Simulated Patient Scenario

Scenario Details

MDT Information

• Non-urgent response - Back Pain
• 40-year-old female with sudden onset back pain
• Patient unable to move easily
• Patient awake and alert
• Patient at home

On Arrival

Patient is found lying on her side on the living room floor. She is visibly uncomfortable and moves very cautiously, grimacing with movement. She states she was bending over to pick up a laundry basket when she felt a sudden "pop" and severe pain in her lower back.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History

Vital Signs/Assessment (Initial)

Physical Examination (Focused Back/Neuro Exam)

• **Observation:** Patient lying still, avoids movement. No obvious deformity.
• **Palpation:** Tenderness over lumbar spine midline (e.g., L4/L5 area) and associated paravertebral muscle spasm bilaterally. No step deformity felt.
• **Range of Motion:** Severely limited in all directions due to pain. Unable to straight leg raise significantly due to back pain (not necessarily radicular pain).
• **Neurological Assessment (Lower Limbs):**
  • **Motor:** Power 5/5 in hip flexion, knee extension/flexion, ankle dorsiflexion/plantarflexion bilaterally. (Assess carefully, limited by pain).
  • **Sensation:** Intact to light touch in all dermatomes bilaterally.
  • **Reflexes:** Knee and ankle reflexes ++ and symmetrical. Plantars downgoing.
• **Red Flag Screening (Crucial):**
  • **Saddle Anaesthesia:** Patient denies any numbness or altered sensation in the groin/buttock/perineal area.
  • **Bowel/Bladder Function:** Denies any recent change in bowel or bladder control (no incontinence, no urinary retention).
  • **Lower Limb Neurology:** No objective weakness or widespread sensory loss found on exam. No sciatica reported.
  • **Systemic Symptoms:** Denies fever, chills, unexplained weight loss.
  • **History:** No history of cancer, recent significant trauma (other than the bending incident), IV drug use, or recent infection.
• Based on assessment, no red flags identified currently suggesting cauda equina syndrome or other serious pathology. Presentation consistent with acute mechanical lower back pain / lumbar strain/sprain.

Assessment and Treatment

Appropriate Management

• Recognise presentation consistent with acute, non-specific (mechanical) lower back pain following minor strain.
• Perform thorough assessment including vital signs and comprehensive red flag screening.
• Primary survey (ABCDE).
• **Pain Management:**
  • Offer analgesia appropriate for severe pain. Paracetamol is an option (consider IV if faster onset desired and available).
  • NSAIDs usually helpful, but patient reports intolerance to Ibuprofen. Consider alternative NSAID if available and appropriate (e.g., Diclofenac, Ketorolac - check contraindications), or proceed to other options.
  • Methoxyflurane ("green whistle") can provide rapid initial relief, especially during movement/extrication.
  • Consider oral opioids (e.g., Oxycodone) or IV opioids (e.g., titrated Fentanyl/Morphine) if pain is severe and not controlled by simpler measures. Use cautiously.
• **Reassurance and Advice:** Explain the likely nature of the pain (mechanical strain), reassure that serious pathology is unlikely based on current assessment (absence of red flags). Advise staying active as tolerated, avoiding bed rest. Explain typical recovery course.
• **Movement/Positioning:** Assist patient into a position of comfort if possible. Encourage gentle movement as tolerated.
• **Heat/Cold:** Application of heat or cold pack may provide symptomatic relief (offer if available/practical).
• **Transport Decision:** Discuss transport options. While red flags are absent, severe pain limiting mobility warrants transport to hospital for further assessment and potentially stronger analgesia/physiotherapy referral. If pain significantly improves with prehospital analgesia and patient feels capable, referral to GP/physio *might* be considered *if local guidelines permit*, but transport is generally appropriate for this level of acute pain and functional limitation.
• **Safe Extrication:** Use appropriate techniques (e.g., scoop stretcher, carry sheet) to minimise pain during movement if transporting. Ensure adequate analgesia prior to moving.
• Pre-notify receiving hospital if transporting, outlining presentation, negative red flag screen, and treatments given.