Here is a
collection of scenerios put together to deal with issues relating to each
chapter in the text. These are
situations that you may find yourself in when you get out into the field. What would you do?
Introduction to Emergency Medical Care
You are a volunteer for a rural ambulance agency and are dispatched to a two-car automobile accident about 12 miles out of town. There are six reported victims, at least two of whom are in bad shape. When you arrive, there are two people on scene who identify themselves as first responders, and they begin telling you what they have been doing. Shortly after your arrival, a car stops, and an EMT from a fire department in another city gets out and assumes control of the scene. It is quickly determined that the EMT is an EMT-B with less than a year of experience.
Describe how you would deal both with the first responders and with the other EMT. What is the primary goal at the scene of any emergency?
Chapter 2
It is 7:30am and you are dispatched to the scene of an unconscious male. Upon arrival, you find a 54-year-old man who apparently died in his sleep during the night. It is obvious that the man has been dead for much of the night. His teenage children and wife are in the room when you enter. A quick check of pulse and breathing confirm that the man is both apneic and pulseless. When you tell the family that there is nothing you can do, they begin yelling at you to do something, and they become a little abusive.
Explain how you would deal
with this situation, including how you would tell the family that the man is
beyond your help and how you would deal with their aggressive behavior.
Chapter 2
Today you are assigned to transfers. Your third transfer of the morning is to take a 54-year-old, terminally ill patient from a hospital to an extended care facility. The hospital staff informs you that the patient has infectious tuberculosis, hands you a surgical mask, and tells you in what room to find the patient. You double-check your chart, and there is no indication that this patient may be infectious. Your ambulance is equipped for standard street care. You have four more transfers before you are scheduled to return to base.
Would you accept this patient? If so, what actions and precautions would you take? If not, how would you justify it?
Chapter 3
Medical, Legal, and Ethical Issues
You and your partner are greeted at the door of a house by a
middle-aged woman and are directed into a bedroom where an elderly woman lies,
unresponsive, in the bed. Her
pulse is very weak and irregular, and her breathing is coming in gasps. While you are assessing her, you hear
her husband telling your partner that she is in the terminal stage of cancer
and he does not want any resuscitation efforts made. He has handed your partner some papers that he says are ³Do
Not Resuscitate Orders.² The woman
who let you in immediately interrupts, saying that she is the daughter and that
the children want their mother to have ³every possible change to live² and so
you must treat her as needed.
Explain how you would handle this situation. If the two sides cannot agree quickly, whose wishes would you follow?
Chapter 4
The Human Body
You respond at 2:00am to a medical distress call of a 24-year-old woman with acute abdominal pain. The patient describes a burning pain in her lower abdomen. She states that she has had diarrhea for two days now and that her period is due any day. The pain is just superior to her public hair. When you palpate the lower quadrants, she complains of pain on both sides.
Would you expose the area for observation? What organs may be involved? What other questions regarding her body functions would you ask?
Chapter 5
Baseline Vital Signs and SAMPLE History
You have responded to a 34-year-old patient who was in-line skating and fell. The patient has scrapes on both knees and is bleeding from an open fracture of the left ulna. While controlling the bleeding, you begin asking SAMPLE history questions. When you ask about pertinent past history, the patient tells you that he is HIV positive but asks you not to tell anyone. The patient is currently quite healthy and does not want others to know. The patient is also afraid that if you tell the hospital, his insurance carrier will find out.
Would you record this information and/or pass it on to the hospital? Why or why not?
Chapter 6
Lifting and Moving Patients
You are working transfers and are assigned to transport a 43-year-old man from his home to the hospital for admission. His bedroom is on the second floor, and the stairway has two turns in it that require you to lift the stretcher above the railing to make the turn. When you enter the bedroom, you find that the patient appears to weigh over 400lb. He has pneumonia and is being hospitalized for treatment. The patient has been able to get up and use the restroom, but only with difficulty. Besides you and your partner, his caretaker, who is of average size, and the patientıs 65-year-old mother are present. Protocols are very clear that the patient is to be moved on the stretcher and at no time should walk. It appears to you that the patient is too large to get down the stairs on the stretcher but that, given enough time, he could walk down the stairs. No other units are available at this time.
How would you deal with this situation? Would you go against protocol? Why or why not? How long would you wait for assistance?
Chapter 7
Airway
You are working a motor vehicle crash, and your patient is unresponsive but breathing and has a pulse. You have her head stabilized and are controlling bleeding on an open fracture of her clavicle. A paramedic comes to assist you and decides to intubate the patient. The paramedicıs technique appears somewhat clumsy, but being a rookie, you just do what you are told. Your partner needs some help with extrication of other patients, and the paramedic tells you to go. At the hospital, you find out that your original patient died and that the endrotracheal tube had been removed before she got to the hospital. You suspect that the patient was improperly intubated.
Who would you tell about this problem and your suspicions?
Chapter 8
Patient Assessment
You and your partner arrive at the scene of a single-car rollover accident. You are first on the scene and find five victims. As you approach the vehicle, you stop at a patient who was thrown from the vehicle. This patient (patient A) has a weak pulse and irregular breathing and is missing about a third of her skull, with obvious brain damage. You continue to the car and find the driver (patient B) holding his arm, which is obviously fractured at midshaft humerus and is very painful. The next two patients are in the back seat. An approximately 10-year-old boy (patient C) is unresponsive, and you can hear gurgling sounds when he breathes in. The other passenger in the back seat (patient D) is an elderly woman with an open fracture of her femur, which is bleeding profusely. The last patient is an infant (patient E), who has somehow become trapped under the front seat of the car. The infant is not making any noise and is not moving, but you are unable to access it quickly to check pulse or breathing. You complete your initial patient assessment and find no significant problems other than the ones listed above. Just you are your partner are present.
In what order would you treat these patients, and why? Justify the order for each patient.
Chapter 9
Communications and Documentation
A lawsuit has been filed against you, your partner, and the ambulance service that you work for. It alleges negligence for your treatment of a 15-year-old patient. When your run report is pulled, it is incomplete, and your notes are very sketchy. You were providing patient care, and your partner filled out the report, but both of you signed it, as is normal protocol. In reviewing the case, you and your partner remember many of the issues differently from one another.
How would you come to agreement on what was done? Would you complete the report now? What other records may be available to help clear up your differences? How could this have been prevented?
Chapter 10
General Pharmacology
You respond to a 34-year-old patient who is complaining of a diabetic problem. When you enter the apartment, you find it to be very messy and dirty. The smell is difficult to bear and is a mixture of urine, body odor, and something rotting. You find the patient on the couch and immediately notice large ulcers and dead tissue on her feet. The patient is less than alert but not unconscious and is able to communicate in slow, slurred speech. She confirms that she is diabetic and says that she has been taking her insulin. You ask to see it, and she tells you it is in a drawer in the kitchen. When you open the drawer, you find many medications, including insulin and syringes. While looking for the most recent insulin, you notice about 30 bottles, most empty, of different painkillers. All of these are dated within the last three months and about half of them are prescribed by one physician; the others are from different physicians.
Why might the patient have so many empty bottles of pain medication? Would you report this? If so, to whom? Was it appropriate to look at the other medications when you asked only about the insulin? Why or why not? Would this affect how you thought of the patient? Would this change how you treat the patient?
Chapter 11
Respiratory Emergencies
You are returning from lunch when you hear the dispatch of another unit to a drowning at an apartment complex about half a block away from where you are. You "jump" the call and turn into the complex. You arrive at the pool as the rescuers hand out an 18-month-old child. The child is cyanotic and unresponsive. You find a pulse but no breathing. Your partner has a child about that same age and is shaken by this call. Just before transport, the child "crashes," losing its pulse also. Even with the best care you could provide, the child does not make it. Now you are back on duty, your partner is barely functioning, and when you close your eyes, you can see the child and the look on your partner's face as you took control of the scene. There are about 6 hours left in your shift.
Would you stay on duty? What would you do to help your partner? What would you do to help yourself?
Chapter 12
Cardiovascular Emergencies
You are first on scene at a cardiac arrest involving a 65-year-old woman. You have initiated CPR while you partner is setting up the AED. Another squad arrives, and one of the older members takes over breaths without saying anything to you. You immediately start counting out loud and on three, the other member gives a breath. You pause long enough for the air to go in and mention that it is suppose to be after the fifth compression. The other member laughs and says, "This ain't no book. Out here, we breathe when it's convenient."
How would you deal with this person both during patient care and afterward?
Chapter 13
Neurologic Emergencies
You arrive at an auto-pedestrian accident involving two children and a middle-aged patient. The two children were crossing the street and one was struck by the car. Your partner goes to the one who was struck and yells that she is bad. You check the other girl and she is uninjured. You ask some bystanders to stay with her and go check on the driver. The driver appears to be unconscious and is bleeding freely from a forehead laceration. As you establish responsiveness, it is obvious that the driver is drunk. The driver complains of neck pain and, when coherent, is quite abusive and won't stay still.
Explain your treatment of the driver, including how you would keep him or her still.
Chapter 14
The Acute Abdomen
You respond to the local high school to find a 15-year-old girl with severe lower abdominal pain. History reveals that she normally has significant pain with menstruation and that she is experiencing vaginal bleeding currently but that it is "more red" than normal. She has not had a period for two months and thought she might be pregnant, so she went to "a guy that her friend knows and had that fixed a few days ago." This "guy" was not a physician, just a friend of a friend. She does not want to go to the hospital because her parents may find out what she has done.
Would you advise her to go to the hospital? Why or why not? How would you encourage her to go to the hospital if you thought it was important?
Chapter 15
Diabetic Emergencies
It is 8:30 A.M., and you are called to a construction site for an unconscious employee. The coworkers are yelling at the patient and tell you that he was slurring his speech and staggering around for about an hour, then complained of feeling nauseated, went into the bathroom, and passed out. His breath smells sweet like alcohol. The patient is not wearing a medical information tag, and nobody knows much about him. The foreman is saying that the company won't pay for an ambulance to take a drunk to sober up.
How would you deal with this situation? What other problems, besides alcohol intoxication, may present the same signs and symptoms? How would you tell them apart? Would you transport this patient?
Chapter 16
Allergic Reactions and Envenomations
You respond to a call to find a 24-year-old unconscious patient. Her face is quite cyanotic and swollen, and she appears to have a rash over most of her body. There is some respiratory effort, but there does not appear to be any air exchange. You contact the hospital and get a new physician, whom you do not recognize. The physician denies your request to administer epinephrine. By now, your partner has obtained vitals; they are blood pressure of 60/20 mm Hg, pulse of 140 beats/min, and no respirations. Your second request for epinephrine is denied. The hospital is 15 minutes away.
How would you deal with this situation? Would you spend more time trying to convince the physician? What would your treatment include besides epinephrine?
Chapter 17
Substance Abuse and Poisoning
You are called to provide medical support to a police SWAT team when they bust a local drug house. The entry goes well, and no one is injured. You are called into the house for a patient who reportedly had a seizure just a few moments ago. The patient appears to be unconscious. As you approach, you notice that the patient is heavily tattooed and has significant tracks on his arms from IV drug use. From the description provided by witnesses and the patient's response to painful stimulus, you question whether the patient actually had a seizure.
How would you treat this patient? Would you attempt to prove that the patient is faking the seizure?
Chapter 18
Environmental Emergencies
You are at the park with a friend when you hear a yell for help. You turn to find a small group of people standing around someone who is lying on the ground. You identify yourself and take control of the scene. The patient is middle aged and, for religious reasons, is dressed in many layers of clothing, including a covering over the head. You find out that the people are on vacation from Alaska and have been here about a week. The weather is unusually hot, with temperatures over 100F (38C). The patient feels very hot, and what skin you can see is quite red. You suggest removing some of the patient's clothing, and the patient refuses. You move the patient to the shade and offer some water to drink. The patient again refuses to remove any clothing. The patient suddenly loses consciousness. EMS has not been activated and is approximately 15 minutes away.
How would you treat this person? Would you remove some of the patient's clothing? Why or why not?
Chapter 19
Behavioral Emergencies
You respond to an address that you have been to several times before, where you find a woman who has once again been beaten up. She is scared and bruised and may have broken ribs. Her children are scared and crying and hide when you enter. You clean up some of the woman's scrapes and apply cold packs to her face. She has once again refused transport to the hospital. While you are treating her, the door opens. Her husband has returned. He is holding a knife and threatening you, your partner, and his wife.
What is your first concern? What precautions should you have taken? How would you deal with this situation?
Chapter 20
Obstetrics and Gynecological Emergencies
You respond to a woman in labor in a local supermarket. You find her seated in a chair near the checkout stands. The look on her face tells you that she is definitely in labor. She tells you that her due date was three days ago, her bag of waters broke about an hour ago, and she has had a small amount of blood appear about 1 1/2 hours ago. The man with her is encouraging her to go home. He insists that they had planned a home delivery, and that is what they should still do. The man is quite insistent, and the woman appears scared and confused. This is their first child.
What other signs and symptoms would you check to determine whether the woman can be transported anywhere or whether the delivery is imminent? If there is time to transport, would you support the mother going home? Why or why not?
Chapter 21
Kinematics of Trauma
As you approach an auto-pedestrian accident you see a 4-year-old child lying on the pavement about 10' in front of the car. You also notice a person who appears to be a parent running toward the child. Before you can respond, the parent picks the child up to comfort the child. The child immediately goes limp, and you suspect that this is because of a severed spine caused by the movement.
Would you tell the parent what he or she just did? Would you have the parent lay the child back down? If the parent asks why the child suddenly went limp, what would you say? Would you report the parent's actions? If so, to whom would you report them?
Chapter 22
Bleeding
You are called to a local jewelry store in response to a patient who slipped and fell. You are led into the rear of the store, where you find that the patient not only fell, but fell through a display case and is bleeding severely. You immediately recognize the need for much more BSI protection. Your goggles, mask, and gown are out in the truck.
Would you leave this severely bleeding patient to get more protection for yourself? If so, why? If you did leave and the patient died, would you be liable?
Chapter 23
Shock
You are treating a seriously injured motorcycle driver when the driver of the car that turned in front of the motorcycle starts asking you questions. At first, they are the kind you would expect, such as whether the motorcyclist will be okay, but they soon move to whose fault it was. Then the driver begins to get in your way, trying to help treat the patient. After you repeatedly ask the driver to step back, he threatens you and then disappears. You realize that the driver had very pale skin color and was probably suffering from hypoperfusion due to emotional stress (psychogenic shock).
How would you deal with the
driver? Would you send someone after the driver? If so, who?
Is there a chance that the driver will return and carry out the threats?
How does all of this affect your care of the motorcyclist?
Chapter 24
Soft-Tissue Injury
You are providing medical support at a local high school football game and are called to the sideline to check out the star quarterback. He has been hurt a few plays ago and had hopped off the field. He is now able to place a little weight on the injured leg but limps badly. The game is against the rival high school and is for the league championship. The coach and player want him to return to the game. The player's parents want you to check him first. His knee has some swelling and is warm to the touch. The player is sure that he can play on it if he wears a knee brace from one of the other players. The coach has a little sports medicine training, and you are the only other medically trained person there.
Would you allow the player to continue playing if he wants to? Would you help him put on another person's knee brace? Who else may be able to provide assistance with this decision? Do these decisions fall under EMT protocols?
Chapter 25
Eye Injuries
You respond to an industrial accident to find a patient with a 2" x 1" piece of metal stuck in her eye. The patient is very upset because she lost her other eye in a childhood injury and now has an artificial glass eye. It is obvious that there is a great deal of damage, and you suspect that she will lose sight in this eye. The patient asks you very directly whether she is going to lose the sight in her good eye.
How would you answer the patient? Would it be fair to be less than honest with her? Why or why not? Would it be your role to tell her that she may end up blind?
Chapter 26
Face and Throat Injuries
You respond to a neighborhood park to find a patient who has been hit in the throat with a baseball. The patient's throat is quite swollen, he is cyanotic, and it does not appear that he is able to breathe. You apply a cold pack to his throat and prepare to transport. Before you are able to get him loaded into the ambulance, he loses consciousness. You are not trained to perform a cricothyrostomy (create an artificial opening in his throat), but you have seen it done in the hospital twice.
Would you ask medical control for permission to perform a cricothyrostomy? Why or why not? If medical control authorized the procedure, who would be liable for any damages that might occur? What other treatments might you try?
Chapter 27
Chest Injuries
You are assessing a middle-aged woman with chest injury and difficulty breathing. She has cyanosis around her lips, her respirations are 44/min, and they are shallow and labored. She was thrown against the dashboard during an automobile accident. During the trauma assessment, you ask to bare her chest to look for discoloration, deformity, or paradoxical breathing because you suspect a flail chest. The patient refuses to allow you to open her blouse or even lift it up to look. You ask the whether a woman at the scene could look for you, and the patient refuses to allow that also.
How would you adequately assess this woman's injuries? How else might you convince her to allow you to look at the injuries? How would you treat this injury if you could not look for paradoxical breathing? What are some possible reasons why the patient would refuse to be examined?
Chapter 28
Abdomen and Genitalia Injuries
You respond to a person in an alley near the homeless shelter who has been stabbed multiple times in the abdomen. You recognize the patient as a street person who has been around for a couple of years. You have talked with the patient many times before and have enjoyed those encounters. You contact the nearest hospital and establish medical control. It has been a relatively slow night, but when medical control finds out where the patient is located, they assume that the patient is homeless and unable to pay for services. The hospital immediately reports being overloaded and refers you to another hospital that is farther away.
Would you immediately question their decision? If so, how? Would you report this action? If so, to whom? Is there a legal responsibility to accept all patients in the emergency department? Are these wounds possibly life threatening? If so, does that affect the hospital's ability to deny treatment? Does a prehospital response agency fall under these same requirements?
Chapter 29
Musculoskeletal Care
You respond to a roller rink to find a patient with a dislocated shoulder. The patient is complaining of pain and asks you to "pop it back in." The patient explains that the shoulder has dislocated a couple of times before, but she has always been able to get it back into joint. The patient has good circulation and neurologic function in the arm. She explains how to pull gently and rotate the arm to get it to pop back in. The patient refuses to go to the hospital.
Would you assist the patient in reducing the dislocated shoulder? If so, how? Should the patient be seen by a care provider? Why or why not?
Chapter 30
Head and Spine Injuries
You find a patient at an automobile accident on the floor in front of the seat, curled under the dashboard. The patient is conscious and complaining of pain in his abdomen, neck, and left ankle. He also explains that every time he moves, his head, a burning pain shoots down his back. The patient is able to move his fingers and toes, except right after the shooting pain. The patient now begins to complain of nausea. Within a couple minutes of complaining of nausea, the patient beings vomiting.
Would you move this patient? Why or why not? When would you move the patient? How would you move him?
Chapter 31
Pediatric Assessment
You respond to a home in the middle of the night for a "child who can't breathe." When you arrive, you find a three-year-old child who is coughing and has noisy inhalations. The child has good skin color but feels warm to the touch. You attach a pulse oximeter and find that the child is well oxygenated. The parent explains that the child has had a cold but that the coughing is worse tonight. You question whether the child needs medical care at all and are confident that the child does not need to be transported in an ambulance.
Would you refuse to transport the child? What would you tell the parent? What is your liability if you tell the parent that an ambulance is not needed?
Chapter 32
Pediatric Airway and Medical Emergencies
Shortly after your partner begins rescue breathing on an infant, you notice that the infant has developed significant stomach distention. You point it out to your partner and assist in treating it. Within a few breaths, it occurs again, and your partner chooses to ignore it. The infant's skin color is not returning to normal, and the distention is getting worse.
What may be causing this? How would you get your partner to treat the problem? Would you take the infant away from your partner? What would you do for the infant?
Chapter 33
Pediatric Trauma
You respond to a home to find an unconscious infant in a crib. The infant has irregular breathing and a weak, rapid pulse. There is a large red skin discoloration just in front of the infant's ear. The person who met you at the door told you that the baby fell out of the crib and hit its head, but the person in the bedroom says that the baby fell down the stairs. The baby does not appear old enough to have done either on its own. You suspect child abuse.
Would you report this? If so, when and to whom? What would you ask the people who are with the child? How much time would you spend on the scene gathering information? Would you allow the adults to ride in the ambulance to the hospital?
Chapter 35
Ambulance Operations
You have just been paired with a new partner, and after the first week, you are very uncomfortable with this person's driving. Your partner is not as bad when there is a patient on board, but when responding, protocols are not followed, and speed is excessive. When you mention it to your new partner, the response is that the partner has had only one accident in two years and is usually first on the scene. You are very uncomfortable with this situation.
How would you deal with this situation? Would you report your partner? If so, when and to whom?
Chapter 36
Gaining Access
You arrive at the scene of an auto accident to find two vehicles, each with only a driver inside. One vehicle is a delivery van that is on its side with the driver halfway through the windshield. A placard on the van indicates that it is carrying radioactive materials. The driver is bleeding severely from a wound on the head and an open fracture on the left forearm. The driver is also unresponsive. The driver of the other car is responsive and has a bump on the forehead but is not bleeding anywhere and believes that she can walk. You can determine all of this because you initially approached close to the scene. Your partner yells to the conscious patient to walk to where your vehicle is parked and backs away from the scene to a safe location. You partner than says, "Let's not tell anyone how close we were."
How would you deal with this situation? What would be the likelihood that you or your vehicle was exposed? How serious are the radioactive materials that would be carried around in a delivery van?