# NREMT (EMT-B) Medical- HCTZ Situation



## dmfinn (Jan 3, 2013)

Hey guys! First post here so I apologize if it's been answered before or if I have placed it in the wrong area.

Anyway, I recently took my NREMT practical exam (EMT-B) in Connecticut. First time around I passed Trauma,AED,Airway,and Random. KED and Medical posed some problems to me. I registered to take the retake about 2 weeks later.

I took the retake again, and to my disappointment, no joy! I know why I failed KED (I was nervous and did not reassess PMS after moving patient to a LSB), but I have no idea why I failed medical. Honestly I followed the sheet exactly, but I did it appropriately and expanded on my thoughts so I wasn't just reciting it. I was hoping you guys could help me out. Below is the situation, followed by my actions.

SITUATION:

40 y/o male
Woke up complaining of headache, tingling arm, and has slurred speech.
Airway is patent
Breathing is within normal limits
Pulse: Strong ; Skin: Dry, cyanosis around lips and fingerbeds.

OPQRST: Everything was maxed out. Nothing made it worst or better. No radiation. Described the pain as sharp (in regard to the headache)

SAMPLE: Aforementioned signs and symptoms, allergic to penicillin, diagnosed with HBP and is currently on HCTZ, everything else normal.

Pulse: 140
BP: 210/110
BR: 24

MY ACTIONS:

I'll skip all the basic stuff. I know I hit every one of the simple things. Here are my actions that would change based on the situation:

-Questioned "wife" if there were any C-Spine precautions needed
-Immediately began Hi-flow O2 at the sign of cyanosis (15l NRB)
-Made decision for immediate transport (called for ALS)
-Secondary Assessment: Checked lung sounds (equal)
                                  Checked for any JVD (none)
                                  Checked for pedal edema (none)

-Interventions: I said that under my skill set, I could not give HCTZ in the field. This is true, right? Assuming that it was, I said I would continue to monitor the patient every 5 minutes to gain updates on his condition. I would also continue his oxygen therapy. I then gave an accurate report the the incoming ALS.

(SAMPLE,OPQRST,etc were all completed)

sorry for the long post, just hoping someone can help!

Thanks,
Dan


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## VFlutter (Jan 3, 2013)

Never even mention anything out side of your scope, especially meds.


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## kaaatielove (Jan 3, 2013)

Chase said:


> Never even mention anything out side of your scope, especially meds.



Couldn't have said it better..


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## JMorin95 (Jan 3, 2013)

Did you assess for a possible stroke?


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## Veneficus (Jan 3, 2013)

Are you permitted to assist somebody in taking their prescription medication?

(not that it would have worked in minutes anyway)


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## JMorin95 (Jan 3, 2013)

Also they may have wanted you to check pupil reaction too, along with any spine tenderness, bruising, or pain.


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## dmfinn (Jan 3, 2013)

JMorin95 said:


> Did you assess for a possible stroke?



Yes. Patient was a 2/3 on the Cincinnati stroke scale. (Facial droop and slurred speech)


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## shfd739 (Jan 3, 2013)

JMorin95 said:


> Did you assess for a possible stroke?



My thoughts too. 

How were the arms- one weaker than the other and any drifting?

Speech- slurred or difficulty using proper words?


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## PaddyWagon (Jan 3, 2013)

Did you check stroke facial symmetry, arm droop?  I have to agree, basics don't do drugs so the blood pressure medication thing was out of left field but probably not a fail condition.

 Cspine is done during before you ever touch a patient, did you initiate oxygen before vocalizing the cspine assessment or forget to vocalize whether you need more units before continuing with primary assessment?

You must have hit an automatic fail ch3ck box.  I'll grab my sheet when I get home.
Breath 24 is a wee bit above the 12-20 normal range.  No mention of skin temperature.


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## dmfinn (Jan 3, 2013)

PaddyWagon said:


> Did you check stroke facial symmetry, arm droop?  I have to agree, basics don't do drugs so the blood pressure medication thing was out of left field but probably not a fail condition.
> 
> Cspine is done during before you ever touch a patient, did you initiate oxygen before vocalizing the cspine assessment or forget to vocalize whether you need more units before continuing with primary assessment?
> 
> ...



Thanks for the reply! (and for looking at your sheet). C-Spine precautions were taken during the Scene Size-Up as the sheet calls for. I may have missed the "vocalizing for more units", though I did identify that since there was only one patient that it was not my opinion that additional troops were needed. O2 therapy was initiated at the sign of cyanosis. I noticed that BR was high too, but after being placed on O2 all signs of breathing stress disappeared and cyanosis ceased. Not sure of the skin temperature, all I remember was that it was dry.


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## NomadicMedic (Jan 3, 2013)

Did you determine, and verbalize, that this was a CVA and that rapid transport to a stroke center was indicated?


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## VFlutter (Jan 3, 2013)

dmfinn said:


> Thanks for the reply! (and for looking at your sheet). C-Spine precautions were taken during the Scene Size-Up as the sheet calls for. I may have missed the "vocalizing for more units", though I did identify that since there was only one patient that it was not my opinion that additional troops were needed. .



That may have got you. I would think to request ALS


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## JMorin95 (Jan 3, 2013)

dmfinn said:


> Yes. Patient was a 2/3 on the Cincinnati stroke scale. (Facial droop and slurred speech)



There are four parts to the scale. Speech facial droop arm and motor skills.


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## NomadicMedic (Jan 3, 2013)

JMorin95 said:


> There are four parts to the scale. Speech facial droop arm and motor skills.



Uh, no. The Cincinnati stroke scale is three items; facial droop, pronator drift and slurring of speech. 

http://www.strokecenter.org/wp-content/uploads/2011/08/cincinnati.pdf


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## JMorin95 (Jan 3, 2013)

n7lxi said:


> Uh, no. The Cincinnati stroke scale is three items; facial droop, pronator drift and slurring of speech.
> 
> http://www.strokecenter.org/wp-content/uploads/2011/08/cincinnati.pdf



I don't use the scale anyway I use the MEND stroke assessment which more fully covers neurological deficits. 

theemtspot.com/2012/09/12/the-mend-stroke-assessment-for-prehospital-care/

Here is an article that explains it quite well.


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## NomadicMedic (Jan 4, 2013)

You choice of assessment tool wasn't the issue. However, you made a statement attempting to correct the OP on the Cincinnati Prehospital Stroke Scale, which was wrong. 

The CPSS is, in most cases, the criteria used to initiate a "stroke alert"and is taught to every level of provider, starting with Red Cross basic first aid. (Only they call it FAST; Face, Arm, Speech and Time of onset)

Thanks for the link. The MEND assessment is a decent ongoing assessment tool and can provide additional information to the ED, but it shouldn't be your FIRST stroke assessment. 

And by the way, there are 12 steps in the MEND assessment.


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## Handsome Robb (Jan 4, 2013)

dmfinn said:


> Thanks for the reply! (and for looking at your sheet). C-Spine precautions were taken during the Scene Size-Up as the sheet calls for. I may have missed the "vocalizing for more units", though I did identify that since there was only one patient that it was not my opinion that additional troops were needed. O2 therapy was initiated at the sign of cyanosis. I noticed that BR was high too, but after being placed on O2 all signs of breathing stress disappeared and cyanosis ceased. Not sure of the skin temperature, all I remember was that it was dry.



Don't take this as me being an ***, just trying to dissect your post. 

If I'm reading this correctly, you put this patient in c-spine. Why? That could be a fail right there depending on your proctor. I'd be tempted to, it's not indicated by any way, shape or form from the information you provided us and despite popular belief, can be harmful to the patient. Generally you want the pt to have their torso and head elevated in a suspected or known CVA rather than positioning them supine. Why is that? I'll let you tell me 

If you did call for ALS in your scene sizeup that could be it to. There's not a whole lot ALS is going to do for a CVA outside of ACLS or airway control if necessary and IV access though. 

The cyanosis is a curveball, without spo2 you're shooting blind. Sounds like a poorly designed scenario as well. Respiratory rate of 24 with adequate tidal volume, clear lung sounds AND cyanosis would indicate a oxygenation problem, not generally a problem in a CVA patient unless they have more diseases processes going on that weren't listed but they may have been trying to test your competence on CVA management guidelines. This will make more sense when you get to the next sentence... Current CVA management guidelines indicate low-flow o2 administration in the presence of a known or suspected CVA rather than high flow BUT the NREMT is ridiculous when it comes to o2 administration so I doubt this is what made you fail, but who know. Again, I'll let you tell me why low flow o2 is preferred in CVA patients 

Also, the HCTZ comment could have blown it for you to. Probably what did it to be honest. Why did you bring it up? Because it's his home medication for HTN, I'm assuming? Hypertensive emergencies are generally managed with IV beta blockers, not HCTZ. So again, you indicated an inappropriate treatment as well as one that's out of your scope of practice.

Not sure if it's in the NREMT-B scope but a CBG/BGL/FSBG (whatever you want to call it) is indicated to r/o hypoglycemia since it's a CVA imitator. If the NREMT allowed it, this could have lost you points as well, not a critical fail by any means though.


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## NomadicMedic (Jan 4, 2013)

Hey OP, how about you look at the sheet and see where you missed. 

https://www.nremt.org/nremt/downloads/E202 Medical Assessment.pdf


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## PaddyWagon (Jan 4, 2013)

For reference in this thread NREMT psychomotor check-off sheets

I thought it might be handy.


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## JMorin95 (Jan 4, 2013)

n7lxi said:


> You choice of assessment tool wasn't the issue. However, you made a statement attempting to correct the OP on the Cincinnati Prehospital Stroke Scale, which was wrong.
> 
> The CPSS is, in most cases, the criteria used to initiate a "stroke alert"and is taught to every level of provider, starting with Red Cross basic first aid. (Only they call it FAST; Face, Arm, Speech and Time of onset)
> 
> ...



Here we also check mental status with the stroke scale.


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## NomadicMedic (Jan 4, 2013)

JMorin95 said:


> Here we also check mental status with the stroke scale.



Again, fundamentally incorrect. The CPSS does NOT assess mental status, it only focuses on key points that may help a provider determine neuro deficit that would indicate stroke. You may (and most decidedly should) assess mental status on your possible CVA patient, but know that it is NOT a segment of the CPSS.


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## JMorin95 (Jan 4, 2013)

n7lxi said:


> Again, fundamentally incorrect. The CPSS does NOT assess mental status, it only focuses on key points that may help a provider determine neuro deficit that would indicate stroke. You may (and most decidedly should) assess mental status on your possible CVA patient, but know that it is NOT a segment of the CPSS.



I never said it was, in my state we have it included.


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## PaddyWagon (Jan 4, 2013)

Is not mental status something you get during normal process anyways? And part of the focused assessment ? If I have a poor internal mapping of the process I'd like to fix it sooner than later =)


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## NomadicMedic (Jan 4, 2013)

JMorin95 said:


> I never said it was, in my state we have it included.



In your state, it's included as part of the assessment, but not as part of the CPSS. (Maine Protocols, Gold 9)


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## JMorin95 (Jan 4, 2013)

n7lxi said:


> In your state, it's included as part of the assessment, but not as part of the CPSS. (Maine Protocols, Gold 9)



Again I'm not claiming it as part of it but if the OP did not state mental status during the exam to the examiner that could be another fail.


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