals remain unchanged (C). If respiratory parameters are not ordered by minute 12, patient becomes more dyspneic with shallow breathing (D). If antidote is not ordered by minute 12, vitals worsen more markedly (E). Case ends after antidote is ordered, respiratory parameters obtained, and the MICU is contacted for admission (or minute 15/facilitator’s discretion). If the team does not ask to call for admission, the nurse should prompt, “We need this bed; triage is full. What are we doing for dispo?”	C: T 99.8°F HR 40 BP 116/86 RR 12 O2 sat 88% RA O2 sat 92% on NRB or nasal cannula oxygen D: T 99.8°F HR 38 BP 116/86 RR 26 O2 sat 85% RA O2 sat 88% on NRB or nasal cannula oxygen E: T 99.8°F HR 35 BP 116/86 RR 30 O2 sat 85% RA O2 sat 88% on NRB or nasal cannula oxygen