# trauma scenario help



## Murzilka (Aug 13, 2010)

Hi everyone. Please help! I recently had EMT-B certification exam where I failed Trauma because in my class we NEVER had a scenario like that. All our "patients" were always in supine position. I am not sure what to do. 

Basically the patient fell down. The big things are:

1. Seated patient (would you leave her seated or help her get to supine position while holding C-spine?)
2. Contusion on left side of forehead
3. Broken left arm with bone sticking out and is bleeding heavily (ask assistant to splint it? Elevate it because you shouldn't put pressure on broken bones?)


----------



## Melclin (Aug 13, 2010)

Murzilka said:


> Hi everyone. Please help! I recently had EMT-B certification exam where I failed Trauma because in my class we NEVER had a scenario like that. All our "patients" were always in supine position. I am not sure what to do.
> 
> Basically the patient fell down. The big things are:
> 
> ...



1. A seated patient has probably already done a fair bit of moving and chances are what little support you can provide by holding c-spine won't make any difference. Is the patient indicated for spinal immobilisation? Or do you just have to collar and board every idiot with a broken toe?

2. What about it?

3. I'd probably go with some combination of combine, ring pads & elevation but its a bit hard to tell without actually being presented with the injury. 


You're going to run into problems here because what you are asked to do for your EMT-B exam is not necessarily - in fact often not - best practice. The answers you get here will be more along the lines of best practice, but that won't help you pass your exam. You need to find out what you assessor wants and play their game.


----------



## AtlantaEMT (Aug 13, 2010)

What materials did they have available to you?

1.  In a seated position for possible spinal injury you'd use a K.E.D.  For trauma assessment you shouldn't have to actually put them in a KED becuase that is a potential Random station.  Also you'd have to put them in the KED and then transfer them to the backboard and no instructor is going to sit through that 100 times.

2.  Noted and probably an indication for rapid transport making it a Load and Go

3.  Don't splint it.  I'm assuming your main priority is to get the patient ready for transport.  I believe you should say that you will control the bleeding (life threat) and use a backboard (if you use it) for your initial splint and splint it during transit if time allows.

But as the poster above said, what you do for NREMT and what you do in real life is probably totally different.


----------



## JPINFV (Aug 13, 2010)

1. Depends on if you're going to immobilize, which will depend on the rest of the exam, taking into account that an open fracture very likely is (almost 100% for testing purposes) a distracting injury. If immobilization is indicated, then immobilize with a vest immobilizer (i.e. KED) unless rapid extraction is indicated. 

2. Document it. What's the neuro exam like? (GCS/orientation? Neuro deficits? Pupils, including extra ocular muscles (the entire "look straight ahead and follow my fingers with just your eyes" and have the fingers make an H. This tests cranial nerves III, IV, VI. If you really want to be impressive, learn the rest of the cranial nerve exams). Normal doesn't necessarilly mean nothing is wrong (especially with older patients with smaller brains), but it will start to give you an idea of how critical the patient is. I wouldn't necessarilly say that a contusion is reason for load and go. 

3. Cover wound with gauze essentially providing as much pressure as possible without drastically hurting the patient, then splint in the position found as best as possible. Bleeding control is going to really be determined by what the proctor's definition of "heavily" is.


----------



## Murzilka (Aug 13, 2010)

Melclin, yea pretty much have to take C-spine if the skill is trauma. Since the patient was seated it threw me off cause I've never seen that before so I didn't take C-spine and that was one of the reasons I failed. 

To everyone, the only "tools" we have is BP cuff, stethoscope, and penlight. We have to verbalize transferring to a backboard etc. That is a separate skill we're tested on though, so is KED. I am hearing for the first time using KED on a patient who was not in a car accident. 

AtlantaEMT, so for the broken arm, would it be a good idea to apply as much pressure as possible w/o putting the patien in agony and then elevate and apply pressure on the artery? 

They definitely did not teach us well enough. Also this was an unluckly scenario to get. Everyone else I know got a different scenario and they all passed. I know how to do trauma assessment on a supine patient without any life threatening injuries (except for chest injuries). It's not like we're let loose on patients the day we pass. There is a whole lot of ride-alongs to do before they actually let us do anything important.


----------



## AtlantaEMT (Aug 13, 2010)

Murzilka said:


> AtlantaEMT, so for the broken arm, would it be a good idea to apply as much pressure as possible w/o putting the patien in agony and then elevate and apply pressure on the artery?



I haven't actually done practicles yet (doing mine tommorow) so I am not hte best person to ask.  I'm also not very strong in trauma becuase in my ride alongs I didn't have a single trauma.  My only traumas were in the ER but they are already packaged (only me).

I'm kind of confused on your scenerio and question.  I get the patient is sitting vs supine, but that doesn't change your steps for taking care of a patient.  If your patient is laying prone and their back looks like a jigsaw puzzle but they aren't breathing you aren't going to attach that person to the backboard then roll them.  You are going to roll that patient and get them breathing regardless of spinal condition.  You'll do the long board later after you establish ABCs and do a rapid trauma assessment.

Imagine your scenerio except the patient is laying supine.  Same head contusion, same LOC, same ABCs, and you have heavy bleeding on your left arm.  How would you handle it?

I'd control the heavy bleeding by having my assistant apply direct pressure and bandage it with a dry sterile dressing until bleeding is controlled. After that I then tackle the ABCs.  No point to do CPR if all you are going to do is pump blood out of the body (I could be wrong on that).  If the fracture was open but there wasn't heavy bleeding then I wouldn't worry about it until I did my ABCs and a rapid trauma assessment and had the patient loaded into the ambulance where I take care of secondary injuries if time allows.  

I may be wrong but that's why I'm here.  I want to learn.

Oh yeah, don't do "as much pressure as possible".  Use as much pressure until bleeding is controlled.


----------



## Melclin (Aug 14, 2010)

*Good on u for wanting to learn*



AtlantaEMT said:


> 2.  Noted and probably an indication for rapid transport making it a Load and Go



I bumped my head on the cuboard the other day while cooking my dinner. Had a pretty big contusion. I swore a lot, but I didn't need to be rushed to hospital l/s. Just food for thought.



AtlantaEMT said:


> I'd control the heavy bleeding by having my assistant apply direct pressure and bandage it with a dry sterile dressing until bleeding is controlled.
> 
> Oh yeah, don't do "as much pressure as possible".  Use as much pressure until bleeding is controlled.



Hehe, You're not wrong technically I suppose, but get a stop watch and apply heavy pressure to an open fracture. I don't reckon you'll get past a second before the pt knocks u out cold.


----------



## MrBrown (Aug 14, 2010)

I swear I am going to smack the next person who splutters "but, but, but the patient bumped thier head/stubbed thier toe so we have to throw him on a longboard and tie him down!"

Without significant mechanisim of injury or findings of neurological abnormality I wouldn't consider even collaring this person.

Splint thier arm, analgesia, take to hospital.

Simple.


----------



## Murzilka (Aug 14, 2010)

MrBrown said:


> I swear I am going to smack the next person who splutters "but, but, but the patient bumped thier head/stubbed thier toe so we have to throw him on a longboard and tie him down!"
> 
> Without significant mechanisim of injury or findings of neurological abnormality I wouldn't consider even collaring this person.
> 
> ...



Maybe that would work in real life, but not in trauma testing


----------



## AtlantaEMT (Aug 14, 2010)

Murzilka said:


> Maybe that would work in real life, but not in trauma testing



Yeah, I know a lot of these situations for NREMT are nowhere close to real life.  When it comes to IVs if my instructors or evaluator caught me doing IVs the way I see nurses, paramedics, or even them in real life do it, they'd drop kick me out of there.

Hell, our fake arms started flashbacking clear later on in the day.


----------



## EMTinNEPA (Aug 14, 2010)

What kind of EMT program doesn't cover immobilization of seated patients?


----------



## JPINFV (Aug 14, 2010)

More appropriate question, "How many EMT programs teach immobilizing seated patients other than one inside a vehicle?"


----------



## Murzilka (Aug 14, 2010)

EMTinNEPA said:


> What kind of EMT program doesn't cover immobilization of seated patients?



We covered it only in car accidents where we used KED. But yea seated NOT in a car we really didn't cover it. Even if it was mentioned (which I do not remember), we never practiced in the MANY scenarios we did for supine patients.


----------



## jjesusfreak01 (Aug 15, 2010)

We actually only practiced KED use indoors taking people out of chairs. I find it unlikely that I would ever actually use one on a patient in a chair, though I do see how it would be possible. I suppose someone could fall off a roof, break their back and then sit on a chair inside. Again, unlikely but possible.


----------



## ems4gd_185 (Aug 15, 2010)

Murzilka said:


> Hi everyone. Please help! I recently had EMT-B certification exam where I failed Trauma because in my class we NEVER had a scenario like that. All our "patients" were always in supine position. I am not sure what to do.
> 
> Basically the patient fell down. The big things are:
> 
> ...



Someone hold c-spine how pt is found, AVPU, ABC's, control bleeding of arm depending on if arterial or venous (if venous then how bad is it flowing decides whether it gets bandaged or not), decide (load and go or stay and play). SAMPLE/OPQRST from one person while the other does a Rapid Trauma Assessment. If no other injuries then splint arm in place (PMS before and after splint), place c-collar, KED, backboard, stretcher, move to ambulance. Vital signs (trendelenburg if hypotensive), transport to trauma center. Call report and be done. THIS IS FOR BLS PROVIDERS ONLY!!!!

I have proctored NREMTexams so I know what is on most of the sheets for BLS and ALS and what they are looking for.


----------



## Hellsbells (Aug 15, 2010)

> Yeah, I know a lot of these situations for NREMT are nowhere close to real life. When it comes to IVs if my instructors or evaluator caught me doing IVs the way I see nurses, paramedics, or even them in real life do it, they'd drop kick me out of there.



Can I ask what you mean by this?


----------



## AtlantaEMT (Aug 15, 2010)

Hellsbells said:


> Can I ask what you mean by this?



In the IV testing for NREMT once you insert the stylette and advance the catheter and remove the stylete, your can not let go of the catheter.  If you let go it is an automatic fail.  Working the ER/ambulance I've watched nurses, paramedics, and even a doctor stick a patient, let go of it, and do whatever and come back to it.  It is rare for me to see someone stick someone starting with a 45degree angle and then go to 15.  Most just do it at 15 or flush against the skin.  Infact I've been told by them to not do the 45 and just start with 15.  That's just what I have observed and many others in my class have noticed.

Same for insertion of a combitube.  They want you do do a jaw-tongue lift.  No way in hell my fingers are going into someone's mouth.


----------



## Murzilka (Aug 18, 2010)

ems4gd_185 said:


> Someone hold c-spine how pt is found, AVPU, ABC's, control bleeding of arm depending on if arterial or venous (if venous then how bad is it flowing decides whether it gets bandaged or not), decide (load and go or stay and play). SAMPLE/OPQRST from one person while the other does a Rapid Trauma Assessment. If no other injuries then splint arm in place (PMS before and after splint), place c-collar, KED, backboard, stretcher, move to ambulance. Vital signs (trendelenburg if hypotensive), transport to trauma center. Call report and be done. THIS IS FOR BLS PROVIDERS ONLY!!!!
> 
> I have proctored NREMTexams so I know what is on most of the sheets for BLS and ALS and what they are looking for.



Wow whoever is being tested like this is lucky because we have no assistant and have to do everything by ourselves within 10 min. We just have BP cuff, stethoscope, and pen light and we verbalize placing pt on backboard, transporting, etc.


----------



## AtlantaEMT (Aug 19, 2010)

Murzilka said:


> Wow whoever is being tested like this is lucky because we have no assistant and have to do everything by ourselves within 10 min. We just have BP cuff, stethoscope, and pen light and we verbalize placing pt on backboard, transporting, etc.



Are you testing in America?  Becuase you have assistants during your trauma exam.  They usually give you 2 people and will have 2 people in the room with you.  If there aren't then maybe you forgot to ask "What resources do I have available".  Then they will tell you you have 2 or all resources available.


----------



## Murzilka (Aug 19, 2010)

AtlantaEMT said:


> Are you testing in America?  Becuase you have assistants during your trauma exam.  They usually give you 2 people and will have 2 people in the room with you.  If there aren't then maybe you forgot to ask "What resources do I have available".  Then they will tell you you have 2 or all resources available.



Yes I am. Actually we are not supposed to have assistants in testing. That's what they told us all 3 months during class and before testing too. We have "imaginary" assistants who splint, bandage, and hold C-spine, and help us turn them over to assess the back. We have to do vitals, sample, opqrst, all that.


Now I have a really dumb question. Please don't judge me. For patients with step-off, aren't you supposed to put a collar on?


----------



## thatJeffguy (Aug 20, 2010)

Murzilka said:


> Yes I am. Actually we are not supposed to have assistants in testing. That's what they told us all 3 months during class and before testing too. We have "imaginary" assistants who splint, bandage, and hold C-spine, and help us turn them over to assess the back. We have to do vitals, sample, opqrst, all that.



That sounds incredibly, incredibly easy.

If *all* EMT's are assuming that the imaginary assistant is performing C-spine, rolling, posterior assessment during the "rapid trauma assessment", as well as spliting and bandaging... who's going to do those things on scene?  They'll never have been assessed on those aspects of the trauma patient.

What state are you in, if you don't mine me asking?  I'll remember to pray extra hard while driving through 



> Wow I have a really dumb question. Please don't judge me. For patients with step-off, aren't you supposed to put a collar on?



A step-off?  Falling off or down a flight of stairs?  If I find them there?  Sure.  

If I show up and they've walked around for ten minutes?  Neuro exam, distal pulse/motor/sensory function intact?  I'd like to think I could make an educated decision and not board them.  I'll have to check our protocols for the exact specifics.

My trauma test was a breeze!  We had a bystander that could help with the log roll and hold c-spine when the patient wasn't being rolled.  My partner is a bright guy and we planned our entire assessment with both of us in each role.


----------

