NREMT Mental conditioning

Question 1

You observe a patient in tripod position.

What does this indicate? What are the implications for patient criticality?

Answer 1

Tripod position (hands placed on legs or knees, leaning forward) is an indicator of respiratory distress.

It tends to indicate more severe respiratory distress (more severe than a person who is sitting casually) but alone does not indicate respiratory failure.

If you see this on an examination or in a patient you should look for additional clues to criticality and respiratory adequacy:

More severe:

Speaking only a few words per sentence

Altered mental status

Significant accessory muscle use

Low oxygen saturation reading

Less severe:

Speaking full sentences

Normal mental status

Normal oxygen saturation

No accessory muscle use

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Question 2

You are responding to an auto-pedestrian collision. You arrive to find a patient lying in the road. He is not moving and bystanders look concerned.

What are your thoughts on approach?

What are your initial priorities going to be?

Answer 2

The patient isn’t moving and the bystanders look concerned. You should plan on this being a serious trauma call.

Think of the opposite scenario: The patient is sitting up and joking with the bystanders. This doesn’t appear as serious. You should use scene clues as an important part of your size-up.

If this continues to be serious you’ll expedite transport doing c-spine precautions, ABCs, a quick head-to-toe exam and spinal immobilization on scene. The rest will be done enroute. A majority of your actions will revolve around the primary assessment.

Don’t forget to call for additional help or resources early.

Question 3

A patient has an altered mental status and appears to have bitten her tongue. What condition is likely to have caused this presentation?

Answer 3

Seizure.

While it isn’t guaranteed, this is a very common presentation for a post-ictal patient after a seizure. Biting the tongue is common in a seizure. If no one witnesses the seizure, the patient appears to have an altered mental status which he or she gradually recovers from.

Question 4

Your patient tells you that she gets winded easily. She tried to walk up the stairs and had to stop half way to catch her breath.

What is this called?

What does this indicate?

Answer 4

This condition is called dyspnea on exertion (DOE). She has difficulty breathing when she is exerting herself.

There are several potential causes of this. Perhaps most significantly, you should ask the patient if it has gotten worse recently. This may indicate a worsening of an underlying condition. It is also potentially serious in a normally healthy person who suddenly develops DOE.

Many times this is caused by heart failure, pulmonary edema or worsening of chronic obstructive lung conditions.

Question 5

You are called to treat a 3 year old male patient who fell down some stairs. The baby is siting in his mother’s lap. He is holding tightly around mom’s neck and doesn’t want to let go.

What does this initial scenario tell you?

Answer 5

It is normal for a child to want to be with a parent. This indicates that the mental status is relatively normal. The fact that the child can establish a firm grip around Mom’s neck is an indicator of less serious injury.

Remember that limp, quiet children are generally considered sicker than screaming children or those who cling to mom.

The facts above do not rule out injury however. Be alert for pale, cool or moist skin and respiratory difficulty. Look for any indications the child is in pain and for asymmetry in movement which might indicate spinal or musculoskeletal injury.

Spinal immobilization may be necessary. You should work with the child’s parents to assess and treat the child in the calmest, safest and most expeditious method.

Question 6

Your patient has pain in the shoulder. He denies trauma. What could cause this pain?

Answer 6

Pain in the shoulder may caused by many different conditions. Arthritis or old shoulder injuries could be the cause of the pain.

Pain from the chest and abdomen may also be referred to the shoulder. Causes may include:

Pancreatitis

Gallstones

Myocardial infarction

Pneumonia

In each of these cases, a complete physical examination may help to isolate the cause. Recognizing that shoulder pain may be referred from the chest or abdomen will help the EMT recognize when cardiac, pulmonary and abdominal exams may be necessary.

Question 7

You arrive at the side of a patient who has snoring sounds coming from his airway. What should you do?

Answer 7

Open the airway.

Snoring sounds are caused by a mechanical obstruction in the airway (usually the tongue). Opening the airway will stop the snoring sound.

Question 8

You are called to a patient “spitting up blood.”

What are your initial concerns?

What are your longer-term concerns?

Answer 8

Initially you should be thinking airway and quantity of blood. Is the blood significant enough to be causing an airway problem? Is there enough blood to cause shock? You should also take appropriate standard precautions (gloves, face protection) if there is spraying blood.

After the primary assessment is completed you can begin to think more about the condition:

Is the blood coming from the lungs (coughed up) or the GI system (vomited)? Based on this you will focus your history on either the pulmonary system or the gastrointestinal system (or both if the origin is undetermined).

Question 9

You arrive at a call for difficulty breathing and you observe a man slumped over in a chair. He has poor color.

What are your initial thoughts/actions?

What are your secondary thoughts/actions?

Answer 9

In this case you might never get to the secondary concerns (diagnosis, detailed examinations).

If the patient is as bad as he looks (poor mental status) he should be moved from the chair to the floor immediately. From here you will immediately perform a primary survey. Identify and treat issues with the ABCs (or CAB if lifeless).

You have other immediate concerns. Do you need more help? What is your transport priority? Do you need ALS? Making these decisions early and acting upon them is crucial to the success of the call.

Getting a quick patient history might direct you to a cause (e.g. complaints of chest pain or a headache before becoming unresponsive, diabetic history).

More detailed exams may be performed enroute as time and available personnel dictate.

Question 10

Your patient complains of feeling weak. How do you approach this complaint?

Answer 10

Every complaint begins with a primary assessment. Look for problems with the ABCs including respiratory distress and signs of shock.

Once you have completed the primary assessment, begin a secondary assessment. This might be a non-serious complaint but remember that many elderly patients with myocardial infarction present with weakness (they don’t experience pain or discomfort).

Perform a detailed history. If the patient has any medical history (e.g. diabetes) explore those possibilities. Many times clues to the cause may be present but the patient doesn’t know the significance.

Ask about onset (sudden or gradual) and check for fever. Closely examine the patient’s mental status. Tests like a stroke scale may be in order. Check vital signs and pulse oximetry.

Question 11

List four ways you could evaluate for chest pain that isn’t caused by a myocardial infarction.

Answer 11

1. Listen to lung sounds. Diminished or absent sounds may indicate pneumothorax or pneumonia.
2. Palpate the chest. Tenderness or deformity may indicate broken ribs.
3. Ask the patient if the pain changes on a deep inspiration. This may indicate pleuritis, trauma and other conditions. This doesn’t rule out a heart attack but it does bring other suspicions into the picture.
4. Ask about fever, chills, night sweats, cough and other signs of infection.

Question 12

You approach a young female patient who is wheezing.

What are your initial concerns?

What are your secondary concerns?

What causes wheezing?

Answer 12

Your first concern with any patient with respiratory distress is the adequacy of breathing. Observe the rate and depth of breathing as well as mental status and skin color for indications of respiratory failure. Always care for life threats first.

Since the patient is young, it is more likely that asthma or anaphylaxis is a cause of the wheezing rather than emphysema or chronic bronchitis. There are other possibilities you may consider including airway irritants (gasses).

Your initial analysis will help you choose the right questions in the patient history and the right treatment. It will also give you things to examine for (history of asthma or allergies, hives, etc.).

Wheezes are caused by air being forced through a narrowed air passage.

Question 13

You are called to a physician’s office for exacerbation of COPD. What does that mean?

Answer 13

Exacerbation means worsening or increasing severity. In this case the patient’s COPD is getting worse.

This might be indicated by increased difficulty breathing (including retractions and accessory muscle use), worsening or productive cough, hypoxia, change in sputum color and other signs and symptoms.

Question 14

You are providing medical coverage for a large political rally. Someone comes to you and reports that “a lot” of people are “passing out” at the other side of the auditorium.

What are your first impressions?

What are your initial actions based on that?

Answer 14

There are several important elements in the scene size-up here. The fact that several people, not just one person, are down is very important. Safety is always your first concern.

1. This is a multiple casualty incident. You should put yourself in that mindset immediately.
2. Calmly report to dispatch what has been reported to you.
3. Consider the dangers that may be involved. Is this a bleacher collapse or some sort of weapons of mass destruction incident? The fact that it is a political rally means WMD should be considered initially. You may also consider the environment (e.g. is it very hot) as a possible cause. You must not fall victim to what caused others to go down.
4. Do not approach until it is safe to do so.
5. Remember that you will be a part of a large response team. Follow the incident command system.

Question 15

You arrive on scene and meet a mother who tells you that her baby has had diarrhea. Mom is concerned.

How would you determine criticality initially? How would you assess this patient initially and in a secondary exam?

Answer 15

The first concerns with most pediatric patients can be effectively identified through the pediatric assessment triangle. Look for:

Appearance - limp, lethargic babies are sick babies.

Breathing - increased work of breathing indicates a sick baby.

Circulation - pale, mottled or cyanotic skin indicates a sick baby.

If abnormalities are found in the areas above, initiate immediate care and transport and call for ALS. Do not delay transport and BLS procedures.

Secondarily, the history and physical examination will provide additional information. Specifically, ask the following questions to determine the extent of the dehydration from diarrhea. Again, never delay transport of a critically ill baby to perform these history questions and examinations.

• How has the baby been feeding? Any changes in feeding patterns or amounts?
• How frequent is the diarrhea?
• Has the baby been wetting diapers (if this can be determined separate from the diarrhea)?
• Depending on the age of the baby, the anterior fontanelle may be present. Is it sunken?
• Is the capillary refill time delayed?

Question 16

What are early indications that help differentiate a critical trauma patient from a non-critical trauma patient?

Answer 16

One of the most significant indicators of criticality - altered mental status - is also a good early sign. Any patient with an altered mental status should be considered critical until proven otherwise. The altered mental status may range from restlessness or anxiety to unresponsiveness.

Your initial observations may reveal serious injuries. These include multiple long bone fractures, significant blood loss, paralysis, proximal amputations, head trauma or evidence of significant chest or abdominal trauma.

In your primary assessment you may identify elevated pulse and/or respiratory rates. This indicates a more serious patient as does cool, pale and moist skin. These indicate shock. Trending vital signs throughout the call will give you more definitive answers but you should consider these patients to be serious until proven otherwise.

Question 17

You arrive at the side of a patient who has gurgling sounds coming from his airway. What should you do?

Answer 17

Open the airway and suction.

Gurgling is the sound of air passing through fluid in the airway.

Question 18

You approach a scene and see wires down. What should you do?

Answer 18

You should stay a safe distance from the scene until the wires can be removed by trained personnel–usually the power company.

There are many scene hazards including wires down, fire, overturned vehicles, and violence. Both on exams and on actual calls, be sure the scene is safe as part of the scene size-up process.

Never approach or enter an unsafe scene.

Question 19

You are sent to a “man down” in a parking lot. You arrive to find a patient lying face-down and apparently unresponsive.

Consider two different patients you could find at this scene when you arrive. One is a 19-year-old male. The other is a 69-year-old male.

What differences might you expect in your clinical thinking assuming all other scene elements are the same?

Answer 19

The big difference between these two patients is that the 69-year-old man is more likely to have a medical problem than a 19-year-old man.

Since medical problems are less likely, the 19-year-old may be more prone to drug or alcohol emergencies and trauma.

This doesn’t mean that a 19-year-old can’t have a heart attack or a 69-year-old man couldn’t be a heroin addict.

Clinically, it is acceptable to consider some things to be more likely than others. It helps shape decision-making and intuition.

Question 20

You are called to a patient with respiratory distress. You arrive to find the patient on a nasal cannula at home.

What does this mean?

How do you deal with the patient’s home oxygen?

Answer 20

As with any patient, the first priority will be the primary assessment. Assure the patient is not in respiratory failure and in need of ventilation or requires oxygenation greater than the nasal cannula will deliver.

Clinically, the presence of a nasal cannula at home indicates a chronic hypoxic condition. This is often a result of COPD but may also be due to heart failure. In some cases patients with lung cancer will have a nasal cannula. These patients will usually have home medications for breathing including inhalers and home nebulizer devices. Be sure to ask what medications or treatments they have taken prior to your arrival.

You should switch the patient over to your oxygen. This eliminates the chance that the patient’s home oxygen system may be empty or malfunctioning. Using your own cannula or mask is also best in the event the patient’s tubing is kinked or disconnected.

Question 21

What are the differences in assessment and care between a critical and a non-critical patient?

Answer 21

While a critical patient is obviously more severe, there are several differences in assessment and care:

1. Critical patients usually require a more aggressive and/or detailed primary assessment.
2. Critical patients must be assessed quickly and efficiently.
3. Critical patients are usually only given life-saving care at the scene. Additional care can be performed enroute.
4. Critical patients must be moved to the ambulance and transported quickly.
5. Critical patients can deteriorate rapidly and require careful reassessment throughout the call.

Question 22

You are performing a primary assessment. List at least three things you would observe that would be an early indication of shock.

Answer 22

Shock can–and should–be identified early. This can easily be performed in the primary assessment. The following signs and symptoms will give you an indication that shock may be present:

1. Altered mental status. Restlessness and anxiety are early signs of shock.
2. Rapid respirations
3. Rapid pulse (You don’t need to get an exact rate but you will know an abnormally rapid pulse when you feel it.)
4. Cool, moist skin
5. Pale skin
6. As you examine the chest as part of the “B” in ABC you may note injuries that may be serious and indicate the potential for shock.

Question 23

You are called for an unresponsive man at 7:00 am. His wife says she can’t wake the 75-year-old male patient up.

How would you proceed as you begin patient assessment?

Answer 23

These calls are somewhat common in EMS. It could be an unresponsive diabetic or a major stroke. There is a significant chance the patient is in cardiac arrest.

The question that should be on your mind is whether the patient’s heart stopped a short time ago or whether it was some time overnight. This will affect your resuscitation decision.

You will always begin with a primary assessment. This will include a pulse check. If the pulse is absent and the patient doesn’t appear to have a prolonged down time your will move the patient to the floor and begin CPR. Be sure to call for any additional help you may need early.

You should also be alert for signs of obvious death where you wouldn’t begin resuscitation. These include dependent lividity (discoloration of skin which is at the lowest point). This is caused by blood settling into these low (dependent) places. Rigor mortis (a stiffening of the body) may also be present.

Since the patient may be under the covers, body temperature is not as reliable a sign as dependent lividity and rigor mortis. Follow your local protocols regarding resuscitation decisions.

Question 24

You are called for an infant in respiratory distress. You arrive to find the baby crying loudly and flailing. What does this tell you?

Answer 24

Crying loudly and flailing requires oxygen. It appears this baby has enough oxygen - at least for now.

Loud, crying babies may not be pleasant. But they are breathing and not as sick as the quiet, limp ones.

Question 25

Your patient was getting off the bus and twisted her ankle. She is alert and conscious.

What are your initial priorities?

Do you have to assess the whole body if it is an isolated injury?

Answer 25

Initially you will do a primary assessment and ABCs. If the patient is alert and oriented this should be uncomplicated.

You should think about two other things as you assess:

Was there a fall or something that could cause c-spine injuries?

Is there something that could make this more serious than it seems (medical emergency causing the fall, hidden injury, loss of consciousness)?

If the answers to these are negative and it is an isolated ankle injury you can focus solely on the ankle.

Question 26

What are the main differences in assessment between a medical and a trauma patient?

Answer 26

The primary difference between the assessment of the medical and trauma patient is the approach.

Medical assessments usually focus on the history. A physical examination is done but the history usually provides a majority of useful information.

Trauma assessments are more hands-on than medical exams. This is because injuries can often be palpated externally.

These concepts are important because you should begin with the most relevant and valuable assessments for each patient type.

In all patients the primary assessment is done before the secondary assessment.

Question 27

You are called to a 20-year-old female patient with abdominal pain.

What are you considering as you approach?

What signs upon your arrival would indicate criticality or instability?

Answer 27

Consider possible causes. It is a tenet of medicine that ectopic pregnancy must be considered in a patient of this age group until proven otherwise. Other OB/GYN causes include cysts, painful menstruation, pelvic inflammatory disease and others.

There are many other causes of abdominal pain including appendicitis, constipation, ulcer and others.

Signs of criticality include poor skin color, cool and moist skin, altered mental status, rapid pulse and respirations.

Question 28

You arrive on scene and observe an alert patient. What does this mean to you?

Answer 28

The fact that a patient appears alert (knows who/where he is and purpose) tells you that the patient isn’t in respiratory failure or profoundly hypoxic and doesn’t have severe shock.

It is an indication that your primary assessment will progress without manually opening the airway or providing suction. You should still note the rate and depth of breathing and evaluate circulation.

Alertness is a general indicator of stability and indicates that you may progress more slowly than if the patient had an altered mental status.

It does not guarantee stability, however. The patient may have a significant underlying medical or traumatic condition. Your thorough and accurate assessment will help to determine this.

Question 29

You approach a scene and observe a significant mechanism of injury. What does this mean?

Answer 29

It indicates that the patient may have severe injuries as a result of the mechanism but does not guarantee it.

More reliable than mechanism of injury are physiologic and anatomic criteria. These criteria, as defined by the CDC, include:

Indications of physiologic instability:

Respirations below 10 or greater than 29 in an adult, less than 20 in an infant

Systolic BP below 90 mmHg

GCS of 13 or less

Anatomic criteria include:

All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee

Chest wall instability or deformity (e.g. flail chest)

Two or more proximal long-bone fractures

Crushed, degloved, mangled, or pulseless extremity

Amputation proximal to wrist or ankle

Pelvic fractures

Open or depressed skull fracture

Paralysis

Question 30

Several people in one house are complaining of weakness and flu-like symptoms.

What are potential causes?

What actions would you take based on these causes?

Answer 30

Things change dramatically when more than one person is sick at the same location.

Safety is always your first concern. Since this is a classic presentation of carbon monoxide poisoning in a home, if you are in the home you may be in danger. Heating season, recent furnace or heater repairs and alternate heating sources make this more likely.

This could be everyone in the home with the flu at the same time, but until carbon monoxide is ruled out you should err on the side of safety.

Clinically, remember that carbon monoxide has an affinity for hemoglobin. Oxygen saturations can appear falsely normal. Use a carbon monoxide oximeter if you have one available.

Question 31

What is the significance of “tearing” abdominal pain?

Answer 31

While it is far from guaranteed, some patients with an abdominal aortic aneurysm complain of a tearing or ripping pain.

The abdominal aorta is retroperitoneal (behind the peritoneum). Based on this and depending on the location of the aneurysm, it may present as abdominal, back, groin or flank pain. A pulsatile mass may be palpated in the abdomen.

In the event of pain fitting this description, aneurysm should be suspected.

Question 32

You come upon a trauma patient with an obvious angulated extremity fracture.

What are your priorities?

What are the implications for patient assessment and care?

Answer 32

Fractures–especially angulated fractures–are painful and very obvious to the patient. The first rule in this case is to not be distracted by the fracture and stick to your priorities (the primary assessment). It is logical to acknowledge to the patient that you see the fracture and will treat it.

The primary assessment is important because it takes a certain amount of force to fracture a bone. That force may have caused other, more serious injuries (internal bleeding, fractured ribs, pneumothorax, etc.).

Once you have completed the primary assessment and determined a patient status and priority you will be able to decide when and how to treat the fracture. Remember that the fracture is known as a distracting injury because the pain and deformity will distract the patient from being able to identify and communicate with you about other injuries.

Bones bleed. Fractures can cause shock. Remember to complete a full secondary survey as necessary. When multiple long bone fractures are present, this should be considered multiple trauma.