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Paramedic CASE STUDY 1 Phil is a 19-year-old male who has severe Multiple Sclerosis. He uses a wheelchair. He attends a living skills program at a local community centre to maintain his independence. Occasionally Phil engages in behaviour that makes things difficult and awkward for others. He also makes it difficult for people to get to know and get along with him – especially if he does not get his own way or when his routine is suddenly changed. Today Phil arrived at the skills program complaining of not feeling well. He says nothing further even when he is asked if he is okay. Throughout the morning Phil has been irritable towards everyone, yet has remained compliant. Before lunch, Phil goes to the bathroom to empty his catheter bag and Jayne (one of the occupational therapy assistants) notices his urine is very dark and has a pungent aroma. She reports this to the centre manager. Phil comes back from the bathroom looking a little pale. He says that he is nauseous. The centre manager feels his forehead and he is very warm to touch. She phones Phil’s doctor to report it. The doctor thinks that Phil might have a urinary tract infection (UTI) and instructs the manager to call Q Paramedical to transport Phil to the hospital. Phil is not happy about this and is upset that Jayne has reported his condition. He is very upset that he has to leave the centre. He becomes verbally aggressive toward staff and clients at the centre. You arrive with your partner Emily, who is on her first call out as a new emergency response medic. On arrival you observe the surroundings. Clients are eating their lunch and Phil is at the table watching others eat. He appears angry and the manager of the centre confirms this saying, “…he has been told he has to go to hospital and he’s not at all happy with the decision and has become verbally aggressive.” You scan the area identifying exit points and the position of other patients. You receive some history from the centre manager while Emily approaches Phil. She begins to introduce herself but Phil picks up the plate of food next to him and throws it at Emily. He begins shouting obscenities at her. The clients become upset and frightened by his behaviour. Emily is taken back and begins to shake. She is not injured. She turns to you for direction and support. You interact with Phil from a safe distance and talk to him to de-escalate the situation and calm him down. After some communication, intervention and positive affirmation, Phil calms down to a level that enables him to follow instructions and show compliance in acceptable behaviour. He gives permission for you assess to his physical status and take some vital observations. Your assessment identifies the following: • Pulse = 110, Reg GSC= 15 Nausea • BP = 115/75 PEARL Temp = 39.6C • Resp Rate = 24 BGL= 4.4 mmol Pain in the hypogastric region • SaO2= 96% Diaphoretic Urine = dusky yellow, foreign bodies ? blood clots Phil agrees to be transported to a health facility and Emily and yourself proceed to transfer him from his chair to a stretcher and then in to the emergency vehicle. You observe Phil throughout the transfer and notice he is becoming anxious again, verbalising he needs his wheelchair. He is worried about his mobility once he gets to the venue. You reassure him you will also load his wheelchair. When you arrive at the medical venue you provide a clinical handover of the patient. 1.Identify the behaviours of concern that Phil is exhibiting. 2.Outline your duty of care requirements in this scenario. 3. describe three (3) measures you would use to prevent Phil’s behaviour from escalating. Explain why these measures would be effective. 4. List three (3) considerations you would need to make in regards to a planned response to Phil’s behaviour. 5.Describe and explain what triggers (physical, psychological and environmental) may have contributed to Phil’s behaviour. 6.List and describe at least four (4) legislative and/or procedural requirements that would be relevant to this situation. 7.Identify at least one (1) other professional or emergency resource that you may have needed to contact had Phil’s behaviour not de-escalated. Explain what assistance they could provide. 8.Identify the two (2) key documents that would be filled out when reporting this incident. 9.Explain why Emily should access debriefing. Identify the type of support available to her. CASE STUDY 2 You and your colleague Gavin are called to attend a male patient, Julio, who has been waiting to be transported to the local hospital for renal dialysis and a palliative care consultation. Julio is 75 years old and has end-stage kidney failure. He who also has severe dementia. Julio lives with his wife Maria who is his carer. Julio has been ill and is two days overdue for his renal dialysis. You arrive at 10 am to find Julio sitting restlessly next to his bed. Maria gives you an update on her husband. Julio’s dementia diagnosis was made six years ago and is he is slowly deteriorating. Julio is Italian by birth. Maria says he has a strong Roman Catholic belief. With the onset of dementia Julio lost much of his ability to speak English and he has reverted speaking Italian, which is his first language. Maria says that Julio has been quite irritable over the past 24 to 48 hours, which she indicates is common when he is late for dialysis. Julio is fidgeting in his chair and appears unsure whether to sit or stand. Occasionally he says something loudly in Italian. Julio also looks unwell – he is slightly pale and sweaty, he has a slight tremor in both hands. Gavin decides to perform a set of vital signs prior to transporting Julio, but you are wary that approaching and performing the vital signs activity may meet with resistance and confusion, given Julio’s current state. Gavin approaches Julio, who begins crying out in Italian and throwing his arms around. He is clearly confused and starts to act aggressive. Following intervention and support from Maria, Gavin manages to communicate successfully about what is happening using Maria as the interpreter. Maria is able to calm Julio enough that he can have his vitals taken. Julio’s vital signs are: BP=135/85 Heart Rate=88 Resp. Rate= 22 SaO2= 95% Temp = 38.0C HNPU 24/7 Other information: A full upper and lower denture, which are ill fitting. Glasses due to his eyesight deteriorating. Halitosis +++ and dry crusty mouth/lips. Nil by mouth since 7pm day previous (refusing all offers of food and water) Frequent outbursts of difficult behaviour over past 24/48 hours Broken restless sleep past 2/7 nights Dozing past 2 days x 3 for 10-20 mins – waking irritable, confused and aggressive Several skin tears to his R (3) and L (2) anterior calves that appear red angry and infected. Julio begins to play with the stretcher while you are organising it, pacing around and placing his hands on the levers and latches. He reaches under the stretcher, scratching around frantically as if looking for something. You are concerned he will get his hands caught in the stretcher and hurt himself. You are ready for Julio to be transported to the hospital. You and Gavin approach Julio to help him on to the stretcher. Julio suddenly shouts something in Italian and begins to wave his fists at you. In doing so, Julio accidently hits Gavin in the face. Gavin’s lip starts to bleed. Maria is startled, upset and begins to cry. You reassure Maria and intervene to support Julio to calm down. Eventually he gets on to the stretcher for transport and you head to the hospital. 1. Identify the medium and high-risk measures that may be present in this case study. As part of your answer, outline at least three (3) strategies you could apply to manage, minimise or de-escalate the behaviours of concern shown by Julio (as a patient with dementia). 2. Explain why it is important to assess Julio’s physical health status and what you would be looking for due to his dementia diagnosis. 3.Outline the behaviours of concern Julio exhibited and possible contributing factors 4. Describe two (2) strategies that you could use to minimise Julio’s behaviour and keep himself, Maria and the attending health care team safe. 5. Identify three (3) relevant human rights that need to be observed and applied when working with Julio, other patients with dementia and those from a different cultural and/or religious background. Provide a reason why you have chosen each human right.

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