A 35-year-old female meets you at the door of the residence. She appears extremely concerned. As she directs you to the bedroom she reports she was at work when she had a “strange feeling” about her husband and phoned home. When she couldn’t get an answer she drove home and found him unresponsive with a suicide note beside him. She believes he may have taken several pills.

You find a 35-year-old 70 kg male lying supine on the bed. He has snoring respirations and there is vomit around his pillow. He is breathing at a decreased rate and depth. He has a radial and carotid pulse, although weak and irregular. There is no sign of trauma. Secondary survey is unremarkable with the exception of old scars on his wrists.

There are various empty pill bottles lying on the floor. Most are over-the-counter drugs, including Tylenol, Entrophen, Advil and antihistamines. There is also an empty bottle of prescribed Prozac (potentially 20 missing) and a half-empty bottle of vodka on the bedside counter.

The patient’s wife reports he has a history of clinicaldepression, which is treated with Prozac and therapy. He was diagnosed three years ago after a suicide attempt (wrist slashing). She reports he has been having a particularly tough time the past few months and has been unable to work or interact socially. However, she felt that he was getting better over the past few days.

Pulse	70 irregular
Blood pressure	90/40
Respiration	8 mm/shallow, decreased air entry to bases, clear throughout
Skin	cool, pale, dry
Pulse Oximetry	95 per cent
Chemstrip	9 mmol/L
E.C.G.

1. Appropriate methods to maintain this patient’s airway include: A. insert OPA B. jaw thrust C. head tilt, chin lift D. all of the above E. A and B only 

2. Ventilation with a bag-valve mask should be initiated immediately for this patient. A. True B.  False 

3. Signs and symptoms of depression include: A. high energy levels B. suicidal thoughts C. hallucinations D. extreme violence 

4. Medications used to treat clinical depression include: A. Prozac B. Elavil C. Flagil D. All of the above E. A and B only 

5. History taking for clinically depressed patients should include: A. suicide risk B. medication compliance C. subjective behavior findings from family members D. A and B are correct 

6. Tranquilizers and sedatives should never be prescribed for clinically depressed patients. A. True B. False 

7. Bipolar disorder is: A. characterized by mood swings  B. typically a disease of the elderly C. caused by head trauma D. all of the above 

8. Bipolar disorder is most often initially treated with: A. Lithium B.  Prozac C.  ECT D.  Tegretol 

9. Bipolar disorder usually first appears in early childhood. A. True B. False 

10.In treating patients with bipolar disorder, you should: A. offer solutions for their problems B. make your expectations clear C. try to "humour" them out of their mood D. act quickly and aggressively 

11. This patient’s oxygen saturation level indicates: A. poor oxygenation B. adequate oxygenation C. good oxygenation D. none of the above 

12. At the BLS level, this patient is considered “stay and stabilize.” A. True B. False 

13. This patient should be transported: A. with c-spine immobilization B. in a High Fowlers position C. supine with legs elevated D. any of the above are correct 

14. Documentation of this call should include: A. where you found the pill bottles B. the patient’s past medical history C. the patient’s past psychiatric history D. all of the above E. A and B only 

15. The E.C.G interpretation is: 

16. Intravenous therapy for this patient: A. is not indicated B. should be initiated as large bore C. should be infused at 250 mL bolus therapy D. B and C are correct 

l7. This patient’s E.C.G rhythm should be treated by: A. atropine B. pacing C. defibrillation D. A and B E. None of the above 

18. Intubation for this patient: A. is not indicated B. should be performed to prevent aspiration C. should be performed to prevent regurgitation D. is contraindicated due to cardiac rhythm 

19. The danger of a second degree block is that it may quickly progress to a third degree block. A. True B. False 

20. The person in a manic phase of bipolar disorder may feel: A. happy B. in control C. restless D.  all of the above 

21.Patients in the manic phase of bipolar disorder may hallucinate. A. True B. False 

22.Depression may be caused by: A. neurotransmitter imbalances B. life events C. medical conditions D. all of the above E. A and C only 

23.To be diagnosed as clinically depressed the patient must be suicidal. A. True B. False 

24.Childbirth is sometimes cited as an event that may cause clinical depression. A. True B. False 

25. You and your service could perform more effectively on this call by: A. practicing good communication skills B. developing good mutual aid plans C. increasing your knowledge of mental illness D.  all of the above 

References

Bipolar Disorder Where’s the Balance? October 1997. Provincial Mental Health Advisory Board. Alberta

Depression—What Is It? What To Do? October 1997. Provincial Mental Health Advisory Board. Alberta

The answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Heather MacKenzie-Carey is a paramedic with over 17 years EMS experience in Nova Scotia and Alberta. She has a Bachelor of Science Degree in Health Education from Dalhousie University, a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate in Social Work from the University of Waterloo. Heather is an instructor for the Paramedic Program at the Southern Alberta Institute of Technology. She can be reached at: geomac@cadvision.com or www.turningpointgroup.com.

Canadian Emergency News and the author of this quiz grant per­mission for readers to copy it for personal and departmental educational purposes. All other reproduction and republication without written consent is prohibited.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News. It originally appeared in the October - November 1998 issue (volume 21, number 5).