Please help an RN with her NREMT-P practicals!!

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RCashRN

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Hi everyone, I'm new around here (first post!) and joined up looking for some help, guidance, suggestions, and even prayers to the voodoo gods if they'll help. I've been an ER nurse for seven years now and have decided to challenge for my EMT-P. My practicals are scheduled for the 2nd week in March... and I'm scared out of my mind! I've never had to do the "hands-on" testing before. I've been going over and over and over my study/checkoff sheets, I have an NREMT-P/evaluator helping me tie up loose ends, and watching videos online and reading everything I can get my hands on. But I'm still scared to death, scared I'm just gonna walk in and draw a blank. Please give any tips, advice, hints you can think of for me!

I'm most nervous about my trauma assessment (when do I "start" my IV - at the circulation check in my ABC's? or after my vital signs? Where does a BGL come in, or does it even have to be done? and I think I get my "rapid trauma assessment" stuck in with my detailed, head-to-toe assessment... should I just do ABC's then the head to toe to be safe? Heck, I cant remember exactly what the "rapid trauma assessment" exactly consists of...)

I'm also a little nervous about my medical assessment... let's just throw a possible scenario out there... anaphylaxis. Yeah, ABC's, high flow O2... during testing, do you have standing protocols like breathing treatments, SQ Epi, IV steroids, or should I just "call medical control" and get orders for everything?

I have a little dummy intubation trouble, but I'm trying to fix that. I cant quite get the hang of pushing out and up on the mandible, I still want to rotate slightly. I'm so scared I'm gonna get in and click the teeth. It's only happened about 2 times in practice, but any pointers for a small, weak, short-armed female would be great, lol. I even try propping my forearm on the dummy's forehead and can't get an increase in leverage/pushing power that way either, it seems.

What should I expect with static cardiology? How in depth do you have to get? Static just seems like a huge gray area to me, just waiting on me to fall on my face.

So anyway, long story short, any help you could give is oh so greatly appreciated. I respect and admire what all of you do, and want to join your ranks, and I'm sure not too proud to ask for help! And no, I'm not one of those B----Y ER nurses that's mean to medics... I love my medics and consider them family! ;-)

Thanks in advance for any advice you can offer.
Looking forward to posting here more.
 
RCashRN said:
Hi everyone, I'm new around here (first post!) and joined up looking for some help, guidance, suggestions, and even prayers to the voodoo gods if they'll help. I've been an ER nurse for seven years now and have decided to challenge for my EMT-P. My practicals are scheduled for the 2nd week in March... and I'm scared out of my mind! I've never had to do the "hands-on" testing before. I've been going over and over and over my study/checkoff sheets, I have an NREMT-P/evaluator helping me tie up loose ends, and watching videos online and reading everything I can get my hands on. But I'm still scared to death, scared I'm just gonna walk in and draw a blank. Please give any tips, advice, hints you can think of for me!

I'm most nervous about my trauma assessment (when do I "start" my IV - at the circulation check in my ABC's? or after my vital signs? Where does a BGL come in, or does it even have to be done? and I think I get my "rapid trauma assessment" stuck in with my detailed, head-to-toe assessment... should I just do ABC's then the head to toe to be safe? Heck, I cant remember exactly what the "rapid trauma assessment" exactly consists of...)

I'm also a little nervous about my medical assessment... let's just throw a possible scenario out there... anaphylaxis. Yeah, ABC's, high flow O2... during testing, do you have standing protocols like breathing treatments, SQ Epi, IV steroids, or should I just "call medical control" and get orders for everything?

I have a little dummy intubation trouble, but I'm trying to fix that. I cant quite get the hang of pushing out and up on the mandible, I still want to rotate slightly. I'm so scared I'm gonna get in and click the teeth. It's only happened about 2 times in practice, but any pointers for a small, weak, short-armed female would be great, lol. I even try propping my forearm on the dummy's forehead and can't get an increase in leverage/pushing power that way either, it seems.

What should I expect with static cardiology? How in depth do you have to get? Static just seems like a huge gray area to me, just waiting on me to fall on my face.

So anyway, long story short, any help you could give is oh so greatly appreciated. I respect and admire what all of you do, and want to join your ranks, and I'm sure not too proud to ask for help! And no, I'm not one of those B----Y ER nurses that's mean to medics... I love my medics and consider them family! ;-)

Thanks in advance for any advice you can offer.
Looking forward to posting here more.
Click to expand...

Make sure you have downloaded and studied the national registry check off sheets. Also as you find a problem you need to fix it before moving on (ex. someone breathing 2 times a minute) you would want to intubate and most will allow for verbal on that.

For most medications you don't not have to call med control, there are certain instances like poisonings and various other things but most you don't. Check your local protocols. If you want to go by the books in the area, go up to your local ambulance station and ask for a protocol book.

Ask whomever about how strict they will be with that.

As far as practicals you have to do everything as you said as far as assessment and treatment. For cardiology you need to know how to treat every dysrhythmia, even if no treatment is indicated. They will put you through a battery they call "mega code" where you basically go through 5 different rhythms on a computer dummy that has pulse lungs sounds and all (at least at my school).

Good luck
 
So do I do my IV at "C" (circulation) if they're exhibiting signs of hypoperfusion, or just do BLS treatment and wait til after the detailed assessment to do my IV (where "treatments" would fall towards the very end of the guidelines on the sheet)? I'm sure I'm overthinking this... I just dont want to blow it...

Thank you very much for your help. :)
 
RCashRN said:
So do I do my IV at "C" (circulation) if they're exhibiting signs of hypoperfusion, or just do BLS treatment and wait til after the detailed assessment to do my IV (where "treatments" would fall towards the very end of the guidelines on the sheet)? I'm sure I'm overthinking this... I just dont want to blow it...

Thank you very much for your help. :)
Click to expand...

If you see hypoperfusion you need to determine what the cause is and fix it. This is where the full assessment comes in, checking face, throat, chest, abdomen etc. This whole assessment should take less than 90 seconds. You need to check blood pressure as well, other vitals signs, mental status etc. most times permissible hypotension approx. 90mmHG is acceptable. If you bolus them to much to quick then you may go ahead and kill them by breaking loose clots and such. It may seem like much, but rely on your nursing skills for the basic stuff.

Now sometimes they will do a stubbed toe call, at least they do for us, while we are practicing and for that its a simple focused assessment.

The thing I am looking forward to most when I get out of school is patient contact and proper assessment, figuring out to the best of my ability what is wrong with this patient and following a treatment plan. If it takes more than one plan then you do whats best for the patient.
 
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You need to complete your rapid assessment, fixing any life threats along the way. Once that is done, then come back to your IV,vitals and secondary assessment.

Learn the critical fails and DON"T do them! Just treat your pt.

Static cardiology is not hard. Identify the strip and give a quick treatment procedure for it.

Remember your BSI at begining of every station. I see more failures from that, then anything else!
 
As stated I would go to a local ambulance provider and request a copy of their protocol book.


Here's a copy of my anaphalyxis protocol just to give you an idea of how they run. Keep in mind, protocols are not a Step A do this, Step B do this. They want you to use your brain, as protocols are more guidelines as to what is typically done, but they also know you treat your patient.




Inclusion Criteria: Patients presenting with rash, hives, shortness of breath, or other signs and symptoms, up to and including shock, apparently due to an allergic reaction.
Basic Level

1. Assess and support ABCs.
2. Place the patient in a position of comfort. If evidence of shock, place the patient supine with the feet elevated.
3. Isolate the patient from the source of the allergen, if possible.
4. Administer oxygen, as needed to maintain an SpO2 of at least 96%
5. Assess breath sounds. If wheezing is present and paramedics are not present at the scene, EMT-Basics may administer epinephrine via the patient’s own autoinjector, if available.

Advanced Level

6. Apply ECG and ETCO2 monitors if respiratory distress or shock is present or develops.
7. Consider establishing IV access at a TKO rate or use a saline lock.

If localized reaction, consider 25-50mg diphenhydramine IV or IM

If dyspnea without shock, hypoperfusion or critical airway
EPI 1:1 0.3-0.5mg SQ
Diphenhydramine 50mg IV or IM
Albuterol 2.5mg

If shock, consider
Epi 1:10 IV 0.3-0.5mg SLOW IV push.
Benadryl 50mg IV or IM
Albuterol 2.5mg
250ml NS boluses
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Few more details in it but I don't feel like writing it all out.
 
so... c-spine; ABC assessment, fix anything there (BVM/ETT; simple adjunct and bagging; splinting flail chest; major bleeding control; etc). Then full assessment and treatment of the non-life-threatening stuff - long bone splinting, minor bleeding control, IV & bolus prn, etc etc. Along with all the other stuff that goes in between there.

I'm going back Thursday to do some more hands-on at one of the EMS stations with my EMT-P/evaluator buddy, I'll flip through his protocol book while I'm there. I've just gotten so used to doing everything all at once (ie, talking to the patient and doing my assessment/history while I'm applying ECG/O2/pulse ox), that it's kinda intimidating to do it in order, orally, and not leave anything out. You should see my poor check-off sheets... dog eared, stained, wrinkled... they look right pitiful. I think my next resort is putting them under my pillow and sleeping on them at night - learning by osmosis! ;)
 
Memorize the checkoff sheets and the critical fail points. If you hit all boxes and none of the fails, you WILL pass. Also, the NREMT testing should not include any local protocols.
 
RCashRN said:
So do I do my IV at "C" (circulation) if they're exhibiting signs of hypoperfusion, or just do BLS treatment and wait til after the detailed assessment to do my IV (where "treatments" would fall towards the very end of the guidelines on the sheet)? I'm sure I'm overthinking this... I just dont want to blow it...

Thank you very much for your help. :)
Click to expand...

For your trauma patient, you will not be initiating IV access or doing a "detailed assessment" on scene.... this should be done in the truck, enroute to the hospital.

It probably seems counter-intuitive, considering your nursing background, but you will have to unlearn a few things/break a few [good] habits to nail this thing. Be very careful when it comes to "distracting injuries", as I have seen this take many people out of their rhythm.
 
I did it the other way (EMT to RN)

Be prepared to "do" more than "tell". Don't get into trying to explain your rationales or nursing diagnoses, learn and practice the protocols. When you take your exam, act rock solid quietly confident, don't tell them you are a nurse, and don't try to hurry. If you "know it", it will go smoothly and quickly on its own.
 
alphatrauma said:
For your trauma patient, you will not be initiating IV access or doing a "detailed assessment" on scene.... this should be done in the truck, enroute to the hospital.

It probably seems counter-intuitive, considering your nursing background, but you will have to unlearn a few things/break a few [good] habits to nail this thing. Be very careful when it comes to "distracting injuries", as I have seen this take many people out of their rhythm.
Click to expand...

so should it go like this?

bsi/scene safe/1 pt/need for assistance
c-spine
general impression (*do i state mine or ask what it is?*)
LOC
airway, open (jaw thrust), simple adjunct
resps/quality, 100% O2 or assist with BVM
pulse/skin/major bleeding
expose chest, inspect for injuries that would impair ABC's (flail chest, sucking chest wound, major injury) and treat appropriately
log roll, inspect back, place on spine board, c-collar, secure and check PMS
transport code 3
vital signs
SAMPLE history, if possible to obtain
detailed head-to-toe assessment for DCAPBTLS (fully expose pt), lung auscultation, abd palpation
treat anything found in head-to-toe assessment, 2 large-bore IVs, ECG monitor
ongoing assessment including reassessment of ABC's, response to treatments, vital signs, etc
 
RCashRN said:
so should it go like this?

bsi/scene safe/1 pt/need for assistance
general impression (*ask what it is?*)
c-spine
LOC
airway, open (jaw thrust), simple adjunct
resps/quality, 100% O2 or assist with BVM
pulse/skin/major bleeding
expose chest, inspect for injuries that would impair ABC's (flail chest, sucking chest wound, major injury) and treat appropriately
log roll, inspect back, place on spine board, c-collar, secure and check PMS
transport code 3
vital signs
SAMPLE history, if possible to obtain
detailed head-to-toe assessment for DCAPBTLS (fully expose pt), lung auscultation, abd palpation
treat anything found in head-to-toe assessment, 2 large-bore IVs, ECG monitor
ongoing assessment including reassessment (every 5 min for unstable "load and go" patients) of ABC's, response to treatments, vital signs, etc
Click to expand...

This is what I used to help put things in order/perspective:

Airway - secure it
Breathing - NRB or BVM
Circulation - pulses/overall perfusion
Decision - stay and treat or load and go
Expose - cut off clothing

- blood sweep
- rapid trauma assessment ( DCAPBTLS )

If you are methodical, you will not miss anything, as the proctor will tell you what is present. Verbalize as much as possible, the proctor may be checking off their sheet and not looking at you at all times.
 
thank you so much everyone. whether yall believe it or not, i've gotten some good info and clarified some questions with this simple thread. :)

10 days til testing...
 
I PASSED MY PRACTICALS!!!

had to re-test two stations - one oral station, and adult airway... the dummy hadn't been lubricated (i was first to test this station) and couldn't get the tube to pass on my first two attempts... then i clicked the dadgum teeth on the third attempt. by the time i re-tested, the dummy acted muuuuccchhh better and i got it on the first attempt. :)

WOOOHOOO!

now onto my first written test for my state provisional, then second test for actual NREMT-P!!
 
RCashRN said:
I PASSED MY PRACTICALS!!!

had to re-test two stations - one oral station, and adult airway... the dummy hadn't been lubricated (i was first to test this station) and couldn't get the tube to pass on my first two attempts... then i clicked the dadgum teeth on the third attempt. by the time i re-tested, the dummy acted muuuuccchhh better and i got it on the first attempt. :)

WOOOHOOO!

now onto my first written test for my state provisional, then second test for actual NREMT-P!!
Click to expand...

strong work
 
When I was looking at working in the US; I was told basically if I stick to the following I'd be ok

- Everybody gets oxygen at 15lpm NRB
- Everybody remotely traumatically injured gets spine boarded
- Everybody gets an IV @ KVO
- Follow the skill sheet

Makes you sort of worried some people actually practice prehopsital medicine like this! :P
 
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