# NREMT-P Exam Trauma Difficulties



## TWTPraetorian (Dec 8, 2019)

All,

I take my first NREMT-P in a little more than a week. I have taken exams from varying sources (school's program, MedicTests, etc) but I am struggling a bit with the trauma portion. I am consistently scoring just below standard. 

I have primarily focused ITLS review and used ATLS information as a supplement. I have been pestering a former 68W (now current Paramedic) and several other Paramedics at my department as well.

I am utilizing all local resources I have available to succeed. *My question is to those who have taken the equivalent, comparable, or higher courses/exams - What did you use to brush up or use as a companion to your education regarding trauma? Are there study guides, reports, articles, journals, or sources that were beneficial to you?*

I can give more specific examples of where I am weak if needed.

Meeting the standard would be sufficient, but irritating. Exceeding the standard is always the goal. Any help or tips would be greatly appreciated!


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## Stretcher Jockey (Dec 8, 2019)

ITLS/PHTLS have always worked very well for me. Using TCCC standards (the MARCH algorithm) is probably the most important trauma related care you can give, even if it isn't care under fire in general street medicine. What specifically do you struggle with?


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## medicchick (Dec 9, 2019)

One thing I always recommend to people is to try and be one of the "test" subjects. I got a chance to talk with the preceptor in between about the testing, written and practical.  My instructor was able to hook me up with doing it, I actually learned a lot.


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## policemedic (Dec 9, 2019)

First, understand the NRP psychomotor exam is not about good medicine, TCCC, PHTLS/ITLS, and definitely not ATLS.  It is about how the NR wants things done.  Pass the test and move on to actual medicine,

Everything you need is in the skill sheets which you should have been given.  Those include the reasons for failing a station.

What specifically are you not doing well on?  Your instructor should be correcting these issues, but if you want to share them maybe we can help.


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## TWTPraetorian (Dec 9, 2019)

Thank you for the replies so far, I really do appreciate it. 

I'm having difficulty with the computer/written based portion of the exam. I've passed the psychomotor exam already. I'm basing my struggle on my final exam breakdown and all third party exams that simulate registry.

@Stretcher Jockey - I used MARCH during my trauma assessment and it is so much faster and efficient than the convoluted primary exam ITLS pushes. It's what I use in the field for pretty much any potential trauma call. I wish they taught it as standard practice in civilian EMS. One problem I'm having with ITLS though is how/when to perform certain interventions. Registry isn't always clear on what is acceptable, what isn't, and in what order. A cric should be last resort, but at what point do you see a presentation and go straight to it? Do you know of any good references to follow or some sage advice on how you decide to answer those questions?

@medicchick - Oh yeah, that is some awesome advice. I volunteered for a NRP motor exam as a subject just to see behind the scenes. I can't stress enough how much that helped when I hit the stations for real. I couldn't get much out of people about the written except "it sucks but there's a calculator now" haha.

@policemedic - I mentioned above that I'm struggling with what interventions to do and when. I also seem to have difficulty managing multi-system trauma. A&P is my weakest link which is a big deal in understanding _why_ BP, HR, RR, MAP, etc suck. I had a ton of questions along the lines of "A 6 year old fell 15 feet from a tree and landed on his head. Based on that, what would you expect his vital signs to be?" on my final. While I can use Cushing's to figure that one out, you get the idea. A deeper understanding than what I currently possess is required.

To give a list -  
Proper sequence of intervention
VS changes between stages of hemorrhage/shock
Cranial nerves/nervous system trauma
Burns and burn management (fluid bolus calculation)
Thoracic trauma
A&P
A&P

I don't expect a lecture on SS about these topics and I can't learn everything in a week, but did you use anything that strengthened your knowledge on these or other subjects? A book or website that you particularly found helpful? Retaining A&P for me is like holding water in a sieve.


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## Stretcher Jockey (Dec 9, 2019)

If you're talking about taking the written test, two things helped me with that. 

A) memorize the sheet that has all your steps. "BSI, scene safe, number of patients is 1, ALS on standby, c spine taken, etc" and when you read the question find out exactly where you are in that sheet. If you know where you are currently at and where you need to go, it's much easier. 

B) narrow down the answer. Before you even look at the possible answers, understand that 95% of the time your first instinct is right. On these tests they'll typically throw in one answer that's completely incorrect, one that's only half correct, one that could be the answer if you overthink, and then the correct one. Rule out what you know is obviously wrong and continue your way down the list. If you start to overthink, flag the question and come back later so you can get your first instinct again. 

At this point since you're a week out, you're gonna have a lot of studying to do. There no specific advice for material I can give besides what was provided in your course thus far. They're not trying to stump you, they want you to pass. If I were you, I'd reach out to an instructor for some tutoring as soon as you can to get some time in.


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## Devildoc (Dec 9, 2019)

Per @policemedic , if you are looking at ATLS and you have a hard time grasping essential A&P, STOP looking at ATLS.

Per @policemedic and @Stretcher Jockey , memorize the skill sheets until you can't get them wrong.  And you do not need to do more than what's on the sheets.  I used to check off/evaluate NR examinees and they'd want to add all sorts of stuff, and it just goofed them up.

Read the PHTLS book, and see if you can get a copy of the TNCC book (trauma nurse core curriculum).  It more than any other mirrors the paramedic information.  It goes deeper in A&P.  The good news, physiology of trauma ain't rocket science.  The bad news, you need to understand it.  A&P is your self-admitted weak link, you need to beat it like it owes you money.

Basic information assimilation strategy: WRT shock, make a visual table: S/S of early shock, late shock, irreversable shock.  Make a picture of Cushing's response.

MARCH/TCCC is cool and all, but if it ain't on the exam, bag it.

Like any primary survey, if it's broke, fix it before you move on.  If it means cric, then cric.  Do not move on until you fix what's broke in the primary survey.

National Registry has the national standards in an outline format.  Print it, go to page 55 (starts the physiology section), just start writing notes.  There's a lot of things they do wrong; one of the biggest is not having a test map or set of comprehensive objectives by which you will tested.  The national standards may be as close as you get.


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## TWTPraetorian (Dec 9, 2019)

@Stretcher Jockey - I'll try to remember that process when I go through. Hopefully that will help me narrow it down and prevent paralysis by analysis. I have a problem with reading into the question and posing too many "what ifs". I contacted my instructor and we have a four hour meeting scheduled for Wednesday. Hoping that will make a big difference.

@Devildoc - Ha, I think you are all right about ATLS. I'll steer clear. I printed off the skill sheets and I've been trying to recite every step from memory. Like Stretcher Jockey said, it should help me even with the written. Using that curriculum you mentioned, I'm currently drawing up some notes based on the major groups. I'm taking it similar to when you don't know a word - instead of skipping over it you grab a dictionary and figure it out. 

I will take the advice given here and move forward. I'll post an update with how everything goes. Thank you, you don't know how cool it is that you all jumped in to help.

For future reference, in case anyone stumbles on this post looking for help, here are the guidelines - 
https://www.ems.gov/pdf/education/N...elines/Paramedic_Instructional_Guidelines.pdf
https://www.ems.gov/pdf/education/Emergency-Medical-Technician-Paramedic/Paramedic_1998.pdf


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## TWTPraetorian (Dec 18, 2019)

I took my NRP cognitive exam today. I'm happy to report that I passed it on the first try! Booted me at 80 questions.

I am really thankful for the help I received, there was quality advice and resources given. I passed a link to this thread to several students and they agreed it was helpful as well. You all did more than you may realize.

I'll keep learning and I'm excited to begin practicing. I'm happy to help anyone that may need it in the future.

Thanks again!


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## Stretcher Jockey (Dec 18, 2019)

Great job! Its not an easy test to pass, and if it kicked you out at 80 questions, then you already know that you killed it. Now comes the hard part. Just try not to kill anyone.


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## policemedic (Dec 18, 2019)

Well done.  Now the learning begins.


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## Muppet (Dec 20, 2019)

Well done. Welcome to the real world of paramedicine. May the power of Christ compel you....


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