# NREMT-I99 Practical Testing Failed 2 Stations



## BeanerMedic90 (Jul 11, 2010)

Took the NREMT-I99 Practical and passed all except ET and Combitube. I retested and failed again. I don't understand why. Here is exactly what I do/say.
(Evaluator speaks his instructions and gives scenario)

Scene Safety, BSI.
Pt is apneic so I going to open my airway and administer two rescue breaths.
(Breaths go in)
I'm going to drop an OPA, attach O2 at 15 LPM and ventilate every 6 seconds.
(No gag reflex pt accepts adjunct. Ventilating at a rate of 10-12 breaths/minute. (Orders to intubate...)I'm going to have you pre-oxygenate my pt while I prepare my equipment. Check my Laryngoscope for light tight and bright and inflate cuff to test for leaks. Select my ET tube and drop a stylet not to exceed eye of murphy. My ETCO2 and suction are ready. I'm ready please remove opa. Insert sweep from right to left midline. Lift for clear view of vocal cords and intubate. No rocking of the teeth or gums. Watch tube go in. Inflate cuff and verify placement via ETCO2, capnography, and condensation in the tube. Ventilate pt every 6 seconds (1-one thousand 2-one thousand 3-one thousand 4-one thousand 5 one thousand and breathe.)(You now hear gurgling) I'm going to have you preoxgenate my pt while I select my french tip and measure ear lobe to ear lobe. I'm going to drop the french tip and then suction on the way up no more then 10 seconds. I'm going to ventilate my patient at every 6 seconds and place my french tip in sterile water.........

I did the same thing twice. I don't know how I failed.


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## bstone (Jul 11, 2010)

BeanerMedic90 said:


> Took the NREMT-I99 Practical and passed all except ET and Combitube. I retested and failed again. I don't understand why. Here is exactly what I do/say.
> (Evaluator speaks his instructions and gives scenario)
> 
> Scene Safety, BSI.
> ...



Did you have the same proctor twice? That might have been the problem.


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## TransportJockey (Jul 11, 2010)

Wait.. ear lobe to ear lobe for ET suctioning? I can't remember what I was taught right now, but that doesn't sound quite right. I need to go look it up now

EDIT: Found it. From the tip of the ET Tube, to the ear, then down to the xyphoid process. At least thats how we were taught in P-school


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## bstone (Jul 11, 2010)

jtpaintball70 said:


> Wait.. ear lobe to ear lobe for ET suctioning? I can't remember what I was taught right now, but that doesn't sound quite right. I need to go look it up now



If I recall correctly (it's been 4 years), it's from the corner of the mouth around the top of the ear to the ear lobe.


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## atticrat (Jul 11, 2010)

I don't see where you  "removed the syringe" immediatly after inflating the cuff, that's a critical fail.  Also I'm not familiar with measuring ear lobe to ear lobe for suction.   What did you do for the combi-tube? Obviously that's a different technique.


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## BeanerMedic90 (Jul 11, 2010)

I would remove syringe. 

For combitube

Inflate blue(100cc) first then white (15cc) 
Then ventilate through blue tube first and auscultate over the epigastrum,  mid-axillary, and mid-clavicular. I should hear sounds only over the lungs and not the stomach. 
(You hear sounds in the epigastrium...)
Switch to the white tube and clamp the blue tube down.
Ventilate and auscultate epigastrium, midaxillary, and midclavicular. 

Secure the tube and ventilate every 6 seconds.

Never let go of the tube


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## TransportJockey (Jul 11, 2010)

Sounds like the ET suctioning measurement might have been what killed ya then


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## atticrat (Jul 11, 2010)

What you've typed for both skills seems appropriate. (Still not sure about the measuring tech. though) The problem might be something you think you are doing or saying, but missing. It's really hard to diagnose something like this on-line.  The best idea I can think of would be for you to hook-up with a medic you trust and have you go through the skill while they watch and check-off the skills sheet. Then get a second opinion with yet another medic, maybe a third. Don't practice until you get it right, Practice until you Cannot Possibly get it wrong!


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## ChorusD (Jul 11, 2010)

Maybe they want you to still auscultate bilaterally after you intubate.  Did you? I don't understand capnography since I am only a basic but it seems to me that if you don't auscultate for breath sounds then you wont know whether or not you advanced the tube into the right main stem bronchus.

Maybe what it is but I don't know just an idea.


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## ffemt8978 (Jul 12, 2010)

atticrat said:


> Don't practice until you get it right, Practice until you Cannot Possibly get it wrong!



Quoted because it should be one of the Fundamental Rules of EMS.


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## BeanerMedic90 (Jul 12, 2010)

I did verbalize auscultating. 

I will definitely repeat it until I can't possibly fail it.

Anyone have tidbits to add.

Ventilatory rates? Every 5-6 seconds for the unintubated adult! or should I just say 10-12/minute. Then every 6-8 seconds for the intubated pt.

Other ways to measure french tip for suctioning?

Finally I feel like even though they said I failed maybe I didn't and the papers got mixed up and thought I failed again both of them. Who does that?

In the end I will power on.


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## 8jimi8 (Jul 12, 2010)

dont  verbalize your auscultation, DO it.  It doesnt matter if you say it, they want to see you do it.  

ear to ear is wrong.

how far do you insert the soft tip suction?


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## BeanerMedic90 (Jul 12, 2010)

8jimi8 said:


> dont  verbalize your auscultation, DO it.  It doesnt matter if you say it, they want to see you do it.
> 
> ear to ear is wrong.
> 
> how far do you insert the soft tip suction?




It's not wrong it's how we were taught to measure. 

What method were you taught?


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## TransportJockey (Jul 12, 2010)

BeanerMedic90 said:


> It's not wrong it's how we were taught to measure.
> 
> What method were you taught?



Go to my first post in this thread.Thsts the commonly taught way. Just cause you were taught one way doesn't make it right


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## 8jimi8 (Jul 12, 2010)

BeanerMedic90 said:


> It's not wrong it's how we were taught to measure.
> 
> What method were you taught?



i wasn't taught to measure it.  But i saw that it needed to be done from the skills sheet. 

I verbalize my measurement by saying  "insert the suction catheter to the the predetermined mark OR until i meet resistance, or coughing."

but to pre-measure it, i pass the suction catheter into the ET before inserting it while examining my equipment.

Any textbook, or research evidence to back up your ear to ear education? Can you tell us what the ear to ear measurement is significant of?


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## Shishkabob (Jul 12, 2010)

BeanerMedic90 said:


> It's not wrong it's how we were taught to measure.
> 
> What method were you taught?



Understood, but places can be taught wrongly.

I say talk to your tester and determine how they like it to be measured.  Don't phrase it like they are giving you a free answer, ask it like "Do you want me to measure from ear to mouth, or ear-to-ear?  I was taught several different ways"


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## kehoffmann1 (Jul 21, 2010)

Did you go over the 30 seconds you have to insert the ET tube from the time you stop ventilations until the time you attach the BVM?


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## feldy (Jul 22, 2010)

Did you ever let go of the ETT or CombiTube at any point in time before you either said or actually secured it. That is a critical fail point. A lot of people fail because of that. Its so easy to let go for just even a second while you inflate the cuffs or even when you hand it off to your partner while you check lung sounds. Most people dont even realize it and would not even think that they let go when they did.


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## BeanerMedic90 (Sep 5, 2010)

Update!!!!!!!!!!!!!!!!!!!!!!!!!!!

I passed my retest!!!!!!!!!!!!!!!!!!

NREMT guy thought I was having a stroke after he told me cause I couldn't believe it and I was trying to speak clearly!

Anywho... on to the written!!!


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## rjddvm (Sep 10, 2010)

Congrats on passing!

FWIW I've never heard of the earlobe-to-earlobe measuring method; not saying it's not correct, just that I've never heard of it.

I had to redo the baby intubation, and so went over it step-by-step with my instructor since I honestly had no idea what I'd done wrong.  She pointed out that the examiner might be looking at the exam grid and not watching at some point during the test, or might have an odd angle while watching.

So her suggestion was to narrate everything (which I was already doing), but specifically to say, when using the laryngoscope, something like "I'm elevating the tongue and mandible without using the teeth or gums as a fulcrum".

That way, unless you are really obviously cranking on the teeth/gums, or the teeth click on the adult mannequin, the examiner at least knows for sure that you know not to use the teeth/gums as a fulcrum, and that might (MIGHT) make a difference.


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## rhan101277 (Sep 13, 2010)

Each check off had two separate stations when I tested, each one having a different preceptor.  I passed them all the first go around, but if I had failed one I would be sent to the different preceptor.


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