TEST BANK FOR PARAMEDIC CARE PRINCIPALS AND PRACTICE 5TH EDITION by QuentinAxel

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 1 Introduction to Paramedicine 130 Minutes

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Teaching Tips Discussion Topics 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 National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

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

II. Introduction A. Understand what the job of paramedic in the twenty-first century involves 1. Member of allied health professions (ancillary health care professions, apart from physicians and nurses) 2. Highly regarded by society 3. Significant advances in EMS system over the past 30 years 4. Not long ago, the ambulance was simply a vehicle that provided rapid, horizontal transport to the hospital. 5. Today the modern ambulance is equipped with the latest in equipment and technology and is truly a mobile emergency room on wheels. 6. Twenty-first century paramedic is a highly trained health care professional who provides comprehensive, compassionate, efficient prehospital emergency care B. Description of the Profession 1. Paramedic is highest level of prehospital care and leader of prehospital care team 2. Four nationally recognized levels of EMS providers in the United States: a. Emergency Medical Responder (EMR) b. Emergency Medical Technician (EMT) c. Advanced Emergency Medical Technician (AEMT) d. Paramedic

Teaching Tips Before starting the Introduction, ask students to list on the board what roles paramedics serve and how they help the public.

Discussion Topics List the four levels of EMS, what each level can do, and the skills each level is not permitted to perform.

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Content Outline C. The Modern Paramedic 1. Roles and responsibilities of paramedic are diverse and encompass disciplines of health care, public health, and public safety 2. Illness and injury prevention are just as important as acute health care and public safety 3. Totality of roles and responsibilities of paramedic practice known as paramedicine 4. Primary tasks of paramedic include a. Providing emergency medical care in an out-of-hospital setting b. Using advanced training and equipment to extend the care of emergency physician to patient in the field c. Making accurate independent judgments in a timely manner (This is essential, as it can mean the difference between life and death for the patient.) 5. In order to function as a paramedic, you must: a. Fulfill prescribed requirements of appropriate licensing or credentialing body b. Be licensed, registered, or otherwise credentialed by appropriate agency in area of employment c. Function only under the direction of the EMS system’s medical director 1) Medical director must be appropriately licensed or credentialed. 2) Medical director must approve paramedic before allowing practice of advanced prehospital care. 6. Emerging roles and responsibilities include public education, health promotion, participation in injury and illness prevention programs 7. As a paramedic, you must: a. Recognize that you are an essential component in the continuum of care. b. Serve as a link between various health resources in the community. c. Understand that you may be a gatekeeper to the health care system as health care costs increase.

Master Teaching Notes Class Activities Ask students to list all the illness and injury prevention programs they can think of. Discuss with them the ways they can participate in these programs as paramedics. Examples include but are not limited to: - DARE - Safety Town - Bike Rodeos - Blood Pressure Screenings - MADD - Mock Auto Accidents at Schools - First Aid/CPR - Babysitting Courses - No Texting and Driving

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Content Outline 1) For example, you ensure that your patient gets to an appropriate health care facility in a timely manner, even though it may not be a hospital ED. d. Strive toward maintaining high-quality health care at a reasonable cost. e. Always be an advocate for your patient and ensure that the patient receives the best possible care, without regard to patient’s ability to pay or insurance status. f. Continue to fill the well-defined and traditional role of 911 response. g. Take on additional responsibilities. 1) Mobile integrated health care/community paramedicine is community-based health care focused on appropriate use of emergency care resources 2) Become a facilitator of access to care, individual treatment provider h. Be responsible and accountable to the system medical director, their agency, the public, and your peers. i. Always act in the best interest of the patient. D. Paramedic Characteristics 1. As a paramedic, you may work for a fire department, private ambulance service, third city service, hospital, police department, or other operation. 2. You must: a. Be flexible to meet the demands of the ever-changing emergency scene. b. Be a confident leader. c. Have excellent judgment. d. Be able to prioritize decisions to act quickly and in the best interest of the patient. e. Be able to develop rapport with a wide variety of patients and communicate with members of diverse cultural and age groups. f. Function independently at an optimum level in a nonstructured, constantly changing environment.

Master Teaching Notes

Class Activities Have students give examples of situations in which they had to be flexible in their job.

Class Activities Have students list skills they learned as 3

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Content Outline E. The Paramedic: A True Health Professional 1. Emergency medical services now recognized as an important part of health care system 2. Paramedics are highly respected members of health care team. 3. Paramedics must always strive to earn acceptance as a professional. 4. Completion of initial paramedic course is start of professional education 5. Participation in continuing education programs and routine peerevaluation is essential in your career. 6. Standards for paramedics raised with the 2009 publication of National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines a. Guidelines have taken paramedic education to a higher level b. Based on a national EMS practice analysis completed by the National Registry of EMTs in 2004 c. Anatomy and physiology course now a prerequisite to paramedic course d. Curriculum provides for improved understanding of pathophysiology of various illnesses and injury processes paramedics encounter e. Material in 2009 DOT EMS Instructional Guidelines is the foundation for this textbook 7. Strong practice now based on research a. Must be active in design, development, evaluation, and publication of research b. In the past, paramedicine was based on anecdotal data and tradition. c. In the last 20 years, application of scientific methods introduced into paramedic care after it was found that there was little to no scientific data to support many prehospital practices d. As a result of research, many traditional EMS treatments have been abandoned or refined. 8. Essential aspect of the health profession is acceptance and adherence to professional ethics and etiquette a. Ethics are standards of right and honorable behavior; often

Master Teaching Notes EMTs that they have not used since class. If time permits, pull that equipment out and have a few students attempt to use it only by memory.

Teaching Tips Touch on research just briefly, since this will be discussed in later chapters. Focus on the changes research initiated, such as CPR and compressions first, O2 for chest pain/MI patients with low PSO2 saturations, rapid transport, decreased scene time for stroke victims and trauma victims, etc.

Class Activities Have one student change into a dirty shirt (an old shirt that you provide with spilled coffee on it, ink stains, etc.) and perform a patient assessment. Have another student perform an assessment using a poor attitude and no listening skills. Discuss with students their initial impressions. When discussing public expectations, use the scenario of calling a plumber to your house to fix your pipes, then finding out that he doesn’t know what he is doing. Have students give examples of how they can review their performance. Take students through a mock run review using an imaginary call that you make up.

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Content Outline arise in relationships with patients and the public b. Etiquette refers to good manners; often related to behavior between health professionals 9. Public expectations a. Public must feel confident and know that their interests are always placed above personal, corporate, or financial interests b. Emergency patient is always the primary concern F. Legal Considerations: Which Hat Are You Wearing? 1. As a modern paramedic, you must wear several hats as a result of overlapping of duties. a. Cross trained as a fire fighter and police officer b. May participate in rescue operations, directing traffic, and other tasks on the emergency scene 2. Cross training can cause a certain degree of confusion and conflict. a. Police officer/paramedic and HIPAA considerations b. Remember that, as a paramedic, you must put care of the patient above other tasks. 3. Laws regarding responsibilities of cross-trained individuals vary from state to state.

III. Expanded Scope of Practice 15

A. Critical Care Transport 1. Critical care transport vehicles used to move critically ill patients between facilities 2. Specialized ground ambulances, fixed-wing aircraft, and helicopters B. Helicopter air Ambulance (HAA) 1. Helicopters part of EMS system for more than 30 years 2. Most programs staff helicopter with two medical crew members and often include paramedics 3. Skills of flight paramedic very similar to those of critical care paramedic but include additional education in flight physiology, aircraft operations, flight safety, and similar areas C. Tactical EMS 1. Designed to enhance safety of special operations personnel and the

Master Teaching Notes

Teaching Tips Stress to students that, even if they are cross trained, they will be providing only one service at a time.

Teaching Tips If possible, have a paramedic who is trained in extended scope of practice speak to students briefly about their positions.

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Content Outline

F. G.

Master Teaching Notes

public 2. Role of tactical paramedic is to provide life-saving care, sometimes in dangerous environments, until patient can be safely evacuated to general EMS system Mobile Integrated Health Care 1. Several EMS systems have designated specialized crews to periodically assess and monitor high-risk patients in their community. Industrial Medicine 1. Paramedics as principal health care provider on oil rigs, movie sets, and similar industrial operations 2. Specially trained for industry in question 3. Increased employee safety and decreased time lost from work Sports Medicine 1. Paramedics trained to deal with injuries specific to sport in question Corrections Medicine 1. Paramedics as emergency and medical care providers in jails and prisons 2. Responsible for medical emergencies, initial intake assessment, and overseeing medical needs of prison population Hospital Emergency Departments 1. Hospitals faced with a nursing shortage; paramedics founds to be suitable providers for emergency departments and minor care centers 2. Roles vary significantly from state to state, on the basis of local laws.

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Content Outline

IV. Summary A. EMS is now recognized as a staple in the health care system. B. Paramedics have been identified as underutilized medical experts and are

Master Teaching Notes

being offered opportunities that were unheard of a few years ago.

C. As the scope of practice for paramedicine expands, so will the demand for skilled practitioners.

D. The paramedic of the twenty-first century can have a more significant impact on health care than ever before.

E. The paramedic is often the first person of the health care system with whom the patient interacts; the results of those actions can affect the patient’s opinion of the health care system in general. F. EMS is a profession in which you can make a difference on every call and interaction with a patient. G. Few professions carry such awesome responsibility.

V. Case Study 5

VI. You Make the Call 5

Class Activities Read and discuss the You Make the Call scenario, and answer the critical thinking questions as a group.

VI. Review Questions 5

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 2 EMS Systems 90 Minutes

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Teaching Tips Discussion Topics Class Activities Points to Emphasize Knowledge Application

Chapter 2 objectives can be found on text pp. 12–13. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. EMS is a comprehensive network involving personnel, equipment, and resources established to deliver aid and emergency medical care to the community. 1. Out-of-hospital components a. Members of community trained in first aid and CPR b. Communications system c. EMS providers, including paramedics d. Fire/rescue and hazardous materials services e. Law enforcement officers f. Public utilities, such as power and gas companies g. Resource centers, such as regional poison control centers 2. In-hospital components a. Emergency nurses b. Advanced practice providers c. Emergency physicians and specialty physicians d. Ancillary services (e.g., radiology and respiratory therapy) e. Specialty physicians (e.g., trauma surgeons and cardiologists) f. Social workers g. Mental health providers h. Rehabilitation services

Teaching Tips Discuss with students the different out-ofhospital and in-hospital components.

Class Activities Assign members of the class a particular role as an out-of-hospital and in-hospital component. Give students a scenario, and have them stand in a line as their part in the EMS call arrives. Once you have gone through the call, repeat with removal of one or two student roles, which allows students to visualize where the care is jeopardized when there is a break in the EMS and hospital components.

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Master Teaching Notes

B. Weakness in any one component will diminish the overall quality of patient care. 1. Usually, the first EMS provider to respond to the scene of an emergency is a police officer, firefighter, lifeguard, teacher, or other community member who has received basic medical training in an approved Emergency Medical Responder program. 2. Some areas of the country use a tiered response, sending multiple levels of emergency care and personnel to the same incident. 3. Once emergency care has been initiated, EMS providers quickly decide on the medical facility to transport the patient to. 4. Patient is assigned a priority of care upon arriving at medical facility 20

III. History of EMS A. Early Development 1. EMS developed from traditional and scientific beliefs of multiple cultures. 2. Most significant advances in EMS occurred during past 50 years 3. Ancient Times a. Evidence that emergency medicine has a very long history. b. Scribes in Mesopotamia (approximately 4,000–5,000 years ago) inscribed clay tablets with some of the earliest medical records. c. 1862: Egyptologist Edwin Smith purchased papyrus scroll dating back to 1500 B.C.E.; contained 48 medical case histories with data arranged in head-to-toe order of severity d. King Hammurabi of Babylon commissioned a large painting of 282 case laws known today as the “Code of Hammurabi.” 1) One section of code devoted to regulation of medical fees and penalties e. Around 900 C.E., Anglo Saxons used a hammock suspended across a horse-drawn wagon for transport. f. By 1100, Normans devised a litter carried between two horses to transport patients. g. First recorded use of ambulance in the Siege of Malaga in 1487 4. The Napoleonic Wars

Teaching Tips Explore the history of EMS with students, expanding on the role the military has played, as well as the most recent developments with curriculum changes.

Discussion Topics Discuss with students why EMS struggles with funding at the city and state level and through insurance and changes that have occurred in the standard of care for the paramedic.

Class Activities Create a timeline of dates and important events in EMS history. Have students match them. (You may want to do this ahead of time. It works well if cards are laminated, which allows taping to the board.)

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Master Teaching Notes

a. Ambulances often used to evacuate the wounded in wars between Napoleon’s French Empire and other European countries 5. The United States in the Nineteenth Century a. Development of ambulances in U.S. occurred in first part of nineteenth century b. Civil War surgeon Jonathan Letterman c. Clara Barton – concept of ambulance volante d. First civilian ambulance established in 1860 (before the Civil War) in Cincinnati, Ohio, by Commercial Hospital e. Bellevue Hospital began to operate an ambulance service in 1869. f. Michael Reese Hospital began to operate a motorized ambulance in 1899. B. The Twentieth Century 1. From World War I to World War II a. High mortality rate associated with evacuation time of 18 hours b. System of transportation to increasing echelons was created c. Physician interns on ambulances d. 1926: Phoenix Fire Department “inhalator” service e. 1928: First bona fide rescue squad, the Roanoke Life Saving Crew, started f. 1929: Period of the Great Depression; few changes in civilian ambulance services 2. Effects of World War II a. Demands of war caused many hospital-based ambulance services to shut down b. Many city governments turned ambulance services over to local police and fire departments. c. No requirements for minimal training or care d. Ambulance work often seen as a punishment 3. Post–World War II a. End of war brought prosperity to U.S. b. Several medical advances occurred simultaneously. 4. The 1950s a. Use of helicopters in Korean War and Vietnam War ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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Master Teaching Notes

b. 1956: Peter Safar and James Elam pioneered use of mouth-tomouth resuscitation c. 1959: First portable defibrillator used at Johns Hopkins Hospital 5. The 1960s a. 1966: Publication of Accidental Death and Disability: The Neglected Disease of Modern Society (National Academy of Sciences, National Research Council) 1) “White Paper” spelled out deficiencies in prehospital emergency care 2) Suggested guidelines for development of EMS systems, training of prehospital emergency medical providers, and upgrading ambulances and their equipment 3) Identified numerous problems b. Civilian EMS, as we know it today, evolved significantly in 1960s c. 1966: Highway Safety Act promulgated initial EMS guidelines for the U.S. 6. The 1970s a. 1970: National Registry of Emergency Medical Technicians established b. 1973: Congress passed Emergency Medical Services Systems Act 7. The 1980s a. Passage of the Consolidated Omnibus Budget Reconciliation Act (COBRA) essentially wiped out funding for EMS b. 1988: Statewide EMS Technical Assessment Program established by NHTSA 1) Regulation and policy 2) Resources management 3) Human resources and training 4) Transportation 5) Facilities 6) Communications 7) Trauma systems 8) Public information and education 9) Medical direction ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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10) Evaluation c. Helicopter air ambulances 8. The 1990s a. 1990: Trauma Care Systems and Development Act passed by Congress b. 1993: Emergency Medical Services for Children, published by the Institute of Medicine c. 1995: Significant variability in trauma system care across U.S. d. Ontario Prehospital Advanced Life Support (OPALS) study 9. EMS Agenda for the Future a. In 1966, National Highway Traffic Safety Administration (NHTSA) published EMS Agenda for the Future; proposed 14 core EMS attributes 1) Integration of health services 2) EMS research 3) Legislation and regulation 4) System finance 5) Human resources 6) Medical direction 7) Education systems 8) Public education 9) Prevention 10) Public access 11) Communication systems 12) Clinical care 13) Information systems 14) Evaluation C. The Twenty-First Century 1. Department of Homeland Security established 2. National Incident Management System (NIMS) 3. Less than ideal emergency response in 2005: Hurricane Katrina and Hurricane Rita a. Additional changes made to improve Federal Emergency Management Agency (FEMA) following these disasters ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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4. 2010: EMS began to fill nontraditional roles through community paramedicine and mobile integrated health care programs. 5. EMS at the Crossroads a. Current delivery system suffers in a number of key areas: 1) Insufficient coordination 2) Coordination of transport within regions is limited. 3) Disparities in response time 4) Uncertain quality of care 5) Lack of readiness for disasters 6) Divided professional identity 7) Limited evidence base 6. National Report Card on the State of Emergency Medicine a. The National Report Care on the State of Emergency Medicine: Evaluating the Environment of Emergency Care Systems State by State (2006) 1) Pointed out significant problems in all aspects of emergency care 2) Primarily addressed problems in hospital departments but also EMS issues 3) Overall, report detailed that emergency services in U.S. are so overstressed that quality of care has been compromised 4) Each state given a letter grade that reflected the reported standard of emergency care in that state 7. Helicopter Air Ambulance Recommended Improvements a. 2001: Federal reimbursement for medical helicopters improved b. 2008: Record number of helicopter air ambulance crashes c. 2009: National Transportation Safety Board (NTSB) held hearings and later recommended sweeping changes for industry

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Content Outline

IV. Today’s EMS Systems A. Various service types of EMS: 1. Fire-based 2. Third service 3. Private (profit or nonprofit) 4. Hospital-based 5. Volunteer 6. Hybrid A. Chain of Survival 1. Emergency health care may begin long before an emergency occurs. a. Preventive health care measures b. EMS personnel may periodically visit high-risk and homebound citizens and assess their health status and needs. 2. Chain of survival – consists of the five most important factors affecting survival of a cardiac arrest patient a. Immediate recognition and activation of EMS b. Early CPR c. Rapid defibrillation d. Effective advanced life support e. Integrated post–cardiac arrest care

Master Teaching Notes Teaching Tips Review all of the components with the student. Most information should be familiar.

V. Essential Components for Continuum of Care A. Health Care System Integration 1. EMS recognized as major component of modern health care

system 2. Renewed emphasis on roles and responsibilities of EMS system

in all types of cardiac emergencies 3. PSAPS are primary interface between EMS and communities it

serves 4. Role of EMS extremely important in identification of acute

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Master Teaching Notes

5. EMS stepping up and assuming important role as initial

component and gatekeeper of modern health care system B. Levels of Licensure/Certification 1. Emergency Medical Responder (EMR) 2. Emergency Medical Technician (EMT) 3. Advanced EMT (AEMT) 4. Paramedic C. Quality of Education 1. National EMS Core Content, published by NHTSA in 2005

a. Defined body of knowledge, skills, and abilities desired in EMS personnel 2. The National EMS Scope of Practice, published in 2005 a. Consensus document; supported a system of EMS personnel licensure that was common in other allied health professions b. Serves as a guide for states and territories in developing their scope of practice legislation, rules, and regulations D. Oversight by Local- and State-Level Agencies 1. Oversight agency responsible for managing local system’s resources, developing operational protocols, and establishing standards and guidelines 2. Agency designates who may function within the system and develops policies consistent with existing state requirements 3. Creates quality assurance or quality improvement program E. Medical Oversight 1. Medical director – a physician who is legally responsible for all clinical and patient-care aspects of the system 2. Roles of medical director a. Educate and train personnel b. Participate in personnel and equipment selection c. Develop clinical protocols in cooperation with expert EMS personnel ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Points to Emphasize Focus on medical direction and off-line, online, prospective, and retrospective. Explain to students what to do if they have a physician arrive on their scene. Discuss with students the importance of safety. Have them list examples of unsafe practices in EMS and how those practices

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Content Outline d. Participate in quality improvement and problem resolution e. Provide direct input into patient care f. Interface between EMS system and other health care agencies g. Advocate within the medical community h. Serve as the “medical conscience” of the EMS system, including advocating for high-quality patient care 3. On-Line Medical Direction a. Occurs when a qualified physician gives direct orders to a prehospital care provider by either radio or telephone b. Medical direction may be delegated to a mobile intensive care nurse (MICN), advanced practice practitioner, or paramedic. c. Offers several benefits to the patient 1) Gives EMS provider direct and immediate access to medical consultation for specific patient care 2) Allows for transmission of essential data 3) Recordings can be used for peer review d. When a nonaffiliated physician or intervener physician is on scene and on-line medical direction may not exist, the paramedic should relinquish responsibility to the physician. 4. Off-Line Medical Oversight a. Refers to medical policies, procedures, and practices that a system medical director has established in advance of a call b. Includes prospective medical oversight and retrospective medical oversight c. Clinical protocols – policies and procedures of all medical components of an EMS system; the responsibility of the medical director d. Protocols designed around the four “Ts” of emergency care 1) Triage 2) Treatment

Master Teaching Notes can be improved.

Class Activities If not already done, take students through a mock peer review, first using a positive approach, then a negative approach. Discuss with students how a negative approach affects the review.

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Content Outline 3) Transport 4) Transfer F. Public Information and Education 1. EMS should have a plan to educate the public on recognizing an emergency, accessing the system, and initiating basic life support (CPR, bleeding control). 2. Teachable moment – an unplanned opportunity to present information when circumstances are such that a person is likely to understand and accept the information G. Effective Communications 1. Comprehensive, flexible communication plan includes: a. Citizen access b. Single control center c. Operational communications capabilities d. Medical communications capabilities e. Communications hardware f. Communications software 2. Emergency Medical Dispatcher a. Sends ambulances to the scene b. Makes sure system resources are in constant readiness to respond c. Must be medically and technically trained 3. Emergency Dispatch a. Nerve center of EMS system b. Means of assigning and directing appropriate medical care to patients c. Should be under full control of medical director and EMS agency d. Priority dispatching – EMDs are trained to medically interrogate a distressed caller, prioritize symptoms, select an appropriate response, and give life-saving prearrival

Master Teaching Notes

Knowledge Application Assign students a 5-minute homework project that includes presenting a safety program to family/friends in an informal setting, and have the participants write an evaluation on how the information given will aid them in staying safe and healthy (e.g., texting and driving, use of seat belts, rugs in the kitchen)

Discussion Topics Discuss different education programs paramedics might be called on to present. Discuss with students why they think it is important for the initial training program to 10

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Content Outline instructions e. Effective system places first responding units on scene within minutes of onset of the emergency H. Initial and Continuing Education Programs 1. Initial education – original courses for prehospital providers a. Three specific learning domains: 1) Cognitive 2) Affective 3) Psychomotor b. Accreditation process: primary accrediting body is CAAHEP 2. Continuing education – programs that include refresher courses for recertification and periodic in-service training sessions b. Traditional lectures and prepackaged programs c. Web-based programs, podcasts, videos, and similar alternative delivery methods d. Continuing education is mandatory. I. Licensure, Certification, Registration, and Reciprocity 1. Licensure – a process of occupational regulation a. Governmental agency grants permission to engage in a certain trade or profession to an applicant who has attained the degree of competency required to ensure the public’s protection 2. Certification – process by which an agency or association grants recognition to an individual who has met its qualifications 3. Registration – accomplished by entering one’s name and essential information within a particular record 4. Reciprocity – the process by which an agency grants automatic certification or licensure to an individual who has comparable certification or licensure from another agency 5. National Registry of EMTs a. Nonprofit entity based in Columbus, OH

Master Teaching Notes follow a standard teaching curriculum. Discuss what could happen if there were no standard rules for education in EMS.

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Master Teaching Notes

b. Prepares and administers standardized tests for various EMS provider levels c. Establishes qualifications for registration and serves as a vehicle for establishing a national minimum standard of competency J. Staying Abreast 1. Professional Organizations a. National Association of Emergency Medical Technicians (NAEMT) b. National Association of Search and Rescue (NASAR) c. National Association of EMS Educators (NAEMSE) d. National Association of EMS Physicians (NAEMSP) e. International Flight Paramedics Association (IFPA) f. National EMS Management Association (NEMSMA) g. National Council of State EMS Training Coordinators (NCSETC) 2. Professional Journals and Magazines a. Academic Emergency Medicine b. American Journal of Emergency Medicine c. Annals of Emergency Medicine d. Emergency Medical Services e. Journal of Emergency Medical Services (JEMS) f. Journal of Pediatric Emergency Medicine g. Journal of Trauma: Injury, Infection and Critical Care h. Prehospital Emergency Medicine 3. The Internet a. Numerous websites designed for EMS providers b. Trade magazines and similar entities offer websites c. Numerous websites provide quality, accredited continuing education programs d. Didactic portion of initial EMS education also available on ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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Internet e. International EMS discussions and networking K. Effective Patient Transportation 1. Air Transport a. Trauma care systems today use law enforcement, municipal, hospital-based, private, and military helicopter transport services to transfer patients. b. Fixed-wing aircraft used when patients must be transported long distances, usually more than 200 miles 2. Ambulance Standards a. All transport vehicles must be licensed and meet local and state EMS standards. b. Equipment lists should be consistent with statewide standards. c. “KKK-A-1822” Federal Specifications for Ambulances 1) Type I 2) Type II 3) Type III d. Only certified ambulances may display the registered “Star of Life” symbol as defined by NHTSA. e. Variety of specialized equipment may be on board ambulances f. Diesel ambulance g. “KKK-A-1822A” aimed at improving ambulance electrical systems to reduce overload. h. “KKK-A-1822E” provided guidelines to improve occupant protection in patient compartment. i. “KKK-A-1822F” primarily addressed electrical systems, signage, and safety. L. Appropriate Receiving Facilities 1. Hospitals organized into categories that identify readiness and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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capability of each hospital and its staff to receive and effectively treat patients 2. Categorization initially designed to identify trauma care capabilities for hospitals 3. Examples: burn, trauma, pediatric, psychiatric, perinatal, cardiac, etc. M. Mutual Aid and Mass-Casualty Preparation 1. Mutual aid agreements ensure that help is available when needed. 2. Cooperation must transcend geographical, political, and historical boundaries. 3. Disaster plans should be put in place by each EMS system. N. Quality Assurance and Improvement 1. Quality assurance program – designed primarily to maintain continuous monitoring and measurement of the clinical care delivered to patients 2. Continuous quality improvement (CQI) – ongoing effort to refine and improve the system to provide the highest level of service possible a. “Plan, do, check, act.” b. Rules of evidence 1) There must be a theoretical basis for the change. 2) There must be ample scientific human research to support the idea. 3) It must be clinically important. 4) It must be practical, affordable, and teachable. 3. “Take-It-for-Granted” Quality a. Quality improvement through continuous evaluation 4. Service Quality and Customer Satisfaction a. Communication through body language and tone of voice b. Serve the patient by providing the highest-quality service ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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and care available 5. Patient Safety

a. Primary tenet of medicine: primum non nocere (first, do no harm) b. Causes for medical errors: 1) Skills-based failures 2) Rules-based failures 3) Knowledge-based failures c. High-risk areas of EMS: 1) Hand-off 2) Communications issues 3) Medication issues 4) Airway issues 5) Dropping patients 6) Ambulance crashes 7) Death pronouncements O. Research 1. Formal, ongoing research program is essential component for moral, educational, medical, financial, and practical reasons 2. Funding relies heavily on research. 3. Paramedics play a valuable role in data collection, evaluation, and interpretation of research. P. Evidence-Based Medicine (EBM) 1. The conscientious, explicit, and judicious use of the current best scientific evidence in making decisions about the care of individual patients 2. Requires combining clinical expertise with the best available clinical evidence from systematic research Q. System Financing 1. Most common source for funding is fee-for-service revenue, which may be generated from Medicare, Medicaid, private insurance companies, specialty service contracts, or private paying patients. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Knowledge Application Assign students an assignment of finding two to four research articles from professional magazines, journals, Internet, etc. Have them write a few paragraphs on whether they agree or disagree with the information and why.

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2. Third-party reimbursement rarely covers expenses of operating an EMS system.

VI. Summary A. Evolution of EMS has occurred over thousands of years. B. Comprehensive EMS system has many components. C. EMS systems designed with patient as highest priority D. Most EMS systems activated by way of a single, universal number

(911) Mutual aid agreements ensure a continuum of care during multiplecasualty incidents. F. Continuous quality improvement programs document EMS system performance. E.

VI. Case Study

VII. You Make The Call 5

Class Activities Read and discuss the You Make the Call scenario, and answer the critical thinking questions as a group.

VIII. Review Questions 5

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 3 Roles and Responsibilities of the Paramedic 90 Minutes

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

Chapter 3 objectives can be found on text p. 42. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Class Activities Have a student read the case, and have another student document on the board the people involved EXCLUDING the paramedic crew. This will be reviewed after the lecture.

II. Introduction A. Paramedicine is an enormous responsibility that requires physical, mental, and emotional preparedness. B. Strong knowledge of pathophysiology and most up-to-date medical technology is required. III. Primary Responsibilities A. Paramedic’s responsibilities are diverse. B. Include emergency medical care for the patient and a variety of other responsibilities that are attended to before, during, and after the call C. Preparation 1. The paramedic must be mentally, physically, and emotionally ready to meet the demands of the patient, the family, and other health care providers. 2. Ongoing training includes aerobics for cardiovascular fitness, exercises for muscle strength and endurance, stretching for increased flexibility, and understanding of biomechanics of lifting for prevention of lower-back injuries. 3. Ensure that inspection and routine maintenance have been completed on emergency vehicle. D. Response 1. Personal safety is the number-one priority, so care must be taken

Teaching Tips Make sure students understand that their responsibilities do not include just patient care.

Discussion Topics Have students list possible unsafe scenes and think of ways they could make them safe, including what resources they would use.

Critical Thinking Questions What would happen to your patient if you were injured? How would the quality of patient care be affected? Should a paramedic be held accountable for purposely 1

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Content Outline E.

in operating the ambulance and beginning a proper scene size-up before arrival using dispatch information. Scene Size-Up 1. Primary concern during scene size-up is safety of your crew, patient, and bystanders 2. Never enter an unsafe scene until hazards have been dealt with. 3. Any scene has the potential to deteriorate. 4. Identify the mechanism of injury (MOI) or the nature of the illness (NOI). Patient Assessment 1. This is one of the most critical skills you will learn. 2. Basic components: primary assessment, patient history, secondary assessment, and ongoing assessment Recognition of Illness or Injury 1. This is the first aspect of patient prioritization. 2. Most commonly, patient priority is based on urgency for transport Patient Management 1. Always follow your system’s protocols. 2. Ensure use of proper equipment and availability of adequate personnel when moving patients from one location to another. Appropriate Disposition 1. Transportation a. Mode of transportation, via ground or air, is based on time and distance. b. Transport to the appropriate facility in a timely manner is critical for patient outcome. 2. Receiving Facilities a. Knowing the specialty of receiving hospitals allows the paramedic to make a sound decision for patient care. b. Level I, II, III, and IV trauma centers c. Burn, pediatric, psychiatric, perinatal, cardiac, spinal, and poison centers 3. Other Types of Disposition a. In some areas, paramedics provide primary care at the

Master Teaching Notes putting himself in harm’s way? Why or why not?

Class Activities Put together a small jump kit with a laryngoscope, ET tube, airway equipment, etc. Take the batteries out of the laryngoscope, and have students respond to a mock scenario in the classroom with the patient needing intubation. Discuss with them the importance of checking their equipment. Give students a scenario and a blank run report. Have each of them document the call, then have a few students read them to a “pretend” receiving hospital (another student, instructor). Have a few students pretend to be paramedics, a patient, and a receiving hospital. Perform a patient transfer properly, then improperly, to identify the crucial components and dangers of an improper patient transfer.

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scene and then transfer patients to facilities other than a hospital. b. “Treat and release” disposition – paramedics arrive on scene, assess patient, and provide emergency care; if no need for further medical attention, medical direction is contacted and orders not to transport are requested. J. Patient Transfer 1. First priority during patient transfer is the patient. 2. While en route, contact receiving facility and provide ETA and update on patient’s condition. 3. On arrival at destination, seek out contact person (usually a registered nurse or physician) and provide an updated patient report. K. Documentation 1. Patient care report is essential to flow of patient information, to research efforts, and to the quality improvement of EMS system a. Patient care report should be completed in its entirety as soon as emergency care has been completed. b. Record only your observations, not your opinion. c. Report should be complete, neat in appearance, and written legibly with no spelling errors. d. Report will be a reflection of emergency care provided if a lawsuit is filed in the future. L. Returning to Service 1. Clean and decontaminate the unit, properly discard disposable materials, restock supplies, and replace and stow away equipment. 2. Refuel the unit if necessary. 3. Review the call with crew members, including any problems that may have occurred. 4. Paramedic team leader should check crew members for signs of critical incident stress and assist anyone who needs help.

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Content Outline IV. Additional Responsibilities A. Administration 1. Duties the paramedic performs to ensure efficient operation of the EMS system 2. Station duties, record keeping and reporting, special projects, and developing interagency relationships B. Community Involvement 1. Teaching basic first aid measures, how to properly access the EMS system, prevention projects 2. Benefits of community involvement a. Enhances visibility of EMS b. Promotes positive image c. Puts forth EMS personnel as positive role models d. Creates opportunities to improve integration of EMS with other health care and public safety agencies through cooperative programs C. Support for Primary Care 1. Development of prevention and wellness programs that decrease need for emergency services 2. Established protocols that specify mode of transportation for nonemergency patients 3. Transport of patients to freestanding outpatient centers or clinics as an alternative to the emergency department 4. Caution should be taken to ensure that the patient always receives the appropriate emergency care based on need, not cost. D. Citizen Involvement in EMS 1. Helps to give “insiders” an outside, objective view of quality improvement and problem resolution 2. Community members are “customers” and their needs are your priority. E. Personal and Professional Development 1. Continuing education and recertification ensures that high-quality patient care is being delivered consistently. 2. Goal is to review previously learned materials and to receive new

Master Teaching Notes Discussion Topics List ways in which the paramedic can stay current on education, both traditional and nontraditional.

Critical Thinking Questions What guidelines should be in place before a service decides on transport of a patient versus denying transport? What could the legal ramifications be?

Points to Emphasize At no point should a patient not be transported because of an inability to pay.

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information. 3. New technology and data emerge rapidly. 4. Participate in activities designed to address work-related issues. 5. Alternative career paths may open as well.

V. Professionalism A. Professional Ethics 1. Ethics are the rules or standards that govern the conduct of members of a particular group or profession. 2. Ethics are not laws, but they are a standard for honorable behavior. B. Professional Attitudes 1. Health care professionals put their patients first and set high standards for themselves. 2. A professional paramedic is responsible for acting in a professional manner both on and off duty. C. Professional Attributes 1. Leadership a. Self-confidence b. Established credibility c. Inner strength d. Ability to remain in control e. Ability to communicate f. Willingness to make a decision g. Willingness to accept responsibility for the consequences of the team’s actions 2. Integrity a. Single most important behavior by which paramedic is judged is honesty. b. You must be trustworthy. c. Follow protocols and accurately document all patient care. 3. Empathy a. Be supportive and reassuring. b. Demonstrate an understanding of the patient’s feelings and the

Teaching Tips Stress to students that they are not just “ambulance drivers.” Paramedicine is a true profession that requires them to act the part all of the time.

Discussion Topics Have students list the traits they think make someone a professional. Go online and pull up some articles relating to EMT and paramedic thefts, poor judgment, etc. Discuss these as a group.

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feelings of the family. c. Demonstrate respect for others. d. Have a calm, compassionate, and helpful demeanor. Self-Motivation a. Complete assigned duties without being asked or told to do so. b. Complete all duties and assignments without the need for direct supervision. c. Correctly complete all paperwork in a timely manner. d. Demonstrate a commitment to continuous quality improvement. e. Accept constructive feedback in a positive manner. f. Take advantage of learning opportunities. Appearance and Personal Hygiene a. Wear a clean, pressed uniform. b. Be well groomed. c. Hair should be kept off the collar. d. If facial hair is allowed, it should be kept neat and trimmed. e. A light-colored t-shirt may be worn under your uniform shirt, which should be buttoned up, with only the top collar button open. f. Jewelry – other than a wedding ring, a watch, or small plain earrings – is unprofessional. g. Long fingernails should be avoided. Self-Confidence a. Have confidence in yourself and your abilities. b. Accurately assess your strengths and limitations, then seek opportunities to improve any weaknesses. c. Ask for assistance when you need it. Communication a. Constant communication is required with the patient, family, bystanders, and other EMS providers and rescuers from other agencies. b. Gather all patient information in a clear, concise format. c. Speak clearly, listen actively, and write legibly.

Master Teaching Notes

Class Activities Have a student dress in old, dirty clothes and perform a patient assessment. Have another student perform an assessment with a disinterested attitude and another with a lack of confidence. Discuss with the class how these examples of a lack of professionalism can hinder patient care.

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d. Speak in a way that is appropriate to your audience. 8. Time Management a. Be punctual for shifts and meetings. b. Complete tasks on or ahead of schedule. c. Tips include making lists, prioritizing tasks, arriving at meetings or appointments early, and keeping a personal calendar. 9. Teamwork and Diplomacy a. Place the success of the team ahead of personal self-interests. b. Never undermine the role or opinion of another team member. c. Provide support for members of the team, both on and off duty. d. Remain open to suggestions from team members, and be willing to change for the benefit of the patient. e. Communicate openly with everyone. f. Above all, respect the patient, other care providers, and the community. 10. Respect a. Show and feel deferential regard, consideration, and appreciation for others. b. Show that you care for the patient and family members. c. Be polite. d. Avoid the use of demeaning or derogatory language toward even the most difficult patients. 11. Patient Advocacy a. Defend, protect, and act in the best interests of your patient. 12. Careful Delivery of Service a. Master and refresh skills. b. Perform complete equipment checks. c. Perform careful and safe ambulance operations. d. Follow policies, procedures, and protocols. D. Continuing Education 1. Maintaining certification is the responsibility of the paramedic. 2. Paramedics cannot work without satisfying continuing education requirements. 3. Continuing education programs provide the opportunity to review ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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material and address weak points inpatient care.

VI. Summary 5

A. As a paramedic, you must be willing to accept the responsibility of being a leader in the prehospital phase of emergency medical care. B. Responsibilities of the paramedic include on-call emergency duties and offduty preparation. C. The best paramedics are those who make a commitment to excellence.

VII. Case Study 5

VIII. You Make the Call

Referring to the list that was created during the Case Study, change an attitude of one of the care providers anywhere during the call, except for the paramedics. Have students discuss what the patient’s attitude may be toward health care workers, even though the prehospital care was appropriate. This scenario can be changed multiple times.

Class Activities

IX. Review Questions

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 4 Workforce Safety and Wellness 100–110 Minutes

     

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

Chapter 4 objectives can be found on text p. 58. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. Ensuring the safety and well-being of the workforce is a fundamental aspect of top-notch performance as a paramedic B. Death, dying, stress, injury, infection, and fear all threaten wellness. C. Most paramedic injuries are caused by lifting and being in or around motor vehicles. 1. Those who train to be physically prepared for their jobs as paramedics stand a better chance of avoiding early forced retirement due to an injured back or knees. 2. Those who train themselves to be mentally alert stand a better chance of staying alive and uninjured.

Teaching Tips

III. Prevention of Work-Related Injuries A. Ambulance collisions, lifting of patients, and long shifts all contribute to injuries and illness among EMS personnel. B. Because of a renewed interest in EMS provider safety and injury prevention, strategies are in place to prevent injuries and illness. C. Sleep, nutrition, and physical fitness play roles in long-term survival in EMS.

Discussion Topics

Stress to students that safety issues are the most important component of the prehospital professional.

Have students give you different scenarios that can cause injuries or illnesses at work and how they can prevent these. Discuss with students the different pieces of equipment that have made the workplace safer (needleless IVs, sharps containers, etc.).

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Content Outline IV. Basic Physical Fitness A. Unfortunately, physical fitness has not been a major emphasis in EMS. B. Benefits of achieving physical fitness:

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

Decreasing resting heart rate and blood pressure Increased oxygen-carrying capacity Increased muscle mass and metabolism Increased resilience to illness and injury Slows progression of osteoporosis Positive self-image Improved mental outlook Reduced anxiety levels

C. Core Elements 1. Muscular strength, cardiovascular endurance, and flexibility 2. Isometric exercise – active exercise performed against stable resistance, in which muscles are exercised in a motionless manner 3. Isotonic exercise – active exercise during which muscles are worked through their range of motion 4. Weight-lifting helps to achieve muscular strength and is excellent all-around training for the body. 5. Cardiovascular endurance results from exercising at least three days a week vigorously enough to raise your pulse to its target heart rate. 6. Even modest exercise programs will improve cardiovascular endurance and muscle strength. 7. Stretching every day improves flexibility. D. Nutrition 1. Good nutrition is fundamental to your well-being. 2. ChooseMyPlate chart (U.S. Department of Agriculture) a. Balance calories. b. Enjoy your food but eat less. c. Eat certain foods more often. d. Make half your plate fruits and vegetables. e. Switch to fat-free or low-fat (1%) milk. f. Make half your grains whole grains. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Master Teaching Notes Teaching Tips Make sure students understand the mechanisms of lifting.

Class Activities Using a dummy, have students practice different lifts, using correct body mechanics. Have students find their target heart rate.

Knowledge Application For homework, have students journal everything they eat and drink for a week.

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g. Eat some foods less often (e.g., foods high in solid fats and added sugars). h. Compare sodium in foods. i. Drink water instead of sugary drinks. 3. Review standardized nutrition labels. 4. Plan ahead and pack a cooler. 5. Monitor your fluid intake; your body needs plenty of fluids. 6. Exercising and eating well can help to prevent cancer and cardiovascular disease. 7. Exercise will improve cardiovascular endurance. 8. Include appropriate periodic risk-assessment screening and selfexamination habits in your personal well-being program. E. Habits and Addictions 1. High-stress jobs can lead to overuse and abuse of substances such as caffeine, nicotine, and alcohol. 2. Smoking cessation programs usually accessed in local areas or on the Internet 3. Many approaches to smoking addiction: medications, behavior modification, nicotine replacement therapy (patches), aversion therapy, hypnotism, and going “cold turkey” F. Back Safety 1. Always use proper lifting techniques every time you pick up a load, whether the load is heavy or light. 2. Condition the muscles that support the spinal column. 3. Muscles of the abdomen are also crucial to overall spinal-column strength and safe lifting. 4. Correct posture will minimize the risk of back injury. 5. Important principles of lifting: a. Move a load only if you can safely handle it. b. Ask for help when you need it. c. Position the load as close to your body and center of gravity as possible. d. Keep your palms up whenever possible. e. Do not hurry. f. Bend your knees, lower your buttocks, and keep your chin up. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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g. “Lock in” the spine with a slight extension curve, and tighten the abdominal muscles to support spinal positioning. h. Always avoid twisting and turning. i. Let the large leg muscles, not your back, do the work of lifting. j. Exhale during the lift. Do not hold your breath. k. Given a choice, push. Do not pull. l. Use help when moving patients up and down stairs and into and out of the ambulance. m. Look where you are walking or crawling. If you are walking, take only short steps. Move forward rather than backward whenever possible. n. When rescuers are working together as a team to lift a load, only one person should be in charge of verbal commands.

V. Personal Protection from Disease A. Personal protection from all disease is your goal and responsibility. B. Infectious Disease 1. Infectious diseases are caused by pathogens such as bacteria and viruses, which may be spread from person to person. 2. Bloodborne and airborne pathogens 3. HIV/AIDS, hepatitis B, hepatitis C, and tuberculosis are diseases of great concern because they are life threatening. 4. New and emerging diseases can also pose threats to EMS personnel. 5. You must consider the blood and body fluids of every patient you treat as infectious. 6. Safeguards against infection are mandatory for all medical personnel. C. Standard Safety Precautions 1. Following the standard safety precautions will minimize the risk for you, your patient, your partners, other responders, and the community. D. Infection Control Measures 1. Infection control practices are those procedures and practices used by health care personnel to minimize disease transmission and

Critical Thinking Questions Do you think that a paramedic who refuses vaccinations, then is exposed and develops the infection, is eligible for work compensation? Why or why not?

Class Activities Mix a small amount of red food coloring into clear Karo Syrup. Have each of students put on a pair of gloves, and spread the liquid on their gloves. Then have students remove their gloves in the proper manner. Look at their hands for any stickiness, then stress that any leftover liquid would be a potential exposure.

Knowledge Application For homework, have students list common viruses and their incubation periods.

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transmission of infectious agents. E. Standard Precautions 1. Strategies that include the major features of what were once called universal precautions (UP) – blood and body fluid precautions designed to reduce the risk of transmission of bloodborne pathogens 2. Also include body substance isolation (BSI) precautions designed to reduce the risk of transmission of pathogens from moist body substances 3. Standard Precautions apply UP and BSI concepts to all patients receiving care. They apply to: a. Blood b. All body fluids, secretions, and excretions except sweat, whether or not they contain visible blood c. Nonintact skin d. Mucous membranes 4. Appropriate personal protective equipment (PPE) should be available in every emergency vehicle: a. Protective gloves b. Masks and protective eyewear c. HEPA and N-95 respirators d. Gowns e. Resuscitation equipment f. Hand-washing supplies 5. Infectious diseases minimized through use of disposable equipment 6. Probably the most important infection control practice is handwashing. E. Ebola Virus Disease 1. Ebola virus is causative agent of Ebola virus disease (EVD) 2. EVD contracted through broken skin or mucous membranes by direct contact with: a. Blood or body fluids (included but not limited to urine, saliva, seat, feces, vomit, breast milk, and semen) of a person who is sick with or has died from EVD b. Objects (such as needles and syringes) that have been ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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contaminated with body fluids from a person who is sick with EVD or the body of a person who has died from EVD c. Infected fruit bats or primates (apes and monkeys) d. Possibly, semen from a man who has recovered from EVD 3. Recommended PPE for EVD includes: a. PAPR (powered-air purifying respirator) or N-95 respirator b. Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood c. Single-use (disposable) nitrile examination gloves with extended cuffs d. Single-use (disposable) fluid-resistant or impermeable boot covers that extend to at least mid-calf or single-use (disposable) shoe covers e. Single-use (disposable) fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if patients with EVD have vomiting or diarrhea 4. CDC recommendations for PPE protection levels for EMS personnel based on: a. PPE wearer’s possible exposure to Ebola b. Proximity to symptomatic patients F. Vaccinations and Screening Tests 1. There are many immunizations available to the EMS provider, including rubella (German measles), measles, mumps, chicken pox, other childhood diseases, tetanus/diphtheria, polio, influenza, hepatitis A and B, and Lyme disease. 2. Strains of influenza such as H1N1 (swine flu) or H5N1 (bird flu) can quickly reach endemic or pandemic levels. 3. Follow warnings from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and state and local public health officials. F. Decontamination of Equipment 1. Properly dispose of any PPE designed for single use and contaminated medical devices after they have been used. a. Discard in a red bag marked with a biohazard seal ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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2. Needles and other sharp objects should be discarded in properly labeled, puncture-proof containers. a. Dispose of container according to local guidelines 3. Nondisposable equipment that has been contaminated must be cleaned, disinfected, or sterilized. a. Cleaning refers to washing an object with soap and water. b. Disinfection means cleaning with a disinfecting agent. c. Sterilization is the use of a chemical or physical method such as pressurized steam to kill all microorganisms on an object. 4. If equipment requires more extensive cleaning, bag it and remove it to an area designated for this purpose. G. Post-Exposure Procedures 1. An exposure is any occurrence of blood or body fluids coming into contact with nonintact skin or the eyes or other mucous membranes or by parenteral contact. 2. If you experience an exposure: a. Wash the affected area with soap and water. b. Get a medical evaluation. c. Take the proper immunization boosters. d. Notify the agency’s infection control liaison. e. Document the circumstances surrounding the exposure, including the actions taken to reduce chances of infection. 10

VI. Death and Dying A. Paramedics encounter death much more frequently than most other people do, and this can lead to a cumulative sense of overload. 1. Paramedic must recognize and deal with this overload in a health manner through appropriate grief work and stress management B. Cultural Considerations 1. Emotional response to death varies significantly among cultures and individuals 2. People grieve differently, and you must recognize this. 3. Use simple terms and avoid euphemisms. C. Loss, Grief, and Mourning 1. Five predictable stages of grief, as categorized by Elisabeth Kübler-

Class Activities Set up a scenario with a dying patient, family members, and paramedics. Have each person go through a particular stage of grief while on scene, and assess each paramedic’s response.

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Ross: a. Denial, or “Not me” b. Anger, or “Why me?” c. Bargaining, or “Okay, but first let me …” d. Depression, or “Okay, but I haven’t …” e. Acceptance, or “Okay, I’m not afraid.” 2. Patients and their loved ones experience the stages in their own unique way. 3. Use every opportunity to process a specific incident in a healthy manner by appropriately grieving losses that have an impact on you. 4. Grief is a feeling; mourning is a process. 5. A sense of loss is most intense and incapacitating for the survivor in the first 5 to 15 minutes. A survivor cannot function during this grief spike. 6. A period of intense feelings that continues for around 4 to 6 weeks follows the grief spike. 7. People cope in various ways, and there are a wide variety of responses to death among different peoples and cultures. Be flexible, and be ready for anything. D. What to Say 1. Use caution in delivering the news of death, as you have no idea how people will respond. 2. Before speaking to survivors, position yourself between them and the door or other escape route. 3. Do not deliver the news to a large group. 4. Keep yourself at eye level with the survivor, and make sure that the survivor has a support system in place. 5. Use the term “died” or “dead” rather than euphemisms that may be misinterpreted or misunderstood. 6. Explain the local procedures such as the inspection of the scene by the medical examiner or coroner, and so on. 7. Do not include statements about God’s will or relief from pain or any subjective assessment. E. When It Is Someone You Know ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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1. You may respond to a call where you recognize or know the deceased. 2. There is a lot of support for paramedics in small communities. 3. You must manage the stress and grieve your loss.

VII. Stress and Stress Management A. Stress is the “nonspecific response of the body to any demand.” (Seyle) 1. Stress responses are natural reactions that help you to adapt to a new environment or a sudden change in the usual environment. 2. A stimulus that causes stress is known as a stressor. 3. Stress can be beneficial (eustress) or detrimental (distress). 4. Mechanisms that allow you to deal with stress include: a. Defensive strategies b. Coping c. Problem-solving skills 5. To manage stress, you should learn: a. Your personal stressors b. The amount of stress you can take before it becomes a problem c. Stress management strategies that work for you B. Phases of Stress Response 1. Three phases of a stress response: a. Alarm: the fight-or-flight phenomenon; occurs when the body physically and rapidly prepares to defend itself against a perceived threat. Hormones are released, increasing heart rate and blood pressure; blood sugar increases; pupils dilate; digestion slows; and the bronchial tree relaxes. b. Resistance: stage when the individual begins to cope with stress by desensitization or adaptation to stressors c. Exhaustion: prolonged exposure to the same stressors leads to exhaustion of an individual’s ability to resist and adapt C. Shift Work 1. EMS is a 24-hour, 7-days-a-week endeavor, which means that someone must be functional at all times. 2. Working different shifts affects the circadian rhythm, which is the

Discussion Topics Discuss with students what positive physical findings occur with the fight-orflight response and how it can help them perform their job.

Class Activities Have students list signs and symptoms they may observe in their partners or themselves if they are suffering from stress.

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biological 24-hour clock that regulates sleeping, appetite, etc. 3. If you work at night and have to sleep in the daytime: a. Sleep in a cool, dark place that mimics the nighttime environment. b. Stick to sleeping at your anchor time, even on days off. c. Unwind appropriately after a shift to rest well. Do not eat a heavy meal or exercise right before bedtime. d. Post a “day sleeper” sign on your front door, turn off your phone’s ringer, and lower the volume of the answering machine. Signs of Stress 1. Signs and symptoms may be physical, emotional, cognitive, or behavioral, and all signs are unique to each person. Common Techniques for Managing Stress 1. Two main types of defense mechanisms and techniques for managing stress: beneficial and detrimental 2. Detrimental techniques: substance abuse, overeating or other compulsve behaviors, chronic complaining, freezing out or cutting off others, avoidance behaviors, dishonesty about actual state of well-being 3. Beneficial techniques: controlled breathing, reframing thoughts, and attending to medical needs of patient Specific EMS Stresses 1. Daily stress 2. Small incidents 3. Large incidents and disasters Post-Traumatic Stress Disorder (PTSD) 1. An anxiety disorder that develops following exposure to traumatic events 2. Commonly seen in military personnel exposed to horrors of war 3. Recognized under various names (e.g., shell shock, combat exhaustion, survivor’s guilt) 4. Symptoms include: a. Recurrent, unwanted distressing memories of the traumatic event(s) b. Reliving the traumatic event as if it were happening again

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(flashbacks) c. Recurring and unsettling dreams about the traumatic event(s) d. Severe emotional distress or physical reactions to something that reminds the person of the event 5. May include avoidance of situations and places that bring back thoughts and images of traumatic event(s) 6. Research is unclear as to whether there is an increased incidence of PTSD in EMS personnel 7. Code Green Campaign – serves to raise awareness of mental health issues in first responders 8. Tema Conter Memorial Trust – provides peer and psychological support for public safety personnel H. Mental Health Services 1. Basic principles of psychological first aid include: a. Contact and engagement b. Safety and comfort c. Stabilization d. Information gathering (current needs and concerns) e. Practical assistance f. Connection with social supports g. Information on coping h. Link to collaborative services 2. These services attempt to deal with emotional responses as they occur. H. Disaster Mental Health Services 1. Evidence shown that CISM and CISD to no appear to mitigate the effects of traumatic stress, and may interfere with normal grieving and healing process and should not be used 2. Mental health practitioners recommend resiliency-based care. a. Includes techniques and activities that promote emotional strength, while at the same time decreasing vulnerability to stress, adversity, and challenges

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Content Outline VIII.General Safety Considerations A. Topic of scene safety is vast and requires career-long attention B. Risks include violent people, environmental hazards, structural collapse, motor vehicles, and infectious disease. C. Wear whatever protective equipment you have. D. Interpersonal Relations 1. Interpersonal safety begins with effective communication. 2. Building rapport depends on the ability to put your personal prejudices aside. 3. Learn about the cultural backgrounds of people in your area and how to work with them effectively. E. Roadway Safety 1. Motor vehicle collisions are the greatest hazard for EMS personnel. 2. For all related emergency situations, acquire the necessary training for emergency rescue and for the safe use of emergency rescue equipment. 3. Learn the principles of: a. Safely following an emergency escort vehicle b. Intersection management c. Noting hazardous conditions d. Evaluating the safest parking place e. Safely approaching a vehicle in which someone is slumped over the wheel f. Patient compartment safety g. Safely using emergency lights and siren 4. An ambulance escort can create additional hazards. 5. Multiple-vehicle responses can be dangerous as well; extreme caution must be taken when approaching intersections. 6. Wear protective gear. 7. AWAYS wear your seatbelt.

Master Teaching Notes Critical Thinking Questions What can you do as a paramedic to make your scene safer?

Points to Emphasize Be aware of dangerous activities that other drivers do that may prevent them from observing an ambulance (texting, talking on the phone, eating, etc.).

IX. Summary A. The paramedic is a leader within the prehospital care community. B. Paramedics who attend to their own well-being are not only helping themselves, but they are also providing a positive role model for other EMS

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providers and the community at large. C. Continuous assessment of personal lifestyle ranges from practices that affect the immediate future to practices that affect the paramedic in old age. D. There are numerous elements to the topic of well-being, and the paramedic must continually address each one. X. Case Study 5 XI. You Make the Call 5

Class Activities Go back to the list created in the beginning, and take out the safe practices. Discuss with students how removal of safety completely changes the call.

XII. Review Questions 5

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 5 EMS Research 130–140 Minutes

    

Teaching Tips Discussion Topics Class Activities Points to Emphasize Knowledge Application

Chapter 5 objectives can be found on text p. 84. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. Scientific research has played a major role in the evolution of modern EMS. B. When EMS was developed 30 years ago, EMS practice was based on opinions and rational conjecture. C. As we move into the twenty-first century, many EMS practices have been examined through research methods. D. A solid and objective research program is what should and will drive EMS practices in the coming years. E. Outcomes-based research can help to determine whether a procedure, drug, treatment, or similar strategy actually improves patient outcomes (morbidity, mortality, and quality of life). F. National EMS Research Agenda provided a guide to future research in the U.S. 1. Develop a cadre of EMS researchers and support them early in their careers. 2. Facilitate collaboration between EMS researchers and those from other disciplines. 3. Establish a reliable funding stream for EMS research within government. 4. Establish an alternative funding source for EMS research outside of government. 5. Recognize the need for EMS research.

Teaching Tips Discuss with students some patient care that is now outdated because of current research (MAST pants, etc.)

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6. View research as necessary for the improvement of patient care. 7. Enhance ethical approaches to research.

III. Research and the Scientific Method A. Use of the scientific method to study a given issue is known as research. B. Scientific method – a process by which scientists, collectively and over time, endeavor to construct an accurate representation of the world C. Scientific method follows these steps: 1. Observe and ask questions. 2. Conduct research, data collection, analysis, and synthesis. 3. Construct a hypothesis. 4. Test the hypothesis by experimentation. 5. Analyze results and draw conclusions. 6. Revise the hypothesis. 7. Report results.

Discussion Topics

IV. Types of Research A. Quantitative research – describes phenomena in numbers B. Qualitative research – describes phenomena in words C. Mixed research – a combination of quantitative and qualitative research; uses both numbers and words to describe the phenomena being studied D. Quantitative versus Qualitative 1. Quantitative research is objective and subjective, and it determines the relationship between an independent variable and a dependent or outcome variable. a. Independent variable – the variable that affects the dependent variable under study b. Dependent variable – the variable being affected or presumed affected by the independent variable 2. Qualitative research primarily relies on collective of nonnumeric data and seeks the “why” and not the “how” of the phenomena being studied. a. Primarily occurs in a natural setting b. Plays an important role in quality assurance

Points to Emphasize

Using an example of a research topic, take students through the scientific method.

Explain to students the importance of all types of research and how EMS applies to these types to current research.

Class Activities With the class, write out an independent variable that students can research. This could be the 10-minute scene time for major trauma, 8-minute ALS response time, etc. Have students decide what type of research would allow the most reliable information.

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Content Outline c.

Customer surveys and patient satisfaction rely heavily on this method E. Prospective versus Retrospective Studies 1. Prospective studies use a particular starting date and look at what happens from that date on. 2. Retrospective studies look at existing data. 3. Generally speaking, prospective studies have greater validity than retrospective studies. 4. There is more chance for the introduction of bias in the data gathering for retrospective studies. V. Experimental Design A. Different types of experiments include: 1. Experimental study a. Has both a control group and a treatment group (also called an experimental group) b. Subjects randomly assigned to one of the groups c. Considered among the most valid studies 2. Quasiexperimental study a. Subjects not randomly assigned to groups b. Useful study when randomization is unethical or impossible 3. Observational study a. No control group b. A single group or multiple groups are studied without comparison to a control. c. Considered less valid than experimental or quasiexperimental studies d. Play an important role in medicine B. Specific Study Types 1. Meta-analysis of randomized controlled trials a. Uses all research from randomized controlled trials b. Data are entered into a database, allowing analysis and conclusions c. Most valid type of study d. Labor intensive and difficult to perform 2. Randomized controlled trials a. Closely adheres to the scientific method

Master Teaching Notes

Discussion Topics Discuss with students the different types of studies. Use these to have students come to conclusions on which studies would be safest for the patient.

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b. c.

Extremely valid Subjects randomized into treatment group (or groups) and control group d. Single-blind and double-blind study and placebos e. Ability to avoid bias by subjects and/or researcher not knowing who is in each group Nonrandomized controlled trials a. Also called quasiexperimental studies b. Have a control group and a treatment group, but assignment to these groups is not randomized c. Study has less validity than an RCT Cohort study a. Observational study in which subjects who have a certain condition and/or who receive a particular treatment are followed over time and compared with another group who are not affected by the condition under investigation b. This study allows a better understanding of what factors cause differences (genetics, environment, etc.). Cross-sectional study a. Also called a cross-sectional analysis b. Various groups compared without a control c. Looks at a single point in time Case series a. A study that looks at a group of patients with a similar condition b. For example: “This research studies patients with similar disease findings and looks at the similarities and differences between patients in order to isolate a possible cause.” Case report a. A structured study of a single patient who is unique or interesting to the medical community in general b. Usually short reports with limited scientific validity Expert opinions, editorials, and rational conjecture a. Suitable for use before scientific research is available or while scientific research is occurring b. Can be problematic when research finally shows that the resulting

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practices are ineffective or harmful c. As additional information is revealed by the research process, these practices, or specific aspects of these practices, are considered to be of questionable benefit. 9. Animal research a. Also called in vivo (within the living) research b. Important in understanding how certain drugs and procedures affect biological systems c. Findings in one species do not necessarily apply to other species. d. Computer modeling is starting to replace some aspects of animal research. 10. Bench research a. Scientific research at its most basic level b. Often called in vitro (within the glass) research c. Often the first step in a research strategy that leads to animal and human research C. Study Validity 1. Important part of research that concerns whether or how well the study supports the conclusions 2. External validity – ensures that the results stay generalized or possess generalizability (the results will hold true for other persons at other places and in other times) 3. Internal validity – ensures that the results can be attributed to the cause and not to other possible causes 5

VI. Ethical Considerations in Human Research A. Ethical practices must be followed in regards to medical human research. 1. Nuremburg Code of 1947 – the first code to guide ethical practice in human research; established in response to experiments conducted on prisoners, primarily Jews, in German concentration camps 2. Between 1928 and 1972, the U.S. Public Health Service and researchers from Tuskegee University in Alabama allowed African American men with syphilis to remain untreated in order to study the natural progression of the disease. a. Men were never told they were infected, and little, if any, treatment

Discussion Topics Discuss with students the Nuremburg Code of 1947 and the Tuskegee University studies.

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was provided. 3. Fundamental principles of Helsinki Declaration of 1964 (last amended in 2013) a. Respect for the individual b. Ability of the subject to make an informed decision about participating in the research (initial and ongoing) c. Assurance by the researcher that the patient’s safety will be protected 4. The Belmont Report (formerly titled Ethical Principles and Guidelines for the Protection of Human Subjects of Research) released in 1979 B. Institutional Review Boards 1. Sometimes called the ethical review board or independent ethics committee 2. Approve, monitor, and review human research 3. Goal is to protect human subjects 4. Have the power to approve or disapprove a study before it begins 5. Have the power to require researchers to modify or even terminate a study if they think that the subjects are at risk

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Content Outline VII. An Overview of Statistics A. Statistics is the mathematics of collecting and analyzing data to draw conclusions and make predictions. B. Descriptive Statistics 1. Used to describe the basic features of the data obtained in a study 2. Provide a summary of the sample 3. With sample graphics, they form the basis of virtually every quantitative analysis of data 4. Most common descriptive statistic is the mean, or average 5. When data are not normally distributed, the median is a better way of finding a typical value 6. The mean and median are called measures of central tendency because they indicate the center of the group. 7. Two closely related measures of dispersion are the variance and standard deviation. 8. The mode is the most common value in a set of data. C. Inferential Statistics 1. Draw information from the sampled observations of a population, and make conclusions about the population 2. Sampling errors look at the difference between information gathered from values of samples and values from entire population 3. Variability can be added to and subtracted from the original proportion to give what is called a confidence interval. 4. Confidence intervals are very important because they allow for conclusions of statistically significant or insignificant results. D. Quantitative and Qualitative Statistics 1. Qualitative – nonnumeric data (nominal data/ordinal data) 2. Quantitative – numerical data (sometimes referred to as continuous data) E. Other Types of Data 1. t test, analysis of variance (ANOVA), chi square test 2. Odds ratio a. Used in case-control studies b. Describes how strong the association is between a risk factor and the condition with which it is associated

Master Teaching Notes Knowledge Application Give students the key terms, and assign the definitions for homework. In addition, have them give an example for each term.

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VIII. Format of a Research Paper A. Abstract (brief paragraph that summarizes the need for the study, the research methods used, and the results encountered) B. Introduction (first section of the paper; briefly describes the pertinent, previously published papers on the subject of the investigation and describes why the study was undertaken) C. Methods (describes how the authors conducted the study, including what population they wished to study, how subjects were selected, and what intervention was performed) D. Results (researchers provide data, or summary of data with tables, charts, and graphs; this section presents the data but does not elaborate on it) E. Discussion (authors’ interpretation of their findings and description of their significance F. Summary or Conclusion (very brief recap of the main findings of the study)

Knowledge Application

IX. How a Research Paper Is Published A. Once the paper is complete, it is sent to a scientific journal for publication. B. The paper is read, reviewed, and evaluated in a peer-review process. C. Your paper may not be published, based on selectivity of journal.

Discussion Topics

X. Accessing the Scientific Literature A. You may access scientific journals in medical school and university libraries, online, in community college and hospital libraries, through the National Libraries of Medicine database (PubMed), and through the National Libraries of Medicine document retrieval service, Loansome Doc.

Class Activities

XI. What to Look for When Reviewing a Study A. Questions to ask when reviewing a study include the following: 1. Was the research peer reviewed? 2. Was there a clear hypothesis or study purpose? 3. Was the study approved by an IRB, and was it conducted ethically? 4. Was the study type appropriate? 5. What population were the researchers studying? 6. What inclusion and exclusion criteria did the researchers use? 7. How did the investigators draw their sample? 8. How many groups were patients divided into, and were patients

Discussion Topics

For homework, have students write out the format of a research paper on the subject of your choice.

Bring in a scientific journal (JEMS, etc.) so that students can review a published study. Discuss the findings as a group. Go online with students to PubMed to look up a research paper of your choice.

Discuss with your students the information in Table 5-3 of this chapter. Allow them to respond “yes” or “no” to the questions. Then lead a discussion on why the research may not be valid with negative answers.

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assigned to control groups and study groups properly? 9. Were the control and study groups the proper size? 10. Were the effects of confounding variables (other things that may have affected the study outcome) taken into account? 11. What kind of data did the investigators collect, and did they analyze the data with proper statistical tests? 12. Were the results reported properly? 13. How likely is it that the study results would occur by chance alone? 14. Are the author’s conclusions logical and based on the data? 15. How “good” was the EMS system in which the study was done? 5

XII. Applying Study Results to Your Practice A. You must look at other studies and your own experience to construct an informed opinion. B. Evaluate the field and its knowledge base before making an informed decision about how to interpret a piece of research. C. Before applying results of a piece of research to a particular patient, be sure the patient is similar enough to the study group to benefit from the intervention. D. Speak to the management of your organization and your medical director before implementing any significant changes in your practice. XIII. Participating In Research A. Ask a question involving something of practical importance. B. Generate a hypothesis (a statement of exactly what you are going to test). 1. Null hypothesis, research hypothesis/alternate hypothesis C. Decide what you want to measure and how you will do it. D. Define the population you will be studying. E. Determine the limitations of your study. F. Obtain approval from an institutional review board. 1. Allows for outside evaluation of study methodology 2. Considerably reduces the chance you will be accused of conducting an unethical study 3. A principal investigator will be familiar with consent requirements and should also gain approval of other appropriate agencies. G. Gain informed consent and gather data.

Class Activities As a group, write out a mock consent form for research study participants.

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H. Analyze your data. I. Consider submission of results to peer-review journal or present findings at a conference 1. Negative studies show conclusions. 2. A well-conducted study will result in more questions. 5

XIV. Evidence-Based Decision Making A. Involves first formulating a question about appropriate treatments B. Medical literature is searched and organized for evaluation. C. Scientific evidence is then stratified on the basis of validity and reliability. D. If the evidence supports a change in the practice, the change is made. E. Ongoing evaluation must be carried out to determine whether the practice is correctly applied to the proper group of patients. F. An ongoing outcomes study should occur to determine whether the change in practice is improving essential parameters such as mortality, morbidity, and costs. XV. Summary A. Solid, well-conducted scientific research is the key to improving prehospital care. B. It is essential that paramedics make a difference in terms of reducing mortality, morbidity, and pain and suffering. C. The future of EMS depends on an aggressive research program, and prehospital research depends on knowledgeable and engaged paramedics. XVI. Case Study

5 XVII.

You Make the Call

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

XVIII.

Review Questions

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding 10

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Master Teaching Notes of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 6 Public Health 115 Minutes

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Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Knowledge Application Class Discussion

Chapter 6 objectives can be found on text p. 106. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

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

II. Introduction A. This chapter discusses the interaction between paramedicine and the public, focuses on the following questions: 1. How many injuries could have been prevented? 2. How many lives could be saved?

Discussion Topics

III. Basic Principles of Public Health A. Public health is defined as the science and practice of protecting and improving the health of the community through the use of preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards. B. Primary tenet of public health is to identify and prevent injury and illness and take steps to remedy a situation before it results in an injury or an illness

Discussion Topics

IV. Accomplishments in Public Health A. Public health has improved both the quality of life and the lifespan of humankind through research, epidemiology, surveillance, prevention, and other strategies.

Class Activities

With students, list injuries and illnesses that could benefit from preventive medicine.

Use the example of texting and driving as cause for injury that is preventable. Ask students what other causes of injury/illness are preventable.

Have students list all of the prevention programs they have attended or that they know exist.

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V. Public Health Laws A. Illness and prevention 1. These laws give public health officials the necessary legal tools to perform their job. B. Police powers for public health agencies 1. These laws allow public health entities to act in the general interest of the public when necessary. C. Epidemiological tools 1. These laws allow health agencies to use epidemiological tools to analyze legal issues related to public health practice and enforcement.

Critical Thinking Questions

VI. Epidemiology A. The branch of medicine that deals with the incidence and prevalence of disease in large populations B. Many concepts involved, including: 1. Years of productive life a. Subtract age at death from 65 2. Injury a. Intentional or unintentional damage to a person resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat and oxygen 3. Injury risk a. Hazardous or potentially hazardous situation that puts people in danger of sustaining injury 4. Injury surveillance program a. Ongoing systematic collection, analysis, and interpretation of injury data essential to the planning, implementation, and evaluation of public health practice 5. Primary prevention a. Keeping an injury from occurring 6. Secondary prevention a. Medical care that helps to prevent further problems from occurring 7. Tertiary prevention a. Rehabilitation activities that help to prevent further problems from

Discussion Topics

What would happen in a catastrophic event if there were no public health laws? How would patient care and your safety be affected?

Discuss with your students what would happen to patient outcome if they were not properly prepared to treat a presenting injury or illness.

Class Activities Arrange for a member of your local public health agency to come in to lecture on the beginnings of disease incidence.

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Content Outline occurring C. Six major roles in public health 1. Public health surveillance a. Ongoing and systematic collection, analysis, interpretation, and dissemination of health data 2. Field investigation a. Typically begun following detection of a health concern through public health surveillance b. Involves identification of the extent and cause of the health problem in question 3. Analytic studies a. Used when health problem is more complex b. AIDS investigation and detection is prime example. 4. Evaluation a. Ongoing process that determines the effectiveness, efficiency, and impact of activities related to public health initiatives b. Verifies that public health policies are doing what they are supposed to do and are cost effective 5. Linkage a. Interaction between multiple government agencies b. Protocols, agreements, sharing of information 6. Policy development a. Assistance in development of policies, rules, and regulations that have a positive impact on the health and welfare of a specific population D. EMS Public Health Strategies 1. Roles for EMS in the public health arena: a. Health promotion 1) EMS can provide health screenings, vaccinations, education, and assist high-risk populations. b. Disease surveillance 1) EMS is often first to encounter evolving public health emergency. 2) EMS can be an effective monitor of the community.

Master Teaching Notes

Class Discussion Review FirstWatch® with students so they can observe the real-time data application.

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3) FirstWatch® real-time surveillance provides ongoing data analysis to identify patterns and trends that emerge. c. Disaster management 1) EMS system is at the core of disaster response. 2) EMS personnel less prepared for recovery efforts d. Injury prevention 1) Many injuries may be predictable and thus preventable.

VII. Public Health and EMS A. EMS providers experience aftermath of illness and injury directly B. By being first on the scene, EMS personnel are prime candidates to be advocates of injury prevention. 1. Organizational Commitment a. EMS organizational commitment is vital to development of prevention activities b. Become familiar with available resources and your responsibilities in preventing illness and injury. 1) Protection of EMS providers 2) Education of EMS providers 3) Data collection 4) Financial support 5) Empowerment of EMS providers 2. EMS Provider Commitment a. As a provider, your priority is to protect yourself from harm. b. Employers have an obligation to provide a safe working environment. c. Written guidelines and policies should promote wellness and safety among employees. d. Protection includes: 1) Standard precautions 2) Physical fitness 3) Stress management

Critical Thinking Questions What would happen to your ability as a provider to prevent illness or injury if the tools you required for the job were not available? How can you stress the importance of prevention to your employer?

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4) Seeking professional care 5) Driving safety 6) Scene safety e. See the chapter “Workforce Safety and Wellness” for more information on the topics listed above. 20

VIII. Prevention in the Community A. EMS has a responsibility in preventing illness and injury among EMS workers as well as members of the public. B. Areas of Need 1. Infants and Children a. Prematurity, motor vehicle collisions, fire and burn injuries, falls, firearm deaths, bicycle injuries, media and Internet stressors, selfdestructive behavior, gang violence, and assaults b. Prevention programs would include children and parents. 2. Motor Vehicle Collisions a. Alcohol is a factor in about half of all motor-vehicle fatalities. b. Referred to as motor vehicle collisions (MVCs) because few collisions cause accidents: something caused the crash to occur 3. Geriatric Patients a. Falls account for the largest number of preventable injuries for persons over 75 years of age. b. Falls frequently result in fractures and can cause dangerous bleeding inside the cranium of an elderly person. c. Most geriatric patients are coherent, although some may suffer from some degree of dementia. 4. Work and Recreation Hazards a. Back, eye, hand, and finger injuries are responsible for many disabling injuries. b. Sports activities are a common cause of injuries seen in all age groups. 5. Medications a. Medications can be taken improperly, causing serious medical problems.

Class Discussion Have students make a list of possible prevention programs for every listed area of need.

Knowledge Application For homework, have students compare the areas of need list they created to what is actually available in their area.

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Content Outline 6. Early Discharge a. Patients may be discharged early due to insurance reasons, which results in EMS response for supportive care and intervention. C. Implementation of Prevention Strategies 1. Preserve the safety of the response team. 2. Recognize scene hazards. 3. Document findings. 4. Engage in on-scene education. 5. Know your community resources. 6. Conduct a community needs assessment.

Master Teaching Notes

Teaching Tips List the community resources available in your area; if available, pull up statistics on before and after prevention programs.

IX. Summary A. Each EMS member shares the responsibility of promoting wellness and preventing injury among coworkers and the community. B. It is commonplace for EMS services to offer programs to the public such as first aid and CPR classes, infectious disease prevention classes, safe driving classes, child safety seat classes, and even swimming lessons. C. Partner with members of your community in new and innovative ways to make everyone more aware of how to prevent avoidable illness and injury. X. Case Study

5 XI. You Make the Call 5

Class Activities Discuss the call with students and have them answer the questions as a group.

XII. Review Questions 5

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 7 Medical-Legal Aspects of Out-of-Hospital Care 195 Minutes

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

Chapter 7 objectives can be found on text pp. 119-120. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

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

II. Introduction A. As a paramedic, you must be familiar with the legal issues likely to be encountered in the field. B. Laws vary from state to state, and protocols can vary from county to county. C. Always rely on your attorney’s advice when faced with a legal question. III. Legal Duties and Ethical Responsibilities A. You have specific legal responsibilities to your patient, crew, medical director, and the public. B. These duties are largely based on generally accepted standards and are often set by statutes and regulations. C. If you do not perform your job appropriately, it may result in civil or criminal liability. D. Your best protection from liability is to always perform a systematic patient assessment, provide the appropriate medical care, and maintain accurate and complete documentation of all incidents. E. The paramedic is also responsible for meeting the ethical standards expected of a professional emergency medical care provider. F. Ethical responsibilities of the paramedic include: 1. Respond promptly to both the physical and emotional needs of every patient.

Discussion Topics Pull up various cases involving EMTs and Paramedics. Discuss these with students.

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Content Outline 2. Treat all patients and their families with courtesy and respect. 3. Maintain mastery of your skills and medical knowledge. 4. Participate in continuing education programs, seminars, and refresher training. 5. Critically review your performance, and constantly seek improvement. 6. Report honestly and with respect for patient confidentiality. 7. Work cooperatively with and respect other emergency professionals. G. The Legal System 1. Sources of Law a. Four primary sources 1) Constitutional law: based on the Constitution of the United States 2) Common law: also referred to as “case law” or “judge-made law”; based on society’s acceptance of customs and norms over a period of time 3) Statutory law (or legislative law): created by lawmaking or legislative bodies; takes precedent over common-law decisions 4) Regulatory law (administrative law): enacted by an administrative or governmental agency at either the federal or state level 2. Categories of Law a. Criminal law: deals with crime and punishment; prosecution on behalf of society for violating laws meant to protect society b. Civil law: deals with noncriminal issues; plaintiff seeks to recover damages from defendant 1) Tort law is a branch of civil law; deals with civil wrongdoings committed by one individual against another 2) Tort law includes negligence, medical malpractice, assault, battery, and slander. H. Two Court Systems 1. Federal court system: cases involving federal law 2. State court system: trial courts and appellate courts; most likely location

Master Teaching Notes

Points to Emphasize Paramedics usually are involved with tort law.

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for cases a paramedic may become involved in Anatomy of a Civil Lawsuit 1. Incident: actual starting point of injury 2. Investigation: inquiry into facts and circumstances surrounding incident to determine whether case has merit 3. Filing of the complaint: plaintiff files complaint with court, commencing beginning of lawsuit; defendant is served with a copy of complaint 4. Answering the complaint: defendant’s attorney files an answer with court, which addresses each allegation 5. Discovery: all relevant information about incident is shared with both parties a. Deposition: witnesses answer questions under oath b. Interrogatory: written questions that require written responses c. Requests for document production: requests from both sides for relevant documents 6. Trial: each side given opportunity to present evidence and testimony in court 7. Decision: judge or jury determines guilt or liability and amount of damages to be awarded 8. Appeal: appeal of decision usually limited to errors of law made by the court 9. Settlement: offer of money that is less than what defendant is being sued for; can occur anytime during lawsuit J. Laws Affecting EMS and the Paramedic 1. Scope of Practice a. Range of duties and skills paramedics are allowed and expected to perform; set by state law or regulation and/or by local medical direction 1) Circumstances in which an order from medical direction may be legitimately refused include when you are ordered to provide treatment that is beyond the scope of your training or inconsistent with established protocols or procedures, and when you are ordered to administer a treatment that you reasonably I.

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Content Outline believe would be harmful to the patient 2. Licensure and Certification a. Certification: recognition granted to an individual who has met predetermined qualifications to participate in a certain activity; usually granted by a certifying agency (not necessarily a governmental agency) b. Licensure: a process used to regulate occupations; usually granted by a governmental agency 3. Motor Vehicle Laws a. Laws vary from state to state. b. Usually apply to vehicle maintenance and use of the siren and emergency lights c. Many states and jurisdictions have enacted laws and ordinances governing the use of phones, tablets, and GPS devices, which may or not apply when operating an emergency vehicle. 4. Reporting Requirements a. Most states have laws that require a health care worker to report suspected spousal abuse, child abuse, abuse of the elderly, violent crimes, animal bites, and communicable diseases. b. You may be criminally and civilly liable if you fail to make a required report. 5. Legal Protection for the Paramedic a. Particular laws have been enacted to protect paramedics. 1) Criminal punishment for assault or battery against a paramedic while he or she is providing medical care 2) Obstruction of paramedic activity 3) Immunity (exemption from legal liability): judicial doctrine that prohibits a person from bringing a lawsuit against a government without its consent; does not generally protect individual paramedics 4) Good Samaritan laws: provide immunity to people who assist at scene of a medical emergency; laws of many states have been expanded to protect both paid and volunteer prehospital

Master Teaching Notes

Discussion Topics Discuss with students instances in which they may find themselves acting as “Good Samaritans” rather than paramedics.

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personnel 5) Use of physical restraints, restricted areas, and hazardous material sites: each state may have particular laws governing action of paramedic. 6) Ryan White CARE Act: protection for paramedic in event of exposure to bloodborne or airborne pathogens; this allows access to medical records to determine whether patient has tested positive for an infectious disease. 35

IV. Legal Accountability of the Paramedic A. You are required to provide a level of care that is consistent with your education and training and equal to that of any other competent paramedic with equivalent training. 1. Most civil claims center around negligence, but some are based on intentional tort (civil wrong committed by one person against another based on a willful act) B. Negligence and Medical Liability 1. Negligence: deviation from accepted standards of care recognized by law for the protection of others against the unreasonable risk of harm 2. In health care professions, negligence is synonymous with malpractice. a. Can result in legal accountability of liability b. Duties expected of the paramedic: 1) Duty to respond to the scene and render care to ill or injured patients 2) Duty to obey federal, state, and local laws and regulations 3) Duty to operate the emergency vehicle reasonably and prudently 4) Duty to provide care and transportation to the expected standard of care 5) Duty to provide care and transportation consistent with the paramedic’s scope of practice and local medical protocols 6) Duty to continue care and transportation through to appropriate conclusions 3. Components of a Negligence Claim

Class Activities As a group, list various skills that, if performed incorrectly, can result in a negligence charge.

Points to Emphasize Explain the four components of a negligence claim, including “actual damages to patient.”

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Content Outline a. Duty to act: legal obligation to provide care b. Breach of that duty: standard of care not met 1. Malfeasance: performance of a wrongful or unlawful act 2. Misfeasance: performance of a legal in a manner that is harmful or injurious 3. Nonfeasance: failure to perform a required act or duty 4. Res ipsa loquitur: damages would not have occurred in absence of negligence 5. Negligence per se (automatic negligence): violation of a statute that results in injury c. Actual damages to patient or other individual: individual harmed in a way that can be compensated by the award of damages – essential component of lawsuit; without proof of actual ill effect, the lawsuit cannot be won. d. Proximate cause: action or inaction of the paramedic immediately caused or worsened damage suffered by the plaintiff; may be thought of in terms of “foreseeability” 4. Defenses to Charges of Negligence a. Potential defenses to negligence 1) Good Samaritan laws 2) Governmental immunity 3) Statute of limitations 4) Contributory or comparative negligence b. It is essential for every paramedic to be covered by medical liability insurance. C. Special Liability Concerns 1. Medical Direction a. If a paramedic makes a mistake in the field and is sued by the injured patient, it is possible that the patient will also sue the paramedic’s medical director and on-line physician. 2. Borrowed Servant Doctrine a. Depending on the degree of supervision and the amount of control the paramedic has over other emergency care providers, the

Master Teaching Notes Knowledge Application Create several scenarios from each of the four components of negligence. For homework, have students identify which component the scenario is referring to.

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Content Outline 3.

Master Teaching Notes

paramedic may be liable for any negligent act committed by these providers. Civil Rights a. In addition to suing for negligence, the patient may be able to sue under certain circumstances for violation of his or her civil rights if the paramedic fails to render care for discriminatory reasons. Off-Duty Paramedics a. Liability may also arise in a situation in which an off-duty paramedic renders assistance at the scene of an illness or injury. Airway Issues a. Failure to secure an airway or failure to recognize that an airway has been improperly placed can result in devastating or fatal injuries for the patient. b. Numerous lawsuits and settlements filed related to airway management, especially failure to recognize that an endotracheal tube has been improperly placed Restraint Issues a. Increase in negligence suits against EMS and law enforcement personnel related to deaths and injuries that occur during restraint b. Excited delirium syndrome (ExDS) c. Restraint asphyxia (positional asphyxia)

IV. Paramedic–Patient Relationships A. Confidentiality: any medical or personal information about a patient – including medical history, assessment findings, and treatment – will not be released to a third party without the express permission of the patient or legal guardian 1. Circumstances under which a patient’s confidential information may be released: a. Patient consents to release of his records. b. Other medical care providers have a need to know. c. EMS is required by law to release a patient’s medical records. d. There are third-party billing requirements. B. Health Insurance Portability and Accountability Act (HIPAA) of 1996

Class Activities Have students list examples of the key terms highlighted in the text.

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Content Outline

C. D. E.

V. 25

Master Teaching Notes

1. Changed the methods EMS providers use to file for insurance and Medicare payments 2. Adds important new layers of privacy protection for EMS patients 3. EMS employees must be trained in HIPAA compliance. 4. EMS providers must develop administrative, electronic, and physical barriers to unauthorized disclosure of patients’ protected health information. Defamation: occurs when a person makes an intentional false communication that injures another person’s reputation or good name Libel: the act of injuring a person’s character, name, or reputation by false statements made in writing or through the mass media with malicious intent or reckless disregard for the falsity of those statements Slander: the act of injuring a person’s character, name, or reputation by false or malicious statements spoken with malicious intent or reckless disregard for the falsity of those statements Invasion of Privacy: release of confidential information, without legal justification, regarding a patient’s private life, which might reasonably expose the patient to ridicule, notoriety, or embarrassment

Consent

Knowledge Application

A. Consent is the granting of permission to treat; more accurately, it is the granting of permission to touch. 1. Patient must be competent to give or withhold consent 2. A competent adult is one who is lucid and able to make an informed decision about medical care. B. Informed consent: consent given on full disclosure of information C. Expressed consent: the most common; occurs when a person directly grants permission to treat – verbally, nonverbally, or in writing D. Implied (sometimes called “emergency doctrine”): assumption that the patient would want lifesaving treatment if he were able to give informed consent; effective only until the patient no longer requires emergency care or until the patient regains competence E. Involuntary Consent: court orders a patient to undergo treatment 1. Most commonly encountered with patients who must be held for mental

Give the consent terms to students for homework, requiring the definition and example of each.

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Content Outline F.

G. H. I.

J. K.

health evaluation or as directed by law enforcement personnel who have the patient under arrest Special Consent Situations: 1. Minor: depending on state law, usually a person under age 18 a. Consent should be obtained from a parent, legal guardian, or courtappointed custodian. 2. Emancipated minor: considered an adult; a person under 18 years of age who is married, pregnant, a parent, a member of the armed forces, or financially independent and living away from home Withdrawal of Consent: a competent adult may withdraw consent; however, refusal must be informed; document all information Refusal of Service: competent adult may refuse service; however, refusal of care must be informed; document all information Problem Patients: include patients who are violent, victims of drug overdose, intoxicated adults or minors, or ill or injured minors with no adult available to provide consent for medical treatment Boundary Issues: professional boundaries that can be breached by being too tired, unprepared, seduced (Keep priorities straight.) Legal Complications Related to Consent 1. Abandonment a. The termination of paramedic–patient relationship without providing for appropriate continuation of care while it is still needed and desired by the patient b. Physically leaving a patient unattended, even for a short time, may also be grounds for a charge of abandonment. 2. Assault and Battery a. Assault: unlawfully placing a person in apprehension of immediate bodily harm without his consent b. Battery: the unlawful touching of another individual without his consent 3. False Imprisonment a. May be charged by a patient who is transported without consent or who is restrained without proper justification or authority

Master Teaching Notes

Discussion Topics Discuss with the class different skills that if performed without consent could be classified as battery; do the same with assault and false imprisonment.

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Master Teaching Notes

4. Reasonable Force a. The minimum amount of force necessary to ensure that the patient does not cause injury to himself, you, or others b. Use of excessive force can result in liability for the paramedic. L. Patient Transportation 1. Involves emergency vehicle operations, choice of destination, patient’s insurance company protocols 2. In general, facility selection should be based on patient request, patient, need, and facility capability Patient’s preference should be honored unless the situation or the patient’s condition dictates otherwise 10

VI. Resuscitation Issues A. Advance directive: a document created to ensure that certain treatment choices are honored when a patient is unconscious or otherwise unable to express his choice of treatments B. Living will: a legal document that allows a person to specify the kinds of medical treatment he wishes to receive, should the need arise C. Do Not Resuscitate Order: a common type of advance directive that is usually signed by the patient and physician; a legal document that indicates to medical personnel which, if any, life-sustaining measures should be taken when the patient’s heart and respiratory functions have ceased D. Physician’s orders for life saving treatment (POLST): designed for terminally ill patients: the terminally ill patient and the physician have an opportunity to consult on the patient’s wishes and incorporate these wishes into a set of specific orders as to the patient’s care, signed by the physician, to be honored by health care providers who deal with that patient during a medical crisis. E. Potential Organ Donation: consult with on-line medical direction when you have identified a patient as a potential donor F. Death in the Field 1. Must be appropriately dealt with and thoroughly documented 2. Carefully follow state and local protocols. 3. Contact on-line medical direction for guidance.

Critical Thinking Questions What would you do if your patient has a valid DNR but his family wants you to resuscitate him?

Minutes 5

Content Outline VII. Crime and Accident Scenes A. Do not sacrifice patient care to preserve evidence or to become involved in detective work. B. Assist investigating officers by properly treating the patient and by doing your best to avoid destroying any potential evidence. C. Ensure your own safety and the safety of your crew. D. Treat patients as medically indicated. E. Use resources available to you. F. Be prepared to summon additional personnel and rescue equipment as necessary.

Master Teaching Notes Discussion Topics Discuss with the group different scenarios of crime scenes and how they can avoid altering the scene.

VIII.Duty to Report A. Many states require EMS personnel to report suspected abuse of elderly, children, and invalids to the proper authorities in an objective and timely manner. IX. Documentation A. Properly document the entire incident, from initial response to the transfer of patient care to the hospital emergency department staff. B. A complete, well-written patient care report is your best protection in a malpractice action. C. A well-documented patient care report has the following characteristics: 1. It is completed promptly after patient contact. 2. It is thorough. 3. It is objective. 4. It is accurate. 5. It maintains patient confidentiality. X. Employment Laws A. Americans with Disabilities Act B. Title VII C. Amendments to Title VII D. Family Medical Leave Act E. Fair Labor Standards Act

Discussion Topics As a group, look up and discuss the benefits of each employment law listed.

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F. Occupational Safety and Health Act G. The Ryan White CARE Act

XI. Summary A. The very nature of a paramedic’s job requires interaction with law enforcement authorities and frequent involvement in situations that can give rise to litigation. B. Learn and follow all state laws and local protocols related to your practice as a paramedic. C. Receive good training and keep current by attending continuing medical education programs and conferences, reading industry journals, and obtaining recertification or relicensure as required by law. D. Always act in good faith and use common sense. E. High-quality patient care and high-quality documentation are your best protection from liability. XII. Case Study

5 XIII.You Make the Call 5

Class Activities Read and discuss the call as a group. Identify the particular events that could result in litigation.

XIV.

Review Questions

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 8 Ethics in Paramedicine 80–90 Minutes

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Teaching Tips Discussion Topics Class Activities

Chapter 8 objectives can be found on text p. 145. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. Although ethical problems often have a legal aspect, most ethical problems are solved in the field, not in a courtroom. B. Ethical issues often begin with specific circumstances and lead to broad general rules or principles for behavior. III. Overview of Ethics A. Ethics and morals are closely related concepts. 1. Morals are generally considered to be social, religious, or personal standards of right and wrong. 2. Ethics, also known as moral philosophy, is a branch of philosophy that addresses questions about morality. a. Ethics more often refers to the rules or standards that govern the conduct of members of a particular group or profession and how our institutions should function. B. Relationship of Ethics to Law and Religion 1. In general, laws have a much narrower focus than ethics. 2. Laws frequently describe what is wrong in the eyes of society. 3. Ethics looks at what is right, or good, behavior. 4. Ethics must be understood and applied to people who hold a broad range of religious beliefs or no religious beliefs at all.

Discussion Topics Discuss with students scenarios in which ethical dilemmas can occur.

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Master Teaching Notes

a. Ethics cannot derive from a single religion. b. Religion can enhance and enrich one’s ethical principles and values. C. Cultural Considerations 1. People of different cultural backgrounds respond to illnesses and injuries in different ways. 2. Never criticize or chastise patients for beliefs that differ from yours. 3. Paramedics are expected to acknowledge and respect each person’s cultural beliefs. D. Making Ethical Decisions 1. Ethical relativism: a decision based on how a person behaves, and whatever decisions they make are fine 2. Deontological method: a decision based on fulfilling your duties 3. Consequentialism: actions can be judged as good or bad only after we know the consequences of those actions E. Codes of Ethics 1. National Association of EMTs code of ethics adopted in 1978 2. Ethical codes often address: a. Honesty b. Objectivity c. Integrity d. Carefulness e. Openness f. Legality g. Confidentiality h. Responsible publication i. Responsible mentoring j. Respect for colleagues k. Social responsibility l. Nondiscrimination m. Competence n. Respect for intellectual property o. Human subjects protection ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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F. Impact of Ethics on Individual Practice 1. By consistently displaying ethical behavior, paramedics will gain and maintain the respect of their colleagues and their patients. G. The Fundamental Questions 1. The single most important question a paramedic must answer when faced with an ethical challenge is “What is in the patient’s best interest?” 2. As long as the patient is competent and his or her desires are consistent with good practice, the paramedic is obligated to respect the patient’s desires. 3. Paramedics must be very cautious in accepting a family’s description of what the patient desires. H. Fundamental Principles 1. Beneficence: doing good (the paramedic’s obligation to the patient) 2. Maleficence: doing harm 3. Nonmaleficence: not doing harm 4. Autonomy: refers to a competent adult patient’s right to determine what happens to his own body, including treatment for medical illnesses and injuries (wishes of the patient) 5. Justice: the paramedic’s obligation to treat all patients fairly, regardless of their sex, race, ability to pay, or cultural background, among other conditions I. Resolving Ethical Conflicts 1. The paramedic should have in place a system for resolving ethical conflicts, one that will allow him to weigh the various factors, including all relevant facts, principles, and values, that lead to responsible, defensible actions. 2. Three tests suggested by Iverson: a. Impartiality test 1) Asks whether you would be willing to undergo this procedure or action if you were in the patient’s place 2) A version of the Golden Rule (do unto others as you would have them do unto you) 3) Helps to reduce the possibility of bias ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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b. Universalizability test 1) Asks whether you would want this action performed in all relevantly similar circumstances 2) Helps the paramedic avoid shortsightedness c. Interpersonal justifiability test 1) Asks whether you can defend or justify your actions to others 2) Helps to ensure that an action is appropriate by asking the paramedic to consider whether other people would think the action reasonable 20

IV. Ethical Issues in Contemporary Paramedic Practice A. Resuscitation Attempts 1. Every state that has laws or rules regarding Do Not Resuscitate (DNR) orders requires that you see the order and verify its legitimacy in some manner. 2. If the order is not available for you to see, you are under no legal obligation to withhold care. B. Confidentiality: maintaining confidentiality is based on patient and circumstance (abuse, violence, etc.) C. Consent: make sure patient completely understands issues of consent D. Allocation of Resources: What are the ethics of triage? 1. The key to resolving the issue of allocation of scarce resources is to examine the competing theories in light of the circumstances at hand. E. Obligation to Provide Care: paramedics obligated to provide medical care for those in need regardless of their ability to pay F. Teaching: students should be clearly identified as such by the uniform they wear 1. When appropriate, inform patients of the presence of a student and request the patient’s consent before the student performs a procedure 2. Factors to consider when students are rendering care: a. Student’s skill level b. Anticipated difficulty of the procedure c. The relative importance of the procedure 3. It is important to have a limit, at least initially, for the number of times a

Class Activities Use the scenarios listed under each bullet point in the chapter to help students gain insight on various ethical issues. Each scenario allows for discussion and feedback.

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Master Teaching Notes

student will be allowed to attempt a procedure; such a procedure will need to be decided by each system in consultation with the medical director. G. Professional Relations: paramedic has to determine how to best serve patient’s interests 1. Three potential sources of conflict between paramedics and physicians a. When a physician orders something the paramedic believes is contraindicated b. When the physician orders something that the paramedic believes is medically acceptable but not in the patient’s best interests c. When the physician orders something the paramedic believes is medically acceptable, but morally wrong 2. Ultimately, the paramedic must determine for himself how the patient’s interests are best served. H. Research 1. EMS research is relatively new but absolutely important for the profession to advance. 2. Research will help to introduce new innovations that improve patient outcomes and remove those that do not. 3. Paramedics will become instrumental in implementing research protocols and gathering data. 4. Goal of research is to help future patients by gaining knowledge about a specific intervention

V. Summary A. The paramedic’s decision-making process should always be based on the patient’s best interest. B. Cultural sensitivity should also be included in the decision and respected, even if it is against your personal beliefs. C. The patient has the right to determine what happens to his or her own body and can legally dictate that.

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D. There is a clear distinction between ethics, religion, and law even though there is common ground between them. E. If you are called upon to depend your actions, the best defense results from being able to state that your actions were legal and within your scope of practice (justice), helpful (beneficence), not harmful (nonmaleficence), and the direct wishes of the patient (autonomy). VI. Case Study 5 VII. You Make the Call 5 5

Class Activities Read and discuss the call as a group.

VIII.Review Questions

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 9 EMS System Communications 125 Minutes

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

Chapter 9 objectives can be found on text p. 159 These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. Communication has changed radically in the past 40 years. B. The way we communicate in EMS has remained largely unchanged. 1. In EMS, person-to-person communication has typically been face to face, telephone, and voice radio dialogue; cycles of telemetry data use; and handwritten records. 2. Mobile phones and other voice radio systems (e.g., trunked systems) have augmented these methods, but EMS, by and large, still communicates as it did in the 1970s. III. Effective Communications A. Knowledge of communications plays an important role in paramedic training. B. During a routine transfer or life-threatening emergency, you will communicate with a wide variety of people, including: 1. Emergency medical dispatcher (EMD) 2. Patient, his or her family, bystanders, and others 3. Personnel from other responding agencies 4. Health care staff 5. Medical direction physician IV. Basic Communication Model A. Communication: the process of exchanging information between individuals

Critical Thinking Questions Do you think that, as the paramedic, it is

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Content Outline B. Communication process: 1. Having an idea or message you would like to convey to someone else 2. Encoding that information in the language best suited for the situation (words, numbers, symbols, or special codes) 3. Choosing the medium for sending the message (face-to-face, fax, voice message, letter or email, speaking directly via phone or radio, etc.) 4. Person receiving your message decodes and understands your message 5. Person receiving the message acknowledges receipt of the message by repeating key data 6. Sender confirms and concludes the communication

V. Verbal Communication A. Factors that enhance or impede effective communication may be semantic (meaning of words) or technical. B. Codes are not recommended outside one system. C. Plain English is standard radio communication. D. U.S. Department of Security’s SafeCom Program E. Reporting Procedures 1. Relay all relevant medical information to the receiving hospital staff. 2. Communication continues with patient transfer at hospital and may include additional information 3. Following your local communication protocols ensures proper and correct communication. F. Standard Format 1. Always use a standard format in your communication; this allows for a systematic communication approach and proper patient care. 2. In general, verbal reports to medical direction should include the following information: a. Identification of unit and provider b. Description of scene c. Patient’s age, sex, and approximate weight (for drug orders) d. Patient’s chief complaint and severity e. Brief, pertinent history of the present illness or injury f. Pertinent past medical history, medications, and allergies

Master Teaching Notes always your responsibility to make sure that the patient or hospital, for example, understands your message? What medical and legal ramifications could occur if you do not make sure your message is understood?

Class Activities Create two run reports for the same call. For the first run report, write the report in an unprofessional manner, using slang, opinions, no documentation of care, etc. Have a student pretend to call the receiving hospital with the report. Do the same for the second run report, but write it correctly. Compare the improvement in communication with the receiving hospital.

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Master Teaching Notes

g. Pertinent physical exam findings h. Treatment given so far/request for orders i. Estimated time of arrival at the hospital j. Other pertinent information G. General Radio Procedures 1. All transmissions over the radio must be clear and crisp, with concise, professional content. a. Listen to the channel before transmitting to ensure that it is not in use. b. Press the transmit button for one second before speaking. c. Speak at close range, approximately 2 to 3 inches, directly into, or across the face of, the microphone. d. Speak slowly and clearly. Pronounce each word distinctly, avoiding words that are difficult to understand. e. Speak in a normal pitch, keeping your voice free of emotion. f. Be brief. Know what you are going to say before you press the transmit button. g. Avoid codes unless they are part of your EMS system (if they are, work to change to plan English). h. Do not waste airtime with unnecessary information. i. Protect your patient’s privacy. j. Use proper unit or hospital members and correct names or titles. k. Do not use slang or profanity. l. Use standard formats for transmission. m. Be concise, to hold the attention of the person receiving your ratio report. n. Use the echo procedure when receiving directions from the dispatcher or orders from the physician. o. Always write down addresses, important dispatch communications, and physician orders. p. When completing a transmission, obtain confirmation that your message was received and understood.

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Content Outline

VI. Written Communication A. Prehospital care report (PCR) 1. Written or electronic, keyboard/mouse-entered record of events 2. Includes administrative information such as times, location, agency, and crew, as well as medical information 3. Medical and legal document that is used by all components of the health care system B. Be objective, write clearly, thoroughly document your patient’s assessment and care, and use terminology that is widely accepted in the medical community. C. Data elements collected on the PCR and how they are interpreted are usually defined in a data dictionary. 1. All states and territories have agreed to adopt, as soon as it is practical for each, the National Emergency Medical Services Information System (NEMSIS) data dictionary and to participate in reporting data to a NEMSIS national database.

Master Teaching Notes

Class Activities Give students a scenario and run report. Have them complete the run report on the basis of the information they have been given.

VII. Terminology A. Every industry develops its own terminology. B. Medical field uses an extensive list of terms, acronyms, and abbreviations that allow quick, accurate communication of complex information C. The emergency services industry has developed its own terms for radio communication (refer to Table 9-1 in the text). VIII. The Importance of Communications in EMS Response A. Your ability to communicate effectively during a stressful EMS response is likely to determine the success or failure of your efforts. B. Dealing effectively with your patient and bystanders requires a variety of communication skills, such as empathy, confidence, self-control, authority,

Minutes

Content Outline and patience. C. Delegating tasks, listening to initial reports, and coordinating the scene require effective communication and interpersonal skills. D. Sequence of Communication in an EMS Response 1. Detection and Citizen Access a. 911 system b. Automatic number identification (ANI) and/or automatic location identification (ALI) c. Automatic crash notification (CAN) d. Public safety awareness points (PSAPs) e. Call routing f. Terrestrial-based triangulation/global positioning systems (GPS) g. Voice over Internet protocol (VOIP) technology 2. Advanced Automatic Crash Notification (AACN) a. Can improve outcomes among seriously injured patients by: 1) Predicting the likelihood of serious injury among vehicle occupants. 2) Decreasing response times by prehospital care providers. 3) Assisting with field triage destination and transportation decisions. 4) Decreasing the time it takes for patients to receive definitive trauma care. b. Data collection and transmission mechanisms that may change the way we assess and treat victims of car crashes 3. Emergency Medical Dispatch a. Emergency medical dispatcher (EMD): the public’s first contact with the EMS system; plays a crucial role in every EMS response b. Priority dispatching c. Prearrival instructions (a service that is considered the standard of care) d. Call coordination and incident recording 4. Discussion with the medical direction physician a. Contact the medical direction physician to discuss the case. b. Continue treatment and prepare your patient for transfer after

Master Teaching Notes Class Activities Assign members of the class roles pertaining to the sequence of EMS communications. Have them go through a scenario and choose one link in the sequence to NOT communicate effectively. You can do this several times with different links, and it allows students to visually observe the communication delay.

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Master Teaching Notes

consulting the medical direction physician. c. Contact your dispatcher, who will record the time when you leave the scene and the time when you arrive at your destination. 5. Transfer Communications a. As you transfer care of your patient to the receiving facility staff, give the receiving nurse or physician a formal verbal briefing (handoff report). It should include: 1) Patient’s vital information 2) Chief complaint and history 3) Physical exam findings 4) Any treatments that have been rendered 20

IX. Information and Communications Technology A. Situational awareness (SA) and a common operating picture (COP) are important considerations in EMS. 1. Address how a paramedic and his team are to perform their jobs effectively at any given moment, particularly when time is a factor 2. Both are improved by having just the right amount of updated information exactly when it is needed – information about resources the team can bring to bear and events that may affect their current situation. B. Modern EMS communications needed to provide adequate SA and COP require both voice and data communications support 1. This becomes a blending of two sets of systems and communication skills: traditional communications technology and data systems technology. 2. Information communication technology (ICT) is the new concept that blends traditional communications technology (CT) systems and information technology (IT) systems. C. Technology Today 1. Communication network must consist of reliable equipment designed to afford clear communication among all agencies within the system 2. Repeaters: devices that receive transmissions from a low-powered source and rebroadcast them at a higher power 3. Radio bands and radio frequencies

Discussion Topics As a group, discuss what medical procedures can be improved with enhanced technology.

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Master Teaching Notes

4. Ultrahigh frequency (UHF) and very high frequency (VHF) D. Radio Communication 1. Simplex transmissions: these systems transmit and receive on the same frequency and thus cannot do both simultaneously 2. Duplex transmissions: allow simultaneous two-way communications by using two frequencies for each channel 3. Multiplex systems: duplex systems with the additional capability of transmitting voice and data simultaneously 4. Trunking: trunked systems pool all frequencies E. Digital Communications 1. Trend toward combining radio technology with computer technology has encouraged a shift from analog to digital communications a. Mobile data unit b. Mission-critical communications c. Cell phones and mobile broadband 1) Cellular telephone system 2) Smart phones d. Expanding computer uses e. Software-defined radio 1) Multiband radio 2) Cognitive radio F. New Technology 1. Future diagnostic and treatment technologies that require voice/data technology and bandwidth use a. Medical quality video and imaging b. Call volume c. Community paramedicine d. Other EMS applications 1) Patient multi-vital-signs monitoring 2) Responder multi-vital-signs monitoring 3) Stand-off vital-signs monitoring 4) Infrared crowd disease detection 5) Wireless speech-to-text translation 6) Receipt of electronic patient records in real time ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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7) Creation of ad-hoc multi-component patient databases 8) EMS-mediated remote patient monitoring systems and “just in time” patient warning and reference guidance

9) Advanced automatic crash notification (AACN) data rebroadcasting and “just in time” training and reference material rebroadcasting 10) Closed circuit television (CCTV) scene transmission 11) Robotic remove hazard suppression and patient extrication 12) Wireless vehicle systems, equipment, and supply monitoring 13) Syndromic surveillance and quick alerting to specific populations 5

X. Public Safety Communications System Planning and Funding A. Since 9/11, the need for statewide systems with nationwide capability for interoperability has changed the ways public safety communications systems are planned and implemented. B. Today’s paramedic and agency officials should be aware of opportunities to be part of communications system planning and funding initiatives. C. Role of U.S. Department of Homeland Security’s Office of Emergency Communications (OEC) in ensuring well-planned development of interoperable public safety communications systems on the national, state, and regional and local levels 1. 2009: National Emergency Communications Plan (NECP) developed by OEC XI. Public Safety Communications Regulation A. FCC (Federal Communications Commission) controls and regulates all nongovernmental communications in the United States B. FCC’s primary functions include: 1. Licensing and allocating radio frequencies 2. Establishing technical standards for radio equipment 3. Licensing and regulating the technical personnel who repair and operate

Points to Emphasize Go over the dos and don’ts of radio communication.

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Master Teaching Notes

radio equipment 4. Monitoring frequencies to ensure appropriate usage 5. Spot-checking base stations and dispatch centers for appropriate licenses and records C. FCC requires all EMS communications systems to follow appropriate governmental regulations and laws D. FCC requires public safety agencies to use frequency coordinators (International Municipal Signal Association [IMSA]) 5

XII. Summary A. Advances in communications technology are dramatically improving the communications among patients, paramedics, and physicians. B. Accurate and effective communications help to ensure an EMS system’s efficiency and improve a patient’s survivability. C. Communications include not only your radio traffic, but also your spoken and nonspoken messages. D. All communications must be concise, professional, and complete and must conform XIII. Case Study

5 XIV. You Make the Call 5

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

XV. Review Questions 5

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 10 Documentation 110 Minutes

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

Chapter 10 objectives can be found on text p. 183. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. The prehospital care report (PCR) is a factual record of events that occur during an EMS call or other patient contact. B. Three major goals of the PCR include: 1. To provide information to subsequent health care professionals about the patient and treatments provided in the prehospital setting 2. To provide essential information for proper billing of the patient 3. To provide a legal record of the call’s circumstances III. Uses for Documentation A. The PCR will be a valuable resource for a variety of people, including medical professionals, EMS administrators, researchers, and occasionally lawyers. 1. Medical: original condition of patient, initial care provided 2. Administrative: information applied for quality improvement and system management, including response times, call location, the use of lights and siren, and date and time 3. Research: PCR data may be analyzed; written documentation provides the basis for continuously improving patient care in your EMS system 4. Legal: PCR becomes a permanent part of your patient’s medical record; may be used in legal proceedings

Points to Emphasize Remind students to write every run report as if they will have to explain it five years in the future to a room full of people.

Minutes 20

Content Outline

Master Teaching Notes

IV. General Considerations A. Every EMS system has its own specific requirements for documentation. B. The type of call record used also varies from system to system (e.g., some use check boxes, others use bubble sheets). C. The general characteristics of a well-written PCR remain consistent among all agencies and systems. 1. Medical Terminology: use correct terms and spelling. 2. Abbreviations and Acronyms: ensure that they are understood by others. 3. Times: record times accurately for medical and legal purposes; times recorded on the PCR are considered the official times of incident. 4. Communications: document any medical advice or orders you receive and the results of implementing that advice and those orders. 5. Pertinent Negatives: seeking pertinent negatives demonstrates a thorough patient assessment. 6. Oral Statements: record statements from patients, witnesses, and bystanders; use quotes whenever possible. 7. Additional Resources: document all resources involved in the event; can be particularly important in mutual aid calls.

Class Activities

V. Elements of Good Documentation A. A well-written PCR is accurate, legible, timely, unaltered, and professional. Each of the following traits is essential. 1. Completeness and Accuracy a. Precise but comprehensive b. Check boxes as well as written narrative (core of documentation) 2. Legibility 3. Timeliness a. Ideal time to complete report is immediately after completion of the emergency call. 4. Absence of Alterations a. If you make a mistake writing your report, simply cross through the error with one line and initial it.

Class Activities

As a group, go over as many abbreviations and acronyms as can be thought of, along with the EMS meanings.

Points to Emphasize Discuss the importance of pertinent negatives and how these negative statements reflect a thorough patient assessment.

Knowledge Application Assign for homework a short number of medical complaints (SOB, chest pain, headache) and have student write out the pertinent negatives they would ask to rule out other problems.

Walk students through writing a run report, showing examples of how to line out an error, importance of correct grammar and spelling, legible handwriting, etc.

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Master Teaching Notes

b. If you find the error after you’ve already written several more sentences, submit an addendum. 5. Professionalism a. Avoid jargon. b. Always write and speak carefully.

VI. Narrative Writing A. The narrative is the part of the written report in which you depict the call at length. B. The narrative is broken into three sections: 1. The subjective narrative typically comprises any information that you elicit during your patient’s history. a. Includes chief complaint (CC), past history (PH), current health status (CHS), and review of systems (ROS) 2. The objective narrative usually includes your general impression of the patient and any data that you derive through inspection, palpation, auscultation, percussion, and diagnostic testing. a. Includes vital signs, physical exam, and tests such as cardiac monitoring, pulse oximetry, and blood glucose determination b. Head-to-toe approach c. Body systems approach 3. Assessment/Management Plan: field diagnosis (impression); interventions; orders from the medical control physician; description of transport; effects of any interventions such as drug administration or other invasive procedures; results of ongoing assessments; changes in patient’s medical condition; and patient’s condition when transferred to emergency medical staff C. General Formats 1. SOAP and CHART formats serve as a memory aid in organizing a narrative. 2. SOAP: Subjective, Objective, Assessment, and Plan

Discussion Topics Go over the four formats listed that aid in writing the narrative.

Knowledge Application Give students a scenario, and have them write out a narrative based on the SOAP and CHART formats.

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3. CHART: Chief complaint, History, Assessment, Rx (treatment), and Transport D. Other Formats 1. Patient management format preferred for some critical patients, such as those in cardiac arrest, when you focus on immediately managing a variety of patient problems and not on conducting a thorough history and physical exam a. Chronological account b. Emphasizes assessment and management of conditions c. Record everything in real time and in absolute chronological order d. Always include results of your interventions. 2. Call incident a. Emphasis is on mechanism of injury, surrounding circumstances, and how incident occurred b. Most suitable when events surrounding the call might be significant c. Style can be used in both subjective and objective sections of PCR

VII. Special Considerations A. Some circumstances create special problems for EMS documentation. In these and other unusual circumstances, take extra care to document everything that happened during the call. 1. Patient Refusals a. Person who is not seriously ill or injured and simply does not want to go to the hospital b. Patient refuses against medical advice (AMA) 2. Services Not Needed a. Transport may not be needed. b. Documentation must clearly demonstrate that transport was not necessary. 3. Multiple Casualty Incidents

Critical Thinking Questions What would happen if you had a patient in cardiac arrest, your documentation was inappropriate, and the patient later died and the family brought a lawsuit against you for inadequate care? Could you be held liable for negligence even if you did the care but did not document it?

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Master Teaching Notes

a. Number of individuals requiring care may be overwhelming b. Obtaining complete patient information might be impossible. c. Completing documentation for one patient before going on to another might be impractical.

VIII. Consequences of Inappropriate Documentation A. Inappropriate documentation can have medical and legal consequences. B. Do not guess about your patient’s medical problems if you are not certain. C. If poor documentation results in inappropriate care, you may be held responsible. D. Inaccurate, incomplete, illegible documentation also reflects poorly on the EMS provider writing the report. E. Good documentation enhances the EMS provider’s professional stature.

Points to Emphasize

IX. Electronic Patient Care Records A. Electronic patient care records (ePCRs) 1. Computerized patient record-keeping software 2. Benefits of ePCR include: a. Greater ease of data collection and analysis b. A consistent, uniform, easily read patient chart c. The reduction of poor penmanship and spelling errors d. The opportunity for an EMS administrator to configure and alter the software e. Integration with dispatch software, billing services, and regulatory agencies f. Interface with medical devices g. Better quality assurance processes, chart reviews, and feedback to the EMT or paramedic

Teaching Tips

If you didn’t write it down, you didn’t do it.

Obtain an electronic clipboard for students to view.

Minutes 5

Content Outline

Master Teaching Notes

X. Closing A. As a paramedic, you will assume responsibility for your documentation. B. Ensuring complete, accurate, legible, and appropriate documentation is one of your professional responsibilities. C. Your report’s confidentiality cannot be overemphasized. Confidentiality is your patient’s legal right. D. Electronic charting will become common in the future. XI. Summary A. Regardless of the system you use for documentation, all EMS records should possess the same basic attributes. B. Prehospital care providers may use many systems of documentation, including the CHART and SOAP formats. Whatever system is used, it should be used consistently. C. Although EMS providers frequently dislike documentation, it is one of the most important parts of the EMS call. D. Your PCR, whether written or electronic, is the only permanent record of the ambulance call and the only permanent reflection of your professionalism. XII. Case Study

5 XIII. You Make the Call 5

Class Activities Read and discuss the call as a group.

XIV.

Review Questions

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 11 Human Life Span Development 100 Minutes

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Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points To Emphasize Knowledge Applications Media Resources

Chapter 11 objectives can be found on text p. 208. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. Even though human anatomy and physiology basically stay the same, people do change over the span of a lifetime. B. Many of the changes experienced over a lifetime can be identified in developmental stages: 1. Infancy: birth to 12 months 2. Toddler:12–36 months 3. Preschool age: 3–5 years 4. School age: 6–12 years 5. Adolescence: 13–18 years 6. Early adulthood: 19–40 years 7. Middle adulthood: 41–60 years 8. Late adulthood: 61 years and older

Teaching Tips The paramedic will learn the differences between age groups and the importance of each group and its unique set of problems. It is important to stress that infants and children are not “small adults” and require a different approach during management.

Minutes 10

Content Outline III. Infancy A. Physiological Development 1. The greatest changes in the range of vital signs are in the pediatric patient. a. Heart rate settles to about 120 beats per minute after birth. b. Respiratory rate is about 30–40 breaths per minute after the first few minutes of life. c. Tidal volume begins at 6–8 mL/kg initially and increases to 10–15 mL/kg by 12 months of age. d. Average systolic blood pressure increases from a range of 60–90 at birth to a range of 87–105 at 12 months. 2. Normal birth weight of an infant is usually between 3.0 and 3.5 kg but usually drops by 5–10 percent in the first week of life; however, infants usually exceed their birth weight by the second week. 3. Several important cardiovascular changes occur in the first few days after life begins. The following changes lead to an immediate increase in systemic vascular resistance and a decrease in pulmonary vascular resistance: a. Ductus venosus constricts b. Blood pressure changes, and the foramen ovale closes c. Ductus arteriosus constricts after birth 4. In general, an infant’s airway is shorter, narrower, less stable, and more easily obstructed than at any other stage in life. 5. Usually, newborn kidneys are not able to produce concentrated urine, so the baby excretes a relatively dilute fluid with a specific gravity that rarely exceeds 1.0. 6. Passive immunity may remain effective for six months after birth. 7. A young infant is capable of feeling pain but lacks the ability to localize it and isolate a response to it. 8. Infant has several reflexes that disappear over time: Moro, palmar, rooting, and sucking reflexes 9. Closing of fontanelles 10. Newborn usually sleeps for 16–18 hours daily, with periods of sleep and wakefulness distributed evenly over a 24-hour period; sleep gradually

Master Teaching Notes Discussion Topics Discuss ways you can utilize the patient’s family to help during treatment of the ill or injured infant.

Critical Thinking Questions Consider the physiologic development in infants. How does this correlate with the vital signs? How do abnormal vital signs reflect the critical nature of your patient?

Points to Emphasize Infants have very poor capacity to compensate for their injuries or illness. Treatment of these patients should occur before changes are noted in vital signs, as their vitals will not change until the patient is critically ill.

Knowledge Application Have your students research some congenital defects that occur in newborns and how they relate to the specific organ system they affect.

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decreases to 14–16 hours per day, with a 9–10 hour period at night. 11. The developing infant’s extremities grow from epiphyseal and growth plates. 12. Expect rapid changes during an infant’s first year of life. B. Psychosocial Development 1. Psychosocial development begins at birth and develops as a result of instincts, drives, capacities, and interactions with the environment. 2. A newborn’s only means of communication is through crying. 3. Bonding is initially based on secure attachment, or an infant’s sense that his needs will be met by his caregivers. 4. Anxious resistant attachment leads to a child who is always prone to separation anxiety, causing him to be clinging and anxious about exploring the world. 5. Anxious avoidant attachment occurs when the infant has no confidence that he will be responded to helpfully when he seeks care. 6. From birth to approximately 1 ½ years of age, the infant goes through the stage called trust vs. mistrust. 7. Infants learn through scaffolding, or building on what they already know. 8. Infants may be classified as easy child, difficult child, or slow-to-warmup child. 9. Infants who have good relationships with their parents usually follow a predictable sequence of behaviors when they experience a situational crisis, such as being separated from parents. 10

IV. Toddler and Preschool Age A. Physiological Development 1. Vital signs for toddlers and preschool children are not the same as those of infants. 2. For toddlers: a. Heart rate ranges from 80 to110 beats per minute. b. Respiratory rate ranges from 24 to 40 breaths per minute. c. Systolic blood pressure ranges from 75 to110 mmHg. 3. For preschoolers: a. Heart rate ranges from 70 to 110 beats per minute. b. Respiratory rate ranges from 22 to 34 breaths per minute.

Discussion Topics Discuss the differences between infants and toddlers physiologically. Have the students give examples and describe how they relate to patient care.

Critical Thinking Questions Toddlers undergo significant changes as they progress through infancy. How does this relate to the vital signs? How will their personality affect your patient care?

Minutes

Content Outline c. Systolic blood pressure ranges from 75 to 100 mmHg. 4. Normal temperature for both ranges from 99.6 to 99.6 °F. 5. Average toddler or preschooler gains approximately 2.0 kg per year 6. The capillary beds in the toddler are better developed and assist in thermoregulation of the body more efficiently. 7. The terminal airways in the toddler continue to branch off from the bronchioles and alveoli increase in number, providing more surfaces for gas exchange to take place in the lungs. 8. The kidneys are well developed by the toddler years. 9. Passive immunity is lost, and the child becomes more susceptible to minor respiratory and gastrointestinal infections. 10. The toddler’s brain is at 90% of adult weight. 11. Both muscle mass and bone density increase during this period. 12. All primary teeth have erupted by the age of 36 months. 13. Visual acuity is 20/30 during the toddler years. 14. Hearing reaches maturity at 3 to 4 years of age. B. Psychosocial Development 1. Children begin to use actual words at about 10 months but do not grasp that words “mean” something until they are about 1 year of age. 2. Exploratory behavior accelerates at this stage. 3. Sibling relationships become complicated. 4. Peers are very important to the development of toddler and school-age children. 5. There are three basic styles of parenting. a. Authoritarian parents are demanding and desire instant obedience from children. b. Authoritative parents respond to the needs and wishes of their children. They believe in parental control but attempt to explain their reasons to the child. c. Permissive parents take a tolerant, accepting view of their child’s behavior, including aggressive behavior and sexual behavior. 6. The effects of divorce on a child’s development depends greatly on the child’s age, his cognitive and social competencies, the amount of dependency on his parents, how the parents interact with each other

Master Teaching Notes Points to Emphasize It is imperative that at this stage of life, parents are involved in the toddler’s care.

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Master Teaching Notes

and the child, and even the type of child care. 7. Television violence increases levels of aggression in toddlers and preschoolers, and it increases passive acceptance of the use of aggression by others. 8. Toddlers and school age children begin to recognize sexual differences and, through modeling, incorporate gender-specific behaviors they observe in parents, siblings, and peers. 10

V. School Age A. Physiologic Development 1. Between the ages of 6 and 12 years: a. Heart rate is between 65 and 110 beats per minute. b. Respiratory rate is between 18 and 30 breaths per minute. c. Systolic blood pressure ranges from 97 to112 mmHg. d. Body temperature is approximately 98.6°F 2. Average child of this age gains 3 kg per year and grows 6 cm per year 3. In most children, vital signs reach adult levels during this time, but their lymph tissues are proportionately larger than those of an adult. 4. Brain function increases in both hemispheres. 5. Primary teeth are being replaced by permanent ones. B. Psychosocial Development 1. School-age children have developed decision-making skills. a. Usually allowed more self-regulation b. Parents provide general supervision. 2. According to one theory, there are three levels of moral development: a. Preconventional reasoning b. Conventional reasoning c. Postconventional reasoning

Teaching Tips

VI. Adolescence A. Physiological Development 1. Vital signs in adolescents: a. Heart rate is between 60 and 90 beats per minute. b. Respiratory rate is between12 and 26 breaths per minute. c. Systolic blood pressure is between 112 and128 mmHg. d. Body temperature is approximately 98.6°F.

Discussion Topics

As your patients reach developmental milestones, it is important to recognize how they react and respond to strangers. This will allow for better communication with all age groups of patients.

Points to Emphasize At this stage, children can be very difficult to communicate with, especially when scared. Explain the importance of gaining trust and utilizing parents and family.

Discuss some of the issues facing adolescents today and how we can help them feel comfortable when treating them.

Critical Thinking Questions

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2. Adolescent usually experiences a rapid 2- to 3-year growth spurt, beginning distally with enlargement of the feet and hands followed by enlargement of the arms and legs 3. Girls are usually finished growing by the age of 16 and boys by the age of 18. 4. Muscle mass and bone growth are nearly complete at this stage. B. Psychosocial Development 1. Adolescence can be a time of serious conflicts as the adolescent strives for autonomy and parents strive for continued control. 2. Biological changes cause inner conflict in both adolescents and their parents. 3. Privacy becomes extremely important; the adolescent prefers that parents not be present during physical examinations. 4. It is likely that questions asked in the presence of parents will not be answered honestly. 5. Children experience an increase in idealism during adolescence. C. Development of Identity 1. At this age, adolescents are trying to achieve more independence. 2. Progression through the various stages of identity development depends on how well adolescents are able to handle crises. 3. Body image is a great concern. a. Eating disorders are common during this age period. b. Self-destructive behaviors also begin (use of alcohol, tobacco, and illicit drugs). c. Depression and suicide are more common at this age group than in any other. D. Ethical Development 1. As adolescents develop their capacity for logical, analytical, and abstract thinking, they begin to develop a personal code of ethics.

Adolescents are finding their identities and experimenting. How does that change how we approach patient care with them?

Points to Emphasize It is important to give adolescents privacy while caring for them and to respect their rights as a patient.

Knowledge Application Have your students compare and contrast the distinct age groups up to this point and summarize what the important differences are and how they relate to patient care.

Minutes 10

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VII. Early Adulthood A. Physiologic Development 1. Between the ages of 19 and 40 years: a. Heart rate averages 70 beats per minute. b. Respiratory rates range between 12 and 20 breaths per minute. c. Blood pressure averages 120/80 mmHg. d. Body temperature averages 98.6°F. e. This is the period of life during which adults develop lifelong habits and routines. f. Peak physical condition occurs between 19 and 26 years of age. B. Psychosocial Development 1. The highest levels of job stress occur at this point in life.

Critical Thinking Questions

VIII. Middle Adulthood A. Physiologic Development 1. Vital signs are unchanged from early adulthood. 2. The body still functions at a high level with varying degrees of degradation based on the individual. 3. Usually some vision and hearing changes 4. Cardiovascular health becomes a concern, with cardiac output decreasing and cholesterol levels increasing 5. Cancer often strikes this group. 6. Weight control becomes more difficult. 7. Menopause commences for most women in the late 40s to early 50s. B. Psychosocial Development 1. Adults are concerned with the social clock and accomplishing lifetime goals. 2. Those in middle adulthood approach problems as challenges instead of threats. 3. Some women feel depression or a sense of loss and purposelessness at this time, feelings made worse by menopause. 4. Adults often find themselves burdened by financial commitments for elderly parents, as well as for young adult children.

Critical Thinking Questions

Patients that have peak physical conditioning may exhibit abnormal vital signs. What is the physiology behind this and what should we expect to see?

Class Activities Have your students talk about what they enjoy doing outside of school or work to relieve stress.

For many people, EMS becomes their source of primary medical care. How does that affect the system, and how does that change our role of treatment to one of prevention?

Points to Emphasize As our patients age, they begin to face struggles with health, finances and accomplishing goals. As health care providers, we need to be able to sympathize with our patients’ fears and help them understand the care they are receiving.

Minutes 10

Content Outline IX. Late Adulthood A. Maximum life span: the theoretical, species-specific, longest duration of life, excluding premature or “unnatural” death B. Life expectancy: based on the year of birth; the average number of additional years of life expected for a member of a population C. Physiologic Development 1. At 61 years of age or older, vital signs – heart rate, respiratory rate, and blood pressure – depend on the individual’s physical health status. 2. Body temperature still averages 98.6°F. 3. Walls of blood vessels thicken, causing increased peripheral vascular resistance and impaired blood flow to organs. 4. Decreased baroreceptor sensitivity, and by 80 years of age, there is approximately a 50% decrease in vessel activity 5. The trachea and large airways increase in diameter, and enlargement of the end units of the airway result in a decreased surface area of the lungs. 6. Glucose metabolism and insulin production decrease. 7. Tooth loss affects the GI system. 8. There is a 25–30% decrease in kidney mass. 9. All of the body’s senses diminish. 10. There is a decrease in neurotransmitters and a loss of neurons in the cerebellum, which controls coordination, and in the hippocampus, which is involved in some aspects of memory function. 11. Sleep–wake cycle is disrupted, causing older adults to have sleep problems. D. Psychosocial Development 1. Terminal-drop hypothesis asserts that there is a decrease in cognitive functioning over a five-year period prior to death. 2. Individual may or may not be aware of diffuse changes in mood, mental functioning, or the way his body responds to various stimuli. 3. Housing a. Home-care services not affordably available in all communities as a viable alternative to nursing homes b. To be eligible for these services under Medicare, patient must

Master Teaching Notes Teaching Tips Spend time discussing how treatment and care of the elderly patient affects EMS and the differences between these patients and the other age groups.

Discussion Topics Different cultures have different ideas about their elderly population and how they should be cared for. How does this affect patient care?

Critical Thinking Questions How do changes in our bodies as we age manifest themselves into a patient’s chief complaint? How do changes in a patient’s senses lead to other injuries, and how can we help prevent some of these injuries?

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be home-bound, need an intensive level of services, and be expected to benefit from such services over a reasonable amount of time. c. Assisted living is an alternative to home-care services. d. About 95% of older adults live in communities from simple groupings of homes to continuing-care retirement communities. 4. Challenges a. Maintaining self-worth b. Financial burdens c. Dying companions or impending death

X. Summary A. The changes that take place during the span of a lifetime are innumerable. B. The stages of infant through adolescent constitute our pediatric population. C. By knowing the typical developmental characteristics of each age group, you will be better prepared to evaluate a sick or injured pediatric patient. D. Remember that not every person develops at the same rate and in the same way. E. Established norms are only guidelines that should never take the place of a thorough assessment and history obtained from someone who is intimately familiar with the patient. XI. Case Study

5 XII. You Make the Call 5

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

XIII. Review Questions 5

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

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 12 Pathophysiology

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Teaching Tips Discussion Topics Critical Thinking Questions Points To Emphasize Knowledge Applications Media Resources

250 Minutes Chapter 12 objectives can be found on text pp. 224-225. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes

Content Outline I.

Case Study

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

II. Introduction A. The human body normally maintains its internal environment in a steady state of balance called homeostasis. B. A significant disruption in homeostasis often leads to disease. C. Disease is an abnormal structural or functional change within the body. D. Pathophysiology is the study of disease and can be defined as the functional changes that occur within living cells and tissues that are associated with, or result from, disease or injury. E. Pathology is the medical science that deals with all aspects of disease. F. Hierarchical Structure of the Body 1. Cells, the smallest units of life, are made up of chemical molecules, which are made up of individual atoms. 2. A group of similar cells performing a common function is known as tissue. 3. Tissues working together to perform a single function is called an organ. 4. A group of organs working together to perform a common or similar function is referred to as an organ system. 5. A group of organ systems functioning together is called an organism. 6. A human being is an organism.

Teaching Tips Physiology is very complicated. It is the basis of life and has a great effect on our application of patient care.

Points to Emphasize It is important to emphasize that understanding the concepts presented will dictate how our patients respond to treatment and to disease.

Chapter 12 objectives can be found on text pp. 224-225. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

Minutes 15

Content Outline III. Predisposing Factors to Disease A. Factors that lead to the development of disease: 1. Age 2. Gender 3. Genetics 4. Lifestyle 5. Environment B. Risk Analysis 1. Some predisposing factors can be modified; others cannot. 2. Minimizing some of the predisposing factors can also slow the effects of age. 3. There is some cross-pollination of pathophysiologic factors, where risk factors figure in more than one kind of disease, and diseases become risk factors for other diseases. 4. Using data from large-population studies, one can predict, with some degree of accuracy, whether a given person will develop any particular disease and how rapidly he will develop it. 5. Risk analysis can now be used to look at a person’s whole life. C. Disease 1. Normally a defined sequence of events leads to development of a disease; referred to as pathogenesis of the disease 2. Disease is idiopathic if predisposing factors cannot be identified. 3. Etiology is the study of disease and comprises the occurrences, reasons, and variables of disease; often defined as consisting of causality, contribution, and correlation. 4. The manifestation of disease is known as the clinical presentation. 5. The clinical presentation includes both the signs and symptoms. 6. A symptom is what the patient tells you about the disease – a subjective complaint. 7. An objective finding that you can identify through physical examination is referred to as a sign. 8. Some diseases have a specific constellation of commonly found signs and symptoms; these are referred to as a syndrome. 9. Diagnosis is identifying and assigning a name to a disease in a patient

Master Teaching Notes

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Master Teaching Notes

or group of patients. 10. Some diseases have a sudden onset and are referred to as acute. 11. Other diseases have a much slower onset and are referred to as chronic or insidious. 12. Abnormalities that result from the original problem are referred to as complications. 13. When resulting complications are common or even expected, they are referred to as sequalae of the disease. 14. The expected outcome of disease is the prognosis. D. Classification of Disease 1. Infectious 2. Immunologic 3. Inflammatory 4. Ischemic 5. Metabolic 6. Nutritional 7. Genetic 8. Congenital 9. Neoplastic 10. Trauma 11. Physical agents 12. Iatrogenic 13. Idiopathic 30

IV. The Chemical Basis of Life A. The Atom 1. Fundamental chemical unit 2. Protons and neutrons exist within the nucleus of the atom. 3. Protons have a positive electrical charge. 4. Neutrons are electrically neutral. 5. Electrons have a negative electrical charge. 6. An element is a substance that cannot be separated into simpler substances. 7. The number of protons in the nucleus of an atom (the atomic number) defines the element.

Teaching Tips Use diagrams and draw the structures on the board so that students can visually see what it is you are describing.

Critical Thinking Questions Why is acid–base balance important to our bodies? How much of a role do the kidneys

Minutes

Content Outline 8. Elements are usually classified by their atomic number in a scheme known as the periodic table of elements. 9. Chemical Bonding a. Most atoms become stable by bonding to other atoms. b. The equal sharing of electrons results in a covalent bond. c. Ionic bonds are formed between atoms with an electrical charge that are attracted to one another. d. Hydrogen bonds are an ionic bond created with hydrogen and oxygen. B. Inorganic and Organic Chemicals 1. Inorganic chemicals do not contain carbon. 2. Organic chemicals contain carbon. 3. More than 90% of all known chemicals are organic; most chemicals found in plants and animals are organic. 4. Six elements make up approximately 98% of the body weight of most living organisms: a. Carbon b. Hydrogen c. Nitrogen d. Oxygen e. Phosphorus f. Sulfur 5. The major elements of living systems: a. Carbon b. Hydrogen c. Oxygen d. Nitrogen C. Classes of Biological Chemicals 1. Carbohydrates: compounds that contain the elements carbon, hydrogen, and oxygen a. Provide the majority of calories in most diets b. Typically divided into the sugars and the polysaccharides c. Sugars divided into monosaccharides or disaccharides 2. Proteins: nitrogen-based complex compounds; the basic building blocks

Master Teaching Notes play? The renal system and acid base balance plays an important role in many medical patients. How do these processes regulate the body’s response to changes in homeostasis?

Knowledge Applications Why is it important to understand acid–base balance in the renal patient? How does dialysis affect the balance of pH in the body?

Minutes

Content Outline of cells a. Essential for the growth and repair of living tissues b. Amino acids held together by peptide bonds c. Four levels of structure: primary, secondary, tertiary, and quaternary d. Enzymes: substances that speed up chemical reactions 3. Nucleic Acids a. DNA is the nucleic acid that contains the genetic instructions for life. b. RNA plays a major role in protein synthesis, serving as a template for protein synthesis. 4. Lipids: chemicals that do not dissolve in water a. Triglycerides b. Phospholipids c. Steroids D. Water 5. The “universal solvent” 6. Plays a significant role in numerous biological processes 7. A polar molecule; dissolves in both polar and charged substances 8. Plays a major role in the transport of substances throughout the body 9. Helps to maintain the body’s temperature E. Acids and Bases 10. Acids are substances that give up protons during chemical reactions. 11. Bases are substances that acquire protons during chemical reactions. 12. Any chemical reaction resulting in a transfer of protons is termed an acid–base reaction. 13. To express whether a solution is acidic or basic, the pH scale is used. a. The scale ranges from 0 to 14; a pH of 7.0 is neutral. b. The lower the pH, the higher the concentration of hydrogen ions and therefore, the more acidic the solution c. The higher the pH, the lower the concentration of hydrogen ions and the more basic the solution F. There are three major buffer systems: 1. The carbonic acid–bicarbonate buffer system is the most important

Master Teaching Notes

Minutes

Content Outline buffer system in the extracellular fluid, including the blood. a. It is also the most rapidly acting of the three buffer systems. 2. The protein buffer system works by way of selective amino acid monomers accepting or releasing hydrogen ions. a. This system plays a major role in pH regulation in both the extracellular fluid (ECF) and intracellular fluid (ICF) compartments. b. It interacts significantly with other systems. 3. The phosphate buffer system plays a role in the buffering the pH of the ICF and the urine. G. Acid–Base Balance 1. To maintain acid–base balance, the body uses three systems in coordination with one another. 2. The buffer systems react the fastest by secreting or absorbing hydrogen ions. 3. The respiratory system is activated next and increases or decreases the respiratory rate to affect PCO2. 4. If PCO2 rises, the pH falls; conversely, if the PCO2 falls, the pH rises. 5. The renal system also plays a major role in acid–base balance; however, it tends to work more slowly than the other body systems. 6. The renal system works by either secretion or reabsorption of hydrogen ions. H. Acid–Base Disorders 1. Any significant deviation of pH outside of normal operating parameters (7.35–7.45) can be classified as an acid–base disorder. 2. Respiratory acid–base disorders result from inequality in carbon dioxide generation in the peripheral tissues and carbon dioxide elimination in the respiratory system. 3. Respiratory acidosis occurs when the respiratory system cannot effectively eliminate all the carbon dioxide generated through metabolic activities in the peripheral tissues. 4. Respiratory alkalosis occurs when the respiratory system eliminates too much carbon dioxide through hyperventilation, resulting in hypocapnia. 5. Metabolic acidosis is a deficiency of bicarbonate in the body.

Master Teaching Notes

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Master Teaching Notes

6. Metabolic alkalosis is relatively uncommon and is due to an increase in HCO3 levels or a decrease in circulating acids.

V. The Cell A. The cell is the basic unit of all living organisms and can typically be divided into two types: prokaryotic or eukaryotic. 1. Prokaryotic cells have no nucleus or organelles. 2. Eukaryotic cells have a nucleus and organelles. B. The Plasma Membrane and Cytoplasm 3. Cells are surrounded by a plasma membrane. 4. The cytoplasm fills the inside of the cell and contains water, salts, organic molecules, and many enzymes. a. The water component is referred to as intracellular fluid. 5. Membrane functions and their proteins include the following: a. Linkers b. Enzymes c. Receptors d. Transporters 6. The plasma membrane has several functions. a. It plays a major role in the ability of cells to adhere to one another. b. It helps with cell–cell recognition. c. It maintains the structural integrity of the cell. d. It plays a major role in communications between cells. e. The cell membrane regulates the movement of substances into and out of the cell. 7. Simple diffusion allows substances to move from an area of high concentration to an area of lower concentration until the substance is equal in both areas. a. Osmosis is the movement of water molecules from high concentration to low concentration. b. When the concentration of solutions on both sides of a semipermeable membrane is equal, it is said to be isotonic.

Teaching Tips It helps to use diagrams or drawings to demonstrate the parts of the cell as well as the transport of substances.

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c. When the concentration is higher, it is hypertonic; when it is lower, it is hypotonic. 8. Facilitated diffusion occurs through the use of plasma proteins in one of the following two ways: a. Carrier proteins bind a specific type of solute and transport the solute to the other side of the membrane. b. Ion channels allow certain types of solutes to pass through. 9. Active transport uses a carrier protein but also uses energy in the form of ATP. a. Active transport moves substances from region of low concentration to region of high concentration (against the concentration gradient). b. The transport of sodium ions out of the cell and potassium ions into the cell, against the concentration gradient, is achieved by the sodium–potassium pump. 10. With endocytosis, large molecules, single-celled organisms (bacteria), and fluid containing dissolved substances can enter the cell. a. Often divided into two categories: phagocytosis (the process whereby the cell engulfs large particles or bacteria) and pinocytosis (the process by which the cell engulfs droplets of fluid carrying dissolved substances) 11. The process of exocytosis moves large molecules out of a cell. 20

VI. The Cellular Environment: Fluids and Electrolytes A. Water 1. The most abundant substance in the human body 2. Accounts for approximately 60% of total body weight 3. Distributed among various compartments throughout the body a. Intracellular fluid is all the fluid found inside body cells; approximately 70% of all body water is found within this compartment. b. Extracellular fluid compartment contains the remaining 30% of all body water 1)The intravascular fluid is found within the circulatory system. 2)The interstitial fluid is found outside the cell membrane yet not within the circulatory system.

Critical Thinking Questions How does IV fluid affect the balance of water and electrolytes?

Points to Emphasize Diffusion is a very important concept. Be sure to stress the concept and the understanding of it.

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Content Outline 4. The volume of water remains relatively constant due to intake and output of water, and a balance is required to maintain homeostasis. 5. Dehydration can result from several factors: a. Gastrointestinal losses b. Increased sensible loss c. Increased sweating d. Internal losses e. Plasma losses 6. Overhydration a. Major sign is edema b. Heart failure may present in severe cases of overhydration. B. Electrolytes 1. Electrolytes are substances that dissociate into electrically charged particles when placed into water. 2. Ions with a positive charge are called cations. 3. Ions with a negative charge are called anions. C. The Transport of Water and Electrolytes 1. Diffusion is the tendency of molecules to move from an area of higher concentration to an area of lower concentration; it is a passive process that does not require energy. 2. Active transport is the movement of a substance across the cell membrane against the osmotic gradient; it requires energy. 3. Facilitated diffusion is when carrier proteins move molecules across the cell membrane. D. Water Movement between Intracellular and Extracellular Compartments 1. The mechanisms by which water and solutes move across cell membranes ensure that the osmolality of body water inside and outside the cells is normally in equilibrium. 2. Sodium is responsible for the osmotic balance of the extracellular space; potassium plays the same role in the intracellular space. 3. Generally, the osmolality of intracellular fluid does not change very rapidly. a. When there is a change in the osmolality of extracellular fluid, water will move from the intracellular to the extracellular compartment or vice

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Content Outline versa until osmotic equilibrium is regained. E. Water Movement between Intravascular and Interstitial Compartments 1. In general, the movement of water across a cell membrane is governed by osmotic pressure. 2. Hydrostatic pressure is the blood pressure, or force against the vessel walls, created by contractions of the heart. 3. Together, osmotic pressure and hydrostatic pressure are responsible for net filtration, which is normally zero. F. Edema 1. Edema is the accumulation of water in the interstitial space. 2. Edema occurs when net filtration is disrupted by one or more of the following: a. A decrease in plasma oncotic force b. An increase in hydrostatic pressure c. Increased permeability of the capillary membrane d. Lymphatic obstruction 3. Edema can be localized or generalized. 4. Edema is a sign of underlying disease and a source of problems. a. Edema interferes with movement of nutrients and waste between tissues and capillaries. b. It may diminish blood flow, depriving tissues of oxygen. c. It prevents gas exchange when it occurs in the lungs or respiratory system. d. It can cause a relative condition of dehydration. G. Intravenous Therapy 1. Intravenous (IV) therapy is the introduction of fluids and other substances into the venous side of the circulatory system. a. It is used to replace blood lost through hemorrhage, for electrolyte or fluid replacement, and for introduction of medications directly into the vascular system. 2. Blood consists of the liquid portion (plasma) and the formed elements (blood cells). a. Plasma is made up of approximately 92% water, 6–7% proteins, and a small portion consisting of electrolytes, lipids, enzymes,

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Content Outline clotting factors, glucose, and other dissolved substances. b. Formed elements: erythrocytes, leukocytes, and thrombocytes 3. The most desirable fluid for blood loss replacement is whole blood. 4. Before blood, or blood products, can be administered to a patient, they must be typed and cross-matched to prevent a severe allergic reaction. 5. Transfusion reactions occur when there is a discrepancy between the blood type of the patient and the blood type of the blood being transfused. a. Common signs and symptoms of transfusion reaction include fever, chills, hives, hypotension, palpitations, tachycardia, flushing of the skin, headaches, loss of consciousness, nausea, vomiting, and shortness of breath. 6. IV fluids are the most common products used in prehospital care for fluid and electrolyte therapy. They occur in two standard forms: a. Colloids, which contain proteins or other high-molecular-weight molecules that tend to remain in the intravascular space for an extended period of time 1) Examples: plasma protein fraction, salt-poor albumin, dextran, and hetastarch b. Crystalloids, which are the primary compounds used in prehospital IV fluid therapy 1) Isotonic solutions, hypertonic solutions, hypotonic solutions H. The Internal Cell 1. Within the cell are numerous specialized structures called organelles, as well as a permeating structure called the cytoskeleton. I. Organelles and Their Functions 1. Eukaryotic cells contain specialized internal compartments, enclosed by membranes, called organelles. a. The nucleus is among the largest organelle and contains all of the cell’s genetic information. b. Ribosomes are spherical structures that can account for up to 25% of the dry weight of a cell; they synthesize polypeptides and proteins. c. The endoplasmic reticulum is a network of tubules, vesicles, and

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Content Outline sacs that interconnect with the plasma membrane, nuclear envelope, and many of the other organelles in the cell; it stores enzymes, contains ribosomes, and helps to replenish and maintain the plasma membrane d. The portion of the endoplasmic reticulum without ribosomes is called smooth endoplasmic reticulum (SER). e. The Golgi apparatus (also called the Golgi complex) processes proteins for the cell membrane and other organelles. f. Lysosomes serve to degrade and remove products of ingestion. g. Vacuoles are membrane-bound organelles used for temporary storage or transport of substances such as food sources. h. Peroxisomes have the ability to generate and degrade hydrogen peroxide. i. The mitochondria are the “powerhouses” of the cells in that they provide the energy needed for all of a cell’s biochemical processes. J. The Cytoskeleton and Other Internal Cell Structures 1. Within eukaryotic cells is a complex system of filaments, microtubules, and intermediate filaments referred to as the cytoskeleton. 2. The cytoskeleton forms a three-dimensional structure that fills the cytoplasm and serves as a skeleton for cell stability and as a muscle for cell movement. 3. Cilia are numerous hairlike structures that move in a back-and-forth motion; this motion can sweep debris away from the cell and play an important role in protection of the respiratory system and the reproductive system. 4. Flagella are much longer than cilia and move in an undulating wavelike manner.

VII. Cellular Respiration and Energy Production A. Cellular respiration is one of two metabolic pathways cells use to convert nutrients to energy and occurs in three phases. 1. Glycolosis breaks down the six-carbon sugar glucose yielding 2 ATP. 2. The citric acid cycle (Krebs cycle) oxidizes the remainder of the glucose molecule, and yields two molecules of ATP and several molecules of NADH and FADH2, and releases carbon dioxide as waste.

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3. NADH and FADH2 donate their electrons to the electron transport chain, which releases energy in the form of ATP as it passes from one molecule to the next, yielding 32 molecules of ATP (for a total of 36 ATP from the process of cellular respiration). B. Fermentation breaks down glucose when oxygen is not available. 1. The glucose molecule proceeds through glycolysis. 2. The chemical reaction then occurs in the mitochondria in the absence of oxygen. 3. NADH is transferred to pyruvate, which generates NAD. 4. This helps to generate ATP through glycolysis, but at a much lower yield (only 2 ATP total compared to 36 ATP from cellular respiration). 5. Two types of fermentation can occur in humans: lactic acid fermentation and alcohol fermentation. 6. Lactic acid fermentation has a by-product of lactic acid. 10

VIII.Cellular Response to Stress A. Severe stresses and pathological conditions may require the cell itself to change. 1. Such physiologic and structural changes to the cell, in response to change or stress, are referred to as cellular adaptation. B. Cellular Adaptation 1. Hyperplasia is an increase in the number of cells in a tissue or organ. a. Hormonal hyperplasia occurs during puberty and pregnancy. b. Compensatory hyperplasia is an increase in tissue mass following injury. 2. Hypertrophy is an increase in the size of cells in a tissue or organ. a. Physiologic hypertrophy usually results from increased physical demand. b. Pathological hypertrophy results from abnormal stress. 3. Atrophy is a decrease in the size of a cell and can result from several factors, including a decreased workload, decreased blood supply, loss of nervous control, inadequate nutritional intake, lack of endocrine stimulation, and aging. 4. In certain situations, a cell can change from one adult cell to another adult cell type; this is called metaplasia and is reversible.

Teaching Tips The cellular response to stress can be likened to other physiologic processes. Use examples of this when discussing these topics.

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Content Outline C. Cell Injury and Cell Death 1. When cells are stressed to the point at which they can no longer adapt or when they are exposed to toxic agents, cell injury can result. 2. If cell injury is persistent or severe, cell death may ultimately occur. 3. Cellular necrosis is cell death caused by outside forces such as infection that attack the cell membrane; it is sometimes called “cell murder.” 4. Numerous factors can cause cell injury and possibly cell death: a. Hypoxia b. Physical agents c. Chemical agents d. Infection e. Immune reactions f. Genetic problems g. Problems with nutrition 5. Cell death (apoptosis) occurs as a normal process of keeping the body healthy by sloughing off old or damaged cells and making room for new, healthy cells. 6. Numerous factors can cause cell injury and possibly cell death: a. Ischemic and hypoxic injury 1) Ischemia results from diminished blood flow. 2) Hypoxia is due to decreased availability of oxygen. b. Oxidative stress: some cells that are reversibly injured will die even after blood flow resumes – by either necrosis or aptosis. c. Chemical injury: various chemicals, including drugs, can cause injury to a cell. d. Apoptosis: occurs when a cellular program is activated that causes the release of enzymes that destroy the genetic material within the nucleus of the cell and selected proteins in the cytoplasm e. Dysplasia: abnormal or disordered growth in a cell

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Content Outline IX. Tissues A. Tissue is a group of cells that serve a common purpose. B. Origin of Body Tissues 1. All the tissues of the body are derived from three distinct cell lines seen during early embryonic development. 2. There are three germ layers (cell layers): endoderm, mesoderm, and endoderm. a. The endoderm is the innermost germ cell layer. b. The mesoderm is the middle germ layer. c. The ectoderm is the outermost germ layer. d. Epithelium is derived from all three germ layers. C. The germ layers differentiate into primary tissue types. 1. Epithelial tissue covers internal and external body surfaces. a. Provides physical protection b. Controls permeability c. Provides special senses d. Produces special secretions 2. Connective tissue provides a framework. a. Consists of primarily of a substance called the extracellular matrix b. Connective tissue contains collagen fibers, elastic fibers, or reticular fibers. c. Cell types found in connective tissue include fibroblasts, macrophages, adipocytes, mast cells, and other cells (e.g., white blood cells reacting to injury or infection). d. Connective tissue is classified as loose, adipose, dense, or specialized. 3. Muscle tissues are specialized for contraction. a. Responsible for movement b. Skeletal muscle is usually attached to bones and is under voluntary control. c. Smooth muscle contains no striations and is under involuntary control. d. Cardiac muscle is found only in the heart and generates its own impulses.

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Content Outline 4. Nervous tissue coordinates the body’s activities. a. It is found in the brain, spinal cord, and peripheral nerves. b. It conducts electrical impulses from one part of the body to another. D. Neoplasia 1. Neoplasia is an abnormal type of tissue growth in which cells multiply and grow in an uncontrolled fashion. 2. The mass of uncontrolled cell growth is called a tumor and may be benign or malignant. a. Benign neoplastic lesions are slow growing, are usually encased by cells that are adherent, do not invade local tissue, do not spread to other body areas, and do not recur once removed. b. Cancerous tumors have the opposite characteristics. 3. Most cancers are either of epithelial origin or connective tissue origin. 4. Various factors have been associated with the development of cancer, termed oncogenesis. a. Carcinogens b. Radiation 5. Viruses that produce cancers are called oncogenic viruses. 6. Genetics is thought to be responsible for some cancers. 7. The environment is a definite risk factor for the development of cancer. 8. Hormones are thought to play a role in the development of cancer (breast cancer in women, prostate cancer in men). 9. The process of developing a malignant neoplasia is called carcinogenesis and occurs in three stages: a. Initiation b. Promotion c. Progression 10. Once cancer develops, it becomes invasive. 11. Cancer cells are usually graded by the degree of cell differentiation present: Grade X, Grade 1, Grade 2, Grade 3, and Grade 4.

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X. Genetic and Other Causes of Disease A. Genetics, Environment, Lifestyle, Age, and Gender 1. Inherited traits are determined by molecules of DNA, which form structures called genes that reside on larger structures called chromosomes within the nuclei of all our cells. 2. Some diseases are thought to be purely genetic; others are caused by a combination of genetic and environmental factors and are called multifactorial disorders. B. Family History and Associated Risk Factors 1. Most diseases with a genetic component that come on during adulthood also have associated risk factors that can be modified to prevent, delay, or reduce the impact of the disease. 2. Personal habit is among the publicized and controllable causes of disease in our society. 3. Immunologic Disorders a. Rheumatic fevers b. Allergies c. Asthma 4. Cancer a. Breast cancer 1) Greatest risk factor is female gender 2) Second greatest risk factor is age 3) History of breast cancer in first-degree relative increases risk by two or three times b. Colorectal cancer 1) Risk factors include age and family history. 2) Incidence in a first-degree relative increases risk by two or three times 3) Rectal cancer more common in men 4) Colon cancer more common in women c. Lung cancer 1) Causes overwhelmingly environmental 2) Smoking is main cause 3) Can also be caused by inhaling substances such as

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Content Outline asbestos, arsenic, and nickel, usually in the workplace 5. Endocrine Disorders a. Most common is diabetes mellitus; two types: type 1 and type 2 6. Hematologic Disorders a. Hemophilia: bleeding disorder caused by a genetic clotting factor deficiency b. Hemochromatosis: caused by a histocompatibility complex dysfunction c. Anemia: reduction in circulating red blood cells 7. Cardiovascular Disorders a. Prolongation of the QT interval: a delay between depolarization and repolarization of the ventricles as revealed in an electrocardiogram b. Mitral-valve prolapse: an upward ballooning of the valve between the left ventricle and atrium that allows blood to regurgitate back into the atrium when the ventricle contracts c. Coronary artery disease: deposits on the walls of the coronary arteries that reduce blood flow to the heart muscle d. Hypertension: high blood pressure e. Cardiomyopathy: disease affecting the heart muscle 8. Renal Disorders a. Renal (kidney) failure 9. Rheumatic Disorders a. Gout: a condition that may have both genetic and environmental causes; characterized by severe arthritic pain caused by deposits of crystals in the joints, most commonly in the great toe 10. Gastrointestinal Disorders a. Lactose intolerance: inability of patient to tolerate milk and some dairy products b. Crohn’s disease: chronic inflammation of the wall of the digestive tract that usually affects small intestine, large intestine, or both c. Peptic ulcers: develop when the normal protective structures and mechanisms break down and areas in the lining of the stomach or duodenum are inflamed by stomach acid and digestive juices d. Cholecystitis: inflammation of the gallbladder that usually results

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from blockage by a gallstone e. Obesity: being more than 20% over the ideal body weight 11. Neuromuscular Disorders a. Huntington’s disease: results in uncontrollable jerking and writhing movements b. Muscular dystrophy: results in progressive muscle weakness c. Multiple sclerosis: affects nerves of the eye, brain, and spinal cord d. Alzheimer’s disease: thought to cause about 50% of dementias, or progressive mental deterioration 12. Psychiatric Disorders a. Schizophrenia: individual loses contact with reality and suffers from hallucinations, delusions, abnormal thinking and disrupted social function. b. Manic-depressive illness, now called bipolar disorder: person experiences alternating periods of depression.

XI. Hypoperfusion A. The Physiology of Perfusion 1. The circulatory system, in conjunction with the respiratory and gastrointestinal systems, provide the body’s cells with essential nutrients and removal of wastes. 2. Perfusion is the constant and necessary passage of blood through the body’s tissues. a. Hypoperfusion, commonly called shock, is inadequate perfusion of body tissues. 3. Oxygen is brought into the body by the respiratory system and transported to the tissues via the circulatory system after diffusion in the lungs. 4. The movement of oxygen to the tissues is dependent upon the following conditions and is known as the Fick principle: a. Adequate concentration of inspired oxygen b. Appropriate movement of oxygen across the alveolar–capillary membrane into the arterial bloodstream c. Adequate number of red blood cells to carry the oxygen

Critical Thinking Questions How can we relate shock to the changes happening at the cellular level? Try to describe shock by taking it all the way to the cellular components.

Points to Emphasize Shock is inadequate perfusion. It is important to discuss that early intervention can reverse many of the signs of shock.

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Content Outline d. Proper tissue perfusion e. Efficient offloading of oxygen at the tissue level 5. The waste products of cellular metabolism are expelled from the cells and carried away by the blood. 6. There is some local control of both tissue perfusion and waste removal. B. The Pathophysiology of Hypoperfusion 1. Hypoperfusion is almost always a result of inadequate cardiac output. a. Inadequate pump b. Inadequate fluid c. Inadequate container 2. The ultimate outcome of shock is impairment of cellular metabolism. 3. Two characteristics of impaired cellular metabolism in any type of shock are impaired oxygen use and impaired glucose use. 4. Compensation a. In shock, the fall in cardiac output, detected as a decrease in arterial blood pressure by the baroreceptors, activates several body systems that attempt to reestablish a normal blood pressure 5. Decompensation a. If the conditions causing shock are too serious or progress too rapidly, compensatory mechanisms may not be able to restore normal function. b. In those cases, decompensation is said to occur, and the patient is in a state of decompensated shock. C. Types of Shock 1. Shock is classified according to its cause. a. Cardiogenic shock is usually the result of severe left ventricular heart failure secondary to acute myocardial infarction or congestive heart failure. b. Hypovolemic shock is due to a loss of intravascular fluid volume. c. Neurogenic shock results from injury to the brain or the spinal cord. d. Anaphylactic shock occurs when the body attempts to rid itself of a foreign invader. e. Septic shock begins with septicemia (also called sepsis), an infection that enters the bloodstream and is carried throughout the

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Content Outline body. 2. Multiple Organ Dysfunction Syndrome (MODS) is the progressive impairment of two or more organ systems resulting from an uncontrolled inflammatory response to a severe illness or injury. a. Primary MODS is the first stage and is organ damage directly resulting from a specific cause, such as ischemia or inadequate perfusion resulting from an episode of shock, trauma, or major surgery. b. Secondary MODS occurs when the cells are activated by a second insult producing an exaggerated response. c. Clinical presentation of MODS 1) Dysfunction may develop in the pulmonary, gastrointestinal, hepatic, renal, cardiovascular, hematologic, and immune systems. 2) Decreased cardiac function and myocardial depression 3) MODS does not occur in one intense crisis; usually develops over a period of two, three, or more weeks.

XII. Self-Defense Mechanisms A. The body has powerful ways of defending and healing itself, and medical intervention is needed only when natural defense mechanisms become overwhelmed. B. Infectious Agents 1. Bacteria a. Single-celled organisms that consist of internal cytoplasm surrounded by a rigid cell wall b. Can be cultured and identified readily in most hospital laboratories c. Can cause many common infections in medicine, including middle ear infections in children, many cases of tonsillitis, and meningitis d. Some bacteria protect themselves by forming a capsule outside the cell wall that protects the organism from digestion by phagocytes e. Many bacteria release poisonous chemicals: exotoxins and endotoxins. f. The body counters bacterial invasion and release of enzymes and toxins through activation of the immune system.

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2. Viruses a. Most infections are causes by viruses. b. Viruses are much smaller than bacteria and can be seen only with an electron microscope. c. A virus has no organized cell structure except a protein coat surrounding the internal genetic material, DNA, or RNA. d. Some viruses develop a coating in addition to the capsid, called an envelope. e. The symptoms of a virus may not be readily apparent because it is hidden within the host cell. f. Viruses do not produce toxins but can still cause serious illness. g. Unlike bacteria, viruses are very difficult to treat. 3. Other Agents of Infection a. Fungi: include yeasts and molds; rarely cause human disease other than minor skin infections and some common vaginal infections b. Parasites: range in size from protozoa to large intestinal worms c. Prions: differ from viruses in that they are smaller, are made entirely of proteins, and do not have protective capsids. C. Three Lines of Defense 1. The anatomic defenses are external and nonspecific. 2. The inflammatory response, or inflammation, begins within seconds of injury or invasion and is nonspecific. 3. The immune response develops more slowly and is specific. 15

XIII. The Immune Response A. The immune system detects antigens as being foreign, or “non-self,” and responds with antibodies that combine with antigens to control or destroy them. B. Characteristics of the Immune Response and Immunity 1. The immune response can be classified as natural versus acquired immunity, primary versus secondary immune responses, and humoral versus cell-medicated immunity. 2. Natural immunity is part of the genetic makeup of the individual. 3. Acquired immunity develops as an outcome of the immune response and can be either active or passive.

Critical Thinking Questions How do vaccines disrupt or affect the physiology of viruses? Why are some bacteria resistant to antibiotics?

Points to Emphasize The body has powerful resources to protect itself. Through medicine, we can augment these systems and help our patients overcome the illnesses they face.

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Content Outline 4. Primary immune response occurs after the first exposure to an antigen as the body creates antibodies to the antigen. 5. Secondary immune response occurs as a result of antibodies produced after the primary immune response. 6. Humoral immunity refers to the long-lasting antibodies present in the blood and lymph nodes. 7. Cell-mediated immunity occurs when an antigen is attacked directly without the use of antibodies. C. Induction of the Immune Response 1. The immune response must be triggered, or induced. 2. Antigens that can trigger the immune response are called immunogens. 3. Antigens that trigger an immune response must have specific characteristics: a. Sufficient foreignness b. Sufficient size c. Sufficient complexity d. Present in sufficient amounts 4. The body recognizes whether a substance is self or non-self as a result of certain antigens called histocompatibility locus antigens (HLA) that are present on almost all cells in the body. 5. Blood group antigens exist on the surface of red blood cells. a. Rh system b. ABO system D. Humoral Immune Response 1. Humoral immune response is provided by secretions at the body surfaces. 2. Lymphocytes are specialized cells that are involved in the immune response. a. Lymphocytes travel through a set of lymphoid tissues, where they mature. b. Each mature B cell recognizes an antigen and produces antibodies specific to the antigen. 3. Immunoglobulins a. Antibodies are proteins secreted by plasma cells that are produced

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Content Outline by B cells in response to an antigen. b. All antibodies are immunoglobulins, but researchers have not yet determined whether all immunoglobulins function as antibodies. c. The structure of immunoglobulins consist of Y-shaped chains, arranged somewhat differently in the different immunoglobulin classes. d. An antibody circulates in the blood or is suspended in body secretions until it meets and binds to its specific antigen. e. Direct effects of antibodies on antigens 1) Agglutination 2) Precipitation 3) Neutralization f. Indirect effects of antibodies on antigens 1) Enhancement of phagocytosis 2) Activation of plasma proteins 3) Neutralization of bacterial toxins 4) Neutralization of viruses 5) Opsonization of bacteria 6) Activation of inflammatory processes g. Classes of immunoglobulins 1) IgM 2) IgG 3) IgA 4) IgE 5) IgD h. Antigenic determinants on human antibody molecules 1) Isotypic antigens 2) Allotypic antigens 3) Idiotypic antigenic determinants i. Monoclonal antibodies: pure and specific to a single antigen 4. The secretory immune system consists of lymphoid tissues and primarily protects the body from pathogens that are ingested or inhaled. 5. Cell-mediated immune response occurs through T cells, which attack antigens directly.

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Content Outline a. T cells do not produce antibodies. b. T cells travel through the thymus gland. c. Five types of mature T cells: memory cells, Td cells, Tc cells, Th (helper) cells, Ts (suppressor) cells d. Specialized functions of T cells: memory, delayed hypersensitivity, cytotoxicity, control E. Cellular Interactions in Immune Response 1. Immune and inflammatory responses are interacting, not separate. 2. Three key interactions occur during an immune response: a. Antigen-presenting cells interact with Th cells. b. Th cells interact with B cells. c. Th cells interact with Tc cells. 3. Cytokines, proteins produced by white blood cells, are the “messengers” of the immune response. e. Monokine: a cytokine released by a macrophage f. Lymphokine: a cytokine released by a lymphocyte 4. Before immune response can begin, a sequence of three processes is necessary: a. Antigen processing b. Antigen presentation c. Antigen recognition 5. T cells and B cells are not differentiated until antigens present in the system react with the appropriate receptors on the cell surfaces. 6. Several parameters control immune responses, activating them when needed but stopping or inhibiting them when not needed, thus preventing them from destroying the body’s own tissues. F. Fetal and Neonatal Immune Function 1. The human infant develops some immune response capabilities, even in utero, but the immune system is usually not fully mature when the infant is born. 2. During the first few months of life, the infant relies on antibodies which crossed the placenta into fetal circulation. G. Aging and the Immune Response 1. As the human body ages, immune function begins to deteriorate.

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Content Outline XIV. Inflammation A. Inflammation Contrasted to the Immune Response 1. Inflammation, also called the inflammatory response, is the body’s response to cellular injury. 2. Inflammation develops swiftly. 3. Inflammation is nonspecific. 4. Inflammation is temporary. 5. Inflammation involves several types of plasma protein systems. B. How Inflammation Works: An Overview 1. There are several phases of inflammation: a. Phase 1: Acute inflammation b. Phase 2: Chronic inflammation c. Phase 3: Granuloma formation d. Phase 4: Healing 2. Four functions of inflammation a. Destroy and remove unwanted substances b. Wall off the infected and inflamed area c. Stimulate the immune response d. Promote healing C. Acute Inflammatory Response 1. Acute inflammation is triggered by an injury to the body’s cells. 2. Blood vessels contract and dilate to move additional blood to the site. 3. Vascular permeability increases. 4. White blood cells and plasma proteins move through the capillary walls. D. Mast Cells 1. Mast cells are the chief activators of the inflammatory response, and degranulation is the process by which mast cells empty granules from their interior into the extracellular environment. 2. Degranulation occurs when the mast cell is stimulated by physical injury, chemical agents, or immunologic and direct processes. 3. During degranulation, biochemical agents in the mast cell granules are released, notably vasoactive amines and chemotactic factors. 4. When stimulated, mast cells synthesize, or construct, two substances that play important roles in inflammation: leukotrienes and

Master Teaching Notes Discussion Topics Follow an injury (such as a laceration) through the entire process from initial insult to resolution while describing the phases involved.

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Content Outline prostaglandins. E. Plasma Protein Systems cells 1. Plasma protein systems mediate white blood cells and other products of inflammation. 2. The complement system consists of 11 proteins and takes part in all the events of the inflammatory response. a. Classic pathway b. Alternative pathway F. The Coagulation System 1. The coagulation system (also called the clotting system) stops the spread of infectious agents and products of inflammation as well as forming the foundation for repair and healing. 2. The kinin system causes vasodilation, extravascular smooth muscle contraction, increased permeability, and chemotaxis (which causes pain). 3. Control of plasma protein synthesis is important for two reasons: a. Inflammatory response is essential for protection of the body from unwanted invaders b. The inflammatory processes are powerful and potentially very damaging to the body. G. Cellular Components of Inflammation 1. Exudate: a collective term for all the helpful substances, including white cells and plasma, that move out of the capillaries and into the tissues to attack unwanted substances and promote healing. This occurs in the following sequence: a. Vascular response b. Increased permeability c. Exudation of white cells 2. Inflammatory response involves granulocytes and monoctyes. 3. Phagocytes have the ability to ingest other cells and substances such as bacteria and cell debris. 4. Neutrophils are the first phagocytes to reach the inflamed site. 5. Eosinophils, basophils, and platelets also migrate to the site to join the inflammatory response.

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6. Eosinophils are the primary defense against parasites. 7. Basophils are thought to function in the same way within the blood as mast cells do outside the blood. 8. Platelets are fragments of cytoplasm that circulate in the blood; they act with components of the coagulation cascade to promote blood clotting and also release serotonin. Cellular Products 1. Cytokines 2. Lymphokines 3. Monokines 4. Interleukins Systemic Responses of Acute Inflammation 1. Three chief manifestations of acute inflammation are fever, leukocytosis, and an increase in circulating plasma proteins. Chronic Inflammatory Response 1. Chronic inflammation is any inflammation that lasts longer than two weeks. 2. During chronic inflammation, large numbers of neutrophils degranulate and die. 3. As neutrophils, lymphocytes, and macrophages die, they infiltrate the tissues, sometimes forming a cavity that contains these dead cells, bits of dead tissue, and tissue fluid, a mixture called pus. 4. Occasionally, a granuloma will form to wall off the infection from the rest of the body. 5. Tissue repair and possible scar formation are the final stages of inflammation. Local Inflammatory Responses 1. Exudate has three functions: a. To dilute toxins released by bacteria and the toxic products of dying cells b. To bring plasma proteins and leukocytes to the site to attack the invaders c. To carry away the products of inflammation Resolution and Repair

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1. Resolution is the complete restoration of normal structure and function; this can happen if the damage was minor, there are no complications, and the tissues are capable of regeneration. 2. If resolution is not possible, repair takes place, scarring being the end result. 3. Reconstruction of a wound processed through four steps: initial wound response, granulation, epithelialization, and contraction. 4. During maturation, scar tissue is remodeled; blood vessels disappear, leaving an avascular scar; and the scar tissue becomes stronger. 5. Dysfunctional wound healing can result in an insufficient repair, an excessive repair, or a new infection. Causes include disease states and the use of certain drugs. a. Dysfunctional healing during inflammation b. Dysfunctional healing during reconstruction M. Age and the Mechanisms of Self-Defense 1. Newborns and the elderly are particularly susceptible to problems of insufficient immune and inflammatory responses. 2. B cell and especially T cell functions of the immune system decrease markedly after age 60. 3. The elderly are also prone to impaired wound healing. 4. The elderly are more prone to wounding as the protective fat layer diminishes and skin loses its elasticity and becomes more vulnerable to tearing. 5

XV. Variances in Immunity and Inflammation A. Hypersensitivity: Allergy, Autoimmunity, and Isoimmunity 1. Allergy, autoimmunity, and isoimmunity are examples of harmful, exaggerated immune responses. a. Allergy is an exaggerated immune response to an environmental antigen. b. Autoimmunity is a disturbance in the body’s normal tolerance for self-antigens. c. Isoimmunity is an immune reaction between members of the same species. 2. Three factors seem to be involved in pathological immune responses.

Critical Thinking Questions What is the mechanism of a severe allergic reaction? How does this relate to the immune system?

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3. 4.

5. 6.

a. The original insult b. The person’s genetic makeup c. An immunologic process that boosts the response beyond normal bounds 3. Hypersensitivity reactions are classified as immediate hypersensitivity reactions or delayed hypersensitivity reactions. 4. Mechanisms of hypersensitivity reaction: a. Type I: IgE reactions b. Type II: Tissue-specific reactions c. Type III: Immune-complex-mediated reactions d. Type IV: Cell-mediated reactions 5. Antigens are the targets of the immune response and of the exaggerated immune response called hypersensitivity. 6. The source of the target antigen is what defines the type of hypersensitivity: a. Allergy: Environmental antigens b. Autoimmunity: Self-antigens c. Isoimmunity: Other person’s antigens 7. Autoimmune and isoimmune diseases a. Graves’ disease b. Rheumatoid arthritis c. Myasthenia gravis d. Immune thrombocytopenic purpura (ITP) e. Isoimmune neutropenia f. Systemic lupus erythematosus (SLE) g. RH and ABO isoimmunization B. Deficiencies in Immunity and Inflammation 1. Congenital, or primary, immune deficiency develops if the development of lymphoctyes in the fetus or embryo is impaired or halted. a. DiGeorge syndrome: a lack or partial lack of thymus development, resulting in a severe decrease in T cell production and function b. Bare lymphocyte syndrome: lymphocytes and macrophages are unable to produce Class I or Class II HLA antigens, resulting in severe infections that are usually fatal before age 5.

Master Teaching Notes

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c. Wiskott-Aldrich syndrome: IgM antibody production is reduced. d. Selective IgA deficiency: individuals frequently suffer from sinus, lung, and gastrointestinal infections e. Chronic mucocutaneous candidiasis: T lymphocytes are unable to respond against candida infections. 2. Acquired, or secondary, immune deficiencies develop after birth and do not result from genetic factors. a. Nutritional deficiencies b. Iatrogenic deficiencies c. Deficiencies caused by trauma d. Deficiencies caused by stress e. AIDS 3. Replacement therapies include the following: a. Gamma globulin therapy b. Transplantation and transfusion c. Gene therapy 5 1. 2.

4. 5.

XVI. Stress and Disease A. Concepts of Stress 1. General adaptation syndrome (GAS), coined by Dr. Selye, is a response to a wide array of stimuli. 2. Triad of stress effects: a. Enlargement of the cortex of the adrenal gland b. Atrophy of the thymus gland and other lymphatic structures c. Development of bleeding ulcers of the stomach and duodenum 3. Stages of GAS a. Stage I alarm: activates the sympathetic nervous system b. Stage II resistance: the point when the person begins to cope c. Stage III exhaustion: also known as burnout 4. The stages of GAS begin with physiologic stress. 5. The three components of physiologic stress are: a. The stressor that initiates the disturbance b. The chemical or physical disturbance the stressor produces c. The body’s counteracting (adaptational) response 6. Psychological mediators and specificity

Discussion Topics How does the mind affect the healing process or cause illness?

Critical Thinking Questions Is there a correlation between mental status and illness? Do patients suffering mental health illnesses suffer more illness in general, according to this theory?

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a. Experiments have shown that there isn’t a direct correlation between stressor and response; people make react differently to the same stressor. b. It is now thought that the total body response to different stressors must be specific – that is, targeted toward correction of the specific disturbance. 7. Recently, homeostasis has been described as a dynamic steady state. a. Stressors can cause a series of reactions that alter the dynamic steady state. B. Stress Responses 1. The interactions of psychological, neurologic/endocrine, and immunologic factors that lead to alteration of the immune response are known as psychoneuroimmunologic regulation. 2. The stress response is imitated by a stressor 3. Hormones released in response to stress: a. Catecholamines b. Cortisol c. Beta-endorphins d. Growth hormone e. Prolactin 4. The specific mechanisms by which stress leads to immune-related disorders is the subject of ongoing research. a. Research points to the substances that serve as communicators between the cells of the nervous system, the endocrine system, and the immune system – including hormones, neurotransmitters, neuropeptides, and cytokines – as the pathways of cause and effect. 1) Pathway 1: Central nervous system to immune system 2) Pathway 2: Immune system to central nervous system C. Stress, Coping, and Illness Interrelationships 1. Physiologic stress is caused by events that directly affect the body, such as a burn, extreme cold, or starvation. 2. Psychological stress consists of the unpleasant emotions caused by life events, such as taking exams or a divorce.

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Content Outline 3. The effects of stress, including the degree to which stress causes or affects illness, are moderated by the type, duration, and severity of the stressor in combination with the individual’s ability to cope with it. 4. Effective and ineffective coping has been seen to have potentially different effects in health persons, symptomatic persons, and persons who are undergoing medical treatment.

XVII. Summary A. The cell is the basic unit of life. B. The body’s cells interact via electrochemical substances, including hormones, neurotransmitters, neuropeptides, and cytokines. C. Cells exist in an environment of fluids and electrolytes. D. Disease can begin or advance when something interferes with normal cell function, the normal cell environment, or normal cell intercommunication. E. Groups of cells that perform similar functions form tissues. F. A group of tissues functioning together is an organ. G. A group of organs that work together is an organ system. H. Perfusion of the cells is necessary to provide essential nutrients to the cells and to remove wastes. I. Cells can be injured in a variety of ways, including hypoxia, chemicals, infectious agents, immunologic/inflammatory injuries, and others. J. Diseases can be caused by genetic factors, environmental factors, or a combination of factors. K. The body responds to cellular injury in a variety of ways to restore homeostasis, the body’s normal dynamic steady state. L. The body’s chief means of self-defense is the immune system and the immune and inflammatory responses, which work to attack and destroy infectious agents and other unwanted invaders. M. An understanding of the cell is essential to an understanding of all physiologic and pathophysiologic systems and processes.

Master Teaching Notes

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Content Outline XIX.You Make the Call

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

XX.Review Questions 5

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 13 Emergency Pharmacology 150 Minutes

      

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points To Emphasize Knowledge Applications Media Resources

Chapter 13 objectives can be found on text pp. 351-352. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

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

II. Introduction 5

Master Teaching Notes

A. The use of herbs and minerals to treat the sick and injured has been documented as long ago as 2000 B.C.E. 1. During the seventeenth and eighteenth centuries, tinctures of opium, coca, and digitalis were available. 2. By the nineteenth century, atropine, chloroform, codeine, ether, and morphine were in use. 3. The discoveries of animal insulin and penicillin in the early twentieth century dramatically changed the treatment of endocrine/metabolic diseases and infectious disease. 4. Technology has markedly changed the treatments of many diseases.

Teaching Tips The use of medications to treat patients requires a great deal of personal and professional responsibility. It is important to study not only the medications and their effects, side effects, and uses, but also the physiology of the body and how the medications can both help and hurt our patients.

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Content Outline III. General Aspects

A. Names 1. Drugs, also called medications, are chemicals used to diagnose, treat, or prevent disease. 2. Pharmacology is the study of drugs and their actions on the body. 3. The most detailed name for any drug is its chemical description. 4. The generic name becomes the FDA official name. 5. Companies will give the drug a brand name or trade name. B. Sources 1. There are four main sources of drugs: plants, animals, minerals, and the laboratory (synthetic). C. Reference Materials 1. There are multiple sources of information about drugs. 2. The United States Pharmacopeia (USP) is official source for drug information in the U.S. a. Nongovernmental, official, public standards-setting authority for prescription and over-the-counter medicines and other health care products manufactured or sold in the U.S. 3. The Physician’s Desk Reference contains drug inserts and photographs of drugs. 4. Drug Information is published by the American Hospital Formulary Service. 5. The Internet provides an enormous amount of information, but we must be especially cautious when using it as a source; we must consider the source and validity of the information. D. Components of a Drug Profile 1. A typical drug profile includes: a. Names b. Classification c. Mechanism of action d. Indications e. Pharmacokinetics f. Side effects/adverse reactions g. Routes of administration

Master Teaching Notes Discussion Topics Have the students discuss the most appropriate way for them to learn drugs and their uses. By having the class discuss it together, they can share helpful hints with one another.

Critical Thinking Questions There are many drug references. How can we identify references that are appropriate for use? Why must we be careful about using the Internet as a source?

Points to Emphasize Many drugs have different names and may be used for many different purposes. It is very important to have a sound reference source as well as a good foundational knowledge of major drugs and what they are used for.

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h. Contraindications i. Dosage j. How supplied k. Special considerations 2. Drug profiles may also include other components, such as its interactions with other drugs or with foods, when appropriate.

IV. Legal Aspects 10

A. Knowing and obeying the laws and regulations governing medications and their administration will be an important part of your career. These laws and regulations come from federal law, state laws and regulations, and individual agency regulations. B. Federal 1. Drug legislation in the United States has been aimed primarily at protecting the public from adulterated or mislabeled drugs. 2. The Pure Food and Drug Act of 1906 was enacted to improve the quality and labeling of drugs and named the United States Pharmacopeia as the official source of drug information 3. The Federal Food, Drug, and Cosmetic Act of 1938 empowered the FDA to enforce and set premarket safety standards for drugs. 4. In 1951, the Durham-Humphrey Amendments to the 1938 act required pharmacists to have a written or verbal authorization to dispense certain drugs. 5. The Kefauver-Harris Amendment to the 1938 act required pharmaceutical manufacturers to provide proof of the safety and effectiveness of their drugs before being granted approval to produce and market the products. 6. The Comprehensive Drug Abuse Prevention and Control Act (also known as the Controlled Substances Act) of 1970 replaced the Harrison Narcotic Act. a. Created five schedules of controlled substances b. Requires supervision of a health care practitioner when administered (physician, dentist, and, in some states, nurse practitioner or certified physician assistant)

Discussion Topics Discuss the five schedules of drugs and which drugs paramedics administer on a regular basis. How does the scheduling affect our use of the medications?

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c. For EMS, this means that the physician medical director is, in effect, prescribing the drugs in advance, based on assessments and judgments of EMS in the field 7. Federal drug laws require that certain substances be appropriately secured, distributed, and accounted for. C. State 1. Since state laws vary widely, you must know the laws of the state where you practice. 2. Local control varies as well. 3. In all cases, the physician medical director can delegate to paramedics the authority to administer medications, by either verbal, written, or standing order. D. Local 1. Local EMS agencies have the responsibility to create local policies and procedures to ensure the public well-being. E. Standards 1. Standardization of drugs is a necessity. 2. An assay determines the amount and purity of a given chemical in a preparation in the laboratory (in vitro). 3. The relative therapeutic effectiveness of chemically equivalent drugs is their bioequivalence. 4. Bioequivalence is determined by a bioassay, which attempts to ascertain the drug’s availability in a biological model (in vivo).

V. Drug Research and Bringing a Drug to Market 10

A. Proving the safety and reliability of new drugs requires extensive research and testing B. Phases of Human Studies 1. Phase 1 determines the drug’s pharmacokinetics, toxicity, and safe dose in humans. 2. Phase 2 tests the drug on a limited population of patients who have the disease it was intended to treat. The primary purpose is to find the therapeutic drug level and watch carefully for toxic and side effects. 3. Phase 3 testing is done to refine the usual therapeutic dose and to collect

Critical Thinking Questions Prescription drug prices and affordable health care are important topics that affect a large percentage of our patient population. How does the process of bringing a drug to market affect prices and in turn, our use of medications?

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relevant data on side effects. a) These studies are usually double-blind. b) A new drug application is filed with the FDA after phase 3. 4. Phase 4 testing involves postmarketing analysis during conditional approval. C. FDA Classification of Newly Approved Drugs 1. Classification of newly approved drugs is conducted by the FDA and includes numerical (chemical), and letter (treatment or therapeutic potential) classifications.

VI. Patient Care Using Medications 15

A. Paramedics are personally responsible – legally, morally, and ethically – for the safe and effective administration of medications. B. The six rights of medication administration help paramedics to meet that responsibility. C. Six Rights of Medication Administration 1. Right medication 2. Right dose 3. Right time 4. Right route 5. Right patient 6. Right documentation D. Special Considerations 1. There are three patient populations that require special considerations. 2. Pregnant patients must be considered because of a drug’s effects on the mother and fetus. 3. Factors to consider for newborns and young children: a. Body weight and surface area are the two most common factors when calculating dosage. b. Absorption of oral medications is diminished. c. Because of lower plasma protein content, pediatric patients are susceptible to higher free drug availability. d. Premature infants have a weak blood–brain barrier. e. Newborns have a lower metabolic rate and incompletely developed hepatic system.

Points to Emphasize The six rights are a method of reminding us to pay special attention before, during, and after medication administration. It is very important to do them each and every time we administer a medication.

Critical Thinking Questions Many geriatric patients take multiple medications and have multiple disease processes. How does this relate to their symptoms, their lack of symptoms and how we care for them? How can medications mask the true complaint or symptoms of a patient?

Class Activities Choose a few medications that paramedics administer regularly. Have the class present how they are used and what effects they have on each of the special populations.

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4. Geriatric patients have decreased plasma proteins, affecting distribution and free drug availability. a. They are likely to be taking multiple medications and/or have multiple underlying disease processes.

VII. Pharmacology 30

A. Pharmacology is the study of drugs and their interactions with the body. 1. Drugs do not confer new properties on cells or tissues; they only modify or exploit existing functions. B. Pharmacokinetics 1. Pharmacokinetics is the study of the basic processes that determine the duration and intensity of a drug’s effect. 2. It is dependent on the body’s various physiologic mechanisms that move substances across the body’s compartments. 3. Most drugs travel through the body by means of passive transport. a. If a drug is given orally or injected anywhere but the bloodstream, absorption is the first step in its process. 1) The greater the surface area, the faster the absorption. 2) Higher concentration equals more rapid absorption. b. Once the drug has been absorbed or enters the bloodstream, it must be distributed throughout the body. 1) Most drugs will pass easily from the bloodstream, through the interstitial spaces, into the target cells. 2) Sustained release drugs will bind to a protein. 3) The therapeutic effects of a drug are primarily due to the unbound portion of the drug in the blood. 4) Certain organs exclude some drugs from distribution to a certain area, such as the CNS (blood–brain barrier). c. The name given to the metabolism of drugs is biotransformation. d. Once metabolized, most drugs are excreted in the urine. 4. The route of a drug’s administration has an impact on the drug’s absorption and distribution. a. Enteral routes deliver medications by absorption through the GI tract.

Teaching Tips There are many routes of medication administration. Emphasize the common routes, but do not forget to describe the other routes and the situations in which they are used and appropriate. It is also helpful to review the anatomy of the microvasculature and how it applies to pharmacokinetics.

Discussion Topics Patients respond differently to medications. How does a drug’s mechanism of action and dose response relationship relate to the following patients? - Pediatrics - Geriatrics - Pregnant patients - Patients with a history of substance abuse

Points to Emphasize Once a medication is given, it cannot be taken back. It is important to understand the implications of giving a medication and be prepared to deal with the medication’s effects, side 6

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Content Outline This includes oral (PO), orogastric/nasogastric tube (OG/NG), sublingual (SL), buccal, and rectal (PR) b. Parenteral routes are any route outside of the GI tract. This includes intravenous (IV), endotracheal (ET), intraosseous (IO), umbilical, intramuscular (IM), subcutaneous (SC, SQ, SubQ), inhaled/nebulized, topical, transdermal, nasal, instillation, and intradermal c. Drugs come in many forms, including solids and liquids. d. Solid forms, generally given orally, include: 1) Powders 2) Tablets 3) Suppositories 4) Capsules e. Liquid drugs are usually solutions of a solid drug dissolved in a solvent and include: 1) Solutions 2) Tinctures 3) Suspensions 4) Emulsions 5) Spirits 6) Elixirs 7) Syrups f. Certain guidelines should dictate the manner in which drugs should be stored; their properties may be altered by the environment in which they are stored. C. Pharmacodynamics 1. Pharmacodynamics is the mechanism of action and the relationship between concentration and effect of the drug. 2. Drugs act in four different ways; each action involves a physiochemical interaction between the drug and a functionally important molecule in the body. a. Drugs that bind to a receptor site b. Drugs that act by changing a physical property c. Drugs that act by chemically combining with other substances

Master Teaching Notes effects, and any untoward reaction. By understanding the mechanism of action, the paramedic may better predict the outcome of a medication administration.

Knowledge Applications Drugs come in many different forms and preparations. How do some of these forms help a drug’s action? How might it hinder the use? Relate a drug and its form to its action. What path does it take to reach its target?

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d. Drugs that act by altering a normal metabolic pathway 3. When a drug is administered, the body has a response. a. Response may be the one desired or a side effect. b. Every time we administer a medication, we must weigh the risks against the benefits. c. Some common unintended adverse responses to drugs include: 1) Allergic reaction 2) Idiosyncrasy 3) Tolerance 4) Cross tolerance 5) Tachyphylaxis 6) Cumulative effect 7) Drug dependence 8) Drug interaction 9) Drug antagonism 10) Summation 11) Synergism 12) Potentiation 13) Interference d. To have its optimal desired or therapeutic effects, a drug must reach appropriate concentrations at its site of action. e. The drug response relationship is affected by several factors: 1) Pharmaceutical (concentration) 2) Pharmacokinetics (absorption distribution, metabolism and excretion) 3) Pharmacodynamic (drug receptor interaction) f. Different individuals may have different responses to the same drug given. Factors that alter the standard drug-response relationship include: 1) Age 2) Body mass 3) Sex 4) Environmental milieu 5) Time of administration ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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6) Pathological state 7) Genetic factors 8) Psychological factors g. Drug–drug interactions occur whenever two or more drugs are available in the same patient.

VIII. 40

Classifying Drugs

A. Drugs can be classified many ways; however, grouping medications according to their uses is a very practical way of classifying them.

IX. Drugs Used to Affect the Nervous System A. Drugs used to affect the nervous system are broken into two divisions. B. Central Nervous System Medications 1. Many pathological conditions involve the central nervous system (CNS). As a result, a great number of drugs have been developed to affect the CNS: b. Analgesics and antagonists c. Opioid agonists d. Nonopioid analgesics e. Opioid antagonists f. Adjunct medications g. Opioid agonist-antagonists h. Anesthetics i. Antianxiety and sedative-hypnotic drugs j. Antiseizure or antiepileptic drugs k. CNS stimulants 1) Amphetamines 2) Methylphenidates 3) Methylxanthines l. Psychotherapeutic medications 1) Antidepressants i. Tricyclic antidepressants ii. Selective serotonin reuptake inhibitors iii. Monoamine oxidase inhibitors m. Drugs used to treat Parkinson’s disease ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Teaching Tips Drugs are sometimes difficult for students to learn and require quite a bit of memorization. Encourage the students to find the best method to learn common drugs and to practice regularly.

Discussion Topics Have your students think about some medications they have seen, had experience with, or have been prescribed. Classify these medications, and discuss their uses. Include overthe-counter medications.

Critical Thinking Questions Adrenergic receptors play an important role in two types of patients that we treat on a regular basis: cardiac and respiratory patients. What is the relationship between alpha and beta adrenergic receptors and cardiac and respiratory patients? What drugs do we carry that act on these receptors?

Class Activities 9

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Content Outline C. Autonomic Nervous System Medications 1. Autonomic nervous system medications affect either the parasympathetic nervous system (PNS) or the sympathetic nervous system (SNS). a. Stimulation of the parasympathetic nervous system results in the following complications: 1) Pupillary constriction 2) Secretion by digestive glands 3) Reduction in heart rate 4) Bronchoconstriction 5) Increased smooth muscle activity along the digestive tract b. Acetylcholine is the neurotransmitter for the somatic nervous system and is present in the neuromuscular junction. 1) Medications that stimulate receptors for acetylcholine are called cholinergics (parasympathomimetics). 2) Medications that block them are called anticholinergics or cholinergic blockers (parasympatholytics). c. Neuromuscular blocking agents produce a state of paralysis without affecting consciousness. d. Drugs affecting the SNS result in: 1) Stimulation of secretion by sweat glands 2) Constriction of blood vessels in the skin 3) Increase in blood flow to skeletal muscles 4) Increase in heart rate and force of cardiac contractions 5) Bronchodilation 6) Stimulation of energy production e. SNS stimulation results in the release of the hormones norepinephrine and epinephrine into the circulatory system. f. Adrenergic receptors are divided into four types. 1) Alpha1 receptors cause peripheral vasoconstriction, some bronchoconstriction, and stimulation of metabolism. 2) Alpha2 receptors inhibit norepinephrine. 3) Beta1 receptors result in increased heart rate, cardiac contractile force and automaticity.

Master Teaching Notes Have the class get into small groups. Assign each group a few medications that paramedics use on a regular basis. Have the groups present the medications to the class based on components such as names, chemical names, mechanism of action, effects, side effects, special considerations, intended uses, other uses, dosages, and routes and forms.

Points to Emphasize Many drugs and classes of drugs are not widely used and are rarely seen. Emphasize the importance of studying drugs and their usages throughout your career. Continuing education is an important component of EMS.

Knowledge Applications Many experienced paramedics can ascertain a medical history of a patient on the basis of the medications prescribed to the patient. Given a list of medications, what types of disease processes and medical history does this patient have? Given a list of a patient’s medical conditions, can you predict what medications the patient might be prescribed?

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4) Beta2 receptors cause vasodilation, and bronchodilation.

X. Drugs Used to Affect the Cardiovascular System A. Cardiovascular Physiology Review 1. The heart is essentially a two-sided pump. a. The right side is a low-pressure pump responsible for pulmonary circulation. b. The left side is a high-pressure pump responsible for systemic circulation. 2. The key to the precise cardiac cycle is the electrical conduction system. a. It is composed of specialized cardiac tissue that generates electrical impulses and conducts them rapidly through the heart to ensure that the chambers contract in the proper sequence. 3. Arrhythmias are generated at various places in the heart through either abnormal impulse formation or abnormal conductivity. a. The two most prevalent types are tachycardia and bradycardia. B. Classes of Cardiovascular Drugs 1. Cardiovascular drugs generally fall into two broad functional classifications: antiarrhythmics and antihypertensives. a. Antiarrhythmics 1) Sodium channel blockers (Class I) 2) Beta-blockers (Class II) 3) Potassium channel blockers (Class III) 4) Calcium channel blockers (Class IV) 5) Miscellaneous antiarrhythmics b. Antihypertensives 1) Diuretics 2) Adrenergic inhibiting agents 3) Beta adrenergic antagonists 4) centrally acting adrenergic inhibitors 5) Peripheral adrenergic neuron blocking agents 6) Alpha1 antagonists 7) Combined alpha/beta antagonists ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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2. Angiotensin-Converting Enzyme (ACE) Inhibitors d. Angiotensin II receptor antagonists e. Calcium channel blocking agents f. direct vasodilators c. Hemostatic agents are used to combat the body’s response to injury during a cardiac event. 3. The body responds to damage within the blood vessels and myocardium by initiating the clotting cascade. 4. By utilizing platelet aggregation inhibitors, anticoagulants, and antifibrinolytics, blood flow can be restored to the myocardium. 5. The best way to lower LDL levels is through dietary modification; however, when this is not sufficient, antihyperlipidemic medications may be used.

XI. Drugs Used to Affect the Respiratory System A. Drugs that affect the respiratory system are useful for several purposes. B. Antiasthmatic Medications 1. Antiasthmatic medications are aimed at relieving bronchospams and inflammation 2. Beta2 specific agents are the mainstay in treating asthma-induced shortness of breath. 3. Nonselective sympathomimetics stimulate both beta1 and beta2 receptors as well as alpha receptors and are rarely used. 4. Methylxanthines are used only when other beta2 drugs are ineffective. 5. Anticholinergics are used to combat the stimulation of muscarinic receptors causing bronchoconstriction. a. Nebulized medications such as ipratropium and albuterol cause bronchoconstriction. 6. Glucocorticoids have anti-inflammatory properties and help to reduce mucous and edema secondary to decreasing vascular permeability. 7. Leukotrienes antagonists contribute powerfully to both inflammation and bronchoconstriction . C. Drugs Used for Rhinitis and Cough 1. Drugs used for rhinitis and cough include nasal decongestants, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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antihistamines, and cough suppressants.

XII. Drugs Used to Affect the Gastrointestinal System A. The main purposes of drug therapy in the gastrointestinal system are to treat peptic ulcers, constipation, diarrhea, and emesis and to aid digestion. B. Drugs Used to Treat Peptic Ulcer Disease 1. Drugs used to treat peptic ulcer disease primarily block the secretion of gastric acid and also include some antibiotics. 2. H2 receptor antagonists 3. Proton pump inhibitors 4. Antacids 5. Anticholinergics C. Drugs Used to Treat Constipation 1. Drugs used to treat constipation are typically laxatives, which are typically grouped into four categories based on their mechanism of action: a. Bulk-forming b. Surfactant c. Stimulant d. Osmotic D. Drugs Used to Treat Diarrhea 1. Drugs used to treat diarrhea are typically antibiotics used to treat the cause. E. Drugs Used to Treat Emesis 1. Drugs used to treat emesis interfere with the transmitters involved in the vomiting reflex. a. Antiemetics b. Serotonin antagonists c. Dopamine antagonists d. Cannabinoids F. Drugs Used to Aid Digestion 1. Several drugs are available to aid the digestion of carbohydrates and fats. 2. These agents are similar to digestive enzymes released into the duodenum in response to vagal stimulation. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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XIII.

Drugs Used to Affect the Eyes A. Ophthalmic drugs are used to treat conditions involving the eyes, primarily glaucoma and trauma. 1. Tetracaine is a local anesthetic of the ester class and is used to treat pain and sensation in the eye from trauma or during ophthalmic procedures.

XIV.

Drugs Used to Affect the Ears

A. Drugs used to affect the ears are aimed at eliminating underlying bacterial or fungal infections or at breaking up impacted earwax. 1. Chloramphenicol (Chloromycetin Otic) and gentamicin sulfate otic solution (Garamycin) are common antibiotics. 2. Carbamide peroxide (Auro Ear Drops) and carbamide peroxide and glycerin (Ear Wax Removal System) are both used to treat earwax. 3. Several drugs are available to treat swimmer’s ear, including isopropyl alcohol (Auro-Dri Ear Drops) and boric acid and isopropyl alcohol (Aurocaine 2).

XV. Drugs Used to Affect the Endocrine System A. Drugs that are used to affect the endocrine system are important in helping the body maintain homeostasis. The pituitary, pineal, thyroid, parathyroid, thymus, and adrenal glands as well as the pancreas, ovaries, and testes are all part of the endocrine system. B. Drugs Affecting the Pituitary Gland 1. Drugs affecting the pituitary gland treat either the anterior or posterior pituitary gland. a. The only conditions treated with anterior pituitary-like drugs are those associated with abnormal growth. b. The two posterior pituitary hormones are oxytocin and antidiuretic hormone (ADH). C. Drugs Affecting the Parathyroid and Thyroid Glands 1. The parathyroid glands are primarily responsible for regulating calcium levels. a. Hypoparathyroidism is treated with calcium and Vitamin D ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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supplements. b. Hyperparathyroidism is treated with removal of all or part of the parathyroid glands. c. Hypothyroidism is treated with thyroid hormone. d. Hyperthyroidism is treated with radiation or removal of the thyroid. D. Drugs Affecting the Adrenal Cortex 1. Two diseases typify the disorders associated with the adrenal cortex: Cushing’s disease and Addison’s disease. a. Treatment of Cushing’s disease is typically surgical; symptomatic pharmacological intervention with an antihypertensive may be necessary. b. Treatment of Addison’s disease is aimed at replacement therapy. Cortisone and hydrocortisone are the drugs of choice. E. Drugs Affecting the Pancreas 1. Diabetes mellitus is the most important disease involving the pancreas. 2. Type 1 diabetes is insulin dependent and manifests at an early age. 3. Type 2 diabetes is most common and occurs later in life 4. The two main substances involved with regulating blood glucose are insulin and glucagon. 5. The main intervention for patients with type 1 diabetes is insulin replacement therapy. 6. The most effective therapy for patients with type 2 diabetes is weight loss through diet modification and exercise. 7. When weight loss and exercise are not effective, oral hypoglycemic agents and occasionally insulin are used. a. Insulin comes from beef or pork intestines or recombinant DNA. b. Oral hypoglycemic agents stimulate insulin secretion from the pancreas in patients with Type II diabetes. c. Hyperglycemic agents increase blood glucose levels and are used in emergency treatment of hypoglycemia. F. Drugs Affecting the Female Reproductive System 1. Drugs affecting the female reproductive system are estrogens, progestins, oral contraceptives, drugs effecting uterine contraction, and those used to ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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treat infertility. G. Drugs Affecting the Male Reproductive System 1. Drugs affecting the male reproductive system include those that treat testosterone deficiency and benign prostatic hyperplasia. H. Drugs Affecting Sexual Behavior 1. The largest category of drugs affecting sexual behavior do so as a side effect of their intended purpose.

XVI.

Drugs Used to Treat Cancer

A. Drugs used to treat cancer are called antineoplastic agents. 1. There are many different agents and most are used in chemotherapy and in conjunction with surgery to remove tumors. 2. Most of these agents have the greatest effect on cancer cells during mitosis and on young, small cancers that are undergoing rapid growth. 3. The agents used to kill cancer are grouped according to their mechanism of action.

XVII.

Drugs Used to Treat Infectious Diseases and Inflammation

A. Drugs used to treat infectious diseases and inflammation, which are typically caused by bacteria, viruses, or funguses, are developed specifically for the particular invaders. 1. Antibiotic agents kill bacteria or decrease the bacteria’s growth. 2. Antifungal and antivirals inhibit growth of funguses and viruses. 3. Drugs used to treat malaria are called schizonticides. 4. Drugs commonly used to treat tuberculosis include isoniazid and rifampin. 5. Nonsteroidal anti-inflammatory drugs are commonly used as analgesics and antipyretics. 6. Uricosuric drugs are used to treat and prevent episodes of gout. 7. Serums, vaccines, and other immunizing agents may augment the immune system. 8. Immune suppressing and enhancing agents are used for special procedures such as organ transplants and skin grafts or in HIV. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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XVIII. Drugs Used to Affect the Skin A. Dermatologic drugs are used to treat skin irritations. B. They are common over-the-counter medications. C. Many different preparations, including baths, soaps, solutions, cleansers, emollients, skin protectants, wet dressings or soaks, and rubs and liniments D. Sunscreens help to prevent skin disease and irritation.

XIX.

Drugs Used to Supplement the Diet

A. Dietary supplements can help to maintain needed levels of essential nutrients and fluids. B. Vitamins and Minerals 1. Vitamins are organic compounds necessary for many physiologic processes, including metabolism, growth, development, and tissue repair. 2. Iron is an essential mineral necessary for oxygen transport and several metabolic processes. Iron supplements are the most common mineral supplement. C. Fluids and Electrolytes 1. The chapter “Pathophysiology” reviews the physiology of fluids and electrolytes and discusses acid-base balance. 2. The indications and contraindications for administering fluids and electrolytes, as well as these medications’ interactions, are covered in the chapter titled “Intravenous Access and Medication Administration.”

XX.Drugs Used to Treat Poisoning and Overdoses A. The treatment for poisoning and overdose depends greatly on the substance involved. 1. Sodium bicarbonate 2. Dialysis 3. Activated charcoal 4. Specific antidotes XXI. 5

Summary A. Pharmacology is a cornerstone of paramedic practice. B. Paramedics must have a solid understanding of its foundations,

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pharmacokinetics, and pharmacodynamics if they are to practice their profession safely. C. Emergency treatments are constantly changing, based on the latest results of pharmacological studies. Remaining current on the latest changes in this field will help you to gain confidence in your ability to give your patients the care they deserve.

XXII.

Case Study

XXIII. You Make the Call 10

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

XXIV. Review Questions 5

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 14 Intravenous Access and Medication Administration 210 Minutes

      

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points To Emphasize Knowledge Applications Media Resources

Chapter 14 objectives can be found on text pp. 440-441. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Case Study

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

II. Introduction A. Drugs are foreign substances put into the human body. B. Medications are drugs used for medical purposes. C. Medication administration is an important part of medical care provided by a paramedic. 1. You may have to use medications to correct or prevent life-threatening situations. 2. You may also use medications to stabilize or comfort a patient in distress. III. General Principles A. As a paramedic, you are responsible for correct and timely medication administration. 1. You must ensure that all emergency medications are in place and ready for use. 2. You can attain effective pharmacological therapy and eliminate medication errors by following the “six rights” of medication administration. a. Right person b. Right drug c. Right dose

Discussion Topics What are the legal and moral consequences of medication errors? Medication errors kill tens of thousands of people each year. How can we be sure that we don’t allow that to happen?

Points to Emphasize Explain to students the importance of following the six rights of medication

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Content Outline d. Right time e. Right route f. Right documentation 3. If use or dosage of a medication is ever in question, contact medical direction immediately. a. Repeat back all medication orders issued by on-line medical direction. b. Pharmacological therapy permits you to function as an extension of the physician. B. Medical Direction 1. Paramedics operate under the license of a medical director who is responsible for all of the paramedic’s actions. 2. The medical director (or EMS system) determines which medications you will use and the route by which you will deliver them. 3. Knowing all administration protocols is essential, especially which medications to administer under standing orders and which to deliver only after getting authorization from medical direction. C. Standard Precautions 1. Formerly called body substance isolation (BSI), Standard Precautions are measures taken during administration of medications to decrease your risk of exposure to blood or body fluids. 2. During most patient care, you will wear gloves and eye protection. 3. A mask is often required for procedures and patient care conditions in which there is an increased likelihood that splashes or sprays of blood, body fluids, or secretions may occur. 4. The simplest standard precaution is handwashing. D. Medical Asepsis 1. Medical asepsis describes a medical environment that is free of pathogens. 2. Many paramedic procedures, especially those related to medication administration, place the patient at increased risk for infection. a. Use of sterilization, disinfectants, and antiseptics help to lessen the risk of infections. b. Minimize the risk of an inadvertent needle stick by using the

Master Teaching Notes administration each and every time a medication is given.

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following procedures: 1) Minimize the tasks you perform in a moving ambulance. 2) Immediately dispose of used sharps in a sharps container. 3) Recap needles only as a last resort. c. By law, every medical organization must have a biological hazard exposure plan. E. Medication Administration and Documentation 1. Proper documentation is extremely important. a. Document the indication for administration. b. Document the dose and route of delivery. c. Document the patient’s response to the medication, both positive and negative. d. Document the patient’s condition and vital signs before and after medication administration. 15

IV. Percutaneous Medication Administration A. Percutaneous medications are applied to and absorbed through the skin or mucous membranes. B. Transdermal Administration 1. Transdermal medications are given through the skin and promote slow, steady absorption. 2. These medications include lotions, ointments, creams, foams, wet dressings, adhesive-backed applications, and suppositories. 3. To administer a transdermal medication, use the following technique: a. Use Standard Precautions. b. Avoid contaminating the medication and inadvertently getting it on your skin. c. Clean and dry your patient’s skin at the administration site. d. Apply medication to the site as specified by the manufacturer. e. Avoid overdosing or underdosing when using lotion, ointment, cream, or foam. f. Leave the medication in place for the required time, and monitor the patient for desirable or adverse effects. C. Mucous Membranes 1. The mucous membranes absorb medications at a moderate to rapid

Critical Thinking Questions What factors can affect the administration of these types of medications? Why must we use Standard Precautions when administering them?

Class Activities Have the class demonstrate the areas that are appropriate for this type of medication administration.

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rate. 2. Medication delivery through the mucous membranes avoids the digestive tract and complications associated with that route. 3. Sublingual medications are absorbed beneath the tongue and are absorbed rapidly as this area is extremely vascular. 4. To administer sublingual medications, follow these steps: a. Use Standard Precautions. b. Confirm the indication, medication dose, route, and expiration date. c. Have your patient lift his tongue toward the top and back of his oral cavity. d. Place the pill or direct the spray between the underside of the tongue and the floor of the oral cavity, making sure to instruct the patient not to swallow. e. Monitor the patient for desirable or adverse effects. 5. Buccal medications are generally tablets and are placed between the cheek and gum. 6. To administer a medication buccally, follow these steps: a. Use Standard Precautions. b. Confirm the indication, medication dose, buccal route, and expiration date. c. Place the medication between the patient’s cheek and gum, and instruct the patient to allow the pill or other preparation to dissolve. Ensure that the patient does not swallow the medication. d. Monitor the patient for desirable or adverse effects. 7. Ocular medications are topical medications that are administered through the mucous membranes of the eye. 8. Ocular medications are typically local medications for alleviating eye pain, treating infection decreasing intraocular pressure, or lubricating the eyelid. 9. To administer medication via eye drops, use the following technique: a. Use Standard Precautions. b. Have your patient lie supine or lay his head back and look toward the ceiling. c. Pull the lower eyelid downward to expose the conjunctival sac. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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Never touch the eye. d. Use a medicine dropper to place the prescribed dosage on the conjunctival sac. Never administer medications directly on the eye unless specifically instructed. e. Instruct the patient to hold his eye(s) shut for 1–2 minutes. 10. Another common mucous membrane used for medication administration is the nasal mucosa. 11. To administer a medication via the nose, use the following technique: a. Use Standard Precautions, including face mask. b. Have the patient blow his nose, and tilt his head backward. c. Use a medicine dropper or squeezable nebulizer to administer the medication into the appropriate nare(s) according to the manufacturer’s instructions. d. Hold the naris or nares shut and/or tilt the head forward to distribute the medication. e. Monitor the patient for desirable or adverse effects. 12. Aural medications are delivered to the mucosal membranes of the ear and ear canal through drops or medicated gauze. 13. To administer medicated drops, use the following technique: a. Use Standard Precautions. b. Confirm the indication, medication, dose, and expiration date. c. Have the patient lie in the lateral recumbent position with the affected ear upward. d. Manually open the ear canal: for adult patients, pull the ear up and back; for pediatric patients, pull it down and back. e. Administer the appropriate dose of medication with a medicine dropper. f. Have the patient continue to lie with his ear up for 10 minutes. g. Monitor the patient for desirable or adverse effects. 15

V. Pulmonary Medication Administration A. Medications can be administered into the pulmonary system via inhalation or injection. B. Nebulizer 1. Typically, medications administered by inhalation are delivered with the

Discussion Topics What patients will benefit from this type of medication administration?

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Content Outline aid of a small volume nebulizer (SVN) or handheld nebulizer (HHN). 2. A nebulizer uses pressurized oxygen or air to disperse a liquid into a fine aerosol spray or mist 3. To administer medications with a nebulizer, use the following procedure: a. Use Standard Precautions including a mask. b. Put the medication in the medication reservoir. If the medication is not diluted, combine it with 3–5 mL sterile saline solution. c. Assemble the nebulizer. d. Attach oxygen tubing to the oxygen port and oxygen source. e. Set the oxygen source regulator for 5–8 liters per minute. 1) Less than 5 liters per minute will not provide enough pressure to aerosolize the medication. 2) More than 8 liters per minute will provide too much pressure to accurately nebulizer the medication f. Place the nebulizer in the patient’s mouth, and instruct him to exhale and then seal his lips around the mouthpiece. Then have him hold the nebulizer and slowly inhale as deeply as possible. On maximum inhalation, instruct the patient to hold in the medication for 1–2 seconds before exhaling. Continue this process until the medication is gone. Typically, this takes 3–5 minutes. C. Metered Dose Inhaler 1. Inhaled medications may also be delivered by using a metered dose inhaler (MDI) 2. To assist a patient in the use of an MDI, follow this technique: a. Insert the medication canister into the plastic shell. b. Remove the cap from the mouthpiece. Make sure the cap is clean. c. Gently shake the MDI for 2–5 seconds. d. Instruct the patient to maximally exhale. e. Place the mouthpiece in the patient’s mouth, and have him form a seal with his lips. f. As the patient inhales, press the canister’s top downward to release the medication. g. Have patient hold his breath for several seconds. h. Remove the inhaler from the patient’s mouth, and instruct him to

Master Teaching Notes Critical Thinking Questions Which adrenergic receptors play a role in this type of medication?

Class Activities Have the class familiarize themselves with the delivery devices used.

Points to Emphasize Nebulized medication must be kept at the proper oxygen flow to be delivered appropriately.

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breathe slowly. If a second dose is necessary, wait according to the manufacturer’s instructions. Then repeat. D. Endotracheal Tube 1. Although rarely used for medication delivery, the endotracheal tube provides a pulmonary route for medication administration. i.

VI. Enteral Medication Administration A. The enteral route is the delivery of medication to be absorbed through the gastrointestinal (GI) tract. 1. It is the most common route used in medicine and is very convenient and easy to use. 2. It is the least expensive route for medication delivery. 3. It can be affected by physical activity, emotions, or food. 4. The condition of the liver can reduce the medication’s effectiveness. 5. A patient must be compliant with the self-administration of the medication. B. Oral Medications 1. Oral medications are swallowed and absorbed by the GI tract into circulation. 2. The patient must have an adequate level of consciousness. 3. Oral medications come in several forms: capsules, tablets, enteric coated/time-release capsules and tablets, elixirs, emulsions, lozenges, suspensions, and syrups. 4. To administer medications orally, use the following technique: a. Use Standard Precautions. b. Note whether to administer the medication with food or on an empty stomach. c. Gather any necessary equipment; mix liquids or suspensions, or otherwise prepare medications as needed. d. Have your patient sit upright (when this is not contraindicated). e. Place the medication in your patient’s mouth. Allow selfadministration when possible; assist when needed. f. Follow administration with 4–8 ounces of water or other liquid. g. Ensure that the patient has swallowed the medication and it is not

Critical Thinking Questions Why is it important to know what medications the patient is taking and whether the patient has eaten recently? How does food or lack of food affect medications?

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hidden in his mouth. C. Gastric Tube Administration 1. For patients who have difficulty swallowing or who have poor nutritional status, a gastric tube may be used to administer medications. 2. Properly placed orogastric or nasogastric tubes may be used. 3. To administer a medication via a gastric tube, use the following technique: a. Use Standard Precautions. b. Confirm proper tube placement. Disconnect the tube from the drainage or suction unit or clamping device. Clamp the tube from the drainage or suction unit to prevent gastric contents spilling from either device. Attach a cone-tipped syringe to the proximal end of the gastric tube. Gently inject air while auscultating over the stomach. Following this, withdraw the plunger while observing for the presence of gastric fluid or contents, which indicates appropriate placement. Leave the tube disconnected from the drainage or suction unit. c. Irrigate the gastric tube. To irrigate the gastric tube, draw up 50 to 100 mL of normal saline into a cone-tipped syringe. Insert the syringe into the open end of the gastric tube. With the syringe tip pointed at the floor, gently inject the saline into the tube. If the saline encounters resistance, look for problems such as tube kinking. Have the patient lie on his left side and reattempt injection. If the saline still meets resistance, reattach the tube to the drainage or suction unit and contact medical direction for further directives. d. Prepare the medication by crushing it and adding to 30 mL of warm water. Ensure that all particles are small so that they will not occlude the tube. You may administer liquid medications without further preparation. e. Draw the medication using a 30–50 mL cone-tipped syringe and place the tip into the open gastric tube. Gently administer the medication into the gastric tube. f. Draw 50–100 mL of warm normal saline into a cone-tipped syringe, and attach it to the open end of the gastric tube. Gently inject the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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saline. Repeated administrations may be necessary. g. Clamp off the distal tube. Use a commercially manufactured device or hemostat to clamp shut the distal portion of the gastric tube for approximately 30 minutes after you administer the medication. Do not reattach to the drainage or suction unit. D. Rectal Administration 1. The rectum’s extreme vascularity promotes rapid medication absorption. 2. The rectal route is typically used for sedation and control of seizure activity in the absence of an IV but may also be used for sedatives, antiemetics, or other specially prepared medications. 3. To administer medications rectally, use the following procedure: a. Use Standard Precautions. b. Confirm the indication for administration and dose, and draw the correct quantity of medication into a syringe. c. Place the hub of a 14-gauge Teflon catheter on the end of a needless syringe. d. Insert the Teflon catheter into the patient’s rectum, and inject the medication, keeping it in the lower part of the rectum. e. Withdraw the catheter, and hold the patient’s buttocks together. 4. An alternative technique utilizes a small endotracheal tube instead of the Teflon IV catheter. 5. In the nonemergent setting, suppositories or enemas are common methods for rectal administration. 30

VII. Parenteral Medication Administration A. Parenteral route denotes the administration of medication outside of the GI tract and typically involves the use of needles as medications are injected into the circulatory system or tissues. B. Syringes and Needles 1. Syringes range in size from 1 to 100 mL and greater. 2. Hypodermic needles are hollow metal tubes used with the syringe to administer medications. 3. A hypodermic needle’s gauge ranges from 18 to 27 (the smaller the number, the larger the gauge). 4. Because syringes and hypodermic needles frequently involve invasive

Teaching Tips This is a common skill for paramedics and should be practiced regularly. All equipment used should be available during the lecture for discussion and demonstration.

Discussion Topics It is important to document clearly and maintain security for certain medications. Discuss how that is done and why it is important, especially for narcotics. 9

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Content Outline procedures, they are packaged sterile. C. Medication Packaging 1. Parenteral medication is packaged in several ways. 2. Be thoroughly familiar with the information included on the labels of all medication containers: a. Name of medication b. Expiration date c. Total dose and concentration 2. Glass ampules a. Glass ampules must be broken open to retrieve the medication, and they contain a single dose of medication. b. To open medication from a glass ampule, you will need a needle and a syringe. Use the following technique: 1) Confirm medication indications and patient allergies. 2) Confirm the ampule label. 3) Hold the ampule upright, and tap its top to dislodge any trapped solution. 4) Place gauze around the thin neck, and snap its top off with your thumb. 5) Place the tip of the hypodermic needle inside the ampule, and withdraw the medication into the syringe. 6) Reconfirm the indication, medication, dose, and route of administration. 7) Administer the medication appropriately via the indicated route. 8) Properly dispose of the needle, syringe, and broken glass ampule. c. Single-dose and multidose vials are plastic or glass and have a selfsealing rubber top. To obtain medication from a vial, follow these steps: 1) Confirm medication indications and patient allergies. 2) Confirm the vial label (name, dose, and expiration). 3) Determine the volume of medication to be administered. 4) Prepare the syringe and hypodermic needle. Replace the volume of medication removed with air to maintain equilibrium in

Master Teaching Notes Class Activities Have the class look at each type of package and practice with each medication packaging type. Students should also practice each delivery route. Once they are comfortable, they should practice on one another (if the school permits it) so that they can understand what the patient experiences. Normal saline can be used in place of medications.

Points to Emphasize There are specific procedures to follow with controlled substances. Discuss how that affects how you utilize medications and what to do with the wasted medication.

Knowledge Applications Drugs are packaged in many ways. Utilizing local resources, have the students evaluate the drugs and how they are packaged. Have the students become familiar with the ones they will be utilizing.

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the vial. Withdraw the plunger to draw a volume of air into the syringe equal to the volume of medication to be administered. 5) Cleanse the vial’s rubber top with an antiseptic alcohol preparation. 6) Insert the hypodermic needle inside the ampule, and withdraw the medication into the syringe. 7) Reconfirm the indication, medication, dose, and route of administration. 8) Administer appropriately via the indicated route. 9) Properly dispose of the needle, syringe, and vial. d. Nonconstituted medication vials consists of two vials: one containing a powdered medication and one containing a liquid mixing solution. e. To prepare a medication from a nonconstituted medication vial, use the following technique: 1) Confirm medication indications and patient allergies. 2) Confirm the vial’s label (name, dose, expiration date) 3) Remove all mixing solution from the vial containing the mixing solution as you would if withdrawing from a single-dose or multidose vial. 4) With an alcohol preparation, cleanse the top of the vial containing the powdered medication, and inject the mixing solution. 5) Gently agitate the vial to ensure complete mixture. 6) Determine the volume of newly constituted medication to be administered. 7) Prepare the syringe and hypodermic needle. By withdrawing the plunger, place into the syringe a volume of air equal to the volume of medication that will be removed. 8) Cleanse the medication vial’s rubber top with an antiseptic alcohol preparation. 9) Insert the hypodermic needle into the rubber top with an antiseptic alcohol preparation. 10) Insert the hypodermic needle into the rubber top, and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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withdraw the appropriate volume of medication. 11) Reconfirm the indication, medication, dose, and route of administration. 12) Administer appropriately via the indicated route. 13) Monitor the patient for the desired effects. 14) Properly dispose of the syringe and needle. f. Prefilled syringes are packaged in tamper-proof containers with the medication already in the syringe. g. Follow these steps to administer medication from a prefilled syringe: 1) Confirm medication indications and patient allergies. 2) Confirm the prefilled syringe label (name, dose, and expiration date). 3) Assemble the prefilled syringe. Remove the pop-off caps and screw together. 4) Reconfirm the indication, medication, dose, and route of administration. 5) Administer appropriately via the indicated route. 6) Properly dispose of the needle and syringe. h. Intravenous medication solutions are packaged in an IV bag and may be premixed with specific medications. D. Parenteral Routes 1. Parenterally administered medications can be absorbed locally or systemically. 2. Intradermal injections deposit medication into the dermal layer of the skin. 3. To administer an intradermal injection, follow these steps: a. Assemble and prepare the needed equipment. b. Use Standard Precautions. c. Confirm the indication, medication, dosage, and need for intradermal injection. d. Draw up the medication as appropriate. e. Prepare the site with antiseptic solution. f. Pull the patient’s skin taut with your nondominant hand. g. Insert the needle, bevel up, at a 10- to15-degree angle. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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6. 7. 8.

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h. Slowly inject the medication; look for a small bump or wheal to form as medication is deposited and collects in the intradermal tissue. i. Remove the needle, and dispose of it in the sharps container. j. Place the adhesive bandage over the site; use the gauze for hemorrhage control if needed. Subcutaneous injections: place medication into the subcutaneous tissue, which prolongs the medication’s effects and slows absorption. To administer a subcutaneous injection, use the following technique: a. Assemble and prepare equipment. b. Use Standard Precautions. c. Confirm the indication, medication, dosage, and need for subcutaneous injection. d. Draw up the medication as appropriate. e. Prepare the skin with antiseptic solution. f. Gently pinch a 1-inch fold of skin. g. Insert the needle just into the skin at a 45-degree angle with the bevel up. h. Pull the plunger back to aspirate tissue fluid. i. If blood appears, restart the procedure with a new syringe. j. If no blood appears, proceed with the following step. k. Slowly inject the medication. l. Remove the needle and dispose of it in a sharps container. m. Place an adhesive bandage over the site; use the gauze for hemorrhage control if needed. n. Monitor the patient. Intramuscular injections: deposit medication into muscle, delivering medication at a moderate absorption rate. Several sites are used, including the deltoid, dorsal gluteal, vastus lateralis, or rectus femoris muscle. To administer a medication intramuscularly, use the following technique: a. Assemble and prepare the need equipment. b. Use Standard Precautions. c. Confirm the indication, medication, dosage, and need for intramuscular injection.

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d. Draw up medication as appropriate. e. Prepare the site with antiseptic solution. f. Stretch the skin taut over the injection site with your nondominant hand. g. Insert the needle just into the skin at a 90-degree angle with the bevel up. h. Pull the plunger back to aspirate for tissue fluid. i. If blood appears, restart the procedure with a new syringe. j. If no blood appears, proceed with the following step. k. Slowly inject the medication. l. Remove the needle, and dispose of it in a sharps container. m. Place an adhesive bandage over the site; use gauze for hemorrhage control if needed. n. Monitor the patient. 45

VIII.Intravenous Access A. Intravenous (IV) access is a routine paramedic procedure used for the following indications: 1. Fluid and blood replacement 2. Medication administration 3. Obtaining venous blood specimens for laboratory analysis B. Types of Intravenous Access 1. Medical care providers use two types of intravenous access: peripheral and central. 2. Central venous access is rarely, if ever, performed in the out-of-hospital setting. 3. Peripheral venous access is challenging but relatively easy to master. a. Common sites include the arms and legs and, when necessary, the neck. 4. When looking for a suitable vein, some veins will be readily accessible, and others must be located anatomically. a. Start distally and work proximally. b. Rapid fluid administration requires larger veins. c. The external jugular vein may be used when other sites are unavailable.

Critical Thinking Questions Why is it important to be as sterile as possible when performing these skills? Is it necessary to start IVs on all our patients if they all have the potential to become more ill?

Class Activities The class should practice each skill and, when comfortable, perform it on one another (if the school permits it) to feel what their patients will undergo. The students should not perform external jugular cannulation on each other because of the risk and complications involved. Mannequins can be substituted for any procedure.

Points to Emphasize IV access is a simple procedure but should 14

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Content Outline 5. Central venous access utilizes veins deep within the body and are typically placed for long-term use and invasive monitoring. a. This is typically reserved for placement in hospital due to its highly invasive nature and high risk for complications. C. Equipment and Supplies for Venous Access 1. Peripheral venous access requires specialized equipment. 2. Intravenous fluids are chemically prepared solutions tailored to the body’s specific needs. a. Colloid solutions contain large proteins and are used to increase intravascular volume. b. Crystalloids are the primary out-of-hospital solutions and contain electrolytes and water. 1) Isotonic solutions have a tonicity equal to that of blood plasma. 2) Hypertonic solutions have a higher solute concentration than do the cells and cause fluid shift out of the cells into the extracellular compartment. 3) Hypotonic solutions have a lower solute concentration than do the cells and cause fluid to move from the extracellular compartment into the cells, c. The three most commonly used IV fluids in out-of-hospital care are: 1) Lactated Ringer’s 2) Normal saline solution 3) 5% dextrose in water (D5W) d. The most desirable fluid for replacement is whole blood. e. IV fluids are packaged in soft plastic or vinyl bags ranging in size from 50 to 3,000 mL. Some medication is incompatible with plastic or vinyl and must be packaged in glass bottles. b. Administration tubing connects the solution bag to the IV cannula that is inserted into the patient’s vein. c. To effectively deliver intravenous fluids, you must be familiar with the microdip and macrodip administration sets, their components, and their subtle differences. 1) Spike 2) Drip chamber

Master Teaching Notes be reserved for administering fluid or medications.

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3) Drop former 4) Tubing 5) Clamp 6) Flow regulator 7) Medication injection ports 8) Needle adapters 9) Inside the drip chamber is a drop former. d. IV extension tubing is used to extend the original macrodip or microdip setup. e. Electromechanical pump tubing: Mechanical infusion devices may require specially manufactured pump tubing. f. Measured volume administration sets can deliver specific volumes of fluid with or without medication. Components include: a. Flanged spike b. Clamp c. Airway handle d. Medication injection port e. Burette chamber f. Float valve g. Drip chamber h. Flow regulator i. Medication injection port j. Needle adapter g. Administering whole blood or blood components requires blood tubing, which contains a filter that prevents clots and other debris from entering the patient. h. Some tubing now has a manual dial that can set drops per minute or specific flow rates. i. Technology now makes it possible to heat IV fluids to near body temperature in the field. j. Intravenous cannulas permit actual vein puncture and venous access. 1) Over-the-needle catheters comprise a semiflexible catheter enclosing a sharp metal stylet (needle) that is hollow and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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beveled at the distal end. 2) Hollow-needle catheters are smaller and reserved for accessing smaller veins. 3) The catheter inserted through the needle, also called an intracatheter, is used in the hospital setting to implement central lines. Its placement requires great skill. k. Other miscellaneous equipment include antiseptics, venous constricting bands used for locating veins, and securing devices. D. Intravenous Access in the Hand, Arm, and Leg 1. Your most common site of IV insertion will be the hand, arm, or leg; the likelihood of complications is less with these veins, they are easier to access, and they cause less pain. 2. To establish a peripheral IV in the hand, arm, or leg, use the following technique: a. Confirm indication and type of IV setup needed. Gather and arrange all supplies and equipment beforehand. 1) IV fluid 2) Administration set 3) Intravenous cannula 4) Tape or commercial securing device 5) Venous blood drawing equipment 6) Venous constricting band 7) Antiseptic solution b. Prepare all needed equipment. 1) Examine the IV fluid for clarity and expiration date. 2) Insert the administration tubing spike in the IV solutions bag’s administration set port. 3) Squeeze fluid from the IV fluid container into the drip chamber until it reaches the fill line. 4) Open the clamp and or/flow regulator to flush the solution through the administration tubing and expel trapped air bubbles. 5) Shut down the flow regulator, and replace the cap over the needle adapter. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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c. Select the venipuncture site. d. Place the constricting band proximal to the intended site of puncture. Tighten it enough to impede venous blood flow without restricting arterial blood passage. e. Cleanse the venipuncture site with alcohol or antiseptic solution. Start at the site itself, and work outward in an expanding circle. f. Insert the intravenous cannula into the vein. With your nondominant hand, pull the skin taut to stabilize the vein and prevent it from rolling. g. With the distal bevel of the metal stylet up, insert the cannula at a 10- to 30-degree angle. Continue until you feel the cannula “pop” into the vein or see blood in the flashback chamber. h. Advance approximately 0.5 cm. i. Holding the metal stylet stationary, slide the Teflon catheter over the needle into the vein. j. Tamponade the vein on or near the catheter’s end, and remove the needle and the constricting band k. Obtain venous samples. l. Attach the administration tubing to the cannula. Remove the protective cap from the needle adapter, and tightly secure the needle adapter into the cannula hub. Open the flow regulator, and allow the fluid to run freely for several seconds. Adjust the flow rate. Do not let go of the cannula and administration tubing until you have secured them (see the following step. m. Cover the catheter and puncture site with an adhesive bandage or other commercial device. Loop the distal tubing, and secure with tape. Continue by taping the administration tubing to the patient, proximal to the puncture site. n. Label the intravenous bag with the date and time initiated, as well as the person initiating the intravenous access. o. Continually monitor the patient and flow rate. E. Intravenous Access in the External Jugular Vein 1. External jugular vein cannulation is reserved for patients who require immediate and rapid fluid administration and patients who have ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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decreased or complete loss of consciousness and no other accessible veins. 2. To access the external jugular, use the following technique: a. Prepare all equipment as for peripheral IV access in an arm, hand, or leg. Fill the 10-mL syringe with 3–5 mL of sterile saline. Attach the distal part of the syringe to the flashback chamber of a large bore, over-the-needle catheter. b. Place the patient supine and/or in Trendelenburg position. c. Turn the patient’s head to the side opposite of access. d. Cleanse the site with antiseptic solution. Start at the center site of intended puncture and work outward 1–2 inches in ever-increasing circles. e. Occlude venous return by placing a finger on the external jugular vein just above the clavicle. f. Position the intravenous cannula with the vein, midway between the angle of the jaw and the clavicle. Point the catheter at the medial third of the clavicle, and insert it, bevel up, at a 10- to 30degree angle. g. Enter the external jugular while withdrawing on the plunger of the attached syringe. h. Once inside the vein, advance the entire catheter another 0.5 cm until the tip of the Teflon catheter lies within the lumen of the vein. Then slide the Teflon catheter into the vein, remove the metal stylet, and retract the needle. Immediately dispose of the metal stylet. i. Obtain venous samples. j. Attach the administration tubing to the IV catheter. Allow the intravenous solution to run freely for several seconds. Set the flow rate, and secure as appropriate. k. Monitor the patient for complications. F. Intravenous Access with a Measured Volume Administration Set 1. When using a measured volume administration set, follow this procedure: a. Prepare the tubing by closing all clamps, and insert the flanged ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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spike into the IV solution bag’s spike port. b. Open the airway handle. Open the uppermost clamp, and fill the burette chamber with about 20 mL of fluid. c. Squeeze the drip chamber until fluid reaches the fill line. d. Open the bottom flow regulator, and purge the air from the remainder of the tubing. When all air is purged, close the bottom flow regulator. e. Continue to fill the burette chamber with the desired amount of solution. f. Close the uppermost clamp, and open the flow regulator until you reach the desired drip rate. Leave the airway handle open. g. To refill the burette chamber, open the uppermost clamp until you have delivered the desired volume. 2. To establish an IV with blood tubing, use the following procedure: a. Prepare the tubing by closing all clamps, and insert the flanged spike into the spike port of the blood and/or normal saline solution (Y-configured tubing) b. Squeeze the drip chamber until it is one-third full and blood covers the filter. Repeat for the normal saline if using Y tubing. c. If you are using straight tubing, piggyback a secondary line of normal saline into the blood tubing unless you plan to piggyback the straight blood tubing into a large-bore primary line. d. Flush all tubing with normal saline and blood as appropriate. e. Attach blood tubing to the intravenous cannula or into a previously established IV line. f. Ensure patency by infusing a small amount of normal saline. Shut down when you have confirmed patency. g. Open the clamp(s) and or flow regulator(s) that allows blood to move from the bag to the patient. Adjust the flow rate accordingly. h. When blood therapy is complete or must be discontinued, shut down the flow regulator from the blood supply and open the regulator(s) for the normal saline solution. 3. If the IV does not flow properly, check for the following problems: a. Constricting band ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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b. Edema at the puncture site c. Cannula abutting the vein wall or valve d. Administration set control valves e. IV bag height f. Completely filling drip chamber g. Catheter patency G. Complications of Peripheral Venous Access 1. Even though it is a routine procedure, IV access is not trouble free. It can cause a number of complications including pain, local infection, pyrogenic reactions, allergic reactions, catheter shear, inadvertent arterial puncture, circulatory overload, thrombophlebitis, thrombus formation, air embolism, necrosis, and complications of hematoma or infiltration. H. Changing and IV Bag or Bottle 1. Change the IV solution when there is 50 mL or less of fluid left and your patient requires more fluid a. Prepare the new IV solution bag or bottle by removing the protective cover from the IV tubing port. b. Occlude the flow of solution from the depleted bag or bottle by moving the roller clamp on the IV administration tubing. c. Remove the spike from the depleted IV bag or bottle. Be careful not to drop or contaminate the spike in any way. d. Insert the spike into the new IV bag or bottle. Ensure that the drip chamber is filled appropriately. e. Open the roller clamp to the appropriate flow rate. I. Intravenous Medication Administration 1. Medications administered through a patent IV line distributes them instantly into the blood. It avoids many of the barriers to medication absorption in other routes. 2. An intravenous bolus involves injecting the circulatory system with a concentrated dose of medication through the administration port of an established IV. 3. To administer an intravenous medication bolus, use the following technique: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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a. Ensure that the primary IV line is patent. b. Confirm the medication, indication, dosage, and need for an IV bolus. c. Confirm that the medication is compatible with the solution being infused. d. Draw up the medication or prepare a prefilled syringe as appropriate. e. Cleanse the medication port nearest the IV site with an antiseptic preparation. f. Insert a hypodermic needle above the medication g. Pinch the IV line above the medication port to prevent the medication from traveling toward the fluid bag. h. Inject the medication as appropriate. i. Remove the hypodermic needle and syringe, and release the tubing. j. Open the flow regulator to allow a 20-mL fluid flush. k. Dispose of the hypodermic needle and syringe as appropriate. 4. An intravenous medication infusion delivers a steady, continual dose of medication through an existing IV line. a. Establish a primary line and ensure patency. b. Confirm administration indications and patient allergies. c. Prepare the infusion bag or bottle. 1) Draw up the appropriate quantity of medication from its source with a syringe. 2) Cleanse the IV bag medication port with an antiseptic wipe. 3) Insert the hypodermic needle into the medication port, and inject the medication. 4) Gently agitate the bag or bottle to mix its contents. 5) Label the bag or bottle. d. Connect administration tubing to the medication bag or bottle and fill the drip chamber to the fluid line. e. Place the hypodermic needle on the administration tubing’s needle adapter and flush the tubing with solution. f. Cleanse the medication administration port on the primary line with ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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alcohol, and insert the secondary line’s hypodermic needle. Secure the hypodermic needle and the secondary administration line with tape or another securing device. g. Reconfirm the indication, medication, dose, and route of administration. h. Shut down the primary line so no fluid will flow from the primary solution bag. i. Adjust the secondary line to the desired drip rate. If you are using a mechanical infusion pump, set it accordingly. j. Properly dispose of the needle and syringe. 5. A heparin or saline lock is used for medication administration when the patient does not need continuous IV fluids. a. The same procedure is used when starting an IV. b. Instead of attaching tubing to the hub of the catheter, attach heparin or saline lock tubing to the end and secure it. c. Administering medication is the same procedure as utilizing a medication port on IV tubing. 6. A venous access device is surgically implanted and permits repeated access to the central venous circulation. a. Use Standard Precautions. b. Fill a 10-mL syringe with approximately 7 mL of normal saline. c. Place a 21- or 22-gauge Huber needle (or other specialized needle) on the end of the syringe d. Cleanse the skin over the injection port with an antiseptic solution. e. Stabilize the site with one hand while inserting the Huber needle at a 90-degree angle. Gently advance it until it meets resistance. f. Pull back on the plunger to observe for blood return. g. Slowly inject the normal saline to ensure patency. 7. Electromechanical infusion devices permit the precise delivery of fluids and/or medications through electronic regulation; these devices require special devices and specific tubing. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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a. Infusion controllers b. Infusion pumps 8. The use of portable ultrasound to aid in placement of peripheral intravenous lines is now common in hospital emergency departments. With the advent of newer portable ultrasound machines, it is also being used in the out-of-hospital setting. J. Venous Blood Sampling 1. Venous blood sampling provides valuable information and may save considerable time for the patient. a. It should be considered prior to medication administration and completed during peripheral access. b. It should not delay care. c. It requires strict attention to detail if the sample is to remain viable. d. To obtain blood directly from the IV catheter, use the following procedure: 1) Assemble and prepare all equipment. Inspect the blood tubes for expiration or damage, and insert the multidraw needle into the vacutainer. 2) Establish IV access with the IV catheter. Do not connect IV administration tubing. 3) Attach the end of the multidraw needle adapter to the hub of the cannula. 4) In correct order, insert the blood tubes so that the rubbercovered needle punctures the self-sealing rubber top. Blood should be pulled into the blood tubing. 5) Fill all blood tubes completely, as the amount of anticoagulant is proportional to the tube’s volume. Gently agitate the tubes to mix the anticoagulant evenly with the blood. 6) Tamponade the vein, and remove the vacutainer and multidraw needle. Attach the IV, and ensure patency. 7) Properly dispose of all sharps. 8) Label all blood tubes with the patient’s first and last name, patient’s age and gender, date and time drawn, and the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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name of the person drawing the blood. K. Removing a Peripheral IV 2. Remove a peripheral IV if it has stopped flowing or has fulfilled its need. a. Occlude the tubing with the flow regulator and/or clamp. b. Remove all tape and securing devices. c. Place sterile gauze over the puncture site. d. Apply pressure to the gauze with the fingers or thumb of your nondominant hand. e. Swiftly remove the catheter while maintaining pressure over the IV site. f. Keep direct pressure over the site for at least 5 minutes or until bleeding stops. 20

IX. Intraosseous Infusion A. Intraosseous (IO) infusions involve inserting a rigid needle into the cavity of a long bone or into the sternum. 1. Peripheral IVs are preferred; however, IOs are reliable in the absence of other available sites. B. Access Site 1. The proximal tibia is the bone most used in both pediatric and adult patients. 2. The medial malleolus, the humoral head, and the sternum are other sites utilized in adult patients. C. Equipment for Intraosseous Access 1. IO infusions require a special needle and a 10-mL syringe. a. A 14- to 18-gauge hollow needle with a trocar inside (provides strength and rigidity) b. Commercial IO devices are also available for both pediatric and adult IO infusions. D. Placing an Intraosseous Infusion 1. Placing an IO is done using the following technique: a. Determine the indication for intraosseous infusion. b. Assemble and check all equipment. c. Position the patient. Rotate the leg toward the outside to expose the medial, proximal aspect of the tibia.

Teaching Tips This is an infrequent skill that should be practiced regularly. Chicken legs can be used for practice and are great for simulation of real patients.

Discussion Topics This is a skill that many paramedics are reluctant to do, as it causes a great deal of pain. It is important to understand the benefits and disadvantages and to discuss them as a group.

Critical Thinking Questions Why is the IO route almost as effective as the peripheral IV if it is placed in a bone?

Points to Emphasize This is an important skill and should be considered when peripheral access is unavailable.

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d. Locate the access site. 1) In pediatric patients, palpate the tibial tuberosity. Move 1 to 2 fingerbreadths below the tibial tuberosity and the flat expanse medial to the anterior tibial crest. 2) In adult or geriatric patients, find the medial locations. e. Cleanse the site with antiseptic solution. Start at the puncture site, and work outward in an expanding circular motion. f. Perform the puncture. Holding the needle perpendicular site, insert it with a twisting motion until you feel a decrease in resistance or a “pop.” g. Remove the trocar and attach the syringe. Slowly pull back the plunger to attempt aspiration into the syringe. Easy aspiration of bone marrow and blood confirms correct medullary placement. h. Once you have confirmed placement, rotate the plastic disk toward the skin, and secure the needle. Remove the syringe, and attach the prepared administration tubing and solution. Set the appropriate flow rate. i. Secure the intraosseous needle as if securing an impaled object by surrounding it with bulky dressings and taping them securely in place. E. Intraosseous Access Complications and Precautions 1. IO access poses potential for serious complications, including fractures, infiltration, growth plate damage, complete insertion, and pulmonary embolism. F. Contradictions to Intraosseous Placement 1. Do not attempt IO placement in the following situations: a. Fracture to the tibia or femur on the side of access b. Osteogenesis imperfecta c. Osteoporosis d. Establishment of a peripheral IV line

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X. Metric System A. Medication doses are most often expressed and measured in metric units. B. Conversion between Prefixes 1. To convert a measurement to a smaller unit, multiply the original measurement by the numerical equivalent of the smaller measurement’s prefix. 2. To convert a measurement to a larger unit, divide the original measurement by the numerical equivalent of the smaller measurement’s prefix. 3. When converting a measurement to or from a prefix that is not the fundamental unit, first convert the existing measurement to the fundamental measurement. Then convert the fundamental measurement to the desired unit. C. Household and Apothecary Systems of Measure 1. In the past, pharmacology traditionally used the household and apothecary systems to measure medication dosages. 2. Gradually, the metric system has replaced those systems, but you may occasionally encounter them. D. Weight Conversion 1. To convert pounds to kilograms divide by 2.2. E. Temperature 1. To convert between degrees Fahrenheit and degrees Celsius, use °F = 9/5°C + 32 or °C = 5/9(°F − 32) F. Units 1. Some medications are measured in units and cannot be converted.

Points to Emphasize

XI. Medical Calculations A. Most medications are provided in stock solution. Therefore, you must calculate the exact amount of medication to remove, using three facts: 1. Desired dose – the specific quantity of medication needed 2. Dosage on hand – the weight (grams, milligrams or micrograms) 3. Volume on hand – the amount of liquid in which it is dissolved 4. The following equation is used:

Teaching Tips

The metric system is the standard in medicine. It is important to understand how to use the metric system and convert between values.

Math is difficult for many students. It helps to plan for extra time to practice.

Critical Thinking Questions Why is it important to calculate a patient’s weight appropriately? How much of a difference in medication dosage can be related to weight conversions? 27

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dosage on hand XII. Calculating Dosages for Oral Medications A. Refer to the example presented in the text (pages 503–504), which illustrates how to calculate the volume of a specific medication dosage. B. Converting Prefixes 1. When a drug is expressed in a different prefix (such as grams instead of milligrams) the dosage on hand must be converted into the appropriate prefix (1 gram = 1,000 milligrams). C. Calculating Dosages for Parenteral Medications 1. Refer to the example presented in the text (page 505). D. Calculating Weight-Dependent Dosages 1. Occasionally, you will need to calculate a dose on the basis of a patient’s weight. 2. You must convert pounds to kilograms. 3. Calculate your dose and multiply by the kilograms for your weight-based dose. E. Calculating Infusion Rates 1. To deliver fluid or medication through an IV infusion, you must calculate the infusion using drops per minute.

Class Activities Practice in small groups. Have the students who are comfortable with math help the students who are not as comfortable.

Knowledge Applications This is a good opportunity to have the students complete homework solving medical math problems. There are several resources available with sample calculations.

drops /minute = volume on hand x drip factor x desired dose dosage on hand F. Fluid Volume over Time 1. To deliver fluid correctly, you must calculate volume/overtime. This calculation requires the following information: the volume to be administered, drip factor (drops/mL), and total infusion time (minutes). drops/minute = volume to be administered(drip factor) time in minutes G. Calculating Dosages and Infusion Rates for Infants and Children 1. It is imperative to calculate medication accurately for infants and children, as they cannot tolerate underdoses or overdoses of ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

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medications.

IX. Summary A. Medication administration is a fundamental skill used in the treatment of the sick and injured. B. Many different routes of administration are available to the paramedic; however, specific medications require specific routes for administration. C. Dosage errors and inappropriate medication administration can result in serious side effects or even death for the patient. D. Keep in mind that medical calculations can be completed by a variety of methods. What is important is to find a method that works for you and gets you the right answer every time you work a problem. E. Always remember that it is your responsibility to be familiar with all routes of administration and the techniques for establishing and using them.

X. Case Study 5

XI. You Make the Call 10

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

XII. Review Questions 5

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 15 Airway Management and Ventilation 315 Minutes

      

Teaching Tips Discussion Topics Critical Thinking Questions Class Activities Points To Emphasize Knowledge Applications Media Resources

Chapter 15 objectives can be found on text pp. 512-513. These objectives, which form the basis of each chapter, were developed from the National Education Standards and the accompanying Paramedic Instructional Guidelines.

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Case Study

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

II. Introduction A. Airway management and ventilation are the first and most critical steps in the primary assessment of every patient you encounter. 1. Without airway maintenance and ventilation, the patient will succumb to brain injury or death in as little as 4 minutes. B. With regard to airway and ventilation problems, paramedics should approach the patient more globally and consider the whole picture rather than following predetermined steps.

Teaching Tips

III. Anatomy of the Respiratory System A. Upper Airway Anatomy 1. The upper airway extends from the mouth and nose to the larynx. 2. The nasal cavity is the most superior part of the airway and contains several structures including the sinuses, the eustachian tubes and the lacrimal ducts. 3. Nasal hairs just inside the external nares initially filter the incoming air. 4. Turbulence helps to filter the air by depositing airborne particles on the mucous membrane lining the nasal cavity. 5. The mucous membrane has a rich blood supply and immediately warms and humidifies the air entering the nose. 6. The cheeks, hard and soft palates, and tongue form the oral cavity. a. The tongue is the most common airway obstruction.

Critical Thinking Questions

Airway management is an important topic for paramedics and the first priority of patient care. Emphasize how important it is to know the basics. Use equipment and anatomical models to demonstrate important areas of the body.

Consider the airway anatomy and how it relates to airway management. How can understanding anatomy help with the skills that we will be learning?

Points to Emphasize Be sure to point out the important structures that will be prominent during all the airway procedures, especially the advanced airway procedures. Take time to demonstrate the vallecula, epiglottis, and cricoid membrane.

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Content Outline b. The hyoid bone, located just beneath the chin, is the only bone in the axial skeleton that does not articulate with any other bone. 7. The pharynx is a muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus and is divided into three regions. a. Nasopharynx, oropharynx, and laryngopharynx 8. The oropharynx extends from the plane of the soft palate to the hyoid bone. 9. The laryngopharynx extends posteriorly from the hyoid bone to the esophagus and anteriorly to the larynx and is especially important in airway management. 10. The mouth and pharynx serve dual purposes for respiration and digestion; therefore, a number of mechanisms are in place to help prevent accidental blockage. a. The gag reflex prevents foreign materials from entering the trachea. b. The epiglottis is a leaf-shaped cartilage that prevents food from entering the respiratory tract during swallowing. 11. The vallecula lies just anterior and superior to the epiglottis and is a fold formed by the base of the tongue and epiglottis. a. The vallecula is an important landmark in intubation 12. The larynx joins the pharynx with the trachea and consists of the thyroid and cricoid cartilage, glottic opening, vocal cords, arytenoid cartilage, pyriform fossae, and cricothyroid membrane. a. The thyroid cartilage houses the glottis opening, which is the narrowest part of the adult trachea. b. The true vocal cords lie within the laryngeal cavity. c. The cricoid cartilage lies beneath the thyroid cartilage and in front of the esophagus and is considered the first tracheal ring. B. Lower Airway Anatomy 1. The lower airway extends from below the larynx to the alveoli, where respiratory exchange of oxygen and carbon dioxide occur. 2. As air enters the lower airway from the upper airway, it first enters then passes through the trachea. a. The trachea contains C-shaped cartilaginous rings to maintain structure and is lined with respiratory epithelium and mucusproducing cells.

Master Teaching Notes

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b. The mucus traps particles missed by the upper airway. At the carina, the trachea bifurcates into the left and right mainstem bronchi. a. The right mainstem bronchus is almost straight; the left mainstem bronchus angles to the left. b. The mainstem bronchi enter the lung tissue at the hilum and then divide into the secondary and tertiary bronchi. c. The secondary and tertiary bronchi ultimately branch into the bronchioles, or small airways. d. The respiratory bronchioles terminate at the alveoli. The alveoli are balloonlike clusters of sacs that are only one or two cell layers thick. a. Most oxygen and carbon dioxide gas exchange takes place in the alveoli. b. The alveoli’s surface area is massive, totaling more than 40 square meters. c. The alveoli resist collapse largely because of the presence of surfactant, which decreases surface tension and makes it easier for them to expand. The lung parenchyma is arranged into two lobes forming the anatomical division of the lungs. a. The right lung has three lobes: the upper, middle, and lower. b. The left lung has two lobes: the upper and lower. The pleura is a membranous connective tissue that covers the lungs. a. The visceral pleura envelops the lungs and contains no nerve fibers. b. The parietal pleura lines the thoracic cavity and is rich with nerve fibers. c. The potential space between the two layers is called the pleural space. It holds a small amount of fluid to reduce friction during respiration. The pediatric airway is fundamentally the same as an adult’s but has several anatomic differences. a. The jaw is smaller, and the tongue is relatively larger. b. The epiglottis is more rounded and significantly more “floppy.” c. The larynx lies more superior and anterior and is funnel-shaped. d. The cricoid cartilage is the narrowest portion of the airway.

Master Teaching Notes

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e. The ribs and thoracic cage are softer and more pliable.

IV. Physiology of the Respiratory System A. Respiration and Ventilation 1. Respiration is the exchange of gases between an organism and its environment. 2. Pulmonary (external) respiration occurs in the lungs when the respiratory gases are exchanged between the alveoli and red blood cells in the pulmonary capillaries through the capillary membranes. 3. Cellular (internal) respiration occurs in the peripheral capillaries and is the exchange of the respiratory gases between the red blood cells and the various body tissues. a. Cellular respiration in the peripheral tissues produces carbon dioxide. 4. Ventilation is the mechanical process that moves air into and out of the lungs. 5. The respiratory cycle depends on changes in pressure within the thoracic cavity. a. The respiratory cycle begins when the pressure inside the thoracic cavity equals the atmospheric pressure (at the end of normal expiration) b. The brain signals the diaphragm via the phrenic nerve to contract. 1) When the diaphragm contracts, it draws downward, away from the thoracic cavity, enlarging it. 2) When the intercostal muscles contract, they draw the rib cage upward and outward, increasing volume in the thoracic cavity upward. 3) As the thoracic cavity increases in size, pressure within it becomes lower than that of the atmosphere creating a negative pressure that invites air into the thorax through the

Teaching Tips Physiology can be complicated. Make sure to review respiratory physiology before the lecture. It also helps to have containers marked in liters so that you can have an actual representation of the amounts of air involved in the concepts discussed in this section.

Class Activities Have the class demonstrate how the lungs work, using a balloon. This will demonstrate the process of passive exhalation and active inhalation.

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Content Outline airway 4) The alveoli inflate with the lungs and become thinner as they expand, allowing oxygen and carbon dioxide to diffuse across the membranes. 5) When the pressure in the thoracic cavity reaches that of the atmosphere and alveoli are maximally inflated, stretch receptors are stimulated, signaling the vagus nerve to inhibit respiration. 6) The muscles relax, decreasing the size of the thoracic cavity and increasing intrathoracic pressure. i. Air is forced out through the airway (expiration) until the intrathoracic and atmospheric pressure are equal again. ii. Normal expiration is passive and requires no energy; inspiration is active and requires energy. 6. Respiration also requires an intact circulatory system a. In the capillaries, cells take oxygen from the red blood cells and give up carbon dioxide to the venous system. b. The venous system carries the deoxygenated blood to the right side of the heart and into the pulmonary artery. c. The pulmonary vein takes the oxygenated blood to the left side of the heart, which then delivers it into the arterial system for transport around the body. B. Measuring Oxygen and Carbon Dioxide Levels 1. Oxygen and carbon dioxide levels in the body can be determined by measuring their partial pressures or the pressure exerted by each compartment or gas mixture. 2. The partial pressure of oxygen at normal atmospheric pressure is 21% (0.21) multiplied by the atmospheric pressure at sea level (760 torr), which is 159.6 torr. 3. Alveolar and arterial partial pressures are essentially the same in a normal lung. C. Diffusion is the movement of gas from an area of higher concentration (partial pressure) to an area of lower concentration, attempting to reach equilibrium. 1. Diffusion transfers gases between the lungs and the blood and between

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Content Outline the blood and the peripheral tissues. D. Oxygen diffuses into the blood plasma, where most of it combines with hemoglobin and is measured as oxygen saturation (SaO2). 1. The remainder is dissolved in the blood and measured as the PaO2. 2. Approximately 97% of the oxygen is bound to hemoglobin. 3. Several factors can affect oxygen concentrations in the blood. a. Decreased hemoglobin concentration (anemia, hemorrhage) b. Inadequate alveolar ventilation due to low inspired oxygen, respiratory muscle paralysis, and pulmonary conditions such as emphysema, asthma, or pneumothorax c. Decreased diffusion across the pulmonary membrane (pulmonary edema, pneumonia, COPD) d. Ventilation/perfusion mismatch occurs when a portion of the alveoli collapses, as in atelectasis. 4. Correcting oxygen derangements is achieved by increasing ventilation, administering supplemental oxygen, using intermittent positive-pressure ventilation, or administering medications to correct underlying problems such as pulmonary edema, asthma, or pulmonary embolism. E. The blood transports carbon dioxide in the form of bicarbonate ion (HCO3-). 1. Approximately 70% is carried as bicarbonate, and approximately 23% combined with hemoglobin. Less than 7% is dissolved in the plasma. 2. Several factors influence carbon dioxide’s concentrations in the blood including increased CO2 production and/or decreased CO2 elimination: a. Hyperventilation lowers CO2 levels and results from increased respiratory rate or deep respiration. b. Increased CO2 production is caused by: 1) Fever 2) Muscle exertion 3) Shivering 4) Metabolic processes resulting in the formation of metabolic acids c. Decreased CO2 elimination results from decreased alveolar ventilation. Common causes include hypoventilation due to: 1) Respiratory depression by drugs 2) Airway obstruction 3) Impairment of the respiratory muscles

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Content Outline 4) Obstructive diseases such as asthma and emphysema F. Regulation of Respiration 1. Regulation of respiration occurs as a result of both involuntary and voluntary nervous system mechanisms. 2. Nervous impulses from the respiratory center, which lies in the medulla 3. Stretch receptors send impulses to the medulla inhibiting respiration. 4. Chemoreceptors in the medulla, carotid bodies, and aortic arch are stimulated by decreased PaO2, increased PaCO2, and decreased pH. 5. Hypoxic drive causes the chemoreceptors to stop responding to PaCO2 and instead to stimulate respirations when PaO2 falls and inhibit respirations when PaO2 climbs. 6. The respiratory rate is the number of respiratory cycles per minute, normally 12–20 breaths per minute in adults, 18–24 in children, and 40– 60 in infants. 7. Several factors affect respiratory rate: a. Fever b. Emotion c. Pain d. Hypoxia e. Acidosis f. Stimulant drugs g. Depressant drugs h. Sleep 8. Paramedics must fully understand ventilator mechanisms and capacities for the average adult respiratory system. a. Total lung capacity is the maximum lung capacity (approximately 6 liters in the average adult male). b. Tidal volume is the average volume of gas inhaled in one respiratory cycle (approximately 500 mL or 5–7 mL/kg). c. Dead space volume is the amount of gas in a tidal volume that remains in the passages and is unavailable for gas exchange (approximately 150 mL in the adult male). d. Alveolar volume is the amount of gas in the tidal volume that reaches the alveoli for gas exchange (approximately 350 mL in the adult male). e. Minute volume is the amount of gas moved into and out of the

Master Teaching Notes

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respiratory tract in 1 minute (tidal volume x respiratory rate). Alveolar minute volume is the amount of gas that reaches the alveoli for gas exchange in 1 minute (alveolar volume x respiratory rate). g. Inspiratory reserve volume is the amount of air that can be maximally inhaled after a normal inspiration. h. Expiratory reserve volume is the amount of air that can be maximally exhaled after a normal expiration. i. Residual volume is the amount of air remaining in the lungs at the end of a maximal expiration. j. Functional residual capacity is the volume of gas that remains in the lungs at the end of normal expiration. k. Forced expiratory volume is the amount of air that can be maximally expired after maximum inspiration. f.

V. Respiratory Problems A. Airway Obstruction 1. Blockage of the airway is an immediate threat to the patient’s life and a true emergency. 2. Upper airway obstruction can be defined as an interference with air movement through the upper airway. 3. May be either partial or complete 4. The tongue, foreign bodies, teeth, spasm, trauma, edema, vomitus, and blood can all obstruct the upper airway. B. Inadequate Ventilation 1. Insufficient minute volume respirations can compromise adequate oxygen intake and carbon dioxide removal. VI. Respiratory System Assessment A. Primary Assessment 1. The purpose of the primary assessment is to identify any immediate life threats, specifically airway, breathing, and circulation problems. 2. Assess the airway for patency. 3. Determine the adequacy of breathing. 4. Observe the chest wall for asymmetrical movement (paradoxical breathing). 5. If the patient is not breathing or you suspect airway problems, open the

Teaching Tips It is important for you to give the students the opportunity to practice what is discussed in this section. If you can gather different types of pulse oximeters and capnometers, it helps to use them for demonstration of the concepts.

Class Activities

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airway using the head-tilt/chin-lift or jaw-thrust maneuver. 6. If breathing is adequate, provide supplemental oxygen and assess circulation. 7. If breathing is inadequate or absent, begin artificial ventilation. 8. When assisting a patient’s breathing with a ventilator device or after placing an airway adjunct or endotracheally intubating, monitor the chest’s rise and fall to determine correct usage and placement. B. Secondary Assessment 1. After the primary assessment and correction of immediate life threats, the secondary assessment occurs while the patient’s airway, breathing, and circulation are continuously monitored. 2. History, both present and past medical history, will put the complaints into perspective and help to identify likely diagnoses. 3. Physical examination of a patient with respiratory problems should continue the evaluation of his airway, breathing and circulation begun during primary assessment. a. Inspection is the first step in the secondary assessment: skin color, dyspnea, respiratory rate, and use of accessory muscles 1) Determine whether the respiratory pattern is normal or abnormal. 2) Observe for altered mentation. 3) Modified forms of respiration a) Coughing b) Sneezing c) Hiccoughing (hiccups) d) Sighing e) Grunting 4) Abnormal respiratory patterns: a) Kussmaul’s respirations b) Cheyne-Stokes respirations c) Biot’s respirations d) Central neurogenic hyperventilation e) Agonal respirations b. Auscultation should be performed next. 1) Listen at the mouth and nose for adequate air movement. 2) Listen to the chest with a stethoscope over the left and right

Have the class practice respiratory assessments on one another. Give them the opportunity to listen to adventitious lung sounds so that they know the difference between normal and abnormal. If you have a pulse oximeter, show them how holding their breath affects the saturation percentage.

Points to Emphasize It is important to master the respiratory assessment. Encourage your students to evaluate as many people as they can, children and adults. If they are comfortable assessing people without respiratory complaints (classmates and family), they will have a good baseline to compare when they come across a respiratory patient.

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Content Outline apex, the left and right base, and the thoracic back. 3) Breath sounds should be equal and absent of snoring, gurgling, stridor, wheezing, crackles or ronchi. Quiet or diminished or absent breath sounds are an ominous finding and indicate a serious problem. c. Palpate for the movement of air and for chest rise and fall. d. If you are ventilating, gauge airflow into the lungs by noting compliance. C. Noninvasive Respiratory Monitoring 1. Several devices are available to measure the effectiveness of oxygenation and ventilation. a. Pulse oximetry measures the saturation of hemoglobin in the peripheral tissues 1) Normal SpO2 varies between 96 and 99% at sea level. b. Pulse CO oximetry detects abnormal hemoglobins such as carboxyhemoglobin and methemoglobin. c. Capnography is a graphic recording or display of the exhaled carbon dioxide levels as measured by capnometry. d. Various terms have been applied to capnography: 1) Capnometry 2) Capnography 3) Capnograph 4) Capnogram 5) End-tidal CO2 (ETCO2) 6) PETCO2 7) PaCO2 8) End-tidal gradient e. The colorimetric device is a disposable ETCO2 detector that contains pH-sensitive, chemically impregnated paper encased within a plastic chamber. A color scale on the device estimates the ETCO2 level. f. Electronic exhaled CO2 detectors use an infrared technique to detect CO2 in the exhaled breath. g. There are two major types of capnography: mainstream and sidestream. h. The capnogram reflects exhaled CO2 concentrations over time. It is

Master Teaching Notes

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Master Teaching Notes

typically divided into four phases: 1) Phase I: the respiratory baseline (end of inhalation). 2) Phase II: the respiratory upstroke (beginning of exhalation). 3) Phase III: the respiratory plateau (full exhalation) and the point of ETCO2 measurement. 4) Phase IV: the inspiratory phase (beginning of inhalation). 5) At its most basic, qualitative capnography may be used to assess correct initial endotracheal tube placement and confirm placement. It may also be used to monitor other medical conditions. a. Obstructive disease b. Rebreathing c. Curare cleft d. Esophageal intubation e. Endotracheal tube or circuit leak f. Ventilation/perfusion (V/Q) mismatch g. Apnea h. Hyperventilation i. Hypoventilation

VII. Proper Positioning A. Conscious medical patients should be maintained in their position of comfort. B. Unconscious medical patients who do require airway and ventilation interventions are usually best maintained in an ear-to-sternal notch position. C. Sniffing Position 1. To place non-obese patients in the sniffing position, first achieve an earto-sternal notch horizontal alignment by slightly flexing the patient’s neck and extending the head (assuming that no cervical spine injury is suspected). D. Ramped Position 1. The strategy for positioning obese patients requires elevating the upper portion of the body to achieve alignment of the ear and sternal notch.

Critical Thinking Questions Why is positioning so important? What does it take to properly position someone?

Points to Emphasize Positioning is vital to airway management success and should be taken very seriously.

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Content Outline VIII.Oxygenation A. Oxygen Supply and Regulation 1. Oxygen is supplied as either a compressed gas or a liquid. B. Oxygen Delivery Devices 1. Oxygen delivery is measured in liters of flow per minute (L/min). 2. A nasal cannula is a catheter placed in the nares that delivers oxygen at 1–6 L/min and is used for low to moderate oxygen requirements 3. A Venturi mask is a high-flow mask that delivers 24%, 28%, 35%, or 40% oxygen. The liter flow depends on the oxygen concentration desired. These masks are rarely placed by EMS providers. 4. The simple face mask is indicated for patients who require moderate oxygen concentrations. Flow rates generally range from about 6 to 10 L/min, depending on the patient’s respiratory rate and depth. 5. Partial rebreather masks deliver oxygen at up to 10 L/min and are indicated for patients requiring moderate-to-high oxygen concentrations when satisfactory clinical results are not obtained with the simple face mask. 6. Nonrebreather masks have an attached reservoir bag and provide the highest oxygen concentration of all oxygen delivery devices available, or about 80% when set at 15 L/min of oxygen and the mask is fit tightly to the face. 7. Small volume nebulizers are attached to face masks with 3–5 mL of fluid and when attached to oxygen, nebulize the medication for delivery to the respiratory system. 8. An oxygen humidifier can be attached, allowing sterile water to be delivered with the oxygen to prevent mucous membranes from drying out. 9. Positive airway pressure (PAP) is delivered via a face mask to maintain a constant level of pressure within the airway, which assists a patient in breathing by preventing collapse of the airway during inhalation. a. Continuous positive airway pressure (CPAP) maintains a steady level of pressure b. Bilevel positive airway pressure (BiPAP) maintains a higher level of pressure during inhalation and a lower level of pressure during exhalation.

Master Teaching Notes Teaching Tips CPAP and BiPAP have been recently introduced into paramedic practice, so take time to discuss the advantages of each.

Critical Thinking Questions What are some uses of CPAP and BiPaP outside of prehospital care? How does this relate to our treatment?

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Content Outline IX. Manual Airway Maneuvers A. Head-Tilt/Chin-Lift 1. In the absence of cervical spine trauma, the head-tilt/chin-lift is the best technique for opening the airway in an unresponsive patient who is not protecting his own airway. a. Place the patient supine, and position yourself at the side of the patient’s head. b. Place one hand on the forehead and, using firm downward pressure with your palm, tilt the head back. c. Put two fingers of the other hand under the bony part of the chin, and lift the jaw anteriorly to open the airway. B. Jaw-Thrust Maneuver without Head Extension 1. The jaw-thrust maneuver is acceptable for any unresponsive patient who may have a cervical spine injury a. Lift the jaw, using fingers behind the mandibular angles; do not tilt the head. b. Prop the thumbs on the cheekbones to provide some counterforce. X. Basic Airway Adjuncts A. Nasopharyngeal Airway 1. The nasopharyngeal airway (NPA), or “nasal trumpet,” is an uncuffed tube made of soft rubber or plastic that follows the natural curvature of the nasopharynx. 2. Specific indications for use include obtunded patients and unconscious patients. 3. To insert a nasopharyngeal airway: a. Ensure or maintain effective ventilation with supplemental oxygen. b. Lubricate the exterior of the tube with a water-soluble gel. c. Select the naris that appears largest. Push gently up on the tip of the nose, and pass the tube gently into the nostril with the bevel oriented toward the septum and the airway directed straight back along the nasal floor, parallel to the mouth. Avoid pushing against any resistance. d. Verify the appropriate position of the airway. Resolution of noisy breathing and improved compliance during BVM ventilation support correct positioning. Also, feel at the airway’s proximal end for airflow on expiration.

Master Teaching Notes

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Master Teaching Notes

e. Provide supplemental oxygen and/ or ventilate as indicated. B. Oropharyngeal Airway 1. The oropharyngeal airway (OPA) is a noninvasive semicircular plastic or rubber device designed to follow the palate’s curvature. 2. The OPA holds the base of the tongue away from the oropharynx and is indicated in patients without a gag reflex. 3. To insert the OPA: a. Open the mouth, and remove any visible obstructions. b. Ensure or maintain effective ventilation with supplemental oxygen. c. Grasp the patient’s jaw, and lift anteriorly. d. With your other hand, hold the airway device at its proximal end, and insert it into the patient’s mouth. Make sure the curve is reversed, with the tip pointing toward the roof of the mouth. e. Once the tip reaches the level of the soft palate, gently rotate the airway 180 degrees until it comes to rest over the tongue. f. Verify appropriate position of the airway. Clear breath sounds and chest rise indicate correct placement. g. Apply supplemental oxygen and/or positive pressure ventilation if indicated. 10

XI. Ventilation A. Mouth-to-Mouth/Mouth-to-Nose Ventilation 1. Mouth-to-mouth and mouth-to-nose ventilation are the most basic but are not used often because of the exposure to bodily fluids and lack of supplemental oxygen. B. Mouth-to-Mask Ventilation 1. Mouth-to-mask ventilation prevents direct contact between you and your patient’s mouth and expired air, thus reducing the risk of contamination and subsequent infection. C. Bag-Valve-Mask Ventilation 1. Bag-valve-mask ventilation is the primary method of providing ventilatory support to apneic or inadequate breathing patients 2. 10–15 L/min oxygen should be applied to the BVM. 3. One, two, or three rescuers may perform BVM ventilations. a. One-person BVM ventilation is the most difficult to master because obtaining and maintaining the mask seal while delivering ventilations can be challenging.

Class Activities Make sure the class practices basic BVM ventilation and demonstrates a proper seal. You should also have a Broselow tape for them to use as a reference for pediatric patients.

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b. BVM ventilation should generally be performed with at least two providers, one to squeeze the bag and one to open the airway and maintain the mask seal. 4. Compressing the esophagus between the back of the cricoid ring and the front of the spinal column is called cricoid pressure. It helps to mitigate gastric distention. 5. The rule of threes was developed to help providers recall the components of optimal BVM ventilation. 6. Whenever BVM ventilation is difficult, the rule of threes should be employed. a. Three providers b. Three inches c. Three fingers d. Three airways e. Three PSI f. Three seconds g. Three PEEP 7. Ventilating a pediatric patient requires some variation in technique a. Bag size depends on the child’s age. b. A Broselow tape will help to determine proper mask size c. Ventilate according to current standards, obtaining chest rise with each breath. d. Allow adequate time for exhalation. e. Assess for clinical improvement (skin color and heart rate). D. Demand-Valve Device 1. The demand-valve device, also called the manually triggered, oxygenpowered ventilation device or flow-restricted, oxygen-powered ventilation device, will deliver 100% oxygen to a patient at its highest flow rates (40 liters per minute maximum). 2. These devices have fallen out of favor because of the risks of gastric distension and barotrauma in unconscious patients. 10

XII. Extraglottic Airway Devices A. Extraglottic airway (EGA) devices are inserted blindly into the airway to facilitate oxygenation and ventilation via a self-inflating bag or transport ventilator but do not enter the glottis. They may be used as a primary or secondary device.

Teaching Tips It is important to have all the equipment nearby so that you can pass it around during the lecture. Also allow time for the students to practice each skill, if only for

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Content Outline B. Retroglottic Airway Devices 1. Dual-lumen retroglottic airways are designed to be blindly inserted into the esophagus. 2. The Esophageal Tracheal Combitube™ (ETC) is available in two sizes for patients over 4 feet tall. 3. To place the ETC: a. Perform optimal BVM ventilation with high-concentration oxygen. b. Place the patient supine in a neutral position if possible. c. Prepare and check equipment. d. Stabilize the cervical spine if cervical spine injury is possible. e. Perform the Lipp maneuver (or modified Lipp maneuver) to preshape the ETC. f. Grab and lift the jaw or, if within your scope of practice, use a laryngoscope to create a channel and visualize the esophagus. Insert the ETC gently in midline, and advance it past the hypopharynx to the depth indicated by the markings on the tube. The black rings on the tube should be between the patient’s teeth. g. Inflate the proximal cuff with 100 mL of air and the distal cuff with 10–15 mL of air. h. Ventilate through the longer, blue, #1, proximal port with a bagvalve device connected to 100% oxygen while auscultating over the chest and stomach. If you hear bilateral sounds over the chest and none over the stomach, secure the tube and continue ventilating. i. If you hear gastric sounds over the epigastrium and no breath sounds, change ports and ventilate through the clear, shorter, #2, distal port to direct oxygen into the trachea. Confirm breath sounds over the chest with absent gastric sounds. j. Use multiple confirmation techniques k. Secure the tube, and continue ventilating with 100% oxygen. l. Frequently reassess airway and adequacy of ventilation. 4. The Pharyngeo-Tracheal Lumen Airway (PtL) is also a dual-lumen airway. To insert the PtL: a. Complete basic manual and adjunctive maneuvers, and provide supplemental oxygen and ventilatory support with a BVM and hyperventilation. b. Place the patient supine, and kneel at the top of his head.

Master Teaching Notes one attempt, shortly after talking about it. This will facilitate the learning of the skill.

Class Activities Spend a few moments with mannequins practicing insertion of each of the devices.

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c. Prepare and check the equipment. d. Place the patient’s head in the appropriate position. Hyperextend the neck if there is no risk of cervical spine injury. Maintain neutral position with stabilization of the cervical spine if cervical spine injury is possible. e. Insert the PtL gently, using the tongue-jaw-lift maneuver. f. Inflate the distal cuffs on both PtL tubes simultaneously with a sustained breath into the inflation valve. g. Deliver a deep breath into the green oropharyngeal tube. If the patient’s chest rises and you auscultate breath sounds, the long tube is in the esophagus. Inflate the pharyngeal balloon and continue ventilations via the green tube. h. If the chest does not rise and you auscultate no breath sounds, the long clear tube is in the trachea. Remove the stylet from the clear tube, and ventilate the patient through that tube. i. Attach the bag-valve device to the 15-mm connector, secure the tube, and continue ventilatory support with 100% oxygen. j. Multiple placement confirmation techniques are essential, as are good assessment skills. 5. The King LT™ airway is a single-lumen retroglottic airway device that has a large silicone cuff that disperses pressure over a large mucosal surface area. C. Supraglottic Airway Devices 1. Supraglottic airways are placed blindly and sit over the larynx. a. Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T.®) b. Laryngeal Mask Airway (LMA™) c. LMA Supreme™ d. LMA Fastrach™ e. CookGas air-Q® f. Ambu® Laryngeal Mask

XIII.Endotracheal Intubation A. Endotracheal (ET) intubation involves inserting an endotracheal tube into the trachea typically via direct laryngoscopy. 1. It provides optimal aspiration protection and ventilation. 2. It bypasses the physiologic functions of the upper airway: warming,

Teaching Tips This is a skill that will require practice. Make sure the students have opportunity to practice this skill soon after discussing it and then continually throughout the rest of

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Content Outline filtering, and humidifying air. B. Oral Endotracheal Intubation Indications – Non-Medication-Assisted 1. OETI is generally restricted to patients in cardiac or respiratory arrest or to patients in extreme respiratory failure, which will allow such an invasive procedure to be performed. C. Equipment 1. Endotracheal intubation requires specialized equipment. 2. The laryngoscope is an instrument for lifting the tongue and epiglottis out of the line of sight so that you can see the vocal cords. a. It consists of a handle and a blade, with a light at the tip of the blade that illuminates the airway. 1) The blade is curved or straight. 2) The curved (Macintosh) has a flange for sweeping the tongue to the right and fits into the vallecular. 3) The straight (Miller, Philips, Wisconsin) fits under the epiglottis and manually lifts it out of the way. 2. The endotracheal tube (ETT) is a flexible, translucent tube that is open at both ends and available in lengths ranging from 12 to 32 cm, with centimeter markings along its length. a. Typical tube size is 7.0–7.5 mm for average-sized females and 7.5– 8.0 mm for average-sized adult males. b. Adult tubes come with an inflatable cuff at the distal end to provide a seal between the tube and the trachea. 3. A malleable stylet is a plastic-covered metal wire that may be placed inside the ETT, stopping just short of the distal end, to allow the tube to be stiffened and maintained in the optimal shape for intubation. 4. The endotracheal tube introducer (gum-elastic bougie) is also used to facilitate intubations when only the epiglottis can be visualized. 5. A 10-mL syringe is used to inflate the distal cuff to avoid air leaks around the tube. 6. The ETT tube may be secured with tape, cloth, or a commercial device. 7. Magill forceps are scissor-style clamps with circular tips used primarily to remove foreign bodies in the airway. 8. Water-soluble lubricants facilitate inserting the ETT. 9. A suction unit helps to remove secretions and foreign materials from the oropharynx during intubation attempts.

Master Teaching Notes the course.

Discussion Topics Discuss the advantages and disadvantages of endotracheal intubation.

Critical Thinking Questions Prehospital endotracheal intubation is often criticized for its poor success rates. Why do we continue to use this skill if the success rates are so low? What are the implications of doing the skill?

Class Activities Take the opportunity to practice intubation. Have the students look over the equipment and spend a moment intubating without formally using the checklist. This gives them the opportunity to understand the importance of following the steps. It is also helpful to have them practice intubation in less than desirable positions and situations. Give them the opportunity to try it in many different ways, and help them find things that will facilitate the process for them.

Points to Emphasize Intubation carries serious complications and should be treated with the utmost respect. It is important to continually practice, evaluate, and study the procedures to maintain competency. The basic airway maneuvers should also be stressed. Without them, the advanced procedures are worthless.

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Content Outline 10. Confirmation of the intubation is essential and is assisted by the endtidal CO2 detector device. 11. Protective equipment includes, but is not limited to, gloves, mask, protective eyewear, and possibly a gown. D. Complications of Endotracheal Intubation 1. Intubation presents a number of potential complications: a. Equipment malfunction b. Tooth breakage and soft tissue laceration c. Aspiration d. Elevated intracranial pressure e. Transport delays f. Hypoxemia g. Esophageal intubation h. Endobronchial intubation i. Tension pneumothorax E. Orotracheal Intubation 1. To perform orotracheal intubation in the absence of suspected trauma, use the following procedure: a. Use Standard Precautions. b. Place the patient supine, and properly position the patient’s head and neck. The ear and sternal notch should be on the same horizontal level. In obese patients, it is necessary to place padding under the upper back, shoulders, and head to achieve the same position. c. Perform BVM ventilation with 100% oxygen, utilizing the “rule of threes.” Avoid aggressive hyperventilation. d. Prepare your intubation equipment. e. Turn on the suction, and attach the appropriate tip. f. Remove any dentures or partial dental plates. g. Hold the laryngoscope in your left hand, and insert the laryngoscope blade into the right side of the patient’s mouth. 1) If using a curved blade, gently sweep the tongue to the left and work in the midline. 2) If using a straight blade, remain on the right side of the mouth. Your primary goal at this point is to visualize the epiglottis. h. Advance the curved blade until the distal end is at the base of the tongue in the vallecular. Advance the straight blade until the end is

Master Teaching Notes

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Content Outline under the epiglottis. Alternatively, with a straight blade, you may fully advance until the distal tip is in the esophagus and then visualize while slowly withdrawing the blade. If you cannot visualize the epiglottis, withdraw the blade, reposition the blade, and repeat. i. Keeping your left wrist straight, use your left shoulder and arm to continue lifting the mandible and tongue to a 45-degree angle to the ground until landmarks are exposed. Be careful not to put pressure on the teeth. Consider having an assistant perform the jaw-thrust simultaneously. At this point, you may need to suction any large amounts of emesis, blood, or secretions in the posterior pharynx. j. If you cannot see the landmarks clearly, have your partner release cricoid pressure. If you still cannot visualize the posterior cartilages, perform external laryngeal manipulation. k. Hold the ETT in your right hand with your fingertips, as you would a dart or a pencil. Advance the tube through the right corner of the patient’s mouth, and direct it toward the midline. Pass the ETT gently through the glottic opening until the distal cuff disappears beyond the vocal cords; then advance it another 1–2 cm. Hold the tube in place with your hand to prevent its displacement. Do not let go under any circumstance until it is taped or tied securely in place. l. Remove the stylet (if used) and attach a bag-valve device to the 15/22mm connector on the tube. m. Objectively confirm tube placement with capnography, and check for equal breath sounds to be sure the tube is not too deep. n. Ventilate the patient with 100% oxygen. o. Gently insert an oropharyngeal airway to serve as a bite block, and secure the ETT with umbilical tape, adhesive tape, or a commercial tube-holding device. p. Place the patient on the transport ventilator, and monitor the continuous capnography waveform. q. Reconfirm appropriate tube placement periodically, especially after any major patient movement or if there is any deterioration of patient status. F. Verification of Proper Tube Placement 1. It is absolutely imperative that endotracheal placement of the tube be confirmed immediately after placement and continuously throughout care, particularly if the patient is moved or deteriorates.

Master Teaching Notes

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Content Outline 2. Subjective methods are important but should not be the only method 3. Direct visualization of the cords is considered the gold standard for subjective methods but should not be the sole method use. 4. Tube misting, or condensation, occurs with successful placement but can occur even when the tube is in the esophagus. 5. Auscultation of the breath sounds bilaterally and absence of epigastric sounds should be noted but can be misleading, especially in the pediatric patient. G. Objective Techniques 1. Objective methods of tube confirmation should be used in addition to the subjective methods. 2. Capnography is considered the gold standard of tube confirmation if the patient is producing enough carbon dioxide to detect. a. Qualitative detection indicates the presence or absence of carbon dioxide and is performed with a colorimetric device. b. Quantitative detection provides a value and a waveform. c. False negatives may occur in the setting of cardiac arrest.. 3. The esophageal detector device (EDD) is a bulb syringe that is placed on the end of the ETT. a. A syringe or bulb is placed on the end of the endotracheal tube to create suction. 4. The endotracheal tube introducer (bougie) may also be used to facilitate difficult intubations as well as to confirm tube placement. a. The bougie will meet resistance when it reaches the smaller airways when passed through the ET tube if properly placed in the trachea. b. The bougie will not meet resistance if passed through a tube placed in the esophagus. 5. Other methods include increased oxygen saturation, chest rise, and absence of gastric distention. H. Retrograde Intubation 1. Retrograde intubation is a technique in which a needle is inserted into the airway through the cricoid membrane from the outside and is directed superiorly. 2. A guidewire is passed through the needle and ideally is retrieved in the oral cavity and withdrawn through the mouth. 3. An endotracheal tube is then passed over the wire into the airway.

Master Teaching Notes

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Optical Laryngoscopes Several devices allow visualization of the glottic opening using fiber-optic technology 1. Several devices allow visualization of the glottic opening using fiber optic technology. Among these is the AirTraq™. J. Video Laryngoscopes 1. Video laryngoscopes have a camera on the distal end of the device that transmits a high-quality magnified image to a video screen that is attached to the device either directly or by cable. 2. The technique is considered indirect in that the intubator looks at the screen while intubating, not directly in the patient’s mouth, much as in playing a video game. K. Improving Endotracheal Intubation Success 1. Most studies of prehospital intubation show relatively poor success rates when using first-attempt and overall successful placement as the marker of success. 2. Several factors may increase success of the first attempt: a. Good initial training b. Ongoing practice c. Using the endotracheal tube introducer d. Managing neck pressure e. Optimal positioning f. Video laryngoscopy g. Other technology, h. Using rapid sequence intubation 15

XIV. Blind Nasotracheal Intubation A. Blind nasotracheal intubation may be the best or only option in the patient with trismus or an anticipated difficult laryngoscopy. 1. It is relatively contraindicated in suspected nasal and basilar skull fractures, elevated intracranial pressure, combative or uncooperative patients, coagulopathies, significantly deviated nasal septum or other nasal obstruction, or hypoxemia. 2. It is absolutely contraindicated in cardiac or respiratory arrest. B. Blind Nasotracheal Intubation Technique 1. Use Standard Precautions. 2. Using basic manual and adjunctive maneuvers, open the airway and ventilate the patient with 100% oxygen.

Discussion Topics Discuss the advantages and disadvantages of this procedure.

Critical Thinking Questions What are some situations in which this procedure might benefit your patient? When might it not be an option? How will you know what option to choose?

Class Activities Spend some time practicing this procedure

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Content Outline 3. Prepare your equipment. 4. Place the patient in his position of comfort. If the patient is unconscious or if you suspect cervical spine injury, place the patient supine and use manual inline stabilization as appropriate. 5. Inspect the nose, and select the largest nostril as your passageway. 6. Select the correct size endotracheal tube. Normally, use a tube one-half to one full size smaller than for oral intubation. For an average adult male, a size 7 mm is appropriate. For an average adult female, a size 6.5 mm is appropriate. 7. Lubricate the tube generously. Topical lidocaine may be preferred for long-term comfort but probably does not affect the initial attempt. 8. Insert the ETT into the nostril with the bevel along the floor of the nostril or facing the nasal septum, directed posteriorly. 9. As you feel the tube enter the posterior pharynx, listen closely at its proximal end for the patient’s respiratory sounds, which are loudest when the ETT is proximal to the epiglottis. Observe for end-tidal CO2. When the ETT tip reaches the posterior pharyngeal wall, you must take care to direct it toward the glottic opening. 10. With the patient’s next inhaled breath, advance the ETT gently but quickly into the glottic opening, observing exhaled CO2. If you inflated the tube cuff to help with anterior displacement, the cuff must be deflated at this point. Continue passing the ETT until the distal cuff is just past the vocal cords, which should occur at a depth of approximately 26 cm in an average adult female and 28 cm in an average adult male. 11. Holding the ETT with one hand to prevent displacement, inflate the distal cuff with enough air to eliminate any audible leak, connect a bagvalve device, ventilate the patient with 100% oxygen, and confirm proper placement of the ETT using multiple techniques. 12. Secure the ETT, and reconfirm proper placement. Continue to observe the patient’s condition, maintain ventilator support, and frequently recheck ETT placement. Use continuous waveform capnography to monitor tube placement and ventilation.

XV. Digital Intubation A. Digital intubation is an older technique that has largely been replaced by newer extraglottic airways and devices such as lighted stylets.

Master Teaching Notes using mannequins.

Points to Emphasize Emphasize the indications and contraindications. If you have any tips to help your students, share them.

Points to Emphasize It is important to rule out other methods of airway management before utilizing this

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Content Outline B. It is still a viable option in some circumstances. C. To perform digital intubation: 1. Use Standard Precautions. 2. Continue oxygenation with BVM and high-concentration oxygen. 3. Prepare and check your equipment. 4. Remove the front of the collar, and have an assistant stabilize the neck as appropriate. 5. Place a bite block between the patient’s molars to protect your fingers. 6. Insert your left middle and index fingers into the patient’s mouth. “Walk” your hand down the midline while simultaneously tugging gently forward on the tongue. 7. Palpate the arytenoid cartilage posterior to the glottis and the epiglottis anteriorly with your middle finger. Press the epiglottis forward, and insert the endotracheal tube into the mouth, anterior to your fingers. 8. Advance the tube, pushing gently with your right hand. Use your left index finger to keep the tip of the ETT against your middle finger. 9. Use your middle and index fingers to direct the tip of the ETT between the epiglottis (in front) and your fingers (behind). Then, with your right hand, advance the ETT through the cords while simultaneously maneuvering it forward with your left index and middle fingers. 10. Hold the tube in place with your hand to prevent its displacement, remove stylet, and inflate cuff. 11. Confirm placement with multiple techniques. 12. Ventilate the patient with 100% oxygen. Gently insert an oropharyngeal airway to serve as a bite block. Secure the ETT with umbilical tape. Repeat steps to confirm proper ETT placement and maintain ventilator support. Continue your airway assessment periodically.

XVI. Special Intubation Considerations A. Trauma Patient Intubation: To perform direct laryngoscopy with in-line stabilization, use the following procedure. 1. Use Standard Precautions. 2. Perform basic airway management, including BVM ventilation with cricoid pressure. 3. Remove the front of the collar, and have an assistant maintain in-line stabilization. 4. Immediately before laryngoscopy, have the assistant perform a jaw-

Master Teaching Notes skill.

Class Activities Have the students try this immediately after doing a regular intubation to see the difference.

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Content Outline thrust and release cricoid pressure. 5. Perform external laryngeal manipulation, and have the assistant who was performing cricoid pressure maintain optimal position of the larynx. B. Foreign Body Removal under Direct Laryngoscopy 1. Basic airway maneuvers should be carried out on the patient with a foreign body obstruction prior to use of the Magill forceps. 2. The procedure for visualizing the airway is identical to that used for endotracheal intubation. C. Pediatric Intubation 1. When managing the pediatric airway, be aware of the following differences: a. Structures are smaller. b. Nasal openings are small, and adenoids are large. c. Nasal airway diameters are inadequate. d. Cricoid pressure can worsen the situation. e. Surgical airways are unavailable. f. Tube size is critical. g. Depth of ETT insertion is different. h. The occiput is relatively large. i. The epiglottis is floppy and round (“omega” shaped). j. The tongue is larger in relation to the oropharynx. k. The glottic opening is higher and more anterior in the neck. l. The narrowest part of the airway is the cricoid cartilage, not the glottis opening as in adults. m. Infants have greater vagal tone. n. Higher basal metabolism combined with less functional residual capacity (smaller volume of air present in the lungs) 2. The procedure for intubation in the pediatric patient is the same except for the use of an uncuffed tube in smaller patients and infants, and a straight blade is usually preferred (although cuffed tubes are being used more commonly today). D. Monitoring Cuff Pressure 1. Monitoring cuff pressure is important and ideally is done with a cuff manometer. E. Post-Intubation Agitation and Field Extubation 1. Use Standard Precautions.

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Master Teaching Notes

2. Ensure adequate oxygenation. 3. Prepare intubation equipment and suction. 4. Confirm patient responsiveness. 5. Position patient on his side if possible. 6. Suction the patient’s oropharynx. 7. Deflate the ETT cuff. 8. Remove the ETT upon cough or expiration. 9. Provide supplemental oxygen as indicated. 10. Reassess the adequacy of the patient’s ventilation and oxygenation.

XVII. Cricothyrotomy A. Occasionally, extreme circumstances require an invasive approach, and cricothyrotomy may be your only option. 1. Indications that warrant cricothyrotomy include severe facial trauma, trismus, total upper airway obstruction, inability to identify anatomical landmarks, tracheal transaction, or anatomical abnormalities that prevent normal intubation. 2. Needle cricothyrotomy is performed using the following procedure: a. Use Standard Precautions, including face mask and shield. b. Manage the patient’s airway as well as possible with basic maneuvers and supplemental oxygen while you prepare your equipment. Attach a large-bore IV needle with a catheter to a 10- to 20-mL syringe. If time permits, you may fill the syringe with sterile water or saline to facilitate detection of air when aspirating. c. Place the patient supine, and hyperextend the head and neck. (Maintain neutral position if you suspect cervical spine trauma.) d. Palpate the inferior portion of the thyroid cartilage and the cricoid cartilage, and find the cricoid membrane in between the two e. Prepare the anterior site with antiseptic solution. f. Firmly grasp the laryngeal cartilages, and reconfirm the site of the cricothyroid membrane. g. Carefully insert the needle into the cricothyroid membrane at midline, directed 45 degrees caudally. Often you will feel a pop as the needle penetrates the membrane. h. Advance the needle while aspirating with the syringe, noting air return. If blood returns or you feel resistance to return, reevaluate

Teaching Tips Have all equipment available during the lecture, and then allow the students to practice the cricothyrotomy procedure soon after.

Discussion Topics This is an infrequent skill and requires a great deal of accuracy. What is the best way to be prepared for this skill?

Class Activities Have the students find their own cricoid membrane, then have them find it on other students. They should then practice the skill on a mannequin.

Minutes

Content Outline needle placement. After you confirm proper placement, hold the needle steady and advance the catheter. Then withdraw the needle. j. Reconfirm placement again by withdrawing air from the catheter with the syringe. Secure the catheter in place. k. Attach the jet-ventilation device to the catheter and a 50-psi oxygen supply. If this is unavailable, connect a BVM to the catheter using the inner adapter from a 7.5-mm endotracheal tube. The bag-valve device must be connected to oxygen. l. Open the release valve to introduce an oxygen jet into the trachea. Then adjust the pressure to allow adequate lung expansion (usually about 50 psi compared with about 1 psi through a regulator). m. Watch the chest carefully, and turn off the release valve as soon as the chest rises. n. Deliver at least 20 breaths per minute, keeping the inflation-todeflation time approximately 1:3. Keep in mind that you may need to adjust this to the patient’s needs. o. Continue ventilator support as needed, assessing for adequacy of ventilations and looking for the development of any complications. p. Anticipate the need for an alternative means of oxygenation and ventilation within approximately 30 minutes. B. Open Cricothyrotomy 1. An open cricothyrotomy has the same indications and is performed by using the following procedure: a. Use Standard Precautions, including face mask and shield. b. Use BVM ventilation and supplemental oxygen to maintain oxygenation and ventilation as well as possible. c. Locate the thyroid cartilage and cricoid cartilage. Identify the cricothyroid membrane between these two cartilages. d. Cleanse the site with antiseptic solution. e. Stabilize the cartilages with one hand while using a scalpel in the other hand to make a 2- to 4-cm vertical skin incision in the midline over the membrane. f. Relocate the cricothyroid membrane (using blunt dissection if necessary). g. Make a 1- to 2-cm incision in the horizontal plane through the i.

Master Teaching Notes

Minutes

Content Outline

Master Teaching Notes

membrane.

h. Insert a tracheal hook on the inferior portion of the thyroid cartilage to help maintain the opening. This may also be improvised with an adult or pediatric stylet. i. Insert curved hemostats into the membrane incision, and spread it open. j. Insert either a curved endotracheal tube or a tracheostomy tube into the opening, directing the tube distally into the trachea. k. Insert the cuff, and ventilate. l. Confirm placement with multiple methods as available and appropriate. m. Secure the tube in place. C. Other methods of performing a cricothyrotomy include: 1. Rapid four-step 2. Bougie-aided D. Minimally Invasive Percutaneous Cricothyrotomy 1. A number of hybrid techniques are available to perform a cricothyrotomy using a needle but allowing for a much larger diameter ventilation catheter. 2. In general, there is no advantage to these needle techniques over the open techniques, and complications may actually be higher, although there is substantial variation among devices and techniques. 3. Individual agencies should consult their medical director and evaluate each device and technique on a case-by-case basis. 15

XVIII. Medication Assisted Intubation A. Rapid Sequence Intubation 1. Occasionally, you may encounter an awake patient with an airway disorder who is hypoxemic despite high-concentration oxygen. 2. Assisting respirations with a BVM is challenging because of patient anxiety. 3. Nasal intubation is difficult and often exacerbates hypoxemia. 4. The entire RSI procedure is intended to minimize the risk of aspiration in a high-risk population and requires preoxygenation and avoiding positive pressure ventilation until absolutely necessary.

Teaching Tips This is a specialized procedure that is done only in selected areas. If this is practiced in your area, be prepared to discuss the medications used and the procedure in detail.

Minutes

Content Outline

Master Teaching Notes

4. Preoxygenation is required to maintain an oxygen saturation of 100% in order to have a functional reserve for the procedure. 5. Premedication drugs are given early in the course of RSI to mitigate anticipated complications. 6. Induction agents render the patient unaware during the procedure. 7. Neuromuscular blocking agents temporarily stop skeletal muscle function without effecting cardiac or smooth muscle. 8. Sedatives and analgesics are essential to keep the patient comfortable after intubation. 9. To perform rapid sequence intubation, use the following procedure: a. Preoxygenate to achieve nitrogen washout and create an oxygen reserve. b. Protect the C-spine if indicated. c. Position optimally if possible. d. Apply pressure to the cricoid if there is sufficient assistance available. e. Ponder whether intubation is really necessary. f. Premedicate if time permits and allowed by protocol and scope of practice. g. Prepare equipment, using a checklist to ensure that all supplies are ready. h. Sedate and paralyze. i. Pass the tube with direct or indirect visualization or an endotracheal tube introducer. j. Post-intubation management begins with objective tube confirmation, using capnography. B. Rapid Sequence Airway 1. Rapid sequence airway (RSA) is a new airway management technique in which the preparation and pharmacology of RSI is paired with intentional placement of an extraglottic airway device without prior attempt at direct, laryngoscopy, in selected patients. 15

XIX. The Difficult Airway A. The concept of the difficult airway includes difficult BVM ventilation, difficult extraglottic airway placement and ventilation, difficult intubation, and difficult cricothyrotomy. B. Predictors of a Difficult Airway or Ventilation

Discussion Topics Predicting a difficult airway is a very important skill that will help to alleviate some of the anxiety associated with highacuity patients. Spend some time

Minutes

Content Outline 1. Predictors of difficult airway include facial trauma, facial hair, obesity, lack of teeth, poor mouth opening, increased Mallampati class, short thyromental distance, short sternomental distance, limited neck mobility, and difficulty finding the cricothyroid membrane. 2. Airway classification systems include the Mallampati classification system, the Cormack and LeHane grading system, and the percentage of glottic opening (POGO) scoring system. 3. “LEMONS” is an acronym used to remember assessments and findings associated with a difficult airway. a. Look externally b. Evaluate 3-3-2 rule c. Mallampati score d. Obstruction e. Neck mobility f. Saturations C. Effects of Obesity 1. The airway effects of obesity are complex but, overall, negative. 2. Much of the anatomic problem with intubation in the morbidly obese can be overcome with proper positioning. 3. Obesity limits the effects of preoxygenation because of reduced functional residual capacity as well as increased oxygen demand. 4. Some extraglottic airway devices may not generate enough airway pressure to lift a very heavy chest. D. Predicting Difficulty: An Imperfect Scene 1. Providers should look for and heed obvious warnings of a difficult intubation or BVM ventilation accordingly. 2. Do not let the absence of any predicted difficulties create a sense of complacency. 3. Any patient may prove difficult or impossible to intubate.

XX. Managing Patients with Stoma Sites A. Patients who have had a laryngectomy or tracheostomy may breathe through a stoma. 1. These patients have a secure airway, but it may become clogged or dislodged, may cause bleeding, or may cause respiratory distress.

Master Teaching Notes discussing ways in which students can put this into practice and how they can utilize the assessment tools each and every time they assess a patient.

Minutes

Content Outline

Master Teaching Notes

2. If a tracheostomy becomes dislodged, it should be replaced immediately; an ET tube may be used short-term. B. Excessive secretions need to suctioned; this may be done after injecting 3 mL of sterile saline into the stoma. 10

XXI. Suctioning A. Suctioning Equipment 1. Many kinds of suctioning devices are available, and the most commonly used are hard/rigid catheters (“Yankauer”) and soft catheters (“whistle tip”). 2. Suctioning should be limited to 10 seconds, and the patient should be hyperventilated before and after. B. Suctioning Techniques 1. Use Standard Precautions, including protective eyewear, gloves, and face mask. 2. Preoxygenate the patient; this may require brief hyperventilation. 3. Determine the depth of catheter insertion by measuring from the patient’s earlobe to his lips. 4. With the suction turned off, insert the catheter into the patient’s pharynx to the predetermined length. 5. Turn on the suction, and place your thumb over the suction control orifice; limit suction to 10 seconds. 6. Continue to suction while withdrawing the catheter. When using a whistle-tip catheter, rotate it between your fingertips. 7. While maintaining ventilator support, hyperventilate the patient with 100% oxygen. C. Tracheobronchial Suctioning 1. Tracheobronchial suctioning is done through an endotracheal tube or tracheostomy and should be done utilizing sterile technique.

Class Activities

XXII. Gastric Distention and Decompression A. Gastric distention is inevitable with prolonged ventilation and may be alleviated with placement of a nasogastric or orogastric tube. 1. Nasogastric tube placement is generally preferred in awake patients; however, this is rarely necessary in the prehospital setting. 2. Orogastric tube placement is recommended for unconscious patients. B. To place an orogastric tube in the unconscious patient, use the following

Teaching Tips

Have the students practice donning sterile gloves that they will use for tracheal suctioning.

Have all equipment ready for your students, and allow them some time to inspect it. Demonstrate how the procedure is done, and have them practice it as well.

Class Activities

Minutes

Content Outline procedure: 1. Use Standard Precautions. 2. Place the patient’s head in a neutral position while ventilating via the endotracheal tube or EGA. 3. Select the correct size gastric tube. Most adults take a 16 Fr when placed orally. 4. Determine the approximate length of tube insertion by measuring from the epigastrium to the angle of the jaw, then to the mouth opening or to the proximal end of the EGA. 5. Generously lubricate the distal tip of the gastric tube, and gently insert it into the oral cavity at midline. 6. Advance the tube gently to the length you determined prior to insertion. 7. Check that the tube has not curled in the mouth. 8. Confirm placement by injecting 30–50 mL of air while listening to the epigastric region for air entry into the stomach. 9. Apply gentle suction to the tube to evacuate gastric fluids and gas. 10. Secure the tube in place. 11. Document the indication for gastric decompression, the size tube placed, the technique, means of confirmation, any complications incurred, the type and volume of gastric contents evacuated, and the clinical response.

Master Teaching Notes Have the class practice the technique on a mannequin.

XXIII. Transport Ventilators A. Transport ventilators allow for precise control of ventilatory support in the prehospital setting. B. There are two general varieties of ventilators for prehospital use. 1. Simple out-of-hospital ventilators are designed for convenience and usually have fixed oxygen concentrations and very few options. 2. Critical care transport ventilators offer several features, and some can be used to provide mask CPAP as well. XXIV. Documentation A. Accurate and thorough documentation of airway management is critical for clinical care. B. Documentation should include what was done, the thought process of why it was done, and any complications that occurred.. C. Because patients who require prehospital airway management are at high

Class Activities Integrate documentation of all skills into the documentation portion of class. Have your students practice documenting skills and assessments throughout the course of the class, and give them feedback that will help

Minutes

Content Outline risk for a bad outcome from the onset, and because airway management literally determines whether the patient lives or does not, the greatest emphasis should be placed on detailed documentation of these issues.

Master Teaching Notes them become more accurate with documentation.

XXV. Summary A. Airway assessment and maintenance is the most critical step in managing any patient. B. Basic airway and management skills can make the difference between a successful outcome and a poor patient prognosis. C. Once you have mastered basic skills, you should learn and use advanced skills. D. You must maintain proficiency in all airway skills, especially the more advanced techniques, through ongoing education, physician medical direction, and testing with each EMS service.

XXVI. Case Study 5

XXVII. You Make the Call 10

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

XXVIII. Review Questions 5

Chapter 1 Introduction to Paramedicine

HANDOUT 1-1

Student’s Name __________________ EVALUATION CHAPTER 1 QUIZ

Write the letter of the best answer in the space provided. ______1. The National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines for paramedic training is published by the: a. National Registry of EMTs. b. U.S. Department of Transportation. c. National Association of State EMS Training Coordinators. d. U.S. Department of Health, Education, and Welfare. ______2. As a rule, the less a paramedic uses a particular skill or procedure: a. the more frequently he should review that skill or procedure. b. his retention of that skill or procedure remains the same. c. the less he needs to practice that skill or procedure. d. the more it is evidence that the skill or procedure may no longer be necessary. ______3. Providing care at home without transport to a hospital is an example of the extended scope of: a. critical care. c. primary care. b. industrial medicine. d. advanced care. ______4. The paramedic’s expanding roles and responsibilities include: a. minor surgery. c. industrial medicine. b. prescribing medications. d. extended pediatric care. ______5. Through research over the past twenty years, it has been found that: a. all EMS treatments used have been proven beneficial. b. little scientific evidence supports many prehospital practices. c. all current paramedic practices have been scientifically proven. d. treatments have been scientifically proven effective before they are used in the field. ______6. The level of EMS provider that focuses on providing both basic and limited advanced emergency medical care is the: a. Emergency Medical Responder. c. Advanced EMT. b. Emergency Medical Technician. d. Paramedic. ______7. The paramedic functioning in critical care transport must be educated in: a. additional state liscensing requirements. b. helicopter air ambulance (HAA). c. techniques used in the intensive care setting. d. CDL driving requirements. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______8. Which of the following is TRUE about the 2009 National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines? a. It requires approximately the same number of hours as the previous curriculum. b. It requires a less extensive foundation of medical knowledge than the previous curriculum. c. A human anatomy and physiology course is a prerequisite. d. Content regarding the pathophysiology of illnesses and injuries is basically the same as in the previous curriculum. ______9. Paramedics may function only under the direction of: a. the state EMS director. b. the system’s medical director. c. the National Registry of EMTs. d. the emergency department charge nurse. _____10. A state or provincial agency typically provides a paramedic’s: a. standing orders. c. license or registration. b. medical direction. d. liability insurance.

HANDOUT 1-2

Student’s Name __________________ EVALUATION

CHAPTER 1 SCENARIO Review the following real-life situation. Then follow the directions at the end of the scenario. You and your EMT partner are assigned to Medic 5 one morning. At 10:40, you are dispatched to a motor vehicle crash on Clear Creek Road. A bystander has called 911 on his cell phone to report that a car ahead of him swerved off the road, plunged into a ditch, and hit a tree. The crash occurred in a rural portion of the county some distance from your quarters, so you have an extended response time. A local Emergency Medical Responder (EMR) team has also been dispatched, with an ETA of 10 minutes. Your unit arrives 20 minutes after being dispatched, and you find the EMR team already on scene. One of the responders is holding manual C-spine stabilization on a male in his thirties lying on the ground next to the crushed vehicle. Other EMRs are readying a cervical collar and oxygen. As you approach the patient, you can easily see that his shirt and pants are soaked with blood. Another emergency responder is applying direct pressure to the patient’s upper right leg. The lead EMR has completed the initial assessment and tells you that the patient is conscious, alert, and breathing; he has bruising to the chest and a large, open wound, possibly a fracture, to the right thigh. He apparently got out of the vehicle on his own and collapsed due to the leg injury before responders arrived. You advise the emergency medical responders to apply the cervical collar and high-concentration oxygen. You examine the patient’s chest and note the bruising as well as some breathing difficulty. As you quickly examine the leg wound, you note an open femur fracture. The patient appears to have lost a large amount of blood. Your assessment shows that he has a rapid, thready pulse; an increased respiratory rate; and cool, moist skin. On the basis of your initial assessment, you have your partner radio for a helicopter response to the scene for transport to the area trauma center. You continue your patient assessment and find no other serious injuries. While waiting for the helicopter, you and your partner apply the cardiac monitor, noting no abnormalities, and assist the EMRs in applying a traction splint to the injured leg and immobilizing the patient on a long backboard. You contact medical direction at the trauma center and have time to start two large-bore IVs before the helicopter arrives. A deputy sheriff who is also on scene assists in setting up a landing zone, and the helicopter arrives. The helicopter crew’s critical care paramedic quickly reassesses the patient. The patient is loaded into the helicopter within 5 minutes of its landing. He is taken to St. Luke’s Medical Center, the designated trauma facility for the area. 1. Describe the characteristics displayed by the paramedic at the scene. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

2. What aspects of patient care exhibited during this call might not have been available 30 years ago?

HANDOUT 1-3

Student’s Name __________________ REINFORCEMENT CHAPTER 1 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. The paramedic is the ____________ level of prehospital care. 2. The ability to make ____________ decisions in a(n) ____________ manner can mean the difference between life and death for the patient. 3. Paramedics may function only under the direction and license of the EMS system’s ____________ ____________ . 4. Licensing or credentialing is typically provided by a(n) ____________ or ____________ agency. 5. As a paramedic, you must realize that you are an essential component in the ____________ of care. 6. Emerging roles and responsibilities of the paramedic include public ____________, health ____________, and participation in injury and illness ____________. 7. If you always act in the best interest of the ____________, you will seldom have problems. 8. Paramedic students must have completed a(n) ____________ course before training begins.

____________ and

9. The 2009 National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines provide for a much improved understanding of the ____________ of various illnesses and injury processes. 10. Professional development should be a ____________, ____________ pursuit.

HANDOUT 1-4

Student’s Name __________________ REINFORCEMENT EMT CODE OF ETHICS

Professional status as an Emergency Medical Technician–Paramedic is maintained and enriched by the willingness of the individual practitioner to accept and fulfill obligations to society, other medical professionals, and the profession of Emergency Medical Technician. As an Emergency Medical Technician at the basic level or an Emergency Medical Technician–Paramedic, I solemnly pledge myself to the following code of professional ethics. A fundamental responsibility of the Emergency Medical Technician is to conserve life, to alleviate suffering, to promote health, to do no harm, and to encourage the quality and equal availability of emergency medical care. The Emergency Medical Technician provides services based on human need, with respect for human dignity, unrestricted by consideration of nationality, race, creed, color, or status. The Emergency Medical Technician does not use professional knowledge and skills in any enterprise detrimental to the public well-being. The Emergency Medical Technician respects and holds in confidence all information of a confidential nature obtained in the course of professional work unless required by law to divulge such information. The Emergency Medical Technician, as a citizen, understands and upholds the law and performs the duties of citizenship; as a professional, the Emergency Medical Technician has the never-ending responsibility to work with concerned citizens and other health care professionals in promoting a high standard of emergency medical care to all people. The Emergency Medical Technician shall maintain professional competence and demonstrate concern for the competence of other members of the Emergency Medical Services health care team. The Emergency Medical Technician assumes responsibility in defining and upholding standards of professional practice and education. The Emergency Medical Technician assumes responsibility for individual professional actions and judgment, both in dependent and independent emergency functions, and knows and upholds the laws which affect the practice of the Emergency Medical Technician. The Emergency Medical Technician has the responsibility to be aware of and participate in matters of legislation affecting the Emergency Medical Technician and the Emergency Medical Services System. The Emergency Medical Technician adheres to standards of personal ethics which reflect credit upon the profession. Emergency Medical Technicians, or groups of Emergency Medical Technicians, who advertise professional services, do so in conformity with the dignity of the profession. The Emergency Medical Technician has an obligation to protect the public ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

by not delegating to a person less qualified any service which requires the professional competence of an Emergency Medical Technician. The Emergency Medical Technician will work harmoniously with and sustain confidence in Emergency Medical Technician associates, the nurse, the physician, and other members of the Emergency Medical Services health care team. The Emergency Medical Technician refuses to participate in unethical procedures, and assumes the responsibility to expose incompetence or unethical conduct of others to the appropriate authority in a proper and professional manner. The National Association of Emergency Medical Technicians

HANDOUT 1-5

Student’s Name __________________ REINFORCEMENT THE OATH OF GENEVA AND THE EMT OATH

THE OATH OF GENEVA I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; the health of my patient will be my first consideration; I will respect the secrets which are confided in me; I will maintain by all the means in my power the honor and noble traditions of the medical profession; my colleagues will be my brothers; I will not permit considerations of religion, nationality, race, party, politics, or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from the time of conception; even under threat, I will not make use of my medical knowledge contrary to the laws of humanity. I make these promises solemnly, freely, and upon my honor. THE EMT OATH Be it pledged as an Emergency Medical Technician, I will honor the physical and judicial laws of God and man. I will follow that regimen which, according to my ability and judgment, I consider for the benefit of patients and abstain from whatever is deleterious and mischievous, nor shall I suggest any such counsel. Into whatever homes I enter, I will go into them for the benefit of only the sick and injured, never revealing what I see or hear in the lives of men unless required by law. I shall also share my medical knowledge with those who may benefit from what I have learned. I will serve unselfishly and continuously in order to help make a better world for mankind. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. Should I trespass or violate this oath, may the reverse be my lot. So help me God. Adopted by the National Association of Emergency Medical Technicians, 1978

CHAPTER 1 Answer Key Handout 1-1: Chapter 1 Quiz 1. b

4. c

7. c

9. b

2. a

5. b

8. c

10. c

3. c

6. c

Handout 1-2: Chapter 1 Scenario 1. The paramedic took control of the scene as a confident leader, interacting with emergency medical responders and law enforcement. He functioned independently in ensuring that the correct prehospital care was initiated for the patient, and he prioritized treatment and transport of the patient, making the decision to transport by helicopter to the trauma center. 2. Advanced life support and paramedic-level care were not readily available. Prehospital care was provided primarily by basic life support personnel. EMS services were still using soft cervical collars, and cardiac monitoring and IVs would not have been used. The availability of helicopter transport to a trauma center was also unlikely. This patient would most likely have been transported to the closest hospital by ground ambulance. Handout 1-3: Chapter 1 Review 1. highest 2. independent, timely 3. medical director 4. state, provincial 5. continuum 6. education, promotion, prevention programs 7. patient 8. anatomy, physiology 9. pathophysiology 10. never-ending, career-long

Chapter 2 EMS Systems

HANDOUT 2-1

Student’s Name ___________ EVALUATION CHAPTER 2 QUIZ

Write the letter of the best answer in the space provided. ______1. One member of the in-hospital component of an EMS system is the: a. EMR. c. paramedic. b. EMT. d. respiratory therapist. ______2. A ________________________ emergency response system sends multiple levels of emergency care personnel to a single incident. a. basic c. tiered b. public utility model d. failsafe franchise ______3. The ________________________ defined ten elements necessary to all EMS systems. a. 1966 National Highway Safety Act b. 1973 Emergency Medical Services Systems Act c. 1981 Consolidated Omnibus Budget Reconciliation Act d. 1988 Statewide EMS Technical Assessment Program ______4. State EMS agencies are responsible for all of the following EXCEPT: a. allocating funds to local systems. b. enforcing state EMS regulations. c. developing local quality assurance programs. d. certifying field providers. ______5. The responsibility for all clinical and patient care aspects of an EMS system rests with the a. senior paramedic. c. EMS system director. b. system’s medical director. d. quality assurance committee. ______6. A well-designed communications plan for an EMS system should include: a. multiple control centers. b. operational communications capabilities. c. satellite uplinks. d. federally approved medical protocols. ______7. The most common source of financing for EMS funding is: a. fee-for-service. c. private pay. b. subsidy from local entities. d. service contracts. ______8. The evaluation of objective data, such as response times, adherence to protocols, and patient survival, is emphasized by: a. hospital categorization. c. peer reviews. b. QA programs. d. research programs. ______9. An effective EMS dispatching system aims to place a BLS unit on the scene of an emergency in: a. the “golden hour.” c. 8 minutes. b. 14 minutes. d. 4 minutes. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______10. Training curricula for four levels of prehospital providers have been issued by the: a. American College of Emergency Physicians. b. American College of Surgeons Committee on Trauma. c. U.S. Department of Transportation. d. U.S. Department of Health, Education, and Welfare. ______11. The process by which a governmental agency grants permission to engage in a given occupation to an applicant who has attained the degree of competency required to ensure the public’s protection is called: a. registration. c. certification. b. licensure. d. recognition. ______12. In 1973, Congress passed an act that made EMS systems eligible for funding if they included 15 components. This act was called the a. Ryan White Act. b. Emergency Medical Services System Act. c. National Highway Safety Act. d. Statewide EMS Technical Assessment Act. ______13. One of the four “Ts” of emergency care is: a. trauma. c. telemetry. b. triage. d. tactical. ______14. Guidelines for permitting a new medication, process, or procedure to be used in EMS are the: a. laws of medicine. c. laws of research. b. rules of ethics. d. rules of evidence. ______15. What is the first step at the municipal level in developing a comprehensive EMS system? a. Protocol development b. Formation of a QA board c. Establishment of an administrative oversight agency d. Formation of a planning board ______16. Which of the following is NOT one of the areas that has been identified as causing medical errors? a. Rules-based failures

b. Skills-based failures

c. Equipment-based failures

d. Knowledge-based failures

HANDOUT 2-2 EVALUATION CHAPTER 2 SCENARIO Review the following real-life situation. Then answer the questions that follow. A call comes in to the 911 dispatch center from Damon, a resident on Hohman Avenue, who reports that a motor vehicle collision involving a car with two elderly occupants has just taken place. The dispatcher sends police, fire department, and EMS vehicles to the scene. Damon, who phoned in the call and is a local volunteer firefighter and Emergency Medical Responder, runs out to see whether he can help. He finds that the car has collided head-on with a large tree. A woman in the passenger seat is holding a man, who is slumped over in her lap. Damon determines that the scene is safe and moves to check on the woman. As he does, she tells him that her husband, who is a diabetic, appeared to have a seizure while they were driving, causing him to lose control of the car and hit the tree As Damon is checking the woman, a fire truck arrives. Another firefighter/EMR helps to maintain stabilization of the woman’s head while Damon checks her husband. He is breathing but unconscious, and his legs appear to be wedged in place by crumpled metal. Meanwhile, the police and EMS units have arrived. The police officer directs traffic around the accident scene while the EMS crew assumes control of the patients and, with the aid of the firefighters, begins the process of removing the victims from the car. The senior paramedic, having had a chance to study the scene, now radios dispatch, requesting a second ambulance. The response team members remove the woman fairly easily. The EMTs immobilize her, treat a cut on her head, and transport her to the hospital in the first EMS unit. The process of extricating her husband takes longer. EMS personnel remain with him in the vehicle, stabilizing him and protecting him from debris. Once they have freed the patient’s legs, the team immobilizes him and removes him from the car. ALS procedures are initiated, and he is transported rapidly to the hospital in the second ambulance, which has arrived during the extrication process. The emergency department has already been alerted to the collision by the dispatcher, and crews of both ambulances give radio reports as they begin transporting the patients. Thus, the ED physicians and nurses are prepared to treat both patients on their arrival. 1. What components of the EMS system were involved in this scenario? 2. What are the emergency medical dispatcher’s primary roles in this incident? 3. What responsibilities did Damon, the Emergency Medical Responder, assume? 4. Why is teamwork so important to the functioning of the EMS system in ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

this scenario?

HANDOUT 2-3

Student’s Name ______________ REINFORCEMENT CHAPTER 2 REVIEW

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

In the eighteenth century Jean Larrey developed the method of sorting patients by severity of their injuries that is called ________________________.

In 1966, Congress passed the National ________________________ ________________________ ________________________, which established the U.S. Department of Transportation.

Medical policies, procedures, and practices that are available to providers either on-line or off-line are called ________________________ ________________________.

An evaluation program that emphasizes service and uses customer satisfaction as the ultimate indicator of system performance is called ________________________ ________________________ ________________________.

The Statewide ________________________ ________________________ ________________________ Program defined ten elements necessary to all EMS systems.

The ________________________ ________________________ is the physician who is legally responsible for all of the clinical and patient care aspects of an EMS system.

________________________ medical direction occurs when a qualified physician gives direct orders to a prehospital care provider by either radio or telephone.

________________________ medical direction is the medical policies, procedures, and practices that medical direction has established in advance of the call.

A licensed physician who attempts to assist EMS providers with patient care at a scene is called a(n) ________________________ ________________________.

10. The four “Ts” of emergency care are ________________________, ________________________, ________________________, and ________________________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

11. The EMS person responsible for assignment of emergency medical resources to a medical emergency is the ________________________ ________________________ ________________________. 12. A job or trade that involves mastery of a specialized body of knowledge or skills is a(n) ________________________. 13. The process by which an agency or association grants recognition to an individual who has met its qualifications is ________________________. 14. The process by which a governmental agency grants permission to engage in a given occupation to an applicant who has attained the degree of competency required to ensure the public’s protection is ________________________. 15. The process of entering your name and essential information within a particular record is called ________________________. 16. The four nationally recognized levels of licensure in the National EMS Scope of Practice Model are ________________________ ________________________ ________________________, ________________________ ________________________ ________________________, ________________________ ________________________ ________________________ ________________________, and ________________________. 17. A _________ ________ is an unplanned opportunity to present information to a patient when he is more likely to understand and accept the information. 18. A conventional cab and chassis on which a module ambulance body is mounted, with no passageway between the driver’s and patient’s compartments, is called a type ________________________ ambulance. 19. The conduct and qualities that characterize a practitioner in a particular field or occupation are called ________________________. 20. The rules or standards that govern the conduct of members of a particular group or profession are called ________________________.

HANDOUT 2-4

Student’s Name ____________ REINFORCEMENT EMS SYSTEMS MATCHING

Write the letter of the term in the space next to the appropriate description. a.

COBRA

f. Medical director

Standing orders

b. CPR

g. Medical error type

Triage

h. Fee-for-service

m. Type I

EMD

d. Intervener physician i. QA

o. Type III

MASH

j. CQI

Type II

______1.

Preauthorized treatment procedures

______2.

Quality evaluation program focused on clinical care delivered to patients

______3.

1981 act that wiped out most federal funding for EMS

______4.

Physician responsible for clinical and patient care aspects of an EMS system

______5.

Method of funding EMS systems

______6.

Ambulance with modular patient compartment mounted on conventional cab and chassis

______7.

Sorting patients according to severity of injury

______8.

Licensed physician, unrelated to patients, who attempts to assist EMS crews in the field

______9.

EMS team member trained in telecommunications skills, medical interrogation, and dispatch prioritization

______

10. Ambulance with standard van, body, and cab forming an integral unit

______11. First established during the Korean war, near the front lines to provide prompt surgical care ______ 12. Program designed to refine and improve an EMS system, emphasizing customer satisfaction ______13. Ambulance that is a specialty van with passageway from driver’s to patient’s compartment ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______14. One component of basic life support ______15. Knowledge-based failure

HANDOUT 2-5

Student’s Name ___________ REINFORCEMENT EMS TRUE OR FALSE

Indicate if the following statements are true or false by writing T or F in the space provided. ______ 1. The Emergency Medical Responder’s role is to stabilize the patient until the EMT or paramedic arrives. ______ 2. Most EMS systems today receive the largest part of their operating expenses directly from the federal government. ______ 3. The 15 components of an EMS system were laid out in the “White Paper” of 1966. ______ 4. The director or manager of an EMS system is legally responsible for all of the clinical and patient care aspects of the system. ______ 5. Medical direction communications may be delegated to a mobile intensive care nurse or a physician assistant. ______ 6. If an intervener physician is present at an emergency scene and direct medical control does exist, the on-line physician has ultimate responsibility for the patient. ______ 7. The four “Ts” of emergency medical care are triage, treatment, transport, and transfer. ______ 8. Standing orders take precedence over on-line communications. ______ 9. In priority dispatching, medical dispatchers interrogate callers, prioritize symptoms, select appropriate responses, and give prearrival instructions. ______10. The goal of emergency response is for BLS care to arrive in fewer than 4 minutes and ALS care to arrive in fewer than 8 minutes. ______11. Ambulances that display the “Star of Life” symbol must meet the standards set by the NAEMT. ______12. The U.S. Department of Transportation has developed curricula for four levels of prehospital care providers. ______13. Advanced EMTs should successfully complete an ACLS and PALS course.

______14. “Ethics” refers to the moral conduct or qualities that characterize a practitioner in a particular field or occupation. ______15. “Citizen access” refers to an advanced form of EMS communications.

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

5. b

9. d

13. b

2. c

6. b

10. c

14. d

3. d

7. a

11. b

15. c

4. c

8. b

12. b

16. c

Handout 2-2: Chapter 2 Scenario 1. EMRs, EMTs, and paramedics; hospital personnel: emergency nurses and physicians; support personnel: emergency medical dispatchers, firefighters, law enforcement. 2. The emergency medical dispatcher serves as the primary point of contact with the public and assigns and directs appropriate medical care to the victim. 3. He alerted the EMS system by calling 911. He also performed a rapid triage of both patients and directed another Emergency Medical Responder to stabilize one of the patients. 4. Teamwork is a vital component of EMS because many individuals with different types of training and skills must work together to see the incident through to completion. The individuals in the scenario recognize one another’s talents and put aside individual egos in the best interests of the patients. Handout 2-3: Chapter 2 Review 1. triage 2. Highway Safety Act 3. medical direction (or control) 4. continuous quality improvement 5. EMS Technical Assessment 6. medical director 7. On-line 8. Off-line 9. intervener physician 10. triage, treatment, transport, transfer 11. emergency medical dispatcher 12. profession ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

13. certification 14. licensure 15. registration 16. Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), Paramedic 17. teachable moment 18. I 19. professionalism 20. ethics Handout 2-4: EMS Systems Matching 1. k

5. h

9. c

13. o

2. i

6. m

10. n

14. b

3. a

7. l

11. e

15. g

4. f

8. d

12. j

Handout 2-5: EMS True or False 1. T

5. T

9. T

13. F

2. F

6. T

10. T

14. F

3. F

7. T

11. F

15. F

4. F

8. F

12. T

Chapter 3 ROLES AND RESPONSIBILITIES OF THE PARAMEDIC

HANDOUT 3-1

Student’s Name __________________ EVALUATION CHAPTER 3 QUIZ

Write the letter of the best answer in the space provided. ______1. EMS has changed dramatically over the past 10 years. Today, paramedic emergency care emphasizes all of the following actions EXCEPT: a. providing competent emergency care. b. prescribing certain medications to patients who are not transported. c. providing emotional support to patients and their families. d. drawing on a strong knowledge of pathophysiology. ______2. The paramedic’s primary responsibility is: a. community involvement. c. patient care. b. support for primary care. d. research. ______3. Identifying a patient’s mechanism of injury is accomplished as part of which primary responsibility of a paramedic? a. Patient assessment c. Scene size-up b. Recognition of injury d. Appropriate disposition ______4. The force or forces that cause an injury are called the: a. kinematics of injury. c. nature of trauma. b. chief complaint. d. mechanism of injury. ______5. The American College of Surgeons categorizes receiving facilities by the level of care they provide. A hospital that has surgery facilities available but no specialty physicians on-site is classified as: a. Level I. c. Level III. b. Level II. d. Level IV. ______6. A primary responsibility of the paramedic is returning to service after a call. Aspects of this include: a. reviewing the call with crew members. b. providing the ED staff a copy of the prehospital care report. c. turning the patient over to the hospital staff. d. calling the dispatch center for run report times. ______7. The term used to describe members of health care professions, apart from physicians and nurses, that includes paramedics, respiratory therapists, and laboratory technicians is a. ancillary health professions. c. allied health professions. b. paramedical health professions. d. auxiliary health professions. ______8. Leadership, integrity, and empathy are a few of the paramedic’s professional: a. attitudes. c. duties. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

b. attributes.

d. responsibilities.

______9. Completing assigned duties without being asked or told is one example of the professional attribute of: a. self-confidence. c. careful delivery of service. b. time-management skills. d. self-motivation. _____10. An example of the professional attribute of teamwork and diplomacy is: a. mastering and refreshing skills. b. being supportive and reassuring. c. placing the success of the team ahead of personal self-interest. d. accepting constructive feedback in a positive manner. _____11. The benefits of continuing education include all the following EXCEPT: a. expanding a paramedic’s knowledge and skill. b. providing an opportunity to address weak points in patient care. c. providing an employer with a mechanism to discipline paramedics with weak patient care skills. d. exposing the paramedic to new and emerging technology.

HANDOUT 3-2

__________________ EVALUATION CHAPTER 3 SCENARIO

Review the following real-life situation. Then answer the questions that follow. Medic 3 from the Springfield substation has been dispatched to assist an elderly woman who has fallen down a flight of stairs. While checking on her, a neighbor had found her and called 911. The crew had just finished cleaning and restocking the ambulance after a run when they received the dispatch. Medic 3 reaches the patient’s house about 6 minutes after receiving the call. A quick scene size-up assures the crew that the scene is safe. The neighbor lets them into the house and leads them to the patient. As she does, she tells them that the woman, Mrs. Gombert, apparently tripped sometime yesterday, fell down the stairs, hurt her leg, and has been unable to move since then. The crew finds Mrs. Gombert lying at the foot of the stairs. They note that she is highly anxious and somewhat confused. The neighbor states that Mrs. Gombert often appears confused and fears that she is growing senile. The senior paramedic, Jo, takes charge of the call. She directs the other members of the crew as they carefully provide spinal immobilization, perform an initial assessment and physical exam, immobilize Mrs. Gombert’s right hip and leg, and carefully move her to a long backboard. Following protocol, the crew administers oxygen, starts an IV, attaches and monitors an ECG machine, and prepares the patient for transport. While doing these tasks, the crew speaks gently to Mrs. Gombert, telling her what they are doing and seeking to calm and reassure her. En route to the hospital, Jo radios a report of Mrs. Gombert’s condition and the expected time of arrival to the emergency department. Despite an apparent fractured hip and dehydration, reassessment indicates that the patient is stable, and she is transported without incident. Upon arrival at the hospital, Jo turns Mrs. Gombert over to the ED personnel with an oral update on her condition. Jo prepares a written run report describing the circumstances under which the patient was found, a brief history related by the patient and the neighbor, vital signs taken at the scene and during transport, and care given by the EMS crew. Back at the substation, as Jo writes the patient care report, the other crew members again clean and restock the ambulance. When all personnel have finished their tasks, Jo informs the dispatcher that Medic 3 is back in service and ready for another call. 1. How does this scenario illustrate the overall purpose of paramedic emergency care? 2. What primary responsibilities of the paramedic are demonstrated in this scenario?

HANDOUT 3-3

Student’s Name __________________ REINFORCEMENT CHAPTER 3 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. The primary responsibility of the paramedic that includes familiarity with all local EMS protocols, policies, and procedures is known as ________________________. 2. During an emergency response, ________________________ ________________________ is a paramedic’s number one priority. 3. The force or forces that cause an injury are called the ________________________ ________________________ ________________________. 4. A patient’s general medical condition or complaint is called the ________________________ ________________________ __________________. 5. Potential hazards at an emergency scene are assessed during the ________________________ ________________________. 6. You should look for and immediately treat life-threatening conditions during the ________________________ ________________________. 7. Most commonly, patient priority is based on the ________________________ ________________________ ________________________. 8. Proper record keeping helps to ensure ________________________ ________________________ ________________________ ________________________ from the emergency scene to the hospital setting. 9. The highest level of trauma care is delivered at a Level ________________________ facility. 10. Basic health care provided at the patient’s first contact with the health care system is called ________________________ ________________________. 11. Additional responsibilities of the paramedic may include teaching CPR to the public or other demonstrations. These are aspects of ________________________ ________________________. 12. The ancillary health care professions, apart from physicians and nurses, are called ________________________ ________________________ ________________________. 13. Self-confidence, establishing credibility, and inner strength are characteristics of ________________________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

14. The paramedic should always be a(n) ________________________ for the patient, acting in his best interests. 15. The best paramedics are those who make a commitment to ________________________. 16.

A paramedic who provides emergency care on an offshore oil rig is employed in a(n) ____________ _________

17.

When you put the patient’s needs above your own, you are acting as the patient’s ________.

HANDOUT 3-4

__________________ REINFORCEMENT ROLES AND RESPONSIBILITIES LISTING

Complete each of the following lists. 1. List the eight primary responsibilities of a paramedic. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 2. List four additional responsibilities of a paramedic. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 3. List the 12 professional attributes of a paramedic. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

4.List four ways in which a paramedic can show empathy to a patient. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Chapter 3 Answer Key Handout 3-1: Chapter 4 Quiz 1. b

4. d

7. c

10. c

2. c

5. b

8. b

11. c

3. c

6. a

9. d

Handout 3-2: Chapter 3 Scenario 1. The overall purpose of paramedic emergency care is to provide competent emergency medical care and emotional support for the patient and family members. In this case, through their professional support and care for Mrs. Gombert, the crew of Medic 3 provided the patient with both. 2. Among the responsibilities illustrated are response to the emergency; scene size-up and safety; patient assessment, treatment, and management; determination of the patient’s disposition and transport; documentation of the call; preparation of the ambulance for the next call; and resuming inservice posture. Handout 3-3: Chapter 3 Review 1. preparation 2. personal safety 3. mechanism of injury 4. nature of illness 5. scene size-up 6. primary assessment 7. urgency for transport 8. continuity of patient care 9. I 10. primary care 11. community involvement 12. allied health professions 13. leadership 14. advocate 15. excellence 16. nontraditional career ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

17. advocate Handout 3-4: Roles and Responsibilities Listing 1. Preparation Response Scene size-up Patient assessment Treatment and management Disposition and transfer Documentation Clean-up, maintenance, and review 2. Community involvement Support for primary care Citizen involvement Personal and professional development 3. Leadership Integrity Empathy Self-motivation Professional appearance and hygiene Self-confidence Communication skills Time management skills Diplomacy in teamwork Respect Patient advocacy Careful delivery of service 4. Being supportive and reassuring Demonstrating an understanding of the patient’s feelings and the feelings of the family Demonstrating respect for others Having a calm, compassionate, and helpful demeanor

Chapter 4 Workforce Safety and Wellness

HANDOUT 4-1

Student’s Name __________________ SKILLS PARAMEDIC WELL-BEING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently

PLAN FOR THE PROPER CLEANING, DISINFECTION, AND DISPOSAL OF EQUIPMENT AND SUPPLIES Procedure 1. Plans for proper disposal of single-use personal protective equipment in appropriate red bag 2. Plans for proper disposal of single-use medical equipment in appropriate red bag or puncture-proof container 3. Plans for disposal of red bags and sharps containers according to local guidelines 4. Plans for washing work areas with approved soaps 5. Plans for disposal of single-use cleaning supplies in proper biohazard container 6. Selects equipment for disinfection, such as backboards and splints that had direct contact with the intact skin of the patient 7. Selects approved commercial disinfectant, selects properly diluted bleach, or follows local guidelines 8. Selects items for sterilization, such as a laryngoscope blade, that were inserted into the patient’s body 9. Plans for sterilization using proper mechanical process or EPA-approved solution 10. Plans for bagging and removal of equipment requiring more extensive cleaning to an area designated for that purpose 11. Plans for proper disposal of work gloves worn during cleaning, disinfecting, and decontamination 12. Plans to bag and wash contaminated clothing in accordance with local guidelines 13. Plans to shower after removing contaminated clothing before dressing again

1 2 3

ASSESS AND IMPROVE SCENE SAFETY Procedure 1. Notes hazardous conditions, such as spilled hazardous materials, downed power lines, and proximity to moving traffic 2. Notes adverse environmental conditions 3. Selects the safest parking place 4. Determines proper method of approaching patients 5. Suggests correct methods for reducing or eliminating hazardous conditions

1 2 3

HANDOUT 4-2

Student’s Name __________________ EVALUATION CHAPTER 4 QUIZ

Write the letter of the best answer in the space provided. ______1. An active exercise performed against stable resistance, in which muscles are exercised in a motionless manner, is called: a. isotonic. c. anaerobic. b. isometric. d. aerobic. ______2. Exercising vigorously enough to raise your pulse to its target heart rate will increase: a. flexibility. c. cardiovascular endurance. b. muscle strength. d. respiratory endurance. ______3. Which of the following is NOT one of the ChooseMyPlate dietary guidelines? a. Whole grains c. Fruits and vegetables b. Dairy d. Starches ______4. According to the ChooseMyPlate guidelines, you should fill half of your plate with ____________________, and at least half of your grains should be ____________________ grains. a. vegetables, whole c. meat, refined b. fruits, dried d. vegetables, refined ______5. In general you should avoid or minimize your intake of: a. milk. c. fats. b. whole grains. d. lean proteins. ______6. Your body needs plenty of fluids to flush food through your system and eliminate toxins. The drink that is most thirst quenching and best for you is: a. diet soda. c. coffee. b. milk. d. water. ______7. Which of the following is TRUE regarding back fitness? a. One of the best exercises for the back is the old-fashioned sit-up. b. While important for appearance, posture has little to do with the risk of back injury. c. Abdominal muscles are crucial to overall spinal-column strength and safe lifting. d. Smoking has not been shown to contribute to intervertebral disk deterioration. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______8. Important principles of lifting include: a. positioning the load as far from your body as is comfortably possible. b. keeping your palms down whenever possible. c. pulling rather than pushing, when given a choice. d. exhaling during the lift. ______9. Microorganisms that are capable of producing disease, such as bacteria and viruses, are called: a. pathogens. c. germs. b. infections. d. microbes. _____10. An example of a disease transmitted by airborne droplets is: a. hepatitis B. c. AIDS. b. chicken pox. d. staphylococcal skin infections. _____11. Acquired immune deficiency syndrome (AIDS) has an incubation period of: a. several months or years. c. two to six weeks. b. one to three days. d. 10 to 12 days. _____12. The time between contact with a disease organism and the appearance of the first symptoms is called the: a. contagious period. c. incubation period. b. asymptomatic period. d. developmental period. _____13. Standard precautions are a strict form of infection control that: a. outline procedures to use if you believe the patient may have an infectious disease. b. assume that all blood and other body fluids are infectious. c. require the use of protective gloves, mask, and gown for every patient contact. d. dictate minimal physical contact with a patient. _____14. Equipment used by EMS personnel to protect against injury and the spread of infectious disease is called: a. biohazard protective equipment (BPE). b. infection protective equipment (IPE). c. patient protective equipment (PPE). d. personal protective equipment (PPE). _____15. If you suspect that your patient is infected with tuberculosis, you should use a: a. HEPA respirator. c. cotton mask. b. plastic respirator. d. surgical mask.

_____16. A situation that would usually call for the use of a gown as protection is: a. any patient contact. c. venous bleeding. b. childbirth. d. tuberculosis. _____17. HIV/AIDS, hepatitis B, and tuberculosis are diseases of great concern because they are: a. contagious. c. transmitted by airborne pathogens. b. untreatable. d. life-threatening. _____18. The most important infection control practice is: a. wearing protective gloves when in contact with every patient. b. placing a mask on both yourself and the patient. c. washing your hands properly. d. being up to date on all vaccinations and immunizations. _____19. Contaminated wastes, such as bloody dressings and bandages, should be disposed of: a. only at the hospital emergency department. b. in a red bag with a biohazard seal. c. in a cardboard box sealed with tape. d. in any normal garbage container. _____20. In most areas, an EMS provider who has had an exposure to an infectious disease should do all of the following EXCEPT: a. immediately washing the infected area with a disinfecting agent. b. getting a medical evaluation. c. getting the proper immunization boosters. d. notifying the agency’s infection control liaison. _____21. The use of a chemical or physical method to kill all microorganisms on an object is called a. cleaning. c. disinfecting. b. washing. d. sterilizing. _____22. According to Elisabeth Kübler-Ross, there are five predictable stages of loss. One is a. denial. c. fear. b. elation. d. confusion. _____23. A dying patient who is sad, mourning things not accomplished and dreams that will not come true, is in which stage of loss? a. Denial c. Depression b. Anger d. Acceptance _____24. How people of different ages cope with death varies. When dealing with children from ages 3 to 6, you should: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. encourage sharing of memories to facilitate the grief response. b. encourage the child to talk about and/or draw pictures of his feelings. c. locate a support group for the child. d. get a trusted friend to provide appropriate support. _____25. When telling a survivor that a loved one has died, your message should include the: a. use of encouraging statements, such as saying that the person is “no longer in pain.” b. use of terms such as “passed on” instead of the harsher word “dead.” c. statement that it was “God’s will” (if the survivor is religious). d. statement that “there was nothing more anyone could have done.” _____26. While stress is usually understood to be harmful, some stress is beneficial. It is called: a. positive stress. c. eustress. b. antistress. d. distress. _____27. As a person adapts to stress, he develops: a. defensive strategies. c. illusions. b. resistance. d. desensitization. _____28. To manage stress, you must: a. learn to become detached. b. think of patients only as signs and symptoms, not as people. c. know the amount of stress you can take before it becomes a problem. d. immerse yourself in work. _____29. The three phases of a stress response include: a. excitement. c. fear. b. exhaustion. d. desensitization. _____30. The physiological phenomena that occur over intervals of approximately 24 hours are: a. anchor time events. c. hormonal rhythms. b. second-wind responses. d. circadian rhythms. _____31. In situations in which your stress response threatens your ability to handle the moment, you should: a. concentrate on the medical needs of the patient. b. “retreat” and get away from the stressor. c. take medication to help you temporarily deal with the situation. d. increase your breathing rate and the amount of oxygen in your system. _____32. All of the following are clearly defined types of EMS stress EXCEPT: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. small incident. b. cumulative. _____33. Psychological first aid includes: a. assessing needs b. conveying compassion.

c. daily d. large incident or disaster. c. not forcing personnel to talk. d. all of the above.

_____34. An emotional warning sign of excessive stress is: a. fatigue. c. withdrawal. b. difficulty in making decisions.

d. depression.

_____35. Since one of the greatest hazards in EMS is motor vehicles, you should learn: a. basic engine repair. b. how to safely approach a vehicle in which someone is slumped over the wheel. c. high-speed pursuit driving. d. to safely follow escort vehicles, such as police cars.

HANDOUT 4-3

Student’s Name __________________ EVALUATION CHAPTER 4 SCENARIO

Review the following real-life situation. Then answer the questions that follow. Lately, you have noticed that your partner seems to have changed. He used to get to work at least a half hour before your shift started; now he’s just barely on time. Wearing his uniform, he used to look like an ad in a catalog; now it just barely meets the standards of your service. He used to be easygoing and always good-natured; now everything and everyone seems to make him angry. Today presented a good example of the changes you’ve observed. This morning at change of shift, you were told that a mandatory training session for a new piece of equipment has been scheduled for your next day off. Your partner has been grumbling about the training session and the “lousy administration who think they own us every minute of every day.” The irony is that he had been on the committee that recommended the purchase of the equipment. Then about midmorning, when you transported Mrs. Jonas (one of your “regulars”) for her radiation treatment, your partner was very short-tempered and rude to her. You were particularly surprised by that, since he had told you once that she reminded him of his grandmother. You have also heard rumors that he’s having some troubles at home, but he has said nothing about them to you. 1.

What do you think is going on with your partner?

What should you do?

HANDOUT 4-4

Student’s Name __________________ REINFORCEMENT CHAPTER 4 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. Core elements of physical fitness are ________________ _________________, _________________ _________________, and _________________. 2. Active exercise performed against stable resistance, in which muscles are exercised in a motionless manner, is called _________________ exercise. 3. Active exercise during which muscles are worked through their range of motion is called _________________ exercise. 4. The ChooseMyPlate chart includes _________________, _________________, _________________, _________________, and _________________. 5. _________________ and _________________ well can help you prevent both cancer and cardiovascular disease. 6. If given a choice when lifting, _________________; do not _________________. 7. Always avoid _________________ and _________________ when lifting. 8. Any disease caused by the growth of microorganisms, which may spread from person to person, is called a(n) _________________ _________________. 9. Microorganisms capable of producing disease, such as bacteria and viruses, are called _________________. 10. While hepatitis B is a(n) _________________ disease, tuberculosis is a(n) _________________ disease. 11. The time between contact with a disease organism and the appearance of the first symptoms is called the _________________ period. 12. A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious is _________________ _________________. 13. Equipment used by EMS personnel to protect against injury and the spread of infectious disease is called _________________ _________________ _________________. 14. In addition to protective gloves, the paramedic should wear a(n) _________________ and _________________ _________________ whenever blood spatter is likely to occur, as with arterial bleeding or oral suctioning. 15. Whenever caring for a patient with tuberculosis, you should wear a(n) _________________ _________________ _________________ _________________ respirator. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

16. Perhaps the most important infection control practice is _________________ _________________. 17. Washing an object with cleaners, such as soap and water, is called _________________. 18. Cleaning with an agent that can kill some microorganisms on the surface of an object is called _________________. 19. The use of a chemical or physical method, such as pressurized steam, to kill all microorganisms on an object is called _________________. 20. Any occurrence of blood or body fluids coming into contact with nonintact skin or mucous membranes or delivered by parenteral contact is called a(n) _________________. 21. There are five predictable stages of loss. The inability to believe the reality of the event is called the _________________ stage. 22. A patient is in the _________________ stage of loss when he mourns things not accomplished and dreams that will not come true. 23. Generally, children ranging in age from _________________ to _________________ believe that death is a temporary state and may ask continually when the dead person will return. 24. When a patient of yours has died, a basic element of your message to survivors should include a statement that the loved one has _________________. 25. Adaptation to stress involves the development of _________________ and _________________ strategies and _________________ skills. 26. Your job in managing stress is to learn your personal _________________. 27. The three phases of a stress response are stage I, or _________________; stage II, or _________________; and stage III, or _________________. 28. Physiological phenomena that occur at approximately 24-hour intervals are _________________ _________________. 29. A set of hours when a night-shift worker can reliably expect to rest without interruption is called _________________ _________________. 30. _________________ occurs when coping mechanisms no longer buffer job stressors. 31. Warning signs of excessive stress fall into four categories. These categories are _________________, _________________, _________________, and _________________. 32. For long-term well-being, the best stress management technique is to take care of _________________. 33. _________________ _________________ _________________ can provide the information and education needed for rescuers to understand trauma, what to expect, and where to get help if needed. 34. Mental health professionals should be available during two months after a critical incident to screen and assist anyone who may be developing _________________ symptoms.

35. Principles of roadway safety include evaluating the safest _________________ _________________ when arriving at a roadway incident.

HANDOUT 4-5

Student’s Name __________________ REINFORCEMENT WELL-BEING BASICS LISTING

Complete the following lists. 1. List the five basics of physical fitness. __________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 2. List the components of the ChooseMyPlate chart. ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 3. List the five minimum pieces of recommended PPE. ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 4. List at least five warning signs of excessive stress. ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 5. List the five stages of loss, as defined by Elisabeth Kübler-Ross. ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

HANDOUT 4-6

Student’s Name __________________ REINFORCEMENT UNDERSTANDING THE GRIEF PROCESS

Complete the table by naming and describing the stages of the grief process. Stage 1. 2. 3. 4. 5.

Description

CHAPTER 4 Answer Key Handout 4-2: Chapter 4 Quiz 1. b 2. c 3. d 4. a 5. c 6. d 7. c 8. d 9. a

10. b 11. a 12. c 13. b 14. d 15. a 16. b 17. d 18. c

19. b 20. a 21. d 22. a 23. c 24. b 25. d 26. c 27. a

28. c 29. b 30. d 31. a 32. b 33. d 34. d 35. b

Handout 4-3: Chapter 4 Scenario 1. Your partner is showing classic signs and symptoms of excess stress. His coping mechanisms are no longer working. He is showing up to work later and is directing his anger toward patients and administrators. He is showing a change in his interaction with others. The common term for his condition is “burnout.” 2. Encourage your partner to talk to you. Discuss things that may be bothering him. Perhaps one particular situation is getting to him, or it could be an accumulation of unresolved problems over a long period of time. Encourage him to take some time off and increase time with his family and friends. If he continues to feel excessive anger, he may need professional counseling. Emphasize that his feelings are normal and seeking help does not make him any less a professional. Handout 4-4: Chapter 4 Review 1. muscular strength, cardiovascular endurance, flexibility 2. isometric 3. isotonic 4. grains, fruits, vegetables, dairy, protein 5. Exercising, eating 6. push, pull 7. twisting, turning 8. infectious disease 9. pathogens 10. bloodborne, airborne 11. incubation 12. Standard Precautions ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

13. personal protective equipment 14. mask, protective eyewear 15. high-efficiency particulate air 16. hand washing 17. cleaning 18. disinfection 19. sterilization 20. exposure 21. denial 22. depression 23. three, six 24. died 25. defensive, coping, problem-solving 26. stressors 27. alarm, resistance, exhaustion 28. circadian rhythms 29. anchor time 30. Burnout 31. physical, emotional, cognitive, behavioral 32. yourself 33. Mental health professionals 34. stress-related 35. parking place Handout 4-5: Well-Being Basics Listing 1. Cardiovascular endurance Strength and flexibility Nutrition and weight control Freedom from addictions Back safety 2. Physical activity Grains Fruits ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Vegetables Protein Dairy 3. Protective gloves Masks and eyewear HEPA and N-85 respirators Gowns Resuscitation equipment 4. Any five from Table 4-5 5. Denial Anger Bargaining Depression Acceptance Handout 4-6: Understanding the Grief Process 1. Denial. This is the inability or refusal to believe the reality of the event. It is a defense mechanism by which the patient puts off dealing with the inevitable. 2. Anger. The patient’s anger is really frustration related to his inability to control the situation. That anger could focus on anyone or anything. 3. Bargaining. In the patient’s mind, he tries to make a deal to “buy additional time” to put off or change the expected outcome. 4. Depression. The patient is sad and despairing, often mourning things not accomplished and dreams that will not come true. The patient withdraws, or retreats, into a private world and is unwilling to communicate with others. 5. Acceptance. The patient may come to accept his fate and achieve a reasonable level of comfort with the anticipated outcome. At this stage, the family may need more support than the patient.

Chapter 5 EMS Research

HANDOUT 5-1

Student’s Name___________ EVALUATION CHAPTER 5 QUIZ

Write the letter of the best answer in the space provided. ______1. The sixth step in the scientific method is: a. Construct a hypothesis.

c. Observe and ask questions.

b. Test the hypothesis.

d. Revise the hypothesis.

______2. Most medical research is: a. qualitative.

c. qualitative and quantitative.

b. quantitative.

d. None of these are used.

______3. When independent variables cannot be manipulated for one reason or another, ____________ research is often used. a. qualitative

c. quantitative

b. nonexperimental quantitative

d. nonexperimental qualitative

______4. Most prehospital medical research findings are published in: a. medical journals.

c. peer-review journals.

b. textbooks.

d. local newpapers.

______5. The type of study that does not have a control group is a(n): a. experimental study.

c. coordinated study.

b. quasiexperimental study.

d. observational.

______6. An observational study is also called a: a. case series.

c. randomized controlled study.

b. nonrandomized control trial.

d. cohort study.

______7. Research at the most basic level is: a. in vitro research.

c. expert opinions.

b. case report.

d. cohort study.

______8. Ensuring that the results of a study can be attributed to the cause in the hypothesis and not to other causes is known as: a. internal validity.

c. specific validity.

b. external validity.

d. nonspecific validity.

______9. A committee that approves, monitors, and reviews human research is an: a. investigational review board.

c. institutional review board.

b. interagency review board.

d. instructional review board.

______10. Adding all the values in a study and then dividing the sum by the number of values will produce the: a. mean.

c. standard deviation.

b. median.

d. central tendancy.

HANDOUT 5-2

Student’s Name __________ EVALUATION CHAPTER 5 SCENARIO

Review the following real-life situation. Then answer the questions that follow. An EMT, his paramedic partner, and a second paramedic are sitting at the station relaxing after a long day of running calls when the subject of success in paramedic school and prior experience comes up. The EMT is trying to decide between two schools: one that requires two years of field experience before admission and one that does not require any field experience. The EMT has been working for one year, so if he chooses the school that requires experIence, he will have to wait another year before applying. If he chooses the school that does not require experience, he can apply right away and become a paramedic faster. “I think you should wait,” says his partner. “Having a lot of field experience before starting school will result in a better chance of passing the state exam.” He goes on to say, “I’ve seen hundreds of students over the years, and the ones that come from schools that require prior experience always pass the state exam on the first attempt. And remember, if you don’t pass the state exam, you won’t get to work as a paramedic.” “Wait just a minute,” says the second paramedic. “I went straight from EMT training to paramedic training, and I passed the exam the first time I took it. Lots of my classmates did as well. I think it has to do with the individual student and not the entrance requirements.” “You guys were probably just the exception,” says the first paramedic. “You’ll never convince me that having field experience doesn’t affect your chances of success on the state exam.” “Great, now I’m even more confused,” says the EMT. “You guys are two of the best paramedics that I know, and I respect both of you, so how am I supposed to decide?” “I have an idea,” says the first paramedic. “I need to do a research project for my master’s degree, and I think this would be a perfect topic. We can settle this debate once and for all.” “Sounds great to me,” says the second paramedic. “I’d love to help, just to prove you wrong!” “Okay, here’s what we need to do. We need to determine what type of research study it will be, develop a hypothesis, gather data, test our hypothesis, analyze our results, possibly revise our hypothesis, then report our results.” “All that just to answer one simple question?” asks the EMT. “It might be easier just to flip a coin!” “It won’t be quick or easy, but this is a big decision for you, and after we’re ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

done, you’ll know, based on research, how you should make your decision. Trust me, it will be worth it. So let’s get started.” 1. What would be the best type of research to answer this question? 2. Develop a hypothesis for this study. 3. What are some potential limitations to this study?

HANDOUT 5-3

Student’s Name_________ REINFORCEMENT CHAPTER 5 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. One of the hallmarks of a profession, when compared to a trade, is creating change based on _____________ ___________. 2. The scientific method used for mixed research is ________________________ and ________________________. 3. When setting up an experiment to test a hypothesis, the experiment must be ________________ and _______________. 4. ______________ studies are generally less expensive but also carry less validity. 5. In an ______________ study, subjects are randomly assigned to a control group or a treatment group. 6. The most labor-intensive and difficult study to perform, yet the most valid type of study, is a _________ _________ _________ _________ _________. 7. ___________ ____________ ensures that the results of a study can be generalized or possess generalizability. 8. ___________ is the mathematics of collecting and analyzing data to draw conclusions and make predictions. 9. The goal of the IRB is to _________ _________ _________. 10. To determine the _________, take each value and subtract the mean from it. 11. The _________ is a brief paragraph that summarizes the need for the study. 12. The _____________ of a study are normally discussed in the discussion section. 13. The purpose of the study is defined in the __________ section of the report. 14. _________ is a free database of medical and scientific literature. 15. A _________ _________ is a statement that there is no difference between the groups that are sampled from.

HANDOUT 5-4

Student’s Name________ REINFORCEMENT RESEARCH MATCHING

Write the letter of the term in the space next to the appropriate description. a. Independent variable

i. Case report

b. Mixed

j. Descriptive

c. Retrospective

k. Standard deviation

d. Prospective

l. Inferential

e. Quantitative

m. Methods

f.Double blind

n. Data snooping

g. Cross-sectional

o. Principal investigator

h. Bench research ______1. Person who oversees the study ______2. Study methodology that looks at existing data ______3. Study in which neither the experimenters nor the subjects know which group the subjects are assigned to ______4. Research that is objective and specific ______5. Study methodology that has greater validity ______6. The variable that affects the dependent variable ______7. Type of study that looks at a single patient ______8. Often the first step in a research strategy that leads to animal or human research ______9. Type of statistics used to describe the basic features of the data obtained _____10. Performing additional tests in order to obtain the result you are desiring _____11. Determined by taking the square root of the variance _____12. Type of statistics that draws information from the sampled observations of a population _____13. Section of the study that describes how the sample size was determined _____14. Type of study that looks at a single point in time _____15. Type of research that uses qualitative and quantitative data

Chapter 5 Answer Key Handout 5-1: Chapter 5 Quiz 1. d

5. d

9. c

2. b

6. d

10. a

3. b

7. a

4. c

8. a

Handout 5-2: Chapter 5 Scenario 1. A retrospective quantitative research study would be the best choice. Data could be gathered from paramedics who passed the state exam on their first attempt and compared with the entry requirements from the schools that they attended. 2. A higher success rate on the state paramedic exam is achieved after attending a college that requires prior field experience. 3. Potential limitations are the ability to gain pass rates from the state exam, the willingness of participants to disclose their success or failure on the state exam, the ability to define what “experience” means. Handout 5-3: Chapter 5 Review 1. evolving research 2. deductive, inductive 3. rair, reproducible 4. Retrospective 5. experimental 6. meta-analysis of randomized controlled trials 7. External validity 8. Statistics 9. protect human subject 10. variance 11. abstract 12. limitations 13. introduction 14. PubMed 15. null hypothesis

Handout 5-4: Research Matching 1. o 2. c 3. f 4. e 5. d 6. a 7. i 8. h 9. j 10. n 11. k 12. l 13. m 14. g 15. B

Chapter 6 Public Health

HANDOUT 6-1

Student’s Name___________ SKILLS INJURY PREVENTION DATA Charting Student Progress: 1.

Learning skill

Performs skill with direction

Performs skill independently

DOCUMENT PRIMARY AND SECONDARY INJURY PREVENTION DATA Procedure 1. Properly documents scene conditions at the time of EMS arrival 2. Properly documents mechanism of injury 3. Properly describes any risks that were overcome 4. Properly documents protective devices that were used (or not used) during the emergency

HANDOUT 6-2

Student’s Name___________ EVALUATION CHAPTER 6 QUIZ

Write the letter of the best answer in the space provided. _____1. Public health has improved the quality and life span of humans by using: a. epidemiology. b. surveillance. c. prevention. d. all of the above. _____2.

_____3.

Years of productive life is calculated based on subtracting the age at death from a. 60.

c. 70.

b. 65.

d. 75.

Interaction between the public health department and EMS is an example of which role of epidemiology in public health practice? a. Surveillance b. Policy development c. Linkage d. Field investigation

______4. Based on the recommendations of the ____________, there has been a greater emphasis placed on integrating EMS and public health. a. National Standard Curriculum b. EMS Agenda for the Future c. The White Paper d. NHTSA regulations ______5. Instead of motor vehicle “accident,” we now use the term “motor vehicle: a. incident.”

c. mishap.”

b. collision.”

d. casualty.”

______6. The study of factors that influence the frequency, distribution, and causes of injury, disease, and other health-related events in a population is: a. anthropology.

c. epidemiology.

b. sociology.

d. pathology.

______7. Keeping an injury from occurring is ______ prevention. a. primary

c. tertiary

b. secondary

d. initial

______8. EMS organizational commitment is vital to the development of any prevention activities. Organizational commitment includes: a. Standard Precautions.

c. data collection.

b. safe driving.

d. stress management.

______9. The first priority of EMS providers is to: a. care for the patient.

c. provide public education.

b. protect themselves from harm.

d. obtain billing information.

______10. The most frequent cause of injury to children younger than six years is: a. firearms.

c. physical abuse.

b. vehicle/bicycle collisions.

d. falls.

______11. ________________________ are responsible for over half of all deaths from unintentional injuries. a. Motor vehicle collisions

c. Falls

b. Firearms

d. Burns

______12. About half of all motor vehicle fatalities involve: a. pedestrians.

c. alcohol.

b. elderly patients.

d. drivers falling asleep.

______13. Twenty-two percent of all disabling injuries in the workplace are to the patient’s: a. back.

c. legs.

b. hips.

d. arms.

______14. Most preventable injuries for persons over 75 years of age are caused by: a. motor vehicle collisions.

c. burns.

b. firearms.

d. falls.

______15. Patient documentation forms should include _________, which are the best determinant of patient care on scene. a. statements from bystanders b. patient health insurance verifications c. mechanisms of injury ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

d. patients’ consents

HANDOUT 6-3

Student’s Name __________ EVALUATION CHAPTER 6 SCENARIO

Review the following real-life situation. Then answer the questions that follow. You have a well-deserved day off and are taking advantage of it by driving to a nearby resort town for some fishing. It’s a weekday, and traffic is light on the county road, with a speed limit of 45 mph. Suddenly, about a quarter-mile ahead, a 1995 Pontiac traveling in the opposite direction weaves, then crosses into opposing traffic. The car crashes nearly head-on into another car on your side of the road. You quickly use your cell phone to call for emergency assistance as you pull up to the scene. You park your vehicle safely on the side of the road, then proceed with a quick scene assessment. You decide that the scene is safe to approach, so you begin assessing the patients. One adult male was in the car that crossed the median, and two adults and two children are in the other car. The driver of the first car was not restrained by a seat belt and was thrown from the vehicle. You note several empty beer cans in the car. The driver is lying on the ground, approximately 15 feet from the crash site. Your initial assessment shows him to be pulseless and apneic. His neck is angulated. The adults in the second vehicle were wearing seat belts, both air bags deployed, and the young children in the back seat are in car seats. The children are frightened and crying but appear uninjured. Both adults are conscious and breathing, are talking, and appear stable. The local fire department and volunteer ambulance arrive within a few minutes and take over assessment and treatment of the patients. You give the lead EMT a report of your assessment. The lead EMT calls for a second ambulance. Law enforcement arrives shortly, and you give your report to the officer also. When you go back to work the next day, a message from the lead EMT of the ambulance service is waiting for you. You return his call and receive an update on the incident. The first driver was dead at the scene. An autopsy revealed a blood alcohol level of 0.18, over twice the legal limit. The family in the other car was doing well and had received only some minor abrasions and contusions. They all spent one night in the hospital for observation and were released the next morning. 1. In what areas of this scenario would injury prevention programs have been useful? 2. What teachable moments existed in this scenario?

HANDOUT 6-4

Student’s Name_________ REINFORCEMENT CHAPTER 6 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. ________________________ is the study of factors that influence the frequency, distribution, and causes of injury, disease, and other healthrelated events in a population. 2. The calculation made by subtracting the age at death from 65 produces what is called ________________________ ________________________ ________________________ ________________________. 3. ________________________ is the intentional or unintentional damage to a person resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat and oxygen. 4. A real or potentially hazardous situation that puts people in danger of sustaining injury is called a(n) ________________________ ________________________. 5. A(n) ________________________ ________________________ ________________________ is the ongoing systematic collection, analysis, and interpretation of injury data essential to planning, implementing, and evaluating public health practice. 6. ________________________ ________________________ occur shortly after an injury, when the patient and observers remain acutely aware of what has happened and may be more receptive to learning about how similar injury or illness could be prevented in the future. 7. Keeping an injury from ever occurring is called ________________________ prevention. 8. Medical care after an injury or illness that helps prevent further problems from occurring is called ________________________ prevention. 9. Rehabilitation after an injury or illness that helps prevent further problems from occurring is called ________________________ prevention. 10. An aspect of organizational commitment to illness and injury prevention is to ensure the ________________________ of EMS providers. 11. An aspect of EMS provider commitment is managing ________________________ in personal, family, and work life. 12. The first priority of a paramedic is always ________________________ ________________________. 13. Areas in need of prevention activities include ________________________ ________________________ ________________________ in newborns, ________________________ firearm-related deaths, and ________________________ in the elderly. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

14. Alcohol is a factor in about ________________________ of all motor vehicle fatalities. 15. One prevention strategy is conducting a community ________________________ ________________________.

HANDOUT 6-5

Student’s Name________ REINFORCEMENT PREVENTION MATCHING

Write the letter of the term in the space next to the appropriate description. a. Epidemiology

i. Teachable moments

b. Years of productive life

j. EMS provider commitment

c. Injury

k. Organizational commitment

d. Injury risk

l. Safety

e. Primary prevention

m. Falls

f. Secondary prevention

n. Alcohol

g. Tertiary prevention

o. Back

h. Low birth weight ______1. Collecting and distributing illness and injury data ______2. Keeping an injury from occurring ______3. The study of factors that influence the frequency, distribution, and causes of injury, disease, and other health-related events in a population ______4. A factor in about half of all motor vehicle fatalities ______5. A real or potentially hazardous situation that puts people in danger of sustained injury ______6. Taking Standard Precautions ______7. Intentional or unintentional damage to a person resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat and oxygen ______8. Medical care after an injury or illness that helps to prevent further problems from occurring ______9. Accounts for 22 percent of all disabling injuries in the workplace _____10. Always the paramedic’s first priority _____11. The most frequent cause of injury to children under six years of age _____12. Occur shortly after an injury, when the patient and observers remain acutely aware of what has happened _____13. Rehabilitation after an injury or illness that helps to prevent further problems from occurring _____14. Causes the death of over 4,000 infants each year. _____15. Calculation made by subtracting the age at death from 65 ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

HANDOUT 6-6

Student’s Name_________

REINFORCEMENT COMMUNITY RESOURCES Locate the primary agency or organization responsible for the following injury and illness prevention programs. ILLNESS/INJURY PREVENTION PRIMARY CONTACT AGENCY 1. DUI prevention 2. Firearm safety 3. Seat-belt usage 4. Car-seat usage 5. Injuries to the elderly 6. Poisoning prevention 7. Child/elder abuse 8. Critical incident stress in EMS workers

Chapter 6 Answer Key Handout 6-2: Chapter 6 Quiz 1. d

5. b

9. b

13. a

2. b

6. c

10. d

14. d

3. c

7. a

11. a

15. c

4. b

8. c

12. c

Handout 6-3: Chapter 6 Scenario 1. The first and most obvious would be the prevention of driving under the influence of alcohol. Other aspects of prevention illustrated here are seat-belt usage and child car-seat usage. The deployment of the air bags in the newer vehicle points to the growing number of safer vehicles. 2. DUI prevention, seat-belt usage, and car-seat usage can be discussed with the survivors and observers. Handout 6-4: Chapter 6 Review 1. Epidemiology 2. years of productive life 3. Injury 4. injury risk 5. injury surveillance program 6. Teachable moments 7. primary 8. secondary 9. tertiary 10. protection 11. stress 12. personal safety 13. low birth weight, unintentional, falls 14. half 15. needs assessment

Handout 6-5: Prevention Matching 1. k 2. e 3. a 4. n 5. d 6. j 7. c 8. f 9. o 10. l 11. m 12. i 13. g 14. h 15. b

Chapter 7 Medical/Legal Aspects of Prehospital Care

HANDOUT 7-1

Student’s Name __________________ EVALUATION CHAPTER 7 QUIZ

Write the letter of the best answer in the space provided. ______1. As a paramedic one of your ethical responsibilities is: a. transporting patients to whatever facility they request. b. attempting resuscitation cardiac/respiratory arrest.

every

patient

who

c. treating all patients and their families with courtesy and respect. d. performing a skill or procedure that you have been trained to do, even if not within your scope of practice. ______2. Your best protection from liability is to: a. provide as little advanced-level treatment as possible. b. always transport to the closest hospital. c. always be kind to patients, because “nice people” don’t get sued. d. perform systematic assessments. ______3. The area of law in which the federal, state, or local government will prosecute an individual on behalf of society for violating laws meant to protect society is: a. civil law.

c. law of torts.

b. criminal law.

d. common law.

______4. The filing of complaint, answering complaint, and settlement are three components of a: a. civil lawsuit.

c. legislative lawsuit.

b. criminal lawsuit.

d. constitutional lawsuit.

______5. If a paramedic intubates the esophagus of a patient instead of the trachea, does not confirm tube placement, and leaves the tube in place, he has breached his duty by: a. malfeasance.

c. nonfeasance.

b. misfeasance.

d. cofeasance.

______6. Elements of negligence include proof that the paramedic: a. committed the act on purpose. b. committed the act during the commission of a crime. c. was the proximate cause of actual damages to the patient. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

d. exceeded his scope of practice. ______7. To show the existence of proximate cause, the plaintiff needs to prove that the damage to the patient was: a. reasonably foreseeable. b. willfully caused by the paramedic. c. caused by the paramedic’s violating a criminal law. d. the result of the paramedic’s misdiagnosing the patient’s condition. ______8. A patient may sue you for violating his civil rights if you: a. exceed your scope of practice. b. fail to render care for a discriminatory reason. c. breach patient confidentiality. d. commit libel. ______9. The act of injuring a person’s character, name, or reputation by false or malicious statements spoken with malicious intent or reckless disregard for the falsity of those statements is called: a. libel.

c. assault.

b. battery.

d. slander.

______10. If you respond to a seven-year-old child with a life-threatening injury and no parent or guardian is available, you may still treat the child because of: a. expressed consent.

c. involuntary consent.

b. implied consent.

d. special consent.

______11. If a competent adult refuses care, you should: a. have the patient placed in police custody. b. restrain the patient and transport. c. document the situation thoroughly. d. not argue with the patient and notify dispatch that you are back in service. ______12. The termination of the paramedic-patient relationship without assurance that an equal or greater level of care will continue is: a. assault.

c. battery.

b. abandonment.

d. false imprisonment.

______13. A paramedic who starts an IV on a patient who does not consent to such treatment may be sued for: a. res ipsa loquitur. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

c. nonfeasance.

b. false imprisonment.

d. battery.

______14. During transport of a patient to a health care facility, the level of care the patient receives must (may): a. be greater than the level of care received at the scene. b. be at least the same level of care received at the scene. c. be a lesser level of care than received at the scene if the patient agrees to it. d. be at least at the EMT-Basic level. ______15. A document created to ensure that certain treatment choices are honored when a patient is unconscious or otherwise unable to express his choice of treatment is called a(n): a. DNR order.

c. advance directive.

b. living will.

d. durable power of attorney.

______16. If you have any doubt about whether a DNR order is valid, you should: a. withhold CPR. b. contact the patient’s personal physician before beginning CPR. c. contact medical direction before beginning CPR. d. initiate resuscitation efforts. ______17. Which type of instruction on a DNR order is legal? a. “Chemical code only”

c. “Withhold CPR”

b. “Slow code”

d. All of the above

______18. When you are treating a patient at a crime scene, your responsibilities include: a. picking up weapons and other evidence and handing them to law enforcement so that no one gets injured. b. cleaning up blood and body fluids on carpets, furniture, and so forth before leaving the scene to avoid further contamination. c. trying not to touch the body at all if the patient has an obvious mortal wound, such as decapitation. d. entering the scene to treat the patient before law enforcement personnel arrive if necessary, because the patient is your primary concern. ______19. Which of the following statements regarding documentation is CORRECT? a. Patient refusals do not need to be documented except for the release-from-liability form signed by the patient. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

b. Subjective statements, such as “The patient was drunk,” are appropriate. c. Altering a patient care report is permissible if both you and your partner agree on the changes. d. The patient report should be completed promptly after patient contact. ______20. A legal document that allows a person to specify the kinds of medical treatment he wishes to receive, should the need arise, is called: a. a living will.

c. medical proxy.

b. a DNR order.

d. durable power of attorney.

HANDOUT 7-2

Student’s Name __________________ EVALUATION CHAPTER 7 SCENARIO

Review the following real-life situation. Then answer the questions that follow. An EMT who is also a paramedic student is completing ride-along training with a paramedic crew that has been dispatched to the scene of a multivehicle collision. Aeromedical transport by the local rotor wing service is unavailable because of inclement weather. Six patients require transport, and the resources available consists of three BLS ambulances, each with two EMTs, and the paramedic ALS ambulance with its two paramedics and paramedic trainee. One BLS ambulance transports two conscious patients with minor fractures and cuts, which were stabilized on the scene. The second BLS ambulance transports two more patients with similar stabilized injuries. The paramedic ALS ambulance will have to transport the most critical multiple-trauma patient, who is unconscious and will require both paramedics to maintain the airway with advanced techniques, initiate an IV, and maintain bleeding control interventions they have already initiated. An EMT from the third BLS ambulance will drive the paramedics’ ALS ambulance to the trauma center. This leaves one EMT and the paramedic student to transport the last patient in the third BLS ambulance. Before the paramedics leave, they oversee the immobilization of this patient with the PASG applied before immobilization (but not yet inflated), and they initiate an IV of normal saline. Oxygen is also being administered per protocol. The EMT will drive while the paramedic student rides with the patient and provides care while en route to the hospital. The patient is conscious with a possible fractured pelvis, a blood pressure of 86/68, and a pulse rate of 120/minute. Before starting for the trauma center, the paramedic student rechecks the blood pressure and gets a systolic reading of 80 mmHg. The PASG is inflated, and the IV flow is reassessed to ensure that it is still infusing as expected. A second blood pressure reading after PASG inflation is 82/64; the pulse is 112. The 24-year-old male patient is diaphoretic and ashen and is complaining of pain. Analgesics and antispasmodic drugs are not stocked in the BLS ambulance, so the paramedic student explains to the patient that he will get pain medication at the hospital when they arrive in about 14 minutes. The paramedic student continues to monitor the interventions and vital signs and ignores the patient’s continued requests for pain medication. He is, however, concerned by the patient’s threats to sue and wishes that one of the paramedic crew members had been on board. 1. Could the paramedics be held negligent or be charged under res ipsa loquitur? Explain. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

2. Describe the types of consent that could apply to this case. How is each used? 3. Did the paramedics adhere to the proper standard of care? Is abandonment an issue? 4. Did the paramedics act appropriately in leaving the paramedic student to act alone?

HANDOUT 7-3

Student’s Name ______________ REINFORCEMENT CHAPTER 7 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. The best protection from liability is to perform _______ _______, provide appropriate _______ _______, and maintain accurate and complete _______. 2. The paramedic must treat patients and their families with _______ and _______. 3. A civil wrong committed by one individual against another is called a(n) _______. 4. Law that is derived from society’s acceptance of customs and norms over time is called _______ law. 5. _______ is a process used to regulate occupations. 6. _______ is the recognition granted to an individual who has met predetermined qualifications to participate in a certain activity. 7. The range of duties and skills paramedics are allowed and expected to perform is their ______________ ______________ ______________. 8. You may function as a paramedic only under the _______ _______ of a licensed physician through a delegation of authority. 9. The commonly mandated reporting that is expected of the paramedic includes __________________, __________________, and __________________. 10. An example of _______ is a paramedic’s breaching his duty by failing to immobilize a patient from a rollover motor vehicle collision. 11. The maximum time period during which certain actions can be brought into court is called the _______ _______ _______. 12. _______ _______ is the action or inaction of the paramedic that immediately causes or worsens the damage suffered by a patient. 13. _______ is the act of injuring a person’s character, name, or reputation by false or malicious statements written with malicious intent or reckless disregard for the falsity of those statements. 14. If your patient is able to make an informed decision about medical care, he is considered _______. 15. Consent for treatment granted by the authority of a court order is called _______ consent. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

16. A person under the age of 18 years who is married, pregnant, a parent, a member of the armed forces, or financially independent and living away from home is considered a(n) ______________ ______________. 17. The unlawful touching of another individual without his consent is _______. 18. Intentional and unjustifiable detention of a person without his consent or other legal authority is called ______________ ______________. 19. Preserve _______ at a crime scene whenever possible. 20. A well-documented patient report is completed promptly after _______ _______.

HANDOUT 7-4

Student’s Name __________________ REINFORCEMENT MEDICAL/LEGAL MATCHING

Write the letter of the term in the space next to the appropriate description. a. Liability b. Criminal law c. Civil law d. Tort e. Scope of practice f. Immunity g. Good Samaritan law h. Negligence i. Duty to act j. Battery k. Standard of care l. Malfeasance m. Misfeasance n. Nonfeasance o. Proximate cause p. Confidentiality q. Defamation r. Implied consent s. Abandonment t. Assault __________ 1.

Termination of the paramedic–patient relationship without assurance that an equal or greater level of care will continue

__________ 2.

Consent for treatment that is presumed for a patient who is mentally, physically, or emotionally unable to grant consent

__________ 3.

Range of duties and skills paramedics are allowed and expected to perform

__________ 4.

Legal responsibility

__________ 5.

A breach of duty by failure to perform a required act or duty

__________ 6.

Exemption from legal liability

__________ 7.

An intentionally false communication that injures another person’s reputation or good name

__________ 8.

A formal contractual or informal legal obligation to provide care

__________ 9.

The unlawful touching of another individual without his consent

__________ 10.

A civil wrong committed by one individual against another

__________ 11.

A breach of duty by performance of a wrongful or unlawful act

__________ 12.

Provision that gives immunity to certain people who assist at the scene of a medical emergency

__________ 13.

The division of the legal system that deals with wrongs committed against society or its members

__________ 14.

Action or inaction of the paramedic that immediately causes or worsens the damage suffered by the patient

__________ 15.

The division of the legal system that deals with noncriminal issues and conflicts between two or more parties

__________ 16.

Deviation from accepted standards of care recognized by law for the protection of others against the unreasonable risk of harm

__________ 17.

The degree of care, skill, and judgment that would be expected under similar circumstances by a similarly trained, reasonable paramedic in the same community

__________ 18.

A breach of duty by performance of a legal act in a manner that is harmful or injurious

__________ 19.

The principle of law that prohibits the release of medical or other personal information about a patient without the patient’s consent

__________ 20.

An act that unlawfully places a person in apprehension of immediate bodily harm without his consent

Chapter 7 Answer Key Handout 7-1: Chapter 6 Quiz 1. c

6. c

11. c

16. d

2. d

7. a

12. b

17. c

3. b

8. b

13. d

18. c

4. a

9. d

14. b

19. d

5. b

10. b

15. c

20. a

Handout 7-2: Chapter 7 Scenario 1. Possibly. Although the case may not clearly meet the three areas of res ipsa loquitur and the paramedics performed an accepted standard of patient care, they then left that patient in the care of a paramedic student who was an EMT not licensed to perform the level of care the patient required without the oversight of a paramedic preceptor. Therefore, leaving the patient with an EMT as the paramedic preceptor did could be considered patient abandonment. As the patient decompensated, the paramedic student performed care that he was not licensed to perform without a paramedic preceptor, and it is unclear from the scenario whether the patient was further injured by the lower level of care provided. Additionally, if the paramedic student was not an employee of the same company, the paramedics could be liable under the borrowed servant doctrine for the acts of the trainee. 2. Expressed, by all patients who permitted care by arriving provider crews; probably informed, because provider crews likely explained treatment before they began any intervention; implied, for the unconscious patient being treated by the paramedic crew; possibly expressed, for the unconscious patient if related to one of the other conscious patients 3. Crews provided standard care for the situation and followed medical direction. The paramedics left that patient in the care of a paramedic student, who, in the absence of a paramedic preceptor, can function only as an EMT. Yes, this could be an abandonment issue. 4. No, they left a paramedic student who is capable of EMT authorized provider skills to oversee a patient who had received and was being transported with ALS care in place. The patient appeared to be in a state of decompensation and therefore was potentially unstable.

3. tort 4. common 5. Licensure 6. Certification 7. scope of practice 8. direct supervision 9. Any three of: • Spouse abuse • Child abuse and neglect • Elder abuse • Sexual assault • Gunshot or stab wound • Animal bite • Communicable disease 10. nonfeasance 11. statute of limitations 12. Proximate cause 13. Libel 14. competent 15. involuntary 16. emancipated minor 17. battery 18. false imprisonment 19. evidence 20. patient contact Handout 7-4: Medical/Legal Matching 1. s

6. f

11. l

16. h

2. r

7. q

12. g

17. k

3. e

8. i

13. b

18. m

4. a

9. j

14. o

19. p

5. n

10. d

15. c

20. t

Chapter 8 Ethics in Paramedicine

HANDOUT 8-1

Student’s Name _______________ EVALUATION CHAPTER 8 QUIZ

Write the letter of the best answer in the space provided. ______1. The rules or standards that govern the conduct of members of a particular group or profession are known as: a. guidelines. b. morals. c. ethics. d. laws. ______2. Social, religious, or personal standards of right and wrong are a. ethics. b. morals. c. mores. d. beliefs. ______3. Allowing a person to decide how to behave and accepting whatever decision that person makes is called: a. consequentialism. b. the deontological method. c. ethical relativism. d. the Golden Rule. ______4. Utilitarians, who believe that the purpose of an action should be to bring the greatest happiness to the greatest number of people, believe in: a. consequentialism. b. the deontological method. c. ethical relativism. d. the Golden Rule. ______5. The single most important question a paramedic has to answer when faced with an ethical challenge is: a. “What are my protocols?” ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

b. “What are the patient’s family’s wishes?” c. “What is in the patient’s best interest?” d. “Does the patient have a valid DNR?” ______6. The principle of doing good for the patient is known as: a. autonomy. b. justice. c. beneficence. d. nonmaleficence. ______ 7. The obligation to treat all patients fairly is known as: a. autonomy. b. justice. c. beneficence. d. nonmaleficence. ______8. The term for a competent adult patient’s right to determine what happens to his own body is: a. autonomy. b. justice. c. beneficence. d. nonmaleficence. ______9. The Latin phrase primum non nocere, or “First, do no harm,” sums up the principle of: a. autonomy. b. justice. c. beneficence. d. nonmaleficence. ______10. One of the three basic steps in solving an ethical problem is: a. stating the action in a situation-specific form. b. listing the implications or consequences of the action. c. comparing implications or consequences to current protocols. d. applying the impartiality test. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______11. Asking whether you can justify or defend your actions to others is called the: a. interpersonal justifiability test. b. universalizability test. c. autonomizability test. d. relevantability test. ______12. A general principle for paramedics to follow regarding advance directives is that you should: a. always follow the family’s wishes. b. accept verbal DNR orders from other health care providers. c. when in doubt, resuscitate. d. under no circumstances accept any DNR order in the prehospital setting. ______13. A competent patient of legal age has the right to decide what health care he does not wish to receive. To exercise this right, a patient must have: a. an attorney present to witness the patient’s decision. b. an advance directive document physically with him. c. the mental faculties to weigh the risks and benefits. d. a consultation with his personal physician. ______14. An ethical issue raised by the role of a paramedic as a preceptor is whether: a. the paramedic may function in the hospital setting. b. patients should be informed that a student is caring for them. c. the paramedic can allow the student to perform advanced skills under his supervision. d. the paramedic should allow the student to drive the EMS vehicle. ______15. One of the three most common sources of conflict between physicians and paramedics is a situation in which: a. the physician refuses to allow the paramedic to perform a procedure. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

b. the physician orders something that the paramedic believes is medically acceptable but morally wrong. c. the physician requires the paramedic to perform a skill outside the paramedic’s scope of practice. d. the physician requires the paramedic to obtain on-line direction for all advanced procedures.

HANDOUT 8-2

Student’s Name _____________ EVALUATION CHAPTER 8 SCENARIO

Review the following real-life situation. Then answer the questions that follow. At 2 A.M., Medic 6 is dispatched to assist EMTs on the scene of an attempted suicide. On arrival, they find the scene in the kitchen under control, with one EMT getting a history of the patient, a 24-year-old female, from her distraught husband. The other EMT is rechecking the patient’s blood pressure, which is only 78 palpated, down from 84/60. The patient’s cut wrists are bandaged, and the EMTs, who have been there less than 5 minutes, are preparing to apply a PASG. Meanwhile, the husband states that he woke up and found his wife unconscious on the kitchen floor with blood everywhere. He explains that she has been troubled over a recent miscarriage. While setting up the IV and preparing to intubate per protocols, the paramedics quickly explain the need for these treatments to the husband, who nods affirmatively while watching. As the paramedics prepare to transport, the husband tells them that he wants his wife to go to Doctor’s Hospital, where her physician has privileges. The medics explain that, per protocol, she must go to County Hospital because it is the closest hospital with a psychiatric ward and works with the county health department on social service and mental health referrals. The husband continues to insist on transport to Doctor’s Hospital and refuses to allow further treatment until the paramedics agree. The paramedics finally agree and transport the patient to Doctor’s Hospital, where her physical wounds are treated and she is released. Three days later, the paramedic crew learns that another duty crew later transported the same woman to County Hospital, suffering from a sedative overdose. The husband was at work, and the call came in from a neighbor. These medics started an IV per protocol and gave naloxone per medical direction, but the woman was pronounced dead after 40 minutes of resuscitation efforts at the hospital.

1. Discuss how this scenario illustrates the conflict of implied consent versus the wishes of the husband. 2. How could the paramedics have resolved this ethical dilemma in the patient’s best interest?

HANDOUT 8-3

Student’s Name ___________ REINFORCEMENT CHAPTER 8 REVIEW

Write the word or words that best complete each sentence in the space provided. 1. The social, religious, or personal standards of right and wrong are called _______________________. 2. The rules or standards that govern the conduct of members of a particular group or profession are called _______________________. 3. Allowing each person to decide how to behave and accepting whatever decision that person makes is called _______________________ _______________________. 4. Saying that people should just fulfill their duties is known as the _______________________ method. 5. Believing that actions can be judged as good or bad only after we know the consequences of those actions is called _______________________. 6. The single most important question a paramedic has to answer when faced with an ethical challenge is “_______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________?” 7. The principle of doing good for the patient is called _______________________. 8. The obligation not to harm the patient is called _______________________. 9. A competent adult patient’s right to determine what happens to his own body is called _______________________. 10. The obligation to treat all patients fairly is called _______________________. 11. Primum non nocere is Latin for “_______________________, _______________________ _______________________ _______________________.” ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

12. The first element in solving an ethical problem is “State the action in a(n) _______________________ form.” 13. The second element in solving an ethical problem is “List the _______________________ or _______________________ of the action.” 14. The third element in solving an ethical problem is “Compare the results to _______________________ values.” 15. One of the quick ways to test ethics is by asking whether you would be willing to undergo this procedure or action if you were in the patient’s place. This is called the _______________________ test. 16. Asking whether you can defend or justify your actions to others is called the _______________________ _______________________ test. 17. The _______________________ test asks whether you would want this action performed in all relevantly similar circumstances. 18. The general principle for paramedics to follow regarding DNRs is “When in doubt, _______________________.” 19. Providing the most care to the most seriously injured patients is the _______________________ method of triage. 20. Military triage has traditionally concentrated on helping the _______________________ _______________________ _______________________.

HANDOUT 8-4

Student’s Name _______________ REINFORCEMENT ETHICS LIST COMPLETION

Complete the following lists regarding ethics in advanced prehospital care. 1. List three different approaches for determining how a medical professional should behave under different circumstances. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 2. List the four fundamental principles used in solving bioethics problems. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 3. List the three steps in solving an ethical problem. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 4. List the three quick ways to test ethics. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

Chapter 8 Answer Key

Handout 8-1: Chapter 8 Quiz 1. c

5. c

9. d

13. c

2. b

6. c

10. b

14. b

3. c

7. b

11. a

15. b

4. a

8. a

12. c

Handout 8-2: Chapter 8 Scenario 1. When a patient is unconscious, EMS providers, using implied consent, assume that the patient would wish to be treated appropriately. This includes being transported to the most appropriate medical facility. The closest facility may not always be the most appropriate. In this case, the patient’s husband wanted transport to a particular hospital because the patient’s physician had privileges there. However, that hospital was not equipped to handle the psychiatric component of the patient’s condition. The conflict involved the paramedics’ wanting to do what was in the best interest of the patient and the husband’s wanting transport to a less appropriate facility. 2. The paramedics should have explained why one hospital was more appropriate than the other. Proper patient care should have outweighed where the patient’s physician had privileges. If time permitted, the paramedics could also have had medical direction talk with the husband briefly by telephone. As a last resort, law enforcement could have been summoned if the husband became uncontrollable and was continuing to refuse proper care for his wife. Handout 8-3: Chapter 8 Review 1. morals 2. ethics 3. ethical relativism 4. deontological 5. consequentialism 6. What is in the patient’s best interest 7. beneficence ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

8. nonmaleficence 9. autonomy 10. justice 11. First, do no harm 12. universal 13. implications, consequences 14. relevant 15. impartiality 16. interpersonal justifiability 17. universalizability 18. resuscitate 19. civilian 20. least seriously injured Handout 8-4: Ethics List Completion 1. Ethical relativism Deontological method Consequentialism 2. Beneficence Nonmaleficence Autonomy Justice 3. State the action in a universal form. List the implications or consequences of the action. Compare them to relevant values. 4. Impartiality test Universalizability test Interpersonal justifiability test

Chapter 9 EMS System Communications

Student’s Name __________

HANDOUT 9-1

REINFORCEMENT RADIO SKILLS Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Skill/Behavior

1. Verifies open channel before speaking 2. Presses transmit button 1 second before speaking 3. Holds microphone 2 to 3 inches from mouth 4. Speaks slowly and clearly 5. Speaks in a normal pitch, avoiding emotion 6. Is brief, knows what to say before transmitting 7. Does not waste air time 8. Protects privacy of patient 9. Echoes dispatch information or physician’s orders 10. Writes down dispatch information and physician’s orders 11. Confirms that message has been received 12. Demonstrates ability to troubleshoot basic equipment malfunction Comments:

Student’s Name __________

HANDOUT 9-2 EVALUATION

CHAPTER 9 QUIZ Write the letter of the best answer in the space provided. ______1. The process of exchanging information between individuals is called: a. transmitting. b. communication. c. verbal skills. d. Sending and receiving. ______2. In the basic communications model, the: a. sender gives feedback to the receiver. b. receiver requests contact with the sender. c. sender encodes message. d. receiver decodes feedback to sender. ______3. The term _________ can be defined as “related to the meaning of words.” a. technical b. semantic c. encoded d. mutual ______4. The SafeCom program recommends that agencies: a. develop a 10-code system for radio communications. b. have a statewide 10-code system for radio communications. c. all use a standardized 10-code system for radio communications. d. all use plain English for radio communications. ______5. When you repeat back each statement to confirm accurate reception and understanding, you are employing what type of procedure? a. Model b. Repetition c. Mimic d. Echo ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______6. Structures that contain steel and concrete: a. always interfere with radio transmissions. b. may interfere with radio transmissions. c. improve radio transmissions. d. do not affect radio transmissions. ______7. An incomplete patient care report indicates: a. a need for additional time in between responses to complete paperwork. b. inefficient care. c. that patient care took priority over documentation. d. that some portions of the patient care report did not apply to that particular patient. ______8. The first link in the chain of events of an EMS response is: a. call taking and emergency response. b. prearrival instructions. c. detection and citizen access. d. call coordination and incident recording. ______9. A dispatcher’s telling callers how to perform appropriate emergency measures while waiting for emergency responders to arrive is called: a. priority drill. b. prearrival instructions. c. call coaching. d. medical direction. ______10. A ______ communications system allows simultaneous two-way communications by using two frequencies for each channel. a. simplex b. duplex c. multiplex d. trunking

______11. Ambulances responding within a city will usually transmit radio communications on: a. ultrahigh frequency. b. very high frequency. c. ultralow frequency. d. very low frequency. ______12. If a communications system is described as “trunked,” it means that all frequencies are: a. independent. b. divided by jurisdiction. c. pooled. d. divided into UHF and VHF. ______13. The gathering of specific patterns of patient complaints and signs and symptoms in a specific demographic region is known as: a. symptomatic surveillance. b. demographic surveillance. c. syndromic surveillance. d. serial surveillance. ______14. General radio procedures include: a. using codes whenever possible to shorten transmissions. b. giving the patient’s name so that the hospital can look up admission records. c. not waiting for confirmation that your message was received, to shorten transmission time. d. being concise to hold the attention of the person receiving your radio report. ______15. The agency that regulates all nongovernmental communications in the United States is (the): a. FTC. b. NHTSA. c. FCC. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

d. DOT.

HANDOUT 9-3

Student’s Name _________ EVALUATION CHAPTER 9 SCENARIO

Review the following real-life situation. Then answer the questions that follow. A woman walking down a city side street notices a man lying on the sidewalk. He appears to be having a seizure. The woman dials 911. The dispatcher asks the woman to describe the problem and to give her location. The woman describes the man’s condition to the best of her ability, but she is a visitor to the area and does not know the street’s name or her exact location. The dispatcher, through an enhanced 911 system, locates the site of the call and dispatches an ALS ambulance and police to the scene. The EMS unit arrives and begins patient care. The paramedics recognize the patient as an individual with diabetes-related problems whom they have assisted in the past. After managing the patient’s airway and taking cervical spinal precautions, the paramedics initiate an IV, complete a rapid test for blood glucose, and administer 50 percent dextrose solution. They contact the hospital, report their findings and treatment to the emergency room physician, and continue on to the hospital. There, the paramedics turn the patient over to the emergency room staff. They then complete the prehospital care report, clean and restock the ambulance, and inform EMS dispatch that they are back in service. 1. List the EMS response communications chain of events illustrated in this scenario. 2. Why was the local 911 system of great importance in this scenario? 3. What tasks did the dispatcher perform? 4. What information about the patient and the situation should the paramedics have conveyed to the emergency room physician? 5. Why is a written prehospital care report important in a case like this?

Student’s Name __________

HANDOUT 9-4

REINFORCEMENT CHAPTER 9 REVIEW Write the word or words that best complete each sentence in the space provided. 1.

________________________ barriers to effective communication are those related to the meanings of words.

The feature of combining a wide range of radio bands is called ________________________ ________________________.

The written report of an EMS response is a(n) ________________________ ________________________ ________________________.

The radio term meaning “end of transmission” is “________________________.”

________________________ ________________________ ________________________ are electronic devices that capture crash data in the few seconds before, during, and after a crash.

The public’s first contact within the EMS system is the ________________________ ________________________ ________________________.

The dispatcher’s directions to a caller for appropriate emergency measures are known as ________________________ instructions.

A medical dispatcher’s interrogating a distressed caller and following established guidelines to determine the appropriate level of response is called ________________________ dispatching.

A(n) ________________________ communications system transmits and receives on the same frequency.

10. A(n) ________________________ communications system can transmit voice and data simultaneously. 11. A(n) ________________________ communications system pools all frequencies and routes transmissions to the next available frequency. 12. A vehicle-mounted computer keyboard with display is called a(n) ________________________ ________________________ ________________________.

13. Using your patient’s ________________________ on the radio violates FCC regulations. 14. _________ __________ ________ __________ has the potential to significantly reduce death and disability because of the need for rural crashes to be “discovered.” 15. The federal agency that has the authority to spot-check base stations and dispatch centers is the ________________________.

Student’s Name __________

HANDOUT 9-5

REINFORCEMENT ORGANIZING THE PATIENT MEDICAL REPORT Below are elements of the patient report given by a paramedic to the hospital physician. Place the elements in correct order by writing a 1 next to the information that should be given first, a 2 next to the information that should be given second, and so on. ______Past medical history ______Vital signs; level of consciousness, general appearance/degree of distress; ECG findings; glucose testing results; trauma index/Glasgow Coma Scale score; other pertinent physical findings ______Scene description/mechanism of injury ______Associated symptoms ______Brief history of present illness ______Chief complaint ______Patient’s age, sex, weight ______Agency, unit designation, paramedic’s name and level of certification

Student’s Name __________

HANDOUT 9-6

REINFORCEMENT COMPOSING THE PATIENT MEDICAL REPORT Listed below are elements of a patient report for a call by Medic Unit 4, with a crew of one paramedic and one EMT-Basic. The information is not necessarily in the proper order for a radio report, nor is all of the information relevant to the present circumstances. Use the information to assemble a clear, concise, and orderly radio report to the hospital on this patient. The unit is about 5 minutes’ traveling time from the hospital. Patient is an 83-year-old female patient. Patient states she became dizzy and fell on the floor in her hallway. Lungs are clear bilaterally. Patient complains of pain to her left hip and leg. Patient lives by herself and has four cats. Distal pulses are present in the left leg. Patient denies chest pain or shortness of breath. Daughter lives three blocks away and is not on the scene. Patient appears confused and not totally aware of her surroundings. Skin of the left leg is warm and pink. Patient’s physician is Dr. Allen Miller. Patient has been immobilized to backboard. Daughter says patient has cardiac history and takes digoxin and Lasix daily. IV has been established. ECG shows atrial fibrillation. There is lateral rotation and shortening of the patient’s left leg. Supplemental oxygen is being provided. Vital signs are: B/P—110/70; pulse—136, weak; respirations—28, shallow.

Student’s Name __________

HANDOUT 9-7

REINFORCEMENT SPECIAL PROJECT: RADIO INVENTORY Complete this radio inventory for the EMS vehicles and agencies in your area. Indicate each channel, its designated frequency, and what it is used for. BASE STATION RADIOS Location

Channel

Frequency

Use

MOBILE RADIOS Location

Channel

Frequency

Use

PORTABLE RADIOS Location

Channel

Frequency

Use

Chapter 9 Answer Key Handout 9-2: Chapter 5 Quiz 1. b 2. c 3. b 4. d

5. d 6. b 7. b 8. c

9. b 10. b 11. a 12. c

13. c 14. d 15. c

Handout 9-3: Chapter 9 Scenario 1. Detection and citizen access, call taking and emergency response, prearrival instructions, call coordination and incident recording, discussion with medical direction physician, transfer communications, back in service, ready for next call 2. The enhanced 911 system permitted the dispatcher to recognize the location of the call and dispatch the EMS unit to the proper site. 3. The dispatcher obtained basic information about the call, directed the appropriate vehicles to it, and noted the unit’s return to service. 4. The paramedics should have conveyed the following: their unit and paramedic identifications; scene description; patient’s age, sex, and weight; patient’s chief complaint, associated symptoms, history of present illness, pertinent past medical history, physical exam findings, ECG results, and Glasgow Coma Scale score, if appropriate; treatment rendered; ETA at the hospital; name of the patient’s physician, if known. 5. The written record helps to ensure a continuum of care for the patient and can help provide legal protection for the paramedics should any legal issues arise. Handout 9-4: Chapter 9 Review 1. Semantic 2. multiband radio 3. patient care report 4. clear 5. Event data recorders 6. emergency medical dispatcher 7. prearrival 8. priority 9. simplex 10. multiplex 11. trunked 12. mobile data terminal 13. name ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

14. Advanced automatic crash notification 15. FCC Handout 9-5: Organizing the Patient Medical Report Numbers reading from top to bottom should be 7, 8, 2, 6, 5, 4, 3, 1 Handout 9-6: Composing the Patient Medical Report One suggested example follows; variations are acceptable. Medical control, this is Unit 4, Paramedic ______. We are en route to your location with an 83-year-old female who states that she became weak and dizzy and fell at home. Her chief complaint is pain to her left leg and hip. She appears rather confused and is not oriented to time or place. Current vitals are B/P 110/70, pulse 136 and weak, respirations 28 and shallow. Her left leg is laterally rotated and shortened. Distal pulses to the leg are present, and the skin is warm and pink. She has a cardiac history and takes digoxin and Lasix daily. Patient denies chest pain or shortness of breath. Her ECG reads atrial fibrillation, and her lungs are clear bilaterally. We have immobilized the patient on a backboard, applied oxygen, have an IV in place, and will continue to monitor. Our ETA is 5 minutes. Patient’s physician is Dr. Allen Miller.

Chapter 10 Documentation

Student’s Name ________________

HANDOUT 10-1

SKILLS DOCUMENT SKILLS Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Skill/Behavior 1. Records all pertinent administrative information using a consistent format 2. Identifies and records all pertinent, reportable clinical data for each patient, including pertinent negatives 3. Uses appropriate medical terminology, abbreviations, and acronyms 4. Records accurate, consistent times 5. Includes relevant oral statements of witnesses, bystanders, and patient 6. Completely identifies all additional resources and personnel 7. Uses correct spelling and grammar 8. Writes legibly 9. Uses appropriate narrative format and includes all appropriate information 10. Thoroughly documents patient refusals, denials of transport, and call cancellations 11. Properly corrects errors and omissions 12. Writes cautiously and avoids jargon, inferences, or any remarks that might be construed as derogatory or libelous 13. Completes report as soon as possible after the call

Student’s Name ________________

HANDOUT 10-2

EVALUATION CHAPTER 10 QUIZ Write the letter of the best answer in the space provided. ______1. Uses for prehospital care reports include: a. medical. c. research. b. administrative. d. all of the above. ______2. Using the information on a prehospital care report to identify problems with an EMS system is an example of a(n) ____use. a. medical c. administrative b. legal d. research ______3. Analyzing data from a prehospital care report to determine the efficacy of certain medical devices or interventions such as drugs is a(n)_____ use. a. administrative c. legal b. medical d. research ______4. A scannable run sheet on which you fill in boxes to record assessment and care information is known as a: a. bubble sheet. c. fill-in-the-dot report. b. narrative report. d. check-box report. ______5. Which of the following is a characteristic of a well-written PCR? a. Deletion of any negative findings b. Times approximated by the paramedics c. Complete identification of all additional resources and personnel d. Use of as much medical terminology as possible, even if the spelling is not accurate ______6. A patient who has a history of CABG in 1978 has had a: a. coronary artery bypass graft. b. chronic abdominal growth. c. calcium arterial blockage. d. cardiac artery balloongeoplasty. ______7. The abbreviation for paroxysmal nocturnal dyspnea is: a. PXD. c. PNOCD. b. PND. d. PXNOCD. ______8. If a medication is labeled to be taken “Pc,” it should be taken: a. on an empty stomach. c. after eating. b. with a full glass of water. d. before bed.

______9. The letter a in the abbreviation “a.c.” means: a. before. c. when needed. b. after. d. in the morning. _____10. The route of administration of a medication abbreviated “Po” means: a. injected in the muscle. c. rectally. b. orally. d. under the tongue. _____11. One common problem with documenting times is that: a. dispatch does not record times so will not be able to provide them to you. b. paramedics rarely wear watches because of potential contamination and only guess at time. c. inconsistencies exist between dispatch times, equipment times, and paramedic watches. d. there are more important things to do than document times. _____12. Additional or supplemental information to the original PCR is called a(n): a. epilog. c. supplement. b. postscript. d. addendum. _____13. To make a correction on a PCR that you have written, you should: a. completely black out the error before making the correction. b. destroy the PCR and rewrite it, making the correction. c. cross out the error with red ink, and write the correction above it. d. draw a single line through the error and initial it. _____14. An example of subjective information written in the narrative portion of your PCR is a: a. blood glucose of 102 mg/dL. b. chief complaint of chest pain. c. cardiac monitor showing first-degree block. d. trachea deviated to the left. _____15. The initials of the SOAP format of organizing a narrative report include: a. symptoms. c. assessment. b. overall impression. d. past medical history. _____16. The initials of the CHART format of organizing a narrative report include: a. chief complaint. c. relevant history. b. abnormalities. d. time. _____17. The refusal-of-care documentation checklist includes: a. contacting the patient’s family and advising of his refusal. b. having a police officer present to witness the refusal. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

c. assessing the competency of the patient. d. elimination of the need for a completed PCR. _____18. Which statement about denying transport is CORRECT? a. People with even the most minor injuries should be evaluated if they refuse transport. b. The risks of patient refusals are greater than those of denying transport. c. If a call is canceled en route, completing a PCR is optional but not necessary. d. The difference between “no patients found” and “only minor injuries, patient refusing transport” is relatively insignificant in documentation. _____19. Which of the following is CORRECT regarding mass casualty incidents? a. A complete PCR must be done on each patient. b. If you cannot remember details to include on your PCR, make an educated guess. c. Proper documentation takes precedence over patient care. d. Completing documentation for one patient before going on to care for others might be impractical. _____20. Which statement about inappropriate documentation is CORRECT? a. High-pressure, fast-paced situations eliminate the need for neatness. b. An inaccurate report can affect patient care days after the ambulance call ends. c. Paramedics are legally excused for any harmful consequences of poor documentation. d. Misspelled words do not reflect on the care provider’s professionalism.

Student’s Name ________________

HANDOUT 10-3

EVALUATION CHAPTER 10 SCENARIO Review the following real-life situation. Then follow the directions at the end of the scenario. You were dispatched to a senior citizens’ high-rise for a diabetic emergency. On arrival, you find your patient, 74-year-old Mr. Herbert, seated in the lobby. One of the other residents reports that Mr. Herbert is an insulin-dependent diabetic. Mr. Herbert complains that he has a headache and feels nauseated. His skin is pale, cool, and diaphoretic. Vital signs are as follows: B/P 100/80, pulse 64, and irregular, respirations 22 and shallow. Pulse oximetry shows an oxygen saturation of 96% on room air. You place him on high-flow oxygen via a nonrebreather mask. Your partner obtains a blood sample and determines the blood glucose to be 50 mg/dL. You start an IV and administer 50 milligrams of 50% dextrose. You contact medical direction and prepare to transport. Mr. Herbert reports that he is feeling much better now but has been having problems with his blood sugar for the past several days. You complete a focused physical exam and find no other acute problems. The ECG monitoring shows atrial fibrillation with a slow ventricular response. By the time you arrive at the hospital, they have obtained Mr. Herbert’s medical records. After giving your report and restocking your unit, you stop at the desk to look at his medical records. You read the following: 74 y/o WM with long history of CAD. CABG x 5 in 1986. Angina controlled with NTG PRN. DD insulin-dependent DM in 1980. Diabetic retinopathy and neuropathy. Meds: dig 0.25 mg q day, semilente insulin 25 units subcutaneous daily. Rewrite this paragraph, spelling out the acronyms and abbreviations.

Student’s Name ________________

HANDOUT 10-4

REINFORCEMENT CHAPTER 10 REVIEW Write the word or words that best complete each sentence in the space provided. 1. Providing hospital staff such as nurses and physicians with information regarding the patient is a(n) ________________ use for PCRs. 2. Gathering information for quality improvement and system management is a(n) ________________ use for PCRs. 3. One characteristic of a well-written PCR is the inclusion of ________________ negatives. 4. If you do not know how to spell a word, ________________ ________________ ________________ or use ________________ ________________. 5. Whenever possible, record all times from the ________________ ________________. 6. An element of good documentation is the absence of ________________. 7. Because many people must be able to read your PCR, one element of good documentation is ________________. 8. Ideally, PCRs should be completed ________________ ________________ the call. 9. If you find an error after you’ve already written several more sentences, submit a(n) ________________ to the PCR. 10. If you make a mistake writing your report, simply cross out the error with a(n) ________________ ________________. 11. “The patient is a 58-year-old male, conscious and breathing, complaining of shortness of breath” is an example of the ________________ part of your narrative. 12. Vital signs, physical exam findings, and tests are examples of the ________________ part of your narrative. 13. The two common patterns of organizing a narrative report are known by the mnemonics ________________ and ________________. 14. If your patient refuses care, you should explain to the patient about the possible ________________ of refusing care. 15. ________________ ________________ affixed to patients at a mass casualty incident contain vital patient information.

Student’s Name ________________

HANDOUT 10-5

REINFORCEMENT STANDARD CHARTING ABBREVIATIONS Write the standard abbreviation for each word or phrase listed in the space provided. ______ 1. Chief complaint ______ 2. Private medical doctor ______ 3. Abdomen ______ 4. Ear, nose, and throat ______ 5. No apparent distress ______ 6. Chronic obstructive pulmonary disease ______ 7. Coronary artery disease ______ 8. Insulin-dependent diabetes mellitus ______ 9. Upper respiratory infection ______ 10. Aspirin ______ 11. Nitroglycerin ______ 12. Nonsteroidal antiinflammatory drug ______ 13. Sodium bicarbonate ______ 14. Antecubital ______ 15. Arterial blood gas ______ 16. Complete blood count ______ 17. Computerized tomography ______ 18. Electrocardiogram ______ 19. Palpation ______ 20. After (post-) ______ 21. As needed ______ 22. Nothing by mouth ______ 23. Drop(s) ______ 24. Millimeters of mercury ______ 25. Premature ventricular contraction

CHAPTER 10 Answer Key Handout 10-2: Chapter 10 Quiz 1. d

8. c

15. c

2. c

9. a

16. a

3. d

10. b

17. c

4. a

11. c

18. a

5. c

12. d

19. d

6. a

13. d

20. b

7. b

14. b

Handout 10-3: Chapter 10 Scenario 1. 74-year-old white male with long history of coronary artery disease. Five coronary artery bypass grafts in 1986. Angina controlled with nitroglycerin as needed. Differential diagnosis insulin-dependent diabetes mellitus in 1980. Diabetic retinopathy and neuropathy. Medications: digoxin 0.25 mg every day, semilente insulin 25 units subcutaneously daily. Handout 10-4: Chapter 10 Review 1. medical 2. administrative 3. pertinent 4. look it up, another word 5. same clock 6. alterations 7. legibility 8. immediately after 9. addendum 10. single line 11. subjective 12. objective 13. SOAP, CHART 14. consequences ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

15. Triage tags Handout 10-5: Standard Charting Abbreviations 1. CC

10. ASA

19. Palp

2. PMD 11. NTG

20. p

3. Abd

12. NSAID

21. prn

4. ENT

13. NaHCO3 22. NPO

5. NAD

14. AC

23. gtt(s)

6. COPD 15. ABG

24. mmHg

7. CAD

25. PVC

16. CBC

8. IDDM 17. CT 9. URI

18. ECG, EKG

Chapter 11 Human Life Span Development

Student’s Name___________

HANDOUT 11-1 EVALUATION Chapter 11 Quiz

Write the letter of the best answer in the space provided. ______1. The greatest changes in the range of vital signs are in: a. pediatric patients. c. middle adulthood patients. b. early adulthood patients. d. late adulthood patients. ______2. An infant’s head is equal to what percentage of the total body weight? a. 10 percent c. 20 percent b. 15 percent d. 25 percent ______3. After birth, an infant’s cardiovascular system changes by constricting the ductus arteriosus. Once this closes, a. there is an immediate decrease in systemic vascular resistance. b. blood can bypass the lungs by moving from the pulmonary trunk directly into the aorta. c. there is a decrease in pulmonary vascular resistance. d. it becomes a fibrous cord embedded in the wall of the heart. ______4. The lungs of a full-term fetus continually secrete surfactant, the purpose of which is to: a. hold the moist membranes of the lungs together. b. reduce the surface tension so that the lungs expand more easily. c. increase the efficiency of the oxygen–carbon dioxide exchange. d. regulate blood flow from the pulmonary arteries to the lungs. ______5. Which of the following is TRUE regarding an infant’s pulmonary system? a. The infant is primarily a “mouth breather” until at least four weeks of age. b. An infant’s lung tissue is prone to barotrauma. c. Breathing becomes ineffective at rates higher than 30 breaths per minute. d. Slow respiratory rates lead to rapid heat and fluid loss. ______6. An infant can easily become dehydrated and develop water and electrolyte imbalance because: a. infants tend to perspire a great deal. b. infants’ urine is highly concentrated until the kidneys mature. c. infants’ stool has a large amount of water in it. d. infants’ urine is a relatively dilute fluid with a specific gravity that rarely exceeds 1.0. ______7. A reflex that occurs when a newborn is startled, causing the arms to be thrown wide and the fingers to spread, followed by a grabbing motion, is called the: a. palmar reflex. c. rooting reflex. b. Moro reflex. d. sucking reflex. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______8. The fontanelles allow for: a. growth of the heart and lungs. b. growth of long bones. c. compression of the head during childbirth. d. intracranial pressure changes when the infant sucks. ______9. An infant’s sense that his needs will be met by his caregivers is called: a. bonding. c. scaffolding. b. secure attachment. d. anxious resistant attachment. ______10. A stage of psychosocial development that lasts from birth to about 11⁄2 years of age is: a. passive-aggressive. c. trust vs. mistrust. b. secure attachment. d. scaffolding. ______11. A child characterized by regularity in body functions, low or moderate intensity of reactions, and acceptance of new situations is called a(n): a. difficult child. c. quick-to-warm child. b. easy child. d. slow-to-warm child. ______12. Which of the following statements is TRUE regarding the physiological development of the toddler to school-age child? a. The brain is now at 60 percent of adult weight. b. Chest muscles mature and can sustain excessively rapid respiratory rates. c. Passive immunity born with the infant will continue to function for a few more years. d. The kidneys are well developed by the toddler years. ______13. The parenting style in which parents are demanding and desire instant obedience from a child is called: a. permissive. c. authoritarian. b. prescriptive. d. militaristic. ______14. Which of the following statements best describes the psychosocial development of school-age children? a. The development of a self-concept occurs at this age. b. The school-age child strives for autonomy, and the parents strive for control. c. Capacity for logical, analytical, and abstract thinking is developed at this age. d. Separation anxiety is developed, as the child begins clinging and crying when a parent leaves. ______15. School-age children experience three levels of moral development. The punishment and obedience stage takes place at which level? a. Postadaptive reasoning c. Preconventional reasoning b. Communicative reasoning d. Cognitive reasoning ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______16. Depression and suicide are most common in which age group? a. Adolescence c. Middle adulthood b. Early adulthood d. Late adulthood ______17. Cardiovascular health becomes a major concern, with cardiac output decreasing and cholesterol levels increasing, for which age group? a. Adolescence c. Middle adulthood b. Early adulthood d. Late adulthood ______18. At 61 years of age and older, which of the following physiological changes takes place? a. Cortisol from the adrenal cortex is diminished by 50 percent. b. There is a 25 to 30 percent decrease in kidney mass. c. An increase in neurotransmitters in the nervous system results in a decrease in coordination. d. The ear canal atrophies, and the eardrum thins. ______19. A hearing loss of pure tones that increases with age is called: a. tone-deafness. c. audioporosis. b. presbycusis. d. cochlearitis. ______20. The major cause of death for adults 40 years of age and older is: a. suicide. c. falls. b. ill health. d. motor vehicle crashes.

Student’s Name___________

HANDOUT 11-2 EVALUATION

CHAPTER 11 SCENARIO Review the following real-life situation. Then answer the questions that follow. “Hammond Medic 5, respond priority one to 1324 170th Street for a seven-yearold child who has been vomiting and has a fever. Cross street is Chestnut Ave. Time out is 1750.” When you arrive on scene, the child’s mother meets you at the door. She appears anxious and concerned. She leads you to the child’s bedroom, where he is lying on the bed, obviously not feeling well, tightly holding a stuffed bear. His mother tells you that he has been sick for a couple of days and came home from school sick today. He began to vomit frequently this afternoon and “can’t keep anything down.” The child looks at the paramedics and begins to whimper. 1. How would you approach this patient? 2. How would you conduct your physical exam of this patient? 3. What are the normal vital signs for a child this age?

Student’s Name___________

HANDOUT 11-3

REINFORCEMENT CHAPTER 11 REVIEW Write the word or words that best complete the following sentences in the space provided. 1. The younger the child, the more ________________________________ the pulse and respiratory rate. 2. The infant’s head is equal to ________________________________ percent of total body weight. 3. An infant’s airway is ________________________________, ________________________________, less ________________________________, and more ________________________________ ________________________________ than that of an adult. 4. The ________________________________ ________________________________ occurs when a newborn is startled and its arms are thrown wide and fingers spread and a grabbing motion follows. 5. The ________________________________ ________________________________ is a reflex in the newborn that is elicited by placing a finger firmly in the infant’s palm. 6. The ________________________________ ________________________________ occurs when an infant’s cheek is touched by a hand or cloth and the hungry infant turns his head to the right or left. 7. The ________________________________ ________________________________ occurs when an infant’s lips are stroked. 8. Diamond-shaped soft spots of fibrous tissue at the top of an infant’s skull are called ________________________________. 9. ________________________________ is initially based on secure attachment. 10. ________________________________ ________________________________ ________________________________ is a type of bonding that occurs when an infant learns to be uncertain about whether his caregivers will be responsive or helpful when needed. 11. A type of bonding that occurs when an infant learns that his caregivers will be responsive and helpful when needed is called ________________________________ ________________________________.

12. ________________________________ ________________________________ ________________________________ is a type of bonding that occurs when an infant learns that his caregivers will not be responsive or helpful when needed. 13. ________________________________ ____ ________________________________ is a stage of psychosocial development that lasts from birth to about 11⁄2 years of age. 14. ________________________________ is a teaching/learning technique in which one builds on what has already been learned. 15. An infant who can be characterized by regularity of body functions, low or moderate intensity of reactions, and acceptance of new situations is called a(n) ________________________________ ________________________________. 16. An infant who can be characterized by a low intensity of reactions and a somewhat negative mood is called a(n) ________________________________ ________________________________. 17. Children develop separation anxiety between the ages of ________________________________ and ________________________________ months. 18. A(n) ________________________________ parenting style demands absolute obedience without regard for a child’s individual freedom. 19. ________________________________ parenting takes a tolerant, accepting view of a child’s behavior. 20. The stage of moral development during which children desire approval from individuals and society is called ________________________________ ________________________________. 21. Because of ________________________________, the adolescent prefers that parents not be present during physical examinations. 22. During middle adulthood, the body still functions at a high level with varying degrees of degradation based on the ________________________________. 23. The theoretical, species-specific, longest duration of life, excluding premature or “unnatural” death, is called ________________________________ ________________________________ ________________________________. 24. The ability to learn and adjust ________________________________ throughout life. 25. The theory that death is preceded by a five-year period of decreasing cognitive functioning is called the ________________________________ ________________________________.

Student’s Name___________

HANDOUT 11-4

REINFORCEMENT NORMAL VITAL SIGNS Complete the following chart, filling in pulse, respiration, and blood pressure for each of the developmental stages of life. Life Stage Infancy (at birth) Infancy (at 1 yr) Toddler (12–36 mo) Preschool age (3–5 yrs) School age (6–12 yrs) Adolescence (13–18 yrs) Early adulthood (19–40 yrs) Middle adulthood (41–60 yrs) Late adulthood (61+ yrs)

Pulse

Resp.

Chapter 11 Answer Key Handout 11-1: Chapter 11 Quiz 1. a 2. d 3. c 4. b 5. b

6. d 7. b 8. c 9. b 10. c

11. b 12. d 13. c 14. a 15. c

16. a 17. c 18. b 19. b 20. b

Handout 11-2: Chapter 11 Scenario 1. Remember that individuals in this age group have developed decisionmaking skills and are allowed more self-regulation. It is important to talk to the child, not just the parent. Introduce yourself to this patient as you would to any patient, and even though a parent is there, ask the patient’s permission to treat him or to take a look at him. While you can gain much of your medical history information from the mother, ask the patient questions also. A child this age can be a good source of information, especially about his current medical problem. Since this age group begins to develop selfesteem, your inclusion of the patient in the process will help him psychologically as well. 2. Be sure to involve the patient in the process. Do not ignore him and just talk with the parent. Explain what you are doing and why. Ask permission to perform vital signs and any portion of the physical exam you feel is necessary. The child will respond well to you if you treat him with respect, but do not forget that he is a child. Allow him to continue to hold onto his stuffed bear if possible. You may even perform some portions of the physical exam on the bear first, to show the child what will happen. Be sure to get down to the patient’s eye level or below when talking with him. You are an authority figure, especially in your uniform, so do whatever you can to allay his fears. 3. School-age children have a pulse rate of 65 to 110 beats per minute, a respiratory rate of 18 to 30 breaths per minute, a blood pressure of 97 to 112 systolic, and an average body temperature of 98.6°F. Handout 11-3: Chapter 11 Review 1. rapid 2. 25 3. shorter, narrower, stable, easily obstructed 4. Moro reflex 5. palmar grasp 6. rooting reflex 7. ducking reflex 8. fontanelles ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

9. Bonding 10. Anxious resistant attachment 11. secure attachment 12. Anxious avoidant attachment 13. Trust vs. mistrust 14. Scaffolding 15. easy child 16. slow-to-warm-up child 17. 18, 24 18. authoritarian 19. Permissive 20. conventional reasoning 21. modesty 22. individual 23. maximum life span 24. continues 25. terminal-drop hypothesis Handout 11-4: Normal Vital Signs Life Stage Infancy (at birth) Infancy (at 1 yr) Toddler (12–36 mo) Preschool age (3–5 yrs) School age (6–12 yrs) Adolescence (13–18 yrs) Early adulthood (19–40 yrs) Middle adulthood (41–60 yrs) Late adulthood (61+ yrs)

Pulse Resp. BP 100–180 30–60 60–90 systolic 100–160 30–60 87–105 systolic 80–110 24–40 95–105 systolic 70–110 22–34 95–110 systolic 65–110 18–30 97–112 systolic 60–90 12–26 112–128 systolic 60–100 12–20 120/80 60–100 12–20 120/80 Depends on individual health status

Chapter 12 Pathophysiology

HANDOUT 12-1 Student’s Name __________________ EVALUATION CHAPTER 12 QUIZ PART 1: DISEASE Write the letter of the best answer in the space provided. _______1.

_______2.

_______3.

_______4.

_______5.

_______6.

_______7.

_______8.

_______9.

______10.

______11.

______12.

The steady state of balance that the body tries to maintain is called: a. homeostasis. c. turnover. b. stress. d. adaptation. A group of tissues functioning together is called a(n): a. organ system. c. organ. b. tissue group. d. multifunction tissue. A group of organ systems functioning together is called a(n): a. body. c. organism. b. structure. d. animal. Organisms of the same species that reside in a distinct geographic area are called a(n): a. community c. population b. territory d. ecosystem Obesity is classified as which type of predisposing factor? a. Genetics c. Social b. Environment d. Lifestyle The normal sequence of events that lead to a disease is called: a. stages. c. sequencing. b. pathogenesis. d. mutation. A symptom is: a. objective. c. subjective. b. something that you see. d. something that you can smell. A disease that has a sudden onset is called: a. chronic. c. insidious. b. acute. d. abrupt. Sequelae of a disease are: a. side effects. c. complications. b. unexpected. d. life-threatening events. Diabetes is a disease that is classified as: a. metabolic . c. idiopathic. b. genetic. d. congenital. A disease that occurs because of medical treatment is called: a. neoplastic. c. ischemic. b. idiopathic . d. iatrogenic. The cause of an idiopathic disease is:

a. genetic. b. unknown.

c. environmental. d. congenital.

HANDOUT 12-2 Student’s Name __________________ EVALUATION CHAPTER 12 QUIZ PART 2: DISEASE AT THE CHEMICAL LEVEL Write the letter of the best answer in the space provided. ______1. The fundamental chemical unit is the: a. electron. c. neutron. b. atom. d. cell. ______2. Any charged atomic particle is called a(n): a. cation. c. ion. b. anion. d. electrolyte. ______3. An ion with a negative charge is called a(n): a. anion. c. electrolyte. b. cation. d. dissociate. ______4. The chemical notation for sodium chloride is: a. H2CO3. c. Ca++. b. Na+.d. NaCl. ______5. Chemicals that do not contain carbon are: a. organic . c. inorganic. b. isotonic. d. compound. ______6. Glycogenolysis is the breakdown of: a. glucose into glycogen. c. glycogen into glucose. b. glycogen into disaccharide. d. glucose into disaccharide. ______7. The nucleic acid that contains the genetic instructions for life is: a. ATP. c. RNA. b. DNA. d. ADP. ______8. A high-energy compound that is present in all cells is: a. cytoplasm. c. hysosome. b. adenosine triphosphate. d. deoxyribonucleic acid. ______9.The constructive phase of metabolism in which cells convert nonliving substances into living cytoplasm is called: a. anabolism. c. apoptosis. b. catabolism. d. necrosis. _____10. Substances that give up protons during chemical reactions are called: a. acids. c. bases. b. carbohydrates. d. proteins. _____11. Which of the following, based on the pH, is considered a base? a. Stomach secretions c. Saliva b. Blood d. Urine ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______12. The most rapidly acting buffer system is the: a. phosphate buffer system. b. carbonic acid–bicarbonate buffer system. c. respiratory buffer system. d. protein buffer system. ______13. Hypoventilation results in: a. respiratory acidosis. c. metabolic acidosis. b. respiratory alkalosis. d. metabolic alkalosis. ______14. Patients with diabetes or other kidney disease are at risk for developing: a. respiratory acidosis. c. metabolic acidosis. b. respiratory alkalosis. d. metabolic alkalosis. ______15. Vomiting is the most common cause of: a. respiratory acidosis. c. metabolic acidosis. b. respiratory alkalosis. d. metabolic alkalosis. ______16. Hyperventilation syndrome will cause: a. respiratory acidosis. c. metabolic acidosis. b. respiratory alkalosis. d. metabolic alkalosis.

HANDOUT 12-3 Student’s Name __________________ EVALUATION CHAPTER 12 QUIZ PART 3: DISEASE AT THE CELLULAR LEVEL Write the letter of the best answer in the space provided. _______1. The basic structural unit of all plants and animals is the: a. DNA. c. organelle. b. cell. d. tissue. _______2. The thick fluid that fills a cell is called the: a. nucleus. c. ectoplasm. b. endoplasm .d. cytoplasm. _______3.The membrane of a cell allows certain substances to pass from one side to another but does not allow other substances to pass. This means that the cell membrane is: a. dissociated. c. semipermeable. b. anaerobic. d. filterizable. _______4.The organelle that contains the genetic material, DNA, and enzymes is the: a. nucleus. c. endoplasmic reticulum. b. Golgi apparatus. d. mitochondria. _______5.The difference in concentration between solutions on opposite sides of a semipermeable membrane is called: a. the osmotic gradient .c. osmosis. b. diffusion. d. the facilitated balance. _______6.When a solution on one side of a semipermeable membrane is hypotonic, it: a. has a greater concentration of solute molecules. b. is equal in concentration of solute molecules. c. has a lesser concentration of solute molecules. d. will not move through the membrane. _______7.The pressure exerted by the concentration of solutes on one side of a membrane that, if hypertonic, tends to “pull” water from the other side of the membrane is called: a. hydrostatic pressure. c. oncotic force. b. osmotic pressure.d. net filtration. _______8. What percentage of an average adult’s body is water? a. 80 percent c. 70 percent b. 75 percent d. 60 percent _______9. Approximately 70 percent of all body water is: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. intracellular. c. extracellular. b. interstitial .d. intravascular. _______10. The fluid outside the body cell is called: a. intravascular fluid .c. extracellular fluid. b. interstitial fluid .d. intracellular fluid. _______11. Dehydration may be caused by internal losses, such as: a. burns, surgical drains, or open wounds. b. diaphoresis. c. bowel obstruction. d. hyperventilation. _______12. Poor skin turgor is often seen in a patient presenting with: a. hypertension. c. diaphoresis. b. dehydration. d. vasodilation. _______13. The total amount of water lost from blood plasma across the capillary membrane into the interstitial space is called: a. osmotic pressure.c. net filtration. b. oncotic force. D. osmolarity. _______14. Edema is the accumulation of water in the: a. interstitial space. c. intracellular space. b. extracellular space.d. intravascular space. _______15. Plasma is made up of approximately what percentage of water? a. 98 percent c. 86 percent b. 92 percent d. 82 percent _______16. The component of blood that contains hemoglobin and transports oxygen is the: a. erythrocyte. c. thrombocyte. b. leukocyte. d. plasma. _______17. Intravenous fluids that contain proteins are called: a. colloids. c. pasma. b. crystalloids. d. albumins. _______18. Lactated Ringer’s solution is an example of a(n) ____ solution. a. isotonic c. hypotonic b. hypertonic d. normotonic _______19. An electrolyte solution of sodium chloride in water is: a. D5W. c. normal saline. b. lactated Ringer’s solution. d. Harman’s solution. _______20. Every human cell contains how many pairs of chromosomes? a. 45 c. 23 b. 37 d. 12 _______21. An increase in the number of cells resulting from an increased workload is known as: a. hyperplasia. c. atrophy. b. hypertrophy. d. dysphasia. _______22. Aerobic exercise gradually causes ______ of the myocardium. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. dilation c. hypertrophy b. atrophy d. hyperplasia _______23. A decrease in cell size resulting from a decreased workload is called: a. hyperplasia. c. atrophy. b. mitosis. d. dysplasia. _______24. “Necrosis” means: a. an injured cell destroying itself.c. oxygen deficiency. b. cell death. d. a buildup of waste products. _______25. The most common cause of cellular injury is oxygen deficiency, or: a. ischemia. c. infarction. b. hypoxia. d. inflammation.

HANDOUT 12-4 Student’s Name __________________ EVALUATION CHAPTER 12 QUIZ PART 4: DISEASE AT THE TISSUE LEVEL Write the letter of the best answer in the space provided. _______1. The innermost germ cell layer is called the: a. endoderm.

c. exoderm.

b. mesoderm.

d. extoderm.

_______2. The tissue that lines internal and external body surfaces and protects the body is called: a. connective tissue. b. epithelial tissue.

c. smooth tissue. d. muscle tissue.

_______3. Simple squamous epithelial tissue is found in the: a. lungs.

c. kidneys.

b. stomach.

d. heart.

_______4. Connective tissues: a. are not directly attached to one other. b. are directly attached to one another. c. are derived from ectoderm. d. are derived from endoderm. _______5. The most abundant cell type found in connective tissue is: a. mast cells.

c. adipocytes.

b. fibroblasts.

d. macrophages.

c. adipocytes.

b. fibroblasts.

d. macrophages.

_______7. Ligaments attach bones to: a. muscles.

c. cartilage.

b. bone.

d. tendon.

_______8. The type of muscle tissue encircling blood vessels is: a. skeletal muscle.

c. connective muscle.

b. smooth muscle.

d. cardiac muscle.

_______9. “Metastasis” occurs when malignant cells: a. reproduce in the original location. b. die off. c. shed to other areas of the body. d. develop their own blood supply. _______10. The event that begins the transformation from normal tissue to cancer is: a. transformation.

c. initiation.

b. promotion.

d. development.

HANDOUT 12-5 Student’s Name __________________ EVALUATION CHAPTER 12 QUIZ PART 5: DISEASE AT THE ORGAN LEVEL Write the letter of the best answer in the space provided. _______1. Diseases caused by a combination of genetic and environmental factors are called: a. multisystem failure. b. multifactorial disorders.

c. multiple defect. d. geno-environmental.

_______2. All of the following are immunological disorders, EXCEPT: a. diabetes. b. rheumatic fever.

c. allergies. d. asthma.

_______3. The disease caused by a genetic clotting factor deficiency is: a. hemochromatosis.

c. hemophilia.

b. anemia .

d. encephalitis.

_______4. A neuromuscular disorder known to be caused by a genetic defect is: a. cholecyctitis. b. Huntington’s disease.

c. Crohn’s disease. d. schizophrenia.

_______5. The supplying of oxygen and nutrients to the body tissues is called: a. circulation.

c. perfusion.

b. hydration .

d. output.

_______6. a. Which of the following is NOT one of the three components of the circulatory system? a. Siphon

c. Container

b. Fluid

d. Pump

a. amount of blood pumped by the heart with each contraction of the ventricles. b. force of the blood pumped by the heart with each contraction fo the ventricles. c. resistance that a contraction of the heart must overcome in order to eject blood. d. amount of blood pumped by the heart in 1 minute. _______8. The pressure against which the heart must pump is called: a. afterload.

c. preload.

b. peripheral vascular resistance. d. cardiac contractile force. _______9. The dependence on a set of conditions for oxygen movement and utilization is known as: a. the Fick principle.

c. the Frank-Starling principle.

b. Cushing’s triad.

d. the principle of Willis.

_______10. Your patient has received a large traumatic injury. Blood pressure is normal, but the heart rate and respiratory rate are increased, and the skin is cool and clammy. Your patient is in: a. homeostasis. b. compensated shock.

c. decompensated shock. d. irreversible shock.

_______11. A drop in blood pressure in the patient described in question 10 means the patient is in: a. homeostasis. b. compensated shock.

c. decompensated shock. d. irreversible shock.

_______12. Abnormal distribution and return of blood from vasodilation, vasopermeability, or both, is the definition of: a. cardiogenic shock. b. ischemic shock.

c. obstructive shock. d. distributive shock.

b. replacing fluid rapidly with a crystalloid solution. c. keeping the patient warm. d. applying and inflating the PASG. _______14. The type of shock resulting from arteries losing tone and dilating is known as: a. hypovolemic shock.

c. hemorrhagic shock.

b. cardiogenic shock.

d. neurogenic shock.

_______15. The progressive impairment of two or more organ systems resulting from an uncontrolled inflammatory response to a severe illness or injury is called: a. multiple organ system failure. b. multiple organ dysfunction syndrome. c. multiple system failure. d. multiple sepsis syndrome.

HANDOUT 12-6 Student’s Name __________________ EVALUATION CHAPTER 12 QUIZ PART 6: THE BODY’S DEFENSE AGAINST DISEASE AND INJURY Write the letter of the best answer in the space provided. _______1. The systemic spread of toxins through the bloodstream is called: a. infection.

c. pathogenia.

b. septicemia.

d. toxemia.

_______2. Which of the following begins within seconds of injury or invasion by a pathogen? a. Immune response

c. Inflammatory response

b. Febrile response

d. Leukocyte response

_______3. Which of the following is NOT one of the three lines of defense for infection? a. Anatomic barriers

c. Immune response

b. Febrile response

d. Inflammatory response

_______4. Protection from infection or disease that is developed by the body after exposure to an antigen is called: a. acquired immunity. b. natural immunity.

c. primary immune response. d. syntheic immunity.

_______5. The special type of leukocyte that is responsible for recognizing foreign antigens, producing antibodies, and developing memory is the: a. lymphocyte b. cytoplast

c. thrombocyte d. erythrocyte

_______6. The type of white blood cell that does not produce antibodies but instead attacks antigens directly is the: a. T lymphocyte.

c. IgM lymphocyte.

b. B lymphocyte.

d. IgD lymphocyte.

_______7. Molecules that do not trigger an immune response on their own but can become immunogenic when combined with larger molecules are called: a. HLA antigens. b. MHC antigens.

c. Haptens. d. Immunogens.

_______8. Someone is considered a universal donor if he has blood type: a. O.

c. B.

b. A .

d. AB.

_______9. The development, by B lymphocyte precursors in the bone marrow, of receptors for every possible type of antigen is called: a. clonal selection .

c. clonal integration.

b. clonal diversity.

d. clonal application.

_______10. Antigen–antibody complex is the: a. substance formed when an antibody combines with an antigen to deactivate or destroy it. b. substance formed when an antibody to a specific antigen is developed by the body. c. result of an antibody’s attaching to a normal red blood cell. d. DNA from an antigen being absorbed by an antibody. _______11. The first antibody produced during the primary immune response is the: a. IgM. b.IgG .

c. IgA. d. IgE.

_______12. The cells that transfer delayed hypersensitivity and secrete proteins that activate other cells are called: a. Td cells.

c. Th cells.

b. Tc cells.

d. Ts cells.

_______13. Proteins produced by white blood cells, the “messengers” of the immune response, are the: a. monokines. b. prokines.

c. cytokines. d. antokines.

_______14. The organ that is responsible for T cell development is the: a. spleen. b. pancreas.

c. thymus. d. hypothalamus.

_______15. Which of the following statements is TRUE regarding the difference between the immune response and the inflammatory response? a. The immune response is specific; inflammation is nonspecific. b. The immune response is temporary; inflammation is long-lasting. c. The immune response develops swiftly; inflammation develops slowly. d. The immune response involves many types of white cells; inflammation involves one type of white blood cell. _______16. One of the four functions of inflammation is: a. walling off the infected and inflamed area. b. attacking foreign substances. c. developing a memory for antigens. d. producing whIte blood cells. _______17. The type of cells that are responsible for activating the inflammatory response are the: a. T cells.

c. mast cells.

b. B cells.

d. plasma cells.

_______18. The substance released by platelets that, through constriction and dilation of blood vessels, affects blood flow to an injured or affected site is called: a. histamine.

c. granules.

b. serotonin.

d. pus.

_______19. The plasma protein system that causes vasodilation, extravascular smooth muscle contraction, increased permeability, and possibly chemotaxis is the: a. kinin system .

c. clotting system.

b. coagulation system

d. cascade system.

_______20. Cells that can ingest other cells and substances, such as bacteria and cell debris, are: a. neutrophils.

c. basophils.

b. phagocytes.

d. macrocytes.

_______21. A tumor or growth that forms when foreign bodies cannot be destroyed and that is surrounded and walled off is called a: a. fibroblast.

c. melanoma.

b. granuloma.

d. cyst.

_______22. The complete healing of a wound and return of tissues to their normal structure and function is called: a. regeneration. b. repair.

c. debridement. d. resolution.

_______23. Graft rejection and contact allergic reactions, such as poison ivy, are examples of: a. Type I reactions.

c. Type II reactions.

b. Type III reactions.

d. Type IV reactions.

_______24. In stage I of a general adaptation syndrome, a person: a. experiences “burnout.”

c. begins to cope.

b. experiences “fight or flight.”

d. experiences physical illness.

_______25. The adrenal cortex releases a steroid hormone that regulates the metabolism of fats, carbohydrates, sodium, potassium, and proteins. That hormone is: a. cortisol. b. testosterone.

c. growth hormone. d. beta-endorphins.

HANDOUT 12-7 Student’s Name __________________ REINFORCEMENT CHAPTER 12 REVIEW PARTS 1–3: DISEASE, DISEASE AT THE CHEMICAL LEVEL, DISEASE AT THE CELLULAR LEVEL Write the word or words that best complete each sentence in the space provided. 1. The basic structural unit of all plants and animals is the _______________. 2. _______________ means that a cell membrane allows certain substances, but not all, to pass through. 3. The thick fluid that fills a cell is the _______________. 4. Structures that perform specific functions within a cell are called _______________. 5. The organelle within a cell that contains the DNA is the _______________. 6. _______________ _______________ is a high-energy compound present in all cells, especially muscle cells. 7. A group of cells that perform a similar function is called _______________. 8. Every human somatic cell contains _______________ chromosomes. 9. Characteristics of impaired cellular metabolism in shock include the impaired use of _______________ and _______________. 10. _______________ is the natural tendency of the body to maintain a steady and normal internal environment. 11. The total changes that take place during physiological processes are called _______________. 12. An increase in cell size resulting from an increased workload is called _______________. 13. An increase in the number of cells resulting from an increased workload is called _______________. 14. A blockage in the delivery of oxygenated blood to the cells is called _______________. 15. The destructive phase of metabolism in which cells break down complex substances into simpler substances to release energy is called _______________. 16. A substance that separates into electrically charged particles in water is called a(n) _______________. 17 Movement of a substance through a cell membrane against the osmotic gradient is called _______________ _______________. 18. Diffusion of a substance, such as glucose, through a cell membrane that requires the assistance of a “helper” is called _______________ _______________. 19. A substance that can crystallize and can diffuse through a membrane is called a(n) _______________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

20. The _______________ _______________ _______________ is a measure of relative acidity or alkalinity. 21. A pH below 7.35 is referred to as _______________. 22. An increase in plasma bicarbonate due to diuresis, vomiting, or ingestion of too much sodium bicarbonate is called _______________ _______________.

HANDOUT 12-8 Student’s Name __________________ REINFORCEMENT CHAPTER 12 REVIEW PARTS 4–6: DISEASE—CAUSES AND PATHOPHYSIOLOGY Write the word or words that best complete each sentence in the space provided. 1. ______ tissue is the protective tissue that lines the internal and external body surfaces. 2. The supplying of oxygen and nutrients to the body tissues as a result of the constant passage of blood through the capillaries is called _______________. 3. Inadequate perfusion of the body tissues is known as _______________, or _______________. 4. The circulatory system consists of three components: the _______________ (_______________), the _______________ (_______________), and the _______________ (_______________ _______________). 5. The amount of blood delivered to the heart during diastole is called _______________. 6. The strength of a contraction of the heart is called _______________ _______________ _______________. 7. Epinephrine and norepinephrine are _______________. 8. The resistance a contraction of the heart must overcome in order to eject blood is known as _______________. 9. The amount of blood pumped by the heart in 1 minute is called the _______________ _______________. 10. _______________ _______________ are involved in the long-term regulation of sodium and water balance, blood volume, and arterial pressure. 11. A group of tissues functioning together is called a(n)_____________. 12. _______________ metabolism is the second stage of metabolism and requires oxygen. 13. _______________ metabolism is the first stage of metabolism and does not require oxygen. 14. The early stage of shock during which the body’s compensatory mechanisms are able to maintain normal perfusion is called _______________ shock. 15. _______________ shock has progressed so far that no medical intervention can reverse the condition and death is inevitable. 16. _______________ shock is caused by a loss of intravascular fluid volume. 17. _______________ shock is the result of a brain or spinal cord injury. 18. The shock that develops as the result of infection carried by the bloodstream is called _______________ shock. 19. The progressive impairment of two or more organ systems resulting from an uncontrolled inflammatory response is called _______________ ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

_______________ _______________ _______________. 20. Patients in _______________ shock should have their head and shoulders elevated, with fluid administration kept to a minimum. 21. A single-cell organism with a cell membrane and cytoplasm but having no organized nucleus is a _______________. 22. Toxic substances secreted by bacterial cells during their growth are called _______________. 23. Molecules in the walls of certain Gram-negative bacteria that are released when the bacterium dies or is destroyed, causing toxic effects on the host body, are called _______________. 24. The systemic spread of toxins through the bloodstream is called _______________. 25. An organism that is visible only under an electron microscope and that can grow only with the assistance of another organism is a(n) _______________. 26. A marker on the surface of a cell that identifies it as “self” or “nonself” is a(n) _______________. 27. A(n) _______________ is a substance produced by B lymphocytes in response to the presence of a foreign antigen. 28. _______________ is a long-term condition of protection from infection or disease. 29. Proteins that are produced in response to foreign antigens and that destroy or control the antigens are called _______________. 30. The swift, strong response of the immune system to repeated exposures to an antigen is called the _______________ _______________ _______________. 31. The long-term immunity to an antigen provided by antibodies produced by B lymphocytes is called _______________ immunity. 32. _______________ immunity is the short-term immunity to an antigen provided by T lymphocytes. 33. _______________ antigens are antigens the body recognizes as self or nonself. 34. The _______________ _______________ _______________ is a group of genes on chromosome 6 that provide the genetic code for HLA antigens. 35. _______________ cells are undifferentiated cells in the bone marrow from which all blood cells develop. 36. An antibody that is very pure and specific to a single antigen is a(n) _______________ antibody. 37. _______________ are proteins produced by white blood cells; they regulate immune responses by binding with and affecting the function of the cells that produce them. 38. The body’s response to cellular injury is _______________. 39. The substance released during the degranulation of mast cells is _______________. 40. _______________ are substances synthesized by mast cells during ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

inflammatory response that cause vasodilation, vascular permeability, and chemotaxis and may also cause pain. 41. _______________ are substances that penetrate vessel walls to move into the surrounding tissues at the site of an inflammation. 42. _______________ is the adherence of white cells to vessel walls in the early stages of inflammation. 43. The movement of white cells out of blood vessels through gaps in the vessel walls that are created when inflammatory processes cause the vessel walls to constrict is called _______________. 44. Cells that can ingest other cells and substances are called _______________. 45. _______________ is a liquid mixture of dead cells, bits of dead tissue, and tissue fluid that may accumulate in inflamed tissues. 46. Healing of a wound with a scar formation is called _______________. 47. The cleaning up or removal of debris, dead cells, and scabs from a wound, principally through phagocytosis, is called _______________. 48. _______________ is an exaggerated or harmful immune response. 49. A chemical or physical disturbance in the cells or tissue fluid produced by a change in the external environment or within the body is called _______________ stress. 50. Sympathetic nervous system stimulation results in the release of norepinephrine and epinephrine, which constitute the category of hormones called _______________.

HANDOUT 12-9 Student’s Name __________________ REINFORCEMENT CHAPTER 12 MATCHING Write the correct letter in the blank before each item. a. Anion b. Buffer c. Cation d. Dehydration e. Electrolytes f. Extracellular g. Homeostasis h. Interstitial i Intracellular j. Intravascular k. Ion l. Metabolism m. Solvent n. Turgor o. Water ________ 1. The body’s natural tendency to keep the internal environment constant ________ 2. Totality of ongoing biochemical and physiological activity necessary to support life ________ 3. Charged particle ________ 4. Separate or break down ________ 5. Universal solvent, making up 65 percent of the body’s weight ________ 6. Portion of the body fluid outside the body’s cells ________ 7. Resistance of the skin to deformation ________ 8. Positively charged ion ________ 9. Portion of the body fluid found outside the body’s cells yet not within the circulatory system ________ 10. Chemical substances that break down into electrically charged particles when placed in water ________ 11. Substance in which another substance will dissolve ________ 12. Portion of the body fluid outside the body’s cells and within the circulatory system ________ 13. Portion of the body fluid inside the body’s cells ________ 14. Abnormal decrease in total body water ________ 15.Negatively charged ion

HANDOUT 12-10 Student’s Name __________________ REINFORCEMENT CHAPTER 12 COMPLETION THE ROOT “CYT” Fill in each blank with the appropriate word that includes the root “cyt,” meaning cell. 1. _____________ Thick fluid that fills a cell 2. _____________ Clear liquid portion of the thick fluid that fills a cell 3. _____________ Structure of protein filaments that supports the internal structure of a cell 4. _____________ Red blood cell 5. _____________ White blood cell 6. _____________ Blood cell responsible for clotting; also called a platelet 7. _____________ Type of white blood cell that attacks foreign substances as part of the body’s immune system 8. _____________ Cell that has the ability to ingest other cells and substances, such as bacteria and cell debris 9. _____________ Ingestion and digestion of bacteria and other substances by certain cells 10. _____________ White blood cell with a single nucleus; the largest normal blood cell 11. _____________ White cell with multiple nuclei that has the appearance of a bag of granules 12. _____________ Protein produced by a white blood cell that instructs neighboring cells to respond in a genetically preprogrammed fashion 13. _____________ Substance that is poisonous to cells 14. _____________ Poisonous (toxic) to cells

HANDOUT 12-11 Student’s Name __________________ REINFORCEMENT CHAPTER 12 COMPLETION Complete each of the following lists. Pathogen vs. the Body: Three Possible Outcomes 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ Causes of Cellular Injury 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. _________________________________________________________ 5. _________________________________________________________ 6. _________________________________________________________ 7. _________________________________________________________ Causes of Dehydration 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. _________________________________________________________ 5. _________________________________________________________ 6. _________________________________________________________ 7. _________________________________________________________ Types of Shock 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. _________________________________________________________ 5. _________________________________________________________ Classes of Immunoglobulins 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. _________________________________________________________ 5. _________________________________________________________ Types of Mature T Cells ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. _________________________________________________________ 5. _________________________________________________________

HANDOUT 12-12 Student’s Name __________________ REINFORCEMENT CHAPTER 12 CHEMICAL NOTATION Write the appropriate name of the element next to each chemical notation. 1. H _________________________________________________________ 2. O _________________________________________________________ 3. C _________________________________________________________ 4. N _________________________________________________________ 5. Ca _________________________________________________________ 6. Cl _________________________________________________________ 7. I _________________________________________________________ 8. Fe _________________________________________________________ 9. Mg _________________________________________________________ 10. Ph _________________________________________________________ 11. K _________________________________________________________ 12. Na _________________________________________________________ 13. S _________________________________________________________ 14. NaCl ________________________________________________________ 15. H2O _________________________________________________________ 16. H2CO3 _______________________________________________________ 17. Na+ _________________________________________________________ 18. K+ _________________________________________________________ 19. Ca++ ________________________________________________________ 20. Mg++ ________________________________________________________ 21. Cl– _________________________________________________________ 22. HCO–3 _______________________________________________________ 23. HPO–4 _______________________________________________________

HANDOUT 12-13 Student’s Name __________________ REINFORCEMENT CHAPTER 12 TRUE OR FALSE Indicate whether the following statements are true or false by writing a T or an F in the space provided. _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 10. _____ 11. _____ 12. _____ 13. _____ 14. _____ 15. _____ 16. _____ 17. _____ 18. _____ 19. _____ 20.

1. Acid-base balance is a dynamic relationship that reflects the relative concentration of bicarbonate ions in the body. 2. pH 6 represents a hydrogen ion concentration ten times as great as that represented by pH 7. 3. The lower the pH, the greater the alkalinity. 4. Acidosis is a high concentration of hydrogen ions, a pH below 7.35. 5. Normal pH range in humans is 6.0 to 7.0. 6. The fastest mechanism for removing hydrogen ions from the body is the buffer system. 7. One of the mechanisms the body uses to eliminate hydrogen ions is through liver function. 8. In a healthy individual, for every molecule of carbonic acid, there are ten molecules of bicarbonate ion. 9. An increase in hydrogen ions leads to an increase in carbonic acid. Carbonic acid is unstable and will eventually dissociate into carbon dioxide and water. Carbonic anhydrase is found in the blood’s erythrocytes and slows the dissociation of carbonic acid in the blood. Ammonia water is an example of an acidic solution. Drain opener is an example of a basic solution. Increased respirations cause a decrease in hydrogen ions and an increase in pH. Respiratory acidosis is caused by the retention of CO2. Metabolic alkalosis can be the result of diarrhea and vomiting. In metabolic acidosis, the pH is decreased, and the CO2 level is normal. Treatment for metabolic acidosis frequently requires an IV bolus of sodium bicarbonate. An increase in CO2 causes an increase in hydrogen ion concentration and a decrease in pH. Neutral pH is 6.45, which is also the normal pH for the human body.

Chapter 12 Answer Key Handout 1-1: Chapter 12 Quiz, Part 1 1. a 2. c 3. c 4. c

5. d 6. b 7. c 8. b

Handout 1-2: Chapter 12 Quiz, Part 2 1. b 6. c 11. b 16. b 2. b 7. b 12. b 3. a 8. b 13. a 4. d 9. a 14. c 5. c 10. a 15. d Handout 1-3: Chapter 12 Quiz, Part 3 1. b 10. c 19. c 2. d 11. c 20. c 3. c 12. b 21. a 4. a 13. c 22. c 5. a 14. a 23. c 6. c 15. b 24. b 7. b 16. a 25. a 8. d 17. a 9. a 18. a

Handout 1-4: Chapter 12 Quiz, Part 4 1. a 2. b 3. d 4. a 5. b

6. d 7. b 8. b 9. c 10. c

Handout 1-5: Chapter 12 Quiz, Part 5 1. b 2. a 3. c 4. b 5. c

6. a 11. c 7. d 12. d 8. b 13. c 9. a 14. d 10. b 15. b

9. c 10. a 11. d 12. b

Handout 1-6: Chapter 12 Quiz, Part 6 1. b 2. c 3. b 4. a 5. a 6. a 7. c 8. a 9. b

10. a 19. a 11. a 20. b 12. a 21. b 13. c 22. d 14. c 23. d 15. a 24. b 16. a 25. a 17. c 18. b

Handout 1-7: Chapter 12 Review, Parts 1-3 1. cell 2. “Semipermeable” 3. cytoplasm 4. organelles 5. nucleus 6. Adenosine triphosphate 7. tissue 8. 46 9. oxygen, glucose 10. Homeostasis 11. metabolism 12. hypertrophy 13. hyperplasia 14. ischemia 15. catabolism 16. electrolyte 17. active transport 18. facilitated diffusion 19. crystalloid 20. potential of hydrogen 21. acidosis 22. metabolic alkalosis Handout 1-8: Chapter 12 Review, Parts 4–6 1. Epithelial 2. perfusion 3. hypoperfusion, shock 4. pump (heart), fluid (blood), container (blood vessels) 5. preload ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

6. cardiac contractile force 7. catecholamines 8. afterload 9. cardiac output 10. Natriuretic peptides 11. organ 12. Aerobic 13. Anaerobic 14. compensated 15. Irreversible 16. Hypovolemic 17. Neurogenic 18. septic 19. multiple organ dysfunction syndrome 20. cardiogenic 21. bacterium 22. exotoxins 23. endotoxins 24. septicemia 25. virus 26. antigen 27. antibody 28. Immunity 29. immunoglobulins 30. secondary immune response 31. humoral 32. Cell-mediated 33. HLA 34. major histocompatibility complex 35. Stem 36. monoclonal 37. Cytokines 38. inflammation 39. histamine 40. Leukotrienes 41. Exudates 42. Margination 43. diapedesis 44. phagocytes 45. Pus 46. repair 47. debridement 48. Hypersensitivity ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

49. physiological 50. catecholamines Handout 1-9: Chapter 12 Matching 1. g 5. o 9. h 13. i 2. l 6. f 10. e 14. d 3. k 7. n 11. m 15. a 4. b 8. c 12. j Handout 1-10: Chapter 12 Completion 1. Cytoplasm 2. Cytosol 3. Cytoskeleton 4. Erythrocyte 5. Leukocyte 6. Thrombocyte 7. Lymphocyte 8. Phagocyte 9. Phagocytosis 10. Monocyte 11. Granulocyte 12. Cytokine 13. Cytotoxin 14. Cytotoxic Handout 1-11: Chapter 12 Completion Pathogen vs. the Body: Three Possible Outcomes 1. Pathogen wins. 2. Pathogen and body battle to a draw. 3. Body defeats pathogen. Causes of Cellular Injury 1. Hypoxia 2. Chemicals 3. Infectious agents 4. Inflammatory reactions 5. Physical agents 6. Nutritional factors 7. Genetic factors Causes of Dehydration ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

1. Vomiting 2. Diarrhea 3. Perspiration 4. Peritonitis 5. Malnutrition 6. Burns 7. Open wounds Types of Shock 1. Cardiogenic 2. Hypovolemic 3. Neurogenic 4. Anaphylactic 5. Septic Classes of Immunoglobulins 1. IgM 2. IgG 3. IgA 4. IgE 5. IgD Types of Mature T Cells 1. Memory cells 2. Td 3. Tc 4. Th 5. Ts Handout 1-12: Chapter 12 Chemical Notation 1. Hydrogen 2. Oxygen 3. Carbon 4. Nitrogen 5. Calcium 6. Chlorine 7. Iodine 8. Iron 9. Magnesium 10. Phosphorus 11. Potassium 12. Sodium 13. Sulfur ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

14. Sodium chloride 15. Water 16. Carbonic acid 17. Sodium cation 18. Potassium cation 19. Calcium cation 20. Magnesium cation 21. Chloride anion 22. Bicarbonate 23. Phosphate Handout 1-13: Chapter 12 True or False 1. F 6. T 11. F 16. F 2. T 7. F 12. F 17. T 3. F 8. F 13. T 18. F 4. T 9. T 14. T 19. T 5. F 10. T 15. T 20. F

Chapter 13 Emergency Pharmacology

Student’s Name___________

HANDOUT 13-1

EVALUATION CHAPTER 13 QUIZ PART 1: BASIC PHARMACOLOGY Write the letter of the best answer in the space provided. ______1. Which of the following is one of the four drug names? a. biological name

c. official name

b. proper name

d. sales name

______2. The four main sources for drugs include: a. animals.

c. minerals.

b. plants.

d. all of the above.

______3. For many years, the primary source of insulin for treating diabetes mellitus was the extract of: a. primate pancreas.

c. equine pancreas.

b. porcine pancreas.

d. human pancreas.

______4. A compilation of drug inserts, the printed fact sheets that drug manufacturers supply with most medications, is found in the: a. United States Pharmacopeia.

c. AMA Drug Evaluation.

b. Monthly Prescribing Reference.

d. Physicians’ Desk Reference.

______5. Name, classification, mechanism of action, and indications are information contained in a drug’s: a. profile.

c. synopsis.

b. overview.

d. review.

______6. According to the Controlled Substances Act of 1970, heroin is a Schedule 1 drug, meaning that it: a. has a low abuse potential. b. has no accepted medical indications. c. may lead to limited psychological and/or physical dependence. d. has a low physical, but high psychological, dependence potential. ______7. Drug legislation passed in the United States in 1906 to protect the public from adulterated or mislabeled drugs was the: a. Harrison Narcotic Act. b. Federal Food, Drug, and Cosmetic Act. c. Pure Food and Drug Act. d. Comprehensive Drug Abuse Prevention and Control Act. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______8. According to the Controlled Substances Act of 1970, diazepam, lorazepam, and phenobarbital are: a. Schedule V drugs.

c. Schedule III drugs.

b. Schedule IV drugs.

d. Schedule II drugs.

______9. The _________________________________ test determines the amount and purity of a given chemical in a preparation. a. assay

c. bioassay

b. bioequivalence

d. pharmacokinetics

______10. How a drug is absorbed, distributed, metabolized, and excreted is called: a. bioequivalence.

c. pharmacodynamics.

b. pharmacokinetics.

d. pharmacology.

______11. Which of the following is one of the six “rights” of medication administration? a. The right container

c. The right route

b. The right doctor

d. The right pharmacy

______12. Medication packages containing a single dose for a single patient are called: a. one-time-use packaging.

c. single-patient packaging.

b. dose packaging.

d. unit packaging.

______13. A medication that may deform or kill a fetus is called a: a. Category A drug.

c. fetal risk drug.

b. teratogenic drug.

d. fundalgenic drug.

______14. The _________________________________ gives approximation of a child’s weight based on his height. a. Roberts test

c. Weinstein ratio

b. Stanislav meter

d. Broselow tape

______15. How a drug interacts with the body to cause its effects is called: a. bioequivalence.

c. pharmacodynamics.

b. pharmacokinetics.

d. pharmacology.

______16. Facilitated diffusion is: a. the process by which carrier proteins transport large molecules across the cell membrane. b. the movement of a substance without the use of energy. c. the movement of solute in a solution from an area of higher ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

good

concentration to an area of lower concentration. d. the movement of molecules across a membrane from an area of higher pressure to an area of lower pressure. ______17. The movement of solvent in a solution from an area of lower solute concentration to an area of higher solute concentration is called: a. filtration.

c. osmosis.

b. passive transport.

d. diffusion.

______18. Which of the following is TRUE regarding absorption? a. The body absorbs most drugs faster through intramuscular injection than through subcutaneous injection. b. Time-released medications may have an enteric coating that dissolves more readily in an acidic environment than in a more alkaline environment. c. The higher a drug’s concentration, the more slowly the body will absorb it. d. No absorption needs to occur if a drug is injected intramuscularly, as it is already in the tissue. ______ 19. The liver’s partial or complete inactivation of a drug before it reaches the systemic circulation is the _________________________________ effect. a. hepatic filtration

c. liver–blood barrier

b. first-pass

d. antidrug

’______20. Certain organs exclude some drugs from distribution. An example of this is the: a. arterial–venous barrier.

c. blood–brain barrier.

b. endothelial barrier.

d. uterine–fetal barrier.

______21. An example of the enteral route of drug administration is: a. sublingual.

c. subcutaneous.

b. intravenous.

d. topical.

______22. Drugs administered by the parenteral route are delivered: a. through the gastrointestinal tract. b. outside the gastrointestinal tract. c. through an endotracheal or nasogastric tube. d. directly on the skin. ______23. Buccal administration of a drug is accomplished: a. by nasal spray. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

b. through a newborn’s umbilical vein or artery. c. between the cheek and the gum. d. through an intraosseous needle. ______24. A liquid form of a drug that is prepared using an alcohol extraction process is called a(n): a. solution.

c. emulsion.

b. tincture.

d. spirit.

______25. The force of attraction between a drug and a receptor is called: a. efficacy.

c. combining.

b. binding.

d. affinity.

______26. A drug’s ability to cause the expected response is its: a. concentration.

c. viability.

b. affinity.

d. efficacy.

______27. An agonist is a drug that binds to a receptor: a. but does not cause it to initiate the expected response. b. and causes it to initiate the expected response. c. and stimulates some of its effects but blocks others. d. and causes a deformity on the binding site. ______28. By developing a tolerance for morphine sulfate, a patient may develop a tolerance for other opioid agents. This is known as: a. tachyphylaxis.

c. cross tolerance.

b. idiosyncrasy.

d. addiction.

______29. An antagonist drug binds to a receptor: a. but does not cause it to initiate the expected response. b. and causes it to initiate the expected response. c. and stimulates some of its effects but blocks others. d. and causes a deformity on the binding site. ______30. The analogy of a lock and key is used to describe drugs that: a. stimulate a receptor site. b. cause the body to increase the production of a substance. c. escort substances through cell membranes. d. reduce or eliminate an allergic reaction. ______31. The period from the time that a drug’s level drops below its minimum effective concentration until it is eliminated from the body is called: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. duration of action.

c. termination of action.

b. therapeutic index.

d. biological half-life.

______32. Age affects the drug-response relationship because: a. infants and the elderly have less body fat. b. the digestive process in infants and the elderly is not as efficient. c. medication noncompliance occurs frequently in the elderly. d. the liver and kidney functions of the elderly have begun to deteriorate. ______33. Factors that affect the standard drug-response relationship include: a. the gravity of the medication. b. the consistency of the medication. c. time of administration. d. brand-name vs. generic medications. ______34. The unintended adverse response known as summation is due to: a. unintentionally taking too much of one drug. b. one drug’s enhancing the effect of another drug. c. a direct biochemical interaction between two drugs. d. two drugs that have the same effect being given together. ______35. If a patient believes that a drug will have a given effect, then he is much more likely to perceive that the effect has occurred. This is known as the: a. substitution agent.

c. self-defense mechanism.

b. phantom factor.

d. placebo effect.

Student’s Name_________

HANDOUT 13-2

EVALUATION CHAPTER 13 QUIZ PART 2: DRUG CLASSIFICATIONS Write the letter of the best answer in the space provided. ______1. Components of the central nervous system include: a. the autonomic nervous system.

c. the feed-or-breed system.

b. the brain and spinal cord.

d. sensory nerves in the skin.

______2. A drug that best demonstrates a class’s common properties is called a(n): a. prototype.

c. omega.

b. beta.

d. production.

______3. The drug that best demonstrates the common properties of opioid agonists and illustrates their particular characteristics is: a. chloroform.

c. heroin.

b. morphine.

d. codeine.

______4. An agent that enhances the effects of other drugs is a(n): a. secondary medication.

c. booster medication.

b. peripheral medication.

d. adjunct medication.

______5. The prototype opioid antagonist is: a. opium.

c. Narcan.

b. versed.

d. ibuprofen.

______6. Which of the following statements regarding opioid agonist–antagonist drugs is TRUE? a. Respiratory depression is a common side effect in therapeutic doses. b. This class of drug is given in conjunction with other drugs to enhance their effects. c. This class of drug combines decreased sensation of pain with amnesia. d. This class of drug decreases pain response and has few respiratory depressant or addictive side effects.

______7. The major difference between anesthetic and neuroleptanesthetic drugs is that the neuroleptanesthetic drugs: a. decrease pain sensation and produce amnesia while the patient remains conscious. b. induce a loss of all sensation, often impairing consciousness. c. are neuromuscular blocking agents that produce paralysis. d. include halothane, which is the prototype for this class of drug. ______8. Benzodiazepines and barbiturates are the two main pharmacological classes in the functional class of: a. antiseizure or antiepileptic drugs. c. antianxiety and sedative– hypnotic drugs. b. analgesics and antagonists.

d. anesthetics.

______9. The drug that is used primarily to treat absence seizures is: a. phenytoin.

c. phenobarbitol.

b. ethosuximide.

d. carbamazepine.

______10. The central nervous system stimulants known as the methylxanthines include: a. Ritalin.

c. theophylline.

b. Dexedrine.

d. amphetamine sulfate.

______11. Methylphenidate is the most commonly prescribed drug for: a. asthma. disorder.

c. attention deficit hyperactivity

b. congestive heart failure.

d. motion sickness.

______12. Muscle tremors and parkinsonism-like effects are common side effects of antipsychotic medications. These are known as: a. extrapyramidal symptoms.

c. psychotherapeutic symptoms.

b. neuroleptic symptoms.

d. partial seizures.

______13. The prototype phenothiazine drug is: a. Haldol.

c. Benadryl.

b. Thorazine.

d. Ritalin.

______14. Which of the following is TRUE regarding phenothiazines and butyrophenones? a. Both have been the mainstays of psychiatry since the mid-1960s. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

b. With these medications, therapeutic effects appear to come from blocking the alpha1 adrenergic receptors in the peripheral nervous system. c. Medications in this group block dopamine receptors. d. Both are used to treat allergies by blocking histamine receptors. ______15. Acute dystonic reactions are treated with: a. atropine.

c. Dilantin.

b. epinephrine.

d. diphenhydramine.

______16.

SSRIs are used primarily as:

a. antiseizure medications.

c. antidepressant medications.

b. Parkinson’s disease medications. d. bipolar disorder medications. ______17. Which of the following is an MAO inhibitor? a. Nardil

c. Zoloft

b. Paxil

d. Prozac

______18. The part of the nervous system that controls involuntary actions is the: a. central nervous system.

c. somatic nervous system.

b. peripheral nervous system.

d. autonomic nervous system.

______19. Stimulation of the parasympathetic nervous system results in: a. pupillary dilation. b. secretion by digestive glands. c. increase in heart rate and cardiac contractile force. d. bronchodilation. ______20. Stimulation of the _________________________________ receptors promotes the breakdown of lipids for energy production. a. alpha1

c. beta1

b. alpha2

d. beta3

______21. The acronym SLUDGE is helpful in remembering the effects of cholinergic medication. The effects include: a. sedation.

c. urination.

b. lactation.

d. dilation.

______22. The effects of an atropine overdose include the description: a. “Cold as ice.”

c. “Sane as a saint.”

b. “Blind as a bat.”

d. “Wet as water.”

______23. Drugs that produce consciousness are:

state

paralysis

without

affecting

a. ganglionic stimulating agents. agents.

c. neuromuscular blocking

b. ganglionic blocking agents.

d. anticholinergics.

______24. Stimulation of the nerves leaving the collateral ganglia in the abdominal cavity causes: a. increased blood flow to the abdominal organs. b. increased digestive activity. c. relaxation of smooth muscle in the wall of the urinary bladder. d. retention of glucose stores in the liver. ______25. Dopaminergic receptors, although not fully understood, are believed to cause: a. dilation of the renal, coronary, and cerebral arteries. b. constriction of peripheral arteries. c. an increase in respirations and blood flow to the respiratory system. d. constriction of the hepatic arteries. ______26. Stimulation of the alpha1 receptors results in: a. increased heart rate. b. renin release.

c. bronchodilation.

d.arteriole and venous constriction.

______27. Stimulation of beta2 receptors results in: a. increased heart rate. b. inhibition of contractions of the uterus. c. increased cardiac contractility. d. mydriasis. ______28. Terbutaline specifically targets: a. Alpha1 receptors.

c. Beta1 receptors.

b. Alpha2 receptors.

d. Beta2 receptors.

______29. Lidocaine and phenytoin belong to the class of: a. calcium channel blockers.

c. sodium channel blockers.

b. potassium channel blockers.

d. beta blockers.

______30. Procainamide is indicated in the treatment of: a. atrial fibrillation with a rapid ventricular response. b. torsade de pointes. c. hypertension. d. congestive heart failure. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

______31. An endogenous nucleoside with a very short half-life (about 10 seconds), with alarming side effects, such as shortness of breath and chest pain, is: a. Lanoxin.

c. Adenocard.

b. magnesium.

d. verapamil.

______32. Which class of drugs is used to decrease blood pressure by decreasing the amount of circulating angiotensin II and decreasing peripheral vascular resistance? a. Calcium channel blockers

c. Direct vasodilators

b. ACE inhibitors

d. Adrenergic inhibiting agents

______33. Drugs that are used to treat high blood cholesterol are called: a. vasculotensives.

c. LDLs.

b. ACE inhibitors.

d. antihyperlipidemics.

______34. Activase is used to: a. break down thrombi. b. dilate blood vessels to reduce blood pressure. c. decrease the formation of platelet plugs. d. interrupt the clotting cascade. ______35. Beta2-specific agents that are used to treat asthma-induced shortness of breath include: a. Proventil.

c. Flovent.

b. theophylline.

d. Deltasone.

______36. Medications that suppress the stimulus to cough in the central nervous system are called: a. antihistamines.

c. antitussives.

b. expectorants.

d. mucolytics.

______37. The hormone oxytocin causes uterine contraction and milk ejection. It is released by the: a. thyroid.

c. adrenal.

b. pancreas.

d. posterior pituitary.

______38. The substance that is secreted from the pancreatic islets by alpha cells and that increases blood glucose level is: a. insulin.

c. prolactin.

b. glucagon.

d. luteinizing hormone.

______39. A solution containing a modified pathogen that does not actually cause disease but still stimulates the development of antibodies ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

specific to it is a(n): a. serum.

c. immunoglobulin.

b. vaccine.

d. antibiotic.

______40. The antidote for organophosphate poisoning is: a. epinephrine.

c. Benadryl.

b. lidocaine.

d. atropine.

Student’s Name___________

HANDOUT 13-3

EVALUATION CHAPTER 13 SCENARIO Review the following real-life situation. Then answer the questions that follow. You receive a call for a patient with chest pain. When you arrive on scene, you find a 52-year-old male patient complaining of retrosternal chest pain radiating to the left arm. The patient describes his pain as a “squeezing” type and rates it as an 8 on a scale of 1 to 10. The pain began approximately 30 minutes earlier and has been getting steadily worse. The patient says that he has never experienced a pain like this before. His respiratory rate is 16, normal depth; pulse is 90, strong and regular at the radial site; B/P is 130/82. His lungs are clear, JVD is normal, and no edema is present. The ECG shows a regular sinus rhythm. There is no other past pertinent history, no use of medications, and no complaint of allergies. The patient weighs 176 pounds. You explain your intended treatment to the patient, and he consents to your treatment and transport to the hospital. You begin your treatment by applying oxygen via a face mask, then start an IV. Following your service’s chest pain protocols, you prepare to administer nitroglycerin via sublingual spray. 1. Name the six “rights” of medication administration that you should follow with this and every patient. 2. What actions of nitroglycerin decrease chest pain? 3. What are the side effects of nitroglycerin? Which one is of primary concern? The nitroglycerin is given. The patient experiences a headache and tells you that the pain is relieved a little, but he still rates it at about a 4 on the scale of 1 to 10. An additional dose of nitroglycerin brings no further improvement in the chest pain. Your protocols now allow you to administer morphine sulfate for the pain. 4. In therapeutic doses, what effects do you want from the morphine in this patient? 5. What side effects should you watch for when giving the morphine sulfate?

Student’s Name____________

HANDOUT 13-4

REINFORCEMENT CHAPTER 13 REVIEW PART 1: BASIC PHARMACOLOGY Write the word or words that best complete each sentence in the space provided. 1. A chemical used to diagnose, treat, or prevent disease is called a(n) ____________________________________________. 2. The study of drugs and their interactions with the body is called ____________________________________________. 3. Valium is the ____________________________________________ name for the drug diazepam. 4. Diazepam is the ____________________________________________ name for the drug Valium. 5. The four main sources of drugs are ____________________________________________, ____________________________________________, ____________________________________________, and ____________________________________________. 6. How a drug is absorbed, distributed, and eliminated is called ____________________________________________. 7. A test that determines the amount and purity of a given chemical in a preparation in the laboratory is called a(n) ____________________________________________. 8. Phase ____________________________________________ of new drug development involves testing a new drug on a limited population of patients who have the disease that the drug is intended to treat. 9. Medication packages containing a single dose for a single patient are called ____________________________________________ ____________________________________________. 10. Movement of a molecule across a membrane from an area of higher pressure to an area of lower pressure is known as ____________________________________________. 11. ____________________________________________ ____________________________________________ requires the use of energy to move a substance. 12. ____________________________________________ is the measure of the amount of a drug that is still active after it reaches its target tissue. 13. The ____________________________________________ ____________________________________________ can prevent drugs from reaching a fetus. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

14. The specific name given to the metabolism of drugs is ____________________________________________. 15. A medication that is not active when administered but whose biotransformation converts it into active metabolites is called a(n) ____________________________________________. 16. The tight junctions of the capillary endothelial cells in the central nervous system vasculature through which only non-protein-bound, highly lipidsoluble drugs can pass is known as the ______________________ – ______________________ ____________________________________________. 17. Oral, buccal, rectal, and sublingual are all ____________________________________________ routes of drug administration. 18. IV, ET, IO, and IM are all ____________________________________________ routes of drug administration. 19. Pills, tablets, and suppositories are all ____________________________________________ forms of drugs. 20. Solutions, tinctures, and emulsions are all ____________________________________________ forms of drugs. 21. Most drugs operate by binding to a(n) ____________________________________________. 22. The process of binding a drug or hormone to a target cell receptor and thus decreasing the number of receptors is ______________________ ______________________. 23. A drug that binds to a receptor and causes it to initiate the expected response is a(n) ____________________________________________. 24. A competitive antagonist’s permanently binding with a receptor site is called ____________________________________________ ____________________________________________. 25. An unintended response to a drug is called a(n) ____________________________________________ ____________________________________________. 26. A drug effect that is unique to an individual, different from that seen or expected in the population in general, is called a(n) ____________________________________________. 27. ____________________________________________ is a rapidly occurring tolerance to a drug. 28. The ____________________________________________ ____________________________________________ is the ratio of a ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

drug’s lethal dose for 50 percent of the population to its effective dose for 50 percent of the population. 29. The time the body takes to clear one-half of a drug is its ____________________________________________ ______________________ - ______________________. 30. A drug’s ____________________________________________ ____________________________________________ ____________________________________________ describes the lengths of onset, duration, and termination of action, as well as the drug’s minimum effective concentration and toxic level.

Student’s Name____________

HANDOUT 13-5

REINFORCEMENT CHAPTER 13 REVIEW PART 2: DRUG CLASSIFICATIONS Write the word or words that best complete each sentence in the space provided. 1. The two major divisions of the nervous system are the ____________________________________________ ____________________________________________ ____________________________________________ and the ____________________________________________ ____________________________________________ ____________________________________________. 2. The drug that best demonstrates a class’s common properties and illustrates its particular characteristics is called the ____________________________________________. 3. A(n) ____________________________________________ is a medication that relieves the sensation of pain. 4. ____________________________________________ ____________________________________________ are given concurrently with other drugs to enhance their effects. 5. A(n) ____________________________________________ causes the absence of all sensations. 6. Opium is similar to natural pain-reducing peptides called ____________________________________________. 7. Naloxone is the prototype ____________________________________________ ____________________________________________. 8. The state of decreased anxiety and inhibitions is called ____________________________________________. 9. ____________________________________________ is the instigation of sleep. 10. Grand mal seizures are treated with ____________________________________________, ____________________________________________, and ____________________________________________. 11. The psychiatric disorder schizophrenia appears to be related to an increased release of ____________________________________________. 12. ____________________________________________ ____________________________________________ are common side effects of antipsychotic medications, including muscle tremors and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

parkinsonism-like effects. 13. ____________________________________________ ____________________________________________ act by blocking the reuptake of norepinephrine and serotonin. 14. Nardil is the prototype drug for the pharmacological class of drugs known as ____________________________________________ ____________________________________________. 15. ____________________________________________ is the drug of choice for the management of bipolar disorder. 16. The two functional divisions of the autonomic nervous system are the ____________________________________________ and the ____________________________________________ nervous systems. 17. The space between nerve cells is the ____________________________________________. 18. The chemical messenger that conducts a nervous impulse across a synapse is the ____________________________________________. 19. The ____________________________________________ ____________________________________________ ____________________________________________ controls involuntary actions. 20. The acronym SLUDGE stands for ____________________________________________, ____________________________________________, ____________________________________________, ____________________________________________, ____________________________________________ ____________________________________________, and ____________________________________________. 21. The two known types of sympathetic receptors are the ____________________________________________ receptors and the ____________________________________________ receptors. 22. Bronchodilation is the result of stimulation to the ____________________________________________ (adrenergic) receptors. 23. Beta1 stimulation results primarily in actions on the ____________________________________________. 24. Norepinephrine, epinephrine, and dopamine are all ____________________________________________. 25. The ____________________________________________ ____________________________________________ is the heart’s dominant pacemaker. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

26. The ability of all myocardial tissue to self-generate electrical impulses is called ____________________________________________. 27. Administration of ____________________________________________ ____________________________________________ ____________________________________________, such as procainamide, results in a widened QRS and prolonged QT. 28. The prototype beta-blocker drug is ____________________________________________. 29. Beta-blockers are indicated in the treatment of ____________________________________________ resulting from excessive sympathetic stimulation. 30. The only two calcium channel blockers that affect the heart are ____________________________________________ and ____________________________________________. 31. ____________________________________________ ____________________________________________ ____________________________________________ decrease conductivity through the AV node. 32. Side effects of the endogenous nucleoside ____________________________________________ include shortness of breath and chest pain. 33. Antihypertensive drugs affect blood volume control and hypertension by manipulating ____________________________________________. 34. In addition to their role in the treatment of hypertension, ____________________________________________ ____________________________________________ play an important role in the treatment of CHF by decreasing afterload. 35. ____________________________________________ is used to increase cardiac output in CHF and to control the rate of ventricular response in atrial fibrillation. 36. Aspirin is given to patients who are suspected of having an MI because it decreases the formulation of ____________________________________________ ____________________________________________. 37. A drug that acts directly on thrombi to break them down is called a(n) ____________________________________________. 38. Beta2-specific agents are used in the treatment of asthma. ____________________________________________ is the prototype. 39. A medication that is intended to increase the productivity of cough is called a(n) ____________________________________________. 40. A(n) ____________________________________________ is a medication ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

that is used to prevent vomiting. 41. Hypersecretion of adrenocorticotropic hormone is called ____________________________________________ disease. 42. ____________________________________________ is a substance that decreases blood glucose levels. 43. ____________________________________________ is contraindicated in a patient who has taken sildenafil recently. 44. Antibiotic agents are used to treat diseases caused by ____________________________________________. 45. A solution containing whole antibodies for a specific pathogen is a(n) ____________________________________________.

Student’s Name___________

HANDOUT 13-6

REINFORCEMENT MEDICATION CLASSIFICATION Write the letter of the drug classification in the space provided next to the drug to which it applies. You may use the same letter more than once. a. Antihistamines

i. Fibrinolytics

b. Adrenergic agonists

j. Calcium channel blockers

c. Nonopioid analgesics

k. Beta-blockers

d. Adrenergic antagonists

l. Direct vasodilators

e. Opioid agonists

m. Skeletal muscle relaxants

f. Antiseizure drugs

n. Sodium channel blockers

g. Anticoagulants

o. Anticholinergics

h. Neuromuscular blocking agents ___________

Aspirin

___________

Ibuprofen

___________

Morphine sulfate

___________

Phenytoin

___________

Atropine

___________

Succinylcholine

___________

Cardizem

___________

Minipress

___________

Scopolamine

___________

10.

Flexeril

___________

11.

Dibenzyline

___________

12.

Procainamide

___________

13.

Verapamil

___________

14.

Nitroglycerin

___________

15.

Xylocaine

___________

16.

Heparin

___________

17.

Apresoline

___________

18.

Propranolol

___________

19.

Activase

___________

20.

Benadryl

___________

21.

Dopamine

Student’s Name___________

HANDOUT 13-7

REINFORCEMENT AUTONOMIC NERVOUS SYSTEM REVIEW Write the word or words that best complete the following sentences in the space provided. 1. The autonomic nervous system is responsible for control of ____________________________________________ actions in the body. 2. The ____________________________________________ nervous system is the subdivision of the autonomic nervous system that allows the body to function under stress and is sometimes referred to as the fight-or-flight system. 3. The subdivision of the autonomic nervous system that primarily controls basic vegetative functions, such as the digestion of food, is the ____________________________________________ nervous system. 4. The nerves of the autonomic nervous system exit the central nervous system and enter specialized structures called ____________________________________________ ____________________________________________. 5. Nerve fibers that exit the central nervous system and terminate in the autonomic ganglia are called ____________________________________________ ____________________________________________, while the fibers that exit the ganglia and terminate in the target tissues are called ____________________________________________ ____________________________________________. 6. The space between two nerve cells is called a(n) ____________________________________________. 7. Specialized chemicals that conduct electrical impulses between nerve cells or between a nerve cell and its target tissue are called ____________________________________________. 8. The neurotransmitter ____________________________________________ is utilized in the preganglionic nerves of both the sympathetic and the parasympathetic nervous systems. 9. ____________________________________________ is the postganglionic neurotransmitter for the parasympathetic nervous system. 10. ____________________________________________ is the postganglionic neurotransmitter for the sympathetic nervous system. 11. Synapses that use acetylcholine as the neurotransmitter are called ____________________________________________ synapses. 12. Synapses that use norepinephrine as the neurotransmitter are called ____________________________________________ synapses. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

13. Nerves from the ____________________________________________ ____________________________________________ ____________________________________________ stimulate secretion by sweat glands, constriction of vessels in the skin, increase in blood flow to skeletal muscles, and energy production. 14. Stimulating nerves from the ____________________________________________ ____________________________________________ results in reduced blood flow to the abdominal organs, decreased digestive activity, and release of glucose stored in the liver. 15. When the sympathetic nervous system is stimulated, the ____________________________________________ ____________________________________________ also releases the hormones ____________________________________________ and ____________________________________________. 16. The two known types of sympathetic receptors are the ____________________________________________ and the ____________________________________________ receptors. 17. ____________________________________________ receptors cause peripheral vasoconstriction, mild bronchoconstriction, and stimulation of metabolism. 18. ____________________________________________ receptors cause an increase in heart rate, cardiac contractile force, and cardiac automaticity and conductivity. 19. ____________________________________________ receptors cause vasodilation and bronchodilation. 20. ____________________________________________ receptors are believed to cause dilation of the renal, coronary, and cerebral arteries. 21. Drugs that stimulate the sympathetic nervous system are sometimes called ____________________________________________ because they cause effects that mimic sympathetic stimulation. 22. Drugs that inhibit or block the sympathetic nervous system are sometimes called ____________________________________________. 23. When nerves from the ____________________________________________ ____________________________________________ ____________________________________________ are stimulated, among the effects are pupillary constriction, secretion by digestive and salivary glands, increased smooth muscle activity along the digestive tract, bronchoconstriction, and reduced heart rate and cardiac contractile force. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

24. The medications known as parasympatholytics are sometimes referred to as ____________________________________________. 25. One example of a drug that blocks the actions of the parasympathetic nervous system is ____________________________________________.

Chapter 13 Answer Key Handout 13-1: Chapter 13 Quiz, Part 1 1. c

10. b

19. b

28. c

2. d

11. c

20. c

29. a

3. b

12. b

21. a

30. a

4. d

13. b

22. b

31. c

5. a

14. d

23. c

32. d

6. b

15. c

24. b

33. c

7. c

16. a

25. d

34. d

8. b

17. c

26. d

35. d

9. a

18. a

27. b

Handout 13-2: Chapter 13 Quiz, Part 2 1. b

11. c

21. c

31. c

2. a

12. a

22. b

32. b

3. b

13. b

23. c

33. d

4. d

14. c

24. c

34. a

5. c

15. d

25. a

35. a

6. d

16. c

26. d

36. c

7. a

17. a

27. b

37. d

8. c

18. d

28. d

38. b

9. b

19. b

29. c

39. b

10. c

20. d

30. a

40. d

Handout 13-3: Chapter 13 Scenario 1. Right medication, right dose, right time, right route, right patient, right documentation 2. Nitroglycerin primarily dilates veins. This decreases preload and thus decreases myocardial workload. 3. The primary concern with nitroglycerin is orthostatic hypotension. Other side effects include headache and reflex tachycardia. 4. Morphine causes analgesia, euphoria, and sedation. It also decreases cardiac preload and afterload. It is useful in treating myocardial infarction and pulmonary edema. 5. Side effects at higher doses include respiratory depression and hypotension. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Handout 13-4: Chapter 13 Review, Part 1 1. drug 2. pharmacology 3. brand 4. generic 5. plants, animals, minerals, laboratory 6. pharmacokinetics 7. assay 8. 2 9. dose packaging 10. filtration 11. Active transport 12. Bioavailability 13. placental barrier 14. biotransformation 15. prodrug 16. blood–brain barrier 17. enteral 18. parenteral 19. solid 20. liquid 21. receptor 22. down-regulation 23. agonist 24. irreversible antagonism 25. side effect 26. idiosyncrasy 27. Tachyphylaxis 28. therapeutic index 29. biological half-life 30. plasma level profile

Handout 13-5: Chapter 13 Review, Part 2 1. central nervous system, peripheral nervous system 2. prototype 3. analgesic 4. Adjunct medications 5. anesthesia 6. endorphins 7. opioid antagonist 8. sedation 9. Hypnosis 10. carbamazepine, phenytoin, phenobarbitol 11. dopamine 12. Extrapyramidal symptoms 13. Tricyclic antidepressants 14. MAO inhibitors 15. Lithium 16. sympathetic, parasympathetic 17. synapse 18. neurotransmitter 19. autonomic nervous system 20. salivation, lacrimation, urination, defecation, gastric motility, emesis 21. adrenergic, dopaminergic 22. beta2 23. heart 24. catecholamines 25. SA node 26. automaticity 27. sodium channel blockers 28. propranolol 29. tachycardias 30. Verapamil, diltiazem 31. Calcium channel blockers 32. adenosine ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

33. preload 34. ACE inhibitors 35. Digoxin 36. platelet plugs 37. fibrinolytic 38. Albuterol 39. expectorant 40. antiemetic 41. Cushing’s 42. Insulin 43. Nitroglycerin 44. bacteria 45. serum Handout 13-6: Medication Classification 1. c 2. c 3. e 4. n or f 5. o 6. h 7. j 8. d 9. o 10. m 11. d 12. n 13. j 14. l 15. n 16. g 17. l 18. k ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

19. i 20. a 21. b Handout 13-7: Autonomic Nervous System Review 1. involuntary 2. sympathetic 3. parasympathetic 4. autonomic ganglia 5. preganglionic nerves, postganglionic nerves 6. synapse 7. neurotransmitters 8. acetylcholine 9. Acetylcholine 10. Norepinephrine 11. cholinergic 12. adrenergic 13. sympathetic chain ganglia 14. collateral ganglia 15. adrenal medulla, epinephrine, norepinephrine 16. adrenergic, dopaminergic 17. Alpha1 18. Beta1 19. Beta2 20. Dopaminergic 21. sympathomimetics 22. sympatholytics 23. Pprasympathetic nervous system 24. anticholinergics 25. tropine

Chapter 14 Intravenous Access and Medication Administration

Student’s Name __________

HANDOUT 14-1 SKILLS

MEDICATION ADMINISTRATION Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently PERIPHERAL INTRAVENOUS ACCESS Procedure

1. Takes Standard Precautions 2. Explains procedure to patient 3. Selects appropriate fluid, administration set, cannula 4. Examines fluid for clarity and expiration date 5. Assembles administration set and bag/bottle correctly 6. Flushes administration tubing to remove air bubbles 7. Selects venipuncture site 8. Places constricting band proximal to intended site of puncture 9. Cleanses venipuncture site 10. Inserts intravenous cannula into vein 11. Slides Teflon catheter over needle into vein 12. Removes metal stylet and disposes of it in proper container 13. Removes constricting band 14. Attaches administration tubing to cannula 15. Turn on the IV and check the flow 16. Applies antibiotic ointment to site and covers with adhesive bandage 17. Loops distal tubing and secures to patient with tape 18. Labels intravenous solution bag/bottle 19. Monitors patient and flow rate 20. Maintains aseptic technique throughout procedure Comments: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

SUBCUTANEOUS INJECTION Procedure

1. Takes Standard Precautions 2. Elicits patient allergies and explains procedure 3. Selects correct medication 4. Checks label for correct name, concentration, expiration date 5. Inspects medication for discoloration, particles 6. Prepares correct amount of medication 7. Chooses and cleanses injection site appropriately 8. Rechecks correct drug and dose 9. Inserts needle at 45° angle and aspirates for blood return 10. If no blood return, injects medication at appropriate rate 11. Removes needle and disposes of it in proper container 12. Applies pressure to injection site 13. Monitors patient for effects of medication 14. Maintains aseptic technique throughout procedure Comments:

INTRAMUSCULAR INJECTION Procedure

1. Takes Standard Precautions 2. Elicits patient allergies and explains procedure 3. Selects correct medication 4. Checks label for correct name, concentration, expiration date 5. Inspects medication for discoloration, particles 6. Prepares correct amount of medication 7. Chooses and cleanses injection site appropriately 8. Rechecks correct drug and dose 9. Inserts needle at 90° angle and aspirates for blood return 10. If no blood return, injects medication at appropriate rate 11. Disposes of needle and syringe in proper container 12. Applies gauze or adhesive bandage to site and massages 13. Monitors patient for desired or undesired effects 14. Maintains aseptic technique throughout procedure Comments:

INTRAVENOUS MEDICATION ADMINISTRATION THROUGH EXISTING IV LINE Procedure

1. Takes Standard Precautions 2. Elicits patient allergies 3. Selects correct medication and administration equipment 4. Checks label for correct name, concentration, expiration date 5. Inspects medication for discoloration, particles 6. Prepares correct dose • Assembles prefilled syringe and expels air • Draws up correct amount from ampule or vial 7. Cleanses injection site 8. Stops IV flow above injection site 9. Reaffirms correct medication, dose 10. Inserts needle and injects correct dose at appropriate rate 11. Opens and flushes IV line and readjusts IV flow rate 12. Disposes of needle and syringe in appropriate container 13. Observes patient for medication effects 14. Maintains aseptic technique throughout procedure Comments:

IV PIGGYBACK Procedure

1. Takes Standard Precautions 2. Elicits possible allergies 3. Selects correct medication 4. Checks label for correct name, concentration, expiration date 5. Checks medication and IV bag for discoloration, particles 6. Cleanse the IV bag or bottle’s medication port with an antiseptic wipe 7. Injects correct amount of medication into IV bag and mixes it 8. Connects IV tubing to the bag and flushes line 9. Attaches needle to IV line 10. Cleanses medication port and inserts needle 11. Stops flow of primary IV 12. Sets infusion at desired rate and tapes line securely 13. Labels bag or bottle appropriately 14. Observes patient for effects of medication 15. Maintains aseptic technique throughout procedure Comments:

ENDOTRACHEAL DRUG ADMINISTRATION Procedure

1. Takes Standard Precautions 2. Selects correct medication 3. Checks label for correct name, concentration, expiration date 4. Inspects medication for discoloration, particles 5. Prepares correct amount of medication 6. Ventilates patient 7. Removes ventilation device 8. Administers medication down endotracheal tube 9. Replaces ventilation device and ventilates patient 10. Monitors patient for desired and undesired effects Comments:

Student’s Name ___________

HANDOUT 14-2

EVALUATION CHAPTER 14 QUIZ PART 1: PRINCIPLES AND ROUTES OF MEDICATION ADMINISTRATION Write the letter of the best answer in the space provided. ______1. The six “rights” of drug administration include: a. the right person. c. the right time. b. the right drug. d. all of the above. ______2. Drug administration by the paramedic should be done under a condition that is free of pathogens. This condition is called: a. sterile. c. aseptic. b. medically clean. d. antiseptic. ______3. “Medically clean” refers to techniques involving: a. maintaining an aseptic environment. b. cleansing with disinfectants. c. carefully handling sterile equipment to prevent contamination. d. sterilizing equipment that comes into contact with a patient. ______4. To minimize or eliminate the risk of accidental needle stick, precautions include: a. minimizing tasks in a moving ambulance. b. recapping needles immediately after use. c. placing all sharps in a red plastic bag with a biohazard label on it. d. avoiding the use of any needles in the prehospital setting. ______5. Medications given by the transdermal route are: a. placed beneath the tongue. b. absorbed through the skin. c. injected into the subcutaneous layer. d. placed between the patient’s cheek and gum. ______6. Delivering medication through the mucous membranes of the ear is called the: a. buccal route. c. ocular route. b. sublingual route. d. aural route. ______7. A metered-dose inhaler is a(n): a. handheld device that produces a medicated spray for inhalation. b. inhalation aid that disperses liquid into aerosol spray or mist. c. regulator device that administers oxygen along with inhaled medication. d. specially designed regulator used for nitrous oxide administration. _____ 8. Which of the following is TRUE regarding drug administration via a small-volume nebulizer? a. Set the oxygen source regulator for 10 to 15 lpm. b. If the patient’s tidal volume is shallow, place twice the normal amount of medication into the nebulizer. c. It is important for the patient to exhale completely before inhaling ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

the medication. d. Attaching a nebulizer to an oxygen humidifier will enhance absorption of the medication. ______9. If you have not established an IV line, some medications can be given through an endotracheal tube. Which of the following is CORRECT regarding drug administration through an ET tube? a. Dilute the medication in normal saline to create 10 mL of solution. b. Pulmonary absorption of drugs is much slower than in the intravenous route. c. Lidocaine, atropine, and naloxone should not be given via an ET tube. d. Use the same dose of medication for ET tube administration as you would for IV administration. ______10. An example of an enteral route of drug administration is: a. rectal. c. subcutaneous. b. intradermal. d. intravenous. ______11. Guidelines for oral administration of a medication include which of the following? a. Always administer oral medication on an empty stomach. b. Do not give any fluid by mouth for 20–30 minutes after oral administration of a medication. c. Never use household teaspoons to measure medications. d. Place the patient in the semi-Fowler’s position when administering oral medications. ______12. Rectal administration of medication: a. results in rapid drug absorption. b. is subject to hepatic alteration. c. has an unpredictable absorption rate. d. should not be used for Valium. ______13. The least expensive form of single-dose packaging of drugs for injection is the: a. vial. b. nonconstituted drug vial. c. prefilled syringe. d. glass ampule. ______14. Some medications are packaged in a nonconstituted vial. This means that: a. the medication is a highly concentrated solution, given in small doses. b. the vial has two containers; one holds the powdered medication, and the other holds a liquid mixing solution. c. the medication is in powder form and placed in a nebulizer with normal saline. d. the medication is in a viscous liquid form and diluted with sterile water. ______ 15. Intradermal injection is particularly useful for: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. delivery of local anesthetics. b. insulin injection. c. epinephrine injection. d. delivery of antiemetics. ______ 16. Steps in administering medication by subcutaneous injection include: a. gently rubbing the injection site to help initiate systemic absorption. b. inserting the needle at a 10- to 15-degree angle, bevel up. c. pulling the patient’s skin taut with your nondominant hand. d. using a 24- to 26-gauge needle, 1 to 11⁄2 inches long. ______17. When administering medication by the subcutaneous injection route: a. correct placement of the needle is confirmed by a blood return when the plunger of the syringe is pulled back. b. do not rub or massage the site, because this promotes systemic absorption and nullifies the advantage of localized effect. c. you may use an air plug in the syringe, which pushes the medication farther into the subcutaneous tissue. d. avoid pinching the skin at the injection site, as this will result in a slower absorption of the medication. ______18. When administering medication by the intramuscular route, insert the needle at a: a. 10- to 15-degree angle. c. 45-degree angle. b. 25-degree angle. d. 90-degree angle. ______19. Intramuscular injection sites include which of the following muscles? a. Gastrocnemius c. Psoas major b. Vastus lateralis d. Biceps brachii ______20. When administering an intramuscular injection, you should: a. pinch the skin together gently at the site of the injection. b. choose a bruised area for the injection, if possible. c. stretch the skin taut over the injection site. d. inject the medication rapidly.

Student’s Name ___________

HANDOUT 14-3

CHAPTER 14 QUIZ PART 2: INTRAVENOUS ACCESS, BLOOD SAMPLING, AND INTRAOSSEOUS INFUSION Write the letter of the best answer in the space provided. ______1. Which of the following is TRUE regarding intravenous access? a. Arterial access is preferable to venous access. b. Central venous access is most often performed in the prehospital setting. c. When establishing a peripheral IV, start at the distal end of an extremity. d. Peripheral IVs are used when medical conditions require repeated access for medication or fluid delivery. ______2. Which of the following IV sites is NOT considered a peripheral site? a. Antecubital fossa b. External jugular c. Subclavian d. Cephalic ______ 3. Examples of colloid IV solutions include: a. lactated Ringer’s solution. b. normal saline solution. c. albumin. d. 5 percent dextrose in water. ______ 4. One of the most common IV solutions used in the prehospital setting for fluid replacement is: a. dextran. b. lactated Ringer’s solution. c. Plasmanate. d. hetastarch. ______ 5. In standard microdrip administration tubing, 1 mL of fluid is: a. 10 drops. c. 45 drops. b. 15 drops d. 60 drops. ______ 6. A burette chamber on IV administration tubing is: a. a clear plastic chamber that allows visualization of the drip rate. b. the device that regulates the size of the drops. c. a calibrated chamber that enables precise measurement and delivery of fluids and medicated solutions. d. a device that contains a filter to prevent clots or other debris from entering the patient. ______ 7. Hollow-needle catheters do not have: a. a Teflon tube. c. “wings” for guidance and securing. b. a metal stylet. d. clear tubing. ______8. Consider accessing the external jugular vein if a patient requires ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

immediate fluid administration. When using this route, remember: a. to attach a 10-mL syringe with 3–5 mL of sterile saline to the cannula. b. that you will need a larger constricting band than those used with arm or leg sites. c. to insert the catheter at a 45-degree angle, bevel up. d. to place the patient in the semi-Fowler’s position during the procedure. ______9. The most common cause of an IV’s not flowing properly is: a. the cannula abutting the vein wall or valve. b. a constricting band left in place. c. a completely filled drip chamber. d. edema at the puncture site. ______10. If your patient develops an abrupt onset of fever, chills, backache, headache, nausea, and vomiting within 1⁄2 to 1 hour after an IV was started, the cause may be: a. local infection. c. pyrogenic reaction. b. thrombophlebitis. d. air embolism. ______11. Catheter shear is caused by: a. pulling the Teflon catheter through or over the needle after you have advanced it into the vein. b. accidental arterial puncture. c. inflammation of the vein. d. a blood clot caused by the injury to the vessel wall. ______12. Steps in changing an IV bag or bottle include: a. occluding the flow of solution from the depleted bag by moving the roller clamp on the IV administration tubing. b. cleansing the spike with a disinfectant before inserting it into the new bag. c. changing the administration set at the same time. d. flushing the IV site with a heparinized solution before attaching the new bag/bottle to the administration set. ______13. When injecting an intravenous bolus of medication into an existing IV site: a. use a 14- to 16-gauge needle for rapid administration. b. flush the IV site with 20 mL of fluid before giving the medication. c. pinch the IV line above the medication port before giving the medication. d. open the flow regulator to allow a 1- to 2-minute fluid flush after giving the medication. ______14. Some cardiac drugs and antibiotics are given as an intravenous infusion, or piggyback. When mixing an infusion, remember to: a. administer intravenous infusions as a primary IV line. b. agitate the bag or bottle gently to mix its contents. c. keep fluid flowing from the primary line as the medication infusion is administered. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

d. run the infusion in as rapidly as possible, then readjust the primary line to the desired drip rate. ______15. After establishing a saline lock, the medication port should be cleaned and injected with how much normal saline? A. 0.5–1.0mL c. 5.0–7.0mL B. 3.0–5.0mL d. 7.0–10.0mL ______ 16. Which of the following is TRUE regarding drawing blood from your patient? a. Blood tubes may be used in any order, as long as all are filled. b. A green top on a blood tube indicates that it has fluoride in it as an anticoagulant. c. Never place blood tubes into the vacutainer and Luer needle until you are ready to draw blood. d. Veins on the back of the hand are your first choice when drawing a venous blood sample. ______17. Hemoconcentration occurs when: a. a constricting band is left in place too long. b. red blood cells are destroyed during vigorous shaking of blood tubes after they are filled. c. blood tubes are not agitated to mix blood with the anticoagulant in the tube. d. the wrong blood type is given to a patient. ______ 18. The bone most commonly used for intraosseous access is the: a. sternum. c. femur. b. radius. d. tibia. ______ 19. Which of the following is TRUE regarding intraosseous infusion? a. This procedure is performed only on pediatric patients. b. You may attempt intraosseous placement even if a peripheral IV line is in place. c. Periodic flushing of the needle is necessary to keep it from becoming occluded. d. Easy access of bone marrow and blood from the site into a syringe indicates incorrect placement of the needle. ______ 20. Which of the following is a contraindication for intraosseous placement? a. Lordosis c. Patient taking nitroglycerin b. Osteoporosis d. Kyphosis

Student’s Name ___________

HANDOUT 14-4

CHAPTER 14 QUIZ PART 3: MEDICAL MATHEMATICS Write the letter of the best answer in the space provided. ______1. How many milligrams are in a gram? a. 10 c. 1,000 b. 100 d. 10,000 ______2. How many milliliters are in a liter? a. 10 c. 1,000 b. 100 d. 10,000 ______3. How many micrograms are in a gram? a. 100 c. 10,000 b. 1,000 d. 1,000,000 ______4. A patient who weighs 70 kilograms weighs how many pounds? a. 32 pounds c. 140 pounds b. 105 pounds d. 154 pounds ______5. 326 mg is equal to _____ grams. a. 32.6 c. 0.326 b. 3.26 d. 3260 ______6. 0.46 liters is equal to _____ milliliters. a. 4.6 c. 460 b. 46 d. 4600 ______7. One gallon, or 4 quarts, equals how many liters? a. 37.85 c. 0.3785 b. 3.785 d. 0.03785 ______ 8. One teaspoon is equal to: a. 250 milliliters. c. 4 to 5 milliliters. b. 16 milliliters. d. 2 to 3 milliliters. ______9. How many kilograms does a 182-pound person weigh? a. 91 kilograms c. 273 kilograms b. 82.7 kilograms d. 151.1 kilograms ______10. The amount of drug available in a solution is called the: a. volume on hand. c. stock solution. b. desired dose. d. dosage on hand. ______11. The available amount of solution containing a medication is called the: a. volume on hand. c. stock solution. b. desired dose. d. dosage on hand. ______12. How many milliliters of solution would you have to administer to give a patient 90 mg of oral acetaminophen using a concentration of 500 mg in 8 mL of solution? a. 14.4 mL c. 0.144 mL b. 1.44 mL d. 0.0144 mL ______13. Your orders are to give 250 mg of a drug via IV bolus. The multidose vial contains 2 g of the drug in 10 mL of solution. How many milliliters will you administer? ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

a. 125 mL c. 1.25 mL b. 12.5 mL d. 0.125 mL ______14. You are going to administer 1.5 mg/kg of lidocaine, IV bolus, to a patient who has unstable ventricular tachycardia. The lidocaine concentration is 100 mg in a prefilled syringe of 10 mL. The patient weighs 158 pounds. How many milliliters of lidocaine will you administer? a. 10.8 mL c. 0.108 mL b. 1.08 mL d. 0.0108 mL ______15. Your medical direction physician orders an IV drip of lidocaine at 2 mg/min. You mix 2 g of lidocaine in 500 mL of D5W. You are using a microdrip administration set delivering 60 drops/mL. How many drops per minute will your infusion be? a. 15 drops c. 45 drops b. 30 drops d. 60 drops

Student’s Name ___________

HANDOUT 14-5

CHAPTER 14 SCENARIO Review the following real-life situation. Then answer the question that follows. At 2:00 a.m. Medic 12 receives a call for an elderly patient with shortness of breath. The crew reaches the scene, a first-floor apartment in a small three-story building, in 4 minutes. They knock on the door of the apartment and hear a weak call to come in. Upon entering, they find a one-room apartment crammed with boxes, old newspapers, magazines, and heaps of old clothes. The patient, a 72year-old man, is across the room in a recliner, where he apparently sleeps during the night. Upon taking the history, the crew learns that the patient has had several previous episodes of this problem and was last admitted to the hospital four months ago. The patient is in obvious respiratory distress with slight cyanosis in the lips. The senior paramedic decides that interventions and transport are necessary but that the cramped conditions of the apartment are no place to work. He asks the patient to walk to the stretcher in the hall before beginning treatment. Once the patient is lying on the stretcher, the crew continues the assessment and physical exam. The patient has significant jugular vein distension sitting upright, severe pitting edema, and profuse crackles in the posterior bases of the lungs. The patient is supposed to take numerous medications but has not been doing so for the past week. The medications are digitalis, Tonocard, Lasix, and Ventolin. The ECG shows atrial fibrillation at a rate of 110 with frequent PVCs. Respirations are 20 and labored; the pulse is strong but irregular, corresponding to the ECG; the BP is 160/100. The crew places the patient on high-flow oxygen and establishes an IV of D5W at a TKO rate. System protocols call for administration of 60 mg of Lasix. The medication is packaged as 100 mg/10 mL. The senior paramedic estimates that a bit more than half the syringe is appropriate and administers it via rapid IV push. The patient experiences a dizzy spell shortly thereafter. The paramedic gives morphine via rapid IV push, and the dizziness is more profound. The patient almost passes out. The crew lowers the patient’s torso and raises his feet to reverse the profound vasodilation. The patient now experiences significant respiratory distress. The patient is still experiencing frequent PVCs. Protocol permits administration of 1 mg/kg of lidocaine, and the paramedic administers the dose via IV push. The patient experiences some facial twitching a few minutes later, but by this time, he is packaged and en route to the hospital. There, the crew turns him over to the ED staff, and he is soon in the facility’s critical care unit. 1. What faults can you find in Medic 12’s handling of this case?

Student’s Name _______________

HANDOUT 14-6

REINFORCEMENT CHAPTER 14 REVIEW PART 1: PRINCIPLES AND ROUTES OF MEDICATION ADMINISTRATION Write the word or words that best complete each sentence in the space provided. 1.

The six rights of drug administration are the right __________________________________________, the right __________________________________________, the right __________________________________________, the right __________________________________________, the right __________________________________________, and the right __________________________________________.

Measures to decrease your risk of exposure to blood and body fluids are called __________________________________________ __________________________________________.

A condition in which a medical environment is free from pathogens is called __________________________________________.

__________________________________________ means limited to one area of the body.

__________________________________________ means throughout the body.

An environment that is free from all forms of life is __________________________________________.

__________________________________________ __________________________________________ techniques involve the careful handling of sterile equipment and supplies to prevent contamination.

A cleansing agent that is toxic to living tissue is called a(n) __________________________________________.

A cleansing agent that is not toxic to living tissue is a(n) __________________________________________.

10. Percutaneous routes for medications include __________________________________________ administration and __________________________________________ __________________________________________ administration.

11. Mucous membrane medication sites include the __________________________________________, __________________________________________, __________________________________________, __________________________________________, and __________________________________________. 12. The route of medication administration given beneath the tongue is called __________________________________________. 13. __________________________________________ is the route of medication administration between the cheek and gums. 14. Drugs administered through the mucous membranes of the eye are called __________________________________________ medications. 15. Medications are drawn into the lungs along with air while breathing during the process of __________________________________________. 16. __________________________________________ is the placement of medication in or under the skin with a needle and syringe. 17. A(n) __________________________________________ is an inhalation aid that disperses liquid into aerosol spray or mist. 18. A(n) __________________________________________ __________________________________________ __________________________________________ is a handheld device that produces a medicated spray for inhalation. 19. The delivery of any medication that is absorbed through the gastrointestinal tract is called __________________________________________ drug administration. 20. A concentrated mass of medication is called a(n) __________________________________________. 21. A change in a medication’s chemical composition that occurs in the liver is called __________________________________________ __________________________________________. 22. A vial with two containers, one holding a powdered medication and the other holding a liquid mixing solution, is called a(n) __________________________________________ __________________________________________ __________________________________________.

23. When performing a subcutaneous injection, insert the needle at a __________________________________________ angle. 24. Intramuscular injection sites include the __________________________________________, __________________________________________ __________________________________________, __________________________________________ __________________________________________, and __________________________________________ __________________________________________ muscles. 25. When performing an intramuscular injection, insert the needle at a __________________________________________ angle.

Student’s Name ____________

HANDOUT 14-7

REINFORCEMENT CHAPTER 14 REVIEW PART 2: INTRAVENOUS ACCESS, BLOOD SAMPLING, AND INTRAOSSEOUS INFUSION Write the word or words that best complete each sentence in the space provided. 1.

The surgical puncture of a vein to deliver medication or withdraw blood is called __________________________________________ access.

Surgical puncture of a vein in the arm, leg, or neck is called __________________________________________ __________________________________________ __________________________________________.

Surgical puncture of the internal jugular, subclavian, or femoral vein is called __________________________________________ __________________________________________ __________________________________________.

Intravenous solutions containing large proteins that cannot pass through capillary membranes are called __________________________________________.

Intravenous solutions that contain electrolytes but lack the larger proteins are called __________________________________________.

__________________________________________ solutions are those that have a tonicity equal to blood plasma’s.

__________________________________________ solutions have a higher solute concentration than do the cells.

__________________________________________ solutions have a lower solute concentration than do the cells.

__________________________________________ __________________________________________ __________________________________________ is an isotonic electrolyte solution containing sodium chloride, potassium chloride, calcium chloride, and sodium lactate in water.

10. A solution of 0.9 percent sodium chloride in water is also called __________________________________________ __________________________________________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

11. An IV administration tubing that delivers 60 drops/mL is __________________________________________ tubing. 12. Administration tubing that delivers 10 drops/mL is __________________________________________ tubing. 13. The sharp, pointed device inserted into the IV solution bag’s administration setport is the __________________________________________. 14. The calibrated chamber on a specific type of IV administration tubing that enables precise measurement and delivery of fluids and medicated solutions is called the __________________________________________ __________________________________________. 15. IV administration tubing that contains a filter to prevent clots or other debris from entering the patient is __________________________________________ __________________________________________. 16. A hollow needle catheter does not have a __________________________________________ __________________________________________ but is itself inserted into the vein and secured there. 17. If you have exhausted other means of peripheral IV access or when a patient requires immediate fluid administration, consider accessing the __________________________________________ __________________________________________ __________________________________________. 18. The most common cause of an IV that does not flow properly is leaving the __________________________________________ __________________________________________ in place. 19. A foreign protein capable of producing fever is called a(n) __________________________________________. 20. An excess in intravascular fluid volume is called __________________________________________ __________________________________________. 21. Inflammation of a vein is called __________________________________________. 22. A(n) __________________________________________ __________________________________________ is a peripheral IV port that does not use a bag of fluid. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

23. The term __________________________________________ means outside the vein. 24. If the anticoagulant heparin is in a blood tube, the color of the top is __________________________________________. 25. __________________________________________ infusions involve inserting a rigid needle into the cavity of a long bone.

Student’s Name ___________

HANDOUT 14-8

REINFORCEMENT CHAPTER 14 REVIEW PART 3: MEDICAL MATHEMATICS Write the word or words that best complete each sentence in the space provided. 1.

Fundamental metric units are __________________________________________, __________________________________________, and __________________________________________.

3 grams equal __________________________________________ milligrams.

5.39 liters is equal to __________________________________________ milliliters.

7,000 micrograms is equal to __________________________________________ gram.

1 gallon is equal to __________________________________________ quarts, or __________________________________________ liters.

1 quart is equal to __________________________________________ liter.

16 ounces is equal to approximately __________________________________________ pint, or __________________________________________ milliliters.

1 teaspoon is equal to approximately __________________________________________ __________________________________________ __________________________________________ milliliters.

1 kilogram is equal to __________________________________________ pounds.

10. 165 pounds is equal to ___________ kilograms. 11. 98.2° Fahrenheit is equal to __________________________________________ Celsius. 12. 28.4° Celsius is equal to __________________________________________ Fahrenheit.

13. The standard concentration of routinely used medications is called the __________________________________________ __________________________________________. 14. Weight per volume is called __________________________________________. 15. The amount of a drug available in a solution is the __________________________________________ __________________________________________ __________________________________________. 16. The available amount of solution containing a medication is the __________________________________________ __________________________________________ __________________________________________. 17. To administer 120 mg of an oral medication supplied in a concentration of 1,000 mg in 16 mL, you would give __________________________________________ mL. 18. Your medical direction orders administration of 125 mg of a drug via IV bolus. The multidose vial contains 5 g of the drug in 15 mL of solution. You would administer __________________________________________ mL of solution. 19. Your 175-pound patient is to be given lidocaine via IV bolus at 1.5 mg/kg. The lidocaine is supplied in a 20-mL solution with 200 mg of the drug. You would administer __________________________________________ mL of lidocaine. 20. You are to start an IV infusion of lidocaine at 3 mg/min. The concentration is 2 g of lidocaine in 250 mL of solution. You use a microdrip administration set delivering 60 drops/mL. Your drip rate would be __________________________________________ drops/min.

Student’s Name ___________

HANDOUT 14-9

REINFORCEMENT DRUG CALCULATIONS Complete the following drug calculations. 1.

A 154-pound patient needs Lasix. The physician orders 40 mg via IV push. Lasix is supplied as 100 mg/10 mL. How many milliliters will you give to deliver 40 mg as ordered?

You are to start an IV of normal saline with a 10-drops/mL administration set and infuse 300 mL over 2 hours. At how many drops per minute will you set your IV?

You are treating a patient for whom lidocaine is ordered at 1 mg/kg via IV push. The lidocaine is packaged as a 1 percent solution containing 100 mg/10 mL. The patient weighs 198 pounds. What is the patient’s weight in kilograms? How many milliliters will you give? How many milligrams are contained in the amount of fluid given?

You are instructed to prepare and hang a lidocaine drip of 2 mg/min. The lidocaine is packaged as a 20 percent solution containing 1g/mL. You will use a microdrip (60 drops/mL) administration set. At how many drops per minute will you run the IV?

A dopamine drip is ordered at 5 mcg/kg/min. You are to set up your IV drip by injecting 400 mg of dopamine into a 500-mL IV bag of D5W. Use a microdrip (60 drops/mL) administration set. The patient weighs 176 pounds. What is the patient’s weight in kilograms? At how many drops per minute will you run the IV?

Atropine is ordered for symptomatic bradycardia. The desired dose is 0.5 mg. Atropine is packaged as 1 mg/10 mL. How many mL will you give to deliver 0.5 mg?

Chapter 4 Answer Key Handout 4-2: Chapter 4 Quiz, Part 1 1. d

6. d

11. c

16. a

2. c

7. a

12. a

17. c

3. c

8. c

13. a

18. d

4. a

9. a

14. b

19. b

5. b

10. a

15. a

20. c

Handout 4-3: Chapter 4 Quiz, Part 2 1. c

6. c

11. a

16. c

2. c

7. a

12. a

17. a

3. c

8. a

13. c

18. d

4. b

9. b

14. b

19. c

5. d

10. c

15. b

20. b

Handout 4-4: Chapter 4 Quiz, Part 3 1. c

5. c

9. b

13. c

2. c

6. c

10. d

14. a

3. d

7. b

11. a

15. b

4. d

8. c

12. b

Handout 4-5: Chapter 4 Scenario 1. Students should find many errors here; among them are history taking out of order; requesting that the patient walk to the ambulance; having a patient with possible pulmonary edema lie down; estimating rather than calculating the Lasix dose; no indication of checking any medications before administering them; administering Lasix via rapid, rather than slow, IV push; no indication of vital signs being checked after drug administration; no indication of consultation with medical direction when problems were experienced; no altering of lidocaine dosage, as would be appropriate for a patient over age 70.

3. asepsis 4. “Local” 5. “Systemic” 6. sterile 7. Medically clean 8. disinfectant 9. antiseptic 10. transdermal, mucous membrane 11. tongue, cheek, eye, nose, ear 12. sublingual 13. Buccal 14. ocular 15. inhalation 16. Injection or subcutaneous 17. nebulizer 18. metered-dose inhaler 19. enteral 20. bolus 21. hepatic alteration 22. nonconstituted drug vial 23. 45-degree 24. deltoid, dorsal gluteal, vastus lateralis, rectus femoris 25. 90-degree

Handout 4-7: Chapter 4 Review, Part 2 1. intravenous 2. peripheral venous access 3. central venous access 4. colloids 5. crystalloids ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

6. Isotonic 7. Hypertonic 8. Hypotonic 9. Lactated Ringer’s solution 10. normal saline 11. microdrip 12. macrodrip 13. spike 14. burette chamber 15. blood tubing 16. Teflon tube 17. external jugular vein 18. constricting band 19. pyrogen 20. circulatory overload 21. thrombophlebitis 22. heparin lock 23. “extravascular” 24. green 25. intraosseous

Handout 4-8: Chapter 4 Review, Part 3 1. grams, meters, liters 2. 3,000 3. 5,390 4. 0.007 5. 4, 3.785 6. 0.946 7. 1, 473 8. 4 to 5 ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

9. 2.2 10.

11. 36.8° 12. 83.1° 13. stock solution 14. concentration 15. dosage on hand 16. volume on hand 17. 1.92 18. 0.375 19. 11.9 20. 22.5

Handout 4-9: Drug Calculations 1. 4 mL 2. 25 drops/min 3. 90 kg, 9 mL, 90 mg of lidocaine 4. 30 drops/min 5. 80 kg, 30 drops/min 6. 5 mL

Chapter 15 Airway Management and Ventilation

Student’s Name___________

HANDOUT 15-1 SKILLS

MANUAL AIRWAY MANEUVERS Charting Student Progress: 1.

Learning skill

Performs skill with direction

Performs skill independently

HEAD-TILT/CHIN-LIFT Procedure

123

1. Takes Standard Precautions 2. Places patient supine and positions self at the side of the patient’s head 3. Places one hand on the patient’s forehead and, using firm downward pressure with the palm, tilts the head back 4. Puts two fingers of the other hand under the bony part of the chin and lifts the jaw anteriorly to open the airway JAW-THRUST Procedure

123

1. Takes Standard Precautions 2. Places the patient supine and kneels at the top of his head 3. Applies fingers to each side of the jaw at the mandibular angles 4. Lifts the jaw forward (anteriorly) with a gentle tilting of the patient’s head to open the airway JAW-THRUST WITHOUT HEAD EXTENSION (TRAUMA) Procedure

123

1. Takes Standard Precautions 2. A second rescuer applies spinal motion restriction 3. Lifts the jaw using fingers behind the mandibular angles; does not tilt the head 4. Lifts the jaw forward (anterior) and opens the airway without tilting (extending) the patient’s head

Student’s Name _________________

HANDOUT 15-2 SKILLS BASIC AIRWAY ADJUNCTS NASOPHARYNGEAL AIRWAY Charting Student Progress: 1

Learning skill

Performs skill with direction

Performs skill independently

Procedure

123

1. Takes Standard Precautions 2. Hyperextends patient’s head and neck if no history of trauma 3. Ventilates with 100 percent oxygen 4. Measures tube from tip of nose to angle of jaw and the diameter of nostril 5. Lubricates exterior of the tube with water-soluble gel or lidocaine gel 6. Pushes gently up on tip of nose and passes tube into right nostril, bevel toward septum 7. Verifies appropriate position of airway: clear breath sounds, chest rise, airflow at proximal end on expiration 8. Ventilates patient with supplemental oxygen OROPHARYNGEAL AIRWAY Procedure

123

1. Takes Standard Precautions 2. Hyperextends patient’s head and neck if no history of trauma; opens mouth and removes visible obstructions 3. Ventilates patient with 100 percent oxygen, if indicated 4. Measures airway from corner of mouth to angle of the jaw 5. Grasps patient’s jaw and lifts anteriorly 6. With other hand, holds airway at proximal end and inserts into patient’s mouth, with curve reversed and tip pointing toward roof of mouth 7. As tip reaches level of soft palate, gently rotates airway 180° until it comes to rest over the tongue 8. Verifies appropriate position of airway: clear breath sounds and chest rise 9. Ventilates patient with supplimental oxygen

Student’s Name ______________

HANDOUT 15-3 SKILLS

OROTRACHEAL INTUBATION Charting Student Progress: 1.

Learning skill

Performs skill with direction

Performs skill independently

Procedure

123

1. Takes Standard Precautions 2. Places patient supine 3. Uses appropriate basic manual and adjunct airway maneuvers, ventilates with 100 percent oxygen 4. Assembles and checks equipment 5. Places head in sniffing position 6. Turn on the suction and attach an appropriate tip 7. Holds laryngoscope in the left hand; inserts it into the right side of mouth 8. Displaces tongue to the left and brings laryngoscope midline 9. Lifts laryngoscope forward to displace jaw without putting pressure on teeth 10. Suctions the hypopharynx as necessary 11. Places blade in proper position, visualizing tip of epiglottis 12. Lifts jaw at 45-degree angle to the ground, exposing glottis 13. Holds ETT in right hand, and advances tube through right corner of patient’s mouth 14. Directly visualizes vocal cords; passes ETT through the glottic opening until distal cuff disappears beyond vocal cords 15. Removes stylette, inflates distal cuff with 5 to 10 mL of air, attaches bagvalve mask with ETCO2 detector to connector on ETT 16. Checks for proper tube placement: equal bilateral breath sounds, symmetrical rise and fall of chest 17. Ventilates patient with 100 percent oxygen 18. Secures ETT with tape or commercial device 19. Periodically rechecks tube placement

Student’s Name _________________

HANDOUT 15-4

SKILLS TRANSILLUMINATION INTUBATION Charting Student Progress: 1. Learning skill 2 Performs skill with direction 3. Performs skill independently Procedure

123

Takes Standard Precautions

Ventilates patient with 100 percent oxygen

Assembles and checks equipment

Uses 7.5- to 8.5-mm ETT; cuts tube to 25 to 27 cm to accommodate stylette

Places stylette in tube, bending it proximal to the cuff

With patient supine and head in neutral position, kneels along either side of patient, facing patient’s head, and turns on light

With index and middle fingers inserted deeply into patient’s mouth and thumb under his chin, lifts his tongue and jaw forward

Inserts tube/stylette into patient’s mouth, advances it through oropharynx into hypopharynx

Uses “hooking” action with tube/stylette to lift epiglottis out of the way

10.

Holds stylette stationary when circle of light is visible at the level of the patient’s Adam’s apple

11.

Advances tube off stylette into the larynx approximately 1 to 2 cm while retracting internal wire from stylette using O-ring at proximal end

12.

Holds tube in place with one hand and removes stylette

13.

Inflates the cuff with 5 to 10 mL of air

14.

Attaches bag-valve mask with ETCO2 detector and delivers several breaths

15.

Secures ETT with tape or commercial device

16.

Ventilates with 100 percent oxygen

Student’s Name _________________

HANDOUT 15-5

SKILLS DIGITAL INTUBATION Charting Student Progress: 1

Learning skill

2. Performs skill with direction 3. Performs skill independently Procedure

1. Takes Standard Precautions 2. Ventilates with 100 percent oxygen 3. Assembles and checks equipment 4. Instructs partner to stabilize head and neck as needed 5. Kneels at the left shoulder, facing patient 6. Places bite block between patient’s molars to protect fingers 7. Inserts left middle and index fingers into patient’s mouth; walks down midline, tugging forward on the tongue 8. Palpates epiglottis with the middle finger 9. Presses epiglottis forward and inserts ETT anterior to fingers 10. Advances tube, pushing it with right hand, using index finger to maintain the tip of the tube against the middle finger, directing it to the epiglottis 11. Using middle and index fingers, directs the tube tip between the epiglottis and the fingers and advances the tube through the cords 12. Holds tube in place, attaches bag-valve mask with ETCO2 detector, and inflates cuff with 5–10 mL of air 13. Verifies tube placement: clear lung sounds bilaterally, symmetrical chest rise 14. Ventilates with 100 percent oxygen 15. Periodically rechecks tube placement

Student’s Name ____________________

HANDOUT 15-6

SKILLS TRAUMA INTUBATION Charting Student Progress: 1

Learning skill

2. Performs skill with direction 3.

Performs skill independently

Procedure

1. Takes Standard Precautions 2. One team member faces patient on one side, establishes cervical spine stabilization from the front 3. Intubating paramedic sits behind patient on the ground with legs straddling patient’s shoulders, moves up until patient’s head is secured, and applies firm pressure to ensure immobilization 4. Ventilates patient with 100 percent oxygen 5. Assembles and checks equipment 6. Holds laryngoscope in left hand and inserts it into right side of the mouth, displacing tongue to the left, and brings laryngoscope to midline 7. Advances blade until it reaches the base of the tongue 8. Lifts laryngoscope forward to displace the jaw without putting pressure on front teeth 9. Looks for tip of epiglottis and places blade into proper position 10. Lifts jaw at 45-degree angle to the ground until glottis is exposed 11. Grasps tube with the right hand and advances it through right corner of patient’s mouth 12. Advances the tube through the glottic opening until the distal cuff disappears past vocal cords 13. Removes stylette, inflates distal cuff with 5 to 10 mL of air, and removes syringe 14. Verifies proper placement of tube: clear breath sounds, symmetrical chest rise 15. Ventilates patient with 100 percent oxygen ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

16. Periodically rechecks tube placement

Student’s Name ____________________

HANDOUT 15-7

SKILLS RAPID SEQUENCE INTUBATION WITH NEUROMUSCULAR BLOCKADE Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently

Procedure

1. Takes Standard Precautions 2. Assembles required equipment 3. Ensures that IV is in place and running 4. Places patient on cardiac monitor and pulse oximeter 5. Ventilates patient with 100 percent oxygen 6. Considers premedicating as needed with Versed, atropine, lidocaine, and so on, per local protocols 7. Has assistant apply pressure to the cricoid (Sellick’s maneuver) until proper ETT placement is confirmed 8. Sedate and paralyze, using appropriate medications and doses. 9. Watches for apnea and jaw relaxation 10. Performs endotracheal intubation with direct or indirect visualization or an endotracheal tube introducer. 11. Confirms proper placement of ETT, inflates distal cuff, ventilates with bagvalve mask with a CO2 detector attached, watching for chest rise and fall with ventilations, bilateral breath sounds, no gastric sounds over the stomach 12. Releases Sellick’s maneuver 13. Inserts bite-block device, secures ETT in place, and reconfirms ETT placement 14. Ventilates patient with 100 percent oxygen 15. Periodically rechecks tube placement ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Student’s Name _____________

HANDOUT 15-8 SKILLS

PEDIATRIC INTUBATION Charting Student Progress: 1.

Learning skill

Performs skill with direction

Performs skill independently

Procedure 1

1. Takes Standard Precautions 2. Uses towel roll to achieve and maintain sniffing position 3. Ventilates patient with 100 percent oxygen 4. Assembles and checks equipment 5. Places patient’s head and neck in appropriate position 6. Holds laryngoscope in left hand and inserts into right side of mouth 7. Moves blade slightly toward midline, advancing it until the distal end reaches the base of the tongue 8. Looks for tip of epiglottis and positions laryngoscope properly 9. Grasps ETT in right hand and, under direct visualization of the vocal cords, inserts it through the right corner of the patient’s mouth into the glottic opening until distal 10 mm or distal cuff disappears 2 to 3 cm beyond the vocal cords 10. Holds tube in place with left hand and attaches infant- or child-size BVM to the connector with CO2 detector 11. Delivers several breaths, checking for proper tube placement: symmetrical rise and fall of chest, equal bilateral breath sounds 12. Ventilates patient with 100 percent oxygen 13. Secures tube with tape or commercial device 14. Periodically rechecks tube placement

Student’s Name _____________

HANDOUT 15-9

SKILLS NASOTRACHEAL INTUBATION Charting Student Progress: 1.

Learning skill

2. Performs skill with direction 3. Performs skill independently

Procedure

1. Takes Standard Precautions 2. Ventilates patient with 100 percent oxygen 3. Assembles and checks equipment 4. Inspects nose and selects the larger nostril as passageway 5. Applies topical anesthesia with Hurricane spray or topical lidocaine 6. Lubricate the tube generously 7.

Inserts the tube into the nostril with the bevel along the floor of the nostril or facing the nasal septum

As the tube drops into the posterior pharynx, listens closely at its proximal end for the patient’s respiratory sounds

With the patient’s next inhaled breath, advances the ETT quickly into the glottic opening and continues passing it until the cuff is just past the vocal cords

10.

Watches for condensation in the clear tube, feels for exhaled air from the tube

11.

Holding the ETT with one hand to prevent displacement, inflates the distal cuff with 5 to 10 mL of air and removes syringe

12.

Verifies proper placement by observing chest rise, auscultating breath sounds, and monitoring color change in ETCO 2 detector

13.

Secures tube with tape or commercial device

14.

Ventilates patient with 100 percent oxygen

15.

Periodically rechecks tube placement

Student’s Name _______________

HANDOUT 15-10 SKILLS

ESOPHAGEAL TRACHEAL COMBITUBE AIRWAY Charting Student Progress: 1.

Learning skill

2. Performs skill with direction 3. Performs skill independently

Procedure

123

1. Takes Standard Precautions 2. Ventilates patient with 100 percent oxygen 3. Assembles and checks equipment 4. Places the patient supine and kneels at the top of his head 5. Places patient’s head in neutral position 6. Performs the Lipp maneuver to preshape the ETC tube 7. Inserts ETC at midline through oropharynx, using a tongue-jaw-lift maneuver, advancing it past the hypopharynx to the depth indicated by the markings on the tube so that the black rings of the tube are between the patient’s teeth 8. Inflates pharyngeal cuff with 100 mL of air and distal cuff with 10 to 15 mL of air 9. Ventilates through the longer blue proximal port with bag-valve mask connected to 100 percent oxygen 10. Auscultates lungs and stomach 11. If gastric sounds are heard instead of breath sounds, changes ports and ventilates through the clear connector 12. Confirms bilateral lung sounds: visualizes chest rise, watches for color change in CO2 detector 13. Secures tube and continues ventilating with 100 percent oxygen 14. Frequently reassesses airway and adequacy of ventilation

Student’s Name __________________

HANDOUT 15-11

SKILLS PTL AIRWAY

Charting Student Progress: 1.

Learning skill

2. Performs skill with direction 3. Performs skill independently Procedure

1. Takes Standard Precautions 2. Ventilates patient with 100 percent oxygen 3. Assembles and checks equipment 4. Places patient’s head in appropriate position 5. Inserts PtL gently, using the tongue-jaw-lift maneuver 6. Inflates distal cuffs of both PtL tubes simultaneously with sustained breath into inflation valve 7. Delivers breath into green tube and looks for chest rise 8. If chest rises, inflates pharyngeal balloon and continues ventilating through green tube, auscultating bilateral breath sounds 9. If chest does not rise and no breath sounds are audible with auscultation, removes stylette from clear tube and ventilates patient through clear tube 10. Verifies proper placement by watching chest rise and auscultating lungs 11. Attaches bag-valve mask, secures tube, and ventilates patient with 100 percent oxygen 12. Frequently reassesses airway and adequacy of ventilation

Student’s Name _______________

HANDOUT 15-12 SKILLS

FOREIGN BODY REMOVAL UNDER DIRECT LARYNGOSCOPY Charting Student Progress: 1 Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Takes Standard Precautions 2. Confirms airway obstruction and unsuccessful BLS procedures 3. Prepares equipment 4. Places head in sniffing position 5. Inserts laryngoscope and visualizes glottic opening 6. Identifies obstruction 7. Inserts Magill forceps in closed position 8. Opens forceps to grasp object and removes obstruction 9. Removes laryngoscope 10. Reassesses airway and breathing

Student’s Name ______________

HANDOUT 15-13 SKILLS

NEEDLE CRICOTHYROTOMY

Charting Student Progress: 1.

Learning skill

2. Performs skill with direction 3. Performs skill independently Procedure

123

1. Takes Standard Precautions 2. Manages the patient’s airway as well as possible with basic maneuvers 3. Places patient supine and hyperextends head and neck (maintain neutral position if suspected cervical spine injury) 4. Positions at patient’s side 5. Prepares equipment including a 14- or 16-gauge IV needle with cateter for an adult and an 18- to 20-gauge for a child to 10- or 20-mL syringe 6. Palpates inferior portion of thyroid cartilage and cricoid cartilage and identifies cricothyroid membrane 7. Cleanses site appropriately 8. Firmly grasps laryngeal cartilages and reconfirms site of cricothyroid membrane 9. Inserts needle into cricothyroid membrane at midline, directed 45 degrees caudally 10. Advances needle no more than 1 cm and aspirates with syringe 11. Confirms placement and advances catheter; withdraws needle 12. Reconfirms placement and secures catheter in place 13. Checks adequacy of ventilations: chest rise, bilateral breath sounds 14. If spontaneous ventilations are absent or inadequate, begins transtracheal jet ventilation 15. Connects one end of oxygen tubing to catheter, other end to jet ventilator 16. Opens release valve and adjusts pressure to allow adequate lung expansion ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

17. Watches chest carefully, turning off release valve as soon as chest rises 18. Delivers at least 20 breaths per minute 19. Continues ventilatory support, assessing for adequacy of ventilations and watching for potential complications

Student’s Name _______________

HANDOUT 15-14 SKILLS

OPEN CRICOTHYROTOMY

Charting Student Progress: 1.

Learning skill

2. Performs skill with direction 3. Performs skill independently Procedure

123

1. Takes Standard Precautions 2. Manages the patient’s airway as well as possible with basic maneuvers 3. Locates thyroid cartilage and the cricoid cartilage 3. Finds cricothyroid membrane 4. Cleanses site appropriately 5. Stabilizes the cartilages with one hand 6. Uses scalpel to make 1- to 2-cm vertical skin incision over membrane 7. Makes 1-cm incision in the horizontal plane through the membrane 8. Inserts curved hemostats into the membrane incision and spreads it open 9.

Inserts either cuffed endotracheal tube (6 mm or 7 mm) or tracheostomy tube (6 or 8 Shiley), directing the tube into trachea

10. Inflates cuff and ventilates 11. Confirms placement with auscultation, ETCO2 detector, and chest rise 12. Secures tube in place

Student’s Name _____________________

HANDOUT 15-15

SKILLS SUCTIONING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure

1. Takes Standard Precautions 2. Ventilates patient with 100 percent oxygen 3. Determines depth of catheter insertion by measuring from patient’s earlobe to lips 4. With suction turned off, inserts catheter into patient’s pharynx to the predetermined depth 5. Turns on suction unit and places thumb over suction-control orifice 6. Suctions while withdrawing catheter, no more than 10 seconds 7. Ventilates patient with 100 percent oxygen

Student’s Name ______________

HANDOUT 15-16

CHAPTER 15 QUIZ Write the letter of the best answer in the space provided. ______ 1.

Which of the following represents the correct order of the airway structures from the mouth to the lungs?

______ 2.

______ 3.

Trachea, bronchi, larynx, pharynx

Pharynx, larynx, trachea, bronchi

Bronchi, trachea, pharynx, larynx

Larynx, pharynx, trachea, bronchi

The narrowest part of the airway in children is the ______ cartilage. a.

thyroid

cricoid

c. d.

hyoid

ethmoid

Stimulation of laryngeal mucous membrane can cause all of the following EXCEPT:

______ 4.

______ 5.

______ 6.

______ 7.

bradycardia.

cough.

hypotension.

decreased respiratory rate.

The trachea is maintained in an open position by: a.

the Adam’s apple.

surfactant.

the carina.

cartilaginous C-rings.

The lungs are covered by: a.

the visceral pleura.

the parietal pleura.

the parenchyma.

none of the above.

The lung tissue receives most of its blood supply from: a.

bronchial arteries.

bronchial veins.

pulmonary arteries.

pulmonary veins.

In normal respiration, the size of the thoracic cavity can be increased by contracting the diaphragm and the:

______ 8.

strap muscles.

deltoid muscles.

abdominal muscles.

intercostal muscles.

Increases in carbon dioxide production can be caused by: a.

fever.

______ 9.

______10.

muscle exertion/shivering.

metabolic processes (diabetic ketoacidosis).

all of the above.

During inspiration, the lungs become distended, activating the: a.

stretch receptors.

beta receptors.

chemoreceptors.

alpha receptors.

In patients with chronic lung disease, the primary stimulus to breathe is:

______11.

increased pH.

decreased oxygen.

increased carbon dioxide. d.

none of the above.

The average volume of gas inhaled in one respiratory cycle is called the:

______12.

______13.

______14.

tidal volume.

Mminute volume.

alveolar volume.

functional reserve capacity.

The potentially most ominous finding of auscultation is: a.

snoring.

wheezing.

gurgling.

quiet.

SpO2 measures the level of which gas? a.

CO2

Nitrogen

All of the following can cause an error signal or blank screen on an SpO2 monitor EXCEPT:

______15.

nail polish.

asthma.

carbon monoxide poisoning.

cold hands.

Which of the following would cause an increased level of exhaled CO2? a.

Hyperthermia

Pulmonary embolism

Cardiac arrest

d. ______16.

______17.

______18.

______19.

Bronchospasm

Decreased ETCO2 levels can be found in: a.

shock .

cardiac arrest.

pulmonary embolism.

all of the above.

______ is the measurement of expired CO 2. a.

Capnography

Capnometry

Capnograph

Capnogram

A “shark fin” waveform on a capnogram is consistent with: a.

hyperventilation.

asthma.

esophageal intubation.

hypoventilation.

The bag-valve device has an adjunct oxygen reservoir or corrugated tubing that can deliver ______ oxygen.

______20.

______21.

60–70 percent

80–90 percent

70–75 percent

90–95 percent

Both the PtL and the ETC airways: a.

can be inserted into either the esophagus or the trachea.

can be used in patients under 16 years of age.

can be used in patients with a gag reflex.

all of the above.

What was the first intubating laryngeal airway designed to facilitate blind endotracheal intubation with a special tube or a regular tube reverse loaded?

______22.

Cobra Perilaryngeal Airway

LMA Fastrach™

Intubating Laryngeal Mask Airway

Ambu Laryngeal Mask Airway

The laryngoscope permits visualization of the vocal cords by lifting of the tongue and: a.

soft palate.

hyoid bone.

b. ______23.

______24.

______25.

______26.

______27.

epiglottis.

none of the above.

The curved blade made for the laryngoscope is the: a.

Miller.

Flagg.

Wisconsin.

Macintosh.

The curved laryngoscope blade is designed to fit into the: a.

pyriform fossa.

epiglottis.

vallecula

larynx

The greatest advantage of a straight blade is: a.

greater displacement of the tongue.

indirect elevation of the epiglottis .

lessened chance of stimulating the gag reflex.

wider field of vision for intubation.

Stylettes are a valuable asset when intubating a patient with: a.

a short, fat neck.

a posterior larynx.

a long, thin neck.

none of the above.

The dangers of movement of an endotracheal tube once it is positioned include:

______28.

elevation of intracranial pressure.

stimulation of the vallecula .

cardiovascular depression.

all of the above.

Potentially dangerous complications of improper endotracheal intubation include:

______29.

rsophageal intubation.

pyriform sinus intubation.

right mainstem intubation.

all of the above.

Indications of proper endotracheal intubation include all of the following EXCEPT: a.

the presence of bilateral breath sounds.

the absence of abdominal sounds.

______30.

phonation.

the presence of condensation in the tube.

An esophageal detector device (EDD) uses the anatomical principle that the: a.

trachea is rigid and will collapse under negative pressure.

trachea is rigid and will not collapse under negative pressure.

esophagus is rigid and will collapse under negative pressure.

esophagus is rigid and will not collapse under negative pressure.

______31.

______32.

______33.

______34.

Blind nasotracheal intubation is contraindicated if the patient: a.

is apneic.

has sustained a mandibular injury.

is anorexic.

is severely obese.

Nasotracheal tube auscultation devices may be used only in: a.

breathing patients.

nonbreathing patients.

cardiac arrest patients.

nonbreathing trauma patients.

Digital intubation can be useful in which of the following situations? a.

A trauma patient has a suspected cervical spinal injury.

Entrapment prevents proper positioning.

Facial injuries distort the anatomy.

All of the above

All of the following statements about the pediatric airway are true EXCEPT: a.

the tongue is larger in relation to the oropharynx than in adults.

the glottic opening is lower and more posterior than in adults.

the epiglottis is floppy and round.

d. ______35.

______36.

the narrowest part is the cricoid cartilage.

The preferred point of entry when inserting a surgical airway is the: a.

hyoid membrane.

cricothyroid membrane.

arytenoid folds.

pyriform fossa.

The most frequently used system of preintubation airway assessment is the:

______37.

Mallampati classification system.

Revised Cormack and LeHane classifications.

Percentage of Glottic Opening system.

Revised Mallampati and Cormack classifications.

To ventilate the patient with a stoma device, rescue personnel will generally use a(n):

______38.

mouth-to-stoma technique.

bag-valve-mask device.

demand valve device.

automatic transport ventilator.

The minimum acceptable vacuum level in suctioning units for the prehospital setting is:

______39.

200 mmHg. c.

500 mmHg.

300 mmHg. d.

750 mmHg.

Both standard routes of gastric decompression put the patient at risk for all of the following EXCEPT: a.

misplacement into the brain.

vomiting.

misplacement into the trachea.

trauma or bleeding from poor technique.

Student’s Name ___________________

HANDOUT 15-17

CHAPTER 15 SCENARIO 1 Review the following real-life situation. Then answer the questions that follow. The call is for an unknown medical emergency, with a man down on the sidewalk in front of the county building. Medic 6 is literally around the corner from the call. The unit arrives to find a small crowd of people standing around the patient. The patient is well known to the crew as an alcoholic with a history of epileptic seizures. In this case, the patient apparently fell and struck his head, as blood is still oozing from a laceration to his forehead. An EMT ensures stabilization of the head, while the paramedic tries to arouse the patient. Witnesses say that the patient had a seizure that lasted for “several minutes.” None report that he turned cyanotic. After getting no response from the patient to loud questions and commands, the paramedic attempts a painful stimulation. This effort produces only a groan from the patient. The paramedic attempts to insert an oral airway, but the patient gags and spits it out. The paramedic then tries a nasopharyngeal airway. The patient tolerates this, so the crew supplies oxygen and prepares to package the patient for transport. When he is secured to the backboard, the patient suddenly seizes again. The crew rolls him onto his side while on the backboard, suctions his mouth, and reassesses his airway and breathing after he stops seizing. The seizure lasts less than 1 minute. 1. Why was the airway a concern in this patient? 2. Besides epilepsy, what other causes of the seizure might be possible? 3. Why would the paramedic not immediately intubate this unconscious patient on scene?

Student’s Name ____________________

HANDOUT 15-18 EVALUATION

CHAPTER 15 SCENARIO 2 Review the following real-life situation. Then answer the questions that follow. “Engine 5, Ambulance 3, respond to 7439 Burr Oak Road for a 21-year-old female experiencing an asthma attack. Time out 2230.” Responding priority one, lights and siren, you arrive at the scene and are ushered into the kitchen. Even before you enter, you can hear wheezing through the doorway. Inside, at the table, you find the patient, who weighs approximately 100 kilograms, in obvious respiratory distress. Although the patient is conscious, she obviously is exhausted and is having trouble maintaining an upright posture. You assist her to the floor, where she leans against the wall. Asking others in the room to please extinguish their cigarettes, you proceed with your assessment. The patient’s respiratory rate is in the high 40s, with shallow, ineffective breaths. The BLS crew prepares to assist her with ventilations while you listen to the lungs. Wheezes in the upper lobes are present with both inspirations and expirations, but upon listening to her back, you are alarmed to note that the bases are essentially silent. Despite assistance with the bag-valve mask, the patient is having trouble maintaining consciousness. You decide to intubate. You explain to the patient that you intend to intubate her to make her breathing easier. As you do this, you proceed to prepare a number 7 endotracheal tube. Lubricating the nares with lidocaine gel, you slide the tube into the right nare. The tube meets slight resistance and then, after a slight turn downward, slides into the hypopharynx. The patient coughs for a second as the tube passes cleanly into the trachea. After confirming the placement, you secure the ETT and proceed with your examination. The patient has a history of juvenile-onset asthma and two previous episodes requiring intubation and ventilation. She is on a theophylline compound as well as several inhalers. Just before your arrival, she had had an argument with her boyfriend about his smoking. 1. Why would early and aggressive intubation be indicated with this patient? 2. How can you confirm tube placement in this patient? 3. What are some of the dangers in intubating this patient? ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Student’s Name ___________________

HANDOUT 15-19

CHAPTER 15 REVIEW Write the word or words that best complete each sentence in the space provided. 1. The upper airway extends from the mouth and nose to the ________________________________________. 2. The presence of gas or air in the pleural cavity is called a(n) ________________________________________. 3. The exchange of gases between a living organism and its environment is referred to as ________________________________________. 4. The lining in body cavities that handles air transport, usually containing small, mucous-secreting cells, is called ________________________________________ ________________________________________. 5. _______________________________________ maneuver is pressure applied in a posterior direction to the anterior cricoid cartilage, occluding the esophagus. 6. _______________________________________ are the microscopic air sacs where most oxygen and carbon dioxide gas exchanges take place. 7. The term ________________________________________ means alveolar collapse. 8. The pressure exerted by each component of a gas mixture is called ________________________________________ ________________________________________. 9. The abbreviation for alveolar partial pressure is ________________________________________. 10. The abbreviation for arterial partial pressure is ________________________________________. 11. FiO2 is the concentration of ________________________________________ in inspired air. 12. Fever, muscle exertion, shivering, and metabolic processes may cause increased ________________________________________ production. 13. The mechanism that increases respiratory stimulation when PaO 2 falls is ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

called ________________________________________ ________________________________________. 14. The most common cause of airway obstruction is the ________________________________________. 15. _______________________________________ breathing is asymmetrical chest wall movement that lessens respiratory efficiency. 16. The measurement of exhaled carbon dioxide concentrations is called ________________________________________. 17. In the absence of cervical spine trauma, the ________________________________________ ________________________________________ is the best technique for opening the airway of an unresponsive patient. 18. The ________________________________________ airway may be used as a basic airway adjunct in the presence of a gag reflex. 19. Once the tip of a(n) ________________________________________ airway reaches the level of the soft palate, gently rotate it 180 degrees. 20. Miller, Wisconsin, and Flagg are types of ________________________________________ laryngoscope blades. 21. Verification of proper endotracheal tube placement includes absence of ________________________________________ ________________________________________ over the epigastrium, the presence of ________________________________________ breath sounds (lungs), and the presence of ________________________________________ inside the tube. 22. _______________________________________ ________________________________________ capnography is the best way to monitor endotracheal tube placement and ventilation. 23. The BURP maneuver enhances visualization of the cords during endotracheal intubation. The acronym BURP stands for ________________________________________, ________________________________________, and ________________________________________ ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

________________________________________. 24. Giving medications to sedate and temporarily paralyze a patient before performing orotracheal intubation is called ________________________________________ ________________________________________. 25. Partial ingestion of caustic poisons is a contraindication to the use of the ________________________________________ ________________________________________ airway. 26. Often, patients who have had a laryngectomy or tracheostomy breathe through a(n) ________________________________________, an opening in the anterior neck that connects the trachea with the ambient air. 27. Suctioning should be limited to ________________________________________ seconds. 28. In an awake patient with gastric distension, the ________________________________________ approach to decompression is generally preferred. 29. The difference between a partial rebreather mask and a nonrebreather mask is that the nonrebreather mask has a(n) ________________________________________ ________________________________________ ________________________________________ attached. 30. Demand valve devices have fallen out of favor because of the risks of __________________ __________________ and __________________.

Student’s Name _____________

HANDOUT 15-20

UPPER AIRWAY MATCHING Write the letter of the term in the space next to the appropriate description. a. Pharynx

Cricoid

b. Gag reflex

Glottis

c. True vocal cords

Vallecula

d. Septum

Larynx

e. Epiglottis

Laryngeal mucous membrane

__________

Divides the nasal cavity into right and left

__________

Cartilage that lies beneath the thyroid cartilage

__________

Muscular tube from the back of the soft palate to the esophagus

__________

Depression between the epiglottis and the base of the tongue

__________

Structure that joins the pharynx with the trachea

__________

Response triggered by touching the soft palate or the throat

__________

Structure that regulates the passage of air through the larynx and controls the production of sound

__________

Opening through which the endotracheal tube is passed

__________

Stimulation here can cause bradycardia, hypotension, and a decreased respiratory rate

__________

10.

Leaf-shaped cartilage that prevents food from entering the respiratory tract

Student’s Name __________________

HANDOUT 5-21

LOWER AIRWAY MATCHING Write the letter of the term in the space next to the appropriate description. a.

Trachea

Alveoli

Bronchi

Surfactant

Carina

Parietal pleura

Lung parenchyma

Alveolar ducts

Visceral pleura

Lobes

__________

The right lung has three, and the left has two

__________

Final division of the airway before the terminal units

__________

Connects the larynx with the mainstem bronchi

__________

The right one is almost straight, while the left angles more acutely

__________

Lines the thoracic cavity and contains numerous nerve fibers

__________

Connective tissue that covers the lungs and does not contain nerve fibers

__________

Point where the bronchi divide

__________

Chemical that decreases surface friction

__________

Primary respiratory units where an exchange of gases occurs

__________

10.

Arranged in two pulmonary lobules

Student’s Name __________________

HANDOUT 15-22

BASIC RESPIRATORY TRUE OR FALSE Indicate if the following statements are true or false by writing T or F in the space provided. __________ 1. Ventilation occurs when the gases oxygen and carbon dioxide are exchanged in the lungs. __________ 2. The lungs have the intrinsic capacity to expand and contract without the aid of muscles. __________ 3. Contraction of the diaphragm results in its downward motion. __________ 4. Pulmonary embolism or atelectasis can cause a ventilation/perfusion mismatch. __________ 5. Obstructive diseases, such as asthma, decrease the elimination of carbon dioxide. __________ 6. The chemoreceptors are stimulated by increasing PaCO2 and decreasing PaO2. __________ 7. The tidal volume (VT) is the maximal amount of air that can be inspired. __________ 8. “Dead space volume” refers to gases that are unavailable for functional gas exchange. __________ 9. The apneustic center in the pons is the primary controller of respiration. __________10. The average person breathes primarily because of hypoxic drive. __________11. Activation of stretch receptors in the lungs causes the excitation of medulary cells. __________12. Hypercarbia is one complication of the aspiration of foreign matter. __________13. Poorly chewed food is the most common cause of airway obstruction. __________14. The cricoid cartilage represents the narrowest portion of the adult airway. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

__________15. Deoxygenated hemoglobin will make the skin appear bluish.

__________16. Heart sounds can interfere with auscultation of the anterior chest. __________17. Continuous waveform capnography is the best way to monitor endotracheal tube placement and ventilation. __________18. Tachycardia is a common cause of false readings in pulse oximetry. __________19. The pulse oximeter analyzes the oxygen saturation percentage in the plasma. __________20. If an ETCO2 detector indicates a lack of carbon dioxide in exhaled air, it is a good sign that an endotracheal tube has been placed in the esophagus.

Student’s Name _________________

HANDOUT 15-23

ADVANCED AIRWAY MATCHING Write the letter of the term in the space next to the appropriate description. a. Oropharyngeal airway

Succinylcholine

b. EOA

PtL

c. EGTA

ETC

d. Endotracheal tube

Yankauer

e. Macintosh

Demand valve

f. Miller

Nonrebreather

g. Stylet

Venturi

h. Magill __________

Type of scissors-style clamps with circle-shaped tips

__________

Straight laryngoscope blade

__________

Airway designed for insertion into the esophagus that does not provide for suctioning of the stomach

__________

Neuromuscular blocking agent

__________

Airway comprising a short, large-diameter green tube and a longer, narrow-diameter clear tube

__________

Manually triggered, oxygen-powered breathing device

__________

Tonsil tip suction catheter

__________

Semicircular plastic and rubber device that conforms to the palate’s curvature and lifts the base of the tongue

__________

Metal wire covered with plastic

__________

10.

Esophageal airway that permits suctioning of the stomach

__________

11.

Two-tube airway in which tubes are combined with lumens separated by a partition

__________

12.

Oxygen administration device particularly useful with COPD patients

__________

13.

Flexible, 35- to 37-cm tube with adapter at one end and inflatable cuff at the other

__________

14.

Device consisting of tubing, reservoir bag, and

inlet/outlet ports covered by thin rubber flaps __________

15.

Curved laryngoscope blade

Student’s Name __________________

HANDOUT 15-24

AIRWAY MANAGEMENT INDICATIONS, CONTRAINDICATIONS, ADVANTAGES, DISADVANTAGES Complete the following lists. 1. List three advantages of the nasopharyngeal airway. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ _______________________________________________________ 2. List three indications of accidental esophageal intubation. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ _______________________________________________________ 3. List three contraindications for nasotracheal intubation. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ _______________________________________________________ 4. List three indications for rapid sequence intubation. ___________________________________________________________ ___________________________________________________________ ________________________________________________________ 5. List three advantages of the PtL airway. ___________________________________________________________ ___________________________________________________________ ________________________________________________________ 6. List three potential complications of needle cricothyrotomy with transtracheal jet ventilation. ___________________________________________________________ ___________________________________________________________ ________________________________________________________ ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

HANDOUT 15-25

Student’s Name _____________

RAPID-SEQUENCE INTUBATION COMPLETION Fill in the blanks to complete the steps in rapid-sequence intubation with neuromuscular blockade. 1. Preoxygenate the patient with ________________________________________ ________________________________________ ________________________________________ using basic manual and adjunct maneuvers. 2. Be certain to have at least one secure and working ________________________________________ ________________________________________. 3. Place the patient on a cardiac monitor and a(n) ________________________________________ ________________________________________. 4. If the patient is alert, administer a(n) ________________________________________ agent, such as ________________________________________ (________________________________________), before administering any neuromuscular blocking agents. 5. Apply ________________________________________ ________________________________________ and maintain until you confirm proper ETT placement. 6. If the patient is a child, premedicate with ________________________________________ to prevent bradycardia. 7. ________________________________________ and ________________________________________ ________________________________________ are indications that the patient is sufficiently relaxed to proceed with endotracheal intubation. 8. If unable to pass the ETT after ________________________________________ ________________________________________ ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

________________________________________ seconds, stop and ventilate the patient for 2 minutes. 9. Confirm proper placement of the ETT by watching for chest ________________________________________ ________________________________________ ________________________________________ with ventilations, auscultate with each ventilation for ________________________________________ breath sounds over the chest, and no ________________________________________ ________________________________________ over the stomach. 10. The duration of succinylcholine is ________________________________________ ________________________________________.

Student’s Name ________________________

HANDOUT 15-26

ANATOMY OF THE UPPER AIRWAY Label the following diagram:

HANDOUT 15-27

Student’s Name _____________________

INTERNAL ANATOMY OF THE UPPER AIRWAY Label the following diagram:

Student’s Name ___________________

HANDOUT 15-28

ANATOMY OF THE LOWER AIRWAY Label the following diagram:

Chapter 5 Answer Key Handout 5-16: Chapter 5 Quiz 1. b 2. b 3. c 4. d 5. a 6. a 7. d 8. d 9. a 10. c 11. a 12. d 13. c 14. b 15. a 16. d 17. c 18. b 19. d 20. a 21. b 22. b 23. d 24. b 25. a 26. a 27. a 28. d 29. c ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

30. b 31. a 32. a 33. d 34. b 35. c 36. a 37. b 38. b 39. a Handout 5-17: Chapter 5 Scenario 1 1. The unconscious patient has little, if any, control over the airway. Therefore, aspiration becomes a very real threat. 2. Reasonably, the patient may have seized as a result of alcohol withdrawal, epilepsy, hypoglycemia, overdose of antifreeze or wood alcohol, closed head injury (such as a subdural hematoma), or an infectious process. 3. The decision to intubate either the diabetic with hypoglycemia or the postictal epileptic patient must be made carefully. These patients often respond quickly to simple measures and without further complications that might result from the use of advanced airway control methods. Handout 5-18: Chapter 5 Scenario 2 1. The patient was hypoxic and tiring rapidly. Respiratory and cardiac arrest are definite possibilities in this case. Note that deaths secondary to asthma are increasing in this country, while treatments have not made significant advances. This form of intubation is called for because the patient is still conscious. In addition, nasotracheal intubation is recommended with obese patients. 2. If the tube is correctly placed, it should fog up as a result of condensation from the patient’s breath. The breath should also be felt coming from the proximal end of the tube. Placement should be confirmed by auscultation and by watching for chest rise and fall. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

3. The most significant danger would be accidental esophageal intubation and ventilation. The resultant gastric distension would further lessen tidal volume and possibly cause the patient to regurgitate stomach contents into the airway. Blind nasotracheal intubation also risks lacerating the turbinates, causing bleeding into the hypopharynx and further compromising the respiratory tract. Handout 5-19: Chapter 5 Review 1. larynx 2. pneumothorax 3. respiration 4. mucous membrane 5. Sellick’s 6. Alveoli 7. “atelectasis” 8. partial pressure 9. PA 10. Pa 11. oxygen 12. CO2 13. hypoxic drive 14. tongue 15. Paradoxical 16. capnography 17. head-tilt/chin-lift 18. nasopharyngeal 19. oropharyngeal 20. straight 21. gastric sounds, bilateral, condensation 22. Continuous waveform 23. backward, upward, rightward pressure 24. rapid sequence ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

25. esophageal tracheal 26. stoma 27. 10 28. nasogastric 29. oxygen reservoir bag 30. gastric distension, barotrauma Handout 5-20: Upper Airway Matching 1. d 2. f 3. a 4. h 5. i 6. b 7. c 8. g 9. j 10. e Handout 5-21: Lower Airway Matching 1. j 2. i 3. a 4. b 5. h 6. e 7. c 8. g 9. f 10. d Handout 5-22: Basic Respiratory True or False 1. F 2. F ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

3. T 4. T 5. T 6. T 7. F 8. T 9. F 10. F 11. F 12. T 13. F 14. F 15. T 16. T 17. T 18. F 19. F 20. T Handout 5-23: Advanced Airway Matching 1. h 2. f 3. b 4. i 5. j 6. m 7. l 8. a 9. g 10. c 11. k 12. o ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

13. d 14. n 15. e Handout 5-24: Airway Management Indications, Contraindications, Advantages, Disadvantages 1. Rapid insertion, bypasses tongue, can be used with gag reflex, can be used in patients with oral cavity injury, can be used when teeth are clenched 2. Absence of chest rise and breath sounds, gurgling sounds over epigastrium, absence of condensation in ETT, persistent air leak, cyanosis and worsening of patient’s condition, phonation 3. Nasal fractures, basilar skull fractures, significantly deviated nasal septum, nasal obstruction, cardiac or respiratory arrest, unresponsive patient 4. Impending respiratory failure due to intrinsic pulmonary disease, acute airway disorder that threatens airway patency, altered mental status with significant risk of vomiting and aspiration 5. Functions in either trachea or esophagus, no face mask to seal, does not require visualization of the larynx, can be used with trauma patients, helps to protect trachea from upper airway bleeding and secretions 6. May lead to barotrauma, excessive bleeding, subcutaneous emphysema, airway obstruction, hypoventilation Handout 5-25: Rapid-Sequence Intubation Completion 1. 100 percent oxygen 2. IV line 3. pulse oximeter 4. sedative, midazolam, Versed 5. Sellick’s maneuver 6. atropine 7. Apnea, jaw relaxation 8. 20 to 30 9. rise and fall, bilateral, gastric sounds 10. 8 minutes ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 1, 5th Ed.

Handout 5-26 Anatomy of the Upper Airway

Handout 5-27 Internal Anatomy of the Upper Airway

Handout 5-28 Anatomy of the Lower Airway