Free Essay

Emt Education Standards

In:

Submitted By Tecome
Words 36133
Pages 145
Emergency Medical Technician-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

EMT-BASIC: NATIONAL STANDARD CURRICULUM

PROJECT DIRECTOR
David J. Samuels, MBA System Director Samaritan AirEvac/Emergency Medical Services Samaritan Health System Phoenix, AZ

CO-MEDICAL DIRECTORS
Henry C. Bock, MD, FACEP Emergency Physician Methodist Hospital of Indiana, Inc. Indianapolis, IN Kimball I. Maull, MD, FACS Director R Adams Cowley Shock Trauma Center Baltimore, MD

PRINCIPAL INVESTIGATOR
Walt A. Stoy, Ph.D., EMT-P Director of Educational Programs Center for Emergency Medicine Research Assistant Professor of Medicine University of Pittsburgh School of Medicine Pittsburgh, PA

Contract Number DTNH22-90-C-05189

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

i

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

CURRICULUM DEVELOPMENT GROUP
James Bothwell, EMT-P National Flight Paramedics Association William Brown, RN, NREMT-P National Registry of Emergency Medical Technicians Ricky Davidson International Association of Fire Chiefs Karla Holmes, RN National Council of State EMS Training Coordinators Richard Judd, Ph.D., EMSI National Association of Emergency Medical Technicians Kathryn Lewis, RN, Ph.D. Phoenix College, Education Design Expert Paul Maniscalco National Association of Emergency Medical Technicians Susan McHenry National Association of State EMS Directors William Metcalf, EMT-P American College of Emergency Physicians Mary Beth Michos International Association of Fire Chiefs Joe Taylor, RN, Ph.D. Emergency Nurses Association Katherine West, RN, MS Infection Control Expert Roger White, MD American Heart Association Robert Worsing, Jr., MD American Academy of Orthopaedic Surgeons

MEDICAL OVERSIGHT COMMITTEE
Robert Baron, MD, FACEP Emergency Physician Nicholas Benson, MD, FACEP National Association of EMS Physicians Society for Academic Emergency Medicine George Foltin, MD, FACEP American Academy of Pediatrics ii -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum Kathleen Handal, MD, FACEP Emergency Physician James Heckman, MD, FAAOS American Academy of Orthopaedic Surgeons William Roush, MD, FACEP Joint Review Commission

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Preface
The National Highway Traffic Safety Administration (NHTSA) has assumed responsibility for the development of training courses that are responsive to the standards established by the Highway Safety Act of 1966 (amended). Since these training courses are designed to provide national guidelines for training, it is NHTSA's intention that they be of the highest quality and be maintained in a current and up-todate status from the point of view of both technical content and instructional strategy. To this end, NHTSA supported the current project which involved revision of the 1984 Emergency Medical Technician-Ambulance: National Standard Curriculum, deemed of high value to the states in carrying out their annual training programs. This course is one of a series of courses making up a National EMS training program for prehospital care. The curriculum, Emergency Medical Technician-Basic: National Standard Curriculum, is the cornerstone of EMS prehospital training. In addition, the new curriculum parallels the recommendations of the National EMS Education and Practice Blueprint. The EMT-Basic curriculum is a core curriculum of minimum required information, to be presented within a 110-hour training program. It is recognized that there is additional specific education that will be required of EMT-Basics who operate in the field, i.e. ambulance driver training, heavy and light rescue, basic extrication, special needs, and so on. It is also recognized that this information might differ from locality to locality, and that each training program, or system should identify and provide special training requirements. This curriculum is intended to prepare a medically competent EMT-Basic to operate in the field. Enrichment programs and continuing education will help fulfill other specific needs for the EMT-Basic's education.

Acknowledgement
From the very beginning of this revision project, the Department of Transportation relied on the knowledge, attitudes, and skills from hundreds of experts. These individuals sought their own level of involvement and contribution toward accomplishing the goals of this project. These contributions varied from individual to individual, and regardless of the level of involvement, everyone played a significant role in the development of the curriculum. It is essential that those who have assisted with the achievement of this worthy educational endeavor be recognized for their efforts. For every person named, there are 50 or more individuals that should be identified for their contributions. For all who have contributed, named and unnamed, thank you for sharing your vision. Your efforts have helped assure that the educational/training -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum iii

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------needs of EMT-Basics are met so that they can provide appropriate and effective patient care. Special thanks for the knowledge, expertise, and dedication given to this project by the Project Director, Principal Investigator, Co-Medical Directors, and all the members of the Curriculum Development Group and Medical Oversight Committee. NHTSA would also like to recognize the following individuals and/or organizations for their significant contributions to this project: National Organizations National Council of State EMS Training Coordinators Michael O'Keefe, EMT National Registry of EMTs William Brown, RN Phil Dickison, REMT-P Individuals Robert Waters, PhD Joseph Mistovich, MS, REMT-P Michael Tunik, MD Montana Pilot Test Site Marc Racicot, Governor Albert E. Goke, Director, Highway Traffic Safety Division Drew Dawson, Chief, EMS Bureau Ken Threet, State Training Coordinator Dane Castelberry, Course Coordinator Dayle Derrin, Assistant State Training Coordinator Jim Upchurch, MD, REMT-B, Billings, Montana, Indian Health Service, Medical Director for the Pilot Program Pennsylvania Pilot Test Site Kum Ham, PhD, State EMS Director Gail Dubs, EMT, State Training Coordinator Dennis Wargo, M.Div., EMT-P, Regional Training Coordinator Scott Everitt, EMT-P, Lead Instructor Tom Platt, NREMT-P, Course Coordinator Ron Roth, MD, Medical Director for the Pilot Program

iv

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Center for Emergency Medicine Walt Stoy, PhD, EMT-P, Principal Investigator Tom Platt, NREMT-P, Coordinator of EMS Education Gregg Margolis, BS, EMT-P, Associate Director of Education Debra Barclay, EMT-P, Coordinator of Medical Education Paul Paris, MD, FACEP, Chief Medical Director Donald Goodman, MBA, Chief Financial Officer Amy Tremel, BS, EMT-P Division of Emergency Medicine Attending Physicians, University of Pittsburgh Affiliated Residency in Emergency Medicine, University of Pittsburgh Samaritan Health System EMS Division Cindy Ruthem Georgia Snover Thanks to the many outside reviewers who provided diverse knowledge and skills from across the country. They contributed to the content and shared their ideas and visions about the new curriculum. NHTSA would also like to thank two other Federal agencies that supported the pilot testing of the new curriculum: The Maternal and Child Health Bureau and the Office of Rural Health Policy, both within the Department of Health and Human Services.

Process
The content of this curriculum was established by a Curriculum Development Group consisting of emergency medical and educational experts. These individuals met periodically to review, edit, and critique the development of the curriculum. The Medical Oversight Committee developed the medical/clinical component of the curriculum. A six-member writing group and Principal Investigator actually "put pen to paper", once the objectives and format were approved by the Curriculum Development Group and Medical Oversight Committee. The co-medical directors dealt with difficult and controversial issues and sought to achieve consensus with the Curriculum Development Group and Medical Oversight Committee. The National Council of State EMS Training Coordinators made a significant contribution to the overall design, development, and content of the curriculum -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum v

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------throughout the project. More importantly, this organization has assumed the responsibility for implementing the curriculum in the coming years. Two pilot tests were conducted in Ekalaka, Montana (representing the rural/frontier EMT-Basic), and Pittsburgh, Pennsylvania (representing the urban/metropolitan EMT-Basic). Seven students participated in the Montana pilot, and twenty-three students participated in the Pennsylvania pilot. The project team gained valuable insight into the implementation of the new EMT-Basic, and modifications were made to the final curriculum document. The National Registry of EMTs contributed to the design and development of the examinations and final evaluation tools that were used in the pilot program, as well as the tabulation and evaluation of scores. The National Registry also contributed significantly to the design and development of the skill sheets that are contained within this curriculum.

Medical Direction Statement
Medical direction of the EMT-Basic is an essential component of prehospital training, and thus is included in this revised EMT-B curriculum. Physician involvement should be in place for all aspects of EMS training programs, specifically for every ambulance service/rescue squad. On-line and/or off-line medical direction must be in place to allow for EMT-Basics to carry and assist with the administration of medications to patients. Quality improvement is also a required component of EMS training. The role of medical direction is paramount in assuring the provision of highest quality prehospital care. Medical Directors should work with individuals and systems to review prehospital cases and strive to achieve a sound method of continuous quality improvement.

vi

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Curriculum
History
The last revision of the EMT-Ambulance: National Standard Curriculum occurred in the early 1980s with a completed course published in 1984. The current revision came about as a result of the National Highway Traffic Safety Administration's (NHTSA) January 1990 Consensus Workshop on Emergency Medical Services Training Programs. Participants discussed the national training curricula needs of Emergency Medical Service (EMS) providers. Using a nominal group process, the participants identified the top priority needs for EMS training in the United States. The top priorities identified at that meeting led to issuance of a Request for Proposals (RFP) by NHTSA to revise the EMT-Ambulance Curriculum based upon the input provided by many national EMS organizations and representatives at the consensus workshop. The following priorities from the 1990 consensus workshop recommendations played a directing role in the revision of this EMT-Basic Curriculum: ! Review and development of a blueprint/model and core curriculum for each provider level, based upon task analysis focusing on field impact (evaluating positive/negative outcomes) and the most utilized knowledge and skill areas. Identify "need to know" versus "nice to know" content. Conduct an analysis of interventions and outcomes for both the patient and the care provider. (What are we really doing in EMS? What's making a difference? Define what we want to do). Establish a Physician Board to review and approve all medical curriculum content. Emphasize an assessment-based format rather than a diagnostic-based format for all levels and all ages. Ensure that there is adequate focus on primary skills of assessment and ABCs in all provider levels (with emphasis on airway). Include an objective assessment of all published studies in peer journals when revising curricula. Emphasize rescuer and patient safety components, including infection control, in all curricula.

!

!

!

! !

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------! Ensure that prehospital providers have adequate skills to care for children and infants by integrating information throughout the curricula at all levels, within the established course items. Build in clearly defined medical control for all levels, not just EMT-Paramedic. Utilize measurable educational objectives (knowledge, skills, judgement) to determine individuals' learning needs and duration of training program. Develop a nationally acceptable core curriculum for each provider level, with a mechanism for customizing for local needs. Place curriculum revision emphasis on EMT-A and First Responder courses. Revise basic course to be no more than 110 hours in length. Add automated defibrillation (fully automatic and semi-automatic) for CPR by EMTs and First Responders. Develop an integrated/situational (real-world) approach for EMT training. Develop a mechanism for consensus on EMS education among national groups. Evaluate delivery methods of training. Include sufficient information in basic EMT-A curriculum to comply with hazardous materials (HAZMAT) worker protection standard. Include more on medical emergencies as opposed to trauma (including airway).

! !

!

! ! !

! ! ! !

!

2

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Course Goals
This instructor's course guide has been designed and developed to assist the course coordinator, instructors, and others in planning, managing and teaching the Emergency Medical Technician-Basic: National Standard Curriculum. The goals and objectives of this curriculum are to improve the quality of emergency medical care. This course is designed to instruct a student to the level of Emergency Medical Technician-Basic, formerly the EMT-Ambulance, who serves as a vital link in the chain of the health care team. It is recognized that the majority of prehospital emergency medical care will be provided by the EMT-Basic. This includes all skills necessary for the individual to provide emergency medical care at a basic life support level with an ambulance service or other specialized service. Specifically, after successful completion of the program, the student will be capable of performing the following functions at the minimum entry level: ! ! ! ! Recognize the nature and seriousness of the patient's condition or extent of injuries to assess requirements for emergency medical care; Administer appropriate emergency medical care based on assessment findings of the patient's condition; Lift, move, position and otherwise handle the patient to minimize discomfort and prevent further injury; and, Perform safely and effectively the expectations of the job description.

It is obvious that EMT-Basics provide a service in an environment requiring special skills and knowledge in such areas as communications, transportation, and keeping records. They also serve as liaisons with other emergency services. This course provides an introduction to these concepts. Individual orientation to the specific systems and services with which the EMT-Basic will be affiliated is necessary to achieve a full level of competency. On the following page is the diagram of the educational model. This is a graph representing the flow of the curriculum. The model has the medical and trauma information on either side of patient assessment. The curriculum is designed to have the medical module presented after patient assessment and prior to the trauma module, however, this format may be altered. The entire curriculum is surrounded by continuing education, which is designed to reflect two primary goals. First, during the instruction of the EMT-Basic: National -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

3

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Standard Curriculum, additional continuing education in related content may be provided. Secondly, continuing education is an integral component of any educational process and the EMT-Basic should be committed to life-long learning. EMT-BASIC: NATIONAL STANDARD CURRICULUM DIAGRAM OF EDUCATIONAL MODEL
CPR Prerequisite

CONTINUING EDUCATION

PREPARATORY
Introduction to Emergency Medical Care The Well-Being of the EMT-Basic Medical / Legal and Ethical Issues The Human Body Baseline Vitals and SAMPLE History Lifting and Moving AIRWAY

CONTINUING EDUCATION

CONTINUING EDUCATION

Airway Advanced Airway (Elective)

CONTINUING EDUCATION

MEDICAL
General Pharmacology Respiratory Emergencies Cardiovascular Emergencies Diabetic Emergencies Allergic Reactions Poisoning/Overdose Emergencies Environmental Emergencies Behavioral Emergencies Obstetrics

PATIENT ASSESSMENT
Scene Size-up Initial Assessment Focused History and Physical Exam: Medical Focused History and Physical Exam: Trauma Detailed Physical Exam On-Going Assessment Communications Documentation

TRAUMA
Bleeding and Shock Soft Tissue Injuries Musculoskeletal Care Injuries to the Head and Spine

CONTINUING EDUCATION

INFANTS & CHILDREN

CONTINUING EDUCATION

Infants and Children CONTINUING EDUCATION

OPERATIONS
Ambulance Operations Gaining Access Overviews

CONTINUING EDUCATION

CONTINUING EDUCATION

CONTINUING EDUCATION

CONTINUING EDUCATION

4

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------The following pages show the breakdown of hours and objectives for the Emergency Medical Technician-Basic: National Standard Curriculum. In this design there are 46 lessons in the core curriculum. Three additional lessons are needed to complete the advanced airway elective, if offered. The name of each lesson is followed by the recommended time needed to complete the instruction. The cognitive, effective, psychomotor objectives and the total number of objectives for that lesson are provided. The percentage of cognitive and percentage of hours is based on the entire core curriculum. This information may prove to be beneficial in designing written and practical evaluation tools.

Course Design
MODULE 1 PREPARATORY Lesson 1-1 Introduction to Emergency Medical Care Familiarizes the EMT-Basic candidate with the introductory aspects of emergency medical care. Topics covered include the Emergency Medical Services system, roles and responsibilities of the EMT-Basic, quality improvement, and medical direction. Lesson 1-2 Well-Being of the EMT-Basic Covers the emotional aspects of emergency care, stress management, introduction to Critical Incident Stress Debriefing (CISD), scene safety, body substance isolation (BSI), personal protection equipment (PPE), and safety precautions that can be taken prior to performing the role of an EMT-Basic. Lesson 1-3 Medical/Legal and Ethical Issues Explores the scope of practice, ethical responsibilities, advance directives, consent, refusals, abandonment, negligence, duty to act, confidentiality, and special situations such as organ donors and crime scenes. Medical/legal and ethical issues are vital elements of the EMT-Basic's daily life. Lesson 1-4 The Human Body Enhances the EMT-Basic's knowledge of the human body. A brief overview of body systems, anatomy, physiology and topographic anatomy will be given in this session.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

5

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Lesson 1-5 Baseline Vital Signs and SAMPLE History Teaches assessing and recording of a patient's vital signs and a SAMPLE history. Lesson 1-6 Lifting and Moving Patients Provides students with knowledge of body mechanics, lifting and carrying techniques, principles of moving patients, and an overview of equipment. Practical skills of lifting and moving will also be developed during this lesson. Lesson 1-7 Evaluation: Preparatory Module Conduct a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. MODULE 2 AIRWAY Lesson 2-1 Airway Teaches airway anatomy and physiology, how to maintain an open airway, pulmonary resuscitation, variations for infants and children and patients with laryngectomies. The use of airways, suction equipment, oxygen equipment and delivery systems, and resuscitation devices will be discussed in this lesson. Lesson 2-2 Practical Skills Lab: Airway Provides supervised practice for students to develop the psychomotor skills of airway care. The use of airways, suction equipment, oxygen equipment and delivery systems, and resuscitation devices will be included in this lesson. Lesson 2-3 Evaluation: Airway Module Conduct a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. MODULE 3 PATIENT ASSESSMENT Lesson 3-1 Scene Size-Up Enhance the EMT-Basic's ability to evaluate a scene for potential hazards, determine by the number of patients if additional help is necessary, and evaluate mechanism of injury or nature of illness. This lesson draws on the knowledge of Lesson 1-2.

6

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Lesson 3-2 Initial Assessment Provides the knowledge and skills to properly perform the initial assessment. In this session, the student will learn about forming a general impression, determining responsiveness, assessment of the airway, breathing and circulation. Students will also discuss how to determine priorities of patient care. Lesson 3-3 Focused History and Physical Exam - Trauma Patients Describes and demonstrates the method of assessing patients' traumatic injuries. A rapid approach to the trauma patient will be the focus of this lesson. Lesson 3-4 Focused History and Physical Exam - Medical Patients Describes and demonstrates the method of assessing patients with medical complaints or signs and symptoms. This lesson will also serve as an introduction to the care of the medical patient. Lesson 3-5 Detailed Physical Exam Teaches the knowledge and skills required to continue the assessment and treatment of the patient. Lesson 3-6 On-Going Assessment Stresses the importance of trending, recording changes in the patient's condition, and reassessment of interventions to assure appropriate care. Lesson 3-7 Communications Discusses the components of a communication system, radio communications, communication with medical direction, verbal communication, interpersonal communication, and quality improvement. Lesson 3-8 Documentation Assists the EMT-Basic in understanding the components of the written report, special considerations regarding patient refusal, the legal implications of the report, and special reporting situations. Reports are an important aspect of prehospital care. This skill will be integrated into all student practices. Lesson 3-9 Practical Skills Lab: Patient Assessment Integrates the knowledge and skills learned thus far to assure that the student has the knowledge and skills of assessment necessary to continue with the management of patients with medical complaints and traumatic injuries.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

7

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Lesson 3-10 Evaluation: Patient Assessment Module Conduct written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. MODULE 4 MEDICAL/BEHAVIORAL EMERGENCIES AND OBSTETRICS/GYNECOLOGY Lesson 4-1 General Pharmacology Provides the student with a basic knowledge of pharmacology, providing a foundation for the administration of medications given by the EMT-Basic and those used to assist a patient with self-administration. Lesson 4-2 Respiratory Emergencies Reviews components of the lesson on respiratory anatomy and physiology. It will also provide instruction on assessment of respiratory difficulty and emergency medical care of respiratory problems, and the administration of prescribed inhalers. Lesson 4-3 Cardiovascular Emergencies Reviews of the cardiovascular system, an introduction to the signs and symptoms of cardiovascular disease, administration of a patient's prescribed nitroglycerin, and use of the automated external defibrillator. Lesson 4-4 Diabetes/Altered Mental Status Reviews of the signs and symptoms of altered level of consciousness, the emergency medical care of a patient with signs and symptoms of altered mental status and a history of diabetes, and the administration of oral glucose. Lesson 4-5 Allergies Teaches the student to recognize the signs and symptoms of an allergic reaction, and to assist the patient with a prescribed epinephrine auto-injector. Lesson 4-6 Poisoning/Overdose Teaches the student to recognize the signs and symptoms of poisoning and overdose. Information on the administration of activated charcoal is also included in this section. Lesson 4-7 Environmental Emergencies Covers recognizing the signs and symptoms of heat and cold exposure, as well as the emergency medical care of these conditions. Information on aquatic emergencies and bites and stings will also be included in this lesson. Lesson 4-8 Behavioral Emergencies -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

8

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Develops the student's awareness of behavioral emergencies and the management of the disturbed patient. Restraining the combative patient will also be taught in this lesson. Lesson 4-9 Obstetrics/Gynecology Reviews the anatomical and physiological changes that occur during pregnancy, demonstrate normal and abnormal deliveries, summarize signs and symptoms of common gynecological emergencies, and neonatal resuscitation. Lesson 4-10 Practical Skills Lab: Medical/Behavioral Emergencies and Obstetrics/Gynecology Draws on the knowledge and skills learned thus far in this practical lab. Students will be given the opportunity to assess and treat a variety of patients with various medical complaints. Lesson 4-11 Evaluation: Medical/Behavioral Emergencies and Obstetrics/Gynecology Conducts a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. MODULE 5 TRAUMA Lesson 5-1 Bleeding and Shock Reviews the cardiovascular system, describes the care of the patient with internal and external bleeding, signs and symptoms of shock (hypoperfusion), and the emergency medical care of shock (hypoperfusion). Lesson 5-2 Soft Tissue Injuries Continues with the information taught in Bleeding and Shock, discussing the anatomy of the skin and the management of soft tissue injuries and the management of burns. Techniques of dressing and bandaging wounds will also be taught in this lesson. Lesson 5-3 Musculoskeletal Care Reviews of the musculoskeletal system before recognition of signs and symptoms of a painful, swollen, deformed extremity and splinting are taught in this section.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

9

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Lesson 5-4 Injuries to the Head and Spine Reviews the anatomy of the nervous system and the skeletal system. Injuries to the spine and head, including mechanism of injury, signs and symptoms of injury, and assessment. Emergency medical care, including the use of cervical immobilization devices and short and long back boards will also be discussed and demonstrated by the instructor and students. Other topics include helmet removal and infant and child considerations. Lesson 5-5 Practical Skills Lab: Trauma Provides practice of the assessment and management of patients with traumatic injuries. Lesson 5-6 Evaluation: Trauma Module Conducts a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. MODULE 6 INFANTS AND CHILDREN Lesson 6-1 Infants and Children Presents information concerning the developmental and anatomical differences in infants and children, discuss common medical and trauma situations, and also covered are infants children dependent on special technology. Dealing with an ill or injured infant or child patient has always been a challenge for EMS providers. Lesson 6-2 Practical Skills Lab: Infants and Children Provides the EMT-Basic student with the opportunity to interact with infants and children, and to practice the knowledge and skills learned thus far concerning this special population. Lesson 6-3 Evaluation: Infants and Children Conduct a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. MODULE 7 OPERATIONS Lesson 7-1 Ambulance Operations Presents an overview of the knowledge needed to function in the prehospital environment. Topics covered include responding to a call, emergency vehicle operations, transferring patients, and the phases of an ambulance call. Lesson 7-2 Gaining Access

10

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Provides the EMT-Basic student with an overview of rescue operations. Topics covered include roles and responsibilities at a crash scene, equipment, gaining access, and removing the patient. Lesson 7-3 Overviews Provides the EMT-Basic student with information on hazardous materials, incident management systems, mass casualty situations, and basic triage. Lesson 7-4 Evaluation: Operations Conduct a written and skills evaluation will be done to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction.

MODULE 8 ADVANCED AIRWAY (Elective) The course coordinator should consult with state EMS office prior to establishing course outline to determine if this module of instruction may be included. Lesson 8-1 Advanced Airway Instructs students on how to maintain an airway by means of orotracheal intubation. Included is a review of basic airway skills, nasogastric tube insertion for decompression of the stomach of an infant or child patient, and orotracheal intubation of adults, infants and children. This lesson should be presented prior to the medical and trauma modules. Lesson 8-2 Practical Skills Lab: Advanced Airway Demonstrates the skills of advanced airway techniques for the EMT-Basic. This includes insertion of the nasogastric tube in infant and child patients and orotracheal intubation of adults, infants and children. Lesson 8-3 Evaluation: Advanced Airway Conduct a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction. Whenever possible, supervised clinical experience will be provided to the students.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

11

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

How to Use the Curriculum and Lesson Plans
There are seven modules of instruction in the core content (one additional module on advanced airway is provided for those who elect to utilize it). There are 44 lessons within the seven modules. Each lesson has the following components: Objectives The objectives are divided into three categories: Cognitive, Affective, and Psychomotor. Cognitive mental process-perception reasoning intuition

Affective emotional process-feelings

Psychomotor physical process--

muscular activity

To assist with the design and development of a specific lesson, each objective has a numerical value, e.g., 3-2.1. The first number is the module of instruction, followed by a hyphen and the number of the specific lesson. For example, 3-2.1 is: Module 3: Lesson 3-2: Objective 3-2.1 Patient Assessment The Initial Assessment Summarize the reasons for forming a general impression of the patient. (C-1)

At the end of each objective is a letter for the type of objective: C = Cognitive; A = Affective; and P = Psychomotor. (The example above is cognitive). The number following the type of objective represents the level of objective: 1 = Knowledge; 2 = Application; and 3 = Problem Solving. (The example above is knowledge). Preparation Motivation -- Each lesson has a motivational statement that should be read by the instructor prior to teaching the lesson. It is not the intent for the instructor to necessarily read the motivational statement to the students, but more importantly to be familiar with its content and to be able to prepare the students or explain why this is important. Prerequisites -- Prior to starting a lesson, the instructor should assure that the students have completed the necessary prerequisites.

12

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Materials: Audio Visual (AV) Equipment -- In recent years, high quality video materials have become available for the EMS community. They should be used as an integral part of the instruction in this program. The course administrator should assure that the necessary types of AV equipment are accessible for the class. If possible, the course administrator should have a video library available for the student. Emergency Medical Services (EMS) Equipment -- Each lesson plan contains a list of equipment that should be available for instruction. Personnel: Program Director Course Coordinator Primary Instructor Assistant Instructor Course Medical Director The roles of the program personnel are discussed in more detail under Program Personnel. Recommended Minimum Time to Complete -- Each lesson plan has a recommended minimum time for completion. Although the time for each lesson has been pilot tested, due to the varying nature of adult learners, the enrichment and need for remediation may require additional time. Time limits may be extended to bring the students to the full level of competency. Presentation Declarative (What) -- This is the cognitive lesson plan. This is the information that the instructor provides the students. This may be accomplished by various methods, including lectures, small group discussion, and the use of audio-visual materials. Demonstrations, if the instructor desires, may be used as part of the instruction. The instructor must be well versed with the entire content of the lesson plan. It is not appropriate to read the lesson plans word for word to the students. Lesson plans should be considered dynamic documents that provide guidelines for the appropriate flow of information. The lesson plans are based upon changes in national standards and scientific evidence approved by the Course Medical Director. The instructor should feel free to write notes in the margins and make the lesson plan his own. Application Procedural (How) -- This is the skills portion of the program. The students should be able to demonstrate competency in all skills listed in each section. If -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum 13

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------the declarative (what) content was presented as a lecture, the instructor must perform demonstrations prior to having the students perform the skills. If the instructor performed a demonstration as part of the declarative component, the students may begin by practicing skills in the practical setting. When this component of the lesson is being conducted, there should be one instructor for every six students. Students should be praised for their progress. For those students having difficulty performing a skill or skills, remediation is required. It is well known that a demonstration must be followed by practice, which must be drilled to a level that assures mastery of the skill. It has been proven that demonstration followed as soon as possible by organized, supervised practice enhances mastery and successful applications. Contextual (When, Where and Why) -- This section is designed to help the student understand the application of their knowledge and skills as they relate to their performance as an EMT-Basic. This section relates back to the motivational statement and represents the reasoning as to why, where and when the EMT-Basic would need to use the knowledge or perform the skills. It is of utmost importance that the instructor be familiar with the intent of this section and relay that intent to the students. Student Activities -- Students learn by various methods. The three types are auditory, visual and kinesthetic. The intent of this section is to assure that the content of the curriculum is presented to meet the needs of the three different types of learning styles. These three areas should not necessarily be used separately from the lesson plan, but as an adjunct to it. An attempt to provide instruction to the student with these three types of modalities will enhance student learning. Auditory (Hear) -- This section allows the instructor to provide material in a verbal manner. Those students who learn best by hearing will benefit from this method of instruction. Visual (See) -- This section allows the instructor to provide material in a visual manner. Visual learners will benefit from this method of instruction. Kinesthetic (Do) -- This section allows the instructor to provide material in a performance manner. Those students who learn best by doing will benefit from this method of instruction. Instructor Activities -- This section is to remind the instructors that they should always supervise student practice and praise progress. They should reinforce student progress in cognitive, affective and psychomotor domains. If students 14 -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------are having difficulty understanding the content or performing the skills, the instructor should redirect the students. If additional time is needed to complete this task beyond the assigned times of the program, the instructor should complete a remediation form to remind him to schedule additional assistance for the student or group of students experiencing difficulty with the task. Evaluation Written -- The instructor should design and develop various quizzes, verbal reviews, handouts and any other desired materials for the students. Ideally, the instructor should provide a brief quiz after every lesson to determine if the students are comprehending the lesson. Practical -- The instructor should provide students with practical evaluations when applicable. The skill sheets provided within the curriculum will assist the students in preparing for field performance and the final practical evaluation. Remediation The intent of this section is to assure that the instructor meets the needs of those students who are experiencing difficulty understanding the lesson plan. Remediation Sheets supplied in this guide will enable the instructor to keep track of those students. If a student requires remediation frequently a decision should be reached to determine if the student should continue in the program (see Appendix G). Enrichment This section is designed to allow the instructors, the course medical director, the course coordinator, the region, or state to add additional information, or augment the curriculum. Anything that is unique to your area should be added, for example, jellyfish injuries that are unique to coastal areas (see Appendix F).

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

15

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Prerequisites
Cardiopulmonary Resuscitation (CPR) -- To meet the time requirements of this revised EMT-Basic Curriculum, CPR should be a prerequisite. Basic life support is an essential component of any EMS educational experience and this class should be successfully completed prior to entering the EMT-Basic program. This may be accomplished by various alternatives: ! ! ! Assure that the EMT-Basic candidates have a current card prior to entering the program. Offer one or several programs of CPR prior to the start of EMT-Basic program. Set a time prior to the beginning of the EMT-Basic program and require all students seeking to enter that program to participate or test out.

Note: Although CPR is a prerequisite, it should be routinely practiced and integrated throughout the entire instruction of the EMT-Basic. Skill stations should be created to reinforce knowledge and skills.

16

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Instructors
Assessing Student Achievement
This training program includes several methods for assessing student achievement. As mentioned before, quizzes of the cognitive and psychomotor domains should be provided at the completion of each lesson. Time is allocated at the end of each module of instruction for a cognitive and psychomotor evaluation. The primary instructor in conjunction with the course coordinator is responsible for the design, development, administration and grading of all written and practical examinations. The program should feel free to use outside agency-approved psychomotor evaluation instruments or those found in texts. All written examinations used within the program should be valid and reliable and conform to psychometric standards. Instructors should be encouraged to use outside sources to validate examinations and/or as a source of classroom examination items. The primary purpose of this course is to meet the entry-level job expectations as indicated in the job description. Each student, therefore, must demonstrate attainment of knowledge, attitude, and skills in each area taught in the course. It is the responsibility of the course coordinator, medical director, primary instructor and educational institution to assure that students obtain proficiency in each module of instruction before they proceed to the next area. If after counseling and remediation a student fails to demonstrate the ability to learn specific knowledge, attitudes and skills, the program director should not hesitate to dismiss the student. The level of knowledge, attitude and skills attained by a student in the program will be reflected in his performance on the job as an EMT-Basic. This is ultimately a reflection on the program director, primary instructor, medical director and educational institution. It is not the responsibility of the certifying examination to assure competency over successful completion of the course. Program directors should recommend only qualified candidates for licensure, certification or registration. Requirements for successful completion of the course are as follows: Cognitive Students must receive passing grades on all module examinations and the final examination. Special remedial sessions may be utilized to assist in the completion of a lesson or module of instruction. Scores should be in accordance with accepted practices. Students must demonstrate conscientiousness and interest in the program. Students who fail to do so should be

Affective -

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

17

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------counseled while the course is in progress in order to provide them the opportunity to develop and exhibit the proper attitude expected of an EMT-Basic. Psychomotor Students must demonstrate proficiency in all skills in each testing session of selected topic areas and mastery of skills in the final examination. Special remedial sessions may be utilized to assist in the completion of a lesson or module of instruction. Pass/fail scores should be in accordance with accepted practices. Usage of the skill measurement instruments within this curriculum or developed by way of a valid process is strongly recommended to achieve maximum results with the students.

The additional areas that should be utilized for evaluation of student achievement include: Personal appearance - Each student should be neat, clean, well groomed and physically fit enough to perform the minimal entry-level job requirements. Students who fail to exhibit good hygiene habits should be counseled while the program is in session to provide them with the opportunity to correct the habits. Attendance - Students are required to attend all lessons. At the discretion of the program director or designee, a student missing a lesson may demonstrate the fulfillment of all skills and knowledge covered in the missed lesson. Clinical or Field Rotation Experience - Prior to certification of course completion, satisfactory clinical or field experience is required by the student.

Program Personnel
There will often be a number of individuals involved in the presentation of the EMT-Basic program. For clarity, the following terms are defined as they will be used throughout this document. These identified roles and responsibilities are a necessary part of each EMT-B course. The individuals carrying them out may vary from program to program and from locality to locality as the exact roles interface and overlap. In fact, one person, if qualified, may carry out all of the roles in some programs.

18

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Program Director: An individual responsible for course planning, operation and evaluation. While the Program Director is responsible for the overall operation of the education experience, this person need not be qualified or involved in the actual instruction of specific course lessons. The Program Director is responsible for EMT-Basic course planning. The Course Coordinator is the individual responsible for coordinating and conducting the EMT-Basic program. The Course Coordinator acts as the liaison between the students, the sponsoring agency, the local medical community and the state-level certifying or licensing agency and is responsible for assuring that the course goals and objectives (and those set forth by any licensing, registering, or certifying agency as applicable) are met. The Course Coordinator may also serve as the Primary Instructor. This individual should have attended a workshop which reviews the format, philosophy and skills of the new curriculum. This individual is expected to be knowledgeable in all aspects of prehospital emergency care, in the techniques and methods of adult education, and managing resources and personnel. This individual should have attended and successfully completed a program in EMS instruction methodology and an update on this curriculum. This individual should be present at most, if not all, class sessions to assure program continuity and to be able to identify that the students have the cognitive, affective and psychomotor skills necessary to function as an Emergency Medical Technician-Basic. This individual is responsible for the teaching of a specific lesson of the EMT-Basic course. This individual should have attended a workshop which reviews the format, philosophy and skills of the new curriculum. This individual assists the primary instructor of any lesson in the demonstration and practice designed to develop and evaluate student skill competencies.

Course Coordinator:

Primary Instructor:

Assistant Instructor:

Course Medical Director: The Course Medical Director of the EMT-Basic program should be a local physician with emergency medical experience who will act as the ultimate medical authority regarding course content, procedures, and protocols. The -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum 19

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Course Medical Director, Course Coordinator and the Primary Instructor should work closely together in the preparation and presentation of the program. The Course Medical Director can assist in recruiting physicians to present materials in class, settling questions of medical protocol and acting as a liaison between the course and the medical community. During the program the Medical Director will be responsible for reviewing the quality of care rendered by the EMT-Basic in the clinical and field setting. This Course Medical Director or a designee is responsible to verify student competence in the cognitive, affective and psychomotor domains. The Course Medical Director should review all examinations. The Course Medical Director may also serve as the Primary Instructor.

Philosophy of the Adult Learner
Individuals participating in this educational program should be considered adult learners, even in those programs providing instruction to students younger than age 18. Adult learners are responsible for their own learning. There are several characteristics regarding the adult learner as an EMT-Basic student. 1. 2. EMT-Basic students usually want to utilize knowledge and skills they have learned soon after they have learned them. EMT-Basic students are interested in learning new concepts and principles; they enjoy situations that require problem-solving, not necessarily learning facts. It is less difficult for them to use the concepts and principles they have gained if they are able to participate actively in the learning process. EMT-Basic students learn best if they are able to proceed at their own pace. Motivation is increased when the subject content is relevant to the immediate interests and concerns of the EMT-Basic student. Immediate feedback is essential to the EMT-Basic student, who needs to be kept informed of his progress continuously.

3. 4. 5.

The intent of this revised curriculum is to alter the methods of instruction provided by the instructor. This curriculum has been designed and developed to reduce the amount of lecture time and move towards an environment of discussion and practical skills. This way both learners and instructors are active in the process of learning.

Principles of Adult Education
20 -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

1.

Attract and maintain the attention of the EMT-Basic student.

If instructors get off to a bad start, it is often because they fail to successfully gain and maintain the attention of the student. In these situations, students start enthusiastic and may leave with some level of disappointment. A clear statement of the purpose of each lesson is of utmost importance in gaining the student's attention. This may be accomplished by using the information found in the motivational statement or the contextual statement of the lesson plan. There are many methods that may be used to gain the student's attention, e.g., telling a relevant anecdote, posing a unique situation, or asking how they would solve a problem. Once you have gained the attention of the student, you must then maintain it throughout the entire lesson. After about 15-20 minutes of presentation, it is essential that the student be reinvolved in the learning process. There are three methods often utilized to keep the students active in the process: Questioning, brainstorming, and demonstration. Questions should be used to promote thought, to evaluate what has been learned, and to continuously move students toward their desired goal. Questioning students keeps them actively involved and keeps them thinking. It is also appropriate to ask rhetorical questions that are not meant to be answered by the student, but that encourage thinking. Questions should be open-ended and should not have "yes" or "no" answers. Questions should be a significant part of the lesson and should be used in both didactic and practical presentation. Another method of keeping students actively involved in their learning is to use brainstorming. Brainstorming is a special and different type of questioning. This process generates a wide variety of creative ideas. There is no right or wrong answer, only creative thinking. Pose a question to the students and then allow them to provide as many answers as possible. After all the ideas have been presented, move the students toward the appropriate and important points. The third technique is demonstration. By providing the students with actual demonstration, you have bridged the gap between theory and practice. When performing demonstration, it is beneficial to involve the students in the process. It is encouraged that demonstration be used during the didactic component of the presentation to assure breaking up long runs of lecture-type material. 2. Make the presentation clear and keep it organized.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

21

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------By using the lesson plans, your instruction should be clear and organized. However, there are some additional tips that may assist you in your educational endeavors. 1. 2. 3. 4. 5. 6. 7. 8. Tell the students what you are going to tell them. Tell them. Show them. Let them try. Observe. Praise progress and redirect. Tell them what you have told them. Have them summarize what they have learned.

To help keep lessons clear, make sure the students have the objectives. The objectives should be presented to the students on the first day of class. It may be beneficial to present students with entire lesson plans and allow students to write additional information in the margins.

Continuing Education
It will be necessary to provide updates to the lead instructor and assistant instructors regarding the new curriculum material, and annual updates should be scheduled to inform instructors of current trends in prehospital emergency medicine.

22

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Students
Job Description: Emergency Medical Technician - Basic
Career Requirements: Responds to emergency calls to provide efficient and immediate care to the critically ill and injured, and transports the patient to a medical facility. After receiving the call from the dispatcher, drives the ambulance to address or location given, using the most expeditious route, depending on traffic and weather conditions. Observes traffic ordinances and regulations concerning emergency vehicle operation. Upon arrival at the scene of crash or illness, parks the ambulance in a safe location to avoid additional injury. Prior to initiating patient care, the EMT-Basic will also "size-up" the scene to determine that the scene is safe, the mechanism of injury or nature of illness, total number of patients and to request additional help if necessary. In the absence of law enforcement, creates a safe traffic environment, such as the placement of road flares, removal of debris, and re-direction of traffic for the protection of the injured and those assisting in the care of injured patients. Determines the nature and extent of illness or injury and establishes priority for required emergency care. Based on assessment findings, renders emergency medical care to adult, infant and child, medical and trauma patients. Duties include but are not limited to, opening and maintaining an airway, ventilating patients, and cardiopulmonary resuscitation, including use of automated external defibrillators. Provide prehospital emergency medical care of simple and multiple system trauma such as controlling hemorrhage, treatment of shock (hypoperfusion), bandaging wounds, and immobilization of painful, swollen, deformed extremities. Medical patients include: Assisting in childbirth, management of respiratory, cardiac, diabetic, allergic, behavioral, and environmental emergencies, and suspected poisonings. Searches for medical identification emblem as a clue in providing emergency care. Additional care is provided based upon assessment of the patient and obtaining historical information. These interventions include assisting patients with prescribed medications, including sublingual nitroglycerin, epinephrine auto-injectors and hand-held aerosol inhalers. The EMT-Basic will also be responsible for administration of oxygen, oral glucose and activated charcoal.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

23

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------Reassures patients and bystanders by working in a confident, efficient manner. Avoids mishandling and undue haste while working expeditiously to accomplish the task. Where a patient must be extricated from entrapment, assesses the extent of injury and gives all possible emergency care and protection to the entrapped patient and uses the prescribed techniques and appliances for safely removing the patient. If needed, radios the dispatcher for additional help or special rescue and/or utility services. Provides simple rescue service if the ambulance has not been accompanied by a specialized unit. After extrication, provides additional care in triaging the injured in accordance with standard emergency procedures. Complies with regulations on the handling of the deceased, notifies authorities, and arranges for protection of property and evidence at scene. Lifts stretcher, placing in ambulance and seeing that the patient and stretcher are secured, continues emergency medical care. From the knowledge of the condition of the patient and the extent of injuries and the relative locations and staffing of emergency hospital facilities, determines the most appropriate facility to which the patient will be transported, unless otherwise directed by medical direction. Reports directly to the emergency department or communications center the nature and extent of injuries, the number being transported, and the destination to assure prompt medical care on arrival. Identifies assessment findings which may require communications with medical direction for advice and for notification that special professional services and assistance be immediately available upon arrival at the medical facility. Constantly assesses patient en route to emergency facility, administers additional care as indicated or directed by medical direction. Assists in lifting and carrying the patient out of the ambulance and into the receiving facility. Reports verbally and in writing their observation and emergency medical care of the patient at the emergency scene and in transit to the receiving facility staff for purposes of records and diagnostics. Upon request, provides assistance to the receiving facility staff. After each call, restocks and replaces used linens, blankets and other supplies, cleans all equipment following appropriate disinfecting procedures, makes careful check of all equipment so that the ambulance is ready for the next run. Maintains ambulance in efficient operating condition. Ensures that the ambulance is clean and washed and 24 -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------kept in a neat orderly condition. In accordance with local, state or federal regulations, decontaminates the interior of the vehicle after transport of patient with contagious infection or hazardous materials exposure. Determines that vehicle is in proper mechanical condition by checking items required by service management. Maintains familiarity with specialized equipment used by the service. Attends continuing education and refresher training programs as required by employers, medical direction, licensing or certifying agencies. Meets qualifications within the functional job analysis.

Continuing Education and Its Importance in Lifelong Learning
This curriculum is designed to provide the student with the essentials to serve as an EMT-Basic. The 110-hour time constraint of this program as recommended by the national emergency medical services community during the 1990 NHTSA Consensus Workshop on Emergency Medical Services Training Programs necessitates the need for enrichment and continuing education in order to bring the student to full competency. As an entry-level medical education program, we understand that a laborer who works with his hands and even a craftsman who works with his hands and head may be achievable within the 110-hour time limit constraint, but an artist who works with his hands, head and heart cannot be achieved within these constraints. We strongly urge employers and service chiefs to integrate new graduates into specific orientation training programs. It is important to understand that this curriculum does not provide students with extensive knowledge in hazardous materials, blood-borne pathogens, emergency vehicle operations or rescue practices in unusual environments. These areas are not core elements of education and practice as identified in the National EMS Education and Practice Blueprint. Identified areas of competency not specifically designed within the EMT-Basic: National Standard Curriculum should be taught in conjunction with this program as a local or state option.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

25

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Environment
Classroom Environment
The intent of the revised curriculum is to allow for greater interaction between students and the instructors. The instruction should be very active and experiential. By using the procedural (how) section of the application area of the lesson plan, as well as the kinesthetic (do) component of the student activity section, the instructor should be better able to enhance the educational experience for the students.

Clinical/Field Rotations
In addition to the required 110 hours of instruction, this course requires that the student have patient interactions in a clinical setting. Ideally, areas that have access to an Emergency Medical Services system should send students into the field with experienced preceptors. However, in low volume systems or systems with legal considerations, the training program may utilize emergency departments, clinics, or physician offices. The program director or medical director must establish appropriate relationships with various clinical sites to assure adequate contact with patients. The student should interview and assess a minimum of five patients. The student should record the patient history and assessment on a prehospital care report just as he would if he were interacting with this patient in a field setting. The prehospital care report should then be reviewed by the Primary Instructor to assure competent documentation practices in accordance with the minimum data set. Regardless of the clinical educational system, the program must establish a feedback system to assure that students have acted safely and professionally during their training. Students should be graded on this experience. Students who have been reported to have difficulty in the clinical or field setting must receive remediation and redirection. Students should be required to repeat clinical or field setting experiences until they are deemed competent within the goals established by the Program Director. In extreme cases, when students are not able to obtain experiences in a clinical or field setting, it may be necessary to utilize programmed patients. All variances must be approved by the state EMS office or licensing agency.

26

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Maintaining Records
With regard to records, it is recommended that the Program Director/Course Coordinator maintain, as a minimum, information on the following: ! ! ! ! Student recruiting procedures and forms. Instructor recruiting and forms. Conducting an instructor orientation. Student attendance and performance at each lesson, including comments as appropriate regarding need for improvement in skills, knowledge, attitudes or personal habits. Results of evaluation and counseling sessions. Grades for each written examination and completed checklists for each skill evaluation. Number and qualifications of students completing the course. Number and qualifications of students who did not complete the course and the reasons for not completing the course if known. Number and qualifications of the instructional team. Instructor performance. Description of the clinical and field rotations. Adequacy and availability of facilities and resources. Cost - total program costs, costs for each program element and costs per student. Lists of enrichments and add-on courses taught in conjunction with the program. Copies of American Heart Association or American Red Cross Basic Life Support Cards at the professional rescuer level. Results of course entry examinations and qualifications as required by the certifying agency, state EMS office, course medical director or training institution.

! ! ! ! ! ! ! ! ! ! ! !

Licensure, Certification and Registration
State regulatory agencies may require specific evaluation of cognitive and psychomotor performance prior to official licensure, certification or registration as an Emergency Medical Technician-Basic. This is in addition to course completion and may be required by state regulations. The National Registry of EMTs is a recognized agency that provides examinations for certification and registration that may be required by your state. The program director should contact the State Office of Emergency Medical Services for licensure, certification or registration information.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

27

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Program Evaluation
On-going evaluation must be initiated to identify instructional or organizational deficiencies which affect student performance. The evaluation process should be twofold in nature, objective and subjective. Two main methods of objective evaluation generally used are: 1) How well do students measure up to standardized examination? 2) How well do EMT-Basics practice in accordance with established standards of care? Group and individual deficiencies may indicate problems in conducting the training program. Subjective evaluation should be conducted at regular intervals by providing students with written questions on their opinions of the program's strengths and weaknesses. Students should be given the opportunity comment on the primary and assistant instructors, presentation style and effectiveness. Students should also be asked to comment on the program's compliance with specified course of instruction, the quality and quantity of psychomotor skills labs, and the validity of the examinations. The purpose of this evaluation process is to strengthen future training efforts. All information obtained as part of the subjective evaluation should be reviewed for legitimacy and possible incorporation into the course. Due to the important nature of this educational program, every effort should be made to ensure the highest quality instruction.

Facilities
The physical environment for the provision of the EMT-Basic program is a critical component for the success of the overall program. The facility should have a large hall with sufficient space for seating all students. Abundant space should be made available for demonstration during the presentation of the course material. Additional rooms or adequate space should be available to serve as a practice area (one instructor for every six students). It is recommended that all the required equipment for the program be stored at the facility to assure availability for its use. The facility should be well lit for adequate viewing of various types of visual aids and demonstrations. Heating and ventilation should assure student and instructor comfort and the seats should be comfortable with availability of desk tops or tables for taking notes. There should be an adequate number of tables for display of equipment, medical supplies, and training aids. A chalkboard (flip chart, grease board) should be in the main hall. A projection screen and appropriate audio visual equipment should be located in the presentation facility. If possible, light switches should be conveniently located in the presentation area. Practice area should be carpeted and large enough to accommodate six students, one instructor, and the necessary equipment and medical supplies. Tables should be available for practice areas, with appropriate and sufficient equipment and medical supplies. 28 -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Instructor's Course Guide -------------------------------------

Course Cost
The cost for the provision of the EMT-Basic education varies widely across the nation. Training considerations provided in this section may serve as a basis for estimating costs for conducting an EMT-Basic program. Additional costs will be incurred in the management and evaluation of the program. Specifically, the course director should consider costs associated with the following: 1. Salaries ! Medical director ! Course coordinator ! Primary instructor ! Assistant instructors Facilities ! Classroom and associated equipment (tables, chairs, audio-visual equipment) ! Field and clinical training facilities ! Office space and associated equipment (desks, chairs, files) Materials ! Emergency care equipment and supplies ! Educational aids (slides, film, video, flip chart, projection equipment, screens, handouts) ! Documents, e.g., Instructor's Course Guide, Instructor's Lesson Plans, text material, study guides, reference books

2.

3.

Student and instructor recruiting materials, registration forms, data collection forms, records and reports, and postage should be considered in the formal budget. 4. Travel and per diem, as appropriate ! Medical director ! Course coordinator ! Primary instructor ! Assistant instructors ! Students

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

29

EMT-Basic: National Standard Curriculum Instructor's Course Guide ------------------------------------5. Examination and certification costs

Examination and certification costs are as specified by the state emergency medical services office. If it is necessary to provide instruction to the lead instructor or assistant instructors, that cost should also be taken into consideration in calculating the overall cost of the EMT-Basic program. In addition, it will be necessary to provide updates to the lead instructor and assistant instructors regarding the new curriculum material. Annual updates should be scheduled to inform instructors of current trends in prehospital emergency medicine.

30

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Nasic: National Standard Curriculum

MODULE 1 Preparatory Lesson 1-1 Introduction to Emergency Care

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------OBJECTIVES

C=Cognitive P=Psychomotor A=Affective OBJECTIVES LEGEND 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-1.1 Define Emergency Medical Services (EMS) systems.(C-1) 1-1.2 Differentiate the roles and responsibilities of the EMT-Basic from other prehospital care providers.(C-3) 1-1.3 Describe the roles and responsibilities related to personal safety.(C-1) 1-1.4 Discuss the roles and responsibilities of the EMT-Basic towards the safety of the crew, the patient and bystanders.(C-1) 1-1.5 Define quality improvement and discuss the EMT-Basic's role in the process.(C-1) 1-1.6 Define medical direction and discuss the EMT-Basic's role in the process.(C-1) 1-1.7 State the specific statutes and regulations in your state regarding the EMS system.(C-1) AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-1.8 Assess areas of personal attitude and conduct of the EMT-Basic.(A-3) 1-1.9 Characterize the various methods used to access the EMS system in your community.(A-3) PSYCHOMOTOR OBJECTIVES No psychomotor objectives identified.

1-32

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------PREPARATION

Motivation:

The field of prehospital emergency medical care is an evolving profession in which the reality of life and death is confronted at a moment's notice. EMS has developed from the days when the local funeral home and other services served as the ambulance provider to a far more sophisticated system today. EMT-Basics work side by side with other health care professionals to help deliver professional prehospital emergency medical care. This course is designed to help the new EMT-Basic gain the knowledge, skills and attitude necessary to be a competent, productive, and valuable member of the emergency medical services team. BLS MATERIALS Utilize various audio-visual materials relating to emergency medical care. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. None required. PERSONNEL One EMT-Basic instructor knowledgeable in EMT-Basic course overview, administrative paperwork, certification requirements, Americans with Disabilities Act issues, and roles and responsibilities of the EMT-Basic.

Prerequisites:

AV Equipment:

EMS Equipment:

Primary Instructor:

Assistant Instructor: None required. Recommended Minimum Time to Complete: One and a half hours

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-33

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------PRESENTATION

Declarative (What) I. Course Overview A. Paperwork 1. Local 2. State B. Course description and expectations C. Immunizations/physical exam D. Review criteria for certification 1. Successful course completion 2. Mentally/physically meet criteria of safe and effective practice of job functions 3. Written examination 4. Practical examination 5. State and local provisions E. Implications of Americans with Disabilities Act (ADA) - state and local policies F. Implications of harassment - state and local policies The Emergency Medical Services System and the Emergency Medical Technician-Basic A. Overview of the Emergency Medical Services system 1. National Highway Traffic Safety Administration Technical Assistance Program Assessment Standards a. Regulation and policy b. Resource management c. Human resources and training d. Transportation e. Facilities f. Communications g. Public information and education h. Medical direction i. Trauma systems j. Evaluation 2. Access to the system a. 9-1-1 b. Non 9-1-1

II.

1-34

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------3. Levels of training a. First Responder b. EMT-Basic c. EMT-Intermediate d. EMT-Paramedic 4. The health care system a. Emergency departments b. Specialty facilities (1) Trauma centers (2) Burn centers (3) Pediatric centers (4) Poison centers (5) Other specialty centers - locally dependent 5. Hospital personnel a. Physicians b. Nurses c. Other health professionals 6. Liaison with other public safety workers a. Local law enforcement b. State and federal law enforcement 7. Overview of the local EMS system Roles and Responsibilities of the EMT-Basic 1. Personal safety 2. Safety of crew, patient and bystanders 3. Patient assessment 4. Patient care based on assessment findings 5. Lifting and moving patients safely 6. Transport/transfer of care 7. Record keeping/data collection 8. Patient advocacy (patient rights) - patient as a whole Professional attributes 1. Appearance a. Neat b. Clean c. Positive image 2. Maintains up-to-date knowledge and skills a. Continuing education b. Refresher courses 3. Puts patient's needs as a priority without endangering self. 4. Maintains current knowledge of local, state, and national issues affecting EMS. 1-35

B.

C.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------D. Quality improvement 1. Definition - a system of internal/external reviews and audits of all aspects of an EMS system so as to identify those aspects needing improvement to assure that the public receives the highest quality of prehospital care. 2. The role of the EMT-Basic in quality improvement a. Documentation b. Run reviews and audits c. Gathering feedback from patients and hospital staff d. Conducting preventative maintenance e. Continuing education f. Skill maintenance Medical direction 1. Definition a. A physician responsible for the clinical and patient care aspects of an EMS system. b. Every ambulance service/rescue squad must have physician medical direction. c. Types of medical direction (1) On-line (a) Telephone (b) Radio (2) Off-line (a) Protocols (b) Standing orders d. Responsible for reviewing quality improvement 2. The relationship of the EMT-Basic to medical direction a. Designated agent of the physician b. Care rendered is considered an extension of the medical director's authority (varies by state law). Specific statutes and regulations regarding EMS in your state APPLICATION

E.

F.

1-36

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------Procedural (How) None identified for this lesson.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-37

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------Contextual (When, Where, Why) The student will use this information throughout the course to enhance his understanding and provide direction for the EMT-Basic's relationship to the individual components of the EMS system. The lesson will provide the student with a road map for learning the skill and knowledge domains of the EMT-Basic. Additionally, this lesson will identify that not all students meet the mental and physical requirements of the career field. After completion of the course, the EMT-Basic will use this information to understand the process of gaining and maintaining certification, as well as understanding state and local legislation affecting the profession. This lesson sets the foundation for the remaining teaching/learning process. A positive, helpful attitude presented by the instructor is essential to assuring a positive, helpful attitude from the student. STUDENT ACTIVITY Auditory (Hear) Students will hear specifically what they can expect to receive from the training program. Students will hear the specific expectations of the training program. Students will hear actual state and local legislation relative to EMS practice and certification. Visual (See) Students will see audio-visual aids or materials explaining the components of the health care system, EMT-Basic level of care, EMT-Basic's roles and responsibilities, professional attributes, and certification requirements. Students will receive a copy of the cognitive, affective and psychomotor objectives for the entire curriculum. Students will receive the final skill evaluation instruments. Kinesthetic (Do) Students will practice situations in which EMT-Basics portray professional attributes and experience ethical dilemmas. Students will complete the necessary course paperwork. Students will indicate if they will require/request assistance during the course or certification process based on the Americans with Disabilities Act. Additionally, students will provide the necessary documentation to support the requirements/request.

1. 2. 3.

1.

2. 3.

1. 2. 3.

1-38

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation form).

EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Practical:

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide.

ENRICHMENT

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-39

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-1: Introduction to Emergency Medical Care ------------------------------------What is unique in the local area concerning this topic? Complete enrichment sheets from instructor's course guide and attach with lesson plan.

1-40

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 1 Preparatory Lesson 1-2 Well-Being of the EMT-Basic

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-2.1 List possible emotional reactions that the EMT-Basic may experience when faced with trauma, illness, death and dying. (C-1) 1-2.2 Discuss the possible reactions that a family member may exhibit when confronted with death and dying.(C-1) 1-2.3 State the steps in the EMT-Basic's approach to the family confronted with death and dying.(C-1) 1-2.4 State the possible reactions that the family of the EMT-Basic may exhibit due to their outside involvement in EMS.(C-1) 1-2.5 Recognize the signs and symptoms of critical incident stress.(C-1) 1-2.6 State possible steps that the EMT-Basic may take to help reduce/alleviate stress.(C-1) 1-2.7 Explain the need to determine scene safety. (C-2) 1-2.8 Discuss the importance of body substance isolation (BSI).(C-1) 1-2.9 Describe the steps the EMT-Basic should take for personal protection from airborne and bloodborne pathogens.(C-1) 1-2.10 List the personal protective equipment necessary for each of the following situations:(C-1) - Hazardous materials - Rescue operations - Violent scenes - Crime scenes -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-42

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------- Exposure to bloodborne pathogens - Exposure to airborne pathogens AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-2.11 Explain the rationale for serving as an advocate for the use of appropriate protective equipment. (A-3) PSYCHOMOTOR OBJECTIVES 1-2.12 Given a scenario with potential infectious exposure, the EMT-Basic will use appropriate personal protective equipment. At the completion of the scenario, the EMT-Basic will properly remove and discard the protective garments. (P-1,2) 1-2.13 Given the above scenario, the EMT-Basic will complete disinfection/cleaning and all reporting documentation.(P-1,2)

PREPARATION

Motivation:

EMT-Basics encounter many stressful situations providing emergency medical care to patients. These range from death and terminal illness to major traumatic situations and child abuse. EMT-Basics will treat angry, scared, violent, seriously injured and ill patients and family members. The EMT-Basic is not immune from the personal effects of these situations. EMT-Basics will learn during this lesson what to expect and how to assist the patient, patient's family, the EMT-Basic's family and other EMT-Basics in dealing with the stress. This lesson discusses methods of talking to friends and family, without violating confidentiality, but as a means of helping them cope with involvement in EMS. Finally, aspects of personal safety will be discussed. It is important to realize this is only a brief overview and will be readdressed with each specific skill or topic. To put this in

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-43

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------perspective, remember: A dead or injured EMT-Basic is of little or no use to a patient. Prerequisites: BLS

1-44

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------MATERIALS Utilize various audio-visual materials relating to the wellbeing of the EMT-Basic. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. Eye protection, gowns, gloves, masks, forms for reporting exposures. PERSONNEL One EMT-Basic instructor knowledgeable in critical incident stress debriefing, identifying child/elderly abuse, stages of death and dying, and aspects of scene safety.

AV Equipment:

EMS Equipment:

Primary Instructor:

Assistant Instructor: None required. Recommended Minimum Time to Complete: One and a half hours PRESENTATION

I.

Declarative (What) Emotional Aspects of Emergency Care A. Death and dying 1. Stages a. Denial ("Not me.") - defense mechanism creating a buffer between shock of dying and dealing with the illness/injury. b. Anger ("Why me.") (1) EMT-Basics may be the target of the anger. (2) Don't take anger or insults personally. (a) Be tolerant. (b) Do not become defensive.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-45

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------(3) (4) Employ good listening and communication skills. Be empathetic.

1-46

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------Bargaining ("OK, but first let me...") - agreement that, in the patient's mind, will postpone the death for a short time. d. Depression ("OK, but I haven't...") (1) Characterized by sadness and despair. (2) Patient is usually silent and retreats into his own world. e. Acceptance ("OK, I am not afraid.") (1) Does not mean the patient will be happy about dying. (2) The family will usually require more support during this stage than the patient. 2. Dealing with the dying patient and family members a. Patient needs include dignity, respect, sharing, communication, privacy and control. b. Family members may express rage, anger and despair. c. Listen empathetically. d. Do not falsely reassure. e. Use a gentle tone of voice. f. Let the patient know everything that can be done to help will be done. g. Use a reassuring touch, if appropriate. h. Comfort the family. Stressful situations 1. Examples of situations that may produce a stress response a. Mass casualty situations b. Infant and child trauma c. Amputations d. Infant/child/elder/spouse abuse e. Death/injury of co-worker or other public safety personnel 2. The EMT-Basic will experience personal stress as well as encounter patients and bystanders in severe stress. Stress management 1. Recognize warning signs a. Irritability to co-workers, family, friends b. Inability to concentrate c. Difficulty sleeping/nightmares d. Anxiety e. Indecisiveness f. Guilt g. Loss of appetite h. Loss of interest in sexual activities i. Isolation 1-47 c.

B.

C.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------j. Loss of interest in work 2. Life-style changes a. Helpful for "job burnout" b. Change diet (1) Reduce sugar, caffeine and alcohol intake (2) Avoid fatty foods (3) Increase carbohydrates c. Exercise d. Practice relaxation techniques, meditation, visual imagery 3. Balance work, recreation, family, health, etc. 4. EMS personnel and their family's and friends' responses a. Lack of understanding b. Fear of separation and being ignored c. On-call situations cause stress d. Can't plan activities e. Frustration caused by wanting to share 5. Work environment changes a. Request work shifts allowing for more time to relax with family and friends. b. Request a rotation of duty assignment to a less busy area. 6. Seek/refer professional help. Critical incident stress debriefing (CISD) 1. A team of peer counsellors and mental health professionals who help emergency care workers deal with critical incident stress. 2. Meeting is held within 24 to 72 hours of a major incident. a. Open discussion of feelings, fears, and reactions b. Not an investigation or interrogation c. All information is confidential d. CISD leaders and mental health personnel evaluate the information and offer suggestions on overcoming the stress. 3. Designed to accelerate the normal recovery process after experiencing a critical incident. a. Works well because feelings are ventilated quickly. b. Debriefing environment is non-threatening. 4. How to access local CISD system.

D.

1-48

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------E. Comprehensive critical incident stress management includes: 1. Pre-incident stress education 2. On-scene peer support 3. One-on-one support 4. Disaster support services 5. Defusings 6. CISD 7. Follow up services 8. Spouse/family support 9. Community outreach programs 10. Other health and welfare programs such as wellness programs Scene Safety A. Body substance isolation (BSI) (Bio-Hazard) 1. EMT-Basic's and patient's safety a. Hand washing b. Eye protection (1) If prescription eyeglasses are worn, then removable side shields can be applied to them. (2) Goggles are NOT required. c. Gloves (vinyl or latex) (1) Needed for contact with blood or bloody body fluids. (2) Should be changed between contact with different patients. d. Gloves (utility) - needed for cleaning vehicles and equipment e. Gowns (1) Needed for large splash situations such as with field delivery and major trauma. (2) Change of uniform is preferred. f. Masks (1) Surgical type for possible blood splatter (worn by care provider) (2) High Efficiency Particulate Air (HEPA) respirator if patient suspected for or diagnosed with tuberculosis (worn by care provider) (3) Airborne disease - surgical type mask (worn by patient) g. Requirements and availability of specialty training

II.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-49

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------OSHA/state regulations regarding BSI Statutes/regulations reviewing notification and testing in an exposure incident Personal protection 1. Hazardous materials a. Identify possible hazards (1) Binoculars (2) Placards (3) Hazardous Materials, The Emergency Response Handbook, published by the United States Department of Transportation b. Protective clothing (1) Hazardous material suits (2) Self Contained Breathing Apparatus c. Hazardous materials scenes are controlled by specialized Haz-Mat teams. d. EMT-Basics provide emergency care only after the scene is safe and patient contamination limited. e. Requirements and availability of specialized training 2. Rescue a. Identify and reduce potential life threats. (1) Electricity (2) Fire (3) Explosion (4) Hazardous materials b. Protective clothing (1) Turnout gear (2) Puncture-proof gloves (3) Helmet (4) Eye wear c. Dispatch rescue teams for extensive/heavy rescue. 2. 3.

B.

1-50

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------Violence a. Scene should always be controlled by law enforcement before EMT-Basic provides patient care. (1) Perpetrator of the crime (2) Bystanders (3) Family members b. Behavior at crime scene (covered in greater detail in Medical/Legal and Ethical Issues, Module 1, Lesson 1-3). (1) Do not disturb the scene unless required for medical care. (2) Maintain chain of evidence. Safety Precautions in Advance - Suggested Immunizations A. Tetanus prophylaxis B. Hepatitis B vaccine C. Verification of immune status with respect to commonly transmitted contagious diseases D. Access or availability of immunizations in the community E. Tuberculin purified protein derivative (PPD) testing F. Others APPLICATION 3.

III.

1.

Procedural (How) The EMT-Basic will know how to access additional information on hazardous materials and infectious disease exposure, notification and follow-up. Contextual (When, Where, Why) The EMT-Basic will use the aspects of scene safety and personal protection every day and on every emergency run. While the EMT-Basic may not be a member of a hazardous material or heavy rescue team, this lesson should provide the personal incentive to seek out and attend continuing education programs relative to personal safety during hazardous material incidents, rescue situations and violent crime scenes.

1. 2.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-51

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------3. If the EMT-Basic fails to develop personal safety skills, his EMT-Basic career may come to a premature end through serious injury or death.

1-52

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------4. The well-being of the EMT-Basic depends upon his ability to recognize that stressful traumatic situations do occur and the effect of those situations is felt by the patient, family members and the EMT-Basic. In recognizing this, the EMTBasic must be aware of internal and external mechanisms to help himself, the patient, patient's families, EMT-Basic's family and other EMT-Basics deal with reactions to stress. The EMT-Basic will use proper communication techniques when dealing with the grieving process. STUDENT ACTIVITIES Auditory (Hear) The student will hear the instructor demonstrate methods of communicating with patients and family members of terminally ill patients. The student will hear the instructor demonstrate methods of communicating with friends and family members of a dead or dying patient. Visual (See) The student will see various audio-visual aids or materials of scenes requiring personal protection. The student will see various audio-visual aids or materials of personal protection clothing worn by hazardous material/rescue teams. The student will see the gown, gloves, mask and eye protection associated with body substance isolation (BSI). Kinesthetic (Do) The student will practice role play, talking to patients in various stressful/traumatic situations. The student will practice putting on and removing gowns, gloves and eye protection gear.

5.

1. 2.

1. 2. 3.

1. 2.

INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms).

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-53

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-2: Well-Being of the EMT-Basic ------------------------------------EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Practical:

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide. ENRICHMENT

What is unique in the local area concerning this topic? Complete enrichment sheets from instructor's course guide and attach with lesson plan.

1-54

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues -------------------------------------

MODULE 1 Preparatory Lesson 1-3 Medical/Legal and Ethical Issues

1-56

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-3.1 Define the EMT-Basic scope of practice. (C-1) 1-3.2 Discuss the importance of Do Not Resuscitate [DNR] (advance directives) and local or state provisions regarding EMS application.(C-1) 1-3.3 Define consent and discuss the methods of obtaining consent.(C-1) 1-3.4 Differentiate between expressed and implied consent. (C-3) 1-3.5 Explain the role of consent of minors in providing care.(C-1) 1-3.6 Discuss the implications for the EMT-Basic in patient refusal of transport.(C-1) 1-3.7 Discuss the issues of abandonment, negligence, and battery and their implications to the EMT-Basic.(C-1) 1-3.8 State the conditions necessary for the EMT-Basic to have a duty to act.(C-1) 1-3.9 Explain the importance, necessity and legality of patient confidentiality.(C1) 1-3.10 Discuss the considerations of the EMT-Basic in issues of organ retrieval.(C-1) 1-3.11 Differentiate the actions that an EMT-Basic should take to assist in the preservation of a crime scene. (C-3) 1-3.12 State the conditions that require an EMT-Basic to notify local law enforcement officials.(C-1)

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-57

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-3.13 Explain the role of EMS and the EMT-Basic regarding patients with DNR orders. (A-3) 1-3.14 Explain the rationale for the needs, benefits and usage of advance directives.(A3) 1-3.15 Explain the rationale for the concept of varying degrees of DNR.(A-3) PSYCHOMOTOR OBJECTIVES No psychomotor objectives identified. PREPARATION

Motivation:

Medical/legal and ethical issues are a vital element of the EMT-Basic's daily life. Should an EMT-Basic stop and treat an automobile crash victim when off duty? Should patient information be released to the attorney on the telephone? Can a child with a broken arm be treated even though his parents are not at home and/or only his child care provider is around? These and many other medical/legal/ethical questions face the EMT-Basic every day. Guidance will be given in this lesson to answer these questions and learn how to make the correct decision when other medical/legal and ethical questions arise. BLS MATERIALS Utilize various audio-visual materials relating to medical/ legal and ethical issues. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

Prerequisites:

AV Equipment:

1-58

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues -------------------------------------

EMS Equipment:

None.

Primary Instructor:

PERSONNEL One EMT-Basic instructor knowledgeable in the medical/legal aspects and ethical issues that the EMT-Basic will encounter.

Assistant Instructor: None required. Recommended Minimum Time to Complete: One and a half hours PRESENTATION

Declarative (What) I. Scope of Practice A. Legal duties to the patient, medical director, and public 1. Provide for the well-being of the patient by rendering necessary interventions outlined in the scope of practice. 2. Defined by state legislation a. Enhanced by medical direction through the use of protocols and standing orders b. Referenced to the National Standard Curricula 3. Legal right to function as an EMT-Basic may be contingent upon medical direction. a. Telephone/radio communications b. Approved standing orders/protocols c. Responsibility to medical direction B. Ethical responsibilities 1. Make the physical/emotional needs of the patient a priority. 2. Practice/maintenance of skills to the point of mastery. 3. Attend continuing education/refresher programs.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-59

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------Critically review performances, seeking ways to improve response time, patient outcome, communication. 5. Honesty in reporting Advance Directives A. Do Not Resuscitate (DNR) orders 1. Patient has the right to refuse resuscitative efforts. 2. In general, requires written order from physician. 3. Review state and local legislation/protocols relative to DNR orders and advance directives. 4. When in doubt or when written orders are not present, the EMTBasic should begin resuscitation efforts. Consent A. Expressed 1. Patient must be of legal age and able to make a rational decision. 2. Patient must be informed of the steps of the procedures and all related risks. 3. Must be obtained from every conscious, mentally competent adult before rendering treatment. B. Implied 1. Consent assumed from the unconscious patient requiring emergency intervention 2. Based on the assumption that the unconscious patient would consent to life saving interventions C. Children and mentally incompetent adults 1. Consent for treatment must be obtained from the parent or legal guardian. a. Emancipation issues b. State regulations regarding age of minors 2. When life threatening situations exist and the parent or legal guardian is not available for consent, emergency treatment should be rendered based on implied consent. Assault/Battery A. Unlawfully touching a patient without his consent B. Providing emergency care when the patient does not consent to the treatment Refusals A. The patient has the right to refuse treatment. B. The patient may withdraw from treatment at any time. Example: an unconscious patient regains consciousness and refuses transport to the hospital. 4.

II.

III.

IV.

V.

1-60

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------C. D. Refusals must be made by mentally competent adults following the rules of expressed consent. The patient must be informed of and fully understand all the risks and consequences associated with refusal of treatment/transport, and must sign a "release from liability" form. When in doubt, err in favor of providing care. Documentation is a key factor to protect EMT-Basic in refusal. 1. Competent adult patients have the right to refuse treatment.

E. F.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-61

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------Before the EMT-Basic leaves the scene, he should: a. Try again to persuade the patient to go to a hospital. b. Ensure the patient is able to make a rational, informed decision, e.g., not under the influence of alcohol or other drugs, or illness/injury effects. c. Inform the patient why he should go and what may happen to him if he does not. d. Consult medical direction as directed by local protocol. e. Consider assistance of law enforcement. f. Document any assessment findings and emergency medical care given, and if the patient still refuses, then have the patient sign a refusal form. g. The EMT-Basic should never make an independent decision not to transport. Abandonment - termination of care of the patient without assuring the continuation of care at the same level or higher. Negligence - deviation from the accepted standard of care resulting in further injury to the patient. Components: A. Duty to act B. Breach of the duty C. Injury/damages were inflicted 1. Physical 2. Psychological D. The actions of the EMT-Basic caused the injury/damage. Duty to Act A. A contractual or legal obligation must exist. 1. Implied a. Patient calls for an ambulance and the dispatcher confirms that an ambulance will be sent. b. Treatment is begun on a patient. 2. Formal - ambulance service has a written contract with a municipality. Specific clauses within the contract should indicate when service can be refused to a patient. B. Legal duty to act may not exist. May be moral/ethical considerations. 1. In some states, while off duty, if the EMT-Basic comes upon an accident while driving. 2. When driving the ambulance not in the company's service area and EMT-Basic observes an accident. a. Moral/ethical duty to act b. Risk management c. Documentation -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum 2.

VI. VII.

VIII.

1-62

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------3. Specific state regulations regarding duty to act. Confidentiality A. Confidential information 1. Patient history gained through interview 2. Assessment findings 3. Treatment rendered B. Releasing confidential information 1. Requires a written release form signed by the patient. Do not release on request, written or verbal, unless legal guardianship has been established. 2. When a release is not required a. Other health care providers need to know information to continue care. b. State law requires reporting incidents such as rape, abuse or gun shot wounds. c. Third party payment billing forms d. Legal subpoena Special Situations A. Donor/organ harvesting consideration 1. Requires a signed legal permission document a. Separate donor card b. Intent to be a donor on the reverse of patient's driver's license 2. A potential organ donor should not be treated differently from any other patient requesting treatment. 3. EMT-Basic's role in organ harvesting a. Identify the patient as a potential donor. b. Establish communication with medical direction. c. Provide care to maintain viable organs. B. Medical identification insignia 1. Bracelet, necklace, card 2. Indicates a serious medical condition of the patient a. Allergies b. Diabetes c. Epilepsy d. Others Potential Crime Scene/Evidence Preservation A. Dispatch should notify police personnel. B. Responsibility of the EMT-Basic 1. Emergency care of the patient is the EMT-Basic's priority.

IX.

X.

XI.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-63

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------Do not disturb any item at the scene unless emergency care requires it. 3. Observe and document anything unusual at the scene. 4. If possible, do not cut through holes in clothing from gunshot wounds or stabbings. Special Reporting Situations A. Established by state legislation and may vary from state to state B. Commonly required reporting situations 1. Abuse a. Child b. Elderly c. Spouse 2. Crime a. Wounds obtained by violent crime b. Sexual assault C. Infectious disease exposure D. Patient restraint laws e.g. forcing someone to be transported against their will. E. Mentally incompetent, e.g., intoxication with injuries. APPLICATION 2.

XII.

Procedural (How) None identified for this lesson. Contextual (When, Where, Why) Medical/legal and ethical issues are present in every aspect of patient care. The decision to treat or not treat a patient, to release or not release information, to report or not report an incident all require a knowledge of current state and local legislation, policy and protocol. Up-to-date knowledge of the current legal interpretation of issues such a negligence, battery, confidentiality, consent and refusal of treatment is essential for the EMT-Basic.

1-64

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------STUDENT ACTIVITIES Auditory (Hear) Students should hear actual case law and common law decisions relative to EMT-Basic care. Visual (See) Students should see actual copies of medical identification insignia, organ donor cards, Do Not Resuscitate orders, and information release forms. Students should see audio-visual aids or materials of definitions of medical/legal terms such as negligence, abandonment, battery, duty to act, consent, confidentiality. Kinesthetic (Do) Students should practice making decisions while role playing the various medical/legal and ethical situations that occur in the EMS environment (including consent, abandonment, battery, duty to act, negligence, and confidentiality). Students should practice role play situations in which DNR orders are in effect. Students should practice role play situations in which organ donor cards are in effect. Students should practice role playing situations of patients refusing transport.

1.

1. 2.

1.

2. 3. 4.

INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms). EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance

Practical:

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-65

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-3: Medical/Legal and Ethical Issues ------------------------------------with the cognitive and affective objectives and their mastery of the REMEDIATION

psychomotor objectives of this lesson. Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide.

ENRICHMENT

What is unique in the local area concerning this topic? Complete enrichment sheets from instructor's course guide and attach with lesson plan.

1-66

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 1 Preparatory Lesson 1-4 The Human Body

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-4.1 Identify the following topographic terms: Medial, lateral, proximal, distal, superior, inferior, anterior, posterior, midline, right and left, mid-clavicular, bilateral, mid-axillary. (C-1) 1-4.2 Describe the anatomy and function of the following major body systems: Respiratory, circulatory, musculoskeletal, nervous and endocrine. (C-1) AFFECTIVE OBJECTIVES No affective objectives identified. PSYCHOMOTOR OBJECTIVES No psychomotor objectives identified. PREPARATION

1-68

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------Motivation: To perform an adequate patient assessment, the EMT-Basic must be familiar with the normal anatomy of the human body and topographical terminology. This information will provide a solid cornerstone which will enable the EMT-Basic to build the essentials of quality patient assessment and management. BLS MATERIALS Utilize various audio-visual materials relating to the human body. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. Anatomy models PERSONNEL One EMT-Basic instructor knowledgeable in human body systems and topographical terminology.

Prerequisites: AV Equipment:

EMS Equipment:

Primary Instructor:

Assistant Instructor: None required. Recommended Minimum Time to Complete: Two and a half hours PRESENTATION

Declarative (What) XIII. Anatomical Terms A. Normal anatomical position 1. Person standing, facing forward 2. Palms facing forward

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-69

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------B. Anatomical terms - planes 1. Midline a. Imaginary line drawn vertically through the middle of the body: Nose --> umbilicus (belly button) b. Divides the body into right and left. 2. Mid-axillary a. Imaginary line drawn vertically from the middle of the armpit to the ankle. b. Divides the body into anterior and posterior. C. Descriptive anatomical terms 1. Torso 2. Medial 3. Lateral 4. Proximal 5. Distal 6. Superior 7. Inferior 8. Anterior 9. Posterior 10. Right and left 11. Mid-clavicular 12. Bilaterally 13. Dorsal 14. Ventral 15. Plantar 16. Palmar 17. Prone 18. Supine 19. Fowlers 20. Trendelenburg 21. Shock position The Skeletal System A. Function 1. Gives the body shape 2. Protects vital internal organs 3. Provides for body movement B. Components 1. Skull - houses and protects the brain 2. Face a. Orbit b. Nasal bone -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

XIV.

1-70

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------c. Maxilla d. Mandible (jaw) e. Zygomatic bones (cheeks) Spinal Column a. Cervical (neck) - 7 b. Thoracic (upper back) - 12 c. Lumbar (lower back) - 5 d. Sacral (back wall of the pelvis) - 5 e. Coccyx (tailbone) - 4 Thorax a. Ribs (1) 12 pair (2) Attached posterior to the thoracic vertebrae. (3) Pairs 1-10 are attached anterior to the sternum. (4) Pairs 11 and 12 are floating. b. Sternum (Breastbone) (1) Manubrium (superior portion of sternum) (2) Body (middle) (3) Xiphoid process (inferior portion of sternum) Pelvis a. Iliac crest (wings of pelvis) b. Pubis (anterior portion of pelvis) c. Ischium (inferior portion of pelvis) Lower extremities a. Greater trochanter (ball) and acetabulum (socket of hip bone) [Make up the hip joint] b. Femur (thigh) c. Patella (kneecap) d. Tibia (shin - lower leg) e. Fibula (lower leg) f. Medial and lateral malleolus - are the surface landmarks of the ankle joint. g. Tarsals and metatarsals (foot) h. Calcaneus (heel) i. Phalanges (toes) Upper extremities a. Clavicle (collar bone) b. Scapula (shoulder blade) c. Acromion (tip of shoulder) d. Humerus (superior portion of upper extremity) e. Olecranon (elbow) 1-71

3.

4.

5.

6.

7.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------f. g. h. i. j. C. Radius (lateral bone of forearm) Ulna (medial bone of forearm) Carpals (wrist) Metacarpals (hand) Phalanges (fingers)

XV.

Joints 1. Where bones connect to other bones 2. Types a. Ball and socket b. Hinged Body Systems A. Respiratory 1. Nose and mouth 2. Pharynx a. Oropharynx b. Nasopharynx 3. Epiglottis - a leaf-shaped structure that prevents food and liquid from entering the trachea during swallowing. 4. Trachea (windpipe) 5. Cricoid cartilage - firm cartilage ring forming the lower portion of the larynx. 6. Larynx (voice box) 7. Bronchi - two major branches of the trachea to the lungs. Bronchus subdivides into smaller air passages ending at the alveoli. 8. Lungs 9. Diaphragm a. Inhalation (active) (1) Diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity. (a) Diaphragm moves slightly downward, flares lower portion of rib cage. (b) Ribs move upward/outward. (2) Air flows into the lungs. b. Exhalation (1) Diaphragm and intercostal muscles relax decreasing the size of the thoracic cavity. (a) Diaphragm moves upward. (b) Ribs move downward/inward. (2) Air flows out of the lungs. 10. Respiratory physiology a. Alveolar/capillary exchange -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-72

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------(1) Oxygen-rich air enters the alveoli during each inspiration. (2) Oxygen-poor blood in the capillaries passes into the alveoli. (3) Oxygen enters the capillaries as carbon dioxide enters the alveoli. Capillary/cellular exchange (1) Cells give up carbon dioxide to the capillaries. (2) Capillaries give up oxygen to the cells. Adequate breathing (1) Normal rate (a) Adult - 12-20/minute (b) Child - 15-30/minute (c) Infant - 25-50/minute (2) Rhythm (a) Regular (b) Irregular (3) Quality (a) Breath sounds - present and equal (b) Chest expansion - adequate and equal (c) Effort of breathing - use of accessory muscles - predominantly in infants and children (4) Depth (tidal volume) - adequate Inadequate breathing (1) Rate - outside of normal ranges. (2) Rhythm - irregular (3) Quality (a) Breath sounds - diminished or absent (b) Chest expansion - unequal or inadequate (c) Increased effort of breathing - use of accessory muscles - predominantly in infants and children (4) Depth (tidal volume) - inadequate/shallow (5) The skin may be pale or cyanotic (blue) and cool and clammy. (6) There may be retractions above the clavicles, between the ribs and below the rib cage, especially in children. (7) Nasal flaring may be present, especially in children. (8) In infants, there may be "seesaw" breathing where the abdomen and chest move in opposite directions. 1-73

b.

c.

d.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------Agonal respirations (occasional gasping breaths) may be seen just before death. 11. Infant and child anatomy considerations a. Mouth and nose - in general: All structures are smaller and more easily obstructed than in adults. b. Pharynx - infants' and children's tongues take up proportionally more space in the mouth than adults. c. Trachea (windpipe) (1) Infants and children have narrower tracheas that are obstructed more easily by swelling. (2) The trachea is softer and more flexible in infants and children. d. Cricoid cartilage - like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. e. Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the diaphragm for breathing. Circulatory (Cardiovascular) 1. Heart a. Structure/function (1) Atrium (a) Right - receives blood from the veins of the body and the heart, pumps oxygen-poor blood to the right ventricle. (b) Left - receives blood from the pulmonary veins (lungs), pumps oxygen-rich blood to left ventricle. (2) Ventricle (a) Right - pumps blood to the lungs. (b) Left - pumps blood to the body. (3) Valves prevent backflow of blood. b. Cardiac conductive system (1) Heart is more than a muscle. (2) Specialized contractile and conductive tissue in the heart (3) Electrical impulses 2. Arteries a. Function - carry blood away from the heart to the rest of the body. b. Major arteries (1) Coronary arteries - vessels that supply the heart with blood. -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum (9)

B.

1-74

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------Aorta (a) Major artery originating from the heart, lying in front of the spine in the thoracic and abdominal cavities. (b) Divides at the level of the navel into the iliac arteries. (3) Pulmonary (a) Artery originating at the right ventricle. (b) Carries oxygen-poor blood to the lungs. (4) Carotid (a) Major artery of the neck. (b) Supplies the head with blood. (c) Pulsations can be palpated on either side of the neck. (5) Femoral (a) The major artery of the thigh. (b) Supplies the lower extremities with blood. (c) Pulsations can be palpated in the groin area (the crease between the abdomen and thigh). (6) Radial (a) Major artery of the lower arm. (b) Pulsations can be palpated at the wrist thumbside. (7) Brachial (a) An artery of the upper arm. (b) Pulsations can be palpated on the inside of the arm between the elbow and the shoulder. (c) Used when determining a blood pressure (BP) using a BP cuff (sphygmomanometer) and a stethoscope. (8) Posterior tibial - pulsations can be palpated on the posterior surface of the medial malleolus. (9) Dorsalis pedis (a) An artery in the foot (b) Pulsations can be palpated on the anterior surface of the foot. Arteriole - the smallest branch of an artery leading to the capillaries. Capillaries a. Tiny blood vessels that connect arterioles to venules b. Found in all parts of the body 1-75 (2)

3. 4.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------c. 5. 6. Allow for the exchange of nutrients and waste at the cellular level Venule - the smallest branch of a vein leading to the capillaries. Veins a. Function - vessels that carry blood back to the heart.

1-76

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------b. Major veins (1) Pulmonary vein - carries oxygen-rich blood from the lungs to the left atrium. (2) Venae cavae (a) Superior (b) Inferior (c) Carries oxygen-poor blood back to the right atrium. Blood composition a. Red blood cells (1) Give the blood its color. (2) Carry oxygen to organs. (3) Carry carbon dioxide away from organs. b. White blood cells - part of the body's defense against infections. c. Plasma - fluid that carries the blood cells and nutrients. d. Platelets - essential for the formation of blood clots. Physiology a. Pulse (1) Left ventricle contracts sending a wave of blood through the arteries. (2) Can be palpated anywhere an artery simultaneously passes near the skin surface and over a bone. (3) Peripheral (a) Radial (b) Brachial (c) Posterior tibial (d) Dorsalis pedis (4) Central (a) Carotid (b) Femoral b. Blood Pressure (1) Systolic - the pressure exerted against the walls of the artery when the left ventricle contracts. (2) Diastolic - the pressure exerted against the walls of the artery when the left ventricle is at rest.

7.

8.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-77

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------Inadequate circulation - Shock (hypoperfusion): A state of profound depression of the vital processes of the body, characterized by signs and symptoms such as: Pale, cyanotic (blue-gray color), cool, clammy skin, rapid, weak pulse, rapid and shallow breathing, restlessness, anxiety or mental dullness, nausea and vomiting, reduction in total blood volume, low or decreasing blood pressure and subnormal temperature. 10. Perfusion a. Definition - circulation of blood through an organ or a structure. b. Perfusion is the delivery of oxygen and other nutrients to the cells of all organ systems and the removal of waste products. c. Hypoperfusion is the inadequate circulation of blood through an organ or a structure. Musculoskeletal 1. The muscular system function a. Gives the body shape. b. Protects internal organs. c. Provides for movement. 2. Types a. Voluntary (skeletal) (1) Attached to the bones. (2) Form the major muscle mass of the body. (3) Under control of the nervous system and brain. Can be contracted and relaxed by the will of the individual. (4) Responsible for movement. b. Involuntary (smooth) (1) Found in the walls of the tubular structures of the gastrointestinal tract and urinary system, as well as the blood vessels and bronchi. (2) Control the flow through these structures. (3) Carry out the automatic muscular functions of the body. (4) Individuals have no direct control over these muscles. (5) Respond to stimuli such as stretching, heat, and cold. 9.

C.

1-78

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------Cardiac (1) Found only in the heart. (2) Involuntary muscle - has its own supply of blood through the coronary artery system. (3) Can tolerate interruption of blood supply for only very short periods. (4) Automaticity - the ability of the muscle to contract on its own. Nervous system 1. Function - controls the voluntary and involuntary activity of the body. 2. Components a. Central nervous system (1) Brain - located within the cranium. (2) Spinal cord - located within the spinal column from the brain through the lumbar vertebrae. b. Peripheral nervous system (1) Sensory - carry information from the body to the brain and spinal cord. (2) Motor - carry information from the brain and spinal cord to the body. Skin 1. Function a. Protects the body from the environment, bacteria and other organisms. b. Helps regulate the temperature of the body. c. Senses heat, cold, touch, pressure and pain; transmits this information to the brain and spinal cord. 2. Layers a. Epidermis - outermost layer of skin. b. Dermis - deeper layer of skin containing sweat and sebaceous glands, hair follicles, blood vessels and nerve endings. c. Subcutaneous layer Endocrine system function - secretes chemicals, such as insulin and adrenalin, responsible for regulating body activities and functions. c.

D.

E.

F.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-79

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body ------------------------------------APPLICATION

Procedural (How) None identified for this lesson. Contextual (When, Where, Why) It is of utmost importance that the EMT-Basic have a very basic level of knowledge concerning the human body. To accurately communicate (both verbally and through written reports) to other health professionals, the EMT-Basic must be able to identify topographic anatomy. The EMT-Basic must also understand the basic components of the body systems. Knowledge obtained in this lesson will be extremely beneficial in other modules throughout this curriculum. STUDENT ACTIVITY Auditory (Hear) None identified for this lesson. Visual (See) The students should see models of the human body. The students should see diagrams of the human body. The students should see a skeleton of the human body. Kinesthetic (Do) The students should practice identifying various structures of the human body. The students should practice demonstrating their ability to identify topographic anatomy. INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms). EVALUATION

1. 2. 3.

1. 2.

1-80

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-4: The Human Body -------------------------------------

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Practical:

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide. ENRICHMENT

What is unique in the local area concerning this topic? Complete enrichment sheets from instructor's course guide and attach with lesson plan.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-81

MODULE 1 Preparatory Lesson 1-5 Baseline Vital Signs and SAMPLE History

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-5.1 Identify the components of vital signs.(C-1) 1-5.2 Describe the methods to obtain a breathing rate.(C-1) 1-5.3 Identify the attributes that should be obtained when assessing breathing.(C-1) 1-5.4 Differentiate between shallow, labored and noisy breathing.(C-3) 1-5.5 Describe the methods to obtain a pulse rate.(C-1) 1-5.6 Identify the information obtained when assessing a patient's pulse.(C-1) 1-5.7 Differentiate between a strong, weak, regular and irregular pulse.(C-3) 1-5.8 Describe the methods to assess the skin color, temperature, condition (capillary refill in infants and children).(C-1) 1-5.9 Identify the normal and abnormal skin colors.(C-1) 1-5.10 Differentiate between pale, blue, red and yellow skin color. (C-3) 1-5.11 Identify the normal and abnormal skin temperature.(C-1) 1-5.12 Differentiate between hot, cool and cold skin temperature. (C-3) 1-5.13 Identify normal and abnormal skin conditions.(C-1) 1-5.14 Identify normal and abnormal capillary refill in infants and children.(C-1) 1-5.15 Describe the methods to assess the pupils.(C-1) 1-5.16 Identify normal and abnormal pupil size.(C-1) 1-5.17 Differentiate between dilated (big) and constricted (small) pupil size. (C-3) 1-5.18 Differentiate between reactive and non-reactive pupils and equal and unequal pupils. (C-3) 1-5.19 Describe the methods to assess blood pressure.(C-1) -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum 1-83

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------1-5.20 Define systolic pressure.(C-1) 1-5.21 Define diastolic pressure.(C-1) 1-5.22 Explain the difference between auscultation and palpation for obtaining a blood pressure.(C-1) 1-5.23 Identify the components of the SAMPLE history.(C-1) 1-5.24 Differentiate between a sign and a symptom. (C-3) 1-5.25 State the importance of accurately reporting and recording the baseline vital signs.(C-1) 1-5.26 Discuss the need to search for additional medical identification.(C-1) AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-5.27 Explain the value of performing the baseline vital signs.(A-2) 1-5.28 Recognize and respond to the feelings patients experience during assessment.(A-1) 1-5.29 Defend the need for obtaining and recording an accurate set of vital signs.(A-3) 1-5.30 Explain the rationale of recording additional sets of vital signs.(A-1) 1-5.31 Explain the importance of obtaining a SAMPLE history.(A-1) PSYCHOMOTOR OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-5.32 Demonstrate the skills involved in assessment of breathing.(P-1,2) 1-5.33 Demonstrate the skills associated with obtaining a pulse. (P-1,2) 1-5.34 Demonstrate the skills associated with assessing the skin color, temperature, condition, and capillary refill in infants and children.(P-1,2) 1-5.35 Demonstrate the skills associated with assessing the pupils. (P-1,2) 1-5.36 Demonstrate the skills associated with obtaining blood pressure.(P-1,2) 1-5.37 Demonstrate the skills that should be used to obtain information from the patient, family, or bystanders at the scene. (P-1,2)

1-84

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------PREPARATION

Motivation:

An EMT-Basic must be able to accurately assess and record a patient's vital signs. This must be done to record trends in the patient's condition. In addition to vital signs, obtain a SAMPLE history in the event that the patient loses consciousness. BLS MATERIALS Utilize various audio-visual materials relating to vital signs and SAMPLE history. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. Exam gloves, stethoscope (dual and single head)(1:6), blood pressure cuffs (adult, infant and child)(1:6), penlights (1:6). PERSONNEL One EMT-Basic instructor knowledgeable in patient assessment.

Prerequisite Skills:

AV Equipment:

EMS Equipment:

Primary Instructor:

Assistant Instructor: The instructor-to-student ratio should be 1:6 for psychomotor skill practice. Individuals used as assistant instructors should be knowledgeable in assessing baseline vital signs and SAMPLE histories. Recommended Minimum Time to Complete: Two hours

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-85

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------PRESENTATION

Declarative (What) I. General Information A. Chief complaint - why EMS was notified B. Age - years, months, days C. Sex - male or female D. Race Baseline Vital Signs A. Breathing - assessed by observing the patient's chest rise and fall. 1. Rate is determined by counting the number of breaths in a 30-second period and multiplying by 2. Care should be taken not to inform the patient, to avoid influencing the rate. 2. Quality of breathing can be determined while assessing the rate. Quality can be placed in 1 of 4 categories: a. Normal - average chest wall motion, not using accessory muscles. b. Shallow - slight chest or abdominal wall motion. c. Labored (1) An increase in the effort of breathing (2) Grunting and stridor (3) Often characterized by the use of accessory muscles (4) Nasal flaring, supraclavicular and intercostal retractions in infants and children (5) Sometimes gasping d. Noisy - an increase in the audible sound of breathing. May include snoring, wheezing, gurgling, crowing. B. Pulse 1. Initially a radial pulse should be assessed in all patients one year or older. In patients less than one year of age a brachial pulse should be assessed. 2. If the pulse is present, assess rate and quality. a. Rate is the number of beats felt in 30 seconds multiplied by 2. b. Quality of the pulse can be characterized as: (1) Strong (2) Weak (3) Regular (4) Irregular -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

II.

1-86

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------3. If peripheral pulse is not palpable, assess carotid pulse. a. Use caution. Avoid excess pressure on geriatrics. b. Never attempt to assess carotid pulse on both sides at one time. Assess skin to determine perfusion. 1. The patient's color should be assessed in the nail beds, oral mucosa, and conjunctiva. a. In infants and children, palms of hands and soles of feet should be assessed. b. Normal skin - pink c. Abnormal skin colors (1) Pale - indicating poor perfusion (impaired blood flow) (2) Cyanotic (blue-gray) - indicating inadequate oxygenation or poor perfusion (3) Flushed (red) - indicating exposure to heat or carbon monoxide poisoning. (4) Jaundice (yellow) - indicating liver abnormalities 2. The patient's temperature should be assessed by placing the back of your hand on the patient's skin. a. Normal - warm b. Abnormal skin temperatures (1) Hot - indicating fever or an exposure to heat. (2) Cool - indicating poor perfusion or exposure to cold. (3) Cold - indicates extreme exposure to cold. 3. Assess the condition of the patient's skin. a. Normal - dry b. Abnormal - skin is wet, moist, or dry. 4. Assess capillary refill in infants and children less than six years of age. a. Capillary refill in infants and children is assessed by pressing on the patient's skin or nail beds and determining time for return to initial color. b. Normal capillary refill in infants and children is < 2 seconds. c. Abnormal capillary refill in infants and children is > 2 seconds.

C.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-87

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------D. Pupils are assessed by briefly shining a light into the patient's eyes, and determining size and reactivity. 1. Dilated (very big), normal, or constricted (small). 2. Equal or unequal 3. Reactivity is whether or not the pupils change in response to the light. a. Reactive - change when exposed to light b. Non-reactive - do not change when exposed to light c. Equally or unequally reactive Blood pressure 1. Assess systolic and diastolic pressures. a. Systolic blood pressure is the first distinct sound of blood flowing through the artery as the pressure in the blood pressure cuff is released. This is a measurement of the pressure exerted against the walls of the arteries during contraction of the heart. b. Diastolic blood pressure is the point during deflation of the blood pressure cuff at which sounds of the pulse beat disappear. It represents the pressure exerted against the walls of the arteries while the left ventricle is at rest. c. There are two methods of obtaining blood pressure. (1) Auscultation: In this case the EMT-Basic will listen for the systolic and diastolic sounds. (2) Palpation: In certain situations, the systolic blood pressure may be measured by feeling for return of pulse with deflation of the cuff. 2. Blood pressure should be measured in all patients older than 3 years of age. 3. The general assessment of the infant or child patient, such as sick appearing, in respiratory distress, or unresponsive, is more valuable than vital sign numbers. Vital sign reassessment 1. Vital signs should be assessed and recorded every 15 minutes at a minimum in a stable patient. 2. Vital signs should be assessed and recorded every 5 minutes in the unstable patient. 3. Vital signs should be assessed following all medical interventions.

E.

F.

1-88

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------III. Obtain an SAMPLE history. A. Signs/Symptoms 1. Sign - any medical or trauma condition displayed by the patient and identifiable by the EMT-Basic, e.g., Hearing = respiratory distress, Seeing = bleeding, Feeling = skin temperature. 2. Symptom - any condition described by the patient, e.g., shortness of breath. B. Allergies 1. Medications 2. Food 3. Environmental allergies 4. Consider medical identification tag C. Medications 1. Prescription a. Current b. Recent c. Birth control pills 2. Non-prescription a. Current b. Recent 3. Consider medical identification tag D. Pertinent Past History 1. Medical 2. Surgical 3. Trauma 4. Consider medical identification tag E. Last oral intake: Solid or liquid 1. Time 2. Quantity F. Events leading to the injury or illness 1. Chest pain with exertion 2. Chest pain while at rest

APPLICATION

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-89

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History -------------------------------------

1. 2. 3. 4. 5. 6.

7.

Procedural (How) Demonstrate the skill of assessing breathing. Demonstrate the skill of determining a pulse. Demonstrate the skill of determining skin color, temperature, condition. Demonstrate the skill of determining capillary refill in infants and children. Demonstrate the skill of assessing pupils for size, reactivity and equality. Demonstrate the skill of assessing blood pressure a. Auscultation b. Palpation Discussion on questioning techniques to obtain history.

Contextual (When, Where, Why) Accurate measurement and recording of vital signs over a period of time may indicate a trend in the patient's condition and be valuable in the continuum of care. There are a number of interventions that the EMT-Basic can perform; however, these skills cannot be performed without an accurate set of baseline vital signs. The SAMPLE history is important to guide the pace of the EMT-Basic and assist in the continuum of care at the receiving facility. STUDENT ACTIVITIES Auditory (Hear) Students should hear normal and abnormal breathing. Student should hear with a stethoscope and assess systolic and diastolic pressures. Student should hear 5 components of the SAMPLE history. Visual (See) Students should see a simulated or actual patient's chest rise and fall and assess rate and quality of breathing. Students should see appropriate areas of the body to assess the color and condition (and in infants and children < 6 years of age, the capillary refill). Students should see pupils to assess size, reactivity and equality. Kinesthetic (Do) Students should practice methods for assessing breathing. Students should practice methods for obtaining a pulse.

1. 2. 3.

1. 2. 3.

1. 2.

1-90

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------3. 4. 5. 6. Students should practice methods for determining skin color, temperature, condition, (and capillary refill in infants and children < 6 years of age). Students should practice methods for determining pupil size, reactivity and equality. Students should practice methods for determining blood pressure by auscultation and palpation. Students should practice methods for obtaining an SAMPLE history.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-91

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History ------------------------------------7. Students should practice completing a prehospital care report including vital signs and SAMPLE history. INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms). EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Practical:

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide. ENRICHMENT

1-92

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-5: Baseline Vital Signs and SAMPLE History -------------------------------------

What is unique in the local area concerning this topic? Complete enrichment sheets from instructor's course guide and attach with lesson plan.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-93

MODULE 1 Preparatory Lesson 1-6 Lifting and Moving Patients

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-6.1 Define body mechanics. (C-1) 1-6.2 Discuss the guidelines and safety precautions that need to be followed when lifting a patient.(C-1) 1-6.3 Describe the safe lifting of cots and stretchers.(C-1) 1-6.4 Describe the guidelines and safety precautions for carrying patients and/or equipment.(C-1) 1-6.5 Discuss one-handed carrying techniques.(C-1) 1-6.6 Describe correct and safe carrying procedures on stairs.(C-1) 1-6.7 State the guidelines for reaching and their application. (C-1) 1-6.8 Describe correct reaching for log rolls.(C-1) 1-6.9 State the guidelines for pushing and pulling.(C-1) 1-6.10 Discuss the general considerations of moving patients.(C-1) 1-6.11 State three situations that may require the use of an emergency move.(C-1) 1-6.12 Identify the following patient carrying devices: ! Wheeled ambulance stretcher ! Portable ambulance stretcher ! Stair chair ! Scoop stretcher ! Long spine board ! Basket stretcher ! Flexible stretcher (C-1)

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-95

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 1-6.13 Explain the rationale for properly lifting and moving patients.(A-3) PSYCHOMOTOR OBJECTIVES 1-6.14 Working with a partner, prepare each of the following devices for use, transfer a patient to the device, properly position the patient on the device, move the device to the ambulance and load the patient into the ambulance: ! Wheeled ambulance stretcher ! Portable ambulance stretcher ! Stair chair ! Scoop stretcher ! Long spine board ! Basket stretcher ! Flexible stretcher (P-1,2) 1-6.15 Working with a partner, the EMT-Basic will demonstrate techniques for the transfer of a patient from an ambulance stretcher to a hospital stretcher.(P-1,2) PREPARATION

Motivation:

Many EMT-Basics are injured every year because they attempt to lift patients improperly. BLS MATERIALS Utilize various audio-visual materials relating to lifting and moving techniques. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met.

Prerequisites:

AV Equipment:

1-96

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------EMS Equipment: Wheeled stretcher, stair chair, scoop stretcher, flexible stretcher, ambulance, long and short backboards, bed.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-97

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------PERSONNEL One EMT-Basic instructor knowledgeable in this area.

Primary Instructor:

Assistant Instructor: The instructor-to-student ratio should be 1:6 for psychomotor skills practice. Individuals used as assistant instructors should be knowledgeable about lifting and moving patients. Recommended Minimum Time to Complete: Three hours PRESENTATION

I.

Declarative (What) Body Mechanics A. Lifting techniques 1. Safety precautions a. Use legs, not back, to lift. b. Keep weight as close to body as possible. 2. Guidelines for lifting a. Consider weight of patient and need for additional help. b. Know physical ability and limitations. c. Lift without twisting. d. Have feet positioned properly. e. Communicate clearly and frequently with partner. 3. Safe lifting of cots and stretchers. When possible use a stair chair instead of a stretcher if medically appropriate. a. Know or find out the weight to be lifted. b. Use at least two people. c. Ensure enough help available. Use an even number of people to lift so that balance is maintained. (1) Know or find out the weight limitations of equipment being used. (2) Know what to do with patients who exceed weight limitations of equipment. -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-98

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------d. Using power-lift or squat lift position, keep back locked into normal curvature. The power-lift position is useful for individuals with weak knees or thighs. The feet are a comfortable distance apart. The back is tight and the abdominal muscles lock the back in a slight inward curve. Straddle the object. Keep feet flat. Distribute weight to balls of feet or just behind them. Stand by making sure the back is locked in and the upper body comes up before the hips. Use power grip to get maximum force from hands. The palm and fingers come into complete contact with the object and all fingers are bent at the same angles. The power-grip should always be used in lifting. This allows for maximum force to be developed. Hands should be at least 10 inches apart. Lift while keeping back in locked-in position. When lowering cot or stretcher, reverse steps. Avoid bending at the waist.

e.

B.

f. g. h. Carrying 1. Precautions for carrying - whenever possible, transport patients on devices that can be rolled. 2. Guidelines for carrying a. Know or find out the weight to be lifted. b. Know limitations of the crew's abilities. c. Work in a coordinated manner and communicate with partners. d. Keep the weight as close to the body as possible. e. Keep back in a locked-in position and refrain from twisting. f. Flex at the hips, not the waist; bend at the knees. g. Do not hyperextend the back (do not lean back from the waist). 3. Correct carrying procedure a. Use correct lifting techniques to lift the stretcher. b. Partners should have similar strength and height. 4. One-handed carrying technique a. Pick up and carry with the back in the locked-in position. b. Avoid leaning to either side to compensate for the imbalance.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-99

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------Correct carrying procedure on stairs a. When possible, use a stair chair instead of a stretcher. b. Keep back in locked-in position. c. Flex at the hips, not the waist; bend at the knees. d. Keep weight and arms as close to the body as possible. C. Reaching 1. Guidelines for reaching a. Keep back in locked-in position. b. When reaching overhead, avoid hyperextended position. c. Avoid twisting the back while reaching. 2. Application of reaching techniques a. Avoid reaching more than 15 - 20 inches in front of the body. b. Avoid situations where prolonged (more than a minute) strenuous effort is needed in order to avoid injury. 3. Correct reaching for log rolls a. Keep back straight while leaning over patient. b. Lean from the hips. c. Use shoulder muscles to help with roll. D. Pushing and pulling guidelines 1. Push, rather than pull, whenever possible. 2. Keep back locked-in. 3. Keep line of pull through center of body by bending knees. 4. Keep weight close to the body. 5. Push from the area between the waist and shoulder. 6. If weight is below waist level, use kneeling position. 7. Avoid pushing or pulling from an overhead position if possible. 8. Keep elbows bent with arms close to the sides. Principles of Moving Patients A. General considerations 1. In general, a patient should be moved immediately (emergency move) only when: a. There is an immediate danger to the patient if not moved. (1) Fire or danger of fire. (2) Explosives or other hazardous materials. (3) Inability to protect the patient from other hazards at the scene. (4) Inability to gain access to other patients in a vehicle who need life-saving care. 5.

II.

1-100

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------Life-saving care cannot be given because of the patient's location or position, e.g., a cardiac arrest patient sitting in a chair or lying on a bed. 2. A patient should be moved quickly (urgent move) when there is immediate threat to life. a. Altered mental status b. Inadequate breathing c. Shock (hypoperfusion) 3. If there is no threat to life, the patient should be moved when ready for transportation (non-urgent move). Emergency moves 1. The greatest danger in moving a patient quickly is the possibility of aggravating a spine injury. 2. In an emergency, every effort should be made to pull the patient in the direction of the long axis of the body to provide as much protection to the spine as possible. 3. It is impossible to remove a patient from a vehicle quickly and at the same time provide as much protection to the spine as can be accomplished with an interim immobilization device. 4. If the patient is on the floor or ground, he can be moved by: a. Pulling on the patient's clothing in the neck and shoulder area. b. Putting the patient on a blanket and dragging the blanket. c. Putting the EMT-Basic's hands under the patient's armpits (from the back), grasping the patient's forearms and dragging the patient. Urgent moves 1. Rapid extrication of patient sitting in vehicle a. One EMT-Basic gets behind patient and brings cervical spine into neutral in-line position and provides manual immobilization. b. A second EMT-Basic applies cervical immobilization device as the third EMT-Basic first places long backboard near the door and then moves to the passenger seat. c. The second EMT-Basic supports the thorax as the third EMT-Basic frees the patient's legs from the pedals. d. At the direction of the second EMT-Basic, he and the third EMT-Basic rotate the patient in several short, coordinated moves until the patient's back is in the open doorway and his feet are on the passenger seat. b.

B.

C.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-101

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------Since the first EMT-Basic usually cannot support the patient's head any longer, another available EMT-Basic or a bystander supports the patient's head as the first EMT-Basic gets out of the vehicle and takes support of the head outside of the vehicle. f. The end of the long backboard is placed on the seat next to the patient's buttocks. Assistants support the other end of the board as the first EMT-Basic and the second EMT-Basic lower the patient onto it. g. The second EMT-Basic and the third EMT-Basic slide the patient into the proper position on the board in short, coordinated moves. h. Several variations of the technique are possible, including assistance from bystanders. Must be accomplished without compromise to the spine. Non-urgent moves 1. Direct ground lift (no suspected spine injury) a. Two or three rescuers line up on one side of the patient. b. Rescuers kneel on one knee (preferably the same for all rescuers). c. The patient's arms are placed on his chest if possible. d. The rescuer at the head places one arm under the patient's neck and shoulder and cradles the patient's head. He places his other arm under the patient's lower back. e. The second rescuer places one arm under the patient's knees and one arm above the buttocks. f. If a third rescuer is available, he should place both arms under the waist and the other two rescuers slide their arms either up to the mid-back or down to the buttocks as appropriate. g. On signal, the rescuers lift the patient to their knees and roll the patient in toward their chests. h. On signal, the rescuers stand and move the patient to the stretcher. i. To lower the patient, the steps are reversed. 2. Extremity lift (no suspected extremity injuries) a. One rescuer kneels at the patient's head and one kneels at the patient's side by his knees. e.

D.

1-102

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------b. The rescuer at the head places one hand under each of the patient's shoulders while the rescuer at the foot grasps the patient's wrists. c. The rescuer at the head slips his hands under the patient's arms and grasps the patient's wrists. d. The rescuer at the patient's foot slips his hands under the patient's knees. e. Both rescuers move up to a crouching position. f. The rescuers stand up simultaneously and move with the patient to a stretcher. Transfer of supine patient from bed to stretcher a. Direct carry (1) Position cot perpendicular to bed with head end of cot at foot of bed. (2) Prepare cot by unbuckling straps and removing other items. (3) Both rescuers stand between bed and stretcher, facing patient. (4) First rescuer slides arm under patient's neck and cups patient's shoulder. (5) Second rescuer slides hand under hip and lifts slightly. (6) First rescuer slides other arm under patient's back. (7) Second rescuer places arms underneath hips and calves. (8) Rescuers slide patient to edge of bed. (9) Patient is lifted/curled toward the rescuers' chests. (10) Rescuers rotate and place patient gently onto cot. b. Draw sheet method (1) Loosen bottom sheet of bed. (2) Position cot next to bed. (3) Prepare cot: Adjust height, lower rails, unbuckle straps. (4) Reach across cot and grasp sheet firmly at patient's head, chest, hips and knees. (5) Slide patient gently onto cot.

3.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-103

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------III. Equipment A. Stretchers/cots 1. Types a. Wheeled stretcher (1) Most commonly used device (2) Rolling (a) Restricted to smooth terrain. (b) Foot end should be pulled. (c) One person must guide the stretcher at head. (3) Carrying (a) Two rescuers i) Preferable in narrow spaces, but requires more strength. ii) Easily unbalanced. iii) Rescuers should face each other from opposite ends of stretcher. (b) Four rescuers i) One rescuer at each corner. ii) More stability and requires less strength. iii) Safer over rough terrain. (4) Loading into ambulance (a) Use sufficient lifting power. (b) Load hanging stretchers before wheeled stretchers. (c) Follow manufacturer's directions. (d) Ensure all cots and patients secured before moving ambulance. b. Portable stretcher c. Stair chair d. Backboards (1) Long (a) Traditional wooden device (b) Manufactured varieties (2) Short (a) Traditional wooden device (b) Vest type device e. Scoop or orthopedic stretcher f. Flexible stretcher

1-104

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------2. B. Maintenance - follow manufacturer's directions for inspection, cleaning, repair and upkeep. Patient positioning 1. An unresponsive patient without suspected spine injury should be moved into the recovery position by rolling the patient onto his side (preferably the left) without twisting the body. 2. A patient with chest pain or discomfort or difficulty breathing should sit in a position of comfort as long as hypotension is not present. 3. A patient with suspected spine injury should be immobilized on a long backboard. 4. A patient in shock (hypoperfusion) should have his legs elevated 8 - 12 inches. 5. For the pregnant patient with hypotension, an early intervention is to position the patient on her left side. 6. A patient who is nauseated or vomiting should be transported in a position of comfort; however, the EMT-Basic should be positioned appropriately to manage the airway.

APPLICATION

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Procedural (how) Show examples of proper lifting. Show examples of proper carrying. Show examples of proper reaching. Show examples of situations where emergency moves are appropriate. Show examples of situations where urgent moves are appropriate. Show examples of situations where non-urgent moves are appropriate. Demonstrate emergency moves. Demonstrate urgent moves. Demonstrate non-urgent moves. Demonstrate transfer of patient to stretcher. Show examples of different types of carrying devices. Demonstrate knowledge of appropriate selection of each carrying device.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-105

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------12. 13. 14. 15. 16. Demonstrate carrying a patient on a stretcher. Demonstrate loading a patient on a stretcher into an ambulance. Demonstrate use of a stair chair. Demonstrate use of a scoop stretcher. Demonstrate positioning patients with different conditions. A. Unresponsiveness B. Chest pain/discomfort or difficulty breathing A. Suspected spine injury B. Shock (hypoperfusion) E. Patients who are vomiting or nauseous F. Pregnant patient

Contextual (When, Where, Why) When to transport a patient is determined by both the patient's condition and the environment in which he is found. The determination of how to transport the patient is made by considering his complaint, the severity of his condition and his location. STUDENT ACTIVITIES Auditory (Hear) None identified for this lesson. Visual (See) The student should see proper lifting techniques. The student should see proper carrying techniques. The student should see proper reaching techniques. The student should see situations where emergency moves are appropriate. The student should see situations where urgent moves are appropriate. The student should see situations where non-urgent moves are appropriate. The student should see emergency moves. The student should see urgent moves. The student should see non-urgent moves. The student should see a patient transferred to a stretcher. The student should see different types of carrying devices. The student should see a patient carried on a stretcher. The student should see a patient on a stretcher loaded into an ambulance. The student should see a stair chair used. The student should see a scoop stretcher used. The student should see patients with different conditions positioned properly. A. Unresponsiveness B. Chest pain/discomfort or difficulty breathing C. Suspected spine injury -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

1-106

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------D. E. F. Shock (hypoperfusion) Patients who are vomiting or nauseous Pregnant patient

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Kinesthetic (Do) The student should practice proper lifting techniques. The student should practice proper carrying techniques. The student should practice proper reaching techniques. The student should practice determining whether emergency, urgent or nonemergency moves are appropriate. The student should practice emergency moves. The student should practice urgent moves. The student should practice non-urgent moves. The student should practice transferring a patient to a stretcher. The student should practice carrying a patient on a stretcher. The student should practice loading a patient on a stretcher into an ambulance. The student should practice using a stair chair. The student should practice using a scoop stretcher. The student should practice positioning patients with different conditions. A. Unresponsiveness B. Chest pain/discomfort or difficulty breathing C. Suspected spine injury D. Shock (hypoperfusion) E. Patients who are vomiting or nauseous F. Pregnant patients INSTRUCTOR ACTIVITIES

Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms).

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-107

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-6: Lifting and Moving Patients ------------------------------------EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice, or other skill stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Practical:

G. Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide. ENRICHMENT

What is unique in the local area concerning this topic? Complete enrichment sheets from instructor's guide and attach with lesson plan.

1-108

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 1 Preparatory Lesson 1-7 Evaluation: Preparatory

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-7: Evaluation Preparatory Module ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate knowledge of the cognitive objectives of Lesson 1-1: Introduction to Emergency Care. ! Demonstrate knowledge of the cognitive objectives of Lesson 1-2: Well-Being of the EMT-Basic. ! Demonstrate knowledge of the cognitive objectives of Lesson 1-3: Medical/Legal and Ethical Issues. ! Demonstrate knowledge of the cognitive objectives of Lesson 1-4: The Human Body. ! Demonstrate knowledge of the cognitive objectives of Lesson 1-5: Baseline Vital Signs and SAMPLE History. ! Demonstrate knowledge of the cognitive objectives of Lesson 1-6: Lifting and Moving Patients. AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate knowledge of the affective objectives of Lesson 1-1: Introduction to Emergency Care. ! Demonstrate knowledge of the affective objectives of Lesson 1-2: Well-Being of the EMT-Basic. ! Demonstrate knowledge of the affective objectives of Lesson 1-3: Medical/Legal and Ethical Issues.

1-110

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-7: Evaluation: Preparatory Module ------------------------------------! Demonstrate knowledge of the affective objectives of Lesson 1-5: Baseline Vital Signs and SAMPLE History.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-111

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-7: Evaluation Preparatory Module ------------------------------------PSYCHOMOTOR OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate proficiency in the psychomotor objectives of Lesson 1-2: Well-Being of the EMT-Basic. ! Demonstrate proficiency in the psychomotor objectives of Lesson 1-5: Baseline Vital Signs and SAMPLE History. ! Demonstrate proficiency in the psychomotor objectives of Lesson 1-6: Lifting and Moving Patients.

PREPARATION

Motivation:

Evaluation of the student's attainment of the cognitive and affective knowledge and psychomotor skills is an essential component of the EMT-Basic educational process. The modules are presented in a "building block" format. Once the students have demonstrated their knowledge and proficiency, the next lesson should be built upon that knowledge. This evaluation will help to identify students or groups of students having difficulty with a particular area. This is an opportunity for the instructor to evaluate their performance, and make appropriate modifications to the delivery of material. Completion of Lesson 1-1 through 1-6. MATERIALS Typically none required. Equipment required to evaluate the students' proficiency in the psychomotor skills of this module. PERSONNEL One proctor for the written evaluation. -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

Prerequisites:

AV Equipment: EMS Equipment:

Primary Instructor:

1-112

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-7: Evaluation: Preparatory Module -------------------------------------

Assistant Instructor: One practical skills examiner for each 6 students. Recommended Minimum PRESENTATION

Time to Complete: I. II. III.

One hour Declarative (What) Purpose of the evaluation Items to be evaluated Feedback from evaluation APPLICATION

1.

Procedural (How) Written evaluation based on the cognitive and affective objectives of Lessons 11 ----> 1-6. Practical evaluation stations based on the psychomotor objectives of Lessons 11 ----> 1-6.

2.

Contextual (When, Where and Why) The evaluation is the final lesson in this module and is designed to bring closure to the module, and to assure that students are prepared to move to the next module.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

1-113

EMT-Basic: National Standard Curriculum Module 1: Preparatory Lesson 1-7: Evaluation Preparatory Module ------------------------------------This modular evaluation is given to determine the effectiveness of the presentation of materials and how well students have retained the material. This is an opportunity for the students to make necessary adjustments in study habits or for the instructor to adjust the manner in which material is presented. INSTRUCTOR ACTIVITIES Supervise student evaluation. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms).

REMEDIATION

Identify students and/or groups of students who are having difficulty with this subject content. Complete a remediation sheet from the instructor's course guide. If students continue to have difficulty demonstrating knowledge of the cognitive and affective objectives, or demonstrating proficiency in psychomotor skills, the students should be counseled, remediated and re-evaluated. If improvements in cognitive, affective or psychomotor skills are not achieved, consideration regarding the ability of the student to progress in the program should be taken into account.

1-114

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 2 Airway Lesson 2-1 Airway

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 2-1.1 Name and label the major structures of the respiratory system on a diagram. (C-1) 2-1.2 List the signs of adequate breathing.(C-1) 2-1.3 List the signs of inadequate breathing.(C-1) 2-1.4 Describe the steps in performing the head-tilt chin-lift.(C-1) 2-1.5 Relate mechanism of injury to opening the airway. (C-3) 2-1.6 Describe the steps in performing the jaw thrust.(C-1) 2-1.7 State the importance of having a suction unit ready for immediate use when providing emergency care.(C-1) 2-1.8 Describe the techniques of suctioning.(C-1) 2-1.9 Describe how to artificially ventilate a patient with a pocket mask.(C-1) 2-1.10 Describe the steps in performing the skill of artificially ventilating a patient with a bag-valve-mask while using the jaw thrust.(C-1) 2-1.11 List the parts of a bag-valve-mask system.(C-1) 2-1.12 Describe the steps in performing the skill of artificially ventilating a patient with a bag-valve-mask for one and two rescuers.(C-1) 2-1.13 Describe the signs of adequate artificial ventilation using the bag-valve-mask.(C1) 2-1.14 Describe the signs of inadequate artificial ventilation using the bag-valvemask.(C-1) 2-1.15 Describe the steps in artificially ventilating a patient with a flow restricted, oxygen-powered ventilation device.(C-1) -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------2-1.16 List the steps in performing the actions taken when providing mouth-to-mouth and mouth-to-stoma artificial ventilation.(C-1) 2-1.17 Describe how to measure and insert an oropharyngeal (oral) airway. (C-1) 2-1.18 Describe how to measure and insert a nasopharyngeal (nasal) airway. (C-1) 2-1.19 Define the components of an oxygen delivery system.(C-1) 2-1.20 Identify a nonrebreather face mask and state the oxygen flow requirements needed for its use.(C-1) 2-1.21 Describe the indications for using a nasal cannula versus a nonrebreather face mask. (C-1) 2-1.22 Identify a nasal cannula and state the flow requirements needed for its use.(C-1) AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 2-1.23 Explain the rationale for basic life support artificial ventilation and airway protective skills taking priority over most other basic life support skills.(A3) 2-1.24 Explain the rationale for providing adequate oxygenation through high inspired oxygen concentrations to patients who, in the past, may have received low concentrations.(A-3) PSYCHOMOTOR OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 2-1.25 Demonstrate the steps in performing the head-tilt chin-lift. (P-1,2) 2-1.26 Demonstrate the steps in performing the jaw thrust.(P-1,2) 2-1.27 Demonstrate the techniques of suctioning.(P-1,2) 2-1.28 Demonstrate the steps in providing mouth-to-mouth artificial ventilation with body substance isolation (barrier shields).(P-1,2) 2-1.29 Demonstrate how to use a pocket mask to artificially ventilate a patient.(P-1,2) 2-1.30 Demonstrate the assembly of a bag-valve-mask unit.(P-1,2) 2-1.31 Demonstrate the steps in performing the skill of artificially ventilating a patient with a bag-valve-mask for one and two rescuers.(P-1,2) 2-1.32 Demonstrate the steps in performing the skill of artificially ventilating a patient with a bag-valve-mask while using the jaw thrust.(P-1,2) 2-1.33 Demonstrate artificial ventilation of a patient with a flow restricted, oxygenpowered ventilation device.(P-1,2) 2-1.34 Demonstrate how to artificially ventilate a patient with a stoma.(P-1,2) 2-1.35 Demonstrate how to insert an oropharyngeal (oral) airway.(P-1,2) 2-1.36 Demonstrate how to insert a nasopharyngeal (nasal) airway.(P-1,2) 2-1.37 Demonstrate the correct operation of oxygen tanks and regulators.(P-1,2) 2-1.38 Demonstrate the use of a nonrebreather face mask and state the oxygen flow requirements needed for its use.(P-1,2) -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------2-1.39 Demonstrate the use of a nasal cannula and state the flow requirements needed for its use.(P-1,2) 2-1.40 Demonstrate how to artificially ventilate the infant and child patient.(P-1,2) 2-1.41 Demonstrate oxygen administration for the infant and child patient.(P-1,2)

PREPARATION

Motivation: Prerequisites:

A patient without an airway is a dead patient. BLS and Preparatory. MATERIALS Utilize various audio-visual materials relating to airway management. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. Pocket mask, bag-valve-mask, flow restricted, oxygenpowered ventilation device, oral airways, nasal airways, suction units, suction catheters, oxygen tank, regulator, nonrebreather mask, nasal cannula, tongue blade, and lubricant.

AV Equipment:

EMS Equipment:

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------PERSONNEL Primary Instructor: One EMT-Basic instructor knowledgeable in airway management. Assistant Instructor: The instructor-to-student ratio should be 1:6 for psychomotor skill practice. Individuals used as assistant instructors should be knowledgeable in airway techniques and management. Recommended Minimum Time to Complete: Four hours

PRESENTATION

Declarative (What) I. Anatomy review A. Respiratory 1. Nose and mouth 2. Pharynx a. Oropharynx b. Nasopharynx 3. Epiglottis - a leaf-shaped structure that prevents food and liquid from entering the trachea during swallowing. 4. Trachea (windpipe) 5. Cricoid cartilage - firm cartilage ring forming the lower portion of the larynx. 6. Larynx (voice box) 7. Bronchi - two major branches of the trachea to the lungs. Bronchus subdivides into smaller air passages ending at the alveoli. 8. Lungs 9. Diaphragm a. Inhalation (active) (1) Diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------Diaphragm moves slightly downward, flares lower portion of rib cage. (b) Ribs move upward/outward. (2) Air flows into the lungs. b. Exhalation (1) Diaphragm and intercostal muscles relax, decreasing the size of the thoracic cavity. (a) Diaphragm moves upward. (b) Ribs move downward/inward. (2) Air flows out of the lungs. Respiratory physiology a. Alveolar/capillary exchange (1) Oxygen-rich air enters the alveoli during each inspiration. (2) Oxygen-poor blood in the capillaries passes into the alveoli. (3) Oxygen enters the capillaries as carbon dioxide enters the alveoli. b. Capillary/cellular exchange (1) Cells give up carbon dioxide to the capillaries. (2) Capillaries give up oxygen to the cells. c. Adequate breathing (1) Normal Rate (a) Adult - 12-20/minute (b) Child - 15-30/minute (c) Infant - 25-50/minute (2) Rhythm (a) Regular (b) Irregular (3) Quality (a) Breath sounds - present and equal (b) Chest expansion - adequate and equal (c) Minimum effort of breathing - use of accessory muscles - predominantly in infants and children (4) Depth (tidal volume) - adequate d. Inadequate breathing (1) Rate - outside of normal ranges. (2) Rhythm - irregular (3) Quality (a) Breath sounds - diminished or absent -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum (a)

10.

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------(b) Chest expansion - unequal or inadequate

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------Increased effort of breathing - use of accessory muscles - predominantly in infants and children (4) Depth (tidal volume) - inadequate/shallow (5) The skin may be pale or cyanotic (blue) and cool and clammy. (6) There may be retractions above the clavicles, between the ribs and below the rib cage, especially in children. (7) Nasal flaring may be present, especially in children. (8) In infants, there may be "seesaw" breathing where the abdomen and chest move in opposite directions. (9) Agonal respirations (occasional gasping breaths) may be seen just before death. 11. Infant and child anatomy considerations a. Mouth and nose - in general: All structures are smaller and more easily obstructed than in adults. b. Pharynx - infants' and children's tongues take up proportionally more space in the mouth than adults. c. Trachea (windpipe) (1) Infants and children have narrower tracheas that are obstructed more easily by swelling. (2) The trachea is softer and more flexible in infants and children. d. Cricoid cartilage - like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. e. Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the diaphragm for breathing. B. Adequate and inadequate artificial ventilation 1. An EMT-Basic is artificially ventilating a patient adequately when: a. The chest rises and falls with each artificial ventilation. b. The rate is sufficient, approximately 12 per minute for adults and 20 times per minute for children and infants. c. Heart rate returns to normal with successful artificial ventilation. 2. Artificial ventilation is inadequate when: a. The chest does not rise and fall with artificial ventilation. b. The rate is too slow or too fast. c. Heart rate does not return to normal with artificial ventilation. Opening the Airway (c)

II.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------A. Head-tilt chin-lift when no neck injury suspected - review technique learned in BLS course. B. Jaw thrust when EMT-Basic suspects spinal injury - review technique learned in BLS course. C. Assess need for suctioning. Techniques of Suctioning A. Body substance isolation B. Purpose 1. Remove blood, other liquids and food particles from the airway. 2. Some suction units are inadequate for removing solid objects like teeth, foreign bodies and food. 3. A patient needs to be suctioned immediately when a gurgling sound is heard with artificial ventilation. C. Types of units 1. Suction devices a. Mounted b. Portable (1) Electrical (2) Hand operated 2. Suction catheters a. Hard or rigid ("tonsil sucker," "tonsil tip") (1) Used to suction the mouth and oropharynx of an unresponsive patient. (2) Should be inserted only as far as you can see. (3) Use rigid catheter for infants and children, but take caution not to touch back of airway. b. Soft (French) (1) Useful for suctioning the nasopharynx and in other situations where a rigid catheter cannot be used. (2) Should be measured so that it is inserted only as far as the base of the tongue. D. Techniques of use 1. Suction device should be inspected on a regular basis before it is needed. A properly functioning unit with a gauge should generate 300 mmHg vacuum. A battery operated unit should have a charged battery. 2. Turn on the suction unit.

III.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------Attach a catheter. a. Use rigid catheter when suctioning mouth of an infant or child. b. Often will need to suction nasal passages; should use a bulb suction or French catheter with low to medium suction. 4. Insert the catheter into the oral cavity without suction, if possible. Insert only to the base of the tongue. 5. Apply suction. Move the catheter tip side to side. 6. Suction for no more than 15 seconds at a time. a. In infants and children, shorter suction time should be used. b. If the patient has secretions or emesis that cannot be removed quickly and easily by suctioning, the patient should be log rolled and the oropharynx should be cleared. c. If patient produces frothy secretions as rapidly as suctioning can remove, suction for 15 seconds, artificially ventilate for two minutes, then suction for 15 seconds, and continue in that manner. Consult medical direction for this situation. 7. If necessary, rinse the catheter and tubing with water to prevent obstruction of the tubing from dried material. Techniques of Artificial Ventilation A. In order of preference, the methods for ventilating a patient by the EMTBasic are as follows: 1. Mouth-to-mask 2. Two-person bag-valve-mask 3. Flow restricted, oxygen-powered ventilation device 4. One-person bag-valve-mask B. Body substance isolation C. Mouth-to-mouth - review technique learned in BLS course. D. Mouth-to-mask 1. Review technique learned in BLS course. 2. The mask should be connected to high flow oxygen = 15 liters per minute. E. Bag-valve-mask 1. The bag-valve-mask consists of a self-inflating bag, one-way valve, face mask, oxygen reservoir. It needs to be connected to oxygen to perform most effectively. 3.

IV.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------2. Bag-valve-mask issues a. Volume of approximately 1,600 milliliters b. Provides less volume than mouth-to-mask c. Single EMT-Basic may have difficulty maintaining an airtight seal. d. Two EMT-Basics using the device will be more effective. e. Position self at top of patient's head for optimal performance. f. Adjunctive airways (oral or nasal) may be necessary in conjunction with bag-valve-mask. g. The bag-valve-mask should have: (1) A self-refilling bag that is easily cleaned and sterilized. (2) A non-jam valve that allows a maximum oxygen inlet flow of 15/lpm. (3) No pop-off valve, or the pop-off valve must be disabled. Failure to do so may result in inadequate artificial ventilations. (4) Standardized 15/22 mm fittings. (5) An oxygen inlet and reservoir to allow for high concentration of oxygen. (6) A true valve for nonrebreather. (7) Should perform in all environmental conditions and temperature extremes. (8) Available in infant, child and adult sizes. Use when no trauma is suspected. a. After opening airway, select correct mask size (adult, infant or child). b. Position thumbs over top half of mask, index and middle fingers over bottom half. c. Place apex of mask over bridge of nose, then lower mask over mouth and upper chin. If mask has large round cuff surrounding a ventilation port, center port over mouth. d. Use ring and little fingers to bring jaw up to mask. e. Connect bag to mask if not already done. f. Have assistant squeeze bag with two hands until chest rises. g. If alone, form a "C" around the ventilation port with thumb and index finger; use middle, ring and little fingers under jaw to maintain chin lift and complete the seal.

3.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------h. Repeat a minimum of every 5 seconds for adults and every 3 seconds for children and infants. i. If chest does not rise and fall, re-evaluate. (1) If chest does not rise, reposition head. (2) If air is escaping from under the mask, reposition fingers and mask. (3) Check for obstruction. (4) If chest still does not rise and fall, use alternative method of artificial ventilation, e.g., pocket mask, manually triggered device. j. If necessary, consider use of adjuncts. (1) Oral airway (2) Nasal airway Use with suspected trauma a. After opening airway, select correct mask size (adult, infant or child). b. Immobilize head and neck, e.g., have an assistant hold head manually or use your knees to prevent movement. c. Position thumbs over top half of mask, index and middle fingers over bottom half. d. Place apex of mask over bridge of nose, then lower mask over mouth and upper chin. If mask has large round cuff surrounding a ventilation port, center port over mouth. e. Use ring and little fingers to bring jaw up to mask without tilting head or neck. f. Connect bag to mask if not already done. g. Have assistant squeeze bag with two hands until chest rises. h. Repeat every 5 seconds for adults and every 3 seconds for children and infants, continuing to hold jaw up without moving head or neck. i. If chest does not rise, re-evaluate. (1) If abdomen rises, reposition jaw. (2) If air is escaping from under the mask,reposition fingers and mask. (3) Check for obstruction. (4) If chest still does not rise, use alternative method of artificial ventilation, e.g., pocket mask. j. If necessary, consider use of adjuncts. (1) Oral airway (2) Nasal airway -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

4.

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------F. Flow restricted, oxygen-powered ventilation devices 1. Flow restricted, oxygen-powered ventilation devices (for use in adults only) should provide a. A peak flow rate of 100% oxygen at up to 40 lpm. b. An inspiratory pressure relief valve that opens at approximately 60 centimeters water and vents any remaining volume to the atmosphere or ceases gas flow. c. An audible alarm that sounds whenever the relief valve pressure is exceeded. d. Satisfactory operation under ordinary environmental conditions and extremes of temperature. e. A trigger positioned so that both hands of the EMT-Basic can remain on the mask to hold it in position. 2. Use when no neck injury is suspected a. After opening airway, insert correct size oral or nasal airway and attach adult mask. b. Position thumbs over top half of mask, index and middle fingers over bottom half. c. Place apex of mask over bridge of nose, then lower mask over mouth and upper chin. d. Use ring and little fingers to bring jaw up to mask. e. Connect flow restricted, oxygen-powered ventilation device to mask if not already done. f. Trigger the flow restricted, oxygen-powered ventilation device until chest rises. g. Repeat every 5 seconds. h. If necessary, consider use of adjuncts. i. If chest does not rise, re-evaluate. (1) If abdomen rises, reposition head. (2) If air is escaping from under the mask, reposition fingers and mask. (3) If chest still does not rise, use alternative method of artificial ventilation, e.g., pocket mask. (4) Check for obstruction. 3. Use when there is suspected neck injury. a. After opening airway, attach adult mask. b. Immobilize head and neck, e.g., have an assistant hold head manually or use your knees to prevent movement. c. Position thumbs over top half of mask, index and middle fingers over bottom half.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------Place apex of mask over bridge of nose, then lower mask over mouth and upper chin. e. Use ring and little fingers to bring jaw up to mask without tilting head or neck. f. Connect flow restricted, oxygen-powered ventilation device to mask, if not already done. g. Trigger the flow restricted, oxygen-powered ventilation device until chest rises. h. Repeat every 5 seconds. i. If necessary, consider use of adjuncts. j. If chest does not rise and fall, re-evaluate. (1) If chest does not rise and fall, reposition jaw. (2) If air is escaping from under the mask, reposition fingers and mask. (3) If chest still does not rise, use alternative method of artificial ventilation, e.g., pocket mask. (4) Check for obstruction. G. Bag to stoma or tracheostomy tube 1. Definition of tracheostomy - an artificial permanent opening in the trachea. 2. If unable to artificially ventilate, try suction, then artificial ventilation through mouth and nose; sealing stoma may improve ability to artificially ventilate from above or may clear obstruction. 3. Need to seal the mouth and nose when air is escaping when artificially ventilating at the stoma. H. Bag-valve-mask to stoma - use infant and child mask to make seal. Technique otherwise very similar to artificially ventilating through mouth. Head and neck do not need to be positioned. Airway Adjuncts A. Oropharyngeal (oral) airways 1. Oropharyngeal airways may be used to assist in maintaining an open airway on unresponsive patients without a gag reflex. Patients with a gag reflex will vomit. 2. Select the proper size: Measure from the corner of the patient's lips to the bottom of the earlobe or angle of jaw. 3. Open the patient's mouth. 4. In adults, to avoid obstructing the airway with the tongue, insert the airway upside down, with the tip facing toward the roof of the patient's mouth. d.

V.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------Advance the airway gently until resistance is encountered. Turn the airway 180 degrees so that it comes to rest with the flange on the patient's teeth. 6. Another method of inserting an oral airway is to insert it right side up, using a tongue depressor to press the tongue down and forward to avoid obstructing the airway. This is the preferred method for airway insertion in an infant or child. B. Nasopharyngeal (nasal) airways 1. Nasopharyngeal airways are less likely to stimulate vomiting and may be used on patients who are responsive but need assistance keeping the tongue from obstructing the airway. Even though the tube is lubricated, this is a painful stimulus. 2. Select the proper size: Measure from the tip of the nose to the tip of the patient's ear. Also consider diameter of airway in the nostril. 3. Lubricate the airway with a water soluble lubricant. 4. Insert it posteriorly. Bevel should be toward the base of the nostril or toward the septum. 5. If the airway cannot be inserted into one nostril, try the other nostril. Oxygen A. Oxygen cylinders 1. Different sizes a. D cylinder has 350 liters b. E cylinder has 625 liters c. M cylinder has 3,000 liters d. G cylinder has 5,300 liters e. H cylinder has 6,900 liters 2. Need to handle carefully since their contents are under pressure. 3. Tanks should be positioned to prevent falling and blows to the valve-gauge assembly and secured during transport. B. Pressure regulators 1. Full tank approximately 2000 psi. Varies with ambient temperature. 2. Dry oxygen not harmful in short term; humidifier needed only for patient on oxygen for a long time. Not generally needed for prehospital care. 5.

VI.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------C. Operating procedures 1. Remove protective seal. 2. Quickly open, then shut, the valve. 3. Attach regulator-flowmeter to tank. 4. Attach oxygen device to flowmeter. 5. Open flowmeter to desired setting. 6. Apply oxygen device to patient. 7. When complete, remove device from patient, then turn off valve and remove all pressure from the regulator. D. Equipment for oxygen delivery 1. Nonrebreather a. Preferred method of giving oxygen to prehospital patients. b. Up to 90% oxygen can be delivered. c. Nonrebreather bag must be full before mask is placed on patient. d. Flow rate should be adjusted so that when patient inhales, bag does not collapse (15 lpm). e. Patients who are cyanotic, cool, clammy or short of breath need oxygen. Concerns about the dangers of giving too much oxygen to patients with history of chronic obstructive pulmonary disease and infants and children have not been shown to be valid in the prehospital setting. Patients with chronic obstructive pulmonary disease and infants and children who require oxygen should receive high concentration oxygen. f. Masks come in different sizes for adult, children and infants. Be sure to select the correct size mask. 2. Nasal cannula - rarely the best method of delivering adequate oxygen to the prehospital patient. Should be used only when patients will not tolerate a nonrebreather mask, despite coaching from the EMT-Basic. Special Considerations A. Patients with laryngectomies (stomas) 1. A breathing tube may be present. If it is obstructed, suction it. 2. Some patients have partial laryngectomies. If, upon artificially ventilating stoma, air escapes from the mouth or nose, close the mouth and pinch the nostrils.

VII.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------B. Infant and child patients 1. Place head in correct neutral position for the infant and extend a little past neutral for a child. 2. Avoid excessive hyperextension of the head. 3. Avoid excessive bag pressure - use only enough to make chest rise. 4. Ventilate with bag-valve-mask until adequate chest rise occurs. Do not use pop-off valve, must be disabled (placed in closed position) in order to adequately ventilate child or infant. 5. Gastric distention is more common in children. 6. An oral or nasal airway may be considered when other procedures fail to provide a clear airway. Facial injuries 1. Because the blood supply to the face is so rich, blunt injuries to the face frequently result in severe swelling. 2. For the same reason, bleeding into the airway from facial injuries can be a challenge to manage. Obstructions 1. Review the foreign body airway obstruction (FBAO) procedures that the students learned in their BLS training. 2. When foreign body airway obstruction persists, EMT-Basics should perform three cycles of the FBAO procedure, then transport, continuing the FBAO procedure en route. Dental appliances 1. Dentures - ordinarily dentures should be left in place. 2. Partial dentures (plates) may become dislodged during an emergency. Leave in place, but be prepared to remove it if it becomes dislodged. APPLICATION

C.

D.

E.

1.

Procedural (How) Show diagrams of the airway and respiratory system of adults, children and infants.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------2. 3. 4. 5. Show examples of inadequate breathing. Demonstrate the head-tilt chin-lift method of opening the airway. Demonstrate the jaw thrust method of opening the airway. Demonstrate mouth-to-mouth artificial ventilation of a patient.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Demonstrate artificial ventilation of a patient with a pocket mask with oxygen. Demonstrate assembly of a bag-valve-mask. Use a bag-valve-mask to demonstrate artificial ventilation of a non-neck injured patient with and without assistance. Use a bag-valve-mask to demonstrate artificial ventilation of a suspected spinal injured patient with and without assistance. Demonstrate artificial ventilation of a non-neck injured patient with a flow restricted, oxygen-powered ventilation device. Demonstrate artificial ventilation of a neck injured patient with a flow restricted, oxygen-powered ventilation device. Demonstrate insertion of an oropharyngeal (oral) airway. Demonstrate insertion of a nasopharyngeal (nasal) airway. Demonstrate how to check a suction unit. Demonstrate the techniques of suctioning. Demonstrate use of a nasal cannula. Demonstrate use of a nonrebreather mask. Demonstrate correct operation of oxygen tanks and regulators. Demonstrate artificial ventilation of a patient with a stoma. Demonstrate artificial ventilation of an infant or child patient.

Contextual (When, Where, Why) Every patient must have a patent airway to survive. When the airway is obstructed, the EMT-Basic must clear it as soon as possible using the methods described in this lesson. The only exceptions to this would be situations where it is unsafe or the airway problem is such that it cannot be treated in the field and the patient must be transported immediately to a hospital. Once the airway has been opened, the EMT-Basic must determine if breathing is adequate. Patients with inadequate breathing must be artificially ventilated using mouth-to-mouth, mouth-to-mask, bag-valve-mask or flow restricted, oxygen-powered ventilation device. If the patient has adequate breathing, the EMT-Basic must decide if oxygen is indicated. If oxygen is necessary, the EMT-Basic must select the appropriate device and follow the procedure for delivery.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------STUDENT ACTIVITIES Auditory (Hear) The student should hear abnormal airway sounds such as gurgling, snoring, stridor, and expiratory grunting. The student should hear a bag-valve-mask being used on a patient with an open airway. The student should hear a bag-valve-mask being used on a patient with an obstructed airway. The student should hear a flow restricted, oxygen-powered ventilation device being used on a patient with an open airway. The student should hear a flow restricted, oxygen-powered ventilation device being used on a patient with an obstructed airway. The student should hear suction units being operated. The student should hear an oxygen tank and flowmeter in operation. Visual (See) The student should see audio-visual aids or materials of the airway and respiratory system. The student should see normal breathing in other students. The student should see audio-visual aids or materials of abnormal breathing. The student should see audio-visual aids or materials of patients with stomas. The student should see different kinds of oral and nasal airways. The student should see different devices for ventilating patients (pocket masks, bag-valve-masks). The student should see different kinds of suction units. The student should see different kinds of oxygen tanks, regulators, and flowmeters. The student should see nonrebreather masks and nasal cannulas. The student should see audio-visual aids or materials of various dental appliances. Kinesthetic (Do) The student should practice evaluating breathing for adequacy. The student should practice opening the airway with the head-tilt chin-lift maneuver. The student should practice opening the airway with the jaw thrust. The student should practice mouth-to-mouth artificial ventilation. The student should practice artificial ventilation of a patient with a pocket mask with oxygen. The student should practice assembly of a bag-valve-mask.

1. 2. 3. 4. 5. 6. 7.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

1. 2. 3. 4. 5. 6.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. The student should practice using a bag-valve-mask to artificially ventilate a non-neck injured patient (adult, child, and infant) with and without assistance. The student should practice using a bag-valve-mask to artificially ventilate a neck injured patient (adult, child, and infant) with assistance. The student should practice artificial ventilation of a non-neck injured patient with a flow restricted, oxygen-powered ventilation device. The student should practice artificial ventilation of a neck injured patient with a flow restricted, oxygen-powered ventilation device. The student should practice insertion of an oropharyngeal (oral) airway (adult, child, and infant) with and without tongue blade. The student should practice insertion of a nasopharyngeal (nasal) airway. The student should practice checking a suction unit. The student should practice suctioning. The student should practice using a nasal cannula. The student should practice using a nonrebreather mask. The student should practice correct operation of oxygen tanks, regulators, and flowmeters. The student should practice artificial ventilation of a patient with a stoma. The student should practice artificial ventilation of an infant or child patient. INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms). EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance with

Practical:

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-1: Airway ------------------------------------the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson.

REMEDIATION

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide.

ENRICHMENT

What is unique in the local area concerning this topic? Complete enrichment sheets from the instructor's course guide and attach with lesson plan.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 2 Airway Lesson 2-2 Practical Lab: Airway

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate the cognitive objectives of Lesson 2-1: Airway. AFFECTIVE OBJECTIVES Demonstrate the affective objectives of Lesson 2-1: Airway. PSYCHOMOTOR OBJECTIVES Demonstrate the psychomotor objectives of Lesson 2-1: Airway. PREPARATION

!

!

Motivation:

The practical lesson is designed to allow the students additional time to perfect skills. It is of utmost importance that the students demonstrate proficiency of the skill, cognitive knowledge of the steps to perform a skill, and a healthy attitude towards performing that skill on a patient. -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical -------------------------------------

This is an opportunity for the instructor and assistant instructors to praise progress and re-direct the students toward appropriate psychomotor skills. The material from all preceding lessons and basic life support should be incorporated into these practical skill sessions. Prerequisites: BLS and Preparatory. MATERIALS Typically not required. Equipment from the list in Lesson 2-1: Airway.

AV Equipment: EMS Equipment:

PERSONNEL Primary Instructor: One EMT-Basic instructor knowledgeable in airway management. Assistant Instructor: The instructor-to-student ratio should be 1:6 for psychomotor skill practice. Individuals used as assistant instructors should be knowledgeable in airway techniques and management. Recommended Minimum Time to Complete: Two hours APPLICATION

Procedural (How) Instructor should demonstrate the procedural activities from Lesson 2-1: Airway. Contextual (When, Where, Why) Instructor should review contextual information from Lesson 2-1: Airway. STUDENT ACTIVITIES Auditory (Hear) -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------The students should hear the auditory information from Lesson 2-1: Airway. Visual (See) The students should see the visual material from Lesson 2-1: Airway. Kinesthetic (Do) The students should practice the kinesthetic activities from Lesson 2-1: Airway.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms).

EVALUATION

Practical:

Evaluate the actions of the EMT-Basic students during role play, practice or other skills stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide.

What is unique in the local area concerning this topic? Complete enrichment sheets ENRICHMENT from the instructor's course guide and attach with lesson plan.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical -------------------------------------

MODULE 2 Airway Lesson 2-3 Evaluation: Airway

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate knowledge of the cognitive objectives of Lesson 2-1: Airway. AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate knowledge of the affective objectives of Lesson 2-1: Airway. PSYCHOMOTOR OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: ! Demonstrate proficiency in the psychomotor objectives of Lesson 2-1: Airway.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------PREPARATION

Motivation:

Evaluation of the student's attainment of the cognitive and affective knowledge and psychomotor skills is an essential component of the EMT-Basic educational process. The modules are presented in a "building block" format. Once the students have demonstrated their knowledge and proficiency, the next lesson should be built upon that knowledge. This evaluation will help to identify students or groups of students having difficulty with a particular area. This is an opportunity for the instructor to evaluate their performance, and make appropriate modifications to the delivery of material. Completion of Lessons 2-1 through 2-2.

Prerequisites:

AV Equipment: EMS Equipment:

MATERIALS Typically none required. Equipment required to evaluate the student's proficiency in the psychomotor skills of this module. PERSONNEL One proctor for the written evaluation.

Primary Instructor:

Assistant Instructor: One practical skills examiner for each 6 students. Recommended Minimum Time to Complete: One hour

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------PRESENTATION

Declarative (What) I. II. III. Purpose of the evaluation Items to be evaluated Feedback from evaluation

APPLICATION

1. 2.

Procedural (How) Written evaluation based on the cognitive and affective objectives of Lesson 2-1. Practical evaluation stations based on the psychomotor objectives of Lesson 21.

Contextual (When, Where and Why) The final lesson in this module is designed to bring closure to the module and to assure that students are prepared to move to the next module. This modular evaluation is given to determine the effectiveness of the presentation of materials and how well students have retained the material. This is an opportunity for the students to make necessary adjustments in study habits or for the instructor to adjust the manner in which material is presented. INSTRUCTOR ACTIVITIES Supervise student evaluation. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms).

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 2: Airway Lesson 2-2: Airway Practical ------------------------------------REMEDIATION

Identify students and/or groups of students who are having difficulty with this subject content. Complete a remediation sheet from the instructor's course guide. If students continue to have difficulty demonstrating knowledge of the cognitive and affective objectives, or demonstrating proficiency in psychomotor skills, the students should be counseled, remediated and re-evaluated. If improvements in cognitive, affective or psychomotor skills are not achieved, consideration regarding the ability of the student to progress in the program should be taken into account.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 3 Patient Assessment Lesson 3-1 Scene Size-up

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 3-1.1 Recognize hazards/potential hazards.(C-1) 3-1.2 Describe common hazards found at the scene of a trauma and a medical patient. (C-1) 3-1.3 Determine if the scene is safe to enter.(C-2) 3-1.4 Discuss common mechanisms of injury/nature of illness.(C-1) 3-1.5 Discuss the reason for identifying the total number of patients at the scene.(C-1) 3-1.6 Explain the reason for identifying the need for additional help or assistance.(C-1) AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 3-1.7 Explain the rationale for crew members to evaluate scene safety prior to entering.(A-2) 3-1.8 Serve as a model for others explaining how patient situations affect your evaluation of mechanism of injury or illness.(A-2) PSYCHOMOTOR OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 3-1.9 Observe various scenarios and identify potential hazards. (P-1)

3-148

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up ------------------------------------PREPARATION

Motivation:

Size-up is the first and most important aspect of patient assessment. It begins as the EMT-Basic approaches the scene. During this phase, the EMT-Basic surveys the scene to determine if there are any threats that may cause an injury to the EMT-Basic. In addition, this assessment allows the EMT-Basic to determine the nature of the call and obtain additional help. BLS MATERIALS Utilize various audio-visual materials relating to scene sizeup. The continuous design and development of new audiovisual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. None PERSONNEL One EMT-Basic instructor, knowledgeable in scene management.

Prerequisites:

AV Equipment:

EMS Equipment:

Primary Instructor:

Assistant Instructor: The instructor-to-student ratio should be 1:6 for psychomotor skill practice. Individuals used as assistant instructors should be knowledgeable about scene size-up. Recommended Minimum Time to Complete: 30 minutes

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

3-149

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up ------------------------------------PRESENTATION

3-150

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up ------------------------------------Declarative (What) I. Scene Size-up/Assessment A. Body substance isolation review 1. Eye protection if necessary 2. Gloves if necessary 3. Gown if necessary 4. Mask if necessary B. Scene safety 1. Definition - an assessment to assure the well-being of the EMT-Basic. 2. Personal protection - Is it safe to approach the patient? a. Crash/rescue scenes b. Toxic substances - low oxygen areas c. Crime scenes - potential for violence d. Unstable surfaces: slope, ice, water 3. Protection of the patient - environmental considerations 4. Protection of bystanders - if appropriate, help the bystander avoid becoming a patient. 5. If the scene is unsafe, make it safe. Otherwise, do not enter. C. Definition - an assessment of the scene and surroundings that will provide valuable information to the EMT-Basic. D. Mechanism of injury/ nature of illness 1. Medical a. Nature of illness - determine from the patient, family or bystanders why EMS was activated. b. Determine the total number of patients. If there are more patients than the responding unit can effectively handle, initiate a mass casualty plan. (a) Obtain additional help prior to contact with patients: law enforcement, fire, rescue, ALS, utilities. EMT-Basic is less likely to call for help if involved in patient care. (b) Begin triage. 2. Trauma a. Mechanism of injury - determine from the patient, family or bystanders and inspection of the scene what is the mechanism of injury. b. Determine the total number of patients. (1) If there are more patients than the responding unit can effectively handle, initiate a mass casualty plan.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

3-151

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up ------------------------------------(a) Obtain additional help prior to contact with patients. EMT-Basic is less likely to call for help when involved in patient care. (b) Begin triage. If the responding crew can manage the situation, consider spinal precautions and continue care. APPLICATION

(2)

Procedural (How) None identified for this lesson. Contextual (When, Where, Why) Size-up represents the very beginning of patient assessment. It requires the EMT-Basic to evaluate several aspects concerning the situation in a very short period of time. It is essential for assuring the safety of the crew and the patient. This information may be obtained as part of dispatch, but should always be reassessed upon arrival at the scene. For some situations, size-up is an on-going process. As additional information is obtained, modification is made to the size-up of the patient and the situation overall. STUDENT ACTIVITIES Auditory (Hear) The student will hear simulations of various safe and unsafe scenes. Visual (See) The student will see simulations of various safe and unsafe scenes. The student should see the flow chart from Appendix I. Kinesthetic (Do) The student will practice role playing the actions to take at various safe and unsafe scenes. The student should use the flow chart from Appendix I.

1.

1. 2.

1. 2.

3-152

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up -------------------------------------

INSTRUCTOR ACTIVITIES Supervise student practice. Reinforce student progress in cognitive, affective, and psychomotor domains. Redirect students having difficulty with content (complete remediation forms). EVALUATION

Written:

Develop evaluation instruments, e.g., quizzes, verbal reviews, and handouts, to determine if the students have met the cognitive and affective objectives of this lesson. Evaluate the actions of the EMT-Basic students during role play, practice or other skill stations to determine their compliance with the cognitive and affective objectives and their mastery of the psychomotor objectives of this lesson. REMEDIATION

Practical:

Identify students or groups of students who are having difficulty with this subject content. Complete remediation sheet from the instructor's course guide. ENRICHMENT

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

3-153

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-1: Scene Size-Up ------------------------------------What is unique in the local area concerning this topic? Complete enrichment sheets from the instructor's course guide and attach with lesson plan.

3-154

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

MODULE 3 Patient Assessment Lesson 3-2 Initial Assessment

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-2: Initial Assessment ------------------------------------OBJECTIVES

OBJECTIVES LEGEND

C=Cognitive P=Psychomotor A=Affective 1 = Knowledge level 2 = Application level 3 = Problem-solving level

COGNITIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 3-2.1 Summarize the reasons for forming a general impression of the patient.(C-1) 3-2.2 Discuss methods of assessing altered mental status.(C-1) 3-2.3 Differentiate between assessing the altered mental status in the adult, child and infant patient.(C-3) 3-2.4 Discuss methods of assessing the airway in the adult, child and infant patient.(C-1) 3-2.5 State reasons for management of the cervical spine once the patient has been determined to be a trauma patient.(C-1) 3-2.6 Describe methods used for assessing if a patient is breathing.(C-1) 3-2.7 State what care should be provided to the adult, child and infant patient with adequate breathing.(C-1) 3-2.8 State what care should be provided to the adult, child and infant patient without adequate breathing.(C-1) 3-2.9 Differentiate between a patient with adequate and inadequate breathing.(C-3) 3-2.10 Distinguish between methods of assessing breathing in the adult, child and infant patient.(C-3) 3-2.11 Compare the methods of providing airway care to the adult, child and infant patient.(C-3) 3-2.12 Describe the methods used to obtain a pulse.(C-1) 3-2.13 Differentiate between obtaining a pulse in an adult, child and infant patient.(C-3) -------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

3-156

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-2: Initial Assessment ------------------------------------3-2.14 Discuss the need for assessing the patient for external bleeding.(C-1) 3-2.15 Describe normal and abnormal findings when assessing skin color.(C-1) 3-2.16 Describe normal and abnormal findings when assessing skin temperature.(C-1) 3-2.17 Describe normal and abnormal findings when assessing skin condition.(C-1) 3-2.18 Describe normal and abnormal findings when assessing skin capillary refill in the infant and child patient.(C-1) 3-2.19 Explain the reason for prioritizing a patient for care and transport.(C-1) AFFECTIVE OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 3-2.20 Explain the importance of forming a general impression of the patient.(A-1) 3-2.21 Explain the value of performing an initial assessment.(A-2) PSYCHOMOTOR OBJECTIVES At the completion of this lesson, the EMT-Basic student will be able to: 3-2.22 Demonstrate the techniques for assessing mental status.(P-1,2) 3-2.23 Demonstrate the techniques for assessing the airway.(P-1,2) 3-2.24 Demonstrate the techniques for assessing if the patient is breathing.(P-1,2) 3-2.25 Demonstrate the techniques for assessing if the patient has a pulse.(P-1,2) 3-2.26 Demonstrate the techniques for assessing the patient for external bleeding.(P1,2) 3-2.27 Demonstrate the techniques for assessing the patient's skin color, temperature, condition and capillary refill (infants and children only).(P-1,2) 3-2.28 Demonstrate the ability to prioritize patients.(P-1,2) PREPARATION

Motivation:

The EMT-Basic will encounter patients who require emergency medical care. It is important for the EMT-Basic to identify those patients who require rapid assessment critical interventions, and immediate transport.

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

3-157

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-2: Initial Assessment ------------------------------------Following the initial assessment, the EMT-B will use information obtained during this phase with the appropriate history and physical examination. Prerequisites: BLS, Preparatory, and Airway. MATERIALS Utilize various audio-visual materials relating to patient assessment. The continuous design and development of new audio-visual materials relating to EMS requires careful review to determine which best meet the needs of the program. Materials should be edited to assure the objectives of the curriculum are met. Exam gloves, airway management equipment. PERSONNEL One EMT-Basic instructor knowledgeable in patient assessment.

AV Equipment:

EMS Equipment:

Primary Instructor:

Assistant Instructor: The instructor-to-student ratio should be 1:6 for psychomotor skill practice. Individuals used as assistant instructors should be knowledgeable about patient assessment. Recommended Minimum Time to Complete: One hour PRESENTATION

I.

Declarative (What) General Impression of the Patient A. Definition

3-158

-------------------------------------United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic: National Standard Curriculum

EMT-Basic: National Standard Curriculum Module 3: Patient Assessment Lesson 3-2: Initial Assessment ------------------------------------The general impression is formed to determine priority of care and is based on the EMT-Basic's immediate assessment of the environment and the patient's chief complaint. 2. Determine if ill, i.e., medical or injured (trauma). If injured, identify mechanism of injury. 3. Age 4. Sex 5. Race B. Assess patient and determine if the patient has a life threatening condition. 1. If a life threatening condition is found, treat immediately. 2. Assess nature of illness or mechanism of injury. Assess Patient's Mental Status. Maintain Spinal Immobilization if Needed. A. Begin by speaking to the patient. State name, tell the patient that you are an emergency medical technician, and explain that you are here to help. B. Levels of mental status 1. Alert 2. Responds to Verbal stimuli. 3. Responds to Painful stimuli. 4. Unresponsive - no gag or cough Assess the Patient's Airway Status. A. Responsive patient - Is the patient talking or crying? 1. If yes, assess for adequacy of breathing. 2. If no, open airway. B. Unresponsive patient - Is the airway open? 1. Open the airway. Positioning is patient, age, and size specific. a. For medical patients, perform the head-tilt chin-lift. (1) Clear (2) Not clear - Clear the airway. b. For trauma patients or those with unknown nature of illness, the cervical spine should be stabilized/immobilized and the jaw thrust maneuver performed. (1) Clear (2) Not clear - Clear the airway. Assess the Patient's Breathing. A. If breathing is adequate and the patient is responsive, oxygen may be indicated. B. All responsive patients breathing

Similar Documents

Free Essay

Science

...THIRD GRADE SCIENCE GRADE LEVEL CONTENT EXPECTATIONS SCIENCE PROCESSES 3 v.1.09 Welcome to Michigan’s K-7 Grade Level Content Expectations Purpose & Overview In 2004, the Michigan Department of Education embraced the challenge of creating Grade Level Content Expectations in response to the Federal No Child Left Behind Act of 2001. This act mandated the existence of a set of comprehensive state grade level assessments in mathematics and English language arts that are designed based on rigorous grade level content. In addition, assessments for science in elementary, middle, and high school were required. To provide greater clarity for what students are expected to know and be able to do by the end of each grade, expectations for each grade level have been developed for science. In this global economy, it is essential that Michigan students possess personal, social, occupational, civic, and quantitative literacy. Mastery of the knowledge and essential skills defined in Michigan’s Grade Level Content Expectations will increase students’ ability to be successful academically, and contribute to the future businesses that employ them and the communities in which they choose to live. Reflecting best practices and current research, the Grade Level Content Expectations provide a set of clear and rigorous expectations for all students, and provide teachers with clearly defined statements of what students should know and be able to do as they progress through school. PHYSICAL...

Words: 4136 - Pages: 17

Free Essay

Research Topic

...American-Eurasian Journal of Scientific Research 6 (1): 28-31, 2011 ISSN 1818-6785 © IDOSI Publications, 2011 Inquiry Method and Student Academic Achievement in Biology: Lessons and Policy Implications Jacinta A. Opara European School Science Project, 18140 Granada, Spain Abstract: Three research questions with null hypotheses guided the study with the aid of a quasi experimental research design. These students were randomly assigned to two groups (treatment and control group). Treatment group were those taught biology using the sensitized inquiry teaching method while conventional method (lecture) was used for the control group. (1) Biology Achievement Test (BAT) was developed on the following units in biology, flower pollination, muscle structure and function and seed germination. All these were drawn from anatomy and physiology of flowering plants and animal physiology in the biology textbook of SS1, to measure the initial and terminal academic achievement of the students. (2) Lesson notes were prepared on the above mentioned units using the inquiry teaching method and the conventional method using a pre - test, post - test experimental treatment. Thus, it is the contention of the author that the inquiry approach would enhance students’ achievement in biology, hence the thrust of this study. Key words: Inquiry teaching method Conventional method INTRODUCTION Achievement Biology Gender Location explanations from their observations (evidence) by integrating what they...

Words: 2404 - Pages: 10

Premium Essay

Eed 420 Learning Consultant / Tutorialrank.Com

...more course tutorials visit www.tutorialrank.com Description Reviews (1) Week 1 Individual Assignment Social and Cultural Influences Resource: University of Phoenix Material: Appendix A Review the three assignment options provided in Appendix A. Select and complete one of the options. Include the Certificate of Originality with your submission ---------------------------------------------------------- EED 420 Week 2 Assignment Case Study Linda (UOP) For more course tutorials visit www.tutorialrank.com Resource: Annenberg website video case study for Linda found on the student website and University of Phoenix Material: Case Study Linda Click on the View Programs link and scroll down and click on Case Studies in Science Education. Scroll down and click on Linda—Grades 2-4 and view the video. Discuss and review the reflection questions for the University of Phoenix Material: Case...

Words: 498 - Pages: 2

Free Essay

Importance of Research in Education

...to experiment with the familiar (Pinciotti, 2001). For young children, the process in science and art is much more important than whatever product may result (Stivers & Schudel, 2008). The fundamental science process skills for early childhood are to • • • • • observe, communicate, compare, measure, and organize (Sarquis, 2009). Art and science are intrinsically linked. Scientists and artists typically observe life from somewhat different perspectives: A scientist generally takes things apart for study before bringing them together in solutions, while a visual artist interprets beauty and creatively combines media to communicate a sense of aesthetics to others. Linking science and art explorations makes sense in early childhood education for a number of reasons. • Young children have a natural curiosity...

Words: 4433 - Pages: 18

Free Essay

All About Science: Word Scavanger

...Elementary Education Standards (1999 ed-rev. 2003) - Summary DEVELOPMENT, LEARNING AND MOTIVATION 1. Development, Learning and Motivation--Candidates know, understand, and use the major concepts, principles, theories, and research related to development of children and young adolescents to construct learning opportunities that support individual students’ development, acquisition of knowledge, and motivation. CURRICULUM 2.1. English language arts—Candidates demonstrate a high level of competence in use of English language arts and they know, understand, and use concepts from reading, language and child development, to teach reading, writing, speaking, viewing, listening, and thinking skills and to help students successfully apply their developing skills to many different situations, materials, and ideas; 2.2. Science—Candidates know, understand, and use fundamental concepts in the subject matter of science—including physical, life, and earth and space sciences—as well as concepts in science and technology, science in personal and social perspectives, the history and nature of science, the unifying concepts of science, and the inquiry processes scientists use in discovery of new knowledge to build a base for scientific and technological literacy; 2.3. Mathematics—Candidates know, understand, and use the major concepts, procedures, and reasoning processes of mathematics that define number systems and number sense, geometry, measurement,...

Words: 5673 - Pages: 23

Free Essay

Emergency Medical Technitian

...The concept of modern day Emergency Medical Services (EMS) care is widely noted to begin with the academic paper, "Accidental Death and Disability: The Neglected Disease of Modern Society", (or "White Paper") in 1966, according to EMS textbooks and relevant academia in the field. This paper detailed the statistics of highway accidents resulting in injury and death in the mid 60's, as well as other causes of injury and death, and used the statistics to confirm that reform was needed in the United States, especially concerning public education and the amount of CPR and BLS/First Aid training received by police officers, firemen, and ambulance services at the time. The EMT program in the United States began as part of the "Alexandria Plan" in the early 70's, in addition to a growing issue with injuries associated with car accidents. Emergency medicine (EM) as a medical specialty is relatively young. Prior to the 1960s and 70s, hospital emergency departments were generally staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED). EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments (EDs) of the time. During this period, groups of physicians began to emerge who...

Words: 1121 - Pages: 5

Free Essay

Emt Handbook

...          Admission & Application for Programs Application Deadlines   EMT: •Fall Semester: The third Monday in May •Spring Semester: The last Monday in November •Summer Semester: The second Friday in March                                     For more information     IRSC Information Call Center 1-866-792-4772 www.irsc.edu 15-5327 IRSC OVERVIEW INDIAN RIVER STATE COLLEGE is a public, comprehensive college, ranked as one of the best in the nation for its commitment to student success. The College is a national Top Ten Finalist for the prestigious Aspen Prize and ranked as the 9th top public regional college in the South by U.S. News and World Report. Over 30,000 people enroll in IRSC courses each year, attracted by its quality, convenience and affordable tuition. IRSC was designated as the 4th Most Affordable College in the country by the U.S. Department of Education two years in a row, and IRSC students benefit from many scholarship and financial aid opportunities. Every aspect of IRSC is focused on helping students succeed with small classes, an array of student support services, convenient campuses, and online courses. IRSC has been selected as an Achieving the DreamTM college and recognized for its support of students from enrollment to employment. IRSC offers over 150 programs, including Bachelor’s degrees, Associate in Arts degrees for continuing education at IRSC or a university, Associate in Science degrees for in-demand careers after two...

Words: 3237 - Pages: 13

Free Essay

Malpractice

...PROFESSIONAL LIABILITY FOR PARAMEDICS (EMS) ANTHONY L. PETERKIN DEVRY COLLEGE INTRODUCTION: “What ever can go wrong, will go wrong.” This application paper provides a summary of Professional Liability for a Paramedic and EMS personnel in general. We forget (omissions) to perform a needed task or skill and we make mistakes or professional errors for whatever reason when performing our duty in the name of doing no harm. The incident (the liable act) may be minor and reversible; on the other hand it might just be hell’s payday with lawsuits and court dates. A professional liability can cause severe injury to a patient, both patient and care provider and might also include a civilian or two in the mix. Professional Liability can lead to work dismissal, revoking an employee’s license and even paying large sums of money as a result. As a healthcare professional one must make it their personal duty to always perform at their highest level of alertness as possible. Everyone faces many unbearable and stressful personal problems through life, however if your life’s problems are affecting the way you work to the point you can’t perform effectively and efficiently as needed, then one must make up their mind to step back and personally assess themselves. Companies must keep a watchful eye on their employees and their behavior towards their duties and level of performance. Companies must find effective ways to mitigate situations that might lead to Professional Liabilities. What...

Words: 1377 - Pages: 6

Premium Essay

Paramedic Education Research Paper

...Paramedic education programs typically follow the U.S. NHTSA EMS curriculum. While many regionally accredited community colleges offer a paramedic programs and 2 years associate degree a handful of universities also offer a 4 year bachelor's degree component. The national standard course minimum required didactic and clinical hours for a paramedic programs is 1,300 hours or more hours of training to be accredited and nationally recognized. It is required to be a certified EMT prior to starting paramedic training. Common Paramedic skills are ACLS, bleeding control, spinal injury management, fracture management, obstetrics management, advanced airway such as tracheal intubation, triaging of patients in a mass casualty incident and medication...

Words: 498 - Pages: 2

Free Essay

Changing Our Lives

........................................................................................................................3 TYPES OF ADVANCED STANDING ...................................................................................................3 GENERAL PROCEDURES ...............................................................................................................4 EVALUATION RESPONSIBILITIES .....................................................................................................5 SECTION 1—CREDITS FROM POST-SECONDARY INSTITUTIONS ........................................ 7 GENERAL CONDITIONS ................................................................................................................7 GENERAL EDUCATION TRANSFER CREDIT FOR STUDENTS WITH PREVIOUS DEGREES ..................................9 EVALUATION OF INTERNATIONAL TRANSCRIPTS .................................................................................10 SECTION 2—CREDITS EARNED IN NON-TRADITIONAL PROGRAMS ................................... 11 CLINICAL CODING ASSOCIATE OR CLINICAL CODING SPECIALIST ............................................................11 CRIMINAL JUSTICE ACADEMIES .....................................................................................................12 FAIRFAX COUNTY CRIMINAL JUSTICE ACADEMY...

Words: 11912 - Pages: 48

Free Essay

Armyone

...FL#20-306795/11-CECB-F3-2025 Program Expiration Date: 3/31/2014 Instructor: Rommie Duckworth, EMT-P, EMS-1 Date Completed: 7/6/2012 5:35 PM Senior Director of Education Services EMS : This continuing education activity is approved by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS): #11-CECB-F3-2025 for 1.5 basic CEH. CECBEMS represents only that its accredited programs have met CECBEMS’ standards for accreditation. These standards require sound educational offerings determined by a review of its objectives, teaching plan, faculty, and program evaluation processes. CECBEMS does not endorse or support the actual teachings, opinions or material content as presented by the speaker(s) and/or sponsoring organization. CECBEMS accreditation does not represent that the content conforms to any national, state or local standard or best practice of any nature. No student shall have any cause of action against CECBEMS based on the accreditation of the material. If you have any comments regarding the quality of this program and/or your satisfaction with it, please contact CECBEMS at: CECBEMS – 12200 Ford Rd., Ste. 748 - Dallas, Texas - 75324 - 972.247.4442 - lsibley@cecbems.com. Approved by The Florida Bureau of Emergency Medical Services. See your site coordinator to view this program. No individual participant fees for this activity. For questions or comments regarding accreditation, call education services at 1-800-424-4888....

Words: 279 - Pages: 2

Premium Essay

Ppaca

...EMRS in Ambulance Outline I. Introduction: EMRs for Ambulances/Paramedics – The term EMR is an electronic medical record system used to replace paper medical records with an online record which tracks a patient’s hospital history and medical care. A. Benefits: To incorporate the use of EMRs in ambulances would help not only the improvement of the clinical standards in health, but also the ability to manage key performance indicators, and health research. 1. This program is designed to improve such tasks as training for paramedics, review clinical standards, conduct pre-hospital research, audit dispatch priority codes, and design services for the future. 2. Health services will always adapt to meet growing population needs. The EMR will significantly improve the delivery and quality of patient care as well as streamline clinical workflow, therefore is in the best interest to adopt this program. II. Demand Analysis: The expected demand is substantial because of the extent of the geographic service area covered, the huge number of ambulances where EMR’s will be installed in the geographic service area, the real and urgent need the product will address. A. The geographic service area which will benefit from EMR would be the entire United States considering that ambulance service is made available to patients by all hospitals all over the country and by Emergency medical teams in every city. B. The total number of ambulances all over the country...

Words: 2309 - Pages: 10

Premium Essay

Bcp Planning and Development

...Company Virtual Solutions Inc. Foundations of Business Continuity Management Table of Contents Executive Summary 3 Introduction 5 About Company Virtual Solutions 6 The Current Status of Business Continuity Planning 6 Historical Context 6 The New Plan 8 Using Recovery Planner 8 Configuration for TPT 9 Presentation 9 Compliance 10 Comprehensive Planning 10 Leadership Approval 12 The Plan Strategy 12 Team Structure 12 Figure 1: The Business Continuity Plan Team Organizational Chart 13 Emergency Management Team 13 Business Continuity Team 14 Business Unit Teams 15 Fly Out Teams 16 Fire Teams 16 The Four Phases of the Plan 16 Figure 2: The four phases of the Plan 16 Phase I - Appraisal 17 Phase II – Recovery Coordination 18 Phase III - Production 18 Phase IV – Site Restoration 19 Business Unit Plan Structure 20 Alternative Sites 21 Planning Refinement Recommendations 22 Risk Assessment 22 Business Impact Analysis 22 Emergency Response 23 Disaster Recovery 23 Testing and Restoration 24 Future State 25 Comprehensive Business Planning 25 ACP Workflow Planning 26 Awareness and Training 27 Maintaining Support 27 Projected Timeline 28 Figure 3: Projected Timeline 29 Tasks 29 Conclusion 30 Sources 31 Appendix...

Words: 6761 - Pages: 28

Free Essay

The History of Emergency Medical Services

...Emergency Medical Services: The Evolution Behind the System Russell Keogler CED 595: Project Seminar May 3, 2011 Dr. Richard Gatteau Abstract The purpose of this study is to determine the evolutionary process of the emergency medical services system. The research explores the impact of war and prominent military figures on the development of emergency medical services as well as civilian efforts made to establish emergency services within the public sector. The research also discusses the ways in which major medical advancements and various reports and acts of legislation played a crucial part in the development of the modern day EMS system. Overall, results show that the EMS system as we know it today is a fairly modern creation based on centuries’ worth of ideas and discoveries. Introduction In modern day America the three digits 9-1-1 signify an accessible lifeline for individuals in need of emergency medical attention. The vast system is accessible from any telephone line and provides emergency services to even the most remote locations of the country. However, in spite of the simplistic process to initiate services, the emergency medical system is very complex. Thousands of independent agencies working in different capacities must coordinate efforts to insure that the system runs efficiently. Without effective cooperation by organizations the system would undeniably fail to meet the expectations of those calling for medical aid (Limmer &...

Words: 10277 - Pages: 42

Premium Essay

Accomodation

...Promote Access to the General Education Curriculum And Standardized Assessment Procedures The information provided in this document is to serve as guidance for best practices in selecting, administering, and evaluating adaptations, accommodations and modifications in instruction and assessment. This document provides information on federal and state guidance, equal access to grade level content, selecting accommodations for instruction, and strategies that can be used with students to promote their ability to access the general education curriculum. Information about variations, accommodations and modifications for use in the classroom and standardized statewide assessment system is also included. These guidelines are intended for use by individualized education program (IEP) teams, Section 504 Accommodation Teams, Student Success Teams (SST), other types of Educational Monitoring Teams (EMT), general and special education teachers, administrators, and assessment personnel. Federal and State Guidance The inclusion of all students in statewide assessment and accountability systems is not merely a legal obligation; it is a mechanism for ensuring that all students, including those with disabilities, are included in the general education curriculum. Federal and state laws stress the importance of documenting accommodations and/or modifications for instruction and assessment in the student’s IEP as noted below: ... a statement of the special education and related services and supplementary...

Words: 436 - Pages: 2