AEMT - Audio Course

A. E. M. T.

PREFACE

The purpose of this course is to help you prepare for the advanced EMT examination. As an Advanced EMT, you will have a great many more responsibilities than EMTs of lesser skill levels. There is an increased autonomy in the practice of an advanced EMT, which will give you responsibilities you may not have had before in the EMS system. You should already have an understanding of medical terminology, anatomy and physiology, and some pathophysiological mechanisms. You will need this knowledge and skills to pass the examination, along with the new knowledge you will gain in this course.

Chapter one in the course introduces the practice of the advanced EMT by talking about the different EMS systems in the world and the role of the different players in the system. Also discussed are things like ambulance operations, ethics and legal issues in the EMT practice, EMT safety, and the different cultural and religious backgrounds the AEMT might encounter as part of their job. There is a great deal to cover in chapter two. Human developmental stages are first discussed because EMTs will handle patients from all age groups. The basics of human anatomy and physiology are important to review as the basis for the entire rest of the course. Finally, you will encounter numerous disease states as part of your patient encounters so some of the common ones are discussed in this chapter as well.

Chapter three in the course involves a discussion of the different drugs carried by the advanced EMT and how they work. The different routes of administration and elimination of drugs is discussed. This brings us to a discussion of toxicology in emergency medical services. There are certain toxic exposures that need to be managed, starting in the field. Drug overdoses are common reasons for an EMT encounter. These are also covered as part of this chapter.

The focus of chapter four is patient assessment and the initial management of the sick or injured patient. Scene size-up will be a part of the advanced EMT examination so you will need to learn the principles involved. Vital sign evaluation and a SAMPLE history

will be part of the initial evaluation so this is discussed. After the primary survey, a secondary survey is obtained, particularly on trauma patients. All patients need reevaluation, which varies according to their stability. These are covered as part of this chapter.

Chapter five in the course covers the basic advanced EMT skills you may have to know as part of your patient encounters. If you need to be trained in starting IVs, this chapter covers the different IV catheter types and how to start an intravenous line. If IV access is unavailable, you should know how to start an intraosseous line. Performing and reading the basic electrocardiogram are covered as well as the basic types of intravenous fluids you may need to use on different patients.

The focus of chapter six is resuscitation. The advanced EMT will need to be able to evaluate the patient s airway and use airway adjuncts if necessary. There are different ways of ventilating the patient, including the bag valve mask and CPAP, which is continuous positive pressure ventilation. In some cases, the patient will need full resuscitation if there is complete cardiac arrest. Patients in shock require resuscitation as well, which is covered as part of this chapter.

Chapter seven in the course covers the different respiratory emergencies. A relatively urgent respiratory emergency is foreign body aspiration, which can lead to complete or incomplete obstruction. Dyspnea is a common complaint in EMS so it is covered as part of this chapter. As an advanced EMT, you will be called to assess and manage asthma exacerbation and COPD exacerbations, the treatment for which can be started in the field. Respiratory failure can result from many things; it can lead to respiratory arrest if not aggressively treated.

The purpose of chapter eight is to discuss cardiac emergencies. The advance EMT must manage the prehospital care of the patient with acute coronary syndrome and acute myocardial infarction because prehospital care does affect outcomes. There are many different arrhythmias that need to be recognized, even though there aren t a lot of management options in the prehospital setting. Hypertensive emergencies can be partially managed in the field so this is part of the discussion in the chapter.

Chapter nine in the course covers several different medical emergencies not otherwise covered in other chapters. Some abdominal medical emergencies include the acute abdomen, peritonitis, and GI bleeding, which are discussed in this chapter. Urological emergencies are many and sometimes require prehospital diagnosis and treatment. There are several obstetric emergencies, such as placenta previa, preeclampsia, placental abruption, and emergency childbirth, which are covered in the chapter.

Neurological emergencies are the topic of discussion of chapter ten. These include the EMT s role in determining the patient s level of consciousness, the evaluation and treatment of seizures, the recognition and emergency management of an acute stroke, the initial management and recognition of traumatic brain injuries, the evaluation of headache emergencies, and the emergency treatment of syncope or fainting.

Chapter eleven in the course covers the different psychiatric emergencies that an EMS provider might handle. The behavioral emergency can span many different kinds of mental illnesses and crises. You need to be able to recognize these, remain safe yourself, and decide what to do with the patient after evaluation. The suicidal patient and the psychotic patient represent unique challenges to the EMS worker. In some cases, restraints need to be used.

The purpose of chapter twelve is to discuss the management of traumatic injuries. The first thing you ll need to learn is how to evaluate trauma in a real world setting. The different traumatic injuries you may encounter include cervical spine injuries, chest injuries, and abdominal injuries. In some cases, trauma can mean dealing with patients who have burns or frostbite injuries. Also included in this chapter are environmental injuries, such as hypothermia, heat exhaustion, and heat stroke.

Chapter thirteen in the course covers special operations that an advanced EMT might be involved in. The EMT may be part of certain rescue operations in cases where the patient is initially inaccessible. There are different ways of transporting patients, depending on the severity of the illness and the distance from the facility. Triage is discussed as part of dealing with mass casualty incidents. Some incidents are related to terrorism or hazmat situations, which are covered in the chapter. The basics of wilderness medical issues are discussed as well as how to manage them.

CHAPTER ONE: ADVANCED EMT PRACTICES

This chapter introduces the practice of the advanced EMT by talking about the different EMS systems in the world and the role of the different players in the system. Also discussed are things like ambulance operations, ethics and legal issues in the EMT practice, EMT safety, and the different cultural and religious backgrounds the AEMT might encounter as part of their job.

THE EMS SYSTEM AND THE AEMT ROLE

An EMS service includes the different facilities, personnel, and equipment necessary in coordination to handle the delivery of emergency healthcare to victims of injury or illness. The goal is to prevent needless injury or death. The EMS function is to provide access to emergency care, provide care in the field, provide care en route to a facility, and assist in care at the receiving facility.

There are two main EMS systems in the world. The first is the Anglo American model and the second is the Franco German model both developed in the 1970s. In some cases, EMS is divided into different categories according to the level of care provided, such as BLS or Basic Life Support and ALS or Advanced Life Support.

The different levels of service you can expect in the US include the following:

• An EMR or emergency medical responder provides basic care like airway, breathing, and circulation as well as bandaging or splinting but cannot care for a patient in an ambulance.

• An EMT I can assess and treat sick or injured patients. They can administer medications or help patients take their own medications. They can care for patients in the back of an ambulance.

• AEMT or advanced EMT can apply advanced skills in assessment and treatment. They can start IVs and use airway devices, such as intubation.

• Paramedic this is often a 2 year program, which helps the paramedic provide the highest level of prehospital care. They have advanced assessment skills and can apply critical thinking to handle a variety of emergencies.

The Franco German model involves a philosophy of stay and stabilize”. This is often physician-operated and attempts to bring the hospital to the patient. It makes more use of helicopters and water based ambulance systems and is used in parts of Europe. Fewer patients get transported to the hospital and those that do are directly admitted. The Anglo American model involves a scoop and run” philosophy. There are fewer prehospital interventions, with operations based on paramedics as leads with oversight from incident command. It makes more use of ground ambulance systems and is considered a separate medical specialty. The patients enter the hospital through the emergency department. These two systems operate so differently that it is difficult to make a comparison as to which system is considered better than another.

When looking at EMS services based on level of service provided, there are BLS and ALS transport levels. In BLS, the philosophy is load and go” with non invasive interventions given in the field. The ALS system, on the other hand, is based on stay and stabilize”, with the addition of advanced procedures in order to save some people who need it while still in the field. Some communities have all ALS ambulances, while others have a mixture of ALS and BLS rigs. You need to be aware of who is on your team and what type of services they can provide. As the advanced EMT, you may be the designated leader of the team, except in cases where the team is led by a paramedic, as would be the case in many ALS rigs in the Anglo-American system of care.

WORKFORCE SAFETY

There are four aspects of EMS safety. These include BSI or body substance isolation, scene safety, injury protection, and emotional safety. Body substance isolation involves protecting the EMT from exposure to bodily fluids through using disposable booties, gowns, mask and face shields, and disposable gloves. Disposable gloves need to be used at every scene, with the other choices used if there is to be significant exposure to bodily fluids.

Scene safety cannot be a 100 percent certainty but you can make sure the scene is as safe as possible. Listen to the dispatcher en route to determine what the possible risks are. If you are working on a roadway, put on your reflective vest and position the vehicle appropriately. Talk to your partner about the possible risks and have a safe word for alerting the other EMS personnel. Be alert to traffic and place road flares if this has not been done yet upon your arrival.

In a residence or place of business, keep track of where the exits are and be aware of other people at the scene. Have loose pets locked up if this has not been done. You should retreat, leaving your equipment behind, if things become acutely unsafe. Use the police for protection if necessary. Extrication involves any transport of the patient to the ambulance. Consider how you can do this with the greatest degree of safety. Always remain alert to hazards at the scene.

ETHICAL AND LEGAL CONSIDERATIONS

There are some ethical concepts you should know about when working as an advanced EMT. Ethics and the legal system go hand in hand but are somewhat different topics. Here are the different ethics issues you may have to deal with:

• Autonomy this is also referred to as self determination. It means that the patient can make their own decisions about healthcare. In a setting where there are opposing family members, you need to decide if the patient himself is competent to make their own decisions. The patient who is alert, completely

oriented, and can comprehend the situation should be able to determine what care they receive.

• Informed consent you should provide the patient with a complete picture of the risks and benefits of receiving a treatment and you should have them sign a consent to treatment unless there is a clear reason why they cannot do this. You need to document why they cannot sign an informed consent and should have a family member sign the form if it is appropriate.

• Confidentiality this involves the HIPAA act, which states that you cannot share information about the patient with others who do not absolutely need to know the information. There are fines for violating the HIPAA act.

• Beneficence this involves acts you do as an EMT that are carried out to benefit the patient. It involves doing what is best for the patient under the specific circumstances.

• Nonmaleficence this involves first doing no harm. If faced with two choices, you need to do the choice that is least likely to harm the patient and to do something if doing nothing at all would be harmful to the patient.

• Justice this involves providing care to all patients with fairness and without respect to ethnicity, gender, religion, or socioeconomic status. It may involve making tough decisions in a triage system, which aims to provide the most care to the greatest number of patients.

• Respect for persons this means that all patients should have dignity and your respect. Patients are not the same thing as cargo needing to be transported but have basic human rights.

• Honesty this involves being truthful at all times. Every time you lie, you destroy any trust you and your fellow EMTs have built with the public and open yourself up to possible legal problems. Honesty is important both in dealing with patients and in documentation.

• Integrity this involves being adherent to all ethical principles despite any temptations or pressures to do otherwise. It means that you act with your most ethical self whenever you are on or off the job.

• Advocacy this means that you decide to be your patient’s advocate at all times. It means you do things that facilitate coordination of care and step in when the patient themselves cannot seek the help they need because they are in a situation of abuse or neglect.

There are some legal issues that, as an EMT, you will have to deal with. You enter into a legal situation with any patient because you have a duty toward them. Duty involves an unspoken, unwritten connection between a patient and EMT that means you must do something in order to avoid harm to the patient. This is the case anytime you are called to care for a patient.

Primum non nocere means first do no harm”. This is your first duty to the patient. This should be relatively obvious and should guide your decision making when caring for the patient. The second duty is the duty to act. You should respond to all calls, assess the situation, and provide appropriate treatment as necessary, transporting the patient when it is warranted.

Another duty is the duty to respond. It means using lights and sirens and operating the vehicle in a safe and reasonable manner at all times. You should follow all traffic laws and get to the scene as promptly as possible. Now that we re in the age of GPS, you should have a better chance of doing this quickly.

You also have a duty to perform a thorough assessment. The law does not allow for you to do a partial assessment of the patient. You cannot use the judgment that this was not necessary. Certainly, your focus should be on the management of obvious problems but it should not be limited to that.

Treating the patient is another duty. You need to provide whatever treatment is needed under the circumstances you find yourself in. It should be based on the assessment you do on the patient, which needs to be thorough.

The last duty you have is to transport the patient if it is warranted. You need to get consent from the patient and documentation as to why they refused transport if this was done but, in all other situations, you will end your care of the patient with transporting them to an appropriate facility.

There is one duty that isn t always considered but is still important. You have the duty to mitigate the mistakes and incompetence of your fellow providers. This means that you could be held accountable if another provider engages in substandard performance and you do nothing.

AMBULANCE OPERATIONS

Ambulance operations refers to your ability to manage your vehicle and get to and from an incident scene at all times. You need to be able to control your vehicle throughout the call in a variety of environments without compromising the safety of those who are using the roadways and the occupants of the rig. This involves driving defensively, avoiding collisions, being aware of other drivers intentions, and reducing the damage when accidents are unavoidable.

Things you need to do include being aware of blind spots, cross intersections safely, change lanes, maneuver the vehicle, manage distractions, handle fatigue, and drive in a variety of weather conditions you might encounter. This involves practice at handling an ambulance before actually doing it as part of your job and learning how to do vehicle maintenance. There will be blind spots that are partially mitigated by the use of special mirrors to help you see through those blind spots. Cell phones and map reading should not be a part of driving an ambulance.

When driving the ambulance, you need to use the proper signals, drive only when not terribly fatigued, and maintain a safe following distance using the three second rule for stopping behind another vehicle. Intersections are the main location for ambulance accidents so you ll need to slow, even if you are using lights and sirens. If an accident is unavoidable, you should try to reduce the damage to all vehicles.

As for speed, you shouldn t exceed the posted limits by greater than 10 miles per hour and should stay at the posted speed when going through an intersection, even if there is

a signal control device that stops traffic upon the emergence of an emergency vehicle. Turn signals need to be on at 100 feet before the turn in urban areas and at 300 feet before the turn in rural or highway situations. You will need to drive slower in inclement weather and carry supplies for yourself or for other stranded motorists.

CULTURAL AND RELIGIOUS ISSUES

There is a great deal of ethnic diversity in the United States, with the impact of culture on healthcare being extremely important. Culture is defined as the shared attitudes and beliefs of a group of people; it molds their ideas of what illness and how to treat it. This leads to the need to participate in a cross cultural interview, where you get the patient s perception of their illness and any alternative therapies they ve been using so far so you can arrive at a solution to their problem that is mutually acceptable.

In order to see that patient has understood you and knows what they should be doing, you should get them to repeat what you ve said back to you in their own words. You should try not to use friends or family as interpreters in order to protect the patient s confidentiality. You need to remember that people of different cultures differ according to their comfort with eye contact, body language, personal space, and things that are important to them.

Because of things like a more global economy, immigration, and travel, there is a great deal of cultural diversity. The largest US minority group is Latinos, followed by AfricanAmericans and Asians. About 10 percent of people in the US were born on foreign soil with minorities being nearly half of the US population by the year 2050.

While you cannot stereotype people or generalize among people of a given culture, you need to be aware of the fact that the patient s assumptions about reality are linked to their religious and cultural background. These assumptions have a significant impact on the patient s healthcare. Some patients believe in fatalism or predetermined fate so they will not often adhere to treatment, believing it will not help. Others see spiritual causes behind certain illnesses that should be understood by the provider. You should understand that Asians and Latinos believe in a balance between hot and cold with regard to health. Hot diseases must be treated with cold therapies so you need

to know which therapies to use against which illnesses. Others believe that an imbalance between hot and cold can make the patient susceptible to getting an infectious disease. Remedies are often used in certain cultures that they may not tell you about.

In the cross cultural interview, you need first to establish trust through small talk. Use the patient s formal name if you do not otherwise know how to address them. Know that some Islamic people and Orthodox Jews do not allow touching between people of different cultures. Other cultures will not agree to touch unless you explain what you are doing.

While you should use an approved interpreter with your interview, you should also use slow and simple language, and you should use body language. Speak directly to the patient and not to the interpreter. Know that patients may not ask questions of you out of embarrassment or incomprehension of the problem. Smiling in East Asians means embarrassment rather than anything else.

Find out what you can about what the patient s illness means to them and what they think has caused this. Provide instructions in written form when possible and determine if the plan is agreeable to the patient. Have the patient repeat their instructions in their own words.

In some cultures, it is better to relay a bad prognosis to the patient s family first and then to the patient. It is felt that a bad prognosis will lead to hopelessness, which will be a self-fulfilling prophesy. You need to find out what is preferable to the patient and family before giving them your prognosis.

The Latino culture is predominantly Mexicans but can be a person from a number of different countries. There can be distrust of healthcare professionals that leads them to avoid seeking healthcare, even though they have a much higher risk of type 2 diabetes. There are many Latino healing traditions that distinguish natural illnesses and supernatural illnesses. There are midwives that provide obstetrical care and many healing treatments that can actually be harmful to the patient. There are traditional therapies that offer balances between hot and cold illnesses.

Asian cultures can be Chinese but also can be Indian, Filipino, Korean, Japanese, or Vietnamese. The family structure is very important and confrontation is avoided. Personal honor is also important, with loss of honor a devastating thing. Expect traditional Chinese medicine, which focuses on yin and yang, which are hot and cold energies. Hot tea or hot water is favored over cold beverages. You should be aware of the possibility of scars from acupuncture or moxibustion, which is the application of smoldering herbs to the skin or an acupuncture need. Cupping leads to large circular lesions and coining will lead to smaller burned areas from hot coins dragged on the skin. Mongolian spots are birthmarks seen in Asian, Latino, and African babies that can look like child abuse. Asians are more likely to have somatization rather than an obvious psychiatric illness.

Despite the fact that Black Americans have been in the US for generations, there is still a distinctive culture. There are so many differences in education and healthcare that lead to a shorter lifespan in this population. There is an overall distrust of white healthcare institutions. They have a genetic risk for hypertension, which leads to a much higher risk of stroke. Added to this is the fact that they often do not see this as a chronic condition.

Things you should be aware of include falling out”, which is a stress-related collapse, and bad blood”, which is often an STD. Pica or the eating of non nutritive substances is common among black women. Religion and prayer are important influences with Ramadan, a black Muslim fasting tradition, sometimes affecting healthcare. Root medicine is practiced among witch doctors, particularly in the black south.

RELIGIOUS DIVERSITY

You need to be aware of the different religious practices that can affect your care of the patient. Different religions have different rules about healthcare and different ways that they conduct themselves around illness and death.

In Buddhism, mindfulness” is a part of their belief system. Patients may ask for some period of peace or quiet in order to meditate. Modesty is very important, particularly around the opposite gender. Many are vegetarian so they won t take medicines that contain animal products. They may reject medications that cloud their consciousness, including analgesia. They prefer analgesics that do not cloud their thinking.

Chanting or praying out loud is common with Buddhism and a picture of the Buddha may be in the room. They prepare deeply for dying so they may not wish to be disturbed if death is imminent. Death is seen as a transition rather than an end to life. Do not handle the body aggressively after death because they do not believe the soul leaves immediately after death. Religious rites may need to be done by family members after death, which may take hours to accomplish. Organ donation is not generally asked for or desired by Buddhists.

In caring for patients of the Catholic faith, you need to be aware that there will be a focus on sacraments from a Catholic priest with the Last Rites or Sacrament of the Sick done when the patient is very ill or near death. There may be a request for Holy Communion, which involves eating a small wafer. Baptism will be requested if an infant is likely to die, although this rite can be done by anyone with the right intent, including a healthcare person.

Holy Communion may be requested by the patient when they are supposed to have nothing by mouth. This should be cleared by the physician. They often carry religious objects, such as rosaries, on their person, which they may request, even if they are stripped of their clothing. Catholics may also be upset if they might miss Sunday services or Mass and they may seek the advice of the priest about withholding life saving measures in certain circumstances. There may be times when Catholics do not eat meat.

Hindu patients are extremely concerned with modesty around the opposite gender, even if the person is their spouse. Like Buddhists, they tend to be strictly vegetarian and may have times where they wish to fast. Washing up implies running water rather than sponge bathing. The right and is used for clean” things and the left hand is used for things like toileting. They may wear certain religious jewelry. Death is considered a transition and many prefer to die at home. Family may wish to constantly attend to the deceased person s body for an extended period of time.

Jehovah s Witnesses have a strict belief against getting any type of blood products, even if it is their own blood given back to them. Some will allow certain things found in blood, like immunoglobulin or albumin, to be given and some will allow organ donation or organ transplantation. They will otherwise accept most other treatments. They do not belief in faith-healing and do not believe in an immediate afterlife. They do not celebrate popular holidays or birthdays.

Jewish patients may observe the Sabbath from Friday at sundown to Saturday at sundown. Only life-saving procedures are done that day. Jewish holidays of Passover, Rosh Hashana and Yom Kippur are strictly adhered to. Some Jewish people will follow a Kosher diet and some are extremely modest around people of the opposite sex. End of life care may wish to be withheld and, after the patient dies, burial must happen quickly. They may often request the advice of a rabbi. Some Jewish patients may wish to wear a yarmulke or skull cap or a prayer shawl.

Muslim patients often have strong beliefs around modesty and may request their clothing be kept on. They follow a specific diet that avoids gelatin and pork products and many will be vegetarian. Alcohol is strictly avoided. Washing means using running water and they tend to pray five times a day. They may refuse pain medication because they are so emotionally reserved. They do not like to withdraw life sustaining therapy but have family members stay with the dying person. They may wish to die with their head facing Mecca with burial as soon as possible. They celebrate Ramadan with fasting during the daytime hours for a month.

Pentecostal patients often pray loudly with others and practice speaking in tongues. They often pray in large groups and have strong beliefs regarding miraculous healing.

• EMS services differ in the different parts of the world with some services based strictly on the level of care that can be provided by the team.

• There are ethical and legal issues that need to be followed every time you are called to a patient encounter.

• You should know how to safely operate an ambulance when driving in all types of weather.

• There are cultural issues related to shared beliefs that a group of people have about life and healthcare.

• Religious practices need to be considered when caring for patients of different faiths.

1. What prehospital provider provides the highest level of service in managing the patient in the field?

A. EMR

B. Paramedic C. AEMT

D. EMT I

Answer: b. The paramedic has completed a 2 year program of training and can provide a wide range of services to help patients with many different kinds of medical emergencies.

2. What is true of the Anglo American EMS system, rather than the Franco German EMS system?

A. It is physician led

B. Patients are treated extensively at the scene

C. Patients enter the hospital through the emergency department

D. Fewer patients are transported

Answer: c. The Anglo-American EMS system is led by paramedics. Most of the care is done in the emergency department with most patients who need treating getting transported.

3. What is most involved when an EMT practices the ethical principle of justice?

A. They seek not to harm the patient

B. They provide them with dignity and respect

C. They do what is most beneficial to the patient

D. They treat patients without regard to gender, race, or socioeconomic status

Answer: d. Justice means you treat the patient without regard to gender, race, religion, or socioeconomic status.

4. What duty to the patient involves using a GPS system en route?

A. Primum non nocere

B. Duty to act

C. Duty to respond

D. Duty to perform a complete assessment

Answer: c. The duty to respond involves doing what you can to safely get to the patient, even if it involves using GPS in order to find the patient s residence or location.

5. What is the best option for dealing with a significant language barrier?

A. Use gestures to get your point across

B. Speak as slowly as possible

C. Use a family member or spouse as an interpreter

D. Use an on call interpreter for your organization

Answer: d. Because of the complexities of medical care, you will need to converse with the patient. This means using an on call interpreter for your organization or hospital. You should not use family or friends as interpreters because of confidentiality.

6. What is the risk of giving healthcare advice to someone who experiences fatalism with regard to healthcare?

A. The patient will not understand what you have explained to them

B. The patient will not believe that interventions will help

C. The patient will want to pray for miraculous cures

D. There is rarely a problem because these patients usually follow authority

Answer: b. The patient who experiences fatalism will not follow directions because they do not believe that interventions will help.

7. What disease is most likely to lead to significant illness in the black population by virtue of their genetics?

A. Mental illness B. Hypertension

C. Atherosclerosis D. Diabetes

Answer: b. Hypertension is more common in the black or African population, which leads to an increased risk of strokes.

8. In which culture can you expect to see a problem with pica?

A. African B. Middle Eastern C. Asian D. Latino

Answer: a. Pica, which is the eating of non nutritive substances, is a problem mainly among black women in the African or African American culture.

9. Which religion has prohibition against using the left hand for clean practices like eating?

A. Jehovah’s Witness B. Hinduism C. Buddhism

D. Orthodox Judaism

Answer: b. Hindus believe that the left hand is used for toileting and other unclean practices and the right hand is used for clean practices like eating and shaking hands.

10. When is the Jewish sabbath, when only life saving work should be done?

A. Fridays

B. Saturday from morning to night

C. From Friday night to Saturday night

D. From Saturday night to Sunday night

Answer: c. The Jewish sabbath is from Friday at sundown to Saturday at sundown.