{
  "scenario": {
    "id": "respiratory-failure-asthma-01",
    "name": "Pediatric Asthma Exacerbation Progressing to Respiratory Failure",
    "description": "14-year-old male presenting to ED with severe asthma attack, progressive respiratory failure over 2 hours despite nebulized bronchodilators. Rising RR, falling SpO2, compensatory tachycardia with escalation from nasal cannula to non-rebreather mask and IV magnesium sulfate before stabilization.",
    "durationMinutes": 120,
    "tags": [
      "asthma",
      "pediatric",
      "respiratory-failure",
      "ed",
      "deterioration",
      "supplemental-o2"
    ]
  },
  "patient": {
    "firstName": "Ethan",
    "lastName": "Morales",
    "dateOfBirth": "2012-03-15",
    "gender": "Male"
  },
  "encounter": {
    "department": "Emergency",
    "encounterType": "Emergency",
    "attendingPhysician": "Dr. Sarah Okonkwo",
    "roomBed": "ED-03A",
    "admissionReason": "Severe asthma exacerbation, acute respiratory distress, wheezing, accessory muscle use"
  },
  "events": [
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 105,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Triage vitals \u2014 arrives in acute respiratory distress, audible wheezing, accessory muscle use. NEWS2: HR=1 RR=3 SBP=0 Temp=0 SpO2=2 AVPU=0 = 6, single param 3 (RR) \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 26,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 118,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 74,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 93,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "GCS_EYE",
        "value": 4,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "GCS_VERBAL",
        "value": 5,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "GCS_MOTOR",
        "value": 6,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Peak expiratory flow (PEF)",
        "orderedBy": "Dr. Sarah Okonkwo"
      }
    },
    {
      "offsetMinutes": 3,
      "type": "order_result",
      "data": {
        "orderDescription": "Peak expiratory flow (PEF)",
        "resultSummary": "PEF 120 L/min (predicted 380 L/min for age/height) \u2014 32% predicted, severe obstruction"
      },
      "note": "Severely reduced airflow confirms acute severe asthma"
    },
    {
      "offsetMinutes": 5,
      "type": "medication",
      "data": {
        "drugName": "albuterol nebulizer",
        "dose": 2.5,
        "doseUnit": "mg",
        "route": "Nebulized",
        "administeredBy": "nurse-rn-2"
      },
      "note": "First-line bronchodilator \u2014 continuous nebulization initiated"
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 102,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Slight improvement post-albuterol. NEWS2: HR=1 RR=2 SBP=0 Temp=0 SpO2=1 AVPU=0 = 4"
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 24,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 117,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 73,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 94,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 10,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "medication",
      "data": {
        "drugName": "albuterol nebulizer",
        "dose": 2.5,
        "doseUnit": "mg",
        "route": "Nebulized",
        "administeredBy": "nurse-rn-2"
      },
      "note": "Second nebulized albuterol \u2014 incomplete response to first dose"
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 108,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Worsening despite second neb. NEWS2: HR=1 RR=3 SBP=0 Temp=0 SpO2=2 AVPU=0 = 6, single param 3 (RR) \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 27,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 119,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 74,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 92,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 25,
      "type": "medication",
      "data": {
        "drugName": "ipratropium bromide nebulizer",
        "dose": 0.5,
        "doseUnit": "mg",
        "route": "Nebulized",
        "administeredBy": "nurse-rn-2"
      },
      "note": "Added anticholinergic for poor response to albuterol alone"
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 113,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Continued decline \u2014 HR now critical (\u2265111). NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=3 AVPU=0 = 8 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 28,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 117,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 73,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 91,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 30,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Venous blood gas",
        "orderedBy": "Dr. Sarah Okonkwo"
      }
    },
    {
      "offsetMinutes": 35,
      "type": "order_result",
      "data": {
        "orderDescription": "Venous blood gas",
        "resultSummary": "pH 7.36, pCO2 42 mmHg, HCO3 24 \u2014 normal pCO2 in setting of tachypnea suggests impending respiratory failure (should be low if compensating)"
      },
      "note": "Ominous VBG \u2014 normal pCO2 with RR 28 indicates respiratory muscle fatigue"
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 118,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Worsening tachycardia and desaturation. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=3 AVPU=0 = 8 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 30,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 116,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 72,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 90,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 40,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "medication",
      "data": {
        "drugName": "methylprednisolone sodium succinate",
        "dose": 60,
        "doseUnit": "mg",
        "route": "IV",
        "administeredBy": "nurse-rn-2"
      },
      "note": "IV corticosteroid \u2014 systemic anti-inflammatory for severe exacerbation"
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      },
      "note": "Nasal cannula 4L/min started \u2014 SpO2 90% on room air unacceptable"
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 115,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Brief SpO2 improvement on nasal cannula O2. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=2 AVPU=0 O2=2 = 9 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 28,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 116,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 73,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 93,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 120,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Deteriorating on O2 \u2014 bronchospasm overcoming supplemental O2 benefit. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=3 AVPU=0 O2=2 = 10 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 30,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 114,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 71,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 91,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 65,
      "type": "medication",
      "data": {
        "drugName": "albuterol nebulizer",
        "dose": 2.5,
        "doseUnit": "mg",
        "route": "Nebulized",
        "administeredBy": "nurse-rn-2"
      },
      "note": "Third nebulized albuterol \u2014 back-to-back dosing for refractory bronchospasm"
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 124,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "No improvement from third neb. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=3 AVPU=0 O2=2 = 10 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 32,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 113,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 70,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 89,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 70,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 126,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Progressive failure \u2014 approaching critical thresholds. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=3 AVPU=0 O2=2 = 10 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 34,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 112,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 70,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 88,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 80,
      "type": "order",
      "data": {
        "orderType": "Imaging",
        "description": "Chest X-ray portable AP",
        "orderedBy": "Dr. Sarah Okonkwo"
      }
    },
    {
      "offsetMinutes": 85,
      "type": "order_result",
      "data": {
        "orderDescription": "Chest X-ray portable AP",
        "resultSummary": "Hyperinflated lung fields bilaterally, no focal consolidation or pneumothorax, no pleural effusion"
      },
      "note": "CXR confirms air trapping consistent with severe bronchospasm, no pneumonia or PTX"
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 128,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Critical \u2014 escalation to non-rebreather mask at 15L/min. NEWS2: HR=2 RR=3 SBP=1 Temp=0 SpO2=3 AVPU=0 O2=2 = 11 \u2192 EMERGENCY"
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 36,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 110,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 68,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 87,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 88,
      "type": "order",
      "data": {
        "orderType": "Procedure",
        "description": "O2 delivery escalation",
        "orderedBy": "Dr. Sarah Okonkwo"
      }
    },
    {
      "offsetMinutes": 93,
      "type": "order_result",
      "data": {
        "orderDescription": "O2 delivery escalation",
        "resultSummary": "Changed from nasal cannula 4L/min to non-rebreather mask 15L/min"
      },
      "note": "Escalation of respiratory support \u2014 failing nasal cannula"
    },
    {
      "offsetMinutes": 95,
      "type": "medication",
      "data": {
        "drugName": "magnesium sulfate",
        "dose": 40,
        "doseUnit": "mg/kg",
        "route": "IV",
        "administeredBy": "nurse-rn-2"
      },
      "note": "IV magnesium sulfate bolus for refractory severe asthma \u2014 smooth muscle relaxation"
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 131,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Peak deterioration \u2014 HR now \u2265131. NEWS2: HR=3 RR=3 SBP=1 Temp=0 SpO2=3 AVPU=0 O2=2 = 12 \u2192 EMERGENCY (peak score)"
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 37,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 108,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 66,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 86,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 100,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 98,
      "type": "order",
      "data": {
        "orderType": "Lab",
        "description": "Repeat venous blood gas",
        "orderedBy": "Dr. Sarah Okonkwo"
      }
    },
    {
      "offsetMinutes": 103,
      "type": "order_result",
      "data": {
        "orderDescription": "Repeat venous blood gas",
        "resultSummary": "pH 7.31, pCO2 52 mmHg, HCO3 25 \u2014 respiratory acidosis, CO2 retention indicating ventilatory failure"
      },
      "note": "Rising pCO2 confirms respiratory muscle fatigue \u2014 intubation readiness ordered"
    },
    {
      "offsetMinutes": 105,
      "type": "medication",
      "data": {
        "drugName": "albuterol nebulizer",
        "dose": 2.5,
        "doseUnit": "mg",
        "route": "Nebulized",
        "administeredBy": "nurse-rn-2"
      },
      "note": "Continuous nebulization resumed while magnesium takes effect"
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 122,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Treatment response \u2014 MgSO4 + NRB + steroids taking effect. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=3 AVPU=0 O2=2 = 10 \u2192 EMERGENCY (improving)"
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 31,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 112,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 70,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.1,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 91,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 110,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 115,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 3.8,
        "unit": "mEq/L",
        "source": "Lab"
      },
      "note": "Potassium checked \u2014 albuterol can cause hypokalemia; level acceptable"
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 116,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Stabilization \u2014 aggressive treatment working but still critical. NEWS2: HR=2 RR=3 SBP=0 Temp=0 SpO2=2 AVPU=0 O2=2 = 9 \u2192 EMERGENCY. Patient to be transferred to PICU for monitoring."
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 26,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 114,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 72,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 37.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 93,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    }
  ],
  "expectedOutcomes": [
    {
      "afterOffsetMinutes": 0,
      "type": "alert",
      "alertType": "NEWS2_EMERGENCY",
      "description": "NEWS2 = 6 at triage with RR score 3 (single parameter = 3 triggers EMERGENCY). Patient arrives already in emergency state."
    },
    {
      "afterOffsetMinutes": 0,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 6,
      "description": "NEWS2 = 6 at arrival: HR=1(105) + RR=3(26) + SBP=0(118) + Temp=0(37.1) + SpO2=2(93) + AVPU=0"
    },
    {
      "afterOffsetMinutes": 20,
      "type": "alert",
      "alertType": "RAPID_DETERIORATION",
      "description": "SpO2 drops from 94% (T+10) to 92% (T+20) \u2014 rapid decline after brief post-albuterol improvement"
    },
    {
      "afterOffsetMinutes": 30,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 8,
      "description": "NEWS2 = 8 at T+30: HR=2(113) + RR=3(28) + SBP=0(117) + Temp=0(37.1) + SpO2=3(91) + AVPU=0 \u2014 worsening despite bronchodilators"
    },
    {
      "afterOffsetMinutes": 50,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 9,
      "description": "NEWS2 = 9 at T+50: HR=2(115) + RR=3(28) + SBP=0(116) + Temp=0(37.1) + SpO2=2(93) + AVPU=0 + O2=2 \u2014 supplemental O2 adds 2 points"
    },
    {
      "afterOffsetMinutes": 70,
      "type": "alert",
      "alertType": "RAPID_DETERIORATION",
      "description": "SpO2 drops from 93% (T+50 on O2) to 89% (T+70 on O2) \u2014 failing supplemental oxygen therapy"
    },
    {
      "afterOffsetMinutes": 90,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 11,
      "description": "NEWS2 = 11 at T+90: HR=2(128) + RR=3(36) + SBP=1(110) + Temp=0(37.1) + SpO2=3(87) + AVPU=0 + O2=2 \u2014 critical deterioration"
    },
    {
      "afterOffsetMinutes": 100,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 12,
      "description": "NEWS2 = 12 (peak) at T+100: HR=3(131) + RR=3(37) + SBP=1(108) + Temp=0(37.0) + SpO2=3(86) + AVPU=0 + O2=2 \u2014 maximum severity before treatment effect"
    },
    {
      "afterOffsetMinutes": 100,
      "type": "alert",
      "alertType": "NEWS2_EMERGENCY",
      "description": "Sustained NEWS2 EMERGENCY throughout scenario \u2014 peak score 12 at T+100 with HR, RR, and SpO2 all at maximum NEWS2 scores"
    },
    {
      "afterOffsetMinutes": 120,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 9,
      "description": "NEWS2 = 9 at T+120 \u2014 still EMERGENCY but improving from peak of 12. SpO2 recovering to 93% on non-rebreather. Patient stabilized for PICU transfer."
    }
  ]
}
