UNIVERSITY OF FLORIDA EMERGENCY MEDICAL RESPONDER COURSE

Derek J. Hunt UFCCP, CCEMTP, FPC

WELCOME!
!!Flight Paramedic !!Critical Care Training at University of Maryland Shock Trauma and Johns Hopkins !!Lead Instructor UF CCP Program !!10 years of EMT/ Paramedic Instruction

EMERGENCY MEDICAL RESPONDER

!!2 year certification !!R equired by most EMT programs !!5 2 hours+ !!C ertified by UF and UF Health !!P atient assessment and skills.

PATIENT ASSESSMENT

MEDICAL EMERGENCIES

AIRWAY CONTROL

PEDIATRIC PATIENTS

BACKBOARDING

YOU NEED
!!J ones and Bartlett Emergency Medical Responder Book !!P DF of slides posted in Facebook site

YOU WILL NEED

!!S tethoscope !!C heap: Sprague !!N ice: Littmann !!You will need one for the rest of your career

DONT BE THIS GUY/GIRL

!!O ther people in the medical field will laugh at you !!P lus it ruins your stethoscope

BE THIS GUY/GIRL
!!H ave it with you everyday in class !!I f you dont use it, you lose it !!p ractice makes perfectpractice a LOT!

SPHYGMOMANOMETER
!!A KABP Cuff !!M ust be manual !!N O AUTOMATICS

OPTIONAL
!!t rauma shears !!p en light

100 SETS OF VITAL SIGNS

!!B lood pressure !!h eart rate !!r espiratory rate !!p upils !!d ue before the final exam

WHERE TO GET THEM?

!!t ake them on each other !!r oommates !!f riends !!o n campus !!p assed out people at parties

CLICKER QUESTIONS
!!y ou will be assigned one next class !!q uestions each class !!B RING TO EVERY CLASS! !!i f you lose it, you owe me $50 !!Wont get certificate until you turn it in

GRADES
!!m id term !!f inal exam !!c licker questions !!p ractical skills station !!n eed an 80% to pass plus pass both skill stations

RIDE A LONG WITH SHANDSCAIR

!!UF Health Springfield ER !!ShandsCair Ground Crew !!0700-1900 or 1900-0700 shifts !!Sign up on facebook !!Only one student per shift time !!Must complete UF HIPPA and dress appropriately

QUESTIONS?

OK

EMS SYSTEMS
!!First Responder !!EMR !!EMT (Emergency Medical Technician) !!Paramedic !!RN (Registered Nurse) !!PA, ARNP !!Physician !!Allied Health (RT, Techs)

DISPATCH
!!m akes sure the appropriate equipment and personnel are dispatched to the scene !!m ay use pagers, cell phones, radio, or computers

FIRST RESPONSE
!!f irefighters or law enforcement !!M ost firefighters are at least EMT, many are Paramedics !!L EO are first responder/CPR trained

EMS RESPONSE
!!B LS: EMT and EMT/ EMR/FR !!A LS: Paramedic and Paramedic/EMT !!B LS: Basic Life Support !!A LS: Advanced Life Support

EMS RESPONSE
!!E MR can do any skill an EMT can do. !!E MT IS the HIGHER certification !!A irway control !!Treat bleeding/ shock !!A ssist with medications

HOSPITAL CARE
!!E mergency Department works closely with EMS !!S pecialized facilities: !!Trauma Centers !!S troke Centers !!B urn Units !!P ediatrics/Neonatal

EMS AND PUBLIC HEALTH

!!E ducation and Screening: !!C ar seats !!s eatbelt use !!Texting and driving !!E tOH Awareness !!H elmet use !!B P Screening !!B ood glucose checks

THE HISTORY OF EMS

!!In the United States during the 1950s and 1960s, funeral homes, hospitals, and volunteer rescue squads provided most ambulance service.
!! Civilian prehospital medical care lagged behind military emergency care.

THE HISTORY OF EMS

!! In 1966, Accidental Death and Disability: The Neglected Disease of Modern Society was published.
!! This report described the deficiencies of emergency medical care. !! In early 1970s, the US Department of Transportation developed a national standard curriculum for training EMS providers.

THE HISTORY OF EMS

!! First Paramedic class in Miami 1972 !! During the 1980s, the use of ALS within EMS became common. !! ShandsCair began 1984 !! Today, EMS providers are trained through standardized courses.

MEDICAL CONTROL
!!E MS Clinicians work under protocols !!O verseen by physician !!M ay deviate with permission !!D r. David Meurer

TRANSPORT
!!A mbulance, Medic, Rescue, Truck, Bus !!U se of Lights and Sirens !!R apid Transport/ Load and Go

DOCUMENTATION
!!C : Chief Complaint !!H : History (Past medical history and history of events) !!A : Assessment !!R (x): Treatment !!T: Transport

DOCUMENTATION
!!N ever Lie, make stuff up! !!W rite every report like you will go to court !!U se correct grammar !!D ont use abbreviations in final written report !!I f you dont document it, you didnt do it!

COMMON MEDICAL ABBREVIATIONS

!!c /o: complaint of !!A /O: Alert and oriented !!L OC: Level of Consciousness !!P ERRL: Pupils Equal and Reactive to Light !!M OI: Mechanism of injury !!U OA: Upon our arrival !!L UQ/RUQ: Left/Right Upper Quadrant !!R LQ/LLQ: Right/Left Lower Quadrant

COMMON MEDICAL ABBREVIATIONS

!!c with line over it: with !!s with line over it: without !!E TT: endotracheal tube !!C VA: Cerebral vascular accident !!T IA: Transient Ischemic Attack !!A MI: Acute Myocardial Infarction !!R SI: Rapid Sequence Induction

DOS AND DONTS

!! Burn out is common, remember why you choose this field !! A good call for you means a bad day for someone else !! Every call you go to, your patient is having a very bad dayshow compassion !! Treat everyone like they are your family, you never know who you are taking care of !! Show extra compassion to those who need us mostespecially the underprivileged !! Even if they are mean, rude, violent towards you.treat with respect. Their medical condition may dictate their behavior.

STRESS IN EMS
!!l ong hours !!h igh pressure situations !!w ork holidays/ weekends !!e xtended time away from family and freinds !!h igh divorce rate !!d ifficult to have normal relationships !!b ad calls/patients !!p ediatrics !!b ad trauma !!d eath

STRESS IN EMS
!! dealing with stress essential to avoid burnout !! EtOH and tobacco not a solution! !! Find your happy place and positive outlet !! Use CISD! !! Sense of humor is a coping mechanism dont take offense to it! !! Get sleep and exercise! !! Healthy Diet

5 STAGES OF DEATH AND DYING

!! Denial: The person experiencing denial cannot believe what is happening. !! Anger: Anger is a normal reaction to stress and it will sometimes be directed at you. !! Bargaining: The act of trying to make a deal to postpone death and dying. !! Depression: The patient is usually silent or seems to retreat into his or her own world. !! Acceptance: The patient understands that death and dying cannot be changed. Scrubs Death and Dying

STRESS MANAGEMENT
!! Recognizing stress
!! Warning signs to help you recognize stress:

!!Irritability !!Inability to concentrate !!Change in normal disposition !!Difficulty in sleeping or nightmares !!Anxiety !!Indecisiveness !!Guilt

STRESS MANAGEMENT
!! Recognizing stress (cont d)
!! Warning signs: (cont d) !! Loss of appetite !! Loss of interest in sexual relations !! Loss of interest in work !! Isolation !! Feelings of hopelessness !! Alcohol or drug misuse or abuse !! Physical symptoms

INFECTIOUS DISEASE
!!B SI: Body Substance Isolation !!Fungus, Bacteria, Prions, Viruses !!U se gloves, sleeves, eye glasses, surgical masks, HEPA mask

HIV
!!Spread through blood, semen, or vaginal secretions !!Wear gloves !!People with HIV look normal, cannot tell by looking at them !!Usually contract secondary opportunistic disease (Hepatitis, TB)

HEPATITIS
!!A, B, C, D, E !!Hep B&D covered by vaccine !!Hep B more contagious and lethal than HIV !!Hep C most commonly acquired infectious disease amongst HealthCare workers !! Jaundice: results from bilirubin in blood

TUBERCULOSIS (TB)
!!A irborne !!H EPA mask required !!P PD: TD Skin test, can show if youve been exposed !!c oughing, hemoptysis, night sweats, weight loss !!C XR

INFLUENZA
!!A irborne !!C an lead to opportunistic infections !!F or the love of GOD get the flu shot every year!

MRSA
!! Methicillin-Resistant Staphylococcus Aureus !! Gram positive !! Direct contact: mucous, body fluids !! Very common in hospitals/nursing homes !! Can lead to severe sepsis !! 25% population is positive in nasal passage

VRE
!!Vancomycin-Resistant Enterococci !!Can develop in septic patients who become resistant to antibiotics !!Hard to treat !!High mortality !!Use extreme precautions

C-DIFF
!!C lostridium difficile !!g ram +, spore forming rod !!O pportunistic infection !!C an survive standard cleaning measures !!P asses along in hospitals

C-DIFF
!!S evere diarrhea !!o ften comes back after antibiotic treatment !!m egacolon: surgical emergency !!f ecal transplant

PRIONS
!!C reutzfeldt-Jakob !!K uru !!C an survive the autoclave process

BSI
!!WASH YOUR DAMN HANDS! !!T he little EtOH dispensers are NOT enough! !!P rotects you and your patients

RESPONDING TO THE SCENE

!! Scene safety is a most important consideration to you as an EMR.
!! Includes your safety and the safety of all other people present at the scene !! An injured or dead EMR cannot help those in need. !! Drive safely and always fasten your seatbelt when you are in your vehicle.

RESPONDING TO THE SCENE

!! Dispatch
!! Use the dispatch information to anticipate hazards and determine how to approach the scene.

!! Response
!! Fasten your seatbelt, plan the best route, and drive quickly but safely to the scene. !! Technically, you can only go 10 mph over the speed limit while using lights and sirens. !! ALWAYS obey speed limits in school zones !! Motorists should pull over to the right, or the safest place to allow ambulance to pass

RESPONDING TO THE SCENE

!!Parking your vehicle
!! Park your vehicle so that it protects the area from traffic hazards. !! Be sure that the emergency warning lights are operating correctly. !! Be careful when getting out of your vehicle.

ASSESSING THE SCENE

!! Scan the area to determine what hazards are present and address them in the most appropriate order. !! Traffic
!! Control the flow of traffic on a busy highway. !! If you need assistance, call before you get out of your vehicle.

ASSESSING THE SCENE

!! Crime or violence
!! If you have doubts about the safety of a scene, wait at a safe distance and request help. !! If the scene involves a crime, avoid disturbing anything unless it is absolutely necessary. !! Cut around clothing that has bullet holes Scene Safe: -Is it safe to enter -Does Law Enforcement need to secure the scene? -Has a crime been committed? -We are not the police and we do not do their job!

ASSESSING THE SCENE

!!Crowds
!! Assess the crowd before you get into a position from which you cannot exit. !! Request help before the crowd is out of control.

!!Electrical hazards
!! Do not approach the scene and keep other people away from the source of the hazard.

ASSESSING THE SCENE

!! Fire (cont d)

!! If you are not, do not exceed the limits of your training. !! Never enter a burning building without proper turnout gear and SCBA.
Mark Winfrey/ShutterStock, Inc.

!! Hazardous materials

!! Should be marked with placards

ASSESSING THE SCENE

!! Hazardous materials (cont d)
!! If you believe that a crash may involve hazardous materials, stop uphill and upwind and use binoculars to observe the scene. !! Odors or fumes may be the first indication. !! Call for HazMat. !! park up hill and up wind

!! Unstable objects
!! Vehicles, trees, poles, buildings, cliffs, and piles of material

ASSESSING THE SCENE

!! Unstable objects (cont d)
!! Vehicles may need to be stabilized before patient extrication can begin. !! Undeployed air bags are hazards. !! Fires and explosions can result in unstable buildings.

!! Sharp objects
!! Broken glass at the scene of a motor vehicle crash

ASSESSING THE SCENE

!! Sharp objects (cont d)
!! Wear heavy leather or firefighting gloves over your medical gloves to prevent injuries.

!! Animals
!! Can be pets, farm stock, or wild !! Should be secured in a room away from the patient !! May present other hazards such as bites, kicking, or even trampling

MEDICAL LEGAL
!! Laws differ from one location to another, so EMRs should learn the specific laws that apply in their state or jurisdiction. !! Do not lose sight of these concepts:
!! Above all else, do no harm. !! Provide all your care in good faith. !! Provide proper consistent care, be compassionate, and maintain your composure.

DUT Y TO ACT
!! If you are employed by an agency as an EMR and you are dispatched to the scene of an accident or illness, you have a duty to act.
!! You must proceed promptly to the scene and render emergency medical care within the limits of your training and available equipment.

DUT Y TO ACT

!! Failure to respond or render care leaves you and your agency vulnerable to legal action.

Credit: Corbis

STANDARD OF CARE
!! The standard of care is the manner in which you must act or behave. !! You must meet two criteria:
!! You must treat the patient to the best of your ability. !! You must provide care that a reasonable, prudent person with similar training would provide under similar circumstances.

SCOPE OF CARE
!! Scope of care is defined by:
!! The US Department of Transportation, Emergency Medical Responder Educational Standards !! Medical protocols or standing orders !! Online medical direction

ETHICAL RESPONSIBILITIES AND COMPETENCE

!! Treating a patient ethically means doing so in a manner that conforms to accepted professional standards of conduct.
!! Stay up-to-date on skills and knowledge. !! Review your performance and assess your techniques. !! Evaluate your response times. !! Take continuing education classes. !! Participate in quality improvement activities.

ETHICAL RESPONSIBILITIES AND COMPETENCE

!! Ethical behavior requires honesty.
!! Always provide complete and correct reports to other EMS providers. !! Never change a report except to correct an error.

CONSENT FOR TREATMENT

!! Consent simply means giving approval or permission. !! Expressed consent
!! The patient actually lets you knowverbally or nonverballythat he or she is willing to accept treatment. !! The patient must be of legal age and able to make a rational decision.

CONSENT FOR TREATMENT

!! Implied consent
!! The patient does not specifically refuse emergency care. !! Do not hesitate to treat an unconscious patient.

!! Consent for minors

!! Under the law, minors are not considered capable of speaking for themselves.

CONSENT FOR TREATMENT

!! Consent for minors (cont d)

!! Emergency treatment must wait until a patient or legal guardian consents to the treatment. !! If permission cannot be quickly obtained, do not hesitate to give appropriate medical care.

CONSENT FOR TREATMENT

!! Consent of mentally ill patients
!! If the person appears to be a threat to self or others, place this person under medical care. !! Know your state s legal mechanisms for handling these patients. !! Do not hesitate to involve law enforcement agencies.

PATIENT REFUSAL OF CARE

!! Any person who is mentally in control has a legal right to refuse treatment. !! Help the person understand the consequences of refusing care by explaining:
!! The treatment !! The reason that the treatment is needed !! The potential risks if treatment is not provided !! Any alternative treatments that may help !! Patient refusals should be documented on your patient care record according to your agency protocols.

ADVANCE DIRECTIVES
!! An advance directive is a document that specifies what a person would like to be done if he or she becomes unable to make his or her own medical decisions. !! A living will
!! Written document drawn up by a patient, a physician, and a lawyer !! States the types of medical care the person wants or wants withheld

ADVANCE DIRECTIVES
!! A durable power of attorney for health care
!! Allows a patient to designate another person to make decisions about medical care

!! A do not resuscitate (DNR) order

!! Written request giving permission to medical personnel not to attempt resuscitation in the event of cardiac arrest

ADVANCE DIRECTIVES
!!I f you are unable to determine if an advance directive is legally valid, begin appropriate medical care.
!!Some states have systems in place, such as bracelets, to identify patients with advance directives.

ABANDONMENT
!! Abandonment occurs when a trained person begins emergency care and then leaves the patient before another trained person takes over. !! Once you have started treatment, you must continue it until a person who has at least as much training arrives and takes over.

PERSONS DEAD AT THE SCENE

!! If there is any indication that a person is alive, you should begin providing care. !! You cannot assume a person is dead unless one of these conditions exists:
!! Decapitation !! Rigor mortis !! Tissue decomposition !! Dependent lividity

PERSONS DEAD AT THE SCENE

!! If any of the signs of death are present, consider the patient to be dead. !! It is important that you know the protocol your department uses in dealing with patients who are dead on the scene.

Credit: Damian Dovarganese/AP Photos

NEGLIGENCE
!! Negligence occurs when a patient sustains further injury or harm because the care administered did not meet standards. !! These conditions must be present:
!! Duty to act !! Breach of duty !! Resulting injuries !! Proximate cause

CONFIDENTIALIT Y
!! Most patient information is confidential.
!! Patient circumstances !! Patient history !! Assessment findings !! Patient care given

!! Information should be shared only with other medical personnel. !! In certain circumstances, you may release confidential information to designated individuals. !! Health Insurance Portability and Accountability Act of 1996 (HIPAA)
!! Strengthens laws for the protection of the privacy of health care information and safeguards patient confidentiality

GOOD SAMARITAN LAWS

!! Protect citizens from liability for errors or omissions in giving good-faith emergency care !! Vary considerably from state to state !! May no longer be needed
!! Provide little or no legal protection for a rescuer or EMS provider

REGULATIONS
!! Become familiar with the federal, state, local, and agency regulations that affect your job. !! Certification or registration may be required to work as an EMR. !! You are responsible for keeping certifications or registrations current.

REPORTABLE EVENTS
!! Reportable crimes include:
!! Knife wounds !! Gunshot wounds !! Motor vehicle collisions !! Suspected child or elder abuse !! Domestic violence !! Dog bites !! Rape

VITAL SIGNS
!!B lood Pressure !!H eart Rate !!R espiratory Rate !!P upils !!S kin condition

BLOOD PRESSURE
!!S ystolic pressure: high reading during contraction (systole) !!D iastolic pressure: low reading during relaxation (diastole) !!N ormal is patient dependent (not necessarily 120/80)

BLOOD PRESSURE
!!P ump up to around 200 mm Hg or until the beating is no longer auscultated !!T he first beat is the systolic pressure !!T he last beat heard is the diastolic pressure !!P alpating: !!U se cuff and feel for a radial pulse !!P ump up until the pulse is gone !!R elease until pulse returns and that is systolic !!W rite: 120/P

HEART RATE
!!Adult: 60-90 !!>100 tachycardia !!<60 bradycardia !!Child:70-120 !!Infant: 80-130 !!Major: carotid, radial, brachial, femoral, pedal !!Count for 15 s and multiply by 4

HEART RATE AND PULSE PRESSURES

Pulse !! Carotid !! Radial !! Femoral !! Pedal Systolic Blood Pressure !! 60 mm !! 80 mm !! 70 mm !! 90-100 Hg Hg Hg mm Hg

RESPIRATORY RATE
!!D O NOT tell patient youre watching them breathe !!C ount for 30 s and multiply by 2 !!N ormal rate: 6-20 bpm !!> 20/min is tachypnea

RESPIRATORY
!!K ussmals: DKA !!C heyne-Stokes: CVA !!B iots: Head injury !!A gonal: Dead

PUPILS
!!1 -10 mm !!N ormal depends on light conditions !!C onstricted: sympathetic !!D ilated: parasympathetic !!I psilateral pupil dilation: herniation

SKIN
!!C olor: pink, pale, cyanotic (blue/ purple), flushed (red) !!Temperature: warm, cool, hot !!C ondition: dry, diaphoretic !!Turgor: tenting

QUESTIONS?