Quiz 11

It is a snowy Saturday in northern Saskatchewan and you are working in a small town of 4,000 people. You are an Advanced Care Paramedic (ACP) and your partner is a Primary Care Paramedic (PCP).

Your radio tones are activated by your dispatcher. You are called to respond to a village 30 minutes away. Your dispatcher tells you to respond to a wheelchair-bound 52-year-old female with bleeding gums and a lower intestinal bleed.

Your ALS unit arrives at a modest home and a man in his twenties answers the door. The patient is in the kitchen in her wheelchair and acknowledges you as you enter. Her skin is pale. She answers questions appropriately, although her speech is slow and she is a vague historian. She is on Warfarin and has been taking Tylenol for back pain. She has been in the wheelchair since 1987 due to a car accident. During her stay in a Saskatoon hospital she underwent several surgeries and blood transfusions. She is obese and has limited mobility; she has multiple old bruises on her chest, arms and legs “from falling out of her wheelchair” a couple times the last few days. Her son tells you that she was intoxicated when he came home from work yesterday after being away several days. You perform an initial assessment, transfer her onto your stretcher and out to the ambulance. It’s very hard for her to get comfortable due to her back pain.

Your initial assessment of the woman reveals:
• Temperature of 38.0° Celsius
• Respiratory rate of 20, clear lungs
• Pulse 110, irregular
• Sp02 is 95
• BP 110/70
• Blood Sugar is 6.0 mmol/l
• Cardiac monitor shows atrial fibrillation

SAMPLE Hx is as follows:
• Signs/symptoms: oozing blood from gums, around IV site, rectum, under breasts; back pain
• Allergies: none
• Medications: Tylenol, Warfarin
• Past Hx: atrial fibrillation, obesity, previous trauma, severe arthritis, alcohol abuse
• Last meal, last medications: toast and apple juice two hours ago. Can’t remember last dose of medication, but it wasn’t today.
• Events preceding EMS being called: falls, binge drinking. The patient’s vital signs are stable and you begin a code one transport back to the primary care facility emergency room. You think to yourself, “It would be nice to have a hemoglobin level on this lady...”

About the Authors.

Dale Bayliss is an experienced Advanced Care Paramedic and Registered Nurse living in Camrose, Alberta. Dale is an instructor with the University of Alberta, Augustana Faculty’s Paramedic Program. He also works part time as an Emergency Nurse at the University of Alberta Hospital in Edmonton and works casual as a Paramedic with Peace Hills EMS in Wetaskiwin, Alta. and with Beaver EMS in Tofield, Alta.

1. Infection Control guidelines have changed from Universal Precautions, to Routine Practices, Extra Precautions. Routine Practices include all of the following, except:
   A) Gloves.
   B) Eye protection.
   C) Gas mask.
   D) A surgical mask on a coughing patient if tolerated.
2. You can assess her hydration level by checking:
   A) Urine output if she was catheterized.
   B) The condition of her mouth and conjunctiva.
   C) If she is thirsty.
   D) Skin turgor.
   E) All of the above.
3. She does appear to be dehydrated, so the normal saline IV is run at:
   A) TKVO in case there is a risk of congestive heart failure.
   B) 200 ml/hour.
   C) She doesn’t need an IV.
   D) TKVO because she doesn’t need saline, she needs a blood transfusion.
4. The appropriate oxygen therapy for EMS to provide is:
   A) None (21 per cent oxygen).
   B) A nasal cannula at 2 to 4 l/minute (29 to 37 per cent oxygen).
   C) A non-rebreather at 12 l/minute (> 90 per cent oxygen).
   D) The patient needs a ventilator to maintain her respiratory status.
5. What position should the patient be in for transport?
   A) Trendelenburg position due to shock.
   B) High fowlers due to respiratory difficulty.
   C) Low fowlers and positioned so she is most comfortable.
   D) Feet down off the stretcher due to pulmonary edema.
6. This patient has multiple medical problems, but she needs urgent investigation of her:
   A) Blood clotting systems.
   B) Arthritis.
   C) Obesity.
   D) Atrial fibrillation.
7. The oxygen saturation monitor is applied to the patient during your initial exam. You know the wave form deteriorates or is not available with:
   A) Improper probe application.
   B) Poor peripheral circulation.
   C) Cold extremities.
   D) All of the above.
8. A patient complaint of back pain is least likely to be due to:
   A) Arthritis of the spine.
   B) Kidney problems.
   C) Referred pain from a problem with the pancreas, aorta and other organs.
   D) Subdural hematoma.
9. This patient’s assessment by EMS should include the following, except:
   A) CT scan.
   B) Primary and secondary trauma assessment from head to toe.
   C) Head to toe assessment with a medical focus.
   D) Assess the abdomen for tenderness, distension or rigidity.
10. Active internal bleeding might be evident by the following vital sign changes:
    A) Lower heart rate, lower respiratory rate.
    B) Increased heart rate, lower blood pressure.
    C) Deeper respirations and lower Sp02.
    D) Constricted pupils and higher blood pressure.
11. You know that this patient will have the following diagnostic tests ordered:
    A) Complete blood count (CBC) which includes hemoglobin and platelets
    B) Urinalysis.
    C) Abdominal X-rays.
    D) All of the above.
12. You suspect the patient’s atrial fibrillation is chronic because:
    A) She has diabetes.
    B) She has an irregular heart rate.
    C) Of her age.
    D) She is on Warfarin
13. You stay around to help the two RNs in the emergency room. They insert a urinary catheter and the urine appears very concentrated and cloudy. Other signs of urinary tract infection when testing the urine are:
    A) White blood cells present.
    B) Red blood cells present.
    C) Protein present.
    D) Bacteria reported from the microscopic analysis.
    E) All of the above.
14. The findings of a fever, back or flank pain, a WBC count of 30 x 109/l and a urinalysis showing UTI means the following is indicated:
    A) Penicillin PO.
    B) IV antibiotics.
    C) Gravol PRN.
    D) Heparin.
15. The lab results come back and include critically high kidney function tests. Urea (BUN or blood urea nitrogen) and creatinine are both four times the upper limit of the normal range. This may be caused by:
    A) 1000 ml of Fresh Frozen Plasma.
    B) Pentaspan.
    C) Red Blood Cell transfusion.
    D) Vitamin K IM
16. The laboratory reports an INR of > 10.0 and PTT of 103 seconds on this patient. Normal values are INR 0.8 to 1.2 and PTT 25 to 32 seconds. The differential diagnosis now includes:
    A) Liver failure.
    B) Typical Warfarin therapy.
    C) Sepsis and Disseminated Intravascular Coagulation (DIC).
    D) High mortality gum disease.
    E) All of the above.
    F) A and C.
17. One of the most effective and almost immediate treatments to reverse this severe coagulopathy is:
    A) 1000 ml of Fresh Frozen Plasma.
    B) Pentaspan.
    C) Red Blood Cell transfusion.
    D) Vitamin K IM.
18. You assist the RN in starting a second peripheral IV. A reason or reasons to have a second IV site in this patient would be to:
    A) Draw initial and serial blood work.
    B) Backup site in case the primary IV site is dislodged.
    C) Have one site for blood products and another for medication.
    D) All of the above.
19. The laboratory records show that the patient has a red blood cell antibody called Anti-Kell. When considering transfusion of uncrossmatched blood, we weigh the risks and the benefits. The major risk is:
    A) Possible immediate transfusion reaction which is associated with a very high mortality rate.
    B) No more risk than with any other patient.
    C) Neurogenic shock.
    D) A and C above.
20. Once crossmatched blood is ready, the Paramedic or RN must follow their protocols for administration which would include the following, except:
    A) Proper identification of the patient which must match the tag on the blood.
    B) Transfuse each unit within 10 hours of issuing from the blood bank lab.
    C) Take vital signs before, during and after the transfusion.
    D) Save the empty blood bag and send it back to the lab.
21. Ten hours after admission, the patient’s blood pressure drops to 78/50 and dopamine is considered. The starting dose would be:
    A) 2.5 to 5 mcg/kg/minute.
    B) 5 to 10 mcg/kg/minute.
    C) 10 to 20 mcg/kg/minute.
    D) 20 to 50 mcg/kg/minute.
22. With regards to the atrial fibrillation, the next action should be:
    A) Synchronized cardioversion.
    B) External Pacing.
    C) A 15 lead ECG and then adenosine.
    D) A or C.
    E) None of the above.
23. Sepsis is associated with the following pathophysiology:
    A) Positive blood cultures; i.e., bacteria circulating in the blood.
    B) Elevated neutrophil count—a response from the bone marrow to fight bacterial infection.
    C) DIC (disseminated intravascular coagulation).
    D) A and C above.
    E) All of the above.
24. When administering fresh frozen plasma, the following is incorrect:
    A) AB is “universal donor”; i.e., any patient can receive this type.
    B) It is stored frozen and can be kept for one year past donation date.
    C) It can be kept for seven days in the fridge once it is thawed out.
    D) It should be administered over no more than four hours
25. A description of DIC (disseminated intravascular coagulation) is:
    A) Sickle cell anemia crisis due to hypoxia.
    B) Vascular coagulation that spins out of control leading to bleeding because the clotting factors get used up.
    C) Factor XIII deficiency such as with hemophilia A.
    D) Factor XIII deficiency such as with hemophilia A.