Scenario — Severe flank pain — suspected renal colic

foundation Medical · Adult · 35yr · female

Patient Information

Dispatch	A 35YO female has come to the FAP at the Perth Royal Show reporting severe right-sided abdominal and back pain. She is conscious and distressed. (Sarah Nguyen)
Patient	Sarah Nguyen — 35yr (65kg)
Incident History	Pt reports sudden onset severe right flank pain approximately 40 minutes ago while walking through the showgrounds. Pain has been constant and is the worst she has ever experienced. She is nauseated and has vomited once.
Emergency Contact	David Nguyen (Husband) — 0412 774 203

Initial Rapid Assessment

Response	Alert
Airway	Patent. No airway obstruction. Nil stridor. Speaking in full sentences between bouts of distress.
Breathing	Breathing at an adequate rate and depth. No accessory muscle use. No abnormal breath sounds.
Circulation	Radial pulse present, regular, slightly elevated rate. Skin pale and diaphoretic. No active bleeding.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Restless and unable to find a comfortable position.
Exposure	No visible rashes or injuries. Patient guarding right flank. No obvious swelling or bruising.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Nil	18	102	128/84	<2s	15	4 4 ++	37.1	5.6 mmol/L	9
10 mins	98% (RA)	Nil	16	94	122/80	<2s	15	4 4 ++	37.1	5.6 mmol/L	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from suspected renal colic (ureteric calculus), presenting with severe right flank pain radiating to the groin, nausea, and vomiting in an otherwise haemodynamically stable adult female.

Facilitator Triggers — if trainees miss a critical step

! (If the EHS officer does not perform a BGL — remind them that any patient presenting with significant pain and altered behaviour/distress should have a full vital sign survey including BGL to exclude other causes.)
! (If pain assessment is not performed before and after analgesia — prompt the trainee: 'How do you know if your treatment is working?')
! (If Methoxyflurane is not offered within 5 minutes of assessment and pain score confirmed ≥4 — patient becomes increasingly distressed and begins dry retching, making assessment more difficult.)
! (If nausea and vomiting are not addressed with Ondansetron — patient vomits again at the 8-minute mark, increasing her distress and asking 'Is there anything you can give me for the vomiting?')
! (If the EHS officer attempts to administer a medication outside EHS scope such as opioid analgesia or IV fluids — facilitator prompts: 'What medications are you authorised to administer at this event?')
! (If the EHS officer does not arrange ambulance transport — patient asks 'Do I need to go to hospital?' Facilitator expects trainee to recognise this requires hospital assessment and arrange Priority transport.)

Treatment Objectives

1. Ensure scene and personal safety — don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, adequate breathing, circulation intact, GCS 15.
3. Position patient in a position of comfort — seated or semi-recumbent as tolerated; do not leave patient standing.
4. Perform full Vital Sign Survey — HR, BP, RR, SpO2, BGL, temperature, pain score.
5. Record pain score prior to analgesia: 9/10.
6. Prepare and administer Methoxyflurane (Penthrox) 3 mL inhaled via Penthrox inhaler device — for moderate to severe pain. Attach charcoal filter. Hand device to patient. Instruct patient to self-administer by inhaling through the mouthpiece. Onset of pain relief expected after 6–10 inhalations.
7. Reassess pain score after Methoxyflurane administration — expect improvement to approximately 5/10 at 10 minutes.
8. Administer Ondansetron 4 mg oral wafer — for active nausea and vomiting. Allow wafer to dissolve on tongue. Do not exceed 8 mg within 8 hours. Second dose may be given after 15 minutes if patient remains symptomatic.
9. Monitor patient persistently — record full observations every 10 minutes.
10. Reassess for clinical deterioration: monitor for fever (which may indicate infected stone — sepsis risk), worsening hypotension, altered conscious state, or inability to tolerate oral medications.
11. Arrange ambulance transport to hospital for definitive assessment and management — this condition is beyond EHS definitive treatment capability.
12. Prepare IMISTAMBO handover including: identity (Sarah Nguyen, 35F), mechanism/complaint (sudden onset right flank pain radiating to groin, nausea, vomiting), injuries/findings (suspected renal colic, haemodynamically stable), signs (HR 94, BP 122/80, SpO2 98% RA, GCS 15, pain 5/10 post analgesia), treatment (Methoxyflurane 3 mL inhaled, Ondansetron 4 mg oral wafer), allergies (NKDA), medications (OCP), other (nil significant past history).
13. Scenario ends on arrival of ambulance and IMISTAMBO handover.
14. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Methoxyflurane · Ondansetron · Pain Assessment · Primary Survey · Pulse & Respirations · Blood Pressure · Pulse Oximetry · Blood Glucose Monitor · Tympanic Thermometer

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Signs/Symptoms	Severe right-sided flank and lower abdominal pain, nausea, one episode of vomiting. Restless and unable to find a position of comfort. No urinary symptoms reported at this time.
Allergies	Nil known allergies.
Medications	Oral contraceptive pill. No other regular medications.
Pertinent History	No previous episodes of this type of pain. No known kidney problems. No recent urinary tract infections. Last menstrual period 2 weeks ago. Not pregnant.
Last Oral Intake	Ate a meat pie and soft drink approximately 1 hour ago.
Events Leading	Patient was walking around the Royal Show with her husband when the pain came on suddenly. She made her way to the FAP with assistance from her husband.
Treatment Prior	Nil. No analgesia taken prior to arrival at FAP.

Onset	Sudden onset approximately 40 minutes ago while walking around the showgrounds.
Pain	Severe, constant, cramping/colicky right flank pain radiating to the right lower abdomen and groin.
Quality	Described as cramping and constant — 'like being stabbed in the back and side'. Comes in waves of intensity.
Radiates	Right flank to right lower abdomen and into the groin.
Severity	9/10