General Discussion

Clinical Judgement Scenarios

• Approx. 40% of the exam

• 4-7 Scenarios (8-12 questions per scenario)

  
  

Clinical judgement questions test your ability to:

• Choose the NEXT BEST step, NOT just the correct one

• Understanding the pathophysiology of the conditions, and determining the importance of the patient's history and risk factors

• Prioritizing interventions correctly

• Clinical Judgement does NOT reward MEMORIZATION!!!!!!

For example, you may know how to administer oxygen, but clinical judgement tests....

• When oxygen is needed

• Why oxygen is needed

• What may come first before oxygen

Important techniques for Clinical Judgement questions

• Do NOT look at the question in the scenario first!!!

  
  
  
  
  
  

   

  Read the dispatch notes, the on scene note, or the post scene information before reading the actual question, and start to breakdown and interpret the info

Always pay attention to the following:

• Who you are working with (Another Medic, AEMT, EMT)-delegation, additional resources

• The time of day (Night, Afternoon, Morning)

• The Weather & Road Conditions

• Patient's allergies

• The age, history, risk factors and home medications of the patient

• The ETA in time/miles or minutes of your destination hospitals

• If the ETA is ever >30 min-Consider a helicopter (Medical or Trauma)-Weather permitting (Raining, Snowing, Storming)

Remember-You will not always get the answers that you want to see!!! Be flexible and think outside the box.

CASH

• Ischemic CP!!!

• AMS

• Syncope/SOB w/ severe hypoxia

• Hypotension

For example-SVT

• You have a 62 Female who c/o palpitations, dizziness, and nausea. VS are BP-118/64, HR-162, RR-24, Spo2-96% on RA. 12 lead EKG shows a narrow complex tachycardia. What is your initial intervention?

A. Perform bilateral Carotid Sinus Massage

B. Perform the Mammalian diving reflex

C. Perform immediate cardioversion

D. Have the pt. perform Huff breathing

Vagal maneuvers

• Valsalva=Bearing Down

• Diving Reflex "mammalian)-Place their face in a bowl of ice or cold water

• Huff breathing/coughing

• CSM (carotid sinus massage)

EXTREMELY IMPORTANT!!!! ⚠️⚠️⚠️

• If you are going to do an intervention or give a medication, make for DAMN SURE there are NO contraindications or allergies

DO NOT GET LOST IN THE SCENARIO!!!!

• ALWAYS keep track of what you have done throughout the scenario and pay attention if the patient is improving or getting worse. Use the whiteboard provided!!!!!!

• Always check for additional information from 1 part of the scenario to the next part (They DO add information)

• Do NOT re-invent the wheel (If they have done something or are doing something in the question, and it is NOT working, don't turn around and choose the same or similar intervention

• Asthma patient, asthma attack, they state they took their MDI of albuterol and a nebulizer PTA w/ no relief=You would not go w/ Albuterol as an answer, because it is clearly NOT working

• Know your treatment algorithms and apply them to the scenario!!!

• Remember, start low and go slow-BLS to ALS & Least invasive to most invasive

Drowning

• Crackles=Pulmonary Edema

• AOx4

• BP-142/98

• 5-inch laceration to the forehead

CPAP/BiPap (Contraindications)

• Hypotension-less than 100

• AMS

• Apnea

• Active vomiting

• Head Trauma

• Chest trauma

• Unable to maintain a seated position

COPD

1. Chronic bronchitis

2. Emphysema

Causes

• Smoking

• Secondhand smoke

• Environmental-people working in factories, garages, around chemicals, mines

Chronic->3 months

Chronic Bronchitis (Blue Bloaters)

Patho-Chronic inflammation of the bronchioles, causing an accumulation of thick mucus

• A problem getting air in!!!!!

• Cyanosis

• Heavy/Obese

• SOB

• Dyspnea

• Productive cough

• Lung sounds=Rhonchi & Wheezing

Emphysema (Pink Puffers)

Patho-Destruction of the alveoli, causes swelling and a decreased surface area, loss of elasticity, leading to air trapping

• A problem getting air out

• Elderly

• Thin

• Pursed Lip breathing

• Barrel Chested

• Pink skins

• SOB

• Dyspnea

• Hypoxic Drive (Breath off CO2 levels)

• Normal Spo2-88-91%

• Do NOT give high flow o2 via NRB mask

• Lung sounds=Quiet chest OR Diminished sounds OR wheezing

Differential Diagnosis

1. Emphysema exacerbation-Low Spo2

   
   

2. Asthma-Low Spo2

Atmospheric oxygen

• 21% Fio2 (Fractional Inspired oxygen)

Nasal Cannula (1-6 lpm)-24-44%

1 L-24%

2 L-28%

3 L-32%

4 L-36%

5 L-40%

6 L-44%

Bleb

• A pocket or a blister filled w/ air or fluid

• Caused by infections and COPD