Clinical Cases in Paramedicine. Группа авторов
Remember the patient is scared, he has never had chest pain before and is frightened of what might happen.
3 What history would you like from the patient?The patient appears to be having chest pain, so it is important to ascertain what type of chest pain this is. Cardiac chest pain can be fatal and needs to be treated and assessed appropriately. In this case we need to find out when the pain began, does anything make it better or worse, what it feels like, does it radiate anywhere, what is the quality of the pain, has he ever experienced this pain before and if so does he know what it was. Use the OPQRST mnemonic:Onset: What were you doing when the pain came on?Provocation: Does anything make the pain better or worse?Quality: How do you describe the pain?Radiation: Does the pain move anywhere?Severity: On a scale of 1–10, what number would you give the pain?Timing: How long have you had it?
4 What are some of the differential diagnoses for this patient?Trauma to the area – broken ribs, pneumothorax (tension).Pulmonary embolus.Muscle strain.Pericarditis.Myocarditis.Abdominal aortic aneurysm (AAA).Aortic dissection.
5 How would you treat this patient? (Use a bulleted list.)Pharmacology:Aspirin.GTN.Oxygen (to treat hypoxia).Antiemetic (anti‐sickness).Pain relief.Make the patient as comfortable as possible.Rapid removal to a cardiac cath lab.Lots of reassurance.Close monitoring for deterioration.Prepare for cardiac arrest.Thorough history taking.
LEVEL 3 CASE STUDY
Hyperkalemia
| Information type | Data |
| Time of origin | 14:30 |
| Time of dispatch | 14:31 |
| On‐scene time | 14:39 |
| Weather | 34 °C, very humid |
| Nearest hospital | 15 minutes |
| Nearest backup | CCP, 15 minutes |
| Patient details | Name: Steve Roberto DOB: 09/09/1965 |
CASE
You have been dispatched code 1 to the residence of a 55‐year‐old male who has been unwell for several days. He has collapsed and is not breathing.
Pre‐arrival information
The male is unconscious and his breathing is absent. CPR instructions are currently being provided over the phone.
Windscreen report
The house is a located in a low socioeconomic neighbourhood that is well known by your ambulance service for many different calls, including a fatal stabbing on your last run of shifts. There are several people gathering outside the house due to the commotion occurring inside. You are advised that the police have also been dispatched due to the location.
Entering the location
The residence appears safe, with no pets in the yard and a large driveway to the side of the house. You are met at the door by a very distressed female. She states that the patient is in the bedroom and their 18‐year‐old son is performing CPR. She is extremely anxious and yelling at you to ‘hurry up and do something’. She states that the patient has been very unwell for 5 days and has missed his appointments at the renal centre. You walk through a well‐kept house into the bedroom.
On arrival with the patient
The male patient has been moved to the floor, where the son is performing good‐quality CPR. You note the patient has significant swollen lower peripheries and scratch marks on his lower limbs.
Patient assessment triangle
General appearance
The patient is unresponsive, lying on the floor.
Circulation to the skin
Pale in colour, cool to touch.
Work of breathing
The patient does not appear to be breathing.
SYSTEMATIC APPROACH
Danger
Nil.
Response
No response.
Airway
Vomit in the airway.
Breathing
Nil.
Circulation
No pulse.
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 Think about the location you have been dispatched to. Discuss, as you would with your partner, what actions you may take to ensure your safety prior to arriving on scene.Often we attend areas where police assistance is required for our safety. Discussion should include early activation of police (if this has not already been arranged), staging prior to arrival and awaiting police attendance to ensure scene safety, utilising prior history you or comms have on the location, parking your vehicle in a position that would allow for a quick egress if required (this may involve backing into a driveway or ensuring you are not facing a dead‐end street), identifying risks as they arise and using your ‘gut instinct’ to assess the scene. These are just a few to mention. Utilise other paramedics’ experiences to gain knowledge into how others approach these scenes.
Case Progression
History taking
You ask the patient’s partner what has occurred and she does not directly respond to your questions, continually yelling ‘Fix him, fix him, hurry up and do something to fix him’. She is visibly distressed and emotional despite your attempts to calm her.
TASK
What must you do in this situation where an accurate/thorough history cannot be gained quickly from the patient’s partner due to her emotive state? Discuss/write down what options you have.
Consider the utilisation of others on scene – the patient’s son may be of benefit and could possibly be a source of information. Other family members or neighbours who are present may assist with information and/or reassurance to the patient’s wife.
Look for other information on scene such as medications, doctor’s letters, medical aids or medical bracelets. You notice leftover boxes of dialysis solution in the hallway as you walk in – what does this tell you?
Case Progression
History taking (cont.)
The son states that the patient has not been well lately. His medical history includes diabetes, hypertension, hypercholesterolemia and end‐stage renal failure.