Welcome to your patient assessment and management medical skill. In this skill you have 10 minutes to perform your assessment, patient interview, and voice treat all conditions discovered. You should conduct your assessment as you would in the field stating everything you are assessing.
You may assume you have two partners working with you who are trained to your level of care. They can only perform the interventions you indicate necessary, and I will acknowledge all interventions you order. I may also supply additional information and ask questions for clarification.
Do you have any questions at this time? No. Okay, awesome.
You are going to be dispatched to Miramar College for a mid-20s year old male complaining of difficulty breathing. Okay. Alright, so whenever you are ready. Alright, I'm going to take my stand in precautions. Is my scene safe?
Your scene is safe. Alright, based on dispatch, I believe it is a nature of illness. Looks like I have one patient.
I'm going to call for ALS at this time and I'm going to withhold C-spine. Coming in, I make my general impression. Mid-20s male. Appears to be unstable, having a little bit of difficulty breathing. Okay, my introduction.
Hi, I'm Jesse. I'm an ENT. Hey, how's it going man?
I'm Mark. Alright, Mark, nice to meet you. Where are we right now? I'm at Miramar College.
Can you tell me what year it is? It's 2020. Alright, and why did you call us today? I'm having a really hard time breathing and I'm kind of itchy all over. Okay, so chief complaint is going to be difficulty breathing.
Do I see any life threats? Not at this time. Alright, based on the fact that he's speaking to me in full sentences, I do believe he has a patent airway, is that correct? That is correct.
Alright, I'm looking at breathing rate and tidal volume. What am I seeing? You're seeing rapid respirations at about 24. They're labored but adequate.
Okay, I'm going to... going to place a pulse ox on him what does that say? It is currently 91 on room air. Okay based on the nature of illness and his respiratory difficulty we're going to put him on non-rebreather at 15 liters per minute of high flow O2. Great patient accepts.
Okay I'm going to check a pulse now what do I feel? It is rapid and a little weak. Okay I'm going to do a quick blood sweep do I see any blood? No blood.
Okay and just checking skins real quick what do I feel? Warm, flushed, and moist. Okay based on the these findings I'm going to say he is a private patient we're going to expedite transport in the back of the ambulance we're going to get a quick history. Alright so Mark what were you doing when this difficulty breathing started? I was just on break from class you know hanging out talking with some classmates.
Okay was it a rapid onset or was it gradual? It was pretty sudden yeah. Okay does anything you do make it feel better?
I sat down and I took a break stopped talking that made it better. Okay anything make it worse? When I walked around and you know had to talk a lot that made it quite a bit worse. Okay in your own words can you describe the difficulty? difficulty you're having?
It's like I can't catch a breath. Okay, alright. Can you tell me, has this ever happened before?
It happened to me the first time about a year ago. I had my first allergic reaction to peanuts, but it hasn't happened since. What did you do last time that helped? I went to the hospital, they gave me a couple medications, and I was on my way.
Okay, on a scale from 1 to 10, can you rate your difficulty breathing? 1 being no difficulty at all, 10 being you can't breathe. It's about a 6. Okay, sounds good. And then as far as time, how long ago did this start?
It's been going on for about 20 minutes maybe. Okay, has it been constant or has it been coming and going? Pretty constant.
Okay. Any nausea or vomiting right now? No. Okay, dizziness, lightheadedness? Yeah, definitely lightheaded.
Okay. Now, you said you were allergic to penis. Do you have any other allergies to foods or medications?
No, not that I'm aware of. Okay, do you currently have any medications? You're prescribed?
Not with me. They did prescribe me an epinephrine pen, however, I don't. I don't have one.
Ok, so you were prescribed FB but you don't have it with you right now. Right. Alright, any other pertinent medical history that we should know about?
No. Alright, and what was the last thing that you ate? The last thing I ate, a classmate of mine made a bunch of cookies and we were all sharing them and I didn't think to ask for peanut ingredients so I ate one.
Got you. And you think there was some peanuts in that? Yeah. Ok, and I just want to sum it up real quick just to make sure I didn't miss anything. About 20 minutes ago, a classmate brought in some cookies, you ate some, you think you may have ingested some peanuts.
which you are allergic to and you've had issues with that in the past, correct? Okay, any recent trauma, any getting injured, any chest trauma, anything like that? No?
Okay, I'll rule out trauma this time. Alright, is it okay if I take a look at your chest? Sure.
Okay, so I'm going to expose the patient's chest. I'm looking for hives, redness, swelling, what do I see? You're noting a rash and hives all across the chest and arms.
Okay, at this point I'm going to withhold palpation because he's having difficulty breathing, but I am going to auscultate at the second. and third intercostal space midclavicular lines. Osculate at the fourth, fifth, and sixth intercostal space midaxillary and at the inferior angle of the scapula on the back.
You are hearing expiratory wheezes in all six fields. Okay at this point I'm going to get some vitals. I would like pulse, respiration rate and quality, as well as blood pressure and an updated O2 saturation.
All right so pulse is a little rapid at 100, blood pressure is hypotensive at 80 over 50, respiration ...operations are still rapid at 24, labored but adequate, and your update SBO2 has climbed to 95%. You can hold on to this for the time being. Alright, thank you. Alright, so I like that O2 stat, so we're going to keep him on the non-rebreather, 15 liters per minute.
Based on what I'm finding, my field impression... do have a 20 mid-20s male mark had some issues with anaphylaxis in the past based on peanut allergy says he's experiencing that again today after ingesting what he believes was peanuts and based on the vials as well I do believe he's having anaphylactic reaction so we're going to go into our epinephrine protocols now my partner get the epinephrine from the ambulance here So in San Diego County, I have a standing order to administer a patient experiencing or showing signs and symptoms of anaphylaxis. One dose of epinephrine via our auto-injector that we carry on the ambulance. There are no contraindications for this.
I'm going to go into my five right now. So I have the right patient, this is Mark, he's experiencing and showing signs of anaphylaxis. This is the right medication, epinephrine.
Right dose is going to be 0.3 milligrams because he's an adult over 60 pounds. The right route is going to be intramuscular through the right lateral. thigh or the left lateral thigh and we are going to check the date and make sure it's not expired for correct time which is not. I'm going to have my partner check, I'm going to check again with a triple check.
So we're going to administer it into your right thigh. So I'm going to make sure there's nothing in the pocket. What I'm going to do is I'm going to just inject this into your thigh here. You might feel a little pinch.
Please don't move my hand. We're going to leave it in for 10 seconds, okay? This epinephrine is going to help you.
I'm going to remove the trainer here. I'm going to hold it like this, not placing my thumb on either side, bracing the leg. One, two, three.
counting 1-1000, 2-1000, 3-1000, 4-1000, 5-1000, up to 10-1000. I'm going to remove it and place it in a sharps container over here. At this point, we're going to reassess our patient every 5 minutes because he is unstable.
I'm going to reassess for LOC, ABCs, GCS, as well as updated vitals every 5 minutes. I'm also going to ask Mark, you said it was a 6 out of 10 severity difficulty. Can you rate it again? One through ten.
That's a drop down to a three. Okay, wonderful. Then when we arrive at the hospital, I'm going to give a turnover to the nurse telling her, Hey, this is Mark.
He's a mid-20s male. He was experiencing difficulty breathing when we arrived on scene. His O2 saturation was 91%.
He was having a difficult time breathing, so we put him on a non-rebreather, 15 liters per minute. He says that he is allergic to peanuts, and he did ingest cookies that he believes had peanuts. Felt like he was experiencing anaphylactic reaction. We assisted him with our epinephrine, 0.3 milligrams in the right lateral thigh.
He was difficulty breathing at a 6. Now he's at a 3. Here are his updated vitals. Can I get you anything else? No, that is great.
Thank you very much. Awesome.