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Prehospital, Disaster, Administration
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1.You are on an emergency medical services (EMS) ride along when your team receives a call for multiple injured pedestrians after a device is detonated in a downtown When you arrive at the scene, there is an incident commander who instructs you that there are dozens of injured casualties and delegates you to triaging the wounded. You are directed to a secure area where the fire department EMS at the scene has brought out dozens of injured office workers. You approach a patient who has sev- eral abrasions on his torso, face, and extremities. He has no spontaneous respirations. You perform a chin lift and note chest wall movement and audible respirations. He has a palpable radial pulse and the patient can squeeze your hand on command. He is able to maintain his respiratory effort and you count a respiratory rate (RR) of 24 breaths per minute. Using the simple triage and rapid treatment (START) system, what color would you assign this patient?
2. You take a dispatch call while working a shift in the ED from EMS regarding a 38-year-old woman who developed acute severe respiratory distress while eating a peanut-soy–based dish at a Chinese You are also told that she has erythematous wheals all over her body and has diffuse wheezes on auscultation. Her blood pressure (BP) is 92/55 mm Hg, heart rate (HR) 115 beats per minute, RR 28 breaths per minute, pulse oximeter 98% on room air, and she is afebrile. EMS informs you that they are a basic unit. What are the most appropriate initial orders for the EMS unit given their level of training?
- Perform no procedures in the field, administer supplemental oxygen, and pro- ceed to the ED as quickly as safely possible.
- Establish an intravenous (IV) and administer IV epinephrine and a normal saline bolus.
- Establish an IV and administer a normal saline bolus.
- Administer intramuscular (IM) epinephrine.
- Perform orotracheal intubation for impending respiratory failure; then establish an IV and administer IV epinephrine.
3. While a couple are hiking up a mountain in a large national park, the husband slips and falls down a steep hill, hits his chest wall on a tree trunk, and a branch impales his left He also hears a “pop” from his left knee and cannot move his lower leg. The injured husband is conscious and tells his wife to go for help because he cannot move and is having dif- ficulty breathing. The wife hikes back to the park ranger’s headquarters for assistance who then calls report over the radio requesting assistance with getting the patient to your ED, which is located approximately 50 miles away. The hiking terrain has a service road, which is adjacent to their hik- ing trail and it is a clear, sunny day. What is the most appropriate transfer modality to send to the scene?
- Send an EMS van via the service road to extricate the patient and transfer him to your emergency department (ED).
- Send the park ranger in his mountain terrain–equipped vehicle to extricate the patient and bring him back to his headquarters where EMS personnel will be awaiting for further transfer.
- Send a rotary-wing helicopter and have the park ranger mobilize ground trans- port to the scene for assistance if necessary.
- Send an EMS pickup chassis with an integrated modular patient care compart- ment as the patient may need advanced monitoring during transfer.
- Send a fixed-wing EMS aircraft and mobilize the park ranger’s mountain terrain–equipped vehicle to extricate the patient and transport him to the aircraft.
4. A railroad freight car is overturned while traveling through a sub- urban area, and hundreds of gallons of chemical waste are spilled at the Several of the crew were heavily exposed to the spilled chemicals and are reported to be in critical condition. Some of the crew have already died from the exposure. The incident commander sets up a hot-zone perimeter and has designated decontamination zones. You receive a call from a HAZMAT (hazardous material) paramedic unit with a patient in distress who they believe will not survive long. Under what circumstances is it acceptable to take the patient directly from the hot zone without going through decontamination?
- If it is reasonably certain that the patient will not survive long enough for the decontamination process.
- If the toxic chemical is identified and the EMS personnel have adequate equip- ment to reasonably ensure their safety.
- If the incident commander orders EMS to bypass the decontamination zone due to the patient’s impending deterioration.
- If the resources at the incident site are overwhelmed by the number of contami- nated people and decontamination cannot be performed rapidly.
- It is never acceptable to bypass the decontamination process after a toxic expo- sure, especially if the toxin is unknown.
5. EMS arrives to your ED with a 60-year-old man in cardiopulmonary arrest. He has a history of three prior heart attacks and cardiac stents due to severe coronary artery EMS tells you that he has been pulse- less for 10 minutes. You immediately continue resuscitative efforts via advanced cardiac life support (ACLS) guidelines. After several administra- tions of ACLS drugs and several rounds of cardiopulmonary resuscitation (CPR), you are contemplating terminating the code due to medical futility. Which of the following factors would lead you to continue your resuscita- tive efforts?
- The patient’s arrest witnessed by a bystander or EMS who immediately began CPR.
- Before the cardiac arrest, the patient has been compliant with taking his cardiac medications.
- The patient has an automated implantable cardioverter-defibrillator (AICD).
- The patient has previously survived an out-of-hospital cardiorespiratory arrest.
- The patient’s initial out-of-hospital rhythm was asystole.
6. In 1966, the National Academy of Sciences published a report enti- tled “Accidental Death and Disability: The Neglected Disease of Modern ” This report quantified the magnitude of traffic-related death and disability while describing the deficiencies in prehospital care in the United States. They made a number of recommendations regarding ambulance systems, including a need for ambulance standards, state-level policies and regulations, and adopting a system for providing consistent ambulance services at the local level. As a result of this report, which of the follow- ing legislations authorized the US Department of Transportation (DOT) to develop prehospital systems?
- Highway Safety Act
- Emergency Medicine Services Act
- Emergency Medical Treatment and Active Labor Act (EMTALA)
- Trauma Care Systems Planning and Development Act
- Joint Commission on Accreditation of Health Care Organizations (JCAHO)
7. A patient is brought in by EMS after sustaining injuries from a motor vehicle The police arrive with the patient and inform you that he is in their custody. Your patient’s vital signs are stable. You send basic blood work, including a blood alcohol level, a chest radiograph, and a urinalysis. The blood alcohol level comes back above the legal limit for operating a motor vehicle. The rest of the workup is unremarkable. The police officer requests a copy of the patient’s medical record. What is the proper response to his request?
- Because the patient is in police custody, he does not have the same right to privacy as nonincarcerated citizens; hence you are obliged to give the officer the records.
- Refusal to give the officer the records is considered obstruction of justice and you can be found criminally liable if you do not comply with his request.
- Unless the patient consents, you are obligated to refuse the officer’s request for a copy of the medical records as this violates the patient’s rights to privacy under Health Insurance Portability and Accountability Act (HIPAA) laws.
- As a licensed physician you are allowed to use your best judgment in a case- by-case basis regarding the release of medical records of incarcerated patients to law enforcement officers. You also must document your rationale in the medical record.
- You may release all pertinent medical information but can withhold certain data from your workup, which can incriminate the patient in order to protect their rights in a subsequent trial.
8. A 67-year-old man is brought to the ED by EMS with a chief com- plaint of chest He is found to be short of breath and diaphoretic. He reports that he vomited 1 hour ago and subsequently feels better. He describes substernal chest pressure that started while doing yard work. He has a history of coronary artery disease and hypertension. He has regularly scheduled appointments with a cardiologist at a neighboring hospital. He requested to be taken to that hospital, but EMS refused and brought him to your ED because it was only 5 minutes away. The patient is angry and requests a transfer to his cardiologist’s hospital, which is 20 minutes away. What is the best course of action?
- You must politely refuse his request and work the patient up for acute coronary syndrome and admit him to your hospital if indicated.
- Contact the neighboring hospital and speak to the patient’s cardiologist. If he agrees to accept the transfer, authorize an ambulance transfer for continuity of care.
- Transfer the patient only if he has stable vital signs and his cardiologist is on-call at the neighboring hospital.
- Transfer the patient immediately and inform EMS that they should have respected the patient’s wishes in the prehospital setting.
- Perform the appropriate medical screening examination (MSE), in this case at least an electrocardiogram (ECG) and basic laboratory tests including a tro- ponin, before considering a transfer.
9. EMS responds to a call for a suicide The patient is a 58-year- old man who was recently diagnosed with pancreatic cancer and, accord- ing to the family, has been extremely depressed. The patient tried to hang himself in his room in a suicide attempt, and, when family found him still gasping for air, they cut him down. He has a weak, thready pulse, sonorous respirations with stridor and poor air entry. He also has crepitus over the soft tissue of his neck and he appears pale. The family informs EMS that he recently signed a DNR and they have the proper documentation. EMS calls in for your advice on how to proceed. Which of the following is the most appropriate response?
- The patient has a DNR order; therefore EMS must abide by his advance directive and take no intervention.
- Take no intervention but bring the patient to the ED as quickly as possible and provide supportive care.
- Secure the patient’s airway but inform EMS that they cannot proceed with CPR if the patient loses his pulse.
- Secure the patients airway and provide full supportive care, disregarding the patient’s DNR directive due to the circumstance of a suicide attempt.
- Tell EMS to stand by and contact your hospitals medical ethics board for coun- sel immediately.
10. You are working as an ED physician in a small, single-coverage com- munity ED in a level-5 trauma Which of the following scenarios can safely be managed at your facility and should not prompt a transfer?
- A 33-year-old man involved in a high-speed motorcycle accident with multiple traumatic injuries. You have stabilized his vitals and there is no in-house trauma surgeon, but you have a general surgeon.
- An 11-day-old girl’s sepsis and your lumbar puncture results are consistent with bacterial meningitis. You have initiated the proper treatment, including antibiot- ics and the patient has secure IV access and airway.
- A 75-year-old man with a history of atrial fibrillation and heart failure comes in with shortness of breath. He has an implanted pacemaker. He reports palpita- tions and weakness. His initial troponin is negative and his ECG does not reveal any ST elevations. Other than a heart rate of 55 beats per minute, his vitals are stable, the lung sounds are clear, and he has no dependent edema. You do not have an in-house cardiologist, but one can be called in within an hour.
- A 42-year-old man who fell 20 ft from his roof. Computed tomographic (CT) scan reveals an epidural hematoma. He is intubated and his vital signs are stabi- lized.
- A 22-year-old woman is 29 weeks pregnant and has abdominal pain and vaginal bleeding after being involved in a motor vehicle collision. She has a bruise over her lower abdomen where the seatbelt was applied.
11. EMS receives a call from dispatch regarding a potential domestic dis- turbance. Upon arrival, the neighbors tell EMS that they heard a woman screaming in the house and this prompted them to call When EMS approached the house, an angry man answered the door and said that the call was a mistake, the screams came from the television, and his wife is uninjured. He asks EMS to respect their privacy and asks them to leave. EMS has not seen the wife to corroborate the story. EMS calls you to ask how to proceed. Which of the following is the most appropriate response?
- Tell EMS to return to their ambulance and leave the scene as the homeowner has refused their care and assured them that there is no need for their intervention.
- Tell EMS to return to their ambulance, drive a safe distance away, and call the police for help.
- Ask EMS to politely reason with the husband and explain to him that they are required to perform a quick assessment of the wife based on the nature of their dispatched call.
- Instruct EMS not to enter the house without permission, but tell them to explain to the husband that they will wait outside but cannot leave the scene until they are allowed to interview the wife.
- Tell EMS that they cannot leave the scene until they have reasonably ensured the wife’s safety and ruled out any imminent danger to her.
12. EMS is responding to a call at a local high school football One of the high school football players is not responsive to verbal stimuli after a helmet-to-helmet collision with another football player. His RR is 12 breaths per minute, BP 100/65 mm Hg, and a strong pulse is palpated at 60 beats per minute. There is a small crack at the top of the helmet, but it is other- wise intact and strapped tightly to the patient’s head. EMS wants to remove the helmet to assess for head trauma, but they call you for permission. What is the most appropriate prehospital management of this patient?
- Do not attempt to remove the helmet. Maintain cervical spine precautions and transfer the patient on a backboard to the hospital.
- While maintaining cervical spine precautions, carefully remove the helmet and assess for head injury.
- Check the patient’s pupils if there is asymmetry, remove the helmet with cervical spine precautions, and assess for head injury.
- Wait at the scene for a physician to arrive with an electric saw for removal of the helmet and further on-scene assessment.
- Do not remove the helmet but assess the cervical spine for step-off or any signs of obvious injury before transfer.
13. EMS calls you for assistance regarding a 42-year-old woman with Hodgkin lymphoma who is hypotensive and displaying rapid, shallow res- pirations. They are calling from the oncologist’s office and he has ordered the EMS personnel to administer IV fluids with dextrose and 3 ampules of sodium bicarbonate because he thinks the patient has severe acidosis from tumor lysis The oncologist wants this done en route to the ED as he cannot accompany EMS to the hospital because he has other patients to see in his clinic. This is a deviation from the EMS standard of care protocol; hence they call you as the online medical oversight physician for instruction. What is the most appropriate instruction to give EMS in this situation?
- They cannot deviate from their prehospital Tell them to give normal saline and proceed with transfer.
- The oncologist cannot assume care for the patient without accompanying EMS to the
- Although the oncologist cannot accompany EMS to the hospital as the online medical oversight physician, you may authorize EMS to deviate from their pre- hospital protocols if doing so is in the patient’s best
- Once EMS arrives and begins treatment on the patient, they have established a relationship with the patient and the oncologist’s orders cannot supersede pre- hospital
- As the physician on-scene, the oncologist’s clinical evaluation and orders super- sede both EMS and the online medical oversight physician and EMS is obligated to abide by his