Paramedic Handover for ‘nerve Entrapment’ — Free SCA Practice Case
Paramedic handover for ‘nerve entrapment’
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Mark Roberts
Age
56 years
Consultation Type
TelephoneAge
56
Caller
Paramedic Tom Jenkins (Calling from the patient's home)
Situation
Telephone Consultation (Urgent Professional Handover).
Reason for Encounter
"Paramedic requesting to leave patient at home for a routine GP visit. Triage note states: '56yo male, 4-hour history of left arm paraesthesia. FAST negative. Provisional diagnosis: Nerve entrapment/Cervical radiculopathy.'"
Medical Records (Mark Roberts)
- ●PMH: Essential Hypertension, Hyperlipidemia. Ex-smoker (quit 2 years ago).
- ●Medications: Ramipril 5mg OD, Atorvastatin 20mg OD.
- ●Allergies: NKDA.
Recent Notes
- ●Routine BP check 6 months ago: 145/88.
Patient Script
For the friend playing the patient role
Character Overview: You are Paramedic Jenkins. You are currently at Mark Roberts' house. You are friendly, highly experienced, but currently experiencing severe "anchoring bias." The local A&E is overwhelmed with a 6-hour ambulance handover delay, and you are actively trying to safely deflect patients to primary care to save hospital admissions. Mark woke up 4 hours ago with numbness and intense "pins and needles" in his left arm. You have assessed him: his FAST test (Face, Arms, Speech, Time) is negative for motor weakness. His ECG is normal sinus rhythm. His blood pressure is 158/92. Because his motor strength is intact, you have diagnosed a "trapped nerve in his neck" from sleeping awkwardly. You want to discharge him on the scene and ask the GP to do a routine telephone or home visit later this afternoon to prescribe some Amitriptyline or arrange physiotherapy. You will not volunteer the exact distribution of the numbness or his transient visual symptoms unless the doctor critically cross-examines your clinical assessment.
ICE — Ideas, Concerns, Expectations
These represent the paramedic's perspective on the case — they surface through the paramedic's framing of the handover and responses to the doctor's questions. They are not volunteered as a formal statement but are embedded in the paramedic's reasoning throughout the call.
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Ideas: You are convinced this is a mechanical nerve entrapment — a trapped cervical nerve from sleeping in an awkward position. The intact motor strength and negative FAST test have reinforced this view. You have not seriously considered a vascular cause because the patient "doesn't look like a stroke."
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Concerns: Your primary concern is not the patient's diagnosis but the operational pressure. A&E has a 6-hour ambulance handover delay and you need to clear the scene. You are worried about being stuck with a "non-emergency" patient while genuine emergencies queue up. If pushed, you are also mildly aware that the BP of 158/92 is higher than expected but have put this down to "white coat effect" from your visit.
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Expectations: You want the GP to accept a routine handover — ideally a telephone call to the patient later this afternoon to arrange physiotherapy or prescribe Amitriptyline. You expect the doctor to agree quickly and let you clear the scene.
Consultation Flow & Responses:
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The Opening:
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If the doctor asks for the handover: "Hi Doctor, thanks for taking the call. I'm with Mark Roberts, 56-year-old gent. He woke up 4 hours ago with pins and needles in his left arm. I've done a full set of obs. FAST is completely negative—grip strength is 5/5, face is symmetrical, speech is perfect. ECG is normal. I reckon he's just slept on it funny and trapped a cervical nerve. A&E is a warzone today, so I'd like to leave him at home. Can I just hand him over for a routine GP call later this afternoon?"
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Data Gathering (Challenging the Bias):
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If the doctor accepts your diagnosis without questioning: "Brilliant, thanks Doc. I'll clear the scene and leave him to you." (Candidate critically fails for accepting an unsafe handover and missing a TIA).
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If the doctor asks for the exact distribution of the sensory loss (Dermatomal vs. Global): "It's not just one finger, it's the whole arm. From the shoulder right down to the fingertips. It just feels 'dead' and tingly."
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If the doctor asks about neck pain: "No, he says his neck feels absolutely fine. No pain on movement at all."
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If the doctor asks about ANY other symptoms upon waking: "He did mention the room was spinning for about 10 minutes when he first stood up, and his vision was a bit blurry, but that completely resolved."
If Asked — Medical History and Medications
- ●If the doctor asks about the patient's past medical history: "He's got high blood pressure and high cholesterol, both on tablets. He used to smoke but gave up a couple of years ago."
- ●If the doctor asks specifically about his blood pressure control: "His BP today is 158 over 92, so it's a bit up. He says his last check at the surgery was about six months ago and they said it was 'borderline' — I think his notes say 145 over 88. He takes Ramipril 5mg once a day."
- ●If the doctor asks about his cholesterol medication: "He's on Atorvastatin 20mg. Says he takes it every night, hasn't missed any."
- ●If the doctor asks about smoking history: "He quit about two years ago. Before that he'd been smoking since his twenties — probably 30 years or so. He says he doesn't miss it."
- ●If the doctor asks about diabetes: "No, no diabetes as far as I know — nothing in his notes and he says he's never been told that."
- ●If the doctor asks about any previous strokes or TIAs: "No, nothing like that before. This is completely new for him."
- ●If the doctor asks about family history of stroke or heart disease: "He mentioned his dad had a heart attack in his sixties, but he doesn't know the details. Mum is still going, as far as I know."
- ●If the doctor asks about allergies: "No known drug allergies."
- ●If the doctor asks about anticoagulants or aspirin: "No, he's not on any blood thinners or aspirin. Just the Ramipril and the statin."
Social History and Lifestyle Impact
- ●If the doctor asks what the patient does for work: "He's a delivery driver — does long routes, mainly motorways. He's actually meant to be doing a shift this afternoon, which is partly why he wants to know if he can just get on with his day."
- ●If the doctor asks about the home situation: "He lives with his wife. She's here — she's the one who called 999 actually. She seems more worried than he is, to be honest. He keeps saying he's fine."
- ●If the doctor asks whether the patient drives: "Yes, he drives for a living — HGV licence, I think, or at least a large van. He was asking me if he's alright to drive to work later." (This is a critical safety-netting detail — a suspected TIA with a vocational driving licence requires immediate DVLA notification and cessation of driving.)
If Asked — Associated Symptoms
- ●If asked whether symptoms are still present or have resolved: "The pins and needles are still there now, four hours on. The dizziness and blurry vision stopped after about ten minutes."
- ●If asked about headache: "No, he says he hasn't got a headache at all."
- ●If asked about facial drooping or numbness: "No, his face is completely normal. Symmetrical, no drooping, no numbness."
- ●If asked about speech difficulties: "No, his speech has been totally normal the whole time I've been here — clear, fluent, no word-finding problems."
- ●If asked about weakness in the arm or leg: "No motor weakness at all. Grip strength is 5 out of 5 bilaterally. He can lift both arms, walk normally, no drift."
- ●If asked about leg symptoms or numbness: "No, it's just the left arm. Legs are completely fine."
- ●If asked about swallowing difficulty: "No, he's had a cup of tea since I've been here — no problems swallowing."
- ●If asked about loss of consciousness or collapse: "No, he didn't pass out or fall. He just woke up and noticed the arm."
- ●If asked about chest pain or palpitations: "No chest pain, no palpitations. ECG is normal sinus rhythm."
- ●If asked about the onset — sudden vs. gradual: "He says it was just there when he woke up. Sudden — he noticed it immediately."
- ●If asked about previous similar episodes: "No, he says nothing like this has ever happened before."
- ●If asked about atrial fibrillation or irregular pulse: "His pulse is regular, about 78. ECG shows normal sinus rhythm, no AF."
- ●If asked about recent head injury or trauma: "No, nothing like that."
- ●If asked about seizure activity: "No seizures, no twitching, nothing like that."
- ●Negotiation & Collaborative Management Plan:
- ●If the Doctor agrees to a routine GP visit:
- ●Reaction: "Great, I'll document that primary care has accepted the handover." (Candidate critically fails for leaving an acute Stroke/TIA at home).
- ●If the Doctor asks you to transport to A&E without explaining why:
- ●Reaction: "Take him to A&E? Doctor, the wait times are 6 hours and his FAST is negative. He doesn't need an emergency bed for a trapped nerve. Why can't you just call him later?"
- ●If the Doctor professionally challenges the diagnosis and invokes the Stroke/TIA pathway:
- ●Reaction: "A sensory TIA? Ah... I see your point. The whole arm is involved, and there's no neck pain. Yes, you're right, it doesn't fit a dermatome. Okay, I will convey him to the hospital as a suspected TIA immediately."
- ●If the Doctor raises the driving issue after agreeing on TIA pathway:
- ●Reaction: "Good point — I'll make sure he knows he absolutely cannot drive. I'll tell his wife as well before I leave."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Anchoring Bias and the Limits of the FAST Test
- ●Anchoring bias — the cognitive trap of over-relying on the first diagnosis offered — is a deliberate feature of SCA stations involving a professional handover. The correct response is systematic clinical scepticism, not passive acceptance.
- ●The FAST test (Face, Arms, Speech, Time) is a validated public health screening tool for anterior circulation motor strokes in the MCA territory. It is not designed to detect — and is notoriously unreliable for — posterior circulation strokes, cerebellar infarcts, or isolated sensory strokes such as thalamic lacunar infarcts.
- ●A negative FAST does not exclude stroke or TIA. Any acute-onset focal neurological deficit — sensory or motor — is a vascular event until proven otherwise.
Differentiating Central Sensory Loss from Cervical Radiculopathy
- ●Cervical radiculopathy (a trapped nerve) produces sensory loss in a strictly dermatomal distribution corresponding to a single nerve root — e.g. C6 affecting the thumb and index finger, C7 affecting the middle finger. It is associated with neck pain, pain on cervical movement, and gradual onset.
- ●A central vascular lesion (lacunar infarct or TIA in the thalamus or posterior internal capsule) produces global, non-dermatomal hemisensory loss — often described as the entire limb or side of the body feeling numb or "dead." There is no neck pain.
- ●In this case: whole-arm numbness from shoulder to fingertip, absent neck pain, sudden onset on waking, and associated transient vertigo and blurred vision confirm a central vascular aetiology. The clinical picture does not fit any peripheral nerve or cervical root territory.
Posterior Circulation Features — What to Actively Screen For
- ●The posterior circulation (vertebrobasilar system) supplies the brainstem, cerebellum, thalamus, and occipital cortex. Isolated sensory deficits, vertigo, diplopia, ataxia, dysarthria, and visual field disturbance are its hallmark presentations.
- ●The FAST test does not screen for any of these features. A dedicated posterior circulation screen must be performed in addition to the standard FAST assessment.
- ●In this case, the transient vertigo and blurred vision lasting approximately ten minutes are posterior circulation symptoms that significantly raise the probability of a cerebrovascular event and must be actively elicited — they are not volunteered.
NICE NG128 — Acute Stroke and TIA Pathways
- ●Acute stroke (ongoing symptoms): If focal neurological symptoms are still present, the patient is within the 4.5-hour IV thrombolysis window (NICE NG128). This mandates immediate emergency conveyance to a Hyperacute Stroke Unit (HASU) or Emergency Department with a stroke pre-alert so that non-contrast CT imaging can be arranged on arrival and thrombolysis or mechanical thrombectomy eligibility assessed without delay.
- ●High-risk TIA (fully resolved symptoms): If all symptoms have completely resolved, the presentation is a TIA. NICE NG128 requires specialist assessment within 24 hours. In practice, a TIA within the preceding 7 days warrants same-day TIA clinic or Emergency Department referral.
- ●The "last known well" time — not the time of symptom discovery — determines thrombolysis eligibility. A patient who woke with symptoms was last known neurologically intact at sleep onset; the true onset may extend the window further. Always establish this explicitly.
- ●A GP cannot safely accept this presentation for a routine afternoon review. The timeline mandates immediate emergency intervention.
Aspirin — When to Give and When to Withhold
- ●Do not administer aspirin before imaging in acute stroke. While haemorrhagic stroke cannot be excluded by clinical assessment alone, giving aspirin 300mg in the context of an intracranial haemorrhage is potentially catastrophic. CT head must exclude haemorrhage first.
- ●For confirmed TIA (symptoms fully resolved, haemorrhage excluded): aspirin 300mg loading dose is appropriate and recommended. However, in this case, ongoing arm paraesthesia means haemorrhage has not been excluded — aspirin must be withheld and the decision deferred to the receiving stroke team.
- ●A common candidate error is to instruct the paramedic to give aspirin immediately on the basis that the FAST is negative. This is incorrect and dangerous.
Acute Blood Pressure Management — Do Not Lower in the Community
- ●The observed BP of 158/92 is elevated but should not be pharmacologically lowered prior to hospital assessment. In suspected ischaemic stroke, acute BP lowering reduces cerebral perfusion pressure and risks extending the ischaemic penumbra — potentially worsening the infarct.
- ●NICE NG128 sets the threshold for BP intervention prior to thrombolysis at >185/110 mmHg. At 158/92, no pre-hospital antihypertensive intervention is indicated or safe.
- ●BP management in the acute cerebrovascular setting is a decision for the receiving stroke team, not primary care.
Safe Transfer Directives
- ●Before leaving the scene and during transfer: perform a dysphagia screen (simple water swallow test). If the patient fails or the screen cannot be completed, maintain nil by mouth to prevent aspiration pneumonia — a major source of post-stroke morbidity and mortality.
- ●The patient should remain supine or at no more than 30 degrees head elevation during transfer to maintain cerebral perfusion.
- ●Continuous neurological monitoring en route is required, with immediate re-alerting of the receiving team if there is any deterioration.
Vocational Driving Licences and DVLA Notification
- ●Following any suspected TIA or stroke, all patients must be advised not to drive immediately. This is a legal and patient safety requirement.
- ●Patients holding a Group 2 (vocational) licence — HGV, bus, or large goods vehicle — face stricter DVLA notification requirements than standard Group 1 licence holders. A suspected TIA or stroke must be notified to the DVLA, and Group 2 licence holders face a minimum cessation period of 1 year following TIA before reapplication for a vocational licence can be considered (compared to 1 month for Group 1).
- ●In this case, the patient intends to drive a large van on a motorway this afternoon. This is an immediate and serious patient and public safety risk requiring explicit, unambiguous instruction to the patient and his wife before the paramedic leaves the scene.
- ●The GP must document that driving cessation advice has been given and that DVLA notification will be addressed following the acute assessment.
Secondary Prevention — Downstream Medication Review
- ●This patient's hypertension is inadequately controlled (145/88 at last review six months ago; 158/92 today on Ramipril 5mg). Following the acute assessment, antihypertensive therapy will require review and likely up-titration or addition of a second agent.
- ●The current atorvastatin 20mg dose is subtherapeutic for secondary stroke/TIA prevention. NICE NG128 recommends atorvastatin 80mg for secondary prevention following TIA or stroke — this intensification should be flagged to the hospital team and initiated post-acute assessment.
- ●Dual antiplatelet therapy is the post-acute secondary prevention standard for high-risk TIA once haemorrhage is excluded: aspirin 300mg loading dose, then aspirin 75mg plus clopidogrel 75mg daily for 21 days, followed by clopidogrel 75mg monotherapy long-term (NICE NG128). This replaces the older aspirin monotherapy approach and should not be conflated with the acute aspirin decision.
Vascular Risk Stratification — Integrating the Full Picture
- ●This patient carries multiple major vascular risk factors: age 56, male sex, essential hypertension (poorly controlled), hyperlipidaemia, significant ex-smoking history (~30 pack-years), and paternal history of MI in his sixties.
- ●Each risk factor individually is relevant; in combination, they substantially raise pre-test probability for a cerebrovascular event and should immediately prompt clinical scepticism about any non-vascular diagnosis.
- ●Absence of antiplatelet therapy is additionally relevant to both diagnostic probability and prescribing decisions — the absence of aspirin cover is not reassuring and should be noted.
Common Candidate Errors in This Station
- ●Accepting the paramedic's diagnosis without challenge is the primary fail. The marking scheme treats this as a critical failure — a candidate who agrees to a routine afternoon GP call has missed an acute stroke or TIA.
- ●Using the FAST test as a stroke exclusion tool rather than a screening tool is a fundamental diagnostic error. FAST-negative does not mean stroke-negative.
- ●Prescribing aspirin immediately before haemorrhage has been excluded by CT is a serious prescribing error. The instruction to withhold aspirin until imaging is completed is explicit in NICE NG128.
- ●Failing to address the driving issue despite it being raised in the consultation — this patient's plan to drive an HGV this afternoon represents an immediate, preventable public safety risk.
- ●Treating secondary prevention as outside the scope of this consultation — while acute prescribing is deferred to the hospital team, the GP is responsible for flagging the suboptimal statin dose and uncontrolled hypertension as part of the handover.
Mapped to the RCGP curriculum topic: Urgent & Unscheduled care.
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