Table 2. A stepwise, detailed summary of the learners’ expected actions for each learning objective and the associated patient findings/outcome.

ACLS = Advanced cardiac life support; BP = Blood pressure; CBC = Complete Blood Count; ECG = Electrocardiogram; GCS = Glasgow Coma Score; HR = Heart rate; IV = Intravenous; LBC = Electrolytes, Blood Urea Nitrogen, Creatinine; O2 = Oxygen; PEA = Pulseless electrical activity; pRBC = Packed red blood cells; RA = Room air; RR = Respiratory rate; RSI = Rapid sequence induction; ROSC = Return of spontaneous circulation; SpO2 = Oxygen Saturation; T = Temperature; T&S = Type and Screen; XM = Crossmatch blood.

Summary of Learning Objectives and Expected Learner Actions
Learning Objective #1: Develop an approach to the undifferentiated, acutely unwell patient.
Expected Actions	Pertinent Findings/Outcome
Obtain history: from the patient & collateral history	Initial vital signs:   HR 100 (normal sinus rhythm) // BP 95/60, RR 16 // SpO2 96% RA // T 37.0°C // Glucose 4.6 mmol/L
Note vital signs
Perform focused physical exam
Order cardiac monitoring
Obtain IV access – 2 large bore IVs
Begin oxygen administration as necessary
Request repeat set of vital signs
Learning Objective #2: Formulate an initial approach to the assessment and management of a patient with a suspected upper gastrointestinal bleed
Expected Actions	Pertinent Findings/Outcome
Order bloodwork (CBC, LBC, liver enzymes, coagulation factors, lactate, T&S, XM)	ECG & Bedside ultrasound results are normal and are "retrieved" quickly for learners   See Table 1 for bloodwork findings which take longer to "retrieve"
Investigations: ECG +/- bedside ultrasound
Administration of IV proton pump inhibitor
Fluid resuscitation & consider transfusion of O-negative blood	If adequate (minimum 1 L bolus followed by continuous infusion and initiation of pRBC transfusion) go to 2A If inadequate go to 2B
Verbalize other treatment options depending on patient condition, history, comorbidities, and suspected etiology: Vitamin K, Octreotide, Fresh Frozen Plasma, Octaplex, antibiotics (Ceftriaxone), and/or erythromycin
Stage 2A — Adequate Initial Volume Resuscitation — Vitals: HR 94 // BP 102/66
Adequate volume resuscitation	Patient's vital signs transiently improve before going to Learning Objective #3 ** For junior learners: if all actions to this point have been completed/verbalized, scenario can end here **
Stage 2B — Inadequate Volume Resuscitation — Vitals: HR 122 and BP 85/60
Learners make no further resuscitation attempts after a period of time. Nurse prompt as needed: e.g., “He looks like he is getting sicker”	Go to Learning Objective #3
Learning Objective #3: Recognize and manage a deteriorating hemodynamically unstable patient with a suspected upper gastrointestinal bleed (Advanced Learner) Patient Action: Vomits large amount of frank, red blood (this deterioration occurs in any case, whether or not proper actions taken to this point). Reassessed Vitals :  HR 150 // BP 70/40 // T 37.0°C // RR 6 // SpO2 90–92% 4L O2 via nasal prongs // GCS 7
Expected Actions	Pertinent Findings/Outcome
Appropriate RSI intubation	If all actions completed go to 3A If actions missed go to 3B
Central line inserted correctly (optional)
Administer the following as appropriate to details of the case: Vitamin K, Octreotide, Fresh Frozen Plasma, Octaplex, antibiotics (Ceftriaxone), and/or erythromycin
Verbalize consideration of balloon tamponade device
Activation of massive transfusion protocol
Consult appropriate disposition service
Stage 3A — Completion of all Expected Actions
End Scenario – Vitals HR 95 // BP 105/64 // T 37.0°C // RR 12 // SpO2 96% (intubated)
Patient care taken over by specialist arrival or transfer to critical care unit
Stage 3B — Failure to Complete all Learning Objective/Expected Actions Above
Nurse prompt e.g., “his blood pressure is still low” OR “he is getting more tachycardic”	Learner takes appropriate actions above. Vitals stabilize. Go to 3A.
No further actions by learner	If no actions taken or inadequate in response to nurse prompt, patient remains in critical condition with vitals deteriorating.   End scenario or go to Optional Objective
OPTIONAL Objective – PEA arrest if failure to take appropriate earlier actions
Appropriate resuscitation (using ACLS guidelines)	Patient achieves ROSC. End scenario.
Inappropriate/inadequate resuscitation (using ACLS guidelines)	Failure to resuscitate. End scenario