It is 11:30 on a cold overcast morning. There have been periodsfreezing rain and strong winds throughout the nightmore predicted towards the afternoon. Roads are slick and everyone is busy with minor injury accidents. You are asked to respond to an acreage address a few miles outside town. Dispatch reports there is a house under construction there and a patient who appears to have fallen from the roof. The patient’s wife is the only other person on scene and she reports he is not talking to her but is breathing.

You arrive on scene to find a 35-year-old male lying supine on the ground. There are various construction tools and debris around the site and the patient. The patient’s wife reports he was attempting to get some shingling done on the roof to protect the house from the predicted rain. He had been working on the house since early morning. She was not on site with him but became alarmed when he didn’t meet her for coffee approximately 45 minutes ago and didn’t answer his cellular phone. She drove out to the site and found him as is, lying on the ground. She believes he fell from the roof but has no idea when it might have happened. He has been on site for approximately four hours. She reports he was moaning slightly but not talking to her when she arrived. She reports he has no pertinent past medical conditions, is on no medications and has no allergies.

Primary survey reveals he is unresponsive to verbal and withdraws minimally from painful stimuli. He is breathing spontaneously at what seems to be an adequate rate but shallow depth. Carotid pulses are present weak and fast. Radial pulses are absent. His skin is cold and pale. Pupils are equal, dilated and sluggish. There is no obvious trauma to the face head or cervical area. The left shoulder appears dislocated. The chest appears intact with no signs of deformity. Lung sounds are present although decreased in the left base. The abdomen is rigid although non-distended. The patient moans when you palpate the abdomen or pelvis. There is obvious deformity to the pelvic area and you can feel crepitus on palpation. There is an open fracture to the right tibia/fib. with minimal bleeding at present. There is however a significant pool of blood on the ground.

Pulse	120 regular, weak
Blood pressure	70/40
Respiration	22 non-laboured, shallow decreased in left base, no adventitious sounds
Pulse Oximetry	96 per cent
Level of Consciousness	unresponsive to verbal, withdrawal from pain
E.C.G.

1. This patient is likely suffering from: A. cardiogenic shock B. hyperthermia C. drug overdose D. hypovolemic shock 

2. The poor perfusion that leads to shock is always caused by blood loss. A. True B. False 

3. This patient is considered a load and go patient due to: A. level of consciousness B. decreased lung sounds C. pelvic fracture D. all of the above E. A and C only 

4. Hypovolemic shock may be caused by: A. hemothorax B. pelvic fracture C. metacarpel fracture D. all of the above E. A and B only 

5. This patient should be transported with the head elevated. A. True B. False 

6. P.A.S.G. may be indicated for this patient: A. as a method of restoring circulation B. as a splinting device C. neither of the above are correct D. both A and B are correct 

7. Which type of shock is typically characterized by a slow pulse? A. cardiogenic B. hypovolemic C. septic D. neurogenic 

8. En route you discover the patient’s temperature is 33 degrees Celsius. You should not attempt to warm this patient en route as this may increase the bleeding. A. True B. False 

9. The decreased lung sounds in the left lower lobe is mostly likely due to: A. tension pneumothorax B. hemothorax/pneumothorax C. flail segment D. cardiac tamponade 

10. When immobilizing the patient, the head should be secured prior to the body. A. True B. False 

11. The patient’s extremity fractures should be splinted prior to moving him. A. True B. False 

12. This patient’s shock syndrome would be categorized as: A. low-volume shock B. mechanical shock C. hypoxemic shock D. A and B are correct 

13. You are assisting ventilations with a bag valve mask en route when the patient begins to vomit. You should: A. suction him in a supine position B. turn the patient on his side C. elevate the head D. A and C are correct 

14. A log roll technique is contraindicated for this patient. A. True B. False 

15. A compound fracture is one in which the: A. bone is broken in more than one place B. bone ends are shattered C. bone ends have protruded through the skin D. nerve endings have been severed 

16. Dislocations should generally be: A. splinted in the position found B. reduced in the field C. splinted with a traction splint D. none of the above 

17. By definition, a splint must: A. immobilize the patient B. immobilize the joint  above the fracture site C. immobilize the joint below the fracture site D.    all of the above E. B and C 

18. En route the patient does not open his eyes to pain or verbal response, withdraws from painful stimuli, and makes no verbal response. His Glasgow Coma Score would be: A. 10 B. 8 C. 6 D. 4 

19. The E.C.G is: 

20. This rhythm should be treated by: A. oxygenation B. adenosine C. dopamine D. cardio version 

21. Fluid resuscitation for this patient is indicated. A. True B. False 

22. Intravenous access should be initiated: A. prior to leaving the scene B. en route 

23. Fluid resuscitation for the trauma patient should be aimed at: A. maintaining peripheral perfusion B. restoring blood pressure to 120 systolic C. maintaining cerebral perfusion D. none of the above 

24. En route you intubate the patient and begin ventilations. Auscultation reveals no air entry on the left side, the patient appears more restless and combative and you notice the pulse has increased in rate and is weaker. You should: A. remove the tube and re-intubate B. increase the fluid resuscitation volumes C. decompress the chest D. suction the airway 

25. Your performance on this call can be enhanced by: A. B.T.L.S. certification and review B. team practice in scenario situations C. familiarization of equipment D. all of the above 

References

Campbell, John Emory M.D. F.A.C.E.P., and Alabama Chapter American College of Emergency

Physicians; Basic Trauma Life Support Third Edition;New Jersey: Prentice-Hall Inc. 1995.

Sanders,MickJ.,Mosby’sParamedicTextbook; Toronto: Mosby Lifeline. 1995.

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 the Vice President of Turning Point Group Inc—an Emergency Management consulting firm—and manages it’s Calgary office.

Heather has nineteen years experience in the Health Care Industry as an emergency practitioner, educator, and consultant. Heather has worked in public, private, rural, urban, Mountain Park and multidisciplinary clinical settings. Heather has been an educator/facilitator for the Aberdeen Hospital, Jasper School District, and the Southern Alberta Institute of Technology.

Heather has graduated from Dalhousie University with a Degree in Health Education. She has a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate of Social Work from the University of Waterloo. Heather is completing a Masters of Science in the Study of Risk, Crisis and Disaster Management from the University of Leichester.

Heather has been widely published in the areas of prehospital medicine, crisis communication, and emergency first aid. She publishes regular columns for Canadian Emergency News, has developed various guide­books for Quick Books Publishing Ltd., and pro­duced distance delivery curriculum for 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 February - March 1999 issue (volume 22, number 1).