Quiz 5

It is a turning out to be a nice spring day. The local students are out on spring break. You are on-call today with a rookie ACP as well as a seasoned PCP for this tour. Today your partners are Amanda, the ACP, and Carrie-Ann, the PCP. You are trained at the CCP level but are not recognized in the province because of some political agendas over which you have no control.

You are called to respond to an accident between a CN train and a half-ton truck at the intersection on Main Street and the level crossing. The local police and your second unit will also be dispatched immediately. Your second unit is a BLS unit and will meet you on scene shortly. You are about to help break Amanda in as a “medic” at what can be a disaster in the making.

On arrival, you see the smoking steaming wreckage of the truck wrapped around the front of the train. There are flames coming out directly from around the hood of the truck. The vehicle gas tank has apparently not been ruptured. It is unknown how much fuel is present in the half-ton but you know the train will have thousands of litres of diesel fuel present. The fire department is right behind you and they will set up initial attack lines and hook into the fire hydrant across the road by the local gas station (another hazard). The police are working to block off the intersections and additional RCMP have also been dispatched to assist in this accident. Just so you can appreciate the problems, the train was heading westbound and is blocking Main Street, which runs north and south and is the main access through town. The vehicle was heading north through town and is now wrapped around the lead locomotive engine.

The fire department attacks the steaming smoking remains so you can safely approach the wreckage. You and your crews are staged as close as possible. You see movement in the vehicle; it appears there are multiple patients trapped in the truck wreckage. Additional surrounding ambulances are dispatched by 911, who will also dispatch the regional air ambulance services. They can launch two BK-117s from two different bases. Each can take one critical patient or, in a pinch, two reasonably stable patients.

After the fire captain gives you the all clear you head in to perform triage. You first see the driver, who is obviously DOA as he has a partial head decapitation. That one is now a “black” patient who can stay right there for now. Next you see two unrestrained patients, also in the front seat—one male (patient #1) and one female (patient #2) who have some facial burns, upper extremity burns, as well as being unconscious and unresponsive. They are both breathing and have weak carotid pulses; they are both “reds.” Next, you reach into the back seat and find broken beer bottles littered over two more patients. Neither are breathing but one (patient #3—a female) has a carotid pulse. You reposition her airway and she attempts to breathe at around eight per minute. You decide you have one more “black” patient and one more “red” patient as you have enough rescuers to start three critical patients. You know it is going to max your crews out. You and your crews will do everything humanly possible to save as many of these teenagers as you can, realizing you just had to say “no” to two of their friends who will not get a second chance in life.

You ask for both air ambulances to be launched. They will have been notified of major trauma patients as well as life threatening burns to two of the patients. The local burn centre is about 35 to 45 minutes away by air, and they will arrange for trauma teams and additional burn centre staff. They will take the two burn patients and they will expect you to transport the last patient on scene to your local hospital initially for stabilization. They will decide transport after the initial care is provided on the last patient. A neighbouring ALS service is dispatching two more units to assist under the mutual aid agreement. The next arriving ambulance can assist and take over care of (patient #3). Air ambulances will start to arrive in about 20 minutes so it is time to get these patients extricated, stabilized and packaged for immediate liftoff when the medevac choppers arrive. The Safeway parking lot about one block down will be the landing zone and will be set up by fire and police ASAP.

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.

Canadian Emergency News and the authors of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re-publication without written consent is prohibited.

1. The fire department members help your teams to do “rapid extrications” of the two patients in the front seat. One will go to each waiting ambulance, however patient #3 will be waiting some time to be extricated by the fire crews with the jaws and cutters. Patient #3 tolerates the OPA and you can only apply a NRB for now. There is no room to do anything else at this time. You would apply the NRB at:
   A) 18 LPM.
   B) 10 LPM.
   C) 15 LPM.
   D) 25 LPM.
2. On this patient you can apply a C-collar and you have one firefighter holding C-spine during the extrication period. You would like to apply a BVM but there is no room to adequately perform assisted ventilations. Your next priority for now would be to:
   A) Stop any visible bleeding.
   B) Apply the cardiac monitor.
   C) Apply the Sp02 monitor.
   D) Analyse the blood glucose level.
   E) A and C only.
3. Patient #1 (a male) is taken to your unit “Medic One.” Patient #2 (female)) is taken to “Medic Two.” As soon as patient #1 is put in your ambulance you need to:
   A) Assess the LOC.
   B) Evaluate the airway.
   C) Evaluate the rate of breathing and the patient’s effort of breathing.
   D) Assess for a pulse centrally and peripherally.
   E) All of the above.
4. As soon as patient #1 is placed in your ambulance, you see the femurs are deformed just above the knee regions. The best treatment for the bilateral femur fractures right now is to:
   A) Apply a bilateral traction splint.
   B) Apply the MAST pants.
   C) Apply padding between the legs and lay the patient securely to the spine board.
   D) Ignore the femur injuries until the ABC and LOC are assessed.
5. Patient #1 is struggling to breathe. You hear audible wheezes without a stethoscope. The wheezes are likely from:
   A) A partial airway obstruction.
   B) Facial injuries.
   C) Significant airway burns.
   D) All of the above.
6. You insert an OPA and notice patient #1 start to breathe a little better at about 10 per minute and shallow. The patient still has pronounced wheezes as well as stridulous breathing sounds coming from the upper airway. Your next actions would be to:
   A) Apply a NRB at 8 LPM.
   B) Apply a NRB 15 LPM.
   C) Assist ventilations with a BVM at 12 times per minute.
   D) Assist ventilations with a BVM at 16 to 20 times per minute.
7. Patient #1 has a weak and slow pulse that you can palpate at the radial pulse at around 50 to 60 times per minute. The slower and weaker pulse can be from:
   A) Hypoxia.
   B) Neurogenic shock.
   C) Hypovolemic shock.
   D) Hypothermia.
   E) All of the above.
8. What other injuries are you suspecting with this patient just on the mechanism of injury considerations?
   A) Head injury.
   B) Cervical injury.
   C) Thoracic and intra-abdominal trauma.
   D) All of the above.
9. Both patients in the front seat have extensive 2° and 3° burns. What time period do we have prior to the inflammatory response starting to become a problem as it does in all burn patients?
   A) One hour
   B) Eight hours.
   C) Four hours.
   D) Twenty-four hours.
10. The female (patient #2) is placed in Medic 2. The initial treatment for this patient would require you to perform certain skills in a rapid manner. You would first want to __ _____________ then ___ ___________ as a BLS provider.
    A) Assess the airway.
    B) Apply the cardiac monitor.
    C) Finish the primary survey.
    D) Perform the secondary survey.
    E) A and C.
11. Patient # 2 has a respiratory rate of about 26 per minute with poor tidal volume and minimal chest rise. You would now:
    A) Apply a NRB at 8 LPM.
    B) Assist ventilations with a BVM at 12 times per minute.
    C) Apply a NRB 15 LPM.
    D) Assist ventilations with a BVM at 16 to 20 times per minute.
12. This patient has what you expect to be either bilateral dislocated pelvis and/or femur fractures. The best BLS care for this type of injury at the end of the primary survey would be to ________________ due to time constraints and other major priority problems.
    A) Apply padding between the legs and splint in a neutral but straight position.
    B) Apply a bilateral traction device.
    C) Apply a pelvic wrap and tighten it to lessen pelvic bleeding.
    D) All of the above.
13. Patient # 3 is being extricated by the fire department. The firefighters have performed a roof roll and the roof is removed. The quickest manoeuvre to remove this patient would be to use the:
    A) Scoop stretcher.
    B) KED.
    C) Short board and apply then to a long spine board.
    D) A and C.
14. With patient #3, the pulse remains weak at the radial with only a 70/36 obtained after the extrication is completed. The heart rate is 148 bpm. The most appropriate therapy would be:
    A) Place the patient in a supine position and elevate the feet a few inches.
    B) Initiate a 20 ml/kg IV bolus of N.S. or ringers lactate.
    C) Fluid bolus 250 ml increments to see if the cardiac output improves. Listen and evaluate lungs sounds after every 250 ml bolus.
    D) All of the above.
    E) A and B only.
15. This patient can be tachycardiac and hypotensive from:
    A) Bilateral fractured femurs.
    B) Closed head injury.
    C) Cervical injury.
    D) Thoracic and intra-abdominal trauma.
    E) A and D.
16. Patient #1 needs to be intubated to secure the airway. The first medication required for this procedure in this patient can be:
    A) Lidocaine 1.5 mg/kg 2 to 3 minutes prior to intubation.
    B) Atropine 0.5 mg IVP.
    C) Magnesium sulphate at 2 grams over 20 to 30 minutes as an antiarrhythmia medication.
    D) A and C only.
    E) All of the above.
17. This patient has not responded to any stimulation. His GCS is 3/15. What medications are required prior to the intubation in this case?
    A) Versed 2.5 to 5.0 mg slow IV.
    B) Morphine 2.5 to 5.0 mg slow IV.
    C) Anectine 1.0 to 1.5 mg/kg IV.
    D) None is required at this time.
18. You have intubated this patient and you notice the patient’s Sp02 slowly dropping. You would expect:
    A) The endotracheal tube to be in the esophagus.
    B) The oxygen source is not hooked up
    C) The patient’s ventilations might just be too slow.
    D) B and C.
19. Your partner corrects the problem. You now have a positive end tidal C02 waveform, there is also “misting” within the endotracheal tube, and the patient’s Sp02 is registering and climbing slowly. The best way to secure the endotracheal tube in the field would be to apply:
    A) Thomas Tube Lock.
    B) Apply a cervical collar.
    C) Apply a ventilation extension circuit to the BVM.
    D) All of the above.
20. Other advanced life support concerns would be to:
    A) Apply and insert at least 2 large bore IVs.
    B) Insert an oral gastric tube.
    C) Administer Ventolin and Atrovent treatment and repeat prn.
    D) All of the above.
21. Patient #2 also needs to be intubated to secure the airway. The patient is now clenched and being difficult to ventilate. She still has a GCS of around 6/15. It will not take much to make the patient unresponsive. What medications may be required in this patient to secure the endotracheal tube:
    A) Lidocaine 1.5 mg/kg IVP 2 to 3 minutes prior to intubation.
    B) Anectine 1.5 mg/kg IVP.
    C) Versed 2.5 to 5.0 mg.
    D) B and C only.
    E) All of the above.
22. This patient has now been pharmacologically relaxed. Her GCS is 3/15. What medications are likely required to maintain sedation and analgesia in this case?
    A) Versed 2.5 to 5.0 mg Slow IV.
    B) Morphine 2.5 to 5.0 mg Slow IV.
    C) Anectine 1 to 1.5 mg/kg IV.
    D) A and B only.
    E) None are required at this time.
23. Your patient’s BP has now dropped to 60/32 and the heart rate is 162 beats per minute. You would now administer:
    A) A fluid bolus of 20 ml/kg of N.S. or Ringers Lactate.
    B) 250 ml N.S. Bolus
    C) Ephedrine 100 mg slow IVP.
    D) Atropine 1 mg IVP.
    E) Cardioversion with 100 joules
24. Your patient’s BP has now increased to only 70/38 and the heart rate is 154 beats per minute. You would now administer:
    A) Repeat the fluid bolus of 20 ml/kg of N.S. or Ringers Lactate.
    B) Administer dopamine at 10 mcg/kg/min.
    C) Assess the patient for active bleeding or changes in the chest, abdomen or pelvic regions.
    D) A. and C.
    E) All of the above.
25. Patient #3 goes into cardiac arrest prior to arriving to “at the hospital” the hospital. The most likely reasons for this would be:
    A) Hypovolemic shock.
    B) Tension pneumothorax.
    C) Multiple internal injuries.
    D) All of the above.
26. You see significant bleeding from a laceration to the patient in the back seat from the mid lateral femur region. The best way to stop bleeding initially is to apply:
    A) A tourniquet.
    B) A bulky dressing.
    C) Direct pressure with a 4x4s or ABD pad with a gloved hand.
    D) A burn dressing with flamazine ointment.