Severe flank pain — suspected renal colic

Patient Information

Dispatch: A 38YO 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 — 38yr (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

Treatment Response

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 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 sublingual tablet — for active nausea and vomiting. Place tablet under the tongue and allow to dissolve. Do not exceed 8 mg within 8 hours. Second dose may be given after 15 minutes if patient remains symptomatic. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
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 sublingual tablet), 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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