Help with practical stations....

[Emilea PA C]

City,

First a few details: I am basing this on what has been presented in lectures, as well as from Brady's Emergency Care - 10th ed. I will testing in the Commonwealth of PA.

Now, onto the question. Below I have typed on a generic "call flow" for both the medical and trauma stations for the state practical. Am I leaving anything out? Have I included anything that shouldn't be there? Is there a sequence problem (i.e. something should be done earlier than noted?) Are there any recommendations for improving the line of questioning, especially in OPQRST?

Medical

4 questions (BSI, Scene Safety, ALS, # Pts)

Hi, I'm Emilea. I'm an EMT. Why did you call 9-1-1 today?

After pt give cc, I am now applying 15 lpm O2 via NRB.

When did this problem start?

What were you doing when this problem started? Is there anything that makes this problem better or worse?

Can you describe this pain/illness?

How would you rate this pain on a scale of 1-10, with 10 being the worst?

Does it hurt anywhere else?

Have you ever felt this before?

Do you have any allergies?

Are you taking any medications? Any OTC meds? If women, are you on BC?

What is your past medical history?

What was the last thing you ate or drank? When was that?

Physical Exam, as indicated.

Interventions.

Call Medical Command.

"I am going to keep an ongoing assessment."

Trauma

4 Questions (BSI, Scene Safety, ALS, # Pts)

Hi. I'm Emilea. Can you hear me?

Evaluate LOC & responsiveness (verbal, pain, unconscious, etc.)

Rapid Trauma Assessment.

Assess PMS in all 4 extremities.

Split as indicated.

Recheck PMS.

Log roll onto LSB.

Strap down - start with chest strap, then abdo/hips, legs, feet, then CID and head.

Recheck PMS.

"My pt is ready for transport."

Vital signs.

Detailed physical exam of anything found on RTA.

Contact medical command.

"I'm going to keep an ongoing assessment."

So, what do you guys think?? Give me suggestions. I don't want there to be any question as to whether or not I passed the State Practicals!!

TIA, Emilea

[mobey]

Sounds good to me!!

Remember to get their name after your intro. Also investigate everything thoroughly ex. allergy to Pennicilin... what happends when you take it?

Have you ever had this pain before?... did you see the doc last time?... what did he diagnose you with?... did he give you meds?... did you take them today?

Have you ever had shortness of breath this bad before? Did the doc give you an inhaler? How many sprays have you taken? Have you ever been intubated before?

How long have you felt weak and dizzy? have you been running a temp? any ABD pain? N&V? recent trauma?

And so on. Just never stop asking questions, patients never tell you the pertinant info till you ask. However make sure you are assesing phisicaly @ the same time... kind of a balancing act.

BTW women under 60= Is there a chance you could be pregnant?

(not just for ABD pain.. everone)

[shauniedarko]

Emilea PA C,

Happy new year to you. I just came across this and thought I'd throw my 2 cents in. I've only just graduated and passed my practical a month ago, but that might be a good thing since it's all still fresh in my head. There was one major thing that concerned me about this and it's that neither line assesses for ABC's or even really for mentation. I noticed in medical that you got the cc and then threw a nrbm at 15 lpm on, but omitted waiting to find out if the pt was even breathing.

Hopefully this will help you. I managed to compress both pt assesments to managable bits:

BSI

General Impression

S-M-D-D-C (Sometimes My Daddy Drinks Corona)

S-Scene Safety

M-MOI/NOI

D-Determine # Pt's

D-Determine if ALS needed

C-Consider C-Spine

CC & Obvious Life Threats

AVPU-A-B-C-D-E

AVPU-Mentation Test

A-Airway

B-Breathing (At this point you should make the decision on O2)

C-Circulation

D-Determine transport priority

E-Expose Pt.

At this point you want to do a rapid or focused. If they have chest pain, for example, focus in on examining the chest.

SAMPLE

S-Signs and Symptoms

At this point OPQRSTI come into play You want to know When it started, what makes it better or worse, what kind of pain it is, whether it radiates anywhere, what it is on a scale of 1 to 10, the time and what they've done to treat it (if they've taken asprin or nitro ect)

A-Allergies

M-Medical Problems

P- Past hx

L-Last oral intake

E-Events leading to

At that point you should get a full set of V/S and perform some interventions if you can (Epi, Nitro, treat for shock, oral glucose)

Then load em up, do a detailed, and reasses initial assessment (Mentation, ABC's), Reasses v/s, Reasses focused, and check your interventions.

The Trauma is similar except you don't really worry about OPQRST.

Some other words of advice - Don't forget breath sounds... If you're doing a focused on the chest or a rapid, get breath sounds. Also pay attention to what the instructors tell you. On the trauma scenario, I went first. The next 15 people had to retest because they put a traction splint on a pt with a midshaft femur fracture AND crepitus in the pelvis.

Don't forget that Circulation isn't just pulse. It's also skin color, temp and condition. Forget that and you could miss someone in decompensated shock.

Last, on traumas, if it's not life treatening, treat it during transport. Don't waste time splinting an ulnar fracture when you're on scene and the pt has a systolic bp of 60.

Good luck. Just stay calm, be methodical and take your time and you'll rock it out.

[Just Plain Ruff]

it's been so long since I had to do any of this but I'm curious Emilea(sorry for misspelling if I did), why did you put a generic apply 15 liters oxygen on the patient? Is this just how it's done in testing or is there another reason?

[emsbrian]

If you don't put O's on the patient you fail NREMT practical.

Get your skills sheets off the NREMT web page, while it is a skills test, it is still a test. It can be passed hitting every point in only about 4 minutes (sadly). I recommend you learn the failing criteria on every skill so you don't pass and make some little mistake and fail (Like oxygen) Treating things like difficulty breathing in trauma is normally simple, like suction. Don't go for the needle decompression, you may forget to suction and fail. I cant give way scenarios but I've performed many NREMT practical tests as an instructor and can tell you they are not all inclusive. There are key points, that are fairly simple, just make sure you learn the skills seat. Don't waist time, get your skill done hit all the key points.

All the advice is good above, remember you have time, a lot of people write out their list of what they are going to do to begin with. Just be thorough a lot of people miss points in things like genitalia or abdomen vs. pelvis. Also remember medical is medical and trauma is trauma. Your trauma patient will not have a heart attack (if he does your examiner needs to have a talking to) Also remember that vital signs will either get better or worse depending on how your doing. But don't expect them to change too much, or necessarily more then once from the patients baseline. Lets see other things the National Registry doesn't require are things like a verbal report. I've seen many fail by going over their amount of time just to try to do a run report which gains and looses NO points.

If you need more advice just e-mail me through www.medicaltrainingspecialists.com , we teach skills training but I also do alot for free. --Brian

[Just Plain Ruff]

Like I said, I haven't had to take a test like this in about 12 years so I'm a little rusty on the skills sheets heck I don't really care at this point, but what I meant to ask is does everyone get 15lpm nrb or can you put them on less like 6lpm nc or something like that.

I don't really have the desire to go to the nremt website to get the sheets as they don't benefit me either way. I was just curious.

I also know that if you don't put them on O2 you fail but I was just wondering if it had to be 15 lpm

[emsbrian]

I was replying to the main topic of the thread, not just to you O2 curiosity.

As far O2 for the NREMT tests just about every patient is in "shock" of one kind or another so get high flow O2, cover to retain heat and position of comfort (or whatever depending)

So yes for test purposes you have to say hi flow O2 which is clearer to the instructor if you say 15lpm by NRB, other wise we have to ask you to make sure you don't think Hi-flow is a NC at 20lpm or something like that LOL. In general 12LPM is acceptable but 15LPM is the best answer. Any less than 12 on a a NRB is dangerously low, so we wont take that. If you want you can pump up higher then 15, but no reason. I'm sure all that is pretty obvious. And of course NC is not hi-flow for us.

Hope that answers your questions direct about Oxygen and the National Registry Practicals. :-)

[OzMedic]

Emilea, just a question as I don't know the format of your scenario exams. In your plan, you go into great detail about all the questions that you are going to ask which is great but you sum up your treatment in one line "Interventions". If I was examining you, this is the area where I would be most interested as it is ultimately what is going to determine the patients outcomes! I am wondering how you are going to make these decisions as the questions you ask are only a small part of the picture. I want to know how you are going to assess the patient and what observations you are going to take, in what order and most importantly WHY? I will be happy to provide feedback if you like as well as a far more simplified assessment method.

If what you are doing is just trying to tick the relevant boxes to pass a specific assessment then I probably can't help as I have no experience with EMT/basic type education and I'm sure plenty of guy's on here can tell you what to do to pass. Thats totally OK because if you don't jump through the hoops then you don't get to play or get paid but if you pass and go out on the road thinking that you need to put oxygen on every medical patient or splint every fracture on every trauma patient then that is sad for you and the EMS system as a whole.

[Emilea PA C]

To pass the state practical in PA (as well as other states, I'm sure) you must fill in the checkboxes on the eval form. So, yes, that's mainly what I'm after -- filling in those lil' boxes!

I believe it's Dust that always says (maybe it's Rid....maybe it's someone completely different) .... you can't learn this whole profession in 120 hrs of night school! It just doesn't happen...

I'm more interested in filling in the evaluator's boxes so that I can start field work are really learn some skills! (EMT-B curriculum in PA doesn't include an ride time :roll: :x

[emsbrian]

A good point is made above by Ozmedic. My advice in the thread IS STRICTLY NREMT PRACTICAL EXAM ADVICE.

Please do not apply it to real life by any means.

Your knowledge should be so great as to pass no problem. A majority of my advice centers around test taking for the exam. While a practical exam should be infinitely more comprehensive there is only so much that can be test in 10 minutes. Sadly NREMT examiners are only meant to ask questions to clarify. We can not ask leading questions or questions not related. For example we can not actually ask what % oxygen is in air. But if you bag the patient we can ask you what tidal volume you will use, but not why. Get the idea? Why is a written test thing in there opinion. Expect to answer more questions on the verbal as their is a little more to do there, but its not horrible. When you learn to take the test anybody can pass is, which is why we always wait until the last month of classes to begin to teach test taking technique that way students learn. This is the reason that FTO's and company entrance exams can be very tough. The reason we teach the test at all is time constraints, stupid things like HAVING to put high flow O2, and HAVING to say BSI fail to many people. Personally I feel to forget BSI is important but why not fail for forgetting to check scene safety?

I digress. Feel free to call me, or e-mail me. The company line will get me most the time, as I prefer to keep track of business.

Oz, I hate to say it, the NREMT practical offers very little in the way of EMS screening. Especially at an EMT basic level, which has been made even easier. Most skills can be passed in less than five minutes if you know the checkoff and critical criteria. I could say I could teach someone with NO EMS knowledge to pass them in a week :-( Because we know what questions will be asked. (Excluding paramedic only skills) But this is a topic for another post. Skills teaching, and skills training are sadly two very different things.