Case Study 27

The Answer

Assessment

  • Hyperventilation.
  • Anxiety attack?
  • Cardiac?
  • Abrasions on hands

The Plan

  •  Calm the patient. Try to get him to slow his breathing. 
  • Clean and dress the hand abrasions. 

Anticipated Problems

  • Inability to resolve the hyperventilation.
  • This is a cardiac event.
  • Inability to resolve the emotional event.

The Tale Continues

It's 1050. Charlie is breathing easier and the tingling and numbness in his hands has abated. He is unable to calm down. He appears nervous, will not sit down. He continues to complain of a pounding heart, while his radial pulse is regular and 84. You have the group return to the camp and you spend some time privately with Charlie. He's worried about his performance affecting his employment. He denies history of heart disease and describes a series of panic attacks three years ago. He does not want his supervisor to learn of his panic attack history. 

Vital Signs

TIME

1030 hrs

1050hrs

LOR

A+Ox4 A+Ox4

HR

104, strong, regular

84, strong, regular

RR

40, regular, deep, unlabored

20, regular, deep, unlabored

SCTM

flushed, warm, moist

flushed, warm, moist

BP

radial pulses present

radial pulses present

Pupils

PERRL

PERRL

Not taken

Not taken

 

History

Symptoms:

Patient is emotionally agitated. Light-headed and dizzy.  Patient states he feels "wired" and that his heart is racing/pounding in his chest and his "stomach is a mess". 

Allergies:

He denies allergies.

Medications:

He apparently takes several medications but is unwilling to discuss details.

Pertinent Hx:

Patient has been anxious on steep terrain. He was initially unwilling to discuss his medical history due to fear for his job. He now (1050) denies history of heart disease and describes a series of panic attacks three years ago.

Last in/out:

Patient ate breakfast today, is well-hydrated; urine has been clear and bowel movements normal.

Events:

Patient developed symptoms while rappelling.   

Assessment at 1050 hrs

  • Anxiety attack?
  • Cardiac?
  • Cleaned and dressed abrasions.

Plan

  • Continue to try to calm the patient, maintain a normal RR, and talk to the patient to determine history and treatment options. 
  • Evacuate the patient.

End of the Tale

This scenario has possible physical and mental health components. First aid for stress and anxiety responses is to calm the patient, try to allay their fears, and complete a patient assessment. We don’t want to overlook a physical problem in the midst of the emotional event. Patients whose responses abate might be able to stay in the field. An anxiety or stress response that is unpredictable or persistent usually requires evacuation. In this case you can't rule out a heart problem, a potential life threat, and your evacuation guidelines say to evacuate any patient with chest pain that is not clearly musculoskeletal. Charlie does not complain specifically of chest pain, but the overall picture is suspicious for a heart problem, and we know that not all cardiac events present with classic squeezing, sub-sternal, radiating-to-the-left-side chest pain.

 A short time later local EMS arrives with a vehicle to transport Charlie on the dirt road to the ambulance at the pavement. You brief the EMS crew. Charlie tells the group he needs to have his heart checked.

The group abandons the backpacking idea and moves to a campsite on the shore of Lake Mead. Charlie returns that evening feeling much better and excited about the prospect of water skiing.