Download MBBS Procedures Skills and Administration Lecture Notes

Procedures, Skills & Administration
Model of the Clinical Practice
of Emergency Medicine 2009
? Appendix 1
?Procedures and skil s integral to the practice of

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EM
? Appendix 2
?Other components and core competencies of
the practice of EM
1

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Procedures
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Airway (1)
Cricothyroidotomy
? Absolute contraindications?

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? Relative contraindications
?Age < 10 (leads to subglottic stenosis)
?Bleeding diathesis
?Poor landmarks
? Complications

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?Hemorrhage, aspiration, misplaced tube,
hypoxemia, neurovascular injury, mediastinal
emphysema
Needle cricothyroidotomy is the emergency
surgical airway of choice for age < 10

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Airway (2)
? Transtracheal jet ventilation (PTJV)
?Temporizing device
?Provides temporary oxygenation/ventilation

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?Limitation: Hypercapnea
?4:1 expiratory/inspiratory ratio
?2.8-3.0 mm I.D./ 6 F kink
resistant catheter
?50 psi

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?Max: 30 minutes
?Facilitates ETT placement due to glottic
opening
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Airway (3)

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Airway (3)
Confirmation of endotracheal intubation
? Visualization
? Auscultation

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? Capnometry
?Reliable if pulse is present
?False negative in cardiac arrest
? Esophageal detector devices
?Bulb does not re-expand in esophageal intubation

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?False negatives: pregnancy, obesity, COPD
?False positives: uncommon
? Chest x-ray: used to rule out right main stem
intubation
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Airway(4)
? CAPNOGRAPHY: A VALUABLE TOOL
FOR AIRWAY MANAGEMENT, Nagler, J.,
et al, Emerg Med Clin North Am, 26(4):

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881, November 2008.
Indications
Procedural sedation
BiPAP
DKA

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Mech Ventilated Pts
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Regional Nerve Blocks
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Radial Nerve Block

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? Supination
? 3-5 cm proximal
to the joint
? 10cc lidocaine or

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bupivicaine
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Ulnar Nerve Block
? Supination
? 3 finger widths from distal

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crease
? Inject between the flexor
carpi ulnaris and the
ulnar artery. Paresthesias,
withdraw slightly and inject

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? 3-5 cc lidocaine or
bupivicaine
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Median Nerve Block
? Inject between the

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flexor carpi radialis
and the palmaris longus
? 3-5cc lidocaine
or bupivicaine
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Ankle Blocks (1)
? Superficial peroneal nerve
?Inject SQ between the lateral maleolus and
the anterior border of the tibia
? Posterior tibial nerve

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?Medial aspect of the calcaneal tendon anterior
toward the posterior tibia. The nerve is just
posterior to the tibial artery.
?If paresthesias, inject 3-5 cc
?If not, contact the tibia and inject 5-7 cc

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Ankle Blocks (2)
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Paracentesis
?

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Thomsen TW, Shaffer RW, et al.
Contraindications
Paracentesis. N Engl J Med. Nov
?
2006;355(19):e21.

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Acute abdomen (absolute)
?Platelet less than 20K
?INR greater than 2.0
?Pregnancy
?Distended bladder

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?Distended bowel
?Cel ulitis
?Adhesions
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Excision of Thrombosed

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Hemorrhoids
? 48-72 hours within
onset of symptoms
? Local infiltration
of lidocaine

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? Elliptical incision/
excision of clot and
overlying skin
? > 72 hours, conservative medical
therapy

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Nail Trephination
? Trephination as good as nail bed
exploration
? Needle or cautery

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Wound Care
Karounis et al. COSMETIC OUTCOMES WITH
ABSORBABLE VS. NONABSORBABLE SUTURES
ACAD EMERG MED. July 2004, Vol. 11, No. 7

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? Absorbable plain gut suture
?No need for suture removal
?No difference in cosmetic result
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New AHA Guidelines

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? BLS
? ACLS
? PALS
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BLS

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Summary
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ACLS

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ACLS Cardiac Arrest Circular Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
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Copyright ?2010 American Heart Association

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ACLS Cardiac Arrest Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
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Copyright ?2010 American Heart Association

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Bradycardia Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
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Copyright ?2010 American Heart Association

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Tachycardia Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
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Copyright ?2010 American Heart Association

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Summary
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PALS
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PALS Pulseless Arrest Algorithm
Kleinman, M. E. et al. Circulation 2010;122:S876-S908
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Copyright ?2010 American Heart Association

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PALS Bradycardia Algorithm
Kleinman, M. E. et al. Circulation 2010;122:S876-S908
30
Copyright ?2010 American Heart Association

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PALS Tachycardia Algorithm
Kleinman, M. E. et al. Circulation 2010;122:S876-S908
31
Copyright ?2010 American Heart Association

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Newborn Resuscitation Algorithm
Kattwinkel, J. et al. Circulation 2010;122:S909-S919
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Copyright ?2010 American Heart Association

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Summary
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Rosenberg M. Comparison of Broselow tape measurements
versus physician estimations of pediatric weights
The American Journal of Emergency Medicine; April, 2010

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? 372 Patients
? Mean age: 45.7 months
? Obesity
?Physician 26.4%

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?Broselow 16.0%
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Joint Reductions
? Posterior elbow dislocations

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?Procedural sedation
?Supine: slight flexion/
supination with opposing
traction on the humerus
and forearm

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?Prone: flexed to 90o
hand toward ground
traction on forearm with
pressure on olecranon
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Joint Reductions (2)
? Posterior hip dislocations
?Procedural sedation
?Hip flexed, bed lowered, Shoulder in the
popliteal fossa with arm under injured leg and

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hand on uninjured leg, pelvis stabilized,
traction at 90o, internal rotation
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Joint Reductions (3)
? Shoulder dislocations

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? Scapular manipulation
?Prone or sitting
?Scapula rotated external y
? Traction-counter traction
? Stimson technique

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Cunningham Technique
? Kocher maneuver (leverage)
?Higher complication rate
?Axil ary nerve injury
?Capsular damage

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?Humeral shaft fracture
? External rotation
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Central Venous Access

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? Complications
?Pneumothorax (subclavian > IJ approach)
?Hemothorax, venous thrombosis, arterial or
neurologic injury, arteriovenous fistula,
infection, air embolism, great vessel injury

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?Femoral anatomy, lateral to medial: N-A-V-L
? Trauma considerations
?Place line on side of trauma/pneumothorax
?Place line on side opposite potential vascular
injury

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Contraindication: coagulopathy
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Umbilical Line Insertion
? Hemostasis with
umbilical tape or suture

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? Two arteries
and one vein
? 5 F catheter: Term
? 3.5 F catheter: Pre-term
? Advance 1-2 cm

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beyond the point
of blood return
? 4-5 cm: Term
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Intraosseous Access

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? Rapid temporary vascular access
? Anterior tibia is preferred pediatric site
? Prox humerus, distal tibia, medial mal eolus and
preferred adult sites
? Complications: infection, subcutaneous

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infiltration, hematoma, growth plate injury,
osteomyelitis
"When venous access cannot be
quickly and reliably established"
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Chest Tube Thoracostomy
? Complications
? Infection

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? Great vessel
? Intercostal neurovascular injury
? Persistent pneumothorax
? Subcutaneous emphysema
? Re-expansion pulmonary edema (rare)

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? Intra-abdominal placement (intrathoracic
abdomen: 4th intercostal space anteriorly to the 7th
intercostal space posteriorly to the inferior costal
margins)
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Pericardiocentesis
? Pericardial effusion: d iagnostic and therapeutic
? Ultrasound guidance is recommended
? EKG-guided: unipolar EKG electrode attached to
exploring needle

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? Complications
?Cardiac laceration,
?ventricular fibril ation
?Pneumothorax
? Non-clotting blood is

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? diagnostic
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ED Thoracotomy (1)
? Indication: penetrating thoracic injuries
?Arrest imminent despite airway control and fluids

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?Loss of vital signs
?Better for preventing arrest rather than treating arrest
?Pericardial tamponade (pericardiocentesis is
temporizing)
?CPR < 15 min, particularly with electrical activity

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? Poor prognostic signs
?Non-intubated field arrest >5 min
?Intubated field arrest >10 min
?Initial rhythm agonal or asystole
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ED Thoracotomy (2)
? Goals of procedure
?Evacuation of pericardial tamponade (left
phrenic nerve can be injured when opening
pericardium)

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?Control hemorrhage
?Open cardiac massage
?Cross clamp aorta
? Not routinely indicated in blunt trauma,
penetrating abdominal trauma

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ED Ultrasound
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Procedural Sedation
? Preparation is the key

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? Is the patient an appropriate candidate?
? NPO guidelines (controversial and not
mandatory)
? Informed consent
? Know the adverse effects

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? Continuous monitoring
? Safe discharge
? Not every patient can or should undergo PSA
in the ED
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ASA Classifications
? ASA I A normal y healthy patient
? ASA II A patient with mild systemic disease
? ASA III A patient with severe systemic
disease and functional limitations

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? ASA IV A patient with severe systemic
disease that is a constant threat to life
? ASA V A moribund patient who is not
expected to survive without the
procedure

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? Classes III and IV may require consultation with an
anesthesiologist
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Equipment (minimum)
? High flow O source
2
? Suction
? Vascular access

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? Airway management
equipment
? Monitor pulse ox, blood pressure,
capnography
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NPO Guidelines
? No oral liquids within 2 hours for children <2
years; 3 hours if >2 years
? Prefer no milk or solids

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within 8 hours
? In the emergency
department setting
- Delay sedation if possible
- Use lightest sedation possible

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- Have airway equipment at bedside
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Medications (1)
Opioids: analgesia and sedation
Opioids + Benzos = Opioids given first

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? Morphine
?Poor lipid solubility (slow blood-brain
penetration)
?Histamine release (hypotension,
bronchospasm)

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?Liver metabolites 4 times more potent and
longer lasting
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Medications (2)
? Fentanyl

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?Low complication rate for PSA in ED
?Chest wal rigidity (seen with large doses and
rapid administration, not relieved by naloxone,
may need to paralyze and intubate)
?Highly lipid soluble, penetrates blood-brain

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barrier rapidly, accumulates in adipose tissue
?Does not release histamine (no hypotension
or bronchospasm)
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Medications (3)

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Anxiolytics (sedation, amnesia, anxiolysis)
? Methohexital (Brevital)
?Twice as potent as thiopental
?Ultra-rapid onset (30 sec.) / duration = 10 minutes
?Causes unconsciousness

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?A direct myocardial depressant and vasodilator
?Avoid in hemodynamical y compromised patients
?Can cause hypoventilation / apnea
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Medications (4)

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Anxiolytics (sedation, amnesia, anxiolysis)
? Midazolam
?High lipid solubility, rapid CNS effect
?Combination with EtOH or opioids causes
increased sedation, respiratory and cardiac

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depression
?Administer in smal doses
?Chronic alcohol user may require higher doses
?Broselow issues with overweight children
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Medications (5)
? Propofol
?Supplied as an emulsion
?Injection causes burning sensation
?No egg al ergy (egg protein)

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?No preservatives, therefore increased risk of
bacterial contamination
?Sedation is rapid, amnesia unreliable
?Significant cardiovascular depression
?Antiemetic properties

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?Dedicated IV line
?Less likely to cause resp depression v. Etomidate
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Medications (6)
? Etomidate: sedation and hypnosis (induction)

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?Metabolized by liver
?No decreased blood pressure, no decreased
RR
?Side effects: N/V, myoclonus, adrenal
suppression

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Medications (7)
? Ketamine: dissociative anesthetic
?Emergence reactions more common over 16
years old

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?Benzos may decrease emergence reaction
?Increased ICP
?Respiratory and cardiovascular depression
rare
?Bronchorrhea (pre-medicate with

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glycopyrolate or atropine)
?Laryngospasm rare
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Medications (8)
? Reversal Agents

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?Naloxone (Narcan)
?Duration 1-2 hours
?May need repeat dosing
?Duration action the same as Fentanyl
?Flumazenil (Romazicon)

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?Watch for re-sedation
?Complications: seizures, withdrawal in
chronic benzo users
?Duration of action same as Versed
?Contraindicated for empiric OD Tx

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Morphine
Fentanyl
Brevital
Propofol

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Etomidate Ketamine
Histamine
X
release
Chest

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X
rigidity
Bronchorrhea
X
Hypotension

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X
X
X
Adrenal
X

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suppression
Resp
X
X
X

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X
X
Emergence
X
reaction

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Myoclonus
X
Bronchodilat
X
or

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Antiemetic
X

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EM Administration
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ED Design
? New ED design
?Allow for 25% increase in current patient load
by the time new ED completed and 25%
increase over the next 5 years (total increase

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50%)
? One treatment area for every 2000 visits or 5-7
spaces per ED physician on duty
? Each treatment area at least 9' X 9'
? Parking: 12-14 spaces per 20,000 visits

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? Pediatric EDs have greater equipment needs
? EDs with >100 visits/day must have a major
trauma room and an eye room
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Patient Satisfaction
? Most common complaints
? Physician and nursing issues
? Operational inefficiency
? Lack of comfort

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? Not being informed
? Improper bil ing
? Most common physician complaints
? Misdiagnosis of presenting problem
? Unprofessionalism

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? Less common complaints
? Inadequate treatment, incomplete explanation
? Department cleanliness
? Communication is critical
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EMS
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Standards / Training (1)
? National highway safety act of 1966 / EMS
system act of 1973

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?Defined goals for improving EMS on a national
scale
?Federal funding for EMS operations, training and
research
? National highway traffic safety administration

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(NHTSA)
? Federal EMS oversight
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Standards / Training (2)
? Certification criteria vary from state to state

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?National standards inconsistently adopted
?EMT scope and practice may vary regional y
? State EMS laws and regulations define
?Ambulance service capabilities
?Training requirements

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?Physician leadership requirements
? State health department is lead agency
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Standards / Training (3)

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? Dept. of Transportation (DOT) EMS training
curricula
1. U.S. DOT first responder: 20 hours. First aid,
CPR, AED, EMT-A (no longer exists)
2. EMT-B: 110 hours. Ambulance operations, BLS

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training, CPR
3. EMT-I: 300 hours. EMT-B + IVs + airways
(Combitube, LMA) + limited drugs (dextrose,
naloxone)
4. EMT-P: 1100 hours. EMT-B + EMT-I + advanced

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airways, ACLS, medications
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Medical Control (1)
? Paramedics act under a physician's license
? Standing orders al ow paramedics to function

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when online medical contact is not available
? The ultimate responsibility for quality assurance
lies with the local EMS medical director
? EMS system is regulated by state law
? Federal regulations specify ambulance

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standards
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Medical Control (2)
? Immediate (online, direct)
?Orders to EMTs in the field (radio contact)

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?Direct field observation (ride along)
?Best method for assessing quality of care
?Most complete data gathering, prompt feedback
? Prospective (offline, indirect)
?Development of policies and procedures

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?Standing order approval
?Training, testing and education
? Retrospective (offline, indirect)
? Review of run sheets
? QA EMS training based on deficiencies

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Refusal of Care
? Online medical direction should be requested
? High liability area
? Implied consent if patient is impaired

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? Documentation is key to legal protection
? Non-transports do not = AMA
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Disaster Medicine: General (1)
? Disaster: "When the destructive effects of

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natural or man-made forces overwhelm the
ability of a given area or community to meet
the demand for healthcare"
?External: occurs outside hospital (plane
crash)

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?Internal: occurs within hospital (fire, power
failure)
?Both can occur together
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Disaster Medicine: General (2)

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? Phases of disaster management
? Planning & Preparedness
? Mitigation
? Response
? Recovery

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? Evaluation
? Important factors for response success
?Established EMS system
?Correct assessment of extent of disaster
?Mobilization of resources

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Disaster Medicine: General (3)
? No one agency in charge of nation's trauma and
emergency care systems
? Federal emergency management agency (FEMA)

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?2,600 FTEs
?Partnerships: 27 federal agencies, State and local EMAs
and Red Cross
?Federal response plan (response to al disasters and
emergencies)

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?Helps state and local organizations prepare, respond and
recover
? Federal emergency aid
?Requested by Governor
?Authorized by President

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Disaster Medicine: General (4)
? National disaster medical system (NDMS)
?Section of the Dept. of Homeland Security
?Supplemental medical response in case of

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catastrophic disaster
?Domestic disasters
?Natural Disasters, Technological Disasters,
Major Transportation Accidents , Acts of
Terrorism including Weapons of Mass

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Destruction Events
?DMATs (disaster medical assistance teams):
medical volunteers responding to NDMS
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Disaster Medicine: General (5)

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? Communication is the first problem in disasters
(telephone lines)
? Lack of back-up resources is the most
common problem
75

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Disaster Medicine: Operation (1)
? Hospital / ED Plan
?JC disaster plan and participate in two dril s per
year
?Key functions: activation, capacity assessment,

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command center, communications, supplies,
designated areas, training, dril s
?Media
?Designated administrator should be assigned
?Restricted to designated non-care area

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Disaster Medicine: Operation (2)
? Incident command system
?Standardized EMS command and control for
an organized response

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?Management of multi-agency / multi-
jurisdictional response
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Disaster Medicine: Operation (3)
? Disaster triage tags

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? Red = life-threatening injury
? Yel ow = serious but stable
? Green = non-serious injury
? Black = dead or moribund
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Medicolegal Aspects of EM
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Emergency Medical Treatment and
Active Labor Act (EMTALA) (1)
? Purpose: to prevent denial of emergency care, or

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transfer of patients, based solely on the patient's
ability to pay (anti-dumping law)
? Medical Screening Exam (MSE): al patients
presenting to the emergency department must
receive a MSE regardless of their ability to pay

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Emergency Medical Treatment and
Active Labor Act (EMTALA) (2)
? "Campus means the physical area
immediately adjacent to the provider's

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main buildings, other areas and structures
that are not strictly contiguous to the main
buildings but are located within 250 yards
of the main buildings, and any other areas
determined on an individual case basis, by

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the CMS regional office, to be part of the
provider's campus."
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Emergency Medical Treatment and
Active Labor Act (EMTALA) (3)

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? Scope and extent of MSE based on
?Chief complaint, emergency condition
?Hospital resources
?May include ancil ary tests and on-cal specialists
available to hospital

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? Accuracy of diagnosis is less important than
adherence to process
? MSE cannot be delayed for financial information
?Rule out emergent medical condition / active labor
?Stabilize patient

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Emergency Medical Treatment and
Active Labor Act (EMTALA) (4)

? Who can do the MSE?

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?"Qualified" medical personnel
?Determined by hospital
?Designation must be outlined in hospital bylaws
? Federal transfer law applies to hospitals
receiving Medicare payments

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? Patients in active labor are considered unstable
? On Cal Physician responsibilities
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Emergency Medical Treatment and
Active Labor Act (EMTALA) (5)

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? Patient transfer requirements
?Good medical reason for transfer (benefits >risks and
if higher level of service)
?Informed consent (risks and benefits)
?Facility-to-facility communication and agreement to

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accept transfer
?Space available
?Transferring facility determines mode of transportation
? Violations: hospital and physician fines $50,000
and loss of ability to bil Medicare

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84

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HIPAA
Health Insurance Portability & Accountability Act
of 1996.
"Portability" ? COBRA.

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"Accountability" ? 4 Parts:
Patient Confidentiality.
Transactions & Code Sets.
Security.
Patient Identifiers.

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85

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Enforcement and Penalties
? Civil Monetary Penalties
?Fines range from $100 to $25,000 annual y
for the same offense.

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? Criminal Penalties
?Fines up to $250,000 and/or 10 years in
prison.
86

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HIPAA Privacy Rule

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? Established Federal protections for Protected
Health Information (PHI) that is maintained or
transmitted in ANY form.
? Provides patients with the right to control their
medical information and to NOT have it used or

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divulged to others against their wishes.
87

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Protected Health Information
Health information relating to the past, present or
future health conditions of the individual.

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This covers al information, maintained
electronical y, in paper form or communicated
verbal y.
Information that actual y identifies an individual, or
that can be used to identify an individual.

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Key: Did you learn the patient information through
your job? It must be protected
88

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Disclosure of PHI

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? HIPAA Authorizations
?Strict legal requirements for the contents of
the form.
?Must specifical y describe the information to
be released.

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?Must contain the name of person authorized
to make the disclosure and the person to
whom the disclosure wil be made.
?Do not honor an authorization form unless it
meets the strict HIPAA criteria.

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89

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Violence / Abuse
Child Abuse
? Mandatory reporting in al states. Report any
suspicion

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? Legal immunity
? Consider failure to thrive, emotional and
psychological trauma
? Admission is recommended
? Multiple injuries in various stages

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? Commonly seen with delays in treatment or
frequent visits with vague complaints
90

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Violence / Abuse (2)
Child Abuse

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? Fractures suspicious for abuse
?Greatest in children <5, majority <18 months
?Long bone, posterior rib (most common child
abuse fracture in infants), metaphyseal,
bilateral, multiple, various stages of healing

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?Fractures with low specificity for abuse
?Linear skul
?Long bone age > 5
?Clavicle
?Consider CT of the Brain

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91

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Patient Rights (1)
Decision-Making Capacity (DMC)
? Determined by clinical circumstances
? Comprehension of options

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? Awareness of consequences
? Comprehension of risks and benefits
? A patient with DMC has the right to refuse treatment
? Forcing treatment on a refusing patient with DMC
could be charged as assault and battery

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N Engl J Med 2007;357:1834-40.
Competence is a legal term
requiring a court ruling
92

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Patient Rights (2)

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Civil Commitment
? Being psychotic is no t, in itself, a reason for
commitment
? Must demonstrate danger to self or others, or
grave disability

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? Strongest predictor: Lack of insight
Informed Consent
? The physician's responsibility
? Includes disclosure of risks and benefits
? Review viable alternatives

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? Explain risks of not being treated
93

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Patient Rights (3)
Implied Consent
? Consent is implied in an emergency situation

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? Need to document
?Nature of emergency
?Treatment for patient's benefit
?Reason consent could not be obtained
94

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Patient Rights (4)
Minors: Consent
? Parent or legal guardian must consent to
treatment if age < 18 (age may vary by state)
? If parent or guardian unavailable

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?Evaluate and treat, especial y if delay may
result in harm
?Make repeated attempts to contact parent(s)
?Document al of the above
95

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Patient Rights (5)
Minors: Consent
? Laws vary by state
? Emancipated minor (may treat without parental
consent)

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?Married or pregnant
?Active military duty
?Living away from home
?Condition is a public health hazard
96

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Patient Rights (6)
Minors: Consent
? EMTALA 1st!!

? EMTALA (federal law) pre-empts state law

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?MSE for al patients presenting to the
emergency department
?Must provide stabilizing treatment
?Not age-specific
? State courts almost always affirm a physician's

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(reasonable) judgment
? Withholding treatment is more likely to be held
negligent
97

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Patient Rights (7)

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Advanced Directives
? Applies to acute cardiac or respiratory arrest
? Does not imply presence of terminal il ness or
refusal of other care
? "When in doubt, resuscitate"

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98

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Patient Rights (8)
Patient Restraints

? Team approach, minimum necessary force

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? Behaviors dangerous to patient or staff
?Behavioral
?Medical y necessary
? Close observation required for safety
? Chemical before physical

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? Documentation: reason, physician order, re-
evaluation
99

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Duty to Third Party
? Named third party

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?If patient identifies someone that they plan to
injure, notification of police is recommended
? Unnamed third party
?Written "do not drive" discharge instructions for
sedatives, narcotics, eye patch, seizures

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?Treatment of partners of STD patients
100

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Good Samaritan Laws

? No duty to act

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? Protect non-compensated responders
? Do not apply to patients in the ED
? Do not protect if grossly negligent
? Can't be used to defend a malpractice claim
101

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Mandatory Reporting by
Healthcare Providers
? Varies with jurisdicti
on
? Communicable diseases

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?STDs, hepatitis (reported by lab)
?Highly contagious (anthrax, measles) reported
if suspected
? Violent acts
?Child abuse, domestic abuse, elder abuse

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?Death
102

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Disclosure of medical error
? Thomas H. Gal agher, M.D., David Studdert, LL.B.,
Sc.D., M.P.H., and Wendy Levinson, M.D. Disclosing

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Harmful Medical Errors to Patients. N Engl J Med 2007;
356:2713-2719
?Inform the patient asap
?Express regret for the error
?Advise them of the fol ow up that wil occur

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?Demonstrate a plan of avoidance
103

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Medical Malpractice: Terms (1)
? Duty to treat
?Established when patient presents to the ED

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? Standard of care
?Actions a reasonable physician with similar training would
take under similar circumstances
? Direct cause ("causation")
?Injury occurred as a direct result of actions by the treating

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physician
? Proximate cause ("causation")
?No superseding or intervening forces interrupting the chain
of causation.
? Damages

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?Wages, medical expenses, pain and suffering
104

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Medical Malpractice: Terms (2)
? Professional negligence
?Conduct fails to meet accepted standard of care

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? Joint & several liability ("deep pocket" rule)
?Several physicians held accountable
?A physician may be only 1% at fault but could pay
entire judgment
105

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Medical Malpractice: Overview (3)
? Most common reasons
? Failure to diagnose
? Complications from treatment/procedures
? Delays in definitive management

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? Most frequent claims
? Missed fractures and dislocations
? Wound care (infection, tendon injury,
neurovascular injury, foreign body)
? Expensive claims

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? AMI
? Meningitis
? Spinal cord injury
106

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POLICIES & PROCEDURES

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QUESTIONS
107

---

Regarding EMS, which statement is
true?
A. Paramedics are licensed practitioners

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B. Standing orders al ow paramedics to function
without any medical control
C. EMS systems are state regulated
D. Certification requirements are consistent from
state to state

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E. On-line medical control is not suggested for
refusals
PPS 1

---

In a disaster, which problem is
usually encountered first?

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A. Lack of back up resources
B. Insufficient volunteers
C. Communication problems
D. Water supply contamination
E. Jurisdiction disputes

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PPS 2

---

A roofer working on a hospital owned office
building 150 yards from the hospital has fallen
and is unconscious and unresponsive. What is
the hospital's responsibility in this case?

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A. Cal 911
B. The hospital has no legal responsibility to this
patient
C. The hospital must mobilize an internal
response to assist this patient

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D. The hospital is obligated to pay for al
medical expenses associated with his injuries
E. The hospital must contact his employer and
family
PPS 3

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With respect to EMTALA and Medical Screening
Examinations, which statement is true?
A. The extent of the MSE is based solely on the
chief complaint
B. The MSE may be performed after obtaining

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financial information if the delay is < 30
minutes
C. Stabilization is considered part of the MSE
D. Delays in performing the MSE are acceptable
on busy days

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E. Patients in early labor, < 5 cm dilated, are
considered stable
PPS 4

---

A 2 m/o child has not been using his right arm
after he crawled off the changing table 3 days

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ago. Radiographs show a spiral mid-shaft
humerus fracture. Regarding this patient's
condition, which of the following is accurate?
A. All states have mandatory reporting laws,
except for West Virginia and Texas.

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B. Admission is rarely necessary
C. Multiple injuries with various stages of
healing are often present
D. Linear skul fractures are pathognomonic
E. Most occur between 5 and 10 years

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PPS 5

---

Which of the following most
accurately describes PTJV?
A. A minimum of 20 psi is required for adequate
oxygenation and ventilation

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B. An Inspiratory to expiratory (I:E) ratio of 4:1
wil ensure adequate ventilation
C. Wil always sustain adequate ventilation for
greater than 1 hour
D. The primary limitation is hypercapnea

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E. IV catheters are the preferred catheter choice
for this procedure
PPS 6

---

Of the following, which patient most
likely has medical decision making

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capacity?
A. A 3 y/o with a thumb laceration
B. A 24 y/o patient with MR who is oriented to person,
place and time. She does not ful y understand the
risks and benefits of the proposed treatment

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C. A 79 y/o patient oriented to person only
D. A 28 y/o uncooperative, very intoxicated patient who
is oriented to person, place and time who was struck
in the head with a brick.
E. A 52 y/o patient with metastatic breast cancer and

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brain metastases. She is oriented to person, place
and time. She understands the risks and benefits of
the proposed treatment
PPS 7

---

Which of the following is a required

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component of a medical malpractice
lawsuit?
A. Breech of a good Samaritan law
B. Probable cause
C. Duty to act

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D. Gross negligence
E. Adequate malpractice coverage
PPS 8

---

A 22 y/o female patient suffers a laceration to the
palmar surface of her hand over the mid, 2nd

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metacarpal. Which nerve block should provide
anesthesia for this location?
A. Radial nerve
B. Median nerve
C. Superficial peroneal nerve

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D. Ulnar nerve
E. Palmaris longus
PPS 9

---

A 42 year old emergency physician presents
with a 2-day old, thrombosed external

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hemorrhoid, following 4 days of board review,
which is the most appropriate treatment ?
A. Elliptical incision with excision of the
overlying tissue and the clot
B. Linear incision with clot expression

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C. Clot removal by electrocautery
D. Conservative medical therapy
E. Wait 3 more days until it is good and ready
for treatment
PPS 10

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---

Which governmental agency is most likely to
assume primary responsibility for overseeing
the development of emergency and trauma care
in the US?
A. Department of Health and Human Services

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B. Department of Homeland Security
C. The Office of the Inspector General
D. The Department of Agriculture
E. The Department of Defense
PPS 11

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---

In procedural sedation, capnography
is used to detect which of the
following?
A. Hypoxemia
B. Hyperventilation

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C. Level of sedation
D. Tidal volume
E. Hypoventilation
PPS 12

---

A 45 year old female patient with poor vascular

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access required a central line. A right internal
jugular line was placed. Two days later, it was
identified that the line was placed in the carotid
artery. What is the most appropriate course of
action?

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A. Remove the line, advising the patient you are
just repositioning the line.
B. Blame the resident.
C. Tel the patient that medications are delivered
more effectively this way.

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D. Show remorse for the error.
E. Look for another job.
PPS 13

---

A 73 y/o patient presents to the ED with an
anterior shoulder dislocation. The patient has a

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history of COPD, NIDDM and CAD. What is this
patient's ASA level?
A. ASA I
B. ASA II
C. ASA III

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D. ASA IV
E. ASA V
PPS 14

---

Which of the following is true, regarding
medications for sedation/analgesia?

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A. Ketamine precipitates bronchospasm
B. Etomidate may be associated with adrenal
suppression
C. Fentanyl is a dissociative anesthetic
D. Propofol induces nausea

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E. Midazolam is reversed with naloxone
PPS 15

---

An 82 y/o patient presents with a sinus
bradycardia at 32 bpm. Her BP = 134/82. The
patient denies chest pain and shortness of

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breath and is asking to use the phone to call her
son. What is the most appropriate treatment per
ACLS?
A. Atropine 0.5 mg IVP
B. Emergent transcutaneous pacing

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C. Observation
D. Epinephrine drip 2-10 mcg/min
E. Vasopressin 40 U IVP
PPS 16

---

Which of the following is an EMTALA

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requirement for transfers?
A. Facility to facility discussion and agreement
of transfer acceptance is necessary
B. Pre-authorization by the insurance company
C. Patients must be transferred by ambulance

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D. Benefits should be equal to the risks
E. The transfer should not be delayed for
stabilization
PPS 17

---

A 75 y/o COPD patient arrives via EMS in severe

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respiratory distress with cyanosis. "The patient
is a DNR." However, no paperwork could be
located. What is the most appropriate action?
A. Provide the patient with comfort measures
only

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B. Do not treat the patient until his DNR status is
verified
C. Treat the patient with multiple doses of
morphine until he is comfortable
D. Intubate the patient and initiate mechanical

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ventilation
E. Treat the patient with nebulized
bronchodilators and oxygen only
PPS 18

---

Which of the following is true

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regarding "Good Samaritan"
legislation?
A. Covers al acts, including gross negligence
B. Applies to indigent ED patients
C. Can be used in defense of an emergency

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department malpractice claim
D. Protects uncompensated care providers
E. Discourages bystander assistance
PPS 19

---

An 8 y/o boy is in an ATV accident. He is awake

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and alert, mildly tachycardic and has a deformity
to the left forearm. His parents cannot be
located. What is the most appropriate action?
A. Locate the parents and obtain consent before
treating the patient

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B. Cal child protective services
C. Locate the closest relative who can give
consent before providing treatment
D. Perform a medical screening examination
and stabilize the patient prior to parental

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consent
E. Stabilize the patient and then send to the OR
for ORIF without parental consent
PPS 20

---

Policies & Procedures Answer Key

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1. C
11.A
2. C
12.E
3. C

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13.D
4. C
14.C
5. C
15.B

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6. D
16.C
7. E
17.A
8. C

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18.D
9. B
19.D
10.A
20.D

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