EZE
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Here is a question adapted from a q bank question:
A 68-year-old man is recovering in the hospital after surgery for colon cancer... The surgery did not go well ... unexplained internal bleeding. Infection sets in after the surgery... The patient asks the physician to include “Do Not Resuscitate” (DNR) instructions in his medical record. The physician does so and informs the staff accordingly. A fourth year medical student visits the patient ... to collect some additional history. The patient confirms the DNR instructions. As the interview progresses, the patient’s face becomes suddenly becomes red. He begins coughing and gasping for breath. Unable to speak, the patient points to his throat to indicate that he is choking.
Given the patient's recent instructions, the student's next action should be?
A.) Ask the patient if he wishes to revoke the DNR order and would like assistance
B.) Go and find a physician and bring him/her back to assist the patient
C.) Go to the patient’s door and call for someone to come at once to help
D.) Hold the patient’s hand to provide comfort but do not intervene because of the DNR order
E.) Perform the Heimlich maneuver
F.) Ring the call button for the nurse
G.) Sit quietly and watch the patient, but do not intervene because of the DNR order
H.) Slap the patient repeatedly on the upper back to dislodge the obstruction
Answer below:
The answer that I chose is C, but Kaplan was looking for E. It's pretty obvious that the DNR would not apply in this case, which would leave options B, C, E, F, and H. Choices B and F would take too long, and H is the incorrect procedure for a choking patient.
I think the first thing the student should do is run to the door and call for help. The SECOND step would then be to perform the Heimlich maneuver. My reasoning is that running to the door and calling for help will waste about 5 seconds. If the Heimlich maneuver works, then that 5 seconds is very unlikely to adversely affect the patient. However, if the Heimlich maneuver does not work, then that extra 5 seconds may save the patient's life, as a more experienced doctor may be able to save him. The question does not state that the patient was even eating anything at the time or provide any other explanation, so who knows what is causing the patient to choke.
It seems to me that in rejecting answer C Kaplan is assuming that the medical student would simply wait for help to come and do nothing in the mean time. However, the question simply asks what is the NEXT course of action, and although answer C does say to call for help, it does not say to wait for help to arrive before doing anything else.
Does anyone else agree?
Also, does anyone have any advice on how to answer these questions? I tend to read questions as a lawyer would, and I don't make any assumptions about what the question is really asking or what an answer is really stating, as it seems Kaplan expects you to here (i.e. that student would not do anything else while waiting for help). This has gotten me into trouble in many a med school test, but I would expect a higher quality of question writing on the USMLE. Are the questions sometimes vague like this on the actual exam, or is this just a failing of Kaplan in this instance?
Has anyone heard of students contesting the NBME about actual board exam answers to questions? I don't know if this is even possible since they don't release all of the questions and answers.
Sorry for the long question with lots of questions, but I'm running short on time here!
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| rida
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I think the best way to answer these questions is to ask yourself. what is the best for the PATIENT? Most of the time, i have found that the answer that makes the patient comfortable in every way is the best, hence, i would have chosen F as well, because if the student can save the patient's life who is choking ot death infront of him, he/she should for sure, and then after that can get the nurse or whoever. Hope this helps!!!
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| Bela
Forum Guru
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EZE,
I think the DNR applies only to cardiovasc collapse....so they can't call code blue for the patient if the situation presents.
Can this case considered a cardiovasc collapse? :?
Also in this case, the pt is even making faces to indicate that he is choking, which would invalidate his initial request not to rescusitate (b/c I think a pt can change that request at any time, even verbally). Besides, if he didn't want the service, he'd just lay there, close his eyes and be peaceful 
Now, why is C wrong? In my opinion, by the time the student goes to ask for help, the pt could be dead. Yes, he could push the emergency button at the head of the pt and start the manover but not leave the pt unattended.
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| PsychDr2B
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Given that this is a Kaplan Qbank question, I turned to Kaplan ethics notes. A reminder, these questions have a clear, correct answer. these aren't meant to be subjective questions. This is not a question of opinion. There is supposed to be one correct answer. For the USMLE purposes, never leave the patient. That, even according to Kaplan is an ethical rule. Rule #9 states: Never abandon the patient. Rule #16 says that Patients should be given a chance to state DNR orders; and physicians should follow them. DNR refers ONLY to cardiopulmonary resuscitation, so the physician must continue with on-going treatment. These "ethical rules" are for ideal exam scenarios only and not strictly in real life. So, according to these rules you can rule out choices ABCDG. This leaves E,F,H. Choice H is wrong procedure. Choice F could work since you never really leave the patient's room, however, it does not directly help the patient right away. Personally, I would like to think the next best thing to do would be to confirm choking by asking the patient if he is choking. The patient could gesture a yes since he is unable to verbalize anything while choking. BUT since it is not an answer choice, the next best thing would perform the Heimlich assuming choking (especially since the question stem blatently says it). These questions have real answers. The rules can be adapted to each scenario. Also some key concepts for any other ethics-related questions on USMLE (according to Kaplan): PATIENT ABOVE EVERYTHING; pick the choice that keeps the patient alive longer; avoid choices that require passing off patient to someone else; pick the choice that tells the patient (and no one else, i.e. spouse, relative) the truth about his/her condition. I hope this was helpful. I just know that when it comes to the actual exam day, I hope I can remember to do the right thing that is in the Best Interest Standard.
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| docofthebigapple
Forum Senior
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A very ticklish question , i'd say. But as stated, it has to have a single best response, thet response might not be the only good response, but here we are to pick trhe best answer.
If faceds with this question in exam, i'd go with e. Heimlich maneuver.
As seen in the stem of the question , the patient starts choking suddenly while in the interview and he's also giving gestures indicating choking by pointing to his throat. He is demanding something be done immediately by bringing attention to his throat.
The first reaction of the student should be to perform the maneuver immediately, then go to the door and call attention and help.
DNR order doesn't apply here because the patient isn't dying of the bad surgery here, he's just choked while speaking.
And even if the order applied, it was over-ruled when the patient pointed his choked throat.
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| olena_r
Forum Junior
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There are standards of CPR for healthcare provider set by American Heart Association. For the foreign body airway obstruction in responsive adult first step is Heimlich maneuver. "Shout for help" is the first step in unresponsive victim.
Heimlich maneuver is considered very effective. But if it does not help (the victim becomes unresponsive) you go call for help.
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| adeelmd
Forum Elite
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you could go out and smoke a cigarette if you wanted to. this isn't real life, don't try to confuse real life situations with usmle questions. NEVER ask for help!... NEVER REFER.... if you follow this thinking, you will get 9/10 of these types of questions right....
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| KEROCHI
Forum Guru
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agree w/ olena_r
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