# Nremtp scenario



## Lopester (Apr 22, 2014)

I need help with this scenario. I got it twice by chance on my nremt paramedic practical and I don't know what I am doing wrong.

Unconscious apneic make slumped over the steering wheel in a parked vehicle. You notice food in his lap.
(Vitals I cannot remember)
Pt is bradycardic, hypotensive apneic and cyonosis present around the lips.
Pale cool cyonosis skin condition with pinpoint pupils.

Sounds like a piece of cake. Right?
I did not hit any failure criteria but still somehow failed


Please help.


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## rmabrey (Apr 22, 2014)

Im not really sure what I can and cant say on this so ill help you work through it. Im pretty sure I know where you went wrong. 

So start by sharing with everyone what treatment you did.


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## Medic Tim (Apr 22, 2014)

what did you do. We are not going to just answer the question for you. We can help steer you int he right direction.  What was your assessment. what was your thought process?

Welcome to EMTlife


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## Angel (Apr 22, 2014)

I THINK I also know what you could've possibly done wrong but im also curious your thought process.


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## xrsm002 (Apr 22, 2014)

People fail these because they forget to say "BSI, is my scene safe" that's a critical.


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## rmabrey (Apr 23, 2014)

Come back and twll us already. Im 99% sure I know what you did, so now I want to see if im right!


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## Angel (Apr 24, 2014)

rmabrey said:


> Come back and twll us already. Im 99% sure I know what you did, so now I want to see if im right!



pm me, im curious as well. I ran this call in my head and THINK I covered everything, but who knows


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## MedicSlayer (Apr 28, 2014)

Lopester said:


> I did not hit any failure criteria but still somehow failed.



You had to have hit a failure criteria, but my curiosity is raised as well as to what exactly your interventions were.


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## Lopester (May 5, 2014)

In sorry all, of course you won't just give me the answer. 

   Interventions are as follows:

   Bsi/scene safety
   Number of pts moi/noi 
   can I rule out spinal trauma (yes)

General impression (see scenario)
Apneic and cyonotic
Notice food in the pts lap. (Thoughts go to obstruction)

Airway:
Pt is apneic began to bag with nasopharyngeal airway
(Was told there was resistance)
Take a look with McGill forceps low and behold obstruction.
Remove obstruction pt begins spontaneous respirations but is slow and shallow
Continue to bag.

Breathing: 
Bagging at 18per min
Pt sats are "in the 80s"

Circulation:
Pt is bradycardic (pulse in 50s I think)
Pt still slightly cyonotic

No medical alert bracelets or necklace upon exposure.

Vitals (from what I remember)
Sinus Brady on monitor
Pt hypotensive
Pupils pinpoint

Interventions:
Iv line plus 200 ml bolus
.4 mg narcan

Was asked "that's it?"
At this point I'm doubting everything now

Replied "I can give up to 2mg so yes at this point just .4)

Reasses vitals
(Makes up vitals)

"Pt becomes slightly responsive but than goes unresponsive again"

Repeat dowse of .4
(Same response)

Decided just to transport and get pt to hospital.

Radio report given.

2nd attempt went similarly but this time I asked for a bgl (which I forgot last attempt.. Figuired that was the main issue. It was not. Bgl "within normal limits")

So as opposed to depending on narcan to work I went big (which was probably my problem)
Intubated 
Gave .5 atropine started a drip of dopamine .5mcg per kilo
And .4 dopamine.

Pt become responsive and is fighting the tube.

Stated "I cannot extirpate in the field" so transfer of care to ALS transport is imperative. (This time around I don't transport I transfer to ALS transport crew.)

Gave report.

Looking at what I wrote just now seems panicked. 

After second attempt I was told that this was a tricky one and there was "something everyone misses"

Just wanna know what it is..

Pm me if you want


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## phideux (May 6, 2014)

I don't see anywhere when you say you put the pt on O2. You're bagging a little fast.


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## rmabrey (May 6, 2014)

Yep. You missed exactly what I thought you would (or you just didn't type it). However, you had the right thinking. I can't say much on a public forum since this scenario is still being used,  but ill say, that You didnt do a full physical assessment.


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## chaz90 (May 6, 2014)

I'm not familiar with this scenario at all, but I imagine if a  patient repeatedly responds to Narcan and then relapses they may still be somehow using opioids. Check the mouth, back, legs, and feet for some kind of Fentanyl patch...


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## rmabrey (May 6, 2014)

chaz90 said:


> I'm not familiar with this scenario at all, but I imagine if a  patient repeatedly responds to Narcan and then relapses they may still be somehow using opioids. Check the mouth, back, legs, and feet for some kind of Fentanyl patch...



Winner


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## Medic Tim (May 6, 2014)

chaz90 said:


> I'm not familiar with this scenario at all, but I imagine if a  patient repeatedly responds to Narcan and then relapses they may still be somehow using opioids. Check the mouth, back, legs, and feet for some kind of Fentanyl patch...




Yep. I have encountered this before more than a few times ... I have pulled fentanyl patches off of some "odd" areas of the body.


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## Lopester (May 6, 2014)

Spontaneous Normal respiration is 12 - 20.
Why is 18 fast?
And the bvm was on 02.. I just figuired that was implied.


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## phideux (May 7, 2014)

Lopester said:


> Spontaneous Normal respiration is 12 - 20.
> Why is 18 fast?
> And the bvm was on 02.. I just figuired that was implied.



By protocol you bag at 8-12 breaths per minute. Nothing is ever implied, if you don't state it, it never happened.


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## Angel (May 7, 2014)

phideux said:


> By protocol you bag at 8-12 breaths per minute. Nothing is ever implied, if you don't state it, it never happened.



nremt? or protocol? because they are 2 very different things, for adults, with assisted ventilations (not intubated) is 12-20, so he is correct. 
you want oxygen, of course, maybe he just omitted it here in the thread and not on the actual test? doesnt sound like he failed for lack of verbalizing oxygen. 

its hard to tell tone online but you sound like youre jumping down his throat rather than helping.


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## DesertMedic66 (May 7, 2014)

Angel said:


> nremt? or protocol? because they are 2 very different things, for adults, with assisted ventilations (not intubated) is 12-20, so he is correct.
> you want oxygen, of course, maybe he just omitted it here in the thread and not on the actual test? doesnt sound like he failed for lack of verbalizing oxygen.
> 
> its hard to tell tone online but you sound like youre jumping down his throat rather than helping.



Where did you find values of 12-20 for assisted ventilations? Everywhere I looked (including my ACLS book and NREMT skill sheets) states 10-12.


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## phideux (May 7, 2014)

Angel said:


> nremt? or protocol? because they are 2 very different things, for adults, with assisted ventilations (not intubated) is 12-20, so he is correct.
> you want oxygen, of course, maybe he just omitted it here in the thread and not on the actual test? doesnt sound like he failed for lack of verbalizing oxygen.
> 
> its hard to tell tone online but you sound like youre jumping down his throat rather than helping.



Wasn't jumping down his throat .Don't know if he just omitted O2 here or on the test, but O2 is a critical fail. If you don't state it, it didn't happen. If he forgot to write it in his description here, maybe he forgot to say it to the instructor, don't know, I wasn't there, and he failed it for some reason. Maybe that was it, maybe it was something else. He probably ain't the first one to fail a test for forgetting the O2, won't be the last, no biggie, do it again.


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