Australian Critical care Paramedic
PST6105 Turnitin Case Study Assignment
• This assessment consists of one case study divided into six (6) questions.
• There is a total of 16 pages.
• Answer all questions on the paper.
• This assessment task has a maximum limit of 18 pages (any answers beyond this limit will not be marked)
• Font size = 12
• Subheadings and dot points answers are acceptable, but you need to explain and rationalise your answers.
• In terms of scope of practice,
Assume you are an Australian Critical Care Paramedic (CCP) or Intensive Care Paramedic (ICP); expect to answer questions in line with guidelines from the Australian New Zealand Committee on Resuscitation (ANZCOR) and Pre-Hospital Trauma Life Support (PHTLS). You will also be expected to consider options such as Rapid Sequence Induction (RSI), finger thoracostomy, blood products, inotropes etc.
•note interventions that you consider but reject (rationale).
• If you wish to work within different protocols, for example, if your service uses different dosages of a certain drug, then note this clearly.
• Equipment; assume you have the necessary equipment for advanced life support, including syringe drivers and a simple transport ventilator.
• Evidence. Referencing is not required for this assessment task. You will get additional marks if you can justify your management in line with contemporary evidence-based practice (e.g. ‘Research now supports….’). Even better if you can state the name of the trial.
• Total number of marks = 100.
• Once you have completed the assignment please submit via Turnitin in the appropriate submission area in the Case Study assessment folder.
Crew mix
You are working as a Critical Care Paramedic (CCP) on a medium lift Emergency Medical Service (EMS) rotary wing aircraft (helicopter). The three-person crew consists of a pilot, aircrew and yourself. The aircrew is trained to the level of basic life support (BLS) and can assist under your direction on the ground and in the rear of the aircraft when not assisting the pilot with navigation. The aircraft can accommodate two seated or stretcher patients and has sufficient equipment for ALS interventions/transport for two ventilated patients. The aircraft can carry six persons in total.
Note:
In terms of definitions of skill sets, assume that CCP is synonymous with the highest tier of paramedic practitioner in the Australian context.
Call received: 0100hrs
You are tasked to attend a motor vehicle crash on a country road, 60 minutes flight time from your base. You are advised it is car v car. There are two adults in car 1, and one adult in car 2. All are described as time critical. There is one road ambulance at the scene, with a crew mix of one basic life support (BLS) and one advanced life support (ALS) officer. There is no further information at this time. You are airborne within 15 minutes of receiving the call.
Question 1 (10 marks)
During your 60-minute flight time, what arrangements, instructions, equipment or medications would you prepare, given that you will be working in a dark, remote environment with limited backup?
On arrival at scene: 0215hrs
You land on the unlit, country main road. The scene has been secured by police and fire appliances. There is one road ambulance crew at the scene.
You see a late model, large 4WD passenger vehicle (car 1) lying on its left side, twenty metres from the road shoulder. There is a light utility (car 2) on the road, close to the apparent site of impact. The crash site is at a T-junction where the bitumen road is intersected by a minor, unsealed, gravel road. There are no skid marks evident prior to the site.
Police report they believe the 4WD had been travelling on the bitumen road (110kph speed limit) when it was struck by the utility which failed to give way whilst travelling along the intersecting gravel road. The speed limit of this gravel road is 60kph.
The 4WD has significant impact to the right side, driver’s door area, with intrusion of approximately 0.5m into the driver’s seating area. The vehicle appears to have rolled laterally to the left multiple times. Airbags have not deployed. There is some damage to the roof of the 4WD.
The utility has significant impact to the front of the bonnet. The windscreen is shattered, and airbags have deployed. The engine block has been dislodged by the force.
All three patients were extricated prior to your arrival and are being attended to by the road crew. Police report that the crash was not witnessed; it was discovered by another road user at 0100hrs. The engines were still warm at this time, so it is assumed the crash occurred shortly prior.
You are given the following handover by the ALS officer:
Three patients:
1. Driver in utility / car 2. (Seatbelt on). Significant head and thoracic trauma evident. Male, approximately 40 years of age. CPR in progress by fire crew and police.
2. 4WD / car 1. Front left side passenger (seatbelt on) had self-extricated and was ambulant when ambulance crew arrived. Male, 25 years of age. Complaining of c-spine tenderness. Glasgow coma score (GCS) 14, mildly confused and unable to provide previous medical details of other occupants. Denies alcohol or drugs taken by himself or driver. This patient is now supine on ground, spinal precautions in situ. Being monitored by BLS officer.
3. 4WD / car 1. Driver (seatbelt on). Male, approximately 20 years old. Patient was trapped in the vehicle between the door intrusion and the vehicle’s centre console. He was extricated by the fire crew and is now in the ambulance being treated by the ALS officer who states:
AIRWAY: Patent but at risk due to lowered GCS and blood in mouth.
BREATHING: Breathing is laboured, shallow and irregular. Air entry is significantly reduced on the right side. Respirations are approximately 36/minute. SpO2 was 70% on arrival and is now 86% on 10L/minute via non-rebreather mask (NRBM). Trachea appears midline.
CIRCULATION: Brachial pulse is regular, rapid and weak at 140bpm. ECG shows sinus tachycardia with some PVCs. Blood pressure is 82/50mmHg and equal bilaterally. Blanch is delayed at 3 seconds. There is one patent, large bore cannula in situ in left antecubital fossa (ACF), with isotonic crystalloid running at keep vein open (KVO).
DISABILITY: Blood sugar level (BSL) is 6.7mmol/L. GCS 13 (eyes 4, verbal 4, motor 5). Pupils are both sluggish to react but equal. Patient can move all four limbs; right leg mobility limited by pain in upper leg.
EXPOSURE: Clothing has been cut away and a blanket is in situ. The night temperature is 11 degrees Celsius. The patient feels cool to touch peripherally.
SECONDARY: Injuries noted include:
• Multiple external venous bleeds and lacerations which have been addressed by ambulance crew
• There is a boggy mass palpable in the right temporal area
• There is developing ecchymosis to the right side of chest
• Right upper leg is rigid and painful to touch
• Patient is complaining of pain to right side of his head/face, right side of chest and flank, and right upper leg.
Your own observations confirm the above.
Past medical history, medications, allergies all unknown.
Question 2 (10 marks)
A rural hospital with a general practitioner (GP) is 15 minutes away, compared with a flight time of 60 minutes to a tertiary, level 1 State trauma centre.
What is your choice of destination?
How many patients will you transport under your care?
Justify your rationale.
Question 3 (10 marks)
During the handover by the ALS paramedic and during your initial assessment, you note the patient is experiencing more respiratory distress, is becoming more hypotensive and less responsive.
• GCS 8 (E2, V2, M4)
• Patient is becoming agitated and combative when stimulated
• HR 150bpm
• BP 70/- mmHg
• Respirations 40/minute
What are your provisional diagnoses for this patient?
Which injury is the most urgent?
Justify your answers.
Question 4 (40 marks)
Outline your management of this patient in his current presentation. You should sequentially list your clinical management choices and provide a clear rationale for each. Note any interventions you may consider but reject, again with justification.
You should focus on airway, breathing and circulation. Your answer should specify landmarks, equipment choices and sizes, and drug dosages.
You are not required to include simple steps such as extrication.
Question 5 (15 marks)
With regard to Rapid Sequence Induction (RSI) intubation:
a) Differentiate between the actions of (i) neuromuscular blocking agents, and (ii) sedative or induction agents.
b) Why is it important to administer both classes of drugs when performing RSI?
c) Give an example of each class of drug.
d) Discuss the use of reversal agents for neuromuscular blocking agents.
Question 6 (15 marks)
Regardless of your previous management choices, you are now in flight at 2500 feet with your patient intubated and mechanically ventilated, 20 minutes from your destination.
The patient has been becoming progressively more hypotensive. The peak inspiratory pressure (PIP) alarm on the monitor keeps alarming.
What could be the cause of this increased PIP, and how could you address this? Comment on the relevant flight physiology concepts.
End of Case Study Assignment
