**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Instructor Course Guide**

**Table of Contents**

**Section/Area Page**

> Introduction
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> i
>
> Course Overview
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> ii
>
> Course Planning Considerations
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> v
>
> Course Conduct and Evaluation
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> viii
>
> Testing and Evaluating the Student
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> x
>
> Program Evaluation
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> xi
>
> Acknowledgment
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> xiii
>
> Module I, Preparatory
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> I - 1
>
> Module II, Airway
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> II - 1
>
> Module III, Patient Assessment
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> III - 1
>
> Module IV, Medical/Behavioral
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> IV -1
>
> Module V, Trauma
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> V - 1
>
> Module VI, Obstetrics, Infants, and Children
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- VI -1
>
> Appendix A, USDOT Curriculum Objectives EMT-Basic
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- A - 1

**INTRODUCTION**

**HISTORICAL PERSPECTIVE**

> In 1994 the U.S. Department of Transportation\'s, National Highway
> Traffic Safety Administration completed an extensive revision of the
> national standard EMT-Basic Curriculum. The curriculum received
> national EMS community and physician review and input during
> development and resulted in additional skills and knowledge being
> available to Emergency Medical Technicians. The curriculum was widely
> accepted and implementation was scheduled throughout the country.
>
> In 1995 the National Registry of Emergency Medical Technicians funded
> a national project to develop a transition program for currently
> certified and licensed EMT-Basics that were educated based upon the
> 1984 USDOT EMT-Ambulance Curriculum. A committee comprised of the
> National Council of State EMS Training Coordinators, the National
> Association of State EMS Directors, the National Association of EMS
> Physicians, the American College of Emergency Physicians and the
> National Registry of Emergency Medical Technicians, approved and
> disseminated a transition program. The programs goal was to bring all
> EMT-Basics within the nation to the same level of competency over the
> new skills and knowledge presented in the 1994 USDOT EMT-Basic
> Curriculum.
>
> In 1995 the National Registry of EMTs was asked by the National
> Council of State EMS Training Coordinators and the National
> Association of State EMS Directors to expand the role of the
> transition program, fund and develop a national standard EMT-Basic
> education program based upon the content of the 1994 EMT-Basic
> Curriculum. The independent transition committee accepted the
> responsibility to develop, review and seek input on a refresher
> curriculum. The US Department of Transportation, National Highway
> Traffic Safety Administration, in a true public/private partnership
> agreement, agreed to accept and publish this refresher curriculum
> after consensus was achieved by the committee and the states.

**PHILOSOPHY**

> The EMT is responsible for a wide range of knowledge and skills which
> includes material originally learned, as well as new information
> resulting from the constant growth and evolution of the field of
> emergency medical care. In order to maintain up-to-date proficiency,
> an EMT must regularly participate in educational programs which review
> the essential components of the national standard curriculum (NSC) as
> well as those which provide exposure to new knowledge and skills
> resulting from advances in emergency medical care.
>
> This document is a course guide for the basic EMT refresher training
> program. It will provide information which will help program
> administrators and instructors plan and implement a course. The
> companion lesson plans contain the essential components of the NSC in
> a format which may be adapted to a variety of presentation schedules,
> formats and methods.

**COURSE OVERVIEW**

**ORGANIZATION**

> The EMT-Basic Refresher curriculum is the minimum acceptable content
> that must be included in any EMT-Basic refresher educational program.
> This program should consist of a minimum of 24 classroom hours. The
> refresher training program is divided into six modules. This
> organizational plan was chosen to begin a process of standardization
> among National Standard Curricula.
>
> The six modules are:
>
> I. Preparatory
>
> II\. Airway
>
> III\. Patient Assessment
>
> IV\. Medical/Behavioral
>
> V. Trauma
>
> VI\. Obstetrics, Infants and Children
>
> This refresher course is competency based. Specific number of hours to
> complete each module have not been included. EMTs who successfully
> complete this course must demonstrate competency over the knowledge
> and skills outlined in this refresher education program.
>
> The first part of each module lists the specific patient care task in
> a bold face font. Immediately below the listed task is the cognitive
> learning objectives which correspond to the specific task. The list of
> tasks indicates the minimum level of proficiency required of the
> EMT-Basic to assure safe and effective practice. The psychomotor and
> affective objectives relate to the overall content of the module.

**LESSON PLANS**

> The Instructor Lesson Plans are designed to provide the technically
> competent instructor with the educational materials needed to conduct
> EMT refresher training programs. The 1994 USDOT EMT-Basic National
> Standard Curriculum should serve as the reference and minimal
> supplemental material for each lesson. Each lesson has the following
> components:

**OBJECTIVES**

> The objectives are divided into three categories: Cognitive, Affective
> and Psychomotor. To assist with the design and development of a
> specific lesson, each objective has a numerical value. This numerical
> value follows the same objective numbering system presented in the
> EMT-Basic National Standard Curriculum.

**PREPARATION**

> **Motivation** ‑‑ Each lesson has a motivational statement that should
> be read by the instructor prior to teaching the lesson. It is not the
> intent for the instructor to necessarily read the motivational
> statement to the students, but more importantly to be familiar with
> its intent and to be able to prepare the students or explain why this
> is important to them.

**MATERIALS**

> **Audio Visual (AV) Equipment** ‑‑ In recent years the design and
> development of high quality video has become available for the EMS
> community. They should be used as an integral part of the instruction
> in this program. The course administrator should assure that the
> necessary types of AV equipment are accessible to the class. If
> possible, the course administrator should have a video library
> available.
>
> **Emergency Medical Services (EMS) Equipment** ‑‑ Each lesson plan
> contains a list of equipment that should be available.

**PERSONNEL**

> **Primary Instructor** ‑‑ Each lesson plan clearly defines the
> necessary qualifications of the primary instructor.
>
> **Assistant Instructor** ‑‑ Each lesson plan clearly defines the
> necessary qualifications of the assistant instructor.

**PRESENTATION**

> **Declarative (What)** ‑‑ This is the cognitive lesson plan. This is
> the information that the instructor provides. This may be accomplished
> by various methods, including lectures, small group discussion, and
> the use of audio-visual materials. Demonstrations, if the instructor
> desires, may be used as part of the instruction. The instructor must
> be well versed with the entire content of the lesson plan. These
> lesson plans are not to be read word for word. Lesson plans should be
> considered dynamic documents that provide guidelines for the
> appropriate flow of information. The lesson plans are based upon the
> content of the EMT-Basic National Standard Curriculum. The instructor
> should feel free to write notes in the margins and make the lesson
> plan their own.

**APPLICATION**

> **Procedural (How)** ‑‑ This is the skills portion of the program.
> EMT-Basics should be able to demonstrate competency in all skills
> listed in each section. If the declarative (what) content was
> presented as a lecture, the instructor must perform demonstrations
> prior to having the EMT-Basic perform the skills. If the instructor
> performed a demonstration as part of the declarative component, the
> EMT-Basic may begin by practicing skills in the practical setting.
>
> When this component of the lesson is being conducted the
> instructor/EMT ratio should be no more than 1 to 6. EMT-Basics should
> be praised for their progress. For those EMT-Basics having difficulty
> performing a skill or skills, remediation is required. It is well
> known that a demonstration must be followed by practice, which must be
> drilled to a level that assures mastery of the skill. It has been
> proven that demonstration followed as soon as possible with organized,
> supervised practice enhances mastery and successful applications.
>
> **Contextual (When, Where and Why)** ‑‑ This section is designed to
> help EMT-Basics understand the application of their knowledge and
> skills as they relate to their performance as an EMT‑Basic. This
> section relates back to the motivational statement and represents the
> reasoning as to why, where and when the EMT‑Basic would need to use
> the knowledge or perform the skills. It is of utmost importance that
> the instructor be familiar with the intent of this section and relay
> that intent to the EMT-Basics.
>
> **Program Participant Activities** ‑‑ EMT-Basics learn by various
> methods. The three types are: auditory, visual and kinesthetic. The
> intent of this section is to assure that the content of the curriculum
> is presented to meet the needs of the three different types of
> learning styles. These three areas should not necessarily be used
> separately from the lesson plan, but as an adjunct to it. If lessons
> are presented in this format, EMT-Basics with separate or combined
> learning styles will learn.
>
> **Auditory (Hear)** ‑‑ This section allows the instructor to provide
> material in a verbal manner. Those EMT-Basics that learn best by
> hearing will benefit from this method of instruction.
>
> **Visual (See)** ‑‑ This section allows the instructor to provide
> material in a visual manner. Visual learners will benefit from this
> method of instruction.
>
> **Kinesthetic (Do)** ‑‑ This section allows the instructor to provide
> material in a performance manner. Those EMT-Basics who learn best by
> hands-on performance will benefit from this method of instruction.
>
> **Instructor Activities** ‑‑ This section is to remind the instructors
> that they should supervise EMT-Basics while they practice psychomotor
> skills. They should reinforce EMT-Basics progress in the cognitive,
> affective and psychomotor domains. If they are having difficulty
> understanding the content or performing the skills, the instructor
> should remediate as needed.

**REMEDIATION**

> Identify students or groups of students who are having difficulty with
> this subject content.

**ENRICHMENT**

> This section is designed to allow the instructor or training program
> to add information or augment the curriculum with approval of the
> State EMS Office .

**COURSE PLANNING CONSIDERATIONS**

**NEEDS ASSESSMENT**

> The first step in course planning is the performance of a
> comprehensive analysis of the many factors which influence the
> pre-hospital emergency care delivery system in the area. Factors which
> should be included in this analysis are:

-   Recertification requirements (local, state, national, professional).

-   System structure.

-   Call characteristics (i.e., volume, type).

-   Community demographics.

-   Community hazard assessment.

> The second step of the needs assessment is an analysis of the
> education needs of the potential course participants.
>
> Information obtained through the assessment process should be used as
> a guide to selection of specific material to be presented in the
> classroom, within the limitations imposed by local, state, and/or
> national standards. The assessment results should also be used in
> determining course format, schedule, and methods.

**COURSE DESIGN**

> Once the needs assessment has been performed, the following steps
> should be accomplished to design and implement an education course
> which meets participant and community identified needs:
>
> **Determine regulatory requirements for course conduct:**

-   course and sponsoring agency approval through local or state agency.

-   hours, content, faculty requirements or restrictions.

> **Develop schedule:**
>
> The refresher education course is divided into lessons which can be
> presented as individual lessons of one or more hours duration, or
> lessons can be combined into a variety of formats.
>
> **Identify and orient program staff:**
>
> **medical director**: Each program should have a medical director who
> is a licensed physician experienced in emergency medical care. The
> medical director should be familiar with all aspects of program design
> and is responsible for the medical content of the training program.
>
> **program director**: The program director is responsible for the
> overall direction and coordination of the planning, administration,
> periodic review, continued development, funding and effectiveness of
> the program. The following are specific examples of the
> responsibilities listed above:

-   processing student applications.

-   scheduling classes.

-   assigning faculty and providing them with appropriate lesson plans
    and resource materials.

-   conducting a faculty orientation session which should cover such
    topics as:

-   This program in relation to the state\'s overall emergency medical
    service plan.

-   Objectives, scope and orientation of the EMT refresher education
    course.

-   Functions of the EMT.

-   Medicolegal aspects of the EMT-Basic\'s job.

-   Using the lesson plans.

-   Using the education aids and sources.

-   Importance of being on time and adhering to the course schedule.

-   Importance of keeping discussion oriented toward emergency care
    rather than definitive care.

-   Educational levels and previous emergency care experience of
    participants.

-   Managing fiscal aspects of the program.

-   Maintaining records.

-   Familiarization with the testing and evaluation process.

-   Coordinating examination and evaluation of students including the
    preparation of assessment materials.

-   Assuring the availability of necessary equipment and materials for
    each class, including audio-visual resources.

-   Assuring the availability of academic counseling and support.

-   Establishing and maintaining effective positive relationships among
    students, program staff and the sponsoring agency.

-   Teaching as necessary and appropriate.

> **Identify and provide for equipment needs:**
>
> Training equipment utilized in the course should be approved for use
> based upon local and state protocols.
>
> **Determine course cost:**
>
> Because of variations in factors such as the length of an education
> program, reimbursement rates for instructors, and costs in the
> purchase of education aids, an average cost per program or per student
> is variable. When calculating the fees for the program, however, the
> following should be considered:

-   faculty reimbursement.

-   sponsoring agency administrative costs.

-   equipment costs (new purchase, depreciation, rental, parts
    replacement).

-   printing and reproduction costs.

-   expendable supplies and materials.

-   advertising costs.

-   liability and malpractice insurance.

-   text cost (unless purchased directly by student).

-   miscellaneous costs:

-   refreshments.

-   name tags.

> **Determine class size:**
>
> This course emphasizes evaluation of student skills and discussion of
> field experiences as teaching methods. In addition, for certain
> skills, individual student practice is provided. In order that maximum
> student participation can be achieved, the class size necessarily must
> be small.
>
> The class size for lecture-demonstration-discussion lessons must be
> small enough to allow interaction between students and instructor and
> to permit demonstrations to be easily viewed by all students. It is
> preferable that the class size for these sessions be limited to 20
> students. (Instructor/student ratio: 1 to 20 or less)
>
> Alternative methods of course presentation may allow for a higher
> instructor to student ratio. Regardless of the method chosen, it must
> allow an avenue for each student to ask questions of an instructor and
> receive answers or assistance from an instructor. Changes in the
> presentation method should receive State EMS Office approval before
> implementation.
>
> Since the instructor must be able to observe and evaluate student
> performance, it is essential that skills practice be accomplished in
> small groups. The group size for skill practice sessions should not
> exceed 6 students per instructor or assistant. (Instructor/student
> ratio: 1 to 6 or less)
>
> **Establish student selection process:**
>
> To be eligible for participation in the refresher education program,
> the students should:

-   have completed the initial training program for EMT-Basic.

-   meet local/state requirements for eligibility for
    licensure/certification at the EMT level.

**Advertise program:**

**Order resource materials:**

-   films.

-   books.

**COURSE CONDUCT AND EVALUATION**

**INSTRUCTIONAL APPROACH**

> Given the repetitive nature of refresher education, it is easy for
> participants to become bored quickly and to lack enthusiasm about the
> program. In order to improve the quality of the educational experience
> for instructors and participants, creative and innovative
> instructional activities are strongly suggested. Some specific
> examples and discussion follow:
>
> **Knowledge:** Participants in refresher programs have a wealth of
> experience to draw on and enjoy sharing it. Instructors can direct and
> ensure the helpfulness and medical accuracy of that sharing process by
> using student presented reports, case studies, small group problem
> solving exercises and peer tutoring.
>
> **Skills:** Students rapidly lose interest in repetitive entry level
> skills drills. After a brief review of skills, students might be
> offered the opportunity to prepare a videotaped skill demonstration.
> Using checklists and video equipment, students can film, critique and
> re-film until they have a product with which they and the instructor
> are satisfied. A similar exercise can be used for preparing a live
> demonstration. Events such as skills rodeos, field days or
> competitions are becoming common.
>
> Much thought and careful preparation must go into such events to make
> them safe, educationally sound and fun. Students can assist with the
> preparation and learn much in the process. Students can also design
> and implement patient care simulations including mass casualty or
> disaster drills as a class project. Not only is this a community
> service, but it recognizes the capabilities of the students and
> increases their ability to contribute to their own learning.
>
> **Attitudes:** A significant concern in EMS today is EMT stress caused
> by a variety of factors including indifferent education quality, poor
> community support, excessive demands on personal time and energy, too
> many or too few runs, or feelings of inadequacy when dealing with
> critical patients. The program staff in the refresher course can be
> instrumental in identifying problems and mobilizing resources for
> troubled individuals and systems.
>
> Program staff are in a unique position to correct some of the above
> problems. Education practices which have failed to elicit student
> enthusiasm can be replaced by innovative and student centered learning
> activities. Problem solving exercises to identify and implement
> corrective action for community related problems can be undertaken as
> class projects. Course schedules can be adapted to the students\'
> needs and course content can include time and stress management
> topics.

**Records maintenance**

> The refresher education program must maintain program and student
> records which demonstrate compliance with pertinent program standards
> and local, state or national regulations.

**Program records**

-   Syllabus.

-   Course schedule.

-   Advertising materials.

-   Master attendance records.

-   Copies of exams, lesson plans, handout materials.

-   Equipment maintenance and cleaning.

-   Program staff roster which includes resume and teaching assignments
    for each instructor.

**Student records**

-   Application.

-   Attendance record.

-   Test scores.

-   Skill competency evaluation checklists.

**TESTING AND EVALUATING THE STUDENT**

The primary purpose of refresher training is to assure that EMT-Basics
maintain up-to-date proficiency in the knowledge and skill areas which
are pertinent to their scope of practice. The program objectives
identify these knowledge and skill areas. In order to assure that each
student has met the objectives, it is necessary for the education
program to use a variety of methods for testing and evaluating
participants.

Examples of evaluation methods include: written quizzes, case review
presentations, videotaped skills demonstrations, practical skill exams,
attitude rating scales, hospital or ambulance preceptorships, oral
quizzes, and research papers. Written examinations and practical skills
demonstrations are the most frequently used tools for assessing student
progress.

Requirements for the examination process may be influenced by local,
state or national regulations or standards. A certificate of course
completion should not be issued to the student until the student
demonstrates competency as measured by formal end of course written and
practical examination administered by the training program or certifying
agency with the approval of the State EMS Office and its requirements.

> **Written examinations:** Students should be tested periodically
> throughout the program since unit exams can provide more in-depth
> assessment regarding specific topics that can be obtained from a final
> exam. A final comprehensive exam provides an overview of the
> student\'s broad knowledge base and serves to prepare them for any
> required relicensure of certification examination. Written exams
> should be designed and weighted to measure critical components within
> the broad knowledge base. The student should demonstrate an acceptable
> level of knowledge (a passing grade) in each subject area before
> taking the final exam. If the devices used to measure student
> performance are faulty, then an accurate appraisal of student
> performance will be impossible.
>
> **Skills:** Skills proficiency should also be measured at several
> points in the refresher program. Videotaping of skills demonstrations
> and patient care scenarios for unit or final exams with review and
> grading according to a checklist can provide an unarguable record of
> student performance and a powerful learning experience. The final
> skills examination should assess both component skills and the
> student\'s ability to apply necessary and appropriate skills to
> simulated patient care situations.

Another factor in successful course completion may be:

> **Attendance:** Attendance policies, including minimum attendance
> requirements, should be established in advance and communicated to
> course participants. Minimum attendance requirements may, in fact, be
> stipulated by local, state, or national regulations or standards.
> Students should be encouraged to attend all refresher sessions.

The EMT refresher curriculum is considered the minimum acceptable
content that must be covered in any education program. With certifying
agency approval, the student may meet some of the program objectives by
satisfactorily completing such activities as a Trauma Life Support -
Basic Level; American Heart Association or American Red Cross CPR
course; and run reviews. Although some local and state certifying
agencies permit options for completion of refresher or continuing
education, it is strongly recommended that all providers participate in
regularly scheduled group education sessions.

**PROGRAM EVALUATION**

**PROCESS**

> Process evaluation will help identify specific causes of instructional
> failure (i.e., the reason why trainees fail to achieve satisfactory
> performance during the course). Some possible causes of such failure
> may include:

-   instructional activities do not conform to the lesson plans.

-   resources, facilities, or materials are inadequate.

-   trainees do not meet student selection requirements.

-   practice exercises are not sufficiently comprehensive or
    representative.

-   student/instructor ratio is too high.

-   instructor is not well qualified to teach a particular lesson.

-   course objectives were too difficult to achieve in the time
    allotted.

-   an inadequate testing instrument was used to evaluate students.

> The purpose of process evaluation is to isolate the causes of
> instructional problems and to gather sufficient data to decide how to
> alleviate the problem(s). The internal evaluation process for
> gathering sufficient data and isolating the problem starts with an
> analysis of the course planning and control documents (course guide,
> schedule, lesson plans, etc.). Then each component and procedure
> authorized and/or required by this document is studied to see that it
> conforms with the control document specifications. Discrepancies
> between the planned course and what actually occurs in the training
> program might be found in any of the following:
>
> **Resources:** This course guide and instructor lesson plans indicate
> the requirements for specific training facilities, equipment, tools,
> and supplies in order for the course to accomplish the stated
> objectives. The evaluation will determine whether such facilities and
> services are adequate. When deficiencies are found, corrective actions
> must be taken.
>
> **Classroom facilities and conditions:** Classroom visits of
> sufficient length and frequency to assure a representative sampling
> provide useful information regarding course conduct. Specified
> training aids and media should be checked for condition, operation,
> and appropriateness. Also, the instructional supporting documents,
> including lesson plans and study guides, should be checked for
> availability and quality.
>
> **Instructors:** It is important in refresher education programs that
> instructors be innovative in developing learning activities to help
> students meet course objectives. Instructors must show acceptable
> application of sound instructional techniques and should be able to
> detect student problems and react to student needs.

**DISCUSSION**

> It is possible for an education program to satisfy process evaluations
> while failing to achieve its primary objective of educating EMT-Basics
> to perform on the job safely and effectively. Reasons for this
> include:

-   The customizing process was not handled adequately; education needs
    were incorrectly identified in the beginning.

-   Graduates lack self-confidence in their ability to handle emergency
    medical care problems competently.

-   The graduates know what to do, but are not sufficiently motivated by
    the job itself to perform satisfactorily.

> Follow-up evaluation is absolutely essential even when process
> evaluations and final exam performance are satisfactory. It is still
> necessary to ascertain that the job requirements are being adequately
> accomplished by the EMT-Basics. Supervisors\' and graduates\' opinions
> of how well the training program met their needs should also be
> determined. Their suggestions for improvements are often invaluable.
> Some of the data gathering methods used in assessing training needs
> are also useful in conducting a follow-up evaluation.
>
> Analysis of the follow-up evaluation data will point out strengths and
> weaknesses in refresher training programs. The decision-maker\'s
> attention should focus on those problems which directly compromise the
> goal of preparing EMT-Basics to perform their job. Good evaluation
> will assure a steady flow of timely, pertinent data for maintaining
> the quality and cost-effectiveness of the EMT refresher course.

##### Acknowledgment

> Following publication of the 1994 EMT-Basic Curriculum revision, the
> National Highway Traffic Safety Administration (NHTSA) and the Board
> of Directors of the National Registry of Emergency Medical Technicians
> (NREMT) began a joint endeavor to revise the EMT-Basic Refresher
> Program. The National Association of State EMS Directors (NASEMSD) and
> the National Council of State EMS Training Coordinators (NCSEMSTC) are
> commended for their participation as members of the EMT-Basic
> Refresher Program Task Force and for their valuable input during the
> peer review process. The American College of Emergency Physicians
> (ACEP) and the National Association of EMS Physicians (NAEMSP)
> provided valuable medical oversight during the revision process by
> participating as members of the Task Force. Special thanks is extended
> to NHTSA for facilitating the outside review process and to the many
> outside reviewers who provided valuable content information for
> inclusion in the curriculum. Finally, the NREMT Board of Directors
> should be commended for its consistent dedication to this nation's EMS
> and funding this revision process.

# TASK FORCE MEMBERSHIP

**William E. Brown Jr.,**

Executive Director

National Registry of EMTs

**Drew E. Dawson**

Bureau Chief, Office of EMS

Montana

**Philip D. Dickison**

EMT-Basic Coordinator

National Registry of EMTs

**Louise Goyette**

Director, Office of EMS

Massachusetts

**Kevin Hanson**

Training Coordinator

New Mexico

**Gary Ireland**

Director, Bureau of EMS

Iowa

**Thomas Platt**

Director of Training

Center for Emergency Medicine

Pennsylvania

**Paul Winfield Smith**

Training Coordinator

Connecticut

**Walt Stoy Ph.D.**

Director of Educational Programs

Center for Emergency Medicine

Pennsylvania

**Robert Sutor. D.O.**

Providence Hospital/Medical Center

Michigan

**Howard Werman, MD, FACEP**

The Ohio State University

Ohio

**Roger D. White, MD, FACC**

Mayo Clinic

Minnesota

**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Module I:**

**Preparatory**

# TASK LIST AND EDUCATIONAL OBJECTIVES

At the completion of this lesson, the student will be able to:

**[COGNITIVE OBJECTIVES]{.underline}**

1.  Provide for safety of self, patient and fellow workers

-   Discuss the importance of body substance isolation (BSI).

-   Describe the steps the EMT-Basic should take for personal protection
    from airborne and bloodborne pathogens.

1.  Identify the presence of hazardous materials

-   Break down the steps to approaching a hazardous situation.

1.  Participate in the quality improvement process

-   Define quality improvement and discuss the EMT-Basic\'s role in the
    process.

1.  Use physician medical direction for authorization to provide care

-   Define medical direction and discuss the EMT-Basic\'s role in the
    process.

1.  Use body mechanics when lifting and moving a patient

-   Relate body mechanics associated with patient care and it\'s impact
    on the EMT-Basic.

1.  Use methods to reduce stress in self, a patient, bystanders and
    co-workers

-   Recognize the signs and symptoms of critical incident stress.

-   State possible steps that the EMT-Basic may take to help
    reduce/alleviate stress.

1.  Obtain consent for providing care

-   Define consent and discuss the methods of obtaining consent.

-   Discuss the implications for the EMT-Basic in patient refusal of
    transport.

-   Discuss the importance of Do Not Resuscitate \[DNR\] (advance
    directives) and local or state provisions regarding EMS application.

1.  Assess and provide care to patients and families involved in
    suspected abuse or neglect

-   Discuss the special considerations for assessing and managing a
    patient with suspected abuse or neglect.

**[AFFECTIVE OBJECTIVES]{.underline}**

1.  Assess areas of personal attitude and conduct of the EMT-Basic.

2.  Explain the rationale for serving as an advocate for the use of
    appropriate protection equipment.

3.  Explain the role of EMS and the EMT-Basic regarding patients with
    DNR orders.

4.  Explain the rationale for properly lifting and moving patients.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

1.  Working with a partner, move a simulated patient from the ground to
    a stretcher and properly position the patient on the stretcher.

2.  Working with a partner, demonstrate the technique for moving a
    patient secured to a stretcher to the ambulance and loading the
    patient into the ambulance.

# PREPARATION

Motivation: The field of prehospital emergency medical care is an
evolving profession in which the reality of life and death is confronted
at a moment\'s notice. EMT-Basics work side by side with other health
care professionals to help deliver professional prehospital emergency
medical care. This course will help the EMT-Basic refresh previously
learned material while gaining new knowledge, skills and attitudes
necessary to be a competent, productive, and valuable member of the
emergency medical services team.

**MATERIALS**

AV Equipment: Utilize various audio-visual materials relating to
emergency medical care. The continuous design and development of new
audio-visual materials relating to EMS requires careful review to
determine which best meet the needs of the program. Materials should be
edited to assure the objectives of the curriculum are met.

EMS Equipment: None required.

**PERSONNEL**

Primary Instructor: One EMT-Basic instructor knowledgeable in the
EMT-Basic refresher course overview, administrative paper work,
certification requirements, Americans with Disabilities Act issues, and
roles and responsibilities of EMS.

Assistant Instructor: The instructor to Student ratio should be adequate
to allow for supervision of psychomotor skill practice. Individuals used
as assistant instructors should be knowledgeable in the techniques of
lifting and moving patients.

# PRESENTATION

**[Declarative (What)]{.underline}**

I.  **Scene Safety**

    I.  Body substance isolation (BSI) (Bio-Hazard)

        I.  EMT-B\'s and patient\'s safety

            I.  Handwashing

            II. Eye protection

                I.  If prescription eyeglasses are worn, then removable
                    side shields can be applied to them.

                II. Goggles are NOT required.

            III. Gloves (vinyl and latex)

                 I.  Needed for contact with blood or bloody body
                     fluids.

                 II. Should be changed between contact with different
                     patients.

            IV. Gloves (utility) - needed for cleaning vehicles and
                equipment

            V.  Gowns

                I.  Needed for large splash situations such as with
                    field delivery and major trauma.

                II. Change of uniform is preferred.

            VI. Masks

                I.  Surgical type for possible blood splatter (worn by
                    care provider)

                II. High Efficiency Particulate Air (HEPA) or N-95
                    respirator if patient suspected for or diagnosed
                    with tuberculosis (worn by care provider)

                III. Airborne disease- surgical type mask (worn by
                     patient)

            VII. Requirements and availability of specialty training

        II. OSHA/state regulations regarding BSI

        III. Statutes/regulations reviewing notification and testing in
             an exposure incident.

    II. Personal protection

        I.  Hazardous materials

            I.  Identify possible hazards

                I.  Binoculars

                II. Placards

                III. *Hazardous Materials, The Emergency Response
                     Handbook*, published by the United States
                     Department of Transportation

            II. Hazardous materials scenes are control by specialized
                Haz-Mat teams.

            III. EMT-Basics provide emergency care only after the scene
                 is safe and patient contamination limited.

            IV. Requirements and availability of specialized training

        II. Rescue

            I.  Identify and reduce potential life threats.

                I.  Electricity

                II. Fire

                III. Explosion

                IV. Hazardous materials

            II. Dispatch rescue teams for extensive/heavy rescue.

        III. Violence

             I.  Scene should always be controlled by law enforcement
                 before the EMT-Basic provides patient care.

                 I.  Perpetrator of the crime

                 II. Bystanders

                 III. Family members

II. **Quality improvement**

    I.  Medical Direction

        I.  Medical direction laws and regulations vary from state to
            state

        II. All states mandate medical direction for EMT-Paramedic level

        III. Some states mandate medical direction for EMT-Basics

        IV. Goal of EMS medical direction

            I.  Quality patient care - the cornerstone of medical
                direction

            II. Safety and well being of EMT

            III. Proper education, training, and certification of EMTs

            IV. Specific medical direction responsibilities

                I.  Clinical oversight of training, and other activities
                    including

                    I.  On-line direction

                        I.  May originate from the receiving facility or
                            other site

                        II. Should include radio communication to
                            emergency department physicians

                        III. May be delegated to other than medical
                             director

                    II. Off-line direction

                        I.  May be protocol driven

                        II. Standing orders frequently used

                    III. Assist with patient refusal of treatment either
                         on-line or off-line

                    IV. Quality review

                        I.  Collection, review and reporting of data
                            that provides for discovery of infractions
                            of protocols, procedures which may require
                            re-testing or remedial training

                        II. Data collection useful for research or need
                            for continuing education

III. **Health and Safety**

     I.  Lifting techniques

         I.  Safety precautions

             I.  Use legs, not back, to lift

             II. Keep weight as close to body as possible

         II. Guidelines for lifting

             I.  Consider weight of patient and need for additional help

             II. Know physical ability and limitations

             III. Lift without twisting

             IV. Have feet positioned properly

             V.  Communicate clearly and frequently with partner

             VI. Safe lifting of cots and stretchers. When possible use
                 a stair chair instead of a stretcher if medically
                 feasible

                 I.  Using power-lift or squat lift position, keep back
                     locked into normal curvature. The
                     [power-lift]{.underline} position is useful for
                     individuals with weak knees or thighs. The feet are
                     a comfortable distance apart. The back is tight and
                     the abdominal muscles lock the back in a slight
                     inward curve. Straddle the object. Keep feet flat.
                     Distribute weight to balls of feet or just behind
                     them. Stand by making sure the back is locked in
                     and the upper body comes up before the hips.

                 II. Use [power grip]{.underline} to get maximum force
                     from hands. The palm and fingers come into complete
                     contact with the object and all fingers are bent at
                     the same angles. The power-grip should always be
                     used in lifting. This allows for maximum force to
                     be developed. Hands should be at least 10 inches
                     apart.

                 III. Lift while keeping back in locked-in position

                 IV. When lowering cot or stretcher, reverse steps

                 V.  Avoid bending at the waist

     II. Carrying

         I.  Precautions for carrying - whenever possible, transport
             patients on devices that can be rolled

         II. Guidelines for carrying

             I.  Know or find out the weight to be lifted

             II. Know limitations of the crew\'s abilities

             III. Work in a coordinated manner and communicate with
                  partners

             IV. Keep the weight as close to the body as possible

             V.  Keep back in a locked-in position and refrain from
                 twisting

             VI. Flex at the hips, not the waist; bend at the knees

             VII. Do not hyperextend the back (do not lean back from the
                  waist)

     III. Reaching

          I.  Guidelines for reaching

              I.  Keep back in locked-in position

              II. When reaching overhead, avoid hyperextended position

              III. Avoid twisting the back while reaching

          II. Application of reaching techniques

              I.  Avoid reaching more than 15 - 20 inches in front of
                  the body

              II. Avoid situations where prolonged (more than a minute)
                  strenuous effort is needed in order to avoid injury

     IV. Pushing and pulling guidelines

         I.  Push, rather than pull, whenever possible

         II. Keep back locked-in

         III. Keep line of pull through center of body by bending knees

         IV. Keep weight close to the body

         V.  Push from the area between the waist and shoulder

         VI. If weight is below waist level, use kneeling position

         VII. Avoid pushing or pulling from an overhead position if
              possible.

         VIII. Keep elbows bent with arms close to the sides

     V.  Stressful situations

         I.  Examples of situations that may produce a stress response

             I.  Mass casualty situations

             II. Infant and child trauma

             III. Amputations

             IV. Infant/child/elder/spousal abuse

             V.  Death/injury of co-worker or other public safety
                 personnel

         II. The EMT-Basic will experience personal stress as well as
             encounter patients and bystanders in severe stress.

     VI. Stress management

         I.  Recognize warning signs

             I.  Irritability to co-workers, family, friends

             II. Inability to concentrate

             III. Difficulty sleeping/nightmares

             IV. Anxiety

             V.  Indecisiveness

             VI. Guilt

             VII. Loss of appetite

             VIII. Loss of interest in sexual activities

             IX. Isolation

             X.  Loss of interest in work

         II. Life style changes

             I.  Helpful for \"job burnout\"

             II. Change diet.

                 I.  Reduce sugar, caffeine and alcohol intake.

                 II. Avoid fatty foods.

                 III. Increase carbohydrates.

             III. Exercise

             IV. Practice relaxation techniques, meditation, visual
                 imagery.

         III. Balance work, recreation, family, health, etc.

         IV. EMS personnel and their family and friend\'s response

             I.  Lack of understanding.

             II. Fear of separation and being ignored.

             III. On-call situations cause stress.

             IV. Can\'t plan activities.

             V.  Frustration caused by wanting to share.

         V.  Work environment changes

             I.  Request work shifts allowing for more time to relax
                 with family and friends.

             II. Request a rotation of duty assignment to a less busy
                 area.

         VI. Seek/refer professional help.

     VII. Critical incident stress debriefing (CISD)

          I.  A team of peer counselors and mental health professionals
              who help EMTs deal with critical incident stress.

          II. Meeting is held within 24 to 72 hours of a major incident.

              I.  Open discussion of feeling, fears, and reactions

              II. Not an investigation or interrogation

              III. All information is confidential.

              IV. CISD leaders and mental health personnel evaluate the
                  information and offer suggestions on overcoming the
                  stress.

          III. Designed to accelerate the normal recovery process of
               experiencing a critical incident.

               I.  Works well because feelings are ventilated quickly.

               II. Debriefing environment is non-threatening.

          IV. How to access local system.

     VIII. Comprehensive Critical Incident Stress Management includes

           I.  Pre-incident stress education

           II. On-scene peer support

           III. One-on-one support

           IV. Disaster support services

           V.  Diffusing

           VI. CISD

           VII. Follow up services

           VIII. Spouse/family support

           IX. Community outreach programs

           X.  Other health and welfare programs such as wellness
               programs

IV. **Medical - Legal**

    I.  Expressed Consent

        I.  Patient must be of legal age and able to make a rational
            decision.

        II. Patient must be informed of the steps of the procedures and
            all related risks.

        III. Must be obtained from every conscious, mentally competent
             adult before rendering treatment.

    II. Implied Consent

        I.  Consent assumed from the unconscious patient requiring
            emergency intervention

        II. Based on the assumption that the unconscious patient would
            consent to life saving interventions

    III. Children and mentally incompetent adults

         I.  Consent for treatment must be obtained from the parent or
             legal guardian.

             I.  Emancipation issues

             II. State regulations regarding age of minors

         II. When life threatening situations exist and the parent or
             legal guardian is not available for consent, emergency
             treatment should be rendered based on implied consent.

    IV. Confidentiality

        I.  Confidential information

            I.  Patient history gained through interview

            II. Assessment findings

            III. Treatment rendered

        II. Releasing confidential information

            I.  requires a written release form signed by the patient.
                Do not release on request, written or verbal, unless
                legal guardianship has been established.

            II. When a release is not required

                I.  Other health care providers need to know information
                    to continue care.

                II. State law requires reporting incidents such as rape,
                    abuse or gunshot wounds.

                III. Third party payment billing forms

                IV. Legal subpoena

    V.  Refusal of Care

        I.  The patient has the right to refuse treatment.

        II. The patient may withdraw from treatment at any time.
            Example: an unconscious patient regains consciousness and
            refuses transport to the hospital.

        III. Refusals must be made by mentally competent adults
             following the rules of expressed consent.

        IV. The patient must be informed of and fully understand all the
            risks and consequences associated with refusal of
            treatment/transport, as well as signing a \"release from
            liability\" form.

        V.  When in doubt, err in favor of providing care.

        VI. Documentation is a key factor to protect the EMT-Basic in
            refusal.

            I.  Competent adult patients have the right to refuse
                treatment.

            II. Before the EMT-Basic leaves the scene, he should:

                I.  Try again to persuade the patient to go to a
                    hospital.

                II. Ensure the patient is able to make a rational,
                    informed decision, e.g., not under the influence of
                    alcohol or other drugs, or illness/injury effects.

                III. Inform the patient why he should go and what may
                     happen to him if he does not.

                IV. Consult medical direction as directed by local
                    protocol.

                V.  Consider assistance of law enforcement.

                VI. Document any assessment findings and emergency
                    medical care given, and if the patient still
                    refuses, then have the patient sign a refusal form.

                VII. The EMT-Basic should never make an independent
                     decision to not transport.

    VI. Do Not Resuscitate (DNR) orders

        I.  Patient has the right to refuse resuscitative efforts.

        II. In general, requires written order from the physician.

        III. Review state and local legislation/protocols relative to
             DNR orders and advance directives.

        IV. When in doubt or when written orders are not present, the
            EMT-Basic should begin resuscitation efforts.

    VII. Abuse and neglect (child or elder)

         I.  Definition of abuse - improper or excessive action so as to
             injure or cause harm.

         II. Definition of neglect - giving insufficient attention or
             respect to someone who has a claim to that attention.

         III. The EMT-Basic must be aware of condition to be able to
              recognize the problem.

         IV. Physical abuse and neglect are the two forms of abuse that
             the EMT-Basic is likely to suspect.

         V.  Signs and symptoms of abuse

             I.  Multiple bruises in various stages of healing.

             II. Injury inconsistent with mechanism described.

             III. Repeated calls to the same address.

             IV. Fresh burns.

             V.  Parent or guardian seem inappropriately unconcerned.

             VI. Conflicting stories

             VII. Fear on the part of the patient to discuss how the
                  injury occurred.

         VI. Signs and symptoms of neglect

             I.  Lack of adult supervision.

             II. Malnourished appearing child.

             III. Unsafe living environment

             IV. Untreated chronic illness; e.g., asthmatic with no
                 medications.

         VII. CNS injuries are the most lethal - shaken baby syndrome

         VIII. Do not accuse in the field

               I.  Accusation and confrontation delays transportation.

               II. Bring objective information to the receiving facility

         IX. Reporting required by state law.

             I.  Local regulations

             II. Objective - what you see and what you hear - NOT what
                 you think.

# APPLICATION

**[Procedural (How)]{.underline}**

1.  Demonstrate proper lifting, carrying and reaching techniques.

**[Contextual (When, Where, Why)]{.underline}**

> EMT-Basics will use the concepts of scene safety, personal protection,
> body mechanics and stress management on a daily basis throughout their
> careers in EMS. Failure to do so may lead to a premature end to their
> careers through serious injury or even death. The well-being of the
> EMT depends on the his/her ability to practice these concepts at all
> times both on and off duty.

**[STUDENT ACTIVITY]{.underline}**

**[Auditory (Hear)]{.underline}**

1.  Students should hear the specific expectations of the training
    program as well as what they can expect to receive from the
    training.

2.  Students should hear actual case law and common law decisions
    relative to EMT-Basic care.

**[Visual (See)]{.underline}**

1.  Students should receive a copy of the cognitive, affective and
    psychomotor objectives for the entire curriculum.

2.  Students should receive the final skill evaluation instruments.

3.  Students should see various audio-visual aids or materials of scenes
    requiring personal protection

4.  Students should see proper lifting, carrying and reaching techniques

5.  Students should see audio-visual aids and materials of definitions
    of medical/legal terms such as consent, confidentiality, refusal of
    care.

**[Kinesthetic (Do)]{.underline}**

1.  Students should complete the necessary course paperwork.

2.  Students should practice proper lifting, carrying and reaching
    techniques.

3.  Students should practice making decisions while role playing the
    various medical/legal and ethical situations that occur in the EMTs
    environment. These scenarios should include, as a minimum, consent,
    confidentiality, refusal of care and DNR orders.

**[Instructor Activities]{.underline}**

1.  Supervise student practice.

2.  Reinforce student progress in cognitive and affective domains.

3.  Redirect students having difficulty with content.

# EVALUATION

Written: Develop evaluation instruments, e.g., quizzes, verbal reviews,
and handouts, to determine if the students have met the cognitive and
affective objectives of this lesson.

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

# REMEDIATION

> Identify students or groups of students who are having difficulty with
> this subject content.

# ENRICHMENT

> What is unique in the local area concerning this topic?

**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Module II:**

**Airway**

# TASK LIST AND EDUCATIONAL OBJECTIVES

At the completion of this lesson, the student will be able

**[COGNITIVE OBJECTIVES]{.underline}**

1.  Perform techniques to assure a patent airway

-   Describe the steps in performing the head-tilt chin-lift.

-   Describe the steps in performing the jaw thrust.

-   Describe the techniques of suctioning.

-   Describe how to measure and insert an oropharyngeal (oral) airway.

-   Describe how to measure and insert a nasopharyngeal (nasal) airway.

1.  Provide ventilatory support for a patient

-   Describe the steps in performing the skill of artificially
    ventilating a patient with a bag-valve-mask for one and two
    rescuers.

-   Describe the steps in artificially ventilating a patient with a flow
    restricted, oxygen-powered ventilation device.

1.  Use oxygen delivery system components (nasal cannula, face mask,
    etc..)

-   Identify a non-rebreather face mask and state the oxygen flow
    requirements needed for its use.

-   Identify a nasal cannula and state the flow requirements needed for
    its use.

**[AFFECTIVE OBJECTIVES]{.underline}**

1.  Explain the rationale for basic life support artificial ventilation
    and airway protection skills taking priority over most other life
    support skills.

2.  Explain the rationale for providing oxygenation through high
    inspired oxygen concentrations to patients who, in the past, may
    have received low concentrations.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

1.  Demonstrate the steps in performing the skill of artificially
    ventilating a patient with a bag-valve-mask for one and two
    rescuers.

2.  Demonstrate how to insert an oropharyngeal and nasopharyngeal
    airway.

3.  Demonstrate the use of a non-rebreather face mask and a nasal
    cannula.

4.  Demonstrate artificial ventilation of a patient with a flow
    restricted, oxygen powered ventilation device.

5.  Demonstrate the techniques of suctioning.

# PREPARATION

Motivation: The most critical intervention an EMT can provide for a
patient is airway management and ventilatory support. A patient without
an airway is a dead patient.

**MATERIALS**

AV Equipment: Utilize various audio-visual materials relating to airway
management. The continuous design and development of new audio-visual
materials relating to EMS requires careful review to determine which
best meet the needs of the program. Materials should be edited to assure
the objectives of the curriculum are met.

EMS Equipment: Pocket mask, bag-valve-mask, flow restricted,
oxygen-powered ventilation device, oral airways, nasal airways, suction
units, suction catheters, oxygen tank, regulator, non-rebreather mask
and nasal cannula.

**PERSONNEL**

Primary Instructor: One EMT-Basic instructor knowledgeable in airway
management.

Assistant Instructor: The instructor to student ratio should be adequate
to allow for supervision of psychomotor skill practice. Individuals used
as assistant instructors should be knowledgeable in airway techniques
and management.

# PRESENTATION

**[Declarative (What)]{.underline}**

A.  **Opening the Airway**

    A.  Head-tilt chin-lift when no neck injury suspected-review
        technique learned in BLS course.

    B.  Jaw thrust when the EMT-Basic suspects spinal injury - review
        technique learned in BLS course.

    C.  Assess need for suctioning.

B.  **Techniques of Suctioning**

    A.  Suction device should be inspected on a regular basis before it
        is needed. A properly functioning unit with a gauge should
        generate 300 mmHg vacuum. A battery operated unit should have a
        charged battery.

    B.  Turn on the suction unit.

    C.  Attach a catheter.

        A.  Use rigid catheter when suctioning mouth of an infant or
            child.

        B.  Often will need to suction nasal passages; should use a bulb
            suction or French catheter with low to medium suction.

    D.  Insert the catheter into the oral cavity without suction, if
        possible. Insert only to the base of the tongue.

    E.  Apply suction.

        A.  Move the catheter tip side to side.

    F.  Suction for no more than 15 seconds at a time.

        A.  In infants and children, shorter suction time should be
            used.

        B.  If the patient has secretions or emesis that cannot be
            removed quickly and easily by suctioning, the patient should
            be log rolled and the oropharynx should be cleared.

        C.  If patient produces frothy secretions as rapidly as
            suctioning can remove, suction for 15 seconds, artificially
            ventilate for two minutes, then suction for 15 seconds, and
            continue in that manner. Consult medical direction for this
            situation.

    G.  If necessary, rinse the catheter and tubing with water to
        prevent obstruction of the tubing from dried material.

C.  **Techniques of Artificial Ventilation**

    A.  In order of preference, the methods for ventilating a patient by
        the EMT-Basic are as follows:

        A.  Mouth-to-mask with supplemental oxygen

        B.  Two person bag-valve-mask

        C.  Flow restricted, oxygen powered ventilation device

        D.  One person bag-valve-mask

            A.  EMTs must be aware of the difficulty of a single
                rescuer\'s maintaining an adequate mask-to-face seal and
                delivering an adequate inspiratory volume.

    B.  Body substance isolation

    C.  Bag-valve-mask

        A.  The bag-valve-mask consists of a self-inflating bag, one way
            valve, face mask, oxygen reservoir. It needs to be connected
            to oxygen to perform most effectively.

        B.  Bag-valve-mask issues

            A.  Volume of approximately 1600 milliliters

            B.  Provides less volume than mouth-to-mask

            C.  EMT-Basics working alone may have difficulty maintaining
                an airtight seal.

            D.  Two EMT-Basics using the device will be more effective.

            E.  Position self at top of patient\'s head for optimal
                performance.

            F.  Adjunctive airways (oral or nasal) may be necessary in
                conjunction with bag-valve-mask.

        C.  Use when no trauma is suspected

            A.  After opening airway, select correct mask size (adult,
                infant or child).

            B.  Position thumbs over top half of mask, index and middle
                fingers over bottom half.

            C.  Place apex of mask over bridge of nose, then lower mask
                over mouth and upper chin. If mask has large round cuff
                surrounding a ventilation port, center port over mouth.

            D.  Use ring and little fingers to bring jaw up to mask.

            E.  Connect bag to mask if not already done.

            F.  Have assistant squeeze bag with two hands until chest
                rises.

            G.  If alone, form a \"C\" around the ventilations port with
                thumb and index finger, use middle, ring and little
                fingers under jaw to maintain chin lift and complete the
                seal.

            H.  Repeat a minimum of every 5 seconds for adults and every
                3 seconds for children and infants.

            I.  If chest does not rise and fall, re-evaluate

                a.  If chest does not rise, reposition head.

                b.  If air is escaping from under the mask, reposition
                    fingers and mask.

                c.  Check for obstruction.

                d.  If chest still does not rise and fall, use
                    alternative method of artificial ventilation, e.g.,
                    pocket mask, manually triggered device.

            J.  If necessary, consider use of adjuncts.

                a.  Oral airway

                b.  Nasal airway

        D.  Use with suspected trauma

            A.  After opening airway, select correct mask size (adult,
                infant or child).

            B.  Immobilize head and neck, e.g., have an assistant hold
                head manually or use your knees to prevent movement.

            C.  Position thumbs over top half of mask, index and middle
                fingers over bottom half.

            D.  Place apex of mask over bridge of nose, then lower mask
                over mouth and upper chin. If mask has large round cuff
                surrounding a ventilation port, center port over mouth.

            E.  Use ring and little fingers to bring jaw up to mask
                without tilting head or neck.

            F.  Connect bag to mask if not already done.

            G.  Have assistant squeeze bag with two hands until chest
                rises.

            H.  Repeat every 5 seconds for adults and every 3 seconds
                for children and infants, continuing to hold jaw up
                without moving head or neck.

            I.  If chest does not rise, re-evaluate:

                a.  If abdomen rises, reposition jaw.

                b.  If air is escaping from under the mask, reposition
                    fingers and mask.

                c.  Check for obstruction.

                d.  If chest still does not rise, use alternative method
                    of artificial ventilation, e.g., pocket mask.

            J.  If necessary, consider use of adjuncts.

                a.  Oral airway

                b.  Nasal airway

    D.  Flow restricted, oxygen-powered ventilation devices (FROPVD)

        A.  Flow restricted, oxygen-powered ventilation devices (for use
            in adults only) should provide

            A.  A peak flow rate of 100% oxygen at up to 40 lpm.

            B.  An inspiratory pressure relief valve that opens at
                approximately 60 centimeters water and vents any
                remaining volume to the atmosphere or ceases gas flow.

            C.  An audible alarm that sounds whenever the relief valve
                pressure is exceeded.

            D.  Satisfactory operation under ordinary environmental
                conditions and extremes of temperature.

            E.  A trigger positioned so that both hands of the EMT-Basic
                can remain on the mask to hold it in position.

        B.  Use when no neck injury is suspected

            A.  After opening airway, insert correct size oral or nasal
                airway and attach adult mask.

            B.  Position thumbs over top half of mask, index and middle
                fingers over bottom half.

            C.  Place apex of mask over bridge of nose, then lower mask
                over mouth and upper chin.

            D.  Use ring and little fingers to bring jaw up to mask.

            E.  Connect flow restricted, oxygen-powered ventilation
                device to mask if not already done.

            F.  Trigger the flow restricted, oxygen powered ventilation
                device until chest rises.

            G.  Repeat every 5 seconds.

            H.  If necessary, consider use of adjuncts.

            I.  If chest does not rise, re-evaluate

                a.  If abdomen rises, reposition head.

                b.  If air is escaping from under the mask, reposition
                    fingers and mask.

                c.  Check for obstruction.

                d.  If chest still does not rise, use alternative method
                    of artificial ventilation, e.g., pocket mask.

        C.  Use when there is suspected neck injury.

            A.  After opening airway, attach adult mask.

            B.  Immobilize head and neck; e.g., have an assistant hold
                head manually or use your knees to prevent movement.

            C.  Position thumbs over top half of mask, index and middle
                fingers over bottom half.

            D.  Place apex of mask over bridge of nose, then lower mask
                over mouth and upper chin.

            E.  Use ring and little fingers to bring jaw up to mask
                without tilting head or neck.

            F.  Connect flow restricted, oxygen-powered ventilation
                device to mask, if not already done.

            G.  Trigger the flow restricted, oxygen-powered ventilation
                device until chest rises.

            H.  Repeat every 5 seconds.

            I.  If necessary, consider use of adjuncts.

            J.  If chest does not rise and fall, re-evaluate

                a.  If chest does not rise and fall, reposition jaw.

                b.  If air is escaping from under the mask, reposition
                    fingers and mask.

                c.  Check for obstruction.

                d.  If chest still does not rise, use alternative method
                    of artificial ventilation, e.g., pocket mask.

D.  **Airway Adjuncts**

    A.  Oropharyngeal (oral) airways

        A.  Oropharyngeal airways may be used to assist in maintaining
            an open airway on unresponsive patients without a gag
            reflex - patients with a gag reflex will vomit.

        B.  Select the proper size: measure from the corner of the
            patient\'s lips to the bottom of the earlobe or angle of
            jaw.

        C.  Open the patient\'s mouth.

        D.  In adults, to avoid obstructing the airway with the tongue,
            insert the airway upside down, with the tip facing toward
            the roof of the patient\'s mouth.

        E.  Advance the airway gently until resistance is encountered.
            Turn the airway 180 degrees so that it comes to rest with
            the flange on the patient\'s teeth.

        F.  Another method of inserting an oral airway is to insert it
            right side up, using a tongue depressor to press the tongue
            down and forward to avoid obstructing the airway. This is
            the preferred method for airway insertion in an infant or
            child.

    B.  Nasopharyngeal (nasal) airways

        A.  Nasopharyngeal airways are less likely to stimulate vomiting
            and may be used on patients who are responsive but need
            assistance keeping the tongue from obstructing the airway.
            Even though the tube is lubricated, this is a painful
            stimulus.

        B.  Select the proper size: measure from the tip of the nose to
            the tip of the patient\'s ear. Also consider diameter of
            airway in nare.

        C.  Lubricate the airway with a water soluble lubricant.

        D.  Insert it posteriorly. Bevel should be toward the base of
            the nare or toward the septum.

        E.  If the airway cannot be inserted into one nostril, try the
            other nostril.

E.  **Oxygen**

    A.  Equipment for oxygen delivery

        A.  Non-rebreather

            A.  Preferred method of giving oxygen to prehospital
                patients.

            B.  Up to 90% oxygen can be delivered.

            C.  Non-rebreather bag must be full before mask is placed on
                patient.

            D.  Flow rate should be adjusted so that when patient
                inhales, bag does not collapse (15 lpm).

            E.  Patients who are cyanotic, cool, clammy or short of
                breath need oxygen. Concerns about the dangers of giving
                too much oxygen to patients with history of chronic
                obstructive pulmonary disease and infants and children
                have not been shown to be valid in the prehospital
                setting. Patients with chronic obstructive pulmonary
                disease and infants and children who require oxygen
                should receive high concentration oxygen.

            F.  Masks come in different sizes for adult, children and
                infants. Be sure to select the correct size mask.

        B.  Nasal cannula - rarely the best method of delivering
            adequate oxygen to the prehospital patient. Should be used
            only when patients will not tolerate a non-rebreather mask,
            despite coaching from the EMT-Basic.

# APPLICATION

**[Procedural (How)]{.underline}**

1.  Demonstrate the steps in performing the skill of artificially
    ventilating a patient with a bag-valve-mask for one and two
    rescuers.

2.  Demonstrate how to insert an oropharyngeal and nasopharyngeal
    airway.

3.  Demonstrate the use of a non-rebreather face mask and a nasal
    cannula.

4.  Demonstrate artificial ventilation of a patient with a flow
    restricted, oxygen powered ventilation device.

5.  Demonstrate the techniques of suctioning.

**[Contextual (When, Where, Why)]{.underline}**

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

**STUDENT ACTIVITIES**

**[Auditory (Hear)]{.underline}**

1.  Students should hear a bag-valve-mask device and a flow restricted,
    oxygen powered ventilation device used on a patient.

2.  Students should hear a suction unit being operated.

3.  Students should hear an oxygen tank and flowmeter in operation.

**[Visual (See)]{.underline}**

1.  Students should see different devices for ventilating a patient such
    as pocket masks, bag-valve masks and flow restricted, oxygen powered
    ventilation devices.

2.  Students should see non-rebreather masks and nasal cannulas.

**[Kinesthetic (Do)]{.underline}**

1.  Students should practice opening a patient\'s airway using a
    head-tilt chin lift and a jaw thrust maneuver.

2.  Students should practice using a bag-valve-mask device and a flow
    restricted, oxygen powered ventilation device.

3.  Students should practice using a non-rebreather mask and a nasal
    cannula

4.  Students should practice correct operation of oxygen tanks,
    regulators and flow meters.

5.  Students should practice suctioning.

**[Instructor Activities]{.underline}**

1.  Supervise student practice.

2.  Reinforce student progress in cognitive, affective, and psychomotor
    domains.

3.  Redirect students having difficulty in content.

# EVALUATION

Written: Develop evaluation instruments, e.g., quizzes, verbal reviews,
and handouts, to determine if the students have met the cognitive and
affective objectives of this lesson.

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

# REMEDIATION

> Identify students or groups of students who are having difficulty with
> this subject content.

# ENRICHMENT

> What is unique in the local area concerning this topic?

**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Module III:**

**Patient Assessment**

# TASK LIST AND EDUCATIONAL OBJECTIVES

At the completion of this lesson, the student will be able to:

**[COGNITIVE OBJECTIVES]{.underline}**

1.  Assess scene safety

-   Recognize hazards/potential hazards

-   Describe common hazards found at the scene of a trauma and a medical
    patient

-   Determine if the scene is safe to enter

1.  Assess the need for additional resources at the scene

-   Explain the reason for identifying the need for additional help or
    assistance

1.  Assess mechanism of injury

2.  Assess nature of illness

-   Discuss common mechanisms of injury/nature of illness

1.  Perform an initial patient assessment and provide care based on
    initial assessment findings

-   Summarize the reasons for forming a general impression of the
    patient.

-   Discuss methods of assessing altered mental status.

-   Discuss methods of assessing the airway in the adult, child and
    infant patient.

-   Describe methods used for assessing if a patient is breathing.

-   Differentiate between a patient with adequate and inadequate
    breathing.

-   Distinguish between methods of assessing breathing in the adult,
    child and infant patient.

-   Describe the methods used to obtain a pulse.

-   Describe normal and abnormal findings when assessing skin color,
    temperature and condition.

-   Explain the reason for prioritizing a patient for care and
    transport.

1.  Obtain a ***SAMPLE*** history (Signs and Symptoms of the present
    illness/injury, Allergy, Medications, Past medical History, Last
    oral intake, Events leading to present illness/injury)

-   Identify the components of a ***SAMPLE*** history

1.  Perform a rapid trauma assessment and provide care based on
    assessment findings

-   State the reasons for performing a rapid trauma assessment

-   Recite examples and explain why patients should receive a rapid
    trauma assessment

1.  Perform a history and physical examination focusing on the specific
    injury and provide care based on assessment findings.

-   Discuss the reason for performing a focused history and physical
    examination.

1.  Perform a history and physical examination focusing on a specific
    medical condition and provide care based on assessment findings.

-   Differentiate between the history and physical examination that are
    performed for responsive patients with no known prior history and
    responsive patients with a known history.

-   Differentiate between the assessment that is performed for a patient
    who is unresponsive or has an altered mental status and other
    medical patients requiring assessment.

1.  Perform a detailed physical examination and provide care based on
    assessment findings

-   State the areas of the body that are evaluated during the detailed
    physical examination.

-   Explain what additional care should be provided while performing the
    detailed physical examination.

1.  Perform on-going assessments and provide care based on assessment
    findings.

-   Discuss the reasons for repeating the initial assessment as part of
    the on-going assessment.

-   Describe the components of the on-going assessment.

1.  Complete a prehospital care report

-   Apply the components of the essential patient information in a
    written report.

1.  Communicate with the patient, bystanders, other health care provider
    and patient family members while providing patient care

-   Discuss the communication skills that should be used to interact
    with the patient.

-   Discuss the communication skills that should be used to interact
    with the family, bystanders, individuals from other agencies while
    providing patient care and hospital personnel, and the difference
    between skills used to interact with the patient and those used to
    interact with others.

1.  Provide a report to medical direction of assessment findings and
    emergency care given

-   Explain the importance of effective communication of patient
    information.

**[AFFECTIVE OBJECTIVES]{.underline}**

1.  Explain the value of performing an each component of the prehospital
    patient assessment.

2.  Recognize and respect the feelings that patients might experience
    during assessment.

3.  Explain the rationale for providing efficient and effective radio
    and written patient care reports.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

1.  Demonstrate the steps in performing a scene size-up.

2.  Demonstrate the steps in performing an initial assessment.

3.  Demonstrate the rapid trauma assessment that should be used to
    assess a patient based on mechanism of injury.

4.  Demonstrate the steps in performing a focused history and physical
    on a medical and a trauma patient.

5.  Demonstrate the skills involved in performing a detailed physical
    examination.

6.  Demonstrate the skills involved in performing an on-going
    assessment.

7.  Complete a prehospital care report.

# PREPARATION

Motivation: The EMT-Basic will encounter patients who require emergency
medical care. It is important to identify those patients who require
rapid assessment, critical intervention and immediate transport. The
components of the assessment will assist the EMT-Basic in making patient
intervention decisions.

**MATERIALS**

AV Equipment: Utilize various audio-visual materials relating to
emergency medical care. The continuous design and development of new
audio-visual materials relating to EMS requires careful review to
determine which best meet the needs of the program. Materials should be
edited to assure the objectives of the curriculum are met.

EMS Equipment: Exam gloves, airway management equipment, stethoscope,
blood pressure cuff and a penlight.

**PERSONNEL**

Primary Instructor: One EMT-Basic instructor knowledgeable in scene
management and patient assessment.

Assistant Instructor: The instructor-to-student ratio should be adequate
to allow for supervision of psychomotor skills practice. Individuals
used as assistant instructors should be knowledgeable in scene
management and patient assessment.

# PRESENTATION

**Declarative (What)**

I.  **Scene Size-up/Assessment**

    A.  Definition - an assessment of the scene and surroundings that
        will provide valuable information to the EMT-Basic.

        Body substance isolation (BSI) review

        Scene safety

        1.  Definition - an assessment to assure the safety and
            well-being of the EMT-Basic.

            Personal protection - Is it safe to approach the patient?

            a.  Crash/rescue scenes

                Toxic substances - low oxygen areas

                Crime scenes - potential for violence

                Unstable surfaces: slope, ice, water

            Protection of the patient - environmental considerations

            Protection of bystanders - if appropriate, help the
            bystander avoid becoming a patient

            If the scene is unsafe, make it safe. Otherwise, do not
            enter.

        Mechanism of injury/nature of illness

        1.  Medical

            a.  Nature of illness (NOI) - determine from the patient,
                family or bystanders why EMS was activated.

                Determine the total number of patients

                1.  If there are more patients than the responding unit
                    can effectively handle,

                    a.  Obtain additional help prior to contact with
                        patients: law enforcement, fire, rescue, ALS,
                        utilities. The EMT-Basic is less likely to call
                        for help if involved in patient care.

                        Begin triage

                    If adequate resources are available at the scene,
                    proceed to the initial assessment

            Trauma

            a.  Mechanism of injury - determine from the patient, family
                or bystanders and inspection of the scene what is the
                mechanism of injury

                Determine the total number of patients

                1.  If there are more patients than the responding unit
                    can effectively handle,

                    a.  Obtain additional help prior to contact with
                        patients. The EMT-Basic is less likely to call
                        for help when involved in patient care.

                        Begin triage

                    If the responding crew can manage the situation,
                    consider spinal precautions and continue care.

    **Initial Assessment**

    A.  General Impression of the Patient

        1.  Definition

            a.  The general impression is formed to determine priority
                of care and is based on the EMT-Basic\'s immediate
                assessment of the environment and the patient\'s chief
                complaint.

                Determine if ill (medical) or injured (trauma). If
                injured, identify mechanism of injury

                Age

                Sex

                Race

            Assess patient and determine if the patient has a life
            threatening condition

            a.  If a life threatening condition is found, treat
                immediately

                Assess nature of illness or mechanism of injury

        Assess patient\'s mental status. Maintain spinal immobilization
        if needed.

        1.  Begin by speaking to the patient. EMT-Basics should state
            their names, tell the patient that they are emergency
            medical technicians, and explain that they are here to help.

            Levels of mental status - (**AVPU**)

            a.  **[A]{.underline}**lert

                Responds to **[V]{.underline}**erbal stimuli

                Responds to **[P]{.underline}**ainful stimuli

                **[U]{.underline}**nresponsive - no gag or cough

        Assess the patient\'s airway status

        1.  Responsive patient - Is the patient talking or crying?

            a.  If yes, assess for adequacy of breathing

                If no, open airway

            Unresponsive patient - Is the airway open?

            a.  Open the airway. Positioning of the patient is age and
                size specific

                1.  For medical patients, perform the head-tilt
                    chin-lift

                    a.  Clear

                        Not clear

                        i.  Noisy respirations

                            a.  Crowing

                                Audible wheezing

                                Gurgling

                                Snoring

                                Stridor

                            Clear the airway

                            a.  Open the airway

                                Suction the airway as needed

                                Insert airway adjuncts

                    For trauma patients or those with unknown nature of
                    illness, the cervical spine should be
                    stabilized/immobilized and the jaw thrust maneuver
                    performed

                    a.  Clear

                        Not clear

                        i.  Noisy respirations

                            a.  Crowing

                                Audible wheezing

                                Gurgling

                                Snoring

                                Stridor

                            Clear the airway

                            a.  Open the airway

                                Suction the airway as needed

                                Insert airway adjuncts

        Assess the patient\'s breathing

        1.  If breathing is adequate and the patient is responsive,
            oxygen may be indicated.

            All responsive patients breathing \>24 or \<8 should receive
            high flow oxygen (defined as a 15 LPM non-rebreather mask).

            If the patient is unresponsive and the breathing is
            adequate, open and maintain the airway and provide high
            concentration oxygen.

            If the breathing is inadequate, open and maintain the
            airway, assist the patients breathing and utilize
            ventilatory adjuncts. In all cases oxygen should be used.

            If the patient is not breathing, open and maintain the
            airway and ventilate using ventilatory adjuncts. In all
            cases oxygen should be used.

        Assess the patient\'s circulation

        1.  Assess the patient\'s pulse

            a.  The circulation is assessed by feeling for a radial
                pulse.

                1.  In a patient one year old or less, palpate a
                    brachial pulse

                    If no radial pulse is felt, palpate carotid pulse

                    a.  If pulseless, medical patient \> or = 12 years
                        old, start CPR and apply automated external
                        defibrillator (AED)

                        Medical patient \< 12 years old or \< 90 lbs,
                        start CPR.

                        Trauma patient, start CPR if consistent with
                        state or local protocol

            Assess if major bleeding is present. If bleeding is present,
            control bleeding

            Assess the patient\'s perfusion by evaluating skin color,
            temperature and condition.

            a.  The patient\'s skin color is assessed by looking at the
                nailbeds, lips and eyes

                1.  Normal - pink

                    Abnormal conditions

                    a.  Pale

                        Cyanotic or blue-gray

                        Flushed or red

                        Jaundice or yellow

                Assess the patient\'s skin temperature by feeling the
                skin

                1.  Normal - warm

                    Abnormal skin temperatures

                    a.  Hot

                        Cool

                        Cold

                        Clammy - cool & moist

                Assess the patient\'s skin condition. This is an
                assessment of the amount of moisture on the skin.

                1.  Normal - dry

                    Abnormal - moist or wet

                Assess capillary refill in infant and child patients
                under six years old.

                1.  Normal capillary refill is less than two seconds

                    Abnormal capillary refill is greater than two
                    seconds

        Identify priority patients

        1.  Poor general impression

            Unresponsive patients - no gag or cough

            Responsive, not following commands

            Difficulty breathing

            Shock (hypoperfusion)

            Complicated childbirth

            Chest pain with BP \<100 systolic

            Uncontrolled bleeding

            Severe pain anywhere

        Expedite transport of the patient. Consider ALS backup

        Proceed to the appropriate focused history and physical
        examination (trauma or medical)

    **Focused History and Physical Examination**

    A.  Trauma

        1.  Perform rapid trauma assessment on patients with significant
            mechanism of injury to determine life threatening injuries.
            In the responsive patient, symptoms should be sought before
            and during the trauma assessment.

            a.  Continue spinal stabilization

                Consider ALS request

                Assess mental status

                Inspect and palpate, looking and feeling for the
                following examples of injuries or signs of injury -
                **DCAP-BTLS**

                1.  **D** eformities

                    **C** ontusions

                    **A** brasions

                    **P** unctures/penetrations

                    **B** urns

                    **T** enderness

                    **L** acerations

                    **S** welling

                Assess the head, inspect and palpate for injuries, signs
                of injury, or crepitation

                Assess the neck, inspect and palpate for injuries or
                signs of injury

                1.  Jugular vein distention (JVD)

                    Crepitation

                Apply cervical spinal immobilization collar (CSIC)

                Assess the chest, inspect and palpate for injuries or
                signs of injuries

                1.  Paradoxical motion

                    Crepitation

                    Breath sounds in the apices, mid-clavicular line,
                    bilaterally and at the bases, mid-axillary line,
                    bilaterally

                    a.  Present

                        Absent

                        Equal

                Assess the abdomen, inspect and palpate for injuries or
                signs of injury

                1.  Firm

                    Soft

                    Distended

                Assess the pelvis, inspect and palpate for injuries or
                signs of injury. If no pain is noted, gently compress
                the pelvis to determine tenderness or motion.

                Assess all four extremities, inspect and palpate
                injuries or signs of injury

                1.  Distal pulse

                    Sensation

                    Motor function

                Roll patient with spinal precautions and assess
                posterior body, inspect and palpate, examining for
                injuries or signs of injury

                Assess baseline vital signs

                Assess ***SAMPLE*** history

                1.  **S** igns and symptoms of present illness or injury

                    **A** llergies

                    **M** edications

                    **P** ertinent past history

                    **L** ast oral intake: solid or liquid

                    **E** vents leading to the injury or illness

            For patients with no significant mechanism of injury, e.g.,
            cut finger

            a.  Perform focused history and physical exam of injuries
                based on the components of the rapid assessment. The
                focused assessment is performed on the specific injury
                site.

                Assess baseline vital signs

                Assess ***SAMPLE*** history

        Responsive Medical Patients

        1.  Assess history of present illness

            Assess complaints and signs or symptoms

            a.  **O-P-Q-R-S-T**

                1.  **O** nset

                    **P** rovocation

                    **Q** uality

                    **R** adiation

                    **S** everity

                    **T** ime

                Assess ***SAMPLE*** history

                Perform rapid assessment

                1.  Assess the head if necessary

                    Assess the neck if necessary

                    Assess the chest if necessary

                    Assess the abdomen if necessary

                    Assess the pelvis if necessary

                    Assess the extremities if necessary

                    Assess the posterior body if necessary

                Assess baseline vital signs

                Provide emergency medical care based on signs and
                symptoms in consultation with medical direction

        Unresponsive Medical Patients

        1.  Perform rapid assessment

            a.  Assess the head

                Assess the neck

                Assess the chest

                Assess the abdomen

                Assess the pelvis

                Assess the extremities

                Assess the posterior aspect of the body

            Assess baseline vital signs

            Position patient to protect airway

            Obtain ***SAMPLE*** history from bystander, family, friends
            prior to leaving

    **Detailed Physical Exam** (contains components of the former
    \"secondary survey\")

    A.  Patient and injury specific; e.g., cut finger would not require
        the detailed physical exam

        Perform a detailed physical examination on the patient to gather
        additional information

        1.  As you inspect and palpate, look and/or feel for the
            following examples of injuries or signs of injury -
            **DCAP-BTLS**

            a.  **D** eformities

                **C** ontusions

                **A** brasions

                **P** unctures/penetrations

                **B** urns

                **T** enderness

                **L** acerations

                **S** welling

            Assess the head, inspect and palpate for injuries or signs
            of injury

            Assess the face, inspect and palpate for injuries or signs
            of injury.

            Assess the ears, inspect and palpate for injuries and signs
            of injury, or drainage

            Assess the eyes, inspect for injuries or signs of injury

            a.  Discoloration

                Unequal pupils

                Foreign bodies

                Blood in anterior chamber

            Assess the nose, inspect and palpate for injuries or signs
            of injury

            a.  Drainage

                Bleeding

            Assess the mouth, inspect for injuries or signs of injury

            a.  Teeth

                Obstructions

                Swollen or lacerated tongue

                Odors

                Discoloration

            Assess the neck, inspect and palpate for injuries or signs
            of injury

            a.  Jugular vein distention

                Crepitation

            Assess the chest, inspect and palpate for injuries or signs
            of injury

            a.  Crepitation

                Paradoxical motion

                Breath sounds in the apices, mid-clavicular line,
                bilaterally and at the bases, mid-axillary line,
                bilaterally

                1.  Present

                    Absent

                    Equal

            Assess the abdomen, inspect and palpate for injuries or
            signs of injury

            a.  Firm

                Soft

                Distended

            Assess the pelvis, inspect and palpate for injuries or signs
            of injury. If the patient does not complain of pain or is
            unresponsive, gently flex and compress the pelvis to
            determine stability.

            Assess all four extremities, inspect and palpate for
            injuries or signs of injury

            a.  Distal pulses

                Sensation

                Motor function

            Roll with spinal precautions and assess posterior aspect of
            body, inspect and palpate for injuries and signs of injury

            Reassess vital signs

    **Ongoing Assessment**

    A.  Repeat initial assessment. For a stable patient, repeat and
        record every 15 minutes, for an unstable patient, repeat and
        record at a minimum every 5 minutes.

        1.  Reassess mental status

            Maintain open airway

            Monitor breathing for rate and quality

            Reassess pulse for rate and quality

            Monitor skin color and temperature

        Re-establish patient priorities

        Reassess and record vital signs

        Repeat focused assessment regarding patient complaint or
        injuries

        Check interventions

        1.  Assure adequacy of oxygen delivery/artificial ventilation

            Assure management of bleeding

            Assure adequacy of other interventions

    **Verbal communication**

    A.  After arrival at the hospital, give a verbal report to the staff

        Introduce the patient by name (if known).

        Summarize the information given over the radio:

        1.  Chief complaint

            History that was not given previously

            Additional treatment given en route

            Additional vital signs taken en route

            Give additional information that was collected but not
            transmitted.

    **Interpersonal communication**

    A.  Make and keep eye contact with the patient.

        When practical, position yourself at a level lower than the
        patient.

        Be honest with the patient.

        Use language the patient can understand.

        Be aware of your own body language.

        Speak clearly, slowly and distinctly.

        Use the patient\'s proper name, either first or last, depending
        on the circumstances. Ask the patient what he wishes to be
        called.

        If a patient has difficulty hearing, speak clearly with lips
        visible.

        Allow the patient enough time to answer a question before asking
        the next one.

        Act and speak in a calm, confident manner.

    **Prehospital care report**

    A.  Functions

        1.  Continuity of care - a form that is not read immediately in
            the emergency department may very well be referred to later
            for important information.

            Legal document

            a.  A good report has documented what emergency medical care
                was provided and the status of the patient on arrival at
                the scene and any changes upon arrival at the receiving
                facility.

                The person who completed the form ordinarily must go to
                court with the form.

                Information should include objective and subjective
                information and be clear.

            Educational - used to demonstrate proper documentation and
            how to handle unusual or uncommon cases.

            Administrative

            a.  Billing

                Service statistics

            Research

            Evaluation and continuous quality improvement

        Use

        1.  Types

            a.  Traditional written form with check boxes and a section
                for narrative.

                Computerized version where information is filled in by
                means of an electronic clipboard or a similar device.

            Sections

            a.  Run data - date, times, service, unit, names of crew

                Patient data - patient name, address, date of birth,
                insurance information, sex, age, nature of call,
                mechanism of injury, location of patient, treatment
                administered prior to arrival of EMT-Basic, signs and
                symptoms, care administered, baseline vital signs,
                ***SAMPLE*** history and changes in condition.

                Narrative section (if applicable)

                1.  Describe, don\'t conclude.

                    Include pertinent negatives.

                    Record important observations about the scene, e.g.,
                    suicide note, weapon, etc.

                    Avoid radio codes.

                    Use abbreviations only if they are standard.

                    When information of a sensitive nature is
                    documented, note the source of that information,
                    e.g., communicable diseases.

                    Be sure to spell words correctly, especially medical
                    words. If you do not know how to spell it, find out
                    or use another word.

                    For every reassessment, record time and findings.

                Other state or local requirements

            Confidentiality - the form and the information on the form
            are considered confidential in many states. Check state and
            local laws.

            Distribution - local protocol and procedures will determine
            where the different copies of the form should be
            distributed.

        Falsification issues

        1.  When an error of omission or commission occurs, the
            EMT-Basic should not try to cover it up. Instead, document
            what did or did not happen and what steps were taken (if
            any) to correct the situation.

            Falsification of information on the prehospital care report
            may lead not only to suspension or revocation of the
            EMT-B\'s certification/license, but also to poor patient
            care because other health care providers have a false
            impression of which assessment findings were discovered or
            what treatment was given.

            Specific areas of difficulty

            a.  Vital signs - document only the vital signs that were
                actually taken.

                Treatment - for example, if a treatment like oxygen was
                overlooked, do not chart that the patient was given
                oxygen.

# APPLICATION

**[Procedural (How)]{.underline}**

1.  Demonstrate all components of patient assessment.

2.  Review methods of questioning to determine history of present
    illness - (***SAMPLE*** history).

3.  Demonstrate proper methods for providing a verbal and a written
    patient care report.

**[Contextual (When, Where, Why)]{.underline}**

> Size-up represents the very beginning of patient assessment. It
> requires the EMT-Basic to evaluate several aspects concerning the
> situation in a very short period of time. It is the essence in
> assuring the safety of the crew and the patient. This information may
> be obtained as part of dispatch, but should always be reassessed upon
> arrival at the scene. For some situations, size-up is an on-going
> process. As additional information is obtained, modification is
> performed to the size-up of the patient and the situation overall.
>
> Perform initial assessment on all patients after assuring scene and
> personal safety. If the scene is safe and the environment permits,
> perform the assessment prior to moving the patient. The initial
> assessment is a rapid means of assessing patient condition and
> priorities of care.
>
> The focused history and physical exam is performed following the
> initial assessment and correction of immediate threats to life. The
> focused history and physical exam differs for medical and trauma
> patients. During this process, obtain additional information regarding
> the patient\'s condition. This assessment may be performed at the same
> location as the initial assessment, unless the scene or patient\'s
> condition requires movement. This assessment is the second hands-on
> approach to gain information to continue providing patient care.
>
> The detailed physical exam is performed following the focused history
> and physical exam. It will be performed after all critical
> interventions have been completed. It is situation and time dependent.
> Depending upon the severity of the patient\'s injury or illness, this
> assessment may not be completed. During this process, additional
> information regarding the patient\'s condition is obtained. Typically
> this assessment will be performed while en route to the receiving
> facility.
>
> The on-going assessment should be performed on all patients after
> assuring completion of critical interventions. Ideally, it is
> completed following the detailed physical exam. However, the patient
> condition may preclude performance of the detailed physical exam. In
> these cases, the on-going assessment is extremely valuable. The
> on-going assessment is a means of determining changes in the
> patient\'s condition.

**[STUDENT ACTIVITY]{.underline}**

**[Auditory (Hear)]{.underline}**

1.  Student should hear simulations of various safe and unsafe scenes.

2.  Students should hear recordings of various patient situations to
    listen for clues concerning the general impression.

3.  Students should hear information input from a simulated patient or
    others regarding symptoms for patients with altered mental status.

4.  Students should hear questions to assist in determining the history
    of the present illness.

**[Visual (See)]{.underline}**

1.  Students should see simulations of various safe and unsafe scenes.

2.  Students should see visual aids or materials of various patient
    situations.

3.  Students should see the inspection and palpation of programmed
    patients for various injuries and patterns of injury.

4.  Students should see the entire assessment completed for each patient
    category.

**[Kinesthetic (Do)]{.underline}**

1.  Students should practice role playing the actions taken at various
    safe and unsafe scenes.

2.  Students should practice all components of the assessment.

3.  Students should practice examining interventions to assure that they
    continue to be effective.

4.  Students should practice recording assessment findings.

**[Instructor Activities]{.underline}**

1.  Supervise student practice.

2.  Reinforce student progress in cognitive, affective, and psychomotor
    domains.

3.  Redirect students having difficulty with content.

# EVALUATION

Written: Develop evaluation instruments, e.g., quizzes, verbal reviews,
and handouts, to determine if the students have met the cognitive and
affective objectives of this lesson.

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

# REMEDIATION

> Identify students or groups of students who are having difficulty with
> this subject content.

# ENRICHMENT

> What is unique in the local area concerning this topic?

**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Module IV:**

**Medical/Behavioral**

# TASK LIST AND EDUCATIONAL OBJECTIVES

At the completion of this lesson, the student will be able to:

**[COGNITIVE OBJECTIVE]{.underline}**

1.  Provide treatment for a patient in respiratory distress

-   List the signs and symptoms of difficulty breathing

-   Describe the emergency medical care of the patient with breathing
    difficulty.

-   Recognize the need for medical direction to assist in the emergency
    medical care of the patient with breathing difficulty.

-   State the generic name, medication forms, dose, administration,
    action, indications and contraindications for the prescribed
    inhaler.

1.  Provide care to a patient experiencing chest pain/discomfort

-   Describe the emergency medical care of the patient experiencing
    chest pain/discomfort.

-   Discuss the position of comfort for patients with various cardiac
    emergencies.

-   Recognize the need for medical direction of protocols to assist in
    the emergency medical care of the patient with chest pain.

-   List the indications for the use of nitroglycerin.

1.  Attempt to resuscitate a patient in cardiac arrest

-   Discuss the circumstances which may result in inappropriate shocks.

-   Explain the considerations for interruption of CPR, when using the
    automated external defibrillator.

-   List the steps in the operation of the automated external
    defibrillator.

-   Discuss the need to complete the Automated Defibrillator:
    Operator\'s Shift Checklist.

-   Explain the role medical direction plays in the use of automated
    external defibrillation.

1.  Provide care to a patient with an altered mental status

-   State the steps in the emergency medical care of the patient taking
    diabetic medicine with an altered mental status and a history of
    diabetes.

-   Evaluate the need for medical direction in the emergency medical
    care of the diabetic patient.

1.  Provide care of the patient experiencing an allergic reaction

-   Recognize the patient experiencing an allergic reaction.

-   Describe the emergency medical care of the patient with an allergic
    reaction.

-   State the generic and trade names, medication forms, dose,
    administration, action, and contraindications for the epinephrine
    auto-injector.

-   Evaluate the need for medical direction in the emergency medical
    care of the patient with an allergic reaction.

-   Differentiate between the general category of those patients having
    an allergic reaction and those patients having an allergic reaction
    and requiring immediate medical care, including immediate use of
    epinephrine auto-injector.

1.  Provide care to a suspected poison/overdose patient

-   Describe the steps in the emergency medical care for the patient
    with suspected poisoning.

-   Discuss the emergency medical care for the patient with possible
    overdose.

1.  Provide care to a patient experiencing a behavioral problem

-   Discuss the characteristics of an individual\'s behavior which
    suggests that the patient is at risk for suicide.

-   Discuss the special considerations for assessing a patient with
    behavioral problems.

-   Discuss the general principles of an individual\'s behavior which
    suggests that he is at risk for violence.

-   Discuss methods to calm behavioral emergency patients.

**[AFFECTIVE OBJECTIVES]{.underline}**

1.  Defend the rationale for the EMT-Basic to carry and assist with
    medications.

2.  Recognize and respond to the feelings of the patient who may require
    interventions to be performed.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

1.  Given medical scenarios, demonstrate the ability to properly assess
    the patient and demonstrate the ability to properly utilize the
    intervention to include inhaler, nitroglycerin, oral glucose and
    activated charcoal.

2.  Demonstrate the use of an epinephrine auto-injector.

3.  Given a cardiac arrest scenario, demonstrate the use of the AED.

# PREPARATION

Motivation: Many of the emergencies that an EMT-Basic responds to will
be of a medical nature. The ability to recognize a medical emergency
through proper assessment and questioning techniques and then providing
the appropriate intervention is critical to the well-being of the
patient.

**MATERIALS**

AV Equipment: Utilize various audio-visual materials relating to general
pharmacology medical emergencies. The continuous design and development
of new audio-visual materials relating to EMS requires careful review to
determine which best meets the needs of the program. Materials should be
edited to assure meeting the objectives of the curriculum.

EMS Equipment: Exam gloves, stethoscope, blood pressure cuff, penlight,
suction equipment, tube of oral glucose, epinephrine auto-injector
trainer, handheld inhaler suitable for training purposes, defibrillator
manikins, automated external defibrillator, nitroglycerin training
bottle, activated charcoal.

**PERSONNEL**

Primary Instructor: An EMT-Basic instructor who is knowledgeable in the
assessment and intervention of common medical conditions.

Assistant Instructor: The instructor to student ratio should be adequate
to allow for supervision of psychomotor skill practice. Individuals used
as assistant instructors should be knowledgeable in general pharmacology
as well as assessment and management of the medical patient .

# PRESENTATION

**[Declarative (What)]{.underline}**

I.  **General Pharmacology**

    I.  Overview - the importance of medications and the dangers
        associated with their administration

    II. Medications (carried on the EMS unit)

        I.  Activated Charcoal

        II. Oral Glucose

        III. Oxygen

    III. Medications (prescribed by a physician and the patient has them
         in his possession; they are not carried on the EMS unit). May
         assist patients in taking, with approval by medical direction).

         I.  Prescribed Inhaler

         II. Nitroglycerin

         III. Epinephrine auto-injector

    IV. Medication names

        I.  Generic

            I.  The name listed in the U.S. Pharmacopeia, a governmental
                publication listing all drugs in the U.S.

            II. Name assigned to drug before it becomes officially
                listed. Usually a simple form of the chemical name

            III. Give examples

        II. Trade

            I.  Brand name is the name a manufacturer uses in marketing
                the drug

            II. Give examples

    V.  Indications - the indication for a drug\'s use includes the most
        common uses of the drug in treating a specific illness

    VI. Contraindications - situations in which a drug should not be
        used because it may cause harm to the patient or offer no effect
        in improving the patient\'s condition or illness

    VII. Medication Form

         I.  Medications the EMT-Basic carries or helps administer

             I.  Compressed powders or tablets - nitroglycerin

             II. Liquids for injection - epinephrine

             III. Gels - glucose

             IV. Suspensions - activated charcoal

             V.  Fine powder for inhalation - prescribed inhaler

             VI. Gasses - oxygen

             VII. Sublingual spray - nitroglycerin

             VIII. Liquid/vaporized fixed dose nebulizers

         II. Each drug is in a specific medication form to allow
             properly controlled concentrations of the drug to enter
             into the blood stream where it has an effect on the target
             body system.

    VIII. Dose - state how much of the medication should be given

    IX. Administration - state route by which the medication is
        administered such as oral, sublingual (below the tongue),
        injectable, or intramuscular

    X.  Actions - state desired effects of a medication

    XI. Side Effects - state any actions of a medication other than
        those desired. Some side effects may be predictable

    XII. Re-assessment strategies

         I.  Repeat vital signs

         II. Must be done as part of the on-going patient assessment

         III. Documentation of response to intervention

II. **Breathing Difficulty**

    I.  Signs and symptoms

        I.  Shortness of breath

        II. Restlessness

        III. Increased pulse rate

        IV. Increased breathing rate

        V.  Decreased breathing rate

        VI. Skin color changes

            I.  Cyanotic (blue-gray)

            II. Pale

            III. Flushed (red)

        VII. Noisy breathing

             I.  Crowing

             II. Audible wheezing

             III. Gurgling

             IV. Snoring

             V.  Stridor

                 I.  A harsh sound heard during breathing

                 II. Upper airway obstruction

        VIII. Inability to speak due to breathing efforts.

        IX. Retractions (the visible sinking-in of the soft tissues of
            the chest between the ribs and above and below the sternum)

        X.  Shallow or slow breathing may lead to altered mental status
            (with fatigue or obstruction).

        XI. Abdominal breathing (diaphragm only)

        XII. Coughing

        XIII. Irregular breathing rhythm

        XIV. Patient position

             I.  Tripod position

             II. Sitting with feet dangling, leaning forward

        XV. Unusual anatomy (barrel chest)

    II. Emergency Medical Care - Focused History and Physical Exam

        I.  Important questions to ask

            I.  Onset

            II. Provocation

            III. Quality

            IV. Radiation

            V.  Severity

            VI. Time

            VII. Interventions

        II. Breathing

            I.  Complains of trouble breathing.

                I.  Apply oxygen if not already done.

                II. Assess baseline vital signs.

            II. Has a prescribed inhaler available.

                I.  Consult medical direction.

                II. Facilitate administration of inhaler

                III. Repeat as indicated.

                IV. Continue focused assessment.

            III. Does not have prescribed inhaler - continue with
                 focused assessment.

            IV. Should be prepared to intervene with appropriate oxygen
                administration and artificial ventilation support.

    III. Medications

         I.  Prescribed inhaler

             I.  Medication name

                 I.  Generic - albuterol, isoetharine, metaproterenol,
                     etc.

                 II. Trade - Proventil, Ventolin, Bronkosol,
                     Bronkometer, Alupent, Metaprel, etc.

             II. Indications - meets all of the following criteria:

                 I.  Exhibits signs and symptoms of respiratory
                     emergency,

                 II. Has physician prescribed handheld inhaler, and

                 III. Specific authorization by medical direction.

             III. Contraindications

                  I.  Inability of patient to use device.

                  II. Inhaler is not prescribed for the patient.

                  III. No permission from medical direction.

                  IV. Patient has already met maximum prescribed dose
                      prior to EMT-Basic arrival.

             IV. Medication form - handheld metered dose inhaler

             V.  Dosage - number of inhalations based upon medical
                 direction\'s order or physician\'s order based upon
                 consultation with the patient.

             VI. Administration

                 I.  Obtain order from medical direction either on-line
                     or off-line.

                 II. Assure right medication, right patient, right
                     route, patient alert enough to use inhaler.

                 III. Check the expiration date of the inhaler.

                 IV. Check to see if the patient has already taken any
                     doses.

                 V.  Assure the inhaler is at room temperature or
                     warmer.

                 VI. Shake the inhaler vigorously several times.

                 VII. Remove oxygen adjunct from patient.

                 VIII. Have the patient exhale deeply.

                 IX. Have the patient put his lips around the opening of
                     the inhaler.

                 X.  Have the patient depress the handheld inhaler as he
                     begins to inhale deeply.

                 XI. Instruct the patient to hold his breath for as long
                     as he comfortably can (so medication can be
                     absorbed).

                 XII. Replace oxygen on patient.

                 XIII. Allow patient to breath a few times and repeat
                       second dose per medical direction.

                 XIV. If patient has a spacer device for use with his
                      inhaler, it should be used. A spacer device is an
                      attachment between inhaler and patient that allows
                      for more effective use of medication.

             VII. Actions - Beta agonist bronchodilators

                  I.  dilates bronchioles reducing airway resistance.

             VIII. Side effects

                   I.  Increased pulse rate

                   II. Tremors

                   III. Nervousness

             IX. Re-assessment strategies

                 I.  Gather baseline vital signs and focused
                     reassessment.

                 II. Patient may deteriorate and need positive pressure
                     artificial ventilation.

             X.  Infant and child considerations

                 I.  Use of handheld inhalers is very common in
                     children.

                 II. Retractions are more commonly seen in children than
                     adults.

                 III. Cyanosis (blue-gray) is a late finding in
                      children.

                 IV. Very frequent coughing may be present rather than
                     wheezing in some children.

                 V.  Emergency care with usage of handheld inhalers is
                     the same if the indications for usage of inhalers
                     is met by the ill child.

III. **Cardiac Emergencies**

     I.  Emergency Medical Care - Initial Patient Assessment Review

         I.  Circulation - pulse absent

             I.  Medical patient \> or = 12 years old - CPR with AED

             II. Medical patient \< 12 years old or \< 90 lbs. - CPR

         II. Responsive patient with a known history - cardiac

             I.  Perform initial assessment

             II. Perform focused history and physical exam

             III. Place patient in the position of comfort

     II. Cardiac

         I.  Complains of chest pain/discomfort

             I.  Apply oxygen if not already done

             II. Assess baseline vital signs

             III. Important questions to ask

                  I.  Onset

                  II. Provocation

                  III. Quality

                  IV. Radiation

                  V.  Severity

                  VI. Time

             IV. Patient has been prescribed nitroglycerin (NTG) and
                 nitro is with the patient

                 I.  Blood pressure greater than 100 systolic

                     I.  One dose, repeat in 3-5 minutes if no relief
                         and authorized by medical direction up to a
                         maximum of three doses

                     II. Reassess vital signs and chest pain after each
                         dose

                 II. Blood pressure less than 100 systolic - continue
                     with focused assessment

             V.  Does not have prescribed nitroglycerin (NTG) - continue
                 with focused assessment

     III. Relationship to Basic Life Support

          I.  Not all chest pain patients become cardiac arrest patients

          II. One Rescuer CPR - rarely done by EMT-Basics while on duty,
              may be done while partner is preparing equipment, or en
              route to facility

          III. Two Rescuer CPR - learning outcomes of a Professional
               Rescuer CPR Course must be enhanced during an EMT-Basic
               course

     IV. Automated External Defibrillation

         I.  Importance of automated external defibrillation to the
             EMT-Basic.

             I.  Fundamentals of early defibrillation - successful
                 resuscitation of out-of-hospital arrest depends on a
                 series of critical interventions known as the chain of
                 survival

                 I.  Early access

                 II. Early CPR

                 III. Early defibrillation

                 IV. Early ACLS

             II. Rationale for early defibrillation

                 I.  Many EMS systems have demonstrated increased
                     survival outcomes of cardiac arrest patients in
                     ventricular fibrillation

                 II. This increased survival was after early
                     defibrillation programs were implemented and when
                     all of the links in the chain of survival were
                     present

         II. Overview of automated external defibrillators

             I.  Types of automated external defibrillators

                 I.  Fully automated - defibrillator operates without
                     action by the EMT-Basic, except to turn on power
                     and attach electrodes

                 II. Semi-automated - defibrillator uses a computer
                     voice synthesizer to advise the EMT-Basic as to the
                     steps to take based upon its analysis of the
                     patient\'s cardiac rhythm

             II. Analysis of cardiac rhythms

                 I.  Defibrillator computer microprocessor evaluates the
                     patient\'s rhythm and confirms the presence or
                     absence of a rhythm for which a shock is indicated

                 II. Accuracy of devices in rhythm analysis has been
                     high both in detecting rhythms needing shocks and
                     rhythms that do not need shocks

                 III. Analysis is dependent on properly charged
                      defibrillator batteries

             III. Inappropriate delivery of shocks or failure to deliver
                  appropriate shocks

                  I.  Operator error examples

                      I.  CPR-induced artifact simulating ventricular
                          fibrillation (inappropriate shock)

                      II. Improper electrode application causing high
                          impedance (failure to analyze and deliver
                          shocks)

                  II. Device error examples

                      I.  Artifact free rhythms resembling ventricular
                          fibrillation (inappropriate shock)

                      II. Pacemaker spikes simulating regular rhythm
                          during ventricular fibrillation (device
                          failure to charge and deliver appropriate
                          shock)

             IV. Ventricular fibrillation

                 I.  Attach defibrillator to only unresponsive,
                     pulseless, apneic patients

                 II. Defibrillator advises shocks for ventricular
                     fibrillation based on predefined ECG criteria such
                     as rate and amplitude of ventricular fibrillation
                     ECG signal

             V.  Ventricular tachycardia

                 I.  Attach defibrillator to only unresponsive,
                     pulseless, apneic patients

                 II. Defibrillator advises shocks for ventricular
                     tachycardia when the rate exceeds a certain value,
                     for example, above 180 beats per minute

             VI. Interruption of CPR

                 I.  Defibrillation is of highest priority, justifying
                     stopping CPR during defibrillator rhythm analysis
                     and shock delivery

                 II. CPR should not be performed during the time
                     interval when up to three (3) successive shocks are
                     delivered

                 III. Resume CPR only after up to three (3) successive
                      stacked shocks have been delivered

                 IV. Patient should not be touched while rhythm is being
                     analyzed or shocks are being delivered.

         III. Use of automated external defibrillators during
              resuscitation attempts

              I.  Follow local or state protocol

              II. Operational steps

                  I.  Take body substance isolation (BSI) - should be
                      done en route to scene

                  II. Arrive on scene and perform initial assessment

                  III. Stop CPR if in progress

                  IV. Verify pulselessness and apnea

                  V.  Have partner resume CPR

                  VI. Attach electrodes to patient

                  VII. Turn on defibrillator power; this may be done as
                       soon as arrival in order to document exact time
                       of arrival at the patient\'s side

                  VIII. Begin narrative if machine has voice recorder

                  IX. Stop CPR

                  X.  Clear patient

                  XI. Initiate analysis of rhythm

                      I.  Machine advises shock

                          I.  Deliver shock

                          II. Re-analyze rhythm (may be automatic in
                              many AEDs)

                          III. If machine advises shock, deliver second
                               shock

                          IV. Re-analyze rhythm (may be automatic in
                              many AEDs)

                          V.  If machine advises shock, deliver third
                              shock

                          VI. Check pulse

                      II. If pulse, check breathing

                          I.  If breathing adequately, give high
                              concentration oxygen by non-rebreather
                              mask and transport

                          II. If not breathing adequately, artificially
                              ventilate with high concentration oxygen
                              and transport

                      III. If no pulse, resume CPR for one minute

                           I.  Repeat one cycle of up to three stacked
                               shocks

                           II. Transport

                      IV. If, after any rhythm analysis, the machine
                          advises no shock, check pulse

                          I.  If pulse is present, check breathing.

                              I.  If breathing adequately, give high
                                  concentration oxygen by non-rebreather
                                  mask and transport

                              II. If not breathing adequately,
                                  artificially ventilate with high
                                  concentration oxygen and transport

                              III. If no pulse is present, resume CPR
                                   for one minute

                                   I.  Repeat rhythm analysis

                                       \(a\) If shock advised, deliver
                                       if necessary up to two sets of
                                       three stacked shocks separated by
                                       one minute of CPR

                                       \(b\) If no shock advised and no
                                       pulse, resume CPR for one minute

                                       \(c\) Analyze rhythm third time

                                       \(I\) If shock advised, deliver,
                                       if needed, up to two sets of
                                       three stacked shocks separated by
                                       one minute of CPR

                                       \(ii\) If no shock advised,
                                       resume CPR and transport

         IV. Standard operational procedures

             I.  Assuming no on-scene ALS, the patient should be
                 transported when one of the following occurs

                 I.  The patient regains a pulse

                 II. Six shocks are delivered

                 III. The machine gives three consecutive messages
                      (separated by one minute of CPR) that no shock is
                      advised

             II. One EMT-Basic operates defibrillator, one does CPR

             III. Defibrillation comes first. Don\'t hook up oxygen or
                  do anything that delays analysis of rhythm or
                  defibrillation

             IV. The EMT-Basic must be familiar with device used in
                 operational EMS setting

             V.  All contact with patient must be avoided during
                 analysis of rhythm

             VI. State \"Clear the patient\" before delivering shocks

             VII. Check batteries at scheduled and documented intervals.

             VIII. Be certain batteries are fully charged and/or carry
                   back-up charged battery

         V.  Age and weight guidelines -automated external
             defibrillation is not recommended at this time for cardiac
             arrest in children under 12 years of age or less than 90
             lbs

         VI. Persistent ventricular fibrillation and no available ALS
             backup

             I.  After six shocks on scene, (three initial, three after
                 one minute of CPR), prepare for transport

             II. Additional shocks may be delivered at the scene or en
                 route by approval of local medical direction

             III. Automated external defibrillators cannot analyze
                  rhythm accurately when emergency vehicle is in motion
                  because vehicle motion can distort the ECG signal.
                  Must completely stop vehicle in order to analyze
                  rhythm if more shocks are ordered

             IV. It is not safe to defibrillate in a moving ambulance

         VII. Recurrent ventricular fibrillation following successful
              resuscitation

              I.  If en route with unresponsive patient check pulse
                  frequently (every 30 seconds). If pulse is no longer
                  present then

                  I.  Stop vehicle

                  II. Start CPR if defibrillator is not immediately
                      ready

                  III. Analyze rhythm

                  IV. Deliver shock if indicated

                  V.  Continue resuscitation as per protocol

              II. If en route with a conscious patient having chest pain
                  who becomes unresponsive, pulseless and apneic then

                  I.  Stop vehicle

                  II. Start CPR if defibrillator is not immediately
                      ready

                  III. Analyze rhythm

                  IV. Deliver up to 3 shocks, if indicated

                  V.  Continue resuscitation as per protocol

              III. If no shock is indicated and no pulse is present

                   I.  Start or resume CPR for one minute

                   II. Analyze rhythm until three consecutive \"no shock
                       indicated\" messages are given, each followed by
                       one minute of CPR; six shocks delivered; or
                       patient regains pulse

                   III. Continue transport

         VIII. Single rescuer with an automated external defibrillator

               I.  Follow sequence

                   I.  Perform initial assessment

                   II. Assure pulselessness and apnea

                   III. Turn on AED power

                   IV. Attach device

                   V.  Initiate analysis of rhythm

                   VI. Deliver shock if necessary

                   VII. Follow protocol

               II. Defibrillation is initial step; CPR should not be
                   performed prior to rhythm analysis

         IX. Pulse checks should not occur during rhythm analysis. Pulse
             checks should occur between each set of three stacked
             shocks.

         X.  Coordination of ALS personnel or EMT-Paramedics when
             EMT-Basics are using automated external defibrillators

             I.  EMS system design establishes protocols

             II. ALS should be notified of arrest events as soon as
                 possible

             III. Considerations for the EMT-Basic transporting the
                  patient or waiting for ALS to arrive on the scene to
                  transport should be in local protocols established by
                  medical direction

         XI. Precautions for the use of the automated external
             defibrillator

             I.  Moving ambulances

             II. Nitroglycerin patches on the chest

                 I.  If in an area where defibrillator electrodes are
                     applied, remove nitroglycerin patches and wipe any
                     residual from the skin

                 II. Nitroglycerin in close proximity to electrodes can
                     short-circuit defibrillator current and cause skin
                     burns

             III. Patients with implanted pacemakers or implanted
                  defibrillators (PCDs, AICDs)

                  I.  Implanted pacemaker or defibrillator malfunction
                      may result from external defibrillator electrodes
                      applied close to implanted devices when shocks are
                      delivered.

                  II. Apply electrode pads 4-5 inches away from
                      implanted devices

         XII. Post resuscitation care

              I.  After automated external defibrillation protocol is
                  completed, patient may

                  I.  Have pulses

                  II. Have no pulse with machine indicating \"no shock
                      indicated\"

                  III. Have no pulse with machine indicating shock

              II. If pulses return

                  I.  Manage airway as appropriate

                  II. Consider awaiting ALS backup if appropriate

                  III. Transport to appropriate facility

                       I.  Continue to keep defibrillator device on
                           patient en route

                       II. Perform focused assessment and reassessment
                           en route

         XIII. Defibrillator maintenance

               I.  Regular maintenance for defibrillators is necessary

               II. Defibrillator clocks must be synchronized with
                   dispatcher clocks at specified intervals

               III. Operators Shift Checklist for Automated
                    Defibrillators must be at scheduled and documented
                    intervals

               IV. Defibrillator failure is most frequently related to
                   improper device maintenance, commonly battery
                   failure. EMT-Basics must assure proper battery
                   maintenance and battery replacement schedules.

         XIV. Training and sources of information - the American Heart
              Association (AHA) publishes a variety of guidelines and
              additional information on automated external
              defibrillation

         XV. Maintenance of skills - AHA recommends 90 days between
             practice drills to reassess competency in use of AEDs

         XVI. Medical direction

              I.  Successful completion of AED training in an EMT-Basic
                  course does not permit usage of the device without
                  approval by state laws/rules and local medical
                  direction authority

              II. Every event in which an AED is used must be reviewed
                  by the medical director or his designated
                  representative

              III. Reviews of events using AEDs may be accomplished by

                   I.  Written report

                   II. Review of voice-ECG recorders attached to AEDs.

                   III. Solid-state memory modules and other forms of
                        data retrieval stored in the device

         XVII. Quality improvement - involves both individuals using
               AEDs and the EMS system in which the AEDs are used

     V.  Medications

         I.  Nitroglycerin

             I.  Medication name

                 I.  Generic - nitroglycerin

                 II. Trade - Nitro-bid, Nitro-stat

             II. Indications - must have [all]{.underline} of the
                 following criteria

                 I.  Exhibits signs and symptoms of chest pain

                 II. Has physician prescribed sublingual tablets

                 III. Has specific authorization by medical direction

             III. Contraindications

                  I.  Hypotension/blood pressure below 100 mmHg systolic

                  II. Patient has already met his/her maximum prescribed
                      dose prior to EMT-Basic arrival

             IV. Medication form - tablet, sublingual spray

             V.  Dosage - one dose, repeat in 3-5 minutes if no relief,
                 BP \> 100, and authorized by medical direction up to a
                 maximum of three doses.

             VI. Administration

                 I.  Obtain order from medical director either on-line
                     or off-line

                 II. Perform focused assessment for cardiac patient

                 III. Take blood pressure - above 100 mmHg systolic

                 IV. Contact medical control if no standing orders

                 V.  Assure right medication, right patient, right
                     route, patient alert

                 VI. Check expiration date of nitroglycerin

                 VII. Question patient on last dose administration,
                      effects, and assures understanding of route of
                      administration

                 VIII. Ask patient to lift tongue and place tablet or
                       spray dose under tongue (while wearing gloves) or
                       have patient place tablet or spray under tongue

                 IX. Have patient keep mouth closed with tablet under
                     tongue (without swallowing) until dissolved and
                     absorbed

                 X.  Recheck blood pressure within 2 minutes

                 XI. Record activity and time

                 XII. Perform reassessment

             VII. Actions

                  I.  Relaxes blood vessels

                  II. Decreases workload of heart

             VIII. Side effects

                   I.  Hypotension

                   II. Headache

                   III. Pulse rate changes

             IX. Reassessment strategies

                 I.  Monitor blood pressure

                 II. Ask patient about effect on pain relief

                 III. Seek medical direction before re-administering

                 IV. Record reassessments

IV. **Emergency Medical Care of a patient with an Altered Mental
    Status**

    I.  Caused by a variety of conditions

        I.  Hypoglycemia

        II. Hyperglycemia

        III. Poisoning

        IV. Post seizure

        V.  Infection

        VI. Head trauma

        VII. Decreased oxygen levels

    II. Emergency medical care

        I.  Assure patency of airway.

        II. Be prepared to artificially ventilate/suction.

        III. Transport.

        IV. Consider trauma, trauma can cause altered mental status

V.  **Emergency medical care of altered mental status with a history of
    diabetes**

    I.  Perform initial assessment

    II. Perform history and physical exam

        I.  Facts surrounding the episode

        II. Onset

        III. Duration

        IV. Associated symptoms

        V.  Evidence of trauma

        VI. Interventions

        VII. Seizures

        VIII. Fever

    III. Performs baseline vital signs and ***SAMPLE*** history

    IV. Assure known history of diabetes (medical identification tags),
        etc.

    V.  Determine last meal, last medication dose, any related illness

    VI. Determine if patient can swallow

    VII. Administer oral glucose in accordance with local medical
         direction or protocol

    VIII. Medication

          I.  Oral Glucose

              I.  Medication Name

                  I.  Generic - Glucose, Oral

                  II. Trade - Glutose, Insta-glucose

              II. Indications - patients with altered mental status with
                  a known history of diabetes controlled by medication

              III. Contraindications

                   I.  Unresponsive

                   II. Unable to swallow

              IV. Medication form - Gel, in toothpaste type tubes

              V.  Dosage - one tube

              VI. Administration

                  I.  Obtain order from medical direction either on-line
                      or off-line

                  II. Assure signs and symptoms of altered mental status
                      with a known history of diabetes

                  III. Assure patient is conscious and can swallow and
                       protect their airway

                  IV. Administer glucose

                      I.  Between cheek and gum

                      II. Place on tongue depressor between cheek and
                          gum

                  V.  Perform ongoing assessment

              VII. Actions - increases blood sugar

              VIII. Side effects - none when given properly. May be
                    aspirated by the patient without a gag reflex

              IX. Re-assessment strategies - if patient loses
                  consciousness or seizes, remove tongue depressor from
                  mouth

VI. **Emergency medical care of allergic reactions**

    I.  Patient has come in contact with substance that caused past
        allergic reaction and complains of respiratory distress or
        exhibits signs and symptoms of shock (hypoperfusion)

        I.  Perform initial assessment

        II. Perform a focused history and physical exam

            I.  History of allergies

            II. What was the patient exposed to

            III. How were they exposed

            IV. What effects

            V.  Progression

            VI. Interventions

        III. Assess baseline vital signs and ***SAMPLE*** history

        IV. Administer oxygen if not already done in the initial
            assessment

        V.  Contact medical direction

        VI. Determine if patient has prescribed preloaded epinephrine
            available. Facilitate administration of preloaded
            epinephrine

        VII. Record and reassess in two minutes

        VIII. Record reassessment findings

        IX. If patient does not have epinephrine auto-injector
            available - transport immediately

    II. Patient has contact with substance that causes allergic reaction
        without signs of respiratory distress or shock (hypoperfusion)

        I.  Continue with focused assessment

        II. Patient not wheezing or without signs of respiratory
            compromise or hypotension should not receive epinephrine

    III. Medications

         I.  Epinephrine auto-injector

             I.  Medication name

                 I.  Generic - Epinephrine

                 II. Trade - Adrenalin

             II. Indications - must meet [all]{.underline} of the
                 following three criteria

                 I.  Emergency medical care for the treatment of the
                     patient exhibiting the assessment findings of an
                     allergic reaction

                 II. Medication is prescribed for this patient by a
                     physician

                 III. Medical direction authorizes use for this patient

             III. Contraindications - no contraindications when used in
                  a life-threatening situation

             IV. Medication form - liquid administered via an
                 automatically injectable needle and syringe system

             V.  Dosage

                 I.  Adult - one adult auto-injector (0.3 mg)

                 II. Infant and child - one infant/child auto-injector
                     (0.15 mg)

             VI. Administration

                 I.  Obtain order from medical direction either on-line
                     or off-line

                 II. Obtain patient\'s prescribed auto injector. Ensure

                     I.  Prescription is written for the patient
                         experiencing allergic reactions

                     II. Medication is not discolored

                 III. Remove safety cap from the auto-injector

                 IV. Place tip of auto-injector against the patient\'s
                     thigh

                     I.  Lateral portion of the thigh

                     II. Midway between the waist and the knee

                 V.  Push the injector firmly against the thigh to
                     activate the injector

                 VI. Hold the injector in place until the medication is
                     injected

                 VII. Record activity and time

                 VIII. Dispose of injector in biohazard container

             VII. Actions

                  I.  Dilates the bronchiole

                  II. Constricts blood vessels

             VIII. Side effects

                   I.  Increases heart rate

                   II. Pallor

                   III. Dizziness

                   IV. Chest pain

                   V.  Headache

                   VI. Nausea

                   VII. Vomiting

                   VIII. Excitability, anxiousness

             IX. Transport

             X.  Re-assessment strategies

                 I.  Continue focused assessment of airway, breathing
                     and circulatory status

                     I.  Patient condition continues to worsen

                         I.  Decreasing mental status

                         II. Increasing breathing difficulty

                         III. Decreasing blood pressure

                         IV. Obtain medical direction

                             I.  Additional dose of epinephrine

                             II. Treat for shock (hypoperfusion)

                             III. Prepare to initiate Basic Cardiac Life
                                  Support measures

                                  I.  CPR

                                  II. AED

                     II. Patient condition improves. Provide supportive
                         care

                         I.  Oxygen

                         II. Treat for shock (hypoperfusion)

         II. Document all responses to medications

VII. **Emergency Medical Care of Poisoning/Overdose**

     I.  Ingested

         I.  Signs and symptoms

             I.  History of ingestion

             II. Nausea

             III. Vomiting

             IV. Diarrhea

             V.  Altered mental status

             VI. Abdominal pain

             VII. Chemical burns around the mouth

             VIII. Different breath odors

     II. Emergency medical care

         I.  Remove pills, tablets or fragments with gloves from
             patient\'s mouth, as needed, without injuring oneself.

         II. Consult medical direction for administration of activated
             charcoal

         III. Bring all containers, bottles, labels, etc. of poison
              agents to receiving facility.

     III. Inhaled

          I.  Signs and symptoms

              I.  History of inhalation of toxic substance

              II. Difficulty breathing

              III. Chest pain

              IV. Cough

              V.  Hoarseness

              VI. Dizziness

              VII. Headache

              VIII. Confusion

              IX. Seizures

              X.  Altered mental status

          II. Emergency medical care

              I.  Have trained rescuers remove patient from poisonous
                  environment.

              II. Give oxygen, if not already done in the initial
                  assessment.

              III. Bring all containers, bottles, labels, etc. of poison
                   agents to receiving facility.

     IV. Toxic injection

         I.  Signs and symptoms

             I.  Weakness

             II. Dizziness

             III. Chills

             IV. Fever

             V.  Nausea

             VI. Vomiting

         II. Emergency medical care

             I.  Airway and oxygen.

             II. Be alert for vomiting.

             III. Bring all containers, bottles, labels, etc. of toxic
                  agents to receiving facility.

     V.  Absorbed

         I.  Signs and symptoms

             I.  History of exposure

             II. Liquid or powder on patient\'s skin

             III. Burns

             IV. Itching

             V.  Irritation

             VI. Redness

         II. Emergency medical care

             I.  Skin - remove contaminated clothing while protecting
                 oneself from contamination.

             II. Powder - brush powder off patient, then continue as for
                 other absorbed poisons.

             III. Liquid - irrigate with clean water for at least 20
                  minutes (and continue en route to facility if
                  possible).

             IV. Eye - irrigate with clean water away from affected eye
                 for at least 20 minutes and continue en route to
                 facility if possible.

VIII. **Behavioral Emergencies**

      I.  Assessment for Suicide Risk

          I.  Depression

              I.  Sad, tearful

              II. Thoughts of death or taking one\'s life

          II. Suicidal gestures - the EMT-Basic must recognize and
              intervene in self-destructive behavior before the patient
              commits the act of suicide. Risk factors may include:

              I.  Male, over 40, single, widowed or divorced, alcoholic,
                  depressed.

              II. A defined lethal plan of action which has been
                  verbalized.

              III. Unusual gathering of articles which can cause death
                   such as purchase of a gun, large volumes of pills,
                   etc.

              IV. Previous history of self-destructive behavior.

              V.  Recent diagnosis of serious illness.

              VI. Recent loss of significant loved one.

              VII. Arrest, imprisonment, loss of job

          III. Assessment findings

               I.  Patient in an unsafe environment or with unsafe
                   objects in hands.

               II. Displaying of self-destructive behavior during
                   initial assessment or prior to emergency response.

      II. Emergency medical care

          I.  Scene size-up, personal safety

          II. Patient assessment

          III. Calm the patient - do not leave patient alone

          IV. Restrain if necessary

          V.  Transport

          VI. If overdose, bring medications or drugs found to medical
              facility.

      III. Medical/Legal Considerations - Emotionally disturbed patient
           who consents to care - legal problems greatly reduced.

           I.  How to handle the patient who resists treatment

               I.  Emotionally disturbed patient will often resist
                   treatment.

               II. May threaten EMT-Basics and others

               III. To provide care against patient\'s will, you must
                    show a reasonable belief the patient would harm
                    himself or others.

               IV. If a threat to self or others, patient may be
                   transported without consent.

               V.  Usually law enforcement is required.

      IV. Avoiding unreasonable force

          I.  Reasonable force depends on what force was necessary to
              keep patient from injuring himself or others.

          II. Reasonableness is determined by looking at all
              circumstances involved.

              I.  Patients size and strength

              II. Type of abnormal behavior

              III. Sex of patient

              IV. Mental state of patient

              V.  Method of restraint

          III. Be aware after a period of combativeness and aggression
               some calm patients may cause unexpected and sudden injury
               to self and others.

          IV. Avoid acts or physical force that may cause injury to the
              patient.

          V.  EMS personnel may use reasonable force to defend against
              an attack by emotionally disturbed patients.

      V.  Police and medical direction involvement

          I.  Seek medical direction when considering restraining a
              patient.

          II. Ask for police assistance if during scene size-up the
              patient appears or acts aggressive or combative.

      VI. Protection against false accusations

          I.  Documentation of abnormal behavior exhibited by the
              patient is very important.

          II. Have witnesses in attendance especially during transport,
              if possible.

          III. Accusing EMT-Basics of sexual misconduct is common by
               emotionally disturbed patients - have help, same sex
               attendants, and third party witnesses.

      VII. Principles for Assessing Behavioral Emergency Patients

           I.  Identify yourself and let the person know you are there
               to help.

           II. Inform him of what you are doing.

           III. Ask questions in a calm, reassuring voice.

           IV. Allow the patient to tell what happened.

           V.  Show you are listening by rephrasing or repeating part of
               what is said.

           VI. Acknowledge the patient\'s feelings.

           VII. Assess the patient\'s mental status.

                I.  Appearance

                II. Activity

                III. Speech

                IV. Orientation for time, person, and place

      VIII. Assessment of Potential Violence

            I.  Scene size-up

            II. History - the EMT-Basic should check with family and
                bystanders to determine if the patient has a known
                history of aggression or combativeness.

            III. Posture - stands or sits in a position which threatens
                 self or others. May have fists clinched or lethal
                 objects in hands.

            IV. Vocal activity - is yelling or verbally threatens harm
                to self or others.

            V.  Physical activity - moves toward caregiver, carries
                heavy or threatening objects, has quick irregular
                movements, muscles tense.

      IX. Methods to Calm Behavioral Emergency Patients

          I.  Acknowledge that the person seems upset and restate that
              you are there to help.

          II. Inform him of what you are doing.

          III. Ask questions in a calm, reassuring voice.

          IV. Maintain a comfortable distance.

          V.  Encourage the patient to state what is troubling him.

          VI. Do not make quick moves.

          VII. Respond honestly to patient\'s questions.

          VIII. Do not threaten, challenge or argue with disturbed
                patients.

          IX. Tell the truth, do not lie to the patient.

          X.  Do not \"play along\" with visual or auditory disturbances
              of the patient.

          XI. Involve trusted family members or friends.

          XII. Be prepared to stay at scene for a long time. Always
               remain with the patient.

          XIII. Avoid unnecessary physical contact.

          XIV. Use good eye contact.

# APPLICATION

**[Procedural (How)]{.underline}**

1.  Demonstrate reading labels and inspecting each medication that will
    be carried on the unit or will be assisting the patient in self
    administering.

2.  Perform the steps in facilitating the use of nitroglycerin for chest
    pain using a substitute candy tablet and breath spray.

3.  Demonstrate application and operation of the automated external
    defibrillator including completion of the daily checklist

4.  Demonstrate the steps in the administration of oral glucose.

5.  Demonstrate the steps in the administration activated charcoal.

6.  Demonstrate the steps in the use of the epi-autoinjector.

7.  Demonstrate the steps in the use of a handheld inhaler.

8.  Demonstrate the steps in caring for a behavioral emergency.

**[Contextual (When, Where, Why)]{.underline}**

For years, the primary care provide by the EMT-Basic to the patient
experiencing a medical emergency was administration of oxygen and rapid
transportation to a treatment facility. While these interventions
continue to be critical to patient outcome, the EMT now has other
specific interventions that will assist in stabilizing the patient prior
to the patients arrival in the emergency department. The EMT-Basic may
now have activated charcoal, oral glucose, epinephrine, handheld
inhalers, nitroglycerin and automated defibrillators on the unit to
administer with medical direction approval.

**STUDENT ACTIVITIES**

**[Auditory (Hear)]{.underline}**

1.  Students should hear information on medications they will use on the
    EMS unit.

2.  Students should hear computer voice simulations made by automated
    external defibrillators giving instructions on protocols or shocks.

3.  Students should hear of actual cases where cardiac arrest
    resuscitation efforts were successful and unsuccessful and the
    reasons for the outcomes.

4.  Students should hear the steps required to appropriately administer
    epinephrine auto-injector, activated charcoal, oral glucose,
    handheld inhaler and nitroglycerin.

5.  Students should hear the various methods used to calm the behavioral
    emergency patient.

**[Visual (See)]{.underline}**

1.  Students should see a demonstration of the proper steps in assisting
    in the usage of handheld inhalers.

2.  Students should see an instructor team appropriately resuscitate a
    simulated cardiac arrest patient using an automated external
    defibrillator.

3.  Students should see re-enactments of cardiac arrest resuscitation
    efforts by EMT-Basics using automated external defibrillators.

4.  Students should see an instructor team appropriately administer a
    small candy or breath spray sublingually to a simulated patient
    presenting with chest pain.

5.  Students should see various methods to calm the behavioral emergency
    patient.

6.  Students should see the administration of oral glucose (as a
    simulated paste) to a simulated patient.

**[Visual (See)]{.underline}**

1.  Students should see the instructor demonstrate the appropriate steps
    in using an auto-injector.

2.  Students should see a demonstration of how to administer activated
    charcoal.

**[Kinesthetic (Do)]{.underline}**

1.  The student will practice inspecting and reading the labels of each
    type of medication they will use on the EMS unit.

2.  The student should practice assessment and management of adult,
    child and infant patients having a respiratory illness who have been
    prescribed a handheld inhaler by his physician.

3.  The student should practice the steps in facilitating the use of a
    handheld inhaler.

4.  The student should practice role play situations where use of
    handheld inhalers is appropriate and inappropriate.

5.  The student should practice the application and operation of the
    automated external defibrillator.

6.  The student should practice maintenance checks of the automated
    external defibrillator.

7.  The student should practice performing the steps in facilitating the
    use of nitroglycerin for chest pain using a suitable candy tablet
    and breath spray.

8.  The student should practice the assessment and documentation of
    patient response to the automated external defibrillator.

9.  The student should practice the assessment and documentation of
    patient response to nitroglycerin.

10. The student should practice assessment, defibrillation, airway
    management, lifting and moving a patient, and transportation out of
    the training laboratory of a manikin in a simulated cardiac arrest
    situation in which a patient does not respond to defibrillation.

11. The student will practice the steps in the administration of oral
    glucose.

12. The student should practice the correct way to use an epinephrine
    auto-injector.

**[Instructor Activities]{.underline}**

1.  Supervise student practice.

2.  Reinforce student progress in cognitive, affective, and psychomotor
    domains.

3.  Redirect students having difficulty in content.

# EVALUATION

Written: Develop evaluation instruments, e.g., quizzes, verbal reviews,
and handouts, to determine if the students have met the cognitive and
affective objectives of this lesson.

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

# REMEDIATION

> Identify students or groups of students who are having difficulty with
> this subject content.

# ENRICHMENT

> What is unique in the local area concerning this topic?
>
> **Emergency Medical Technician:**
>
> **Basic Refresher Curriculum**
>
> **Module V:**
>
> **Trauma**

# TASK LIST AND EDUCATIONAL OBJECTIVES

At the completion of this lesson, the student will be able to:

**[COGNITIVE OBJECTIVES]{.underline}**

1.  Provide care to a patient with shock (hypoperfusion)

-   State methods of emergency medical care of external bleeding.

-   List signs and symptoms of shock (hypoperfusion).

-   State the steps in the emergency medical care of the patient with
    signs and symptoms of shock (hypoperfusion).

1.  Provide care to a patient with suspected spinal injury

-   State the signs and symptoms of a potential spine injury.

-   Describe how to stabilize the spine.

1.  Provide care to a patient with a suspected head injury

-   Relate mechanism of injury to potential injuries of the head and
    spine.

1.  Provide care to a patient with a soft tissue injury

-   Describe the emergency medical care of the patient with a closed
    soft tissue injury.

-   Describe the emergency medical care of the patient with an open soft
    tissue injury.

1.  Perform a rapid extrication of a trauma patient

-   Describe the indications for the use of rapid extrication.

-   List steps in performing rapid extrication.

**[AFFECTIVE OBJECTIVES]{.underline}**

1.  Explain the sense of urgency to transport patients that are bleeding
    and show signs of hypoperfusion.

2.  Explain the rationale for splinting at the scene versus load and go.

3.  Explain the rationale for using rapid extrication approaches only
    when they will make the difference between life and death.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

1.  Demonstrate care of the patient experiencing external bleeding.

2.  Demonstrate care of the patient exhibiting signs and symptoms of
    shock (hypoperfusion.

3.  Demonstrate the steps in the care of open and closed soft tissue
    injuries. (chest injuries, abdominal injuries, burns and
    amputations).

4.  Demonstrate the steps in the care of a patient with a head or spine
    injury.

5.  Demonstrate the procedure for rapid extrication.

# PREPARATION

Motivation: Trauma is the leading cause of death in the United States
for persons between the ages of 1 and 44. Understanding the mechanism of
injury, relevant signs and symptoms and appropriate intervention
techniques is of paramount importance when dealing with the traumatized
patient.

**MATERIALS**

AV Equipment: Utilize various audio-visual materials relating to
bleeding and shock (hypoperfusion). The continuous design and
development of new audio-visual materials relating to EMS requires
careful review to determine which best meet the needs of the program.
Materials should be edited to assure meeting the objectives of the
curriculum.

EMS Equipment: Sterile dressings, bandages, splints, pneumatic
anti-shock garment, triangular bandage, stick or rod, air splints,
gloves, eye protection, blanket, universal dressing, occlusive dressing,
roller bandages, 4 x 4 gauze pads, burn sheets, sterile water or saline.

**PERSONNEL**

Primary Instructor: One EMT-Basic instructor knowledgeable in assessment
and management of the trauma patient.

Assistant Instructor: The instructor to student ratio should be adequate
to allow for supervision of psychomotor skill practice. Individuals used
as assistant instructors should be knowledgeable in assessment and
management of the trauma patient.

# PRESENTATION

**[Declarative (What)]{.underline}**

I.  **Shock** (hypoperfusion syndrome)

    I.  Severity

        I.  Shock (hypoperfusion) results in inadequate perfusion of
            cells with oxygen and nutrients and inadequate removal of
            metabolic waste products.

        II. Cell and organ malfunction and death can result from shock
            (hypoperfusion); therefore, prompt recognition and treatment
            is vital to patient survival.

        III. Peripheral perfusion is drastically reduced due to the
             reduction in circulating blood volume.

        IV. Trauma patients develop shock (hypoperfusion) from the loss
            of blood from both internal and external sites. This type of
            shock (hypoperfusion) is referred to as hypovolemic or
            hemorrhagic shock.

    II. Signs and symptoms of shock (hypoperfusion)

        I.  Mental states

            I.  Restlessness

            II. Anxiety

            III. Altered mental status

        II. Peripheral perfusion

            I.  Delayed capillary refill greater than 2 seconds in
                normal ambient air temperature - infant and child
                patients only

            II. Weak, thready or absent peripheral pulses

            III. Pale, cool, clammy skin

        III. Vital signs

             I.  Decreased blood pressure (late sign)

             II. Increased pulse rate (early sign) - weak and thready

             III. Increased breathing rate

                  I.  Shallow

                  II. Labored

                  III. Irregular

        IV. Other signs and symptoms

            I.  Dilated pupils

            II. Thirst

            III. Nausea and vomiting

            IV. Pallor with cyanosis to the lips

        V.  Infant and child patients can maintain their blood pressure
            until their blood volume is more than half gone, so by the
            time their blood pressure drops they are close to death. The
            infant or child in shock has less reserve.

    III. Emergency medical care

         I.  Body substance isolation.

         II. Maintain airway/artificial ventilation. Administer oxygen
             if indicated.

         III. Control any external bleeding.

              I.  Apply finger tip pressure directly on the point of
                  bleeding.

              II. Elevation of a bleeding extremity may be used
                  secondary to and in conjunction with direct pressure.

              III. Large gaping wounds may require packing with sterile
                   gauze and direct hand pressure if direct finger tip
                   pressure fails to control bleeding.

              IV. If bleeding does not stop or soaks through the
                  dressing, apply additional pressure to site.

              V.  Pressure points may be used in upper and lower
                  extremities.

         IV. If signs of shock (hypoperfusion) are present and the lower
             abdomen is tender and pelvic injury is suspected, with no
             evidence of chest injury, apply and inflate the pneumatic
             anti-shock garment if approved by medical direction.

         V.  Elevate the lower extremities approximately 8 to 12 inches.
             If the patient has serious injuries to the pelvis, lower
             extremities, head, chest, abdomen, neck, or spine, keep the
             patient supine.

         VI. Splint any suspected bone or joint injuries.

         VII. Prevent loss of body heat by covering the patient with a
              blanket when appropriate.

         VIII. Immediate transport.

II. **Emergency medical care of an open chest wound**

    I.  Occlusive dressing to open wound

    II. Administer oxygen if not already done

    III. Position of comfort if no spinal injury suspected

III. **Emergency medical care for an open abdominal injury**

     I.  Do not touch or try to replace the exposed organ.

     II. Cover exposed organs and wound with a sterile dressing,
         moistened with sterile water or saline, and secure in place.

     III. Flex the patient\'s hips and knees, if uninjured.

IV. **Emergency medical care of amputations**

    I.  Wrap the amputated part in a sterile dressing.

    II. Wrap or bag the amputated part in plastic and keep cool.

    III. Transport the amputated part with the patient.

    IV. Do not complete partial amputations, immobilize to prevent
        further injury.

V.  **Emergency medical care of burns**

    I.  Stop the burning process, initially with water or saline.

    II. Remove smoldering clothing and jewelry.

    III. Body substance isolation

    IV. Continually monitor the airway for evidence of closure.

    V.  Prevent further contamination.

    VI. Cover the burned area with a dry sterile dressing.

    VII. Do not use any type of ointment, lotion or antiseptic.

    VIII. Do not break blisters.

    IX. Transport.

    X.  Know local protocols for transport to appropriate local
        facility.

VI. **Injuries to bones and joints**

    I.  Signs and symptoms

        I.  Deformity or angulated

        II. Pain and tenderness

        III. Grating

        IV. Swelling

        V.  Bruising (discoloration)

        VI. Exposed bone ends

        VII. Joint locked into position

    II. Emergency medical care of bone or joint injuries

        I.  Body substance isolation

        II. Administer oxygen if indicated.

        III. After life threats have been controlled, splint injuries in
             preparation for transport.

        IV. Application of cold pack to area of painful, swollen,
            deformed extremity to reduce swelling.

        V.  Elevate the extremity.

    III. General rules of splinting

         I.  Assess pulse, movement, and sensation distal to the injury
             prior to and following splint application and record.

         II. Immobilize the joint above and below the injury.

         III. Remove or cut away clothing.

         IV. Cover open wounds with a sterile dressing.

         V.  Align with gentle traction before splinting if there is a
             severe deformity or the distal extremity is cyanotic or
             lacks pulses.

         VI. Do not intentionally replace the protruding bones.

         VII. Pad each splint to prevent pressure and discomfort to the
              patient.

         VIII. Splint the patient before moving.

         IX. When in doubt, splint the injury.

         X.  If patient has signs of shock (hypoperfusion), align in
             normal anatomical position and transport.

VII. **Head and Spine Injuries**

     I.  Mechanism of injury with a high index of suspicion

     II. Signs and symptoms of Head and Spine injuries

         I.  Tenderness in the area of injury

         II. Pain associated with moving

             I.  Do not ask the patient to move to try to elicit a pain
                 response.

             II. Do not move the patient to test for a pain response.

         III. Pain independent of movement or palpation

              I.  Along spinal column

              II. Lower legs

              III. May be intermittent

         IV. Obvious deformity of the spine upon palpation

         V.  Soft tissue injuries associated with trauma

             I.  Head and neck to cervical spine

             II. Shoulders, back or abdomen - thoracic, lumbar

             III. Lower extremities - lumbar, sacral

         VI. Numbness, weakness or tingling in the extremities

         VII. Loss of sensation or paralysis below the suspected level
              of injury

         VIII. Loss of sensation or paralysis in the upper or lower
               extremities

         IX. Incontinence

     III. Assessing the potential spine injured patient

          I.  Responsive patient

              I.  Mechanism of injury

              II. Questions to ask (ensure patient does not move while
                  answering the questions)

                  I.  Does your neck or back hurt?

                  II. What happened?

                  III. Where does it hurt?

                  IV. Can you move your hands and feet?

                  V.  Can you feel me touching your fingers?

                  VI. Can you feel me touching your toes?

              III. Inspect for contusions, deformities, lacerations,
                   punctures, penetrations, swelling.

              IV. Palpate for areas of tenderness or deformity.

              V.  Assess equality of strength of extremities

                  I.  Hand grip

                  II. Gently push feet against hands

          II. Unresponsive patient

              I.  Mechanism of injury

              II. Initial assessment

              III. Inspect for:

                   I.  Contusions

                   II. Deformities

                   III. Lacerations

                   IV. Punctures/penetrations

                   V.  Swelling

              IV. Palpate for areas of tenderness or deformity.

              V.  Obtain information from others at the scene to
                  determine information relevant to mechanism of injury
                  or patient mental status prior to the EMT-B\'s
                  arrival.

          III. Emergency Medical Care

               I.  Immobilization

               II. Oxygenation

               III. Transportation

     IV. Skull injury - signs and symptoms

         I.  Mechanism of trauma

         II. Contusions, lacerations, hematomas to the scalp

         III. Deformity to the skull

         IV. Blood or fluid (cerebrospinal fluid) leakage from the ears
             or nose

         V.  Bruising (discoloration) around the eyes

         VI. Bruising (discoloration) behind the ears (mastoid process)

         VII. Closed head injury

              I.  Traumatic

              II. Signs and symptoms

                  I.  Altered or decreasing mental status is the best
                      indicator of a brain injury.

                      I.  Confusion, disorientation, or repetitive
                          questioning

                      II. Conscious - deteriorating mental status

                      III. Unresponsive

                  II. Irregular breathing pattern

                  III. Consideration of mechanism of injury

                       I.  Deformity of windshield

                       II. Deformity of helmet

                  IV. Contusions, lacerations, hematomas to the scalp

                  V.  Deformity to the skull

                  VI. Blood or fluid (cerebrospinal fluid) leakage from
                      the ears and nose

                  VII. Bruising (discoloration) around the eyes

                  VIII. Bruising (discoloration) behind the ears
                        (mastoid process)

                  IX. Neurologic disability

                  X.  Nausea and/or vomiting

                  XI. Unequal pupil size with altered mental status

                  XII. Seizure activity may be seen.

         VIII. Open head injury

               I.  Signs and symptoms

                   I.  Consideration of mechanism of injury

                       I.  Deformity of windshield

                       II. Deformity of helmet

                   II. Contusions, lacerations, hematomas to the scalp

                   III. Deformity to the skull

                   IV. Penetrating injury - do not remove impaled
                       objects in the skull

                   V.  Soft area or depression upon palpation

                   VI. Exposed brain tissue

                   VII. Bleeding from the open bone injury

                   VIII. Blood or fluid (cerebrospinal fluid) leakage
                         from the ears and nose

                   IX. Bruising (discoloration) around the eyes

                   X.  Bruising (discoloration) behind the ears (mastoid
                       process)

                   XI. Nausea and/or vomiting

                   XII. Possible signs and symptoms of a closed head
                        injury may exist if brain injury has occurred.

         IX. Emergency medical care

             I.  Body substance isolation

             II. Maintain airway/artificial ventilation/oxygenation.

             III. Initial assessment with spinal immobilization should
                  be done on scene with a complete detailed physical
                  exam en route.

             IV. With any head injury, the EMT-Basic must suspect spinal
                 injury. Immobilize the spine.

             V.  Closely monitor the airway, breathing, pulse, and
                 mental status for deterioration.

             VI. Control bleeding.

                 I.  Do not apply pressure to an open or depressed skull
                     injury.

                 II. Dress and bandage open wound as indicated in the
                     treatment of soft tissue injuries.

             VII. If a medical injury or non-traumatic injury exist,
                  place patient on the left side.

             VIII. Be prepared for changes in patient condition.

             IX. Immediately transport the patient.

VIII. **Rapid Extrication**

      I.  Indications

          I.  Unsafe scene

          II. Unstable patient condition warrants immediate movement and
              transport.

          III. Patient blocks the EMT-B\'s access to another, more
               seriously injured, patient.

          IV. Rapid extrication is based on time and the patient, and
              not the EMT-B\'s preference.

      II. Procedure

          I.  One EMT-Basic gets behind patient and brings cervical
              spine into neutral in-line position and provides manual
              immobilization.

          II. A second EMT-Basic applies cervical immobilization device
              as the third EMT-Basic first places long backboard near
              the door and then moves to the passenger seat.

          III. The second EMT-Basic supports the thorax as the third
               EMT-Basic frees the patient\'s legs from the pedals.

          IV. At the direction of the second EMT-Basic, he and the third
              EMT-Basic rotate the patient in several short, coordinated
              moves until the patient\'s back is in the open doorway and
              his feet are on the passenger seat.

          V.  Since the first EMT-Basic usually cannot support the
              patient\'s head any longer, another available EMT-Basic or
              a bystander supports the patient\'s head as the first
              EMT-Basic gets out of the vehicle and takes support of the
              head outside of the vehicle.

          VI. The end of the long backboard is placed on the seat next
              to the patient\'s buttocks. Assistants support the other
              end of the board as the first EMT-Basic and the second
              EMT-Basic lower the patient onto it.

          VII. The second EMT-Basic and the third EMT-Basic slide the
               patient into the proper position on the board in short,
               coordinated moves.

          VIII. Several variations of the technique are possible,
                including assistance from bystanders. Must be
                accomplished without compromise to the spine.

# APPLICATION

**[Procedural (How)]{.underline}**

1.  Review methods to control external bleeding.

2.  Review methods used to treat the patient in shock (hypoperfusion).

3.  Demonstrate the steps in the care of open and closed soft tissue
    injuries. (chest injuries, abdominal injuries, burns and
    amputations).

4.  Demonstrate the steps in the care of a patient with a head or spine
    injury.

5.  Demonstrate the procedure for rapid extrication.

**[Contextual (When, Where, Why)]{.underline}**

The EMT-Basics will respond to various traumatic emergencies during a
career in EMS. Their ability to quickly control bleeding and recognize
and treat shock are critical to the life of the patient. Failure to
proper immobilize a bone or joint injury can result in damage to soft
tissue, organs, nerves and blood vessels. Failure to recognize the
possibility of a head or spine injury will lead to an increased patient
morbidity and mortality.

**STUDENT ACTIVITIES**

**[Auditory (Hear)]{.underline}**

1.  Students should hear simulated situations to identify signs and
    symptoms of external bleeding, internal bleeding and shock
    (hypoperfusion).

2.  Students should hear simulations of various situations involving
    musculoskeletal injuries and the proper assessment and intervention.

**[Visual (See)]{.underline}**

1.  Students should see audio-visual aids or materials of the proper
    methods to control external bleeding and treat for shock
    (hypoperfusion).

2.  Students should see demonstrations for the proper method of managing
    an open chest wound.

3.  Students should see demonstrations for the proper method of managing
    an open abdominal injury.

4.  Students should see audio-visual aids or materials which illustrate
    superficial, partial thickness and full thickness burns.

5.  Students should see demonstrations for the proper management of
    burns.

6.  Students should see demonstrations for the proper immobilization of
    a painful, swollen, deformed extremity.

7.  Students should see the demonstrations of proper assessment and
    management of patients who have experienced head and spine injuries.

8.  Students should see audio-visual aids or materials illustrating
    situations that would require the use of rapid extrication.

**[Kinesthetic (Do)]{.underline}**

1.  Students should practice the management of patients with external
    bleeding, internal bleeding and shock.

2.  Students should practice the care of patients with open and closed
    soft tissue injuries (chest injuries, abdominal injuries, burns and
    amputations).

3.  Students should practice the management of an injured extremity.

4.  Students should practice the assessment and management of a patient
    who has experienced a head or spine injury.

5.  Students should practice performing a rapid extrication.

**[Instructor Activities]{.underline}**

1.  Supervise student practice.

2.  Reinforce student progress in cognitive, affective, and psychomotor
    domains.

3.  Redirect students having difficulty in content.

# EVALUATION

Written: Develop evaluation instruments, e.g., quizzes, verbal reviews,
handouts, to determine if the students have met the cognitive and
affective objectives of this lesson.

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

# REMEDIATION

> Identify students or groups of students who are having difficulty with
> this subject content.

# ENRICHMENT

> What is unique in the local area concerning this topic?

**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Module VI:**

**Obstetrics, Infants, and Children**

# TASK LIST AND EDUCATIONAL OBJECTIVES

At the completion of this lesson, the student will be able to:

**[COGNITIVE OBJECTIVE]{.underline}**

1.  Assess and provide care to the obstetric patient

2.  Assist with the delivery of an infant

3.  Assess and provide care to the newborn

4.  Assess and provide care to the mother immediately following delivery
    of a newborn

-   Identify pre-delivery emergencies.

-   State the steps to assist in the delivery.

-   Discuss the steps in the delivery of the placenta.

-   List the steps in the emergency medical care of the mother
    post-delivery.

-   Summarize neonatal resuscitation procedures.

-   Describe the procedures for the following abnormal deliveries

1.  Assess and provide care to an ill or injured infant or child with:

-   Respiratory distress

-   Shock (hypoperfusion)

-   Cardiac Arrest

-   Seizures

-   Trauma

**[AFFECTIVE OBJECTIVES]{.underline}**

1.  Explain the rationale for having knowledge and skills appropriate
    for managing infant and child patients.

2.  Understand the provider\'s own response (emotional) to caring for
    infants and children.

**[PSYCHOMOTOR OBJECTIVE]{.underline}**

1.  Demonstrate steps to assist in the normal cephalic delivery.

2.  Demonstrate post delivery care of the infant.

3.  Demonstrate post delivery care of the mother.

# PREPARATION

Motivation: Infant and child patients, as well as expectant mothers,
often cause anxiety for the prehospital care provider. This is caused by
a lack of dealing with this special population as well as a fear of
failure. Understanding the special factors involved, such as body size,
developmental considerations and normal ranged vital signs of infant and
child patients is important in their emergency medical care.

**MATERIALS**

AV Equipment: Utilize various audio-visual materials relating to infants
and children. The continuous design and development of new audio-visual
materials relating to EMS requires careful review to determine which
best meet the needs of the program. Materials should be edited to assure
meeting the objectives of the curriculum.

EMS Equipment: Exam gloves, stethoscope, blood pressure cuff, penlight.

**PERSONNEL**

Primary Instructor: One EMT-Basic instructor, knowledgeable with
childbirth, infants and children.

Assistant Instructor: The instructor to student ratio should be adequate
to allow for supervision of psychomotor skill practice. Individuals used
as assistant instructors should be knowledgeable in infant and child
emergencies.

# PREPARATION

**[Declarative (What)]{.underline}**

I.  **Normal Delivery**

    I.  Pre-delivery considerations

        I.  It is best to transport an expecting mother, unless delivery
            is expected within a few minutes.

        II. Questions to ask

            I.  Are you pregnant?

            II. How long have you been pregnant?

            III. Are there any contractions or pain?

            IV. Any bleeding or discharge?

            V.  Is crowning occurring with contractions?

            VI. What is the frequency and duration of contractions?

            VII. Does she feel as if she is having a bowel movement with
                 increasing pressure in the vaginal area?

            VIII. Does she feel the need to push?

            IX. Rock hard abdomen?

    II. Precautions

        I.  Use body substance isolation.

        II. Do not touch vaginal areas except during delivery and when
            your partner is present.

        III. Do not let the mother go to bathroom.

        IV. Do not hold mother\'s legs together.

        V.  Recognize your own limitations and transport even if
            delivery must occur during transport.

        VI. If you have committed to deliver a newborn and then delivery
            does not occur within 10 minutes - transport.

    III. Delivery procedures

         I.  Apply gloves, mask, gown, eye protection for infection
             control precautions.

         II. Have mother lie with knees drawn up and spread apart.

         III. Elevate buttocks - with blankets or pillow.

         IV. Create sterile field around vaginal opening with sterile
             towels or paper barriers.

         V.  When the infant\'s head appears during crowning, place
             fingers on bony part of skull (not fontanelle or face) and
             exert very gentle pressure to prevent explosive delivery.
             Use caution to avoid fontanelle.

         VI. If the amniotic sac does not break, or has not broken, use
             a clamp to puncture the sac and push it away from the
             infant\'s head and mouth as they appear.

         VII. As the infant\'s head is being born, determine if the
              umbilical cord is around the infant\'s neck; slip over the
              shoulder or clamp, cut and unwrap.

         VIII. After the infant\'s head is born, support the head,
               suction the mouth two or three times and the nostrils.
               Use caution to avoid contact with the back of the mouth.

         IX. As the torso and full body are born, support the infant
             with both hands.

         X.  As the feet are born, grasp the feet.

         XI. Wipe blood and mucus from mouth and nose with sterile
             gauze, suction mouth and nose again.

         XII. Wrap infant in a warm blanket and place on its side, head
              slightly lower than trunk.

         XIII. Keep infant level with vagina until the cord is cut.

         XIV. Assign partner to monitor infant and complete initial care
              of the newborn.

         XV. Clamp, tie and cut umbilical cord (between the clamps) as
             pulsations cease approximately 4 fingers width from infant.

         XVI. Observe for delivery of placenta while preparing mother
              and infant for transport.

         XVII. When delivered, wrap placenta in towel and put in plastic
               bag; transport placenta to hospital with mother.

         XVIII. Place sterile pad over vaginal opening, lower mother\'s
                legs, help her hold them together.

         XIX. Record time of delivery and transport mother, infant and
              placenta to hospital.

    IV. Vaginal bleeding following delivery - up to 500 cc of blood loss
        is normal following delivery.

        I.  A 500 cc blood loss is well tolerated by the mother
            following delivery. The EMT-Basic must be aware of this loss
            so as not to cause undue psychological stress on himself or
            the new mother.

        II. With excessive blood loss, massage the uterus.

            I.  Hand with fingers fully extended.

            II. Place on lower abdomen above pubis.

            III. Massage (knead) over area.

            IV. Bleeding continues - check massage technique and
                transport immediately, providing oxygen and ongoing
                assessment.

        III. Regardless of estimated blood loss, if mother appears in
             shock (hypoperfusion), treat as such and transport prior to
             uterine massage. Massage en route.

    V.  Initial care of the newborn

        I.  Position, dry, wipe, and wrap newborn in blanket and cover
            the head.

        II. Repeat suctioning.

        III. Assessment of infant

             I.  Appearance - color: no central (trunk) cyanosis

             II. Pulse - greater than 100/min

             III. Grimace

             IV. Activity

             V.  Breathing effort

        IV. Stimulate newborn if not breathing.

            I.  Flick soles of feet.

            II. Rub infant\'s back.

    VI. Resuscitation of the newborn follows the inverted pyramid -
        after assessment, if signs and symptoms require either cardiac
        or pulmonary resuscitation, do the following when appropriate:

        I.  Breathing effort - if shallow, slow or absent provide
            artificial ventilations:

            I.  60/min

            II. Reassess after 30 seconds.

            III. If no improvement, continue artificial ventilations and
                 reassessments.

        II. Heart rate

            I.  If less than 100 beats per minute provide artificial
                ventilations:

                I.  60/min

                II. Reassess after 30 seconds.

                III. If no improvement continue artificial ventilations
                     and reassessments.

            II. If less than 80 beats per minute and not responding to
                bag-valve-mask, start chest compressions.

            III. If less than 60 beats per minute, start compressions
                 and artificial ventilations.

        III. Color - if central cyanosis is present with spontaneous
             breathing and an adequate heart rate administer free flow
             oxygen - administer oxygen (10-15 lpm) using oxygen tubing
             held as close as possible to the newborns face.

II. **Abnormal Deliveries**

    I.  Prolapsed Cord - condition where the cord presents through the
        birth canal before delivery of the head; presents a serious
        emergency which endangers the life of the unborn fetus.

        I.  Size up

        II. Initial assessment

        III. Mother should have high flow oxygen.

        IV. History and physical exam

        V.  Assess baseline vitals.

        VI. Treatment based on signs and symptoms.

        VII. Position mother with head down or buttocks raised using
             gravity to lessen pressure in birth canal.

        VIII. Insert sterile gloved hand into vagina pushing the
              presenting part of the fetus away from the pulsating cord.

        IX. Rapidly transport, keeping pressure on presenting part and
            monitoring pulsations in the cord.

    II. Breech birth presentation - breech presentation occurs when the
        buttocks or lower extremities are low in the uterus and will be
        the first part of the fetus delivered.

        I.  Newborn at great risk for delivery trauma, prolapsed cord
            more common, transport immediately upon recognition of
            breech presentation.

        II. Delivery does not occur within 10 minutes.

        III. Emergency medical care

             I.  Immediate rapid transportation upon recognition.

             II. Place mother on oxygen.

             III. Place mother in head down position with pelvis
                  elevated.

    III. Limb presentation - occurs when a limb of the infant protrudes
         from the birth canal. Is more commonly a foot when infant is in
         breech presentation.

         I.  Immediate rapid transportation upon recognition.

         II. Place mother on oxygen.

         III. Place mother in head down position with pelvis elevated.

    IV. Multiple births

        I.  Be prepared for more than one resuscitation.

        II. Call for assistance.

    V.  Meconium - amniotic fluid that is greenish or brownish-yellow
        rather than clear; an indication of possible fetal distress
        during labor.

        I.  Do not stimulate before suctioning oropharynx.

        II. Suction.

        III. Maintain airway.

        IV. Transport as soon as possible.

    VI. Premature

        I.  Always at risk for hypothermia.

        II. Usually requires resuscitation.

III. **Medical Problems in Infants and Children**

     I.  Airway obstructions

         I.  Partial airway obstruction - infant or child who is alert
             and sitting.

             I.  Stridor, crowing, or noisy

             II. Retractions on inspiration

             III. Pink

             IV. Good peripheral perfusion

             V.  Still alert, not unconscious.

         II. Emergency medical care

             I.  Allow position of comfort, assist younger child to sit
                 up, do not lay down. May sit on parents lap.

             II. Offer oxygen

             III. Transport

             IV. Do not agitate child

             V.  Limited exam. Do not assess blood pressure.

     II. Complete obstruction and altered mental status or cyanosis and
         partial obstruction.

         I.  No crying or speaking and cyanosis.

             I.  Child\'s cough becomes ineffective

             II. Increased respiratory difficulty accompanied by stridor

             III. Victim loses consciousness

             IV. Altered mental status

         II. Clear airway.

             I.  Infant foreign body procedures.

             II. Child foreign body procedures.

         III. Attempt artificial ventilations with a bag-valve-mask and
              good seal.

     III. Respiratory emergencies

          I.  Recognize difference between upper airway obstruction and
              lower airway disease

              I.  Upper airway obstruction - stridor on inspiration

              II. Lower airway disease

                  I.  Wheezing and breathing effort on exhalation

                  II. Rapid breathing (tachypnea) without stridor

          II. Complete airway obstruction

              I.  No crying.

              II. No speaking.

              III. Cyanosis is present.

              IV. No coughing

          III. Recognize signs of increased effort of breathing

               I.  Early respiratory distress

                   I.  Nasal Flaring

                   II. Intercostal retraction (neck muscles),
                       supraclavicular, subcostal retractions

                   III. Stridor

                   IV. Abdominal muscles

                   V.  Audible wheezing

                   VI. Grunting

               II. The presence of signs and symptoms of early
                   respiratory distress and any of the following:

                   I.  rate \> 60

                   II. Cyanosis

                   III. Decreased muscle tone

                   IV. Severe use of accessory muscles

                   V.  Poor peripheral perfusion

                   VI. Altered mental status

                   VII. Grunting

               III. Respiratory arrest

                    I.  Breathing rate less than 10 per minute

                    II. Limp muscle tone

                    III. Unconsciousness

                    IV. Slower, absent heart rate

                    V.  Weak or absent distal pulse.

          IV. Emergency medical care

              I.  Provide oxygen to all children with respiratory
                  distress.

              II. Provide oxygen and assist with artificial ventilations
                  for severe respiratory distress.

                  I.  Respiratory distress and altered mental status

                  II. Presence of cyanosis with oxygen

                  III. Respiratory distress with poor muscle tone

                  IV. Respiratory failure

              III. Provide oxygen and ventilate with bag-valve-mask for
                   respiratory arrest.

     IV. Cardiac arrest

         I.  Steps of child CPR

             I.  **Refer to current American Heart Association
                 Guidelines for CPR**

         II. Steps of infant CPR

             I.  **Refer to current American Heart Association
                 Guidelines for CPR**

     V.  Seizures

         I.  May be brief or prolonged.

         II. Assess for presence of injuries which may have occurred
             during seizures.

         III. Caused by fever, infections, poisoning, hypoglycemia,
              trauma, decreased levels of oxygen, head injury or could
              be idiopathic in children.

         IV. History of seizures. Ask the following:

             I.  Has the child had prior seizure(s)?

             II. If yes, is this the child\'s normal seizure pattern?

             III. Has the child taken his anti-seizure medications?

         V.  Emergency medical care

             I.  Assure patency of airway

             II. Position patient on side if no possibility of cervical
                 spine trauma.

             III. Have suction ready.

             IV. Provide oxygen and if in respiratory arrest or severe
                 respiratory distress, assure airway position and
                 patency and ventilate with bag-valve-mask.

             V.  Transport. Although brief seizures are not harmful,
                 there may be a more dangerous underlying condition.

         VI. Inadequate breathing and/or altered mental status may occur
             following a seizure.

     VI. Shock (hypoperfusion)

         I.  Rarely a primary cardiac event.

         II. Common causes

             I.  Diarrhea and dehydration

             II. Trauma

             III. Vomiting

             IV. Blood loss

             V.  Infection

             VI. Abdominal injuries

         III. Signs and symptoms

              I.  Mental status changes

              II. Rapid respiratory rate

              III. Pale, cool, clammy skin

              IV. Weak or absent peripheral pulses

              V.  Delayed capillary refill

              VI. Decreased urine output. Measured by asking parents
                  about diaper wetting and looking at diaper.

              VII. Absence of tears, even when crying

         IV. Emergency medical care

             I.  Assure airway/oxygen.

             II. Be prepared to artificially ventilate.

             III. Manage bleeding if present.

             IV. Elevate legs.

             V.  Keep warm.

             VI. Transport. Note need for rapid transport of infant and
                 child patients with further physical exam completed en
                 route, if time permits.

IV. **Trauma in children**

    I.  Injuries are the number one cause of death in infants and
        children.

    II. Blunt injury is most common.

        I.  The pattern of injury will be different from adults.

            I.  Motor vehicle crashes

                I.  Motor vehicle passengers

                    I.  Unrestrained passengers have head and neck
                        injuries.

                    II. Restrained passengers have abdominal and lower
                        spine injuries.

            II. Struck while riding bicycle - head injury, spinal
                injury, abdominal injury

            III. Pedestrian struck by vehicle - abdominal injury with
                 internal bleeding, possible painful, swollen, deformed
                 thigh, head injury.

        II. Falls from height, diving into shallow water - head and neck
            injuries

        III. Burns

        IV. Sports injuries - head and neck

        V.  Child abuse

    III. Specific body systems

         I.  Head

             I.  The single most important maneuver is to assure an open
                 airway by means of a modified jaw thrust.

             II. Children are likely to sustain head injury along with
                 internal injuries. Signs and symptoms of shock
                 (hypoperfusion) with a head injury should cause you to
                 be suspicious of other possible injuries.

             III. Respiratory arrest is common secondary to head
                  injuries and may occur during transport.

             IV. Common signs and symptoms are nausea and vomiting.

             V.  Most common cause of hypoxia in the unconscious head
                 injury patient is the tongue obstructing the airway.
                 Jaw-thrust is critically important.

             VI. Do not use sandbags to stabilize the head because the
                 weight on child\'s head may cause injury if the board
                 needs to be turned for emesis.

         II. Chest

             I.  Children have very soft pliable ribs.

             II. There may be significant injuries without external
                 signs.

         III. Abdomen

              I.  More common site of injury in children than adults.

              II. Often a source of hidden injury.

              III. Always consider abdominal injury in the multiple
                   trauma patient who is deteriorating without external
                   signs.

              IV. Air in stomach can distend abdomen, interfere with
                  artificial ventilation efforts.

         IV. Extremities - extremity injuries are managed in the same
             manner as adults.

# APPLICATION

**[Procedural (How)]{.underline}**

1.  Review the steps to assist in the normal delivery of an infant.

2.  Review the steps in the post delivery care of the infant and the
    mother.

3.  Review the proper assessment of the infant and child.

**[Contextual (When, Where, Why)]{.underline}**

> Care of expectant mothers, infants and children often causes fear and
> anxiety to the prehospital care provider. Due to this fear and anxiety
> and the relative infrequency in which these individuals request help
> from prehospital care providers, it is essential that the EMT-Basic
> become familiar with the needs of these special populations.

**STUDENT ACTIVITIES**

**[Auditory (Hear)]{.underline}**

1.  Students should hear audio tape of a mother in final stages of
    labor.

**[Visual (See)]{.underline}**

1.  Students should see visual aids or materials of infant and child
    patients with common medical or traumatic complaints.

2.  Students should see various infant or child equipment.

3.  Students should see audio-visual aids or materials illustrating
    normal and abnormal delivery of an infant.

**[Kinesthetic (Do)]{.underline}**

1.  Students should practice post delivery care of the infant and the
    mother

2.  Students should practice using various infant and child devices that
    are available in the area.

**[Instructor Activities]{.underline}**

1.  Supervise student practice.

2.  Reinforce student progress in cognitive, affective, and psychomotor
    domains.

3.  Redirect students having difficulty in content

# EVALUATION

Written: Develop evaluation instruments, e.g., quizzes, verbal reviews,
handouts, to determine if the students have met the cognitive and
affective objectives of this lesson.

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

# REMEDIATION

> Identify students or groups of students who are having difficulty with
> this subject content.

# ENRICHMENT

> What is unique in the local area concerning this topic?

**Emergency Medical Technician:**

**Basic Refresher Curriculum**

**Appendix A:**

**USDOT Curriculum Objectives:**

**EMT-Basic**

# APPENDIX A

The following are the objectives from the entire EMT-Basic National
Standard Curriculum. These were obtained by compiling the cognitive,
affective and psychomotor objectives from each lesson and reflect the
minimum scope of practice for the EMT-Basic.

**OBJECTIVES LEGEND**

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

**MODULE 1: PREPARATORY**

**LESSON 1-1: INTRODUCTION TO EMERGENCY MEDICAL CARE**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-1.1 Define Emergency Medical Services (EMS) systems. (C-1)
>
> 1-1.2 Differentiate the roles and responsibilities of the EMT-Basic
> from other prehospital care providers. (C-3)
>
> 1-1.3 Describe the roles and responsibilities related to personal
> safety. (C-1)
>
> 1-1.4 Discuss the roles and responsibilities of the EMT-Basic towards
> the safety of the crew, the patient and bystanders. (C-1)
>
> 1-1.5 Define quality improvement and discuss the EMT-Basic\'s role in
> the process. (C-1)
>
> 1-1.6 Define medical direction and discuss the EMT-Basic\'s role in
> the process. (C-1)
>
> 1-1.7 State the specific statutes and regulations in your state
> regarding the EMS system. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-1.8 Assess areas of personal attitude and conduct of the EMT‑Basic.
> (A-3)
>
> 1-1.9 Characterize the various methods used to access the EMS system
> in your community. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> No psychomotor objectives identified.

**LESSON 1-2: WELL-BEING OF THE EMT-BASIC**

**[COGNITIVE OBJECTIVES]{.underline}**

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

-   Hazardous materials

-   Rescue operations

-   Violent scenes

-   Crime scenes

-   Exposure to bloodborne pathogens

-   Exposure to airborne pathogens

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-2.11 Explain the rationale for serving as an advocate for the use of
> appropriate protective equipment. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> 1-2.12 Given a scenario with potential infectious exposure, the
> EMT-Basic will use appropriate personal protective equipment. At the
> completion of the scenario, the EMT-Basic will properly remove and
> discard the protective garments. (P-1,2)
>
> 1-2.13 Given the above scenario, the EMT-Basic will complete
> disinfection/cleaning and all reporting documentation. (P-1,2)

**LESSON 1-3: MEDICAL/LEGAL AND ETHICAL ISSUES**

**[COGNITIVE OBJECTIVES]{.underline}**

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

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-3.13 Explain the role of EMS and the EMT-Basic regarding patients
> with DNR orders. (A-3)
>
> 1-3.14 Explain the rationale for the needs, benefits and usage of
> advance directives. (A-3)
>
> 1-3.15 Explain the rationale for the concept of varying degrees of
> DNR. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> No psychomotor objectives identified.

**LESSON 1-4: THE HUMAN BODY**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-4.1 Identify the following topographic terms: medial, lateral,
> proximal, distal, superior, inferior, anterior, posterior, midline,
> right and left, mid-clavicular, bilateral, mid-axillary. (C-1)
>
> 1-4.2 Describe the anatomy and function of the following major body
> systems: Respiratory, circulatory, musculoskeletal, nervous and
> endocrine. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> No affective objectives identified.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> No psychomotor objectives identified.

**LESSON 1-5: BASELINE VITAL SIGNS AND SAMPLE HISTORY**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-5.1 Identify the components of the extended vital signs. (C-1)
>
> 1-5.2 Describe the methods to obtain a breathing rate. (C-1)
>
> 1-5.3 Identify the attributes that should be obtained when assessing
> breathing. (C-1)
>
> 1-5.4 Differentiate between shallow, labored and noisy breathing.
> (C-3)
>
> 1-5.5 Describe the methods to obtain a pulse rate. (C-1)
>
> 1-5.6 Identify the information obtained when assessing a patient\'s
> pulse. (C-1)
>
> 1-5.7 Differentiate between a strong, weak, regular and irregular
> pulse. (C-3)
>
> 1-5.8 Describe the methods to assess the skin color, temperature,
> condition (capillary refill in infants and children). (C-1)
>
> 1-5.9 Identify the normal and abnormal skin colors. (C-1)
>
> 1-5.10 Differentiate between pale, blue, red and yellow skin color.
> (C-3)
>
> 1-5.11 Identify the normal and abnormal skin temperature. (C-1)
>
> 1-5.12 Differentiate between hot, cool and cold skin temperature.
> (C-3)
>
> 1-5.13 Identify normal and abnormal skin conditions. (C-1)
>
> 1-5.14 Identify normal and abnormal capillary refill in infants and
> children. (C-1)
>
> 1-5.15 Describe the methods to assess the pupils. (C-1)
>
> 1-5.16 Identify normal and abnormal pupil size. (C-1)
>
> 1-5.17 Differentiate between dilated (big) and constricted (small)
> pupil size. (C-3)
>
> 1-5.18 Differentiate between reactive and non-reactive pupils and
> equal and unequal pupils. (C-3)
>
> 1-5.19 Describe the methods to assess blood pressure. (C-1)
>
> 1-5.20 Define systolic pressure. (C-1)
>
> 1-5.21 Define diastolic pressure. (C-1)
>
> 1-5.22 Explain the difference between auscultation and palpation for
> obtaining a blood pressure. (C-1)
>
> 1-5.23 Identify the components of the ***SAMPLE*** history. (C-1)
>
> 1-5.24 Differentiate between a sign and a symptom. (C-3)
>
> 1-5.25 State the importance of accurately reporting and recording the
> baseline vital signs. (C-1)
>
> 1-5.26 Discuss the need to search for additional medical
> identification. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-5.27 Explain the value of performing the baseline vital signs. (A-2)
>
> 1-5.28 Recognize and respond to the feelings patients experience
> during assessment. (A-1)
>
> 1-5.29 Defend the need for obtaining and recording an accurate set of
> vital signs. (A-3)
>
> 1-5.30 Explain the rationale of recording additional sets of vital
> signs. (A-1)
>
> 1-5.31 Explain the importance of obtaining a ***SAMPLE*** history.
> (A-1)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-5.32 Demonstrate the skills involved in assessment of breathing.
> (P-1,2)
>
> 1-5.33 Demonstrate the skills associated with obtaining a pulse.
> (P-1,2)
>
> 1-5.34 Demonstrate the skills associated with assessing the skin
> color, temperature, condition, and capillary refill in infants and
> children. (P-1,2)
>
> 1-5.35 Demonstrate the skills associated with assessing the pupils.
> (P-1,2)
>
> 1-5.36 Demonstrate the skills associated with obtaining blood
> pressure. (P-1,2)
>
> 1-5.37 Demonstrate the skills that should be used to obtain
> information from the patient, family, or bystanders at the scene.
> (P-1,2)

**LESSON 1-6: LIFTING AND MOVING PATIENTS**

**[COGNITIVE OBJECTIVES]{.underline}**

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

-   Wheeled ambulance stretcher

-   Portable ambulance stretcher

-   Stair chair

-   Scoop stretcher

-   Long spine board

-   Basket stretcher

-   Flexible stretcher

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 1-6.13 Explain the rationale for properly lifting and moving patients.
> (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> 1-6.14 Working with a partner, prepare each of the following devices
> for use, transfer a patient to the device, properly position the
> patient on the device, move the device to the ambulance and load the
> patient into the ambulance: (P-1,2)

-   Wheeled ambulance stretcher

-   Portable ambulance stretcher

-   Stair chair

-   Scoop stretcher

-   Long spine board

-   Basket stretcher

-   Flexible stretcher

> 1-6.15 Working with a partner, the EMT-Basic will demonstrate
> techniques for the transfer of a patient from an ambulance stretcher
> to a hospital stretcher. (P-1,2)

**MODULE 2: AIRWAY**

**LESSON 2-1: AIRWAY**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 2-1.1 Name and label the major structures of the respiratory system on
> a diagram. (C-1)
>
> 2-1.2 List the signs of adequate breathing. (C-1)
>
> 2-1.3 List the signs of inadequate breathing. (C-1)
>
> 2-1.4 Describe the steps in performing the head-tilt chin-lift. (C-1)
>
> 2-1.5 Relate mechanism of injury to opening the airway. (C-3)
>
> 2-1.6 Describe the steps in performing the jaw thrust. (C-1)
>
> 2-1.7 State the importance of having a suction unit ready for
> immediate use when providing emergency care. (C-1)
>
> 2-1.8 Describe the techniques of suctioning. (C-1)
>
> 2-1.9 Describe how to artificially ventilate a patient with a p­ocket
> m­ask. (C-1)
>
> 2-1.10 Describe the steps in performing the skill of artificially
> ventilating a patient with a bag-valve-mask while using the jaw
> thrust. (C-1)
>
> 2-1.11 List the parts of a bag-valve-mask system. (C-1)
>
> 2-1.12 Describe the steps in performing the skill of artificially
> ventilating a patient with a bag-valve-mask for one and two rescuers.
> (C-1)
>
> 2-1.13 Describe the signs of adequate artificial ventilation using the
> bag-valve-mask. (C-1)
>
> 2-1.14 Describe the signs of inadequate artificial ventilation using
> the bag-valve-mask. (C-1)
>
> 2-1.15 Describe the steps in artificially ventilating a patient with a
> flow restricted, oxygen-powered ventilation device. (C-1)
>
> 2-1.16 List the steps in performing the actions taken when providing
> mouth‑to-mouth and mouth-to-stoma artificial ventilation. (C-1)
>
> 2-1.17 Describe how to measure and insert an oropharyngeal (oral)
> airway. (C-1)
>
> 2-1.18 Describe how to measure and insert a nasopharyngeal (nasal)
> airway. (C-1)
>
> 2-1.19 Define the components of an oxygen delivery system.(C-1)
>
> 2-1.20 Identify a nonrebreather face mask and state the oxygen flow
> requirements needed for its use. (C-1)
>
> 2-1.21 Describe the indications for using a nasal cannula versus a
> nonrebreather face mask. (C-1)
>
> 2-1.22 Identify a nasal cannula and state the flow requirements needed
> for its use. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 2-1.23 Explain the rationale for basic life support artificial
> ventilation and airway protective skills taking priority over most
> other basic life support skills. (A-3)
>
> 2-1.24 Explain the rationale for providing adequate oxygenation
> through high inspired oxygen concentrations to patients who, in the
> past, may have received low concentrations. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 2-1.25 Demonstrate the steps in performing the head-tilt chin-lift.
> (P-1,2)
>
> 2-1.26 Demonstrate the steps in performing the jaw thrust. (P-1,2)
>
> 2-1.27 Demonstrate the techniques of suctioning. (P-1,2)
>
> 2-1.28 Demonstrate the steps in providing mouth-to-mouth artificial
> ventilation with body substance isolation (barrier shields). (P-1,2)
>
> 2-1.29 Demonstrate how to use a pocket mask to artificially ventilate
> a patient. (P-1,2)
>
> 2-1.30 Demonstrate the assembly of a bag-valve-mask unit. (P-1,2)
>
> 2-1.31 Demonstrate the steps in performing the skill of artificially
> ventilating a patient with a bag-valve-mask for one and two rescuers.
> (P-1,2)
>
> 2-1.32 Demonstrate the steps in performing the skill of artificially
> ventilating a patient with a bag-valve-mask while using the jaw
> thrust. (P-1,2)
>
> 2-1.33 Demonstrate artificial ventilation of a patient with a flow
> restricted, oxygen-powered ventilation device. (P-1,2)
>
> 2-1.34 Demonstrate how to artificially ventilate a patient with a
> stoma. (P-1,2)
>
> 2-1.35 Demonstrate how to insert an oropharyngeal (oral) airway.
> (P-1,2)
>
> 2-1.36 Demonstrate how to insert a nasopharyngeal (nasal) airway.
> (P-1,2)
>
> 2-1.37 Demonstrate the correct operation of oxygen tanks and
> regulators. (P-1,2)
>
> 2-1.38 Demonstrate the use of a nonrebreather face mask and state the
> oxygen flow requirements needed for its use. (P-1,2)
>
> 2-1.39 Demonstrate the use of a nasal cannula and state the flow
> requirements needed for its use. (P-1,2)
>
> 2-1.40 Demonstrate how to artificially ventilate the infant and child
> patient. (P-1,2)
>
> 2-1.41 Demonstrate oxygen administration for the infant and child
> patient. (P-1,2)

**MODULE 3: PATIENT ASSESSMENT**

**Lesson 3-1: SCENE SIZE-UP**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-1.1 Recognize hazards/potential hazards. (C-1)
>
> 3-1.2 Describe common hazards found at the scene of a trauma and a
> medical patient. (C-1)
>
> 3-1.3 Determine if the scene is safe to enter. (C-2)
>
> 3-1.4 Discuss common mechanisms of injury/nature of illness. (C-1)
>
> 3-1.5 Discuss the reason for identifying the total number of patients
> at the scene. (C-1)
>
> 3-1.6 Explain the reason for identifying the need for additional help
> or assistance. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-1.7 Explain the rationale for crew members to evaluate scene safety
> prior to entering. (A-2)
>
> 3-1.8 Serve as a model for others explaining how patient situations
> affect your evaluation of mechanism of injury or illness. (A-2)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-1.9 Observe various scenarios and identify potential hazards. (P-1)

**Lesson 3-2: INITIAL ASSESSMENT**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-2.1 Summarize the reasons for forming a general impression of the
> patient. (C-1)
>
> 3-2.2 Discuss methods of assessing altered mental status. (C-1)
>
> 3-2.3 Differentiate between assessing the altered mental status in the
> adult, child and infant patient. (C-3)
>
> 3-2.4 Discuss methods of assessing the airway in the adult, child and
> infant patient. (C-1)
>
> 3-2.5 State reasons for management of the cervical spine once the
> patient has been determined to be a trauma patient. (C-1)
>
> 3-2.6 Describe methods used for assessing if a patient is breathing.
> (C-1)
>
> 3-2.7 State what care should be provided to the adult, child and
> infant patient with adequate breathing. (C-1)
>
> 3-2.8 State what care should be provided to the adult, child and
> infant patient without adequate breathing. (C-1)
>
> 3-2.9 Differentiate between a patient with adequate and inadequate
> breathing. (C-3)
>
> 3-2.10 Distinguish between methods of assessing breathing in the
> adult, child and infant patient. (C-3)
>
> 3-2.11 Compare the methods of providing airway care to the adult,
> child and infant patient. (C-3)
>
> 3-2.12 Describe the methods used to obtain a pulse. (C-1)
>
> 3-2.13 Differentiate between obtaining a pulse in an adult, child and
> infant patient. (C-3)
>
> 3-2.14 Discuss the need for assessing the patient for external
> bleeding. (C-1)
>
> 3-2.15 Describe normal and abnormal findings when assessing skin
> color. (C-1)
>
> 3-2.16 Describe normal and abnormal findings when assessing skin
> temperature. (C-1)
>
> 3-2.17 Describe normal and abnormal findings when assessing skin
> condition. (C-1)
>
> 3-2.18 Describe normal and abnormal findings when assessing skin
> capillary refill in the infant and child patient. (C-1)
>
> 3-2.19 Explain the reason for prioritizing a patient for care and
> transport. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-2.20 Explain the importance of forming a general impression of the
> patient. (A-1)
>
> 3-2.21 Explain the value of performing an initial assessment. (A-2)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-2.22 Demonstrate the techniques for assessing mental status. (P-1,2)
>
> 3-2.23 Demonstrate the techniques for assessing the airway. (P-1,2)
>
> 3-2.24 Demonstrate the techniques for assessing if the patient is
> breathing. (P-1,2)
>
> 3-2.25 Demonstrate the techniques for assessing if the patient has a
> pulse. (P-1,2)
>
> 3-2.26 Demonstrate the techniques for assessing the patient for
> external bleeding. (P-1,2)
>
> 3-2.27 Demonstrate the techniques for assessing the patient\'s skin
> color, temperature, condition and capillary refill (infants and
> children only). (P-1,2)
>
> 3-2.28 Demonstrate the ability to prioritize patients. (P-1,2)

**LESSON 3-3: FOCUSED HISTORY AND PHYSICAL EXAM - TRAUMA PATIENTS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-3.1 Discuss the reasons for reconsideration concerning the mechanism
> of injury. (C-1)
>
> 3-3.2 State the reasons for performing a rapid trauma assessment.
> (C-1)
>
> 3-3.3 Recite examples and explain why patients should receive a rapid
> trauma assessment. (C-1)
>
> 3-3.4 Describe the areas included in the rapid trauma assessment and
> discuss what should be evaluated. (C-1)
>
> 3-3.5 Differentiate when the rapid assessment may be altered in order
> to provide patient care. (C-3)
>
> 3-3.6 Discuss the reason for performing a focused history and physical
> exam. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-3.7 Recognize and respect the feelings that patients might
> experience during assessment. (A-1)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-3.8 Demonstrate the rapid trauma assessment that should be used to
> assess a patient based on mechanism of injury. (P-1,2)

**LESSON 3-4: FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL PATIENTS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-4.1 Describe the unique needs for assessing an individual with a
> specific chief complaint with no known prior history. (C-1)
>
> 3-4.2 Differentiate between the history and physical exam that is
> performed for responsive patients with no known prior history and
> patients responsive with a known prior history. (C-3)
>
> 3-4.3 Describe the unique needs for assessing an individual who is
> unresponsive or has an altered mental status. (C-1)
>
> 3-4.4 Differentiate between the assessment that is performed for a
> patient who is unresponsive or has an altered mental status and other
> medical patients requiring assessment. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-4.5 Attend to the feelings that these patients might be
> experiencing. (A-1)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-4.6 Demonstrate the patient care skills that should be used to
> assist with a patient who is responsive with no known history. (P-1,2)
>
> 3-4.7 Demonstrate the patient care skills that should be used to
> assist with a patient who is unresponsive or has an altered metal
> status. (P-1,2)

**Lesson 3-5: DETAILED PHYSICAL EXAM**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-5.1 Discuss the components of the detailed physical exam. (C-1)
>
> 3-5.2 State the areas of the body that are evaluated during the
> detailed physical exam. (C-1)
>
> 3-5.3 Explain what additional care should be provided while performing
> the detailed physical exam. (C-1)
>
> 3-5.4 Distinguish between the detailed physical exam that is performed
> on a trauma patient and that of the medical patient. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-5.5 Explain the rationale for the feelings that these patients might
> be experiencing. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-5.6 Demonstrate the skills involved in performing the detailed
> physical exam. (P-1,2)

**Lesson 3-6: ON-GOING ASSESSMENT**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-6.1 Discuss the reasons for repeating the initial assessment as part
> of the on-going assessment. (C-1)
>
> 3-6.2 Describe the components of the on-going assessment. (C-1)
>
> 3-6.3 Describe trending of assessment components. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-6.4 Explain the value of performing an on-going assessment. (A-2)
>
> 3-6.5 Recognize and respect the feelings that patients might
> experience during assessment. (A-1)
>
> 3-6.6 Explain the value of trending assessment components to other
> health professionals who assume care of the patient. (A-2)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-6.7 Demonstrate the skills involved in performing the on-going
> assessment. (P-1,2)

**Lesson 3-7: COMMUNICATIONS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-7.1 List the proper methods of initiating and terminating a radio
> call. (C-1)
>
> 3-7.2 State the proper sequence for delivery of patient information.
> (C-1)
>
> 3-7.3 Explain the importance of effective communication of patient
> information in the verbal report. (C-1)
>
> 3-7.4 Identify the essential components of the verbal report. (C-1)
>
> 3-7.5 Describe the attributes for increasing effectiveness and
> efficiency of verbal communications. (C-1)
>
> 3-7.6 State legal aspects to consider in verbal communication. (C-1)
>
> 3-7.7 Discuss the communication skills that should be used to interact
> with the patient. (C-1)
>
> 3-7.8 Discuss the communication skills that should be used to interact
> with the family, bystanders, individuals from other agencies while
> providing patient care and the difference between skills used to
> interact with the patient and those used to interact with others.
> (C-1)
>
> 3-7.9 List the correct radio procedures in the following phases of a
> typical call: (C-1)

-   To the scene.

-   At the scene.

-   To the facility.

-   At the facility.

-   To the station.

-   At the station.

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-7.10 Explain the rationale for providing efficient and effective
> radio communications and patient reports. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-7.11 Perform a simulated, organized, concise radio transmission.
> (P-2)
>
> 3-7.12 Perform an organized, concise patient report that would be
> given to the staff at a receiving facility. (P-2)
>
> 3-7.13 Perform a brief, organized report that would be given to an ALS
> provider arriving at an incident scene at which the EMT-Basic was
> already providing care. (P-2)

**Lesson 3-8: DOCUMENTATION**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-8.1 Explain the components of the written report and list the
> information that should be included on the written report. (C-1)
>
> 3-8.2 Identify the various sections of the written report. (C-1)
>
> 3-8.3 Describe what information is required in each section of the
> prehospital care report and how it should be entered. (C-1)
>
> 3-8.4 Define the special considerations concerning patient refusal.
> (C-1)
>
> 3-8.5 Describe the legal implications associated with the written
> report. (C-1)
>
> 3-8.6 Discuss all state and/or local record and reporting
> requirements. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-8.7 Explain the rationale for patient care documentation. (A-3)
>
> 3-8.8 Explain the rationale for the EMS system gathering data. (A-3)
>
> 3-8.9 Explain the rationale for using medical terminology correctly.
> (A-3)
>
> 3-8.10 Explain the rationale for using an accurate and synchronous
> clock so that information can be used in trending. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 3-8.11 Complete a prehospital care report. (P-2)

**MODULE 4: MEDICAL**

**Lesson 4-1: GENERAL PHARMACOLOGY**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-B student will be able to:
>
> 4-1.1 Identify which medications will be carried on the unit. (C-1)
>
> 4-1.2 State the medications carried on the unit by the generic name.
> (C-1)
>
> 4-1.3 Identify the medications with which the EMT-B may assist the
> patient with administering. (C-1)
>
> 4-1.4 State the medications the EMT-B can assist the patient with by
> the generic name. (C-1)
>
> 4-1.5 Discuss the forms in which the medications may be found. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-1.6 Explain the rationale for the administration of medications.
> (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-1.7 Demonstrate general steps for assisting patient with self
> administration of medications. (P-2)
>
> 4-1.8 Read the labels and inspect each type of medication. (P-2)

**Lesson 4-2: RESPIRATORY EMERGENCIES**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-2.1 List the structure and function of the respiratory system. (C-1)
>
> 4-2.2 State the signs and symptoms of a patient with breathing
> difficulty. (C-1)
>
> 4-2.3 Describe the emergency medical care of the patient with
> breathing difficulty. (C-1)
>
> 4-2.4 Recognize the need for medical direction to assist in the
> emergency medical care of the patient with breathing difficulty. (C-3)
>
> 4-2.5 Describe the emergency medical care of the patient with
> breathing distress. (C-1)
>
> 4-2.6 Establish the relationship between airway management and the
> patient with breathing difficulty. (C-3)
>
> 4-2.7 List signs of adequate air exchange. (C-1)
>
> 4-2.8 State the generic name, medication forms, dose, administration,
> action, indications and contraindications for the prescribed inhaler.
> (C-1)
>
> 4-2.9 Distinguish between the emergency medical care of the infant,
> child and adult patient with breathing difficulty. (C-3)
>
> 4-2.10 Differentiate between upper airway obstruction and lower airway
> disease in the infant and child patient. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-2.11 Defend EMT-Basic treatment regimens for various respiratory
> emergencies. (A-1)
>
> 4-2.12 Explain the rationale for administering an inhaler. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-2.13 Demonstrate the emergency medical care for breathing
> difficulty. (P-1,2)
>
> 4-2.14 Perform the steps in facilitating the use of an inhaler. (P-2)

**Lesson 4-3: CARDIOVASCULAR EMERGENCIES**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-3.1 Describe the structure and function of the cardiovascular
> system. (C-1)
>
> 4-3.2 Describe the emergency medical care of the patient experiencing
> chest pain/discomfort. (C-1)
>
> 4-3.3 List the indications for automated external defibrillation
> (AED). (C-1)
>
> 4-3.4 List the contraindications for automated external
> defibrillation. (C-1)
>
> 4-3.5 Define the role of EMT‑B in the emergency cardiac care system.
> (C-1)
>
> 4-3.6 Explain the impact of age and weight on defibrillation. (C-1)
>
> 4-3.7 Discuss the position of comfort for patients with various
> cardiac emergencies. (C-1)
>
> 4-3.8 Establish the relationship between airway management and the
> patient with cardiovascular compromise. (C-3)
>
> 4-3.9 Predict the relationship between the patient experiencing
> cardiovascular compromise and basic life support. (C-2)
>
> 4-3.10 Discuss the fundamentals of early defibrillation. (C-1)
>
> 4-3.11 Explain the rationale for early defibrillation. (C-1)
>
> 4-3.12 Explain that not all chest pain patients result in cardiac
> arrest and do not need to be attached to an automated external
> defibrillator. (C-1)
>
> 4-3.13 Explain the importance of prehospital ACLS intervention if it
> is available. (C-1)
>
> 4-3.14 Explain the importance of urgent transport to a facility with
> Advanced Cardiac Life Support if it is not available in the
> prehospital setting. (C-1)
>
> 4-3.15 Discuss the various types of automated external defibrillators.
> (C-1)
>
> 4-3.16 Differentiate between the fully automated and the
> semi-automatic defibrillator. (C-3)
>
> 4-3.17 Discuss the procedures that must be taken into consideration
> for standard operations of the various types of automated external
> defibrillators. (C-1)
>
> 4-3.18 State the reasons for assuring that the patient is pulseless
> and apneic when using the automated external defibrillator. (C-1)
>
> 4-3.19 Discuss the circumstances which may result in inappropriate
> shocks. (C-1)
>
> 4-3.20 Explain the considerations for interruption of CPR, when using
> the automated external defibrillator. (C-1)
>
> 4-3.21 Discuss the advantages and disadvantages of automated external
> defibrillators. (C-1)
>
> 4-3.22 Summarize the speed of operation of automated external
> defibrillation. (C-1)
>
> 4-3.23 Discuss the use of remote defibrillation through adhesive pads.
> (C-1)
>
> 4-3.24 Discuss the special considerations for rhythm monitoring. (C-1)
>
> 4-3.25 List the steps in the operation of the automated external
> defibrillator. (C-1)
>
> 4-3.26 Discuss the standard of care that should be used to provide
> care to a patient with persistent ventricular fibrillation and no
> available ACLS. (C-1)
>
> 4-3.27 Discuss the standard of care that should be used to provide
> care to a patient with recurrent ventricular fibrillation and no
> available ACLS. (C-1)
>
> 4-3.28 Differentiate between the single rescuer and multi-rescuer care
> with an automated external defibrillator. (C-3)
>
> 4-3.29 Explain the reason for pulses not being checked between shocks
> with an automated external defibrillator. (C-1)
>
> 4-3.30 Discuss the importance of coordinating ACLS trained providers
> with personnel using automated external defibrillators. (C-1)
>
> 4-3.31 Discuss the importance of post-resuscitation care. (C-1)
>
> 4-3.32 List the components of post-resuscitation care. (C-1)
>
> 4-3.33 Explain the importance of frequent practice with the automated
> external defibrillator. (C-1)
>
> 4-3.34 Discuss the need to complete the Automated Defibrillator:
> Operator\'s Shift Checklist. (C-1)
>
> 4-3.35 Discuss the role of the American Heart Association (AHA) in the
> use of automated external defibrillation. (C-1)
>
> 4-3.36 Explain the role medical direction plays in the use of
> automated external defibrillation. (C-1)
>
> 4-3.37 State the reasons why a case review should be completed
> following the use of the automated external defibrillator. (C-1)
>
> 4-3.38 Discuss the components that should be included in a case
> review. (C-1)
>
> 4-3.39 Discuss the goal of quality improvement in automated external
> defibrillation. (C-1)
>
> 4-3.40 Recognize the need for medical direction of protocols to assist
> in the emergency medical care of the patient with chest pain. (C-3)
>
> 4-3.41 List the indications for the use of nitroglycerin. (C-1)
>
> 4-3.42 State the contraindications and side effects for the use of
> nitroglycerin. (C-1)
>
> 4-3.43 Define the function of all controls on an automated external
> defibrillator, and describe event documentation and battery
> defibrillator maintenance. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-3.44 Defend the reasons for obtaining initial training in automated
> external defibrillation and the importance of continuing education.
> (A-3)
>
> 4-3.45 Defend the reason for maintenance of automated external
> defibrillators. (A-3)
>
> 4-3.46 Explain the rationale for administering nitroglycerin to a
> patient with chest pain or discomfort. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-3.47 Demonstrate the assessment and emergency medical care of a
> patient experiencing chest pain/discomfort. (P-1,2)
>
> 4-3.48 Demonstrate the application and operation of the automated
> external defibrillator. (P-1,2)
>
> 4-3.49 Demonstrate the maintenance of an automated external
> defibrillator. (P-1,2)
>
> 4-3.50 Demonstrate the assessment and documentation of patient
> response to the automated external defibrillator. (P-1,2)
>
> 4-3.51 Demonstrate the skills necessary to complete the Automated
> Defibrillator: Operator\'s Shift Checklist. (P-1,2)
>
> 4-3.52 Perform the steps in facilitating the use of nitroglycerin for
> chest pain or discomfort. (P-2)
>
> 4-3.53 Demonstrate the assessment and documentation of patient
> response to nitroglycerin. (P-1,2)
>
> 4-3.54 Practice completing a prehospital care report for patients with
> cardiac emergencies. (P-2)

**Lesson 4-4: DIABETES/ALTERED MENTAL STATUS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-4.1 Identify the patient taking diabetic medications with altered
> mental status and the implications of a diabetes history. (C-1)
>
> 4-4.2 State the steps in the emergency medical care of the patient
> taking diabetic medicine with an altered mental status and a history
> of diabetes. (C-1)
>
> 4-4.3 Establish the relationship between airway management and the
> patient with altered mental status. (C-3)
>
> 4-4.4 State the generic and trade names, medication forms, dose,
> administration, action, and contraindications for oral glucose. (C-1)
>
> 4-4.5 Evaluate the need for medical direction in the emergency medical
> care of the diabetic patient. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-4.6 Explain the rationale for administering oral glucose. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-4.7 Demonstrate the steps in the emergency medical care for the
> patient taking diabetic medicine with an altered mental status and a
> history of diabetes. (P-1,2)
>
> 4-4.8 Demonstrate the steps in the administration of oral glucose.
> (P-1,2)
>
> 4-4.9 Demonstrate the assessment and documentation of patient response
> to oral glucose. (P-1,2)
>
> 4-4.10 Demonstrate how to complete a prehospital care report for
> patients with diabetic emergencies. (P-2)

**Lesson 4-5: ALLERGIES**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-5.1 Recognize the patient experiencing an allergic reaction. (C-1)
>
> 4-5.2 Describe the emergency medical care of the patient with an
> allergic reaction. (C-1)
>
> 4-5.3 Establish the relationship between the patient with an allergic
> reaction and airway management. (C-3)
>
> 4-5.4 Describe the mechanisms of allergic response and the
> implications for airway management. (C-1)
>
> 4-5.5 State the generic and trade names, medication forms, dose,
> administration, action, and contraindications for the epinephrine
> auto-injector. (C-1)
>
> 4-5.6 Evaluate the need for medical direction in the emergency medical
> care of the patient with an allergic reaction. (C-3)
>
> 4-5.7 Differentiate between the general category of those patients
> having an allergic reaction and those patients having an allergic
> reaction and requiring immediate medical care, including immediate use
> of epinephrine auto-injector. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-5.8 Explain the rationale for administering epinephrine using an
> auto-injector. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-5.9 Demonstrate the emergency medical care of the patient
> experiencing an allergic reaction. (P-1,2)
>
> 4-5.10 Demonstrate the use of epinephrine auto-injector. (P-1,2)
>
> 4-5.11 Demonstrate the assessment and documentation of patient
> response to an epinephrine injection. (P-1,2)
>
> 4-5.12 Demonstrate proper disposal of equipment. (P-1,2)
>
> 4-5.13 Demonstrate completing a prehospital care report for patients
> with allergic emergencies. (P-2)

**Lesson 4-6: POISONING/OVERDOSE**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-6.1 List various ways that poisons enter the body. (C-1)
>
> 4-6.2 List signs/symptoms associated with poisoning. (C-1)
>
> 4-6.3 Discuss the emergency medical care for the patient with possible
> overdose. (C-1)
>
> 4-6.4 Describe the steps in the emergency medical care for the patient
> with suspected poisoning. (C-1)
>
> 4-6.5 Establish the relationship between the patient suffering from
> poisoning or overdose and airway management. (C-3)
>
> 4-6.6 State the generic and trade names, indications,
> contraindications, medication form, dose, administration, actions,
> side effects and re-assessment strategies for activated charcoal.
> (C-1)
>
> 4-6.7 Recognize the need for medical direction in caring for the
> patient with poisoning or overdose. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-6.8 Explain the rationale for administering activated charcoal.
> (A-3)
>
> 4-6.9 Explain the rationale for contacting medical direction early in
> the prehospital management of the poisoning or overdose patient. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-6.10 Demonstrate the steps in the emergency medical care for the
> patient with possible overdose. (P-1,2)
>
> 4-6.11 Demonstrate the steps in the emergency medical care for the
> patient with suspected poisoning. (P-1,2)
>
> 4-6.12 Perform the necessary steps required to provide a patient with
> activated charcoal. (P-2)
>
> 4-6.13 Demonstrate the assessment and documentation of patient
> response. (P-1,2)
>
> 4-6.14 Demonstrate proper disposal of administration of activated
> charcoal equipment. (P-1,2)
>
> 4-6.15 Demonstrate completing a prehospital care report for patients
> with a poisoning/overdose emergency. (P-1,2)

**Lesson 4-7: ENVIRONMENTAL EMERGENCIES**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-7.1 Describe the various ways that the body loses heat. (C-1)
>
> 4-7.2 List the signs and symptoms of exposure to cold. (C-1)
>
> 4-7.3 Explain the steps in providing emergency medical care to a
> patient exposed to cold. (C-1)
>
> 4-7.4 List the signs and symptoms of exposure to heat. (C-1)
>
> 4-7.5 Explain the steps in providing emergency care to a patient
> exposed to heat. (C-1)
>
> 4-7.6 Recognize the signs and symptoms of water-related emergencies.
> (C-1)
>
> 4-7.7 Describe the complications of near drowning. (C-1)
>
> 4-7.8 Discuss the emergency medical care of bites and stings. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> No affective objectives identified.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-7.9 Demonstrate the assessment and emergency medical care of a
> patient with exposure to cold. (P-1,2)
>
> 4-7.10 Demonstrate the assessment and emergency medical care of a
> patient with exposure to heat. (P-1,2)
>
> 4-7.11 Demonstrate the assessment and emergency medical care of a near
> drowning patient. (P-1,2)
>
> 4-7.12 Demonstrate completing a prehospital care report for patients
> with environmental emergencies. (P-2)

**Lesson 4-8: BEHAVIORAL EMERGENCIES**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-8.1 Define behavioral emergencies. (C-1)
>
> 4-8.2 Discuss the general factors that may cause an alteration in a
> patient\'s behavior. (C-1)
>
> 4-8.3 State the various reasons for psychological crises. (C-1)
>
> 4-8.4 Discuss the characteristics of an individual\'s behavior which
> suggests that the patient is at risk for suicide. (C-1)
>
> 4-8.5 Discuss special medical/legal considerations for managing
> behavioral emergencies. (C-1)
>
> 4-8.6 Discuss the special considerations for assessing a patient with
> behavioral problems. (C-1)
>
> 4-8.7 Discuss the general principles of an individual\'s behavior
> which suggests that he is at risk for violence. (C-1)
>
> 4-8.8 Discuss methods to calm behavioral emergency patients. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-8.9 Explain the rationale for learning how to modify your behavior
> toward the patient with a behavioral emergency. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-8.10 Demonstrate the assessment and emergency medical care of the
> patient experiencing a behavioral emergency. (P-1,2)
>
> 4-8.11 Demonstrate various techniques to safely restrain a patient
> with a behavioral problem. (P-1,2)

**Lesson 4-9: OBSTETRICS/GYNECOLOGY**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-9.1 Identify the following structures: Uterus, vagina, fetus,
> placenta, umbilical cord, amniotic sac, perineum. (C-1)
>
> 4-9.2 Identify and explain the use of the contents of an obstetrics
> kit. (C-1)
>
> 4-9.3 Identify pre-delivery emergencies. (C-1)
>
> 4-9.4 State indications of an imminent delivery. (C-1)
>
> 4-9.5 Differentiate the emergency medical care provided to a patient
> with pre-delivery emergencies from a normal delivery. (C-3)
>
> 4-9.6 State the steps in the pre-delivery preparation of the mother.
> (C-1)
>
> 4-9.7 Establish the relationship between body substance isolation and
> childbirth. (C-3)
>
> 4-9.8 State the steps to assist in the delivery. (C-1)
>
> 4-9.9 Describe care of the baby as the head appears. (C-1)
>
> 4-9.10 Describe how and when to cut the umbilical cord. (C-1)
>
> 4-9.11 Discuss the steps in the delivery of the placenta. (C-1)
>
> 4-9.12 List the steps in the emergency medical care of the mother
> post-delivery. (C-3)
>
> 4-9.13 Summarize neonatal resuscitation procedures. (C-1)
>
> 4-9.14 Describe the procedures for the following abnormal deliveries:
> breech birth, prolapsed cord, limb presentation. (C-1)
>
> 4-9.15 Differentiate the special considerations for multiple births.
> (C-3)
>
> 4-9.16 Describe special considerations of meconium. (C-1)
>
> 4-9.17 Describe special considerations of a premature baby. (C-1)
>
> 4-9.18 Discuss the emergency medical care of a patient with a
> gynecological emergency. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-9.19 Explain the rationale for understanding the implications of
> treating two patients (mother and baby). (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 4-9.20 Demonstrate the steps to assist in the normal cephalic
> delivery. (P-1,2)
>
> 4-9.21 Demonstrate necessary care procedures of the fetus as the head
> appears. (P-1,2)
>
> 4-9.22 Demonstrate infant neonatal procedures. (P-1,2)
>
> 4-9.23 Demonstrate post delivery care of infant. (P-1,2)
>
> 4-9.24 Demonstrate how and when to cut the umbilical cord. (P-1,2)
>
> 4-9.25 Attend to the steps in the delivery of the placenta. (P-1,2)
>
> 4-9.26 Demonstrate the post-delivery care of the mother. (P-1,2)
>
> 4-9.27 Demonstrate the procedures for the following abnormal
> deliveries: vaginal bleeding, breech birth, prolapsed cord, limb
> presentation. (P-1,2)
>
> 4-9.28 Demonstrate the steps in the emergency medical care of the
> mother with excessive bleeding. (P-1,2)
>
> 4-9.29 Demonstrate completing a prehospital care report for patients
> with obstetrical/gynecological emergencies. (P-2)

**MODULE 5 TRAUMA**

**Lesson 5-1: BLEEDING AND SHOCK**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-1.1 List the structure and function of the circulatory system. (C-1)
>
> 5-1.2 Differentiate between arterial, venous and capillary bleeding.
> (C-3)
>
> 5-1.3 State methods of emergency medical care of external bleeding.
> (C-1)
>
> 5-1.4 Establish the relationship between body substance isolation and
> bleeding. (C-3)
>
> 5-1.5 Establish the relationship between airway management and the
> trauma patient. (C-3)
>
> 5-1.6 Establish the relationship between mechanism of injury and
> internal bleeding. (C-3)
>
> 5-1.7 List the signs of internal bleeding. (C-1)
>
> 5-1.8 List the steps in the emergency medical care of the patient with
> signs and symptoms of internal bleeding. (C-1)
>
> 5-1.9 List signs and symptoms of shock (hypoperfusion). (C-1)
>
> 5-1.10 State the steps in the emergency medical care of the patient
> with signs and symptoms of shock (hypoperfusion). (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-1.11 Explain the sense of urgency to transport patients that are
> bleeding and show signs of shock (hypoperfusion). (A-1)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-1.12 Demonstrate direct pressure as a method of emergency medical
> care of external bleeding. (P-1,2)
>
> 5-1.13 Demonstrate the use of diffuse pressure as a method of
> emergency medical care of external bleeding. (P-1,2)
>
> 5-1.14 Demonstrate the use of pressure points and tourniquets as a
> method of emergency medical care of external bleeding. (P-1,2)
>
> 5-1.15 Demonstrate the care of the patient exhibiting signs and
> symptoms of internal bleeding. (P-1,2)
>
> 5-1.16 Demonstrate the care of the patient exhibiting signs and
> symptoms of shock (hypoperfusion). (P-1,2)
>
> 5-1.17 Demonstrate completing a prehospital care report for patient
> with bleeding and/or shock (hypoperfusion). (P-2)

**Lesson 5-2: SOFT TISSUE INJURIES**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-2.1 State the major functions of the skin. (C-1)
>
> 5-2.2 List the layers of the skin. (C-1)
>
> 5-2.3 Establish the relationship between body substance isolation
> (BSI) and soft tissue injuries. (C-3)
>
> 5-2.4 List the types of closed soft tissue injuries. (C-1)
>
> 5-2.5 Describe the emergency medical care of the patient with a closed
> soft tissue injury. (C-1)
>
> 5-2.6 State the types of open soft tissue injuries. (C-1)
>
> 5-2.7 Describe the emergency medical care of the patient with an open
> soft tissue injury. (C-1)
>
> 5-2.8 Discuss the emergency medical care considerations for a patient
> with a penetrating chest injury. (C-1)
>
> 5-2.9 State the emergency medical care considerations for a patient
> with an open wound to the abdomen. (C-1)
>
> 5-2.10 Differentiate the care of an open wound to the chest from an
> open wound to the abdomen. (C-3)
>
> 5-2.11 List the classifications of burns. (C-1)
>
> 5-2.12 Define superficial burn. (C-1)
>
> 5-2.13 List the characteristics of a superficial burn. (C-1)
>
> 5-2.14 Define partial thickness burn. (C-1)
>
> 5-2.15 List the characteristics of a partial thickness burn. (C-1)
>
> 5-2.16 Define full thickness burn. (C-1)
>
> 5-2.17 List the characteristics of a full thickness burn. (C-1)
>
> 5-2.18 Describe the emergency medical care of the patient with a
> superficial burn. (C-1)
>
> 5-2.19 Describe the emergency medical care of the patient with a
> partial thickness burn. (C-1)
>
> 5-2.20 Describe the emergency medical care of the patient with a full
> thickness burn. (C-1)
>
> 5-2.21 List the functions of dressing and bandaging. (C-1)
>
> 5-2.22 Describe the purpose of a bandage. (C-1)
>
> 5-2.23 Describe the steps in applying a pressure dressing. (C-1)
>
> 5-2.24 Establish the relationship between airway management and the
> patient with chest injury, burns, blunt and penetrating injuries.
> (C-1)
>
> 5-2.25 Describe the effects of improperly applied dressings, splints
> and tourniquets. (C-1)
>
> 5-2.26 Describe the emergency medical care of a patient with an
> impaled object. (C-1)
>
> 5-2.27 Describe the emergency medical care of a patient with an
> amputation. (C-1)
>
> 5-2.28 Describe the emergency care for a chemical burn.(C-1)
>
> 5-2.29 Describe the emergency care for an electrical burn.(C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> No affective objectives identified.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-2.29 Demonstrate the steps in the emergency medical care of closed
> soft tissue injuries. (P-1,2)
>
> 5-2.30 Demonstrate the steps in the emergency medical care of open
> soft tissue injuries. (P-1,2)
>
> 5-2.31 Demonstrate the steps in the emergency medical care of a
> patient with an open chest wound. (P-1,2)
>
> 5-2.32 Demonstrate the steps in the emergency medical care of a
> patient with open abdominal wounds. (P-1,2)
>
> 5-2.33 Demonstrate the steps in the emergency medical care of a
> patient with an impaled object. (P-1,2)
>
> 5-2.34 Demonstrate the steps in the emergency medical care of a
> patient with an amputation. (P-1,2)
>
> 5-2.35 Demonstrate the steps in the emergency medical care of an
> amputated part. (P-1,2)
>
> 5-2.36 Demonstrate the steps in the emergency medical care of a
> patient with superficial burns. (P-1,2)
>
> 5-2.37 Demonstrate the steps in the emergency medical care of a
> patient with partial thickness burns. (P-1,2)
>
> 5-2.38 Demonstrate the steps in the emergency medical care of a
> patient with full thickness burns. (P-1,2)
>
> 5-2.39 Demonstrate the steps in the emergency medical care of a
> patient with a chemical burn. (P-1,2)
>
> 5-2.40 Demonstrate completing a prehospital care report for patients
> with soft tissue injuries. (P-2)

**Lesson 5-3: MUSCULOSKELETAL CARE**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-3.1 Describe the function of the muscular system. (C-1)
>
> 5-3.2 Describe the function of the skeletal system. (C-1)
>
> 5-3.3 List the major bones or bone groupings of the spinal column; the
> thorax; the upper extremities; the lower extremities. (C-1)
>
> 5-3.4 Differentiate between an open and a closed painful, swollen,
> deformed extremity. (C-1)
>
> 5-3.5 State the reasons for splinting. (C-1)
>
> 5-3.6 List the general rules of splinting. (C-1)
>
> 5-3.7 List the complications of splinting. (C-1)
>
> 5-3.8 List the emergency medical care for a patient with a painful,
> swollen, deformed extremity. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-3.9 Explain the rationale for splinting at the scene versus load and
> go. (A-3)
>
> 5-3.10 Explain the rationale for immobilization of the painful,
> swollen, deformed extremity. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-3.11 Demonstrate the emergency medical care of a patient with a
> painful, swollen, deformed extremity. (P-1,2)
>
> 5-3.12 Demonstrate completing a prehospital care report for patients
> with musculoskeletal injuries. (P-2)

**Lesson 5-4: INJURIES TO THE HEAD AND SPINE**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-4.1 State the components of the nervous system. (C-1)
>
> 5-4.2 List the functions of the central nervous system. (C-1)
>
> 5-4.3 Define the structure of the skeletal system as it relates to the
> nervous system. (C-1)
>
> 5-4.4 Relate mechanism of injury to potential injuries of the head and
> spine. (C-3)
>
> 5-4.5 Describe the implications of not properly caring for potential
> spine injuries. (C-1)
>
> 5-4.6 State the signs and symptoms of a potential spine injury. (C-1)
>
> 5-4.7 Describe the method of determining if a responsive patient may
> have a spine injury. (C-1)
>
> 5-4.8 Relate the airway emergency medical care techniques to the
> patient with a suspected spine injury. (C-3)
>
> 5-4.9 Describe how to stabilize the cervical spine. (C-1)
>
> 5-4.10 Discuss indications for sizing and using a cervical spine
> immobilization device. (C-1)
>
> 5-4.11 Establish the relationship between airway management and the
> patient with head and spine injuries. (C-1)
>
> 5-4.12 Describe a method for sizing a cervical spine immobilization
> device. (C-1)
>
> 5-4.13 Describe how to log roll a patient with a suspected spine
> injury. (C-1)
>
> 5-4.14 Describe how to secure a patient to a long spine board. (C-1)
>
> 5-4.15 List instances when a short spine board should be used. (C-1)
>
> 5-4.16 Describe how to immobilize a patient using a short spine board.
> (C-1)
>
> 5-4.17 Describe the indications for the use of rapid extrication.
> (C-1)
>
> 5-4.18 List steps in performing rapid extrication. (C-1)
>
> 5-4.19 State the circumstances when a helmet should be left on the
> patient. (C-1)
>
> 5-4.20 Discuss the circumstances when a helmet should be removed.
> (C-1)
>
> 5-4.21 Identify different types of helmets. (C-1)
>
> 5-4.22 Describe the unique characteristics of sports helmets. (C-1)
>
> 5-4.23 Explain the preferred methods to remove a helmet. (C-1)
>
> 5-4.24 Discuss alternative methods for removal of a helmet. (C-1)
>
> 5-4.25 Describe how the patient\'s head is stabilized to remove the
> helmet. (C-1)
>
> 5-4.26 Differentiate how the head is stabilized with a helmet compared
> to without a helmet. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-4.27 Explain the rationale for immobilization of the entire spine
> when a cervical spine injury is suspected. (A-3)
>
> 5-4.28 Explain the rationale for utilizing immobilization methods
> apart from the straps on the cots. (A-3)
>
> 5-4.29 Explain the rationale for utilizing a short spine
> immobilization device when moving a patient from the sitting to the
> supine position. (A-3)
>
> 5-4.30 Explain the rationale for utilizing rapid extrication
> approaches only when they indeed will make the difference between life
> and death. (A-3)
>
> 5-4.31 Defend the reasons for leaving a helmet in place for transport
> of a patient. (A-3)
>
> 5-4.32 Defend the reasons for removal of a helmet prior to transport
> of a patient. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 5-4.33 Demonstrate opening the airway in a patient with suspected
> spinal cord injury. (P-1,2)
>
> 5-4.34 Demonstrate evaluating a responsive patient with a suspected
> spinal cord injury. (P-1,2)
>
> 5-4.35 Demonstrate stabilization of the cervical spine. (P-1,2)
>
> 5-4.36 Demonstrate the four person log roll for a patient with a
> suspected spinal cord injury. (P-1,2)
>
> 5-4.37 Demonstrate how to log roll a patient with a suspected spinal
> cord injury using two people. (P-1,2)
>
> 5-4.38 Demonstrate securing a patient to a long spine board. (P-1,2)
>
> 5-4.39 Demonstrate using the short board immobilization technique.
> (P-1,2)
>
> 5-4.40 Demonstrate procedure for rapid extrication. (P-1,2)
>
> 5-4.41 Demonstrate preferred methods for stabilization of a helmet.
> (P-1,2)
>
> 5-4.42 Demonstrate helmet removal techniques. (P-1,2)
>
> 5-4.43 Demonstrate alternative methods for stabilization of a helmet.
> (P-1,2)
>
> 5-4.44 Demonstrate completing a prehospital care report for patients
> with head and spinal injuries. (P-2)

**MODULE 6: INFANTS AND CHILDREN**

**Lesson 6-1: INFANTS AND CHILDREN**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 6-1.1 Identify the developmental considerations for the following age
> groups: (C-1)

-   infants

-   toddlers

-   pre-school

-   school age

-   adolescent

> 6-1.2 Describe differences in anatomy and physiology of the infant,
> child and adult patient. (C-1)
>
> 6-1.3 Differentiate the response of the ill or injured infant or child
> (age specific) from that of an adult. (C-3)
>
> 6-1.4 Indicate various causes of respiratory emergencies. (C-1)
>
> 6-1.5 Differentiate between respiratory distress and respiratory
> failure. (C-3)
>
> 6-1.6 List the steps in the management of foreign body airway
> obstruction. (C-1)
>
> 6-1.7 Summarize emergency medical care strategies for respiratory
> distress and respiratory failure. (C-1)
>
> 6-1.8 Identify the signs and symptoms of shock (hypoperfusion) in the
> infant and child patient. (C-1)
>
> 6-1.9 Describe the methods of determining end organ perfusion in the
> infant and child patient. (C-1)
>
> 6-1.10 State the usual cause of cardiac arrest in infants and children
> versus adults. (C-1)
>
> 6-1.11 List the common causes of seizures in the infant and child
> patient. (C-1)
>
> 6-1.12 Describe the management of seizures in the infant and child
> patient. (C-1)
>
> 6-1.13 Differentiate between the injury patterns in adults, infants,
> and children. (C-3)
>
> 6-1.14 Discuss the field management of the infant and child trauma
> patient. (C-1)
>
> 6-1.15 Summarize the indicators of possible child abuse and neglect.
> (C-1)
>
> 6-1.16 Describe the medical legal responsibilities in suspected child
> abuse. (C-1)
>
> 6-1.17 Recognize need for EMT-Basic debriefing following a difficult
> infant or child transport. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 6-1.18 Explain the rationale for having knowledge and skills
> appropriate for dealing with the infant and child patient. (A-3)
>
> 6-1.19 Attend to the feelings of the family when dealing with an ill
> or injured infant or child. (A-1)
>
> 6-1.20 Understand the provider\'s own response (emotional) to caring
> for infants or children. (A-1)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 6-1.21 Demonstrate the techniques of foreign body airway obstruction
> removal in the infant. (P-1,2)
>
> 6-1.22 Demonstrate the techniques of foreign body airway obstruction
> removal in the child. (P-1,2)
>
> 6-1.23 Demonstrate the assessment of the infant and child. (P-1,2)
>
> 6-1.24 Demonstrate bag-valve-mask artificial ventilations for the
> infant. (P-1,2)
>
> 6-1.25 Demonstrate bag-valve-mask artificial ventilations for the
> child. (P-1,2)
>
> 6-1.26 Demonstrate oxygen delivery for the infant and child. (P-1,2)

**MODULE 7: OPERATIONS**

**Lesson 7-1: AMBULANCE OPERATIONS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 7-1.1 Discuss the medical and non-medical equipment needed to respond
> to a call. (C-1)
>
> 7-1.2 List the phases of an ambulance call. (C-1)
>
> 7-1.3 Describe the general provisions of state laws relating to the
> operation of the ambulance and privileges in any or all of the
> following categories: (C-1)

-   Speed

-   Warning lights

-   Sirens

-   Right-of-way

-   Parking

-   Turning

> 7-1.4 List contributing factors to unsafe driving conditions.(C-1)
>
> 7-1.5 Describe the considerations that should by given to: (C-1)

-   Request for escorts.

-   Following an escort vehicle.

-   Intersections.

> 7-1.6 Discuss \"Due Regard For Safety of All Others\" while operating
> an emergency vehicle. (C-1)
>
> 7-1.7 State what information is essential in order to respond to a
> call. (C-1)
>
> 7-1.8 Discuss various situations that may affect response to a call.
> (C-1)
>
> 7-1.9 Differentiate between the various methods of moving a patient to
> the unit based upon injury or illness. (C-3)
>
> 7-1.10 Apply the components of the essential patient information in a
> written report. (C-2)
>
> 7-1.11 Summarize the importance of preparing the unit for the next
> response. (C-1)
>
> 7-1.12 Identify what is essential for completion of a call. (C-1)
>
> 7-1.13 Distinguish among the terms cleaning, disinfection, high-level
> disinfection, and sterilization. (C-3)
>
> 7-1.14 Describe how to clean or disinfect items following patient
> care. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 7-1.15 Explain the rationale for appropriate report of patient
> information. (A-3)
>
> 7-1.16 Explain the rationale for having the unit prepared to respond.
> (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> No psychomotor objectives identified.

**Lesson 7-2: GAINING ACCESS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 7-2.1 Describe the purpose of extrication. (C-1)
>
> 7-2.2 Discuss the role of the EMT-Basic in extrication. (C-1)
>
> 7-2.3 Identify what equipment for personal safety is required for the
> EMT-Basic. (C-1)
>
> 7-2.4 Define the fundamental components of extrication. (C-1)
>
> 7-2.5 State the steps that should be taken to protect the patient
> during extrication. (C-1)
>
> 7-2.6 Evaluate various methods of gaining access to the patient. (C-3)
>
> 7-2.7 Distinguish between simple and complex access. (C-3)

**[AFFECTIVE OBJECTIVES]{.underline}**

> No affective objectives identified.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> No psychomotor objectives identified.

**Lesson 7-3 OVERVIEWS**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 7-3.1 Explain the EMT-Basic\'s role during a call involving hazardous
> materials. (C-1)
>
> 7-3.2 Describe what the EMT-Basic should do if there is reason to
> believe that there is a hazard at the scene. (C-1)
>
> 7-3.3 Describe the actions that an EMT-Basic should take to ensure
> bystander safety. (C-1)
>
> 7-3.4 State the role the EMT-Basic should perform until appropriately
> trained personnel arrive at the scene of a hazardous materials
> situation. (C-1)
>
> 7-3.5 Break down the steps to approaching a hazardous situation. (C-1)
>
> 7-3.6 Discuss the various environmental hazards that affect EMS. (C-1)
>
> 7-3.7 Describe the criteria for a multiple-casualty situation. (C-1)
>
> 7-3.8 Evaluate the role of the EMT-Basic in the multiple-casualty
> situation. (C-3)
>
> 7-3.9 Summarize the components of basic triage. (C-1)
>
> 7-3.10 Define the role of the EMT-Basic in a disaster operation. (C-1)
>
> 7-3.11 Describe basic concepts of incident management. (C-1)
>
> 7-3.12 Explain the methods for preventing contamination of self,
> equipment and facilities. (C-1)
>
> 7-3.13 Review the local mass casualty incident plan. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> No affective objectives identified.

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 7-3.16 Given a scenario of a mass casualty incident, perform triage.
> (P-2)

**MODULE 8: ADVANCED AIRWAY (Elective)**

**Lesson 8-1 ADVANCED AIRWAY**

**[COGNITIVE OBJECTIVES]{.underline}**

> At the completion of this lesson, the EMT-Basic student will be able
> to:
>
> 8-1.1 Identify and describe the airway anatomy in the infant, child
> and the adult. (C-1)
>
> 8-1.2 Differentiate between the airway anatomy in the infant, child,
> and the adult. (C-1)
>
> 8-1.3 Explain the pathophysiology of airway compromise. (C-1)
>
> 8-1.4 Describe the proper use of airway adjuncts. (C-1)
>
> 8-1.5 Review the use of oxygen therapy in airway management. (C-1)
>
> 8-1.6 Describe the indications, contraindications, and technique for
> insertion of nasal gastric tubes. (C-1)
>
> 8-1.7 Describe how to perform the Sellick maneuver (cricoid pressure).
> (C-1)
>
> 8-1.8 Describe the indications for advanced airway management. (C-1)
>
> 8-1.9 List the equipment required for orotracheal intubation. (C-1)
>
> 8-1.10 Describe the proper use of the curved blade for orotracheal
> intubation. (C-1)
>
> 8-1.11 Describe the proper use of the straight blade for orotracheal
> intubation. (C-1)
>
> 8-1.12 State the reasons for and proper use of the stylet in
> orotracheal intubation. (C-1)
>
> 8-1.13 Describe the methods of choosing the appropriate size
> endotracheal tube in an adult patient. (C-1)
>
> 8-1.14 State the formula for sizing an infant or child endotracheal
> tube. (C-1)
>
> 8-1.15 List complications associated with advanced airway management.
> (C-1)
>
> 8-1.16 Define the various alternative methods for sizing the infant
> and child endotracheal tube. (C-1)
>
> 8-1.17 Describe the skill of orotracheal intubation in the adult
> patient. (C-1)
>
> 8-1.18 Describe the skill of orotracheal intubation in the infant and
> child patient. (C-1)
>
> 8-1.19 Describe the skill of confirming endotracheal tube placement in
> the adult, infant and child patient. (C-1)
>
> 8-1.20 State the consequence of and the need to recognize
> unintentional esophageal intubation. (C-1)
>
> 8-1.21 Describe the skill of securing the endotracheal tube in the
> adult, infant and child patient. (C-1)

**[AFFECTIVE OBJECTIVES]{.underline}**

> At the end of this lesson the EMT-Basic student will be able to:
>
> 8-1.22 Recognize and respect the feelings of the patient and family
> during advanced airway procedures. (A-1)
>
> 8-1.23 Explain the value of performing advanced airway procedures.
> (A-2)
>
> 8-1.24 Defend the need for the EMT-Basic to perform advanced airway
> procedures. (A-3)
>
> 8-1.25 Explain the rationale for the use of a stylet. (A-2)
>
> 8-1.26 Explain the rationale for having a suction unit immediately
> available during intubation attempts. (A-2)
>
> 8-1.27 Explain the rationale for confirming breath sounds. (A-2)
>
> 8-1.28 Explain the rationale for securing the endotracheal tube. (A-3)

**[PSYCHOMOTOR OBJECTIVES]{.underline}**

> At the end of this lesson the EMT-Basic student will be able to:
>
> 8-1.29 Demonstrate how to perform the Sellick maneuver (cricoid
> pressure). (P-1,2)
>
> 8-1.30 Demonstrate the skill of orotracheal intubation in the adult
> patient. (P-1,2)
>
> 8-1.31 Demonstrate the skill of orotracheal intubation in the infant
> and child patient. (P-1,2)
>
> 8-1.32 Demonstrate the skill of confirming endotracheal tube placement
> in the adult patient. (P-1,2)
>
> 8-1.33 Demonstrate the skill of confirming endotracheal tube placement
> in the infant and child patient. (P-1,2)
>
> 8-1.34 Demonstrate the skill of securing the endotracheal tube in the
> adult patient. (P-1,2)
>
> 8-1.35 Demonstrate the skill of securing the endotracheal tube in the
> infant and child patient. (P-1,2)