Couple Skills Assessment Questions!

[Sal]

I have my skills exams on friday on trauma and medical.
Couple questions I ran across, when we come upon our transport decision, most which will be rapid transport to the hospital is it safe to rapid transport all medical assessments to the hospital? (epi, mdi, glycemic, anaphalactic, nitro patients is what i mean by all since this is all we're tested on) and when we state our transport decision as rapid transport verbally, everything after that we are assuming we are en route to the hospital? Is it accurate to say I would transport rapid to nearest hospital but first I would like to get a quick reply incase my patient carries any medications or has any medications hes taking, grab the medications and do OPQRST and SAMPLE en route to the hospital? This is very confusing to me because I failed my first attempt because I stated rapid transport and then did my sample and pt had MDI inhaler and I was going to administer it and the proctor told me I forgot to grab it back at the scene assuming I got on the ambulance after I stated rapid transport?

Question pertaining to medication, if we help assist with pts nitro successfully, do we also have to give 4 tablets of aspirin 324mg if pt shows no allergies, is it a fail if we dont do the aspirin part according to national registry?

And if a pt is hyperglycemic and has insulin, can we still give them oral glucose?

Another question pertains to trauma assessment. So basically all we can treat for trauma is ABCs and obvious bleeding? Bleeding to the chest if active apply 4x4 gauze and occlusive dressing on top? Bleeding thats not actively bleeding like a chest wound or gunshot just apply occlusive dressing? ABCs before bleeding? And when we transport, do we always transport rapid and take sample en route? What differentiates staying in play and doing a detailed physical exam from a quick physical exam, it seems like theyre the exact same?
Again I'm speaking in terms of the national registry, since they are who is going to tell me if I pass/fail.
Thank you!

 

[SpecialK]

The most critical question we must ask when we see a patient is "what is my diagnosis of this patient and what do I need to do about it?"

Everything else is based upon that.

For example - you may diagnose asthma and determine the patient has run out of their salbutamol which is why they called us. If they respond well to nebulised salbutamol and ipratropium and have no other pressing reason to be immediately referred elsewhere, then that's the end of it. If, on the other hand, they were a major trauma patient (or had a nasty big STEMI) then you need to expeditiously take them to a major trauma centre or for pPCI respectively.

I have "rapidly transported" four patients to hospital .... in seven years. The overwhelming majority of patients who do require transport to hospital do not require lights and sirens transport.

SAMPLE and PRQST are not useful ways to take a history. Medical history taking is part art part science developed from a detailed knowledge of the anatomy, pathology and physiology and is always a work in progress. SAMPLE and PRQST are useful to see if you have forgotten anything. On-scene, ask those questions which are going to lead you to a) form a diagnosis and b) form a management plan.

Bottom line- if it doesn't change what you do, or if you are transporting, will not change what needs to happen at the hospital, don't worry about it.

If you give GTN for myocardial ischaemia, yes, you also need to give aspirin as long as they do not have any contraindications. Aspirin will do more than GTN for the STEMI patient anyway!

If the pt is hyperglycaemic no do not give them glucose or glucagon That is for hypoglycaemia.

Occlusive dressings went out of fashion ages ago. Just cover it, we use defibrillation pads for sucking wounds.

Scene time is really dependent on the patient and what they need. Time critical problems are mostly obvious.

 

[Sal]

The most critical question we must ask when we see a patient is "what is my diagnosis of this patient and what do I need to do about it?"

Everything else is based upon that.

For example - you may diagnose asthma and determine the patient has run out of their salbutamol which is why they called us. If they respond well to nebulised salbutamol and ipratropium and have no other pressing reason to be immediately referred elsewhere, then that's the end of it. If, on the other hand, they were a major trauma patient (or had a nasty big STEMI) then you need to expeditiously take them to a major trauma centre or for pPCI respectively.

I have "rapidly transported" four patients to hospital .... in seven years. The overwhelming majority of patients who do require transport to hospital do not require lights and sirens transport.

SAMPLE and PRQST are not useful ways to take a history. Medical history taking is part art part science developed from a detailed knowledge of the anatomy, pathology and physiology and is always a work in progress. SAMPLE and PRQST are useful to see if you have forgotten anything. On-scene, ask those questions which are going to lead you to a) form a diagnosis and b) form a management plan.

Bottom line- if it doesn't change what you do, or if you are transporting, will not change what needs to happen at the hospital, don't worry about it.

If you give GTN for myocardial ischaemia, yes, you also need to give aspirin as long as they do not have any contraindications. Aspirin will do more than GTN for the STEMI patient anyway!

If the pt is hyperglycaemic no do not give them glucose or glucagon That is for hypoglycaemia.

Occlusive dressings went out of fashion ages ago. Just cover it, we use defibrillation pads for sucking wounds.

Scene time is really dependent on the patient and what they need. Time critical problems are mostly obvious.

i understand these... im saying in terms of national registry this doesnt always agree with each other. according to national registry and our course sample and OPQRST is a must and our main form of getting information. My question is what type of medical scenarios do we rapid transport and just dip out vs verbalize we will rapid transport but stay a little bit to find out anything else so we dont forget it. I guess I just answered my own question, so we stay if we suspect this patient is taking a medication we can assist with (nitro epi mdi), and dip out asap if they dont have those conditions and finish everything en route (since we have access to o2, oral glucose, and aspirin any time).
makes sense?

 

[Bluemtnsky]

Another question pertains to trauma assessment. So basically all we can treat for trauma is ABCs and obvious bleeding? Bleeding to the chest if active apply 4x4 gauze and occlusive dressing on top? Bleeding thats not actively bleeding like a chest wound or gunshot just apply occlusive dressing? ABCs before bleeding? And when we transport, do we always transport rapid and take sample en route? What differentiates staying in play and doing a detailed physical exam from a quick physical exam, it seems like theyre the exact same?
Again I'm speaking in terms of the national registry, since they are who is going to tell me if I pass/fail.

I did my skills test two days ago for EMT-B and passed everything first try.

For trauma, you do all your verbal stuff at the beginning, then do LOC, then do ABC's which you will treat as you discover it. Don't forget C, Circulation, Cut the clothes, so that you can actually discover the LIFE THREATENING bleeding. If the bleeding is not a life threat, don't treat it. Finish your ABC's. Verbalize your transport decision (I listed the GCS conditions but didn't add up numbers) "high priority patient, will transport to "name of nearest trauma center". If your patient is unconscious/no bystanders that know them say you can't obtain SAMPLE. Do your rapid head to toe and find all of your secondary injuries but don't treat just say "secondary injury of <whatever it is>, will treat en route.", save the back for last, have an imaginary partner bring your imaginary backboard, roll pt,. examine posterior/spine, roll pt. onto imaginary backboard. Verbalize loading patient, taking baseline vitals, taking care of those secondary injuries, and when to reassess en route.

Detailed vs. quick exam: We were taught head to toe vs focused. If they are conscious, totally oriented and have no potentially distracting (physical/psychological) injuries, then they can tell you their chief complaint and you do a focused exam based on that info. If they don't fit into that description you do a head to toe. Trauma pts won't/can't fit into that description, they always get a rapid head to toe.

 

[Bluemtnsky]

And if a pt is hyperglycemic and has insulin, can we still give them oral glucose?

... I am unaware of a reason to give a hyperglycemic person more glucose.

 

[Bluemtnsky]

Question pertaining to medication, if we help assist with pts nitro successfully, do we also have to give 4 tablets of aspirin 324mg if pt shows no allergies, is it a fail if we dont do the aspirin part according to national registry?

Our area protocols state to give aspirin for possible cardiac chest pain, and that we can administer pts. prescribed nitro. I never got corrected for doing so in practice session for NREMT. If they call you on it, point to the protocols and challenge it.

This is applicable to a different station (CPR/AED) but as our instructor explained, the NREMT is meant to be over everyone, but they (test proctors) design the test to be applicable to the area it's given in, to better match with what is taught in class which is based on the local protocols. I'm in Denver-ish, I don't know if it is common but the Denver Metro protocols were written by a group of medical directors (like 16 or 18) my understanding is that the agencies tweak that set of protocols but are pretty close, so that is what our class was taught .

 

[Bluemtnsky]

Couple questions I ran across, when we come upon our transport decision, most which will be rapid transport to the hospital is it safe to rapid transport all medical assessments to the hospital? (epi, mdi, glycemic, anaphalactic, nitro patients is what i mean by all since this is all we're tested on) and when we state our transport decision as rapid transport verbally, everything after that we are assuming we are en route to the hospital?

I'm a bit less confident on answering this one...(mainly because in real life I'm not sure how I will handle the verbal judo on convincing reluctant pts. to not refuse vs. understanding that the hospital is expensive, but you don't want to die, but is it really that bad? but yes it is just let's go already.)

So when you say rapid transport what do you mean? Like transport emergent? Transport before doing secondary assessment/secondary injuries? or...?
The sheet says "Identify patient priority.." so my two mental categories for the scenarios we did practicing in class were 'high or critical' medical pts. were high, trauma pts. were critical. The other half of that item says "...and makes treatment/transport decision." (To me that is a decision to treat or to transport, not a level of how fast you will go while transporting.)

Trauma is easy, do the assessments and transport. Medical, well in retrospect, every scenario we practiced, and all the you tubes I watched, for national registry you do primary assessment, state you will transport, do secondary assessment, do the proper medication intervention.

 

[Bluemtnsky]

Lastly, I highly recommend practicing a couple videos https://www.youtube.com/results?search_query=nremt+prep+medical+assessment

Specifically for medical assessment scenarios. Watch the video (possibly with a clueless person, I used my dog.) Think about if the medication treatment matches what you would actually do. After you have watched the video, replay the scenario with your assistant/dog/mirror/phone video recorder as you would do it. Don't look at your sheet until after you have done that section. Practice on a couple different scenarios (you can find others if you scroll down/tweak that link)

Good luck!

 

[medichopeful]

And if a pt is hyperglycemic and has insulin, can we still give them oral glucose?

What is your thinking on this OP? Why would you want to give them oral glucose? Or why would you want to withhold it?