Photo by Michael Marston - Department of Emergency Services ...

Clinical challenge
By Drew Hebbron, Acting Senior Clinical Educator
The time is 08:00 and you
have been dispatched to the
main platform at Central Station
in Brisbane for a female patient
complaining of lethargy, fatigue and
light-headedness.
On arrival at Central, it is apparent
you have arrived mid-peak hour with
thousands of commuters making
their way to and from the station.
Your patient is found beside the
platform servicing the north-eastern
area of Brisbane with a Queensland
Rail Security Officer in attendance.
The Security Officer states the
patient was observed trying to board
the train with her bags, walking with
an unsteady gait, having obvious
difficulty in breathing and profuse
diaphoresis.
She was assisted by security to a
bench seat where she is presently
located.
The patient is female, mid 20s and
appears to be of Asian descent.
She is only able to communicate
in broken English and has obvious
extreme dyspnoea. She also has a
fairly constant productive cough.
Upon questioning, the patient is
able to indicate she has felt unwell
for several days and indicates
her condition has been gradually
getting worse.
She states further that she has
experienced diahorrea for the
last five days.
When asked about seeking medical
aid, the patient states she has not.
You are able to ascertain she has
been here visiting family from her
homeland of Indonesia for the
past eight days and is returning
home today.
Her usual occupation at home is
working on her family’s farm. She
states she began feeling unwell
a couple of days after arriving in
Brisbane.
She states she came from a hot
humid climate into Brisbane’s winter.
She states she has not been around
any other people displaying signs of
illness and says she has no allergies
and is currently on no medication.
Her VSS is as follows:
Pulse – 160
BP – 110/60
RR 50 – shallow/rapid
SpO2 – 95% RA
ECG – Sinus Tachy @ 160BPM
BSL – 5.4mmol
Chest Auscultation – Congestion and
“wet” chest sounds with crackles
widespread bi-laterally
GCS – 14
Temp – 39.5C
General Observations – patient is
thin, and short in stature, appears
generally pale and diaphoretic.
The patient complains further of
general aches and pains shortly
before she appears to lose balance
on her seat and falls unconscious.
Her respirations, while still present,
appear to be becoming more and
more laboured.
A head to toe examination reveals
nothing significant.
Oxygen therapy has no effect and
your patient’s condition remains
unchanged en-route to hospital.
Questions
1. What is your provisional
diagnosis for this patient?
2. Is there anything about this
patient’s condition that strikes
you as unusual?
3. What procedures/treatment
regimes would you instigate?
September
Challenge
answers
By David Couper, QAS Paramedic
What is the cause of this
patient’s presentation?
This injury is called wrist
neuropathy or handlebar palsy.
What is the aeitology of that
cause?
Wrist neuropathy is the irritation
and associated inflammation of
a nerve as it crosses the wrist
joint. In this case the Ulnar
nerve is affected, resulting in
numbness of the small and ring
finger and Median nerve with
numbness of the remaining
fingers and thumb.
Other activities that involve
repetitive movements of
the wrist may cause Ulnar
neuropathy, such as using a
computer mouse or typing. It
may also occur from an injury
to your elbow.
Other causes of Ulnar
neuropathy at or distal to the
wrist (ie at Guyon canal) include:
ganglionic cysts; tumours; blunt
injuries with or without fracture;
aberrant artery and idiopathic.
What is the management of
this patient?
Rest, consider use of a sling and
referral to a physiotherapist.
Document in detail all motor and
sensory impairment.
Most importantly, the cyclist
needs to have his bike set up
evaluated by a bike professional.
6 EMERGENCY October 2006 www.emergency.qld.gov.au