9 free Paramedic practice questions: Protocol Application and Independent Judgment

Give half the usual dose to limit the pressure drop: A half dose sounds like a middle ground between treating the pain and protecting the pressure. The exclusion is based on the systolic reading, not on the dose. A pressure of 92/58 crosses the line at any dose, and a smaller dose does not give you permission the protocol took away.

Give the usual dose, since the injury is isolated: An isolated fracture with severe pain is usually the clearest case for a full dose of pain medication. The protocol singles out the systolic pressure as a hard stop, and this patient's systolic pressure is 92. Whether the injury is isolated was never part of the exclusion.

Give the usual dose and document the low pressure: Good charting matters. Writing down the low pressure after you give the drug only records that you crossed the exclusion. The chart entry does not give you permission to give the drug. Only an order from medical control does.

A note that the paramedic used clinical judgment on scene: Writing that you used clinical judgment sounds like an explanation. A line like that gives a conclusion and leaves out the reasoning. From that line, a reviewer cannot tell what you saw, what you did, or what happened next.

A statement that no protocol covered the presentation: Saying no protocol covered the patient describes the situation you were in, and that is worth writing down. The statement explains why you had to decide, not how you decided.

The medical control physician contacted and the order given: A medical control contact has to be documented any time you make one. The contact shows who authorized the treatment. The contact does not show the assessment that made the treatment right for this patient.

Perform synchronized cardioversion to restore sinus rhythm: Synchronized cardioversion is for the truly unstable patient. Unstable means shock, hypotension, or an altered mental status caused by the fast rate. In that patient the rate has to come down right away, even with the clot risk. This patient has a BP of 128/76, is alert, and has warm dry skin. Cardioversion now would risk knocking the mural thrombus loose.

Give adenosine to convert the rhythm to sinus: Adenosine blocks conduction through the AV node, which stops reentry rhythms like AVNRT that loop through that node. Atrial fibrillation comes from chaotic activity in the atria, not from a loop through the AV node. Adenosine will not convert this rhythm. At most, the drug slows the rate for a moment.

Attempt vagal maneuvers to slow the ventricular rate: Vagal maneuvers slow conduction through the AV node too. Vagal maneuvers can stop or unmask rhythms that depend on the AV node, and they do nothing to the fibrillating atria. Even if the rate dipped for a moment, the atrial fibrillation and its clot risk would still be there.

Hold treatment until medical direction identifies the chemical involved: Medical direction and poison control really do help with toxic exposures. Holding treatment while they identify the chemical leaves this patient breathing 8 times a minute through a gurgling airway.

Transport without intervention so the hospital can identify the exposure: Transport is part of the right answer, because the definitive care is at the hospital. Transporting without touching the airway leaves the wet airway and the slow breathing untreated. Those are the problems that will kill this patient first. Transport does not replace ventilation.

Apply the organophosphate protocol, since it is the closest available fit: Organophosphate poisoning does cause a wet airway like this one. Nothing in the question says this chemical was an organophosphate. Starting the organophosphate antidote pathway on a guess treats a diagnosis you do not have.

As adequate, because the paramedic assessed the patient at the bedside: Bedside assessment is a real advantage, and it is the reason paramedics get broad standing orders. Assessing the patient lets you choose a dose within the protocol, not go past its maximum.

As inadequate, because the patient outcome was left out of the report: Documenting the outcome is worth doing, and a thin report is its own problem. The problem under review is the dose that went past the protocol maximum. A complete outcome note would not have made that dose authorized.

As adequate, because experience is what independent judgment rests on: Experience does shape judgment, and a seasoned paramedic reads patients faster and more accurately. Experience works inside the protocol limits and never turns a dose past the maximum into an authorized dose.

Withhold sodium bicarbonate until the patient goes into cardiac arrest: Staying inside the written protocol is disciplined, and cardiac arrest is one of the listed uses. Waiting for the arrest means watching a treatable rhythm get worse when an order is one radio call away.

Give sodium bicarbonate, since the physiology behind both entries matches: The physiology does line up here. Being clinically right is not the same as being authorized. A correct mechanism does not create a protocol entry that was never written.

Give sodium bicarbonate under the hyperkalemia entry in the protocol: The hyperkalemia entry does name sodium bicarbonate, and the drug in the box is the same either way. This patient does not have hyperkalemia. Using an entry whose criteria the patient does not meet is forcing the protocol to fit.

Take another blood pressure only if the patient reports feeling lightheaded: Lightheadedness is a real warning sign, and you should ask about it. Waiting for a symptom means you find the low pressure after it has already happened. The protocol asks for a measured blood pressure before each dose, whatever the patient reports.

Give the second dose, because the first pressure already cleared the drug: The first reading did clear the first dose, and getting it was right. That clearance does not carry over to the next dose. The order asks for a check before each dose because the pressure drop can arrive with a later dose.

Give the second dose, because the patient tolerated the first one well: Tolerating the first dose well is reassuring. The pressure drop can still arrive with the second or third dose. A good response to the first dose does not tell you how the patient handles the next one.

Contact online medical control for verbal approval before administering, since direct physician orders take precedence over standing orders: Online orders matter when the patient falls outside the standing-order criteria or has an unusual complicating factor. Online orders also matter when the patient needs a drug or dose the protocol does not cover. This patient clearly meets the criteria with no complicating factor. The physician's authorization is already in place. Calling first only adds delay and does not add safety.

Withhold the medication entirely until online medical control can specifically confirm the diagnosis first: Holding the medication until medical control confirms a diagnosis fits a patient whose diagnosis is unclear or who does not meet the criteria yet. The question says this patient clearly meets the criteria. Waiting keeps an indicated treatment from the patient.

Administer half the protocol dose first, then contact medical control before giving the remainder of the standing order: A half dose sounds like a safety check, but the protocol does not have that step. No complicating factor is given, so the full standing-order dose is already authorized. Splitting the dose only delays treatment.

Perform the non-protocol procedure first since the continuing education makes it clinically reasonable, then follow with the standing-order medications: The continuing education course made the procedure sound reasonable. No protocol covers the procedure, so doing it first or last is still outside your authorization. Scope of practice comes from your protocols, not from courses you take on your own.

Contact medical control before administering either medication, even though both are already covered by standing orders: Calling medical control makes sense when a treatment falls outside the standing orders. The COPD and pulmonary edema combination is not written up together. Each medication still meets its own standing-order criteria for this patient, so nothing is missing from your authorization. Calling first only delays care for a patient in active distress.

Administer the bronchodilator alone and withhold the diuretic, since combining medications from two separate protocols is not authorized: Giving only the bronchodilator would fit a patient with only the COPD findings. This patient's pulmonary edema findings meet the diuretic's standing-order criteria on their own. Holding the diuretic follows a rule that does not exist and leaves the fluid overload untreated.