Final Study

Question 1

Washing your hands is always a good option?

Answer 1

Proper handwashing is the simplest yet most effective way to control disease transmission (FIGURE 2-8). You should always wash your hands before and after contact with a patient, even if you wear gloves. The longer the germs remain with you, the greater the chance they will get through your barriers. Any breaks in the skin such as tiny cuts and abrasions are potential access points for pathogens. Although soap and water are not protective in all cases, in certain cases they provide excellent protection against further transmission from your skin to others. Rinse your hands using warm water. If running water is not available, you may use waterless handwashing substitutes (FIGURE 2-9). These solutions can prevent many potential bacterial infections. If you use a waterless substitute in the field, make sure you wash your hands using soap and water at the hospital. Finally, dry your hands with a paper towel, and use the paper towel to turn off the faucet.

Question 2

Remember that your safety is always first and foremost!

Answer 2

The personal safety of all those involved in an emergency situation is very important. In fact, it is so important that it is best that you internalize the steps necessary to preserve personal safety so your actions become automatic. A scene that appears safe initially can develop into a hazardous situation at any moment. Take care to notice any suspicious person or activity at the scene, because your first priority must be your own safety. A second accident at the scene or an injury to you or your partner creates more problems. Delays in emergency medical care for patients increase the burden on other EMTs and may result in unnecessary injury or death.
You should begin protecting yourself as soon as you are dispatched. Before you leave the scene, begin preparing yourself mentally and physically. Make sure you wear seat belts (including both the lap belt and shoulder harness) en route to the scene. Also make sure to wear seat belts and shoulder harnesses at all times during transport unless patient care makes it impossible (FIGURE 2-17). Many EMS units have mandatory seat belt policies for the driver at all times, for all EMTs during transit to the scene, and for anyone who is riding with a patient. Don the appropriate PPE prior to departing the ambulance.

Question 3

Discuss the steps necessary to determine scene safety and to prevent work-related injuries at the scene

Answer 3

You should begin protecting yourself as soon as you are dispatched. Before you leave the scene, begin preparing yourself mentally and physically. Make sure you wear seat belts (including both the lap belt and shoulder harness) en route to the scene. Also make sure to wear seat belts and shoulder harnesses at all times during transport unless patient care makes it impossible (FIGURE 2-17). Many EMS units have mandatory seat belt policies for the driver at all times, for all EMTs during transit to the scene, and for anyone who is riding with a patient. Don the appropriate PPE prior to departing the ambulance. Protecting yourself at the scene is also very important. A second accident may damage the ambulance and may result in
injury to you or your partner, or additional injury to the patient. The scene must be well marked (FIGURE 2-18). If law enforcement has not already done so, you should make sure the proper warning devices are placed at a sufficient distance from the scene to properly warn, slow, and divert oncoming traffic. This will alert motorists coming from both directions that a crash has occurred. When you must work in a traffic lane, park a heavy vehicle such as a fire engine (if available) in a position that blocks traffic in the lane where you are working. Park the ambulance at a safe but convenient distance from the scene. Before attempting to access patients who are trapped in a vehicle, check the vehicle’s stability. Then take any necessary measures to secure it. Do not rock or push on a vehicle to find out whether it will move. This can overturn the vehicle or send it crashing into a ditch. If you are uncertain about the safety of a crash scene, wait for appropriately trained personnel to arrive before approaching. It may not be your primary responsibility to ensure safe management of traffic flow, vehicle stabilization, and similar tasks, but it is always your responsibility to see that it has been properly accomplished. Park at least 100 ft (30.5 m) away from all crash sites. Wearing protective clothing and other appropriate gear is critical to your personal safety. Become familiar with the protective equipment that is available to you. Then you will know what clothing and gear are needed for the job. You will also be able to adapt or change items as the situation and environment change. Remember, protective clothing and gear provide protection only when they are in good condition. It is your responsibility to inspect your clothing and gear. Learn to recognize how wear and tear can make your equipment unsafe. Be sure to inspect equipment before you use it; ideally, this is done before reaching the scene so care is not delayed.

Question 4

What are the steps you should take if you are exposed to another persons body fluids

Answer 4

Because health care workers are exposed to so many different types of infections, the CDC developed a set of standard precautions for health care workers to use in treating patients. Standard precautions are protective measures designed to prevent health care workers from coming into contact with objects, blood, body fluids, and other potential risks that could lead to exposure to germs. The CDC recommendation from 2016 is to assume that every person is potentially infected or can spread an organism that could be transmitted in the health care setting; therefore, you must apply infection control procedures-procedures to reduce infection in patients and health care personnel. OSHA refers to the same concept using the term universal precautions. TABLE 2-4 summarizes the CDC recommendations.
You must also notify your designated officer if you are exposed.

Question 5

What does carbon monoxide do to your body?

Answer 5

A typical building fire emits a number of toxic gases, including carbon monoxide, cyanide, and carbon dioxide. Carbon monoxide is a colorless, odorless gas that is responsible for more fire deaths each year than any other by-product of combustion. Carbon monoxide combines with the hemoglobin in your red blood cells about 200 times more readily than does oxygen. It blocks the ability of the hemoglobin to transport oxygen to your body tissues. Cyanide is a product of the combustion of many materials that burn. Inhaling cyanide prevents cells from using oxygen. In sufficiently high concentrations, it causes signs and symptoms of shock and severe hypoxia leading to death. Carbon dioxide is also a colorless, odorless gas. Exposure causes increased respirations, dizziness, and sweating. Breathing concentrations of carbon dioxide greater than 10% to 12% will result in death within a few minutes.

Question 6

Describe the EMTs legal duty to act

Answer 6

Duty to act is an individual’s responsibility to provide patient care. Responsibility comes from either statute or function. A bystander is under no obligation to assist a stranger in distress and therefore has no duty to act. For an EMT, there may be a duty to act in certain instances, including the following:
• You are charged with emergency medical response.
• Your service or department’s policy states that you must assist in any emergency.
Once your ambulance responds to a call or treatment is begun, you have a legal duty to act. In most cases, if you are off duty and happen to see a motor vehicle crash, you are not legally obligated to stop and assist patients. There may be some circumstances where this is not true, and you should be familiar with the laws and policies that apply in your service area. If you choose to intervene while off duty, you must continue to provide competent care until an equal or higher medical authority assumes care of the patient.

Question 7

____is the type of consent given when the patient specifically acknowledges that he or she wants you to provide care or transport.___ may be verbal or nonverbal. For example, if you ask a patient if you can check his or her blood pressure and the patient says yes, that is verbal consent; if the patient nods yes or extends an arm to you, the patient is expressing consent nonverbally.

Answer 7

Expressed consent (or actual consent)

Question 8

To be valid, the consent the patient provides must be___, which means that you explained the nature of the
treatment being offered, along with the potential risks, benefits, and alternatives to treatment, as well as potential consequences of refusing treatment. Often, the prehospital environment requires that consent be obtained more quickly than in the hospital setting. Paramedics will often provide additional information if advanced life support (ALS) interventions are necessary. In such cases, there is a greater potential for side effects and other adverse responses associated with drug administration and other forms of advanced care.
_____is valid if given verbally, but it may be difficult to prove at a later point in time. Rarely do EMS providers
have patients sign a consent form, so it is always advisable to document consent in your run report. Having someone witness the patient’s consent may be helpful if the issue of consent is later challenged in court.
Remember, a patient may agree to certain types of emergency medical care but not to others. The patient’s right to
refuse treatment is discussed later in this chapter.

Answer 8

informed consent

Question 9

When a person is unconscious or otherwise incapable of making a rational, informed decision about care and unable to give
consent, the law assumes that the patient would consent to care and transport to a medical facility if he or she were able to do so (FIGURE 3-1). Patients who are intoxicated by drugs or alcohol, mentally impaired, or suffering from certain conditions such as head injury might be included in this category. The legal principle that allows treatment under such circumstances is called___._____ applies only when a serious medical condition exists and should never be used unless there is a threat to life or limb. For this reason, the principle of____ is known as the emergency doctrine.
Sometimes what represents a serious threat may be unclear. This may result in legal proceedings and a medicolegal judgment, which should be supported by your best efforts to obtain consent and a thoroughly documented run report. In most instances, the law allows a spouse, a close relative, or next of kin to give consent for an injured person who is unable to do so, and you should make every effort to obtain consent from an available relative before treating based on implied consent; however, treatment should never be delayed when the patient has imminently life-threatening injuries. It is also important to understand that if a patient being treated based on implied consent were to regain consciousness and appear capable of making an informed decision, the doctrine of_____ would no longer apply. This often occurs with calls involving diabetic emergencies, overdoses, syncope, and seizures.

Answer 9

implied consent

Question 10

Assisting patients who are mentally ill, developmentally delayed, or who are in behavioral (psychological) crisis is complicated. An adult patient who is mentally incompetent is not able to give informed consent. From a legal perspective, this situation is similar to those involving minors. Consent for emergency care should be obtained from someone who is legally responsible for the patient, such as a guardian or conservator. In many cases, however, such permission will not be readily obtainable. Many states have protective custody statutes allowing such a person to be taken, under law enforcement authority, to a medical facility. Under certain conditions, law enforcement and prison officials are legally permitted to give consent for any individual who is incarcerated or has been placed under arrest. However, a prisoner who is conscious and capable of making decisions does not necessarily surrender the right to make medical decisions and may refuse care. Know the provisions in your area and involve online medical control in the process.

Answer 10

Involuntary consent

Question 11

Describe local Ems system protocols for using forcible restraint

Answer 11

Forcible restraint is sometimes necessary when you are confronted with a patient who is in need of medical treatment and transportation but is combative and presents a significant physical risk of danger to himself or herself, rescuers, or others (FIGURE 3-3). Such behavior may result from an underlying psychiatric or behavioral condition, the effects of drugs, or a medical condition such as a head injury or hypoxia. Typically, you should consult medical control for authorization to restrain or contact law enforcement personnel who have the authority to restrain people. In some states, only a police officer may forcibly restrain an individual. You should be knowledgeable about local laws. Restraint without legal authority exposes you to potential civil and criminal penalties. Restraint may be used only in circumstances of risk to the patient or others. When a patient is combative and poses a risk to the rescuer, it is advisable to wait for law enforcement to arrive on scene before attempting to treat the patient. See Chapter 23, Behavioral Health Emergencies, for a complete discussion of the use of restraint. Your service should have clearly defined protocols to deal with situations involving restraint. Restraints should be considered only if the patient has a medical condition that appears serious or if he or she suffers from an apparent behavioral disorder that poses a risk to the patient or others. Verbal deescalation should always be attempted prior to considering physical restraints. The patient’s decision-making capacity should be assessed and thoroughly documented. After restraints are applied, they should not be removed en route unless they pose a risk to the patient, even if the patient promises to behave. Appropriate safe strategies for restraint should be used to minimize the risk of harm to the patient. It is essential that you protect the patient’s airway and monitor the patient’s respiratory and circulatory status while restrained to avoid asphyxia, aspiration, and other complications. Consider calling for ALS backup to provide chemical pharmacologic restraint, as this may be safer than physical restraint depending on the situation

Question 12

A medicolegal term relating to certain personnel who either by statute or by function have a responsibility to provide care

Answer 12

Duty to act

Question 13

There is a ____ when the EMT does not act within an expected and reasonable standard of care.

Answer 13

Breach of duty

Question 14

There must be a reasonable cause-and-effect relationship between the breach of duty and the damages suffered by the patient. This is often referred to as proximate causation. An example is dropping the patient during lifting, causing a fracture of the patient’s leg. If an EMT has a duty and breaches it, thereby causing harm to a patient, the EMT, the agency, and/or the medical director may be sued for negligence if that breach of duty was the direct cause of the patient’s injury.

Answer 14

Causation

Question 15

Negligence is the failure to provide the same care that a person with similar training would provide in the same or a similar situation. It is deviation from the accepted standard of care that may result in further injury to the patient. Determination of negligence is based on the following four factors:

Answer 15

1. Duty. The EMT has an obligation to provide care and to do so in a manner that is consistent with the standard of care established by training and local protocols.
2. Breach of duty. There is a breach of duty when the EMT does not act within an expected and reasonable standard of
   care.
3. Damages. There are damages when a patient is physically or psychologically harmed in some noticeable way.
4. Causation. There must be a reasonable cause-and-effect relationship between the breach of duty and the damages suffered by the patient. This is often referred to as proximate causation. An example is dropping the patient during lifting, causing a fracture of the patient’s leg. If an EMT has a duty and breaches it, thereby causing harm to a patient, the EMT, the agency, and/or the medical director may be sued for negligence if that breach of duty was the direct cause of the patient’s injury.

Question 16

Explain the reporting requirements for patient care as well as why it is so important to document everything

Answer 16

A complete and accurate record of an emergency medical incident is an important safeguard against legal complications. The absence of a record, or a substantially incomplete record, increases the likelihood that you may have to testify on memory alone. This can prove to be wholly inadequate and embarrassing in the face of aggressive cross-examination.
You should consider the following two general rules regarding reports and records:
• If an action or procedure is not recorded on the written report, it was not performed.
• An incomplete or untidy report is evidence of incomplete or inexpert emergency medical care.

Most EMS agencies require that exposures to specific communicable diseases be reported. You may be asked to transport certain patients in restraints, which may also need to be reported. Each of these situations can present significant legal problems. You should learn your local protocols regarding these situations.
Not only do the events that need to be reported vary significantly from state to state but so do the methods and procedures by which such reporting must take place. For example, although all states require that suspected child abuse be reported, some states require that the report be filed with law enforcement, others with a designated child protection agency, and yet others with the ED. There are often time-sensitive provisions associated with reporting statutes. As has been noted earlier, it is important that you become familiar with reporting requirements of your state. Failure to report may result in disciplinary action, suspension of your privileges to practice as an EMT, a fine, or even criminal prosecution. State laws vary regarding whether EMS personnel must report rape or sexual assault. In some states, the decision to report these crimes lies with the patient. Note that suspected sexual abuse of children or older adults and domestic abuse must be reported in most states. In some instances, drug-related injuries must be reported. These requirements may affect how you approach documenting the care of a patient. However, it should be stressed that the US Supreme Court has held that drug addiction, in contrast to drug possession or sale, is an illness and not a crime. Therefore, an injury that results from a drug overdose may not be within the definition of an injury resulting from a crime.
Some states, by statute, specifically establish confidentiality and excuse certain specified people from reporting drug cases, either to a government agency or to a minor’s parents, if, in the opinion of those people, withholding reporting is necessary for the proper treatment of the patient. Once again, you must be familiar with the legal requirements of your state. All states have enacted laws to protect abused children, and some have added other protected groups such as the older population and at-risk adults. Most states have a reporting obligation for certain people, ranging from physicians to any person. You must be aware of the requirements of the law in your state. Such statutes frequently grant immunity from liability for libel, slander, or defamation of character to the individual who is obligated to report, even if the reports are subsequently shown to be unfounded, as long as the reports are made in good faith.

Question 17

Use of the___ score can be helpful in providing additional information on patients with changes in mental status. The___ uses parameters that test a patient’s eve opening, best verbal response, and best motor response. The scale provides a numeric score that is associated with the relative severity of a patient’s brain dysfunction (TABLE 10-8). This information provides baseline data on the patient’s overall neurologic status and can be used to help determine if that status is changing for better or worse. A modified__ is used for children and infants, who respord differently from adults.

Answer 17

Glasgow Coma Scale (GCS)

Question 18

Glasgow Coma Scale (GCS) eye-opening numbers

Answer 18

Spontaneous 4
In response to sound 3
In response to pressure 2
None 1

Question 19

Glasgow Coma Scale (GCS) best verbal response numbers

Answer 19

Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1

Question 20

Glasgow Coma Scale (GCS) best motor response numbers

Answer 20

Obeys commands 6
Localizes to pressure 5
Withdraws from pressure 4
Abnormal flexion 3
Abnormal extension 2
None 1

Question 21

How long should you count an irregular heartbeat for

Answer 21

A pulse that is weak and difficult to palpate, irregular, or extremely slow should be palpated and counted for a full minute. A pulse rate is counted as beats per minute.

Question 22

What can cause altered mental status

Answer 22

A change in the way a person thinks and behaves that may signal disease in the central nervous system or elsewhere in the body. Any deviation from alert and oriented to person, place, time, and event, or from a patient’s normal baseline is considered an altered mental status.

Question 23

What is a pulse oximeter used to assess

Answer 23

Pulse oximetry is an assessment tool used to evaluate the effectiveness of oxygenation. The pulse oximeter is a photoelectric device that monitors the oxygen saturation of hemoglobin (the iron-containing portion of the red blood cell to which oxygen attaches) in the capillary beds (FIGURE 10-36). The parts that make up the pulse oximeter include a monitor and a sensing probe. The sensing probe clips onto a finger or earlobe. The light source must have unobstructed access to a capillary bed, so dark fingernail polish might need to be removed. Results appear as a percentage on the display screen. Normally, pulse oximetry values in ambient air will vary depending on the altitude, with most values falling between 94% and 99%.

The goal of applying oxygen therapy is to increase oxygen saturation to a normal level. This device is a useful assessment tool to determine the effectiveness of oxygen therapy, bronchodilator therapy, and artificial ventilations.
However, the pulse oximeter does not take the place of good assessment skills and should not prevent the application of oxygen to any patient who reports difficulty breathing regardless of the pulse oximetry value seen on the monitor.
Because the device functions properly only with adequate perfusion and numbers of red blood cells, any situation that causes vasoconstriction (such as hypothermia or shock) or loss of red blood cells (such as bleeding or anemia) will result in inaccurate or misleading values. The device also presumes that oxygen is saturating the hemoglobin.
Therefore, any chemical that displaces oxygen (such as carbon monoxide) may cause misleading values.
The pulse oximeter is a useful tool as long as you remember that the device is only a tool, not a substitute for a good assessment.

Question 24

Indications and contraindications for oral airway

Answer 24

Indications for the oral airway include the following:
• Unresponsive patients without a gag reflex (breathing or apneic)
• Any apneic patient being ventilated with a bag-mask device
Contraindications for the oral airway include the following:
Conscious patients
• Any patient (conscious or unconscious) who has an intact gag reflex

Question 25

Indications and contraindications for nasal

Answer 25

indications for the nasopharyngeal airway include the following: • Semiconscious or unconscious patients with an intact gag reflex • Patients who otherwise will not tolerate an oropharyngeal airway Contraindications for the nasopharyngeal airway include the following: • Severe head injury with blood draining from the nose • History of fractured nasal bone

Question 26

How does positive pressure ventilation affect cardiac output

Answer 26

The physical act of the chest wall expanding and retracting during breathing helps the circulatory system return blood to the heart. During normal ventilation, the chest wall movement works similarly to a pump. The pressure changes in the thoracic cavity help draw venous blood back to the heart. However, when positive-pressure ventilation is initiated, more air is needed to achieve the same oxygenation and ventilatory effects of normal breathing. This increase in airway wall pressure causes the walls of the chest cavity to push out of their normal anatomic shape. As a result, there is an increase in the overall intrathoracic pressure. This pressure increase affects the return of venous blood to the heart. Considering that the left side of the heart receives only what the right side gives it, reduced venous return would result in reduced cardiac output. Therefore, it is imperative that you regulate the rate and volume of artificial ventilations to help prevent this drop in cardiac output. Cardiac output is a function of stroke volume and heart rate, such that cardiac output = stroke volume × heart rate. Stroke volume is the amount of blood ejected by the ventricle in one cardiac cycle. The heart rate is assessed by taking the pulse for 1 minute. The cardiac output is the amount of blood ejected by the left ventricle in 1 minute.

Question 27

Why is rapid and shallow breathing a problem

Answer 27

Keep in mind that fast, shallow breathing can be just as dangerous as very slow breathing. Fast, shallow breathing moves air primarily in the larger airway passages (dead air space) and does not allow for adequate exchange of air and carbon dioxide in the alveoli. Patients with inadequate breathing require assisted ventilations with some form of positive-pressure ventilation. Remember to follow standard precautions as needed when managing the patient's airway. Shallow breathing (reduced tidal volume )

Question 28

Explain the steps in administering a MDI including evaluation before and after

Answer 28

MDIs and small-volume nebulizers (SVNs) are used to administer liquid medications that have been turned into a fine mist by a flow of air or oxygen (FIGURE 12-10). Respiratory illness can be spread through SVNs. When the medication is atomized, it is breathed into the lungs and delivered to the alveoli. Blood flow to the alveoli is very high and absorption rates are close to those found with IV medications. This route is fast and relatively easy to access. MDis are commonly used because of their convenience and portability. The major disadvantage of an MDI is that the patient needs to be cooperative and control his or her breathing. If the patient is unconscious, an MDI cannot be used, although you could use a nebulizer. Nebulizers are often used for more severe problems. Proper use of an MDI requires some degree of coordination, something that may be difficult to achieve when a person is having trouble breathing. Patients must aim properly and spray just as they start to inhale. If administered improperly, most of the medication ends up on the roof of the patient's mouth. An adapter, called a spacer, fits over the inhaler like a sleeve and can be used to avoid misdirecting the spray (FIGURE 12-11). The patient sprays the prescribed dose into the chamber and then breathes in and out of the mouthpiece until the mist is completely inhaled. Spacer devices are especially useful with young children who have difficulty using an MDI. MDis contain both the medication and a propellant, a chemical used to help push the medication out of the inhaler. It is possible for the medication to be depleted in the MDI, even though it continues to spray. It may be difficult to determine whether a patient's MDI is still providing needed medicine. SVNs are much easier to use than MDIs; however, they take longer to deliver the medication and require an external air or oxygen source. An SVN can be more effective than an MDI in moderate to severe respiratory distress. Assisting a patient with an SVN involves placing the medication into the nebulizer and then running a flow of oxygen through the device, which will atomize the liquid and allow the patient to breathe in the medication (FIGURE 12- 12). You will typically use an oxygen tank to deliver an SVN treatment; however, many respiratory patients have a portable SVN machine at home that can also be used. Consult your local protocol to determine if use of an SVN is within the EMT scope of practice for your agency. Obtain medical direction per local protocol. 2. Confirm correct medication and expiration date. 3. Confirm that the patient is not allergic to the medication. 4. Add the appropriate medication and dose to the nebulizer reservoir and assemble according to the manufacturer's instructions. 5. Perform the medication cross-check. 5. Connect to the nebulizer machine (often in the patient's home) or oxygen tank at 6 to 8 L/min. 7. Place the nebulizer in the patient's mouth and instruct the patient to breathe until the medication is gone (usually about 5 minutes). 8. Reassess the patient and document appropriately. You can activate the spray by pressing the canister into the adapter just as the patient starts to inhale. If relief is not achieved, wait 3 to 5 minutes and repeat this sequence according to the patient's prescription. Above all, it is important to ensure that the patient inhales all of the medication in a single-sprayed dose.

Question 29

Indications and contraindications for administering narcan

Answer 29

Indications - opioid poisoning Contra - hypersensitivity

Question 30

What are the indications and contraindications for CPAP

Answer 30

CPAP can be used for patients who have moderate to severe respiratory distress from an underlying disease, such as pulmonary edema or obstructive pulmonary disease (including emphysema), are alert and able to follow commands, have tachypnea, or have a pulse oximetry reading of less than 90%. One potential contraindication to the use of CPAP is low blood pressure. Because of the increased pressure inside the chest, blood flow returning to the heart is diminished, further decreasing blood pressure. CPAP is also not used in patients in respiratory arrest or who have signs and symptoms of a pneumothorax or chest trauma, a tracheostomy, a decreased level of consciousness, inability to follow commands, or active gastrointestinal bleeding.

Question 31

Explain the hypoxic drive

Answer 31

You will sometimes encounter patients who have an elevated level of carbon dioxide in their arterial blood. The level can rise for many reasons. The exhalation process may be impaired by various types of lung disease. The body may also produce too much carbon dioxide, either temporarily or chronically, depending on the disease or abnormality. If, for a period of years, arterial carbon dioxide levels rise to an abnormally high level and remain there, the respiratory centers in the brain, which sense the carbon dioxide level and control breathing, may work less efficiently. The failure of these centers to respond normally to a rise in arterial levels of carbon dioxide is due to chronic carbon dioxide retention. Normally, the brain senses the levels of carbon dioxide (based on the pH) in the blood and cerebrospinal fluid. (See Chapter 11, Airway Management.) When carbon dioxide levels become elevated, the respiratory centers in the brain adjust the rate and depth of ventilation accordingly. However, patients with chronic lung diseases have difficulty eliminating carbon dioxide through exhalation; thus, they always have higher levels of carbon dioxide. This condition potentially alters their drive for breathing. The theory is that the brain gradually accommodates high levels of carbon dioxide and then uses a backup system to control breathing based on low levels of oxygen, rather than high levels of carbon dioxide. This condition is called hypoxic drive. Hypoxic drive is frequently found in end-stage chronic obstructive pulmonary disease (COPD). Some experts advocate withholding high concentrations of oxygen, for extended periods of time, from patients with chronic lung diseases for fear that the increased oxygen level in the blood could depress, or completely stop, the patient's respiratory drive. Use caution when providing high concentrations of oxygen on a long-term basis to patients with chronic lung disease, but never withhold oxygen therapy from a patient who needs it. Closely monitor patients who are experiencing respiratory distress and be prepared to assist with ventilations if needed.

Question 32

Signs and symptoms of acute pulmonary embolism

Answer 32

A pulmonary embolism is a blood clot formed in a vein, usually in the legs or pelvis, that breaks off and circulates through the venous system. The embolus can also come from the right atrium in a patient with atrial fibrillation. The clot moves through the right side of the heart and into the pulmonary artery, where it becomes lodged, significantly decreasing or blocking blood flow (FIGURE 16-13). Even though the lung itself can continue the process of inhalation and exhalation, no exchange of oxygen or carbon dioxide takes place in the areas of blocked blood flow because there is no effective circulation. In this circumstance, oxygen levels in the bloodstream may drop enough to cause cyanosis. The severity of cyanosis and dyspnea is directly related to the size of the embolism and the amount of tissue affected. Pulmonary emboli may occur as a result of damage to the lining of vessels, a tendency for blood to clot unusually fast, or, most often, slow blood flow in a lower extremity. Slow blood flow in the legs is usually caused by long-term bed rest, which can lead to the collapse of veins. Pregnancy, active cancer, and bed rest are other risk factors. Recent surgery in the legs or pelvis of any type increases the risk of pulmonary embolus. Although uncommon, pulmonary emboli may also occur in active, healthy people in the absence of any other known risk factors. Although they are fairly common, pulmonary emboli are difficult to diagnose. According to the US Department of Health and Human Services, 100,000 cases of pulmonary embolism occur each year in the United States. Symptoms and signs of pulmonary emboli include the following: • Dyspnea (often sudden onset) • Tachycardia • Tachypnea • Varying degrees of hypoxia • Cyanosis • Acute chest pain • Hemoptysis (coughing up blood) With a large enough embolus, complete, sudden obstruction of the output of blood flow from the right side of the heart can result in sudden death.

Question 33

Signs and symptoms of spontaneous pneumothorax

Answer 33

Spontaneous pneumothorax may occur in patients with certain chronic lung infections or in young people born with weak areas of the lung. Patients with emphysema and asthma are at high risk for spontaneous pneumothorax when a weakened portion of lung ruptures, often during severe coughing. Tall, thin young men are also more susceptible than the rest of the population to development of spontaneous pneumothorax, particularly while performing strenuous activities, such as heavy lifting. A patient with a spontaneous pneumothorax has dyspnea and might report pleuritic chest pain, a sharp, stabbing pain on one side that is worse during inspiration and expiration or with certain movement of the chest wall. By listening to the chest with a stethoscope, you can sometimes detect that breath sounds are absent or decreased on the affected side. However, altered breath sounds are very difficult to detect in a patient with severe emphysema. Spontaneous pneumothorax may be the cause of sudden dyspnea in a patient with underlying emphysema. A spontaneous pneumothorax has the potential to evolve into a life-threatening pneumothorax. Continually reassess for anxiety, increased dyspnea, hypotension, absent or severely decreased breath sounds on one side, the presence of jugular vein distention, and cyanosis.

Question 34

Signs and symptoms of aspiration pneumonia

Answer 34

Inhalation injuries can cause aspiration pneumonia that can result in eventual pulmonary edema. The inhaled substance can also cause lung damage. Blood coming from the airway is an ominous sign.

Question 35

Signs, symptoms and treatment for an anaphylactic reaction

Answer 35

Anaphylaxis, or anaphylactic shock, is a severe allergic reaction characterized by airway swelling and dilation of blood vessels all over the body, which may significantly lower blood pressure (FIGURE 16-9). Anaphylaxis may be associated with widespread hives (urticaria), itching, signs of shock, and signs and symptoms similar to asthma. The airway may swell so much that breathing problems can progress to total airway obstruction in a matter of minutes. Most anaphylactic reactions occur within 30 minutes of exposure to the allergen, which can be anything from food (such as peanuts) to medication (such as penicillin). For some patients, the episode of anaphylaxis may be their first; therefore, they may not know what caused the reaction. In other cases, the patient may be aware of what substance he or she is sensitive to but is unaware that an exposure has occurred, such as eating food that was not supposed to contain nuts. In most cases, epinephrine (adrenalin) is the treatment of choice. Patients may have their own prescribed automatic epinephrine injector, or EpiPen. Oxygen and antihistamines are also useful. As always, medical direction should guide appropriate therapy. For more information about anaphylaxis and the EpiPen, see Chapter 21, Allergy and Anaphylaxis.

Question 36

How should oxygen be administered and maintained for a patient with a chronic lung disease

Answer 36

However, patients with chronic lung diseases have difficulty eliminating carbon dioxide through exhalation; thus, they always have higher levels of carbon dioxide. This condition potentially alters their drive for breathing. The theory is that the brain gradually accommodates high levels of carbon dioxide and then uses a backup system to control breathing based on low levels of oxygen, rather than high levels of carbon dioxide. This condition is called hypoxic drive. Hypoxic drive is frequently found in end-stage chronic obstructive pulmonary disease (COPD). Some experts advocate withholding high concentrations of oxygen, for extended periods of time, from patients with chronic lung diseases for fear that the increased oxygen level in the blood could depress, or completely stop, the patient's respiratory drive. Use caution when providing high concentrations of oxygen on a long-term basis to patients with chronic lung disease, but never withhold oxygen therapy from a patient who needs it. Closely monitor patients who are experiencing respiratory distress and be prepared to assist with ventilations if needed.

Question 37

Explain criteria for transport of the patient for advanced life support (ALS) following CPR and defibrillation.

Answer 37

If an ALS service is not responding to the scene and your local protocols agree, you should begin transport when one of the following occurs: • The patient regains a pulse. • Six to nine shocks have been delivered (or as directed by local protocol). • The AED gives three consecutive messages (separated by 2 minutes of CPR) that no shock is advised on a pulseless patient (or as directed by local protocol). The time to defibrillation is critical to survival after cardiac arrest. As an EMT equipped with an AED, you have the one tool that a dying patient in VF needs most. Furthermore, it is impossible to hurt someone in cardiac arrest with an AED. Therefore, if you have an AED available, do not wait for the paramedics to arrive to administer a shock to a patient in VF. Waiting might seem like a good idea, but it is not. It is throwing away the patient's best chance for survival. If the patient is unresponsive and does not have a pulse, apply the AED, and push the Analyze button (if there is one) as quickly as you can. Notify the ALS personnel as soon as possible after you recognize a cardiac arrest, but do not delay defibrillation. After the paramedics arrive at the scene, inform them of your actions to that point and then interact with them according to your local protocols. The fifth link in the chain of survival is ALS and post-cardiac arrest care. This refers to continuing ventilation at 10 breaths/min; maintaining oxygen saturation between 94% and 99%; ensuring systolic blood pressure is above 90 mm Hg; and using targeted temperature management when the patient arrives at the hospital. It also includes cardiopulmonary and neurologic support at the hospital as well as other advanced assessment techniques and interventions when indicated. The final step in the chain of survival, recovery can take a year or longer for many of the 10% of victims of out-of-hospital cardiac arrest who are fortunate enough to survive.

Question 38

Explain acute coronary syndrome

Answer 38

Many patients who call for EMS assistance because of chest pain have acute coronary syndrome. Acute coronary syndrome (ACS) is a term used to describe a group of symptoms caused by myocardial ischemia. As discussed earlier, myocardial ischemia is a decrease in blood flow to the heart, which leads to chest pain through reduced supply of oxygen and nutrients to the tissues of the heart. This can be a temporary situation known as angina pectoris, or a more serious condition, an AMI. Because the signs and symptoms of these two conditions are very similar, they are treated the same under the designation of ACS. To understand them better, we will examine each one separately.

Question 39

Discuss the basic anatomy and physiology of the cardiovascular system

Answer 39

The heart is a relatively simple organ with a simple job. It pumps blood to supply oxygen -enriched red blood cells to the tissues of the body. The heart is divided down the middle into two sides (left and right) by a wall called the septum. Each side of the heart has an atrium, or upper chamber, to receive incoming blood, and a ventricle, or lower chamber, to pump outgoing blood (FIGURE 17-1). Blood leaves each of the four chambers of the heart through a one-way valve. These valves keep the blood moving through the circulatory system in the proper direction. The aorta, the body's main artery, receives the blood ejected from the left ventricle and delivers it to all the other arteries so they can carry blood to the tissues of the body. The right side of the heart receives oxygen-poor (deoxygenated) blood from the veins of the body (FIGURE 17-2A). Blood from the superior and inferior venae cavae enters the right atrium, which then fills the right ventricle. After contraction of the right ventricle, blood flows into the pulmonary artery and travels through the pulmonary circulation in the lungs, where it is rexygenated. As the blood reaches the lungs, it receives fresh oxygen from the alveoli and carbon dioxide waste is removed from the blood and moved into the alveoli. The blood then returns to the heart through the pulmonary veins. The left side of the heart receives oxygen-rich (oxygenated) blood from the lungs through the pulmonary veins (FIGURE 17-2B). Blood enters the left atrium and then passes into the left ventricle. The left ventricle is more muscular than the right ventricle because it must pump blood into the aorta to supply all the other arteries of the body. The heart's electrical conduction system controls heart rate and enables the atria and ventricles to work together (FIGURE 17-3). Normal electrical impulses begin in the sinus node, which is in the upper part of the right atrium and is also known as the sinoatrial (SA) node. The impulses travel across both atria, stimulating them to contract. Between the atria and the ventricles, the impulses cross a bridge of special electrical tissue called the atrioventricular (AV) node. Here, the signal is slowed for about one- to two-tenths of a second to allow blood time to pass from the atria to the ventricles. The impulses then exit the AV node and spread throughout both ventricles via the bundle of His, the right and left bundle branches, and the Purkinje fibers, ultimately causing the muscle cells of the ventricles to contract. Cardiac muscle cells have a special characteristic called automaticity that is not found in any other type of muscle cells. Automaticity allows a cardiac muscle cell to contract spontaneously without a stimulus from a nerve source. Normal impulses in the heart start at the SA node. As long as impulses come from the SA node, the other myocardial cells will contract when the impulse reaches them. However, if no impulse arrives, the other myocardial cells are capable of creating their own impulses and stimulating a contraction of the heart, although at a generally slower rate. The stimulus that originates in the SA node is controlled by impulses from the brain, which arrive by way of the autonomic nervous system. The autonomic nervous system is the part of the brain that controls the functions of the body that do not require conscious thought, such as the heartbeat, respirations, dilation and constriction of blood vessels, and digestion of food. The autonomic nervous system has two parts, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system is also known as the fight-or-flight system and makes adjustments to the body to compensate for increased physical activity. The sympathetic nervous system speeds up the heart rate, increases respiratory rate and depth, dilates blood vessels in the muscles, and constricts blood vessels in the digestive system. The parasympathetic nervous system directly opposes the sympathetic nervous system. The parasympathetic nervous system slows the heart and respiratory rates, constricts blood vessels in the muscles, and dilates blood vessels in the digestive system. Normally, these two systems balance each other, but in times of stress, the sympathetic nervous system gains primary control, whereas in times of relaxation, the parasympathetic system takes control. To perform the function of pumping blood, the myocardium, or heart muscle, must have a continuous supply of oxygen and nutrients. During periods of physical exertion or stress, the myocardium requires more oxygen. The heart must increase cardiac output to meet the increased metabolic requirements of the body. Cardiac output is increased by increasing the heart rate or stroke volume, In the normal heart, this increased oxygen demand of the myocardium itself is accomplished by increasing the amount of blood flowing (and therefore the amount of oxygen being delivered) to the myocardium by dilation. or widening, of the coronary arteries. The coronary arteries are the blood vessels that supply blood to the heart muscle (FIGURE 17-4). They begin at the first part of the aorta, just above the aortic valve. The right coronary artery supplies blood to the right atrium and right ventricle and, in most people, the bottom part, or inferior wall, of the left ventricle. The left coronary artery supplies blood to the left atrium and left ventricle and divides into two major branches, just a short distance from the aorta.

Question 40

Explain ischemic heart disease

Answer 40

Chest pain or discomfort that is related to the heart usually stems from a condition called ischemia, which is decreased blood flow, in this case, to the myocardium. A partial or complete blockage of blood flow through the coronary arteries can cause a portion of the myocardium to be deprived of enough oxygen and nutrients. The tissue soon begins to starve and, if blood flow is not restored, eventually dies. Ischemic heart disease, then, is disease involving a decrease in blood flow to one or more portions of the heart muscle.

Question 41

Why does cardiac output decrease if you are tachycardic

Answer 41

The heart must operate at an appropriate rate because a rate that is too slow or too fast will reduce the volume of blood circulated and, thus, reduce the cardiac output. When the heart beats too rapidly, there is not enough time between contractions for the heart to refill completely, and when the heart beats too slowly, the volume of blood circulated per minute decreases due to the slow pulse rate.

Question 42

Define an AMI. What are the causes and risk factors for an AMI

Answer 42

A heart attack; death of heart muscle following obstruction of blood flow to it. "Acute" in this context means "new" or “happening right now." A thromboembolism is a blood clot that is floating through blood vessels until it reaches an area too narrow for it to pass, causing it to stop and block the blood flow at that point. Tissues downstream from the blood clot will experience a lack of oxygen (hypoxia). If blood flow is restored in a short time, the hypoxic tissues will recover. However, if too much time goes by before blood flow returns, the hypoxic tissues will die. If a blockage occurs in a coronary artery, the condition results in an acute myocardial infarction (AMI), a heart attack (FIGURE 17-9). Infarction means the death of tissue. The same sequence may also cause the death of cells in other organs, such as the brain. The death of heart muscle decreases the heart's ability to pump and can also cause it to stop pumping completely (cardiac arrest). In the United States, coronary artery disease is the number one cause of death for men and women. The peak incidence of heart disease is between the ages of 45 and 64 years, but it can also strike teens and people in their 90s. You must be alert to the possibility that, although less likely, a 26-year-old with chest pain could be having an AMI, especially if he or she has a higher than usual risk. Factors that place a person at higher risk for an AMI are called risk factors. The major controllable factors are cigarette smoking, high blood pressure, elevated cholesterol level, elevated blood glucose level (diabetes), lack of exercise, and obesity. The major risk factors that cannot be controlled are older age, family history of atherosclerotic coronary artery. disease, race, ethnicity, and male sex. Other factors that play a role in heart disease are stress, excessive alcohol, and poor diet.

Question 44

Describe the different types of AEDs

Answer 44

In the late 1970s and early 1980s, scientists developed a small computer that could analyze electrical signals from the heart and determine when VF was taking place. This development, along with improved battery technology, made the automated portable defibrillator—a device that can automatically administer an electrical shock to the heart when needed—possible. AED machines come in different models with different features (FIGURE 17-15). All of them require a certain degree of operator interaction, beginning with turning on the machine and applying the pads. The operator also has to push a button to deliver an electrical shock, regardless of the model. Many AEDs use a computer voice synthesizer to advise the operator which steps to take on the basis of the AED's analysis. Some have a button that tells the computer to analyze the heart's electrical rhythm; other models start doing this as soon as they are turned on. Even though most defibrillators are now semiautomated, we still use the term AED to describe all of these machines. There are few fully automatic AEDs (which would deliver a shock without the operator pressing a button) left. All manufacturers are now producing only semiautomated external defibrillators. AEDs deliver electrical energy from one pad to the other (and then back to the first pad) to electrically stun the heart and allow it to resume normal function. The amount of electricity delivered by the machine varies among the manufacturers, but each one has shown that the energy delivered is adequate to defibrillate the heart. The factors involved in the defibrillation include voltage, current, and impedance. Most AEDs are set up to adjust the voltage based on the impedance (or resistance of the body to the flow of electricity) to deliver the proper amount of current, which is what causes the cells to defibrillate. The computer inside the AED is specifically programmed to recognize rhythms that require defibrillation to correct, most commonly VF. AEDs are extremely accurate. It would be rare for an AED to recommend a shock when a shock is not required, and an AED rarely fails to recommend one when it would be helpful. Therefore, if the AED recommends a shock, you can believe that it is indicated Automated external defibrillation has several advantages. First, the machine is fast, and it delivers the most important treatment for a patient in VF: an electrical shock. It can be delivered within 1 minute of your arrival at the patient's side. Second, AEDs are easy to operate. ALS providers do not have to be on the scene to provide this definitive care Current AEDs offer two other advantages. The shock can be given through remote, adhesive defibrillator pads, which are safe to use. Also, the pad area is larger than manual paddles, which means that the transmission of electricity is more efficient. Usually, there are pictures on the pads to remind you where they go on the patient's chest. As a safety measure, make sure the patient is not lying on wet ground or touching metal objects when he or she is being shocked. Not all patients in cardiac arrest require an electrical shock. Although the cardiac rhythm of all patients in cardiac arrest should be analyzed with an AED, some do not have shockable rhythms (eg, pulseless electrical activity and asystole ). Asystole (flatline) indicates that no electrical activity remains and therefore defibrillation will not help. Pulseless electrica activity refers to a state of cardiac arrest that exists despite an organized electrical complex; defibrillation could possibly make this situation worse. In both cases, CPR should be initiated as soon as possible, beginning with chest compressions.

Question 45

Explain the primary assessment of a patient who is experiencing a neurologic emergency and the necessary interventions and transport.

Answer 45

Your first priority is to look for and treat any life-threatening conditions. Perform a rapid exam. Patients become unresponsive or have an altered level of consciousness, especially from a neurologic cause, for many reasons. Use a sound approach to assessing whether the patient is bleeding and the patient's airway, breathing, and circulation to have significant effect on how well these systems respond to your care and treatment. As you approach the patient, gather information from the scene (is this medical or trauma related?) and note the patient's body position and level of consciousness. This initial impression will help you determine the severity of the situation and help set the pace of your call. A patient lying on the ground in an unnatural position is more likely to have a potentially life-threatening condition than one sitting up in bed. In a call that indicates that a seizure is taking place, you should be able to tell whether the patient is still experiencing a seizure. Unless your arrival time is 1 minute or less, most seizures will be over by the time you arrive. If the seizure is still occurring, the potentially life-threatening condition of status epilepticus may be present. If the patient is in a postictal state, he or she may be unresponsive or starting to regain awareness of the surroundings. When you treat any patient with altered mental status, first determine the patient's level of consciousness. To assess the patient's level of consciousness, use the AVPU scale. As with any other situation, focus on the patient's airway and breathing on arrival. Stroke affects how the body functions in many ways. Patients may have difficulty swallowing and are at risk for choking on their own saliva. Evaluate the airway of an unresponsive patient to make sure it is patent and will remain so (FIGURE 18-9). If the patient requires assistance maintaining an airway, consider an oropharyngeal or nasopharyngeal airway. Be prepared to provide suction, and position the patient to prevent aspiration. If you determine that the patient cannot protect his or her airway, place the patient in the recovery position to help prevent secretions from entering the airway. Your assessment of the patient should continue with a secondary assessment of the entire body, paying particular attention to the system involved. If you suspect your patient is experiencing a stroke, then you should direct particular attention to the neurologic assessment. As always, your secondary assessment shoüld include a complete set of vital signs using the monitoring devices you have available. Patients with significant intracranial bleeding (hemorrhagic stroke) may have a great deal of pressure in the skull that is compressing the brain, thus slowing the pulse and causing respirations to be erratic. Blood pressure is usually high to compensate for poor perfusion in the brain. Unequal pupil size and reactivity indicate significant bleeding and pressure on the brain. If the patient has altered mental status (regardless of the cause), check the blood glucose level if your local protocol allows. Most commonly, this is done using a portable blood glucose monitor (glucometer), similar to the one your patient may use at home. The portable blood glucose monitor measures the glucose level in whole blood, using capillary or venous samples. Chapter 10, Patient Assessment, discusses the use of a glucometer in more detail. Evaluating vital signs is impossible during most active seizures, and this should not be your priority. In most cases, the vital signs of a patient in a postictal state will be within normal limits. Obtain pulse rate, rhythm, and quality; respiratory rate, rhythm, and quality; blood pressure; skin color, temperature, and condition; oxygen saturation; and pupil size and reactivity. Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed by examining mucous membranes inside the inner lower eyelid, the lips, and the nail beds. On general observation, the patient may appear ashen or gray. It is recommended that the first blood pressure reading be taken manually, with a sphygmomanometer (blood pressure cuff) and a stethoscope. You may also use automated noninvasive methods to monitor blood pressure if they are available and you are approved to use them. A stroke assessment tool should be part of your secondary assessment in patients with a neurologic disorder. Many EMS units use stroke scales to rapidly identify stroke in the field. Stroke scales evaluate balance, eyes, the face, arms, speech, and time of onset, which can be remembered with the mnemonic BE-FAST (TABLE 18-3). If the patient does not have a normal response to these evaluations, you should strongly suspect a stroke. Rapid transport to a designated stroke center is indicated.

Question 46

Describe what does EMTALA stipulate

Answer 46

The Emcrgency Medical Treatment and Labor Act (EMTALA) mandates hospitals to provide emergency care regardless of insurance status or ability to pay and prohibits patient dumping.

Question 47

How does treatment differ in patients with hearing impairments?

Answer 47

Use visual cues, written communication, sign language if possible, speak clearly and slowly, maintain eye contact, and ask if a hearing aid is used.

Question 48

Cerebral paisy:

Answer 48

Varies in physical and cognitive impairment; may have Seizures or contructures.

Question 49

Down syndrome:

Answer 49

Associated with cognitive delays, heart defects, airway anomalies.

Question 50

Autism:

Answer 50

Sensory sensitivities, communication challenges; may respond better to a calm and structured approach.

Question 51

Causes of cerebral palsy, Down syndrome , autism :

Answer 51

Genetic/chromosomal abnormalities or developmental brain injury.

Question 52

Describe the specific, limited privileges that are provided to emergency vehicle operators by most state laws and regulations.

Answer 52

Proceed through red lights/stop signs with caution • Exceed speed limits if safe o Pork in restricted areas o Use emergency lanes — only when using lights and sirens

Question 53

Cleaning:

Answer 53

Removing visible dirt/debris

Question 54

Disinfection:

Answer 54

Killing pathogens on surfaces

Question 55

High-level disinfection:

Answer 55

Kills most pathogens except spores

Question 56

Sterlization:

Answer 56

Destroys all forms of microbial life

Question 57

Explain when a KED is used compared to rapid extrication.

Answer 57

KED(Kendrick Extrication Device): Used for stable patients in seated position (c-g., in a vehicle) when time permits. • Rapid extrication: Used when patient has life threats, the scene is unsafe, or immediate transport is needed.

Question 58

Understand the role of EMS in the NIMS at a structure fire.

Answer 58

EMS provides triage, treatment, transport,rehab for firefighters, and coordinates with other agencies under the Incident Command System (ICS) as part of the National Incident Management Systcm (NIMS). EMS BRANCH DIRECTOR

Question 59

Explain the job/function of the safety officer

Answer 59

The safety officer monitors the scene for hazards, ensures responder safety, and has authority to stop operations if unsafe.

Question 60

Describe the role of thc EMT in establishing command under the ICS.

Answer 60

• The first EMT on scene may assume initial command, provide size-up, establish ICS structure, and hand off command as appropriate.

Question 61

Discuss the specilic relerence materials that EMTs use to recogaize a hazmat incident. Explain a placard.

Answer 61

• Usc the Emergency Response Guidebook (ERG), DOT placards, labols, and shipping papors. • Placards display hazard class with numbers and symbols indicuting the substance type.

Question 62

Explain how to perform the START and JumpsTART triage methods.

Answer 62

START (adults): Assess respiration, perfusion, mental status (RPM); classify as Green, Yellow, Red, or Black. • JumpSTART (children): Includes respiratory checks with assisted breaths and age-appropriate mental status evaluation.

Question 63

Understand the different lovels of triage and be able to triage a patient.

Answer 63

Green: Minor Yellow: Delayed Red: Immediate Black: Deceased/expectant

Question 64

Ricin

Answer 64

Inhaled or ingested; causes fever, cough, pulmonary edema, and organ failure.

Question 65

• Smallpox:

Answer 65

Contact or airborne; fever, rash, lesions - highly contagious.

Question 66

• Pneumonic plague:

Answer 66

Airborne; fever, chills, cough with bloody sputum — rapidly fatal if untreated.