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RESPONDING to elderly patients is a different challenge altogether for you as a future EMT. Here you would need patience, kindness and respect to be able to provide care for the patient in the most effective manner. There are a lot of misconceptions about geriatric patients. They are often viewed as weak, sickly, hard of hearing, and with difficulty learning new things. But that is not completely true. As a professional healthcare provider, you are expected to give the same respect to your elderly patients. As Filipinos, we are actually expected to give more. In this chapter, you will have the information you need to assist geriatric patients and identify and deal with the special needs they may have, such as dementia and Alzheimer’s disease. You will also learn about patients with special needs, those with mental illness, intellectual disabilities, visual impairment or deafness.
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Emergencies on Elderly and Specially Challenged Patients
Age-related changes Illness and injury in older patients Patients with special challenges Dealing with abuse and neglect
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CRITICAL CONCEPTS � Although we can make some generalizations about agerelated changes, older people are individuals who can differ significantly in their health care needs. � The prevalence of many diseases increases with age. increasing the proportion of individuals in the older population who require health care. � Age-related decline in body system function alters the body’s response to illness and injury, requiring modified interpretation of assessment findings and complaints. � Multiple medical problems and multiple medications to treat them can lead to unpredictable problems and drug interactions. � Changes in the nervous system, along with isolation, financial problems, loss of loved ones, and chronic health problems, all increase the risk for depression in the elderly. Depression can interfere with a person’s selfcare and ability to communicate. Ang pagbibigay tulong sa matatandang pasyente ang isa sa mga dapat mong pag-aralan bilang EMT. Ibaiba ang puwedeng maging problema ng matatanda. At padami nang padami ang mga matatanda na mangangailangan ng iyong tulong. Habang tumatanda ang isang tao, lumalaki ang posibilidad na magkasakit ito o magkaroon ng emergency.
PRINCIPLES OF EMT CLINICAL PRACTICE
EMERGENCIES ON ELDERLY AND SPECIALLY CHALLENGED PATIENTS LEARNING OBJECTIVES • Describe the assessment and management of the elderly patient with an environmental emergency. • Describe the assessment and management of the elderly patient with a toxicological or substance abuse problem. • Describe the assessment and management of the elderly patient with a behavioral or psychological problem. • Describe the incidence, morbidity/mortality, risk factors, prevention strategies, pathophysiology, assessment, need for intervention and transport, and management of the elderly trauma patient. • Describe the assessment and management of the elderly patient with orthopedic injuries, burns and head and spinal injuries
INTRODUCTION The principles of patient assessment and patient care that you learned in previous chapters are generally applicable to older patients, but there are some special considerations to keep in mind, too. Older Filipinos are expected to account for 10 percent of the population by 2025, up from the current six to seven percent. According to the Population Commission, the life span of Filipinos is now longer at 67 for males and 72 for females due to modern technology. Their quality of life, however, has not improved, and many old Filipinos suffer from health problems and disabilities. They require health care, including EMS, in greater numbers than we might expect from such a relatively small proportion of the total population. Although we define “older” as being 65 years of age or more, such a simple categorization cannot do justice to the wide variation in the lifestyles and health status of older patients. You should approach each older patient with the understanding that this person is an individual who may be quite different from other patients m the same age range. This chapter presents common changes associated with aging, the effects these changes have on the body’s response to disease, and illnesses and injuries that are common among the older population. You will also learn to interpret assessment findings and complaints with consideration for the older patient’s changed response to disease.
THE GERIATRIC PATIENT
According to the Population Commission, the number of those 60 years old and over, or commonly referred to as senior citizens in the Philippines, has increased from 3.2 million in 1990 to 4.6 million in 2000, then to 6.2 million in 2010. On average, 1 out of 4 of these senior citizens live alone, while the rest of them live with their grown-up children in an extended family setting. About one-third of these senior citizens between the ages of 65 and 74 years report that they have a long-term condition or disability, such as sensory impairment,
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limitations in physical activity and cognitive impairment. In the 85-years-and-older age group, almost three-fourths of people report having such problems. These statistics are given to illustrate two important points. First, the elderly are a diverse group, many of whom remain quite active. Second, the prevalence of chronic health problems increases steeply from the 65- to 74-year-old age group to the 85-years-and-older age group. Older people are at least twice as likely to use EMS as younger people, so you are likely to frequently encounter geriatric patients. Both trauma and medical problems can cause older patients to require EMS. However, because age-related changes in anatomy and physiology make the elderly more prone to disease, the prevalence of medical problems increases among older populations. Common reasons for EMS to be called for an older person include cardiac and respiratory problems, neurological problems like stroke and altered mental status, injuries from a fall, and nonspecific complaints like dizziness, weakness, and malaise.
Age-Related Changes It is difficult to measure precisely or to generalize to all individuals, but it is commonly held that starting at about age 30, our organ systems lose about 1 percent of their function each year (the “1 percent rule”). This decline in function does not necessarily produce disease. With age. though, our bodies are less able to compensate for changes and to maintain homeostasis than when we are younger. For example, the maximum heart rate declines with age, and the physiological mechanisms that cause increases in heart rate are not as sensitive. This is not generally a problem on a day-to-day basis, but the elderly person who has been involved in a motor-vehicle collision and has internal bleeding may not exhibit the increase in heart rate we would expect to accompany significant blood loss. EMTs who are not aware of this age-related change may not have an appropriate index of suspicion for shock in an elderly patient when the heart rate is not as rapid as they expect with shock. Table describes some of these age-related changes, how they may he apparent in the assessment, and how they may relate to your patient care decisions.
Inside/Outside WHAT APPEARANCES REVEAL
EMTs who have not had a close relationship with an elderly person may be “put off” by the appearance and/or mannerisms of elderly patients. It may help to understand some of the “inside” changes that occur with aging that are responsible for the “outside” presentation of an elderly person.
INSIDE
OUTSIDE
Decreased collagen and elastin fibers in skin; breakdown of remaining fibers
Thinner, wrinkled skin
Decreased number of melanocytes (pigment-producing cells)
Graying hair
Demineralization of bones (loss of calcium); accumulated “wear and tear” of joints
Stooped posture, arthritic joint deformities
Decrease in muscle mass
Decreased strength and stowed muscle reflexes
Loss of central nervous system neurons
Diminished sensitivity of senses, slower cognitive processing (slower to answer questions), slowed movement and reflexes
Sometimes it is difficult for patients to differentiate between expected age-related changes and the onset of disease. A patient may attribute aches and pain or shortness of breath to “old age” when, in fact, these symptoms may indicate an acute problem that should be treated. As EMTs, we must avoid the pitfall of attributing signs and symptoms of disease to the aging process. There are ways you can reduce your chances of misattributing signs and symptoms when determining a patient’s normal or baseline condition. One way to do this is to ask the patient how things are different now than they were a week ago. For example. Dela Cruz, is there anything different about the way you feel today from the way you felt last week?” This information can be very helpful in distinguishing a chronic condition from a new problem.
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By no means do all older patients have impairments that interfere with communication. However, changes in hearing, vision and working memory, as well as changes in dentition (the number and arrangement of teeth), the residual effects of a stroke, or dementia, sometimes interfere with an older person’s ability to understand you or to make himself understood. Difficulty communicating is a frustrating situation for anyone, regardless of age. Table below lists some common causes of communication difficulty and suggests some ways to improve communication. A few of the elderly have a significant deterioration of memory and overall intellectual ability from dementia, a loss of brain function. The most common cause of dementia in the elderly is Alzheimer’s disease, a chronic organic disorder. However, do not assume that confusion in your elderly patient is “normal” or the result of longterm mental deterioration. Unless someone who knows the patient can confirm that this is a chronic condition, suspect that an altered mental status may be the result of the
BODY SYSTEM Cardiovascular System
Respiratory System
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present illness or injury. Always attempt to communicate directly with an older patient first, rather than assuming she will give an unreliable history and asking others about her. You should only rely on others for information if you are unable to get a satisfactory history from the older patient or if you need to confirm information the patient has provided. When you are speaking to any patient, it is important that the patient see and hear you. This is especially true in the elderly patient who has a hearing impairment or poor peripheral vision. Keep in mind that speaking loudly, slowly, or very clearly to a patient does not mean speaking down to a patient. Treat the patient with respect and dignity. Begin by calling the patient by a title and her last name: for example. Mrs. Sanchez. Ask the patient how she would like to be addressed before assuming that you may use her first name. Never simply call the patient “Honey” or any similarly disrespectful term. Whenever possible, speak to the patient at the same eye level. This may involve crouching, or even kneeling down.
RESULT
ASSESSMENT AND DECISION MAKING
Degeneration of the valves and muscle
Reduced stroke volume and cardiac output may lead to orthostatic hypotension, decreased brain perfusion, and reduced tolerance for activity
Patients may complain of dizziness, fainting, or weakness, especially on changing from a sitting to a standing position. Medicines for high blood pressure and dysrhythmias can contribute to these effects. Prevalence of congestive heart failure increases; assess lung sounds and check for edema.
Degeneration of conduction system
Dysrhythmias, decrease in maximum heart rate
The heart rhythm may be irregular, or may be abnormally fast or slow. The heart rate may not increase as much in response to blood loss, especially if the patient is taking certain medicines for heart problems or high blood pressure.
Thickening and narrowing of coronary and systemic arteries
Decreased delivery of oxygenated blood to the tissues; increased risk of heart attack, stroke, aortic aneurysm, and peripheral artery disease
Determine whether any complaints or changes in mental status or neurological problems are new. Remember, a heart attack in the elderly may not prevent with chest pain.
Decreased elasticity of lungs; decreased lung volume; decreased activity of cilia
Decreased ability to increase oxygen intake when needed; increased risk of pneumonia
Check patient’s oxygenation status, and administer oxygen as needed.
PREHOSPITAL EMERGENCY CARE
BODY SYSTEM
AGE RELATED CHANGES
RESULT
ASSESSMENT AND DECISION MAKING
Diminished cough and gag reflexes
Increased risk of aspiration
Pay particular attention to the patient’s ability to swallow secretions; suction as necessary. Patient may not cough, even with pneumonia or other respiratory infections.
Decreased movement of intestinal tract, decreased secretion of stomach acid, decreased sensation of taste, difficulty chewing and swallowing, decreased food absorption
Constipation, bowel obstruction, weight loss, malnutrition
Maintain a high index of suspicion for bowel obstruction, even with vague or minimal complaints of abdominal pain, fullness, constipation, or bloating.
Changes in gastrointestinal lining, increased risk of cancers, relaxation of sphincters
Increased risk of gastrointestinal bleeding, gastroesophageal reflux (heartburn), and fecal incontinence
When relevant, ask about blood in stools, black tarry stools, or vomiting blood or coffee grounds-appearing material. Be alert to patient hygiene needs. (continued)
Liver and Kidneys
Decreased breakdown and clearance of medications; decreased production of clotting factors and other blood proteins
Increased risk of drug toxicity and drug interactions; increased edema; decreased blood clotting
Always be suspicious of drug tonicity or interactions as a cause of altered mental status and other complaints. Patients can be more prone to uncontrolled bleeding.
Endocrine System
Diminished thyroid function
Decreased energy metabolism, problems with temperature regulation
Patients are more prone to both heatand cold-related emergencies, even in relatively mild temperatures, indoors and outdoors.
Pancreas, changes in insulin production or function
More prone to type 2 diabetes and hyperglycemia
Consider diabetic emergencies as a cause of altered mental status.
Decreased muscle mass and strength; arthritis
Weakness more prone to falls unable to get up from falls, decreased mobility; patients may be less able to care for self
Assess for injuries from falls and immobility. Immobility can lead to decubitus ulcers (bed sores) and increased risk for pulmonary embolism.
Decreased bone mass and strength; especially a problem in females
Fractures may occur with minimal force, and sometimes with little pain
Handle patients gently; assess for fractures.
Decreased pain sensation
Patients may sustain injury, such as hot water burns, without realizing it; patients may experience diffuse or vague pain, even with serious illness
Take all complaints of pain seriously. Realize that conditions such as myocardial infarction may not have typical pain patterns in elderly patients, or may not result In a complaint of pain at all.
Decreased reaction and cognitive processing times
Less able to avoid injury
Assess for injuries, allow time for patient to follow instructions.
Digestive System
Musculoskeletal System
Nervous System
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RESULT
Increased risk of dementia
Patients may be prone to injury, wandering away, being taken advantage of, or abused; patients may neglect themselves
Carefully assess the patient’s degree of orientation and be aware of signs of neglect and abuse.
Increased risk of depression and sleep disorders
May attempt suicide, or neglect self; elderly with sleep disorders are more likely to be physically abused
Don’t rule out medication overdoses or other types of self-harm in the elderly.
The skin becomes thin, dry, and fragile; nails become weak and brittle, and hair becomes dry and more sparse
Skin easily bruised and torn
Assess for signs of injury, even with minor trauma, and handle elderly patients carefully.
ASSESSMENT AND DECISION MAKING
EFFECTS OF AGING AND IMPLICATIONS FOR COMMUNICATION PROBLEM
CAUSES
EMT COMMUNICATION STRATEGIES
Decreased vision, including poor night vision, peripheral vision, and farsightedness possible blindness
Cataracts, glaucoma, retinal degeneration
Increased risk for falls and other injuries, difficulty reading medication directions, difficulty reading and signing consent forms
Position yourself in-front of the patient. Adjust lighting to reduce glare, help patient find glasses, and assist with walking, if needed.
Decreased hearing, especially for higher pitched sounds
Shrinkage of structures in the ear (may also lead to dizziness or difficulty with balance)
Difficulty hearing others
If television or radio is too loud, ask to turn it down. Speak clearly, and assist with hearing aids, if necessary.
Unclear speech
Stroke, poor-fitting dentures
Patient may become frustrated if he cannot make himself understood
Ask patient to put in his dentures, if necessary. Stroke patients with garbled or slurred speech may be able to write; offer a pen and paper.
History and Assessment of Older Adult Patients The steps of assessment for older adult patients are the same as those for other patients. During these steps, however, you should be aware of and look for some findings that are of special concern in older patients.
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Scene Size-Up and Safety When you approach an elderly person’s residence, look both outside and inside for clues to the patient’s physical and mental abilities. Is the outside of the house conscientiously cared for, or is the paint on the house peeling and the garden untended? When you enter the home, besides looking for potential dangers to you and your crew, look at the general condition of the residence. Is half-eaten food sitting in the living room? Is something unrecognizable drying up in a pan on the stove? Is the house
dirty? Are items left out in the open where someone can trip on them? A very important question to ask is, “What is the temperature?” Like infants older people cannot regulate their body temperatures very well. They need an environment that frequently feels uncomfortably warm to younger people. Even at such temperatures, some older people still wear several layers of clothing to retain sufficient heat. This can become a problem when a heat wave occurs and the older person fails to feel the temperature rising. A life-threatening rise in body temperature can result.
PRIMARY ASSESSMENT
Forming a General Impression
Now that you have looked at the patient’s surroundings, look at the patient What is the level of his distress? Is he leaning forward with hands on knees gasping for breath? Is he lying on a hospital bed apparently unresponsive and breathing through an open mouth? Is he sitting in a chair in no acute distress?
Assessing Mental Status
This can be very challenging, because some older people have an abnormal mental status as part of their baseline condition. If family members or caregivers are available, it is important to find out from them what the normal status is for this patient. A recent or sudden onset of confusion or other deterioration in mental status should make you consider a serious underlying medical condition rather than Alzheimer’s disease or other forms of dementia.
Assessing the Airway
Evaluating the airway of an older patient is very similar to evaluating the airway of other patients with two major exceptions. You may find it difficult to extend the head and flex the neck of an older patient because of arthritic changes in the bones of the neck. The best thing to do in this case is try not to force the head back but instead to thrust the jaw forward to pull the tongue out of the airway. The other difficulty you may come across is dentures If a patient’s dentures are secure, there is usually no reason to remove them. If, however, they are loose or ill-fitting; it is best to remove them from the mouth of an unresponsive patient to prevent them from obstructing patients airway.
Assessing Breathing Older patients face higher risk of foreign body airway obstruction. Two major risk factors are large, poorly chewed pieces of food and dentures. If you are unable to ventilate an older patient. reposition the head and try to ventilate again, If this does not work, initiate the sequence of steps to relieve a foreign body airway obstruction.
Assessing Circulation. Finding a radial pulse in an older patient is usually no different from finding a pulse in other patients. What you may notice in these patients, though, is that the pulse is often irregularly irregular (i.e.completely without any kind of repeated cycle or regularity). This is the result of a very common dysrhythmia (abnormal heart rhythm) in older people. The irregularity is not a reason for concern in itself.
Identifying Priority Patients Older patients are less likely to complain of severe symptoms in certain conditions, so it can be difficult to determine a patient’s priority. For example, most people having a heart attack experience significant chest pain. However, an older person is more likely to have just the sudden onset of weakness with no chest pain. Keep a high index of suspicion for serious conditions in elderly patients, even if symptoms are seemingly mild or vague.
SECONDARY ASSESSMENT History
Obtaining a history of the present illness can be challenging when evaluating an elderly patient He may answer questions very slowly or even inappropriately. It may be difficult to understand his speech, or he may have difficulty understanding your questions. Regardless of the particular circumstances, you must gather as much information as you can from the patient and from other sources. Of particular note when assessing the patient’s level of orientation: consider the patient oriented to time if he is able to tell you what year it is. Knowing what day or month it is can be a function of participating in the workforce, reading newspapers, or watching the news on television. A person who does not do these things may not have a good sense of day or month. However, if he knows the year, he can still be considered oriented to time. When interviewing the patient, be sure to introduce yourself, speak slowly and clearly, and position yourself where the patient can easily see you. If he is answering your questions slowly and your primary assessment did not reveal any immediate threats to life, give him additional time. Be sure to ask just one question at a time similarly, if the patient’s speech is slurred but still understandable, do not rush him. Doing so could easily fluster him, delaying responses even more, and destroy any rapport you have established. If the patient’s speech is difficult to understand because his dentures are not in place, ask him to put them in, if appropriate. Sometimes a patient will answer questions very slowly because he is clinically depressed, or so sad or blue that his eating and sleeping habits are altered. He feels fatigued, his memory or concentration is impaired, his self-confidence is LIFELINE
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low, and he may even have thoughts of suicide. Depression is a common problem among the elderly, but the patient may not be diagnosed or receiving treatment for it. However, do not automatically assume that a depressed patient has no other problems. Depression can both mimic and mask other serious medical problems. In fact, having serious health problems is itself a risk factor for depression. Another possibility you may find when interviewing a patient is that the family tells you he was wrong in some of his responses. This is sometimes a result of a neurological condition, but it can also be caused by medications the patient is taking, especially if there are many of them or the dose for some is too high. A variation of this is the patient who gives you a story of having gone out to the movies last night but who. according to family members, has not left the house in years. This is called confabulation. The patient is replacing lost circumstances with imaginary ones. These made- up experiences are usually quite believable and the patient is typically very pleasant to talk to. Nonetheless, the experiences are not real and may very well change if you ask the same question a few minutes later. Confabulation can be caused by a number of neurological conditions. This underscores the importance of gathering information from family members and others who are familiar with the patient’s condition. If the patient lives with a spouse or other family members, they can frequently be an excellent source of information about his medications, past medical history, and even the history of the present illness. Similarly, visiting nurses can often provide or confirm a great deal of this information.
Physical Exam
When performing a physical exam on an older person, keep the patient’s dignity in mind. Explain what you are going to do before you do it and replace any clothing you remove as soon as possible. Many older people have a high threshold for pain, so an extremity that is obviously fractured may cause very little discomfort to some patients. Others have a very low threshold for pain and will find elements of the physical exam extremely uncomfortable. You will need to be sensitive to these possibilities when doing the exam.
Baseline Vital Signs
Vital signs of the elderly are similar to those of other adults with only a few exceptions. As people age, the systolic blood pressure has a tendency to increase. Many older patients you meet will be on medication for hypertension. These medications can have significant side effects, including weakness and dizziness, especially on standing up quickly from a sitting or supine position. The skin loses much of its elasticity with aging, leading to dry skin that is thin and fragile. Applying pressure that is too heavy, even with just your fingertips, can be enough to cause the skin to tear in some patients. Be careful when pulling or lifting a patient to be as gentle as possible. The pupils are not round and reactive to light in some older patients. Eye surgery or pre-existing conditions may have given the pupil an abnormal shape or the inability to react normally to light. Certain eye drops can also prevent normal reaction to light. When you find this condition, inquire as to whether it is normal before assuming the patient has a serious condition based on this sign.
Steps of the Physical Exam The physical exam for older patients is the same as for other adults. However, you may come across some unusual findings because of the patient’s age or condition. Head and Neck. When evaluating the head, he especially attentive. Injuries to the head and face are very common in older patients who have sustained a fall or been involved in a motorvehicle collision, In fact, falls and motor-vehicle collisions account for the overwhelming majority of injuries in patients over 65 years of age. The patient’s neck may be stiff and the head may be far forward of its normal position because of changes in the spine. This can be a challenge to deal with when you suspect a neck injury and must immobilize the patient. Use folded towels or other materials to keep the head in its normal position, prevent hyperextension, and make the patient more comfortable. Chest and Abdomen. Although the chest and abdomen are not commonly injured, keep in mind the decreased sensitivity to pain that many older people have. Serious abdominal problems that would cause a younger person agony may produce only slight discomfort for older patients. The elderly may have diminished breath sounds because of decreased lung capacity and decreased 648
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movement of the chest wall. Also listen to the lungs for wheezes or crackles, which can be signs of respiratory or cardiac problems. Sometimes, elderly patients can have crackles in the bases of the lungs that disappear after the patient has taken a few deep breaths. Pelvis and Extremities. The hip or proximal femur is commonly fractured in a fall, especially in women. This is partly because more women than men survive to be old. but even more so because women are more prone to lose calcium from their bones. This leads to so much weakening of the bone that a fracture is sometimes the cause of a fall rather than a result. Other areas on the extremities are a ho injured sometimes because of this weakening of the bone, most notably the wrists and proximal humerus. be sure to check the patient’s extremities, especially the lower extremities, for edema (swelling). Significant edema can be a sign of underlying heart, vascular, or liver disease. Spine. The back may occasionally be injured in a fall, but it is very commonly injured in motor-vehicle collisions. Again, because of abnormal curvature that sometimes accompanies aging, immobilizing these patients can be challenging. Do your best to keep the vertebrae aligned to reduce the patient’s discomfort.
REASSESSMENT
Children who deteriorate are likely to exhibit sudden changes in condition. Although that can also happen in elderly patients, it is more common for them to show a slow, steady decline in condition. This can be deceiving because the patient does not suddenly tell you or show sudden signs that his condition is going downhill. Instead, you may be lulled into a false sense of security because there is little or no appreciable change from one minute to the next. Guard against this by reassessing the patient at regular intervals and comparing your findings to those you previously recorded Look for trends that indicate trouble. Keep in mind the elements of the reassessment: 1. Reassess mental status 2. Maintain an open airway 3. Monitor breathing 4. Reassess pulse 5. Monitor skin color, temperature, and moisture 6. Reassess vital signs • Every 5 minutes in unstable patients • Every 15 minutes in stable patients 7. Ensure that all appropriate care and treatments are being given
Illness and Injury in Older Patients Older patient are more prone to some problems because or age-related changes in their body systems, For the same reason, these problems may present differently than in younger patients or may present with vague signs and symptoms.
Medication Side Effects and Interactions The elderly use far more medications than other age groups. This is true not only because of the numerous diseases and conditions they have but also because modern medicine is producing more medications to treat these conditions. A significant number of the elderly take more than just one medication: some take as many as six, eight, ten, or even more. Keeping track of which pill to take and when to take it can be challenging even for the bestorganized person. A handy way to help present problems like this is the use of a pill organizer with the pills for each day (or for each time of day) in a separate compartment. Another potential problem is that pills that have very different effects may have very similar appearances If someone with vision problems and limited manual dexterity drops several pills, it becomes very easy to mix them up.
Many medications are expensive. Unfortunately, some elderly people must make the choice between food and medication because they cannot afford both. Obviously, this can lead to noncompliance with medication schedules. This can be even worse when a missed pill was one the doctor had prescribed to correct some of the undesirable effects of another drug that the patient is still taking. Even when a medication is taken as directed, it can have a number of adverse effects. For example, many elderly patients take a medication from a class known as non-steroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen and naproxen (both available without a prescription), relieve the pain and inflammation associated with conditions such as arthritis Unfortunately, these and other NSAIDs are also irritating to the gastrointestinal tract and often cause internal bleeding. More than 16,000 people die every year in the Philippines because of gastrointestinal bleeding when these medications are taken for arthritis. Drug-patient interactions can occur because of the older patient’s inability to clear medications from the body as quickly as before. Most drugs are broken down by the liver and kidneys, then excreted. However, liver and kidney function decrease with age. A dose that would be fine for a 30-year-old may be incapacitating to a 75-year-old. Drug-drug interactions are very common in this age group, especially as the number of medications goes up. When two drugs interact, there are two possibilities: one may block or reduce the effect of the other, or one may increase the effect of the other. This outcome can be so severe that it becomes life threatening. The likelihood of a drug-drug interaction increases when a patient goes to different doctors for different problems and fills prescriptions at different pharmacies. Patients sometimes forget to tell the doctor or pharmacist about the other medications they are taking. Drug-drug interactions are not limited to just prescription drugs. Prescription medications can have serious interactions with over-the-counter drugs, nutrient or herbal preparations, and even food (for example, grapefruit juice can increase the effects of certain cardiac medications).
Shortness of Breath The elderly can experience shortness of breath as a result of the same diseases that cause this symptom in younger patients, such as asthma or pulmonary embolism. The older population, however, is more likely to have conditions such as emphysema, heart failure (pulmonary edema), or a combination of these diseases that cause shortness of breath. Shortness of breath is also often the chief complaint of elderly patients having myocardial infarctions (heart attacks). As a patient gets older, the patient experiencing a cardiac problem is more likely to complain of shortness of breath without chest pain. The EMT must maintain a high index of suspicion for cardiac problems in these patients. LIFELINE
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Chest Pain
A complaint of chest pain can arise from many conditions. Some that are more common in the elderly than other age groups are angina, myocardial infarction, pneumonia, and aortic aneurysm. An aneurysm is an abnormal widening of a blood vessel, usually an artery. As the vessel walls are stretched, they become thinner and weaker, so the vessel can rupture, leading to catastrophic bleeding. The pain from a thoracic aortic aneurysm as it dissects (separates the layers of the artery) is classically described as “tearing” in nature and often radiates to the back between the shoulder blades.
Altered Mental Status
The list of conditions that can cause alteration of mental status is nearly endless. Some of the more common ones in the elderly include adverse effects from medications (many drugs have sedating effects that arc more pronounced in the elderly), hypoglycemia (perhaps from taking too much diabetic medication), stroke (from chronic or untreated hypertension), generalized infection in the bloodstream (the immune system may not fend off microbes as well as it used to), and hypothermia (the elderly patient may lose heat at a temperature that is comfortable for others). As already emphasized, do not assume that an altered mental status is normal for an elderly patient until you check with someone who knows the patient and can describe the patient’s baseline status.
Pneumonia
An inflammation in the tissue of the lung, is the fourth leading cause of death in the elderly. Patients in this age group sometimes cannot cough effectively and have immune systems that are not able to combat disease-causing organisms very well, leading to infection in the lung tissue. The patient with pneumonia classically presents with fever and a cough that brings up sputum. In the elderly, however, these signs may be very subtle or entirely absent. An altered mental status, resulting from hypoxia, may be the only outward sign of a problem such as pneumonia. Despite aggressive treatment with antibiotics in the hospital, some of these patients will not survive.
Abdominal Pain and Gastrointestinal Bleeding Conditions that would cause abdominal pain in a younger patient often do not cause pain in the older patient. Therefore, when an older person complains of abdominal pain, it is often a sign of a serious condition and will be taken very seriously in the emergency department. One of the most serious causes of abdominal pain in this 650
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population is an abdominal aortic aneurysm, which you may hear experienced providers refer to as a “triple A.” If it is stable in size or growing very slowly, the patient may not even know about it. Like the aneurysm in the thoracic aorta. though, as it grows it sometimes causes pain with a tearing nature. The pain is often excruciating in intensity and will be accompanied by severe shock if the artery has ruptured. If it is leaking slowly, the problem can sometimes be surgically repaired if the patient is able to withstand the stress of surgery. Another common cause of abdominal pain in the elderly is bowel obstruction or blockage, which can cause severe pain and may require surgery for repair. Also common in this age group is diverticulosis, condition in which a diverticulum, or outpouching of the intestine, provides a sac where food can lodge and cause inflammation and infection (diverticulitis). Ask the patient with abdominal pain if he has had black, tarry stools, caused by the remains of red blood cells that have gone through the digestive tract, which is one indicator of internal bleeding. Cancers of the gastrointestinal tract, ulcers, and adverse effects of medications can also cause either upper or lower gastrointestinal bleeding. In addition to asking about blood in the stools, ask the patient about vomiting blood or material that looks like coffee grounds. In some patients, the loss of blood occurs over a prolonged period of time. In this case, the patient’s vital signs may be normal, but the patient may be suffering from anemia which is a decreased number of red blood cells In this case, the patient ‘s chief complaint may be shortness of breath, weakness, dizziness, or fainting.
Dizziness, Weakness, and Malaise
Dizziness, weakness, and malaise are vague symptoms that are easy for the EMT to take lightly. These complaints can be associated with a number of serious conditions, including some life-threatening ones. Dizziness, especially upon standing, may be the only indication that a patient is experiencing significant internal bleeding. Weakness can be the result of cardiac dysrhythmias. When an 80-year-old’s heart is beating 180 times a minute, there isn’t time for the heart to fill between contractions. More commonly in the elderly, the heart experiences bradycardia, a pulse rate less than 60 beats per minute. Fortunately, either condition can be treated with medications, a pacemaker, or both. Many other extremely serious conditions may present in an elderly patient with no more than the complaint that, “I’m not feeling myself today.” Be diligent in your assessment of this seemingly minor problem.
Depression and Suicide Depression is very common in the elderly, sometimes because of medical conditions that limit activity, medications that sap the patient’s energy, loss of friends or a spouse (especially widowers), or just a biochemical imbalance in the brain. For this reason, many elderly patients are on antidepressants. When evaluating a patient’s illness or injury, observe the patient’s mood, speech, and activity. Referral to an appropriate source of assistance may be lifesaving. The segment of the population most likely to be successful in a suicide attempt is elderly males. It is not possible to predict accurately who will attempt or complete suicide, so mention any suspicions of this nature to the emergency department staff when you turn over the patient.
Rash, Pain, and Flulike Symptoms
Falls The significance of a fall for an older person should not be underestimated. Of older patients seen in an emergency department for a fall, one-quarter will die within a year. Death may not be a direct result of the fall, but instead may result from complications of the fall. For example, while recuperating from bruised ribs sustained in a fall, a 74-year-old woman may not breathe as deeply as normal because of the pain associated with inhalation. As a result of not being able to cough, as well as other changes in the aging lungs, if this patient comes down with pneumonia she is more likely to die from it. Often, a fall is just an indication of a more serious problem. A number of older people fall because of abnormal heart rhythms. Others fall because of a stroke or internal bleeding from an ulcer. Whenever possible and when time allows, assess the patient not only for injuries from the full, but also for a cause of the fall. EMTs can help prevent falls. When you enter an older person’s home, look for potential hazards. List number of hazards and what you or the patient’s family or friends can do to correct them is on the following page.
A condition much more common in the older population is herpes zoster or shingles. This condition is the result of varicella, the same virus that causes chicken pox. In shingles, the virus reawakens after Elder abuse and neglect have occurred for many years of inactivity. The patient experiences pain, often years but have only recently received the attention quite severe, on one side of the body over a dermatome, they deserve. There are essentially three ways in the area associated with one of the nerves coming from which elders can be abused or neglected: physically, the spinal cord. Within a few days, a small rash with psychologically, and financially. Physical abuse blisters over red skin appears in that area. A shingles includes pushing, shoving, hitting, or shaking of an rash often appears as a belt-like band on the torso older person. It occasionally includes sexual abuse. extending from the middle back around to the chest Physical neglect includes improper feeding, poor on one side (following the path of the affected spinal hygiene, or inadequate medical nerve). However, the rash can appear care. Psychological abuse and anywhere on the body, including the Ang pag-abuso at neglect include threats. insults, face. After a few days, the blisters dry pagpapabaya sa mga matatanda or ignoring an older person (“the out and scab over. Further healing ay nabibigyang pansin na sa silent treatment). Financial abuse takes a few more weeks. Like the rash kasalukuyan. Ang mga matatanda and neglect include exploitation already described, the pain of shingles ay naabuso nang pisikal, mental or misuse of an older person’s commonly occurs somewhere on one o financial. Ipagbigay alam belongings or money. side of the torso, but it also can occur agad sa kinauukulan kung may Detecting elder abuse and higher up. Symptoms of a shingles senyales na ang pasyenteng neglect can be difficult. Don’t outbreak may also, in some patients, matanda ay inabuso automatically assume that an include headache, sensitivity to light, o pinabayaan injury is the result of a simple and flulike symptoms including ng kanyang fall, even though falls arc stomach pain, diarrhea, chills, and pamilya. common among the elderly. fever. Unfortunately for many older Evaluate any injury in this age patients, healing of the shingles rash is group with an eye toward not the end of the problem. In almost recognizing signs of abuse half of the patients over 60 years of or neglect. Report incident age. the area remains quite painful, to Central dispatch and requiring strong pain medication for prepare report for DSWD.. relief.
Elder Abuse and Neglect
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Loss of Independence
It is hard for younger adults to understand how disruptive a serious injury or illness can be loan older person. Years of independence can vanish in an instant, leaving the patient in the care of strangers. Even worse, the patient goes to a hospital where many friends and perhaps a spouse have gone, never to return. The EMT can help by treating the patient with dignity. Do not minimize the patient’s, fears and concerns. Instead, acknowledge them and try to put them in perspective. Ask the patient if he would like you to lock up before you leave the house inquire about the care of
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any pets and whether there is a trusted neighbor who can take care of them for awhile. If you can honestly say it, reassure the patient that most patients you have seen with this particular problem do well and return home in good condition. A friendly hand on the forearm, if you feel the patient will accept it. can be very reassuring. Talking with the patient during transport about what he has done over the course of a lifetime can be not only therapeutic for the patient, but enlightening for you as well. Above all, treat the patient in a respectful, empathetic manner.
MAKING A HOME SAFER FOR THE ELDERLY HAZARD
CONSEQUENCE
INTERVENTION
Torn or slippery rugs
Slipping, tripping, falling
Remove, repair or replace
Chairs without arm-rests
Patient cannot get leverage to get out of chair
Replace chairs, or install armrests
Chair with low back
Does not support neck; allows patient to laid backward when attempting to get up
Replace with a high-back chair
Chair with wheels or castors
Chair may roll away as patient tries to sit, causing her to fall
Use the brake for wheel-chairs; replace chairs with castors
Temperature too low or too high
Patient may develop hypothermia or hyperthermia
Set a temperature of 72°f ; ensure adequate ventilation and cooling in summer
Hot water temperature is too high
Bums from washing dishes or bathing
Adjust hot water heater temperature to 120°F or lower
Bathtub or slippery shower
Unable to get out of tub; slipping and falling in the shower
A walk-in tub or shower that allows comfortable sitting, has a nonslip surface, and uses hand-rails is safest
Stairs without hand-rails
Risk of falling
Install handrails
The principles of emergency medical care you have learned so far apply to a widen variety of patients. For some patients with special challenges, you will need to adapt these principles to meet their particular health care needs. Patients with special challenges include patients with sensory impairments, patients with developmental disorders, the terminally ill, patients who are very obese, those who are homeless or living in poverty, and patients who are dependent on advanced medical devices. The health problems associated with these special challenges increase the likelihood that these persons will need EMS at one time or another. In addition, like other vulnerable people, such as the elderly and children, some patients with special needs are at higher risk for abuse and neglect. This chapter focuses on meeting the unique emergency care needs of patients with special challenges.
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PATIENTS WITH SPECIAL CHALLENGES When we speak of patients with special challenges, sometimes referred to as patients with special needs, we are really referring to patients with many different types of challenges that require special considerations. As health care
professionals, one of the few generalizations we can make about caring for such a diverse group is that empathy and respect for the patient, the patient’s dignity, and the patient’s rights are key factors in treatment.
Disability Unfortunately, many special needs groups are discriminated against or viewed negatively by others. Because of the stigma that may be associated with certain conditions, and because we are often unsure about what descriptive terms are acceptable, we often feel uncomfortable with these patients or struggle to find the correct terminology to refer to their situation without causing offense. The term disability is used to refer to a condition that interferes significantly with a person’s ability to engage in activities of daily living, such as working and caring for oneself. Disabilities include vision impairment and loss, hearing impairment and loss, loss of mobility, and emotional and cognitive impairments. It is preferable to speak of a person having a disability, rather than using the term handicapped. Experts use term developmental disability to mean a chronic (persistent or lasting) mental and/or physical impairment beginning at any age up to 22 years and causing significant impairment in the person’s major life activities. Developmental disabilities include cerebral palsy and
CONDITION
Down syndrome, among others. Other disabilities are not developmental in nature but may occur from traumatic injury or medical conditions. Multiple sclerosis. Parkinson’s disease, stroke, traumatic brain injury, spinal cord injury, and other conditions can result in cognitive, emotional, and/or physical disability. Table describes some impairments associated with particular conditions. Many patients with disabilities can live independently, often with some type or assistive equipment or accommodations. For example, wheelchair tamps, lowered countertops, handrails, and modified bathrooms can allow someone who relies on a wheelchair to live alone. Service animals can also be of great assistance to people with many different disabilities, increasing their independence. Some patients with more severe disabilities live at home but require special assistance, such as ventilators, feeding tubes, and home health care services. You may also encounter patients with special challenges in a variety of group home and institutional settings
DESCRIPTION
IMPLICATIONS
Autism
A developmental disorder in which the patient has impaired social functioning and communication. The patient may have repetitive or restricted behaviors.
There is a wide spectrum of autism disorders. Patients with Asperger’s syndrome may have social challenges and unusual behaviors, but normal language and intellect. Patients with classic autism usually have language delays, communication problems, and, often, intellectual disability.
Cerebral palsy
A permanent impairment in motor control, present at birth. Cerebral palsy is not progressive. Movements are characterized by lack of coordination, exaggerated reflexes, and tightness of muscles,
Although some patients with cerebral palsy may also have cognitive impairment, do not assume this is the case.
Cognitive disabilities
These may result from mental retardation due to a variety of genetic and congenital problems; for example, Down syndrome and fetal alcohol syndrome. It may also result from stroke, dementia, or past traumatic brain injury.
Patients have varying levels of impairment in intellectual functioning, including learning, judgment, problem solving, social skills, and communication with others. Some patients may live independently, whereas others have only limited ability to interact with others.
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CONDITION
DESCRIPTION
IMPLICATIONS
Hearing impairment
This condition may be congenital, due to trauma, or due to age. Hearing loss may be partial or complete.
Patients may have hearing aids, use TTY devices, or use sign language. Some patients can lip-read, so It Is important to face the patient and talk to him directly, even if he has complete hearing loss.
Kidney failure
This condition may be a consequence of diabetes, high blood pressure, or other medical problems. Patients can have varying levels of kidney function, and receive dialysis at different frequencies.
Patients are prone to a number of metabolic disturbances, especially if a dialysis appointment is missed. Dialysis access devices (shunts or fistulas) can malfunction and bleed. Don’t take a blood pressure in an extremity with dialysis access. Patients with continuous ambulatory peritoneal dialysis will usually know the best way 10 manage their device.
Neuromuscular disorders
Examples include muscular dystrophy, multiple sclerosis, and Lou Gehrig’s disease.
Patients have varying levels of muscular weakness, which can be intermittent or progressive, resulting in paralysis. Complications can include respiratory paralysis, in which the patient depends on a ventilator.
Stroke
Levels of disability vary from mild to incapacitating. Specific problems relate to the area of Ihe brain affected, and may involve emotional, behavioral, communication, intellectual, or physical limitations.
Don’t make assumptions about a patient’s ability to hear and understand, even though communication skills may be impaired.
Spinal cord Injury
With complete spinal cord injury, patients experience lack of sensation and function below the level of injury.
Patients with high spinal cord injuries may be ventilator dependent. This, combined with an inability to cough, increases the chances of pneumonia. Patients with urinary catheters are also prone to infection, Immobility may result in ischemia of compressed tissues, leading to breakdown of the skin and tissue beneath it (decubitus ulcer, pressure sore, or bedsore).
Vision impairment
This condition may be congenital or acquired, and may be either complete or partial.
Often, visually impaired patients cope well and are able to find their way through familiar surroundings. Ask the patient about the best way to help him navigate. If the patient uses a cane or service animal, be sure to transport them with the patient. Always explain what you are going to do before you do it.
Terminal Illness
Terminally ill patients, such as patients with endstage cancer, heart failure, or kidney failure, or those with progressive fatal diseases such as Huntington’s disease or Lou Gehrig’s disease, may prefer to stay at home under the care of family, possibly with assistance from hospice or home healthcare providers. Alternatively, they may spend the final weeks or days of their lives in a specially designated hospice facility. 654
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Terminally ill patients may be depending on technology to sustain life or relieve pain. Often, terminally ill patients have advance directives that specify what type of emergency care they are willing to accept Terminally ill patients and their families also have special emotional needs. Unfortunately, the cost of end-of-life care can also create financial problems, compounding the patient’s and family’s concerns.
Obesity Bariatric is the branch of medicine that deals with the causes, prevention, and treatment of obesity. Obesity is defined as a body mass index (BMI) of 30 or more. Body mass index is calculated by dividing your weight in pounds by the square of your height in inches, and multiplying by 703. For example, for a woman who weighs 135 pounds and is 5 feet. 5 inches tall (65 inches): BMI = 135/(65 x 65) x 703 = 22.46 A BMI of up to 24.u is considered healthy for people over 20 years of age. A BMI of 25 to 29 is considered as overweight, while a BMI of 30 or greater is considered obese. Keep in mind that BMI does not measure body fat directly, and that an extremely muscular person could end up with a BMI of 30 or more without being obese. For most people, though, BMI is a good indicator of healthy weight. Obesity is a significant and growing health concern in the Philippines for both adults and children. Obesity increases the risk of some cancers, type 2 diabetes, hypertension, heart attack, stroke, liver and gallbladder disease, arthritis, sleep apnea, and respiratory problems. Because of the prevalence of obesity and because of the serious health issues related to obesity, you will frequently encounter obese patients. As an EMT, you will need to take special measures to care for the obese patient, as well as special care in lifting to avoid injury to yourself, your co-workers, and the patient. Very obese patients may have difficulty breathing when they are supine, because of the extra weight that must be moved by the diaphragm during inspiration. If possible, allow the patient to assume a comfortable position for breathing. Monitor the patient’s oxygen saturation, and provide oxygen and ventilatory assistance as needed. Make sure you have enough assistance when lifting and moving obese patients, and use special equipment if the patient ‘s weight exceeds the maximum toad capacity of your stretcher.
Homelessness and Poverty Homelessness is a state of not having a regular place to live, often because of an inability to afford or otherwise maintain regular, safe, and adequate housing. The homeless may live in vehicles, parks, on the street, in makeshift dwellings, or in abandoned buildings. In many communities, homeless shelters arc available hut may not have the capacity to provide for the number of homeless seeking shelter. In addition, many homeless individuals choose not to use shelters even when space is available. The homeless include men, women, children, and families. Disproportionate numbers of veterans and minorities make up the homeless population. Several serious health problems are related to homelessness: mental health problems, malnutrition, substance abuse problems. HIV/AIDS, tuberculosis, bronchitis and pneumonia, environmental emergencies,
wounds, and skin infections. The lack of access to health care also means that conditions that begin as minor problems can go untreated until they become emergencies. Underlying chronic health problems and malnutrition can impair the body’s ability to respond to injuries and acute illnesses, making these issues of more serious concern than they might be otherwise. Homeless women may be victims of domestic or sexual abuse. A high number of the estimated 1.35 million homeless children suffer from emotional problems. Poverty, which may be a cause of homelessness. means that a person’s or family’s income is not adequate to allow them a standard of living considered acceptable in society. For 2009, the U.S. Department of Health and Human Services determined the poverty guideline for a single person as an income of $10,830 or less, and $22.050 for a family of four. However, there are also large numbers of individuals and families whose incomes are above this, yet not enough to provide all their necessities, including health care, health insurance, prescription medications, and adequate nutrition. Therefore, the poor are prone to many of the same health issues as the homeless.
Autism
Autism spectrum disorders (ASD) are developmental disorders that affect, among other things, the ability to communicate, report medical conditions, self-regulate behaviors, and interact with others to gel needs met. This can create serious problems for emergency responded Traditional assessment techniques and treatment protocols may need to be modified for the ASD patient. With autism spectrum disorders affecting approximately 1 million Filipinos, you are likely to encounter a patient with an ASD. A mnemonic to use when dealing with patients who have autism is ABCS: Awareness, Basic, Calm, and Safety.
Awareness
It is very important for EMTs to understand that people with an ASD will not behave or react in the same manner as most patients. Since they may not be able to adapt to the situation. EMTs will need to change their approach and strategies to meet the needs of the person with autism. Persons with autism are susceptible to the same medical emergencies as the general population: often have coexisting medical conditions, such as seizure disorders: and are prone to sustaining certain types of injuries, all of which increase the likelihood of an EMS response. However, persons with autism have rigid routines and a strong preference for things to be predictable and as expected. Disruption is not well tolerated.
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Communication with the patient with an ASD can be challenging. Persons with autism often have literal perception and difficulty distinguishing patterns of speech such as humor, slang, sarcasm, or idioms from unambiguous statements. Body language, such as gesturing or facial expression, may also not be recognized. Approximately 25 to 30 percent of persons with ASD will stop speaking, usually between 15 and 24 months of age. About a quarter of those will remain nonverbal at age 9. In a stressful situation, even those with good verbal ability may be unable to speak. Consider using a picture card system, which can help the patient express his needs and may assist you in explaining procedures and interventions to the patient. Escalation and meltdown, which can occur in a person with an ASD. can be described as an involuntary increase in tantrum like behaviors that include
screaming, swearing, stomping, throwing objects, hitting and/or kicking (people or objects), pushing, and biting. There are several causes of this behavior, with the most common involving sensory, emotional, or cognitive over-stimulation, social skills deficits, excessive demands being placed on the individual, interruption of established routines, and being put in a situation that was unexpected or is unpredictable. If a person with an ASD is behaving aggressively or is escalated, it is rarely from what most of us would refer to as malicious or defiant behavior. It is much more likely that the individual is reacting to extreme stress and is out of control. These persons often know that they are out of control but do not have the ability to regain control effectively and may need your help to return to a calm sense of being. Simply put. they want circumstances to change, but do not know how to implement that change.
Basic One of the most important aspects of interacting with persons with autism is to keep things basic. There are a few ways that this concept applies: • Keep your instructions basic. Simple, clear, precise directions are easiest to follow for persons with autism. For example, say ‘ Sit down here” (pointing at a chair), not “Why don’t you have a seat?” Don’t be sarcastic, use figures of speech, or tell jokes. • Ask basic questions. Many people with autism will do better answering short, closed-ended question) than open-ended questions. Allow extra time to answer even simple questions. If the person still does not answer, he may be nonverbal, may not understand the question, or may not know the answer. People w ho have an ASD have difficulty asking for clarification when they do not understand questions or instructions. • Basic means less “stuff”! Our radios, cell phones, and even things like flashlights and stethoscope covers may overstimulate the senses of a person with autism. They frequently have hyperacute responses in stimulations of one or more of the five senses that a majority of people tolerate well or don’t even notice. For example, they may be able to see strobelike flickering in fluorescent lights. A gentle touch on the shoulder, intended to be reassuring, may feel like a powerful blow. They may also have difficulty separating loud foreground noise from faint background noise. Your radio, even if turned way down, may be perceived as being as loud as your speech. Sensors’ stimulus overload can easily be an antecedent to escalation and meltdown. Therefore, it is important to keep as much “stuff” as possible turned off and out of sight. If you are aware that your
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potential patient is autistic, it also is advisable to discontinue use of lights and siren as you approach the scene. • Keep your treatment basic. Since persons with autism do not adapt well to sudden changes, it is best to minimize as many unplanned experiences as possible. In an emergency, the routines of these patients are interrupted, they are being bombarded with questions, things are being demanded of them from every direction, and an injury or illness may be causing significant pain or discomfort. Their alreadyheightened levels of anxiety, stress. and frustration are being pushed lo the limit. The last thing that they need is to be “attacked” by EMTs wanting to poke them here and put stickers there. Although you should not withhold absolutely necessary treatment, it is usually best to defer treatment interventions that arc done routinely as precautions or to help the emergency department staff. In other words, ask yourself, “Must this be done to get the patient to the hospital safely?” before initialling specific treatments. It is critically important to remember, however, that the patient with autism may not offer typical complaints, may have very high pain thresholds (thereby tolerating injuries that most patients would describe as excruciating), and may choose to engage in a pleasurable activity (such as playing with a toy or listening to music) over dealing with an obvious injury or medical condition, despite the amount of discomfort it may be causing. In some cases these trails may cause serious conditions to be missed. Therefore, careful assessment is always needed and you should never withhold treatment that the patient needs.
Calm When dealing with a person with autism, particularly if the patient is escalating or having a meltdown, it is imperative that you remain calm. Posturing aggressively, commanding loudly, becoming aggravated—even telling the patient to “calm down”—will be either ineffective or counterproductive. Just because the individual has temporarily lost control of his behavior is no reason for you to do so. Remember: Calm creates calm. Although a “show of force” may be an effective deterrent against aggressive behavior for many people, this strategy will likely be lost on the patient with autism. If anything, extra people add to confusion, increase frustration, and heighten anxiety, causing negative behaviors to escalate. A better approach is to allow one person to make direct contact with the patient with autism, preferably accompanied by a parent, family member, or caregiver. Keep your tone of voice clear and controlled. Offer empathy and compassion, and reassure the patient that you are there to help him. Allow the patient to express his concerns and frustrations. Maging kalmado kapag ang pasyente ay autistic. Sa pagiging kalmado, hindi ka dapat nagmamadali. Huwag mong puwersahing kumilos ang pasyente. Maging mahinahon at pasensyoso. Kung aburido na ang pasyente, mas lalo itong magiging agresibo kung mamadaliin mo. Tandaan: Ang pagiging kalmado mo ay magreresulta sa pagiging kalmado ng iyong pasyente.
Safety
Having a sense of safely and security is important to patients with autism. Often the environment where you find the patient offers a feeling of familiarity and security, even if it does not seem apparent to you. On the other hand, your ambulance is a strange and unfamiliar place, representing unpredictability to the patient with autism. Therefore, it is usually best to begin patient interaction where the patient is found. Remove things from around the person that may be aggravating to him (for example, turn off fluorescent lights), and disperse unnecessary personnel and bystanders. Consider doing the physical exam in toe-to-head instead of head-to-toe order. Move slowly and do one thing at a time, such as assessing a leg or taking a blood pressure. Tell the patient what you are going to assess next and how you will assess it. Allow time for the patient to ask questions (e.g.. some patients might want to know why) and make
sure he is ready for you to do the next part of the assessment before you do it. If the patient begins to show signs of agitation or discomfort, and if his condition permits, consider taking a break before continuing the assessment. You may need to “segment” your exam and pause several times before completing it. The concept of preparing the patient at each step along the way is essential to establish a sense of safely. The patient needs to know what to expect next. What can he expect to see? When will it occur? How long will it last? Use solid, descriptive terms to explain how an intervention will feel, as persons with autism often perceive pain quite differently than other people do. For example, when describing how it feels to have a blood pressure taken, don’t say “It won’t hurt.” Instead, say, “This cuff is going to tightly squeeze your arm.” Allowing the patient to tell you when he is ready for you to perform procedures or treatments provides the patient with a much-needed sense of control. Let the patient tell you when he is ready to move to the ambulance. He may want to look around the ambulance, look in cabinets and drawers, and even handle equipment before he is comfortable settling down. He may want to sit in a specific seat, such as the captain’s chair, or sit in various seats before deciding where he would prefer to sit. Involving the patient in his care and accommodating these needs, when possible, will likely build trust and increase compliance and cooperation. Even if the person with autism is escalated or having a meltdown, restraining the individual is frightening and terrifying. It should be avoided, used only as a last resort, and performed only when the person is in imminent danger of causing harm to himself or others.
GENERAL CONSIDERATIONS IN RESPONDING TO PATIENTS WITH SPECIAL CHALLENGES In many respects, responding to and caring for a person with special challenges is like any other call for service in that it may be for an emergencies such as a fall, general illness, chest care for a patient with special pain, seizures, or shortness of breath. What is different for you, the EMT, is that the patient’s challenges pre-existing condition can complicate and quickly overwhelm your ability to assess and treat the patient. To ensure proper care for such a patient, you must be able to recognize, understand, and evaluate the patient’s specific special healthcare needs in addition to the presenting problem or chief complaint that led to the 16-911 call. In addition to increasing your knowledge about patients with special challenges in general, you can also take steps to be prepared for specific patients or types of patients in your response area.
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Advanced Medical Devices in the Home
In recent years, medical advances and insurance coverage changes have allowed more and more people to have medical devices and care at home that were formerly seen only in the hospital. Patients who previously may have been unable to survive at home are now afforded the opportunity and relative comfort of living and working in a normal, nonhospital environment. As a result, prehospital providers are faced with an increasing number of calls to patients with devices and conditions that EMTs previously did not encounter. These calls may be for a problem with the device the patient relies on or it may be for a medical or traumatic problem unrelated to the device.
Variety of Health Care Settings Patients with special care needs can be encountered in a variety of locations. With the proliferation of varied levels of health care settings, an EMT may respond to calls at private residences, nursing homes, specially rehabilitation centers, and specialized care facilities. As an EMT. you should take the time to become familiar with any special health care settings in your community so you can be better prepared for calls of this nature. In addition to identifying the locations of such facilities. EMTs should meet and develop plans with facility representatives in order to minimize confusion that could occur during an emergency call. Facility representatives may be able to arrange for you to see various medical devices in operation prior to any problems or medical distress. Some communities have programs in place through their dispatch system to help identify people who may require additional help with medical devices in case of a disaster or evacuation from a building.
Knowledgeable Caregivers One of the advantages EMTs have when encountering patients with special challenges is that these patients will often have on site, or will be accompanied by. a person who has been trained in the use of the patient’s devices and conditions. This person may be medically trained, such as a Registered Nurse, a Certified Nursing Assistant, or a home health aide: however, more often it will be a family member or friend. Although family members may not have had formal medical training or certification, they are generally very familiar and comfortable with using the devices the patient relies on. Many learned about the equipment and techniques for using it from medical professionals before their family member (the patient) was discharged from a hospital.
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Because they have a vested interest in being competent with the devices, family members are very thorough and deliberate with their understanding and application of the devices and their features. Therefore, it is advisable to seek their input on any problem that may be occurring with devices the patient has and to ask if they have been in a similar situation before. Itanong sa pamilya o kamag-anak ng pasyente kung ang problema bang kinakaharap nila ngayon ay nangyari na dati. Kung oo ang sagot nila, itanong kung ano ang kanilang ginawa para masolusyunan iyon. Kung hindi naman, itanong kung meron bang itinuro ang doktor o sinumang eksperto na solusyon sakaling dumating ang ganong problema. Additionally, asking questions such as “How do you normally move him?” or “Has she ever been transported by ambulance, and what worked well for the transfer?” will allow family members to be pan of the solution. Family members do not necessarily expect the arriving members of EMS to know or be familiar with the patient’s medical device, and they can help guide the EMTs in the device’s use and function. It is a good idea to assign a member of the EMS team to work with the family member regarding the medical device while others on the team concentrate on assessment, treatment, and moving the patient to the ambulance. Despite the family’s willingness to help you. they will still be apprehensive about the problem that occasioned the EMS call and eager to ensure that the device is not damaged or allowed to malfunction. Therefore, proceed with deliberate steps and explain alt of your actions to the family.
A Knowledgeable Patient The patient may also be a great help to the EMT regarding his condition, need for the device, functioning of the device, and how the device operates. The patient has likely been using and/or watching the use of this device for some time and has most likely been trained by medical providers to correctly use the device. Ask the patient about the device and any problems he may be having with it. This approach will depend greatly on the patient’s mental status and baseline level of functioning If the patient has an altered mental status or if medical conditions dictate otherwise, the family will be the primary source of knowledge. Regardless of the patient’s mental status or condition, always explain what you are doing. One of the last senses a patient may lose is hearing, so talking and explaining your actions to the patient may help alleviate any stress the patient may be feeling yet unable to show.
Following Protocols One note of caution is that, as an EMT. your actions fall under specific regional and state scopes of practice. Thus, you should confer with medical direction if the treatment or skill required is not something you are trained in or allowed to do under these protocols. Specific considerations should be given, such as: • Is the problem with the device life threatening? • Do I have the knowledge to fix this problem? • Do I have the supplies needed to fix this problem? • Is this within my protocols or within medical control authorization?
DISEASES AND CONDITIONS
A disease or condition may be congenital or acquired. A congenital disease or condition is one that is present at birth. Some congenital diseases may be genetic, others may not. One example of a congenital disease is congenital head disease (the most common birth defect), where the heart or large blood vessels of the heart arc malformed. Other examples include cleft palate and congenital deafness. An acquired disease or condition is one that occurs after birth and may be the result of exposure to a virus or bacteria or the result of another medical condition or trauma. Examples of acquired diseases include OOPD. AIDS, and traumatic spinal cord injury. Some diseases or conditions may be either congenital or acquired, depending on how they occurred. An example of this would be deafness. A patient may be congenitally deaf from a birth defect or may become deaf from a disease or from a loud explosion. It is important to understand that a patient with a chronic disease, whether it is congenital or acquired, may develop a sudden, acute worsening of the disease that prompts a call to 16-911. In addition, the patient with a chronic disease may develop an acute illness, and this acute illness may be potentially more devastating than the same disease would be for a patient who did not have a coexisting chronic disease.
ADVANCED MEDICAL DEVICES
As an EMT. you may encounter patients of any age or physical condition who have advanced medical devices. Take into consideration what the device is doing for the patient and how important the device is to the patient’s survival. Some devices are intended to allow the patient to improve the quality of life or to have the fullest life possible, whereas others actually sustain life. Many patients who rely on such devices for life support have limited life expectancies. Even with proper use of the devices, their diseases or conditions may be terminal. As already noted, you should include family caregivers, as appropriate, in care decisions and patient transportation.
RESPIRATORY DEVICES Continuous Positive Airway Pressure Devices Continuous positive airway pressure (CPAP) is a form of non-invasive positive-pressure ventilation (NPPV) provided by a device that blows oxygen or air under constant low pressure, through a tube and mask, to prevent airway pas-sages from collapsing at the end of a breath. It is often prescribed to patients who suffer sleep apnea (periods when breathing stops during sleep) to help keep airway passages open as the patient sleeps. CPAP can help such patients prevent exacerbation of other medical conditions and conquer the chronic fatigue and irritability that are likely to result from interrupted sleep caused by the apneic periods, and may be especially helpful in moderating behavioral problems that can occur in children with sleep apnea. A related device is the biphasic continuous positive airway pressure (BIPAP) device, which provides assistance with both inhalation and exhalation. EMT Assessment and Transport. A patient who uses a CPAP device at night is unlikely to have a medical emergency directly related to the device and will not need the device during transport. However, the patient may wish to bring the device along to the hospital. Hospital personnel should also be alerted that the patient uses a CPAP device during sleep.
Tracheostomy Tubes A tracheostomy is a surgical opening through the neck into the trachea. When the opening created is permanent, it is called a stoma. A tracheostomy is usually created near the second to fourth tracheal ring. A tracheostomy lube (a short breathing tube and flange) is inserted into the airway to allow the patient to breathe through the stoma instead of through the nose and mouth. It is often called a “trach” (pronounced trayk) tube. Tracheostomy tubes used by older children and adults are usually double-cannula tubes. A doublecannula lube has an inner cannula fa tube within a tube) that can be locked into place and removed periodically for cleaning. Tracheostomy lubes for young children are usually single-cannula tubes that don’t have the removable inner cannula. A bag-valve mask can be connected to either type of trach tube—to the inner cannula of a double-cannula tube or directly lo a singlecannula tube. Trach tubes usually come with an obturator, which is a long “plug”’ that is placed inside the tube to help guide it during insertion and that also prevents material from getting into and clogging the tube during insertion. The obturator is removed after the trach tube is in LIFELINE
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Day 25 place. A tracheostomy procedure may be performed for long-term reasons in patients with neuromuscular disorders, spinal cord injuries, tumors, congenital deformities, coma, and a variety of other conditions that affect the patient’s ability to breathe. A patient with a tracheostomy tube may or may not be on a home ventilator. Tracheostomy patients who are on ventilators may be on them all the time or only when sleeping. Tracheostomy patients range from newborns to the very elderly. A patient with a tracheostomy may or may not be able to speak, depending on his condition. Some are able to speak by covering the tracheostomy tube briefly and making use of a speaker valve attached to the lube or an electronic box applied to the larynx. Do not assume that a patient with a tracheostomy either can or cannot speak. A frequent problem with tracheostomy tubes is a buildup of mucus that forms in the tube. Because the tube bypasses the upper airway’s function of warming, filtering, and humidifying inspired air, suctioning of the tube is needed regularly, often every few hours. This is especially common during times of distress, the first few weeks after tube insertion, or if the patient has an infection. Other problems with the tube can range from dislodgement to infection around the stoma to general respiratory distress. A patient with a tracheostomy requires extensive care, and their caregivers are given substantial training. Caregivers should be very familiar with the procedures used to suction the tube. They should also know how to change and replace the tracheostomy tube, since it needs to be regularly cleaned. These procedures are outside the scope of practice for most EMTs, so check with your local protocols before attempting them. EMT Assessment and Transport. Carefully assess the tracheostomy tube for any blockage, and clear it (under protocol, or by having caregivers perform this). To clear a blockage, carefully insert a whistle tip catheter (a soft, flexible catheter used to suction tracheostomy or endotracheal tubes) into the stoma. Determine the correct depth of insertion by measuring the suction tubing against the length of the obturator, which is the same length as the trach tube itself You will usually be able to find the obturator among the patients tracheostomy supplies. If you can’t locate the obturator for measurement, stop inserting the suction catheter when you feel resistance. Suction as the catheter is being withdrawn, using a twisting motion as it is slowly removed. The patient may “buck” during this procedure. If the patient requires further suctioning (indicated by viable or audible mucus), insert the suction tip into a container of sterile water to remove any mucus left in the catheter, then repeat. If the patient is on a ventilator, he may need lobe ventilated by a bag-valve mask between suctionings. During transport, the patient should be positioned with his head slightly elevated to allow for mucus drainage. 660
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Home Ventilators A ventilator’s a device that breathes for a patient. A home ventilator weighs anywhere from several pounds to over 20 pounds and can range from the size of a desktop computer to the size of this textbook. It is programmed to take over the functions of inhalation, exhalation, timing, and rate of breathing. The ventilator is attached to a ribbed tube called a ventilator circuit, which may come in various lengths, that enters the trachea. The tube from the ventilator may be attached to a plastic or metal port (called a cannula) that enters through a stoma in the neck. It may also be attached to an endotracheal lube through the mouth. Although the patient is dependent on the ventilator for breathing, he may still lead an active life. One of the best examples of this was Christopher Reeve, the actor who once played Superman, who was paralyzed from the neck down in a 1995 riding accident. With the assistance of a ventilator, he was able to lead an active professional and family life until his death in 2004. The patient on a home ventilator may call EMS for a variety or problems with his device. As with a tracheostomy tube, mucus plugs and secretions develop that require suctioning, and the patient may develop infections or respiratory distress. Additionally, the home ventilator depends on AC power, so power failures may because for concern. Ventilators do have backup batteries that generally last an hour or more. Home ventilators are tailored with settings that are the most comfortable for the patient. In the case of a mechanical failure, or during transport of the patient, a bag-valve-mask (BVM) device can take over the function of the ventilator. During this procedure, should adjust the rate, volume, and pressure of the BVM to the patient’s comfort level, This can often be accomplished with guidance from the patient or his caregivers. If the patient or caregivers are unable to provide guidance, you should observe for adequate chest rise and improving skin color. EMT Assessment and Transport. While caring for a patient with a home ventilator, ensure that the ventilator tube does not have any mucus buildup, and suction as needed. During transport, it may be easier to use a BVM while moving the patient to the ambulance, depending on the location and situation (e.g.. stairs or a heavy patient). If you use a BVM at any point, ensure that it is the appropriate size for the patient and that it is connected to oxygen. If the patient has a tracheostomy tube and the BVM does not fit the tube attachment, use the face mask from the BVM to cover the stoma and secure the mask to provide a good seal against the neck, then ventilate as normal. If the ventilator is left attached to the patient, firmly affix it to the stretcher. Secure the ventilator to prevent movement in the ambulance during transport. Consider transport time versus battery life, and plug the ventilator into the ambulance’s inverter if available. If a BVM will be used during transport, obtain extra help so you can continue to provide assessment and care.
CARDIAC DEVICES Implanted Pacemakers and Cardiac Defibrillators A patient may have an implanted pacemaker or automatic implanted cardiac defibrillator. These devices are both designed to respond lo potentially lethal electrical rhythm chant, in the heart. In the case of a pacemaker, a small device is implanted under the skin and wires are in planted into the heart. The pacemaker is designed to prevent the heart rate from becoming too slow. Early pacemakers were set at a fixed rate, but modern pacemakers are “rate-responsive”, that is. they detect what the patient is doing and modify the heart rate accordingly. For example, if the patient is moving around and performing an action, a sensor will detect this and increase the rate to allow for the activity. Additionally, if the breathing rate increases, the pacemaker will increase the heart rate as well. The pacemaker delivers a series of low-energy pulses at set intervals to stimulate the heart to heal at a faster rate. These pulses are not felt by the patient and cannot be detected on the skin or felt by providers. The pacemaker does not squeeze the heart or fix damaged muscle: rather, it helps regulate the timing of each beat. Like a pacemaker, an automatic implanted cardiac defibrillator (AICD) is placed under the skin with wires inserted into the heart. The AICD varies in size from slightly larger than a 9-volt battery to the size of a wallet. It is usually implanted in the upper left chest area, although occasionally it may be implanted in the area of the left upper quadrant of the abdomen, it is generally palpable through the skin. The implanted defibrillator is designed to detect life-threatening cardiac rhythms (ventricular fibrillation and ventricular tachycardia). Newer models may have a pacemaker feature built in as well. The AICD delivers a single shock when a life-threatening rhythm is detected. This shock is often very painful to the patient, and is generally rated as 6 on a 1-to-10 pain scale. Ang shock mula sa If the single shock does implanted defibrillator ay not correct the rhythm, masakit para sa pasyente. or if the rhythm returns, Mauulit ito hanggang hindi pa other shocks will be tumatama ang ritmo ng tibok delivered, one at a time, ng puso ng pasyente. until the dysrhythmia is Importante na resolved or the machine maipaliwanag is turned off. The AICD ito sa kanya. can be turned off only by a special magnet and generally only in a hospital setting. Although muscle twitches may be seen on the patient, providers and caregivers will not be shocked or harmed if the AICD shocks while they are touching
the patient. The AICD is not dangerous if it shocks when the patient is wet. Patients are generally instructed to call their doctor if they feel fine after a shock. However, if they have any symptoms such as dizziness chest pain, shortness of breath, not feeling well, or if they are shocked more than twice in any 24-hour period, they should go to the hospital or call EMS. The functioning of pacemakers and AICDs can be affected by certain electro-magnetic and radio frequency signals, so people with these devices should not standstill in the doorway of a business with an electronic anti-theft device nor stand still in a walk-through metal detector (although walking through cither of these without stopping is not harmful)- Stereo speakers and cellular telephones should not be held against a pacemaker or AICD device. Additionally, electric motors (as in power tools) and gas-powered tools (such as chainsaws and snow blowers) must be kept at least 6 inches away from the AICD or pacemaker when they are running. Most patients who have one or both of these devices have had a significant cardiac medical history. They may be on multiple medications and may carry wallet cards or wear bracelets stating that they have one of these devices in use. EMT Assessment and Transport. Depending on the nature of the call and chief complaint, the BMT may wish to have ALS transport for a patient with a pacemaker or AICD device. A patient who merely has a pacemaker as part of his medical history may not need ALS. but if the pacemaker is malfunctioning or if an AICD has discharged, this patient is a high-risk cardiac patient and should he treated as such with high-concentration oxygen and frequent reassessment. If the patient goes into cardiac arrest. CPR and an AED should be used as indicated.
Left Ventricular Assist Devices
A recent advance in cardiac care is the left ventricular assist device (LVAD). The left ventricle is the cardiac chamber that pumps blood through the aorta to the body. When there is severe left ventricular heart failure, a heart transplant may be required. While the patient is waiting for a suitable donor, the LVAD serves as a “bridge to transplant.”The LVAD moves blood from the left ventricle through an inserted tube to a pump implanted in the abdomen where the blood is pressurized and sent to the aorta for transport to the body. A tube extends from the LVAD through the abdominal wall loan external pump battery and control panel. Problems that may be associated with LVADs are infection, air leakage, and battery failure. All require rapid transport to a hospital. EMT Assessment and Transport. The patient with an LVAD will have an external battery pack that maybe the size of a small backpack or briefcase. This should be carefully secured and prevented from lugging on the attached LIFELINE
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Day 25 tubing. Failures of the battery system should first be addressed by attempting to plug the unit into an AC source in the home, inverter in an ambulance, or other power source. This will begin recharging the battery, and allow functioning of the pump. If the pump itself fails, a hand or foot pump is included with the system as a backup. The pump looks similar to the bulb on a blood pressure cuff and must be squeezed for each beat of the heart. Heart transplant centers will generally provide training to local EMS personnel if someone in the community has an LVAD. The training is specific to the model used by local patients.
GASTROURINARY DEVICES Feeding Tubes A feeding tube is used in a patient who is unable to feed himself or can’t swallow. It may be used short term (during recovery from surgery) or long term (for chronic conditions). A feeding tube is most commonly seen in one of two forms, a nasogastric tube or a gastric tube. A nasogastric tube (NGtube) is a long tube inserted through the nose into the stomach that can be used to deliver nutrients. Additionally. the device can be used in emergency departments and by some ALS providers to suction out the stomach’s contents, for example, in the case of certain overdoses. The NG-tube is generally taped to the patient’s nose or check to prevent the tube from dislodging. A gastrostomy tube (G-tube) is a feeding tube surgically implanted through the abdominal wall and into the stomach. It is used to provide longer term nutrient delivery than would be provided by an NGtube. The G-tube is held in place by a balloon inside the stomach. It can also be used by hospital personnel to drain stomach contents, Some feeding tubes are placed through the abdominal wall, directly into the small intestine. For example, a J-tube is placed into the jejunum section of the small intestine. Common problems with both NG-tubes and G-tubes include dislodgement. infection at the site of insertion, or a clog that prevents nutrients from being provided to the patient. All of these conditions warrant transport and evaluation in a hospital setting. EMT Assessment and Transport. Ensure that the feeding tube is secured with tape to the patient’s body before transport. If protocols allow, and nutrients are being administered during transport, keep the nutrient source higher than the level of the NG-tube or G-tube and hang it like an IV bag. Although the tube is not pressurized when nutrients are not being administered, the protective end cap should be placed on the tube to prevent leakage.
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Urinary Catheters A urinary catheter is used for a patient who has lost the ability to urinate or the ability to control when he urinates. Most commonly seen as indwelling Foley catheters, other types include the externally applied condom catheter. Most catheters are inserted into the bladder through the urethra and use a balloon to hold the tubing in place. The external tubing is connected to a collection bag, which may be a bag strapped to a leg or a larger drainage bag, called a down drain. that may hang on the side of a patient’s bed. Patients with leg bags are generally those who are more active than patients with down drains, as the leg bag may be hidden under clothing when the patient is in public. Common problems EMTs see with urinary catheters include infection, blockages causing lack of urinary output, discoloration of urine, and dislodgement of the catheter. EMT Assessment and Transport. During transport, keep the catheter bag lower than the level of the patient (but not on a floor), and DM care not to damage the bag with a stretcher or lifting device. Document and report any discoloration of the urine or any odors from the urine itself, Drainage bags should be emptied when they are one-third to one-half full. EMTs may want caregivers to empty the bag before transport to prevent overfilling, which will cause back flow into the bladder. Some patients are required to keep track of their total urine output every day, so document the amount emptied.
Ostomy Bags As an EMT, you may also encounter a patient who has an ostomy bag, also called an ostomy pouch. An ostomy bag is connected to the site of a colostomy or an ileostomy. A colostomy or ileostomy is the result of a surgery that brings a section of the intestine through the abdominal wall in order to divert the flow of stool away from the normal path to the rectum. An ostomy may be necessary because of a medical condition such as Crohn’s disease or ulcerative colitis or cancer, especially colon cancer. An ostomy bag is usually attached to the patient’s leg and often will not be visible under clothing. Common problems include infection at the stoma site, blockage, or, in some cases, dislodgement. EMT Assessment and Transport. Use care when moving a patient if an ostomy bag is present to prevent breakage or dislodgement through rough handling.
Dialysis
A patient who requires dialysis has renal failure. The kidneys are unable to remove the buildup of toxins that occurs with the metabolism of daily life. Dialysis removes these toxins and filters the blood, taking over some of the roles the kidneys play in detoxifying the blood. Dialysis serves two important roles: waste removal and fluid removal. There are two forms of dialysis: hemodialysis and peritoneal dialysis.
Hemodialysis Is performed by attaching the patient to an external machine called a dialyzer. The procedure is usually performed at a dialysis center, although home units do exist. Hemodialysis requires the use of large needles and tubing to remove and return the blood. The needles are inserted into a site where an artery has been surgically connected to a vein: an arteriovenous (A-V) fistula. Common complications encountered with patients on hemodialysis include bleeding from the A-V fistula site after dialysis and infection at the site of external dialysis catheters.
Peritoneal dialysis
- Requires a permanent catheter that is implanted through the patient’s abdominal wall and into the peritoneal cavity. Several liters of a specially formulated dialysis solution are run into the abdominal cavity to be absorbed into the intestines. Peritoneal dialysis can be performed at home. Common complications encountered with patients on peritoneal dialysis include dislodging of the catheter and infection in the peritoneal cavity (peritonitis), which results in the normally clear dialysis fluid turning cloudy. EMT Assessment and Transport. Do not take a blood pressure on any arm with an A-V shunt, fistula, or graft, as this can cause damage that requires surgical repair. If a shunt, graft, or fistula ruptures, significant blood loss (up to 500 mL/minute or more) will occur very quickly. In the case of a bleeding shunt, stop the bleeding by direct pressure. In the case of a fistula or graft bleed, which may be indicated by significant swelling under the skin at the site, apply direct pressure. Do not release the pressure until advised by a physician to do so. because the pressure is unlikely to allow clotting that would stop the bleeding. In all cases of bleeding from a shunt, fistula, or graft, the patient should be treated for shock, transported, and carefully monitored.
Central IV Catheters
Sometimes a patient you encounter will have a central IV catheter A patient who receives frequent IV therapy, such as with chemotherapy or total parenteral nutrition, may have one of a variety of such catheters. Inserted in a hospital with surgery or under radiography, central IV catheters prevent patients from having to endure multiple needle sticks in their arms. A common problem with central IV catheters is infection at the site. Central IV catheters are usually inserted via a surgical venous puncture to introduce medications or fluids into the central circulation. One form of central IV catheter is the peripherally inserted central catheter (PICC) line, which has an external lube slightly larger than IV tubing. The catheter is inserted into a peripheral vein, then threaded into the central circulation. A PICC line is often found inserted into the patient’s arm.
Physical Impairments
Patients who call EMS may have a variety of impairments that affect their hearing, sight, or speech. When one of these senses has been adversely affected or removed, you should take extra care and time to help the patient adjust. It is important to remember, however, that these impairments do not necessarily affect the patient’s ability to think. Each limitation requires different approaches and considerations when you are assessing and treating the patient. Although hearing loss is more common in the elderly than in younger persons it is not restricted to the older patient. Approach each patient individually and ascertain his abilities. Not all patients with hearing loss can read lips, and in most cases yelling or slowing down your speech will only make matters May mga pagkakataon worse. One of the easiest na ang pasyente ay bingi o ways to communicate with bulag. Kailangan mong maga patient with hearing loss is adjust sa pakikipag-usap to write your questions and dito. Importante na hindi explain your actions on a piece of paper. Many dispatch ka nagmamadali at pinagiisipan mong mabuti kung centers and communities papaano mo mabibigyan ng also have TDD/TTY phones, pinakamagandang lunas ang and may be able to relay problema ng pasyente. information through these devices.
ABUSE AND NEGLECT Keep in mind that patients with special challenges can be more vulnerable to physical or sexual abuse, exploitation, and neglect because of their dependence on others. This vulnerable cases of abuse and neglect population can include children and adults, especially the elderly. Be alert to this possibility during your scene size-up, history taking, and assessment Stories that are inconsistent with injuries, multiple injuries in various stages of healing, repeated injuries, and caregivers’ indifference to the patient should bring to mind the possibility of abuse or neglect . As with any suspected case of abuse or neglect, do not make accusations. Do your best to get the patient out of the environment and report your suspicions according to the requirements of your jurisdiction. LIFELINE
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BY now you already have the basic knowledge of what to do in times of various medical emergencies. The next thing that you should aspire for is to be able to put all these together and apply them in your work as an EMT. Now the real action begins. In preceding chapters, what we taught you was how to provide care for persons who are injured or ill. These skills are definitely important for you as a healthcare provider. But there are certain non-medical operational skills that are just as important. In this chapter, you will learn about EMS support and operations, including the phases of an ambulance or other transport vehicle call and air medical response. You will know how ambulances are prepared, how calls are received, and how ambulances go to the patient and transfer him to the hospital. As a future EM, you may never be involved in all of these situations but, as a part of your training, you should have a brief overview of the important aspects of out-of-hospital care. You have a lot of things to learn in this chapter. Master these things and you would be able to avoid problems later on in your work as an EMT.
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26
EMS Operations
Ambulance inspection Receiving and responding to a call Operating the ambulance Securing the patient Transporting the patient to the hospital Terminating the call Air rescue LIFELINE
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INTRODUCTION Day 26
AMBULANCE OPERATIONS IN EMT PRACTICE
EMS OPERATIONS
UNIT DAY
LEARNING OBJECTIVES
INTRODUCTION EMS OPERATIONS
• Identify what is essential for completion of a call. • State what information is essential in order to respond to a call. Your responsibilities may differ somewhat • Discuss the medical and non-medical equipment needed to depending on the type of EMS agency you respond to a call. join. However, most nonmedical operational • Discuss “Due Regard For Safety of All Others” while responsibilities include the following five operating an emergency vehicle. phases: • Discuss various situations that may affect response to a call. • Preparing for the ambulance call. • List the phases of an ambulance call. • Receiving and responding to a call. • List contributing factors to unsafe driving conditions. • Transferring the patient to the • Describe the considerations that should by given to: Request ambulance. for escorts, Following an escort vehicle and intersections. • Transporting the patient to the hospital. • Describe the general provisions of state laws relating to the • Terminating the call. operation of the ambulance and privileges in any or all of the following categories: Speed, Warning lights, Sirens, Right-of-way, Parking and Turning. Sa chapter na ito ay matututunan mo ang • Describe how to clean or disinfect items following patient ² Limmer, O’Keefe, “Emergency Care”, 12th Edition. Brady, NJ (2012) basics ng operasyon ng Emergency Medical care. ³ Pollack, “Emergency Care and Transport of Sick and Injured”, 10th Edition. AAOS, MS (2011) Service o EMS.Department Ituturo sa iyo • Differentiate between the various methods of moving a ⁴ National Highway and Traffic Safety Administration (NHTSA), “EMT Basic Standard Curriculum“, of dito Transportation, USA, (2005) kung ano ang mga importanteng patient to the unit based upon injury or illness. kagamitan sa loob ng ambulansya, • Apply the components of the essential patient information papaano ginagamit ang mga ito, in a written report. at kung ano ang mga • Summarize the importance of preparing the unit for the dapat tandaan para next response. maging laging handa sa • Distinguish among the terms cleaning, disinfection, highpagtugon sa mga pasyente. level disinfection, and sterilization.
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Receiving and responding to a call Transferring the patient to the ambulance Transporting the patient to the hospital Terminating the call
PREPARING FOR THE AMBULANCE CALL PREPARING FOR THE AMBULANCE CALL The modern ambulance has come a long way from its primitive beginnings. Far more than just means of transport, today’s ambulance is a well-equipped and efficiently organized mobile prehospital emergency department and communications unit. Department of Health (DOH) has issued an Administrative Order called the National Policy on Ambulance Use and Services that details the functions and responsibilities of ambulances in the Philippines. It outlines the general policies in the operations of ambulances, and mandates other agencies to develop guidelines in the use of such emergency vehicles. Among the agencies directed by this order to act is the Land Transportation Office and the Toll Regulatory Board to regulate the use of ambulances and, at the same time, provide them with certain privileges such as free access to tollways.
T4 26 AMBULANCE OPERATIONS IN EMT PRACTICE
The modern ambulance has come a long way from its primitive beginnin Far more than just means of transport, today's ambulance is a well-equipp and efficiently organized mobile prehospital emergency department and co munications unit.
Ambulance Supplies and Equipment
Ambulance Supplies and Equipment “
Ensuring Ambulance Readiness for Service
The U.S. Department of Transportation has issued specifications for Typ Type II, and Type III ambulances. Because of the extra equipment now pla on ambulances for specialty rescue, advanced life support, and hazardous terials operations, their gross vehicle weight has been easily exceeded in so communities. This has necessitated introduction of a medium-duty truck ch sis built for rugged durability and large As a professional storage and work areas. As evolve, bulance standards will also continuerescuer, you are expected to evolve. by the public and your organization to be ready when an emergency occurs. Therefore, you must be sure that you. your vehicle, and your equipment are ready to respond. Most services require that an inspection of the vehicle and equipment be conducted If an ambulance does not have the proper equipment for patient care and at the start of every shift to transportation, it is just a ride to the hospital. Each locality has a list of equipment ensure “readiness.” ² Limmer (Brady) required to be carried by EMS response units. Please refer to your province or If an ambulance does not have the proper equipment for patient care and ³ Pollack, (AAOS) ⁴ NHTSA regional office for your specific regulations and an equipment list. transportation, it is just a ride to the hospital. Each locality has a list of equipCompare the items included in the list of equipment required by your locality or ment required to be carried by EMS response units. Please refer to your state or region—with the inventory of your ambulance. Learn where each item is stored, what regional office for your specific regulations and an equipment list. every item is for. and when it should be used. If the item is a mechanical device, also learn how it works and how it should be maintained.
Compare the items listed in Table and lists of equipment required by your locality or region—with the inventory of your ambulance. Learn where each item is stored, what every item is for. and when it should be used. If the item is a mechanical device, also learn how it works and how it should be maintained.
Ensuring Ambulance Readiness for Service As a professional rescuer, you are expected by the public and your organization to be ready when an emergency occurs. Therefore, you must be sure that
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2. Head immobilization device (not • sandbags) Short (extrication, head-to-pelvis l • Firm padding or commercial device head-to-feet length) with at least 3. Lower extremity (femur) traction devices straps (chin strap alone should • Lower extremity, limb-support slings, padded ankle hitch, pad- not tion) and with padding for children ded pelvic support, traction strap (adult and child sizes) AMBULANCE OPERATIONS IN EMT PRACTICE Day 26 patients devices 4. Upper and lower extremity immobilization • Joint-above and joint-below fracture (sizes appropriate for adults and children), rigid-support constructed with appropriate material (cardboard, metal, pneumatic, vacuum, wood, or plastic) A. Ventilation and airway equipment 5. Impervious 1. Portable fixed suction apparatus with a regulator (per backboards (long, short; radiolucent preferred) & extricafederal specifications; see specification KKK-A-1822F tion device reference) • Short (extrication, head-to-pelvis length) and long (transport, • Wide-bore tubing, rigid pharyngeal curved tip; head-to-feet length) with at least three appropriate restraint tonsillar flexible suction catheters, 6F-16F are straps (chin strap alone should not be used for head immobilizacommercially available (have one between 6F and 10F tion) and with padding for children and handholds for moving and 12F and 16F). 2. Portable oxygen apparatus, capable of metered flow patients
Required equipment for basic life support ambulances
adequate tubing. 3. Portable and fixed oxygen supply equipment • variable flow regulator. 4. Oxygen administration equipment • Adequate length tubing; transparent mask (adult and child sizes), both nonrebreathing and valveless; nasal cannulas (adult, child). 5. Bag-valve mask (manual resuscitator) • Hand-operated, self-reexpanding bag; adult (>1,0O0 mL) and child (450-750 mL) sizes, with oxygen reservoir/accumulator; valve (clear, disposable, operable in cold weather); and mask (adult, child, infant, and neonate sizes). 6. Airways • Nasopharyngeal (16F-34F; adult and child sizes). • Oropharyngeal (sizes 0-5; adult, child, and infant sizes). 7. Pulse oximeter with pediatric and adult probes. 8. Saline drops and bulb suction for infants.
B. Monitoring and Defibrillation ² Limmer (Brady)
³ Pollack, (AAOS) All ambulances should be equipped with an automated ⁴ NHTSA external defibrillator (AED) unless staffed by advanced life support personnel who are carrying a monitor/defibrillator. The AED should have pediatric capabilities, including childsized pads and cables.
C. Immobilization
1. Cervical collars • Rigid for children ages 2 years or older; child and adult sizes (small, medium, large, and other available sizes). 2. Head immobilization device (not sandbags). • Firm padding or commercial device. 3. Lower extremity (femur) traction devices. • Lower extremity, limb-support slings, padded ankle hitch, padded pelvic support, traction strap (adult and child sizes). 4. Upper and lower extremity immobilization devices • Joint-above and joint-below fracture (sizes appropriate for adults and children), rigid-support constructed with appropriate material (cardboard, metal, pneumatic, vacuum, wood, or plastic).
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² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
5. Impervious backboards (long, short; radiolucent preferred) and extrication device. • Short (extrication, head-to-pelvis length) and long (transport, head-to-feet length) with at least three appropriate restraint straps (chin strap alone should not be used for head immobilization) and with padding for children and handholds for moving patients.
D. Bandages
1. Commercially packaged or sterile burn sheets 2. Triangular bandages • Minimum two safety pins each 3. Dressings • Sterile multitrauma dressings (various large and small sizes) • ABDs, 10* x 12” or larger • 4’ x 4” gauze sponges or suitable size 4. Gauze rolls • Various sizes 5. Occlusive dressing or equivalent • Sterile, 3* x 8” or larger 6. Adhesive tape • Various sizes (including 1” and 2”) hypoallergenic • Various sizes (including 1” and 2”) adhesive 7. Arterial tourniquet (commercial preferred)
length) and long (transport, t three appropriate restraint be used for head immobilizan and handholds for moving
E. Communication
Two-way communication device between EMS provider, dispatcher, and medical direction.
F. Obstetrical Kit (commercially packaged is available)
1. Kit (separate sterile kit) • Towels, 4” x 4” dressing, umbilical tape, sterile scissors or other cutting utensil, bulb suction, clamps for cord, sterile gloves, blanket. 2. Thermal absorbent blanket and head cover, aluminum foil roll, or appropriate heat-reflective material (enough to cover newborn).
G. Miscellaneous
1. Sphygmomanometer (pediatric and adult regular and large size cuffs) 2. Adult stethoscope 3. Length/weight-based tape or appropriate reference material for pediatric equipment sizing and drug dosing based on estimated or known weight 4. Thermometer with low temperature capability 5. Heavy bandage or paramedic scissors for cutting clothing, belts, and boots 6. Cold packs 7. Sterile saline solution for irrigation (1 -liter bottles or bags) 8. Flashlights (2) with extra batteries and bulbs 9. Blankets 10. Sheets (minimum 4), linen or paper, and pillows 11. Towels 12. Triage tags 13. Disposable emesis bags or basins 14. Disposable bedpan 15. Disposable urinal 16. Wheeled cot (conforming to national standard at the time of manufacture) 17. Folding stretcher 18. Stair chair or carry chair 19. Patient care charts/forms 20. Lubricating jelly (water soluble)
H. Infection Control (latex-free equipment should be available)
1. Eye protection (full peripheral glasses or goggles, face shield) 2. Face protection (for example, surgical masks per applicable local guidance) 3. Gloves, nonsterile 4. Coveralls or gowns 5. Shoe covers 6. Waterless hand cleanser, commercial antimicrobial (towelette, spray, liquid) 7. Disinfectant solution for cleaning equipment 8. Standard sharps containers, fixed and portable 9. Disposable trash bags for disposing of biohazardous waste
10. Respiratory protection (e.g., N-95 / N-100 mask—per applicable local guidance.
I. Injury Prevention Equipment
1. All individuals in an ambulance need to be restrained (there is currently no national standard for transport of uninjured children) 2. Protective helmet 3. Fire extinguisher 4. Hazardous material reference guide 5. Traffic signalling devices (reflective material triangles or other reflective, nonigniting devices) 6. Reflective safely wear for each crew member
Optional Basic Equipment This section is intended to assist EMS providers in choosing equipment that can be used to ensure delivery of quality prehospital care. Use should be based on local resources. The equipment in this section is not mandated or required. However, it is used by Lifeline Ambulances.
A. Optional Equipment
1. Glucose meter (per state protocol) 2. Elastic bandages • Nonsterile (various sizes) 3. Cellular phone 4. Infant oxygen mask 5. Infant self-inflating resuscitation bag 6. Airways • Nasopharyngeal (12Fr, 14Fr) • Oropharyngeal (size 00) 7. Alternative airway devices (for example, a rescue airway device such as the ETDLA [esophageal-tracheal double lumen airway], laryngeal tube, or laryngeal mask airway) as approved by local medical direction. 8. Alternative airway devices for children (few alternative airway devices that are FOA approved have been studied in children. Those that have been studied, such as the IMA, have not been adequately evaluated in the prehospital setting). 9. Neonatal blood pressure cuff 10. Infant blood pressure cuff 11. Pediatric stethoscope 12. Infant cervical immobilization device 13. Pediatric backboard and extremity splints 14. Topical hemostatic agent 15 Appropriate CBRNE PPE (chemical- biological radiological, nuclear, explosive personal protective equipment), including respiratory and body protection. 16. Applicable chemical antidote auto-injectors (at a minimum for crew members’ protection; additional for patient treatment based on local or regional protocol; appropriate for adults and children).
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1.
Hydraulic jack/spreader/cutter combination cutting tools
2. Air-cutting Saws (hacksaw, fire, windshield, pruning, 6. Jackets Jackets coats //reciprocating) boots 3. gun kit 6. // coats boots B. Optional Basic Life Support E. Miscellaneous 2. SawsMedications (hacksaw, fire, windshield, pruning, reciprocating)
3. Air-cutting gun kit E. E. Miscellaneous Miscellaneous Albuterol 3. Air-cutting gun kit C. Pulling Tools/Devices C. Pulling Tools/Devices 1. Shovel Shovel 1. 1. Ropes/chains EpiPens C. Pulling Tools/Devices 1. Ropes/chains 2. Lubricating oil 2. Lubricating oil 2. Come-along Oral glucose 1. Ropes/chains 2. Hydraulic Come-along 3. Wood/wedges 3. Wood/wedges 3. truck jack Nitroglycerin (sublingual tablet or paste) 2. Come-along 3. Air Hydraulic 4. Generator Generator bags truck jack 4. 3. Hydraulic truck jack 4. Day 26 4. Air bags 5. Floodlights 5. Floodlights D. Protective Devices C. Interfacility Transport4. Air bags D. Protective Devices 1. Reflectors/flares D. Protective Devices Additional equipment may be needed by ALS and1.BLSReflectors/flares prehospital 2. Transfers Hard hats 1. Reflectors/flares care providers who transport patients between facilities. may 2. Hard hats 3. on Safety Goggles 2. Hard be done 1. Albuterol to a lower or higher levelhats of care, depending the specific 3. Safety Goggles 4. and Fireproof blanket 3. teams, Safetyincluding Goggles pediatric need. Specialty transport neonatal 2. EpiPens 4. Fireproof blanket 5. Leather gloves 4. personnel Fireproof blanket teams, may include other such as respiratory therapists Local extrication needs may 3. Oral glucose 5. LeatherLocal 5. needs Leather gloves Local extrication needs may extrication may gloves 6. may Jackets / coats / boots nurses and physicians. Training and equipment needs benecessitate differadditional equip6. Jackets / coats / boots 4. Nitroglycerin (sublingual tablet or paste) necessitate additional equipnecessitate additional equip6. needed Jacketsduring / coatstransport / boots E. Miscellaneous ent depending on the skills of these patients. ment for water, aerial, or E. Miscellaneous ment for water, aerial, or ment for water, aerial, or E. Miscellaneous 1. detailed Shovel There are excellent resources available that provide lists of rescue. mountain mountain rescue. rescue.1. Shovel Shovel mountain Lubricating equipment needed for 1. interfacility transfer such 2. as the American 2. Lubricating oil oil 2. Lubricating oiland Ground 3. Wood/wedges Academy of Additional equipment may be needed by ALS and Pediatrics Guidelines for Air Transport of 3. Wood/wedges 3. Wood/wedges 4. NeonatalBLS prehospital care providers who transport patients and Pediatric Patients. 4. Generator Generator 4. Generator between facilities. Transfers may be done to a lower or 5. 5. Floodlights Floodlights 5. Floodlights TRICATIONhigher level of care, depending on the specific need. EQUIPMENT 1. 2. 3. 4.
1. 2. 3. 4. 5.
Shovel Lubricating oil Wood/wedges Generator Floodlights
AMBULANCE OPERATIONS IN EMT PRACTICE
B. Optional Basic Life Support Medications
C. Interfacility Transport
Specialty transport teams, including pediatric and
neonatal teams, may include other personnel such as quate extrication equipment must be readily available to the emergency respiratory therapists nurses and physicians. Training ical service responders, but is more often found on heavy rescue vehicles and equipment needs may be different depending on the n on the primary responding ambulance. In general, the devices or tools skills needed during transport of these patients. There are d for extrication fall into several broadmay categories: disassembly, spreading, Local extrication needs Local extrication needs may on may excellent resources available that provide detailed lists of ng, needs pulling, protective, and patient-related. necessitate additional equipnecessitate additional equip- The following is necessary ditional equippment that should be either equipment needed for interfacility transfer such as the ment for water, or ment for available water, aerial, aerial,on orthe primary response vehicle or ter, aerial, or heavy rescue vehicle. American Academy of Pediatrics Guidelines for Air and mountain mountainrescue. rescue. e. Ground Transport of Neonatal and Pediatric Patients.
Limmer(Brady) (Brady) ²²Limmer Pollack,(AAOS) (AAOS) ³³Pollack, NHTSA ⁴⁴ NHTSA
EXTRICATION EQUIPMENT
er (Brady) ck, (AAOS) SA
² Limmer (Brady)
³ Pollack, (AAOS) ⁴ NHTSA
² Limmer (Brady) ² ³Limmer Pollack,(Brady) (AAOS) ³ ⁴Pollack, NHTSA(AAOS) ⁴ NHTSA
Adequate extrication equipment must be readily available to the emergency medical service responders, but is more often found on heavy rescue vehicles than on the primary responding ambulance. In general, the devices or tools used for extrication fall into several broad categories: disassembly, spreading, cutting, pulling, protective, and patient-related. The following is necessary equipment that should be available either on the primary response vehicle or on a heavy rescue vehicle.
A. Disassembly Tools
1. Wrenches (adjustable) 2. Screwdrivers (flat and Phillips head) 3. Pliers 4. Bolt cutter 5. Tin snips 670
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6. Hammer 7. Spring-loaded center punch 8. Axes (pry, fire) 9. Bars (wrecking, crow) 10. Ram (4 ton)
B. Spreading Tools
1. Hydraulic jack/spreader/ cutter combination cutting tools 2. Saws (hacksaw, fire, windshield, pruning, reciprocating) 3. Air-cutting gun kit
C. Pulling Tools/Devices 1. Ropes/chains
² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
2. Come-along 3. Hydraulic truck jack 4. Air bags
D. Protective Devices
1. Reflectors/flares 2. Hard hats 3. Safety Goggles 4. Fireproof blanket 5. Leather gloves 6. Jackets / coats / boots
E. Miscellaneous
1. Shovel 2. Lubricating oil 3. Wood/wedges 4. Generator 5. Floodlights
Do a brief shift report with the off-going crew. Learn whether they experienced any problems with either the ambulance or its equipment during their shift. Make a thorough bumper-to-bumper inspection of the ambulance, using the checklist provided by your service. There are usually two components to the inspection: a vehicle component and an equipment component. In most cases, the EMT assigned to be the driver completes the vehicle component check and the EMT crew leader completes the medical equipment check.
Ambulance Inspection, Engine Off The following inspection steps can be taken while the ambulance is in quarters: 1. Inspect the body of the vehicle. Report any damage that may be evident. 2. Inspect the wheels and tires. Check for damage or worn wheel rims and tire sidewalls. Check the (read depth. Use a pressure gauge to ensure that all tires arc properly inflated. Do not forget to inspect the inside rear tires. 3. Inspect the windows and mirrors. Look for broken glass and loose or missing parts. See that mirrors are clean and properly adjusted for maximum visibility. 4. Check the operation of every door and all latches and locks. 5. Check the level of the fluids: oil, coolant, and brake and transmission fluids, 6. Check the battery. Inspect the battery cable connections for tightness and signs of corrosion. 7. Inspect the interior surfaces and upholstery for damage and cleanliness. 8. Check the windows for operation. See that the interior surface of each window is clean. 9. Test the horn, siren, and emergency lights 10. Adjust the driver’s seat and ensure the seat belts are operational. 11. Check the fuel level. Refuel after each call whenever practical. Mahalaga na i-check ang ambulansya para anumang oras ay handa itong rumesponde. I-check palagi ang mga ilaw ng sasakyan -- mula sa headlight, park light, at emergency lights. I-check din palagi ang makina at mga pang-ilalim na bahagi ng sasakyan at ayusin na ang mga kailangang ayusin. Huwag maghintay na tumirik pa ang ambulansya bago mo ito ayusin.
Ambulance Inspection, Engine On The next steps require you to start the engine. Pull the ambulance from quarters if engine exhaust fumes will be a problem. Set the parking brake, put the transmission in “park.” and have your partner check the wheels before undertaking the following steps: 1. Check the dash-mounted indicators to see if any light remains on to indicate a possible problem with oil pressure, engine temperature, or the vehicle’s electrical system. 2. Check dash-mounted gauges for proper operation. 3. Depress the brake pedal. Note whether pedal travel seems correct or excessive. Check air pressure as needed. 4. Test the parking brake. Move the transmission level to a drive position. Replace the level to the “park” position as soon as you are sure that the parking brake is holding. 5. Turn the steering wheel from side to side. 6. Check the operation of the windshield wipers and washers. The glass should be wiped clean each time the blade moves. 7. Turn on the vehicle’s warning lights. Have your partner walk around the ambulance and check each flashing and revolving light for operation. Turn off the warning lights. 8. Turn on the other vehicle lights. Have your partner walk around the ambulance again, this time checking the headlights (high and low beams), turn signals, four-way flashers, brake lights, side and rear scene illumination lights, and box marker lights. 9. Check the operation of the heating and airconditioning equipment in both the driver’s compartment and the patient compartment. This is also a good time to check the onboard suction if the engine is running. 10. Check transmission fluid. 11. Operate the communications equipment. Test portable as well as fixed radios and any radio telephone communications. 12. Return the ambulance to quarters. While you are backing up. have your partner note whether the backup alarm is operating (if the vehicle is so equipped).
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1.
Using your checklist, conduct a detailed inspection and inventory the equipment and supplies. 2. Check treatment supplies and equipment and rescue equipme Items should not only be identified, they should also be checked f completeness, condition, and operation. Check the pressure of ox gen cylinders. Inflate air splints and examine them for leaks. Test ox Day 26 gen and ventilation equipment for proper operation. Examine resc tools for rust and din. Operate battery-powered devices to ensu that the batteries have a proper charge. Some equipment, such as t AED. may require additional testing. See that an item-by-item inspe tion of everything carried on the ambulance is done, with findin recorded on the inspection report. Shut off the engine and complete your inspection by checking the patient compartment and all exterior cabinets: 3. When you are finished, complete the inspection report. Correct a deficiencies Replace missing items. Make your supervisor aware 1. Using your checklist, conduct a detailed inspection an item-by-item inspection of everything carried on any deficiencies that cannot be immediately corrected. and inventory of the equipment and supplies. 4.the ambulance is done, with findings recorded on the Finally, clean the unit for infection control and appearance. Mainta 2. Check treatment supplies and equipment and rescue inspection report. ing the ambulance's appearance enhances your organization's ima equipment. Items should not only be identified, they 3. When you are finished, complete the inspection in the public's eye. People who take pride in their work show it should also be checked for completeness, condition, report. Correct any deficiencies. Replace missing taking pride in the appearance of their ambulance.
AMBULANCE OPERATIONS IN EMT PRACTICE
Inspection of Patient Compartment Supplies and Equipment
and operation. Check the pressure of oxygen cylinders. “ Inflate air splints and examine them for leaks. Test oxygen and ventilation equipment for proper operation. Examine rescue tools for rust and din. Operate battery-powered devices to ensure that the batteries have a proper charge. Some equipment, such as the AED. may require additional testing. See that
items. Make your supervisor aware of any deficiencies that cannot be immediately corrected. RECEIVING AND RESPONDING TO A CALL 4. Finally, clean the unit for infection control and appearance. Maintaining the ambulance’s appearance In many areas of the country, a person needs only to dial 911 to access amb lance,enhances your organization’s image in the public’s eye. fire, or police services 24 hours a day. A trained Emergency Medical D People who take pride in their work show it by taking patcher (EMD) records in-formation from callers, decides which service needed, and alerts that service to respond (Always say "nine-one-one" wh pride in the appearance of their ambulance.
talking to community or school groups. Children cannot find "eleven" on th phone dial or key pad.)
RECEIVING AND RESPONDING TO A CALL
In many areas of the country, a person needs only to dial 911 to access ambulance, fire, or police services 24 hours a day. A trained Emergency Medical Dispatcher (EMD) records information from callers, decides which service is needed, and alerts that service to respond (Always say “nine-one-one” when talking to community or school groups. Children cannot find “eleven” on the phone dial or key pad.) Lifeline uses 16-911 as it emergency number.
Role of the Emergency Medical Dispatcher Many cities and communication centers train and certify Emergency Medical Dispatchers (EMDs) based on the medical priority card system. This system originated in 1979 through the leadership of Jeffrey Clawson, MD. An EMD is trained to perform the following tasks: • Ask questions of the caller and assign a priority to the call. • Provide pre-arrival medical Instructions to callers and information to crews. • Dispatch and coordinate EMS resources. • Coordinate with other public safety agencies. When answering a call for help, the EMD must obtain as much information as possible the situation that may help the responding crew. The questions the HMD should ask are: 1. What is the exact location of the patient? The EMD must ask for the house or building number and the apartment number, if any. It is important to ask for the street name with the direction designator (e.g.. North, East), the 672
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² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
nearest cross street, the name of the development or subdivision, and the exact location of the emergency. 2. What is your call-back number? (Enhanced system will show the number.) “Stay on the line. Do not hang up until I (the EMD) tell you to.” In life-threatening situations, the EMD will offer instructions to the caller, after the units have been dispatched, that the caller or others on the scene should follow until the units arrive. It is also important for the caller to stay on the line in case a question arises about the location that was given. 3. What is the problem? This will provide the chief complaint. It will help the EMD decide which line of questioning to follow and the priority of the response to send. 4. How old is the patient? Most ambulances are set up to respond to the scene with a pediatric kit if the patient is a child rather than an adult. If pre-arrival CPR instructions are given, it will be necessary to distinguish between an infant, a child, and an adult. 5. What’s the patient’s sex? Ask this if it is not obvious from the information given. 6. Is the patient conscious? An unconscious patient is a higher response priority. 7. Is the patient breathing? If the patient is conscious and
of
ent. for xyxycue ure the ecngs
breathing, the EMD will often ask many additional questions relative to the chief complaint to determine the appropriate level of response: for example. Emergency Medical Respondent EMTs, or ambulances may respond “cold” (at normal speed—sometimes called Priority 3) or “hot” (an emergency, lights-and-siren mode—sometimes called Priority I). If the patient is not breathing, or the caller is not sure, the EMD will dispatch the maximum response and begin the appropriate pre-arrival instructions for a non-breathing patient, which may also involve telephone CPR if the patient does not have a pulse.
any of
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buDisis hen he
If the call is for a traffic collision, a series of key questions must be asked to help determine the priority and amount of response. With thorough questioning of the caller, it may be possible for the EMD to appropriately dispatch one unit “hot” and backup units “cold,” which in turn will help prevent emergency vehicle collisions.
Lifeline uses “Code 66” to identify a “Hot” emergency.
Operating the Ambulance
Even if you will only occasionally be driving an ambulance, you may be mandated to attend emergency vehicle operator training, which has both classroom and in-vehicle road sessions.
Being a Safe Ambulance Operator
UNIT 4 DAY 26
To be a safe ambulance operator, you must: • Be physically fit. You should not have any impairment that prevents you from operating the ambulance or any medical condition that might disable you while driving. • Be mentally fit. with your emotions under control. The Some additional safety tips include: judgment of someone operating • Never drive while under the an ambulance should not be influence of alcohol, illicit or compromised by the excitement of “recreational” drugs such as AMBULANCE EMT PRACTICE lights and sirens. OPERATIONS IN marijuana or cocaine, medicines • Be able to perform under stress. such as antihistamines, “pep pills.” • Have a positive altitude about your or tranquilizers. ability as a driver but not be an • Never drive with a restricted overly confident risk taker. license. Operating the Ambulance • Be tolerant of other drivers. • Always wear your glasses or contact Always keep in mind that people lenses if required for driving. Even if you will only occasionally be driving an ambulance, you may be manreact differently when they see an Evaluate your ability to drive based dated to attend emergency vehicle operator • training, which has both classroom and in-vehicle road sessions. emergency vehicle. Accept and on personal stress, illness, fatigue, tolerate the bad habits of other or sleepiness. drivers without flying into a rage. Being a Safe Ambulance Operator
To be a safe ambulance operator, you must: Be physically fit. You should not have any impairment that prevents you from operating the ambulance or any medical condition that might disable you while driving. Be mentally fit. with your emotions under control. The judgment of someone operating an ambulance should not be compromised by
Importante na maging malinis palagi ang inyong ambulansya. Panatiliing malinis ito, labas at loob. Ang kalinisan ng loob nito ay importante dahil puwedeng ang pasyenteng iyong isinakay ay may nakakahawang sakit. Siguruhin na i-sterilize mo ang loob ng ambulansya matapos ang responde. At importante rin na malinis ang labas ng iyong ambulansya dahil ito ang nakikita ng publiko. Ang ambulansyang marumi at hindi well-maintained ay nagsasabi na ang mga nakasakay din dito ay burara at walang malasakit sa kalusugan ng kanilang pasyente. Laging isaisip na ang ambulansya ang lumilikha ng “First Impression” sa isip ng mga nakakakita rito. Kung anong hitsura ng ambulansya n’yo, yun din malamang ang klase ng impression na iniiwan n’yo sa isip ng publiko.
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Unit 3
Day 26
Understanding the Law Every city has statutes that regulate the operation of emergency vehicles. Emergency vehicle operators are generally granted certain exemptions with regard to speed, parking, passage through traffic signals, and direction of travel. However, the laws also state that if an emergency vehicle operator does not drive with due regard for the safety of others, he must be prepared to pay the consequences, such as tickets, lawsuits, or even time in jail. The following list contains some points typically included in laws regulating ambulance operation: • An ambulance operator must have a valid driver’s license and may be required to complete a training program. • Privileges granted under the law to the operators of ambulances apply when the vehicle is responding to an emergency or is involved in the emergency transport of a sick or injured person. When the ambulance is not on an emergency call, the laws that apply to the operation of nonemergency vehicles also apply to the ambulance. • Even though certain privileges are granted during an emergency, the exemptions granted do not provide immunity to the operator in cases of reckless driving or disregard for the safety of others. • Privileges granted during emergency situations apply only if the operator uses warning devices in the manner prescribed by law. Most statutes allow emergency vehicle operators to: • Park the vehicle anywhere if it does not damage personal property or endanger lives. • Proceed past red stop signals, flashing red stop signals, and stop signs. Some states require that emergency vehicle operators come to a full stop, then proceed with caution. Other localities require only that an operator slow down and proceed with caution. • Exceed the posted speed limit as long as life and properly are not endangered. • Pass other vehicles in no-passing /ones after properly signaling, ensuring that the way is clear, and taking precautions to avoid endangering life and property. This does not include passing a school bus with its red lights blinking. Wait for the bus driver to clear the children and then turn off the red lights of the bus. • With proper caution and signals, disregard regulations that govern direction of travel and turning in specific directions. 674
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AMBULANCE OPERATIONS IN EMT PRACTICE If you ever become involved in an ambulance collision, the laws will be interpreted by the court based upon two key issues: 1. Did you use due regard for the safety of others? And 2. Was it a true emergency? The requirement of due regard actually sets a higher standard for drivers Of emergency vehicles than for other drivers. This is why an investigation by the district attorney or grand jury, as well as your ambulance service, is not uncommon following a collision. Most cities reserve the emergency mode of operation for a true emergency, defined as one in which the best information available to you is that loss of life or limb is possible. When dispatched to a call, there is often not much information to go on. so a “collision” will get an emergency response. However, once you arrive and find that your patient is stable with no life-threatening injuries or conditions, it is no longer a true emergency. A lightsand-siren, high speed response to the hospital in such a situation would be improper The exemptions described here are just examples of those often granted to ambulance operators. Do not assume that they are granted in your city. Obtain a copy of your local rules and regulations and carefully study them,
UNIT 4 DAY 26
Using the Warning Devices Safe emergency vehicle operation can be achieved only when proper use of warning devices is coupled with sound emergency and defensive driving practices. Studies show that other drivers do not see or hear an ambulance until it is within 50 to 100 feet, so never let the lights and siren give you a false sense of security.
The Siren
Although the siren is the most commonly used audible warning device, it is also the most misused. Consider the effects that sirens have on other motorists, patients in ambulances, and ambulance operators themselves: • The continuous sound of a siren may cause a sick or injured person to suffer increased fear and anxiety, and his condition may worsen as stress builds up. • Ambulance operators themselves are affected by the continuous sound of a siren. Tests have shown that inexperienced ambulance operators tend to increase their driving speeds from 20-30 kilometers per hour while continually sounding the siren. In some cases, operators using a siren were unable to negotiate curves that they could pass through easily when not sounding the siren. Sirens also affect hearing, especially if used for long periods with the siren speaker over the cab. The best placement for the speaker is in the vehicle grill.
Many cities have laws that regulate the use of audible warning signals. In areas where there are no statutes, ambulance organizations usually create their own policies. If your organization does not, you may find the following suggestions helpful: • Use the siren sparingly, and only when you must. Some cities require use of the siren at all times when the ambulance is responding in the emergency mode. Others require it only when the operator is exercising any of the exemptions discussed earlier. • Never assume that all motorists will hear your signal. Buildings, trees, and dense shrubbery may block siren sounds. Soundproofing keeps outside noises
from entering vehicles, and radios or CD players also decrease the likelihood that an outside sound will be heard. • Always assume that some motorists will hear your siren but ignore it. • Be prepared for the erratic maneuvers of other drivers. Some drivers panic when they bear a siren. • Do not pull up close to a vehicle and then sound your siren. This may cause the driver to jam on his brakes and you may be unable to stop in time. Use the horn when you are close to a vehicle ahead. • Never use the siren indiscriminately, and never use it to scare someone.
UNIT 4 DAY 26 AMBULANCE OPERATIONS IN
The Horn
The horn is standard equipment on all ambulances. Experienced operators find that the judicious use of the horn often clears traffic as quickly as the siren. The guidelines for using a siren apply to the horn as well.
4 Visual WarningOPERATIONS Devices IN EMT PRACTICE 6 AMBULANCE Whenever the ambulance is on the road, night or day, the headlights should be on. This increases the vehicle’s visibility to other drivers. In some cities, headlights are now required of all vehicles in low visibility conditions or whenever the windshield wipers are in use. Alternating flashing headlights should be used only if they are attached to secondary head lamps. In most cities, it is illegal to drive at night with one headlight out.
The large lights on the outermost corners of the box should blink in tandem, or unison, rather than wigwagging or alternating. This helps the vehicle that is The large lights on the outermost corners of the box approaching from a distance identify the full size of your unison, rather than wigwagging or alternating. Th vehicle. There are several types of lights on ambulances, approaching from a distance identify the full size including rotating lights, flashing lights, strobe lights, and the newer LED (light-emitting diode) lights. When several types of lights on ambulances, including ro planning the lighting package of an ambulance, check strobe lights, and the newer LED (light-emitting dio the research before making your decision. In general, it is wisest for the package to combine different types of lights the lighting package of an ambulance, check the re in strategic places rather than just one type of lighting decision. In general, it is wisest for the package to system. lights in strategic places rather than just one type of Four-way flashers and directional signals should not be used as emergency lights. This is very confusing to the public, as well as being illegal in some cities. Drivers Four-way flashers and directional signals should n expect a vehicle with four-way flashers on to be traveling lights. This is very confusing to the public, as well as at a very slow speed. Additionally, the flashers disrupt the function of the directional signals. When the ambulance Drivers expect a vehicle with four-way flashers on lo is in the emergency response mode, either en route to the speed. Additionally, the flashers disrupt the functio to the station. However, this practice is very confusing to the scene or to the hospital with a high-priority patient, all public. Do not be surprised if other drivers do not pull over the emergency lights should be used. The vehicle should When the ambulance in the emergency respons The large lights on the outermost corners of the box should blink inis tandem, or when you are on an emergency run if they constantly see be easily seen from 360 degrees. the scene or to the the vehicle hospitalthat withisa high-priority unison, In some communities, ambulances still follow an old rather than wigwagging or alternating. This helps your ambulance with emergency lights on. Save the use of lights be used. TheThere vehicleare should be easily s lights and siren for life- or limb-threatening emergencies. tradition of using their emergency lights when returning approaching from a distance identify the full sizeshould of your vehicle.
several types of lights on ambulances, including rotating lights, flashing lights, In some communities, ambulances still follow an LIFELINE planning PREHOSPITAL EMERGENCY CARE 675 strobe lights, and the newer LED (light-emitting diode) lights. When emergency lights when returning to the station. Ho the lighting package of an ambulance, check the research before making your confusing to the public. Do not be surprised if oth decision. In general, it is wisest for the package to you combine types of when arc ondifferent an emergency run if they cons lights in strategic places rather than just one type of lighting system.
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Speed and Safety
Factors That Affect Response
You are often told to drive in a slow and careful manner. At this point, you may be thinking something like, “How will I ever get a seriously ill or injured person to a hospital if I poke along?” We are not suggesting that you “poke along.” However, we do suggest you drive with these facts in mind: • Excessive speed increases the probability of a collision. • Speed increases stopping distance, reducing the chance of avoiding a hazardous situation.
Most ambulance collisions take place in seemingly safe conditions. In New York State, 18 years of ambulance-collision statistics show that the typical collision happens on a dry road (60 percent) with clear weather (55 percent) during daylight hours (67 percent) in an intersection (72 percent). During this period, there were 5.782 ambulance collisions, which involved 7,267 injuries and 48 fatalities! Remember that the laws in most cities excuse you from obeying Additionally, an ambulance response can be certain traffic laws only in a true emergency and only with due regard affected by several factors: for the safety of others. Except in these circumstances, obey speed • Day of the week. Weekdays usually have limits, stoplights and signs yield signs, and other laws and posted the heaviest traffic because people are limits. Approach intersections with caution, avoid sudden turns, commuting to and from work. In resort UNIT 4 and always properly signal lane changes and turns. Be sure that the areas, weekend traffic may be heavier. DAY 26 ambulance driver and all passengers wear seat belts whenever the • Time of day. In major employment centers, ponses ambulance is in motion. traffic over major roads tends to be heavy in all directions during commuter hours. • Weather. Adverse weather conditions Escorted or Multiple-Vehicle Responsesreduce driving speeds and thus increase response times. A heavy rainfall can temporarily prevent any response at all. Be careful to lengthen your following distance whenever there is decreased road grip due to inclement weather. • Road maintenance and construction. Traffic can be seriously impeded by road construction and maintenance activities. Be aware of area road construction and plan responses as needed. • Railroads. There are still more than a quarter-million railroad crossings in the Metro Manila with traffic often blocked When the police provide an escort for an ambulance, by long, slow passenger trains. Some there are additional hazards. Too often, the inexperienced When the police provide an escort for an ambulance, there arc additional hazambulance, there arc additional hazcommunities may use a secondary response ambulance operator follows the escort vehicle too closely and ards. Too often, the inexperienced ambulance operator follows the escort vehince operator follows the escort vehisystem on the other side of train tracks that is unable to stop when the lead vehicle(s) make an emergency cle loo closely and is unable 10 stop when the lead vehicle(s) make an emern the lead vehicle(s) make an emergency stop. Also, the inexperienced operator maysplits the city in half. assume that other drivers stop. Also, the inexperienced operator may assume that other know his vehicle is following the escort. In fact, other drivers will often pull out ator may assume that other drivers drivers know his vehicle is following the escort. In fact, other • Bridges and tunnels. Traffic over bridges in front of the ambulance just after the escort vehicle passes. Because of the drivers will often pull out in front of the ambulance just after and through tunnels slows during rush fact, other drivers will often pull out dangers involved with escorts, most EMS systems recommend no escorts unless the escort vehicle passes. Because of the dangers involved hours. scort vehicle passes. Because of the the operator is not familiar with the location of the patient (or hospital) and with escorts, most EMS systems recommend no escorts • Schools and school buses. The reduced stems recommend no escorts unless must be given assistance from the police. unless the operator is not familiar with the location of the speed limits in force during school hours ion of the patient (or hospital) and patient (or hospital) and must be given assistance from the slow the flow of vehicles. An emergency In multiple-vehicle responses, the dangers can be the same as those generated police. vehicle should never pass a stopped school by escorted responses, especially when the responding vehicles travel in the In multiple-vehicle responses, the dangers can be the bus with its warning lights flashing. Wait same direction, close together. A great danger also exists when two vehicles same as those generated by escorted responses, especially can be the same as those generated approach the same intersection at the same time.for the school bus driver to signal you to Not only may they fail to he responding when the responding vehicles travel in the same direction, vehicles travel in the yield for each other; other drivers may yield for the proceed by turning off the lights. In addition, first vehicle but not the secclose together. A great danger also exists when two vehicles emergency vehicles attract children, who nger also exists when two vehicles ond. Obviously, great care must be used at intersections during multipleapproach the same intersection at the same time. Not only often venture out into the street to see them. vehicle responses. me time. Not may they fail to yield for each other; other drivers may yield only may they fail to The operator of every emergency vehicle d for the first vehicle but not the secfor the first vehicle but not the second. Obviously, great should slow down when approaching a school Factors That Affect Response d at intersections during multiplecare must be used at intersections during multiple-vehicle or playground. Obey the directions given by responses. school crossing guards. Most ambulance collisions take place in seemingly safe conditions. In New York
NS IN EMT PRACTICE
AMBULANCE OPERATIONS IN EMT PRACTICE
Escorted or Multiple-Vehicle Responses
State, 18 years of ambulance-collision statistics show that the typical collision happens on a dry road (60 percent) with clear weather (55 percent) during 676 LIFELINE PREHOSPITAL EMERGENCY CARE daylight hours (67 percent) in an intersection (72 percent). During this period, there were 5.782 ambulance collisions, which involved 7,267 injuries and 48 mingly safe conditions. In New York fatalities! Additionally, an ambulance response can be affected by several facistics show that the typical collision tors: clear weather (55 percent) during Day of the week. Weekdays usually have the heaviest traffic because
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Getting There: Navigating to the Scene Many EMS services have global positioning satellite (GPS) navigation installed in their emergency vehicles. This is an excellent tool for navigation to emergency scenes and hospitals. However, there is still no substitute for an intimate knowledge of the response area. Often a GPS suggests a route that may not be possible because of recent road construction or other changes in the area. GPS devices can also be a significant distraction! Be careful about attempting to operate the GPS while driving. Driving while distracted increases the chance of a crash. Obtain detailed maps of your service area. Hang one map in quarters and place another in the ambulance. Even if you have GPS navigation, check the maps before you leave for a call. If you get lost while responding to a call, turn off your emergency lights and siren and pull over. Recheck the map and recheck the GPS. Call the central dispatch on the radio and obtain additional instructions.
Safety at Highway Incidents Operation at highway incidents exposes EMTs to significant danger. EMTs, firefighters, and police officers are injured and killed every year while operating at the scenes of highway incidents. The following are some tips for improving the safety of highway operations. Keep Unnecessary Units and People Off the Highway. If you are not the primary or first-arriving unit, stay off the highway. Park or stage your unit near the on ramp until the first unit has sized up the incident and determined the resources needed. You don’t want to expose people to any more risk than necessary when working on the highway. The more vehicles and people gathered, the greater the risk.
Avoid Crossovers Unless a Turn Can Be Completed without Obstructing UNIT 4 Crossovers on limited access highways involve high risk. Avoid using this Traffic. AMBULANCE OPERATIONS IN EMT PRACTICE DAY 26 maneuver if possible. It may be safer to go to the next off ramp and change directions. If Yours Is the First Unit On-Scene. The first unit on-scene blocks the incident
by parking the apparatus “upstream” from the incident. The apparatus is placed to block the crash from traffic by using the vehicle as a barrier. The best vehicle for this is a fire
RESPONSE SAFETY SUMMARY The following list summarizes important points about how to make a safe response. � Minimize lights-and-siren “hot” responses. Remember: Driving with lights and siren involves high risk. � Wear your seat belts. � Know where you are going before you respond. Use the GPS and check the maps. Be familiar with your response area. � Come to a complete stop at intersections. � Don’t be a distracted driver. Have the crew leader operate the radio, siren. GPS, computer, and other devices. � Don’t eat or drink when responding under emergency conditions. Pay complete attention to the task at hand. � Don’t listen to music, text, talk on cell phones, or indulge in any other distracting activities. Pay 100 percent attention to safe driving.
Kaligtasan ang unangunang dapat ilagay sa isip ng isang EMT. Kahit pa may sirena at blinkers ang ambulansya, hindi ito dapat tumatakbo nang sobrang tulin. Ang pagmamaneho nang sobrang bilis ay naglalagay sa iyo, sa iyong grupo at sa pasyente ninyo sa mas malaking panganib. Maging maingat sa pagmamaneho upang makarating nang ligtas ang lahat sa inyong dapat puntahan.
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truck because of its size and weight. Ideally, ambulances should be parked “downstream” in a safe loading area.
The EMT should conduct a scene size-up and then transmit an arrival report. At that point, he should
cancel or request additional resources, as needed. To avoid overcrowding the site, cancel anything that is not absolutely needed. Remember: The more vehicles and people gathered, the greater the risk. Wear Your PPE. If there is no extrication in progress, wear an ANSI Class 2 safety vest and a helmet. If extrication is indicated, then you should wear turn-outs. The basic idea is this: EMS workers should match the level of protection being worn by other responders, such as fire department personnel.
Place Cones/Flares and Reduce Emergency Lighting. Place cones/flares up-stream to warn and direct
traffic around the incident. Remember that response lights can blind approaching drivers and increase scene risks. Consider reducing emergency lighting to prevent blinding motorists.
Unit Placement Is Important! Consider crash scene preservation when placing apparatus. Avoid driving
over debris and skid marks, because the police consider these to be crime scene evidence. If extrication is necessary. leave room for placing rescue vehicles that will be needed to do the extrication. Create a “safe area” downstream; place ambulances downstream past the incident. This is also a good area for the placement of command/staff vehicles. Prevent anyone from blocking the egress of ambulances, and try to keep all ambulances heading in the same direction.
Try to keep the ambulance on the same side of the road as the incident. It is very dangerous to
carry stretchers across lanes of moving traffic Do not have emergency personnel crossing in traffic. Backing Up. As an operator of an emergency vehicle, you should avoid backing up. If possible, especially during emergencies. There are large blind spots in your mirrors and a danger of striking a pedestrian, an object, or another vehicle. If you must back up, position someone at the rear of the ambulance as a spotter to guide the backing process.
² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
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SIMULATED AMBULANCEPARKING PARKINGAND AND SIMULATED ATED AMBULANCE PARKINGAMBULANCE AND CONING—STRAIGHTDIRECTION DIRECTION CONING—STRAIGHT ONING—STRAIGHT DIRECTION
SIMULATED AMBULANCE PARKING AND CONING—STRAIGHT DIRECTION
UNIT44 UNIT UNIT AMBULANCE OPERATIONS OPERATIONS IN IN EMT EMT PRACTICE PRACTICE DAY 264AMBULANCE DAY DAY26 26 AMBULANCE OPERATIONS IN EMT PRACTICE
“SIMULATED SIMULATED AMBULANCE AMBULANCE PARKING PARKING AND AND SIMULATED AMBULANCE PARKING AND CONING—STRAIGHT DIRECTION CONING—STRAIGHT CONING—STRAIGHT DIRECTION DIRECTION ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA
² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA
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ERATIONS IN EMT PRACTICE OPERATIONS IN EMT PRACTICE AY 26 AMBULANCE
MBULANCE PARKINGAMBULANCE AND SIMULATED AND AMBULANCE OPERATIONS IN EMT PRACTICE Day 26PARKING —CURVE DIRECTION CONING—CURVE DIRECTION SIMULATED AMBULANCE PARKING AND CONING—CURVE DIRECTION
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Limmer (Brady) (Brady) ²² Limmer Pollack, (AAOS) (AAOS) ³³ Pollack, ⁴ NHTSA ⁴ NHTSA
² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
TRANSFERRING THE PATIENT TO THE AMBULANCE On most ambulance runs, you will be able to reach a sick or injured person without difficulty, assess his condition, carry out emergency care procedures where he lies, and then transfer him to the ambulance. At times, however, dangers at the scene or the priority of the patient will dictate moving the patient before assessment and emergency treatments can be completed. When a spinal injury is suspected, you must manually stabilize the patient’s head, apply a cervical collar, and immobilize the patient on a spine board. 680
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³³ Pollack, Pollack, (AAOS) (AAOS) ⁴⁴ NHTSA NHTSA
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Transfer to the ambulance is accomplished in four steps regardless of the complexity of the operation: 1. Select the proper patientcarrying device. 2. Package the patient for transfer. 3. Move the patient to the ambulance. 4. Load the patient into the ambulance.
Kung may suspetsa na may spinal injury ang pasyente, importante na ma-immobilize mo agad ito, malagyan ng cervical collar, at mailagay siya sa spine board bago n’yo ito ilipat ng puwesto.
seated, avoid unnecessary movement during emergency response and transavoidunnecessary unnecessarymovement movementduring duringemergency emergencyresponse responseand andtranstransseated, seated,avoid port port port Unsecured equipment turns into projectiles upon collision, threatening both equipmentturns turnsinto intoprojectiles projectilesupon uponcollision, collision,threatening threateningboth both Unsecured Unsecuredequipment the patient and EMT Always ensure that all equipment in the patient compartthe patient and EMT Always ensure that all equipment in the patient compartthe patient and EMT Always ensure that all equipment in the patient compartment (e.g..oxygen cylinders, kits) has been secured. ment(e.g..oxygen (e.g..oxygencylinders, cylinders,kits) kits)has hasbeen beensecured. secured. ment
SECURINGTHE THEPATIENT PATIENT SECURING SECURING THE PATIENT
The wheeled ambulance stretcher is the most commonly used device for transferring the patient to the ambulance. The term packaging refers to the sequence of operations required to ready the patient to be moved and to combine the patient and the patient-carrying device into a unit ready for transfer. A sick or injured patient must be packaged so that his condition is not aggravated. You must complete all necessary care for wounds and other injuries, stabilize impaled objects, and check all dressings and splints before the patient is placed on the patient-carrying device. The properly packaged patient is covered and secured to the patient-carrying device. When packaging the severely ill or injured patient, packaging is a balance between expedience and function. The patient “““ should be firmly secured to transport devices and backboards so he will not fall or worsen his current condition in any way. Yet the EMT recognizes that packaging must be done quickly and efficiently in order to promptly and safely gel the patient to the hospital. Covering a patient helps to maintain body temperature, prevents exposure to the elements, and helps ensure privacy. A single blanket, or perhaps just a sheet, may be all that is required in warm weather. A sheet and blankets should be used in cold weather. When practical, cuff the blankets under the patient’s chin, with the top sheet outside. Do not leave sheets and blankets hanging loose. Tuck them under the mattress at the fool and sides of the stretcher. In wet weather, place a plastic cover over the blankets during transfer. Remove it once you are in the ambulance to prevent overheating. In cold or wet weather, cover the patient’s head, leaving the face exposed. A patient-carrying device should have a minimum of ² ²Limmer (Brady) (Brady) ² Limmer ² Limmer Limmer (Brady) (Brady) ³ ³Pollack, (AAOS) (AAOS) ³ Pollack, ³ Pollack, Pollack, (AAOS) (AAOS) three straps for securely holding the patient. The first should ⁴ ⁴NHTSA NHTSA ⁴ ⁴NHTSA NHTSA be at the chest level, the second at hip or waist level, and the third on the lower extremities. Sometimes there is a fourth strap if two are crossed at the chest. Newer stretchers have straps that act as a harness and restrain the upper body. By combining over-the-shoulder straps with encircling straps, the patient is more securely held on the stretcher in the event of a collision. All patients, including those receiving CPR. must be secured to the patient-carrying device before transfer to the ambulance. If your patient is not on a carrying device such as a spine board but instead is just on the ambulance stretcher, some cities, as a matter of policy, require shoulder
harnesses that secure the patient to the stretcher to prevent him from sliding forward in case of a short stop. Although much has been said about protecting the patient from a possible ambulance collision, perhaps not enough has been said about protecting the EMT in the patient compartment, who is actually at greater risk-The patient is secured to the stretcher and obtains some safety benefit from that. Most of the time, however, the EMT is unsecured and vulnerable in the event of a collision. When traveling in an ambulance you should remain seated, wearing a seat belt or harness when possible. Although it isn’t always possible to remain seated, avoid unnecessary movement during emergency response and trans-port. Unsecured equipment turns into projectiles upon collision, threatening both the patient and EMT Always ensure that all equipment in the patient compartment (e.g.. oxygen cylinders, kits) has been secured.
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IT T T4 4 IT T26 4 AMBULANCE AMBULANCE OPERATIONS OPERATIONS IN IN EMT EMT PRACTICE PRACTICE 26 AMBULANCE OPERATIONS IN EMT PRACTICE 26 Day 26
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PATIENT PATIENT TO TO AMBULANCE AMBULANCE (LOADING (LOADING THE THE PATIENT) PATIENT) PATIENT TO AMBULANCE (LOADING THE PATIENT)
PATIENT TO AMBULANCE (LOADING THE PATIENT)
TRANSPORTING THE PATIENT TO THE HOSPITAL
Transport involves more than just driving to the hospital. A series of tasks must be undertaken from the time a patient is loaded into the ambulance until he is handed over to hospital personnel.
Preparing the Patient for Transport The following activities may be required to prepare the patient for transport once he is in the ambulance: • Continue your assessment. Make sure that a conscious patient is breathing without difficulty once you have positioned him on the stretcher. If the patient is unconscious with an airway in place, make sure he has an adequate air exchange once you have moved him into position for transport.
• Secure the stretcher in place in the ambulance. Always ensure that the patient is safe
during the trip to the hospital. Before closing the door, and certainly before signaling the ambulance operator to move, make sure that the cot is securely in place. Patient compartments are equipped with a locking device that prevents the wheeled stretcher from moving about while the ambulance is in motion. Failure to fully engage the locking device at both ends of the stretcher can have disastrous consequences once the ambulance is in motion. • Position and secure the patient. During transfer to the ambulance, the patient must be firmly secured to a stretcher. This does not mean that he must be transported in that position. Positioning in the ambulance should be dictated by the nature of his illness or injury. 1. If he was not transferred to the ambulance in that position, shift an unconscious patient who has no potential spine injury, or one with an altered mental status, into the recovery position (on his side). This will promote maintenance of an open airway and the drainage of fluids. 2. Remember that the head and foot ends of the ambulance stretcher can be raised. A patient with breathing difficulty and no possibility of spinal injury may be more comfortable being transported in a sitting position. 3. A patient with a potential spinal injury must remain immobilized on the long spine board, with the patient and board together being secured to the stretcher. If resuscitation is required, he must remain supine with constant
Limmer (Brady) (Brady) ²² Limmer (Brady) Limmer (Brady) Pollack, (AAOS) (AAOS) ³²³² Limmer Pollack, Pollack, Pollack, (AAOS) (Brady) NHTSA(AAOS) ⁴³²⁴³ Limmer NHTSA ⁴³⁴Pollack, NHTSA NHTSA(AAOS) ⁴ NHTSA
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monitoring of the airway and suctioning equipment ready. If resuscitation is not required, the unresponsive patient and spine board can be rotated as a unit and the board propped on the stretcher so that the patient is on his side for drainage of fluids and vomitus from the mouth. • Adjust the security straps. Security straps applied when a patient is being prepared for transfer to the ambulance may tighten unnecessarily by the time he is loaded into the patient compartment. Adjust the straps so they still hold the patient safely in place but are not so tight that they interfere with circulation or respiration or cause pain.
• Prepare for respiratory or cardiac complications. If the patient is likely to develop
cardiac arrest, position a short spine board or CPR board underneath the mattress prior to starting on the trip. Then, if he does go into arrest, time will not be wasted locating and positioning the board. Riding on a hard board may not be comfortable, but temporary discomfort is better than permanent injury or even death from delayed resuscitation. • Loosen constricting clothing. Clothing may interfere with circulation and breathing. Loosen ties and belts and open any clothing around the neck. Straighten clothing that is bunched under safety straps. Remember that clothing bunched at the crotch may be painful. Before you do anything to rearrange the patient’s clothing, however, explain what you are going to do and why.
• Load a relative or friend who must accompany the patient. Consider the following guidelines if your service does not prohibit the transportation of a relative or friend with a patient: First, encourage the person to seek alternative transportation, if available. If there is just no other way the relative or friend can get to the hospital, allow him to ride in the operator’s compartment—not in the patient’s compartment w here he may interfere with patient care. Make certain the person buckles his seat belt. If an uninjured child must come along, bring the family’s child car seat and use it. • Load personal effects. If a purse, briefcase, overnight bag, or other personal item is to accompany the patient, make sure it is properly secured in the ambulance. If you load personal effects at the scene of a collision, be sure to tell a police officer what you are taking. Follow policies and fill out forms, if any. required by your local system for safe-guarding personal effects. • Talk to your patient. Apprehension often mounts in a sick or injured person after he is loaded in an ambulance. Not only is he held down by straps in a strange, confined space, but he may also be suddenly separated from family members and
friends. Maintaining a conversation with the patient helps allay his fears and concerns and simply helps pass the time.
• Avoid letting patients sit on the bench or airway seat. Unless it’s a multiple-casualty
incident or there is some other extenuating circumstance, patients belong on the stretcher. Simply put. it’s the safest place for them to be. If the patient suddenly becomes uncooperative and wants to jump out of a moving vehicle or assault the EMT, the stretcher and its restraints will slow him down. This restraint might even avert a tragedy.
When you are satisfied that the patient is ready, signal the operator to begin the trip to the hospital. If this is a high-priority patient, most of the preparation steps—loosening clothing, checking bandages and splints, reassuring the patient, even vital signs—can be done en route rather than delaying transport.
Caring for the Patient en Route Having at least one EMT in the patient compartment is minimum staffing for an ambulance, although having two is preferred. Seldom will you be able to merely ride along with your patient. You may have to undertake a number of activities en route: • Notify the hospital. Most EMS services radio the hospital with a patient report.
• Continue to provide emergency care as required. If life-support efforts were initiated prior
to loading the patient into the ambulance, they must be continued during transportation to the hospital. Maintain an open airway, resuscitate, administer to the patient’s needs, provide emotional support, and do whatever else is required, including updating your findings from the primary patient assessment. • Use safe practices during transport. In most cases, the patient packaging and preparation will be completed prior to loading. En route to the hospital, vitals may need to be repeated, the patient has to be tended to, and the hospital must be called on the radio. Remain seat-belted as much as possible. If a crash occurs, being belted improves your chances of survival and helps reduce injuries Stow any unnecessary equipment, because equipment can become projectiles in a crash. Probably the most important safety consideration is this: Is it really necessary to transport this patient with lights and siren on? When you are running “hot,” the chances
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Day 26 of a crash significantly increase. In most EMS systems, true emergencies needing a “hot” ride to the hospital constitute less than 5 percent of all transports. Don’t use lights and siren for the drive to the hospital unless it is a life-threatening situation! • Compile additional patient information. If the patient is conscious and emergency care efforts will not be compromised, record the patient information. Compiling information during the trip to the hospital serves two purposes. First, it allows you to complete your report. Second, supplying information temporarily takes your patient’s mind off his problem. Remember, however, that this is not an Interrogation session. Ask your questions in an informal manner. • Continue assessment and monitor vital signs. Keep in mind that vital sign changes indicate a change in a patient’s condition. For example, an unexplained increase in pulse rate may signify deepening shock. Record vital signs and he prepared to report changes to an emergency department staff member as soon as you reach the medical facility. Reassess vital signs every 5 minutes for an unstable patient, and every 15 minutes for a stable patient. • Notify the receiving facility. Transmit patient assessment and management information and provide your estimated time of arrival. The collision scene, confusion, noise, injuries, possible pain, disappearance of a parent EMTs caring for injuries, and gathering information -all create a terrifying experience for a child. The presence of a female EMT or police officer may be helpful; sometimes young children feel more comfortable talking to a woman. A smile and a calm, reassuring tone of voice are things that cannot be learned from a textbook, yet they may be the most critical care needed by the frightened child. Kung ang pasyente mo ay bata, malaki ang nagagawa ng laruan gaya ng teddy bear para pakalmahin ito. May mga ambulansya na may dala-dalang sanitized na laruan para sa mga batang pasyente. Nakakatulong ito para mas magtiwala ang bata sa EMT.
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TRANSFERRING THE PATIENT TO THE EMERGENCY DEPARTMENT STAFF You should take the following steps to ensure that the patient transfer to the care of emergency department personnel is accomplished smoothly and without incident. Brief as it may be, the transfer is a crucial step during which your primary concern must be the continuation of patientcare activities. • In a routine admissions situation or when an illness or injury is not life-threatening, check first to see what is to be done with the patient. If emergency department activity is particularly hectic, it might be better to leave your patient in the relative security and comfort of the ambulance while your operator determines where he is to be taken. Otherwise, the patient may be subjected to distressing sights and sounds and perhaps be in the way (If you do this, make sure an EMT remains with the patient at all times) Under no circumstances should you simply wheel a nonemergency patient into a hospital, place him in a bed, and leave him! This is an important point. Unless you transfer care of your patient directly to a member of the hospital staff, you may be open to a charge of abandonment. Staff members may be treating other seriously ill and injured persons, so suppress any urge to demand attention for your patient. Simply continue emergency care measures until someone can assume responsibility for the patient. When properly directed, transfer the patient to a hospital stretcher. • Assist emergency department staff as required and provide a verbal report. Stress any changes in the patient’s condition that you have observed. • As soon as you are free from patient-care activities, prepare the pre-hospital care report. Remember, the job is not over until the paper-work is complete. Find a quiet spot and complete your prehospital care report (PCR). • Transfer the patient’s personal effects. If a patient’s valuables or other personal effects were entrusted to your care, transfer them to a responsible emergency department staff member. Some services have policies that involve obtaining a written receipt from emergency department personnel as protection from a charge of theft. • Obtain your release from the hospital. This task is not as formal as it sounds. Simply ask the emergency department nurse or physician if your services are still needed. In rural areas where not all hospital services are available, it may be necessary to transfer a seriously ill or injured person to another medical facility. If you leave and have to be recalled, the patient will lose valuable time.
dressings, bandaging materials, towels, disposable oxygen masks, disposable gloves, sterile water, and oral airways. • Do not abuse this exchange program. Keep in mind that the constant abuse of a supply-replacement program usually leads to its discontinuation. At the very least, abuse places a strain on ambulance-hospital relations.
TERMINATING THE CALL
An ambulance run is not really over until the personnel and equipment that comprise the prehospital emergency care delivery system are ready for the next response. The functions of EMTs in this final phase of activity include more than just changing the stretcher linen and cleaning the ambulance. A number of tasks must be accomplished at the hospital, during the return to quarters, and after arrival at the station.
4 Exchange equipment according to your local policy:
At the Hospital While still at the hospital, the ambulance crew should begin making the ambulance ready to respond to another call. Time, equipment, and space limitations sometimes preclude vigorous cleaning of the ambulance while it is parked at the hospital. However, you should make every effort to quickly prepare the vehicle for the next patient:
1. Quickly clean the patient compartment while taking appropriate Standard Precautions. Follow
biohazard disposal procedures according to your agency’s OSHA exposure control plan. Examples of biohazards are contaminated dressings and used suction catheters. • Clean up blood, vomitus, and other body fluids that may have soiled the floor. Wipe down any equipment that has been splashed. Place disposable towels used to clean up blood or body fluids directly in a red bag, • Remove and dispose of trash such as bandage wrappings, open but unused dressings, and similar items. • Sweep away caked dirt that may have been tracked into the patient compartment. When the weather is inclement, sponge up water and mud from the floor. • Bag dirty linens or blankets to be appropriately laundered. • Use a deodorizer to neutralize odors of vomit, urine, and feces. Various sprays and concentrates are available for this purpose.
2 Prepare respiratory equipment for service.
• Clean and then properly disinfect nondisposable, used bag-valve-mask units and other reusable parts of respiratory-assist and inhalation-therapy devices to keep them from becoming reservoirs of infectious agents that can easily contaminate the next patient. Disinfect the suction unit. • Place used disposable items in a plastic bag and seal it. Replace the items with similar ones carried in the ambulance as spares.
3. Replace expendable items.
• If you have a supply replacement agreement with the hospital, replace expendable items from hospital storerooms on a one-for-one basis—such as sterile
5.
• Exchange items such as splints and spine boards. Several benefits arc associated with an equipment exchange program: There is no need to subject patients to injuryaggravating movements just to recover equipment, crews are not delayed at the hospital, and ambulances can return to quarters fully equipped for the next response. • When equipment is available for exchange, quickly inspect it for completeness and operability. Parts are sometimes lost or broken when an immobilizing device is removed from a patient. • If you do find that a piece of equipment is broken or incomplete, notify someone in authority so the device can be repaired or replaced. Make up the ambulance cot. The following procedure is one of many that can be used to make up a wheeled ambulance stretcher • Raise the stretcher to the high-level position, if possible: this makes the procedure easier. The stretcher should be flat with the side rails lowered and straps unfastened. • Remove unsoiled blankets and pillows, and place them on a clean surface. • Remove all soiled linen, and place it in the designated receptacle. • Clean the mattress surface with an appropriate KPAapproved, low-level disinfectant unless there is visible blood, which should be cleaned up using a 1:100 bleach/ water solution. • Turn the mattress over: rotation adds to the life of the mattress. • Center the bottom sheet on the mattress and fully open it. If a full-sized bed sheet is used, first fold it lengthwise. • Tuck the sheet under each end of the mattress; form square corners and then tuck under each side. • Place a disposable pad. if one is used, on the center of the mattress. • Fully open the blanket. If a second blanket is used, open it fully and match it to the first blanket. This task should be done with an EMT at each end of the stretcher. Ang malinis at maayos na stretcher ay nakapagbibigay ng lakas ng loob sa pasyente. Tandaan: Palitan agad ang kumot stretcher pagkatapos gamitin. Siguruhin mo na laging malinis ang stretcher sa ambulansya n’yo. Importante ito para sa trabaho mo.
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Day 26 • Open a top sheet in the same way, placing it on top of the blanket. Fold the blanket(s) and top sheet together lengthwise to match the width of the stretcher; fold one side first, then the other. • Tuck the foot of the folded blanket(s) and sheet under the foot of the mattress. • Tuck the head of the folded blanket(s) and sheet under the head of the mattress. • Place the slip-covered pillow lengthwise at the head of the mattress and secure it with a strap. • Buckle the safety straps and tuck in excess straps. • Raise the side rails and foot rest
En Route to Quarters (P.O.D) When heading back to quarters your emphasis should be on a safe return. An ambulance operator may practice even1 suggestion for safe vehicle operation while en route to the hospital and then totally disregard those suggestions during the return to quarters. Defensive driving must be a full-time effort. Do not forget that the driver and all passengers must wear seat belts. 1. Radio the EMD. Let him know that you are returning to quarters and that you are available (or not available) for service. Valuable time is lost if an EMD has to locate and alert a backup ambulance when he does not know that a ready-for-service unit is on the road. Be sure that you notify the HMD if you slop and leave the ambulance unattended for any reason during the return to quarters. 2. Air the ambulance, if necessary. If the patient just delivered to the hospital has an airborne communicable disease, or if it was not possible to neutralize disagreeable odors while at the hospital, make the return trip with the windows of the patient compartment partially open, weather permitting. If the unit has sealed windows use the air-conditioning or ventilating system (do not set on “recirculate”) to air the patient compartment out. 3. Refuel the ambulance. Local policy usually dictates the frequency with which an ambulance is refueled. Some services require the operator to refuel after each call regardless of the distance traveled. In other services, the policy is to refuel when the gauge reaches a certain level. At any rate, the fuel should be at such a level that the ambulance can respond to an emergency and then to the hospital without fear of running out.
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AMBULANCE OPERATIONS IN EMT PRACTICE The stretcher is now ready for the next patient. It must be reemphasized that this is one of many techniques for preparing a wheeled ambulance stretcher for service. Whatever the method, it should meet the following objectives: • Prepare for the next call as soon and as quickly as possible, • Store all linens, blankets, and pouches neatly on the stretcher • Fold or tuck all linens and blankets so that they will be contained within the stretcher frame. • Replace the cot in the ambulance. • Replace any nondisposable patient-care items. • Check for equipment left in the hospital.
In Quarters (P.O.D) When you return to quarters, a number of activities need to be completed before the ambulance can be placed in service and before it is ready for another call. With the emphasis today on protection from infectious diseases, you need to take every precaution to protect yourself. It is essential that you follow your agency’s OSHA exposure control plan. Always wear gloves when handling contaminated linen, cleaning the equipment, handling the respiratory equipment, and cleaning the ambulance interior (there may be many hidden nooks and crannies where the patient’s blood or body fluids could be gathered). Once in quarters, you are ready to complete the cleaning and disinfecting chores. Consult lists below for the levels of reprocessing to be used for equipment. 1. Place badly contaminated linens in a biohazard container, and non-contaminated linens in a regular hamper. 2. As necessary, clean any equipment that touched the patient. Brush stretcher covers and other rubber, vinyl, and canvas materials clean, then wash them with soap and water. 3. Clean and disinfect used nondisposable respiratory-assist and inhalation therapy equipment. • Disassemble the equipment so that all surfaces are exposed. • Fill a large plastic container with the cleaning solution outlined in your service’s infection control plan. • Clean the inner and outer surfaces with a suitable brush. Inner surfaces can be cleaned with a small bottle brush, whereas outer surfaces can be cleaned with a hand or nail brush. Make sure all encrusted matter is removed. • Rinse the items with tap water. • Soak the items in an EPA-approved germicidal solution. An inhalation therapist at a local hospital can suggest a germicide suitable for respiratory equipment. Follow directions for dilution, safe handling, and soaking lime. Gloves are recommended when using some germicides. • After the prescribed soaking period, hang the equipment
in a well-ventilated clean area and allow it to dry for 12 to 24 hours. 4. Clean and sanitize the patient compartment. Use an EPA-approved germicide to clean any fixed equipment or surfaces contacted by the patient’s body fluids. 5. Prepare yourself for service. • Wash thoroughly, paying attention to the areas under your fingernails. Remember that contaminants can collect there and become a source of infection not only to you but also to the persons whom you touch. • Change soiled clothes. Clean contaminated clothing as soon as possible, especially if you were exposed to someone with a communicable disease. It is a good policy to bring a spare uniform to work, and each EMS agency should have a washer and dryer. It is against OSHA regulations for blood- or body fluid-soiled clothes to be taken home to be washed. 6. Replace expendable items. Exchange them with items from the unit’s storeroom. 7. Replace or refill oxygen cylinders. Do this in accordance with your service’s procedures. 8. Replace patient-care equipment. 9. Carry out post-operation vehicle maintenance procedures as required. If you find something wrong with the vehicle, correct the problem or make someone in authority aware of it. 10. Clean the vehicle. A clean exterior lends a professional appearance to an ambulance. Check for broken lights, glass and body damage, door operation, and other parts that may need repair or replacement. 11. Complete your paperwork. Complete any unfinished report forms as soon as possible, and report the unit ready for service.
AIR RESCUE
In some circumstances, it is best for a patient to be transported by an air rescue helicopter or fixed-wing aircraft. The following are some considerations for use of this kind of transport. Since geographic and other circumstances, as well as the availability of such transport, will vary in different localities, follow your local protocols.
When to Call for Air Rescue
Patients with certain medical conditions may also be flown by helicopter. Cardiac patients requiring catheterization or surgery, stroke patients, and those patients requiring hyperbaric oxygen treatment (e.g.. after carbon monoxide poisoning) are examples of medical patients who may also be flown by air. In many cases, you will transport these patients to your local hospital for stabilization and the helicopter will transfer the patient from one hospital to another- Cardiacarrest patients are usually not transported by air rescue unless they are hypothermic. Follow your local protocols.
How to Call for Air Rescue
In some areas, rescue may be called for by any law enforcement, fire, or EMS command officer at the scene of an incident. In addition, as an EMT. you may radio dispatch for advice if you think such a service is needed. When calling an air rescue service, give your name and call-back number, your agency name, the nature of the situation, the exact location including crossroads and major landmarks, and the exact location of a safe landing zone. Follow your local protocols.
How to Set Up a Landing Zone A helicopter requires a landing zone, or LZ, approximately 100-by-100 feet (approximately 30 large steps on each side) on ground that has a slope of less than 8 degrees. The landing zone and approach/departure path should be clear of wires, lowers, vehicles, people, and loose objects. The landing zone should be marked with one flare in an upwind position. During night operations, never shine a light into the pilot’s eyes during landing or takeoff or while the aircraft is running on the ground. Keep emergency red lights on. Ang air rescue ay ginagawa ng Lifeline 16-911 sa mga lugar na mahirap puntahan at ang mga pasyente ay kailangang-kailangan madala agad sa ospital. Gumagamit ang Lifeline 16-911 ng mga helicopter at, paminsan-minsan, ng eroplano, para matugunan ang pangangailangan ng pasyente na nasa bingit ng kamatayan.
Air rescue may be required for any of the following reasons: • Operational reasons. Operational reasons for air rescue include: 1. to speed transport to a distant trauma center or other special facility. 2. when extrication of a high-priority patient is prolonged and air rescue can speed transport, or 3. when a patient must be rescued from a remote location that can only be reached by helicopter. Follow your local protocols. • Medical reasons, Medical reasons for air rescue primarily affect patients who are high priority for rapid transport; for example, a patient in shock, a patient with a Glasgow Coma Scale total of less than 10, a patient who has a head injury with altered mental status, a patient with chest trauma and respiratory distress, a patient with penetrating injuries to the body cavity, a patient with an amputation proximal to the hand or foot, a patient with extensive burns, or a patient with a serious mechanism of injury. LIFELINE
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ON December 16, 2013 in Bicutan, Taguig, a bus fell off from the Metro Manila Skyway, crashing onto a delivery van. The incident left 18 people dead and 20 others wounded. The incident is described as the worst to have happened along the Skyway. Lifeline 16-911 responded to that emergency, which is considered a Multiple Casualty Incident. As a future EMT, how would you handle a case where more than a dozen people are affected? In this chapter you would be taught how to restore
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order out of chaos in incidents with multiple casualties. You would learn how to work with other rescuers in providing aid to the sick and the injured. The goal is to keep you calm and composed -- because with the high stakes involved, multiple casualty incidents can really be overwhelming. In Lifeline, we have protocols in place to handle such events, and all of us receive training in responding to them. These protocols and training enable our EMTs to assess emergencies involving hazardous materials, car crashes and many more.
DAY
27
Multiple Casualty Incident Dealing with hazardous materials Decontamination procedures Establishing an incident command Highway emergency operations / vehicle extrication
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AMBULANCE OPERATIONS IN EMT PRACTICE
MULTIPLE CASUALTY INCIDENT LEARNING OBJECTIVES
• List the phases of an ambulance call. • Identify what is essential for completion of a call. • Describe how to clean or disinfect items following patient care. Describe the general provisions of state laws relating to the operation of the ambulance and privileges in any or all of the following categories: Speed, Warning Lights, Sirens, Right-of-way, Parking and Turning. • Describe why defensive driving is critical to safe ambulance vehicle operation. • Describe the importance of being familiar with your
INTRODUCTION
You have already learned how to deal with many situations in which an individual patient needs emergency care. However, you also need to know what to do if you are called to the scene of an explosion, an airline crash, a multiple vehicle pile-up. an earthquake, or some other situation in which there may be many known or potential patients. Although you are not trained to deal with all the complexities of such emergencies, you must be able to recognize them and call for the appropriate assistance. This chapter offers the essentials that every EMT should know about special operations involving multiple patients and/or hazardous materials.
HAZARDOUS MATERIALS
Hazardous materials (hazmats) are everywhere, and EMS frequently responds to incidents involving them. Because many incidents begin as routine EMS calls, it will be up to you to recognize a hazmat early, be familiar with your local plan for management of a hazardous materials incident, and understand your role in such an incident. A hazardous material is defined as “any substance or material in a form which poses in unreasonable risk to health, safety, and property when transported in commerce.” One of the undesirable aspects of our modern world is the growing number or such materials. Hazardous materials are used for the manufacture of products and also can be the waste products of manufacturing. Even though safety procedures have been established and are followed for the most part, accidents involving hazardous materials do occur. Hazardous materials incidents are especially likely to
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EMS response area • Describe the importance of anticipating special conditions that may complicate or create hazardous driving conditions. • List contributing factors to unsafe driving conditions. • Describe how an unsafe scene will vary ambulance response • Describe the importance of “staging” when responding to unsafe or unstable scenes. • Explain the use of the Incident Command System in ambulance operations. take place at factories; along railroads: and on local, state, and federal highways. As an EMT, you will be highly skilled in emergency care. However. without specialized training, you are still a layperson when it comes to hazardous materials. Special training is required to understand hazmats, to work at the scene of incidents involving these materials, and to render the scene safe. You cannot judge the state of a container or the probability of explosion without the benefit of such training. Do not assume that you can use safety equipment unless you are trained in the care, field testing, and use of the equipment. With hazmat incidents, you may be able to do nothing more than stay a safe distance away from the scene until expert help arrives.
Training Required by Law The Philippine government has developed regulations to deal with the increasing frequency of hazmat emergencies. These regulations are meant to enhance the knowledge, skills, and safety of emergency response personnel, as well as lo bring about a more effective response to hazmat emergencies. According to the regulations, employers are responsible for determining, providing, and documenting the appropriate level of training for each employee. Training is required for “all employees who participate, or who are expected to participate, in emergency response to hazardous substance accidents.”
The regulations identify four levels of training:
• First Responder Awareness. Rescuers at this level are likely to
witness or discover a hazardous substance release. They are trained only to recognize the problem and initiate a response from the proper organizations. There are no minimum training hours required. • First Responder Operations. This level of training is for those who initially respond to releases or potential releases of hazardous materials in order to protect people, property, and the environment. They stay at a safe distance, keep the incident from spreading, and protect others from any exposures A minimum of 8 hours of training is required. • Hazardous Materials Technician. This level is for rescuers who actually plug, patch, or stop the release of a hazardous material. A minimum of 24 hours of training is required. • Hazardous Materials Specialist. This level of rescuer is expected to have advanced knowledge and skills and to command and support activities at the incident site. A minimum of 24 hours of additional training is required.
Kadalasan, sa mga lugar na may mga delikado o hazardous materials ay may nakatutok rin na mga safety officers ng mga kumpanya. Makakatulong sila sa iyo para makaiwas ka sa disgrasya. Bagama’t hindi sila nakapagsanay sa paraan ng EMS, matutulungan ka pa rin nila kung papaano kokontrolin ang mga hazardous materials para mas mabilis mong magawa ang iyog tungkulin.
Examples of Hazardous Materials MATERIAL
POSSIBLE HAZARD
Benzene (benzol)
Toxic vapors; can be absorbed through the skin; destroys bone marrow
Benzoyl peroxide
Fire and explosion
Carbon tetrachloride
Damages internal organs
Cyclohexane
Explosive; eye and throat irritant
Diethyl ether
Flammable and can be explosive; irritant to eyes and respiratory tract; can cause drowsiness or unconsciousness
Ethyl acetate Irritates eyes and respiratory tract Ethylene chloride
Damages eyes
Ethylene dichloride
Strong irritant
Heptane
Respiratory irritant
Hydrochloric acid
Respiratory irritant; exposure to high concentration of vapors can produce pulmonary edema; can damage skin and eyes
Hydrogen cyanide Highly flammable; toxic through inhalation or absorption Methyl isobutyl ketone
Irritates eyes and mucous membranes
Nitric acid
Produces a toxic gas (nitrogen dioxide); skin irritant; can cause selfignition of cellulose products (e.g., sawdust)
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Whether hazmat incidents are very obvious or very subtle recognize one for what it is. It helps to be aware of th hazmats arc likely. They include highway incidents involvin trucking CASUALTY terminals, chemical plants or places where chemi MULTIPLE INCIDENT ery trucks, agriculture and garden centers, railway incidents
Every Materials community has chemical hazards. Identification sta Examples of Hazardous and knowledge of what exists in the community. Spend so
police POSSIBLE and fireHAZARD agencies, and learn about or develop pre common hazardous materials.
MATERIAL Organochloride (Chlordane, DDT, Dieldrin, Lindane, Methoxyclor) Perchloroethylene Silicon tetrachloride Tetrahydrofuran (THF) Toluol (toluene) Vinyl chloride
Irritates eyes and skin; fumes and smoke toxic
When you arrive at a potential incident as an EMT, you natural impulse to take action. Never assume the scene is s patients, Toxic if inhaled or swallowed EMTs are the most likely to become injured or tend to quickly react. Therefore, assess the situation first. Water-reactive toposition form toxic and hydrogen staychloride a safefumes distance from the site before you t hazmat is recognized, only those personnel trained to the te Damages eyes and mucous membranes level and equipped with the proper personal protective the immediate site. All patients leaving the site of the Toxic vapors; canenter cause organ damage considered contaminated until proven otherwise. Flammable and explosive; listed as a carcinogen
RESPONSIBILITIES OF THE EMT
Control the Scene
Your prima scene of a h incident ar the safety patient, and arrive first hazardous establish a a "safe zon out of the try to conv the immedia safe zone arrives and safe to ente
Your responsibilities as an EMT at a hazardous materials incident include recognizing that a hazardous materials incident exists, controlling the scene, and identifying the substance.
Recognize a Hazmat Incident “ Whether hazmat incidents are very obvious or very subtle, you must quickly recognize one for what it is. It helps to be aware of the locations where hazmats are likely. They include highway incidents involving common carriers, trucking terminals, chemical plants or places where chemicals are used, delivery trucks, agriculture and garden centers, railway incidents, and laboratories. Every community has chemical hazards. Identification starts with awareness and knowledge of what exists in the community. Spend some time with local police and fire agencies, and learn about or develop pre-incident plans for common hazardous materials. When you arrive at a potential incident as an EMT, you must restrain your natural impulse to take action. Never assume the scene is safe. After the initial patients, EMTs are the most likely to become injured or killed because they tend to quickly react. Therefore, assess the situation first. Take a Command position and stay a safe distance from the site before you take action. Once a hazmat is recognized, only those personnel trained to the technician level and equipped with the proper personal protective equipment should enter the immediate site. All patients leaving the site of the incident should be considered contaminated until proven otherwise. 692
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The safe zo the same le from, the h incident s downhill in case there are flowing liquids or gases that ar Your primary concerns at the scene of a hazardous wise unsafe. Avoid low-lying areas in ease fumes are esca materials incident are your safety and the safety of your close to the ground. Avoid placing yourself higher than th crew, the patient, and the public. If you arrive first at the that you will not be in the path of escaping gases or heated scene of a hazardous materials incident, establish a “danger zone” and a “safe zone.” Keep all people out of the danger that a sewer system can rapidly spread hazardous materials
Control the Scene
zone, and try to convince them to leave the immediate area. Stay in the safe zone until expert help arrives and makes other areas safe to enter. The safe zone should be on the same level as. and upwind from, the hazardous materials incident site. Avoid
² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA
e, you must quickly he locations where ng common carriers, icals are used, delivs, and laboratories. being downhill in case there are flowing liquids or
arts withgases that are burning or otherwise unsafe. Avoid awareness low-lying areas in ease fumes are escaping and hanging ome time with local close to the ground. Avoid placing yourself higher than e-incident plans for
the accident scene so that you will not be in the path of escaping gases or heated air. Also be aware that a sewer system can rapidly spread hazardous materials over a large area.your must restrain Call for the help that you will need. The support safe. After the initial services required at the scene of a hazardous materials killed because they incident may include fire services, special rescue per. Take asonnel, local or state hazardous materials experts, and Command take action. Once a law enforcement personnel for crowd control. If the incident has taken place at an industrial site or along a echnician railway, the company experts in hazardous materials equipment should need to be notified. Much of this can be done by a e incident should be single call to your dispatcher. Implement your agency’s Incident Management System. Establish and remain in Command until you are relieved by someone higher in the chain of command. The situation must be prevented from becoming ary concerns at the worse. Establish a perimeter, evacuate people if necessary, and direct bystanders to a safe area. It hazardous materials re your cannot be overemphasized that EMTs should not risk safety and personal safely by initiating rescue attempts. of your crew, the While help is on the way. establish control zones. d the public. If you Isolate the hot zone (the area of contamination or the at the area of danger). Establish a decontamination corridor scene of a (area where patients will be decontaminated) in the materials incident, "dangerHarm zone, an area immediately adjacent to the hot zone" and zone. Equipment and other emergency rescuers should ne." Keepbe staged in the next adjacent area— the cold zone. all people dangerStation yourself in the cold zone. zone, and
vince them to leave ate area. Stay in the until expert help As a responding EMT. you may be the first to makes other areas recognize that a hazardous materials situation exists. er.
Identify the Substance
For example, you may answer a call to a business where four employees are ill after being in the one should be on warehouse. When there are multiple medical patients “think hazmat.” evel as. and upwind You must make an attempt to identify the hazardous materials hazardous material and assess the severity of the site. Avoid being situation. Until that is done, it will be difficult to re burning or otherdetermine the risk to the public, rescuers, patients, aping and hanging and the environment. You must try to find out what the substance is and what its properties and dangers he accident scene so might be: whether or not there is imminent danger d air. Also be aware of the contamination spreading; what you can hear, s over a large area. see, and smell: how many patients are involved; and if there is any danger of secondary contamination from the patients. (Secondary contamination occurs when a contaminated person makes contact with someone who previously was “clean.”)
Ang unang-una mong dapat pagtuunan ng atensyon sa lugar kung saan may mga delikadong bagay o hazardous materials ay ang iyong kaligtasan at ang kaligtasan ng iyong grupo, ng pasyente, at ng publiko. Gawing malinaw kung saan ang “danger zone” at ilayo ang lahat ng tao mula dito. Manatili sa “safe zone” hanggang dumating ang mga eksperto. Ang safe zone ay dapat nasa isang lugar na mas mataas kesa sa mga hazardous materials. Pero hindi rin dapat ito nasa lugar kung saan dumadaan ang usok o mainit na hangin. Huwag mag-atubili na humingi ng tulong sa mga eksperto sa hazardous materials gaya ng mga bumbero o safety officers.
Because it is not safe to approach the scene, you must obtain information indirectly or from a distance. Ways of obtaining information safely may include the following: • Use binoculars to look for identifying signs, labels, or placards from a safe distance. In many cases, there will be a colored placard on the storage container, vehicle, tank, or railroad car. • Look for labels. The Philippine Department of Transportation requires that packages, storage containers, and vehicles containing hazardous materials have labels or placards with markings that identify the nature of the contents. Diamondshaped placards used in the transportation of dangerous goods not only show the hazard class, such as “explosives,” “flammable gas,” “poison.” or other, they also bear a division number which provides more specific information on the material. In addition, a four-digit identification number may appear on the placard itself or on a panel near the placard. Older placards are usually orange and have an identification number preceded by the letters UN or UA. Your dispatcher may have access to the name of the material through this identification number. • Check invoices, bills of lading (trucks), and shipping manifests (trains). If you can safely obtain them, these documents will identify the exact substance being transported, the exact quantity, its place of origin, and its destination. • Review material safety data sheets (MSDS). MSDS must be provided on hazardous materials by all manufacturers. These sheets must be maintained at the work site by the employer and available to all employees on the grounds that employees working with hazardous materials have a right to know about them. If you can safely obtain these sheets, they generally name the substance, its physical properties, fire and explosion hazard information, health hazard information, and emergency first aid treatment • Interview workers or others leaving the hot zone. These people may be good sources of information about the substance involved. Vehicle drivers, plant and railroad personnel, and perhaps even bystanders may be able to tell you the name of the hazardous material. Workers at a manufacturing site often understand very well what chemicals are used, the processes, and their reactions. However, note that workers may identify a substance by its trade name and not realize that it is a mixture of many chemicals.
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Day 27 EMTs are only expected to understand some of the common substance-identifying systems available and to make a preliminary identification based on this information. On the basis of this preliminary information, you can obtain advice about what initial actions should be taken at the scene from your dispatcher, a hazardous materials expert, or from the Priority Chemical List (PCL) of the Department of Environment and Natural Resources (DENR) Environment Management Bureau (EMB). The PCL is a list of existing and new chemicals that the DENR-EMB has determined to potentially pose unreasonable risk to public health, workplace, and the environment. Among the chemicals in the PCL, the DENR-EMB determines which chemicals should be regulated. In addition, the DENR-EMB imposes special reporting requirements that apply only to chemicals included in PCL. This is an essential aspect of the PCL process since these reports will enable the DENR-EMB to obtain the necessary information concerning the priority chemicals and their uses. Such information will assist the DENR-EMB in making informed decisions on which chemicals should be regulated. Assessment of the potential hazards and risks posed by each chemical in the PCL is not a continuing process. It not only requires knowledge of the toxicity of a substance, but also other characteristics of a substance that may influence the severity and duration of adverse impacts. These include a chemical’s persistence and tendency to bioaccumulate through the food chain. The criteria for the PCL was established on standards used in industrialized countries as well as qualitative and quantitative information that is unique to the Philippines such as chemical’s use and management, production quantity, percentage of release, occupational exposure, disposal methods, and technical and economic feasibility of its regulation are considered:
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MULTIPLE CASUALTY INCIDENT
When you call one of the previously named sources for advice, do the following: 1. Give your name, call-sign, mobile number and e-mail address. 2. Explain the nature and location of the problem. 3. Report the identification number(s) of the material(s) involved, if there is a safe way for you to obtain this information. 4. Give the name of the carrier, shipper, manufacturer, consignee, and point of origin. 5. Describe the container type and size. 6. Report if the container is on rail car, truck, open storage, or housed storage. 7. Estimate the quantity of material transported and released. 8. Report local conditions (e.g.. the weather, terrain, and proximity to schools or hospitals). 9. Report injuries and exposures. 10. Report local emergency services that have been notified. 11. Keep lines of communication open at all times.
Huwag magpadalus-dalos at magmadali sa mga sitwasyon na may mga hazardous materials. Hangga’t maaari, humingi ng tulong sa mga eksperto na mas kabisado ang gagawin. Gawin lamang ang mga bagay na napag-aralan mo na. Kung hindi mo alam kung anong hazardous material ang naroon, at walang nakasulat na magsasabi sa iyo kung ano ang iyong kinakaharap, maghintay na lamang na dumating ang mga eksperto. Huwag magmarunong. Ang iyong kaligtasan ang pangunahin mong dapat alalahanin.
CLASS 1—EXPLOSIVES Division 1.1
Explosives with a mass explosion hazard
Division 1.2
Explosives with a projection hazard
Division 1.3
Explosives with predominantly a fire hazard
Division 1.4
Explosives with no significant blast hazard
Division 1.3
Very insensitive explosives; blasting agents
Division 1.6
Extremely insensitive detonating articles
CLASS 2—CASES Division 2.1
Flammable gases
Division 2.2
Nonflammable, nontoxic, compressed gases
Division 2.3
Cases toxic by inhalation
Division 2.4
Corrosive gases
CLASS 3—FLAMMABLE LIQUIDS AND COMBUSTIBLE LIQUIDS
CLASS 4—FLAMMABLE SOLIDS; SPONTANEOUSLY COMBUSTIBLE MATERIALS; AND DANGEROUS WHEN— WET MATERIALS Division 4.1
Flammable solids
Division 4,2
Spontaneously combustible materials
Division 4.3
Dangerous-when-wet materials
CLASS 5—OXIDIZERS AND ORGANIC PEROXIDES Division 5.1
Oxidizers
Division 5.2
Organic peroxides
CLASS 6—TOXIC MATERIALS AND INFECTIOUS SUBSTANCES Division 6.1
Toxic materials
Division 6.2
Infectious substances
CLASS 7—RADIOACTIVE MATERIALS CLASS 8—CORROSIVE MATERIALS CLASS 9— MISCELLANEOUS DANGEROUS GOODS Division 9.1
Miscellaneous dangerous goods
Division 9.2
Environmentally hazardous substances
Division 9.3
Dangerous wastes
Establish a Treatment Area
All EMS personnel and equipment must be staged in the cold zone. EMS personnel have two responsibilities at a ha/ mat incident: to monitor and rehabilitate the hazmat team members and to take care of the injured.
Rehabilitation Operations In order to safely enter the hot zone, the hazmat team members must wear chemical-protective clothing and breathing apparatus that both slows heat loss and prevents heat stress. Team members must be carefully monitored prior to, during, and after emergency operations. This is done to make sure that their condition does not deteriorate to a point where safety or the integrity of the operation is jeopardized. To address this need, you should establish an area of operations called rehabilitation (rehab). Although the rehab area supervisor may not be an EMS provider, all rehab operations must include EMTs or advanced-level EMTs.
The characteristics of the rehab area must include the following: • Located in the cold zone. • Protected from weather (shielded from rain or snow, a warm area in a cold environment, a cool area in a warm environment). • Large enough lo accommodate multiple rescue crews. • Easily accessible to EMS units. • Free from exhaust fumes. • Allows for rapid re-entry into the emergency operation. While suiting up in chemical-protective equipment, hazmat team members should have their baseline vital signs taken. When the hazmat team members show signs of fatigue or when they have had 45 minutes of work time, they are sent to rehab. As soon as possible after exit from the hot zone, reassess their vital signs. If a member’s heart rate exceeds 110 beats per minute, take an oral temperature. If a member’s temperature exceeds I00.6°F, the rescuer must stay in rehab until his pulse slows and temperature returns to normal. Always follow your local protocols and consult medical direction. All pre-entry and exit vitals should be tracked on a flow sheet. In addition to medical monitoring, rehab should be set up for pre-hydration and hydration, rest, and in some cases nourishment of hazmat team members. Proper hydration is an important clement in preventing heat stress and promoting optimal physical performance. Heat injury is usually caused by imbalances of water and electrolytes during periods of high heat stress and physical exertion. During physical exertion, members should consume at least 1 quart of water per hour. For short-duration emergency operations, electrolyte sport drinks usually are not necessary. However, if they are used they should be diluted to half strength. Coffee and caffeinated beverages should be avoided because they promote dehydration. When incidents will be of extended duration, some type of nourishment may be provided in rehab. Foods low in salt and saturated fats are ideal. Bananas, apples, oranges, and other fruits are excellent for fast nourishment. In cold environments, soups and stews are more easily eaten and digested than sandwiches.
Care of Injured and Contaminated Patients Hazardous materials or terrorist incidents involve civilians and/or EMRs. Prompt, safe, and effective decontamination procedures are essential to protect against, or reduce the effects of, exposure to both patients and EMRs. Decontamination is performed to protect citizens personnel, equipment, and the environment from the harmful effects of the contaminants.
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The Department of Environment and Natural Resources (DENR) defines decontamination as a chemical and/or physical process that reduces or prevents the spread of contamination from persons or equipment. According to the Environment Management Bureau (EMB), decontamination is the removal of hazardous substances from employees and their equipment to the extent necessary to preclude foreseeable health effects. EMTs must work with Incident Command and hazmat team members to determine the most appropriate course of action. The decision to stay at the scene and decontaminate or to begin evacuation must be made after careful consultation with the EMB’s Priority Chemical List and other reference materials. In the decontamination (decon) corridor in the warm zone, the hazmat team will decontaminate hazmat team members and any patients rescued. EMS is responsible for setting up the medical treatment area in the cold zone to receive decontaminated patients. Unless EMS personnel are trained to the hazmat technician level, they must remain in the cold zone. The field decon process is designed to remove contaminants and deliver a relatively “clean” patient to EMS personnel for care and transportation. However, there is a chance of secondary contamination from patients to EMS personnel. It is important that EMS personnel work closely with the decon officer and consult with medical direction on both treatment and appropriate protection during transportation. The following points are important when treating and transporting hazmat patients: • Field-decontaminated patients are not completely “clean.” Chemicals that pose a risk of secondary contamination to rescuers sometimes settle in hardto-clean areas of the body. These areas are typically the scalp/hair, groin, buttocks between fingers and toes, and the armpits. • Personal protective equipment or clothing (PPE/ PPC) is needed to prevent secondary contamination of rescuers. EMS personnel need to wear PPF such as Tyvek coveralls and booties to prevent contamination and exposure. They may also need to wear a double layer of gloves. Often nitrite or neoprene is best, because these are more resistant to chemicals than standard latex or vinyl gloves. Consult with the decon officer to determine if your PPE is suitable or if they have more appropriate PPE. • Protect vehicles from contamination. In the decon process, patients are washed and are usually dripping wet. Since they cannot be completely decontaminated in the field, some of their water runoff could contaminate an emergency vehicle. To prevent this, the water runoff must be contained by either placing the patient in a disposable decontamination pool or covering the inside of an ambulance with plastic. • Consider used equipment as disposable. When 696
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an item such as a spine board, splint, blood-pressure cuff, or stethoscope is used, it may not be able to be decontaminated and may require disposal. • Structural fire fighting clothing is not designed or recommended for use when working in hazardous materials environments. If personnel in fire fighting gear encounter a hazardous chemical environment, they should take precautions to minimize the chance of contamination. A team in hunker gear can stand back and apply a fog stream to contaminated persons. When treating a contaminated patient is unavoidable, it is crucial to identify the hazardous material. Always check with the Priority Chemical List. Four types of patients are likely to be encountered by EMTs: • Uninjured and not • Uninjured and contaminated contaminated • Injured and not contaminated • Injured and contaminated If you are confronted with contaminated patients prior to the arrival of the hazmat team, do the following: 1. Take precautions appropriate to the substance as listed in the Priority Chemical List. This usually means isolation from the substance. Be sure to use personal protective equipment similar to what you would use for splash protection from blood-borne pathogens. 2. Follow first aid measures. 3. Manage the patient’s critical needs. Do not forget to manage the ABCs. 4. If treatment calls for irrigation with water, remember that water only dilutes most substances. It does not neutralize them. Cut the patient’s clothing off and irrigate the patient’s body with large amounts of water. Try to contain the runoff If possible, use tepid or warm water to prevent hypothermia. Try to avoid flushing contaminants directly into open wounds. Pay particular attention to cleaning areas such as dense body hair, ear canals, navel, fingernails, crotch, armpits, and soon. Use disposable equipment whenever possible. Discard it later. 5. After treating the patient, decontaminate yourself. Your clothing may need disposal. Remember that the severity of any poisoning depends on the substance, route of entry, dosage, and duration of contact. Immediate emergency care measures may decrease the severity of the poisoning and save lives. Whenever possible, the entire decontamination process should be carried out by qualified personnel from the hazmat team before the EMT touches the patient. Contaminated personnel (injured or not) pose a secondary contamination risk and should be decontaminated prior to leaving the scene. If scene decontamination is not performed, patients must be decontaminated at an appropriate hospital decon site before they enter the emergency department.
An example of a held decontamination process.
9-STATION DECONTAMINATION PROCEDURE STEPS
Station 1
Rescuers enter decon areas and mechanically re-move contaminants from victims. Tools are dropped in tool drop area. Rescuers are in SCBA and protective clothing. Proceed to Station 2.
Remove Contaminants Tool Drop
Station 2
Gross Decontamination: Victims and rescue personnel are showered and/or scrubbed by decon personnel. Dilution is conducted inside diked area. Victims may be transported directly to Station 6. Proceed to Station 6.
Gross Decontamination
Station 3
Protective Clothing Removal: Rescuers remove protective clothing, clothing is isolated and labelled for later disposal. Clothing is placed on contaminated side. Proceed to Station 4.
PPC Removal
Station 4
SCBA Removal: Rescue personnel remove and isolate their SCBA. If reentry is necessary, personnel don new SCBA from non-contaminated side. Proceed to Station 5.
SCBA Removal
Station 5
Personal Clothing Removal: All clothing and personal items are removed. Victims who have not been undressed are undressed here. All clothing and personal items are isolated in plastic bags and labelled for later disposal. Proceed to Station 6.
Personal Clothing Removal
Station 6
Body Washing: Full body washing is performed using soft scrub brushes or sponges and soap or mild detergent. Cleaning tools are bagged for later disposal. Proceed to Station 7.
Body Washing
Station 7
Dry Off. Towels and sheets are used to dry off. Rescuers and victims are dressed in clean clothes. Towels/sheets are bagged for later disposal. Proceed to Station 8.
Dry Off
Station 8
Medical Assessment: Rapid patient assessment is conducted by rescuers. Necessary stabilization procedures are accomplished. Proceed to Station 9.
Medical Assessment
Station 9
Transport: Transfer of patient to hospital for medical attention or to recovery areas for rest and observation.
Transport
Phases of Decontamination
The two major phases of decontamination are gross decontamination and secondary decontamination. There is usually a third or tertiary decontamination phase, but it generally occurs at a medical facility and may involve such processes as sterilization or debridement. Gross decontamination is the removal or chemical alteration of the majority of the contaminant. It must be assumed that some residual contaminant will always remain on the host after gross decontamination. This residual contamination can cause cross-contamination. Secondary decontamination is the alteration or removal of most of the residual product contamination. It provides a more thorough de-contamination than the gross effort. However, some contaminant may still remain attached to the host.
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Mechanisms for Decontamination
There are seven common mechanisms for performing decontamination. They are: • Emulsification. This is the production of a suspension of ordinarily immiscible (unmixable)/insoluble materials using an emulsifying agent such as a surfactant, soap, or detergent. • Chemical reaction. This is a process that neutralizes, degrades, or otherwise chemically alters the contaminant. Normally, a chemical reaction does not ensure that all hazards have been eliminated, and reaction procedures can be both difficult and dangerous to perform. Chemical reaction is therefore not recommended for use on living tissue. • Disinfection. This is a process that removes the biological (etiological) contamination hazards as the disinfectant destroys microorganisms and their toxins.
MULTIPLE CASUALTY INCIDENT • Dilution. This is a process that simply reduces the
concentration of the contaminant. It is most commonly used for substances that are miscible (mixable)/soluble. Huge quantities of solvent may be required to dilute even small volumes of some solute contaminants. • Absorption and adsorption. This is the penetration of a liquid or gas into another substance. An example is water soaking into a sponge. • Removal. This is the physical process of removing contaminants by pressure or vacuum. Most efforts involve the use of water, though solids can be removed with brushes and wipes; even air can be used. • Disposal. This is the aseptic removal of a contaminated object from a host, after which the object is disposed of. Aseptic means using sterile instruments and/or otherwise preventing the spread of the contaminant.
Decontamination Procedures The objectives of the responders assigned to decontamination are to: • Determine the appropriate level of protective equipment based on materials and associated hazards • Properly wear and operate in PPE • Establish operating time log • Set up and operate the decontamination line • Prioritize the decontamination of patients according to a triage system • Perform triage in PPE • Be able to communicate while in PPE A basic list of equipment required for decontamination is: • Buckets • Brushes • Decontamination solution • Decontamination tubs • Dedicated water supply • Tarps or plastic sheeting • Containment vessel for water runoff • Pump to transfer wastewater from decontamination tubs to a containment vessel • A frame ladder (to reach the top of the responder’s suit) • Appropriate-level PPE for responders performing decontamination
Decontamination for Patients Wearing PPE Take the following steps to decontaminate a patient who is wearing PPE: 1. Rinse, starting at the head and working down. 2. Scrub the suit with a brush, starting at the head and working 698
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down. Pay special attention to heavily contaminated areas (e.g., hands, feet, front of suit). 3. Rinse again, starting at the head and working down. 4. Assist the responder in removing PPE. 5. Contain the runoff of hazardous wastewater.
Decontamination for Patients not Wearing PPE The decontamination of patients not wearing PPE proceeds in a different manner. As always, the first and foremost consideration is responder safely. If responders are incapacitated, they are unable to help others. You should use a public address system to direct ambulatory patients to a decontamination line. This provides a rapid form of triage. Patients should be instructed to begin decontamination by removing their clothing. Have people remove shoes, socks, jewelry, watches, and other items that trap materials against the skin. They should also remove contact lenses as soon as possible. Double-bag their clothing for disposal or decontamination later. Valuables and identification should be bagged and may (based on hazards) be carried by the patients. Next, the patients should receive a 2- to 5-minute water rinse. Solid or particulate contaminants should be lightly brushed off (dry decontamination) as completely as possible prior to washing (wet decontamination). Viscous liquid contaminants (including vesicants, which are blistering agents) should be blotted off prior to washing. If the material is water reactive, it must be brushed off prior to the application of water. Rinsing is done as needed to flush remaining chemicals that may ream with the moisture of the skin and eyes. You should also use an
appropriate decontamination solution. Washing and rinsing should start at the head to reduce contamination on or near the nose, mouth, cars, and eyes. If the patient has removed his contact lenses, the eyes should be irrigated. Open wounds should be irrigated starting from the area nearest the body core and working outward. You may use plastic wrap to isolate the wound once it has been cleaned. Use a low-water-pressure system to avoid aggravating soft-tissue injuries and to avoid overspray and splashing. A low-pressure system will also help prevent the creation of an aerosol out of dry product. During decontamination, patients should be given some type of cover for modesty and protection from the elements. Although not strictly a form of selfprotection, “decon” is vital to prevent, reduce, and remove contamination for both responders and patients.
MULTIPLE-CASUALTY INCIDENTS
A multiple-casualty incident (MCI)—or. in some areas, a multiple-casualty situation (MCS)—is an event that places a great demand on EMS equipment and personnel resources. The number of patients required before an MCI can be declared varies in practice. Some jurisdictions will declare an MCI for as few as three patients on the grounds that practice with smaller-scale incidents will help EMTs prepare for larger ones. Other jurisdictions reserve the MCI designation for five, seven, or more patients. The most common MCI is an automobile collision with three or more patients. You will likely respond to many incidents with 3 to 15 potential patients. Incidents with large-scale casualties are rare and apt to be “once in a career” events. The important ingredient in defining an MCI is that, for whatever reason, the EMS system’s ability to respond to the situation is challenged or hampered by the situation itself. For any MCI plan to be effective, it must be flexible and expandable enough to be used from small three-patient incidents to large-scale incidents of 15 or more patients. In other words, the plan for “the big one” should be a logical extension of the same plan used to manage smaller incidents.
Multiple-Casualty-lncident Operations
Though the principles of managing small- and largescale MCIs are generally the same, large-scale MCIs unfold over a longer period of time and require greater support from outside agencies. Well-trained and practiced EMTs can usually cope with a small-scale MCI pretty well. However, experience has shown that even the best-trained EMTs have a difficult time managing an incident of greater magnitude.
One way to minimize the operating difficulties of a large-scale MCI is for every EMT to be familiar with the local disaster plan. A disaster plan is a predefined set of instructions that tells a community’s various emergency responders what to do in specific emergencies. Although no disaster plan can address every problem that could arise, there are several features common to every good disaster plan. The disaster plan should be: • Written to address the events that are conceivable for a particular location. • Well publicized. Each emergency responder should be familiar with the plan and how it is to be put into operation. • Realistic. The plan must be based on the actual availability of resources. • Rehearsed. Experience has proven that the only way to get a plan to work correctly is to exercise it and, in so doing, work out the unforeseen “bugs.” It is beyond the scope of this text to teach you how to write a disaster plan or even to impart enough knowledge for you to be in charge of a disaster operation. However, it is important to introduce basic information about your potential roles in such an incident. Bagama’t pareho lang ang dapat gawin ng EMT, konti man o madami ang pasyente, nag-iiba naman ang klase ng management na kailangan dahil sa mga sitwasyon na tatlo o higit pa ang bilang ng pasyente, nadadagdagan ang pressure sa mga EMTs. Kahit ang pinakamahuhusay na EMTs ay nahihirapan kapag ang mga pasyente ay higit na sa tatlo. Kailangan na handa ang grupo mo sa mga ganitong sitwasyon. Gumawa kayo ng disaster plan kung saan nakasulat ang inyong mga kakailanganin at dapat gawin sa mga panahon na madami ang biktima. At praktisin ninyo ang planong ito para makabisado ng lahat ang dapat gawin.
Command
Command, which must be established at all incidents, is the person who assumes responsibility for incident management. This individual stays in Command unless that function is transferred to another person or until the incident is brought to a conclusion. IMS systems recognize that the manageable span of control is six people. As the MCI escalates and becomes more complex. The number of people and span of control LIFELINE
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become too large for one person to effectively manage. At this point. Command designates people to handle the specific functions needed to manage the operation. The basic elements of the Incident Management System—with sections such as Operations being subordinate to Command—are: • Operations • Logistics • Finance • Planning Command assumes all incident management functions except those that Command may delegate to someone else. Unless an incident is very complex, the most common function designated is Operations. Two methods of Command defined under NIMS are single incident command and unified command. In single incident command, a single agency controls all resources and operations. In many communities, for example. EMS is managed by fire services. Accordingly, single incident command is often used at fire and rescue incidents with the Incident Commander provided by the fire service. However, if police agencies have major involvement, if there is a separate EMS provider, or if other agencies are involved. unified command is more appropriate. In unified command, several agencies work independently but cooperatively rather than one agency exercising control over the others. In most communities, unified command is the best way to manage resources. It recognizes that large-scale incidents tend to be complex and that the right agency must take the lead at the right time, with Command officers from all agencies cooperating.
Command Functions
Initially. Incident Command is assumed by the most senior member of the first service on the scene. Very often, this will be an EMS unit. Depending on jurisdiction, laws, or protocols, Incident Command may be later transferred to another individual or may be continued by whoever established it. Two modes or phases of action must then be undertaken: scene size-up/triage and organization/delegation. First. Command and the crew do an initial scene size-up, start the triage process, and call for backup. While waiting for help, initial triage is completed and Command gets ready for arriving resources. When reinforcements arrive, there are two options for the person who initially assumed Command: Continue to be in Command or transfer Command to someone of higher rank. In a unified system. Incident Command would be assumed cooperatively by the Command of each service. Command is positioned at a location close enough to allow observation of the scene but secure enough to permit management of incoming resources and communication with others. In a unified command system. EMS, Police, and Fire Command establish one field command post together and stay there. Some plans call for the field command vehicle or command post to be designated by placing two traffic cones on top of the vehicle being used. In a single incident command mode, one person acts as Command, and EMS would typically be a group under the Operations section. 700
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Scene Size-Up Size-up the scene by making a sweep to determine what needs must be met: 1. Arrive at the scene and establish Incident Command. Put on the proper identification. 2. Do a quick walk through the scene (or. if it is a hazmat scene, observe from a safe distance) and assess the number of patients, hazards, and degree of entrapment. Identify the number of patients, including the “walking wounded.” apparent priority of care, need for extrication, number of ambulances needed, other factors affecting the scene and corresponding resources needed to address them, and areas where resources can be staged. 3. Get as calm and composed as possible to radio in an initial scene re-port and call for additional resources.
Communications
Once scene size-up has been done, you should make an initial scene report to the communications center. Keep the report short and to the point, but give enough information for the communications center and other responders to understand the severity of the situation and react accordingly. Give yourself a unique Command name to distinguish yourself and your incident location from other personnel and incidents that may be using the same radio system. Example: MEDCOM, this is Medic 640. We are on the scene of a two-car MVA with severe entrapment of four Priority 1 patients. Dispatch a rescue company and four paramedic ambulances. I will now be called Roxas Boulevard Command- Police are needed at the scene to assist with traffic and crowd control as soon as possible. If the disaster plan is to be put into operation, it is critical that other responding units be informed of this fact. Your communications may also include telling other units what equipment to bring, what they should plan on doing once they arrive, how best to access the scene, and where to park. As help begins to arrive, control of on-scene communication is important. Once units arrive, as much face-to-face communication as possible should be used, especially between Command and Command’s direct subordinates. This will help to reduce radio channel crowding. If you feel you are getting too tied up in radio communications, designate a radio aide. Basically, the flow of communications at the scene should correspond to the organizational chart being used. Accordingly, the only unit talking to the communications center and requesting resources is Command. The only ones who talk to Command are those directly subordinate to Command. All others talk only to the officer or supervisor they are assigned to.
Organization Getting organized early and aggressively is very important. You must have a plan to deploy resources when they arrive. In addition, you must decide what subordinate officers will be needed and where resources will be placed. A common mistake is to underestimate the resources that will be needed. Somehow new patients not found during scene size-up have a way of appearing. Think big. Order big. Put resources in the staging area if they are not needed right away. In urban/suburban incidents, backup can be fast and oven helming. If you do not think about supply and staging areas early, you take the chance of being overrun It is important to prevent “freelancing.” Freelancing is uncoordinated or undirected activity at the scene. Given the opportunity, most rescuers will arrive on the scene and begin setting their own priorities. Command can prevent this problem. When Command is established early, people and crews arc assigned to tasks as they arrive. Often it is helpful to have some personal tools to help get organized. For example, many organizations have distilled the major points of their plans into a “tactical worksheet” they can use in the field. With enough use. the plan can become committed to memory.
Scene Management The senior person on the first-arriving EMS unit will likely assume Incident Command (known simply as Command). He will establish a command post to over-see the incident’s medical aspects and the safety of all personnel, designate area supervisors, and work closely with the fire and police commanders. On larger incidents. Command may have an aide to assist with communications as well as a public information officer and a safety officer. It is important to keep uninjured people from becoming injured. This will probably require restricting access to the scene to only those personnel performing triage (explained later), extrication from wreckage, and patient care. As resources arrive at the scene, police officers or safety officers may take over this function.
EMS Branch Functions Under NIMS, in a very large and complex multiplecasualty incident, EMS will function as a branch under the Operations section. For smaller MCls, the EMS person who has assumed Incident Command may be able to handle all aspects of management without delegating tasks to others. However, as an incident increases in size and complexity, additional staff and area supervisors will be needed. EMS operations generally include the following: • Mobile command center • Extrication (in cases of entrapment) • Staging area
• Triage area • Treatment area • Transportation area • Rehabilitation area Individuals and agencies on the scene will be assigned particular roles in one or more areas. Most systems use brightly colored reflective vests that can be worn over protective clothing to make each incident sector officer easy to identify. Any EMT arriving at the scene at this time would be expected to report to an area supervisor for assignment of specific duties. Once assigned a specific task, the EMT should complete the task and report back to the area supervisor.
Triage
Once organization has been established, the next task is to quickly assess all the patients and assign each a priority for receiving emergency care or transportation to definitive care. This process is called triage, which comes from a French word meaning “to sort “The most knowledgeable EMS provider becomes the triage supervisor. The triage supervisor calls for additional help (if needed), assigns available personnel and equipment to patients, and remains at the scene to assign and coordinate personnel, supplies, and vehicles.
Primary Triage
When faced with more than one patient, your goal must be to afford the greatest number of people the greatest chance of survival. To accomplish this goal, you must provide care to patients according to the seriousness of illness or injury while keeping in mind that spending a lot of time trying to save one life may prevent a number of other patients from receiving the treatment they need. To properly triage a group of patients, you should quickly classify each patient into one of four groups:
• Priority 1: Treatable Life-Threatening Illness or Injuries. Patients with airway and breathing difficulties,
uncontrolled or severe bleeding, decreased mental status, severe medical problems, shock (hypoperfusion), and/or severe burns.
• Priority 2: Serious but Not Life-Threatening Illness or Injuries. Patients who have burns without airway
problems, major or multiple bone or joint injuries, and/or back injuries with or without spinal cord damage. • Priority 3: “Walking Wounded.” Patients with minor musculoskeletal injuries or minor soft-tissue injuries.
• Priority 4 (sometimes called Priority 0): Dead or Fatally Injured. Examples include patients with exposed
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Day 27 Patients in arrest are considered Priority 4 (or 0) when resources are limited. The time that must be devoted to rescue breathing or CPR for one person is not justified when there are many patients needing attention. Once ample resources are available, patients in arrest become Priority 1. How triage is performed depends on the number of injuries, the immediate hazards to personnel and patients, and the location of backup resources. Local operating procedures will give you more guidance on the exact method of triage for a given situation. Basic principles of triage are presented here. The first triage cut can be done rapidly by using a bullhorn. PA system, or loud voice to direct all patients capable of walking (Priority 3) 10 move to a particular area. This has a two-fold purpose. It quickly identifies the individuals who have an airway and circulation, and it physically separates them from patients who will generally need more care. You must rapidly assess each remaining patient, stopping only to secure an airway or stop profuse bleeding. lt is important that you not develop “tunnel vision”—spending time rendering additional care to any one patient and thus failing to identify and correct life-threatening conditions of the remaining patients. If Priority 3 patients are nearby and well enough to help, they may be employed to assist you by maintaining an airway or direct pressure on bleeding wounds of other patients. Priority 3 patients who have been reluctant to leave ill or injured friends or relatives may be permitted to stay near them where they can be of possible help later. Once all patients have been assessed and treated for airway and breathing problems and severe bleeding, more thorough treatment can be initiated. You will need to render care to the patients who are most seriously injured or ill but who stand the best chance of survival with proper treatment. This requires treating all the Priority 1 patients first. Priority 2 patients next, and Priority 3 patients last. Priority 4 patients do not receive treatment unless no other patients are believed to be at risk of dying or suffering long-term disability if their conditions go unattended. Usually patients will be immobilized on backboards if necessary, and carried by “runners” to the appropriate secondary sector (as described later). Extensive treatment does not occur at the incident site since it is in a hazard zone and could impede rescue and initial treatment of other patients. 702
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START Triage: A National Standard for Rapid Primary Triage The most commonly used method of prioritizing patients in the Philippines is the START method of triage. It was developed by the Newport Beach, California, Fire Department and the Hoag Hospital in Newport Beach, California. START stands for Simple Triage and Rapid Treatment. The foundation of the system is the speed, simplicity, and consistency of its application. It relies on some simple commands and the following physiologic parameters that can be remembered by the mnemonic RPM: Respiration, Pulse and Mental Status START triage is intended to be completed in about 30 seconds per patient. Begin by asking all patients who can walk to get up and go to a collection point such as an ambulance or a building. Since those who can do this are ... • Conscious • Able to follow commands • Able to walk They obviously are perfusing their brain, are breathing, have a pulse, and have a nervous system that is currently working. All of these patients are considered to be Priority 3 (green tag) patients for right now. (They are often called the “walking wounded”) This also leaves people at the site who are unable to hear, walk, or follow commands and are the Priority 0.1, or 2 patients. Among these patients, you must now focus your attention on those who are likely to be of higher priority. Ang triage ay ginagawa dahil may mga pasyente na mas nangangailangan ng tulong ng EMT. Importante na malaman mo kung sino ang mga pasyenteng ito para mabigyan mo sila agad ng lunas. Ang paraan ng triage ay depende sa dami ng mga pasyente, sa klase ng mga injuries nila, at sa dami ng mga EMTs at mga kagamitan. Importante sa triage ang komunikasyon. Maging kalmado palagi.
Assess Respiration (Breathing Status) First. If the patient is not breathing and your attempts to open the airway do not start breathing, tag the patient as a Priority 0 (black tag) patient. If the patient starts breathing alter the airway is opened, then tag as a Priority 1 (red tag). Is the patient breathing more than 30 times per minute? If so. tag the patient as a Priority 1 (red tag) patient. Is the patient breathing less than 30 times per minute? If so, go to the next step. Assess Radial Pulse Second. If the patient is unresponsive, not breathing, and has no pulse, tag the patient as a Priority 0 (black tag) patient. If the patient is breathing but has no pulse, tag as a Priority 1 (red tag) patient. If the patient is breathing and has a pulse, good skin signs, and capillary refill less than 2 seconds, go to the next step. Assess Level of Consciousness (Mental Status) Third. If alert,
tag as a Priority 2 (yellow tag) patient If there is any altered mental status, tag as a Priority I (red tag) patient.
Now Re-Triage the Priority 3 “Walking Wounded” Patients. Just because they could initially walk does not mean some of the Priority 3 patients do not have serious medical conditions! Many could have an altered mental status, be bleeding, and have significant signs of shock, which could cause them to be recategorized as a higher priority patient. Move methodically using the same START assessment of (1) respiration. (2) pulse, and (3) mental status.
A START Summary is as follows:
1. Order the walking wounded to some type of temporary collection point. They are considered Priority 3 (green) for now. 2. Assess all others for RPM (respiration, pulse, and mental status) and tag as follows: Priority 1 (red) are patients who have: • Altered mental status, or… • Absent radial pulse, or… • Respirations of greater than 30/minute Priority 2 (yellow) are patients who: • Are alert, and … • Have radial pulses present, and … • Have respirations less than 30/minute Priority 0 (black) are patients who: • Are not breathing (after an attempt to open the airway), or.. – • Have no pulse and are not breathing 3. Re-triage all walking wounded.
Patient Identification
By now, it should be clear that a system will be required to group and identify patients by treatment priority. A widely used system is to color-code patients according to their priority. The START system, discussed previously, is one example of a color-coding system. Other systems’ color codes may be slightly different. For example. Priority 1 might be red: Priority 2,yellow: Priority 3.green:and Priority 4 (if a separate category) might be black or gray. Since different localities have different systems, it is important that you know and understand the system used in your area. It is equally important that different services in the same region use the same coding system. This is because many MCls are multiple-agency events. If each agency were to use a different system, there would be no way to correctly coordinate the order in which patients are to receive care. As you move among patients to conduct initial triage, you should affix a triage tag to each patient, indicating the priority group to which that patient has been assigned. Triage tags are color-coded and may have space in which limited medical information can be recorded.
There are some local variations of the triage tag. Some use adhesive-backed colored shipping labels. Others use colored surveyor’s tape or duel tape to classify patients. Surveyor’s tape can be quickly tied on as an arm band. Duct tape will stick to just about anything in any kind of weather. For this reason, it is particularly useful in an MCI setting. It is also useful to have a laundry marker or wax pencil handy for wet conditions when a standard pen or pencil will not write well. Whatever system you use. it is vital that the color coding be easily located and identified. When properly performed, this coding allows a later EMT to quickly identify which treatment group patients belong to and to institute treatment in that manner.
Secondary Triage and Treatment As more personnel arrive at the incident scene, they should be directed to assist with the completion of initial triage. If triage has been completed, these EMTs can initiate treatment. Secondary triage is generally performed at a patient collection point or triage area from which patients are assigned to a treatment group. Patients are physically separated into treatment groups based on their priority level as designated by a triage tag. Some systems call for vehicles to carry red, yellow, and green tarps. which are used to designate these areas. An area to which triaged patients are removed is referred to as a treatment area. Each treatment area should have its own treatment supervisor, an EMT responsible for overseeing the triage and treatment within that area. The treatment supervisor should re-triage the patients in that area to determine the order in which they will receive treatment. Secondary triage is important to ensure that patient are treated and transported according to their priority. During secondary triage, it may be necessary to recategorize a patient whose condition has deteriorated or improved, or who was incorrectly triaged. to a higher or lower priority groups than was medically wanted. This will necessitate moving the patient to the proper treatment area as resources permit. Some systems use a different disaster tag during secondary triage on which more detailed information about the patient can be recorded. The treatment area EMTs will need supplies and equipment from the ambulances such as bandages, blood pressure cuffs, and oxygen.
Transportation and Staging Logistics Once patients have been properly assessed and triaged. and once treatment for the patients has been initiated according to their priority, consideration must be given to the order in which the patients will be transported to a hospital. Again, this is done according to triage priority. LIFELINE
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Day 27 It is advisable to have a staging area from which ambulances can be called to transport patients. The staging area will be the responsibility of the staging supervisor, who must keep track of the ambulance vehicles and personnel. In large-scale incidents, the staging supervisor may need to arrange for certain human needs, such as rest rooms, meals, and rotation of crews. No ambulance should proceed to a treatment area unless requested by the transportation supervisor and directed by the staging supervisor. The staging supervisor is responsible for communicating with each treatment area regarding the number and priority of the patients in that area. This information can then be used by the transportation supervisor to arrange for transport of patients from the scene lo the hospital in the most efficient way. It is vital that no ambulance transport any
Communicating with Hospitals
It is important that receiving hospitals be alerted to the nature of the MCI or disaster as soon as the magnitude of the incident is known. This allows the hospitals to call in additional personnel or to clear beds as necessary to accept the anticipated number of patients. Because radio communicator channels will be heavily used, the transportation officer, not individual EMTs, should communicate with the hospitals. This will keep unnecessary radio usage to a minimum. It will also ensure that the proper information is recorded at both ends of the ambulance ride. In large-scale MCls, it is not necessary to give a patient report for each patient since the treating and transporting EMTs will most likely be different and there will generally be too many patients to allow EMTs to give a good patient radio report under the circumstances. In these instances, the hospital may be told only basic information; for example, that they are receiving a Priority 1 patient with respiratory problems.
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MULTIPLE CASUALTY INCIDENT patient without the approval of the transportation supervisor, since the transportation supervisor is responsible for maintaining a list of patients and the hospitals to which they are transported. This information is relayed from the transportation supervisor to each receiving hospital. In a largescale incident, the transportation officer may actually have an aide who does nothing but speak to hospitals. In this way, the hospitals know what to expect and receive only the patients they are capable of handling. It is critical that the EMTs on the ambulance comply with the instructions of the transportation supervisor. Failure to do so may result in patients being transported to the wrong facilities. Once an ambulance has completed its run to a hospital, it will probably be directed to return to the staging area, perhaps bringing needed supplies, to await its next instructions from the staging supervisor.
Psychological Aspects of MCls During MCls, EMTs often encounter another, frequently overlooked condition: psychologically stressed patients. Although they may outwardly exhibit few signs of injury or emotional stress, people involved in MCls have been subjected to devastating circumstances with which they are normally unprepared to cope. Proper early management of the psychologically stressed patient can support later treatment and help ensure a faster recovery. Adequately managing a patient during an MCI may require you to administer “psychological first aid.�This may take the form of talking with a terrified parent, child, or witness. You should not attempt to engage in psychoanalysis and should not say things that are untrue in an attempt to calm a patient. However, a caring, honest demeanor can reassure a patient, as will listening to the patient and acknowledging his fears and problems. Often this is all the patient will need. Patients are not the only ones subject to emotional stress during a multiplecasualty incident; emergency responders are as well. It is very important that you understand that large-scale or horrific MCls may affect rescuers as much as, if not more than, non-rescuers.
Ang mga EMTs na sobra na ang pagod at nagiging emosyonal na ay kailangang “ tratuhin bilang pasyente na rin. Kailangan ilayo sila sa area kung saan naroon ang mga pasyente para maging kalmado sila. Kailangan silang pagpahingahin at bantayan hanggang sila ay kumalma. Huwag silang papayagan na bumalik sa eksena nang hindi sila nasusuri at nakakapagpahinga.
LEARNING OBJECTIVES Describe the purpose of extrication Discuss the role of the EMT-Basic in extrication. Identify what equipment for personal safety is required for the EMT-Basic. Define the fundamental components of extrication. State the steps that should be taken to protect the patient during extrication. Evaluate various methods of gaining access to the patient. Distinguish between simple and complex access.
HIGHWAY EMERGENCY OPERATIONS/ VEHICLE EXTRICATION
INTRODUCTION
LEARNING OBJECTIVES
• Describe the purpose of extrication. • Discuss the role of the EMT-Basic in extrication. • Identify what equipment for personal safety is required for the EMT-Basic. • Define the fundamental components of extrication. • State the steps that should be taken to protect the patient during extrication. • Evaluate various methods of gaining access to the patient. • Distinguish between simple and complex access.
INTRODUCTION
HIGHWAY EMERGENCY OPERATIONS
At least 10 types of specialty rescue teams may be available in various communities, depending on each community’s hazards. Each specialty requires a signifiAt least 10 types of specialty One of the greatest hazards emergency respondent face cant amount of additional training over and above your EMT course. These sperescue teams may be available in today is oncoming traffic at highway incidents. Drivers are cialties include vehicle rescue, water rescue, ice rescue, high-angle rescue, hazvarious communities, depending in quid cars with distractions ranging from cell phones to ardous materials response, trench rescue, dive rescue, back-country or wilderness onboard video players. Distracted drivers pose a great risk to on each community’s hazards. rescue, farm rescue, and confined space rescue. Training that is available in each everyone operating at a highway incident. It requires a team Each specialty requires a significant of these amount of additional training over specialties often depends on the types of emergency responses that effort of police, fire, and EMS to ensure a work area that is as might be and above your EMT course. These required in your community. safe as possible from as many hazards as possible. EMTs are not typically in charge of highway incidents but play a key role, specialties include vehicle rescue, The focuswater rescue, ice rescue, highof this chapter is the EMT's role at a vehicle collision where extrication because they are called to treat the injured who are likely to be of the patient is required, since this is the most common type of rescue across the entrapped in wreckage. angle rescue, hazardous materials United States. response, trench rescue, dive rescue, The care of the injured and safety of the responders are both back-country or wilderness rescue, high priorities at a highway incident. To achieve these goals, it is farm rescue, and confined space important that; rescue. Training that is available • EMS response should be limited to only the manpower and in each of these specialties often vehicles needed to accomplish the mission and should not depends on the types of emergency expose more people than necessary to the risks of highway responses that might be required in operations. your community. • The first-arriving unit should institute “blocking” to The focus of this chapter is the protect the work area. Because of its size and weight, fire EMT’s role at a vehicle collision apparatus is preferred for this purpose. where extrication of the patient • If it is necessary to block lanes of traffic, they should be is required, since this is the most ² Limmer (Brady) cleared as quickly as possible so the flow of traffic can common type of rescue across the ³ Pollack, (AAOS) ⁴ NHTSA return to normal. Philippines.
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Initial Response On limited-access highways, only the primary or first-due units should proceed directly to the scene. Units sent for backup should stage off the highway until they are requested to the scene.
The first-arriving units should:
• Establish Command and confirm the exact location of the incident in the dispatch center. • Use apparatus to institute “upstream blocking “of the scene to protect the work area. Although fire apparatus is ideal, as already noted, any first-arriving unit can institute blocking. If Tire apparatus responds subsequently, they can be placed behind the lighter units. • Rescue trucks (police or EMS) arriving to perform extrication should be positioned downstream of the initial blocking vehicle. Congestion at incidents is a big problem. To minimize scene congestion, units should park in the same direction and remain in single file, if possible. Again, larger units should provide upstream blocking whereas Command and EMS units are downstream in the “safe zone”. Responding units need to exercise extreme caution in performing turnarounds on limited-access highways. These should be done only when a turn can be completed without obstructing the flow of traffic in either travel direction or when all traffic movement has stopped. EMS personnel should avoid parking their units and conducting ambulance loading on the side that is across traffic flow from the side where the crashed vehicle or vehicles are located. Unless a roadway is completely shut down. EMS crews should avoid crossing over lanes of traffic on foot, especially when they are trying to move patients. Doing so is extremely dangerous. Whenever possible, park downstream from the crash in a safe zone created by blocking from upstream apparatus.
Positioning Blocking Apparatus The apparatus that is used to block should be positioned to create one-and-a-half to two lanes of blockage. This will usually create a large enough work zone. The driver of the apparatus must also consider preservation of the crash scene and must avoid running over road debris or crash evidence. Ideal blocking placement has the fire apparatus positioned at an angle, with its working side toward the work zone to protect the crew The front wheels are rotated away from the incident. In the event that a motorist strikes the engine, the engine will be a barrier. If the engine is pushed by the striking vehicle on impact, the unit will move away from the work zone. Some incidents may require more than one piece of blocking apparatus. 706
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It is important to leave space in the area immediately next to the crash to position vehicle extrication units. Ambulances, command vehicles, and other units should be positioned downstream from the crash. Positioning units in this manner allows for safer patient loading and rapid departure from the scene.
Exiting the Vehicle Safely Responders who are exiting apparatus are at high risk of being struck by a passing vehicle. They should always exit into the safe zone, if possible, after checking to be sure that traffic has stopped. Be sure everyone in the responding vehicle is communicating, looking out for traffic, and being aware of when it is safe to exit the unit.
Be Seen and Warn Oncoming Traffic Before exiting the vehicle, all responders should be in full protective clothing or. at a minimum. To help slow oncoming traffic, flares, traffic cones, or other devices should he placed to channel traffic away from the incident and establish a safe work zone. Cones and/or flares should be placed on an angle across the road and around the site. Some apparatus have amber flashing directional arrows to direct traffic that should be activated to assist in alerting oncoming traffic. If it is necessary to channel traffic around a curve, hill, or ramp, the first cone or flare must be placed before the hill or curve. The intent is to warn on-coming traffic of a hazard ahead. The rest of the cones, as already noted, should be placed diagonally across the lanes and around the work zone.
Night Operations At night, headlights or flashing lights can temporarily blind drivers that are approaching an emergency scene, preventing them from seeing emergency workers. In this circumstance, reflective safety vests become ineffective. Therefore, drivers of emergency apparatus parked at highway incidents should turn off vehicle headlights. In addition, they should shut off any white response lighting that could blind oncoming drivers. The best combination of lights to provide maximum visibility is: • Red/amber warning lights—on • Headlights—off • Fog lights—off • Traffic directional boards operating
UNIT 4 DAY 27 AMBULANCE OPERATIONS IN EMT PRACTICE VEHICLE EXTRICATION
VEHICLE EXTRICATION Extrication is the process by which entrapped patients are rescued from vehicles, buildings, tunnels, or other places. There are 10 phases of the extrication or rescue process that you, as an EMT, should understand: 1. Preparing for rescue 2. Sizing up the situation 3. Recognizing and managing hazards 4. Stabilizing the vehicle prior to entering 5. Gaining access to the patient 6. Providing primary patient assessment and a rapid trauma assessment 7. Disentangling the patient 8. Immobilizing and extricating the patient from the vehicle 9. Providing assessment, care, and transport to the most appropriate hospital 10. Terminating the rescue
Positioning Cones or Flares Control Traffic Extrication is the to process by which entrapped patients are rescued from vehiBilang EMT,
cles, buildings, tunnels, places. are 10 responsable phases ofkathe extrication sa mga Posted speed Stopped distance Posted speed or other Distance of theThere farthest pangangailangang or rescue process that you, as an EMT, should understand: (mph) for that speed 1. Preparing (in feet) for rescuewarning device medikal ng mga biktima sa aksidente. Hindi mo 2. + Sizing 20 mph 5O feet 20 up feetthe situation = 70 feet responsibilidad ang 3. + Recognizing and managing hazards pagkuha sa sasakyan 30 mph 75 feet 30 feet = 105 feet 4. Stabilizing the vehicle prior lo entering o iba pang trabahong 40 mph 125 feet + 40 feet = 1*5 feet mabibigat. Tandaan palagi 5. Gaining access to the patient na may kanya-kanya 5O mph 175 feet 50 feet primary = patient 225 feet 6. + Providing assessment and a rapid trauma assessment kayong trabaho. Ang 7. Disentangling the patient 60 mph 275 feet + 60 feet = 335 feet trabaho mo ay magbigay 8. Immobilizing and extricating the patient fromlunas the vehicle sa mga pasyenteng 70 mph 375 feet + 70 feet = 445 feet 9. Providing assessment, care, and transport to the most appropriate nangangailangan ng iyong serbisyo. hospital As an EMT. you are responsible for the 10. Terminating the rescue
Preparing for Rescue
medical component of the rescue process; others are responsible for the mechanical or Modem rescue is a sophisticated process. physical components. As you carry out your PositioningIt requires preparation that is a combination of Cones or Flares to Control Traffic responsibilities, attention to safety must be training, practice, and the right protective gear your highest priority—to help minimize and tools. As previously noted, training and the potential for injury to yourself and the Posted speed Stopped disPosted speed other rescuers as well as any additional (mph) practice for specific types of rescue, including tance for that (in feet) vehicle rescue, will be above and beyond your injury to your patient. Although you may speed basic EMT course. The availability of such never personally perform disentanglement, training will depend to a great extent on the it is important for you to understand the 20 mph SO feet + 20 feet kinds of rescues most likely to be required in rescue process so you can keep your patient your area. The kinds of protective gear and tools informed and anticipate any dangerous steps 30 mph 75 feet that should be available for vehicle rescue will be + 30 feet in the extrication action plan. discussed throughout this chapter.
40 mph
125 feet
+
40 feet
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SO mph
175 feet
+
50 feet
60 mph
275 feet
+
60 feet
Distance of the farthest warning device
= 70 feet = 105 feet = 1*5 feet
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= 225 feet = 335 feet
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Sizing Up the Situation As you arrive on the scene of a vehicle crash, it is important to conduct a good “sizeup” to evaluate hazards and assess the need for additional resources. Quickly determine how many patients are involved, their priority, and the mechanisms of injury. Will additional ambulances be needed? If so. call them right away. You can always cancel them if they are not actually needed. What is the extent of the patient’s entrapment? Conduct an initial triage sweep and. using START triage, sort and tag the patients as soon as possible During scene size-up, you must be able to assess the extrication needs well enough to communicate with the extrication team and anticipate what they will be doing. Effective rescue requires a balance of medical and mechanical skills, with the right amount of each applied at the right time. During all of this, you will keep in mind that the most seriously injured patients must reach the hospital or trauma center for lifesaving surgery as quickly as possible. As the EMT, you must plan how you can begin emergency care and initiate transport as rapidly as possible. Although a low-priority trauma patient has time for elective packaging and more time-consuming elective extrication procedures, a critical patient does not. For example, a stable patient complaining of neck pain has the lime for careful short spine board or vest immobilization, whereas a highpriority trauma patient cannot afford the 15 to 20 minutes this may take. Rapid extrication to a long spine board, taking 2 minutes, may be more appropriate for this patient. The patient’s medical needs must always drive the process of extrication and patient care. The principles of spinal immobilization remain the same whether the patient is low or high priority, although the requirements for speed of removal will dictate the specific technique you use.
Recognizing and Managing Hazards
As explained in the following sections, some collision-related hazards must be managed, if not eliminated, even before any attempt is made to reach injured persons in damaged vehicles. 708
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Protective Gear for EMS Responders
At a crash, any personnel who are working in the “inner circle”—that is, the area immediately around and including the vehicle—should wear full protective gear to avoid being injured. Figure shows an EMT dressed for a rescue operation with minimal hazards. Protective gear is important. Get your own if your service does not provide it. EMS personnel have a wide selection of personal protective equipment (PPE) available to them. Until recently, most PPE was designed for structural fire fighting and not for rescue/EMS operations. Today, rescuers have a wide variety of compact lightweight helmets with integral eye protection. There are now PPE garments designed for urban search and rescue (USAR) operations that are ideal for EMS. They are lightweight, breathable, and provide protection from flame. Fluids, and common chemicals. This is in stark contrast to fire- fighter PPE. which is designed with greater insulation to provide protection from heat/flame. As a result, firefighter PPE is much heavier and more bulky.
Working in Traffic As discussed at the beginning of this chapter, being struck by a vehicle while working in traffic is a major hazard facing the EMT. All emergency respondent wear safety vests when working in highway operations. To enhance safety, they should also wear helmets. Safety vests greatly enhance both day and night visibility, giving rescuers added protection because motorists can see them. The best way to understand this is to study them, which show clothing with reflective elements in daytime and night time settings.
During Extrication Operations When extrication is in progress at a motor-vehicle collision, the rescuer has an increased exposure to flame, glass, fluids, and sharp objects. The best practice is to wear EMS or firefighter turnout clothing, including a helmet and eye protection, the inner circle because they do little to protect the EMT from jagged metal, broken glass, or flash fires. Good upper body protection is offered by wearing either a short or mid-length turnout coat. A heavy-duty EMS or rescue jacket can be used to protect you from bad weather and minor injury. As with helmets, bright colors and reflective material will help make your jacket more visible. Good lower body protection can be provided by wearing either turnout pants with cuffs wide enough to pull over work shoes or fire-resistant trousers or jumpsuits. Serious consideration should be given to wearing high-top. steel toe work shoes with extended tops to protect the ankles.
Safeguarding Your Patient When your patients have been injured in a collision, it is your responsibility to see to it that further injuries are not inflicted during the rescue operation. You can minimize the chance of such additional injuries by shielding the patient and exercising care. The following items can be used to protect the patient from heat, cold, flying particles, and other hazards: • An aluminized rescue blanket offers protection from bad weather and. to a degree, from flying particles. A paper blanket docs not afford this protection; it merely hides the patient’s view of the debris that is about to strike him. • A lightweight vinyl-coated paper tarpaulin can protect the patient from bad weather. • A wool blanket should be used to protect the patient from cold. Cover the wool blanket with an aluminized blanket or a salvage cover whenever glass must be broken near a patient, since glass particles are just about impossible to remove from wool blankets. • Short and long spine boards can shield a patient from contact with tools and debris. • Hard hats, safety goggles, industrial hearing protectors, disposable dust masks, and thermal masks (in cold weather—and unless the patient has airway or breathing problems or is on oxygen) will protect a patient’s head. eyes, ears, and respiratory passages.
Managing Traffic Collisions almost always produce traffic problems. Often the wreckage blocks lanes of traffic. Even if it does not. backups are caused when curious drivers slow down to “rubberneck.” or stare at the scene. Rescuers, firefighters and police usually handle traffic control. However, what if the ambulance EMTs are responding alone or ahead of other emergency service units? Obviously, personal safety, rescue, and emergency care have priority. However, an ambulance crew should still initiate basic traffic control, channelling vehicles past the scene. Re-member to be extremely watchful and careful when you work to control traffic to be sure that you are not struck by an approaching or passing vehicle. Your ambulance and its warning lights will serve as the first form of traffic control. However, you should position other warning devices as soon as possible. Bad weather, darkness, vegetation, and curved or hilly roadways may keep approaching motorists from seeing your ambulance soon enough to safely stop.
Using Flares for Traffic Control Although some argue that flares are unsafe, when used properly they are still a good device for warning motorists of dangerous conditions. Moreover, several dozen flares can be carried behind the front seat of an ambulance, whereas batterypowered flashing lights—an alter-native to flares—take up valuable compartment space. Scan, which shows the proper positioning of cones or flares at collision scenes, including a straight road, a cursed road, and a hill. Keep in mind that the stopping distance for large trucks is much greater than for cars. When the road carries truck traffic, extend the flare strings beyond the distances shown.
Supplemental Restraint Systems: Air Bags Auto air bag systems have revolutionized automobile safety. Manufacturers emphasize that air bags are not designed to replace seat belts but rather to be used in conjunction with seat belts; consequently, air bags are often referred to as supplemental restraint systems (SRS). Air bags are designed to inflate on impact, dissipate kinetic energy, and minimize trauma to the body. During rescue, it is important to see if an air bag has deployed. Witnesses may have noticed “smoke” inside the vehicle during air bag deployment. This is not actually smoke but rather dust from the cornstarch or talcum used to lubricate the bag as well as from the seal and particles within the bag. The powder may contain sodium hydroxide, which can irritate the skin. For this reason, it will be important to wear protective gloves and eyewear when you gain access to the passenger compartment. It also will be important to protect the patients from getting additional dust in their eyes or wounds. Experts recommend that the EMT lift a deployed air bag and examine the steering wheel and dash, which may reveal if the patients struck any of these areas with enough energy to damage them. One hazard to watch for is an air bag that remains undeployed after a crash. If an air bag deploys during the extrication process, it can seriously injure rescuers. To disable the air bags, the battery must be disconnected. Disconnecting the power will cause the system to power off in 2 to 3 minutes, depending on the type of system. Keep in mind that turning off the ignition alone may not disable the system, because most systems operate independently of the ignition.
Remember the following points when you place flares: • Look for and avoid spilled fuel, dry vegetation, and other combustibles before you ignite and position flares, especially at a road edge. • Do not throw flares out of moving vehicles. • Position a few flares at the edge of the danger zone as soon as the ambulance is parked. They will supplement the ambulance warning lights. • Take a handful of flares and walk (carefully) toward oncoming traffic.
• Position the flares every 10 feel, if possible, to channel vehicles into an unblocked lane. (Do not turn your back to traffic while placing flares.) • If the collision has occurred on a two-lane road, position flares in both directions. • Never use a flare as a traffic wand; flares can spew molten phosphorous, which can cause third-degree burns to the skin.
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Energy-Absorbing Bumpers Most cars are equipped with 15 kilometers-perhour bumpers designed to absorb low-speed front and rear-end collision forces. If the bumpers were involved in the collision, you may notice that the bumper’s shock absorber system is compressed, or “loaded.” Never stand in from of a loaded bumper. If it springs out and strikes your knees, it could cause serious injury. Some rescuers chain the shock absorber to prevent an uncontrolled release.
Spectators
Spectators do more than just create problems for passing motorists. If allowed to wander freely, they will close in on the wreckage just to get a better view. In fact, they may get so close that they interfere with rescue and emergency care efforts. Rescue squads, police, and fire units have personnel and equipment for crowd control: ambulances usually do not. However, an EMT can usually initiate some crowd-control measures. If local policies permit it, ask for assistance from one or more responsible-looking bystanders. Ask the persons you recruit to keep the spectators away from the danger zone. Give them a roll of barricade tape if you have one. Be sure not to put the recruited personnel in unsafe positions such as near spilled fuel or an unstable vehicle.
Electrical Hazards Electricity poses many dangers at vehiclecollision scenes. When there is an electrical hazard, establish a danger zone and a safe zone. The danger zone should only be entered by individuals responsible for controlling the hazard, such as power company personnel or specially rescue. The safe zone should be sufficiently far away to ensure that an arcing or moving wire could not possibly injure any of the rescue personnel or bystanders. Keep in mind the safety points in the following list. Many have to do with taking precautions around conductors. A conductor is a wire or any other object or material that will carry electricity. • High voltages are not as uncommon on roadside utility poles as people often think. In some areas, wood poles support conductors of as much as 500,000 volts. • Assume that the entire area is extremely dangerous. Conductors may have touched and energized any part of the system, including electrical, telephone, cable TV. and other wires supported by the utility pole, guy wires, 710
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AMBULANCE OPERATIONS IN EMT PRACTICE ground wires, the pole itself, the ground surrounding the pole, and nearby guard rails and fences. Assume that severed or displaced conductors may be touching and energizing every wire and conductor at the highest voltage present. Dead wires may be reenergized at any moment. Energized conductors may arc to the ground. • Ordinary protective clothing does not protect against electrocution.
Broken Utility Pole with Wires Down. A broken utility pole with wires down is very dangerous. You probably cannot work safely in the area until the power company representative assures you that the power is off and the scene is safe. If you discover that a utility pole is broken and wires are down: • Park the ambulance outside the danger zone. • Before you leave the ambulance, be sure that no portion of the vehicle, including the radio antenna, is contacting any sagging conductors. • Order spectators and nonessential emergency service personnel from the danger zone. Use perimeter tape to set up a large safety zone. • Discourage occupants of the collision vehicle from leaving the wreckage. • Prohibit traffic flow through the danger zone. • Determine the number of the nearest pole you can safely approach, and ask your dispatcher to advise the power company of the pole number and its location. • Do not attempt to move downed wires. Metal implements will, of course, conduct electricity, but even implements that may not appear to be conductive, such as tools with wood handles or natural fiber ropes, may have a high moisture content that will conduct electricity and may electrocute a well-intentioned rescuer. • Stand in a safe place until the power company cuts the wires or disconnects the power. Maging maingat sa paglapit sa aksidente na nasa liblib at madilim na lugar. Habang papalapit ka dito, tingnan mabuti ang paligid. Posible kasi na may nabunggo ang naaksidenteng sasakyan na poste ng kuryente at may mga nakalawit na kable na maaaaring makakuryente sa iyo. Kung mapansin mo na may posteng nakatumba, isipin mo na agad na maaaari kang makuryente kapag lumapit ka nang hindi protektado. Sometimes, especially in wet weather, a phenomenon known as ground gradient may provide your first clue that a wire is down. Voltage is greatest at the point where a conductor touches the ground, then diminishes with distance from the point of contact. That distance may be several inches or many feet. Being able to recognize and respond properly to energized ground can save your life. Stop your approach immediately if you feel a tingling sensation in your legs and lower torso. This sensation means that you are on energized ground. Current is entering one foot,
passing through your lower body, and exiting through your other foot. If you continue on, you risk being electrocuted! Turn 180 degrees and take one of two escape measures. Hop to a safe place on one foot. Alternatively, shuffle away from the danger area with both feet together, allowing no break in contact between your two feet or between your feet and the ground. Either technique helps prevent your body from completing a circuit with energized ground, which can cause electrocution. (A circuit is a circular path for electrical flow, such as up one leg. down the other, and through the ground. Hopping on one leg or keeping your feet together creates a straight path rather than a circular circuit, which may prevent electrocution.)
Broken Utility Pole with Wires Intact. Even if wires are intact, a broken utility pole is still dangerous. Wires that are still holding up the pole can break at any time, dropping the pole and wires onto the scene. If you arrive to find such a situation: • Park the ambulance outside the danger zone. • Notify your dispatcher of the situation. • Stay outside the danger zone until power company representatives can deenergize the conductors and stabilize the pole. • Keep spectators and other emergency service personnel out of the danger zone. Damaged Pad-Mounted Transformer. When electrical cables run underground, the transformer may be mounted on a pad above ground. When an above-ground padmounted electrical transformer is struck and damaged, il poses a serious threat. In such a situation: • Request an immediate power company response. • Do not touch either the transformer case or a vehicle touching it. and warn other emergency service personnel not to touch it, either. • Stand in a safe place until the power company deenergizes the transformer. • Keep spectators out of the danger zone.
Vehicle Fires
When you find a vehicle on fire, always request the response of fire fighting apparatus. Do not assume that someone else has called the fire department. In fact, fire apparatus should always stand by during vehicle extrication. Extinguishing a vehicle fire is the responsibility of persons w ho are trained and equipped for the job: firefighters. Nonetheless, there are some measures that trained EMTs can take when they arrive before fire units For small fires, a 15- or 20-pound class A:B:C dry chemical fire extinguisher can extinguish virtually anything that may be burning in a vehicle, including upholstery, fuel, and electrical components. Only burning magnesium and other flammable metals cannot be extinguished by an A:B:C extinguisher. Before you try to put out a fire, always put on a full set of protective gear.
Fire in the Engine Compartment If the hood is fully open, stand close loan A-post (front roof-supporting post) of the vehicle and, if possible, with your back to the wind to guard against the agent blowing back into your face or entering the passenger compartment. (Dry chemical extinguishing agents irritate respiratory passages and may contaminate open wounds.) Then sweep the extinguisher across the base of the fire with short bursts. Use no more than necessary to extinguish the fire. You will need what is left if there is a subsequent flare-up. If the hood is open to the safety latch, do not raise the hood farther—leave it where it is. This will help to restrict air flow and deprive the fire of oxygen. Direct the agent through any opening to the engine compartment: between hood and fender, around the grill, under a wheel well, or through a broken head lamp assembly. Again, use no more agent than is needed. If the hood is closed tight, let the fire burn under the closed hood, leaving its extinguishment to the fire department, and continue to get the patients out of the vehicle. The firewall should protect the passenger area long enough to get the patients out of the vehicle, using emergency moves.
Extinguishing Fires in Collision Vehicles • Markings that identify an extinguisher that can be used for Class A, B, and C fires. • Extinguishing a fire in the engine compartment when the hood is fully open. • Extinguishing a fire in the engine compartment when the hood is partially open. • Extinguishing a fire under the dash. Care must be taken not to fill the vehicle’s interior with a cloud of agent. • Extinguishing fuel burning under a vehicle. Flames are swept away from the vehicle.
Fire in the Passenger Compartment or Trunk If the fire is under the dash or in upholstery or other combustibles, carefully apply the agent directly to the horning material. Apply sparingly to avoid creating a cloud of powder that may be harmful to occupants. If there is fire in the trunk, as with fire under a closed hood, leave extinguishment to the fire department and continue working to gel patients out of the vehicle.
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AMBULANCE OPERATIONS IN EMT PRACTICE
Fire under the Vehicle
Using a portable unit to extinguish burning fuel under a vehicle may be an exercise in futility when the spill is large. However, when people are trapped in the vehicle, you may feel the urge to try. Attempt to sweep the flames from under the passenger compartment as you apply the agent. If you do extinguish the fire, be sure that sources of ignition are then kept away. The vehicle sown catalytic converter (usually found in the area under the front passenger’s feet) can be an ignition source since its temperature can reach over 1,200 degrees.
Truck Fires
An A:B:C extinguisher can also be used to combat truck fires. Be aware, however, that burning truck tires are especially dangerous. Flames can quickly spread to the vehicle’s body and its cargo, or the tires can blow apart when heated by fire. Never stand directly in front of a truck wheel when there is a fire; instead, approach from a 45-dcgrcc angle. May mga pagkakataon na makikita mo na tumutulo ang gasolina mula sa naaksidenteng sasakyan subalit wala itong apoy. Sa mga ganitong sitwasyon, humingi agad ng tulong sa bumbero. Huwag ka na lumapit sa nasabing sasakyan hangga’t hindi ligtas. Sabihan mo rin ang mga tao sa paligid na may posibilidad na magsimula ang sunog. Huwag gumamit ng flare sa ganitong sitwasyon. Iparada rin ang iyong ambulansya nang malayo sa sasakyan na may tumutulong gasolina.
Disabling a Vehicle’s Electrical System Many rescue units routinely disable the electrical system of every collision vehicle by cutting a battery cable. Unless gasoline is pooled under a vehicle or undeployed air bags need to be disabled, cutting the battery out of the electrical system may not only be a waste of time, it may actually hinder the rescue operation. Remember that many cars have electrically powered door locks, window operators, and seat adjustment mechanisms. Being able to lower a window rather than breaking it eliminates the likelihood of spraying occupants with glass. Being able to operate door locks may eliminate the need to force doors open. And being able to operate a powered seat will create space in front of an injured driver. If there is a reason to disrupt the electrical system, disconnect the negative cable from the battery. In this way. you will not be likely to produce a spark that can drop onto spilled fuel or ignite battery gases. Such a spark can be created when the positive cable is pulled away from the battery terminal, or when a tool touches a metal component while in contact with the positive terminal or cable. 712
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Stabilizing a Vehicle Unstable collision vehicles pose a hazard to rescuers and patients alike. Scan shows methods for stabilizing a vehicle involved in a collision. May mga pagkakataon na makikita mo na tumutulo ang gasolina mula sa naaksidenteng sasakyan subalit wala itong apoy. Sa mga ganitong sitwasyon, humingi agad ng tulong sa bumbero. Huwag ka na lumapit sa nasabing sasakyan hangga’t hindi ligtas. Sabihan mo rin ang mga tao sa paligid na may posibilidad na magsimula ang sunog. Huwag gumamit ng flare sa ganitong sitwasyon. Iparada rin ang iyong ambulansya nang malayo sa sasakyan na may tumutulong gasolina. If your ambulance is equipped with stabilization equipment, you should attend a formal vehicle rescue course that includes basic stabilization procedures taught by a qualified instructor. If the ambulance is not equipped for stabilization procedures, or if you are not trained, stand by until a rescue unit has stabilized the vehicle, even if roof posts are intact and the vehicle appears to be stable. The information on vehicle stabilization that follows is intended only to help you. as an EMT, understand the process that trained personnel will be following. It is not a substitute for formal training in stabilization procedures.
Stabilizing Vehicles Involved in a Collision
• Stabilizing a car on its wheels with cribbing while patient contact is initiated. • A vehicle on its side stabilized with cribbing. • Placing a step chock. Keep the hands clear of the vehicle while placing the chock. • A vehicle on its side stabilized with struts. • A vehicle on its side stabilized with cribbing and struts.
Vehicle on Its Wheels
A collision vehicle that is upright on four inflated tires looks stable. However, it is easily rocked up and downside to side, and back and forth on its suspension as rescuers climb into and over it. These motions can seriously aggravate occupants’ injuries. First, if rescuers have access to the inside of the vehicle, they should make sure the engine is turned off. the vehicle is in park, the keys are removed from the ignition, and the parking brake is set. The best method of stabilizing a vehicle on its wheels is using three step chocks, one on each side and a third under the front or back of the vehicle.
Then—in situations where significant “tool work” must be done to extricate, such as door or roof removal—all the tires should be deflated. This can be accomplished by simply pulling the valve stems from their casing with pliers. (Slashing the tires is an inappropriate technique for deflating tires.) A police officer should be told the tires have been deflated so investigators will not think that the tires are flat as a result of the collision. If the ambulance is not equipped with step chocks, a degree of stabilization can be accomplished by placing wheel chocks or 2” x 4” cribbing in front of and behind two tires on the same side. If a car has rolled over several times and comes to rest on its wheels, the roof may be crushed, which may preclude access through windows. In this case, the roof may need to be raised before doors can be opened or the roof can be removed. Minsan kailangan mong maglagay ng kalso sa sasakyan na bumaligtad o gumulong. Sa ganitong sitwasyon, iwasan na lumuhod. Magsquat ka lang para mas mabilis ka makatayo kung kinakailangan. Kapag nastabilize mo na ang sasakyan at nabuksan mo na ang pinto, itali mo munang mabuti ang pinto para hindi aksidenteng sumara bago ka pumasok.
Vehicle on Its Side
When a vehicle is on its side, spectators will often attempt to push it back onto its wheels. They fail to realize that this movement may injure, or more severely injure, the vehicle’s occupants. Instead, the vehicle should be stabilized on its side. If the vehicle is on its side, do not attempt to gain access before it is stabilized using ropes, stabilization struts, and/or cribbing. Although a car on its side may appear stable, simply climbing onto one side in an attempt to open a door may cause the vehicle to drop onto its roof or wheels. Moreover, you can be trapped under the vehicle when it topples. A person w ho will act as a safety guide can be placed at each end of the vehicle to “feel” the vehicle’s movement and quickly warn the rescuers who are placing cribbing, struts, or ropes to get back if the vehicle begins to fall over. Some services will deploy two ropes looped around the same wheel in both directions so that personnel can temporarily hold the vehicle stable while placing struts and/or cribbing. There are many ways to stabilize a vehicle on its side, from using manpower alone to using hydraulic rams and pneumatic jacks. The objective is to increase the number of contacts with the ground to make the vehicle on its side more stable.
Vehicle on Its Roof
If the vehicle is resting on its roof, roof posts are intact, and the vehicle appears stable, it may be tempting to try to reach the vehicle’s occupants by gaining access through window or door openings—immediately, and without stabilizing the vehicle. However, if the posts collapse, as is often the case when the windshield integrity has been broken, the vehicle may come crashing down and injure the EMT who is attempting to climb into the vehicle or who has an arm in a window opening. You must wait to gain access until the rescue crew has stabilized the vehicle. This is usually accomplished by building a box crib with 4 x 4 under the vehicle. A vehicle on its roof is likely to be in one of four positions: • Horizontal, with the roof crushed flat against the vehicle’s body and both the trunk lid and hood contacting the ground • Horizontal, resting entirely on the roof, with space between the hood and the ground and space between the trunk lid and the ground • Front end down, with the front edge of the hood contacting the ground and the rear of the car supported by the C-posts (rear posts) • Front end up. with the trunk lid contacting the ground and much of the weight of the vehicle supported by the A-posts (front posts) If the vehicle is tilted with the engine, which is the heaviest part of the vehicle, on the ground and the trunk in the air. it can often be stabilized by using two step chocks upside down under the trunk. When the roof is crushed flat against the body, as when all the roof posts have collapsed, the car is essentially a steel box resting on the ground with the occupants completely trapped inside. Unless the vehicle is on a hill or perched precariously on debris or another vehicle, this is the one time when stabilization is unnecessary. The structure is rigid. In such a situational may be impossible to gain access through a window, door, or the roof. However, it may be possible to cut through the door pan and have an EMT cither crawl inside, if the opening is big enough or the EMT small enough, or to reach through the opening to touch and offer emotional support to the occupants until rescue personnel can lift or open the vehicle. If the vehicle is unstable and cannot be safely approached by an EMT. get as close as you safely can so you can talk or signal to the occupants to reassure them that help is on its way and begin getting an idea of their condition. Remember that when the vehicle is found in any of the previously described positions, it should be considered unstable and must be stabilized by trained personnel prior to entry by an EMT. LIFELINE
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AMBULANCE OPERATIONS IN EMT PRACTICE
Supplies and Equipment for Vehicle Stabilization and Gaining Access QUANTITY
ITEM
10
2” x 4” x 8” cribbing
10
4” x 4” x 18” cribbing
4
Step chocks
6
Wood wedges
2
Vehicle wheel chocks
100 feet
Nylon 1/2” utility rope
2 sets
Struts
1
“Door-and-window kit” with hand tools such as.. 1 1 1
pair, battery pliers 12” adjustable wrench 3- or 4-pound drilling hammer 1 spring-loaded center punch 2 hacksaws with spare blades 1 10” locking-type pliers 1 10” water-pump pliers Several 12” to 15” flat prybars 1 8” flat blade screwdriver 1 12” flat blade screwdriver 1 spray container of power steering fluid as a lubricant
714
1
Flat head ax
1 1
Glas-Master windshield saw Combination forcible entry tool such as a Halligan or Biel tool
500 feet
Perimeter tape_
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Gaining Access Why does a car door not fly open in a crash? The answer is the Nader pin (named for Ralph Nader, the consumer advocate who lobbied for the device), a case-hardened pin in an automobile door. In a collision, the cams in the door locks grasp the pin to keep the door from flying open, preventing occupants from being thrown from the vehicle. All cars sold in the United States since 1966 have the Nader pin. The Nader pin is a safety device, since being thrown from a vehicle is far more dangerous than being kept inside during a crash. However, the device does make gaining access to vehicle occupants more difficult. Prior to the Nader pin. rescue personnel could open a door with a crowbar. Subsequently, rescuers had to start using a hydraulic spreader to peel the cams off the pins. Ironically, safely features designed to keep occupants inside wrecked vehicles were keeping rescuers out! Each new safety improvement to vehicles created a new challenge to rescue personnel. Vehicle rescue training became a complicated business, and rescuers were asked to learn dozens of techniques, some of which could be used only on certain models of cars. The need for effective but simplified procedures became evident. The next few pages will describe a procedure that has been developed to meet this need.
Simple Access
First, remember that, as an EMT, your responsibility is not to rescue the vehicle but to rescue the patient. You will usually assume that an occupant or occupants of the vehicle have sustained life-threatening injuries, and that at least one EMT needs to gain quick access to the patient, even while rescuers are working to gain a more wide-open access, create exit-ways, and disentangle occupants. After the vehicle is stable enough for you to approach it safely, check to see if a door can be opened or if an occupant of the vehicle can roll down I window or unlock a door. (Try before You Pry!) Such ordinary ways of getting into the vehicle are known as simple access.
Complex Access
If simple access fails, you may need to use tools or special equipment to break a window and gain access even while the rescue crew is dismantling the vehicle for extrication of the occupants. When tools or equipment are used for this purpose, the process is known as complex access. All automotive glass is one of two types: laminated or tempered. Windshields and some side and rear van and truck windows are laminated safety glass—two sheets of plate glass bonded to a sheet of tough plastic like a glass-and-plastic sandwich. Most passenger car side and rear windows are tempered glass. They are very resilient, but when they do break, rather than shattering into sharp fragments, they break into small, rounded pieces. You will usually try to gain access through a side or rear window as far as possible from the passengers. Use a spring-loaded center punch against a lower corner to break the glass. Punch out finger holds in the top of the window and use your gloved fingers to pull fragments away from the window. A flathead ax is usually required to break through a windshield. This can also be done very quickly using a Glas-Master saw. Although a windshield is usually not broken to gain access, the rescue squad may need to remove it if they plan to displace the or steering column or remove the roof. Before breaking the windshield, cover the passengers with aluminized rescue blankets or tarps, if possible. Avoid the use of hospital-style blankets that will allow the tiny slivers of glass to pass through and come in contact with the patient. Once you gain an entry point, at least one EMT. who is properly dressed, should crawl inside the vehicle and immediately begin the primary assessment and rapid trauma assessment, as well as manual cervical stabilization. Do not forget to explain what is going on and provide emotional support to the patient by talking and reassuring him that everything that can be done for him is being done. Access holes are usually small, so do not be tempted to pull a patient out of an access hole prior to spinal immobilization.
Disentanglement: A Three-Part Action Plan
In most instances. EMTs will not be directly involved in disentanglement other than to act as the patient’s advocate and be the EMT inside the vehicle. However, it is helpful to understand the plan for complex access that may be used by rescue personnel to free the trapped patient. The following is a description of a three-part procedure that can be accomplished by fire, rescue, and EMS personnel with the appropriate equipment. The
procedure is not vehicle-specific; that is, it can be used on virtually any car or truck. Furthermore, the procedure does not include a lot of techniques that require special equipment. Personnel can be trained in a short course. Most important to EMS personnel, there is no need to fill several compartments of the ambulance with rescue equipment.
Steps One and Two:
Gain Access by Disposing of Doors and the Roof. For more than 25 years, emergency service personnel have been trained to carry out a progression of procedures to reach the occupants of a wrecked vehicle: first try the doors; if that fails, unlock and unlatch the doors by non-destructive or destructive means; when all else fails, gain access through window openings. However, this multipart procedure is time-consuming and requires a number of tools. A quicker and far more efficient procedure is first to dispose of the Tandaan palagi: doors and then to dispose of the Ang tungkulin mo ay roof as soon as hazards have been iligtas ang pasyente, controlled and the vehicle is stable. hindi iligtas ang Disposing of the doors and roof has sasakyan. three benefits; • It makes the interior of the vehicle accessible. EMS personnel can stand beside or climb into the vehicle and pursue emergency care efforts while rescuers earn* out disentanglement procedures. • It creates a large exit-way through which an occupant can be quickly removed when he has a life-threatening injury or when fire or another hazard is threatening the operation. • It provides fresh air and helps cool off the patient when heat is a problem.
Step Three:
Disentangle Occupants by Displacing the Front End.
Most vehicle rescue training courses include procedures for displacing or removing seats, dash assemblies, steering wheels, steering columns, and pedals. A quicker and more efficient way to disentangle an injured driver and/ or passenger from these mechanisms of entrapment is to displace the entire front end of the vehicle. Although the task sounds difficult, it is not. Scan illustrates a procedure for displacing the front end of a passenger car with a hydraulic rescue tool. A dash displacement can also be accomplished with heavy-duty jacks and hacksaws. If the steering wheel hub is large and rectangular, the car probably has an air bag or bags (the passenger-side bag being in the glove compartment area). If the bags have LIFELINE
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not deployed, they are not likely to deploy now unless extrication involves displacing the dash or steering wheel. If such displacement is to be done, air bag manufacturers recommend following these guidelines: • Disconnect the battery cables, starting with the negative terminal. • Avoid placing your body or objects against an air bag module or in its path of deployment. (Even after disconnecting the battery cables, a slight electrical charge capable of deploying an air bag remains.) • Do not displace or cut the steering column until the system has been fully deactivated. • Do not cut or drill into an air bag module. • Do not apply heat in the area of the steering wheel hub. You may wonder, must the three-part procedure just described be used for all extrication operations? Must the three procedures always be accomplished in the same order? Must these procedures always be used? Not at all. In some cases, it may be necessary only to force a door open to reach a single patient and create an exit-way for his removal. In other cases, it may be prudent to open doors before disposing of the roof or to dispose of the roof before displacing the doors. In still other situations, there may be no need to displace the front end of a collision vehicle. The extent to which you, as an EMT, will participate in vehicle rescue procedures depends on the role your EMS unit plays in vehicle rescue and whether or not your ambulance arrives ahead of fire and rescue units. The main purpose for the EMT to know extrication procedures is to incorporate them into the patient care plan.
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AMBULANCE OPERATIONS IN EMT PRACTICE
Disposing of the Doors and Roof • Displace the door to expose hinges and move the door away from the patient compartment. • Remove the door, Cut the A-post to begin roof removal. • With B- and C-posts cut, roll the roof away while a rescuer enters the rear seat to stabilize the patient’s head and neck. • For a vehicle on its side, cut the posts. • Then remove the roof to expose and extricate the patient.
Displacing the Front End of a Car
• Make cuts for the spreader tool. • Use the spreader to roll back the dash. • Displace the dashboard to gain access to the patient.
Lifeline in Action They are in the frontlines when it comes to disasters. And it is only fitting that the men and women of the 505th Search and Rescue Group of the Philippine Air Force be trained in emergency medical care. Members of the 505th SRG received a scholarship from Lifeline Academy – free schooling for two months and 250 hours of practical ambulance work – as part of the school’s corporate social responsibility program.
SAVING LIVES THROUGH THE AIR FORCE
MEMBERS OF THE 505TH SRG RECEIVED A SCHOLARSHIP FROM LIFELINE ACADEMY – FREE SCHOOLING FOR TWO MONTHS AND 250 HOURS OF PRACTICAL AMBULANCE WORK – AS PART OF THE SCHOOL’S CORPORATE SOCIAL RESPONSIBILITY PROGRAM.
Lifeline Academy Managing Director Michael Deakin said they are simply doing their share in uplifting the knowledge and skills of our Air Force rescuers who are often sent to the remote places of the country to provide assistance of victims of natural and man-made disasters. In the first batch of Air Force Lifeliners, First Lieutenant Christine Pingot graduated third honors. Deakin congratulated and encouraged the graduates to be committed and to make every second count to save lives because theirs may be the last face or last voice that the victim would see or hear after going through a disaster. As a token of its gratitude, the 505th SRG recognized Lifeline Academy as a valued partner in its 20th anniversary celebration, giving Lifeline a plaque of appreciation. The 505th SRG traces its roots from the Search and Rescue Squadron that mounted daring rescue missions on top of burning buildings or in distressed sea vessels. LIFELINE
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WE began this course with a chapter on Basic Life Support where we taught you the basics of cardiopulmonary resuscitation (CPR) in helping victims of sudden cardiac arrest or heart
attack. We cannot overemphasize the importance of this topic in your career as an EMT. Indeed, more lives would be saved if only more people would know how to do CPR.
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Introduction To Advance Cardiac Life Support BLS by healthcare provider BLS by untrained lay rescuer Cardiovascular emergency drugs Advanced Cardiac Life Support Algorithm Yet there is a more complex way of treating heart attack. And this is what Advanced Cardiac Life Support (ACLS) is all about. ACLS involves the use of medications in providing care to patients who suffer a cardiac arrest. These medications and how to administer them are taught in this chapter, together with procedures on what to do for certain conditions like an abnormal heartbeat.
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knowledge will be reviewed and strengthen to accomplish advance ered to be the “Bread and Butter of an EMT, thereforetheone mustcardiac be at the mas life support. This will help the EMT perform skills and do understand their roles level of BLS. in this practice.
INTRODUCTION BLS (Basic Life Support) - is the level of medical care which is used for EMT ADVANCEMENTS TOPIC Day 28 tims of life-threatening illnesses or injuries until they can be given REVIEW OF BASIC LIFE SUPPORT (BLS) medical care at a hospital. It can be provided by trained medical per nel Basic andLife laySupport persons. is the foundation of Advanced Cardiac Life Support. It is consid-
INTRODUCTION TO ADVANCE CARDIAC LIFE SUPPORT
ered to be the “Bread and Butter of an EMT, therefore one must be at the mastery level of BLS.
BLS (Basic Life Support) - is the level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel and lay persons.
LEARNING OBJECTIVES
This enhancement topic will reinforce your knowledge of basic medication and management applied in cardiac arrest patient. Basic Life Support and ECG rhythm knowledge will be reviewed and strengthened to accomplish the Advance Cardiac Life Support. This will help you perform skills and understand your role in this practice.
INTRODUCTION REVIEW OF BASIC LIFE SUPPORT (BLS) Basic Life Support is the foundation of Advanced Cardiac Life Support. It is considered to be the “bread and butter” of an EMT, therefore one must be at the mastery level of BLS. BLS - is the level of medical care which is used for victims of lifethreatening illnesses or injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel and lay persons.
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* Adult Chain of Survival*
* Adult Chain of Surv
stery
BLS Halthcare Provider
r vicn full rson-
vival*
High-Quality CPR
Adult Cardiac Arrest Algorithm - 2015 UPDATE
• Rate at least 100/min • Compression depth at least 2 inches (5 cm). • Allow complete chest recoil after each compression. • Minimize interruptions in chest compressions. • Avoid excessive ventilation.
Verify scene safety.
Victim is unresponsive. Shout for nearby help. Activate emergency response system via mobile device (if appicable). Get AED and emergency equipment or send someone to do so. Normal breathing has pulse Monitor until emergency responders arrive.
Look for no breathing or only gasping and check pulse (simultaneously) is pulse definetely felt within 10 second?
No normal breathing has pulse
Provide rescue breathing 1 breath every 5-6 seconds or about 10-12 breaths. Activate emergency response system (if not ready done) after 2 minutes Continue rescue breathing, check pulse about 2 minutes. If no pulse begin CPR, go to CPR box. If possible avoid overdose, administer naloxene if available per protocol. By this time in all scenarios, emergency response system or back-up is activated and AED and emergency equipment are retrived or someone is retrieving them.
CPR Begin cycle of 30 compression and 2 breaths. Use AED as soon as it is available.
Ang Basic Life Support ang itinuturing na “bread and butter” o pinakaimportanteng trabaho ng isang EMT. Kaya naman inaasahan na ang isang EMT ay master sa larangang ito.
AED arrives.
Check rhythm Shockable rhythm? Yes, Shockable
No, non shockable
Give 1 shock (resume CPR immediately for 2 minutes, until prompted by AED to allow rhythm check).
Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).
Continue until ALS providers take over or victim starts to move.
Continue until ALS providers take over or patients starts to move.
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Untrained Lay Rescuer
If a bystander is not trained in CPR, he/she should provide Hands-Only (chest compresson) CPR with an emphasis on “push hard and push fast.” The rescuer should continue Hands-Only CPR until an AED arrives and is ready for use or healthcare providers take over care of the victim. Lay Rescuers should assume cardiac arrest based on assessing unresponsiveness and absence of normal breathing (i.e. the victim is not breathing or only gasping). “Look, Listen and Feel (LLF) Position” was removed from the BLS Algorithm because Lay Rescuers should not interrupt chest compressions to palpate pulses or check for ROSC (Return Of Spontaneous Circulation).
Trained Lay Rescuer
Lay Rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained Lay Rescuer is able to perform rescue breaths, he/she should add rescue breaths in a ratio of 30:2 (30 compressions to 2 breaths). The Rescuer should continue CPR until AED arrives and is ready for use of EMS. Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
Healthcare Providers
All healthcare providers should be trained in BLS. In this population, it is reasonable for both EMS and In-Hospital Professional Rescuers to provide chest compressions and rescue breaths for cardiac arrest victims. This should be performed in cycles of 30 compressions to 2 ventilations (30:2) until an advanced airway is placed; then compressing rescuer should give continuous chest compressions at a rate
Cardiopulmonary Resuscitation (Rescue Breaths)
ADVANCE CARDIAC LIFE SUPPORT of at least 100-120 bpm without pauses for ventilations. The rescuer delivering ventilation can provide a breath every 6 to 8 seconds (which yields 8 to 10 bpm). A compression-ventilation ratio of 30:2 is reasonable in adults, but farther validation of this guideline is needed.
Cardiopulmonary Resuscitation (Compressions) Correct performance of chest compressions requires several essential skills. The adult sternum should be depressed at least 2.4 inches (5cm), with chest compression and chest recoil/relaxation times approximately equal. Allow the chest to completely recoil after each compression. Although rescuers may not recognize that fatigue is present for 5 minutes. Avoid excessive chest compression depth of more than 2.4 inches when a feedback device is available. When two (2) or more rescuers are available, it is reasonable to switch chest compressions approximately every two (2) minutes or after about 5 cycles of compressions and ventilations at a ratio of 30:2 to prevent decrease in the quality of compressions.
Electrical Therapies
After shock delivery, the rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse. After about 5 cycles of CPR (about 2 minutes, although this time is not firm), ideally ending with compressions, the AED should then analyze the cardiac rhythm and deliver another shock if indicated. If a non-shockable rhythms is detected, the AED should instruct the rescuer to resume CPR immediately, beginning with chest compressions .
Deliver each Rescue Breath (RB) every 1 second. Give a sufficient Tidal Volume to produce visible chest rise. Studies in anesthetized adults (with normal perfusion) suggest that a tidal volume of 8 to 10mL/kg maintains oxygenation and elimination of CO2 (carbon dioxide). During CPR, cardiac output is 25% to 33% of normal, so oxygen uptake from the lungs and (CO2) delivery to the lungs are also reduced. As a result, a low minute ventilation (lower than normal tidal volume and respiratory rate) can maintain effective oxygenation and ventilation. For that reason during adult CPR, tidal volumes of approximately 500 to 600mL (6 to 7mL/kg) should suffice. This is consistent with a tidal volume that produces visible chest rise. 722
LIFELINE
PREHOSPITAL EMERGENCY CARE
Tamang dami lamang ng hangin ang dapat ibuga sa bibig ng pasyente habang binibigyan ito ng CPR. Sundan ang 30:2 ratio sa compression at breathing. Ang ibig sabihin, 30 diin sa dibdib, at dalawang buga sa bibig. Ang hangin na ibubuga ay dapat sapat lang para umangat ang dibdib ng pasyente.
utes, utes,although althoughthis thistime timeisisnot notfirm), firm),ideally ideallyending endingwith withcompressions, compressions,the theAED AED Electrode Placement should shouldthen thenanalyze analyzethe thecardiac cardiacrhythm rhythmand anddeliver deliveranother anothershock shockif ifindicated. indicated. IdIda anon-shockable non-shockablerhythms rhythmsisisdete4cted, dete4cted,the theAED AEDshould shouldinstruct instructthe therescuer rescuertoto resume resume CPR CPRimmediately, immediately, beginningwith with chest chestcompressions compressions . . For ease of placement andbeginning education, anterolateral is a reasonable default elec-
trode placement. Then studies indicated that larger pad/paddle size (8 to 12cm Electrode Electrode Placement impedance. diameter) lowersPlacement transthoracic
Electrode Placement
For ease of ofof placement and education, anterolateral anterolateral is anterolateralisisa areasonable For For ease ease placement placement and andeducation, education, reasonabledefault defaulteleceleca reasonable default electrode placement. Studies indicate trode trodeplacement. placement.Then Thenstudies studiesindicated indicatedthat thatlarger largerpad/paddle pad/paddlesize size(8(8toto12cm 12cm that larger pad/paddle size (8 to 12cm diameter) lowers diameter) diameter) lowers lowers transthoracic transthoracic impedance. impedance. transthoracic impedance.
Advanced Airway Management
Advanced Advanced Airway Management AdvancedAirway AirwayManagement Management
management of defibrillation in adults with In-Hospital and Out-of-Hospital cardiac arrest is uncertain. Performing During the first few minutes of witnessed cardiac arrest, CPR while a defibrillator is readied for use is strongly During the first few minutes witnessed cardiac arrest, a lone rescuer a lone rescuer should not interrupt chest of compressions for recommended for all patients in cardiac arrest. should During Duringthe thefirst firstairway few fewminutes minutes ofwitnessed witnessed cardiac cardiac arrest, arrest, a alone lonerescuer rescuer should should ventilation. Advanced placement inofcardiac arrest not interrupt chest compressions for ventilation. Advanced airway placement in not notinterrupt interrupt chest chest compressions for for ventilation.Advanced Advanced airway airway placement placement inin should not delay initial CPRcompressions and defibrillation for VFventilation. (Ventricular Fibrillation) cardiac arrest. cardiac arrest should not delay CPR and defibrillation for VF (Ventricular cardiac cardiac arrest arrest should should not not delay delayinitial initial initialCPR CPRand and defibrillation defibrillation for forVF VF(Ventricular (Ventricular Empirical use of 100% inspired oxygen during CPR Fibrillation) Fibrillation) cardiac cardiac arrest. arrest. Fibrillation) cardiac arrest. optimizes arterial oxyhemoglobin content and in turn oxygen delivery; therefore, use of 100% inspired oxygen Because there are no valves in the inferior vena cava, (FiO2 = 100%)use as soon it becomes availableoxygen isoxygen reasonable Empirical Empirical use ofofas100% 100% inspired inspired during during CPR CPR optimizes optimizes arterial arterial oxyhemooxyhemoretrograde blood flow into thearterial venous system may produce Empirical use of 100% inspired oxygen during CPR optimizes oxyhemoduring resuscitation from cardiac arrest. At this time there is femoral vein pulsations. Thus, palpation of a pulse globin globincontent content and and ininturn turn oxygen oxygen delivery; delivery;therefore, therefore,use useofof100% 100%inspired inspiredoxyoxy- in insufficient evidence to support the removal of ventilations globin content and in turn oxygen delivery; therefore, use of 100% inspired the femoral triangle during compressions, may indicate gen gen (FiO2 (FiO2 = =1.0) 1.0) assoon soon asasitofitbecomes becomes available available isisreasonable reasonableduring duringresuscitaresuscita- oxyfrom CPR performed by as ACLS providers the use of pasvenous rather than arterial blood flow. Carotid pulsations gen (FiO2 = delivery. 1.0) as soon itthis becomes available is reasonable during resuscitasive oxygen tion tion from from cardiac cardiac arrest. arrest.as AtAtthis time timethere there isisinsufficient insufficient evidence tosupport supportthe the during CPR doevidence not indicateto the Kailangan suriin efficacy of myocardial or cerebral tion from cardiac arrest. At this time there is insufficient evidence to support removal removalofofventilations ventilationsfrom fromCPR CPRperformed performedbybyACLS ACLSproviders providersofofthe theuse useofofpaspas- the ang pulso ng pasyente perfusion during CPR. Palpation sive siveof oxygen oxygen delivery. delivery.from CPR performed by removal ventilations ACLS of thekada use of pasdalawang minuto of a pulse whenproviders chest compressions habang nagbibigay ng CPR. During treatment of Ventricular Fibrillation (VF) are paused is a reliable indicator sive oxygen delivery. Importante na malaman and Pulseless Ventricular Tachycardia (VT), healthcare of ROSC, but is potentially less kung nagsisimula nang providers must ensure that coordination between CPR and sensitive than other physiologic tumibok ang puso nito. shock delivery is efficient. When VF is present for more than measures discussed below and a few minutes, the myocardium is depleted of oxygen and requires a lengthy pause without metabolic substrates. A brief period of chest compressions compressions. can deliver oxygen and energy substrates and “unload� the Is it reasonable for providers to volume-overloaded right ventricle, increasing the likelihood establish IO (Intraosseous) access that a perfusing rhythm will return after shock deliver. At if IV access is not readily available. this time, the benefit of delaying defibrillation to perform Commercially available kits can CPR is unclear. The value of VF wave form analysis to guide facilitate IO access in adults.
Discovering ROSC (Return Of Spontaneous Circulation)
CPR before Defibrillation
LIFELINE
PREHOSPITAL EMERGENCY CARE
723
Lido
EMT cain
e
ADV
ANC
EME
Lido ADVANCE CARDIAC LIFE SUPPORT Day 28 dias caine i s an tolic EMTveADVANCEMENTS TOPIC dep An nt and ricles. It olariza ti-dysrh t con irritabi also de ion an ythmic l traccardio-respiratory . It d initiate crea occurs, When arrest auto CPR tion ity Still witthe sefor d s then do defibrillation, chance the patient h m s v out . atici epresse e n I n t RDIOPHARMA r to survive d isislim nothing will really de work without ty ic s catiand ons medications. creasin ular exc in the administering 1. Fo emergency g th it r rinitiate io-Respiratory Arrest2.occurs, hyth CPR then do defibrillation, eStillfo ability V m for the patient to surviveen nothing s th will really work without rce of ricand 3. V is tnil a u l ng emergency medications. a Ad entricu r tach t are ve n y lar F ve e R ibril cardia wtricular Dep rsDrugs scular Emergency e l a a ith p in ori laxis ression, ctions: tion gin ulse e Do * STOP Nause Brady c a an saEpinephrine IisNaFnaturally ge Hormone d Vo ardia, H Uproduces e is a naturally S 1occurring I O hormone produced in .occurring Card systolic BP (blood mi ypo N nal glands. It tens iacglands. theincreases adrenal It increases IMME ting, t D ion, Arrepressure), o 10BP output, DIA heart rate and cardiac automaticity o u systolic (blood b TEL st (V 0mg H 2.consumption. l e dial oxygen R V Y eperate and cardiac output, heart ! Dr F/PV ision eart B a a 3 , Blu lock, wb alin .M T) automaticity ay b t doand se myocardial lood Lidocaine give rredis an Anti-dysrhythmic. Sinu e oxygen consumption. 1, Beta 14and Beta 2 stimulant e v . Lid n as ery s give V p i It depresses diastolic depolarization e s o ion, s Modand 5 to cime • Adrenalin c n 1 a e Tropic Effects v i t n e o i AnIta also decreases mi• Alpha 1, Beta 1 and Beta 2 10 m a ET the eD 1.5m automaticity in n * ventricles. p rip: Resistance onstrictor—increases T o acPeripheral i h n *Co n tstimulant u ventricular excitability and irritability g/kg y- without hiev mix 2 be (do utes fo nsta tions I decreasing the force of contractions. V e lev g in rat uble nt E • Positive Tropic Effects initi cF/Pulseless otal VT• that areCunresponsive defi- 50 els to aina t G h Vasoconstrictor—increases 0 e o M of 3• Indications ally usu UNIT mL 44 f 1.5 d o llation mid o n UNIT s ( itori e) d1.osFor rhythms that arealventricular e Peripheral Resistance 4 mg to 6 l y ystole or PEA (Pulseless Electrical Activity) e n 50 in origin s or /mL mcg g is • Indications DAY 2. Ventricular tachycardia with 28 pulse inam Bradycardia, ) 3 n DAY 28 mptomatic Severe Hypotension and Anaphylaxis / m m o e f D5• Adverse Reactions: Bradycardia, Hypotension, Heart cess to defig/kg L 1. VF/Pulseless VT that are unresponsive ide a W Hypotension, Pulmonary Edema r asenReactions—Tachycardia, yw . Sta Sinus Mode Depression, Nausea and Vomiting, d T is secbrillation Block, th in rt at aindications—Myocardial and Angina because of iIncrease Asystole or PEA (Pulseless Electrical Activity) nd Ischemia d A hird lin 2. o fusio Double Vision, Anaphylaxis * STOP 1 tBlurred l i n ardialtrdemand. e o 4m Vision,Draw 3. Symptomatic Bradycardia, Severe Hypotension ns* INFUSION IMMEDIATELY! for V e for Atropine blood specimen* aeses ial Flutt and g/ Atropine V Anaphylaxis T T e • Dosage w t r w h , i th p solution eIV Bolus ith p SVTof 1:10,000 tial: or P 10mL h• eaAdverse Reactions—Tachycardia, Hypotension, de1mg 1. Lidocaine Drip: mix 2g in 500mL (4mg/mL) of accelerate the ra ulsevery Atropine creadose: . Edema r P t e Pulmonary bsequent 0.5mg repeated at least 3 tou5lsminutes. r Atropine accelerate the r e . o r s a I D5W. Start at 1 to 4mg/min to achieve levels of conduction c t e i t a y f e, c s• au enhances thro inam assis t h Contraindications—Myocardial Ischemia and carwith sholine 10cc NSS * enhances e o 1.5 to 6mcg/mL *Constant ECG Monitoring is conduction thr tom because t wdemand. dial Angina ndofuIncreaseidMyocardial p a e t i Indications—for a ient th c ane has ticity ction tioisnout: depr necessary with infusions* Indications—for sym sy o i a s e n • Dosage for cardiac arrest : , , with hypotension an ssio ouble the vers dep indose it ha aller irrita itiall 1. Initial: with hypotension a iopt tchest n r i g o 1mg Bolussora 10mL ofb1:10,000 e buIV akescompression n i s y, it momentarily i c to lity sing l Dosage and Admini o t s o i f t i a Dosage and Admin solution A too s rbefore a m the medication mafter L ive a n and ngpositive a c instilling arel dose: 1.1. Asystole—1mg lo recu ventilation ld veveryd 3prol ction o trial Fib ido2.nSubsequent 1mgyrepeated at ileast a y Asystole—1mgI yperventilate) u g u a o s rren to 5 tminutes. r n s g e i n o l 2. For e lais-second line for VT with pulse if2.theFor non-cardiac al e the gs t Procainamide hea d to ach t VF non-cardia f h r h f e i t e e t e / sinus bradycar c r ve aNSS * eat bloc * FlushPline t on patientreisfrallergicartot,Lidocaine and Third line for VT with VT.with 10cc se— sinus bradyca deq Ven ks. a t slow • If IV Line is out: c h 0.5mg e o pulse. It assisttwith conversion of Atrial Fibrillation and0.5mg and u t r and rep re r a A y he t i c t V i e u n 1.Double the dose lar F maximum dose jecti bloo noSVT. Atrial Flutter, Procainamide has a depressing action otal maximum dose d o ib e d leas nonnchest likise a naturally of 52.Stop occurring antidiuretic momentarily hormone. It act of 1compression veinlsthe rillatioon the heart, it decreases the heart rate, conduction, Hyp vasoconstrictor 0 0 3.Give positive ventilation before and after 0 peripheral and it promotes water reabsorption n , m irritability and prolongs the refractory period, it 0mg nal but (VF) g h the medication ensi instilling widandotcauses (hyperventilate) i tubules vasoconstriction and increase muscle tone of the a t f decreases automaticity, it has also a mild vagal effect on s o b is ef on a r5 et . Blood oT,nUreters, en g fenode vessels. an alternative nd t Itbisealso min to the first (1st) the AV causing myocardial depression but it may —M hand c tive AA - utes ix 2of Epinephrine. he Q iven cause heart blocks. n(2nd) g in ce ddose TT - R o o S co r r • Indication: initially, it is rarely used to treat tions: ose 500 mpl Adver 20mg RR - w m ith a se R ex is / Pulseless VT unresponsive L toDdefibrillation per Ventricular Fibrillation (VF) because it takes too long 5 e OO - m m w Wa o to adequate blood levels, but it is effective in ystole Activity a xim iden action inachieve ne or Pulseless Electrical u n t e d PP - e u sodilatory shock (Septic Shock) m hastreating recurrent VF/PVT. d by infu tota it has o s 5 II -e ay be helpful in prolonged arrest since a longer half life than c 0% l do enephrine from se o at 1 to pola NN - 4mg rizat Hypertension, Tremor, Myocardialf Ischemia, 17m Angina ose, itReactions: EE - io g/kg /min afincrease (pro resistance) fect nperipheral it can . for l ng EMERGENCY CARE s o a 724 sLIFELINE e diumoPREHOSPITAL s re , po as 20frunits/mL runits ringIV for 1 dose (provided Dopamine tory ampule) tminutes, assiu acresume Dopamine V NO RESPONSE in 10 to 20 epinephrine. DO NOT F p / m yPEAT e P r VTVASOPRESSIN. unsDOSE OF i a o nd c d t Dopamine alciu ). It bl Dopamine had had an an alpha alpha Arrh able VT oc peripheral arterial vasocon m y
ACLS CARDIOPHARMA
NTS T
OPI
C
CARDIOVASCULAR EMERGENCY DRUGS Epinephrine
Lidocaine
EM EM
Procainamide
Dosage and Administration 1. Asystole—1mg IV push X 3
1. Asystole—1mg IV push X 3 patients (symptomatic 2. For non-cardiac arrest 2. For sinus non-cardiac arrest patients bradycardia or heart(symptomatic blocks) - give sinus bradycardia or every heart 5blocks) - give 0.5mg and repeat minutes with a 0.5mg and repeat minutes with a maximum dose ofevery up to 53mg. maximum dose of up to 3mg. ATROPINE ATROPINE • Dosage A acts on Bradycardia and Asystole 1. IV dose—slow injection of 100mg for 5 minutes A actsTo ongive Bradycardia and Asystole T 3mg or 20mg per minute until the total of 500mg has T R- - To Dopamine give 3mg Reduces effect Vagal Stimulation has anon alpha adrenergic effect, it produces been given or Adverse Reaction has occurred like R Reduces effect on Vagal Stimulation O Opposes cholinergic effects peripheral arterial vasoconstriction and increases Hypotension and the QRS complex is widened by 50% O P- -pulmonary Opposes cholinergic effectsAlso, Parasympathetic blocking agent vascular resistance. dopamine increases from its original width. P Parasympathetic blocking agent -heartInduces rate that tachycardia may exacerbate or induce SVT and 2. IV Infusion—Mix 2g in 500mL D5W and infuse at 1 I I N- -pulmonary Induces edema, therefore it must be administered via IV No totachycardia Glaucoma to 4mg/min for a maintenance dose with a maximum N No to Glaucoma drip only. total dose of 17mg/kg. E ECG Monitoring Dosage: 400mg mixed in 250mL D5W. Initial rate of E - • ECG Monitoring infusion = 2.5 to 5mcg/kg/min to keep systolic BP at least 90mmHg. Dopamine Dopamine Amiodarone delays repolarization (prolongs refractory Dopamine had an alpha COMPUTATION: adrenergic effect, it produces period). It blocks alpha and beta receptors, also, ithad affects Dopamine an alpha adrenergic effect, it produces 1mg = 1000mcg peripheral arterial vasoconstriction and increases pulmosodium, potassium and calcium channels. Given: Patient weighs 80kg; peripheral arterialresistance, vasoconstriction and increases pulmonary vascular also dopamine increases heart • Indication Initial order of 5mcg/kg/min nary vascular resistance, also dopamine increases heart rate that may exacerbate or induce SVT and pulmonary 1. Frequently recurring VF/PVT that may exacerbate or induce SVT and pulmonary therefore it must be administered via IV drip 2. Hemodynamically unstable VTrateedema, X IV drip edema, administered via only. therefore it must be250mL/400,000mcg 3. Effective for Atrial Arrhythmias 60min/1hr X 80kg X 5mcg/ only. Dosage: 400mg mixed • Dosage in 250mL kg/min = 15mL/hrD5W. Initial rate 1. For VF/PVT: Give 300mg rapid IV (bolus followed Dosage: 400mg= mixed 250mL D5W. of infusion 2.5 to in 5mcg/kg/min toInitial keep rate systolic by 20cc steinle saline infusion in 20 to 30mL D5W— of infusion = 2.5 to 5mcg/kg/min to keep BP at least 90mmHg.Double concentration: systolic if still refractory VF/PVT,) give 150mg 3 to 590mmHg. BPafter at least 60 X weight X order minutes “Despite all the efforts, electriCOMPUTATION: divided by 1600 2. all Forthe VT with pulse: give 150mg IV infusion in 100mL “Despite efforts, cal therapy, CPR andelectriMedicaCOMPUTATION: D5W every 10 minutes as needed cal tions, therapy, CPR and MedicaNothing will work unless Single concentration: 1mg = 1000mcg 3.patient For Continuous start 900mg in 500mL D5W tions, will work unless BP ourNothing has a infusion: viable 60 weighs X weight 80kg; X order Initial order of 1mgGiven: = 1000mcg Patient with 360mg or our(Blood patient has a in-fused viable for BP the first 6 hours (1mg/min Pressure)” divided by 800 Initial order of Given: Patient weighs 80kg; 5mcg/kg/min 33.3mL/hr), followed by 540mg infused over 18 hours (Blood Pressure)” 5mcg/kg/min (0.5mg/min or 16.6mL/hr) *Maximum dose: 2.2g/24 250mL/400,000mcg X 60min/1hr X 80kg X 5mcg/kg/min = 15mL/hr hours* Ang dopamine ay nagpapaluwag ng ugat 250mL/400,000mcg X 60min/1hr X 80kg X 5mcg/kg/min = kung 15mL/hr mababa lamang dosageXna ibibigay. Subalit Double concentration: 60 Xang weight order divided bykung 1600 lampas sa dosage, nagpapasikip Double concentration: 6010mcg/kg/min X weight X ang order divided byby 1600 ate of SA Node discharge and Single concentration: 60 X weight X order divided 800 rate of SA Node discharge and naman60 ito Xngweight ugat. Maging maingat sa by 800 Single concentration: X order divided ough AV rough AVNode. Node. pagbibigay ng gamot na ito. Ito Note: mptomatic sinus ay ibinibigay lamang sa ymptomatic sinus bradycardia bradycardia Note: nd Asystole/PEA. pamamagitan ng IV pump. and Asystole/PEA. Dopamine in low doses will produce vasodilation of renal, mesenteric and cereKung ito ang ginagamit istration Dopamine in low doses will produce vasodilation mesenteric and cerenistration bral arteries. If the dosage is over 10mcg/kg/min, will act as vasoconstrictor. ng pasyente, huwag itigil of itrenal, IV push X 3 bral arteries. If the dosage is over 10mcg/kg/min, it will act as vasoconstrictor. IV push X 3 nang bigla. Kailangan c arrest ac arrest patients patients (symptomatic (symptomatic It causes tissue necrosis “Extravasations”. It is paunti-unti, depende sa only administered by IV infusion, rdia or It causes necrosis “Extravasations”. It is be only administered infusion, never tissue as an IV push or askondisyon a Bolus. It infused using anby IV IV pump. Do not ardia or heart heart blocks) blocks) - - give give ngmust pasyente. peat every 5 minutes with a never as an IV push or as a Bolus. It must be infused using an IV pump. discontinue abruptly. Must be tapered gradually to maintain within Do thenot blood epeat every 5 minutes with a discontinue abruptly. Mustaccording be tapered graduallyresponse. to maintain within the blood level. Dosage is titrated to patient’s eof ofup upto to3mg. 3mg. level. Dosage is titrated according ATROPINE to patient’s response. Atropine accelerate the rate of SA Node discharge ATROPINE ATROPINE and enhances conduction through AV Node. A - Acts on Bradycardia • Indications—for symptomatic sinus bradycardia acts on Bradycardia and Asystole T - To give 3mg acts on Bradycardia and Asystole with hypotension and Asystole/PEA. R - Reduces effect on Vagal Stimulation To give 3mg • Dosage and Administration To give 3mg O - Opposes cholinergic effects Reduces effect on Vagal Stimulation 1. Asystole—1mg IV push X 3 Reduces effect on Vagal Stimulation P - Parasympathetic blocking agent Opposes effects 2. For non-cardiac Opposescholinergic cholinergic effects arrest patients (symptomatic I - Induces tachycardia Parasympathetic blocking agent sinus bradycardia or heart blocks) - give 0.5mg Parasympathetic blocking agent N - No to Glaucoma and repeat every 5 minutes with a maximum Induces E - ECG Monitoring Inducestachycardia tachycardia dose of up to 3mg. No to Glaucoma No to Glaucoma ECG ECGMonitoring Monitoring
Dopamine
Amiodarone
MT MT ADVANCEMENTS ADVANCEMENTS TOPIC TOPIC
Atropine
a adrenergic adrenergic effect, effect, itit produces produces nstriction and increases pulmo-
LIFELINE
PREHOSPITAL EMERGENCY CARE
725
EMT ADVANCEMENTS TOPIC Day 28 Adenosine
ADVANCE CARDIAC LIFE SUPPORT
Adenosine
• Contraindications Adenosine is considered as an Antitachyarrhyt hmic Drug, 1. Use with caution for diabetic patients since it it depresses SA and AV Node activity. Adenosine is considered as an may mask symptoms of hypo/hyperglycemia. Complication: Heart blocks (AV Blocks) Antitachyarrhythmic Drug, it depresses 2. Do not give to patients with asthma and Indication SVT/P Only , it will not convert Atrial SA s:and AVSVT Node activity. COPD. Flutter, Atrial Fibrillation and Ventricular Tach • Complication: Heart blocks (AV ycar• Adverse Reactions: hypotension, CHF, dia. Blocks) Bronchospasm and Bradycardia Dosage• Indications: SVT/PSVT Only, it • Dosage: 1 to 3mg slow IV push (no faster than 1. 6mg rapid IV push (1 to 2 seconds) will not convert Atrial Flutter, 1mg/min) Repeat in 2 minutes if needed. 2. If no conversion after 1 to 2 minutes, you may Atrial Fibrillation and Ventricular Additional dose should be given 4 hours after double the dose 12mg for 2 rapid IV push withi n Tachycardia. 2nd dose. 1 to 2 seconds. • ces Dosage 3. Produ a short lived response of less than 5 6mg rapid IVflush pushthe (1 to 2 seconds) seconds.1. Make sure to line with 10 to If noorconversion after to 2 admi minutes, you may double 20 mL of2.NSS IV Solution after 1each nistration dose 12mg for 2 rapid IV push within 1 to 2 Adverse Reactthe Calcium channel blockers slows the conduction ions seconds. 1. Patients takin and prolongs refractory in the AV Node. It has negative g theophylline or caffeine are less sensitive to adenosine 3.res Produces a short lived response of less than 5 seconds. and requi larger doses Inotropic and Chronotropic Actions. It suppresses 2. Watch outMake sure) to flush the line with 10 to 20 mL of NSS or for (WOF flushing, Chest pain, sinus bradycardia with automaticity of the SA Node, depresses conduction PVC’s. Patient shou IVldSolution each administration be supinafter e durin velocity and prolongs refractory period. You need to g admi nistration.
CALCIUM CHANNEL BLOCKERS
• Adverse Reactions
BETA ADRENERG1. ICPatients BLOCKERS taking theophylline or caffeine are less
sensitive to adenosine and requires larger doses
watch out for Hypotension.
Verapamil
Beta Adrenergic Blockers depresses the pump 2. Watch out for (WOF) flushing, Chest sinus ing funct ionpain, of the Heart that decreases the heart rate. It blocks sympathet ic Patient stimulation bradycardia with PVC’s. should be supine and contr ols hypertenVerapamil is a calcium channel sodium flux blockers. sion, angina, SVT/PSVT and has an adverse effects on Beta 2. These drugs areIt has negative Inotropic effect that reduces the myocardial during administration. known for their names ending in “lol” (e.g. propanolol, atenolol, metoprolol, oxygen consumptions and causes coronary vasodilation. It esmolol)
BETA ADRENERGIC BLOCKERS
slows the conduction in the AV Node and prolong refractory period making it useful in treating SVTs. Beta adregenic blockers depresses the pumping • Dosage: function of the heart thateffec decreases the heart rate. It blocks nderal is a non-s elective 1. Initial dose: 2.5 to 5mg slow IV bolus over 2 to 3 agen t with t on beta 1 and beta 2 receptors reduces heartsympathetic stimulation controls hypertension, angina, rate, BP, myoc minutes. ardial contrand actilit y and myoc ardial oxygen demand) and has an adverse effects on Beta 2. These drugs IndicationSVT/PSVT 2. Subsequent dose: 5 to 10mg every 15 to 30 minutes s known their names ending in “lol” (e.g. propanolol, 1. Atrial are Fibril lation, for until total dose of 30mg is achieved. Atrial Flutte r, PAT and SVT atenolol, metoprolol, esmolol). 2. Hypertens ion and tachycardia
nderal
3. Recurrent VF.VT and SVT’s refractory to other
Inderal
Contraindications
therapies
1. Use with caution for diabetic patients since it may mask symptoms of hypo/hypeInderal rglycemia is a non-selective agent with effect on beta 1 2. Do notand give to patie nts with(reduces beta 2 receptors rate, BP, myocardial asthma heart and COPD Adverse React ions: hypo contractility and myocardial oxygen demand) tensio n, CHF, Bron chosp asm and Bradycardia Dosage: 1• toIndications 3mg slow IV push (no faster than 1mg/min) Repe utes if needed. 1. Addit Atrialional Fibrillation, Atrial SVT at in 2 mindose shou ld beFlutter, given 4PAT hourand s after 2nd dose. 2. Hypertension and tachycardia ALCIUM CHANNEL KERS VF.VT and SVT’s refractory to other 3. BLOC Recurrent
therapies
alcium channel blockers slows the conductio n and prolongs refractory in the V Node. It has negative Inotropic and Chronotro pic Actions. It suppresses autoaticity of the SA Node, depresses conductio n velocity and prolongs refractory eriod. You need to watch out for Hypotensio n.
Sa kabila ng lahat ng puwedeng gawin – mula CPR, AED at pagbibigay ng gamot – walang puwedeng makatulong para mabuhay ang pasyente kung wala itong matatag na blood pressure. Kaya lubhang napakaimportante na makontrol ang blood pressure ng pasyente.
726
LIFELINE
PREHOSPITAL EMERGENCY CARE
COMPARISON BETWEEN SYMPATHETIC AND PARASYMPATHETIC RESPONSE
Sympathetic Response
Parasympathetic Response
Adrenergic Effect
Acetylcholine or Cholinergic Effect
Increase Cardiopulmonary Function
Decrease Cardiopulmonary Function
Decrease GIT/ GUT Function
Increase GIT/GUT Function
NOTE:
NARCAN, ATROPINE VASOPRESSIN EPINEPHRINE, LIDOCAINE (N-A-V-E-L) are the drugs that can be given via ET (Endotracheal) Tube. If these drugs will be given via ET Tube, always double the dose except for Vasopressin.
ACLS (Advanced Cardiac Life Support) ALGORITHM Adult Cardiac Arrest Shout for Help/Activate Emergency Response 1 Start CPR *Give oxygen *attach monitor/defibrillator
Yes 2
9
VF/VT
Return of Spontaneous Circulation (ROSC) • Pulse and blood pressure • Abrupt sustained increase in PETCO2 (typically >40mm HG) • Spontaneous arterial pressure waves with intra-arterial monitoring
Asystole/PEA
3 4
No
Rhythm shockable?
Shock
CPR 2 min *IV/IO access
5 6
Shock
10
CPR 2 min *Epinephrine every 3-5 min *consider advanced airway, capnography
Yes
Shock
Drug Theraphy • Epinephrine IV/IO dose: 1 mg every 3-5 minutes • Amiodarone IV/IO Dose: First dose: 300 mg bolus. Secon dose: 150 mg.
CPR 2 min *IV/IO access *Epinephrine every 3-5 min *consider advanced airway, capnography
No
Rhythm shockable?
7
Shock Energy • Biphasic: Manufacturer recommendation (120-200J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be consider. • Monophasic: 360J
No
Rhythm shockable?
Rhythm shockable?
Yes
No
11
CPR 2 min *Treat reversible causes
8 CPR 2 min *Amiodarone *Treat reversible cause
12
CPR Quality • Push hard(>2-2.4 inches / 5 cm) and fast (>100-120/min) and allow complete chest recoil • Minimize interruptions in compressions • Avoid excessive ventilation • Rotate compressor every 2 minutes • If no advanced airway, 30:2 compression ventilation ratio • Quantitative waveform canography *If PETCO2<10mmHG, attempt to improve CPR quality • Intra arterial pressure *If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR
No
*If no signs of return of spontaneous circulation (ROSC), go to 10 or 11 * If ROSC, go to Post-Cardiac Arrest Care
Rhythm shockable?
Yes
Go to 5 or 7
Advance Airway • Supragiottic advanced airway or endotracheal intubation • Waveform capnography to confirm and monitior ET tube placement • 10 breaths per minute with continuous chest compressions Reversible Cause • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardia • Toxins • Thrombosis, pulmonary • Thrombosis, coronary
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ADVANCE CARDIAC LIFE SUPPORT
ACLS (Advanced Cardiac Life Support) ALGORITHM Adult Cardiac Arrest
Shout for Help/Activate Emergency Response
Return of Spontaneous Circulation (ROSC) • Pulse and blood pressure • Abrupt sustained increase in PETCO2 (typically >40mm HG) • Spontaneous arterial pressure waves with intra-arterial monitoring
Start CPR Give oxygen Attach monitor/defibrillator
2 minutes
Return of Spontaneous Circulation (ROSC)
If VF/VT shock
Drug Therapy IV/IO access Epinephrine every 3-5 minutes Amiodarone for refractory VF/VT Consider Advance Airway Quantitative waveform capnography
Treat Reversible Cause
Mon y t i l a itor CPR Qu
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Post-Cardiac Arrest Care
tinuous CPR Con
Continuous CPR
Rhythm shockable?
CPR Quality • Push hard(>2-2.4 inches / 5 cm) and fast (>100120/min) and allow complete chest recoil • Minimize interruptions in compressions • Avoid excessive ventilation • Rotate compressor every 2 minutes • If no advanced airway, 30:2 compression ventilation ratio • Quantitative waveform canography If PETCO2<10mmHG, attempt to improve CPR quality • Intra arterial pressure If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR
Shock Energy • Biphasic: Manufacturer recommendation (120200J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be consider. • Monophasic: 360J Drug Theraphy • Epinephrine IV?IO dose: 1 mg every 3-5 minutes • Amiodarone IV/IO Dose: First dose: 300 mg bolus. Secon dose: 150 mg. Advance Airway • Supragiottic advanced airway or endotracheal intubation • Waveform capnography to confirm and monitior ET tube placement • 8-10 breaths per minute with continuous chest compressions Reversible Cause • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardia • Toxins • Thrombosis, pulmonary • Thrombosis, coronary
BRADYCARDIA ALGORITHM Adult Bradycardia (with pulse) 1 Assess appropriateness for clinical condition. Heart rate typically <50/min if bradyarrhythmia
2
Identity and treat underlying cause * Maintain patient’s airway; assist breathing as necessary. * Oxygen (if hypoxemic). * Cardiac monitor to identify rhythm; monitor blood pressure and oximetry. * IV access. * 12-Lead ECG if available; don’t delay therapy.
3
4 Monitor and observe
Persistent bradyarrhythmia causing; * Hypotension? * Acutely altered mental satus? * Signs of shock? * Ischemic chest discomfort? * Acute heart failure?
No
Yes 5 Atropine If atropine ineffective: • Transcutaneous pacing or • Dopamine infusion or • Epinephrine infusion
Doses/Details Atropine IV dose: First dose: 0.5 mg bolus Repaeat every 3-5 minutes Maximum: 3 mg Dopamine IV Infusion: 2-10 mcg/kg per minute
6 Consider: * Expert consultation * Transveneous pacing
Epinephrine IV Infusion: 2-10 mcg per minute
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ADVANCE CARDIAC LIFE SUPPORT
TACHYCARDIA ALGORITHM Adult Tachycardia (with pulse) 1 Assess appropriateness for clinical condition. Heart rate typically <50/min if tachyarrhythmia.
2
Identity and treat underlying cause * Maintain patient’s airway; assist breathing as necessary. * Oxygen (if hypoxemic). * Cardiac monitor to identify rhythm; monitor blood pressure and oximetry.
3 Persistent bradyarrhythmia causing; * Hypotension? * Acutely altered mental satus? * Signs of shock? * Ischemic chest discomfort? * Acute heart failure?
5
4 Synchronized cardioversion * Consider sedation * If regular narrow complex, consider adenosine
Yes
*
Yes
* * *
No
7 * * * * *
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IV access and 12-lead ECG if available Vagal maneuvers Adenosine (if regular) B-Blocker or calcium channel blocker Consider expert consultation
PREHOSPITAL EMERGENCY CARE
Adenosine IV Dose: First dose: 6 mg rapid IV push; follow with NS flush Secod dose: 12 mg if required Antiarrhythmic infusions for Stable Wide_ QRS Tachycardia
6
No Wide QRS? >0.12 second
Doses/Details Synchronized Cardioversion Initial recommended doses: • Narrow regular: 50-100 J • Narrow irregular: 120-200 J biphasic or 200 J monophasic • Wide regular: 100 J • Wide irregular: Defibrillation dose (Not synchronized)
IV access and 12- lead ECG if available Consider Adenosine only if regular and monomorphic Consider Antirrhythmic infusion Consider expert consultation
Procainamide IV Dose: 20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. avoid if prolonged QT or CHF. Amiodarone IV Dose: First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours. Sotalol IV dose: 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.
Lifeline in Action
LIFE AFTER LIFELINE
Lifeline Academy students spend eight weeks of schooling and 250 hours of on-the-job-training with Lifeline 16-911. After this, most move to various EMT positions here and abroad. And all of them swear that the training they got in Lifeline prepared them well for the challenges of the EMT profession. The demand for well-trained and experienced EMTs is growing. All over the world -- from Europe to the United States of America all the way to Asia -- EMTs are being sought after by hospitals, airports, military installations, shopping malls, universities, railway companies, shipping companies, and so on and so forth. Female EMT’s are even in demand in Muslim countries due to the religious prohibition of male EMT’s touching female patients. In those countries, only female EMT’s are allowed to respond to female patients. The increasing need for EMT’s is prompting graduates of other healthcare professions such as nursing
to undergo EMT training just to be able to be hired abroad. On this page are photos of four Lifeline Academy graduates who are now working abroad. One of then, Aliman Usman Abdulla is 30 years old and part of the Praetorians batch. He entered Lifeline Academy after working as an Emergency Room nurse for 3 years. He swears that his Lifeline Academy education made him realize more the important role EMTs play in saving lives. “I just want to be the first person to intervene in case of emergency. It feels good to be able to save lives,” he said. Abdulla now works as a paramedic in the Saudi military. His advise to would-be EMTs is this: “Don’t choose the EMT profession because you don’t have any other choice. Choose the EMT profession because it is your passion to save lives and it is where you are good at,” he said. LIFELINE
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AS a future EMT, you will find yourself having the need to establish an intravenous (IV) access to a patient. This is when the patient badly needs hydration or medication and there is no other way to administer it but through an IV access. In this chapter, you will know the important safety precautions that you must observe in employing IV therapy. You will also know the important fluids and electrolytes that our Lifeline EMTs use on the field, as well as the medications they give, including the techniques they use.
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29
Intravenous Therapy For Prehospital Providers Protective equipment Fluids and electrolytes Intravenous techniques and administration Medication administration Glossary of Important Medical Terms
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EMT ADVANCEMENTS TOPIC
INTRAVENOUS THERAPY FOR PREHOSPITAL PROVIDERS LEARNING OBJECTIVES
PROTECTIVE EQUIPMENT
• To identify peripheral and central IV sites. • To identify areas of cannulation. • To perform peripheral IV cannulation.
INTRODUCTION This course is designed to prepare the EMT student to handle patients with preestablished IV access. EMT’s with allied health profession may use this skill given that the EMT is under medical control.
Gloves will protect you from contact with body fluid substance. You should wear latex or vinyl gloves during patient contact.
Infection Control Protection from infection is a major concern for EMS Practitioners. If you have patient contact, you must be aware of the possibility of exposure to infectious body fluids and must take the necessary precautions. Ultimately, the responsibility for your personal safety rests in your hands. If you ignore the importance of personal protection, you place yourself and others at extreme risk.
Disposable paper gowns are ideal for protection from heavily contaminated patients who are covered with blood or chemicals, or who have systemic infections that can contaminate your uniform without you being aware of the exposure.
Infectious Disease
Serious infection is possible whenever you come into contact with any contaminated material or substance. Diseases can be transmitted in various ways, including casual contact, airborne transmission and blood borne transmission. Most transmittable diseases are nothing more than inconveniences (such as cold), but some can be very serious.
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You should wear safety goggles whenever body fluids are splashing or spraying is a possibility.
FLUIDS AND ELECTROLYTES
Charged atoms and charged compounds are called Electrolytes because of their ability to conduct electricity. Electrolytes are also called ions. They are reactive and dangerous if left to circulate in the body. But the body uses the energy stored in these charged particles. Electrolytes help to regulate everything from water levels to cardiac function and muscle contractions. Water in the body helps to stabilize the electrolyte charges so that the electrolytes can be used to perform the metabolic functions that are necessary to life.
Sodium (Na+)
Sodium is the principal extracellular cation needed to regulate the distribution of water throughout the body in the intravascular and interstitial fluid compartments, making it a major factor in adequate cellular perfusion. This gives rise to the saying “where sodium goes, water follows.” Sodium is also a major component of the circulating buffer sodium bicarbonate (NaHCO3).
Potassium (K+)
About 98% of all body is potassium. It is found inside the cells of the body, making it the principal intracellular cation. Potassium plays a major role in neuromuscular function as well as in the conversion of glucose into glycogen. Cellular potassium levels are regulated by insulin. The sodium-potassium pump is helped by the presence of insulin and epinephrine. Hypokalemia is the term used for low potassium level in the serum (blood plasma) that can lead to decreased skeletal muscle function, gastrointestinal (GI) disturbances and alterations in cardiac function. Hyperkalemia is the term used for high potassium level in the serum that can lead to hyperstimulation of neural cell transmission resulting in cardiac arrest.
Calcium (Ca+) Calcium is the principal cation needed for bone growth. It plays an important part in the functioning of heart muscle, nerves and cell membranes and is necessary for proper blood clotting. Hypocalcemia is the term used for low serum calcium level that can lead to overstimulation of nerve cells, resulting in the following signs and symptoms: • Skeletal muscle cramps • Abdominal cramps • Carpal and pedal spasms • Hypotension • Vasoconstriction
Hypercalcemia is the term used for high serum calcium level that can lead to decreased stimulation of nerve cells resulting in the following signs and symptoms: • Skeletal muscle weakness • Lethargy • Ataxia • Vasodilation
Bicarbonate (HCO3-) Bicarbonate levels are the determining factor between acidosis and alkalosis in the body. Sodium bicarbonate is the primary buffer used in all circulating body fluids.
Chloride (Cl-)
Chloride primarily regulates the pH of the stomach. It also regulates extracellular fluid levels.
Phosphate (PO4-) Phosphate is an important component in the formation of adenosine triphosphate (ATP), the powerful energy supplier of the body.
OSMOSIS
Osmosis is the movement of water across a cell membrane. When molecules of solute are added to a solution, an equal number of molecules of solvent are displaced from the solution. An isotonic solution has the same concentration of sodium as does the cell. In this case, water doesn’t shift and no change in cell shape occurs. A hypertonic solution has a greater concentration of sodium than does the cell. Water is drawn out of the cell, and the cell collapses from the increased extracellular osmotic pressure. A hypotonic solution has a lower concentration of sodium than does the cell. Water flows into the cell, causing it to swell and possibly burst from the increased intracellular osmotic pressure.
FLUID COMPARTMENTS The body stores water in various locations called fluid compartments. It is defined by their relationship to cells— the water is interstitial either inside the cell (intracellular) or outside the cell (extracellular). Although water levels in these compartments constantly shift, homeostatic intracellular control mechanisms ensure that balance is restored whenever water is lost.
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FLUID BALANCE
The balance among intracellular, intravascular and interstitial compartments is dynamic. Changes always occur, and the body adjusts to these changes by retaining or eliminating water. Fluid levels in the body are balanced when intakes equal outputs. Daily intakes of water include fluid from liquid, food, and cellular metabolism, daily outputs occur from respiration and excretion of urine and feces.
Homeostasis Maintenance of the internal environment of the cell is regulated by elaborate systems of checks and balances. As systems in the body become imbalanced and begin to shift, feedback systems create an appropriate response to return the internal environment to normal. This normally balanced condition is referred to as homeostasis or the resistance to change.
Dehydration Dehydration is defined as depletion of the body’s total systemic fluid volume. It is usually a chronic condition of the elderly or the very young, and may take days to manifest. As fluid is lost from the vascular compartment, the body reacts by shifting interstitial fluid into the vascular area. This then forces a shift of fluid from the intracellular to the extracellular compartments. A total systemic fluid deficit occurs. Signs and Symptoms of dehydration includes: • Dry mucous membrane • Tachycardia • Poor skin turgor • Flushed, dry skin • Insufficient fluid /food intake
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INTRAVENOUS THERAPY
Overhydration When the body’s total systemic fluid volume increases, overhydration occurs. Fluid fills the vascular compartment, filters into the interstitial compartment, and finally Signs and Symptoms is forced from the engorged of Overhydration interstitial compartment into includes: the intracellular compartment. • Shortness of breath Fluid backup occurs and the • Polyuria patient can succumb from • Puffy eyelids these increased fluid levels. • Moist Crackles Causes of overhydration include • Edema unmonitored IV, prolonged • Acute weight gain hypoventilation and kidney failure.
Respiratory Alkalosis Respiratory alkalosis is always the result of hyperventilation. Carbon dioxide level drops in the blood forcing a reduction of circulating carbonic acid. The renal system then begin retaining hydrogen ions to rebalance the depleted acid levels. As this is happening, hydrogen ions begin to shift from the extracellular to the intracellular fluid compartments. Calcium shifts into the intracellular compartment to rebalance depleted hydrogen levels. Hypocalcemia leads to increase neural cell permeability. Muscle contractions create the classic signs of carpal and pedal spasms that accompany hyperventilation.
H2CO3 = Carbonic Acid Breathing =
Carbon Dioxide (CO2) =
Carbonic Acid (H2CO3) = pH
Some effects of respiratory alkalosis includes decreased cerebral perfusion, vertigo, decreased Level of Consciousness (LOC), lightheadedness and confusion. When assessing these patients, you must check LOC, skin color and temperature, respiratory rate and effort, determine if the patient has blurred vision, has nausea and vomiting, fever and assess for hypocalcemia.. Some causes of hyperventilation and respiratory alkalosis can be drug overdose especially aspirin and improper bag-valve-mask (BVM) technique. In this case evaluate patient’s lung sounds, hydration and cardiac rhythm changes.
Respiratory Acidosis Respiratory acidosis is always related to hypoventilation of some type because the acidosis problem is a result of insufficient breathing, the compensatory mechanism is the slower reacting renal system. Some causes of respiratory acidosis are airway obstruction, pulmonary edema, cardiac arrest, closed head injury, narcotic drug use, chest trauma, drowning and carbon monoxide poisoning. Hypoventilation that develops from any of these conditions is considered serious, life-threatening condition. The acidosis that results is quick, overwhelming and usually fatal, making it impossible for the
slower reacting renal system to compensate in time for the pH shift. The increasing acidosis causes potassium ions to shift into the extracellular fluid leading to fatal cardiac dysrrhythmias. Calcium also shifts into the extracellular spaces, resulting in hypercalcemia and decreased neural cell permeability and creating lethargy and a decreasing LOC. Breathing =
Carbon Dioxide (CO2) =
Carbonic Acid (H2CO3) =
pH
Metabolic Acidosis
Any acidosis that is not related to the respiratory system is considered metabolic in origin. Tachypnea is the compensatory mechanism for these patients as the respiratory system attempts to restore acid/base balance by eliminating carbon dioxide. Patient presentations for metabolic acidosis are similar to those for respiratory acidosis. As with any acidosis, extracellular hydrogen levels increase and the extracellular buffers attempt to neutralize the excess acid. Ion shifts occur, hydrogen leaks into the cell and potassium shifts into the extracellular spaces, raising the serum potassium levels which can lead to potentially life-threatening cardiac dysrrhythmias. Along with the potassium ion shift, calcium also shifts into extracellular spaces. The resulting Hypercalcemia leads to decreased neural cell permeability. Impulses sent to muscle and nerve cells are obstructed and the patient becomes lethargic with a decreased LOC.
Signs and Symptoms of respiratory acidosis include: • Central nervous system vasodilation • CNS depression • Headaches • Bradypnea • Red, flushed skin • Nausea and vomiting • Hypercalcemia
Metabolic Alkalosis
Metabolic alkalosis results anytime there is excessive loss of acid wether from excessive urination or from decreased acid levels in the stomach. Several factors related to upper GI losses can lead to metabolic alkalosis like excessive vomiting, excessive intake of base, excessive water intake, eating disorders and nasogastric suctioning.
Major causes of metabolic alkalosis are as follows:
• Upper GI losses of acid resulting from illness or anorexia “When the patient expels a great deal of acid from the stomach a complex metabolic pathway can lead to metabolic alkalosis. • Drinking large amounts of water during Carbonic Acid (H2CO3) = Hydrogen (H+) + Bicarbonate (HCO3) = pH heavy exertion. The water not only dilutes the stomach acid but also stimulates the digestive system to prepare for incoming food from the stomach. This stimulation • Lactic acidosis created by anaerobic cellular respiration due to causes a dump of very basic digestive hypoperfusion of tissues and organs as seen with shock and cardiac enzymes into the lower GI tract, adding arrest. to the acid/base imbalance. As with • Ketoacidosis resulting when cells are forced to switch to metabolizing respiratory alkalosis, there is a shift of fatty acids for energy because they are unable to utilize glucose, either calcium out of the cell (hypercalcemia) because of insulin insufficiency or desensitization of the cells to insulin. causing overstimulation of the nervous The by-products of fat metabolism are ketones which are extremely system and leads to muscle cramps. This acidotic. cramping is analogous to carpal and • Aspirin (acetylsalicylic acid) overdose (10 to 30g for adults) directly pedal spasms, except that it occurs in the stimulates the respiratory centers of the brain creating tachypnea and abdominal area and is referred to as heat leading to respiratory alkalosis. Compensatory mechanisms involve the cramps. renal system resulting in metabolic acidosis. • Excessive intake of base-like antacids. This • Alcohol (ethyl) Ingestion can lead to alcoholic Ketoacidosis. Methanol is important to remember when dealing (wood alcohol) and ethylene glycol can produce fatal forms of acidosis with cardiac patients because one of their often with amounts as small as 30mL. main complaints tends to be feelings of • GI losses like diarrhea for example removes bases from the lower nausea or indigestion. Often, the patient intestinal tract. has self-medicated for hours or days with When assessing over-the-counter antacids, which can result Signs and symptoms of metabolic acidosis: patients with metabolic in metabolic alkalosis. Another cause of acidosis, evaluate the LOC, • Vasodilation • Headaches excessive base intake is the use of sodium skin color and temperature, • Hypercalcemia • Nausea and Vomiting bicarbonate (NaHCO3) through an IV Respiratory rate and effort, • CNS Depression • Hot, Red Flushed skin line. Introducing one ampule (amp) of lung sounds, hydration and • Tachypnea • Dysrrhythmias sodium bicarbonate through an IV line can cardiac rhythm. seriously alter pH levels.
Bicarbonate ion = HCO3
Major causes of metabolic acidosis includes:
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CRITICAL CONCEPT
OSMOSIS CRITICAL CONCEPTS
fluid moves passively from areas with more fluid to areas with less OSMOSIS fluid (FLUID MOVES) Fluid moves passively from areas with more fluid to areas with less fluid. DIFFUSION DIFFUSION Solutes Solutes (particles) move from an (particles) areamove of higher concentration from an area of higher to an areaconcentration of lesser to anconcentration area of (PARTICLES MOVES) lesser concentration.
Excessive intake of base-like antacids. This is important to remember when
dealing with cardiac patients because one of their main complaints tends to UNIT 4 be feelings of nausea or indigestion. Often, the patient has self-medicated DAY 29 INTRAVENOUS THERAPY Day 29 for hours or days with over-the-counter antacids, which can result in metabolic alkalosis. Another cause of excessive base intake is the use of sodium bicarbonate (NaHCO3) through an IV line. Introducing one ampule (amp) The compensatory mechanism for metabolic alkalosis is the respiratory of sodium bicarbonate through an IV line can seriously alter pH levels. system. To correct the reduced hydrogen levels, Bradypnea develops to retain carbon dioxide and drive up the levels of circulating acids. The compensatory mechanism for metabolic alkalosis is the respiratory system. To correct the reduced hydrogen Bradypnea develops to retain carbon Hydrogen (H+) = Carbonic Acidlevels, (H2CO3) = pH = Bradypnea dioxide and drive up the levels of circulating acids. Signs and Symptoms of Metabolic Alkalosis Hydrogen (H+) = Carbonic Acid (H2CO3) = includes: pH = Bradypnea • Confusion • Muscle tremors and cramps Signs and Symptoms of Metabolic includes: • Bradypnea • Alkalosis Hypotension Confusion Bradypnea Muscle tremors and cramps Hypotension
INTRAVENOUS (IV) TECHNIQUES and ADMNISTRATION INTRAVENOUS (IV) TECHNIQUES and ADMNISTRATION Assembling Your Equipment
Assembling Your Equipment Ang maling fluid para sa maling pasyente ay may malaking epekto sa magiging resulta ng gamutan. Kailangan alam mo kung para saan ang bawat fluids na ibibigay mo sa pasyente upang maibigay mo ang tamang fluids sa tamang dami nito.
The wrong fluid for the wrong patient can make a critical difference in their outcome. Don’t depend only on the physician… It is better to KNOW YOUR FLUIDS as well.
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Choosing an IV Solution
To avoid delays or the possibility of IV site contamination, gather and prepare all Prehospital patient care and yourTo avoid delays or the possibility equipment before you attempt to start an IV. Sometimes the “condition and of IV site contamination, gather and IV therapy center on identifying presentation of the patient make full preparation difficult. This is where working prepare all your equipment before as a team becomes critical. It is often thethe type of situation and the members of your own crew who by you attempt to start an IV. Sometimes anticipating your needs help make the IV needs of the patient. Ask yourself equipment assembly possible. the condition and presentation of if the patient is a trauma or the patient make full preparation medical patient or does the Choosing an IV Solution difficult. This is where working as a patient need fluid replacement. team becomes critical. It is often the Prehospital patient care and IV Therapy center on identifying the type of situamembers of your own crew who by tion and the needs of the patient. Ask yourself if the patient is a trauma or medianticipating your needs help make the cal patient or does the patient need fluid replacement. IV equipment assembly possible. Types of Solution
Types of Solution
There are two types of solution, the crystalloids which composed of Isotonic, There are two types of solution, the Crystalloids which composed of Isotonic, Hypotonic and Hypertonic Solutions and the Colloids that are always hypertonic. Hypotonic and Hypertonic Solutions and the Colloids that are always hypertonic. Crystalloids are solutions with small molecules that flow easily from the bloodCrystalloids are solutions with small molecules that flow easily from the bloodstream into cells and tissues. stream into cells and tissues.
Isotonic
Osmotic p shrink nor of Isotonic and Dextro
Uses: fo
challeng metabol mia
Special
caution ure, ede solution
Uses: fo
tract flu and Hyp
Special
tion con cause H tients. P cannot converte liver.
Uses: for
and Hyp
Special
tion be dextrose use for tiously i tients.
and Dextrose 5% in water (D5W). Normal Saline (0.9% Sodium Chloride)
Uses: for shock, resuscitation, fluid
Uses: for dehydration, burns, GI
challenges, blood transfusions, metabolic alkalosis and Hyponatremia
tract fluid loss, acute blood loss, and Hypovolemia.
Special Considerations: this solu-
EMT ADVANCEMENTS TOPIC Special Consideration:
tion contains potassium that can cause Hyperkalemia in renal patients. Patients with liver disease cannot metabolize lactate that is converted into bicarbonate by the liver.
Use with caution in patients with heart failure, edema or Hypernatremia, this solution can lead to overload.
Isotonic Fluid
c Fluid
Lactated Ringer’s (LR)
“
Osmotic pressure is the same both inside and outside the cell. The cells neither shrink nor swell with fluid movement and it has same tonicity as plasma. Samples of isotonic fluids are 0.9% sodium chloride (normal saline), lactated ringers and dextrose 5% in water (D5W). Lactated Ringer’s (LR)
pressure is the same both inside and outside the cell. The cells neither r swell with fluid movement and it has same tonicity as plasma. Samples c Fluids are 0.9% Sodium Chloride (Normal Saline), Lactated Ringers ose 5% in water (D5W).
D5W (0.5% Dextrose in Water
Normal Saline (0.9% Sodium Chloride)
Uses: for dehydration, burns, GI
or shock, resuscitation, fluid ges, blood transfusions, lic alkalosis and Hyponatre-
Uses: for fluid loss and dehydration
tract fluid loss, acute blood loss, and Hypovolemia. Special Considerations: this solution contains potassium that can cause Hyperkalemia in renal patients. Patients with liver disease cannot metabolize lactate that is converted into bicarbonate by the liver.
Consideration: Use with in patients with heart failema or Hypernatremia, this n can lead to overload.
“
Normal Saline (0.9% Sodium Chloride)
Lactated Ringer’s (LR)
and Hypernatremia
Special Considerations: the Solution becomes Hypotonic when dextrose is metabolized. Do not use for resuscitation and use cautiously in renal and cardiac patients.
Lactated Ringer’s (LR)
D5W (0.5% Dextrose in Water
D5W (0.5% Dextrose
• Uses: for dehydration, burns, in Water GI tract fluid loss, acute blood • Uses: for shock, resuscitation, • Uses: for fluid loss fluid challenges, blood and dehydration and UNIT 4 loss, and Hypovolemia. • Special considerations: This EMT ADVANCEMENTS TOPIC transfusions, metabolic hypernatremia DAY 29 solution contains potassium alkalosis and hyponatremia. • Special considerations: The that can cause hyperkalemia • Special consideration: Use solution becomes hypotonic in renal patients. Patients with with caution in patients when dextrose is metabolized. Hypotonic Fluid liver disease cannot metabolize with heart failure, edema or Do not use for resuscitation lactate that is converted into hypernatremia. This solution and use cautiously in renal and Osmotic pressure is less than the intracellular fluid. Water is drawn into the cells from the extracellular fluid causing them to swell. Inappropriate use can result in bicarbonate by the liver. can lead to overload. cardiac patients. D5W (0.5% Dextrose in Water
or dehydration, burns, GI uid loss, acute blood loss, povolemia. Considerations: this soluntains potassium that can Hyperkalemia in renal paPatients with liver disease metabolize lactate that is ed into bicarbonate by the
r fluid loss and dehydration pernatremia Considerations: the Soluecomes Hypotonic when e is metabolized. Do not resuscitation and use cauin renal and cardiac pa-
Uses: for fluid loss and dehydration and Hypernatremia Special Considerations: the Solution becomes Hypotonic when dextrose is metabolized. Do not use for resuscitation and use cautiously in renal and cardiac patients.
Hypotonic Fluid
Osmotic pressure is less than the intracellular fluid. Water is drawn into the cells from the extracellular fluid causing them to swell. Inappropriate use can result in increased ICP (Intracranial Pressure) and cardiovascular collapse. It may cause blood cells to burst. Example of this solution is 0.45% sodium chloride (1/2 normal saline).
1/2 Normal Saline (0.45% Sodium Chloride)
• Uses: For gastric fluid loss, cellular dehydration from excessive dieresis, hypertonic dehydration and slow rehydration. “ • Special consideration: Do not give to patients at risk of ICP. It is not for rapid rehydration because electrolyte disturbances can occur.
increased ICP (Intracranial Pressure) and cardiovascular collapse. It may cause blood cells to burst. Example of this solution is 0.45% Sodium Chloride (1/2 Normal Saline).
Hypertonic Fluid
1/2 Normal Saline (0.45% Sodium Chloride)
COLLOIDS
Osmotic pressure is greater than that of Uses: for Gastric fluid loss, cellular dehydration from excessive dieresis, Colloids are made hypertonic dehydration and slow rehydration. intracellular fluid. Hypertonic solutions have a large up of much larger solutes Special Consideration: Do not give to patients at risk of ICP. It isthan are crystalloids. not for concentration of solutes (particles). Water is drawn rapid rehydration because electrolyte disturbances can occur. from the cells to equalize the concentration, which Plasma expanders are Hypertonic Fluid causes the cells to shrink. Examples of this fluid are used if crystalloids do not 0.5% Dextrose in 0.9% Sodium Chloride (D5NS), improve blood volume. Osmotic pressure is greater than that of intracellular fluid. Hypertonic solutions 0.5% Dextrose in Lactated Ringers (D5LR), and 0.5% Colloids pull fluid into the have a large concentration of solutes (particles). Water is drawn from the cells to Dextrose in 0.45% Sodium Chloride (D51/2NS). bloodstream because it is equalize the concentration, which causes the cells to shrink. Examples of this fluid are 0.5% Dextrose in 0.9% Sodium Chloride (D5NS), 0.5% Dextrose in Lachypertonic. Watch out for tated Ringers (D5LR),inand 0.5% Dextrose in 0.45% Sodium Chloride (D51/2NS). 0.5% Dextrose 0.9% increased BP, dyspnea and Sodium Chloride 0.5% (D5NS) Dextrose in 0.9% Sodium Chloride (D5NS) bounding pulse. Examples • Uses: for heat related disorders, fresh water of this solution are Uses: for heat related disorders, fresh water drowning and peritonitis drowning and peritonitis Special Considerations: It should not be given to patients with Albumin, Plasma Protein impaired • Special Considerations: It should not be given to fraction, Dextran and cardiac or renal functions. Draw blood before administering to diabetics. patients with impaired cardiac or renal functions. Hetastarch. Draw blood before administering to diabetics. 0.5% Dextrose in Lactated Ringers (D5LR)
0.5% Uses: Dextrose in For Hypovolemic and Hemor of Lactated (D5LR) rhagicRingers Shock and certain cases
acidosis. • Uses: For hypovolemic and Special Considerations: DO not hemorrhagic shock and certain administer in patients with cardiac cases of acidosis. or renal dysfunction. Monitor for circulatory overload. • Special considerations: DO NOT administer in patients with cardiac or renal dysfunction. Monitor for circulatory overload.
COLLOIDS
Colloids are made up of much larger solutes than are crystalloids. Plasma exLIFELINE PREHOSPITAL EMERGENCY CARE panders are used if crystalloids do not improve blood volume. Colloids pull fluid into the bloodstream because it is hypertonic. Watch out for Increased BP, Dyspnea and bounding Pulse. Examples of this solution are Albumin, Plasma Protein fraction, Dextran and Hetastarch.
739
IT 44 IT YY 29 29
UNIT DAY 2
EMT ADVANCEMENTS ADVANCEMENTS TOPIC INTRAVENOUS THERAPY Day 29TOPIC
MEDICATION ADMINISTRATION MATERIALS
MEDICATION ADMINISTRATION ADMINISTRATIONMATERIALS MATERIALS
SYRINGES SYRINGES SYRINGES
NEEDLES NEEDLES
“
UNIT 4
UNIT44 UNIT DAY29 29 DAY
EMTTOPIC ADVANCEM DAYADVANCEMENTS 29 EMT ADVANCEMENTS TOPIC EMT UNIT 4 UNIT 4 DAYAD 29 EMT DAY 29
MEDICATION PREPARATIO MEDICATIONPREPARATION—VIAL PREPARATION—VIAL MEDICATION
MEDICATION P MEDICATION PREPARATION—VIAL
UNIT 4 DAY 29
UNIT44 UNIT
1.
using the syringe, take off
MEDICATION EMTTOPIC ADVANCEMENTS TOPIC some air fromTOPIC the vial apEMT ADVANCEMENTS MEDICATION MEDICATION DAYADVANCEMENTS 29 DAY 29 EMT PREPARATION—VIAL proximately the same PREPARATION—VIAL PREPARATION—VIAL
amountVial: of Check the sterile wa1. Medication the MedicationVial: Vial:Check Checkthe the 1.1. Medication medication vial for the ter you need. medication vial vial for for the the medication name, expira-the vial 2. right Inject the and air from right name, name, and and expiraexpiraright tion date. And appeargoing to the tion date. And And appearappeartion date. MEDICATION PREPARATION—VIAL MEDICATION PREPARATION—VIAL ance. Counter checksterile infor- water MEDICATION PREPARATION—VIAL ance.Counter Countercheck checkinforinforance. vial, tothen turn the sterile mation doctor’s order mationtotodoctor’s doctor’sorder order mation 2. Take off the water vial aluminum upside down Take off off the the aluminum aluminum 2.2. Take cover using your a bandage within eye level, cover using using aa bandage bandage cover scissor or trauma shears. while supporting the scissor oror trauma trauma shears. shears. scissor Careful not to touch the Careful not not toto touch touch the the Careful plunger as it goes rubber underneath it. down. If rubber underneath underneath it.it. IfIf rubber touched it rubthe it with 3. you Bring down vial and youtouched touchedititrub rubititwith with you cotton with hold soaked it firmly onalcothe table cotton soaked soaked with with alcoalcocotton hol. while you the hol. hol. 3. Sterile water vial :remove Check 1. Medication Vial: Check the Sterile water water vial vial : : Check Check 3.3. Sterile syringe. the sterile water vial for medication vial for the right the sterile water vial for the sterile water vial for MEDICATION MEDICATION right name, and expi- within 4. theRaise the syringe MEDICATION theright rightname, name,and andexpiexpithe PREPARATION—VIAL PREPARATION—VIAL ration PREPARATION—VIAL name, and expiration date. And yourdate. eye level, then pull rationdate. date. ration 4. Take off the aluminum appearance. Counter check the using plunger slightly to Take off off the the aluminum aluminum 4.4. Take MedicationVial: Vial:Check Checkthe the 1.1. Medication cover a bandage Medication Vial: Check the cover using a bandage cover using a bandage medication vial for the medication vial for the collect the sterile scissor or trauma shears. water medication vial for information to doctor’s order the scissor oror trauma trauma shears. shears. scissor right name, name, and and expiraexpiraright Careful to touch the to rethen not push it back right name, and2. expiraTake off the aluminum cover Careful not not toto touch touch the the Careful tion date. date. And And appearappeartion rubber underneath it. If sterile tion date. And appearmove air, let some rubber underneath underneath it.it. IfIf rubber ance.Counter Countercheck checkinforinforance. you touched it rub it with using a bandage scissor or ance. Counter check inforwater flow with out of the neeyoutouched touchedititrub rubititwith with you mationtotodoctor’s doctor’sorder order mation cotton soaked alcomation to doctor’s order trauma shears. Careful not to cotton soaked with alcocotton soaked with alco2. Take off the aluminum 2. Take off the aluminum dle to ensure that it is hol. Take off the aluminum hol. hol. cover using using a a bandage bandage cover touch the rubber underneath filled. cover using a bandage scissororortrauma traumashears. shears. scissor scissor or trauma shears. 5. Wipe the rubber with it. If you touched it rub it with Carefulnot nottototouch touchthe the Careful Careful not to touch the alcohol, then Inject the rubber underneath underneath it.it. If If rubber cotton soaked with alcohol. rubber underneath it. If youtouched touchedititrub rubititwith with you sterile water to the medi3. it Sterile water vial : Check the you touched it rub with cottonsoaked soakedwith withalcoalcocotton cation vial slowly ( You cotton soaked with alcohol. sterile water vial for the right hol. hol. can do it in a rotating moSterilewater watervial vial: :Check Check 3.3. Sterile name, and expiration date. Sterile water vial : Check tion) to distribute it the sterile sterile water water vial vial for for the the sterile water4. vialTake off the aluminum cover for theright rightname, name,and andexpiexpithe equally to the medication. the right name, and expirationdate. date. ration 6. Shake the vial well by slidusing a bandage scissor or ration date. Take off off the the aluminum aluminum 4.4. Take ing it back and forth beTake off the aluminum trauma shears. Careful not to cover using using a a bandage bandage cover cover using a bandage tween your palms. scissororortrauma traumashears. shears. scissor touch the rubber underneath scissor or trauma shears. Carefulnot nottototouch touchthe the Careful 7. Wipe the rubber with Careful not to touchit. If you touched it rub it with the rubber underneath underneath it.it. If If rubber alcohol. Get the required rubber underneath it. If you touched it rub it with you touched it rub it with amount of medication, you touched it rub it cotton soaked with alcohol. with cottonsoaked soakedwith withalcoalcocotton cotton soaked with alcoturn the vial upside down hol. hol. hol.
NEEDLES MEDICATIONNEEDLES PREPARATION—VIAL
MEDICATION PREPARATION— VIAL (SYRINGE) 1. 2. 3.
MEDICATION PREPARATION: VIAL
1.
2.
3.
4.
within your eye level.
740
LIFELINE
PREHOSPITAL EMERGENCY CARE
Check the Syringe label, expiration date and proper size to be used. Slightly peel off the cover while slowly revealing the tip of the plunger. Get the syringe, check the plunger if it is working. Check the needle cap if it is easily removed and inspect the appearance of the needle (careful not to touch the needle)
MEDICATION PREPARATION— VIAL (SYRINGE) 1. 2. 3.
Check the Syringe label, expiration date and proper size to be used. Slightly peel off the cover while slowly revealing the tip of the plunger. Get the syringe, check the plunger if it is working. Check the needle cap if it is easily removed and inspect the appearance of the needle (careful not to touch the needle)
4 29
UNIT 4 EMT ADVANCEMENTS EMTTOPIC ADVANCEMENTS TOPIC DAY 29
MEDICATION PREPARATION—VIAL MEDICATION PREPARATION—VIAL
MEDICATION PREPARATION— MEDICATION VIAL (SYRINGE) PREPARATION—VIAL
PREPARATION— 1.MEDICATION the syringe, take off 1. using Check the Syringe label, expiration date and proper size to 6. Bring down the vial and hold it firmly on the table while VIAL some air (SYRINGE) from the vial apbe used. you remove the syringe. proximately the same 2. Slightly peel off the cover while slowly revealing the tip of 7. Raise the syringe within your eye level, then pull the 1. amount Check the Syringe of the sterilelabel, wathe plunger. plunger slightly to collect the sterile water then push it back expiration date and ter you need. Get the syringe, check the plunger if it is working. Check the to re-move air, let some sterile water flow out of the needle proper size be used. 2. 3. Inject the airtofrom the vial 2. going Slightly thewater cover 4 UNIT 4 needle cap if it is easily removed and inspect the appearance to ensure that it is filled. topeel the off sterile while slowly revealing the UNIT 4 vial, then turn the sterile of the needle (careful not to touch the needle) 8. Wipe the rubber with alcohol, then Inject the sterile water 9 DAY 29 tip of the plunger. water vial upside down 4. Get using the syringe, take off some air from the vial to the medication vial slowly ( You can do it in a rotating DAY 29 3. within the your syringe,eye check the level, approximately the same amount of the sterile water you motion) to distribute it equally to the medication. ON—VIAL while plunger if it is working. supporting the need. the 9. Shake the vial well by sliding it back and forth between your Check cap if it plunger as itneedle goes down. isInject the air from the vial going to the sterile water vial, easily removed andand inpalms. 3. 5. Bring down the vial spect the appearance of then turn the sterile water vial upside down within your eye 10. Wipe the rubber with alcohol. Get the required amount of hold it firmly on the table MEDICATION MEDICATION PREPAR the needle toPREPARATION—VIAL while you (careful removenotthe PREPARATION—VIAL level, while supporting the plunger as it goes down. medication, turn the vial upside down within your eye level. MEDICATION PREPAR touch the needle) MEDICATION syringe. MEDICATION PREPARATION—VIAL 4. Raise the syringe within PREPARATION—VIAL your eye level, then pull 1. using the syringe, take off the plunger slightly to 1. using somethe air syringe, from thetake vial off apcollect the sterile water some air from the approximately thevialsame then push it back to reproximately same amount of thethe sterile wamove air, let some sterile amount of the sterile water you need. water flow out of the neeyouthe need. 2. ter Inject air from the vial dle to ensure that it is 2. Inject thewater vial goingthe to air thefrom sterile filled. going to the sterile vial, then turn the water sterile 5. Wipe the rubber with UNIT vial, then the sterile water vialturn upside down alcohol, then Inject the4 water upside within vial your eye down level, sterile water to DAY the medi29 within eye level, while your supporting the cation vial slowly ( You while the plungersupporting as it goes down. can do it in a rotating moas it goes 3. plunger Bring down the down. vial and tion) to distribute it 3. Bring and hold itdown firmlythe on vial the table equally to the medication. hold the table whileit firmly you on remove the 6. Shake the vial well by slidwhile syringe.you remove the ing it back and forth beMEDICATION PREPARATION—VIAL 4. syringe. Raise the syringe within tween your palms. MEDICATION 4. Raise within your the eye syringe level, then pull 7. Wipe the rubber with PREPARATION—VIAL your level, slightly then pull the eye plunger to alcohol. Get the required the plunger slightlywater to collect the sterile amount of medication, 1. using the vial syringe, take off collect the itsterile then push back water to return the upside down some airyour fromeye the vial apthen it back removepush air, let some to sterile within level. proximately the same move some sterile waterair, flowletout of the neeamount of the sterile wawater out ofthat the needle toflow ensure it is ter you need. dle to ensure that it is filled. 2. Inject the air from the vial 5. filled. Wipe the rubber with going to the sterile water 5. Wipe thethen rubber alcohol, Injectwith the vial, then turn the sterile alcohol, then toInject the sterile water the mediwater vial upside down sterile to the medicationwater vial slowly ( You within your eye level, cation ( You can dovial it in slowly a rotating mowhile supporting the can do ittoin a distribute rotating mo-it tion) plunger as it goes down. tion) distribute it equallyto to the medication. 3. Bring down the vial and to the 6. equally Shake the vialmedication. well by slidhold it firmly on the table 6. Shake vialand wellforth by sliding it the back bewhile you remove the ing it back forth between yourand palms. syringe. 7. tween Wipe your the palms. rubber with 4. Raise the syringe within 7. Wipe theGetrubber with alcohol. the required your eye level, then pull alcohol. required amount Get of the medication, the plunger slightly to amount of upside medication, turn the vial down collect the sterile water turn theyour vial eye upside down within level. then push it back to rewithin your eye level. move air, let some sterile water flow out of the nee741 LIFELINE PREHOSPITAL EMERGENCY CARE dle to ensure that it is filled. 5. Wipe the rubber with alcohol, then Inject the sterile water to the medication vial slowly ( You
MENTS TOPIC
EMTTOPIC ADVANCEMENTS TOPIC DVANCEMENTS
EMT ADVANCEMENTS TOPIC
EMT ADVAN EMT ADVAN
of a of aa of of ce ce ce of of
body body body other other other amamamthe the the
Day 29
INTRAVENOUS THERAPY
MEDICATION PREPARATION—AMPULE 1. Some institution have ampule cutter. But if you don’t have better use some piece of cloth or a gauze to protect you from cutting yourself once he ampule is opened. 2. Check the ampule for its name, appearance, expiration date. Counter check information from doctor’s order 3. Peel off the cover of a gauze or use a piece of cloth. 4. Hold the ampule’s body with your hand the other
head head head Some Some Some rk on rk rk on on d be dd be ou.be ou. ou. take take take ation ation ation amamldambe d be ld be n donn dodoyour your your
hand will hold the ampule’s head with the gauze. 5. Break the ampule head away from you. Some ampule has a dot mark on it, this mark should be pointing away from you. 6. Open a syringe and take the amount of medication you need from the ampule. The bevel should be pointing down when doing so. Do this within your eye level. 7. Pull the plunger down and push the medication until a drop reach the needle.
down own down ation ation ation the the the
INTRADERMAL ROUTE
742
LIFELINE
PREHOSPITAL EMERGENCY CARE
injection of a small amount of fluid into the dermal layer of the skin. Frequently done as a diagnostic measure for tuberculin testing and allergy testing, 26-gauge needle is usually selected
UNIT 4 DAY 29
EMT ADVANCEMENTS TOPIC INTRADERMAL ROUTE (ID) INTRADERMAL ROUTE
1.
injection of a small amount of fluid into the dermal layer of the skin. Frequently done as a diagnostic measure for tuberculin testing and allergy testing, MEDICATION 26-gauge needle is usually selected
Prepare necessary materials. Prepare the medication 0.9mL of Sterile water and 0.1% of your medication. This is done for skin test—if the patient is allergic to the medication to be administered. 2. Choose a site. Usually the inner aspect of the forearm or subscapular region of the back. 3. Position the patient—arm relaxed and elbows are slightly flexed, palm up to better angle of the site. 4. Clean the site (wipe with cotton wet with alcohol— let the site dry) 5. Using the other hand, pull the skin downward (taut the skin) hold it until the needle bevel has been inserted between the skin layers. 6. Hold syringe with fingers and thumb resting on the sides of the barrel. Insert needle with the bevel up at a 10 to 15 degrees anBilugan o markahan ang pantal gle until the bevel is covInjection of a small amount of fluid into the sa balat kung saan mo itinurok ang ered. You should feel dermal layer of the skin. Frequently done as a medikasyon. Isulat sa noteb ook kung some resistance, because diagnostic measure for tuberculin testing and allergy anong oras ka nagturok. Matapos ang if not you have inserted testing, 26-gauge needle is usually selected. 30 minuto, suriin ang minarkahang the needle too deep. bahagi ng balat. Tingnan ito kung 7. Inject the medication, do MEDICATION may pagbabago, pamumula o not aspirate. Create a 1. Prepare necessary materials. Prepare the medication 0.9mL of Sterile water and pamamaga. Ireport agad sa medical wheal at the site this indi0.1% of your medication. This is done for skin test—if the patient is allergic to the director kung may makitang cates that the medication medication to be administered. malaking pagbabago. has entered the area be2. Choose a site. Usually the inner aspect of the forearm or subscapular region of the back. tween the intrademal 3. Position the patient—arm relaxed and elbows are slightly flexed, palm up to tissues. If no wheal is better angle of the site. formed, withdraw the 4. Clean the site (wipe with cotton wet with alcohol—let the site dry). needle and repeat the Note: 5. Using the other hand, pull the skin downward (taut the skin) hold it until the procedure at another site. needle bevel has been inserted between the skin layers. Encircle or mark the wheal using a black or blue ink, write the time to check the 6. Hold syringe with fingers and thumb resting on the sides of the barrel. Insert site (30 minutes after you have injected the medication). Observe the skin for needle with the bevel up at a 10 to 15 degrees angle until the bevel is covered. You any changes and redness. Report and document accordingly. should feel some resistance, because if not you have inserted the needle too deep. 7. Inject the medication, do not aspirate. Create a wheal at the site this indicates that the medication has entered the area between the intrademal tissues. If no wheal is formed, withdraw the needle and repeat the procedure at another site.
INTRADERMAL ROUTE (ID)
LIFELINE
PREHOSPITAL EMERGENCY CARE
743
the subcutaneous fatty (adipose) tissue. Small volumes of medication that are nonirritating to body tissues are administered by this method.
UNIT 4 MEDICATION DAY 29 1. Check Doctor’s orders and
the subcutaneous fatty (adipose) tissue. Small volumes of medication that are nonirritating to body tissues are administered by this method. Day 29
INTRAVENOUS THERAPY
EMT ADVANCEMENTS TOPIC
MEDICATION 1. Check Doctor’s orders and Obtain Medication, Check Obtain Medication, Check for Expiration of medicafor Expiration of medicaRequires a slower absorption rate than IM injections provide. The needle tion, prepare necessary tion, prepare necessary pass through the epidermis and dermis to reach the subcutaneous fatty (adipose) materials. tissue. Small volumes of medication that are non-irritating to body tissues are materials. 2. Wash hands, BSI on. administered by this method. 2. Wash hands, BSI on. SUBCUTANEOUS ROUTE 3. Select injection site (outer 3. Select injection site (outer aspect of upper arm), it is aspectMEDICATION of upper arm), it is requires a slower absorption one hand’s width down 1. Check doctor’s orders and one hand’s width down rate fro than IM injections provide. fro the top of the shoulder obtain medication. Check for the top of the shoulder The and needle pass through the and a third of the way expiration of medication and a third of the way epidermis and dermis to reach prepare necessary materials. around the arm’s outer around the arm’s outer 2. Wash hands, BSI on. fatty the aspect. subcutaneous aspect. and position the and position the 3. Select injection site (outer aspect (adipose) tissue. Small volumes patient. patient. of upper arm), it is one hand’s of medication that are nonirri4. Clean the site with alco4. Cleanwidth down for the top of the the site with alcotating to body tissues are adhol. hol. shoulder and a third of the way ministered by needle this method. 5. Remove needle cap and around the arm’s outer aspect. 5. Remove cap and stabilize the injection site and position the patient. stabilize the injection site 4. Clean the site with alcohol. by pinching up the tissue MEDICATION by pinching up the tissue 5. Remove needle cap and stabilize gently between the 1. gently Check Doctor’s orders and between the the injection site by pinching thumb and index finger. Obtain Medication, Check thumb and index finger. up the tissue gently between the 6. Insert the syringe, and for Expiration of medica6. Insert the syringe, and thumb and index finger. inject medication. 6. Insert the syringe, and inject tion, prepare necessary inject medication. 7. Dispose used/soiled matemedication. 7. materials. Dispose used/soiled materials properly and docu7. Dispose used/soiled materials 2. Wash hands, BSIand on. docurials properly properly and document it. ment it. 3. Select ment it.injection site (outer
SUBCUTANOUS ROUTE (SQ)
DAY 2
SUBCUTANOUS ROUTE (SQ)
4. 5.
6. 7.
aspect of upper arm), it is one hand’s width down fro the top of the shoulder and a third of the way around the arm’s outer aspect. and position the patient. Clean the site with alcohol. Remove needle cap and stabilize the injection site by pinching up the tissue gently between the thumb and index finger. Insert the syringe, and inject medication. Dispose used/soiled materials properly and document it.
744
LIFELINE
PREHOSPITAL EMERGENCY CARE
INTRAMUSCULAR INTRAMUSCULARROUTE ROUTE
preferred preferred route route of of administeradministering ing medication medication when when fairly fairly rapid-acting rapid-acting and and long-lasting long-lasting dosage dosage of of medication medication isis rerequired. safest, quired. safest,easiest, easiest,and andbest best tolerated tolerated of of the the injection injection routes, routes,20 20to to22 22gauge gaugeisiscomcommonly monlyused. used.
UNIT DAY 2
INTRAMUSCULAR ROUTE
preferred route of administering medication when fairly rapid-acting and long-lasting dosage of medication is required. safest, easiest, and best MEDICATION tolerated of the injection routes, 20 to 22 gauge is com1. Check monly used.Doctor’s orders and Obtain Medication, Check for Expiration of medication, prepare necessary materials. 2. Wash hands, BSI on. 3. Select injection site (upper arm—deltoid muscle) 4. Clean the site with alcohol. 5. Remove needle cap and stabilize the injection site by pinching up the tissue gently between the thumb and forefinger. 6. Help patient relax his muscles by distracting his attention. 7. Hold the barrel firmly between the thumb and index finger. 8. Insert the syringe, with the bevel up needle at a 90 degree angle to the skin surface with a
EMT ADVANCEMENTS TOPIC
29
y g t n -
4 29
INTRAMUSCULAR ROUTE (IM)
INTRAMUSCULAR ROUTE (IM) UNIT 4 DAY 29
Preferred route of administering medication when fairly rapid-acting and long-lasting dosage of medication is required. safest, easiest, and best tolerated of the injection routes, 20 to 22 gauge is commonly used.
EMT ADVANCEMENTS TOPIC MEDICATION
MEDICATION Check Doctor’s orders and Obtain Medication, Check for Expiration of medication, prepare necessary materials. 2. Wash hands, BSI on. 3. Select injection site (upper arm—deltoid muscle) 4. Clean the site with alcohol. 5. Remove needle cap and stabilize the injection site by pinching up the tissue gently between the thumb and forefinger. 6. Help patient relax his muscles by distracting his attention. 7. Hold the barrel firmly between the thumb and index finger. 8. Insert the syringe, with the bevel up needle at a 90 degree angle to the skin surface with a straightforward motion. 9. Remove hold of the skin and move the free hand to Aspirate syringe, check for blood, there should be no blood entering the syringe then inject medication. 10. Withdraw the needle then massage the area. 11. Dispose used/soiled materials properly and document it.
1. Check doctor’s orders and obtain medication. Check for expiration of medication and prepare necessary materials. 2. Wash hands, BSI on. 3. Select injection site (upper arm—deltoid muscle) 4. Clean the site with alcohol. 5. Remove needle cap and stabilize the injection site by pinching up the tissue gently between the thumb and forefinger. 6. Help patient relax his muscles by distracting his attention. 7. Hold the barrel firmly between the thumb and index finger. 8. Insert the syringe, with the bevel up needle at a 90 degree angle to the skin surface with a straightforward motion. 9. Remove hold of the skin and move the free hand to Aspirate syringe, check for blood, there should be no blood entering the syringe then inject medication. 10. Withdraw the needle then massage the area. 11. Dispose used/soiled materials properly and document it.
INTRAMUSCULAR ROUTE (IM)
1.
EMT ADVANCEMENTS TOPIC
INTRAMUSCULAR ROUTE (IM)
LIFELINE
PREHOSPITAL EMERGENCY CARE
745
the bevel of needle is in an upward position. MainUNIT 4 tain a minimumUNIT angle 4 from the skin. DAY 29 DAY 29 10. Hook up the IV tubing and adjust the flow. 11. Secure the site. Dispose sharps appropriately and Day 29 document properly.
tion on set e paof the
ate IV VENOUS ROUTE (IV)
riately ck for
EMT ADVANCEMENTS ADVANCEMENTS TOPIC TOPIC EMT INTRAVENOUS THERAPY INTRAVENOUS ROUTE ROUTE (IV) (IV) INTRAVENOUS
ng IV ple of inser-
wipe ohol). band with e is in Mainangle
1. 1.
UNIT 4 29
MEDICATION MEDICATIONDAY
Get your gloves on (BSI Get your gloves on (BSI on) on) 2. Choose a solution—check 2. Choose a solution—check the bag for clarity, expirathe bag for clarity, expiration and correct solution tion and correct solution 3. Choose administration set 3. Choose administration set appropriate for the paappropriate for the patient and the needs of the tient and the needs of the patient. patient. 4. Choose an appropriate IV 4. Choose an appropriate IV site site 5. Choose an appropriately 5. Choose an appropriately sized catheter, check for sizedMEDICATION catheter, check for expiration date. expiration date. 6. Tear tape for securing IV 1. Tear Get your gloves on (BSI 6. tape for securing IV site. Have a couple of on) site. Have a couple of cathetersa ready for inser2. catheters Choose solution—check ready for insertion.bag for clarity, expirathe tion. 1. Get your gloves on (BSI on) 7. tion Open an alcohol wipe andan correct solution 7. Open alcohol wipe (cotton ball with alcohol). 2. Choose a solution—check the bag 3. (cotton Choose administration set ball with alcohol). 8. appropriate Apply a constricting band for the pafor clarity, expiration and correct 8. Apply a constricting band 9. tient Insertand the catheter with needs ofwith the 9. Insert thethecatheter solution the bevel of needle is in patient. the bevel of needle is in 3. Choose administration set an upward position. Main4. an Choose an position. appropriate IV upward Maintain a minimum angle appropriate for the patient and the site tain a minimum angle from the an skin. 5. from Choose needs of the patient. the skin.appropriately 10. sized Hook up the IV tubing MEDICATION catheter, check for 10. Hook up the IV tubing 4. Choose an appropriate IV site and adjust date. the flow. expiration and adjust the flow. 5. Choose an appropriately sized 11.Get Secure the site. Dispose 1. 11. your gloves on (BSIIV 6. Tear tape forsite. securing Secure the Dispose sharpsHave appropriately and site. a coupleand of on) catheter, check for expiration date. sharps appropriately document properly. catheters ready for inser2. Choose a solution—check document properly. 6. Tear tape for securing IV site. Have tion. the bag for clarity, expiraa couple of catheters ready for 7. tion Open an alcohol wipe and correct solution insertion. 3. Choose (cottonadministration ball with alcohol). set 8. appropriate Apply a constricting 7. Open an alcohol wipe (cotton ball for the band paInsert with andthe the catheter needs of the with alcohol). 9. tient the bevel of needle is in patient. 8. Apply a constricting band an upward position. Main4. Choose an appropriate IV 9. Insert the catheter with the bevel tain a minimum angle site from the of needle is in an upward position. 5. Choose anskin. appropriately 10.sized Hookcatheter, up the check IV tubing for Maintain a minimum angle from the and adjust the flow. expiration date. skin. 11. Secure the site. Dispose 6. Tear tape for securing IV sharps appropriately and 10. Hook up the IV tubing and adjust site. Have a couple of document properly. the flow. catheters ready for insertion. 11. Secure the site. Dispose sharps 7. Open an alcohol wipe appropriately and document (cotton ball with alcohol). properly. 8. Apply a constricting band 9. Insert the catheter with the bevel of needle is in an upward position. Maintain a minimum angle from the skin. 10. Hook up the IV tubing and adjust the flow. 11. Secure the site. Dispose sharps appropriately and document properly.
ubing
ispose y and
UNIT 4 DAY 29
INTRAVENOUS ROUTE (IV) MEDICATION
746
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EMT ADVANCEMENTS TOPIC INTRAVENOUS ROUTE (IV)
EMT ADVANCEMENTS TOPIC INTRAVENOUS ROUTE (IV)
GLOSSARY
GLOSSARY Emergency Medical Terms
A
ABCs The critical components of the initial evaluation of an accident or trauma victim. They stand for: A = Airway with cervical spine control. B = Breathing. And C = Circulation with control of bleeding ABGs Arterial blood gases. They are an important routine investigation to monitor the acid-base balance of patients. They may help make a diagnosis, indicate the severity of a condition and help to assess treatment.. Acidosis When your body fluids contain too much acid, this is known as acidosis. Acidosis occurs when your kidneys and lungs can’t keep your body’s pH in balance
Anaphylactic Shock An extreme allergic reaction that usually involves heart failure, circulatory collapse, a severe asthma-like difficulty in breathing and sometimes results in death. Anemia Chronically low hematocrit. Aneurysm A balloonlike swelling in the wall of an artery. Angina Pectoris A severe acute attack of cardiac pain. Angioplasty Plastic surgery of blood vessels during which a balloon is passed into the artery and inflated to enlarge it and increase blood flow. Anhidrosis The abnormal absence of sweat.
Acute Of abrupt onset, in reference to a disease. Acute often also connotes an illness that is of short duration, rapidly progressive, and in need of urgent care.
Anterior Word used to describe the front surface of an organ, muscle, etc.
Agonal A word used to describe a major negative change in a patient’s condition, usually preceding immediate death, such as a complete cessation of breathing.
Aortic Calcification Hardening of the aorta, the main artery coming out of the left ventricle of the heart, usually from cholesterol deposits or some other organic substance.
ALS Advanced Life Support. Alzheimer’s Disease A progressive disease with specific brain abnormalities marked by memory loss and progressive inability to function normally at even the simplest tasks. Ambu-Bag Proprietary name for a Bag-Valve Mask. Amp Abbreviation for Ampule, which is a sealed plastic or glass capsule containing a single dose of a drug in a sterile solution for injection. 748
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Aortic Coarctation A dangerous narrowing of the aorta. Aortic Dissection A tear in the aorta. Aortic Rupture When the aorta bursts. Arterial Stick Insertion of an IV line into an artery. Arrhythmia When the beat of the heart is no longer originating from the sinus node, and the rhythm is abnormal.
GLOSSARY BLS Basic Life Support.
Aspirate, Aspiration To draw in or out using suction. The term can refer to inhaling purposefully (such as breathing in oxygen or inhalants) or inhaling accidentally (such as sucking food into the airway). May also refer to medical interventions to remove harmful substances (such as air, body fluids, or bone fragments) or to remove tissue samples for testing.
Bolus A large dose of a drug that is given (usually intravenously) at the beginning of treatment to raise bloodlevel concentrations to a therapeutic level.
Astrocytoma A slowly growing tumor of the glial tissue of the brain and the spinal cord.
Bowel disimpaction Manual removal of impacted fecal matter from a patient’s rectum.
Asystole A condition in which the heart no longer beats and usually cannot be restarted.
Bradycardic A slowing of the heart rate to less than 50 beats per minute.
Atypical angina A form of angina pectoris that does not manifest the typical angina symptoms of chest pain, shortness of breath, etc, but which comes on suddenly and occurs without a predisposing cause. Awake, Alert and Oriented X3 Nonfocal Medical shorthand indicating that a patient is in a cogent state and aware of their surroundings. “Oriented x3” means the patient is aware of person, place, and time (WHO they are, WHERE they are, and WHAT TIME it is.)
Bronchoscopy The use of an endoscope to examine and take biopsies from the interior of the bronchia.
B
BSA Burn Surface Area. The total area (expressed as a percentage) of the burned area on a patient’s body. BUN Abbreviation for Blood Urea Nitrogen. BVM A handheld squeeze bag, attached to a face mask, used to assist in providing artificial ventilation of the lungs.
B
Babinski’s Reflex Also known as the plantar reflex; the movement of the big toe upward instead of downward; used to test injury to, or diseases of, the upper motor neurons. Barlow’s Syndrome Infantile scurvy. Bilateral Hemothorax Blood in both sides of the pleura, the membrane covering the lung. Blood Gas A test to determine the gas-phase components of blood, including oxygen, carbon dioxide, pH balance, etc. Blood Pressure (BP) A measure of how well blood circulates through your arteries, listen in the format of the systolic pressure over the diastolic pressure. Normal blood pressure is about 120/80. Blood Swab A blood sample taken with a cotton-tipped stick.
C
C
C-Section Shorthand for cesarean section, which is surgical delivery of a baby through the abdominal wall. C-Spine Shorthand for cervical spine, or the neck. Calcium Oxalate Stone A kidney stone. Calot’s Triangle The cystic duct, the common duct, and the liver. Calyx A cup-shaped part of the kidneys. Capillary Refill When a fingernail is pressed, the nail bed turns white. Capillary refill refers to the return of the nail bed to pink color. Good cap refill is two seconds or less. LIFELINE
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GLOSSARY Carboxyhemoglobin A substance formed when the poisonous gas carbon monoxide combines with hemoglobin in the blood. Carboxyhemoglobin is incapable of transporting oxygen to the body’s organs. Large amounts of this compound are found in carbon monoxide poisoning. Cardiomyopathy A disorder of the heart muscle that can often be fatal. Cardiac Tamponade Compression of the heart from fluid such as an effusion or blood. Catheter A flexible tube for withdrawing fluids from, or introducing fluids into, a cavity of the body. Frequently used to drain the urinary bladder (Foley catheter). CBC Abbreviation for Complete Blood Count, which is an all-purpose blood test; combining diagnostic evaluations of red blood cell count, white cell count, erythrocyte indices, hematocrit, and a differential blood count. CC Abbreviation for Cubic Centimeters. Cecum A pouch at the junction of the large and small intestine. The lower end bears the vermiform appendix. Cellulitis A skin infection. Central Line The central location in the circulation of the vein used, usually in the internal jugular and subclavian veins in the neck, or the femoral veins in the groin. This has the benefit of being able to send more fluid into the body. Chem 7 A battery of blood chemistry tests; the seven parts of a Chem 7; blood urea nitrogen (BUN), chloride, CO2, creatinine, glucose, potassium, and sodium. Normal values for these components are: CHF Abbreviation for Congestive Heart Failure. See pulmonary edema. CID Abbreviation for Cervical Immobilization Device.
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Claudication Limping caused by impaired blood supply to the legs. Coag Panel A blood test used to determine the clotting factors of a patient’s blood. COPD Chronic Obstructive Pulmonary Disease. Also known by the acronym COLD (Chronic Obstructive Lung Disease). Disease process that casues decreased ability of the lungs to perform their function of ventilation. Diseases that can cause this are chronic bronchitis, pulmonary emphysema, chronic asthma, and chronic bronchiolitis. Cordotomy Surgical severing of the nerves in the spinal cord to relieve intractable pain in the pelvis and lower limbs. CPR CardioPulmonary Resuscitation. Cricothyroidotomy A procedure used to surgically establish an airway in the patient’s throat when intubation isn’t possibly because of swelling or bleeding. CT scan Computerized tomography (CT) scan which combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CVA Abbreviation for Cerebrovascular Accident, i.e. stroke. Cyanotic When a patient’s skin and mucous membranes are bluish in color from an inadequate supply of oxygen in the blood. Cystic Fibrosis A lung disease that causes the production of thick mucus in the lungs, hampering breathing.
D
D
Debride, Debridement Cleaning an open wound by removing foreign material and dead tissue. Debridement of burns is extremely painful. Decerebration The progressive loss of cerebral function; advanced decerebration (and the resultant deep unconsciousness) occurs with severe damage to the cerebrum, the largest part of the brain.
GLOSSARY Deep Vein Thrombosis A blood clot in a deep vein. Defibrillation The cessation of fibrillation of the cardiac muscle and restoration of a normal rhythm of the heart. Delusional Having an irrational belief that cannot be changed by a rational argument, often found in schizophrenia and manicdepressive psychosis. Diabetic Ketoacidosis Depletion of the body’s alkali reserves due to diabetes, causing a major disruption in the body’s acid-base balance. The breath smells fruity and the patient is usually comatose.
DTP A diphtheria tetanus pertussis toxoid injection. Dyspnea Shortness of breath. Dystocia Difficult labor due to some fetal problem, such as dislocation of the shoulders.
E
E
ECG Electrocardiogram. A machine that measures heart activity.
Diagnosis Determining what’s wrong with a patient by using the patient’s symptoms, signs, test results, medical background, and other factors.
Eclampsia A serious condition affecting pregnant women in which the entire body is affected by convulsions and the patient eventually passes into a coma.
Dialysis The procedure to filter blood for patients with kidney failure, also used to remove absorbed toxins from overdosing and poisoning.
Ectopic pregnancy The development of the fetus in the fallopian tube instead of in the womb.
Diastolic Pressure during the relaxing of the heart. DIC Abbreviation for Disseminated Intravascular Coagulation (no blood clotting).In many hospitals, ER personnel also interpret DIC to mean “death is coming” since disseminated intravascular coagulation usually means death is imminent. Diplopia Double vision. Distal Pulse The pulse farthest from the heart. Diuretic Drug or substance that increasesthe production of urine. Diverticulitis Inflammation of the colon. DNR The abbreviation for Do Not Resuscitate, which is requested or ordered for terminally ill or injured patients. DOA Abbreviation for Dead On Arrival.
Edema Excessive accumulation of fluid. EEG Electroencephalogram. measures brain activity. Electrolyte analysis Tests the basic chemicals in the body; sodium, potassium, chloride, and bicarbonate. Embolectomy Surgical removal of an embolus or a blood clot. EMS Abbreviation for Emergency Medical Service(s). EMT Abbreviation for Emergency Medical Technician. Endocarditis Inflammation of cardiac tissue, usually caused by bacterial infection. Endoscope A long flexible tube with its own special lighting used in looking deep into the body. Endotracheal Tube A tube that serves as an artificial airway and is inserted through the patient’s mouth or nose. It passes through the throat and into the air passages to help breathing. LIFELINE
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GLOSSARY Epidermis The outer layer of the skin. Epidural An epidural block; an injection through a catheter of a local anesthetic to relieve pain during labor, usually done at the lumbar level of the spine. Epiglottitis Inflammation of the epiglottis, thatelastic cartilage tissue attached to the entrance of the larynx or the voice box.
F
F
Fetal Distress A term used to describe a number of critical conditions threatening the live delivery of a fetus. Fibrillation An uncoordinated, quivering of the heart muscle resulting in a completely irregular pulse. First-degree burn A burn affecting only the epidermis. The color of the burn is red, capillary refill is present, the skin texture is normal, and the burn heals in five to ten days with no scarring.
G
Gastric Lavage Irrigation of the stomach when poisoning or bleeding is suspected, or to remove ingested toxins before they enter the blood stream. Glasgow coma scale This scale is used to quickly determine the status and degree of injury of a trauma victim to the head. Golden hour Also known as the golden window. When treating a patient who has had a myocardial infarction, emergency personnel must be extremely careful during the first hour. The ventricles are very sensitive during this period and life threateningarrythmias can occur. GSW Abbreviation for GunShot Wound.
H
H
Heart/Lung Bypass Using a machine to breathe and circulate blood for a patient for any number of clinical or surgical reasons, like to also used to rewarm the blood of severely hypothermic patient. Heimlich Maneuver A first-aid measure used to dislodge something caught in a personâ&#x20AC;&#x2122;s throat that is obstructing breathing. Hematochezia Maroon stools, usually from a lower gastro intestinal bleeding. Hematocrit The proportion, by volume, of red blood cells in a CBC. Hemiparesis Paralysis or weakness on one side of the body. Hemorrhage The dramatic and sudden loss of blood. Hemoperfusion Dialysis of the blood to remove foreign substances such as poisons or drugs. Hemopneumothorax Blood and air in the pleura. Also often referred to as a Collapsed Lung. Hepatolenticular Degeneration Excessive accumulation of copper in the kidney, liver, and brain, which if untreated, is invariably fatal. Holosystolic Murmur A heart murmur that begins with the heart sound S1 and occupying all of the systole, then reaching S2. S1 and S2 refer to heart sounds noted during palpation. Hyperaldosteronism Overproduction of the adrenal hormone aldosterone, causing abnormalities in the sodium, water, and potassium levels in the body. Hypercalcemia An abnormally high concentration of calcium in the blood. Hyperglycemia High values of glucose in the blood. Hyperlipidemia Excessive fat in the blood.
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GLOSSARY Hyperthermia An abnormally high body temperature (fever). Hypoglycemia Low values of glucose in the blood. Hypohemia A lack of blood in the body. Hypotension Abnormally low blood pressure. Hypothermia When the body temperature reaches significantly below normal body temperatures (usually below 95 degrees Fahrenheit or 35 degrees Celcius). Hypothyroidism Subnormal activity of the thyroid gland. Hypovolemia A decrease in the volume of circulating blood; also referred to as being in shock. Hypoxia A severe deficiency of oxygen in the blood and tissues.
I
I
Ileectomy Surgical removal of the small intestine. Infiltrate An abnormal substance (eg. a cancer cell) in a tissue or organ. Intracerebral Inside the brain. Intubation Insertion of an endotracheal tube to help an unconscious patient breathe. Irritable Bowel Syndrome A chronic and unpleasant gastrointestinal condition marked by abdominal cramping, and diarrhea or constipation. Ischemia When the heart is starving for oxygen. IV Abbreviation for Intravenous, meaning through the vein.
L
L
Laparotomy Any surgery involving an incision in the abdominal wall. Laryngoscope An instrument for examining the larynx, also to properly visualize the vocal cords for endotracheal intubation. Lithotripsy Breaking up the renal calculi (kidney stones) with sound waves so they can be passed in the urine. LOC Loss Of Consciousness. Lumbar Puncture The withdrawal of cerebrospinal fluid through a hollow needle inserted into the lumbar region between the L4 and L5 vertebrae. Also referred to as a spinal tap.
M
M
MCI Multiple Casualty Incident. Meningitis An inflammation of the meninges, the membranes surrounding the brain and spinal cord. Metacarpal fracture A fracture of one of the five bones that form that part of the hand between the wrist and the fingers. Mg Abbreviation for milligrams. MI Abbreviation for myocardial infarction, a condition caused by occlusion of one or more of the coronary arteries, more commonly known as a heart attack. MRI Abbreviation for magnetic resonance imaging. Imaging by computer using a strong magnetic field and radio frequencies. Myosis Excessive contraction of the pupil in the eye.
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GLOSSARY
N
Nasogastric Tube A tube that passes through the patient’s nose and throat and ends in the patient’s stomach. This tube allows for direct “tube feeding” to maintain the nutritional status of the patient or removal of stomach acids. Necrotic Dead, as in “necrotic tissue”. NICU Abbreviation for the Neonatal Intensive Care Unit, an ICU for newborns. Normal Sinus Rhythm A normal heart rate, which is between 60 and 80 beats per minute in an adult. Nosocomial infections Opportunistic infections contracted while in the hospital, eg a urinary tract infection a patient develops from his foley catheter. NPO Abbreviation for nothing by mouth (from the Latin Nil Per Os). NS Abbreviation for Normal Saline solution. NSAID Abbreviation for a NonSteroid Anti-Inflammatory Drug (e.g. Motrin, Advil, etc).
O
O
OD OverDose (drug). O negative Type O, Rhesus negative blood; also called universal donor blood since any human can receive O negative blood without complication. Orbital fracture A fracture of the bony socket that holds the eyeball. Osteosarcoma Bone cancer. Otitis media An infection of the middle ear. 754
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P
P
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Palpation This refers to blood pressure taken under emergency conditions when listening for the systolic and diastolic pressures with a stethoscope is impossible. Taken by feeling (palpation) the pulse. Pancreatitis Chronic or acute inflammation of the pancreas. Paresis Partial or slight paralysis. Pericardium The sac that envelops the heart. Peritoneum A transparent membrane enclosing the abdominal cavity. Platelets Components of blood designed to form clots and plug leaks from bleeding arteries and veins. Pleura The lining around the lung. Preeclampsia The physical condition of pregnant woman prior to eclampsia. Symptoms include blood pressure greater than 140/90; persistent proteinuria (protein in the urine); and edema. Preemie Expression for a baby born before full term, usually defined as a child born weighing less than five and a half pounds.
R
R
Reflux Moving backward in the esophagus Respirations Breaths; the act of inhaling and exhaling.
S
S
Saline Solution A blood volume substitute made of salt and water, a temporary substitute for lost blood.
GLOSSARY Schizophrenia A mental disorder marked by hallucinations, delusions, and disintegration of the thought processes. Second-Degree Burn There are two levels of second-degree burn: The first level is a burn in which both the epidermis and the underlying dermis are damaged. The color of the burn is red (and there may be blistering); capillary refill is present; the skin texture is edematous (filled with fluid), and the burn heals in 10 to 21 days with no or minimal scarring. Sepsis A very severe infection. Shock A circulatory disturbance marked by a severe drop in blood pressure, rapid pulse, clammy skin, pallor, and a rapid heart rate. Spleen A part of lymphatic system, helps filter blood of bacteria and impurities. Stasis A slowing or stopping of blood flow. STD Abbreviation for Sexually Transmitted Disease. Sternotomy Surgical opening of the breast bone. Stomach Pumping A large tube called an Ewald is inserted into the stomach, sucks out the contents, then the stomach is flushed out with clear water then charcoal and a cathartic (a fluid that passes through the bowel quickly). Streptokinase An enzyme that can break up and liquefy blood clots. Stridor What breathing sounds like when the larynx or trachea is obstructed. Subdural Outside the brain. Sublingual A medication that is taken by dissolving under the tongue. Systolic Pressure during the contraction of the heart. Systolic murmur A cardiac murmur that occurs between the first and second heart sounds.
T
T
T3, T4, etc Third thoracic vertebrae; fourth thoracic vertebrae, etc. Tachycardia An extremely rapid heart rate, usually signified by a pulse over 100 beats per minute. Tension Pneumothorax A collapsed lung. Third-Degree Burn A burn that damages (or destroys) the full thickness of the skin and the tissues underneath. The color of the burn is white, black, or brown; capillary refill is absent; the skin texture is leathery; and there is no spontaneous healing. Thrombosis A blood clot. Tox Screen Toxicological analysis of the blood, ordered when a drug overdose is suspected and the drugs need to be identified. Tracheal Shift A physical shift of the windpipe due to trauma. Tracheostomy A temporary surgical opening at the front of the throat providing access to the trachea or windpipe to assist in breathing. Trauma Center An emergency room with a trauma surgeon on duty. Triage The system of prioritizing patients in an emergency situation in which there are a great number of injured or ill. Type and Crossmatch Blood typing to identify patientâ&#x20AC;&#x2122;s blood type.
U
U
U/A Urinalysis, used to test for kidney failure, dehydration, diabetes, undernourishment, or bladder or kidney infection. Ulcerative Colitis An inflammatory and ulcerative condition of the colon.
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GLOSSARY Ultrasound A test similar to an x-ray, but which uses sound waves. Unstable Angina Angina pectoris in which the cardiac pain has changed in pattern. Uric Acid An acid formed in the breakdown of nucleoproteins in tissues; often tested when gout is suspected since high uric acid content in the blood often causes gout symptoms and the formation of stones. UTI Abbreviation for urinary tract infection.
V
V
V/Q scan A ventilation-perfusion scan, used to confirm a diagnosis of pulmonary embolism. Valsalva Maneuver When a patient is instructed to blow on his or her thumb to maximize intrathoracic pressure. It is used when cardiac trouble is suspected. Venipuncture The drawing of blood from a vein. Ventricular Septal Rupture Rupture of the ventricular septum caused by mechanical failure of infarcted cardiac tissue. V-fib Ventricular fibrillation.
W
W
WBC Abbreviation for White Blood Cell count, used to determine how many white blood cells there are in the body to defend against bacteria.
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Lifelineâ&#x20AC;&#x2122;s Awards and Recognition
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E in Lifeline 16-911 have received numerous awards and commendations throughout the years. We are honored by such recognition, but at the same time humbled in knowing that though we have already done a lot, still we could do more. We share these awards with all Lifeliners who have been a part of our journey. Together, letâ&#x20AC;&#x2122;s save more lives!
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