NREMT P-medic: Operations

You are assessing a 30-year-old male who is having an emotional crisis. The patient is crying and states, "I am losing it!" Which of the following statements is the MOST appropriate for you to make?

"I think that it's important for you to go to the hospital." When communicating with a patient who is experiencing an emotional crisis, provide honest reassurance; be supportive and truthful. Never tell a patient that "you understand," especially if you've never been in his or her position. Furthermore, statements such as "Everything's going to be all right" will merely convince the patient that you do not understand the significance of his or her feelings. People in crisis need direction. Instead of confronting him or her with an array of decisions (ie, "Do you want to go to the hospital, or would you rather stay home and call your doctor tomorrow?"), state what you think is the best course of action ("I think that it's important for you to go to the hospital. There are doctors there who can help you.").

Which of the following statements is inappropriate to document on a patient care form?

"The patient appears to need psychiatric help." Remember that you must always document factual (objective) findings, not your own opinion. Documenting statements that are reflective of your personal opinion could lead to allegations of libel against you. Documenting that a patient appears to need psychiatric help is not objective, it is your personal opinion. Documenting what the patient tells you (subjective) or observations that you make (objective) should be documented if they are relevant.

Where should you position your ambulance when arriving at the scene of a motor-vehicle crash on a two-lane highway?

100 feet past the scene on the same side of the road. When parking the ambulance at a crash scene, pick a position that will allow for efficient traffic control and flow around a crash scene. Do not park alongside the scene because you may block the movement of other emergency vehicles. Instead, park about 100 feet past the scene on the same side of the road. It is best to park uphill and/or upwind of the scene if smoke or hazardous materials are present.

What is the target heart rate for a 30-year-old man who has a resting heart rate of 70 beats/min?

154 beats/min. In order to maintain good cardiovascular health, you should attempt to achieve your target heart rate every time you exercise. To determine your target heart rate, calculate the following: (1) Measure your resting heart rate; this should be done as soon as you wake up in the morning. (2) Subtract 220 from your age. This is your maximum heart rate. (3) Subtract your resting heart rate from your maximum heart rate. Multiply that number by 0.7. (4) Add that number to your resting heart rate. This is your target heart rate. Therefore, the target heart rate for a 30-year-old man with a resting heart rate of 70 beats/min is 154 beats/min, as follows: (1) Resting heart rate, 70 beats/min. (2) 220 - 30 (your age) = 190 beats/min (maximum heart rate). (3) 190 (maximum heart rate) - 70 (resting heart rate) = 120 × 0.7 = 84 (4) 84 + 70 (resting heart rate) = 154 beats/min.

Which of the following patients could you legally treat and transport without his or her consent?

A 17-year-old conscious male who has a closed fractured femur. Patients younger than age 18 years cannot legally give consent for treatment and/or transport, nor can they legally refuse treatment and/or transport. Exceptions to this include female minors who are emancipated or married. Even if it is obvious to you that the patient's condition is urgent or critical (ie, acute MI in progress), you must still have consent to treat if the patient has decision-making capacity (eg, of legal age; alert to person, place, time, and event). A unique challenge is presented by patients who awaken after the administration of dextrose. Provided that they have decision-making capacity at the time of refusal, they can legally refuse further treatment and/or transport.

Which of the following situations would MOST likely constitute negligence?

A patient involved in a major motor vehicle crash is not immobilized because he was ambulatory at the scene. Negligence is defined as the failure to perform the accepted standard of care. Clearly, a patient involved in a major motor vehicle crash would require full spinal immobilization, regardless of whether or not he or she is ambulatory on EMS arrival. Remember the "4 Ds" that are required to prove negligence: duty to act, duty not performed, direct harm, and disability to the patient.

EMS systems use a fractile response time standard, which means that:

A significant percentage of all responses must be achieved in an established time. Most EMS systems—especially those with high call volumes—use a fractile response time standard in which a significant fraction or percentage (usually 90% or greater) of all responses (ie, from time of dispatch to arrival at the scene) must be achieved in an established time—for example, 8 minutes or less in an urban area. These standards are based on the recommendations of the Commission on the Accreditation of Ambulances (CAAS).

Your assessment of a 33-year-old man with generalized weakness and nausea reveals a blood glucose level of 44 mg/dL. The patient is conscious and alert to person, place, time, and event. As you are preparing the IV equipment and 50% dextrose, the patient tells you that he will not allow you to start an IV on him or give him any drugs; he will only allow you to transport him to the hospital. You should:

Advise him that if you don't give him glucose, his condition could potentially deteriorate and he could die. Mentally competent adults have the right to refuse treatment, in whole or in part, as well as EMS transport. The patient in this scenario, although hypoglycemic, is conscious and alert to person, place, time, and event. Without expressed (actual) consent, you cannot legally start the IV line or administer the dextrose. However, you must inform the patient of the need for the IV and dextrose; doing so will enable him to make an informed decision regarding his health care. Most patients refuse certain treatment interventions because they are either scared or do not understand the gravity of the situation. With education and explanation of the risks of refusing treatment, however, many of these patients will give consent. If the patient still refuses the IV and dextrose, but still consents to transport, transport at once and closely monitor his condition en route. If his mental status deteriorates, proceed under the law of implied consent, start the IV, and give him dextrose. Oral glucose is an alternative to IV dextrose; however, the patient in this scenario is nauseated. Administering anything by mouth may cause him to vomit and potentially aspirate.

You are assessing the 12-lead ECG of a man who presents with chest discomfort. The ECG reveals a normal sinus rhythm without evidence of ischemia, injury, or infarct. The patient tells you that he saw his cardiologist 2 weeks ago, was told that he had a heart attack in the past, and then asks you if you agree. You should:

Advise the patient that he should seek consultation from his cardiologist. Patients and their families often ask EMTs and paramedics for advice, in much the same way they would consult a physician. That is an honor because it conveys their trust. Patients may even ask you to comment on a decision or diagnosis made by their physician. Don't fall for that one—however well-intentioned the question may be! Instead, suggest they obtain medical advice from their physician. In this scenario, a seemingly unremarkable 12-lead ECG does not mean that the patient did not experience a myocardial infarction (MI) in the past, nor does it rule out an MI in progress. The cardiologist's conclusion that the patient experienced an MI in the past was likely based on a comprehensive evaluation (eg, lab work, echocardiography, in-depth history), not a single ECG. Treat the patient based on his clinical presentation and use his current 12-lead ECG to help guide your prehospital care. However, you should advise him to consult with his cardiologist to obtain more information regarding how he or she arrived at the diagnosis of a previous MI. Questioning a physician's diagnosis—especially in front of the patient—is unethical.

A 65-year-old man has crushing chest pain that persists after taking three of his nitroglycerin tablets. He is conscious and alert to person, place, time, and event. You assess his vital signs and find him to be significantly hypertensive. As your partner is preparing the stretcher, the patient tells you that he does not want to go to the hospital. After multiple attempts to convince the patient to allow you to transport him, he still refuses. You should:

Advise the patient that his refusal could ultimately result in death. Any patient that refuses EMS care must be informed of the potential consequences of refusal. The most direct approach is to advise the patient that their condition could ultimately result in death. This ensures that the patient is aware of the potential worst-case scenario. If the patient still refuses, has decision-making capacity (ie, is of legal age, is not mentally impaired), and is willing to take that risk, there is nothing else you can legally do. Be sure to carefully document ALL attempts made by you to convince the patient to allow treatment and/or transport.

After delivering an 80-year-old female to the emergency department, you give your verbal report to the attending physician. As you are completing your patient care report, you hear the patient give the physician information that is vastly different from what she told you. You should:

Advise the physician of the information that the patient gave to you and consider the possibility that she is confused due to a significant underlying problem. Paramedics sometimes find that the patient's history given in the prehospital setting is very different from the history the patient gives to the emergency department physician. Sometimes the information is so different that it seems as if it is an entirely different patient. Patients may be too frightened or embarrassed to give particular information to a paramedic, but will give a physician vital information. The patient may also be confused due to a significant underlying problem (eg, stroke, brain tumor, hypoxia). Do not change your documentation to reflect what the patient tells the physician; doing so makes your patient care report invalid, unreliable, and from a legal standpoint, indefensible. Furthermore, the information provided to you may indeed be more accurate than what he or she told the physician. Due to strict confidentiality provisions imposed by the Health Insurance Portability and Accountability Act (HIPAA), you will likely not be able to obtain information regarding the patient after you have relinquished care to the emergency department staff.

You and your team have been attempting to resuscitate a 68-year-old male in cardiac arrest for the past 15 minutes. The patient's initial cardiac rhythm was asystole, which has remained unchanged despite three doses of epinephrine, high-quality CPR, proper airway management, and a thorough assessment for potentially reversible causes. The patient's wife tells you that her husband does not have a living will. You should:

Advise the wife that her husband is dead and that further resuscitative efforts will not change the outcome. You have performed all of the proper interventions based on the patient's clinical condition, yet he remains in asystole. Asystole—especially when prolonged beyond 10 minutes—has a grim outcome. You should inform the patient's wife that her husband is dead and that further resuscitative efforts will not change the outcome. To continue resuscitative efforts would be futile and may only instill false hope in the patient's wife. The absence of a living will or advance directive, in and of itself, is not an indication to cease resuscitative efforts—especially when the patient's condition has remained unchanged despite appropriate treatment. Nonetheless, if the patient's wife requests that you continue resuscitative efforts, you must do so. Transcutaneous cardiac pacing (TCP) has not demonstrated efficacy in treating asystole—regardless of its duration. Law enforcement personnel should be summoned to the scene; however, you do not need their permission to cease resuscitative efforts. Follow your local protocols or contact medical control as needed.

Which of the following actions demonstrates a paramedic's knowledge of crime scene preservation?

Advising a law enforcement officer after moving a coffee table to access a critically injured patient. After ensuring your own safety, your priority when caring for a patient at a crime scene is to do just that, care for the patient. If you need to move a piece of furniture to gain access to a critically injured patient, move the furniture, treat the patient, and then advise a law enforcement officer of what you moved and where you moved it to. In this way, you are providing immediate care to the patient, but are remaining aware that the location of any obstacles between you and the patient may serve as evidence. Clearly, you are not going to request approval from a law enforcement officer before treating a critically injured patient. Items that may have fingerprints on them, such as knives or guns, should be placed in a paper bag; condensation can accumulate in plastic bags, potentially destroying any evidence. When removing clothing from a gunshot victim, you should make an effort to cut around (not through) the hole in the clothing that was made by the bullet. The hole in a patient's clothing may contain gunshot residue and can provide valuable information regarding the type of weapon used and the distance between the assailant and the victim.

To ensure the safest response to an emergency scene, you should:

Always operate the ambulance with due regard for others. Whenever operating an ambulance, whether in an emergent or nonemergent mode, you must always drive with due regard for those around you. This means that you must be prepared for erratic movements of other drivers and never assume that they will see and/or hear you. Expect the unexpected! The use of escorts is discouraged because of the risk of a "wake effect" collision, which occurs when a police officer or other escort clears a red light for you and then proceeds. Drivers may not be expecting a second response vehicle, thus leading to a crash. Siren use does not guarantee a safe response, and increased speed clearly increases the risk of a crash.

Which of the following BEST describes a critical incident defusing?

An informal process that is held within 2 to 4 hours following the incident. A critical incident defusing is typically performed within 2 to 4 hours after the incident and is an informal process designed to provide immediate relief and support to all who were involved in the incident. A critical incident defusing should be held no later than 12 hours after the incident. A critical incident stress debriefing (CISD) is a formal process that should occur within 24 hours but no later than 72 hours following the incident. Only those directly involved in the incident should attend a CISD.

You and preparing to assess a 22-year-old male whose small passenger car slid sideways around a corner and struck a telephone pole. He is not entrapped, but is still seated in his vehicle. Your partner is maintaining manual stabilization of the patient's head from the backseat. The patient is conscious, but is restless. He is complaining of severe pain to his legs, pelvis, and abdomen. He is tachypneic; tachycardic; and has cool, most skin. Fire personnel are at the scene to assist you. After applying high-flow oxygen to the patient, you should:

Apply a cervical collar, rotate the patient as a unit, place a backboard on the seat, and remove him from the car by sliding him onto the backboard. The patient is in shock and needs rapid extrication from his vehicle. Once he is extricated, a rapid head-to-toe assessment should be performed and preparations for rapid transport should be made. Time-consuming interventions (eg, IV therapy) should be performed en route to the hospital. The rapid extrication technique is used if the patient cannot be properly assessed in the vehicle, if the patient is critical and needs immediate care that requires a supine position, or if the patient blocks access to a seriously injured patient. In such cases, an extrication-type vest or short backboard, which takes too long to apply, is impractical. Although several variations of the rapid extrication technique exist, they all have one thing in common: removing the patient from the vehicle, without manipulating the neck, and sliding him or her onto a long backboard. A cervical collar should be applied before removal from the vehicle; however, someone must still manually stabilize the patient's head. Depending on how access is gained to the patient, he or she can be removed from the driver's side or the passenger's side.

You are caring for a middle-aged female with acute chest pain. She is conscious and alert to person, place, time, and event. You have administered aspirin, applied supplemental oxygen, and obtained a 12-lead ECG tracing. As your partner is retrieving the ambulance stretcher, she states that she does not want to be transported by EMS and would prefer that her husband take her to the hospital. You should:

Ask her why she does not want to be transported by EMS. Adults with decision-making capacity have the legal right to refuse EMS treatment and/or transport—even if it has already been initiated. If a patient refuses treatment and/or transport, you should first ask why he or she is refusing. In many cases, you will be able to convince the patient to consent to treatment, but you must first know why he or she is refusing. Patients usually refuse treatment for one of three reasons: they are scared, they cannot afford it, or they do not understand the gravity of the situation. Ensure that the patient understands the significance of the situation, and provide reassurance that your concern lies with his her healthcare—not his or her financial status. Do not tell the patient that he or she will not be billed for your services; you do not know this. If the patient still refuses, assess his or her decision-making capacity. Ensure that the patient is of legal age, is alert to his or her surroundings, and is not impaired by drugs or alcohol. Assess the patient's blood glucose level if necessary. If you are unable to convince the patient of the need for EMS care, make arrangements to ensure the patient is evaluated by a physician. If a spouse, other family member, or friend is available, advise that person that the patient should be evaluated by a physician as soon as possible. If the patient will not allow anyone to transport him or her to the hospital, advise him or her to call 9-1-1 if he or she feels the need to. Follow your local protocols or contact medical control as needed.

You are triaging first-grade students at a school bus crash and encounter a small child who is unresponsive and apneic. After opening the child's airway, he remains apneic. You should:

Assess for a palpable pulse. The JumpSTART triage system is intended for use in children younger than 8 years of age or who appear to weigh less than 100 pounds. According to the JumpSTART triage system, if you encounter an unresponsive apneic child, you should open his or her airway. If breathing resumes, he or she is triaged as immediate (red tag). If breathing does not resume, assess for a palpable pulse. If there is no pulse, he or she is triaged as deceased (black tag). If a pulse is present, provide 5 rescue breaths. If breathing resumes, triage him or her as immediate. If the child remains apneic after 5 rescue breaths, triage him or her as deceased.

During a triage operation, you encounter a 5-year-old boy who has been injured. He is conscious, cannot walk, and has a respiratory rate of 50 breaths/min. You should:

Assign him an immediate triage category and move to the next patient. The JumpSTART triage system is intended for use in children younger than 8 years of age or who appear to weigh less than 100 pounds. According to the JumpSTART triage system, if the child's respiratory rate is less than 15 breaths/min or greater than 45 breaths/min, he or she should be assigned an immediate triage category (red tag). After placing a red tag on the child, move to the next patient. If the respiratory rate is between 15 and 45 breaths/min, the next step would be to assess for a palpable pulse. The only treatment provided during the JumpSTART triage system would be to deliver 5 rescue breaths if the child remains apneic (and has a palpable pulse) after positioning the upper airway.

Which of the following is considered an effective method in reducing stress in an obviously anxious bystander at the scene of an emergency?

Assign the bystander minor, nonpatient care-related tasks. One of the most effective ways to reduce stress and anxiety in a bystander at the scene of an emergency is to assign him or her minor, nonpatient care-related tasks. This may involve activities such as providing rescuers with water or other needed supplies. The goal is to occupy the bystander's mind and make him or her feel as though they are helping. It is not safe to tell an obviously upset bystander to go home because these people deserve appropriate care and attention as well. Functions such as crowd and traffic control are responsibilities of law enforcement.

When observing standard precautions, you:

Assume that all bodily fluids are potentially infectious. Thanks to research and reporting done by the Centers for Disease Control and Prevention (CDC), we are now more aware that biohazards are an integral part of our profession and can have long-term effects on the health care worker if certain precautions are not followed. The CDC developed a set of universal precautions for health care workers to use when treating patients. EMS follows standard precautions rather than relying on universal precautions. Standard precautions differ from universal precautions in that it is designed to approach ALL bodily fluids as being potentially infectious. In observing universal precautions, you assume that only blood and certain bodily fluids can transmit diseases such as hepatitis B and HIV. The level of precaution taken depends on the type of patient you are caring for. At a minimum, you should wear gloves during all patient contacts, whether there is blood present or not. Many EMS systems also require their medics to wear protective eyewear. Masks are not considered a standard precaution; however, they should be used—in conjunction with eye protection—to prevent disease transmission from certain types of patients, such as those with possible tuberculosis who are coughing or any time there is the risk of blood splatter. The only law that mandates the use of standard precautions is the law of common sense. However, if you contract a disease because of failure to wear the personal protective equipment (PPE) provided by your employer, your employer will likely not assume responsibility. Standard precautions are a personal responsibility.

At the scene of a violent crime, a man has been decapitated with an axe. Which of the following is the MOST appropriate way for you to manage this situation?

Avoid touching the body if at all possible. At the scene of a crime, you should provide needed care, while at the same time manipulating the scene as little as possible. In the case of a decapitation, the patient is obviously deceased; therefore, there should be no need to make any contact with the patient. Contacting the patient's family is generally a responsibility of law enforcement.

When moving a patient from a house without a carrying device, you should:

Avoid twisting when moving around a corner. Whether you are lifting or moving a patient with or without a carrying device, you should avoid twisting at the same time you move around corners. Failure to do so could result in injury to your back.

You and your partner arrive at a residence for a patient with shortness of breath. As you enter the residence, you find the patient, an elderly male, sitting in a recliner in his living room. He is agitated, diaphoretic, and in obvious respiratory distress. As he is rudely commenting about your lengthy response time, you see a handgun on a table next to his recliner. You should:

Back your way out of the residence and request law enforcement assistance. As you enter a patient's residence, you should make it a habit to scan the room for weapons or anything else that poses a threat to you and your partner's safety, regardless of the nature of the call. If you see a knife or gun—especially if it is in close proximity to the patient—back your way out of the residence and request law enforcement assistance. Backing away will enable you to see if he does reach for the gun, thus giving you the opportunity to take immediate cover. If you turn your back, you may take a bullet in the back! Today, many people keep loaded firearms in their home for personal protection. A nightstand, a dresser drawer, and a table next to a comfortable chair (eg, a recliner) are common locations to keep these weapons. It would be an unsafe—and potentially fatal—assumption on your part that an elderly patient cannot quickly grab the gun and open fire! An upset patient and a weapon within easy reach are a recipe for disaster. Scene safety is of utmost importance on any call; the life you save—or attempt to save—may TAKE your own!

You are treating a patient with suspected cardiac chest pain and elect to start an IV line; however, you did not advise the patient of this in advance. As a result, you could be held liable for:

Battery. Battery is defined as touching the patient without his or her expressed consent. You should never assume that a patient will readily accept your treatment; therefore, you must apprise them of what you intend to do prior to carrying out the task. Assault is the instillation of fear in a patient, but does not involve touching him or her. Breach of duty is defined as failing to act as another prudent paramedic would have acted in the same or similar circumstances. Proximate cause is the direct relationship between the paramedic's actions or inactions and the patient's injury or illness.

Your partner, a new paramedic, is experiencing significant anxiety after a call involving a pediatric cardiac arrest in which the child died despite an appropriate resuscitative effort. How can you effectively help your partner?

Be prepared to spend extra time with your partner and allow him or her talk about the call. One of the most effective ways for an EMS provider to allay his or her anxiety after a bad call is to talk with a fellow coworker, especially one who was involved in the call. This will allow for an immediate defusing and can significantly minimize the risk of further stress and anxiety.

An incident command system has been established at the scene of a building explosion in which there are approximately 30 casualties. According to the incident commander, there is no evidence of any hazardous materials or chemicals. As victims are removed from the building, they should:

Be taken to the triage area, which should be a safe distance from the building. The incident command system (ICS) ensures safe and effective management of an incident, regardless of its size or complexity. Deviation from the ICS increases the risk of losing control over the incident, resulting in chaos and lives lost that may have been saved. If the incident commander determines that no hazardous materials or chemicals are involved, prophylactic decontamination will only waste time and delay triage, treatment, and transport. After removing the victims from the building, take them to the triage area, which should be located a safe distance away. Following a building explosion, there is a risk of structural collapse, not to mention the presence of secondary explosive devices left if the explosion was the work of a terrorist. In the triage area, victims are assessed and assigned a triage category. Treatment does not occur in the triage area. If it does, triage efforts will be compromised, resulting in more lives lost that may have been saved. After the victims have been triaged, they are moved to the treatment area. Once there, secondary triage is performed (victim's conditions can change after initial triage), and emergency care is provided. The transport officer then arranges transport of the victims to appropriate medical facilities, starting with the most critically injured. A steady and consistent flow of victims from the extrication area, to the triage area, to the treatment area, and to an appropriate medical facility, will maximize effectiveness of the entire operation and minimize the number of lives lost.

Upon arriving at the residence of an unresponsive patient, you find a middle-aged male lying on the couch. He is unresponsive, apneic, and pulseless. His wife tells you that she does not want you to attempt resuscitation, and further states that he has high blood pressure. The patient's skin is warm and there is no evidence of lividity. You should:

Begin CPR, apply the ECG electrodes, ask her if he has a living will, and contact medical control for guidance. In this scenario, you do not know if the wife's request is based on her personal wishes or if it reflects what is documented in a living will. It appears that the patient has not been in cardiac arrest for an extended period of time (eg, warm skin, absence of lividity). Furthermore, there are no circumstances in which resuscitation would likely be futile (eg, end-stage cancer, other terminal illness). Therefore, in the interest of the patient, you should begin CPR and apply the cardiac monitor to evaluate his cardiac rhythm; if a shockable rhythm is present, defibrillate and resume CPR. Ask his wife if he has a living will; if she acknowledges that he does, kindly ask her to produce it. If a valid living will exists, you should follow its stipulations. However, if a living will does not exist (or the wife cannot produce one), continue resuscitative efforts and contact medical control at once. In this particular situation, few would argue that it is preferable to defend why resuscitation was attempted as opposed to why it was not.

At the scene of a motor vehicle accident, you note that the driver, a young woman, is lying next to her car and has agonal gasps and no palpable pulse. Other than a closed tibial fracture, she has no other obvious trauma. She is wearing a bracelet that identifies her as an organ donor. How should you manage this situation?

Begin aggressive treatment and transport immediately. Once it has been identified that a patient is an organ donor, provided that obvious signs of death are not present (ie, decapitation, rigor mortis, dismemberment), you should provide aggressive treatment and rapidly transport the patient to the hospital, where their organs potentially can be harvested.

You and your partner are triaging patients at the scene of a motor-vehicle crash while awaiting the arrival of additional ambulances. Which of the following patients would be triaged as delayed?

Bilaterally deformed femurs; severe neck pain; conscious and alert. Of the injuries and conditions listed, the conscious and alert patient who has bilaterally deformed femurs and severe neck pain appears to be the least critical and would therefore be triaged as delayed (yellow tag). Patients should be triaged as immediate (red tag) if they have airway or breathing problems, severe or uncontrolled bleeding, altered mental status, signs of shock, severe underlying medical problems, and open chest or abdominal injuries. All of the other patients listed have injuries or conditions that place them in an immediate triage category. Assuming an adequate mental status, a patent airway, no evidence of respiratory or circulatory compromise, and no signs of shock, patients with major or multiple bone or joint injuries and neck or back injuries would be triaged as delayed.

Which of the following victim or bystander reactions would MOST likely escalate the stress associated with a mass-casualty incident?

Blind panic. In a situation involving multiple casualties, such as a train derailment, building collapse, or natural disaster (ie, tornado, flood, earthquake), both victims and bystanders may react by becoming dazed, disorganized, or overwhelmed. The American Psychiatric Association has identified five categories of reactions in such circumstances: anxiety, blind panic, depression, overreaction, and conversion hysteria. In general, people with these reactions should be removed from the scene; they can increase the stress of an already stressful situation. Typical signs of anxiety include sweating, trembling, weakness, nausea, and sometimes vomiting. People experiencing anxiety can recover fully within a few minutes and provide useful assistance if properly directed. Depression is seen in the individual who sits or stands in a numbed, dazed state. The depressed bystander needs to be brought back to reality and removed from the scene. People who overreact tend to talk compulsively, joke inappropriately, become overly active, and race from one task to another without accomplishing anything useful. The person who is overreacting needs to be removed from the area where casualties are being treated. In conversion hysteria, the patient or bystander subconsciously converts anxiety into a bodily dysfunction; he or she may be unable to see or hear or may become paralyzed in an extremity. The most worrisome reaction is blind panic, in which the individual's judgment seems to disappear entirely. Blind panic is particularly dangerous because it is "catchy," and may cause mass panic among others present. For this reason, a panicky bystander must be separated quickly from others and, if at all possible, placed under the supervision of a calmer person.

Which of the following requires immediate removal of an ambulance from service?

Brake fade. Any mechanical malfunction of an ambulance should be addressed by a mechanic as soon as possible; however, not all problems require immediate removal of the unit from service. Tire squeal for example, warrants a mechanic's attention as soon as possible, but does not necessarily require immediate removal of the ambulance from service. Tire squeal is a singing sound that occurs when you turn the vehicle, especially at parking speeds. Squealing is normal on very smooth concrete, but not on asphalt. The most common cause of tire squeal is an underinflated tire, a problem that can easily be fixed by checking the tire pressure and adding air as needed. Belt noise is a chirping or squealing sound, synchronous with engine speed (not road speed). It is usually related to a load on one of the appliances operated by a drive belt. Belt noise is always significant and will eventually keep an ambulance from operating; however, it does not warrant immediate removal of the ambulance from service. Drift is a finding that when you let go of the steering wheel, the vehicle consistently wanders left or right. Any vehicle may normally drift slightly to the right because most roads are built with a crown in the center (so water drains toward the gutters). A vehicle should not consistently drift to the left, however. Any problem with the vehicle's brake system warrants immediate removal of the vehicle from service. Brake fade is a sensation that an ambulance has lost its power brakes. Common causes of brake fade are overheating of brake surfaces, loss of vacuum, loss of brake fluid, wet or greasy brake drums, or a failed master cylinder. Even a single instance of brake fade warrants immediate removal of the vehicle from service.

What disease primarily affects low birth weight infants and is characterized by ongoing respiratory distress, frequent lower respiratory tract infections, and the requirement for mechanical ventilation?

Bronchopulmonary dysplasia. Bronchopulmonary dysplasia (BPD) is a lung disease that typically affects low birth weight infants and is characterized by chronic respiratory distress and frequent lower respiratory tract infections. The basic underlying etiology behind BPD is a deficiency of pulmonary surfactant at birth. Surfactant acts to lubricate the alveolar walls, allowing them to expand and recoil normally. Cystic fibrosis, myasthenia gravis, and congestive heart failure are not exclusive to the newborn population; they can affect anyone.

You and your partner arrive at the scene of a motor vehicle accident, quickly size up the scene, and note that there are two patients, both of which are critically injured. You should:

Call for a second ambulance to respond to the scene. Considering that you can manage only one critical patient effectively per ambulance (with two medics), the most appropriate action is to call for an additional ambulance to respond to the scene. This must be accomplished as soon as you have determined that there are more patients than you can effectively manage.

Which of the following diseases accounts for the highest population of patients who receive home health care?

Cancer. There are approximately 1 million patients with cancer receiving home health care in this country today. Most cancer patients prefer to die in the privacy of their own homes. Additionally, lengthy hospital stays for treatment that could just as efficiently be provided at home are astronomical in cost.

Following an apparent terrorist attack, numerous patients present with shortness of breath and persistent coughing. A green haze is noted in the area in which the patients are located. Which of the following agents should you suspect they were exposed to?

Chlorine (CL). The patient's signs and symptoms are indicative of a pulmonary (choking) agent, specifically chlorine (CL). Chlorine (CL) was the first chemical agent ever used in warfare. It has a distinct odor of bleach and creates a green haze when released as a gas. Initially, it produces upper airway irritation and a choking sensation. Later signs and symptoms include shortness of breath, chest tightness, hoarseness and stridor as the result of upper airway swelling, and gasping or persistent coughing. Phosgene, not to be confused with phosgene oxime (a blistering [vesicant] agent), is also a pulmonary (choking) agent. Tabun (GA) and V agent (VX) are examples of chemical nerve agents. Nerve agents are among the most deadly chemicals developed. Designed to kill large numbers of people with small quantities, nerve agents can cause cardiac arrest within seconds to minutes of exposure.

You are responding to a call for an unconscious child. As you approach a four-way stop, you see a vehicle sitting at the stop sign to your right, and the driver of the vehicle is waving for you to proceed. You should:

Come to a complete stop, look to the left, and cautiously proceed. Most ambulance crashes occur at intersections. When approaching an intersection—even if another vehicle is stopped and is waving at you to proceed—you should still come to a complete stop, look in all directions, and then cautiously proceed through the intersection. The driver in this scenario is to your right; how do you know that there is not an approaching vehicle to your left? Never assume that all drivers will hear and see you. If you run a stop sign or red light and are involved in a crash, you will be held at fault—regardless of whether you were using lights and siren. Always drive with due regard for those around you and expect the unexpected.

Upon returning to your station following a call in which an infant was killed in a motor-vehicle crash, your partner immediately goes into his dorm room, closes the door, and begins to cry. He will not let you open the door and tells that he just needs some time to himself. You should:

Comply with his request and notify your supervisor. A critical incident is any event that overwhelms the ability of an EMS provider or an EMS system to cope with the experience, either at the scene or after the call. Examples of critical indicents include serious injury or death of a coworker in the line of duty, serious injury or death of a child, and mass-casualty incidents. It is impossible to predict how a person will react to a critical incident. A call that may be very disturbing to one paramedic may not affect his or her partner at all. Public safety systems have used critical incident stress debriefings (CISDs) for more than 20 years; however, there is no evidence that they are effective, or that their effects are not actually harmful. Nonetheless, if your EMS system utilizes CISDs, personnel should be offered the opportunity to debrief; debriefings should never be forced upon them. Talking with your partner about a particularly stressful situation can certainly be therapeutic, but if your partner does not want to talk and prefers to be left alone, you should comply with his or her request. However, you should notify your supervisor of the situation. If your partner is so distraught that he cannot safely function, he should be relieved for the rest of the shift and replaced by another paramedic. Your supervisor should offer him the opportunity to debrief if your system utilizes CISDs. Never tell another person that you understand how he or she is feeling; it is an insult to him or her, especially if you don't understand.

You arrive at a residence and find an elderly woman who is pulseless and apneic. Shortly after you and your partner begin CPR, the patient's husband hands you a crumpled piece of paper with the words "do not resuscitate" written on it, and asks that you stop CPR. How should manage this situation?

Continue CPR and notify medical control for guidance. A do not attempt resuscitate (DNAR) order must be validated by a physician. In cases where a DNAR is presented, especially if the document is questionable, it is best to err on the side of providing basic life support until a physician advises you to cease resuscitative efforts. Remember, when in doubt, resuscitate.

While treating an elderly woman who is in cardiac arrest, a man approaches you and states that the patient is his mother and that she did not want to be resuscitated. What is the MOST appropriate course of action?

Continue resuscitation and ask for a valid living will. When in doubt, resuscitate. You should not withhold resuscitative efforts while awaiting proper documentation. If a valid living will or do not attempt resuscitation (DNAR) order is produced, follow your system's protocols regarding the cessation of resuscitative efforts; you may be required to contact medical control. A DNAR order is a document that is signed by a physician and stipulates that resuscitative measures are not to be taken if the patient becomes pulseless and apneic. A living will is a legal document signed by the patient; it stipulates the care that he or she wishes to receive (or not receive) should he or she become incapacitated.

Which of the following is the MOST effective way to reduce the mortality and morbidity resulting from trauma?

Coordinate and conduct injury prevention programs. Clearly, prevention is the best medicine. Recognizing early signs of shock, minimizing on scene time, and recognizing patients with a significant MOI are all critical to the outcome of the patient, but these could be non-issues if the injury were prevented in the first place. EMS providers should be active in their communities by conducting injury and illness prevention programs (ie, blood pressure checks, bicycle helmet education).

Which of the following is an example of providing treatment based on standing orders?

Defibrillating a patient with pulseless V-tach, performing CPR, administering epinephrine, and contacting medical control. Standing orders—a type of indirect or offline medical control—permit the paramedic to perform certain interventions before contacting a physician. Medical directors typically give the paramedic standing orders to carry out interventions that the paramedic knows are clearly indicated for the patient's condition (eg, defibrillation, CPR, epinephrine). Contacting a physician (your medical director or the patient's personal physician) before performing a particular intervention is called online (direct) medical control.

Which of the following statements regarding the anger stage of the grieving process is correct?

Displaced anger is not a personal attack on the individual to whom it is directed. During the anger stage of the grieving process, which is typically the first stage a person enters, not only is the person angry with themselves, as in the case of a person with a terminal illness, but he or she can project that anger toward others, to include EMS personnel. It is important to understand that this displaced anger is not a personal attack on the individual to whom it is directed. All stages of the grieving process, no matter how unpleasant they can be for the patient, family, and paramedic, are healthy responses that will allow the patient or family member to come to terms with the situation.

Which of the following statements regarding to the proper disposal or handling of sharps is correct?

Dispose of the needle in an appropriate container immediately after use. Immediately after using a needle or other sharps device (ie, starting an IV, giving an injection), you should place it in an approved puncture-proof container. Waiting until the end of a call to search the ambulance for needles may result in an accidental needlestick. Prefilled syringes should be disposed of as an entire unit, without removing the needle.

You are preparing to transport a middle-aged male, who is likely experiencing a myocardial infarction, to the hospital. You will be using your lights and siren. The patient's wife, who is calm, tells you that she will follow the ambulance in her personal vehicle. You should advise her to:

Drive at the posted speed limit, obey all traffic signals, and not try to keep up with the ambulance. Family members often prefer to follow the ambulance to the hospital; they don't want to be without transportation. If a family member is upset, a factor that could impair the ability to drive safely, ask him or her to ride in the front seat of the ambulance or, if he or she prefers, to stay at home until someone can take him or her to the hospital. Although the patient's condition could easily deteriorate, asking his wife to ride in the ambulance because of this possibility may turn an otherwise calm wife into a frantic one. If she asks about the seriousness of the situation, be honest, but don't make it sound as though you expect her husband to die. Some family members prefer to stay at home until notified by the hospital. In this scenario, the patient's wife is calm and prefers to follow the ambulance in her personal vehicle. This is acceptable; however, you should advise her to obey ALL traffic laws, including posted speed limits, stop lights, and stop signs, and to avoid trying to keep up with the ambulance (this does NOT mean that you can drive the ambulance with excessive speed!). Advising her to turn on her hazard flashers may give her the impression that it is acceptable to exceed the posted speed limit or disobey other traffic laws. If she follows the ambulance, ask her to stay at least 500 feet behind you. If she follows too closely, both the ambulance and other drivers may be unable to see her following you. If you need to stop suddenly, she may not have time to react and her vehicle could collide with the back end of the ambulance.

You are giving a presentation to a group of non-BLS trained citizens on the importance of recognizing and treating a patient in cardiac arrest. Which of the following would have the greatest impact on the patient's survival?

Effective chest compressions. Educating the public is a crucial aspect of a successful illness and injury prevention program. When you are explaining the importance of recognizing and treating a patient in cardiac arrest, you should advise your audience that early, effective chest compressions with minimal interruptions are absolutely critical to the patient's survival. Ideally, chest compressions should be accompanied by rescue breathing; however, most laypersons do not have a barrier device and would prefer not to perform mouth-to-mouth rescue breathing. Explain to them that compression-only CPR is ideal in these cases. In many cases, an AED will not be immediately available. Further explain to them that the earlier 9-1-1 is called, the earlier advanced life support care can be provided to the patient, which further increases their chance for survival.

Which of the following statements regarding the incident command system is correct?

Emergency response agencies are required to use the incident command system, regardless of the type, size, or complexity of the incident. Historically, numerous agencies have responded to an incident; however, they worked independently. As a result, interagency organization and personnel accountability were nonexistent. Furthermore, it was extremely difficult to determine who was in charge as well as what additional resources were needed at the scene. To remedy this problem, the incident command system (ICS) was established. In 2004, the ICS was included in the National Incident Management System (NIMS). Federal law requires all emergency response agencies to use the ICS, regardless of the type, size, and complexity of the incident. The ICS is not an algorithmic approach to all major incidents; it can easily be applied when the resources at the scene are sufficient to effectively manage the incident and can be adjusted accordingly if the size, duration, or complexity of the incident changes.

After numerous attempts to convince a conscious and alert 50-year-old man with chest pain to consent to EMS assessment, treatment, and transport, he continues to refuse your help. Prior to asking him to sign a refusal of treatment form, it is MOST important to:

Ensure that he is made aware of your proposed treatment and the potential risks of his refusal. If a patient with decision-making capacity refuses treatment, you cannot legally treat. However, you should advise the patient to call 9-1-1 if they change their mind. Documentation of patient refusals is critical, especially if the patient accuses you of abandonment. Carefully document the patient's history, mental status, findings of your physical exam (if the patient consented to one), and all advice given to the patient (ie, explanations of the risks of refusing care). The use of scare tactics to convince a patient to consent is inappropriate; don't tell the patient that he or she has a particular problem, especially if you have not performed an assessment. Even then, you should inform the patient of your suspicions. The report should be signed by the patient and an impartial witness (eg, police officer). The witness must hear the exchange of information between you and the patient, not just to sign a piece of paper. Prehospital refusal forms look like the answer to documentation of a difficult problem; however, they must be backed up with action. Legally, you must have tried to obtain informed consent to treat the patient. A signed refusal must be an informed refusal. You must have informed the patient, in a manner he or she can understand, of your proposed care and the potential risks of refusing that care. In this scenario, the patient has refused all EMS care; this includes vital signs, an ECG, and other assessment. Performing these tasks without consent constitutes assault and battery.

What is the ultimate goal of any quality assurance program?

Ensure that high quality care is consistently delivered. Recognizing and rewarding personnel with good performance, strict adherence to all system protocols, and finding solutions for identified problems are all vital components to any quality assurance program, with the ultimate goal being the provision of patient care that is of consistent high-quality.

Which of the following clinical presentations is MOST consistent with exposure to a chemical nerve agent?

Excessive tearing, hypersalivation, bradycardia, and miosis. Nerve agents are among the deadliest chemicals developed; they are designed to kill large numbers of people with small quantities. Nerve agents, discovered while in search of a superior pesticide, are in a class of chemicals called organophosphates. Nerve agents block acetylcholinesterase, an essential enzyme that regulates the degradation of acetylcholine, thus causing profound parasympathetic nervous system stimulation. Sarin (GB), soman (GD), tabun (GA), and V agent (VX) are examples of chemical nerve agents. Nerve agents all produce similar signs and symptoms but have varying routes of entry into the body. They differ slightly in lethal concentration and dose and also differ in their volatility. Some agents are designed to become a gas quickly (nonpersistent or highly volatile), while others remain liquid for an extended period of time (persistent or nonvolatile). Once a nerve agent has entered the body through skin contact or the respiratory system, the patient will begin to exhibit a pattern of predictable symptoms. Like all chemical agents, the severity of the symptoms will depend on the route of exposure and the amount of the agent to which the patient was exposed. The resulting symptoms can be remembered using the mnemonic "DUMBELS," which stands for defecation, urination, miosis (pupillary constriction), bradycardia and bronchorrhea, emesis, lacrimation, and salivation. Another useful mnemonic is "SLUDGEM," which stands for salivation, lacrimation, urination, defecation, GI distress, emesis, and miosis.

A 65-year-old woman remains in asystole after 20 minutes of attempted resuscitation, including high-quality CPR, adequate airway management, appropriate drug therapy, and assessment for potentially reversible causes. The patient's husband and son are present and have observed your resuscitative efforts. At this point, it would be MOST appropriate to:

Explain the situation to her husband and son and recommend cessation of resuscitative efforts. Bioethical guidelines rely on common sense and reasonable judgment when deciding to stop resuscitative efforts or to not initiate them at all. Resuscitation is sometimes futile at the onset or becomes futile at some point. Futile resuscitation, interventions that have shown no benefit to patients, is not medically or ethically indicated. When attempting resuscitation, focus on providing 15 minutes of your best efforts. If return of spontaneous circulation (ROSC) has not occurred and no extenuating circumstances exist (eg, submersion, hypothermia), consider terminating resuscitation and focus your efforts on the family (ie, emotional support). In this particular case, continued resuscitation is futile; the patient has been in asystole for 20 minutes despite appropriate treatment. Asking the husband what he wants you to do, but not giving information to facilitate an informed decision (ie, recommendation to cease resuscitation), places a tremendous and unnecessary burden on him. Conversely, simply stating that his wife is dead, without explaining what you have done, is also inappropriate. Inform him that you have done everything possible and recommend ceasing resuscitation because his wife is dead. It sounds cold, but the word "dead" cannot be misinterpreted, and is the most humane way of informing the family of the reality of the situation.

What is the MOST common reason why victims of spousal abuse do not report the crime?

Fear of retribution. Men or women who are abused typically do not report the crime to the authorities because they fear retribution from the abuser. It is not that the individuals do not want to come forward; they are simply scared.

Which of the following creates a secure loop at the working end of a rope, which can be used to attach the end of the rope to a fixed object or a piece of equipment?

Figure eight on a bite. Although paramedics infrequently perform special rescue operations (ie, urban search and rescue [USAR]), they should have a basic working knowledge of the different ropes and knots used for rescue purposes. The figure eight on a bite knot creates a secure loop at the working end of the rope, the part of the rope used for forming the knot. This loop can be used to attach the end of the rope to a fixed object or a piece of equipment, or to tie a life safety rope around a person. The loop may be of any size, from an inch to several feet in diameter. The figure eight is a basic knot used to produce a family of other knots, including the figure eight on a bite and the figure eight with a follow-through. A simple figure eight knot is seldom used. The half hitch is not a secure knot by itself, which is why it is used in conjunction with other knots. The clove hitch is used to attach a rope firmly to a round object, such as a tree or fencepost.

The temperature at which a liquid fuel gives off sufficient vapors to cause a fire when an ignition source is present is called the:

Flash point. Flash point is an expression of the temperature at which a liquid fuel gives off sufficient vapors that will result in a flash fire when an ignition source is present. The flash fire involves only the vapor phase of the liquid and will go out once the vapor fuel is consumed. Ignition temperature refers to the minimum temperature at which a liquid fuel will ignite without an ignition source. Flammable range is an expression of a fuel/air mixture, defined by upper and lower limits, that reflects an amount of flammable vapor mixed with a given volume of air; it is the range over which a gas will form a flammable mixture with air. Vapor density is a concept for figuring out where a gas or vapor might go once released from its container. Vapor density compares the hazardous material or gas to air (air has a vapor density of 1). If the gas is heavier than air, the gas will sink into small valleys and ditches.

Which of the following is the MOST effective method for preventing the spread of disease?

Frequent hand-washing, especially in between patients. According to the Centers for Disease Control and Prevention (CDC), frequent hand-washing, especially in between patients, is the most effective method for preventing the spread of disease. Adherence to standard precautions (ie, gloves, mask, gown, etc) will minimize your risk of disease exposure. Keeping your immunizations up-to-date will help protect you from contracting certain diseases if you are exposed to them.

A patient who complains of abdominal pain informs you that she is HIV-positive. Which of the following is appropriate personal protective equipment?

Gloves and safety glasses. Gloves only are no longer considered minimum personal protective equipment by most EMS systems. Safety glasses, which protect your eyes from all angles, should be worn as well. Unless a patient is bleeding heavily or actively coughing, gloves and safety glasses are appropriate. If there is any chance of body fluid splatter (ie, coughing up blood, major penetrating trauma), a full face mask and gown should also be worn. Unless oxygen by face mask is indicated, consider placing a surgical mask on the patient who is potentially immunocompromised; this will help protect him or her from external pathogens. A high-efficiency particulate air (HEPA) mask (N-95 or higher) should be worn by the paramedic when caring for a patient with suspected tuberculosis.

While caring for an unresponsive patient who was stabbed in the chest, you notice a knife underneath the patient's left shoulder. Which of the following actions would be MOST appropriate for you to take?

Have a police officer secure the knife as you continue to treat the patient. When treating a patient at the scene of a crime, the paramedic must provide care, while at the same time making every effort to avoid disturbing the scene or manipulating potential evidence. In this case, it would be most appropriate to have a police officer retrieve and secure the knife as you continue to treat the patient. If the patient in this scenario was conscious, in which case he could potentially grab the knife, you should move the knife to a safe distance if a police officer is not immediately available.

While functioning at a mass-casualty incident, a paramedic falls and fractures his femur. He is conscious and alert, is breathing adequately, and has no open injuries. Which of the following should occur?

He should be assigned an immediate triage category and removed from the scene as soon as possible. A rescuer who becomes sick or injured during the rescue effort should be handled as an immediate priority and should be transported off the site as soon as possible, even if his or her condition is not life-threatening. Sick or injured rescuers can distract the other rescuers from doing their jobs and can have a negative impact on rescuer morale. As a result, the entire operation could be jeopardized.

A man is threatening to kill himself. You see no visible weapons on his person. What should be your initial concern?

His ability to injure you or your partner. Any patient who is threatening suicide should be assumed to have the potential of hurting others as well. In any case involving a psychiatric patient, the safety of you and your partner comes first. Gather any medications the patient may be taking, and safely transport him to the hospital. It is law enforcement's responsibility to search the patient for weapons; if you believe the patient has a gun, knife, or any other weapon, retreat to safety and wait for law enforcement.

You are dispatched for a motor-vehicle crash involving a single vehicle. When you arrive at the scene and exit the ambulance, a police officer tells you that there were two occupants in the car, one of whom was ejected. You should:

Immediately request another ambulance and then begin triaging the patients. In this scenario, you have unexpectedly entered a multiple-patient situation. As soon as you determine (or have been made aware) that there are more patients than you can effectively manage, you should immediately request additional resources and then begin the processes of triage and treatment. With two patients, one of whom has been ejected from the vehicle, you know that you will need at least two ambulances at the scene. One ambulance and two medics can only effectively care for and transport one critical patient. Don't wait to request another ambulance until you have triaged the patients; this only wastes time. If the second ambulance is not needed, you can always cancel their response. Remember, a multiple/mass casualty incident is one in which your available resources are overwhelmed, whether the patients are few or many.

What is the MOST important concept to explain to a group of non-BLS trained citizens when discussing the importance of rapid EMS notification for a patient in cardiac arrest?

Importance of early CPR and defibrillation. Because of the predominance of ventricular fibrillation in the majority of adult cardiac arrest patients, it must be emphasized to laypeople that early, effective CPR and defibrillation are the most critical interventions and have clearly demonstrated increased survival rates from cardiac arrest. Fibrinolytic drugs are contraindicated in patients with cardiac arrest. Early advanced care (ie, intubation, cardiac medications) and rapid transport are important to the patient's survival; however, the vast majority of patients who survive out-of-hospital cardiac arrest received early, effective CPR and prompt defibrillation.

How does a unified incident command system differ from a single incident command system?

In a unified incident command system, plans are made in advance by all agencies that assume a shared responsibility for decision making. Regardless of the type of incident command system (ICS) used, a single incident commander (IC) must be in charge. In a unified incident command system, plans are drawn up in advance by all cooperating agencies that assume a shared responsibility for decision making. The response plan should designate the lead and support agencies for several types of mass-casualty incidents (MCIs). For example, the Haz-Mat team will take the lead in a chemical leak and the medical team will take the lead in a multi-vehicle car crash. Large MCIs often require a unified incident command system. A single incident command system is one in which one person is in charge, even if multiple agencies respond to the scene. It is generally used with incidents in which one agency has the majority of responsibility for incident management. Ideally, it is used for short-duration, limited incidents that require the services of a single agency.

A woman called 9-1-1 when she saw her neighbor, a middle-aged man, pass out in his front yard. When you arrive at the scene, you find the patient sitting in a chair on his porch. He is conscious, appears alert, and has a small laceration to his forehead. The neighbor tells your partner that the man was unresponsive for about 2 minutes. You should:

Introduce yourself and ask the patient what happened. Before providing emergency care, you must obtain the patient's consent. Touching a patient without his or her consent is battery. Patients of legal age, who have decision-making capacity, have the right to refuse all or part of the treatment offered to them. The patient in this scenario has an injury, is conscious, and appears alert. Before you can legally touch him, you must obtain his consent. Introducing yourself and asking him what happened is a good way to determine his decision-making capacity. For example, if his speech is slurred and he is confused, you may determine that his decision-making capacity is impaired and begin treatment under the law of implied consent. In such cases, the paramedic assumes that the patient or the parent of a minor child would want care because of the severity of the injury or condition. Conversely, a patient with decision-making capacity cannot legally be treated until he or she gives expressed (actual) consent; this may be done verbally or nonverbally (eg, holding out his or her arm so you can obtain a blood pressure). The recommendation of the need for a medical evaluation is based on the paramedic's assessment; don't walk up to an obviously stable patient and say, "You need to go to the hospital" without performing an assessment first

According to Haddon's matrix, which of the following is an environmental factor that has a direct effect on the event phase of a motor-vehicle crash?

Lack of guardrails. Haddon's matrix is a tool used to facilitate understanding of all three phases of an injury sequence—pre-event, event, and post-event—and helps paramedics understand that injuries often result from a predictable, and therefore preventable, sequence of events. The pre-event phase is the period of time before the release of energy (ie, before the injury occurs). The event phase is the period of time during which the injury occurs. The post-event phase is the period of time following the injury. Three factors comprise the injury triangle: the host (patient), the agent (energy), and the environment (the place where the host and agent come together). Any of these factors can affect—or can be affected by—any phase of the injury sequence. For example, at the time of a motor-vehicle crash (the event phase), the presence of guardrails (the place where the host and agent come together [the environment]) may have prevented the car from going over the cliff. The presence of guardrails would not necessarily have prevented the injury; however, it would likely have affected the severity of the injury. Driver fatigue, alcohol/drug use, and driving experience are host factors that can affect the pre-event phase. A narrow road shoulder is an environmental factor that can also affect the pre-event phase; if the road was wider, the event—and subsequent injury—may not have occurred.

Which of the following would provide the paramedic with the BEST protection from legal liability?

Maintain a consistently high standard of care when treating all patients. Your best protection from legal liability is to consistently provide a high standard of care to all patients, which includes performing thorough assessments, providing appropriate and timely treatment, and thoroughly and accurately documenting the call. In general, patients should be transported to the hospital of their choice; however, this is not always possible if his or her condition warrants transport to a more appropriate facility.

Which of the following situations would MOST likely require involvement of a technical rescue team?

Man who fell from atop a mountain and landed on a ledge. A technical rescue incident is a complex rescue incident involving vehicle extrication, swiftwater or ice rescue, trench rescue, confined spaces, structural collapse, high-angle rescue, hazardous materials incidents, and wilderness search and rescue. Technical rescue teams have specialized training in dealing with such incidents. A patient who fell and landed on a ledge, for example, would require a high-angle rescue team. A patient who was ejected from a motor-vehicle obviously does not require extrication. A patient found floating in a swimming pool can easily be retrieved without any special equipment. An obese patient in a small bedroom would simply require more manpower (ie, paramedics, firefighters, law enforcement) in order to move him or her to an area that has more workspace.

Who has the ultimate medical authority at the scene of a mass-casualty incident?

Medical director. The incident commander has control over the logistical operations at the scene of a mass-casualty incident (MCI); however, the EMS medical director is ultimately responsible for all patient care-related activities. It is important that the incident commander remain in close contact with the medical director during a MCI.

In order to reduce your risk of personal injury while lifting and moving a patient, you should:

Minimize the number of body lifts you have to perform. Taking the time to stretch before lifting a patient, although optimum, is not practical—especially if the patient is critically ill or injured. However, there are a number of habits that, if routinely practiced, will reduce your risk of injury. For example, a patient with an isolated arm laceration can easily walk to the stretcher and sit down; he or she does not necessarily need to be lifted and carried to the stretcher. You can also reduce the number of ground-level lifts by placing the ambulance cot in a hands-height position instead of fully lowered. When lifting, you should spread your legs about shoulder-width apart and place your feet so that your center of gravity is properly balanced. Although some patients can walk to the ambulance, many patients should not (for example, a patient with a possible myocardial infarction).

While treating a patient with severe pain, the paramedic accidentally gives the patient 10 mg of morphine when he meant to give 5 mg. As a result, the patient becomes bradycardic and hypotensive. The paramedic's action constitutes:

Misfeasance. Negligence is commonly divided into three categories: malfeasance, misfeasance, and nonfeasance. Malfeasance occurs when a paramedic performs an act that he or she was never authorized to perform, such as a medical intervention that is outside his or her scope of practice. Misfeasance occurs when a paramedic performs an act that he or she is legally permitted to do, but does so in an improper manner. For example, a paramedic administers a drug that is clearly within his or her scope of practice, but inadvertently calculates or administers the wrong dose. Nonfeasance occurs when the paramedic fails to perform an act that he or she is required or expected to perform. Failure to administer oxygen to a hypoxemic patient is an example of nonfeasance. Gross negligence is established if the paramedic's actions or inactions were found to be willful or wanton (malicious) under the law. In this case, the paramedic's action was accidental, not intentional. Therefore, gross negligence cannot be established.

Following a research program in which you studied men between the ages of 40 and 50 who have angina, you analyze your data and achieve quantifiable statistics by adding the variables of mean, median, and mode. The mode is the:

Most frequent age of the participants. There are many types and methods of research in EMS—all of which are designed to benefit the patient. As your research program is ongoing, you will compile data. After the research program is complete, you then analyze the data you compiled and achieve statistics. Descriptive statistics—that is, statistics that were achieved by observation only, where no attempt to change or alter an event occurred—can be performed using a qualitative or quantitative style. The qualitative method does not involve the use of numerical information and is the least accurate. The quantitative approach adds several other possible variables to the research: mean, median, and mode. For example, the mean age of study participants in a study on angina in men who are between the ages of 40 and 50 years old is the average age of the subjects, the median is the midpoint age of the subjects, and the mode is the most frequent age of the subjects. Standard deviation outlines how much those scores in each set will deviate from the mean.

Which of the following pieces of personal protective equipment will afford you the BEST protection against exposure to tuberculosis?

N-95 respirator. Tuberculosis (TB) is transmitted via the droplet route. The paramedic may be exposed to TB if he or she inhales airborne droplets from an infected person. Gloves should be used with ALL patients, not just those suspected of being infected with TB. High-efficiency particulate air (HEPA) masks, such as the N-95 respirator, will afford the paramedic the greatest protection from exposure. Surgical masks are insufficient for preventing inhalation of the TB bacterium; however, they do reduce the number of droplet nuclei escaping from the patient. Therefore, it would be more appropriate to place a surgical mask on the patient suspected of being infected with TB, unless he or she requires high-flow oxygen.

An overturned tanker has a solid green placard on its side and rear. What type of hazard does this indicate?

Non-flammable gas. The United States Department of Transportation (USDOT) uses labels, placards, and markings to give responders a general idea of the hazard inside a particular container or cargo tank. These can be found in the Emergency Response Guidebook (ERG). The color of a placard identifies the general type of hazard. A flammable solid is identified by a solid red placard. A non-flammable gas is identified by a solid green placard. Radioactive material is identified by a yellow and white placard. Explosive and blasting agents are identified by a solid orange placard.

You and your partner are the first to arrive at the scene of a motor-vehicle crash involving two cars and a truck. You see four patients, two who are ambulatory and two who are still in their vehicles. You should:

Notify dispatch to send additional ambulances and then begin triaging all patients. In this scenario, your resources are overwhelmed. You have four patients and only one ambulance. Even if all four patients are stable, you will still need at least one additional ambulance because you can effectively care for only two stable patients with one ambulance and one paramedic. Immediately request at least one additional ambulance and then begin the triage process.

You are transporting a 34-year-old woman who has severe flank pain that radiates to the groin area. Her blood pressure is 80/50 mm Hg. She repeatedly demands that you give her something for the pain. What should you do?

Notify medical control and seek guidance on how to manage this situation. When a patient demands that you provide care that is contraindicated for his or her condition, the best action to take is to contact medical control, apprise him or her of the situation, and seek further guidance. In this case, it is not the severe abdominal pain that contraindicates analgesia, but the fact that she is hypotensive. It would obviously be inappropriate to administer sodium chloride, which is clearly not an analgesic, and tell the patient it is for the pain.

The MOST practical and reliable way of ensuring that all pertinent times regarding an EMS call are properly documented is to:

Notify the dispatcher each time an event occurs. Pertinent times during an EMS call include the time of dispatch, when you are en route to the scene, when you arrive at the scene, when you are transporting, when you arrive at the hospital, and when you return to service. While providing emergency medical care, paramedics simply do not have time to keep looking at their watches and recording the moment each of these events occurred. Notifying the dispatcher at the time of each event is clearly more practical; this will ensure consistency and accuracy, and will allow you to focus on caring for your patient. You can then retrieve your times from the dispatcher when the call has been completed. Asking law enforcement personnel to keep track of your times is impractical and leaves room for error; they have their own times—which are usually different than yours—to keep track of.

Which of the following statements regarding a prehospital care report is correct?

Once a copy of the report is left at the hospital, you cannot write on the front of the form. Once you leave a copy of a prehospital care report (PCR) at the receiving facility, you cannot write anything else on the front of the form. Legally, this would make the original and the copy two separate documents, which could be easily scrutinized in a court of law. If further documentation is required after leaving the hospital, you should write on the reverse side of the form or write a separate addendum, which becomes an official part of the PCR. Many EMS systems use electronic PCRs, in which the PCR is electronically transmitted to the emergency department after it is completed. If additional information or clarification is needed after the initial PCR has been submitted, an electronic addendum can be submitted.

You and your partner are triaging four patients at the scene of a motor-vehicle crash. Additional units are responding, and will arrive in approximately 8 minutes. Patient 1 is a 30-year-old male with a unilaterally deformed femur, restlessness, diaphoresis, and tachycardia. Patient 2 is a 49-year-old conscious and alert female with paralysis to her lower extremities and adequate breathing. Patient 3 is a young adult female who is unresponsive and apneic. Patient 4 is a 57-year-old male who is responsive to pain only and is coughing up blood. How should you triage these patients?

Patients 1 and 4, immediate; patient 2, delayed; patient 3, expectant. The goal of triage is to provide the greatest good for the greatest number of people. The triage assessment is brief and the patient condition categories are basic. Given the patients' conditions in this scenario, patient 1 should be categorized as immediate (red tag); although his only visible injury is an isolated closed femur deformity, he has signs of shock that suggest occult hemorrhage. Patient 4 should also be categorized as immediate (red tag); his mental status is decreased and he is coughing up blood—an immediate airway problem. Patient 2 should be categorized as delayed (yellow tag); although she likely has a spinal cord injury, she is conscious and alert, is breathing adequately, and will probably not die before patients 1 and 4. If adequate resources were available at the scene, then patient 3 would be categorized as immediate. However, because your resources are limited (8 minutes until additional resources arrive), you should categorize her as expectant (black tag).

Addressing a patient with an expression such as "Hello, my name is Eryk and I'm a paramedic. What's your name?" allows you to:

Perform a cursory mental status assessment. When you address patients with an expression such as the one in this question, they have to go through a very specific sequence of physical and mental processes in order to appropriately answer your question; this amounts to a mini-mental status assessment. They have to hear your words; locate the source of your voice and meet your gaze; process the meaning of your words; formulate a meaningful, accurate response from memory; and put their response into coherent speech. Many patients do not volunteer their chief complaint without being asked about it. Simply introducing yourself to the patient does not give you consent to treat; the patient must specifically give consent, either verbally (eg, "Please help me") or nonverbally (eg, holding out their arm so you can take their blood pressure). In order to gain a patient's trust, you must show genuine concern, assure him or her that you are there to help, and deliver what you promise.

Which of the following should be your MOST immediate priority when caring for a patient with an acute behavioral crisis?

Personal safety and standard precautions. Remember that your personal safety comes first, regardless of the type of patient you are caring for. Ensure that the scene is safe and take appropriate standard precautions. When caring for a patient with a behavioral crisis, you should avoid confrontation, provide safe transport, and treat any concomitant medical problems that the patient may have. However, these should NOT supercede your own safety.

After threading the catheter off of an IV needle and disposing of the needle in a puncture-proof sharps container, you attach the IV tubing and open the flow control valve. Shortly after doing this, you note that the IV site has infiltrated. After removing the Teflon catheter from the patient's arm, the BEST way to dispose of it is to:

Place it in a puncture-proof sharps container. Many people think of "sharps" as being sharp metal items capable of penetrating the skin, such as a hypodermic needle, IV needle/stylet, or scalpel. Although this certainly is true, the Teflon catheter of an over-the-needle catheter, although not metal, has the potential to lacerate the skin. Therefore, it should be disposed of like any other sharps—by placing it in a puncture-proof sharps container. Health care workers have been lacerated by the tip of the Teflon catheter; its edges are sharper than you think!

If, for some reason, you are unable to place a contaminated needle and syringe in a puncture-proof sharps container while in the back of the ambulance, you should:

Place the needle cover on a stationary surface and then slide the needle into the needle cover with one hand. To keep handling of contaminated needles, catheters, and other sharps to a minimum, you should have at least two sharps containers—readily accessible—in the back of the ambulance. You should also have a smaller sharps container in your jump kit for immediate disposal of sharps while not in the ambulance. Immediately dispose of all sharps in a puncture-proof sharps container. Do not drop the sharps on the floor or into an unapproved container (ie, trash can) for later retrieval; the risk of forgetting about them is too high. Bending and/or breaking a needle clearly increases your risk of getting stuck; don't do it! Recap needles only as an absolute last resort. If you find yourself in the rare situation in which proper disposal of a contaminated needle is not possible, use the one-handed technique to recap the needle. Place the needle cover on a stationary surface, then slide the needle—with one hand—into the needle cover.

When lifting a patient who is on an ambulance stretcher, you should:

Position your palms up whenever possible. Proper technique when lifting a patient involves keeping your palms up whenever possible, which will prevent unnecessary stress and potential injury to the wrists. When lifting, you should always use the powerful muscles of your legs, while keeping your back in a straight, locked-in position.

Which of the following is an example of injury prevention and public education?

Promotion of proper seatbelt use. Promoting proper seatbelt use serves two purposes: it educates the public regarding how to properly wear a seatbelt, which in turn has the potential of preventing an injury. CPR and bleeding control training are examples of public education; they are not injury prevention strategies because they are not needed until an injury has already occurred. Collection and analysis of mortality and morbidity data is a method used to affect change that will minimize the risk of injury or death (eg, there have been several fatal car crashes around this corner; perhaps the road needs to be widened).

Which of the following is the MOST effective way to reduce stress and anxiety in a patient who is experiencing chest pain or pressure?

Provide reassurance and a safe comfortable transport. Reassurance and a safe comfortable transport to the hospital are both very effective ways to reduce stress and anxiety in a patient, perhaps even more so than administering a sedative drug. You should never lie to a patient about their potential condition. Clearly, a patient with a suspected acute myocardial infarction should be transported to the hospital via EMS, not by private vehicle.

Advance directives, such as living wills, are often called "durable" powers of attorney because they:

Remain in effect once a patient loses decision-making capacity. Advance directives are generally executed by the patient while he or she has decision-making capacity. The living will is a type of advance directive in which a patient can express his or her wishes regarding end-of-life medical care. These directives are sometimes called "durable" powers of attorney because they remain in effect once a patient loses decision-making capacity. Living wills generally require some kind of precondition to activate, such as a terminal illness or an irreversible coma. The living will should spell out exactly what kind of treatment a patient wishes to be given should he or she become incapacitated. Living wills often contain a health care power of attorney, which designates another person—spouse, partner, adult sibling, or parent—to make health care decisions for the patient at any time the patient is unable to make those decisions. The person designated to make decisions does not have to be a relative, however, but may be someone close to the patient who understands his or her wishes. The person who makes the health care decisions for another, who carries the power of attorney, is often called the surrogate decision maker. The surrogate decision maker is legally obligated to make decisions as the patient would want, and has presumably discussed these decisions with the patient. Do not confuse a living will with a do not attempt resuscitate (DNAR) order; they are not the same. DNAR orders are written orders designed to tell health care providers when resuscitation is or is not appropriate. The living will allows for decisions to be made regarding DNAR orders if a patient becomes incapacitated or is otherwise unable to make his or her own decisions.

You are sitting in the front passenger seat of a small car assessing the driver after he struck a tree head-on. Your partner is maintaining manual stabilization of the patient's head from the back seat. The driver's side airbag deployed, but the passenger's side airbag did not. The patient's legs are pinned by the dashboard, and rescue personnel are preparing to disentangle him. What should be your MOST immediate priority?

Remaining at least 20 inches from the passenger's side dashboard if possible. You are in a potentially dangerous position! Your most immediate priority should be to remain at least 20 inches away from the passenger's side dashboard if possible; this distance—as recommended by the National Highway Traffic Safety Administration—will minimize the risk of personal injury if the passenger's side airbag spontaneously deploys. Do not place any solid object in between you and an undeployed airbag; this will not protect you—it will only increase the risk of severe injury if the airbag does deploy. After you have taken measures to ensure your own safety, you should then tend to the patient. Complex extrication (ie, hydraulic, gas, or electric-powered tools) is a dangerous procedure; do not allow it to commence until you have maximized the safety of yourself, your partner, and your patient.

A 29-year-old male was exposed to a dry powder chemical. He is conscious and alert, but is restless and in intense pain. You should:

Remove his clothing, brush the chemical off his skin, and then irrigate his skin with copious amounts of water. Second only to your personal safety, the priority in caring for a patient who has been exposed to a hazardous material involves decontamination and prevention of further injury. Hazardous material teams are the most appropriate personnel to decontaminate a patient; however, you may find yourself in a position in which you must perform decontamination. When a patient is exposed to a dry powder chemical, you should first remove the patient's clothing; this alone often removes much of the contaminating chemical. Next, brush away as much of the chemical from the patient's skin as you can. Finally, irrigate the patient's body with copious amounts of water. Applying water to a dry chemical before removing it from the skin may increase the burning process, resulting in further injury. Establishing vascular access prior to decontamination may cause the chemical to enter the patient's circulatory system. After the patient has been properly decontaminated, further care (ie, oxygen, analgesia) should be provided as indicated.

A 50-year-old man was found unresponsive in his greenhouse; an empty container of pesticide is found lying next to him. His respirations are severely labored, his pulse is slow and weak, he is incontinent of urine, and he is producing copious oral secretions. After removing the patient from the greenhouse, you should:

Remove his clothing, suction his oropharynx, assist his ventilations with a bag-mask device, apply the cardiac monitor, establish vascular access, and administer 2 to 4 mg of atropine sulfate. Your patient has experienced a significant exposure to an organophosphate pesticide; organophosphates cause profound parasympathetic nervous system stimulation. After removing the patient from the toxic environment (ensure your own safety first!), you should remove his contaminated clothing; it can continue to release toxic vapors for up to 30 minutes. Next, establish a patent airway by suctioning the secretions from his mouth. His severely labored respirations—which are likely not producing adequate minute volume—should be treated with positive-pressure ventilatory assistance and high-flow oxygen. Advanced airway management may be required, but not before restoring adequate minute volume with a bag-mask device. Establish vascular access and then administer 2 to 4 mg of atropine sulfate. Atropine is one of the reversal agents for organophosphate poisoning; large doses are often needed to reverse the toxic effects of organophosphates. Pralidoxime chloride (Protopam, 2-PAM chloride) is the other reversal agent. For severe toxicity, administer 1800 mg/kg intramuscularly (IM); 600 mg/kg IM is an appropriate dose for mild to moderate toxicity. Organophosphate poisoning should be treated with chemical reversal agents first; transcutaneous pacing (TCP) may be indicated. Follow your local protocols.

You are transporting a patient who has chest pressure that is unrelieved by nitroglycerin. You contact the receiving physician for direction and are ordered to administer 25 mg of morphine. You should:

Repeat the medication order back to the physician word-for-word. As a paramedic, you have been educated on the appropriate doses of a wide array of medications. After receiving a medication order from a physician, you should immediately repeat the order back to the physician, word-for-word, and ask for clarification if the dose is inappropriate (in this case, 5 times the standard dose). In most cases, you either simply misheard the order or the physician made an error. If the physician insists on a dose that is contrary to what you were taught or what is in your protocols, contact your medical director. Do NOT administer a drug in a dose that is clearly too excessive and would likely cause further harm. If you knowingly administer an inappropriate dose of a drug, even if the physician confirms the dose, you should be prepared to be held equally as liable as the physician for the consequences.

You are triaging a female patient who was near a building when it exploded. According to the Simple Triage and Rapid Treatment (START) system, what should you do if she is apneic?

Reposition her airway. The Simple Triage and Rapid Treatment (START) system is a 60-second triage method that enables rescuers to rapidly identify those at greatest risk for rapid death. The START system focuses on four assessment parameters: ability to walk, respiratory effort, perfusion status, and mental status. Victims are classified as being delayed, urgent, immediate, or dead/dying. Based on the patient's classification, an internationally recognized color-coded triage tag is placed on him or her. According to the START system, if a patient is apneic, you should reposition his or her airway and reassess for breathing. If breathing is still absent, the patient is classified as dead/dying and is identified with a black triage tag. If the patient's breathing resumes, however, he or she is classified as immediate and is identified with a red triage tag.

Which of the following clinical presentations is MOST consistent with exposure to chemicals such as tabun, sarin, and soman?

Rhinorrhea, nausea and vomiting, bradycardia, polyuria. Tabun, sarin, and soman are chemical nerve agents; they are in a class of chemicals called organophosphates. Such chemicals inhibit the effects of acetylcholinesterase (AChE)—the chemical mediator of acetylcholine (ACh). ACh is the chemical neurotransmitter of the parasympathetic nervous system. By inhibiting the AChE enzyme from breaking down ACh, both the levels and duration of action of ACh increase; this results in severe parasympathetic nervous system stimulation. In addition to severe bradycardia and hypotension, AChE inhibitor exposure produces signs and symptoms that can be remembered with the mnemonic DUMBELS, which stands for defecation, urination, miosis (pupillary constriction), bradycardia/bronchorrhea, emesis, lacrimation, and salivation.

Which of the following is an active intervention that helps prevent injury?

Routine use of seat belts when driving. As it applies to injury prevention, active interventions are conscious and deliberate actions or measures taken by a person in order to reduce the risk of injury. For example, a person who regularly uses his or her seat belt is making a conscious effort to reduce his or her injury risk; he or she knows that proper seat belt use has clearly been shown to reduce the risk or severity of injury during a vehicle crash. Other examples of active interventions include parents who enforce rules regarding helmet use while bicycling or skateboarding, and those who seek education regarding proper installation of a child safety seat in their vehicle. By contrast, passive interventions do not require a conscious decision to act, and are often the most successful of all interventions. This approach is also referred to as automatic protection. Examples include child-resistant medication bottles; sprinkler systems in commercial buildings; air bags and seat belts in automobiles; and the use of softer, yielding materials for playground surfaces. These measures provide 24-hour protection without requiring a conscious action or decision on the part of the user—that is, the person who benefits from the intervention. The less the personal effort required, the greater the chance that the intervention will be successful.

A 67-year-old woman who slipped and fell reports pain to her left hip area. Which of the following devices would be MOST effective in removing her from her house?

Scoop stretcher. The scoop stretcher, also called an orthopedic stretcher or split litter, is very effective in transporting patients with suspected hip or pelvic fractures. Its contoured design provides excellent support. Additionally, it is easier to manipulate a scoop stretcher in a house than an ambulance stretcher. The Stokes basket, also called a basket litter, is an effective carrying device for moving a patient across rough terrain; however, it is bulky and would not be practical to use when removing a patient from his or her home. The folding stretcher provides much less support than the scoop stretcher, and is more commonly used to secure a second patient to the bench seat in the back of the ambulance.

After attempts to verbally calm a violent 33-year-old male fail, you determine that physical restraint is necessary. When restraining the patient, you should:

Secure him to the stretcher in a supine position and ensure that one person consistently communicates with him. If physical restraint of a violent patient becomes necessary, you must first have a plan—one that everyone involved in the restraint procedure fully understands. To safely restrain the patient, you should have a minimum of five people—one assigned to each extremity and a fifth person to communicate with the patient throughout the procedure. Then, at a signal from the team leader, move in fast from the patient's sides; approaching from the front gives the patient an opportunity to escape to one side or the other. Grasp the patient at the elbows, knees, and head, and apply restraints to all four extremities. The safest position in which to secure the patient to the stretcher is supine, with legs spread-eagled and both arms secured to one side of the stretcher. This position will turn the patient's head to the side, thus minimizing the risk of aspiration if vomiting occurs. Never "hog tie" a patient (tying the ankles and wrists together as one); this type of restraint is humiliating to the patient, and more importantly, has been known to cause death. Placing the patient face-down on the stretcher should also be avoided; it can lead to positional asphyxia. Have one person maintain constant communication with the patient, even if he or she does not appear to be paying attention.

When approaching a vehicle at night, in which a patient is slumped over the steering wheel, you should:

Shine a spotlight in the side view mirror until you determine it is safe. Considering that you and your partner's safety are of primary concern, the best approach to take in the situation where a patient is slumped over the steering wheel of his or her car is to approach the vehicle from the rear. At night, shining a light into the side view mirror will prevent the person from seeing you until you can determine that he or she is safe to make contact with. Unfortunately, it is common for people to fake illness or injury with the intent of hurting the responding personnel.

During a mass-casualty incident, personnel gather at a central point and are sent by the incident commander to various areas of the scene. This central point is referred to as the:

Staging area. The staging area in a mass-casualty incident is where all resources congregate and are dispatched to the most appropriate locations by the incident commander. It is at the staging area that individuals are assigned various tasks by the incident commander, such as triage officer, transport officer, and extrication officer.

You are transporting an 80-year-old female to the hospital and are preparing to call in your radio report. Which of the following is an example of a practice that will maximize the receiving facility's ability to understand your transmission?

State the patient's age as 80, that is, eight-zero. Eighty could easily be misunderstood as eighteen. When transmitting numbers that might be misunderstood, transmit the number as a whole, then digit by digit. Therefore, you would state, "The patient is 80-years-old, that is, eight-zero." If the receiving facility did not hear what you said, you will be asked to repeat yourself; routinely repeating each segment of your report only wastes radio time. You should keep your radio transmission brief whenever possible; however, if you must give a lengthy report, break the message into 30-second segments, checking at the end of each segment to ensure it was received and understood. Low- and high-pitched sounds do not transmit well; therefore, you should speak in a normal pitch.

While responding to a call for a patient who is in cardiac arrest, you approach an intersection in which you have a red light. What is the MOST appropriate action for the ambulance operator to take?

Stop to look for oncoming traffic, and then proceed cautiously. When approaching an intersection with a red light, you must always come to a complete stop, ensure that there is no oncoming traffic, and then proceed with caution through the red light. The majority of emergency vehicle crashes occur at intersections because the vehicle operator did not properly enter the intersection as described.

You are assessing a seriously ill patient when you suddenly become nervous and feel as though you are about to hyperventilate. You should:

Take deep breaths in through your nose and out through your mouth. It is not uncommon to feel the effects of the fight-or-flight response of the sympathetic nervous system (ie, nervousness, tremors, sweating) when caring for a patient—especially if he or she is seriously ill or injured. However, it is important to the care of your patient that you remain calm to help control the fight-or-flight mechanism. Imagine how an already scared and anxious patient would feel if he or she sees you becoming anxious. Perhaps the least obvious way to control your anxiety while caring for a patient is to use controlled breathing—taking deep breaths in through your nose and out through your mouth. If you suddenly dismiss yourself from the patient, he or she will think that something is wrong; you do not want to instill this thought in your patient! It is only human to feel the stress and anxiety of caring for a seriously ill or injured patient; however, you must not let the patient see this. You should especially not tell him or her that you are nervous. Progressive muscle relaxation, although an effective stress-reducing technique, is not practical in the midst of patient care. It requires you to relax and focus exclusively on your own body. Progressive muscle relaxation is a more appropriate technique to use after the call or when you are off duty.

You have obtained a 12-lead ECG tracing on a middle-aged male with chest discomfort. The ECG shows obvious ST elevation in leads II, III, and aVF. The patient, who is obviously anxious, asks you if the ECG looks okay. You should:

Tell him that his 12-lead ECG shows an abnormality and that EMS transport to the hospital is necessary. Your patients deserve to hear the truth, even if what you have to tell them is unpleasant. Do not tell your patients what you think they want to hear; tell them what they need to hear. It's their body, their health, and their life; skirting the truth is completely inappropriate. Tell your patients what you think is happening. Show them what their ECG reveals, tell them their blood pressure, explain what you are doing and why (informed consent), and let them know how they are doing. Provide truthful reassurance; tell the patient that you are going to care for him or her to the best of your ability. As a paramedic, you have been trained to identify an acute myocardial infarction, as well as a variety of other abnormalities, on the 12-lead ECG.

You are transporting a woman with diabetes who was initially unresponsive but improved after the administration of 50% dextrose. The patient is now repeatedly asking you what happened. How should you respond to her questions?

Tell the patient what happened each time she asks. When communicating with a patient who is confused, you must constantly keep him or her aware of their surroundings, what happened, and where you are going. No matter how many times a patient asks you, you must repeat the truth each time. The patient in this scenario clearly cannot recall what happened because she is repeatedly asking you; answering her questions with questions will prove futile and may only serve to add frustration to her confusion.

Which of the following situations is an example of gross negligence?

The defibrillator fails to work because the batteries are dead. Gross negligence occurs when patient care suffers as a result of an inappropriate action or inaction made on the part of the EMT or paramedic, without any attempt at taking corrective action. An example of this is failing to check the batteries on a defibrillator at the start of a shift. Other mistakes can be construed as negligence; however, if the individual accused takes or attempts to take corrective action, the likelihood of being found guilty is minimized.

An off-duty paramedic stops at the scene of a cardiac arrest on the highway. During the course of providing care to the patient, the paramedic successfully performs endotracheal intubation. Which of the following statements regarding this paramedic's actions is correct?

The paramedic could be held liable for practicing medicine without a license. Even though the paramedic performed the skill appropriately and in the correct circumstance, advanced life support providers are not allowed to function as such when not on duty and/or affiliated with an EMS system under the auspices of a physician medical director. Doing so is considered practicing medicine without a license. The standard of care assumes that the EMT or paramedic is on duty and is functioning under a physician's license.

You are completing your patient care report (PCR) after caring for a middle-aged woman who experienced a syncopal episode. Which of the following items is a pertinent negative and should be documented on the PCR?

The patient stated that she does not have a cardiac history. A pertinent negative is the absence of a sign, symptom, or other finding that you may expect to find in a person with a particular chief complaint, but do not. For example, it is pertinent that a patient with syncope does not have a cardiac history. Although a cardiac history is absent (negative), it is pertinent to the patient's chief complaint because an underlying cardiac problem (eg, a dysrhythmia) can cause syncope. Another example of a pertinent negative is a patient with a heart rate of 45 beats/min who denies chest pain or shortness of breath; many patients with bradycardia are symptomatic and present with chest pain and/or shortness of breath. Documenting pertinent negatives is just as important as documenting positive findings—in this case, a heart rate of 45 beats/min and information obtained from the bystander. Documentation of pertinent negatives demonstrates that, based on the patient's chief complaint, a thorough assessment was performed and you actively sought out potential causes that could be causing or contributing to the chief complaint. Of course, all of the items listed in this question should be documented on the PCR.

Using the SOAP documentation format, which of the following is an objective statement?

The patient was found sitting in a chair with his hand against his chest. Many methods for narrative documentation exist. Your EMS agency or medical director may prefer a specific method to be used when documenting an EMS call. The SOAP documentation format is a simple and logical method used to document various aspects of the patient encounter. It stands for subjective, objective, assessment, and plan (for treatment). Subjective findings are statements made to you by the patient, a family member, or other person. Examples include, "My chest hurts," "My husband was recently in the hospital," and "I took two nitroglycerin tablets before calling EMS." The patient's chief complaint—in his or her own words—is the best example of a subjective finding. Whenever documenting statements made by the patient or another person, use quotation marks; this tells other health care providers who read your patient care report that they were not your statements. Objective findings are observations that you make without input from the patient. Examples include, "Upon arrival, found the patient sitting in a chair with his hand against his chest," "The patient appeared anxious," and "There was no evidence of gross hemorrhage." Objective findings are factual, not speculative or representative of your personal opinion. Items such as vital signs, auscultation of breath sounds, ECG findings, and pupillary reaction are included in the assessment part of the narrative. The plan outlines the treatment you provided to the patient—for example, "Administered high-flow oxygen," "Established an IV of normal saline with an 18-gauge catheter," or "Gave 0.5 mg of atropine rapid IV push at 1030 hours." Regardless of the documentation format you use, ensure that it is an accurate reflection of the entire patient encounter.

While en route to a call for an injured person, the dispatcher advises you that law enforcement personnel are at the scene. This information should tell you that:

The scene is potentially unsafe. The presence of law enforcement at the scene should tell you that the scene is potentially unsafe; otherwise, they would not be there. Law enforcement presence is not a guarantee that the scene is safe. Conversely, their presence does not necessarily mean that a crime has been committed, nor does it indicate that the patient's condition is critical. You should make radio contact with on-scene law enforcement personnel before arriving to obtain information regarding scene safety, and if possible, the patient's condition.

Which of the following scene size-up findings is MOST indicative of an unsafe environment when approaching a residence?

The sound of breaking glass coming from the residence. Indications of a potentially unsafe scene include, but are certainly not limited to, the sound of breaking glass, a screaming individual, or gunfire. In cases such as these, the paramedic should not enter the scene until it has been secured by law enforcement. A patient's physical size, although intimidating, is not an indicator of the potential for violence.

During a mass-casualty incident, what officer is responsible for communicating with hospitals to ascertain their capabilities?

Transport. Communication with area hospitals to determine their capabilities is the responsibility of the transport officer. By identifying each hospital's capabilities, the transport officer can direct exiting ambulances from the mass-casualty incident (MCI) to the most appropriate facility. The staging officer is responsible for directing personnel to the appropriate location at an MCI from the staging area. The triage officer is responsible for the initial triage process as patients are moved from the scene to a centralized triage area. Support personnel are individuals who are assigned specific tasks by the incident commander; this may include functioning in the triage or treatment areas.

While responding to an emergency call, a driver in front of you sees you in his rearview mirror, panics, and begins driving erratically. You should:

Turn off your siren, turn on the public address (PA) system, and politely ask him to move to the right and stop. There are plenty of paramedics (some whose careers span 20 years or more) who have never been involved in an ambulance collision, and not by dumb luck. They understand that safety is deliberate, and that operating an ambulance is a public trust. Above all, they never forget that driving an ambulance is dangerous. Remember, the lights and siren on your ambulance are tools you use to ask for—not demand—the right of way. When driving an ambulance in emergency mode, you must always allow for the incompetence of other drivers. Expect some drivers to panic when they see you approaching in their rear-view mirror. If this happens, turn off your siren, turn on the public address (PA) system, and politely ask the driver to pull to the right and stop. The constant blaring of a siren may only serve to increase the driver's level of panic. Never pass a vehicle on the right side; if the driver sees you in his or her rear-view mirror and yields to the right (which is appropriate), he or she may drive into the left side of the ambulance. Stay far enough behind other drivers—at least 500 feet—so they can see your lights in their rear-view mirrors. Anticipate that, when they notice you, their first instinct will be to slam on their brakes.

You are dispatched to a ranch where a tractor has overturned and pinned the operator. Upon arrival at the scene, you should:

Visually assess the stability of the overturned tractor. Upon arriving at the scene of any emergency (medical or trauma), you should always conduct a thorough scene size-up. This begins by surveying the area to ensure that there are no dangers or hazards that would pose a threat to you or your crew. In the case of a motor-vehicle crash or any incident involving a heavy object in which a patient is entrapped, you should visually assess the stability of the vehicle or object. If the vehicle or object is unstable, request fire or rescue personnel to stabilize it before proceeding with patient care. Remember, the life you save, or attempt to save, may TAKE your own.

You are completing your patient care report on a patient who called EMS for shortness of breath. The patient stated that she felt weak. She had cyanosis to her nail beds, diffuse rhonchi in all lung fields, and an oxygen saturation of 89%. Which of these findings should be documented in the "history of present illness" section of your narrative?

Weakness. Weakness is a symptom; it is subjective in that you cannot see, feel, smell, or hear it. Because the patient has weakness in conjunction with her shortness of breath, you should document this, along with other subjective data, in the section of the narrative that addresses the history of present illness. The history of present illness is an elaboration of the patient's chief complaint. By contrast, cyanosis, rhonchi, and oxygen saturation are objective—that is, you can appreciate them with your senses—and should be included in the assessment/physical exam portion of your narrative.

Which of the following situations BEST describes a mass-casualty incident?

When there are two critical patients and one ambulance The first thing that comes to mind when one thinks of mass-casualty incident is the word "mass," which would imply numerous patients. The fact is any situation that depletes your resources and/or ability to effectively manage the situation is a mass-casualty incident. An example would be two critically injured patients and one ambulance. One ambulance and two medics can effectively manage one critical patient. Two critically injured patients would overwhelm them and their resources. Remember, a mass-casualty incident is not defined by patient count but rather how effectively your resources can manage the patient(s), whether they are few or many.

Which of the following is an example of informed consent?

You advise the patient of the potential complications of starting an IV. In order for a patient to give informed consent, he or she must be made aware of your proposed treatment, as well as the potential benefits and risks associated with the treatment. This will give the patient enough information to make an informed decision about his or her health care. Informing the patient of the consequences of refusing EMS treatment and/or transport is called an informed refusal. Expressed (actual) consent is obtained when the patient asks you for help, either verbally or non-verbally (ie, extending their arm so you can take their blood pressure). Implied consent, also known as the emergency doctrine, is based on the assumption that an unresponsive or otherwise impaired person would consent to emergency treatment if they were not in their present condition.

During an attempted resuscitation of a 78-year-old woman in cardiac arrest, you apply the defibrillation pads and turn on the cardiac monitor. Her cardiac rhythm reveals asystole. Suddenly, the machine shuts off and will not turn back on when you push the power button. You continue resuscitative efforts and transport the patient to the hospital, where she was pronounced dead. Upon returning to quarters, you learn that the crew before you also had a cardiac arrest call, but did not replace the batteries in the monitor/defibrillator. In this case:

You and your partner may be held legally accountable for her death. Although the previous crew was derelict in their responsibility to replace the batteries in the monitor/defibrillator, it was you and your partner's responsibility to ensure that all equipment was fully functional when you began your shift. Therefore, you and your partner may be held legally accountable for this patient's death. An attorney would likely be able to prove that failure on your part to replace the batteries resulted in the patient's death (proximate cause). Of course, the previous crew should be reprimanded; however, legal ramifications, if they occur, will rest on your shoulders. Be professionally accountable and take responsibility for your own actions (or inactions). Documenting failure of the off-going crew to replace the batteries does not change the fact that you failed in your job; you obviously did not check your ambulance as you should have. Although asystole is a terminal rhythm in most people, this is completely irrelevant. Furthermore, the patient may have, at some point during her cardiac arrest, been in a shockable rhythm.

A middle-aged man reports severe chest pain. He is conscious and alert to person, place, time, and event. As you are loading him into the ambulance, he tells you that he does not want to be treated or go to the hospital. Which of the following statements regarding this situation is correct?

You must realize that a mentally competent adult can withdraw consent at any time he or she chooses. A mentally competent adult has the legal right to refuse care and to withdraw consent once it has been given. To further treat a mentally competent patient who withdraws consent could constitute assault, battery, or false imprisonment. The patient in this scenario has decision-making capacity; he is conscious and alert to person, place, time, and event.

The MOST effective way to minimize the risk of a single rescuer suddenly bearing unexpected, dangerous weight while lifting a patient is to:

know where rescuers should be positioned as well as how to give and receive commands so that all rescuers lift simultaneously. Lifting and carrying are dynamic processes; regardless of a patient's weight or how many rescuers will be involved in the lift, the effort must be coordinated. To ensure that no individual suddenly bears unexpected, dangerous weight and to reduce the risk of injury to the rescuer or patient, you must know where rescuers should be positioned and how to give and receive lifting commands so that all parties lift simultaneously; this will facilitate a coordinated lift. The patient's weight dictates the number of rescuers needed for safe lifting and carrying, not the individual's maximum weight-carrying ability. You should estimate (or ask) how much the patient weighs before attempting to lift him or her. Commonly, adult patients weigh between 100 and 210 lb. If you use the correct technique—keeping your back straight and using the strength in your legs to lift, not your back—you and one other rescuer should be able to safely lift this weight. However, you should not attempt to lift a patient who weighs more than 250 lb with fewer than four rescuers, regardless of individual strength. If a patient is supine on a backboard or is in a semi-sitting position on the stretcher, his or her weight is not equally distributed between both ends of the device. Between 68% and 78% of the body weight of a patient in a horizontal position is in the torso; therefore, more of the patient's weight rests on the head end of the device than on the foot end.