EMT-B Practical Questions: Please Help!

[SMBand]

Hello everybody,

I am new to this site, and I have my EMT-B State Practical in 4 days. I have a few station-related questions, but different people seem to be giving me conflicting answers!

#1) TRAUMA STATION:

How exactly should I demonstrate the RAPID TRAUMA ASSESSMENT to the proctor? Right now, I going through the entire body AND EXPLAINING EVERYTHING: I am palpating the cranium for any major bleeding, crepitation, DCAP-BTLS --> Checking the neck for bleeding, crepitation, DCAP-BTLS, tracheal deviation, JVD + putting on cervical collar --> palpating the chest for DCAP-BTLS, major bleeding, crepitation, and inspecting for sucking chest wounds, equal/bilateral chest rise, presence of flail segment/paradoxical motion --> Palpating the 4 abdominal quadrants for pain, tenderness, rigidity --> Palpating the pelvis for DCAP-BTLS, major bleeding, abnormal motion/instability and doing a priapism sweep (for male patients) --> palpating/inspecting each extremity x4 for DCAP-BTLS, crepitation, major bleeding and presence of distal pulse/motor/sensory function --> Logrolling the patient and assessing the posterior for DCAP-BTLS, bleeding, and checking for rectal bleeding --> Backboarding patient. This takes me 2-3 minutes to verbalize all this (a rapid exam should be 30-60 seconds.) And this is only my Rapid Trauma Exam! I have to repeat my entire process again (the same exam PLUS inspecting the eyes, nose, ears, mouth, battles and racoons signs, etc) when it comes time to demonstrate the DETAILED PHYSICAL EXAM (later on in the skillsheet, when we are on the ambulance). I have to race through both the RTA and the Detailed Exam because of the 10 minute time limit. I feel like its entirely repetitious to explain the same points to the proctor again in the detailed exam, when I've already explained them in the rapid trauma exam. As a result, I am having a real tough time covering all the points in my skillsheet in under 10 minutes. I am usually at 10 or 11 minutes when I practice (and out of breath from explaining everything as fast as I can)! Do I have to verbalize all the minute details in the Rapid Trauma Exam as I just explained above? Or is there some easier way of doing this in order to save time and so I don't have to repeat myself twice??

#2) KED STATION:

I just want to make sure that the strap order is still Middle torso --> Bottom torso --> Legs --> Head --> Top torso ("my baby looks hot tonight"). This is what I learned in school, but I know there is a critical failure for immobilizing the head before the torso is fully immobilized. Nevertheless, I still have to do the Top torso after I immobilize the head. Am I doing it right, or will I critically fail this way on technicality because I returned to the top torso after I immoblized the head?

#3) TIB-FIB Fracture STATION:

Is there anyway I can test the strength/tightness of my splint (i.e. tugging on the boards) to make sure it is tight enough and fail-safe before I leave the station? I am worried that my splint will be too loose! It's happened before in practice!

#4) CARDIAC ARREST / AED Management STATION***:

In school, we were taught to ask the bystander to stop CPR for 5 seconds in order to get a pulse check and then asking them to resume before proceeding to power on and set up the AED. Should I be asking the bystander to stop CPR momentarily in this way? I want to make sure the patient is truly apneic/pulseless. I am also confused if I should do a 3-5 second pulse check after an AED has delivered a shock then CPR, or should I order the immediate resumption of CPR (without pausing for pulse checks)? Maybe I am only supposed to do a pulse check if I get a "NO SHOCK INDICATED" alert, but not do pulsechecks if I have a SHOCK. Is this the protocol? Some people have said that delaying CPR for even a 5 second pulse check constitutes a critical failure on the grounds of interrupting CPR. Furthermore, one of the last points on the skill sheet is to "Repeat Defibrillator Sequence at Two-Minute Intervals." My routine is: a bystander is doing CPR --> then I use the AED --> then resume CPR (ensuring proper ventilation/compressions/etc.) --> then I reuse the AED --> then resume CPR and transport --> then I'm done. Having already done 2 AED cycles on scene, am I supposed to verbalize continually repeating the AED at 2 minute intervals even after I have transported the patient? At my school exam, I did it my way and passed, but the proctor still circled that I didn't "repeat defibrillator sequence at 2 minute intervals" but I'm not sure what this means in practice?

#5) APNEIC PATIENT (BVM) STATION***:

After BSI/scene safety, I open the airway with a head-tilt/chin-lift, then I verbalize "I am selecting the appropriately sized mask by measuring from the bridge of the nose to the dip of the chin; hooking up my mask to my BVM, then I stand cephalic to the patient, reopen the airway, and begin initial ventilations." This process takes me 10-15 seconds, then I start the ventilations at this point. My question is: does explaining how to size a mask (5 seconds) constitute a prolonged delay, because "Candidate did not immediately ventilate the patient" is listed as critical failure...? As I'm ventilating, I continue to say "I am ventilating with one-second squeeze, every 5-6 seconds, while maintaining a proper mask seal using the E-C Maneuver; ensuring that at least 800 mL of air per ventilation is being pushed into the patient, and ensuring equal and bilateral chest rise." Do I need to verbalize all of these things or will it cause me to waste time? After 30 seconds, I stop to size an OPA and hook up my O2 to the BVM set at 15 LPM, but it seems this process takes me about 30+ seconds to achieve. Is this too long of an interruption? How can I cut out some verbalizations out without risking a critical failure?

***Another thing that bothers me is that the AED and Apneic (BVM) skill sheets on the NREMT.org website are slightly different than the skill sheets we used in school. The AED skillsheet (dated 11-15-08) that we used in school asks the candidate to "Verify absence of spontaneous pulse" after BSI/scene safety and questioning bystanders, but before you even power on the AED. The skillsheet on the NREMT website omits this line. Which skillsheet is more correct?

With Apneic (BVM), the skill sheet that we used in school indicates inserting an airway adjunct inbetween ventilation cycles (i.e. after the initial room-air ventilation, but before the hi-conc O2 ventilation), whereas the skillsheet on the NREMT website indicates the insertion of an airway adjunct immediately (before initial room-air) ventilations. I am feeling like I want to insert the OPA adjunct inbetween ventilation cycles (after the initial ventilation but before my o2-enhanced ventilation) because u must ventilate immediately (so I kind of feeling like the skillsheet on the NREMT website is incorrect).

Which skillsheets should I follow? Which are more up-to-date?

I apologize for the long post, but I want to make sure I get this right. There are so many technicalities to fail on, and I don't want to risk it! If anybody has the time to read this through, knows what the State expects, and can clarify my points of confusion, then I would be greatly appreciative!

Thank you!!

[mobey]

I think you need to email this to your instructor from school!

Those are some pretty specific questions

[firemedic1976]

I've gotta agree with mobey. These are things you should really run past your instructor. If you're that concerned about criticals. What I can tell you is there may be minor differences from state to state depending on protocol. Here in NY we have the state DOH protocol and the more stringent MLREMS protocols in my area alone. In my area, for the trauma station, you're on the right track, but when palpating during the rapid trauma assessment, we cut all the talk and sum it up with palpating the ______ area, checking for DCAP BTLS. One thing you might wanna add when checking the head/neck...we had to make sure we indicated we were checking the spinal column for step down or step off. When you get to the detailed physical exam, you just verbalize that if time allows, once you have the pt in the ambulance, you would perform that step. We never actually performed it at our station. As for you KED station....here, it doesn't matter the order the straps were done as long as they were done and tight enough. The critical failure you're talking about occurs when you secure the head and then return to the torso. AUTOMATIC FAIL for the station. The head is the last thing to be secured. PERIOD. Just with those 2 things, it would appear there are some slight differences in what we do here and what you're being told you're going to do there. Contact your instructor. If your instructor wants to see you succeed, he/she will set up with the correct answers. GOOD LUCK!!!

[CBEMT]

+3. These are not questions to ask random people on the internet. Since you're clearly worried about them, I don't know why you haven't done so already.

[paramedicmike]

Agree with the others. I'll also add that if you're asking such specific questions this close to your exam then your school doesn't seem to have prepared you very well.

Talk to your instructor. Ask him/her these questions. And good luck.