Sample Questions: Paramedic Operations

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? A: Bronchopulmonary dysplasia B: Cystic fibrosis C: Myasthenia gravis D: Congestive heart failure

*A: Bronchopulmonary dysplasia* Reason: 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.

Which of the following should be your MOST immediate priority when caring for a patient with an acute behavioral crisis? A: Personal safety and standard precautions B: Managing any concomitant medical problems C: Avoiding any confrontation with the patient D: Providing safe transportation to the hospital

*A: Personal safety and standard precautions* Reason: 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.

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? A: You must advise the patient that once he is in the ambulance, you must transport him to the hospital. B: You must realize that a mentally competent adult can withdraw consent at any time he or she chooses. C: Inform the patient that he can only refuse care if a family member will assume responsibility for him. D: The patient must be transported to the hospital because he does not have decision-making capacity.

*A: advise the patient that his refusal could ultimately result in death* Reason: 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.

Which of the following clinical presentations is MOST consistent with exposure to chemicals such as tabun, sarin, and soman? A: Hypertension, dysphagia, bronchospasm, blistering B: Photophobia, abdominal pain, tachycardia, headache C: Rhinorrhea, nausea and vomiting, bradycardia, polyuria D: Hematemesis, seizures, diplopia, spontaneous bleeding

*A: explain the situation to her husband and son and recommend cessation of resuscitative efforts* Reason: 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.

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: A: 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. B: quickly suction his airway, intubate his trachea without delay, insert an intraosseous catheter, and give sequential 20 mL/kg boluses of an isotonic crystalloid solution. C: decontaminate him, insert a Combitube and ventilate him, establish vascular access, apply the cardiac monitor, and begin transcutaneous cardiac pacing. D: suction his mouth, irrigate his body with water for at least 5 minutes, apply the cardiac monitor, hyperventilate him with a bag-mask device, and give 600 mg/kg of pralidoxime IM.

*A: 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* Reason: 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.

Which of the following situations would MOST likely constitute negligence? A: A focused physical examination is performed on a patient with an isolated closed fracture of the left femur. B: A patient involved in a major motor vehicle crash is not immobilized because he was ambulatory at the scene. C: A paramedic applies a nasal cannula to a man with respiratory distress who will not tolerate a face mask. D: The paramedic must wait 20 minutes at the hospital because a nurse is not available to take a report.

*B: A patient involved in a major motor vehicle crash is not immobilized because he was ambulatory at the scene* Reason: 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.

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? A: Politely ask the man to leave and resume resuscitation. B: Continue resuscitation and ask for a valid living will. C: Transport the patient to the hospital, providing BLS only. D: Cease your efforts after 5 minutes of full resuscitation.

*B: Continue resuscitation and ask for a valid living will* Reason: 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.

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: A: assess for a peripheral pulse and determine his level of orientation. B: assign him an immediate triage category and move to the next patient. C: move him to the treatment area and administer high-flow oxygen. D: assign him a delayed triage category and move to the next patient.

*B: assign him an immediate triage category and move to the next patient* Reason: 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.

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: A: transport sector. B: staging area. C: triage sector. D: command post.

*B: staging area* Reason: 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.

Which of the following is the MOST effective way to reduce stress and anxiety in a patient who is experiencing chest pain or pressure? A: Allow a family member to drive the patient to the hospital. B: Administer diazepam or a similar medication to the patient. C: Provide reassurance and a safe comfortable transport. D: Tell the patient that he or she is not having a heart attack.

*C: Provide reassurance and a safe comfortable transport* Reason: 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.

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: A: rapidly determine the patient's chief complaint. B: immediately gain the patient's trust. C: perform a cursory mental status assessment. D: obtain expressed consent to provide treatment.

*C: perform a cursory mental status assessment* Reason: 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.

When lifting a patient who is on an ambulance stretcher, you should: A: hold your breath as you lift the patient. B: keep the muscles of the abdomen relaxed. C: position your palms up whenever possible. D: avoid using the muscles of your legs.

*C: position your palms up whenever possible* Reason: 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.

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: A: tell him that only a physician can analyze the 12-lead ECG and determine if he is having a heart attack. B: tell him not to worry, but advise his spouse or another family member of the 12-lead ECG findings. C: tell him that his 12-lead ECG shows an abnormality and that EMS transport to the hospital is necessary. D: minimize his anxiety by telling him that his 12-lead ECG does not reveal any obvious abnormalities.

*C: tell him that his 12-lead ECG shows an abnormality and that EMS transport to the hospital is necessary* Reason: 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.

Which of the following pieces of personal protective equipment will afford you the BEST protection against exposure to tuberculosis? A: Sterile gloves B: A surgical mask C: Gown and gloves D: N-95 respirator

*D: N-95 respirator* Reason: 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.

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: A: tell the patient that there is no evidence that he ever had a heart attack. B: notify his cardiologist and advise him or her that the patient's ECG is normal. C: explain that his cardiologist may have incorrectly interpreted a previous ECG. D: advise the patient that he should seek consultation from his cardiologist.

*D: advise the patient that he should seek consultation from his cardiologist* Reason: 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.

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: A: respect the wife's wishes, notify medical control of the situation, and provide emotional support to the wife. B: advise the wife that you cannot honor her wishes, begin full resuscitative efforts, and transport to the hospital. C: apply the ECG electrodes and withhold all resuscitative efforts if the cardiac monitor displays asystole. D: begin CPR, apply the ECG electrodes, ask her if he has a living will, and contact medical control for guidance.

*D: begin CPR, apply the ECG electrodes, ask her if he has a living will, and contact medical control for guidance* Reason: 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.

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: A: quickly triage both patients in order to determine the severity of their injuries. B: ask the police officer to direct you to the patient who was ejected. C: confirm that there are two patients before requesting additional resources. D: immediately request another ambulance and then begin triaging the patients.

*D: immediately request another ambulance and then begin triaging the patients* Reason: 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.

Which of the following statements is inappropriate to document on a patient care form? A: "The patient appears to need psychiatric help." B: "The possible smell of ETOH was noted at the scene." C: "The patient became very combative on assessment." D: "The patient stated that he is HIV positive."

*A: "The patient appears to need psychiatric help."* Reason: 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.

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? A: Be prepared to spend extra time with your partner and allow him or her talk about the call. B: Advise your partner that most calls end up this way and that he or she must get used to it. C: Send your partner to a busier station so that his or her mind can be taken off the situation. D: Tell your partner to go home for the rest of the shift and sleep for at least 12 to 18 hours.

*A: Be prepared to spend extra time with your partner and allow him or her talk about the call* Reason: 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.

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? A: Bilaterally deformed femurs; severe neck pain; conscious and alert B: Abdominal distention; pallor; responds appropriately to questions C: Anterior neck pain; stridorous breathing; history of type 2 diabetes D: Tibial fracture; hematoma to the forehead; conscious but confused

*A: Bilaterally deformed femurs; severe neck pain; conscious and alert* Reason: 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 diseases accounts for the highest population of patients who receive home health care? A: Cancer B: Diabetes C: Tuberculosis D: AIDS

*A: Cancer* Reason: 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.

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? A: Continue CPR and notify medical control for guidance. B: Do not attempt resuscitation until you have notified medical control. C: Honor the man's request and discontinue resuscitation. D: Tell the man that you are required to perform full ACLS measures.

*A: Continue CPR and notify medical control for guidance* Reason: 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.

Which of the following is the MOST effective way to reduce the mortality and morbidity resulting from trauma? A: Coordinate and conduct injury prevention programs. B: Immediately transport patients with a significant MOI. C: Recognize and manage the early signs of shock. D: Limit on scene time to no more than 10 minutes.

*A: Coordinate and conduct injury prevention programs* Reason: 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 statements regarding to the proper disposal or handling of sharps is correct? A: Dispose of the needle in an appropriate container immediately after use. B: You should detach the needle from a prefilled syringe prior to disposal. C: Wait to retrieve and dispose of all sharps until the call is complete. D: Drop the needle on the floor immediately after starting an IV line.

*A: Dispose of the needle in an appropriate container immediately after use* Reason: 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.

Which of the following clinical presentations is MOST consistent with exposure to a chemical nerve agent? A: Excessive tearing, hypersalivation, bradycardia, and miosis B: Mydriasis, bradycardia, polyuria, constipation, and edema C: Double vision, excessive thirst, diarrhea, and chest pressure D: Abdominal pain, tachycardia, and bilaterally dilated pupils

*A: Excessive tearing, hypersalivation, bradycardia, and miosis* Reason: 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.

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? A: Figure eight on a bite B: Clove hitch C: Half hitch D: Figure eight knot

*A: Figure eight on a bite* Reason: 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.

Which of the following should be your MOST immediate priority when caring for a patient with an acute behavioral crisis? A: Personal safety and standard precautions B: Providing safe transportation to the hospital C: Managing any concomitant medical problems D: Avoiding any confrontation with the patient

*A: Personal safety and standard precautions* Reason: 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.

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? A: Tell the patient what happened each time she asks. B: Give different information each time to assess her level of consciousness. C: Ask the patient if she remembers what happened. D: Tell the patient that the physician will have to tell her what happened.

*A: Tell the patient what happened each time she asks* Reason: 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? A: The defibrillator fails to work because the batteries are dead. B: When carrying a patient, the paramedic slips and drops the patient. C: A medication error was made but corrective action was taken. D: A paramedic inadvertently intubates a patient's esophagus.

*A: The defibrillator fails to work because the batteries are dead* Reason: 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? A: The paramedic could be held liable for practicing medicine without a license. B: The paramedic is legally protected if he notifies medical control after the incident. C: The paramedic followed the standard of care for his level of certification. D: Since the paramedic was off duty, he is protected by the Good Samaritan law.

*A: The paramedic could be held liable for practicing medicine without a license* Reason: 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.

Which of the following situations BEST describes a mass-casualty incident? A: When there are two critical patients and one ambulance B: When there are at least 10 patients and half of them are critical C: When there are three stable patients and two ambulances D: When at least half of the patients are obviously dead

*A: When there are two critical patients and one ambulance* Reason: 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.

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: A: 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. B: ask her why she gave you different information during your prehospital assessment and revise your patient care report to reflect what she told the physician. C: document what the patient told you in the field and then call the hospital after you return to quarters to find out what her admission diagnosis was. D: repeat the entire patient history after the patient has spoken to the physician to ensure that you obtain the most reliable information for your patient care report.

*A: 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* Reason: 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.

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? A: Myasthenia gravis B: Bronchopulmonary dysplasia C: Cystic fibrosis D: Congestive heart failure

*B: Bronchopulmonary dysplasia* Reason: 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 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: A: advise the wife that her husband is dead and that further resuscitative efforts will not change the outcome. B: cease resuscitative efforts only after you have notified law enforcement personnel of the situation. C: attempt transcutaneous cardiac pacing in order to stimulate electrical and mechanical activity in the heart. D: continue CPR and transport since the patient does not possess a living will or advanced directive.

*A: advise the wife that her husband is dead and that further resuscitative efforts will not change the outcome* Reason: 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.

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: A: assess for a palpable pulse. B: place a black tag on the child. C: place a red tag on the child. D: provide five rescue breaths.

*A: assess for a palpable pulse* Reason: 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.

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: A: battery. B: breach of duty. C: proximate cause. D: assault.

*A: battery* Reason: 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.

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: A: be taken to the triage area, which should be a safe distance from the building. B: receive immediate medical care based on the severity of their injuries. C: be moved to the treatment area where they are assigned a triage category. D: be prophylactically decontaminated before being moved to the triage section.

*A: be taken to the triage area, which should be a safe distance from the building.* Reason: 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.

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: A: call for a second ambulance to respond to the scene. B: immediately load both patients and transport. C: contact medical control and request direction. D: provide treatment to both patients and then transport.

*A: call for a second ambulance to respond to the scene* Reason: 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 BEST describes a critical incident defusing? A: A formal process that involves all personnel involved in the incident B: An informal process that is held within 2 to 4 hours following the incident C: An informal process that is held within 24 hours following the incident D: A formal process that is held no longer than 12 hours after the incident

*B: An informal process that is held within 2 to 4 hours following the incident* Reason: 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.

When moving a patient from a house without a carrying device, you should: A: take long steps to expedite your exit. B: avoid twisting when moving around a corner. C: carry the patient over your shoulder if possible. D: walk backwards when moving the patient.

*B: avoid twisting when moving around a corner* Reason: 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.

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: A: comply with his request and notify your supervisor. B: tell him that you understand how he is feeling. C: tell him that talking about it will help him cope. D: arrange a critical incident stress debriefing for him.

*A: comply with his request and notify your supervisor* Reason: 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.

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: A: explain the situation to her husband and son and recommend cessation of resuscitative efforts. B: continue resuscitative efforts and transport only if the patient does not have a terminal illness. C: advise her husband and son that she is dead and ask them if there is anyone you can notify. D: ask the patient's husband if he would like for you to stop or continue and transport his wife.

*A: explain the situation to her husband and son and recommend cessation of resuscitative efforts* Reason: 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.

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: A: immediately request another ambulance and then begin triaging the patients. B: confirm that there are two patients before requesting additional resources. C: ask the police officer to direct you to the patient who was ejected. D: quickly triage both patients in order to determine the severity of their injuries.

*A: immediately request another ambulance and then begin triaging the patients* Reason: 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.

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: A: most frequent age of the participants. B: average age of the research participants. C: midpoint age of the research subjects. D: method used to conduct the research.

*A: most frequent age of the participants* Reason: 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.

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: A: notify dispatch to send additional ambulances and then begin triaging all patients. B: assess the patient's injuries to determine if additional ambulances are needed. C: immediately begin assessing and treating the patients who are still in the vehicles. D: move the ambulatory patients to one area and begin triaging the other patients.

*A: notify dispatch to send additional ambulances and then begin triaging all patients.* Reason: 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.

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: A: place the needle cover on a stationary surface and then slide the needle into the needle cover with one hand. B: place the contaminated needle and syringe in the trash can and properly dispose of it after the call is over. C: carefully bend the needle, break it off at the hub, and tape the needle and syringe to the ambulance wall. D: place the needle on the floor of the ambulance and keep your foot on it until you arrive at the hospital.

*A: place the needle cover on a stationary surface and then slide the needle into the needle cover with one hand* Reason: 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.

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: A: remove his clothing, brush the chemical off his skin, and then irrigate his skin with copious amounts of water. B: administer oxygen, cover him with several blankets to keep the chemical contained, and transport him promptly. C: brush as much of the chemical off his skin as you can and then irrigate his skin with water for 20 to 30 minutes. D: irrigate his skin with copious amounts of water, establish vascular access, and administer a narcotic analgesic.

*A: remove his clothing, brush the chemical off his skin, and then irrigate his skin with copious amounts of water* Reason: 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.

You are assessing a seriously ill patient when you suddenly become nervous and feel as though you are about to hyperventilate. You should: A: take deep breaths in through your nose and out through your mouth. B: initiate progressive muscle relaxation by tensing and relaxing your muscles. C: advise the patient that you are nervous but it will not affect your care. D: calmly dismiss yourself and let your partner resume the assessment.

*A: take deep breaths in through your nose and out through your mouth* Reason: 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.

Where should you position your ambulance when arriving at the scene of a motor-vehicle crash on a two-lane highway? A: 50 feet before the scene on the same side of the road B: 100 feet past the scene on the same side of the road C: 50 feet past the scene on the opposite side of the road D: 100 feet before the scene on the opposite side of the road

*B: 100 feet past the scene on the same side of the road* Reason: 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.

Which of the following patients could you legally treat and transport without his or her consent? A: A 20-year-old male who is now alert after receiving IV dextrose B: A 17-year-old conscious male who has a closed fractured femur C: A 16-year-old married female who is awake and alert after falling D: A 54-year-old male with obvious ST elevation on the 12-lead ECG

*B: A 17-year-old conscious male who has a closed fractured femur* Reason: 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 is an example of providing treatment based on standing orders? A: Requesting permission from your medical director to perform a needle thoracentesis on a patient with a tension pneumothorax B: Defibrillating a patient with pulseless V-tach, performing CPR, administering epinephrine, and contacting medical control C: Administering a bronchodilator medication to an emphysema patient after speaking with his or her personal physician D: Contacting medical control to request following standard protocol for treating a patient with symptomatic bradycardia

*B: Defibrillating a patient with pulseless V-tach, performing CPR, administering epinephrine, and contacting medical control* Reason: 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? A: The patient's anger is typically contained within, with little evidence of his or her feelings. B: Displaced anger is not a personal attack on the individual to whom it is directed. C: The anger stage is typically the last emotional outlet that the patient experiences. D: Anger of the patient, when faced with a terminal illness, is not a typical stage of grieving.

*B: Displaced anger is not a personal attack on the individual to whom it is directed.* Reason: 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.

How does a unified incident command system differ from a single incident command system? A: In a unified incident command system, a single incident commander is identified and will function as such, regardless of the type of incident B: In a unified incident command system, plans are made in advance by all agencies that assume a shared responsibility for decision making C: In a unified incident command system, one agency with several incident commanders has the majority of responsibility for incident management D: In a unified incident command system, a single person is in charge of the entire incident, even if multiple agencies respond to the scene

*B: In a unified incident command system, plans are made in advance by all agencies that assume a shared responsibility for decision making* Reason: 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.

An overturned tanker has a solid green placard on its side and rear. What type of hazard does this indicate? A: Radioactive material B: Non-flammable gas C: Explosive/blasting agent D: Flammable solid

*B: Non-flammable gas* Reason: 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 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? A: Give different information each time to assess her level of consciousness. B: Tell the patient what happened each time she asks. C: Tell the patient that the physician will have to tell her what happened. D: Ask the patient if she remembers what happened.

*B: Tell the patient what happened each time she asks* Reason: 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.

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? A: "I understand how you're feeling; everything will be all right." B: "Things may look bad now, but tomorrow is a different day." C: "I think that it's important for you to go to the hospital." D: "Would you like for us to transport you to the hospital?"

*C: "I think that it's important for you to go to the hospital."* Reason: 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.").

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? A: The cardiac monitor revealed sinus bradycardia at 45 beats/min. B: The patient stated that she does not have a cardiac history. C: According to a bystander, the patient was briefly unconscious. D: Intravenous access was unsuccessful after two attempts.

*B: The patient stated that she does not have a cardiac history* Reason: 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.

Which of the following scene size-up findings is MOST indicative of an unsafe environment when approaching a residence? A: A loud stereo and multiple people making noise inside the residence. B: The sound of breaking glass coming from the residence. C: A dog barking at you as you approach the residence. D: A very large man who greets you as you approach the residence.

*B: The sound of breaking glass coming from the residence* Reason: 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? A: Staging B: Transport C: Triage D: Support

*B: Transport* Reason: 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.

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? A: Cyanosis B: Weakness C: Rhonchi D: Oxygen saturation

*B: Weakness* Reason: 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.

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: A: cease resuscitative efforts only after you have notified law enforcement personnel of the situation. B: advise the wife that her husband is dead and that further resuscitative efforts will not change the outcome. C: attempt transcutaneous cardiac pacing in order to stimulate electrical and mechanical activity in the heart. D: continue CPR and transport since the patient does not possess a living will or advanced directive.

*B: advise the wife that her husband is dead and that further resuscitative efforts will not change the outcome* Reason: 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.

When observing standard precautions, you: A: realize that only blood poses a risk for disease transmission. B: assume that all bodily fluids are potentially infectious. C: are following a safety law established by the federal government. D: should wear gloves and a mask during all patient contacts.

*B: assume that all bodily fluids are potentially infectious* Reason: 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.

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: A: ask your partner to be present so he or she can hear the patient's refusal and sign as a witness. B: ensure that he is made aware of your proposed treatment and the potential risks of his refusal. C: obtain his vital signs and a 12-lead ECG to protect you legally if he is experiencing a heart attack. D: explain to him that because of his age and symptoms, he is probably experiencing a heart attack.

*B: ensure that he is made aware of your proposed treatment and the potential risks of his refusal* Reason: 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.

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: A: continue resuscitative efforts and transport only if the patient does not have a terminal illness. B: explain the situation to her husband and son and recommend cessation of resuscitative efforts. C: ask the patient's husband if he would like for you to stop or continue and transport his wife. D: advise her husband and son that she is dead and ask them if there is anyone you can notify.

*B: explain the situation to her husband and son and recommend cessation of resuscitative efforts* Reason: 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.

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: A: put it in a red bag marked with a biohazard logo. B: place it in a puncture-proof sharps container. C: place it in a clear plastic bag so it can be seen. D: throw it in a trash can that has a plastic liner.

*B: place it in a puncture-proof sharps container* Reason: 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!

You are assessing a seriously ill patient when you suddenly become nervous and feel as though you are about to hyperventilate. You should: A: advise the patient that you are nervous but it will not affect your care. B: take deep breaths in through your nose and out through your mouth. C: calmly dismiss yourself and let your partner resume the assessment. D: initiate progressive muscle relaxation by tensing and relaxing your muscles.

*B: take deep breaths in through your nose and out through your mouth* Reason: 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.

Which of the following is considered an effective method in reducing stress in an obviously anxious bystander at the scene of an emergency? A: Use the bystander for tasks such as crowd and traffic control. B: Tell the bystander that he or she should leave the scene at once. C: Assign the bystander minor, nonpatient care-related tasks. D: Advise the bystander to keep at a safe distance and observe.

*C: Assign the bystander minor, nonpatient care-related tasks* Reason: 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.

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? A: Contact the patient's immediate family. B: Quickly assess the body for other injuries. C: Avoid touching the body if at all possible. D: Apply a cardiac monitor to verify asystole.

*C: Avoid touching the body if at all possible* Reason: 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.

What is the ultimate goal of any quality assurance program? A: Determine solutions to problems that are identified. B: Reinforce the strict adherence to all system protocols. C: Ensure that high quality care is consistently delivered. D: Recognizing those personnel with good performance.

*C: Ensure that high quality care is consistently delivered* Reason: 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 is the MOST effective method for preventing the spread of disease? A: Wearing examination gloves with every patient. B: Wear a mask when caring for patients with tuberculosis. C: Frequent hand-washing, especially in between patients. D: Ensuring that all of your immunizations are up-to-date.

*C: Frequent hand-washing, especially in between patients* Reason: 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? A: Gloves, gown, and a mask B: Gloves and a HEPA mask C: Gloves and safety glasses D: Gloves and a full face mask

*C: Gloves and safety glasses* Reason: 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 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? A: He should receive an immediate assessment, but should not be transported before other critical patients B: He should be assigned a delayed triage category and treated after all critical patients are transported C: He should be assigned an immediate triage category and removed from the scene as soon as possible D: He should be assigned the lowest triage category, but his injury should be splinted as soon as possible

*C: He should be assigned an immediate triage category and removed from the scene as soon as possible* Reason: 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? A: Safely transporting him to the hospital B: Searching him for hidden weapons C: His ability to injure you or your partner D: Gathering any medications that he takes

*C: His ability to injure you or your partner* Reason: 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.

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? A: Timely administration of fibrinolytic drugs B: Criticality of cardiac medication administration C: Importance of early CPR and defibrillation D: Rapid EMS transport to an appropriate facility

*C: Importance of early CPR and defibrillation* Reason: 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.

Which of the following would provide the paramedic with the BEST protection from legal liability? A: Deliver the patient to his or her choice of hospital regardless of the condition. B: Treat all patients and their family members with courtesy and respect. C: Maintain a consistently high standard of care when treating all patients. D: Constantly reinforce your knowledge through continuing education.

*C: Maintain a consistently high standard of care when treating all patients* Reason: 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? A: Woman who was ejected when her car struck a large tree B: Obese woman in cardiac arrest who is in a small bedroom C: Man who fell from atop a mountain and landed on a ledge D: Child who was found floating face-down in a swimming pool

*C: Man who fell from atop a mountain and landed on a ledge* Reason: 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.

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? A: Avoid giving any analgesia because the patient has severe abdominal pain. B: Give the patient 5 mL of sodium chloride and tell her that it is for the pain. C: Notify medical control and seek guidance on how to manage this situation. D: Honor the patient's demands and administer a small dose of morphine.

*C: Notify medical control and seek guidance on how to manage this situation.* Reason: 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.

Which of the following clinical presentations is MOST consistent with exposure to chemicals such as tabun, sarin, and soman? A: Hematemesis, seizures, diplopia, spontaneous bleeding B: Hypertension, dysphagia, bronchospasm, blistering C: Rhinorrhea, nausea and vomiting, bradycardia, polyuria D: Photophobia, abdominal pain, tachycardia, headache

*C: Rhinorrhea, nausea and vomiting, bradycardia, polyuria* Reason: 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.

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? A: Moderately increase the pitch of your voice B: Break a lengthy report into 60-second segments C: State the patient's age as 80, that is, eight-zero D: Repeat each segment of your radio report

*C: State the patient's age as 80, that is, eight-zero* Reason: 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.

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? A: You must advise the patient that once he is in the ambulance, you must transport him to the hospital. B: Inform the patient that he can only refuse care if a family member will assume responsibility for him. C: You must realize that a mentally competent adult can withdraw consent at any time he or she chooses. D: The patient must be transported to the hospital because he does not have decision-making capacity.

*C: You must realize that a mentally competent adult can withdraw consent at any time he or she chooses* Reason: 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.

To ensure the safest response to an emergency scene, you should: A: use escorts such as a police vehicle whenever it is possible. B: exceed the speed limit only when the call is a cardiac arrest. C: always operate the ambulance with due regard for others. D: have your siren on continuously until you arrive at the scene.

*C: always operate the ambulance with due regard for others* Reason: 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.

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: A: perform a rapid head-to-toe assessment while he is in the vehicle, apply a cervical collar, and remove him from the vehicle onto a long backboard. B: establish a large-bore IV line, apply a cervical collar, place a backboard on the seat, and rotate him as a unit as you slide him onto the backboard. C: 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. D: apply a cervical collar, immobilize his torso and head with a vest-style device, place a backboard on the seat, and remove him from the car head first.

*C: 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* Reason: 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.

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: A: apply the ECG electrodes and withhold all resuscitative efforts if the cardiac monitor displays asystole. B: respect the wife's wishes, notify medical control of the situation, and provide emotional support to the wife. C: begin CPR, apply the ECG electrodes, ask her if he has a living will, and contact medical control for guidance. D: advise the wife that you cannot honor her wishes, begin full resuscitative efforts, and transport to the hospital.

*C: begin CPR, apply the ECG electrodes, ask her if he has a living will, and contact medical control for guidance* Reason: 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.

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: A: proceed because the driver has clearly given you the right of way. B: slow your speed and proceed cautiously through the intersection. C: come to a complete stop, look to the left, and cautiously proceed. D: motion to the driver to proceed since he was at the stop sign first.

*C: come to a complete stop, look to the left, and cautiously proceed* Reason: 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.

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: A: turn on her hazard flashers, remain at least 250 feet behind the ambulance, and proceed with caution. B: wait at her residence until a physician evaluates her husband and then notifies her by telephone. C: drive at the posted speed limit, obey all traffic signals, and not try to keep up with the ambulance. D: ride in the front seat of the ambulance in case her husband's condition suddenly deteriorates.

*C: drive at the posted speed limit, obey all traffic signals, and not try to keep up with the ambulance.*/ Reason: 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.

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: A: obtain his vital signs and a 12-lead ECG to protect you legally if he is experiencing a heart attack. B: ask your partner to be present so he or she can hear the patient's refusal and sign as a witness. C: ensure that he is made aware of your proposed treatment and the potential risks of his refusal. D: explain to him that because of his age and symptoms, he is probably experiencing a heart attack.

*C: ensure that he is made aware of your proposed treatment and the potential risks of his refusal* Reason: 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.

The MOST effective way to minimize the risk of a single rescuer suddenly bearing unexpected, dangerous weight while lifting a patient is to: A: ensure that each rescuer involved in the lift is capable of lifting the equivalent of two times his or her individual body weight. B: utilize a minimum of four rescuers when lifting any patient, regardless of the patient's weight or the type of carrying device being utilized. C: know where rescuers should be positioned as well as how to give and receive commands so that all rescuers lift simultaneously. D: routinely place at least two rescuers at the foot of the stretcher or carrying device since this is the heaviest part of the patient.

*C: know where rescuers should be positioned as well as how to give and receive commands so that all rescuers lift simultaneously* Reason: 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.

The MOST effective way to minimize the risk of a single rescuer suddenly bearing unexpected, dangerous weight while lifting a patient is to: A: routinely place at least two rescuers at the foot of the stretcher or carrying device since this is the heaviest part of the patient. B: ensure that each rescuer involved in the lift is capable of lifting the equivalent of two times his or her individual body weight. C: know where rescuers should be positioned as well as how to give and receive commands so that all rescuers lift simultaneously. D: utilize a minimum of four rescuers when lifting any patient, regardless of the patient's weight or the type of carrying device being utilized.

*C: know where rescuers should be positioned as well as how to give and receive commands so that all rescuers lift simultaneously* Reason: 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.

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: A: nonfeasance. B: malfeasance. C: misfeasance. D: gross negligence.

*C: misfeasance* Reason: 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.

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: A: document the order verbatim and administer the medication. B: administer the drug as ordered and then contact medical control. C: repeat the medication order back to the physician word-for-word. D: acknowledge the order, but administer 5 mg as you were taught.

*C: repeat the medication order back to the physician word-for-word* Reason: 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.

When approaching a vehicle at night, in which a patient is slumped over the steering wheel, you should: A: tell the patient to get out of the vehicle so that you may provide care. B: position the ambulance in front of the vehicle when at all possible. C: shine a spotlight in the side view mirror until you determine it is safe. D: approach the patient from the front of the car for maximum visibility.

*C: shine a spotlight in the side view mirror until you determine it is safe* Reason: 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.

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: A: the scene has been secured. B: a crime has been committed. C: the scene is potentially unsafe. D: the patient is critically injured.

*C: the scene is potentially unsafe* Reason: 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.

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: A: recall that when drivers see an emergency vehicle in their rear-view mirror, their instinct is to quickly pull to the right. B: stay at least 250 feet behind him, keep your siren on, and patiently wait for him to recover and yield. C: turn off your siren, turn on the public address (PA) system, and politely ask him to move to the right and stop. D: leave your lights and siren on and observe his behavior while carefully passing him on the right side of his vehicle.

*C: turn off your siren, turn on the public address (PA) system, and politely ask him to move to the right and stop* Reason: 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.

What is the target heart rate for a 30-year-old man who has a resting heart rate of 70 beats/min? A: 162 beats/min. B: 168 beats/min. C: 145 beats/min. D: 154 beats/min.

*D: 154 beats/min* Reason: 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 actions demonstrates a paramedic's knowledge of crime scene preservation? A: Placing a knife in a plastic zip-lock bag and giving it to a law enforcement officer for safe-keeping B: Carefully cutting through the hole in a patient's clothing that was made by a large caliber firearm C: Requesting approval from law enforcement before controlling severe bleeding from a patient's arm D: Advising a law enforcement officer after moving a coffee table to access a critically injured patient

*D: Advising a law enforcement officer after moving a coffee table to access a critically injured patient* Reason: 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.

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? A: Advise your partner that most calls end up this way and that he or she must get used to it. B: Tell your partner to go home for the rest of the shift and sleep for at least 12 to 18 hours. C: Send your partner to a busier station so that his or her mind can be taken off the situation. D: Be prepared to spend extra time with your partner and allow him or her talk about the call.

*D: Be prepared to spend extra time with your partner and allow him or her talk about the call* Reason: 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.

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? A: Cease your efforts after 5 minutes of full resuscitation. B: Politely ask the man to leave and resume resuscitation. C: Transport the patient to the hospital, providing BLS only. D: Continue resuscitation and ask for a valid living will.

*D: Continue resuscitation and ask for a valid living will* Reason: 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 an example of injury prevention and public education? A: Training Boy Scouts to control bleeding B: Community-wide CPR training C: Promotion of proper seatbelt use D: Analyzing mortality and morbidity data

*D: Coordinate and conduct injury prevention programs* Reason: 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 statements regarding the incident command system is correct? A: The incident command system is only practical when dealing with a natural disaster, terrorist attack, or any incident involving mass numbers of patients. B: Agencies involved in a multiple casualty incident must work independently of each other in order to address needs specific to their area of expertise. C: The incident command system provides for an algorithmic approach to all major incidents, regardless of their size, duration, or complexity. D: Emergency response agencies are required to use the incident command system, regardless of the type, size, or complexity of the incident.

*D: Emergency response agencies are required to use the incident command system, regardless of the type, size, or complexity of the incident* Reason: 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.

Which of the following statements regarding the incident command system is correct? A: The incident command system is only practical when dealing with a natural disaster, terrorist attack, or any incident involving mass numbers of patients. B: The incident command system provides for an algorithmic approach to all major incidents, regardless of their size, duration, or complexity. C: Agencies involved in a multiple casualty incident must work independently of each other in order to address needs specific to their area of expertise. D: Emergency response agencies are required to use the incident command system, regardless of the type, size, or complexity of the incident.

*D: Emergency response agencies are required to use the incident command system, regardless of the type, size, or complexity of the incident* Reason: 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.

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? A: Move the knife out of the way so that you can safely care for the patient. B: Leave the knife where it is and notify the police as you move the patient. C: Pick up the knife and hand it to the police officer that is closest to you. D: Have a police officer secure the knife as you continue to treat the patient.

*D: Have a police officer secure the knife as you continue to treat the patient* Reason: 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.

Who has the ultimate medical authority at the scene of a mass-casualty incident? A: Incident commander B: Treatment officer C: Lead paramedic D: Medical Director

*D: Medical Director* Reason: 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.

Which of the following statements regarding a prehospital care report is correct? A: Information in the prehospital care report must include a diagnosis of the patient's condition. B: The report is not a legal document until it is reviewed by the EMS medical director. C: A separate addendum is not legally considered a part of the prehospital care report. D: Once a copy of the report is left at the hospital, you cannot write on the front of the form.

*D: Once a copy of the report is left at the hospital, you cannot write on the front of the form* Reason: 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.

Which of the following is an example of injury prevention and public education? A: Analyzing mortality and morbidity data B: Community-wide CPR training C: Training Boy Scouts to control bleeding D: Promotion of proper seatbelt use

*D: Promotion of proper seatbelt use* Reason: 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).

EMS systems use a fractile response time standard, which means that: A: the total turnaround time for an EMS call should not exceed a certain time limit. B: the EMS crew should be en route to the scene within 2 minutes of being dispatched. C: the average response time of each EMS ambulance is tracked and trended over time. D: a significant percentage of all responses must be achieved in an established time.

*D: a significant percentage of all responses must be achieved in an established time* Reason: 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).

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: A: explain that his cardiologist may have incorrectly interpreted a previous ECG. B: notify his cardiologist and advise him or her that the patient's ECG is normal. C: tell the patient that there is no evidence that he ever had a heart attack. D: advise the patient that he should seek consultation from his cardiologist.

*D: advise the patient that he should seek consultation from his cardiologist.* Reason: 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.

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: A: tell her husband to take her to the hospital as soon as possible. B: assess her blood glucose level before accepting her refusal. C: advise her that she will not receive a bill for EMS transport. D: ask her why she does not want to be transported by EMS.

*D: ask her why she does not want to be transported by EMS* Reason: 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.

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: A: be prophylactically decontaminated before being moved to the triage section. B: receive immediate medical care based on the severity of their injuries. C: be moved to the treatment area where they are assigned a triage category. D: be taken to the triage area, which should be a safe distance from the building.

*D: be taken to the triage area, which should be a safe distance from the building* Reason: 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.

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: A: cover the wound on his forehead and take his vital signs. B: direct your partner to manually stabilize the patient's head. C: advise the patient of the need for a medical evaluation. D: introduce yourself and ask the patient what happened.

*D: introduce yourself and ask the patient what happened* Reason: 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

The MOST practical and reliable way of ensuring that all pertinent times regarding an EMS call are properly documented is to: A: glance at your watch immediately after each event. B: use law enforcement personnel to keep track of your times. C: ask your partner to document each event as it occurs. D: notify the dispatcher each time an event occurs.

*D: notify the dispatcher each time an event occurs* Reason: 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.

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: A: tell him not to worry, but advise his spouse or another family member of the 12-lead ECG findings. B: tell him that only a physician can analyze the 12-lead ECG and determine if he is having a heart attack. C: minimize his anxiety by telling him that his 12-lead ECG does not reveal any obvious abnormalities. D: tell him that his 12-lead ECG shows an abnormality and that EMS transport to the hospital is necessary.

*D: tell him that his 12-lead ECG shows an abnormality and that EMS transport to the hospital is necessary* Reason: 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.

In order to reduce your risk of personal injury while lifting and moving a patient, you should: A: minimize the number of body lifts you have to perform. B: take up to 30 seconds to stretch before lifting a patient. C: have uninjured patients walk to the ambulance if possible. D: keep your feet close together whenever lifting a patient.

*qA: minimize the number of body lifts you have to perform* Reason: 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).

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? A: Tabun (GA) B: Phosgene oxime C: Chlorine (CL) D: V agent (VX)

C: Chlorine (CL) D: V agent (VX) You selected A; The correct answer is C; Reason: 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.