Case Study: Anxiety or Cardiac Episode?

The Setting

You're leading a team building day for a group of business people. Today's plan includes rappelling practice.

One participant, fearing the heights and exposure, is reluctant to participate. It took convincing from his co-workers to get him on the rappel over the cliff edge.

He is now 15 feet below the lip of cliff and looks awful. He's red, sweating, breathing hard, and says he is going to pass out. You engage the belay line to take control of his lowering, and try to get him to release the death grip he has on his brake line. This triggers drama: you hear swearing from below as he grabs the main line above his rappel device with both hands. Eventually he lets go and you lower him to the ground.

SOAP Report

Subjective

The patient is a 49-year-old male lowered to the ground after failing to rappel a short cliff. There is no mechanism for spine injury. He complains of dizziness, numb and painful hands, and thinks he's going to vomit. He says he “can’t breathe.” He is pacing rapidly.

Objective

The patient has superficial abrasions on his hands that look like rope burn. He has tingling and numbness in hands and lips. CSMs in feet are normal. Circulation is good to his hands. No wheezes or coughing while breathing. He denies chest pain.

Vital Signs

History

STOP READING!

What is your assessment and plan?Take a few minutes to figure out your own assessment and make a plan. Don’t cheat—no reading on without answering this first!

Assessment

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

Plan

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

The Tale Continues...

It's 10:50am, about 20 minutes after you started treating your patient, and he’s breathing easier. The tingling and numbness in his hands has abated, but he is still agitated and will not sit down. He continues to complain of a pounding heart, while his radial pulse is regular and 84 beats per minute (bpm).

You have the group return to the camp to give the patient privacy and help him feel more comfortable. He say that he’s worried about his performance affecting his employment. He denies a history of heart disease and describes a series of panic attacks 3 years ago. He does not want his supervisor to learn of his panic attack history.

Vital Signs

Notes from NOLS on Stress Responses

This scenario has possible physical and mental health components. First aid for stress and anxiety responses is to calm the patient, try to address their fears, and complete a patient assessment. However, you also can’t overlook a physical problem in the midst of an emotional event. Patients whose stress 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. Your evacuation guidelines say to evacuate any patient with chest pain that is not clearly musculoskeletal. The patient does not complain specifically of chest pain, but the overall picture is suspicious for a heart problem, and not all cardiac events present with classic squeezing, sub-sternal, radiating-to-the-left-side chest pain

End of the Tale

Because you can’t rule out a cardiac problem, you decide to make the conservative decision and evacuate your patient for further evaluation. Luckily, you have cell reception and are able to call for EMS support. While waiting, you continue to try to calm the patient and help him maintain a normal respiratory rate.

A short while later, local EMS arrives with an off-road vehicle to transport the patient on the dirt road to the ambulance waiting in the closest paved parking lot. You brief the EMS crew, and they take the patient to a hospital.

That evening, the patient returns to the group feeling much better and excited for the next day’s activities, which won’t involve leaving the ground.

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