Last night went much smoother then Monday night. Last night was kind of a big night, we were being tested on Trauma Assessment and vital signs.
Vitals are not tricky - can I use a BP cuff, yes. Can I get a BP in under 90 seconds? Yes. Can I palpate a radial pulse? Yes. Do I know how to listen to lung sounds? Yes. Patient breathes through mouth, w/stethoscope listen to the four quadrants of the chest and there's (depending on how in depth you want to go), 8-9 spots on the back to listen to. Station done. Passed, no problems.
Trauma Assessment - it's like a script you have to memorize and incorporate that script into a scenario given at the time of the test.
Proctor: You are called to a residence where a 35 year old female has fallen 30 feet onto pavement.
Candidate: BSI, scene safe?
Proctor: Your scene is safe.
Candidate: My MOI (mechanism of injury) is a 30 foot fall. I will call for ALS back-up and stabilize the spine.
(Arrive on scene)
Candidate: my general impression of the patient is poor...
I continue to assess LOC (level of consciousness) and if the patient is alert by asking the patient open ended questions and performing a painful stimuli test by rubbing their sternum or pinching a nail bed. (Proctor: there is no reaction, patient is unconscious). I determine the patient's chief complaint is that they are unconscious and I'm making the patient a high priority transport.
I begin assessing the patient's ABCs: Using a jaw-thrust I have my partner open the mouth and airway, I look for any objects in the patient's mouth, (Proctor: you see none), with my ear over patient's open mouth I listen for breath sounds and watch for a minimum of 5 seconds for chest and rise and fall. (Proctor: you hear breath sounds but have uneven chest rise and fall). I expose the chest and auscultate, (listen w/stethoscope).
Candidate: What is the patient's breathing rate, rhythm and quality?
Proctor: She's breathing at 40 breaths per minute, it's rapid and shallow.
Candidate: I'd have my partner use a BVM (bag valve mask) that's connected to high concentrated oxygen at 15 LPM, giving 1 rescue breath every 5 seconds. Throughout this entire assessment I would make sure the patient is getting properly ventilated. Are there any major bleeds or life threats?
Candidate: (back of hand on patient's arm) What is the condition of the skin?
Proctor: cool and clammy.
I begin my rapid physical exam. I use the terms D-CAP BTLS. D-CAP stands for Deformities Contusions Abrasions Punctures. BTLS stands for Burns Tenderness Lacerations Swelling. I use my hands starting at the skull quickly checking for D-CAP BTLS, when I get to the neck/throat I inform the proctor at this time I will perform a detailed physical on the back of the neck, the throat, the clavicles and shoulders b/c I want to put a C-Collar on the patient. I check for tracheal deviation and JVD (jugular venous pressure,). (Proctor: you find nothing.).
I have my partner put a C-Collar on the patient and I continue my rapid exam and D-CAP BTLS the chest, abdominal, check if the pelvis is intact, D-CAP BTLS the legs, D-CAP BTLS the arms - done with rapid. I would instruct my partner to obtain a baseline vitals. Vitals are blood pressure, pulse, breathing rate, check the eyes and skin condition. While my partner obtained the baseline vitals I would get a SAMPLE history from by standers (since the patient is unconscious). I would then have my partner stabilize the patient's spine while we perform a log roll and I would perform a detailed physical exam on the patient's posterior (D-CAP BTLS) and I would put her on a board and I would re-evaluate my transport decision. I would keep her at a high priority transport and we would transport the patient at this time.
During transport I would perform my detailed physical exam. I would start at the head and work my way down perform D-CAP BTLS with a few changes. First, I would inspect the ears, nose, eyes and mouth for any blood or fluids. I would look through the hole on the C-Collar and check for JVD and tracheal deviation. I would "cut and cover" the patient, (remove all clothing), and perform D-CAP BTLS of the entire body. When I get to the pelvis I would check the genitalia and perineum for any injuries or release. When I reach the feet, I'd remove the socks and shoes check for motor skills (have the patient point there toes or push my hands with their feet), check for sensory (can the patient tell me which toe I'm touching without looking) and check for a pedal pulse on both feet. I'd move up the arms, D-CAP BTLS, and check the motor skills of the hands (can the patient squeeze my fingers), sensory (can the patient tell me which finger I'm touching without looking), and take a bi-lateral radial pulse.
I would make sure my partner checks the vitals every 5 minutes and I would manage any secondary injuries/wounds.
That should all happen in under 10 minutes. YIKES!!
I failed my first attempt because I did not verbalize I would have my partner stabilize the spine, but I would have my partner consider stabilitation of spine. So I re-took it, no problems.
Monday 12/07/09 is the big, fat written final and medical assessment. I'm nervous about both. The written is 150 questions and the medical assessment is similar to the trauma, but the patient is awake and you have to ask a lot of questions.
I'm so looking forward to this term being over! I also have my Biology final and Math final next week. Both are on my birthday, 12/10/09. I'll be 26 and my second term in college will be over. What a great birthday present.