MD3006 Pre-Hospital Reflection Assignment: Suspected Intracranial Hemorrhage Case Study Using Gibbs’ Reflective Cycle

Chief Complaint:

Chest Pain shortness of breath

Differentials

The call came in a 61-year-old male patient short of breath with chest pain I was the lead on the call and accompanied by an Advanced Paramedic. We were approximately 30 minutes away from the call the call came in at 0930 in the morning and the patient was at home with his wife and son. I went in first and saw a man sitting on a chair leaning slightly forward red in the face and breathing fast, distressed. I introduced my partner and myself and asked how could we help you today. While taking out the oxygen I continued with my assessment. When did your breathing problem start and did it come on gradually or slowly? He stated it came on quickly and woke up with the pain he was out in the garden yesterday and got wet and was wondering if it was a chest infection. Could he point to where the pain was he pointed to the side of the right middle lobe of chest. I could see he was breathing faster than normal and appeared to be in pain and red in the face. I asked does anything make it worse? If you take a deep breath dose that makes if worse or better. He stated worse. If I palpated your chest worse or better. He stated slightly worse. I auscultated his lungs. I found equal air entry upper and lower lobs but diminished air entry on the right middle lobe. I Let my colleague know and he asked to listen and confirmed my findings. I proceeded with my assessment he described the pain as sharp doesn’t radiate and pain score of 7. I asked about his past medical history, any respiratory issues before, any cardiac issues has this happened before, a list of medications, any change in medication over the last month, how has he been feeling the last few days, and any allergies. Pt stated he had surgery three weeks ago for the removal of varicose veins on his right leg. I assessed the right leg pt denies any pain or tenderness nil redness nil heat. Pt was brought out to the ambulance where a full set of vital signs were obtained. 12 lead obtained finding sinus tachy with inverted T waves poster ECG completed. Hypertension, spo2 86% denies having copd pain score 7. No other remarkable findings. Treatment Position of comfort (sitting upright), Oxygen NRM 100%, IV access, Fentanyl for pain. Pre-alert ED for recuss with ASHICE message. As result pain was reduced to a manageable level. Vital signs stabilized ED was expecting pt and obtained definitive care as quickly as possible. We were back at the hospital later and the doctor said that there was consolidation on the lungs and the patient’s D dimer levels were elevated with consolidation which suggested it could be an infection secondary to pulmonary embolism.

Feelings / thoughts

On the way to call I was thinking of differential diagnoses starting off with the life-treating illness (MI, AAA, pre – respirator/cardiac pre-arrest, Sepsis, etc) rule them in/out then work your way down the list. Has anything been given to pt (aspirin, paracentral) What do we need to bring in with us (oxygen, obs equipment, stretcher/chair)? Checking distance from the incident to the nearest PCI lab if needed was the Helli an option where was closed ED. I felt competent that we could deal with this situation. When we arrived at the scene, Pt appeared to be, working harder than normal trying to breath, so I thought there is something going on here is it cardiac, respirator, or infection? I felt we could manage this situation and was curious as to the cause of the patient’s distress. I put oxygen on straight away, even though I didn’t have a diagnosis yet a bit of oxygen is not going to hurt so no need to be stingy with it (consider Bleomycin lung injury). I did my initial assessment on approach. I think his wife was worried and I think he was concerned. To ease this I explained what I thought was going on and what we were going to do and where we were going. By the time we had left for the hospital the family and patient were feeling relaxed they could see the patient was improving and was looked after that we were competent. I feel we handled the situation well we provided the care the pt required quickly and efficiently while providing reassurance to both patient and family and getting the patient to definitive care while improving his symptoms.

Evaluation

The things that were good and worked well were the fact that we did an extensive examination of the patient and dug deeper to get a better picture of what was going on. That diagnosis and treatment were correct and pt improved from root to hospital. Even after we had a good idea that this was respiratory, we did not stop there and completed a 12 ECG to rule out cardiac issues as well. We provided reassurance to both family and patient and eased their concerns while also being direct as to what we thought was going on. From research even though the most common ECG finding in a PE is sinus Tachycardia. The “S1Q3T3” pattern is a classic sign as well. This is termed the “McGinn-White Sign.” Which is something I was not aware of until after. Also, when listening to the Lung and hearing diminished breath sound with good air entry above and below it can help to narrow down the differential diagnosis from a Pneumothorax as this would present more unilateral. When this clicked in my head it made me feel much more confident if I suspect one or the other to be able to differentiate between the two in the future. Even though the patient’s main issue was PE he also had an infection. When the patient arrived at ed the Doctor listened to the handover and listened to the valves of the heart and performed chest percussions. This is something I did not do. Maybe with experience, I could get better at chest percussions. To perform a more thorough examination.

Analysis

I think our patient assessment and treatment went well. Firstly, I had the education and knowledge to allow me to consider Pulmonary Embolism as a differential diagnosis. Without knowing the signs and symptoms and the possible reason for PE I would not have been able to consider it as a diagnosis. This made it very interesting for me as I only read about PE. It was not until I was present with it did it allow me to see how it could present. Once I could consider this as a diagnosis I could dig deeper and get more info. I recently listened to a lecture recording within this module that most of the younger doctors would use diagnosis equipment e.g., Blood culture, scans, and x-ray, etc. Whereas the older doctors would listen to the story and probe and ask questions. I think this is particularly important to us to having to do a prudent assessment and hx taking as we don’t have the luxury of diagnosis equipment within a hospital and have to make decisions on the limited information, we have so it could be argued that being able to act as an investigator and ask the right question and dig deep is even more vital for pre-hospital medicine.

Conclusion

I learned that I necessarily don’t need a diagnosis to treat signs and symptoms and if the intervention I had done helped I may be on the right track or if pt deteriorating I may need to think again. Until you are faced with an illness you have read you don’t have a good understanding of how it presents. Also, without the theory, you can’t consider it as a diagnosis. That there may be more than one thing going on at a time so do a complete assessment and document what you are told and your finding even if it doesn’t seem relevant at the time. I shall practice percussion going forward to have another tool in my kit and keep reviewing my knowledge base. By controlling the pain we could reduce the breathing rate, heart rate, and blood pressure.

Action Plan

If present with a PE again I will keep in mind not all PE will present the same. I will definitely be looking for diminished breath sound in one area with possible air entry above and below, look out for “McGinn-White Sign” take a prudent hx and dig deeper if something peaks my interest and try and figure out the why.