EMT Certifications - What We Need to Get Certified

EMS Operations • EMT certifications – what we need to get certified o 18 years old, high school diploma/GED, proof of immunizations, BLS/CPR, clear background o Levels of EMS responders ▪ EMR: provide immediate BLS and urgent care using limited equipment • Law enforcement officers, firefighters, park rangers, etc ▪ EMT: has basic knowledge and skills to provide BLS, assumes responsibility for assessment, care, packaging, and transport of the patient • Requires 150 hours of training ▪ AEMT: ALS training in IV therapy, advanced airway adjuncts, administration of limited number of medications ▪ Paramedic: ALS training in endotrachael intubation, emergency pharmacology, cardiac monitoring • Requires 1000-1300 hours of training • Order of operations o Scene Size Up à BSI/PENMAN ▪ Situational awareness: paying attention to the conditions and people around you at all times and the potential risks those conditions or people pose o o General impression: age, sex, race, level of distress, overall appearance, position, C/C, stability, identify life threats Primary Assessment ▪ ABCDTs • Airway: open, clear, maintainable • Breathing: rate, depth, quality o Less than 8bpm, greater than 28bpm, or shallow/labored à give BVM • Circulation: pulse, quality, CRT, CMT, skin signs, obvious bleeding o Rapid scan to look for injuries: 60-90 seconds • Disability: A/O status (LOC through APVU/PPPT), GCS o If altered LOC, check glucose levels using glucometer if ALS available • Transport: Critical or stable? o Golden Hour: time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best o History Taking (SAMPLE, OPQRST) " ▪ C/C, S&S ▪ Demographic: date of incident, age, gender, race, past medical history, current health status o Secondary Assessment ▪ Focused (IPA) assessment • DCAPBTLS • TIC • Lung sounds ▪ Respiratory system • Note RR, tidal volume, rhythm, rate, depth, quality of breathing • Listen for o Signs of airway obstruction, asymmetry, abnormalities in breath sounds, retractions, increased work of breathing o Snoring: suggest an obstruction or narrowing of the lower airways o Wheezing: suggest an obstruction of the lower airways o Crackles: wet, crackling breath sounds may indicate fluid in the lungs o Rhonchi: congested breath sounds may suggest the presence of mucus in the lungs o Stridor: may indicate that the patient has an airway obstruction in the neck or upper part of the chest ▪ Cardiovascular system • Note pulse, respiratory rate, blood pressure, rate, quality, rhythm of heartbeat, bilateral and distal pulses ▪ Neurologic system • Evaluate LOC, APVU, GCS, pupil size ▪ Neurovascular status • Note bilateral muscle strength, PMSCs, pain sensation, position of the patient ▪ Trauma • Head: Eyes PEARRL, raccoon eyes, battle signs, missing teeth, secretions in nose/mouth/ears, CSF in ears • Neck: tracheal deviation, JVD, step offs, medical alert tags, stoma, subcutaneous emphysema • Chest: flail chest, paradoxical movement, sucking chest wound, penetrating wounds o Flail segment Tx: bulky dressing taped on 4 sides o Sucking chest wound Tx: flutter valve/occlusive dressing taped on 3 sides • Abdomen: DRGERM o Eviscerations Tx: moist sterile dressing layered with dry sterile dressing • Pelvis: PIG o Do not palpate if patient complains of pain • Lower Extremities: offset pressure, fractures Tx: splint • Feet: bilateral PMSC • Upper Extremities offset pressure, fractures Tx: splint • Hands: bilateral PMSC • Back: exit wounds, step offs, incontinence, lung sounds o o Vitals (BELLSRP) ▪ Pulse oximetry: used to evaluate effectiveness of oxygenation by measuring oxygen saturation of Hgb (95-99%) ▪ Capnography: monitoring of the concentration or partial pressure of carbon dioxide in ventilation, circulation, metabolism ▪ Blood glucometry: measures the level of glucose in patient’s bloodstream ▪ Sphygmomanometer: blood pressure cuff to measure BP Reassessments during Transport ▪ Chief Complaint (C/C), LOC, ABCs, Vital signs, Interventions ▪ Timing • Every 5 minutes if critical • Every 15 minutes if stable • AVPU o o Alert, verbal, painful, unresponsive Using PPPT: person, purpose, place, time • GCS score calculations o 4 for eyes, 5 for verbal, 6 for motor = 15 total o Lowest = 3 • Infection control o Handwashing is the most effective way to prevent the spread of infection o Education and training, PPE, HepB vaccine program, cleaning and disinfection practice o Routes of Transmission " ▪ Direct contact: touching the infected person ▪ Indirect contact: touching an object that has already been contaminated ▪ Airborne transmission: through particles in the air (ex: cough, TB) ▪ Foodborne transmission: through food ▪ Vector-borne transmission: through touching an infected insect (ex: Zika virus) o Masks, Respirators, and Barrier Devices ▪ Wear a surgical mask for fluid splatter ▪ Wear a particulate respirator if the disease agent is airborne • N95/HEPA Mask for TB patients o Postexposure management ▪ Turn over patient care to another EMS provider. ▪ Clean the exposed area with soap and water. ▪ If your eyes were exposed, rinse your eyes for 20 minutes. ▪ Activate your department’s infection control plan. • How to treat a patient with a DNR o A DNR order (also known as a “do not attempt resuscitation” order) gives permission not to resuscitate. ▪ “Do not resuscitate” does not mean “do not treat.” Even in the presence of a DNR order, you are still obligated to provide supportive measures (oxygen, pain relief, and comfort) to a patient who is not in cardiac arrest, wherever possible ▪ Must document • Statement of the patient’s medical problems • Signature of the patient or legal guardian • Signature of physician or health care provider • Not expired ▪ If a patient does not have a written DNR order, continue all treatments (including CPR) until given proof " • How do you complete a PCR o Patient care report ▪ Legal document that serves to ensure: continuity of care, legal documentation, education, administrative information, essential research record, evaluation and continuous quality improvement ▪ Involves the • C/C • LOC • Vital signs • Initial assessment • Patient demographics: age, gender, ethnic background • Time: incident reported, EMS unit notification, EMS arrival on scene, EMS departure from scene, EMS arrival at hospital, patient care transfer • Narrative section: time of events, assessment findings, Tx provided, changes in the patient after Tx, observations at the scene, final patient disposition, refusal of care, staff person who continued care o o If you leave something out or record something incorrectly, don’t cover it up Do not record your conclusions about the incident, just write facts (ex: patient was intoxicated vs. patient admitted to having 6 shots of vodka) • Know the different types of consent o Consent: permission to render care o Expressed consent: the patient verbally or otherwise acknowledges permission for you to provide care or transport o Informed consent: permission for treatment after explanation of treatment, risks, benefits, alternatives, and potential consequences of Tx o Implied consent (emergency doctrine): applies to patients who are unable to make their own informed decisions ▪ Ex: A/O x 3 or below patients, minors/children, unresponsive patients ▪ Used only when there is a threat to life or limb o Involuntary consent: when you have to “force” treatment onto a patient, after obtaining consent from a guardian or law enforcement ▪ Used for patients who are • Mentally ill • In behavioral crisis • Developmentally delayed • Attempted suicide ▪ Forcible restraints can be used with a combative patient who presents a risk of danger to self or others • Involves law enforcement and medical control o Refusal of care ▪ Patient must be A/O x4: conscious, rational, capable of making informed decisions ▪ Only accepted after you inform the patient of the risks of denying Tx ▪ Sign AMA with signature of patient or non-EMS witness • Scene safety (PENMAN) o Call for ALS, PD, fire, Hazmat • What is an EMT scope of practice o Outlines the care we are able to provide o Medical director further defines the scope of practice by developing ▪ Protocols: national, state, local, department ▪ Standing orders: standards that enable you to do some duties without medical control o Standards of care: the manner in which you must act or behave, compared to what another person with your same scope of practice would do o Negligence: failure to provide standard for care ▪ All 4 elements must be present for negligence to apply • Duty: standard of care • Breach of duty: deviation from the standard of care • Damage: what happened to the patient • Causation: direct cause and effect of the breach and damages o Abandonment: unilateral termination of care by the EMT without the patient’s consent and without making provisions for care to be continued by a medical professional who is competent to provide care for the patient o Roles and responsibilities of the EMT ▪ Keep vehicles and equipment ready for an emergency. ▪ Ensure the safety of yourself, your partner, the patient, and bystanders. ▪ Be familiar with emergency vehicle operation. ▪ Be an on-scene leader. ▪ Perform an evaluation of the scene. ▪ Call for additional resources as needed. ▪ Gain patient access. ▪ Perform a patient assessment. ▪ Give emergency medical care to the patient while awaiting the arrival of additional medical resources. ▪ Give emotional support to the patient, the patient’s family, and other responders. ▪ Maintain continuity of care by working with other medical professionals. ▪ Resolve emergency incidents. ▪ Uphold medical and legal standards. ▪ Ensure and protect patient privacy. ▪ Give administrative support. ▪ Constantly continue your professional development. ▪ Cultivate and sustain community relations. ▪ Give back to the profession. • Removing a patient from a tight space/extrication o Identify the need for rapid extrication ▪ For patients who are in • Shock • Inadequate ventilation • With altered LOC ▪ Rapid extrication with 3-4 EMRs: 1 minute removal from a car - increases damage because skipping immobilization (6-8min) • Used to quickly remove a patient from a vehicle and onto a backboard • Stages of grieving o Denial o Anger, hostility o Bargaining o Depression o Acceptance • START triage, jumpstart triage, reverse triage o 3 basic components: RPM (respirations, perfusion, mental status) o Simple triage and rapid treatment ▪ Green – low priority - determined by calling patients and telling them to come to you • walking wounded , minimal treatment, Tx can be delayed to last ▪ Yellow – delayed • Tx and transport can be temporarily delayed • Burns without air compromise • Major multiple bone injuries • Back injuries without spinal cord damage ▪ Red – immediate • Airway/breathing compromise • Uncontrolled or severe bleeding • Severe medical problems • Shock / hypoperfusion • Severe burns • Open chest or abdominal injuries ▪ Black – deceased • Obvious death • Obvious nonsurvival injuries: major open brain trauma • Respiratory arrest • Cardiac arrest o Jumpstart ▪ For pediatric patients younger than 8 years old and weigh less than 100 pounds ▪ Green: Able to walk ▪ Yellow: Can’t walk and breathing at a rate of 15 – 45 breaths/ min ▪ Red • Can’t walk and… • Not breathing o Reposition airway à breathing = red o Reposition airway à apneic à check pulse o If they have a pulse à give 5 rescue breaths ▪ If they start breathing after rescue breaths = red ▪ Still apneic = black o If they don’t have a pulse = black • Breathing is < 15 or > 45 • Breathing, with no pulse • Breathing, with a pulse, unresponsive o Reverse Triage: used for lightning situations when you would start with the black tagged patients first • MCI – job responsibilities as an EMT o We report to the IC when we first arrive, and then we report to the section supervisor o Job Responsibilities ▪ Incident command: person in charge of the entire incident, most experience, establishes objectives and priorities ▪ finance: responsible for documenting all expenditures ▪ logistics: responsible for communications equip, facilities, food, water, etc ▪ operations: manages and supervises the tactical operations ▪ planning: develops an incident action plan, solves problems as they arise during an incident ▪ command staff " • safety officer – ensures safety of scene • public information officer – talks to media • liaison officer – relays information and concerns ▪ medical branch • triage supervisor – counting and prioritizes patients during triage • treatment supervisor – ensures patients are tiered and has received secondary triage • transportation supervisor – coordinates transportation ▪ staging supervisor – manages the emergency vehicles ▪ physicians on scene ▪ rehab sector – rest area for EMS ▪ extrication and special rescue – if needed ▪ morgue supervisor – works with the deceased • What are the functions of the rescue team o Requires specialized skills and equipment o Search and rescue team o Trench team: collapses that involve dirt weighting >100lbs / cubic foot, risk of secondary collapse, EMT should partk 500 feet away, do not enter trench more than 4 feet wide without shoring o • Jump kit o o Tactical team: EMT who respond to violent info, usually involving swat What it is: everything we need in the first 5 minutes of EMT treatment What is inside: normal PPE, triangle bandages, trauma shears, tape, trauma dressing, self adhere soft roller bandages, OPA/NPA for adult/child/infant, BVM for adult/child/infant, BP cuff, steth, pen light, sterile 4x4, dressing, adhesive strips, oral glucose, activated charcoal ▪ NO AED • How often reassess stable vs critical patient o Stable: 15 minutes o Critical: 5 minutes o What do we reassess first: ABCDT, C/C, interventions, vitals, and LOC • How to use a glucometer o Make sure you have all your equipment o Turn on the glucometer: stick the strip into the glucometer o Clean the patient’s finger with alcohol swab o Prick with the lancet à dispose o Remove the first drop of blood, test the second drop of blood o Clean the finger and place a bandaid on it o Read the glucometer: hypo vs hyperglycemic (80-120 is normal) • O2 saturation, when it can give altered or bad readings o Assisted Ventilations ▪ Blow by O2: 22% ▪ Nasal cannula: 24-44% ▪ NRB: 95% ▪ BVM: 100% o What gives bad readings ▪ Nail polish/acrylic ▪ Poor perfusion of the extremities/peripheral vasoconstiction ▪ Patient is shaking/moving too much ▪ Hypovolemia ▪ CO poisoning • Techniques for decontamination of: rig, equipment o Disinfection: killing the pathogenic agents by directly applying chemicals ▪ High level disinfection: using a potent spra o Sterilization: process of allowing air to dry • How to treat and document for a sexual assault patient o " o When performing your assessment, be aware of drugs used during sexual assault or rape to incapacitate a person ▪ Rohypnol/Roofies: common sexual assault/rape drugs ▪ Sexual Assault Drug Signs and Symptoms •" • Hypotension • Bradycardia • Abdominal complaints • Difficulty breathing • Seizures • Coma ▪ Get a female EMT if possible ▪ Preserve evidence: don’t cut through clothing, don’t throw away things, tell patient not to clean herself, shower, urinate, change clothes, etc Airway " • Anatomy and physiology of the airway o Upper airway: Nose, mouth, tongue, larynx, pharynx, trachea, epiglottis ▪ Function: warm, filter, and humidify air as it enters the body o Lower airway: Thyroid cartilage, cricoid cartilage, cricothyroid cartilage, trachea ▪ Function: deliver oxygen to the alveoli o Structures that help us breathe: diaphragm, chest wall muscles, accessory muscles of breathing, nerves from brain and spinal cord to those muscles • Difference between respiration, ventilation, and oxygenation o Respiration: the exchange of oxygen and carbon dioxide in the alveoli and tissues ▪ Oxygenation: the process of loading O2 molecules onto Hgb molecules ▪ External respiration: brings fresh air into the respiratory system and exchanges O2 and CO2 in the pulmonary capillaries ▪ Internal respiration: exchange of O2 and CO2 between the systemic circulatory system and the cells of the body at the tissue level o Ventilation: the physical act of exchanging air in and out of the lungs ▪ Inhalation: active, muscular part of breathing, when the diaphragm contracts and straightens out ▪ Exhalation: passive part of breathing, when the diaphragm relaxes • Respiratory rates o Adult: 12-20 o Child: 15-30 o Infant: 25-50 • Identify hypoxia signs and symptoms o Hypoxia: failure to meet the body’s need for oxygen, causing the tissues and cells to be low in O2 ▪ For most people, the drive to breathe is based on pH changes in the blood and cerebrospinal fluid (based on levels of CO2, ex: COPD) ▪ Signs: SOB, shallow breathing, cyanosis ▪ Hypoxic drive: form of respiratory drive in which the body uses O2 chemoreceptors instead of CO2 receptors to regulate respiration • Common airway obstructions o Adult: food, sputum, saliva, blood, relaxation of the throat muscles in an unresponsive patient, vomiting, dentures, foreign bodies o Child: toys, small things, tongue, aaaaanything >_> o How do you treat a patient with an airway obstruction ▪ Visualize the airway to see if you can take it out, but never do a blind sweep ▪ Heimlich/abdominal thrusts/chest thrust/back thrust o Signs of normal breathing for adults ▪ 12-20 bpm ▪ Regular pattern of inhalation and exhalation ▪ Bilateral clear and equal lung sounds ▪ Regular, equal chest rise and fall ▪ Adequate depth (tidal volume) o Signs of abnormal breathing for adults ▪ Fewer than 12-20 bpm ▪ Dyspnea: shortness of breath ▪ Irregular rhythm ▪ Diminished, absent, or noisy auscultated breath sounds ▪ Shallow depth (reduced tidal volume) ▪ Retractions: skin pulling in around ribs or above clavicles during inspiration ▪ Agonal gasps: gasping breaths that continue after the heart has stopped ▪ Cheyne-Stokes respirations: breathing with increasing rate and depth followed by apnea (stroke/head injury patients) ▪ Kussmaul respirations: deep, rapid respirations often seen in patients with metabolic acidosis o Foreign object obstruction ▪ When available, perform suctioning to maintain a clear airway ▪ Abdominal thrusts are the most effective method to dislodge and force an object out of the airway of a conscious person ▪ For an unresponsive patient, reassess to confirm apnea and inability to ventilate • Begin chest compressions 30:2 • Check for foreign objects à remove if possible with gloved hand • Techniques for opening airway o No spinal injury: head tilt chin lift o Suspected spinal injury: jaw thrust o Pediatrics: firm surface, place a towel under their neck to lift the neck, do not hyperextend o OPA: no gag reflex, unconscious o NPA: gag reflex, do not use with head trauma • Difference between adult and pediatric airway " o Pediatrics have an underdeveloped airway, smaller lungs, larger tongue, larger occiput, larger epiglottis, easy to kink airway o Adult – normal • Alveolar minute volume o The volume of air moved through the lungs in one minute minus the dead space o Calculation: (tidal volume – dead space) x respiratory rate • CPAP indications o Continuous positive airway pressure (CPAP): forcing air into the chest cavity, could cause gastric distention, vomiting, aspiration ▪ Indications: alert, has moderate to severe respiratory distress from diseases like CHF, and pulmonary edema, <90% O2sat ▪ Contraindications: not alert, respiratory arrest, apneic, S&S of pneumothorax or chest trauma, has a tracheostomy, active GI bleeding/vomiting • How to treat a vomiting patient o Roll to the side à remove the OPA à suction • S&S " o Emphysema ▪ Emphysema: most common type of COPD, Loss of elastic material in the lungs as a result of chronic stretching of the alveoli ▪ Signs and Symptoms: cough, difficulty expelling air from lungs, wheezing, thin appearance with a barrel chest, pursed lips, tripod position, pink skin color, dry lung sounds o o • Medications COPD ▪ Slow process of dilation and disruption of airways and alveoli caused by chronic bronchial obstruction ▪ Signs and Symptoms: chronic cough, difficulty expelling air from longs, long expiration phases, “dry” lung sounds (wheezing), thick sputum SARs – severe acute respiratory syndrome ▪ Caused by virus, spread through droplet and indirect contact with contaminated objects, typically caused by prehospital care and nursing homes ▪ 10 days incubation period ▪ Signs and Symptoms: fever, muscle aches, headache, sore throat, nonproductive cough, sometimes presents with pneumonia , highly contagious ▪ Influenza virus o MDI: Bronchodilator (albuterol) ▪ Side effects: HTN, tachycardia, anxiety, restlessness ▪ Indications: asthma, difficulty breathing, wheezing ▪ Contraindications: hypersensitivity, tachycardia, chest pain of cardiac origin Cardiovascular " • Describe the AHA chain of survival o 5 links ▪ Recognition of early warning signs and immediate activation of EMS ▪ Immediate CPR with emphasis on compressions ▪ Rapid defibrillation ▪ Basic and advanced EMS ▪ ALS and postarrest care o AED defib within 2 minutes ensures highest survival o What to do when a patient is unresponsive: BSI, check for responsiveness, call for ALS, check airway, check pulse, 5 cycles of CPR o What to do when AED is analyzing, shock, etc ▪ Analyzing: clear ▪ Charging: compressions ▪ Administering shock: clear ▪ After shock: compressions • Full treatment of a patient in cardiac arrest at a BLS level o CPR ▪ Adult • 30:2 ventilations using head tilt chin lift/jaw thrust maneuver and full hands o Ventilations: 1 breath every 5-6 seconds o One rescuer: 30:2 o Two rescuer: 30:2 • Depth: 2 inches (1/3 of the person) • Rate: 100-120 compressions per minute ▪ Child • 30:2 ventilations using head tilt chin lift/jaw thrust maneuver and one hand o Ventilation: 1 breath every 3-5 seconds o One rescuer: 30:2 o Two rescuer: 15:2 • Depth: 2 inches (1/3 of the person) • Rate: 100-120 compressions per minute ▪ Infant • 30:2 ventilations using head tilt chin lift/jaw thrust maneuver and two fingers/two thumb encircling hands technique o Ventilation: 1 breath every 3-5 seconds o One rescuer: 30:2 o Two rescuer: 15:2 • Depth: 1.5 inches (1/3 of the person) • Rate: 100-120 compressions per minute o AED