EMERGENCY MEDICAL TECHNICIAN

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EMERGENCY MEDICAL TECHNICIAN

• Review 1st half
• Compiled by Barry Barkinsky EMS-I

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Preparatory
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The EMS System

• Components of the
• Emergency Medical
• Services (EMS) System

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System Access

• Enhanced 911
• 911
• Non-911

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Bystanders
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Emergency Medical Dispatcher
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First Responders
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Emergency Medical Technician-Basic
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Advanced Life Support (ALS)
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Emergency Department Staff
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Specialty Facilities

• Trauma Centers
• Burn Centers
• Pediatric Centers
• Poison Control Centers

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Roles and Responsibilities

• Scene Safety
• Patient Assessment / Care
• Lifting and Moving
• Transport / Transfer of Care
• Documentation
• Patient Advocacy

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Quality Improvement

• Provides documentation
• Reviews audits runs
• Gathers feedback from patients hospital staff
• Conducts preventive maintenance
• Continues education
• Maintains skills

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Medical Direction

• Medical Director
• Sponsor Hospital
• Medical Direction
• On-Line radio, phone patch
• Off-Line standing orders

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Well - Being
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Well Being of the EMT

• Emotion and Stress
• Scene safety
• Exposure Control Plan
• Lifting and Moving

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Emotion and Stress

• Causes
• Signs and Symptoms
• Dealing with Stress
• CISD
• Understanding of Death and Dying

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Scene Safety
Scene safety starts on arrival and continues
throughout the call!
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Medical / Legal
What is ?
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Medical / Legal

• Scope of Practice

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Medical / Legal

• Expressed Consent

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Medical / Legal

• Implied Consent

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Medical / Legal

• DNR

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Medical / Legal

• LIVING WILL

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Medical / Legal

• Abandonment

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Medical / Legal

• Negligence

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Medical / Legal

• Refusal

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Medical / Legal

• Special Reporting Situations

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Medical / Legal

• Crime Scene

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DOCUMENTATION
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Documentation

• Your written prehospital care report (PCR) is the
  only true factual record of events.
• Your PCR is your sole permanent, complete written
  record of events during theambulance call.

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Uses for PCRs

• Medical
• Administrative
• Research
• Legal

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General Considerations

• Use appropriate medicalterminology.
• Use acceptable and approvedabbreviations and
  acronyms.

If you do not know how to spell a word, look it
up or use another word
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Communications

• The communications with thehospital are another
  important item to document.
• Document ANY medical advice ororders you receive
  and the results of implementing that advice and
  those orders.

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Pertinent Negatives

• Document all findings of your assessment, even
  those that are normal.
• Remember you are building a case to support your
  clinical impression

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Oral Statements

• Whenever possible, quote the patientor other
  source of informationdirectly.

Example Bystanders state the patient was acting
bizarre and threatening to jump in front of the
next passing car.
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Elements of Good Documentation

• Accuracy
• Legibility
• Timeliness
• Absence of alterations
• Professionalism

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Professionalism

• Never include slang, biasedstatements, or
  irrelevantopinions.
• Include only objectiveinformation.
• Always write and speak clearly.

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Narrative Writing

• Subjective part of your narrative comprises any
  information that you elicit during your patients
  history.
• Objective part of your narrative usually includes
  your general impression and any data that
  youderive through inspection, palpation,
  auscultation, percussion, and diagnostic testing.

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Special Considerations

• Patient refusals
• Services not needed
• Mass casualty incidents

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Patient Refusals

• Patients retain the right to refusetreatment or
  transportation if theyare competent to make that
  decision.
• Two main types of refusals
• Person who is not seriously injured and does
  not want to go to the hospital
• The patient refuses even though you feel he
  needs it. Also known as AMA

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A patients refusal of care requires careful
documentation.
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Airway Management
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Airway Management

• Anatomy

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Airway Management

• Upper Airway
• Comprised of?

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Airway Management
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Airway Management

• Lower Airway

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Airway Management
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Airway Management

• Opening the Airway
• - No trauma

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Airway Management

• Opening the Airway (Trauma)

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Airway Management

• Breathing
• Ventilation versus oxygenation

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Airway Management

• Signs and Symptoms
• Adequate / Inadequate Breathing
• Can you list them?

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Airway Management

• Suctioning
• How, how long?

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Suctioning

• Purpose
• Devices
• Measurement
• Time
• Procedure

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Airway Management
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Airway Management

• Artificial Ventilations
• Adjuncts-name, measure, insert
• Oxygen devices

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Non-Invasive Respiratory Monitoring
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Pulse Oximeter
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PATIENT ASSESSMENT
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BSI

• B Body
• S Substance
• I Isolation

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MOI / NOI

• M Mechanism
• O of
• I Injury
• N Nature
• O of
• I Illness

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SAMPLE

• S Signs and Symptoms
• A Allergies
• M Medications
• P Past Medical History
• L Last Oral Intake
• E Events Leading to the Injury / Illness

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OPQRST

• O Onset
• P Provocation
• Q Quality
• R Radiation
• S Severity
• T Time

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DCAP-BTLS

• D Deformity
• C Contusions
• A Abrasions
• P Punctures / Penetrations
• B Burns
• T Tenderness
• L Lacerations
• S Swelling

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Baseline Vital Signs

• Respirations
• Pulse
• Skin
• Pupils
• Blood Pressure
• Pulse Ox
• Temperature

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Ongoing Assessment

• Repeat Initial Assessment
• Reassess Vital Signs
• Repeat Focused Assessment
• Check Interventions

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Ongoing Assessment

• Stable Patient
• How often?

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Ongoing Assessment

• Unstable Patient
• How often?

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Rapid Trauma Assessment(Check for DCAP-BTLS)

• Head
• Neck
• Chest
• Abdomen
• Pelvis
• Extremities (PMS)
• Posterior

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Head DCAP-BTLS
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Ears DCAP-BTLS Drainage
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Neck DCAP-BTLS Jugular Vein Distention and
Crepitation
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Chest DCAP-BTLS Crepitation and Breath Sounds
(Presence and Equality)
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Listen to both sides of the chest. Is air entry
present? Absent? Equal on both sides? Compare
left side to right side.
Mid-clavicular
Mid-axillary
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Abdomen DCAP-BTLS Firmness and Distention
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Pelvis DCAP-BTLS (Compress Gently)
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Extremities DCAP-BTLS Distal Pulse, Sensation,
Motor Function
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Posterior DCAP-BTLS
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TYPES OF PATIENTS
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Medical Patient

• Scene Size Up
• Safety
• BSI
• MOI / NOI
• Patients / Resources

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Medical Patient Responsive Patient

• Initial
• General Impression
• Mental Status
• ABCs
• Priority of Patient

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Medical Patient Responsive Patient

• Focused History and Physical Exam
• Physical Exam
• OPQRST
• SAMPLE

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Medical Patient Unresponsive Medical Patient

• Initial
• ABCs
• Rule out Trauma
• Focused Exam
• Rapid Assessment
• Vitals / SAMPLE
• Ongoing

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Patient Assessment Trauma Patient

• Determine MOI
• Significant / Non-Significant
• Initial Assessment
• ABCs
• Patient priority
• Focused History and Physical Exam
• DCAP- BTLS
• Rapid trauma assessment

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Patient Assessment Trauma Patient

• Rapid Trauma Assessment
• C-Collar
• Inspect, palpate, auscultate
• DCAP-BTLS
• SAMPLE
• Detailed Exam
• Ongoing

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Patient Assessment Trauma Patient

• Rapid Trauma Assessment
• C-Collar
• Inspect, palpate, auscultate
• DCAP-BTLS
• SAMPLE
• Detailed Exam
• Ongoing

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Trauma PatientNo Significant MOI

• Initial Assessment
• Focused History and Physical Exam
• Ongoing Assessment

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Pharmacology
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Pharmacology

• Medications on Ambulance
• Oxygen, charcoal oral glucose,

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Pharmacology

• Prescribed Medications
• Which ones can you assist the patient in taking?
  After what?

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Pharmacology

• Indications

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Pharmacology

• Contraindications

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Pharmacology

• The 4 Rights to Med Administration

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Medical Emergencies

• Seizures

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Seizures

• Generalized Seizures
• Tonic-Clonic
• Aura
• Loss of Consciousness
• Tonic Phase
• Clonic Phase
• Postseizure
• Postictal

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Seizures

• Partial Seizures
• Simple Partial Seizures
• Involve one body area.
• Can progress to generalized seizure.
• Also known as focal seizures
• Complex Partial Seizures
• Characterized by auras.
• Typically 12 minutes in length.
• Loss of contact with surroundings.

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Seizures

• Assessment
• Differentiating Between Syncope Seizure
• Bystanders frequently confuse syncope and seizure.

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Seizures

• Management
• Scene safety BSI.
• Maintain the airway.
• Administer high-flow oxygen.
• Treat hypoglycemia if present.
• Do not restrain the patient.
• Protect the patient from the environment.
• Maintain body temperature.

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Seizures

• Management
• Position the patient.
• Suction if required.
• Provide a quiet atmosphere.
• Transport.

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Seizures

• Status Epilepticus
• Two or More Generalized Seizures
• Seizures occur without a return of consciousness.
• Management
• Management of airway and breathing is critical.
• Monitor the airway closely.

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Medical Emergencies

• Stroke (CVA)

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Stroke Intracranial Hemorrhage

• Occlusive Strokes
• Embolic Thrombotic Strokes
• Hemorrhagic Strokes

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Stroke Intracranial Hemorrhage

• Signs
• Facial Drooping
• Headache
• Aphasia/Dysphasia
• Hemiparesis
• Paresthesia
• Gait Disturbances
• Incontinence

Symptoms Confusion Agitation Dizziness Vision
Problems
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Stroke Intracranial Hemorrhage

• Transient Ischemic Attacks
• Indicative of carotid artery disease.
• Symptoms of neurological deficit
• Symptoms resolve in less than 24 hours.
• No long-term effects.
• Evaluate through history taking
• History of HTN, prior stroke, or TIA.
• Symptoms and their progression.

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Stroke Intracranial Hemorrhage

• Management
• Scene safety BSI
• Maintain the airway.
• Support breathing.
• Obtain a detailed history.
• Position the patient.
• Protect paralyzed extremities.

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Medical Emergencies

• Allergic Reaction (Anaphylaxis)

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Allergies and Anaphylaxis

• Allergic Reaction
• An exaggerated response by the immune system to a
  foreign substance
• Anaphylaxis
• An unusual or exaggerated allergic reaction
• A life-threatening emergency
• The most severe form of allergic reaction

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Anaphylaxis

• Causes

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Assessment Findings in Anaphylaxis

• Focused History Physical Exam
• Focused History
• SAMPLE OPQRST History
• Rapid onset, usually 3060 seconds following
  exposure.
• Speed of reaction is indicative of severity.
• Previous allergies and reactions.
• Physical Exam
• Presence of severe respiratory difficulty is key
  to differentiating anaphylaxis from allergic
  reaction.

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Assessment Findings in Anaphylaxis

• Physical Exam
• Facial or laryngeal edema
• Abnormal breath sounds
• Hives and urticaria
• Hyperactive bowel sounds
• Vital sign deterioration as the reaction
  progresses

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Epi-Auto Injector

• Indicationsanaphylaxis requires??

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anaphylaxis

• Difficulty Breathing
• Systemic Skin reactions
• Hypotension

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Epi-Auto Injector

• Contraindications

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Epi-Auto Injector

• Dosage

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Epi-Auto Injector

• Actions

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Epi-Auto Injector

• Side Effects

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Epi-Auto Injector

• Administration

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SHOCK isINADEQUATETISSUEPERFUSION
In a Nutshell..
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OB / GYN
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OB / GYN

• Labor
• Bloody Show
• Crowning
• Predelivery Emergencies

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Labor

• Stage One (Dilation)
• Stage Two (Expulsion)
• Stage Three (Placental Stage)

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Management of a Patient in Labor

• Transport the patient in labor unless delivery is
  imminent.
• Maternal urge to push or the presence of crowning
  indicates imminent delivery.
• Delivery at the scene or in the ambulance will be
  necessary.

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Field Delivery

• Set up delivery area.
• Give oxygen to mother and start
• Drape mother with toweling from OB kit.
• Monitor fetal heart rate.
• As head crowns, apply gentle pressure.

Suction the mouth and then the nose. Clamp and
cut the cord. Dry the infant and keep it
warm. Deliver the placenta and save for transport
with the mother.
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OB / GYN ( Normal Delivery)
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OB / GYN ( Normal Delivery)
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OB / GYN ( Normal Delivery)
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OB / GYN ( Normal Delivery)
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OB / GYN ( Normal Delivery)
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OB / GYN ( Normal Delivery)
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Apgar Scoring
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OB / GYN ( Normal Delivery)

• Care of Newborn

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OB / GYN (Resuscitation)

• HR Less than 100

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OB / GYN (Resuscitation)

• HR less than 80

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OB / GYN (Resuscitation)

• HR less than 60

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Neonatal Resuscitation

• If the infants respirations are below 30 per
  minute and tactile stimulation does not increase
  rate to normal range, assist ventilations using
  bag valve mask with high-flow oxygen.
• If the heart rate is below 80 and does not
  respond to ventilations, initiate chest
  compressions.
• Transport to a facility with neonatal intensive
  care capabilities.

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Causes of Bleeding During Pregnancy

• Abortion
• Ectopic pregnancy
• Placenta previa
• Abruptio placentae

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Ectopic Pregnancy

• Assume that any female of childbearing age with
  lower abdominal pain is experiencing an ectopic
  pregnancy.
• Ectopic pregnancy is life-threatening. Transport
  the patient immediately.

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Placenta Previa

• Usually presents with painless bleeding.
• Never attempt vaginal exam.
• Treat for shock.
• Transport immediatelytreatment is delivery by
  c-section.

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Abruptio Placentae

• Signs and symptoms vary.
• Classified as partial, severe, or complete.
• Life-threatening.
• Treat for shock, fluid resuscitation.
• Transport left lateral recumbent position.

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Abnormal Delivery Situations
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OB / GYN (Abnormal Deliveries)

• Breech

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Breech Presentation

• The buttocks or both feet present first.
• If the infant starts to breath with its face
  pressed against the vaginal wall, form a V and
  push the vaginal wall away from infants face.
  Continue during transport.

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OB / GYN (Abnormal Deliveries)

• Prolapsed Cord

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Prolapsed Cord

• The umbilical cord precedes the fetal presenting
  part.
• Elevate the hips, administer oxygen, and keep
  warm.
• If the umbilical cord is seen in the vagina,
  insert two gloved fingers to raise the fetus off
  the cord. Do not push cord back.
• Wrap cord in sterile moist towel.
• Transport immediately do not attempt delivery.

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OB / GYN (Abnormal Deliveries)

• Limb Presentation

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Limb Presentation With limb presentation, place
the mother in kneechest position, administer
oxygen, and transport immediately. Do not
attempt delivery.
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Other Abnormal Presentations

• Whenever an abnormal presentation or position of
  the fetus makes normal delivery impossible,
  reassure the mother.
• Administer oxygen.
• Transport immediately.
• Do not attempt field delivery in these
  circumstances.

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Other Delivery Complications
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OB / GYN (Abnormal Deliveries)

• Multiple Births

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Multiple Births

• Follow normal guidelines, but have additional
  personnel and equipment.
• In twin births, labor starts earlier and babies
  are smaller.
• Prevent hypothermia.

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OB / GYN (Abnormal Deliveries)

• Meconium

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Meconium Staining

• Fetus passes feces into the amniotic fluid.
• If meconium is thick, suction the hypopharynx and
  trachea using an endotracheal tube until all
  meconium has been cleared from the airway.