TEST BANK FOR PARAMEDIC CARE PTINCIPALS AND PRACTICE by QuentinAxel

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 1 Scene Size-Up 80–85 Minutes

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Teaching Tips Discussion Topics Critical Thinking Questions Class Activities

Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction A. Scene size-up is the essential first step of every emergency call B. Critical decisions about the scene are made as the scene reveals itself C. Safety is the MOST important factor of any EMS call D. Components of scene size-up include: 1. Standard Precautions 2. Scene safety 3. Resource determination 4. Location of patients 5. Mechanism of injury/nature of illness

Teaching Tips

III. Standard Precautions A. Strategy designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection B. Standard Precautions dictate that all EMS personnel take the same (standard) precautions with every patient C. Personal protection equipment (PPE) includes: 1. Hand hygiene (antimicrobial waterless soap) 2. Protective gloves 3. Masks and protective eyewear 4. HEPA and N-95 respirators 5. Gowns 6. Disposable resuscitation equipment

Class Activities

Remember that an injured medic is a hindrance, and a dead medic is useless.

This can get messy, suggested only if people are wearing old clothing. Using a needleless syringe, spray student or yourself with colored water while wearing particular PPE. Remove the PPE and do it again; very good visual on how important PPE really is.

Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

D. All contaminated items disposed of in appropriate biohazard bags E. Handwashing remains the most important infection control practice 15

IV. Scene Safety A. Make sure that your scene is safe for yourself, crew, other personnel, patient, and bystanders B. There is no obligation for you to enter a scene that is unsafe C. Your personal safety is the top priority at any emergency scene D. Factors that can make a scene unsafe include: 1. Environmental hazards 2. Extreme weather conditions (rain, snow, ice, extreme heat/cold) 3. Terrain (flat, rocky, etc.) 4. Water (standing or rushing) 5. Electricity (must be turned off before proceeding) 6. Confined space (only properly trained individuals can enter) 7. Hazardous materials (chemical, biological, radiologic, nuclear, and explosive agents) 8. Violence (angry crowds, weapons, threatening behaviors) 9. Roadway rescue operations (motor vehicle collision on a major roadway, traffic flow)

Class Activities

V. Resource Determination A. This is a critical phase that needs to be done as soon as possible, to save critical minutes B. The resources that are needed are dictated by the scene (police, fire, hazmat, power company, heavy rescue, etc.) C. All responding personnel must have appropriate and adequate equipment D. Safe, orderly, and controlled incident management is essential for everyone’s safety

Class Activities

VI. Location of Patients A. Search the area to locate all patients B. If you have more patients then you can manage, call for assistance early C. Incident management may be implemented for multiple-patient incident calls

Discussion Topics

Have students use mock scenarios to list possible scene hazards, along with resources that would be needed to control the scene.

Critical Thinking Questions Using mock scenarios ask students when they would, and when they would not, feel comfortable entering a situation and why.

With students, compile a list of resources that might be needed on an EMS scene.

Discuss with students scenarios they might encounter in which the number of patients might be unknown and clues they may observe that indicate number of patients (car seats, toys, diaper bag, etc.).

Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 15

Content Outline VII. Mechanism of Injury/Nature of Illness A. Mechanism of Injury 1. The strength, direction, and nature of forces that injured the patient 2. Mechanisms of injury found in automobile accidents, gunshot wounds, pedestrian struck by auto, falls, etc. can cause serious internal injury 3. Most trauma injuries have an index of suspicion, which allows a prediction of injuries based on the mechanism of injury B. Nature of Illness 1. The medical complaint that can be determined by patient, family, and bystanders 2. Look at clues found on scene: pill bottles, medical care equipment, drug paraphernalia, patient complaint, and position of patient to identify 3. Nature of illness may be different from chief complaint

Master Teaching Notes Teaching Tips Stress to student how a MOI or NOI can dictate a call, and how both can cause tunnel vision if a proper exam is not completed.

Class Activities As a group, have students list possible predictable injuries from auto accidents, gunshot wound, etc. Ask them to list what injuries they would expect to see.

VIII.Summary A. Scene size-up is the initial step in the patient care process B. Begins at dispatch and ends once you are clear of the call C. Scene size-up will become second nature to you D. Always make it a point to pause and consciously look around the scene before proceeding into any situation. E. Keep yourself and your crew safe, and ensure necessary resources are focused on patient care and outcomes IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

X. You Make the Call 5

Class Activities Read and discuss the call and questions as a group.

Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline XI. Review Questions

Master Teaching Notes Class Activities Pass out review questions before the lesson starts. Have students answer them. Then go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 2 Primary Assessment 100–105 Minutes

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Teaching Tips Discussion Topics Class Activities Points to Emphasize Knowledge Application

Chapter 2 objectives can be found on text p. 20. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction A. Primary assessment is the basis of all prehospital emergency care B. Steps of the primary assessment include: 1. Form a general impression 2. Stabilize cervical spine as needed 3. Assess baseline mental status 4. Assess and manage airway 5. Assess and manage breathing 6. Assess and manage circulation 7. Determine priorities

Discussion Topics

III. Forming a General Impression A. Involves your first intuitive evaluation of your patient B. The general impression is based on environmental information, MOI or NOI, the patient’s posture and overall look, the chief complaint, and your instincts C. Standard Precautions, consent, and cervical stabilization are included in this stage of assessment

Class Activities

IV. Mental Status Assessment A. Crucial component for every patient B. AVPU levels used to determine mental status 1. A = Alert (awake and alert)

Discussion Topics

With students, discuss what would happen if the paramedic skipped over the primary assessment.

Points to Emphasize Explain to students why the entire primary assessment should take less than 1 minute, unless lifesaving measures need to be taken. Have a few students act as patients with varying medical and traumatic complaints. Students acting as paramedics can practice forming general impressions and initiating care.

Discuss with students different stimuli that are used to determine AVPU.

Chapter 2 objectives can be found on text p. 20. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

2. V = Verbal Response (responds to verbal stimuli) 3. P = Painful Response (responds to painful stimuli) a. Decorticate – arms flexed, legs extended b. Decerebate – arms and legs extended 4. U = Unresponsive (comatose and fails to respond to any noxious stimuli) 15

V. Airway Assessment A. Open the airway with head-tilt/chin-lift or jaw thrust maneuver B. Infants and young children: may be necessary to move the child’s head through a range of positions C. Remember that normal breathing is quiet with free air movement D. Look for chest rise E. A noisy airway is a partially obstructed airway 1. Snoring (partially blocked upper airway, usually the tongue) a. Reposition the head and neck 2. Gurgling (fluid blocking upper airway) a. Suction 3. Stridor (life-threatening upper airway obstruction) a. Look for foreign body, severe swelling, allergic reaction, infection and treat the airway accordingly 4. Wheezing (constricted bronchioles of lower airways) a. Asthma, bronchitis, emphysema, acute pulmonary edema, and bronchiolitis b. Treat with bronchodilator medications 5. No air movement (respiratory arrest) a. Provide ventilation with BVM and high-concentration oxygen F. Use airway adjuncts such as oropharyngeal or nasopharyngeal to maintain the airway G. Advanced airways include intubation, multilumen airways, needle, or surgical cricothyroidotomy H. Hypoxic patients require oxygen delivery via a nonrebreather mask

Teaching Tips If a patient’s airway sounds inadequate, you need to find the cause immediately. Find a lung sounds CD that students can listen to, so they can become familiar with abnormal airway sounds.

Class Activities Pull out the airway equipment and allow students to view all of it as you explain the indications and contraindications of each piece.

Chapter 2 objectives can be found on text p. 20. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 15

Content Outline

Master Teaching Notes

VI. Breathing Assessment A. Assessment for adequate breathing includes looking at: 1. Respiratory rate and quality 2. Respiratory pattern B. Signs of inadequate breathing include: 1. Altered mental status, confusion, apprehension, and agitation 2. Shortness of breath while speaking 3. Retractions 4. Asymmetric chest wall movement 5. Accessory muscle use 6. Cyanosis 7. Audible sounds 8. Abnormally rapid, slow, or shallow breathing 9. Nasal flaring C. If your patient presents with inadequate breathing, immediately assess the patient’s neck and chest, looking for injuries and listening to lung sounds D. Treat the life-threatening breathing problems as you find them (sucking chest wound, tension pneumothorax, etc.) E. Noninvasive devices for assessing adequacy of breathing: pulse oximeter and capnography monitor

Discussion Topics

VII. Circulation Assessment A. The evaluation of the pulse and skin of the patient, as well as controlling any hemorrhage B. If radial pulse is absent, check for carotid pulse C. Assess the pulse for rate and quality 1. Very fast and very slow rates may indicate life-threatening cardiac dysrhythmias and can result in decreased cardiac output 2. Quality of the pulse can indicate cardiac arrhythmias, poor perfusion, head injuries, hypertension, heat stroke, etc. D. Stop any major external bleeding 1. Direct pressure, elevation, tourniquets, and hemostatic agents (HemCon, QuikClot, Celox) E. Assess the skin for temperature, moisture, and color 1. Mottled, cyanotic, pale or ashen, clammy, and cool can indicate poor

Class Activities

Discuss with students the different breathing patterns, including agonal, Cheyne-Stokes, Biot’s, hyperventilation, tachypnea, bradypnea, etc.

Have students find the various pulses on each other.

Chapter 2 objectives can be found on text p. 20. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

perfusion 2. Capillary refill is a reliable indicator of circulatory function in infants and young children when assessing perfusion

VIII. Priority Determination A. Priority is determined once a primary assessment is completed B. Identify other life-threatening injuries or illnesses by performing a rapid head-to-toe assessment C. Four-step process for identifying priority patients: 1. Vital signs and level of consciousness: GCS < 14, systolic < 90, and respiratory rate < 10 or > 29 = transport to highest level trauma center 2. Injuries: penetrating trauma to head, neck, torso, or extremities proximal to elbow or knee, chest wall instability or deformity, two or more proximal long bone fractures, crushed, degloved, or mangled extremity or pulseless extremity, amputation proximal to wrist or ankle, pelvic fracture, open or depressed skull fracture, paralysis = transport to highest level trauma center 3. Mechanism of injury: fall > 20 feet for adult and > 10 feet for child, high-risk auto crash (intrusion, ejection, death of occupant, significant impact, auto-versus-pedestrian, motorcycle crash > 20 mph = transport to closest appropriate trauma facility) 4. Miscellaneous findings: age > 55, children, anticoagulation or bleeding disorders, burns, pregnancy > 20 weeks = contact medical control and consider transport to trauma center or specific resource hospital

Class Activities As a group, give students scenarios and have them decide the priority of a patient based on the four-step process.

Knowledge Application Have students complete a documentation of care that lists the primary assessment and what care they provided. Provide them with various scenarios and have them write their responses on index cards.

IX. Summary A. A primary assessment is the crucial first stage in providing lifesaving measures to seriously ill or injured patients. B. Completing a primary assessment on every patient allows for a systematic approach to identify and correct any life threats in airway, breathing, circulation, and mental status.

Chapter 2 objectives can be found on text p. 20. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline X.

Case Study

Master Teaching Notes Class Activities Discuss the case with students now that they are familiar with the chapter.

XI. You Make the Call 5

Class Activities Read and discuss the call and questions as a group.

XII. Review Questions 5

Class Activities Pass out review questions before the lesson starts. Have students answer them. Then go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 3 Therapeutic Communications 90–100 Minutes

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Teaching Tips Discussion Topics Class Activities Points to Emphasize

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction A. Communication is exchanging common symbols in written or spoken format or other formats (body language, signing, etc.). B. As a paramedic, you must use every available communication strategy to ensure you understand your patients and they understand you. C. Traits that aid communication for the paramedic include liking people and the ability to show empathy. D. Communication consists of a sender, a message, a receiver, and feedback 1. Sender encodes (creates) a message and puts it into an understandable format 2. Receiver must decode (interpret) the message and provide the sender feedback (response to message) 3. Sender must make sure that the message was received accurately E. Failure to communicate can occur because of prejudice, lack of empathy, external distractions, internal distractions, etc.

Class Activities

III. Building Trust and Rapport A. Your voice, body language, gestures, and eye contact communicate to your patient B. Building trust with your patient involves the following: 1. Introduce yourself 2. Use patient’s name 3. Address your patient properly

Discussion Topics

Give a student a brief message and have them encode and send to another student. Create a barrier for decoding and feedback (different language, wrong feedback, etc.).

With students, discuss each way you can build trust, and how not building a rapport can impede patient care

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline 4. 5. 6. 7. 8.

Master Teaching Notes

Modulate your voice Use professional but compassionate tone of voice Explain what you are doing and why Keep a kind, calm facial expression Use appropriate style of communication

Class Activities

IV. Effective Communication Techniques A. Guidelines to effective communication include consistent professionalism, nonjudgmental attitude, and willingness to talk about a concern B. Nonverbal communication: 1. Body Language a. Distance – intimate space is less than 1.5 ft, and comfortable distance is twice the length of patient’s arm b. Relative level – a different message is sent to the patient depending on if you are standing above, below, or at eye level to the patient c. Stance – your stance sends a message to the patient 1. An open stance – arms extended, open hands, relaxed large muscles, and nodding head – shows confidence and ease 2. A closed stance – arms flexed or tightly crossed over the chest, fists clenched, negative head shaking – shows disinterest, discomfort, disgust, anger, and fear 2. Eye Contact a. Use eye contact as much as possible to convey compassion and sincerity 3. Compassionate touch a. Touching in the right circumstances can convey compassion and a calming measure to your patient

Class Activities

Interviewing a Patient

Have several students interview each other as paramedic/patient. Make each patient have a scary, gory, life-threatening injury/illness. Have the paramedic talk to the patient with various facial expressions (angry, scared, etc.). Discuss with students how the patient will look at your facial expression for comfort and confirmation Have students interview each other using various degrees of distance, eye contact, and stance.

Points to Emphasize 2

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 10

Content Outline A. Asking Questions 1. Open-ended questions allow your patient to respond spontaneously without guided responses 2. The chief complaint should drive the questions asked by the paramedic a. Continue to ask open-ended questions b. Use direct questions when necessary c. Ask only one question at a time, and allow the patient to complete his answers d. Listen to the patient’s complete response before asking the next question e. Do not allow interruptions, if possible B. Active Listening 1. The art of listening well is a trait few people practice 2. Listening is crucial for a skilled clinician, as you will learn valuable information about your patient 3. Development of good communication skills takes time and practice 4. Several practices promote active listening: a. Silence – allows patient to gather thoughts b. Reflection – echoing message back to patient c. Facilitation – encouraging patient to provide more information d. Empathy – letting patient know you understand e. Clarification – asking patient to help you understand f. Confrontation – focusing patient on one particular factor of interview g. Interpretation – stating how you are interpreting the information h. Asking about feelings – asking patient how he feels about what he is experiencing i. Explanation – sharing facts and objective information j. Summarization – reviewing the interview 5. Several practices are “traps of interviewing” or common errors that can hinder the patient interview a. Providing false assurances

Master Teaching Notes Explain to students the importance of using effective interviewing techniques and how it helps them to do their jobs more efficiently.

Discussion Topics Talk with students about how they can avoid some of the traps of interviewing. Discuss techniques that they have used that have worked and those that have not.

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

b. Giving advice and abusing authority c. Using avoidance language and distancing d. Talking too much e. Interrupting the patient and using “why did you” questions C. Observing Your Patient 1. Look at external signs during your patient interview that can give you indication of your patient’s condition 2. Observe level of consciousness, body movements, mood, energy level, eye contact, and behavior D. Using Appropriate Language 1. Refrain from sophisticated medical terminology 2. Obstacles include cultural differences, language, deafness, speech impediments, and blindness 20

VI. Special Needs and Challenges A. Most patients are more than willing to answer questions B. Some patients may require more time and various techniques to establish rapport and wiliness to answer questions C. Some patients you encounter will have different communication needs 1. Children a. Talk to the caregivers b. Get down to their eye level and stay calm c. Talk to children and answer their questions honestly, and most importantly, build trust 2. Elderly Patients a. Be respectful and courteous b. Allow the patients time to talk and answer questions c. Use compassionate touch 3. Patients with Sensory Impairment a. Blind, sight-impaired, deaf, or hearing-impaired patients b. Retrieve any necessary communication aids c. Allow more time for the patient interview d. Remember that you may have to change your communication technique to accommodate the patient’s needs

Class Activities As in the other class activities regarding communication, have students role play communication scenarios listed in special challenges and needs. Allowing actual dialog will enforce proper communication techniques for students.

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

4. Angry, Hostile, or Uncooperative Patients a. Set limits and establish boundaries with hostile patients to maintain scene safety b. Avoid confrontation 5. Sensitive Topics a. Remain calm, objective, and nonjudgmental when questioning a patient about a sensitive subject b. Let the patient know that what he tells you is confidential information 6. Silence a. Stay calm and observe your patient’s nonverbal cues b. Determine if your behavior has caused the patient to stop communicating with you 7. Overly Talkative Patients a. Focus on important aspects of the interview b. Ask some closed-ended questions for important information c. Realize that your patient may just want someone to talk to d. Try not to become impatient 8. Patients with Multiple Symptoms a. Sort through the multiple complaints b. Determine why the patient called, to help lead you to the actual chief complaint 9. Anxious Patients a. Anxiety natural reaction to stress b. Observe the anxiety in your patient and encourage your patient to speak freely about it 10. Patients Needing Reassurance a. Listen to your patient before offering reassurance 11. Intoxicated Patients a. Scene safety is most important b. Avoid judgment, confrontation, etc. 12. Crying Patients a. Accept that crying may be a normal response for your patient 13. Depressed Patients ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 2, 5th Ed.

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

a. Determine that your patient is not suicidal 14. Patients with Confusing Behaviors or Histories a. Focus assessment on patient’s mental status (thought, perceptions, mood) b. Differentiate between delirium and dementia, if possible 15. Patients with Limited Intelligence a. Do not assume that your patient will not be able to give you his medical history, or tell you what his complaint is b. Show compassion and patience c. If a patient has mental retardation that impedes his communication abilities, use the family/caregiver or friends 16. Talking with Family or Friends a. Use family and friends when encountering a patient who is unable to give you any information b. Patient confidentiality is always a priority, even when using family and friends 5

VII. Transferring Patient Care A. Using correct communication techniques allows for proper patient transfers between medical professionals B. Always listen and echo responses when needed

Discussion Topics Discuss with students what can happen to a patient when critical information is not transferred, such as allergies, complaints, etc.

VIII. Summary A. To provide the best care, you must be able to quickly and effectively gather information about the patient B. Pay attention to your body language, tone of voice, facial expressions, and personal space C. Showing compassion and empathy will allow you to become an ally to your patients and others IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

Chapter 3 objectives can be found on text p. 36. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline X. You Make the Call

Master Teaching Notes Class Activities Read and discuss the call and questions as a group.

XI. Review Questions 5

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 4 History Taking 100–110 Minutes

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Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points to Emphasize Knowledge Application

Chapter 4 objectives can be found on text p. 55. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction A. The majority of your medical field diagnosis is based on patient history B. A patient history is a well-structured yet flexible tool that is the focal point for your relationship with the patient C. A differential field diagnosis (list of causes) is necessary in explaining signs and symptoms that your patient is complaining of III. Preliminary Data A. Always record the date and time of the physical exam B. Determine your patient’s age, sex, race, birthplace, and occupation C. Record the source of the information you have received D. Establish reliability of information

Critical Thinking Questions

IV. Chief Complaint A. The pain, discomfort, or dysfunction that caused your patient to request help B. “Why did you call us today?” allows your patient to answer freely C. Remember that the chief complaint is a sign or symptom noticed by the patient or bystander, while the primary problem is the principal medical cause of the complaint D. Try to document your patient’s chief complaint in the patient’s own words

Class Activities

Why could patient care be impeded if the reliability of the information given is not established?

Have the class write down examples of chief complaints, then match them with primary problems. (For example, pain in the arm vs. fractured ulna, etc.)

Chapter 4 objectives can be found on text p. 55. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 10

Content Outline

Master Teaching Notes

V. Present Problem A. Once the chief complaint has been determined, look at your patient’s complaints in greater detail B. Using the acronym OPQRST-ASPN allows a template for exploring patient complaints 1. Onset: Did the problem develop suddenly or gradually? What was the patient doing? 2. Provocation/Palliation: Does anything make the symptoms worse or better? 3. Quality: Is the pain crushing, tearing, sharp, dull, crampy, etc.? 4. Region/radiation: Does the pain stay in one location or move? 5. Severity: On a scale of 1 to 10, rate the pain 6. Time: When did the symptoms begin? Constant or intermittent? How long does it last? Any previous episodes? 7. Associated Symptoms: Are there any other symptoms? 8. Pertinent Negatives: Are there any likely symptoms absent?

Discussion Topics

VI. Past Medical History A. The past medical history may provide insight into your patient’s current chief complaint. Look at: 1. General state of health 2. Childhood diseases 3. Adult diseases: Is there a preexisting medical problem? Is the patient on special diets or prescribed medications? What is the name of the patient’s physician? 4. Current medications: Identify all OTC medications, prescriptions, home remedies, vitamins, and minerals a patient is taking 5. Allergies 6. Psychiatric illnesses 7. Accidents or injuries: Has a patient had an injury in the past that has led to hospitalization? Could a past injury be a factor with the current problem? 8. Surgeries or hospitalizations 9. For trauma patients, use SAMPLE: Signs and symptoms, Allergies, Medications, Past history, Last time eaten, Events

Class Activities

Discuss with students how the OPQRSTASPN can actually lead them to the correct field diagnosis by ruling in or out particular complaints.

Have students interview each other with mock past medical histories.

Chapter 4 objectives can be found on text p. 55. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 15

Content Outline

Master Teaching Notes

VII. Family/Social History A. Any information from the family or social history that is relevant to your patient’s current complaint 1. Home situation and significant others 2. Daily life 3. Tobacco 4. Alcohol, drugs, and related substances a. Make sure to only gather information and not pass judgment so that you can direct your patient’s medical treatment b. The CAGE questionnaire can be used to determine the presence of alcoholism 5. Diet 6. Screening tests 7. Immunizations 8. Sleep 9. Exercise and leisure activities 10. Environmental hazards 11. Use of safety measures 12. Important experiences 13. Religious beliefs 14. The patient’s outlook

Discussion Topics

VIII. Review of Body Systems A. This is a system-by-system review of the body by questions to help identify problems in your patient that have not been previously mentioned 1. General: What is the patient’s usual weight? Any recent weight changes? Does your patient experience fatigue, fever, chills, night sweats, etc.? 2. Skin, Hair, Nails: Are there any new rashes, lumps, or changes in nails or hair? 3. Head, Eyes, Ears, Nose, and Throat (HEENT): Has your patient had headaches, hearing problems, vision problems, etc.? Does the patient wear dentures? 4. Chest and Lungs: Is your patient wheezing, coughing up blood, etc.?

Class Activities

Discuss with students how obtaining a family or social history can provide insight into the patient’s current problem.

Points to Emphasize In a nonemergency situation there is more time to gain an in-depth understanding of a patient’s medical history, but in an emergency setting there will not be. Talk with students about how to go about gaining the most important facts from a patient in an emergency setting.

This is an asking and answering activity that the student perfects with practice. Since it is a system-by-system review with questions, the more students can ask these questions, the better their patient interviews will be.

Knowledge Application Assign the Body Systems for homework. Give all students the list of body systems and require them to write out the questions that need to be asked. 3

Chapter 4 objectives can be found on text p. 55. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

5. Heart and Blood Vessels: Does your patient have high blood pressure, murmurs, chest pain, etc.? 6. Lymph Nodes: Are there any enlargements or tenderness? 7. Gastrointestinal System: Does your patient have trouble swallowing, heartburn, nausea/vomiting, etc.? 8. Genitourinary System: Is she having trouble with urination? 9. Male Genitalia: Is he experiencing a hernia, any discharge, or a possible STD? 10. Female Genitalia: When was your patient’s first period? Any difficulties with periods? Any pregnancies and deliveries, and is she postmenopausal? 11. Musculoskeletal System: Is there muscle or joint pain? 12. Neurologic System: Has the patient experienced fainting, blackouts, seizures, etc.? 13. Hematologic System: Is the patient anemic; is there any recent fatigue, or easy bruising? 14. Endocrine System: Has your patient been diagnosed with a thyroid problem, does she experience heat or cold intolerance? 15. Psychiatric History: Does your patient have feelings of nervousness, stress, tension, depression, etc.?

Chapter 4 objectives can be found on text p. 55. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 10

Content Outline IX. Clinical Reasoning A. This is gathering, evaluating, and synthesizing information in a short period of time B. You will use your senses, education, training, clinical experience, and decision-making skills C. You will develop the ability to think and make decisions while under pressure D. Collect this information to make the decisions necessary for your patient 1. Draw on your fundamental knowledge and abilities of anatomy and physiology 2. Gather patient history and relevant information 3. Form a differential diagnosis based on information obtained and patient’s chief complaint 4. Sort through the ambiguities and differentiate between relevant and irrelevant data 5. Recognize patterns by analyzing and comparing factors that will rule in or out a diagnosis 6. Defend your decisions

Master Teaching Notes Critical Thinking Questions Why do you think that pathophysiology is so important for paramedic care? Do you believe that understanding the human body in terms of pathophysiology will affect the paramedic’s decisions and patient care? Explain why.

X. Summary A. A comprehensive history and physical exam will provide you the information you need to begin a treatment regimen B. The most important step is to document the answers to your questions as you receive them XI. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

XII. You Make the Call 5

Class Activities Read and discuss the call and questions as a group.

Chapter 4 objectives can be found on text p. 55. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline XIII. Review Questions

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 5 Secondary Assessment 200–210 Minutes

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Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Knowledge Application

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students the case will be reviewed after the lecture.

II. Introduction A. Secondary assessment is a focused physical exam that investigates the areas involved in the patient’s primary problem or complaint B. Major anatomic regions and body systems are assessed during this exam C. Exam may be limited in prehospital setting based on patient needs III. General Approach A. How you approach the patient will set the stage for the patient assessment B. Patients may feel apprehensive, exposed, or vulnerable etc. C. Perform the assessment systematically and efficiently with compassion and interest

Critical Thinking Questions

IV. Physical Exam Techniques A. Inspection 1. Informed observation that begins when meeting your patient 2. Inspection involves looking at the patient and surroundings B. Palpation 1. Using sense of touch to gather information, including temperature, moisture, texture, and movement 2. Keeping your hands warm, fingernails short, and a gentle touch to allow for a comfortable assessment for patient

Class Activities

How do you think a patient would respond to a physical examination if done by a paramedic who appeared uncomfortable or unsure of the procedure? What can the paramedic do to change the patient’s opinion? Have students pair up and practice the four physical exam techniques on each other.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

C. Percussion 1. Production of sound waves by striking one object against another 2. Types of percussion include direct, indirect, and blunt 3. Percussion sounds include tympany, hyperresonance, resonance, dull, and flat 4. Noise does prevent effective percussion D. Auscultation 1. Listening for sounds 2. Lungs, heart, intestines, and major blood vessels 3. Use of working stethoscope necessary for correct auscultation 15

V. General Survey A. Mental Status 1. Level of consciousness 2. Appearance and behavior 3. Speech and language 4. Mood 5. Thoughts and perceptions 6. Insight and judgment 7. Memory and attention B. General Appearance 1. Signs of distress 2. Apparent state of health 3. Vital statistics 4. General stature 5. Sexual development 6. Skin color and obvious lesions 7. Posture, gait, and motor activity 8. Dress, grooming, and personal hygiene 9. Breath or body odors 10. Facial expressions C. Vital Signs 1. Respiration a. Respiratory rate b. Respiratory effort

Discussion Topics Discuss with students what they are looking for with mental status and general appearance. Explain how changes in these two categories can indicate a medical/trauma issue.

Class Activities Have students pair up and practice the general survey on each other.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline c. 2. Pulse a. b. c.

4. 5.

Master Teaching Notes

Tidal volume (depth and pattern of breathing)

Rhythm, rate, and quality Radial, carotid are locations for pulse Bradycardia may indicate increased parasympathetic stimulation, head injury, hypothermia, severe hypoxia, or overdose d. Treatment occurs if bradycardia compromises cardiac output e. Tachycardia an early indication of shock Blood Pressure a. Force of blood against arterial walls as heart contracts and relaxes b. Systolic and diastolic measurements c. Korotkoff sounds are the blood hitting the arterial walls d. Correlate patient blood pressure with patient presentation (perfusion) e. Pulse pressure is the difference between systolic and diastolic (normal pulse pressure is 30–40 mmHg) f. Determine if hyper- or hypotension is present Body Temperature a. Normal temperature is 98.6°F or 37°C b. Determine if hyper- or hypothermia is present Capillary Refill a. Pinch finger and let go, allowing blood to refill in area b. Less than 2 seconds in adults is a normal response c. More reliable in infants and children Oral Mucosa Color a. Reliable indicator of central circulation and oxygenation b. Should be pinkish-red, smooth, and moist

VI. Anatomic Region Examination A. Situation of patient, your experience, and common sense will indicate how thorough or narrow the focus of the examination needs to be

Class Activities Have students pair up and perform a focused physical exam on each other.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes Knowledge Application For homework, write out the physical exam, leaving out what students are looking for. Have each student write out what they are looking for when performing the physical exam. This can be done for the remainder of the chapter.

VII. Skin A. Anatomy and Physiology 1. Largest organ, 15 percent of our total body weight 2. Layers include epidermis (outer layer) and dermis, which lies above subcutaneous fat B. Assessment 1. Color (normal, pale, cyanotic, jaundiced) 2. Moisture (dry, moist, oily) 3. Temperature (warm, cold) 4. Texture (rough, smooth, scaly, thick, thin) 5. Mobility and turgor (elasticity of skin, tenting, edema) 6. Lesions (a disruption of normal tissue; shape, color, arrangement)

Discussion Topics

VIII. Hair A. Anatomy and Physiology 1. Tactile sensory organ B. Assessment 1. Inspect and palpate (color, quality, quantity) 2. Scalp (dry, flaky, scaling, sores, lesions, lumps, etc.)

Class Activities

IX. Nails A. Anatomy and Physiology 1. Most distal end of fingers and toes 2. Can indicate the past 3 months of patient’s life, based on growth B. Assessment 1. In medical patients, can indicate cardiorespiratory diseases 2. Look for clubbing, color, lesions, ridging, grooves, depressions,

Knowledge Application

Discuss with students how their objectives change during the comprehensive physical exam compared to the primary and secondary assessment. Discuss how much more in-depth they need to go during this step.

Have students practice inspecting and palpating another student’s hair and scalp.

For homework, have students write the definitions for the various disorders of the nails. For a more visual take, pass out a paper with blank nails on it and have students draw the disorders.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

pitting, paronychia, onycholysis, Terry’s nails, white spots, transverse lines, psoriasis, and Beau’s lines

X. Head A. Anatomy and Physiology 1. Acronym SCALP allows for remembrance of layers: skin, connective tissue, aponeurosis, loose tissue, and periosteum 2. Vascular, allows for protection and insulation of brain 3. Consists of cranium and face B. Assessment 1. Inspect and palpate (wounds, bleeding) 2. Symmetrical, raccoon eyes, Battle’s sign, and facial bone integrity

Teaching Tips

XI. Eyes A. Anatomy and Physiology 1. External – eyelid, conjunctiva, lacrimal gland, ocular muscles, and the bony skull orbit 2. Internal – sclera, cornea, iris, lens, and retina B. Assessment 1. Visual acuity, visual fields, external eyes for symmetry, lid shape and size, shape and symmetry of pupils

Teaching Tips

Go over the anatomy and physiology of the head with students. Review the injuries or medical issues that can occur with the head and brain.

Class Activities Have students perform an assessment with each other that focuses on the head. Go over the anatomy and physiology of the eyes with students. Review the injuries or medical issues that can occur with the eyes. Review the visual acuity chart with students.

Class Activities Have students perform an assessment with each other that focuses on the eyes. 5

XII. Ears A. Anatomy and Physiology 1. Outer, middle, and inner ear B. Assessment 1. Observe ears, inspect for discharge, and use otoscope to view tympanic membrane

Teaching Tips Go over the anatomy and physiology of the ear with students. Review the injuries or medical issues that can occur with the ears.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes Class Activities Have students practice using an otoscope.

XIII. Nose A. Anatomy and Physiology 1. Nasal bones, cartilage, and bony septum that divides right and left cavities B. Assessment 1. Shape, color, nasal flaring, deformities, and swelling and tenderness

Teaching Tips

XIV. Mouth A. Anatomy and Physiology 1. Lips, tongue, gums, and teeth B. Assessment 1. Symmetrical shape, lesions, wounds, bleeding, loose or missing teeth, and odors

Teaching Tips

XV. Neck A. Anatomy and Physiology 1. Spinal cord, blood vessels, esophagus, trachea, thyroid gland, and larynx B. Assessment 1. Symmetrical shape, masses, deformities, open wounds, bruising, bleeding, tracheal deviation, jugular vein distention, and subcutaneous emphysema

Teaching Tips

XVI. Chest and Lungs A. Anatomy and Physiology 1. Sternum, 12 pairs of ribs, and spinal column 2. Mediastinum, lungs, and pleura B. Assessment 1. Auscultation of lung sounds, respiratory effort, integrity and

Teaching Tips

Go over the anatomy and physiology of the nose with students. Review the injuries or medical issues that can occur with the nose.

Go over the anatomy and physiology of the mouth with students. Review the injuries or medical issues that can occur with the mouth.

Go over the anatomy and physiology of the neck with students. Review the injuries or medical issues that can occur with the neck.

Go over the anatomy and physiology of the chest and lungs with students. Review the injuries or medical issues that can occur with the chest and lungs.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline symmetrical movement of chest wall, and percussion of chest

Master Teaching Notes Class Activities Play a CD of various lung sounds for students and have them identify the medical or traumatic issue that can occur with each sound.

XVII. Heart and Blood Vessels A. Anatomy and Physiology 1. Heart, aorta, pulmonary artery, superior venae cavae 2. Cardiac output is amount of blood heart ejects each minute (heart rate × stroke volume) 3. Stroke volume is amount of blood ejected in one beat 4. Preload, afterload, and contractile force are factors of stroke volume

Teaching Tips Go over the anatomy and physiology of the heart and blood vessels with students. Review the injuries or medical issues that can occur with the heart and blood vessels.

Class Activities Listen to a CD of the different heart sounds.

Assessment 1. Heart sounds, skin color, carotid arteries for bruits or thrills, venous congestions, pulses and blood pressure, and edema to lower extremities

XVIII. Abdomen A. Anatomy and Physiology 1. Four quadrants of abdomen 2. Major organs: digestive, urinary, female and male reproductive, cardiovascular, and lymphatic system B. Assessment 1. Examine any areas with pain last 2. Auscultate before percussing or palpating 3. Cullen’s sign or Grey Turner’s sign indicate intraabdominal bleeding 4. Ascites, pulsating masses, obvious discoloration, lesions, and borborygmi (prolonged gurgling sounds)

Teaching Tips Go over the anatomy and physiology of the abdomen with students. Review the injuries or medical issues that can occur with the abdomen.

Knowledge Application Assign a definition of the meanings of different signs of bleeding, fluid buildup, etc., for students to complete. For a visual, pass out a page with an abdominal picture and have students color in and name the various areas of possible bleeding.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes 5

Content Outline

Master Teaching Notes

XIX. Female Genitalia A. Anatomy and Physiology 1. External genitalia highly vascular B. Assessment 1. Rarely expected to examine unless cases of trauma or abuse 2. Maintain privacy and explain to patient what you are doing 3. Discharge, trauma, and odor

Teaching Tips

XX. Male Genitalia A. Anatomy and Physiology 1. External organs: penis and scrotum B. Assessment 1. Rarely examined except for trauma 2. Maintain privacy and explain to patient what you are doing 3. Discharge, trauma, inflammation, odor, lumps, swelling, testicular torsion, and priapism

Teaching Tips

XXI. Anus A. Anatomy and Physiology 1. Most distal end of GI system B. Assessment 1. Normally not a prehospital assessment unless patient presents with rectal bleeding 2. Maintain privacy and explain what you are doing 3. Place patient on left side with knees flexed and buttocks near edge of examination table

Teaching Tips

XXII. Musculoskeletal System A. Anatomy and Physiology 1. 206 bones, joints, muscles, tendons, ligaments, and cartilage 2. Wrists, hands, fingers, elbows, shoulders, ankles, feet, knees, hips, and spine B. Assessment 1. Function and structure of joints, bones, and surrounding tissues 2. Range of motion, crepitus, tenderness, movement, swelling,

Teaching Tips

Go over the anatomy and physiology of the female genitalia with students. Review the injuries or medical issues that can occur with the female genitalia.

Go over the anatomy and physiology of the male genitalia with students. Review the injuries or medical issues that can occur with the male genitalia.

Go over the anatomy and physiology of the anus and rectum with students. Review the injuries or medical issues that can occur with the anus and rectum.

Class Activities Obtain an occult blood fecal testing strip for students to view. Go over the anatomy and physiology of the musculoskeletal system with students. Review the injuries or medical issues that can occur with the musculoskeletal system.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

symmetrical impairment, redness, shortened or lengthened limbs, obvious deformity, alignment, and spinal curvatures

XXIII. Neurologic System A. Are findings symmetrical or unilateral? B. If unilateral, are findings from CNS or PNS? 1. Cranial nerves – 12 pairs originating from base of brain, provide sensory, and motor innervation 2. Motor system – 31 pairs arising from spinal foramina; coordinated, skilled movements 3. Sensory system – posterior root of peripheral nerves; assessing involves testing for pain, light touch, temperature, vibration, position, discriminative sensations 4. Deep tendon reflexes – connection of some sensory impulses directly to motor neurons; use of reflex scale allows for reflex assessment

Teaching Tips

XXIV. Reassessment A. Mental Status – repeat AVPU B. Airway Patency – patency can change instantly, be vigilant for potential problems C. Breathing Rate and Quality – changes can indicate improvement or deterioration, constant reevaluation is necessary D. Pulse Rate and Quality – compare current rates with earlier measurements E. Skin Condition – skin quickly reflects hemodynamic status F. Transport Priorities – priority may change based on patient’s condition G. Vital Signs – reassessment allows for trending of potential problems, for critical patients reassess every 5 minutes H. Focused Assessment – review patient’s chief complaint with findings; repeat focused assessment based on patient I. Effects of Interventions – evaluate the effects of any interventions J. Management Plans – evaluate whether your care is working; consider other

Class Activities

Go over the anatomy and physiology of the neurologic system with students. Review the injuries or medical issues that can occur with the neurologic system.

Class Activities Have students review the cranial and spinal nerves, as well as the locations of dermatomes. Have students locate reflexes and review the reflex scale. Have each student perform a secondary assessment on a partner.

Chapter 5 objectives can be found on text p. 70. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

Minutes

Content Outline

Master Teaching Notes

options of treatment, if necessary

XXV. Summary A. Knowledge of anatomy and physiology allows the paramedic to complete a comprehensive examination and thorough secondary assessment B. A systemic head-to-toe examination will help to prevent overlooking any medical or trauma issue in your patient C. Inspection, palpitation, percussion, and auscultation are essential skills for all paramedics XXVI.

Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

XXVII. You Make the Call 5

Class Activities Read and discuss the call and questions as a group.

XXVIII. Review Questions 5

CHAPTER 1 SCENE SIZE-UP

HANDOUT 1-1

STUDENT’S NAME __________________ CHAPTER 1 QUIZ

Write the letter of the best answer in the space provided. __________1.

__________2.

__________3.

__________4.

__________5.

__________6.

__________7.

Scene size-up actually begins: A. as soon as you arrive on scene. B. after you make patient contact. C. when you first receive the call. D. as soon as you determine the mechanism of injury. Standard precautions are designed to: A. eliminate the risk of infection from microorganisms. B. delay the transmission of microorganisms and infection. C. protect the paramedic from physical injury by the patient. D reduce the risk of transmission of microorganisms from the patient to the paramedic. Personal protective equipment (PPE) should be used: A. with all adult patients who appear ill. B. with all patients regardless of complaint. C. only after determining if the patient is infectious. D. only if it does not delay patient care. The top priority at a scene is: A. determining the number of patients. B. establishing who is in charge. C. the safety of the patient. D. your personal safety. One of the dangers of lightning strikes is that ground current can travel and strike someone as much as _____ away from the original strike. A. 1 yard C. 10 yards B. 50 yards D. 100 yards When approaching a hazardous scene, you should do all of the following except: A. don’t use binoculars. B. don’t rush in. C. don’t assume anything. D. don’t become a victim. Emergency responses to methamphetamine (meth) labs pose a double threat because: A. the patients will most likely be in cardiac arrest. B. law enforcement is reluctant to respond to these incidents.

C. the people participating in this illegal activity might be a threat to responders. D. it is difficult to identify a meth lab. __________8.

__________9.

__________10.

__________11.

__________12.

__________13.

When arriving at a door, you should: A. knock loudly, and announce your name. B. stand by a window where the patient can see you. C. knock, then try the door knob to see if the door is unlocked. D. stand off to the side of the door. When talking with agitated people, you should: A. speak in short sentences. B. speak quickly. C. speak calmly. D. speak loudly to appear in control. A safety vest should be worn: A. on every incident. C. only at night. B. on all roadside incidents. D. only by fire department personnel. The mechanism of injury includes all of the following combined elements except: A. weight. B. strength. C. direction. D. nature of forces. Airbags are designed to do all of the following except: A. deploy during front-end collisions. B remain inflated after impact. C. cushion the chest of large adults. D. deflate automatically after inflation. You should expect a pedestrian that has been struck by a vehicle to have: A. chest injuries. B. abdominal injuries. C. back injuries. D. lower extremity injuries.

HANDOUT 1-2

STUDENT’S NAME __________________ CHAPTER 1 SCENARIO

Review the following real-life situation. Then answer the questions that follow. It is 3:00 a.m. on a winter morning when a 68-year-old female calls 911 to request an ambulance. The only chief complaint the dispatcher can obtain from the woman is that she “just doesn’t feel right.” She cannot give any specific problem. You and your EMT-Basic partner, Beth Lynch, are dispatched to the scene. When you arrive, you travel down a long, narrow driveway and stop in front of a house with a high fence and a “Beware of Dog” sign on the gate. There is no indication that there is a dog in the yard. You enter the yard and begin to make your way to the front door. You need to walk past several obstacles in the yard, and lawn is overgrown with weeds and brush. You walk up the steps to the front door, and begin to knock. As you do, the door creaks open about 2 inches. From inside the residence you hear the faint voice of an elderly female saying, “Come in, please help me.” You enter the residence and find your patient sitting in the kitchen appearing anxious. You begin your initial assessment and gather vital signs. You note that the patient is conscious and breathing normally, and skin color is good. Her vital signs are a pulse of 86, respirations of 18, and blood pressure of 146/78. You kneel next to her chair and take her hand. It feels slightly cool. The woman is obviously anxious. You begin a SAMPLE history and learn that your patient has “an upset stomach” and a slight headache that began earlier in the morning. She is allergic to an antibiotic but does not know which one. She takes a “water” pill and something for her heart but cannot recall its name. She had a heart attack about four years ago. She hasn’t eaten since last night, when she ate some homecanned peaches. The sensation came on about an hour ago while she was doing the laundry in the basement. You perform a physical exam without finding anything pertinent. You assist her to the stretcher and move her to the ambulance. Once in the ambulance, you apply supplemental oxygen and begin an IV of D5W, TKO. You gently transport her to the hospital and release her to the emergency department staff. 1.

Based on the description provided, is this scene safe to enter? Why or why not?

What steps should you take in this situation to ensure your safety and that of your partner?

HANDOUT 1-3

STUDENT’S NAME __________________ CHAPTER 1 REVIEW

Write the word or words that best complete each sentence in the space provided. 1.

A strategy designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection is called ________________________________________.

The top priority at any scene is your ________________________________________.

Weather, terrain, water, and electricity are all examples of ________________________________________.

The best tool for assessing a possible hazmat scene may be a ________________________________________.

The ideal time for scene size-up is ________________________________________.

The greatest hazard to any emergency worker during a roadside rescue operation is ________________________________________.

For any multiple-patient incident, it is wise to implement an _____________________________________________________.

The combined strength, direction, and nature of forces that injured the patient determine the ________________________________________.

HANDOUT 1-4

STUDENT’S NAME __________________ LISTING KEY IDEAS

Fill in the blanks to complete the clinical decision-making list. 1. List the components of scene size-up: A. __________________________________________________________ B. __________________________________________________________ C. __________________________________________________________ D. __________________________________________________________ E. __________________________________________________________ 2. The minimum appropriate PPE should include: A. __________________________________________________________ B. __________________________________________________________ C. __________________________________________________________ D. __________________________________________________________ E. __________________________________________________________ F. __________________________________________________________ 3. The order of priorities for scene safety are: A. __________________________________________________________ B. __________________________________________________________ C. __________________________________________________________ D. __________________________________________________________ E. __________________________________________________________ 4. The four “don’ts” when approaching a hazardous scene are: A. __________________________________________________________ B. __________________________________________________________ C. __________________________________________________________ D. __________________________________________________________ 5. To participate in a rescue operation, you should have at least the following equipment immediately available: A. __________________________________________________________ B. __________________________________________________________ C. __________________________________________________________ D. __________________________________________________________ E. __________________________________________________________ F. __________________________________________________________ G. __________________________________________________________

Chapter 1 Answer Key Handout 1-1: Chapter 1 Quiz 1. C

5. B

9. C

2. D

6. A

10. B

3. B

7. C

11. A

4. D

8. D

12. B

13. D

Handout 1-2: Chapter 1 Scenario 1. This scene does not appear to be safe. There are several things that put the responders at risk, including a possible dog in the yard, obstacles that may be potential hiding places or cause a rescuer to fall, a door that is ajar, and the possibility of violence inside the house. 2. Contact with the caller should be attempted by dispatch to determine if a dog is present prior to the responders entering the property. Law enforcement and animal control should also be contacted during the initial assessment of the scene if the rescuers determine this is a dangerous or potentially dangerous environment. If the rescuers deem it safe to enter the yard, flashlights should be used to survey the yard prior to entering and to ensure that there are no objects or people that may injure the rescuer. Rescuers should stand at the side of the door and should not enter until they are certain that there is no danger. Handout 1-3: Chapter 1 Review 1. standard precautions 2. personal safety 3. environmental hazards 4. good pair of binoculars 5. before the incident occurs 6. traffic flow 7. incident management system 8. mechanism of injury

Handout 1-4: Listing Key Ideas 1. A. standard precautions B. scene safety C. resource determination D. location of patients E. mechanism of injury/nature of illness 2. A. hand hygiene B. protective gloves C. masks and protective eyewear D. HEPA and N-95 respirators E. gowns F. disposable resuscitative equipment 3. A. you B. your crew C. other responding personnel D. your patient E. bystanders 4. A. Don’t rush in. B. Don’t assume anything. C. Don’t become a victim. D. Don’t test a foreign substance. 5. A. four-point suspension helmet B. eye goggles or industrial safety glasses C. high-quality hearing protection D. leather work gloves E. high-top steel-toed boots F. insulated coveralls G. turnout gear

CHAPTER 2 PATIENT ASSESSMENT

Student’s Name ______________

HANDOUT 2-1

SKILLS PERFORMING A RAPID TRAUMA ASSESSMENT Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

FORMING A GENERAL IMPRESSION 1. Determines if the patient “appears dead or doesn’t appear dead” 2. Begins CPR immediately if patient appears dead 3. Conducts standard primary assessment if patient does not appear dead ASSESSMENT OF MENTAL STATUS 1. Determines baseline mental status utilizing the AVPU acronym 2. Determines if patient’s eyes are open and if patient appears alert, prior to touching patient 3. If patient does not appear alert, determines if patient responds to voice prompt 4. Demonstrates appropriate use of painful stimuli if patient does not respond to voice 5. Determines that the patient is unresponsive if there is no response to above steps

AIRWAY ASSESSMENT 1. Determines if the patient has an airway that is open and patent 2. If airway is not open and patent, demonstrates the head-tilt/chin-lift maneuver for a nontrauma patient or a jaw-thrust maneuver for a suspected trauma patient 3. Utilizes proper padding and airway manipulation for a pediatric patient to ensure that the head and neck are not overextended 4. Inserts the proper airway adjunct to maintain a patient airway 5. Initiates proper bag-valve-mask ventilations for a patient in respiratory arrest BREATHING ASSESSMENT 1. Assesses patient for signs of adequate or inadequate breathing 2. Assesses the rate and quality of respirations 3. Assesses the respiratory pattern 4. Provides oxygen or assists ventilations as appropriate for patient CIRCULATORY ASSESSMENT 1. Locates the radial pulse on a responsive patient, or a carotid pulse on an unresponsive patient 2. Assesses the quality of the pulse 3. Assesses patient for signs of external bleeding 4. Controls bleeding using appropriate technique 5. Assesses skin for temperature, moisture, and color DETERMINES PATIENT PRIORITY 1. Conducts a rapid head-to-toe assessment as indicated for a trauma patient 2. Determines the most appropriate facility based on patient presentation 3. Completes assessment on-scene when indicated

Comments:

Student’s Name ___________

HANDOUT 2-2 EVALUATION

CHAPTER 2 QUIZ Write the letter of the best answer in the space provided. ______ 1. All prehospital emergency care is based on: a. the complaint of the patient. c. the general impression. b. the scene size-up. d. the primary assessment. ______ 2. The purpose of the primary assessment is to identify and correct: a. scene safety concerns. b. serious injuries such as fractures and dislocations. c. immediately life-threatening conditions. d. minor injuries. ______ 3. The general impression is best defined as: a. the evaluation of your patient based on the entire primary assessment. b. the treatment plan formulated by the initial dispatch information. c. the first, intuitive evaluation of the patient. d. the information provided by the family about the patient. ______ 4. Determining if your patient is a medical patient or a trauma patient is completed: a. prior to arriving on scene. b. during the airway assessment. c. after completing the primary assessment. d. during the general impression. ______5. Which of the following would not influence your index of suspicion regarding a patient’s condition: a. age. b. gender. c. race. d. level of consciousness. ______6. If you determine that your patient is at risk for a spinal injury, you should apply manual stabilization of the head and neck: a. prior to determining the patient’s mental status. b. after the primary assessment. c. only if the patient complains of neck or back pain. d. prior to placing the patient on a spine board. ______7. Determining a baseline mental status is important: a. for any patient who does not answer questions appropriately. b. for trauma patients only. c. for all patients. d. only if there are no life-threatening injuries.

______ 8. The “A” in AVPU stands for: a. alert. b. appropriate. c. altered. d. attitude. ______9. When determining the level of responsiveness for a child, the child that is quiet is usually: a. seriously ill or injured. c. not seriously ill or injured. b. easier to assess. d. more difficult to assess. _____10. A patient who responds to verbal stimuli: a. must open his eyes and speak. b. may only moan or move. c. is usually not seriously injured. d. should be told to open his eyes if he keeps them closed. _____11. Which of the following is NOT an appropriate method for eliciting a response to painful stimuli: a. pinching the area behind the knee. b. pinching the area under the arm. c. applying pressure to the fingernail. d. holding the patient’s arm above his head and dropping it toward his face. _____12. If, after applying painful stimuli, the patient responds with arms flexed and legs extended, the patient is showing ____________ movement. a. decerebrate b. decorticate c. hyperextended d. normal _____13. The appropriate technique for applying a painful stimulus to an infant is to: a. unwrap the infant and expose him to the air. b. apply pressure to the fingernail. c. flick the soles of the feet. d. gently press on the anterior fontanelle. _____14. To record your patient’s mental status, use the acronym AVPU. Which of the following is true? a. A stands for awake. c. P stands for painful stimuli. b. V stands for visual. d. U stands for unilateral. _____15. You should administer oxygen to your patient if he has an impaired mental status until the pulse oximetry reading is: a. between 95 and 100 percent. c. at least 90 percent. b. between 90 and 95 percent. d. at 100 percent. _____16. If you suspect a possible cervical spine injury, you should open the patient’s airway with: a. a nasopharyngeal airway. c. the head-tilt/chin-lift method. b. an oropharyngeal airway. d. the jaw-thrust maneuver.

_____17. An unconscious patient is most at risk for an airway obstruction from the: a. epiglottis c. teeth b. tongue d. uvula _____18. A high-pitched inspiratory sound caused by an upper airway obstruction is known as: a. snoring. c. stridor. b. wheezing. d. whistling. _____19. Which of the following is NOT a sign of inadequate breathing? a. Cyanosis b. Nasal flaring c. Accessory muscle use d. Equal chest rise ______20. The presence of a radial pulse suggests that the systolic blood pressure is at least: a. 80 mmHg b. 70 mmHg c. 60 mmHg d. 50 mmHg

Student’s Name ___________

HANDOUT 2-3 EVALUATION

CHAPTER 2 SCENARIO Review the following real-life situation. Then answer the questions that follow. A 35-year-old man is playing football at a local park with friends when he suddenly collapses. Friends rush to his side, attempt to wake him up, and after realizing that he is not responding, call 911. You and your partner are eating at a local fast-food restaurant just blocks away and, after being dispatched to the location, arrive within 3 minutes. You observe a male patient lying motionless on the ground, surrounded by several bystanders. A bystander runs to meet you and tells you that his friend John was playing football and collapsed. When approaching the patient, you note that he is lying supine with his left arm extended out to his side and his right leg bent at the knee under his left leg. His eyes are closed, and he has some minor bleeding from his nose. You begin your assessment by determining that he is breathing with equal chest rise at a rate of approximately 20 times per minute, has a radial pulse, and does not have any major bleeding. You call out, “John, can you hear me?” and you get no response. You pinch John just above the clavicle, and he moans and pulls away from you. You have your partner begin cervical spine stabilization, and you begin to complete a rapid trauma assessment on your patient. The bleeding from his nose (which has now stopped) appears to be the only injury you can find after completing your assessment. Local fire department personnel arrive on-scene and assist you in placing a cervical collar on John’s neck and securing him to a backboard. En route to the hospital, you complete a detailed physical exam on John, determine that there are no other injuries, and continue to monitor John’s vital signs throughout transport. When you are within 10 minutes of the hospital, you radio in that you are en route with a possible head injury, and place your patient in the trauma room upon arrival at the hospital. 1. What was your general impression of this patient? Was he a trauma or a medical patient? 2. How should John’s airway be managed after it is determined that he is unresponsive? 3. What can you determine by the presence of a radial pulse? 4. What procedures should/should not be done on scene with this patient?

HANDOUT 2-4

Student’s Name ___________ REINFORCEMENT CHAPTER 2 REVIEW

Write the word or words that best complete each sentence in the space provided. 1.

The first step of the initial assessment is ___________ ___ ___________ ___________.

While developing your general impression, you need to determine if your patient is a ___________ or a ___________ patient.

It is important to remember that you are required to obtain _________ or __________consent prior to treating a patient.

If the mechanism of injury is significant, or if your patient is unresponsive, you should ____________ _______________ ___ _______ _________ _______ ______________ prior to establishing his mental status.

The purpose of the initial assessment is to ___________ ___________ ___________- _______________ ___________.

Determining the patient’s priority for transport is a step in the ___________ ___________.

The acronym used to record your patient’s mental status is ___________ ___________ ___________ ___________.

Your unresponsive patient has his arms flexed and legs extended. This is known as ___________ posturing.

If your unresponsive patient has both arms and legs extended, this is known as ___________ posturing.

10.

If you suspect a cervical spine injury, you should open your patient’s airway using the ___________ ___________ maneuver.

11.

When using the head-tilt/chin-lift maneuver on an infant, it is important not to ___________ the head and neck.

12.

Unconscious patients without a gag reflex will tolerate an airway adjunct known as a(n) ___________ airway.

13.

Signs of inadequate breathing include the use of ___________ muscles to breathe.

14.

When assessing an adult patient’s circulation, you should feel for a(n) ___________ pulse first.

15.

Assess an infant’s circulation at the ___________ artery.

16. HemCon, QuickClot, and Celox, are new _______________ ____________ originally used by the military to stop uncontrolled hemorrhage. 17.

___________ ___________ ___________ provides important information about the circulatory status of infants and young children.

18.

______________ _________________ causes a decrease of perfusion to the skin early in shock.

19.

Transport should not be delayed for ____________ ______________ and _______________ that you can provide en route to the hospital.

20. In 2009 the Centers for Disease Control and Prevention published a new set of guidelines for field-triaging injured patients. Their recommendations include a four-step process designed to ____________ _____________ ___________ ___________ from trauma.

Chapter 2 Answer Key Handout 2-2: Chapter 2 Quiz 1. d

6. a

11. d

16. d

2. c

7. c

12. b

17. b

3. c

8. a

13. c

18. c

4. d

9. a

14. c

19. d

5. d

10. b

15. a

20. a

Handout 2-3: Chapter 2 Scenario 1. It is unknown whether the bleeding from the nose occurred before or after the collapse, so if that information cannot be provided by bystanders, this patient is presumed to be a trauma patient until proven otherwise. 2. An unresponsive patient is unable to protect his airway, so an adjunct should be inserted. This patient presents with bleeding from the nose, which may indicate a skull fracture so an NPA is contraindicated in this patient. Insertion of an OPA should be attempted, as long as a gag reflex is not stimulated. Suctioning should be at the patient’s side in case vomiting occurs. 3. A present radial pulse indicates that the blood pressure is 80 mmHg systolic. 4. Only essential or life-saving procedures should be done on scene. For this patient, that would include placement of an OPA, cervical collar, and immobilization to a spine board. Complete assessment, oxygen administration, vital signs, and reassessment should all occur during transport.

Handout 2-4: Chapter 2 Review 1. Forming a general impression 2. Medical, trauma 3. Informed, implied 4. Manually stabilize the patient’s head and neck

5. Immediately identify life-threatening conditions 6. Initial assessment 7. AVPU 8. Decorticate 9. Decerebrate 10. Jaw-thrust 11. Overextend 12. Oropharyngeal 13. Accessory 14. Radial 15. Brachial 16. Hemostatic agents 17. Capillary refill time 18. Peripheral vasoconstriction 19. Detailed assessments, procedures 20. Decrease morbidity and mortality

Chapter 6 Patient Monitoring Technology

HANDOUT 6-1

Student’s Name ____________ SKILLS

PROCEDURE FOR CONTINUOUS ECG MONITORING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Places the ECG monitor at the side of the patient 2. Turns on ECG monitor 3. Makes certain the skin is clean and free of hair 4. Places the electrodes on the chest wall or as high as possible on the extremity 5. For lead II places the positive electrode at the apex of the heart on the chest wall (or on the left leg) 6. For lead II places the negative electrode below the right clavicle (or on the right arm) 7. For lead II places the third electrode, the ground, somewhere on the left upper chest wall (or on the left arm) 8. Asks patient to relax and lie still while student assesses the rhythm

Comments:

HANDOUT 6-2

Student’s Name ____________ SKILLS PROCEDURE FOR 12-LEAD ECG ACQUISITION Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently

Procedure

1. Cleans the area with an alcohol swab and allows to dry 2. Shaves any excess hair as needed 3. Dries the area or uses benzoin spray as needed 4. Makes sure the conductive gel in the electrodes is pliable 5. Has the patient lie supine and places the limb leads 6. Places lead V1 to the right of the sternum at the fourth intercostal space 7. Places lead V2 at the left of the sternum at the fourth intercostal space 8. Places lead V4 at the midclavicular line at the fifth intercostal space 9. Places lead V3 in a line midway between lead V2 and lead V4 10. Places lead V5 at the anterior axillary line at the same level as V4 11. Places lead V6 at the midaxillary line at the same level as V4 12. Ensures that all leads are attached 13. Instructs the patient to lie still while student obtains the 12-lead ECG reading Comments:

HANDOUT 6-3

Student’s Name ____________ SKILLS

PROCEDURE FOR OBTAINING PULSE OXIMETRY Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Connects the probe to the monitor device 2. Attaches the probe-sensor clip to the patient’s finger, toe, or earlobe (or foot, if infant) 3. Turns on the device, and waits for the reading to appear 4. Matches the pulse reading with the patient’s actual pulse 5. Repositions the probe or tries another location if an “error” code is received or if there is a poor signal 6. Locates the patient’s SpO2 reading 7. Reassesses every 5 minutes in the unstable patient and every 15 minutes in the stable patient 8. Titrates oxygen administration to maintain a pulse oximetry reading of 95 percent

Comments:

HANDOUT 6-4

Student’s Name ____________ SKILLS

PROCEDURE FOR END-TIDAL CO2 MONITORING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently 1

QUALITATIVE COLORIMETRIC ETCO2 DEVICE Procedure 1. Places the device between the endotracheal tube and the ventilation device 2. Ventilates patient 3. Observes for color change to yellow 4. Confirms placement if no color change 5. Removes endotracheal tube (ETT) if doubt about placement exists CONTINUOUS WAVEFORM MONITORING (WITHOUT ETT) Procedure 1. Attaches the inline sensor between the endotracheal tube and the ventilation device 2. Ventilates the patient 3. Visualizes the ETCO2 number reading and digital waveform CONTINUOUS WAVEFORM MONITORING (NONINTUBATED PATIENTS) Procedure 1. Applies a special nasal cannula to patient 2. Visualizes the ETCO2 number reading and digital waveform Comments:

HANDOUT 6-5

Student’s Name ____________ SKILLS PROCEDURE FOR CO-OXIMETRY(SPCO),

AND METHEMOGLOBINEMIA (SPMET) MONITORING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Connects the probe to the monitor device. 2. Attaches the probe sensor clip to the patient’s finger, toe, or earlobe (foot, if infant) 3. Turns on the device, and waits for the SpO2 reading to appear 4. Matches the pulse reading to the patient’s actual pulse 5. Repositions or moves probe if poor signal or “error” code is received 6. Presses the SpCO button, and measures the SpCO, SpMet, and SpHb if applicable 7. Reassesses and documents every 5 minutes in the unstable patient and every 15 minutes in the stable patient

Comments:

HANDOUT 6-6

Student’s Name ____________ SKILLS

PROCEDURE FOR OBTAINING BLOOD GLUCOMETRY Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Lets the patient’s arm hang down to allow for better blood flow to the finger student will be using for the test 2. If the patient’s fingers are cold, warms them briefly to provide better flow prior to testing 3. Matches the code number on the screen to the code number on the test strip vial 4. Cleanses the test site with an alcohol wipe; allows to dry completely before testing 5. Squeezes the finger to force blood into the tip; uses a lancet device to prick the fingertip 6. Places a drop of capillary blood onto a chemical reagent strip 7. Waits for the reading to appear on the screen 8. Places a dressing on patient’s finger as needed

Comments:

HANDOUT 6-7

Student’s Name ____________ SKILLS

PROCEDURE FOR OBTAINING BASIC BLOOD CHEMISTRY Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Assembles and prepares all equipment; inspects blood tubes for expiration or damage 2. Inserts the multidraw needle into the vacutainer; never places blood tubes into the assembled vacutainer and multidraw needle until ready to draw blood 3. Establishes IV access with the angiocatheter; does not connect IV administration tubing 4. Attaches the end of the multidraw needle adapter to the hub of the catheter 5. In correct order inserts blood tubes so that the rubber-covered needle punctures the self-sealing rubber top 6. Fills all blood tubes completely 7. Gently agitates tubes to mix the anticoagulant evenly with the blood 8. Tamponades the vein, and removes the vacutainer and multidraw needle 9. Attaches the IV, and ensures patency 10. Properly disposes of all sharps 11. Labels all blood tubes with required information

Comments:

Student’s Name ___________

HANDOUT 6-8 EVALUATION

CHAPTER 6 QUIZ Write the letter of the best answer in the space provided. ______1. The heart itself is perfused by the: a. aorta. c. pulmonary vein. b. coronary arteries. d. carotid arteries. ______2. The pacemaker for the heart is located in the right atrium and is called the: a. AV node. b. SA node. c. Bundle of His. d. SV node. ______3. The type of ECG leads that are most frequently used are called ______ leads. a. augmented b. biphasic c. bipolar d. precordial ______4. In Lead II the negative electrode is placed on the: a. right arm. c. right leg. b. left arm. d. left leg. ______5. The light lines on ECG graph paper are: A. 5 cm apart. B. 1 cm apart. C. 5 mm apart. D. 1 mm apart. ______6. One small box on the ECG paper equals: A. 0.07 seconds. B. 0.05 seconds. C. 0.04 seconds. D. 0.02 seconds. ______7. In lead II the P wave is: a. before the QRS complex. b. after the QRS complex. c. after the T wave. d. after the U wave. ______8. A normal PRI is greater than 0.12 seconds and less than: A. 0.40 seconds. B. 0.30 seconds. C. 0.25 seconds. D. 0.20 seconds.

______9. The QRS complex represents: a. atrial depolarization. c. atrial repolarization. b. ventricular depolarization. d. ventricular repolarization. _____10. Repolarization for the ventricles is represented on the ECG paper as a: a. T wave. b. U wave. c. PR interval. d. QRS complex. _____11. Pulse oximetry measures the amount of: a. free oxygen molecules in the blood. b. hemoglobin bound with carbon dioxide. c. hemoglobin bound with oxygen. d. free carbon dioxide in the blood. _____12. Which of the following will NOT produce an inaccurate pulse oximetry reading? a. A patient who is hypothermic b. A pediatric patient c. A patient who is shivering d. A patient with cyanide poisoning _____13. End-tidal CO2 is a reflection of all of the following EXCEPT: a. cardiac output. b. cellular metabolism. c. circulation. d. ventilation. _____14. A “shark fin” capnography waveform pattern indicates: a. a normal waveform. c. hyperventilation. b. an airway obstruction. d. bronchospasm. _____15. Insulin must be secreted from the pancreas constantly because the liver removes circulating insulin within__________ from the time of secretion. a. 1–2 minutes c. 10–15 minutes b. 30–45 minutes d. 1–2 hours _____16. Hyperglycemia is when the blood glucose level is above: a. 80 mg/dl. c. 130 mg/dl. b.140 mg/dl. d. none of the above. _____17. Prior to obtaining a blood glucose reading, you should clean the site with alcohol and: a. follow the alcohol wipe with a betadine wipe. b. immediately perform the test before the alcohol dries. c. rewipe the area with alcohol a second time. d. allow the alcohol to dry. _____18. Using blood tubes in the correct order: a. helps the hospital to perform more tests. b. is only important if time allows. c. is essential. d. is not necessary.

_____19. The principal buffer in the body is: a. phosphate. b. bicarbonate. c. potassium. d. calcium chloride. ______20. Ultrasound has been shown to be useful in the prehospital setting to detect: a. cardiac contusion. b. myocardial infarct. c. fetal distress. d. abdominal aortic aneurysms.

Student’s Name ___________

HANDOUT 6-9 EVALUATION

CHAPTER 6 SCENARIO Review the following real-life situation. Then answer the questions that follow. A 40-year-old woman is out to dinner one night with friends from work and begins feeling “strange.” She leans back in her chair and says that she is suddenly feeling very weak. She tries to describe exactly how she is feeling to her friends, but when she begins to sweat and feel faint, they decide to call 911. You and your EMT-Basic partner arrive at the scene within 5 minutes. You are directed back to the patient and begin your assessment. You find a 40-yearold female that is in obvious distress but unable to really describe how she feels. As you begin your OPQRST, she tells you that she has been feeling “a little under the weather” for a couple of days and has not found anything that makes it better or worse. She denies any pain but says that her left arm has been aching “from time to time” for about four days. She is unable to provide the severity, just says it is an ache. She denies any SOB or nausea and vomiting until this evening. She states that as she began eating she felt as though she was having indigestion and became very nauseated. She denies any pain but just continues to say she “doesn’t feel right.” In addition, she denies any past medical history, is not currently taking any prescription or OTC medications, and has no allergies. While you continue your assessment, your partner places the patient on oxygen and begins taking vital signs and is asking for direction as to what to do next. 1. Based on this patient’s presentation, what do you think might be her diagnosis? 2. What technological devices would help you complete your assessment and develop a plan for treatment?

HANDOUT 6-10

Student’s Name ___________ REINFORCEMENT CHAPTER 6 REVIEW

Write the word or words that best complete each sentence in the space provided. 1.

Electrolytes such as sodium and potassium cross cell membranes and cause a shift in cell polarity, in a process called ____________________.

A normal electrical impulse is generated in the ________ _________, travels to the ________ ________ then continues to the ________ ________ ________ and finally ends in the ________ ________.

To obtain a Lead II display, the negative electrode is placed on the ________ ________ and the positive electrode is placed on the ________ ________.

A QRS complex reflects ________ depolarization. The Q wave is the first ________ ________ after the P wave, the R wave is the first ________ ________ after the P wave, and the S wave is the first ________ ________ after the R wave.

Deflections on the ECG produced by factors other than the heart’s electrical activity are called ______________.

The ________ ________ ________ supplies blood to the right ventricle, the inferior portion of the left ventricle, and the upper pacemaker sites.

________ occurs when the myocardium is deprived of oxygen for a period of time.

The six chest leads used when obtaining a 12-lead ECG are also called ________ ________.

One limitation of the 12-lead ECG is that it only provides information about the heart’s electrical activity and nothing about the ________ ________.

10. Acquiring a 12-lead ECG is important in the early recognition and treatment of ________ ________ ________ (ACS), especially ________ ________ ________ ________ (STEMI). 11. When oxygen is bound to hemoglobin, the resultant molecule is called ________ and when it is not bound, the molecule is called ________. 12. Pulse oximetry measures the ______________ _______________ in the patient’s hemoglobin.

13. Pulse oximetry is often referred to as the ____________ _________ _________. 14. Excess oxygen can manufacture toxic chemicals called _________ _________. 15. ETCO2 is a reflection of ____________ ______________, ___________, and ______________. 16. The _____________ _______________ is a disposable ETCO 2 detector that is a piece of litmus paper encased within a plastic chamber. 17. The _____________ _________________ _______________ _____________ reflects CO2 concentrations over time. 18. The binding of CO to hemoglobin results in ______________________. 19. The endocrine tissues found within the pancreas are known as the ________ ________ ________. 20. The process that produces glucose from nonsugar sources is known as _____________________.

Chapter 6 Answer Key Handout 6-8: Chapter 6 Quiz 1. b

6. c

11. c

16. b

2. b

7. a

12. b

17. d

3. c

8. d

13. a

18. c

4. a

9. b

14. d

19. b

5. d

10. a

15. c

20. d

Handout 6-9: Chapter 6 Scenario 1. Based on the vagueness of the patient’s symptoms, there are many possibilities. It may be a simple case of indigestion (as expressed by the patient) or may be a viral infection (such as the flu). The most concerning aspect of the presentation is the complaint of “aching” in the left arm. That is highly suspicious of a cardiac condition, especially since women often have an atypical presentation for myocardial infarction. It is always necessary to develop a treatment plan based on worse-case scenario. 2. There are many monitoring devices that should be utilized to assist in determining the nature of the patient’s complaint. Upon initiating your assessment, the patient should be placed on a 3-lead ECG monitor and a pulse oximeter. As the assessment progresses a 12-lead ECG should be obtained, as well as a glucometry reading and capnography reading. Depending on the agreement with the receiving hospital, it may also be appropriate to obtain a blood sample while initiating the IV.

Handout 6-10: Chapter 6 Review 1. Depolarization 2. SA node, AV node, Bundle of His, Purkinje system 3. Right arm, left leg 4. Ventricular, negative deflection, positive deflection, negative deflection 5. Artifact 6. Right coronary artery 7. Ischemia

8. Precordial leads 9. Mechanical pump 10. Acute coronary syndromes, ST elevation myocardial infarction 11. Oxyhemoglobin, deoxyhemoglobin 12. Oxygen saturation 13. Fifth vital sign 14. Free radicals 15. Cellular metabolism, circulation, ventilation 16. Colorimetric device 17. Continuous waveform capnography device 18. Carboxyhemoglobin 19. Islets of Langerhans 20. Gluconeogenesis

Chapter 7 Patient Assessment in the Field

Student’s Name ________________

HANDOUT 7-1

SKILLS PERFORMING A SCENE SIZE-UP AND INITIAL ASSESSMENT Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure Scene Size-Up 1. Ensures scene safety 2. Takes standard precautions 3. Determines necessary resources 4. Locates all patients 5. Determines mechanism of injury/nature of illness Initial Assessment 1. Forms general impression 2. Stabilizes cervical spine as needed 3. Assesses baseline mental status Airway 1. Opens airway with appropriate maneuver 2. Looks, listens, feels for air movement 3. Immediately corrects obstructed airway 4. Inserts oral or nasal airway adjunct as needed

Breathing 1. Assesses breathing rate and quality 2. Inspects chest and back 3. Palpates chest and back 4. Auscultates bilaterally for equality/adequacy of ventilation 5. Immediately corrects injuries that may compromise airway/breathing 6. Administers oxygen, assists ventilations Circulation 1. Checks radial pulses for rate and quality 2. Checks skin color, temperature, condition 3. Checks capillary refill time in children 4. Controls gross hemorrhage 5. Elevates legs, keeps patient warm, as needed 6. Applies and inflates PASG as needed 7. Assigns priority for rapid transport Comments:

Student’s Name ______________

HANDOUT 7-2

SKILLS PERFORMING A RAPID TRAUMA ASSESSMENT Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure Head: DCAP-BTLS and Crepitation 1. Palpates the head 2. Periodically examines gloves for blood Neck: DCAP-BTLS and Crepitation 1. Inspects and palpates the anterior neck 2. Checks for jugular vein distension 3. Checks for tracheal deviation 4. Checks for subcutaneous emphysema Chest: DCAP-BTLS and Crepitation 1. Inspects and palpates the chest 2. Checks for subcutaneous emphysema 3. Auscultates both lungs Abdomen: DCAP-BTLS and Crepitation 1. Inspects and palpates abdomen Pelvis: DCAP-BTLS and Crepitation 1. Evaluates the pelvic ring

Extremities: DCAP-BTLS and Crepitation 1. Inspects and palpates all four extremities 2. Evaluates distal neurovascular functions (pulse, sensation, movement) Posterior: DCAP-BTLS and Crepitation 1. Inspects and palpates posterior trunk, buttocks Comments:

Student’s Name ___________

HANDOUT 7-3 EVALUATION

CHAPTER 7 QUIZ, PART A Write the letter of the best answer in the space provided. ______1. The problem-oriented evaluation of a patient with establishment of priorities based on existing and potential threats to human life is called: a. rapid trauma assessment. c. focused physical assessment. b. patient assessment. d. detailed physical exam. ______2. The purpose of the initial assessment is to identify and correct: a. scene safety concerns. b. serious injuries such as fractures and dislocations. c. immediately life-threatening conditions. d. minor injuries. ______3. Which of the following problems would you be likely to note during your scene size-up of a situation? a. Your patient is having chest pain. b. The closest trauma facility is 30 minutes away. c. You will need three additional ambulances for patient transport. d. Your patient appears awake and alert. ______4. Standard precautions is a component of: a. scene size-up. c. focused history and physical exam. b. initial assessment. d. Detailed physical exam. ______5. In a medical emergency you can sometimes determine the nature of your patient’s illness from clues at the scene. These would include: a. the smell of a lower gastrointestinal bleed. b. the sound of a hissing oxygen tank. c. the sight of drug paraphernalia. d. all of the above. ______6. The most effective method of preventing disease transmission between you and your patients is: a. wearing appropriate eye protection. b. wearing a surgical mask when treating any patient. c. washing your hands before and after patient contact. d. wearing a HEPA filter mask whenever caring for a patient with breathing difficulty. ______7. Which of the following is true regarding scene safety? a. Your personal safety is the top priority at any emergency scene. b. If your scene is unsafe, enter cautiously.

c. All medical scenes may be considered safe. d. It is expected of you, as a paramedic, to risk your life to care for a patient if necessary. ______8. The nature of the patient’s illness: a. is always the same as his chief complaint. b. is always readily apparent. c. can only be obtained from the patient himself. d. may be evident from clues you find at the scene. ______9. Determining the patient’s priority for transport is a component of the: a. scene size-up. c. ongoing assessment. b. initial assessment. d. detailed assessment. _____10. Components of the initial assessment include: a. assessment of the patient’s airway, breathing, and circulation. b. baseline vital signs. c. assessing the body for DCAP-BTLS. d. location of Medic Alert tags or other forms of medical information. _____11. While performing the initial assessment of a patient, you note an open wound to the chest. This injury should be treated: a. during the focused physical examination. b. during the rapid trauma assessment. c. during the initial assessment. d. during the detailed physical exam. _____12. If the mechanism of injury is significant or if your patient is unresponsive: a. immediately apply high-concentration oxygen by nonrebreather mask. b. have your partner manually stabilize the patient’s head and neck. c. immediately transport the patient after completing the initial assessment. d. apply a cervical collar after completing the initial assessment. _____13. Serious external hemorrhage should be controlled: a. during the initial assessment. b. before beginning the initial assessment. c. during the detailed physical exam. d. during the scene size-up. _____14. If you suspect a possible cervical spine injury, you should open the patient’s airway with: a. a nasopharyngeal airway. c. the head-tilt/chin-lift method. b. an oropharyngeal airway. d. the jaw-thrust maneuver. _____15. To record your patient’s mental status, use the acronym AVPU. Which of the following is true? a. A stands for awake. c. P stands for painful stimuli. b. V stands for visual. d. U stands for unilateral. _____16. Signs of inadequate breathing in the adult patient include:

a. symmetrical chest wall movement . b. a respiratory rate over 24. c. a pulse rate over 100. d. swelling or edema in the patient’s lips. _____17. Performing a primary assessment should take ___________ unless you must intervene with lifesaving measures. a. less than 1 minute c. 30 seconds b. 2 to 3 minutes d. 5 minutes _____18. Cyanotic, pale, or ashen skin may indicate: a. hypertension. c. vascular compromise. b. stroke. d. sepsis. _____19. Which of the following statements regarding assessment of an infant’s or a small child’s respiration is true? a. Accessory muscle use indicates uncompromised respiration. b. Infants and small children grunt to maintain back pressure. c. Positive pressure ventilation is never necessary. d. A pulse rate over 100 in an infant or small child indicates respiratory compromise. _____ 20. A female patient with abdominal pain is always considered: a. the highest priority for transport. b. to be having a miscarriage. c. unstable. d. pregnant until proven otherwise.

Student’s Name ___________

HANDOUT 7-4 EVALUATION

CHAPTER 7 QUIZ, PART B Write the letter of the best answer in the space provided. ______1. How the focused history and physical exam are performed is based on the initial assessment and: a. the patient’s chief complaint. b. local protocols. c. consultation with medical direction. d. the patient’s vital signs. ______2. One subclassification of trauma patients includes those: a. with an isolated injury. b. who are responsive. c. who have either internal or external bleeding. d. who are a high priority for rapid transport. ______3. Predictors of serious internal injury of a patient include: a. traumatic amputation of a limb. b. airbag inflation during a vehicle collision. c. death in any of the vehicles involved in a collision. d. motorcycle crash. ______4. The predictors of serious internal injury for infants and children that differ from those for adults include: a. a fall from higher than 10 feet. b. a slow-speed collision. c. the injury of another in the same passenger compartment. d. an unrestrained passenger. ______5. The mnemonic SAMPLE is helpful in evaluating a major trauma patient. The letters represent: a. the patient’s level of consciousness. b. a score based on the assessment findings that predicts survival. c. an abbreviated patient history format. d. conditions that cause the patient to be a high priority for rapid transport. ______6. The M in the mnemonic SAMPLE stands for: a. menstruation. c. mental status. b. medic alert tag. d. medications. ______7. The P in the mnemonic SAMPLE stands for: a. pertinent medical history. c. pertinent negatives. b. past medical history . d. pulse oximetry.

______8. Subcutaneous emphysema is: a. fluid in the lungs causing severe respiratory distress. b. fluid or blood under the skin from damaged blood vessels. c. air just under the skin, causing a crackling sensation. d. a type of pulmonary embolism caused by an air bubble. ______9. Treatment for a tension pneumothorax includes: a. stabilizing the injured side of the chest with a bulky dressing. b. needle cricothyrotomy. c. minimal supplemental oxygen administration to prevent an increase in pressure in the chest. d. needle decompression. _____10. A patient with a ___________ fracture or dislocation risks lacerating the iliac arteries and veins, through which he can lose a significant amount of blood. a. vertebral c. cranial b. pelvic d. rib _____11. When assessing the trauma patient with an isolated injury, you most likely will not need to perform a(n): a. scene size-up. c. SAMPLE history. b. initial assessment. d. detailed physical exam. _____12. The history for a responsive medical patient should include the: a. chief complaint, history of the present illness, and current health status. b. chief complaint, history of the present illness, past medical history, family history, and review of systems. c. chief complaint, history of the present illness, current health status, and 1-minute cranial nerve exam. d. chief complaint and DCAP-BTLS. _____13. Once you have obtained a chief complaint from a responsive medical patient, you should next: a. perform the initial assessment. b. perform a detailed physical exam. c. obtain a history of present illness. d. perform a focused physical exam. _____14. In the acronym OPQRST-ASPN, ASPN stands for: a. amplified sounds, positional nystagmus. b. allergies, skin, pupils, neurologic status. c. associated symptoms, pertinent negatives. d. abdomen, sigmoid (colon), plantar reflex, nervous system. _____15. To quickly test the seventh cranial nerve (CN-VII), you should have your patient: a. stand on one foot.

b. close his eyes and touch his nose with his finger. c. stick out his tongue. d. show his teeth. _____16. After completing the initial assessment of an unresponsive medical patient, you should next: a. obtain a brief history from family or bystanders. b. perform a detailed physical exam. c. immediately transport the patient. d. perform a rapid secondary assessment. _____17. After conducting the focused physical exam for a responsive medical patient, you should next: a. provide necessary emergency medical care authorized by standing orders. b. contact online medical direction to request further orders. c. immediately transport the patient to the correct facility. d. conduct a detailed physical exam. _____18. The detailed physical exam is designed for use: a. on all trauma patients. b. on patients en route to the hospital. c. on all responsive medical patients. d. on patients before transport. _____19. The ongoing assessment: a. detects trends. c. assesses intervention effects. b. determines changes. d. all of the above. _____20. The ongoing assessment should be conducted every ___________ minutes for stable patients and every ___________ minutes for unstable patients. A. 15, 10 C. 10, 5 B. 15, 5 D. 10, 3

HANDOUT 7-5

Student’s Name ___________ EVALUATION CHAPTER 7 SCENARIO

Review the following real-life situation. Then answer the questions that follow. A five-year-old boy playing on his front lawn is startled when a stray dog runs up to him. When he puts out his hand to pet the dog, the dog lunges for the boy’s throat. Shocked by the attack, the child falls unconscious. The dog releases his grip and runs off as neighbors who have witnessed the attack call 911 and rush to the child’s aid. The local volunteer BLS quick-response team arrives and quickly assesses the boy. His airway is compromised by blood from multiple puncture wounds. He is ashen and pale. He is barely moving air. His radial pulses are weak and rapid. As the crew assesses him, they treat him with suction, insertion of an oral airway, oxygen via a nonrebreather mask, and spinal immobilization. When the paramedic ambulance arrives, the QRT crew chief gives his report to the paramedic, who decides to rapidly transport the child to the regional trauma center. En route the paramedic performs a more detailed examination of the boy. She notes the airway difficulty and elects to intubate the child immediately because swelling and discoloration around the throat suggest his airway could collapse despite vigorous suctioning. The child has subcutaneous emphysema around his clavicles. The paramedic is somewhat relieved when auscultation reveals clear breath sounds bilaterally. Nevertheless, she requests pulse oximetry. Meanwhile, the child’s color is visibly improving. The paramedic is also concerned for the child’s cervical spine and assesses the distal neurologic functions but not before obtaining a set of vital signs. Content that the child was hypoxic and not hypovolemic, she begins to evaluate the child’s mental status. The child is conscious but is “in shock” from the attack. The best that can be determined is that he is verbal; he will follow commands such as grasping fingers or moving toes. Upon arrival at the trauma center, the paramedic gives a detailed report of her assessment findings to the surgeons. Rapidly stabilized in the emergency department, the boy is rushed to the operating suite for exploration and repair of his injuries. He has a puncture to the larynx and requires multiple sutures but is otherwise stable. 1. Based on the initial dispatch information, what problems might you anticipate regarding scene size-up and initial assessment findings? 2. Why did this patient warrant rapid transport to a trauma center?

3. What critical interventions did the BLS quick-response team members and the paramedic provide to correct immediate life threats? 4. What were the treatment priorities for this patient?

HANDOUT 7-6

Student’s Name ___________ REINFORCEMENT CHAPTER 7 REVIEW, PART A

Write the word or words that best complete each sentence in the space provided. 1.

The components of patient assessment include the primary assessment, focused history and physical exam, ___________ ___________ ___________, and ___________.

The essential first step at any emergency involves taking time to judge the situation, which is called the ___________ ___________- ___________.

By the end of the primary assessment you should be able to assign ___________ ___________.

The combined strength, direction, and nature of forces that injured your patient is called the ___________ ___________ ___________.

Your anticipation of possible injuries based on your analysis of the event is the ___________ ___________ ___________.

The first step of the initial assessment is ___________ ___________ ___________ ___________.

The purpose of the rapid secondary assessment is to identify and correct ___________ ___________- ___________ ___________.

Determining the patient’s priority for transport is a step in the ___________ ___________.

The acronym used to record your patient’s mental status is ___________ ___________ ___________ ___________.

10. You should not probe the ___________ with your finger tips. 11. Tugging on the trachea to one side during inspiration suggests a _______________. 12. Accessory muscle use always indicates ______________ _____________. 13. Impact to the ribs should result in _______________ which is almost immediately visible. 14. Bruising over the umbilicus is called _______________ ______________.

15. Signs of inadequate breathing include the use of ___________ muscles to breathe. 16. When assessing an adult patient’s circulation, you should feel for a(n) ___________ pulse first. 17. Your ability to analyze data effectively and devise a practical management plan that optimizes patient care is called ______________ ______________. 18. A decreasing pulse rate combined with a rising blood pressure, associated with an irregular respiratory pattern, suggests a(n) ___________ ___________ ___________ ___________. 19. The first step in critical thinking is ____________ a ___________. 20. Following the primary assessment, the unresponsive medical patient should receive a(n) ___________ ___________ ___________.

HANDOUT 7-7

Student’s Name __________ REINFORCEMENT CHAPTER 7 REVIEW, PART B

Write the word or words that best complete each sentence in the space provided. 1.

Trauma patients are classified as one of two types: patients with a(n) ___________ ___________ ___________ ___________ and patients with a(n) ___________ ___________.

Medical patients are classified as either ___________ or ___________.

Predictors of serious internal injury include ___________ from a vehicle, ___________ in the same passenger compartment, and ___________ of the vehicle.

After the initial assessment of a major trauma patient, the paramedic should perform a(n) ___________ ___________ assessment.

The E in SAMPLE stands for ___________ ___________ ___________ ___________ ___________ ___________.

In the semi-Fowler’s position, jugular venous distension beyond ___________ degrees is significant.

The fracture of two or more adjacent ribs in two or more places causes an unstable flail (floating) segment that may be evidenced by ___________ chest wall movement.

Bruising over the flank areas, displayed hours after injury, is called ___________ ___________ ___________.

The ___________ ___________ ___________ may be used as a splint to immobilize an unstable pelvic fracture.

10. Weakness or disability in the extremities on only one side of the body suggests brain injury due to ___________ or ___________ ___________. 11. For major trauma cases when time is critical, you should use the ___________ history format. 12. When caring for an isolated-injury trauma patient, paramedics should avoid ___________ ___________ and develop a(n) ___________ threshold for suspecting other injuries.

13. In the ___________ ___________ patient, the history takes precedence over the physical exam. 14. ___________ ___________ and the seriousness of your patient’s condition will determine which exam techniques you use for your responsive medical patient. 15. When inspecting your patient’s chest, you should look for the typical bulge that indicates a(n) ___________ ___________ or ___________. 16. To test your patient’s twelfth cranial nerve (CN-XII) using the 1-minute cranial nerve exam, you should ask him to ___________ ___________ ___________ ___________. 17. Always base your emergency care on your patient’s ___________ and ___________ as obtained through a thorough focused history and physical exam. 18. The steps in assessing unresponsive medical patients include (1) ___________ ___________, (2) ___________ ___________ ___________, and (3) ___________ ___________. 19. The detailed physical exam is a more focused exam using components of the ___________ ___________ ___________. 20. The three goals of reassessment are to ___________ ___________, ___________ ___________, and ___________ ___________ ___________.

Student’s Name __________

HANDOUT 7-8 REINFORCEMENT

ACRONYM COMPLETION Complete the mnemonics and acronyms for different phases of the assessment process. 1. Mental status A________ V________ P________ U________ 2. Initial assessment A________ B________ C________ 3. History S________ A________ M________ P________ L________ E________ 4. History of present illness O________ P________ Q________ R________ S________ T________ AS________ PN________

Student’s Name ________

HANDOUT 7-9 REINFORCEMENT

VITAL SIGNS PRACTICE Date

Pulse/Location

Respirations

B/P Auscultation

B/P Palpation

Student’s Name ________

HANDOUT 7-10

REINFORCEMENT INITIAL ASSESSMENT IDENTIFICATION For each simulated patient, you will be given a scenario and initial assessment findings. Based on the information given, indicate the appropriate type of physical exam you would perform and whether the patient is a high priority for transport or not. Pt. #

High Priority, Type of Physical Detailed Exam

Exam

Rapid Transport