EMT Pass Section 2 - Test 1

After falling down a set of stairs an 86 year old male is disoriented, tells you his elbow hurts during your assessment and is able to blink his eyes on command. His Glasgow Coma Score is

13.

The anatomy of an umbilical cord includes

2 arteries and 1 vein.

Within a minute following delivery a neonate has blue hands and feet, a heart rate of 160, a strong cry and is moving all extremities. You should record an APGAR score of

9 RATIONALE This is a well newborn. Good HR, crying, moving all extremities and has only some discoloration so the score is 9. The APGAR scale is either a 0, 1 or 2 and the majority of positive findings should cause you to look toward the higher numbers. Remembering an APGAR score in the unlikely event you actually deliver a newborn is not important and should be accomplished when an APGAR scoring chart is present. Care of the newborn and resuscitation is the highest priority. The other choices are not correct. If you are confronted with a "scoring" type question, they are often missed by a majority of candidates so don't get discouraged if you aren't sure of the answer. Just keep answering as many questions as you can correctly.

What change below should cause you the most concern if it occurred during pregnancy?

A BP of 160/88.

Which of the following patients should be transported by helicopter when the hospital is 30 minutes away by ground ambulance?

A car crash victim with a flail chest and hemoptysis

An 84 year old man is in a nursing home recovering from a stroke he had two months ago. The nursing home staff suspect he's had another stroke. What sign or symptom should most likely cause you to also suspect he has had another stroke?

A change in his physical abilities

On arrival a 16 year old boy has irregular chest wall movement after falling from his 4-wheel vehicle. His vital signs are BP 104/82, P 96, R 12. How should you manage his irregular chest wall movement?

Assist his ventilations

Which of the following risk factors can be predictable in regard to the presence of elder abuse?

Bedridden, incontinent, frail, and with dementia

If present, which of the following findings represents the most serious finding in a patient with an eye injury?

Blood in the anterior chamber of the eye RATIONALE Blood in the anterior chamber of the eye is called hyphema, a true medical emergency. This condition is very difficult to assess but if found requires rapid treatment. If the upper eye lid was lacerated it would not cause blood to collect within the chamber of the eye. Ruptured vessels in sclera cause the whites of the eye to be "bloodshot." A detached retina will cause "spotting" in the patient's vision.

A 19 year old male protester was hit on the forehead with a night stick. He has a 3 inch laceration from his scalp line to between his eyebrows. On examination you are able to see his skull. Bleeding continues. What is unique regarding this wound?

Blood vessels in the scalp do not vasoconstrict.

Which of the following is a critical part of the reasoning when forming a field impression in the elderly population?

Comorbidity

What unique aspect of care must you be aware of when caring for a patient who has a dialysis shunt?

Do not take a BP in the extremity with a shunt.

Which of the following factors, if present when treating a burn patient, should cause you the most concern regarding the patient's condition?

If the patient was burned in a closed space area RATIONALE The stem of the question asks for the most concern; all of these are concerns. Being burned in a closed space implies smoke inhalation, and since this also includes burns, impending airway closure via edema is of most concern. Percent body surface burned is a long term care problem. Almost all chemical agents are dusted off and/or washed with copious amounts of water. Patients with critical burns are best managed in a burn center but this stem does not say anything about this being a critical burn.

You arrive and discover your patient is unable to speak due to deafness since childhood. How should you communicate with this patient?

In writing RATIONALE Do not forget that if a patient cannot speak, he/she may be able to read. Unless you and the patient are proficient in sign language don't attempt it - if they are proficient you'll just confuse them. Some patients can read lips, but reading is more likely. You can request patients in pain to point to painful sites but this is not helpful if the patient is not in pain.

Thirty minutes after blunt trauma that has resulted in a liver laceration, inspection of the abdominal wall should show which of the following findings?

Little or no change in appearance

Which of the following is most likely to be injured by the primary blast of an explosion? Heart

Lungs The lungs are hollow organs and hollow organs are most often injured by the primary wave of blasts. The primary wave affects hollow (gas filled) organs via highly pressurized gasses.

Which of the following medications would most likely lead to respiratory depression in a pediatric patient?

Oxycodone RATIONALE Oxycodone is a narcotic and in high doses causes respiratory depression. Diphenhydramine causes drowsiness but not respiratory depression; it's an antihistamine. Pseudoephedrine is a vasoconstrictor drug used to relieve symptoms in a common cold. Aripiprazole does not cause respiratory depression and likely you've never heard of it; don't pick something you've never heard of on a test.

Many trauma systems ask that EMS providers "score" patients at the scene. These scores are then compared upon arrival at the hospital. Trauma scores include which of the following?

Respiratory rate, systolic blood pressure and the total of the GCS

Parents call 9-1-1 when they are unable to arouse a 9 month old baby boy. On arrival he is apneic, pulseless and cold to touch. They tell you he went to sleep four hours ago and they did not disturb him. You should suspect he arrested due to

SIDS.

Which of the following findings should lower your concern as you drive toward a tanker truck crash?

The truck driver is assessing the truck's damage. The truck driver knows the contents of his tanker truck. If he is assessing its damage then most likely the contents are contained or more likely the contents are non-flammable or non-explosive.

A 19 year old fell from a motorcycle. He complains of severe neck pain and is unable to move both of his arms. When requested he moves his toes and tells you he can feel your pinch of his toes. His vital signs are BP 116/76, P 98, R 14. What care should you provide this patient?

Use full immobilization techniques

When compared to an adult, an infant will have

a larger body surface and be prone to hypothermia. RATIONALE Infants have a larger body surface compared to adults and are prone to hypothermia. They have less respiratory reserve and the softer bones of the ribs and long bones make them less susceptible to fractures.

Changes in cognition and sensory ability in the geriatric population are mainly due to

a reduction in the number of brain cells. RATIONALE The brain shrinks as part of the aging process and the result is less cognition (thinking ability). Nothing seems to increase its effectiveness in health as we age. Not all elderly suffer mini-strokes. Nerve cell conduction speed does decrease but loss of brain cells is the best choice based on what was asked in the question. Audio Player

A 6 year old who is allergic to shellfish accidentally ate soup with lobster as an ingredient. This causes an allergic reaction which will cause

a release of histamine in the body.

A 26 year old male who suffered blunt abdominal trauma has bowel sounds in his chest. You should

administer oxygen via non-rebreather mask. RATIONALE He has a ruptured diaphragm and needs oxygen. The lungs have large reserve capacity as one can live with only one lung, so the patient doesn't need assisted ventilations. Applying the anti-shock garment will only make his condition worse; it's contraindicated. Humans breathe better sitting up so laying him flat and elevating his legs (Trendelenburg) will also worsen his condition.

A mother has completed the 2nd stage of labor and you are ready to cut the umbilical cord. You should cut the cord

after it stops pulsating. The most recent guidelines advise allowing as much maternal blood as possible to enter the baby before cutting the cord, so wait until the cord stops pulsating before cutting the cord. Do this before the placenta is delivered. It is unlikely you'll know the second the placenta separates from the uterus, just cut the cord when it stops pulsating. Every delivery will be different so assuming a cord will stop pulsating after you complete the 5 minute repeat APGAR score is incorrect.

A 3 year old boy ingested a corrosive substance. You should expect your care will be centered around

airway management.

A 23 year old female was rescued from a home fire. She has facial burns, singed hair, and speaks with a hoarse voice. Her vital signs are BP 146/88, P 112, R 18. Your primary concern should be her

airway. RATIONALE Any patient with a hoarse voice after being in a burning environment can easily progress into airway obstruction. Airway maintenance is a primary concern. Skin and eye injuries are secondary EMS concerns. An inhalation injury is a serious concern as well but not as much as potential airway obstruction from edema.

Assessment of pediatric patients begins with

appearance, work of breathing and circulation to the skin.

Law enforcement calls you to the scene of a shooting where a 19 year old male is speaking softly that he's been shot in the left leg. You see a small amount of blood spurting from an upper leg wound. His vitals are BP 96/82, P 122, R 16. You should first

apply a tourniquet to his left leg.

You arrive at a small workshop where a worker has his left hand wrapped in a blood-soaked towel. When you inspect the wound, blood spurts out of a vessel. You should dress the wound and

apply direct pressure. RATIONALE Apply direct pressure. This vessel will bleed a long time and require a serious amount of pressure. A tourniquet is an attractive answer but this situation is not emergent or dangerous for the team so direct pressure works best for this stem. Compressing the lower arm arteries is a secondary management technique and so is elevating his hand. Direct pressure is the best answer.

A 32 year old was playing volleyball when he jumped in the air and landed on the external side of his left foot. When you arrive you should first

apply ice to the injured area. RATIONALE Applying ice reduces swelling, most often seen following ankle sprains. You can then assess for distal pulses and sensation. Splinting with a pneumatic splint would be fine but applying ice is more effective for sprains. It is difficult in the field to differentiate an ankle sprain from an ankle fracture; treat them the same.

The majority of hemorrhage that causes an epidural hematoma is a/an

arterial blood vessel. RATIONALE Bleeding into the epidural space is most likely arterial. Subdural bleeds are venous. Meninges can be irritated by blood, virus or bacteria. When bridge veins are torn they cause subdural bleeding.

A 36 year old calls you because he has been unable to stop the bleeding of a right lower arm laceration. The best method for you to determine if he has hemophilia is to

ask him if he has a bleeding disorder.

A 6 year old girl with a history of asthma tells you "my meds aren't working." Her caregiver says she has been using her inhaler all day. As you prepare for transport she becomes sleepy and difficult to arouse. Her vital signs are BP 88/68, P 128, R 26 and shallow and her SpO2 is 88% on oxygen. You should

assist her ventilations with a BVM. RATIONALE Because this child has a decreasing level of consciousness, she has progressed to respiratory failure. You should assist ventilations. Assisting ventilations can occur intermittently, not continuously, until she is oxygenated enough to show improvement. You may have to return to assisting ventilations as the call progresses. Another dose of her inhaler won't help in treating the respiratory failure. Just transporting faster doesn't improve her oxygenation and with decreased LOC she should not receive fluids by mouth.

A male 4 wheel driver turned the vehicle over at a high rate of speed and struck a tree. Your exam reveals a soft, swollen area on his head, an angulated right lower arm and an angulated right upper leg. His vital signs are BP 146/86, P 82, R 6 and irregular. You should first

assist his ventilation with a BVM at 12 bpm. RATIONALE Careful analysis of vital signs is critical. When someone is ventilating at a rate of 6 breaths per minute and it's irregular, that person needs assisted ventilations. Note the stem says "first." EMS does not reduce fractures. Immobilization is correct but it better be rapidly applied because this patient is severely injured. Oxygen by any mask indicates a failure to recognize the need for ventilations.

Ambulance crashes occur most often

at intersections.

A 19 year old was working on a farm when he was struck by machinery. When you arrive the skin and muscle of his upper leg have been torn off and are unattached. You would classify this wound as a/an

avulsion.

Following injury, as blood loss continues the body's feedback systems become alerted by

baroreceptor stimulation.

A 19 year old male was shot in the right upper arm. You arrive minutes later and police have secured the scene. The victim is supporting his lower arm against his abdomen. You see active bleeding and bone fragments in the wound. His vital signs are BP 86/68, P 108, R 16. You should suspect a laceration of the

brachial artery. RATIONALE The answer is brachial artery. He's holding his lower arm against his abdomen and his vital signs represent serious blood loss, thus it's not venous. The glenohumeral artery is up in the shoulder and unlikely the location.

An increase in intracranial pressure that pushes down on the brain will cause hypoperfusion of the

brain stem.

A 16 year old is stabbed in the left side of his chest with a knife. On arrival his vital signs are BP 148/82, P 96, R 18 and SpO2 is 86% on room air. You see jugular vein distention. He has bilateral breath sounds. You should suspect

cardiac tamponade.

A 78 year old man was struck by a car crossing the street. When you arrive he is lying in the roadway, has a scalp laceration and angulation of the right radius and femur. His pelvis is unstable. As you begin to package him, he become unconscious and apneic. You should first

check for a pulse.

A 5 year old girl with a history of asthma is short of breath. When you arrive you find a 40 lb girl who tells you she has not taken her medications because her mother did not buy them. Her development seems retarded. You suspect possible

child neglect.

You are called by law enforcement to a domestic disturbance where a 29 year old man has multiple human bite marks that have capillary bleeding. The man has no other injuries and refuses transport. You should

clean the wounds, explain the likelihood of infection and have him sign a refusal form.

A 3 year old girl has nausea and vomiting for two days. Her parents call because she won't eat. When you arrive she is listless, has delayed capillary refill, dry skin and a rapid, weak pulse. You should suspect

compensated shock.

A 21 year old was shot in the left upper leg. He is in pain, has upper leg swelling and instability. You apply a traction splint in order to

control hemorrhage.

A 14 year old boy fell while riding rounding a curve on his bicycle and struck his head against a curb. He is unconscious and has a long scalp laceration with underlying bone fragments exposed. You should first

control his hemorrhage.

At a bar fight a 24 year old male was struck on the side of his head. When you arrive he is unconscious and has a hematoma on the right side of his head. His skull is soft on palpation. You should suspect a/an

depressed skull fracture.

Injuries to a specific area of the spine can be assessed by palpating the sense of feeling on the skin via

dermatomes.

An apnea monitor sound awoke parents. They assessed their infant son who reportedly was not breathing. They stimulated him and called 9-1-1. When you arrive the infant is breathing on his own. His vital signs are P 160 and R 28 and his SpO2 is 98% on room air. You should first

determine what care the parents provided.

Most chemical burns are initially managed by flushing with large amounts of water for extended periods of time, except chemicals that are

dry powders.

A 26 year old male was in a domestic disturbance 3 hours ago and was struck on the left side of his head with a baseball bat. When you arrive he is unconscious and difficult to arouse. His family says when he was struck he stopped fighting and was unconscious for about 15 minutes. When he awoke he was calm and after a few minutes he went to bed to sleep. You should suspect a/an

epidural hematoma.

At a scene where a chemical weapon was used you should be alert for patients who have

excessive salivation, loss of bowel function and tearing.

When a female has an ectopic pregnancy the ovum has likely attached to the

fallopian tube.

The most frequent cause of trauma and hospital admissions in the elderly is

falls.

You are first to arrive on scene. You determine flares will help secure scene safety. You should place flares

far apart and enough flares to allow approaching vehicles to stop. RATIONALE When placing flares, place them so that oncoming traffic has time to stop.

You arrive to find an unconscious driver in his seat with the doors locked. When you try to arouse him he cannot open the door. You should

gain simple access. RATIONALE Simple access means use of simple extrication tools, such as a spring loaded center punch and other hand tools. There is no need in "cutting the door off" when you can gain access by another method.

While transporting you are attending a neonate and mother following delivery. The mother has a contraction and you see the placenta at the birth canal. You should

guide the placenta out when its delivery is natural.

Alcoholic patients are subject to receipt of subdural hematomas because they

have liver diseases. RATIONALE The liver produces the products necessary for hemorrhage control. When it is diseased these products are reduced and the patient has bleeding tendencies. Alcoholics often have liver disease. They do fall often but the force of the fall does not make them susceptible to subdural hematomas; comorbid liver disease is the cause. The brain of an alcoholic actually becomes smaller, thus hypotrophy is more common. Alcoholics are victims of violence but that does not imply they will have subdural hematomas unless the comorbid liver disease is present.

A 19 year old male was slashed across the throat during a fight. When you arrive at his home his neck is wrapped in a towel and he is unconscious. The wound is deep and not bleeding. His vital signs are BP 86/palp, P 124, R 22 and shallow. You see little blood on scene. You should suspect

he was stabbed in another location. RATIONALE When you suspect a patient is in hypovolemic shock (as this person is) and you do not see large amounts of blood on the scene, then most likely the patient has moved away from the site of the trauma incident. In these cases you must trust your physical findings as large pools of blood are not present in every case. Profound hypotension does decrease bleeding but mainly because there is no blood left in the body to bleed. First aid care could stop arterial bleeding but if that happened his B/P would not be 86 systolic. Note a B/P written as 86/palp means the B/P was taken by palpation. Again, a 19 year old most likely doesn't have cardiac failure so only trauma (specifically arterial bleeding) is the cause of his low B/P.

A 22 year old farm worker has the lower part of his left arm caught in an auger. He is in pain with a moderate amount of bleeding. His vital signs are BP 132/82, P 103, R 16. You should suspect his bleeding is minimal because

his blood vessels are tamponaded. RATIONALE Heavy weights or industrial compressors on injured limbs will result in little bleeding until the compression is released. This mechanism is acting like applying direct pressure. Even an artery injury won't bleed profusely under these circumstances. Crushing injuries can cause severe bleeding especially if the crushing mechanism is removed. That choice is not specific enough to be the correct answer. When someone is caught in an auger and a minimal amount of bleeding is present, it's not because his vessels have clotted and you will discover this when whatever is crushing his limbs is removed.

You are called to a school where a 12 year old girl with diabetes was irritable, weak and disturbing the class. You learn she did not eat her lunch. You should suspect

hypoglycemia.

A 29 year old mother of two children has had RLQ tenderness for the past two hours. She has a low grade fever and denies diarrhea and blood in her urine. She reports she missed her last menstrual period but doesn't believe she is pregnant. Her vital signs are BP 106/86, P 100, R 16. You should treat her for

hypovolemic shock.

In children the most frequent cause of bradycardia is

hypoxia.

A 19 year old male is shot in the right side of his chest. You auscultate his breath sounds for the presence of blood and expect to hear

increased breath sounds over lower right posterior chest when compared to the lower left chest.

A patient has distended jugular veins after being shot in the chest. The presence of this sign indicates

increased pressure in the chest.

When a patient is rescued from a burning building the primary cause of concern is

inhalation injury from toxic gases.

A 42 year old man was struck by a car while crossing the street. On arrival he is unconscious, has a scalp laceration and an angulated lower left leg. His vitals are BP 92/68, P 124, R 16. His breath sounds are clear. You should suspect

intra-abdominal bleeding.

A young male was beaten and stabbed. You find him lying in an alley unconscious with a 12" pool of blood near his head. Your physical exam reveals a deep 3" scalp laceration, multiple body contusions and puncture wounds, fractures of the right lower arm and ribs. His vital signs are BP 92/78, P 116, R 20 and SpO2 is 92%. His breath sounds are increased on the left. You suspect the cause of his hypoperfusion to be

intrathoracic bleeding.

The role of continuing education in EMS is to

know changing therapies.

The origin of bacteria that causes septic shock in a hypotensive victim that has an abdominal gunshot wound is the

large bowel RATIONALE The large bowel contains many bacteria that play a role in digestion of food (called normal flora). If these bacteria escape the bowel into the peritoneum, infection will result. The small bowel contains digestive juices which also digest food but doesn't contain many bacteria. The liver should be aseptic, meaning without bacteria. The bladder does not contain bacteria.

The sign you should assess which indicates a child in respiratory distress has transitioned to respiratory failure is a change in

level of consciousness.

The majority of cervical injuries occur when the

ligaments connecting spinal bones tear. RATIONALE Dislocation of the bones of spinal column occur when the ligaments of the spinal bones tear. Remember ligaments attach bone to bone. A spinal bone can fracture without there being cord damage. Transection of the spinal cord is rare; most commonly injury occurs from compression of the cord. Head striking the windshield following vehicle trauma does occur but the strike causes the tear of the spinal bone ligaments.

A patient with cardiac tamponade will have hypoperfusion of the brain due to a/an

loss of cardiac afterload.

After delivery a newborn is covered with a tarry substance that is greenish black. You suspect this is

meconium.

Irreversible cell death occurs when the cell

membrane ruptures.

A 21 year old male jumped from a window on the third floor to escape fire. He has a left upper leg which is shortened, angulated and deformed. He is in severe pain. You should suspect

mid-shaft femur fracture.

An athlete leaves the field and is unable to answer common questions. When his team resumes play he is acting normal and responding normally. You should

not allow him to resume play.

Your partner requests assistance in managing a bariatric patient. You know he needs assistance because the patient is

obese.

The hormone which increases the strength of uterine contractions and is secreted when a newborn nurses is

oxytocin.

An 89 year old female was walking at home and fell. When you arrive you determine she is not able to ambulate and her left leg is shorter than her right leg. She has point tenderness over the greater trochanter of her left leg. You suspect she has a

pathological fracture.

A 320 pound, 5'6" male calls you because he is having severe lower back pain. Patients with this type of condition most likely are seeking

physician-prescribed pain medications.

A 36 year old female is 8 months pregnant and is experiencing painless vaginal bleeding. You should suspect

placenta previa. RATIONALE Painless vaginal bleeding in the third trimester likely indicates the placenta has grown over the cervix opening and when cervical dilation begins, the bridging blood vessels between the placenta and the uterine wall will rupture and cause bleeding, thus placenta previa. A progesterone imbalance is not the cause. A bloody show happens when the cervix dilates as contractions begin. Endometrial sloughing occurs during normal menstrual bleeding and is not part of pregnancy. Audio Player

A 14 year old fell from his bike striking his clavicle against a curb. On examination you find a fracture of the clavicle and the 1st and 2nd ribs. You should suspect an underlying

pneumothorax and major vessel injury. RATIONALE Injuries high up in the chest that fracture ribs 1 and 2 present with serious underlying complications because vessels and nerves are near the surface of the chest wall in this location. So, pneumothorax and major vessel injury should be suspected. The stem does not indicate ribs 1 and 2 are fractured in two places so flail chest is unlikely. This injury is too far from the heart, so cardiac tamponade is unlikely. There might be some blood in the chest but this injury is far from the trachea and major ventilation anatomy so subcutaneous emphysema is also unlikely.

A 64 year old male with a history of hypertension has epistaxis. You have tried to control the hemorrhage without success. You begin transport and suspect he has a

posterior nasal bleed.

A 22 year old tells you she is expecting her first child and that her contractions are 8 minutes apart. You should

prepare for transport.

A 19 year old male was shot in the abdomen with a small caliber weapon. When you arrive he is conscious and upset about being shot. His vital signs are BP 108/82, P 104, and R 14. He complains of no other injuries. You should first

prepare for transport. RATIONALE The narrow pulse pressure in an upset patient indicates he's bleeding into his abdomen. The definitive care for internal bleeding is surgery, so prepare for transport should be your first priority based upon these assessment findings. Hypovolemia is not caused by an abdominal wall wound. In this case you can treat his abdominal wall wound, administer oxygen and assess his abdomen while in transport.

At the scene of a house fire you approach a man who is lying in the front yard in severe pain with 35% body surface burned. When conducting your physical examination and treatment your focus should be on

prevention of infection.

The important principle to use when applying any type of pelvic splint is to

provide stability to the pelvis in an anatomical position.

You are called because the mother of a 6 month old tells you her son has had diarrhea all day. He only nurses for "a minute or two," and then falls asleep. She tells you his diapers have remained dry most of the day. You assess poor skin turgor. You should

rapidly transport to a pediatric hospital.

A 3 year old has a scalp laceration. You have controlled the bleeding and are preparing for transport. Your ambulance does not have an approved child safety seat. You should

refuse transport until a seat is installed.

A 76 year old male tells you he is unable to see to the right out of his right eye. He says yesterday and this morning he saw, "dots floating in his eyes." You should suspect

retinal detachment.

A 22 year old received blunt trauma to his abdomen. During your assessment you hear bowel sounds in his right chest. You should suspect

ruptured diaphragm. RATIONALE The bowel sounds in the chest indicate the most likely cause of his condition is a ruptured diaphragm. This sign is difficult to detect. A fractured liver is similar to a lacerated liver and there would be considerable bleeding in the patient but not bowel sounds in the chest. The spleen is located on the left and again doesn't cause bowel sounds in the chest. Portal hypertension has nothing to do with trauma.

You are in the warm zone of a scene where a suspected nerve agent was deployed. Suddenly you begin tearing and then have difficulty breathing. Within a few seconds you are nauseated. You should immediately

self administer an injection of DuoDote. RATIONALE You have been exposed to a nerve gas and must self-administer DuoDote. The other options may be OK, but you'll first need the DuoDote.

The major complication that arises from a laceration of the large bowel in a trauma patient is

septic shock. RATIONALE When the large bowel is perforated large amounts of normal flora (bacteria within the colon that helps in digestion of foods) will pour into the abdominal cavity. This will begin the infectious process that if not managed by surgery and antibiotics will lead to sepsis. Hypovolemia results from injury to solid organs (liver, spleen, etc.) and not from hollow organs. Adhesions (like scar tissue, that abnormally bands tissue together) is a complication of injury and surgery so this would not be the major complication in the acute phase of an injury. The bacteria from a large bowel perforation will cause peritoneal irritation if untreated but the infectious process that results will take hours to develop; thus the need for surgery.

You are the first to arrive at a mass casualty event. You should first

set up an Incident Command System. RATIONALE Knowledge of the Incident Command System is a national standard. The first to arrive sets up the system. It is tempting to begin triage but that will take you away from your duties. You can always be relieved by a more senior provider. Make sure you understand the roles and positions of the Incident Command System.

Immediately after delivery of the head you observe the umbilical cord around the neonate's neck. You should

slip the cord over the infant's head.

When driving with red lights and sirens, as you approach a curve you should

slow down, brake and accelerate leaving the curve.

A 56 year old man is in respiratory arrest following a head-on car crash while not wearing a seat belt. As you conduct a rapid extrication you palpate an irregularity in his cervical spine. You should suspect his arrest is due to

spinal cord compression above the C-4 level. RATIONALE This patient has spinal cord compression as evidenced by the irregularity in his cervical spine. He could also have comorbid head trauma but once his cervical spinal cord is compressed above C-4 the cause of respiratory arrest is likely due to the spinal column dislocation and pressure on the cord. Tension pneumothorax is a poor choice in this scenario. There is nothing within this stem to suggest a ruptured diaphragm.

Friends rescued a swimmer from a pond after he dove from a boat pier. When you arrive he is breathing but unconscious. His vitals are BP 90/64, P 72, R 16 and SpO2 is 93% on room air. Your physical examination reveals a scalp laceration which is no longer bleeding. You should suspect

spinal shock. RATIONALE The best choice based upon the vital signs provided in the stem is spinal shock. Near drowning that results in an SpO2 level of 93% is unlikely. A drug overdose could lead to these signs but you better question his friends before you come to this conclusion. A subdural hematoma could result from striking his head but it would be of a slower onset. You will need to immobilize this patient.

A 10 month old boy fell down a flight of stairs. You find him crying. He has an angulated right lower arm and a dislocated left shoulder. You see multiple bruises on his lower extremities. You should first

splint the fractures. RATIONALE Treat the patient first in all cases. If you suspect abuse report that later. In this case, you've likely been called to the home of a very active child who is learning to walk. You'll likely be told by the parents what caused the fall, but it is a good question to ask. The mechanism of injury is the fall. There is no indication this child needs oxygen.

A 34 year old female complains of low abdominal cramping and moderate vaginal bleeding. She says she had a positive urine pregnancy test 6 weeks ago. Her vital signs are BP 122/68, P 96, R 16 and SpO2 is 98% on room air. You should suspect

spontaneous abortion. A spontaneous abortion is one that occurs naturally. This person is 6-8 weeks pregnant and this is often termed a "miscarriage." The true medical term is spontaneous abortion. Menstrual sloughing is normal and does not occur during pregnancy. An ectopic pregnancy happens when a fertilized ovum becomes obstructed in a fallopian tube and continues growth in the tube; it's unlikely to be seen 6-8 weeks following a positive pregnancy test. Endometriosis occurs in some females but has nothing to do with pregnancy. Audio Player

A 15 year old called you because her "menstrual cramps" are more painful than typical. She says she missed her last period. You learn she passed a large "blood clot" which she flushed down the toilet prior to your arrival. You should treat her for

spontaneous abortion. RATIONALE Of the choices, spontaneous abortion is the best answer. An ectopic pregnancy is unlikely as large blood clots are not typically passed when a fallopian tube ruptures. She does not have dysmenorrhea, (painful menstruation), which typically presents with some infection, or from a uterine disease. Pelvic inflammatory disease (PID) is unlikely because she passed a large clot and because PID often presents with foul smelling vaginal discharge.

After a car crash an unconscious victim is found unbelted in a car resting on its side. You should first

stabilize the car.

You are called to a school where a 7 year old boy has a pencil stuck in his eye socket immediately lateral to his nose. He has vision out of that eye. You should

stabilize the pencil RATIONALE Never remove an impaled object unless it is blocking the airway. You should use a method to stabilize the pencil. You do not need consent to treat this child as the school summoned you to treat him. In most cases covering both eyes of a patient with an eye injury now creates a "blind" patient who is much harder to care for. The choice to cover both eyes is a judgment your team should make based upon circumstances or protocols. Audio Player

A newborn has a low 1 minute APGAR score and continues to struggle to adapt. Despite your stimulation, after 60 more seconds his pulse rate is 52 bpm. You should

start chest compressions. RATIONALE A neonate who has an initial pulse below 60 needs chest compressions. Ventilations with a BVM are difficult on a neonate and this child needs circulation support first. Suction should have already been accomplished if necessary. If the pulse rate is not above 60 within one minute, support circulation with chest compressions. Audio Player

A 29 year old was stabbed in the abdomen with a 6" knife during a domestic dispute. When you arrive 30 minutes later he is guarding his abdomen and his hips are flexed. You should suspect

stomach perforation. RATIONALE This patient has chemical peritonitis, meaning his peritonitis is caused by the acidic chemicals found in his stomach. These are the same chemicals that digest food. The guarding and flexed hips point to this type of pain and irritation. The spleen is an encapsulated organ so it will bleed into the capsule first and if bleeding continues it will rupture and cause profound hypotension. Spleen injuries can be difficult to detect. Blood in the abdomen takes time to cause peritonitis as the pH of the blood is not acidic enough to cause rapid onset of peritonitis. Large bowel lacerations leak fecal matter into the peritoneum and this causes infectious peritonitis; a process that also takes longer than 30 minutes to develop. The most likely answer is stomach perforation.

An athlete was running fast and slowed down to immediately hold the posterior section of his upper leg. You are unable to find any edema or discoloration. This type of injury is most likely a

strain.

A 12 year old boy fell from his bicycle and complains of upper leg pain. You begin to assess the injury and he screams, "Don't touch my leg!" In order to assess if he has a bone fracture you should

strike his heel with the palm of your hand.

A patient who shows signs of peritoneal irritation soon after penetrating abdominal trauma should be transported

supine with knees and hips flexed. RATIONALE You can best assess and re-assess a patient who is supine. And this patient will be most comfortable with his knees and hips flexed. The recovery position is a good alternative but not the best choice. Trendelenburg will make it more difficult for him to breathe. High Fowler's with feet elevated will be uncomfortable and he likely will not remain in that position.

A 30 month old toddler boy has ingested an unknown number of Lomotil pills. His mother says she was taking the pills to help with diarrhea. The toddler is tachycardic and drowsy. You begin transport and

take the remaining pills to the hospital.

You should remove an impaled object if it is impaled in

the airway; obstructing airflow. RATIONALE Remove any impaled object that obstructs airflow. Never remove an impaled object in the abdomen, joint or eye.

When you inspect a 2 cm laceration, the decision to transport after bleeding has been controlled should be dependent upon

the type of scar that would develop without proximating the wound edges. RATIONALE Basically when hemorrhage has stopped the next assessment is to determine if "stitches" or proximation of the wound will be necessary. Tetanus vaccine is recommended every 10 years. Location has some bearing on the need for wound closure but the fundamental principle is to decide if closure is necessary. Consent is always necessary but in most systems a wound that does not need proximation of the edges is a non EMS transport call.

Your call is on a single lane roadway where a car has crashed into another car. As you approach the crash you should park your ambulance

to block both lanes of traffic.

You are providing support at a high school football game when you are called to the field. A player has knee pain. You should assess his knee for the presence of

torn ligaments.

You respond and find a 2 year old boy with a 1 inch scalp laceration. His parents insist you take him to the hospital. You should

transport him without lights and sirens.

The major complication with a flail chest is the

underlying pulmonary contusion.

An unbelted 66 year old male driver extracted himself after a car crash. When you arrive he has a bruised chest and you see a cracked steering wheel. He is sitting in a safe area away from the car. His vital signs are BP 116/84, P 104 and irregular and R 22. When you are transporting him you should prepare for

ventricular fibrillation. RATIONALE This man's symptoms and mechanism of injury most likely indicate he has a cardiac contusion. Thus monitoring for an onset of cardiac arrthymia leading to ventricular fibrillation is the answer. The vital signs don't fit with tension pneumothorax as nothing in the stem is reported regarding breath sounds. He will have a pulmonary contusion but that is well tolerated, not treatable in prehospital care and unlikely the cause of his symptoms. Spitting up blood (hemoptysis) isn't the answer.

At a mass casualty event a 22 year old male has a closed fracture of his left lower leg. You should tag him with a

yellow tag. RATIONALE This victim will receive a yellow tag. Even if you don't know the "tag" system used in triage, think that black is dead, green is ambulatory, yellow is caution (some injuries that can be managed later) and red is critical. There is no orange tag.