Assessment in Action 36-41

You respond to a motor vehicle crash with massive damage to the front of the vehicle where it struck a tree head on. The only occupant is a young man, who is restrained, unresponsive, and entrapped. Fire rescue is on scene preparing for extrication, and a responding paramedic unit is attending the patient. The supervisor informs you he has requested a helicopter to respond and has asked you and your partner to prepare a landing zone. What should your considerations be when establishing a landing zone?

-The area should be a hard or grassy level surface that measures 100 feet x 100 feet (recommended) and no less than 60x60. If the site is not level, the flight crew must be notified of the steepness and direction of the slope. ~The area must be cleared of any loose debris that could become airborne and strike the helicopter or the patient and crew: this includes branches, trash bins, flares, caution tape, and medical equipment and supplies. ~You must survey the immediate area for any overhead or tall hazards such as power lines or telephone cables, antennas, and tall or leaning trees. If you see any of these hazards, immediately inform the flight crew because an alternative landing site may be required. The flight crew may request that the hazard be marked or illuminated by weighted cones or than an emergency vehicle with its light be turned on be positioned next to or under the potential hazard. ~To mark the landing site, use weighted cones or position emergency vehicles at the corners of the landing zone with the headlights facing inward to form an "x". This procedure is essential during night landings as well. It is common for fire suppression personnel to help mark the landing site since they are often called to the scene to stand by. never use caution tape or ask people to mark the site. You should also not use flares because not only can they become airborne, but they also have the potential to start a fire or cause an explosion. ~Move all nonessential people and vehicles to a safe distance outside of the landing zone. ~If the wind is strong, radio to the flight crew the direction of the wind. They may request that you create some form of wind directional device to aid their approach.

The patient starts to perform a self-stimulating activity. You should:

A. Allow the patient to continue as long as she does not hurt herself.

The HazMat team members continue their visual examination of the containers. Oxygen is stored in what type of container?

A. Cylinder

The features found in a modern ambulance are defined by which of the following agencies?

A. Department of transportation

A 50-year-old patient is lying on the grass with petechiae (pinpoint hemorrhages on the skin). This patient may have:

A. Hollow organ injury

Which control zone at a HazMat incident includes the area immediately surrounding the release, which is also the most contaminated area and the area that the HazMat team works in?

A. Hot zone

If you are having difficulty gaining the patient's trust, you should:

A. Look around for a favorite toy or object and ask the patient about it

Once the scene is deemed safe to approach, you attempt to gain access to the patients inside the van. Which of the following is an example of simple access?

A. Opening a rear door

The paramedic asks you to assist her with intubation. Your first step should be to:

A. Prepare the patient by continuing to ventilate.

Why is it important to follow the requests of the incident commander?

A. The incident commander best understands incident needs

After your other tasks are completed, you search the house for a medication list or other relevant medical information. To whom should you give this information?

A. The team leader

When responding to a scene where smoke or possible hazardous materials are present it is best to park:

A. Uphill and upwind

Where should you park the ambulance?

A. Uphill and upwind from the hazard

Staging for this suspected WMD incident should be:

A. Upwind and uphill from the incident

Define hazardous materials.

Any substance that are toxic, poisonous, radioactive, flammable, or explosive and cause injury or death with exposure

As an EMT, what is your role at a HazMat incident?

As an EMT, your job is to report to a designated area outside of the hot area and warm zones and provide triage, treatment, transport, or rehabilitation when HazMat team members bring patients to you.

To ensure you have enough reaction time to avoid hitting a motorist who does not move over, you should drive, at a minimum, about _________ seconds behind vehicles traveling at an average speed.

B. 4

While you are attempting to take the patient's blood pressure, another call comes across your radio. The patient covers her ears and starts to cry. What does this indicate?

B. Auditory sensitivity

If you are on an emergency call with your warning lights and sirens turned on, you may be allowed to do which of the following?

B. Drive faster than the posted speed limit

At what point should you give your verbal report?

B. Face to face, inside of the house

You perform a physical assessment on the 50-year-old patient with petechiae. Assessing for traumatic impact from flying debris is most important in the:

B. Head and neck

While providing care for an entrapped occupant of the van, you note the unstable power pole start to sway. What should you do?

B. Immediately cease care and leave the scene

You continue the physical assessment on the 50-year-old patient. You find debris in the patient's lower back, leading you to suspect that there may be internal damage to the:

B. Solid organs

Which of the following techniques should you use when you are communicating with a patient who has autism?

B. Speak normally and provide simple, one-step directions.

The patient is cautious around new people. How should you proceed with your assessment?

B. Start distal to proximal

You are treating a 45-year-old woman who has chest pain. Her blood pressure is 92/40 mm Hg; pulse rate, 132 beats/min and irregular; and respirations, 24 breaths/min and labored. Should you use lights and sirens when transporting this patient? Justify your answer

Because lights and sirens can exacerbate anxiety, using them with a patient having chest pain is not always the best option. However, when weighing the risks versus benefits for this patient, it may be in her best interest to transport with lights and sirens to the closest, most appropriate facility depending on traffic, distance and road conditions. She is borderline hypotensive, complaining of severe chest pain, and is tachycardic with an irregular pulse, and has labored respirations that are a little fast. All of these factors together create a potentially unstable patient who needs to get advanced care quickly. Consider consulting medical control for advice about using lights and sirens on a particular call depending on your local protocol.

Upon arrival at the home, what is the first question you should ask the parent or caregiver?

C. "What can you tell me about the patient's normal functional level? What makes her feel secure?"

If you arrive on the scene of a mass-casualty incident, what is the first thing you should do?

C. Ask for additional resources

When asking the patient questions, you should?

C. Ask her simple, direct questions

Keeping a safe distance between your vehicle and the one in front of you, checking for tailgaters behind your ambulance, and being aware of objects in your mirrors blind spots are considered maintaining a(n):

C. Cushion of safety

During the ________ phase of an ambulance call, the crew should review dispatch information about the nature of the call and the location of the patient.

C. En route

The paramedic asks you to help position the patient to facilitate intubation. What is the best way to position the patient?

C. Help pad under the patient's shoulders

Which toxicity level includes materials that are extremely hazardous to health? Contact with these materials requires full protective gear so that non of your skin surface is exposed.

C. Level three

The incident commander arrives with a notebook contains basic information about the chemical makeup of a substance, the potential hazard it presents, appropriate first aid in the event of an exposure, and other pertinent data for safe handling of the material. This information is contained in which of the following resources?

C. Material Safety Data Sheet (MSDS)

After the paramedic relieves you of your task, you offer to assist the AEMT. He tells you he does not need any help, even though he is clearly having difficulty establishing an IV line. You should:

C. Not engage; calmly speak to the AEMT about the situation after the call.

The HazMat team members enter the hot zone and approach the patients. They visually examine the containers to determine what chemicals may be used in the hot zone. Which type of drum is used for the storage of corrosives such as acids, bases, or oxidizers?

C. Polyethylene

The HazMat team finds a small pesticide bag underneath a patient after lifting him. Which of the following is a requirement when labeling pesticide bags?

C. The EPA establishment number

Now that the ambulance has arrived, who will be the team leader?

C. The paramedic, because she is the highest-level provider on scene

As an EMT, what is your role at the scene of the crash?

C. To assess and provide immediate medical care

There are downed power lines at this scene. How should you handle this situation?

C. Wait for the power company to tell you the scene is safe before approaching either vehicle

You may be required to call CHEMTREC to gain further information on potential exposures. List all the basic information needed when calling CHEMTREC.

CHEMTREC basic information: ~The name of the chemical(s) involved in the incident (if known) ~Name of the caller and callback telephone number ~Location of the incident or problem ~Shipper or manufacturer of the chemical (If known) ~Container type ~Railcar or vehicle markings or numbers ~The shipping carrier's name ~Recipient of material ~Local conditions and exact description of the situation

Once the patient's have been decontaminated and brought to the staging area, how should you continue care?

D. Begin as if they have not received any treatment

In which control zone would you find the staging area for EMS?

D. Cold zone

You note three occupants. There are two adults in the front and a small child in a child safety seat in the rear. Patient care should be initiated:

D. Only after all patients have been triaged

A 35-year-old patient is holding his ear and moaning. WhT is your most serious concern for this patient?

D. Possibility of hearing loss

A 67-year-old patient reports tightness in his chest. The patient is coughing up blood and is in respiratory distress. During the physical assessment, you notice subcutaneous emphysema. What is the condition most likely to be?

D. Pulmonary blast injury

After giving your report, which of the following roles is the most appropriate for you to assume?

D. Request from the team leader

Which of the following is a cause of fatigue?

D. Stress

As you ventilate the intubated patient, which of the following observations would cause you to immediately alert the team leader?

D. The BVM is offering more resistance

If transport is required in this case, you should?

D. Use gestures the patient can understand and explain what is happening.

Reasons for rescue failure can be summarized by the mnemonic FAILURE. What does FAILURE stand for?

F: failure to understand the environment or underestimating it A: additional medical problems not considered I: inadequate rescue skills L: lack of teamwork or experience U: underestimating the logistics of the incident R: rescue versus recovery mode not considered E: Equipment not mastered

What additional resources would you request in this situation?

I would request additional ambulances, HazMat, traffic control, and fire and rescue.

Chapter 37: scenario

It is time for your annual competency assessment. This test includes knowledge and skills assessment. You refer to your EMT textbook to prepare by answering sample questions provided.

Why might airway management be difficult in a patient with Down syndrome?

People with Down syndrome often have larger tongues and small oral and nasal cavities, which can make airway management in a patient with Down syndrome difficult.

How might you improve you team dynamic with other providers in the future?

Preparation and training are always the key to great performance in the field. The more frequently and realistically providers of all levels can train and practice together, the better they will be able to perform as a true team to produce the best possible patient outcome, rather than working as independent providers or a loosely connected group.

Explain how pulmonary WMD agents inflict damage and the signs and symptoms of exposure.

Pulmonary agents, such as chlorine and phosgene, cause immediate damage because they are inhaled by victims. Once exposed to the chemical, lung tissue is damaged and fluid is allowed to enter. This results on the onset of pulmonary edema. Patients exposed to a pulmonary agent will present with an increased work of breathing demonstrated by tachypnea, tachycardia, and anxiety.

Explain what the "reverse stethoscope" technique is and when it is used

The reverse stethoscope technique is used for patients with hearing impairments. With this technique, you will put the earpieces of your stethoscope in the patient's ears and speak softly into the diaphragm of the stethoscope to amplify your voice.

Other than the specific effects of blast injury, what other kinds of things should you assess a patient for who is involved in a WMD incident?

Try to get a history on how close the patient was to the blast and what happened. Was there a collapse of a structure that could have caused a crash injury. Proximity to the blast will help determine whether the patient suffered from primary, secondary, or tertiary blast trauma. We're there toxic effects from the incident of combustion gases? Are there baseline mentation or communication problems that should be factored in? Is age an issue that may make the injury more serious or recovery more difficult? Good patient care will also take into consideration the psychological effects of being a victim of a WMD. Witnessing trauma to others, or perhaps losing a loved one.

As the paramedic and AEMT prepare to transport, they begin to have a disagreement as to how best to package the patient. As they discuss this, you notice the paramedic is no longer ventilating the patient at the appropriate rate. How should you proceed?

While this chapter has provided you with a number of tools to help build better EMS teams, the exact procedure to follow will depend on the situation as well as your own skills and abilities and your working relationship with the other team members involved. However, there is no question that when a disagreement or breakdown in the team dynamic disrupts critical patient care, immediate intervention is needed. In this case, you must do what is necessary to ensure that artificial ventilation continues at the appropriate rate, whether this is to draw attention the attention of the paramedic to the fact that ventilation is inadequate or to offer to take over ventilation yourself so that the other team members can resolve the issue and proceed with the call.

Chapter 40: scenario

You and your partner are dispatched to a stand by for a suspected WMD incident in the federal courthouse. You are aware that a controversial trial is currently in session. This morning, a suspected IED exploded in the packed courtroom, resulting in multiple injuries. You are staged a few blocks away from the incident with police, fire, and other ambulances. The police bomb squad is assessing the scene to ensure it is safe to approach. When you are cleared to enter, the scene is chaotic. Many of the injured are now lying outside on the lawn in front of the courthouse. Police report that those closest to the IED were either critically injured or killed. Incident command is promptly established, and you are immediately assigned to the treatment site.

Chapter 39: Scenario

You and your partner are dispatched to the scene of and industrial incident where an explosion has taken place. En route you receive a call on the radio from thee local fire chief advising the oxygen and multilevel other chemicals are stored at this facility, including pesticides and acids, and HazMat precautions should be followed. After arriving near the scene, you are directed tp the staging area where patients will be brought to you once they become decontaminated by the HazMat team. The HazMat team is made up of properly trained firefighter who are dressed appropriately to enter the scene and are responsible for initiating care of any ill or injured patient's.

Chapter 36: scenario

You and your partner are traveling to headquarters for your monthly in-service training session when you are dispatched to the home of an 18-year-old woman with a high fever. The dispatcher tells you the patient has autism.

Chapter 41: scenario

You are dispatched to a private residence where a 48-year-old woman is lying supine on the bathroom floor. She is alone in the house. The patient is unresponsive, not breathing, and has a weak pulse. You secure her airway with an oral airway and ventilate her with a BVM at a rate of one breath every 5 seconds. An ALS transport ambulance arrives. The paramedic and her AEMT. partner enter the house and approach you and the patient. You continue BVM ventilations. The paramedic prepares to intubate and the AEMT prepares to start an IV line.

Chapter 38: scenario

You are dispatched to the scene of a motor vehicle crash where a gasoline tanker track has struck a small passenger van. the truck has come to rest in the center of the intersection. The van is situated against a power pole and you note downed power lines. Air bags in the van have not deployed.

What are the differences between primary, secondary, tertiary blast injuries?

~Primary: injuries caused by and explosive pressure wave on the hollow organs of the body ~Secondary: a penetrating or non-penetrating injury caused by ordnance projectiles or secondary missiles. ~Tertiary: an injury from whole-body displacement and subsequent traumatic impact with environmental objects.

Once the scene is safe to approach, what steps should you take to perform a primary assessment and provide care prior to the initiation of extrication?

~Provide manual stabilization to protect the cervical spine, as needed. ~Open the airway ~Provide high-flow oxygen ~Assist or provide for adequate ventilation ~Control any significant external bleeding ~Treat all critical injuries