At 8:45 a.m., your unit is dispatched to Fabra Elementary School for a 7-year-old female with difficulty breathing. The outside temperature is 35°F following the recent passage of a cold front. Your response time to the scene is approximately 3 minutes.
Upon arriving at the scene, you are greeted by the school nurse, who tells you that the girl entered her office with mild respiratory distress. The nurse further tells you that the child’s temperature was 97.8°F (oral). You introduce yourself to the patient and perform an initial assessment (Table 1). Your partner begins to initiate treatment.
Table 1 Initial Assessment
| Level of Consciousness | Conscious and alert to person, place, and time; fearful |
| Chief Complaint | “I am having trouble breathing and forgot my medicine at home.” |
| Airway and Breathing | Airway patent; respirations, increased and labored; adequate air movement |
| Circulation | Radial pulse increased, strong, and regular; skin is pink, warm, and dry; no gross bleeding |
1. What initial management is indicated for this child?
The patient is tolerant of your initial treatment and remains conscious and alert. She tells you that she has a “breathing problem” and takes medicine for it. However, she cannot recall the name of the medication. As the school nurse attempts to contact the patient’s mother, you perform a focused history and physical examination (Table 2).
Table 2 Focused History and Physical Examination
| Onset | “This started really fast.” |
| Provocation/Palliation | “I started coughing real bad and then I started having trouble breathing.” |
| Quality | “It feels like I can’t get all the air out of my chest.” |
| Severity | “This is not the worst breathing trouble that I have had.” |
| Time | “This started right after I got to school.” |
| Interventions Prior to EMS Arrival | None |
| Chest Exam | Chest moves symmetrically; slight intercostal retractions; no obvious trauma |
| Breath Sounds | Audible expiratory wheezing |
| Oxygen Saturation | 91% (on 100% oxygen) |
2. What is your field impression of this child?
You proceed to obtain baseline vital signs and a SAMPLE history (Table 3) as your partner prepares to initiate further treatment. The nurse states that she has contacted the child’s mother, who wishes for you to take her to the hospital where she will meet you.
Table 3 Baseline Vital Signs and SAMPLE History
| Blood Pressure | 96/56 mm Hg |
| Pulse | 130 beats/min, strong and regular |
| Respirations | 30 breaths/min, labored |
| Oxygen Saturation | 91% (on 100% oxygen) |
| Signs and Symptoms | Difficulty breathing, intercostal retractions, low oxygen saturation, wheezing |
| Allergies | None |
| Medications | “I take medicine whenever this happens, but I don’t know what it is called.” |
| Pertinent Past History | “I have breathing problems like this every once in a while.” |
| Last Oral Intake | “I had a bowl of cereal before I came to school.” |
| Events Leading to Present Illness | “I started coughing really bad, and then I couldn’t breathe.” |
3. Are the child’s vital signs and SAMPLE history consistent with your field impression?
The girl, clearly frightened, asks you if you are going to stick her with a needle. You tell her that you don’t think that will be necessary. However, you do tell her that you are going to give her a “breathing treatment” that will hopefully make her feel better. You apply a cardiac monitor, which reveals a sinus tachycardia at 130 beats/min.
