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First Responder Program
Student Training ManualLevel III
Prepared by:Paramedic Academy
Justice Institute of British Columbia New Westminster, BC
December 2004
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2 FIRST RESPONDER STUDENT MANUAL LEVEL III
Paramedic Academy
Justice Institute of British Columbia
New Westminster, BC
Content Revised December 2004
© 1990, 1991, 1994, 1999, 2001, 2004
Province of British Columbia.
All rights reserved. No part of this guide may be reproduced or
transmitted in any form, or by any means, electronic or mechanical,
including photocopy, recording, or any information storage and
retrieval system, without written permission from the Province of
British Columbia.
Paramedic Academy
Justice Institute of British Columbia
715 McBride Boulevard
New Westminster, BC
V3L 5T4
Tel: (604) 528-5690. Fax: (604)528-5715
email: [email protected]
www.paracademy.com
www.jibc.bc.ca
Published 1990. Format revised August 1995.
Content revised September 1999. Revised Edition March 2001.
Printed in Canada
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Acknowledgements
PARAMEDIC ACADEMY / MARCH 2001 3
Acknowledgements
The development of the First Responder training program was a collaborative effort of three emergency
services. Representatives of the Police, Fire, and Ambulance Services formed the principal Steering
Committee. In addition, several other departments and units of these services provided the external
validation for the program.
The Steering Committee recognizes the original recommendations made by Chief Coroner Vince Cain
and the impetus his office gave to this project.
Paramedic Academy Project Team (1994)
Director
A.T. Williams, PhD
Program Director
Derek White
Dave Busse
Program Coordinator
Vic Barron
Ron Bowles
Program Planner
Marika Morissette
Medical Coordinator
Dr. Sheldon Glazer
Dr. Jeff Freeman
Content Experts
Geoff Vick
Bill Maser
Jim Bond
Writer
Frank Chow
Layout
Irma Rodriguez
Illustrations
Western Technigraphics
Don Chin
Paramedic Academy Update Team (1999)
A.T. Williams, PhD Director
Urbain Ip, MD Medical Advisor, First Responder Program
Gil Vergilio, MEd Program Director, Basic ProgramsBobbie Walkley, EMA II Program Coordinator
Griff Richards, PhD Program Director, Learning Systems
Tracey Leacock, PhD Project Manager, Editor
Ian Fitzpatrick, First Responder Instructor Subject Matter Expert
F & M Chow Consulting Layout
Training Subcommi ttee (1999)
A.T. Williams, Director, Paramedic Academy
Wayne Markel, Township of Langley Fire Department
Rich Courtney, Workers’ Compensation Board of BC
Urbain Ip, Medical Advisor
Randy Shaw, Port Coquitlam Fire Department
Ian Brethour, EMA Licensing Branch,
Ministry of Health
Wilf Meyer, Superintendent , BC Ambulance Service
Jim Mancell, Police AcademyGil Vergilio, Program Director, Paramedic Academy
Bobbie Walkley, Program Coordinator,
Paramedic Academy
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4 FIRST RESPONDER STUDENT MANUAL LEVEL III
1990 External Validation Committee
Ambulance Service
Fred Bates, Executive Director
Gord Bates, Chief Superintendent
Tom Breiter, Chief Superintendent
Del Collin, Director
Neil Leard, Director
Alan Miller, Superintendent
Gerry Parrott, Superintendent
Fred Platteel, Chief Superintendent
Brian Porritt, Supervisor
Terry Reid, Chief Superintendent
John Schinbein, Director
Dr. Charles Sun, Medical Director
Coroner’s Office
Vince Cain, Chief Coroner
EMA Licensing Branch
Ian Brethour, Registrar of Licensing
Fire Service
Rick Dumala, Fire Commissioner
Fred Eagle, Captain, Prince George
Terry Erskine
Don Gillis, Chief, Fort Nelson
Dave Hill, Chief, Saanich
Brent Hodgins, Chief, Penticton
Ted Lorenz, Chief, RichmondH.A. Maginnis, Chief, Burnaby
Jim Nelson, Trail
Douglas Norman, Chief, Kamloops
Larry Obst, Prince George
Don Pamplin, Chief, Vancouver
Paul Parnell, Chief, New Westminster
Harry Sommerville, Chief, Nelson
Mark Wakefield, Chief, Vernon
Gerry Zimmerman, Chief, Kelowna
Police Service
S.G. Anderson, Chief Constable, Oak Bay
Ron Brock, Chief Constable, Nelson
K.G. Brown, Chief Constable, New Westminster
Barry Daniel, Chief Constable, Matsqui
D. Egan, Sergeant, District of Saanich
H.A. Jenkins, Chief Constable, West Vancouver
Roger Kambel, Inspector, RCMP
G.W. Laughy, Chief Constable, Port Moody
G.T.L. Lawson, Chief, Central Saanich
P. Marriott, Chief Constable, Esquimalt
R. Miller, Chief, Central Saanich
W. Nixon, Chief Constable, Saanich
R.A. Sharp, Superintendent, Director, Ports
Canada Police & Security
W. Snowdon, Chief Constable, VictoriaR.J. Stewart, Chief, Vancouver
P.D. Wilson, Chief Constable, Delta
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Intent and Purpose
PARAMEDIC ACADEMY / MARCH 2001 5
Intent and Purpose
In 1989 the Chief Coroner of British Columbia reviewed the collaboration between the three emergency
services (Police, Fire, and Ambulance). He submitted a series of recommendations to the Deputy
Minister of Health in the fall of that year.
One of these recommendations described the development of a first responder program specific to the
needs of police officers and firefighters. Chief Coroner Vince Cain recommended that the Justice
Institute design a course that would enhance the cooperation between the services when treating the sick
and injured. He emphasized the need for a continuum of care beginning with the first responder(s)
working cooperatively with British Columbia Ambulance Service paramedics.
Subsequently, the Justice Institute formed a three-service Steering Committee to guide the program’s
development. Next, an External Validation Committee representing all three services validated the
content and delivery method. The concentrated efforts of these two groups led to the training program
presented in this manual. The Steering Committee recognizes that the training program supports
operational procedures but does not set them.
Mr. Cain’s conclusions and this subsequent training program have led to an improvement in the
continuity of care in BC in the past few years. Both Mr. Cain and the First Responder Steering Committee
are encouraged by the early acceptance, growth and success of the First Responder program. We look
forward to continued cooperation between the emergency services that will continue to raise the quality
of pre-hospital emergency care.
A.T. Williams, PhD
Chair, First Responder Training Steering Committee
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Content
PARAMEDIC ACADEMY / MARCH 2001 7
Table of Contents
Overview: The First Responder Program .......................................................... 11
How to Work Through the Course ...................................................................................... 13
Icons ....................................................................................................................................13Simulations and Skills Checklists ....................................................................................... 13
Schedule .............................................................................................................................14
Unit 1: Role of the First Responder .................................................................... 15
1.1: Describe the Emergency Medical System (EMS) and the role of the
First Responder ........................................................................................................ 17
Self-Test 1.1 ..............................................................................................................18
1.2: Identify the equipment contained in the First Responder kit ................................. 19
Unit 2: Patient Assessment ............................................................................... 23
2.1: Perform a scene assessment.................................................................................... 25
Case Study 2.1 .......................................................................................................... 26
2.2: Perform a primary survey ....................................................................................... 272.2a: Assess level of consciousness (LOC) using the AVPU method ................... 28
2.2b: Manage a delicate spine .............................................................................. 28
2.2c: Open and maintain the airway ................................................................... 28
2.2c(1): Clear obstructions from the patient’s mouth and throat ............ 29
2.2c(2): Open the airway .......................................................................... 30
2.2c(3): Correctly use an oral airway for unconscious patients ................ 31
2.2c(4): Suction the mouth cavity if required .......................................... 34
2.2c(5): Place unconscious patients and patients with compromised
airways in the recovery position and monitor breathing ............ 35
2.2d: Assess and manage the patient’s breathing ................................................ 42
2.2d(1): Determine when a patient is not breathing adequately .............. 43
2.2d(2): Use a pocket mask to ventilate patients with inadequate breathing ..................................................................................... 43
2.2d(3): Ventilate a pediatric patient (infant or child) with inadequate
breathing using a bag-valve-mask-oxygen reservoir unit........... 44
2.2d(4): Use the bag-valve-mask-oxygen reservoir unit to ventilate adult
patients with inadequate breathing ............................................ 49
2.2e: Assess and manage the patient’s circulation ............................................... 51
2.2f: Perform a rapid body survey (RBS) ............................................................ 53
2.2f(1): Perform a rapid body survey ....................................................... 53
2.2f(2): Give oxygen at high flow (10 L/min) with a standard face mask 53
2.2f(3): Describe the pathophysiology of hypoxic drive and the
management of a COPD patient ................................................. 55
Case Study 2.2 ..........................................................................................................572.3: Perform a secondary survey .................................................................................... 59
2.3a: Establish the chief complaint and history of chief complaint .................... 59
2.3b: Record and monitor the patient’s LOC, pulse, respirations, and skin
colour and temperature ...............................................................................61
Case Study 2.3 ......................................................................................................... 62
2.4: Record data and report it accurately to ambulance personnel ............................... 64
2.5: Describe the principles of triage ............................................................................. 65
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Content
8 FIRST RESPONDER STUDENT MANUAL LEVEL III
Self-Test 2.5 ............................................................................................................. 67
Summary 2 ......................................................................................................................... 68
Unit 3: Management of Medical Emergencies ................................................... 73
3.1: Manage an unconscious medical patient .................................................................75
Case Study 3.1 .......................................................................................................... 76
3.2: Assess and manage heart attack patients ................................................................. 773.2a: List the signs and symptoms of a heart attack ............................................. 77
3.2b: Manage a patient experiencing a heart attack ............................................ 78
Case Study 3.2 ......................................................................................................... 79
3.3: Assess and manage patients with respiratory emergencies .................................... 80
3.3a: List the signs and symptoms of a respiratory emergency .......................... 80
3.3b: Manage a patient experiencing a respiratory emergency ............................81
Case Study 3.3 ......................................................................................................... 82
3.4: Assess and manage stroke patients ......................................................................... 83
3.4a: List the signs and symptoms of a stroke ..................................................... 83
3.4b: Manage a patient experiencing a stroke ..................................................... 83
Case Study 3.4 ......................................................................................................... 85
3.5: Assess and manage patients with diabetes ............................................................. 86
3.5a: List the signs and symptoms of a diabetic emergency ............................... 86
3.5b: Manage a diabetic patient ........................................................................... 87
Case Study 3.5 ......................................................................................................... 88
3.6: Assess and manage overdose/poisoning patients ................................................... 89
3.6a: List the signs and symptoms of an overdose/poisoning ............................ 89
3.6b: Manage a patient suffering from an overdose/poisoning .......................... 90
Case Study 3.6 ..........................................................................................................91
3.7: Assess and manage patients with seizures .............................................................. 92
3.7a: List the signs and symptoms of a generalized seizure ................................ 92
3.7b: Manage a patient experiencing a seizure .................................................... 92
Case Study 3.7 ......................................................................................................... 94Summary 3 ......................................................................................................................... 95
Unit 4: Management of Trauma ........................................................................ 99
4.1: Assess and manage patients who are bleeding/in shock ....................................... 101
4.1a: Describe the signs and symptoms of shock ............................................... 101
4.1b: Describe the different types of bleeding .................................................... 101
4.1c: Control external bleeding ......................................................................... 102
4.1d: Apply dressing and bandages properly......................................................105
4.1e: Manage a patient in shock ........................................................................ 106
Case Study 4.1.........................................................................................................107
4.2: Assess and manage patients with head/neck/spine injuries ................................ 108
4.2a: Describe the signs and symptoms of a head injury .................................. 108
4.2b: Manage a patient with a head injury ........................................................ 109
4.2c: Describe the signs and symptoms of a neck/spine injury ......................... 110
4.2d: Manage a patient with a neck/spine injury ................................................111
Case Study 4.2 ........................................................................................................ 112
4.3: Assess and manage patients with chest injuries .................................................... 113
4.3a: Describe the signs and symptoms of a chest injury ................................... 113
4.3b: Manage patients with open or closed chest injuries .................................. 115
Case Study 4.3 ........................................................................................................ 117
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Content
PARAMEDIC ACADEMY / MARCH 2001 9
4.4: Manage patients with abdominal injuries ............................................................. 118
Case Study 4.4 ....................................................................................................... 120
4.5: Assess and manage patients with fractures/dislocations ...................................... 121
4.5a: Describe the signs and symptoms of fractures and dislocations ............... 121
4.5b: Manage a patient with a fracture or dislocation ........................................ 122
Case Study 4.5 ........................................................................................................1234.6: Assess and manage burn patients ..........................................................................124
4.6a: Describe the different types of burns and their appearance .....................124
4.6b: Manage a burn patient ...............................................................................126
Case Study 4.6 ....................................................................................................... 128
Summary 4 ........................................................................................................................129
Unit 5: Management of Environmental Emergencies ...................................... 133
5.1: Assess and manage patients suffering from smoke inhalation .............................. 135
5.1a: Describe the signs and symptoms of smoke inhalation ............................ 135
5.1b: Manage a patient suffering from smoke inhalation .................................. 136
Case Study 5.1 ......................................................................................................... 137
5.2: Assess and manage carbon monoxide poisoning patients .................................... 138
5.2a: Describe the signs and symptoms of carbon monoxide poisoning .......... 138
5.2b: Manage a patient with carbon monoxide poisoning ................................ 138
Case Study 5.2 ....................................................................................................... 140
5.3: Assess and manage hypothermia patients ............................................................. 141
5.3a: Describe the signs and symptoms of hypothermia ....................................142
5.3b: Manage a hypothermia patient ..................................................................142
Case Study 5.3 ........................................................................................................144
5.4: Assess and manage patients suffering from hyperthermia.................................... 145
5.4a: Describe the signs and symptoms of heat emergencies ............................ 145
5.4b: Manage patients suffering from heat emergencies ...................................146
Case Study 5.4 ........................................................................................................ 147
5.5: Assess and manage drowning/near-drowning patients ....................................... 1485.5a: Describe the signs and symptoms of near-drowning ............................... 148
5.5b: Manage a drowning/near-drowning patient ............................................ 148
Case Study 5.5 ........................................................................................................150
Summary 5 ........................................................................................................................ 151
Unit 6: Legal Aspects ....................................................................................... 153
6.1: Describe legislation that pertains to the First Responder’s duties ........................ 155
6.2: Describe the principles of preservation of evidence .............................................. 156
Case Study 6.2 ........................................................................................................158
6.3: Describe the First Responder Operational Guidelines on
Do Not Resuscitate (DNR) Orders ......................................................................... 159
Summary 6 ........................................................................................................................ 161
Unit 7: Communicable Diseases ......................................................................163
7.1: Describe the ways by which diseases are transmitted ........................................... 165
Self-Test 7.1 ............................................................................................................ 167
7.2: Describe common communicable diseases........................................................... 168
Self-Test 7.2 ............................................................................................................170
7.3: Describe and demonstrate the precautions for managing patients with
communicable disease ........................................................................................... 171
Case Study 7.3 ........................................................................................................ 173
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Content
10 FIRST RESPONDER STUDENT MANUAL LEVEL III
7.4: Describe the procedure for decontaminating equipment ...................................... 174
7.5: Describe the benefits of immunization .................................................................. 175
Self-Test 7.5 ............................................................................................................ 176
Unit 8: Ambulance Orientation ....................................................................... 177
8.1: Identify commonly used ambulance equipment and describe their function ....... 179
8.2: Demonstrate commonly used lifting/transferring techniques ............................. 182Case Study 8.2 ........................................................................................................185
Summary 8 ....................................................................................................................... 186
Appendix A: References and Glossary ............................................................ 189
References ......................................................................................................................... 191
Glossary .............................................................................................................................192
Appendix B: Answer Key ................................................................................ 199
Self-Test 1.1 ...................................................................................................................... 201
Case Study 2.1 .................................................................................................................. 201
Case Study 2.2 .................................................................................................................. 201
Case Study 2.3 .................................................................................................................. 202
Self-Test 2.5 ...................................................................................................................... 202
Case Study 3.1 .................................................................................................................. 203
Case Study 3.2 .................................................................................................................. 203
Case Study 3.3 .................................................................................................................. 203
Case Study 3.4 .................................................................................................................. 203
Case 3.5 ............................................................................................................................ 204
Case Study 3.6 .................................................................................................................. 204
Case Study 3.7 .................................................................................................................. 204
Case Study 4.1 .................................................................................................................. 205
Case Study 4.2 .................................................................................................................. 205
Case Study 4.3 .................................................................................................................. 205
Case 4.4 ............................................................................................................................ 205Case Study 4.5 .................................................................................................................. 206
Case Study 4.6 .................................................................................................................. 206
Case Study 5.1 ................................................................................................................... 206
Case Study 5.2 .................................................................................................................. 207
Case Study 5.3 .................................................................................................................. 207
Case Study 5.4 .................................................................................................................. 208
Case Study 5.5 .................................................................................................................. 208
Case Study 6.2 .................................................................................................................. 208
Self-Test 7.1 ...................................................................................................................... 209
Self-Test 7.2 ...................................................................................................................... 209
Case Study 7.3 .................................................................................................................. 210
Case Study 7.5 .................................................................................................................. 210Case Study 8.2 .................................................................................................................. 210
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Overview:The First Responder Program
Welcome to Level III of the First Responder (FR) Program, a
course designed for independent learning. In it, you will
study and review principles of emergency health care as they
apply to the First Responder.
To get the most out of this program, keep in mind your role as
a First Responder. You will often be the first person to
provide medical attention to the patients at an accident or
medical emergency, and may have to do this until the BC
Ambulance Service arrives. You will have to provide care
immediately – within the first few minutes at the scene and
until more highly trained medical personnel arrive – so that
the injuries do not harm the patient further.
This program focuses on the management of the critical first
moments, when you have to assess the patient and decide if
the injuries are life-threatening and what treatment(s) they
require. This program is designed to sharpen yourassessment skills so that you can size up a patient quickly. It
will also give you the skills you need to respond appropriately
and the self-confidence to act decisively in these situations.
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12 FIRST RESPONDER STUDENT MANUAL LEVEL III
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How to Work Through the Course
PARAMEDIC ACADEMY MARCH 2001 OVERVIEW 13
The course has four components:
• this manual
• skills checklists package
• a video (optional)
• 32 hours of practical classroom sessions
The manual will serve as your main source of information. There are
eight units. Each unit has a set of learning objectives, which you can
think of as a road map to guide you through the material. The
objectives cover two things:
• theoretical knowledge that you will need in order to recognize
various types of injuries and medical conditions, and
• skills that you will use to provide emergency care to your patients
Self-tests, case studies, and checklists will help you to assess yourprogress and to practise what you have learned before reporting to
class. Answers to the self-tests and case studies are in the answer key
at the end of the manual.
As you work through the following pages, you will see several icons,
symbols that will help you identify key information and activities.
Key Points – very important concepts or facts
Skills – things you must do to care for apatient properly
Case Studies – case studies where you apply what you have learned to practical situations
Self-Tests – short tests to help you review thecontent of a particular section
How to WorkThrough the Course
Icons
Simulations andSkills Checklists
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How to Work Through the Course
14 FIRST RESPONDER STUDENT MANUAL LEVEL III
Throughout this manual, you will find simulations that will help you
practise the skills you have learned. Do the following:
1. Make sure you have worked through the material pertaining to
each situation.
2. Read the simulation from beginning to end.3. Gather all the necessary equipment to complete the simulation.
4. Practise each step in the Skill Checklists package with a partner,
friend, or family member until you become proficient in it. You
will be expected to demonstrate and master these skills in class.
You should be able to work through the manual and practise the skills
in about two weeks. If you have any questions, contact your
Departmental FR Instructor for clarification. You will then be ready
for the classroom sessions. Use your manual as a reference during
class.
Begin Unit 1 now. Good luck!
Schedule
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Unit 1:
Role of the First Responder
As a First Responder, you are an important part of the
Emergency Medical System (EMS) in British Columbia. For
the EMS to work successfully, everyone involved should be
familiar with the system’s other elements and with his or her
role in it.
By the time you complete this unit, you should be able to
accomplish the following objectives:
1.1 Describe the Emergency Medical System (EMS) and the
role of the First Responder.
1.2 Identify the equipment contained in the First Responder
kit.
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16 FIRST RESPONDER STUDENT MANUAL LEVEL III
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EMS and the role of the First Responder
PARAMEDIC ACADEMY / MARCH 2001 UNIT 1: ROLE OF THE FIRST RESPONDER 17
The Emergency Medical System (EMS) is a community-wide
coordinated means of responding to sudden illness or injury.
As a First Responder, you may be the first to arrive at the scene of an
accident or emergency. By being the first emergency medical services
worker at the scene, you have the potential to save a life or to reduce
the chances of further harm to the patient.
You have six main patient-related duties at the emergency scene.
These are:
1. to control an accident scene in order to protect yourself and your
patients and to prevent additional accidents
2. to determine the number of patients at an accident scene
3. to gain access to the patient
4. to find out what is wrong with the patient and to provide
emergency care with available equipment
5. to lift or move the patient only when required, and to do so without causing additional injury
6. to transfer care of the patient and provide information about
his/her condition to ambulance personnel when they arrive at the
scene
1.1:Describe the
Emergency MedicalSystem (EMS) and the
role of the FirstResponder
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EMS and the role of the First Responder
18 FIRST RESPONDER STUDENT MANUAL LEVEL III
Answer the following questions and compare your answers with
those provided in Appendix B. Review this section if you make any
mistakes.
1. What does EMS stand for?
____________________________________________
2. Which of the following may be First Responders?
a) Emergency Medical Attendants
b) Air Ambulance personnel
c) in-hospital emergency workers
d) Police officers and Firefighters
e) all of the above
3. List the First Responder’s six main patient-related duties.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________ ____________________________________________
Self-Test 1.1
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First Responder kit
PARAMEDIC ACADEMY / MARCH 2001 UNIT 1: ROLE OF THE FIRST RESPONDER 19
Your First Responder kit has five compartments, as shown in the
following diagram.
Take a few moments to inspect each compartment and identify the
following items. Quantities are minimum recommended amounts.
Item Function
COMPARTMENT A
• Bag-valve-mask reservoir unit • To assist respirations. With reservoir and
oxygen flow at a minimum of 15L/min, delivers
oxygen concentration of 90%.
• 1 Set oral airways • Sizes 00, 0 and 1 to 6 (metric sizes 5-12). Used
to maintain an open airway in unconscious
patients.
• 1 Suction unit • For removal of mucus, blood, and vomitus from
the upper airway.
• 2 Standard O2 masks/tubing • Delivers oxygen to patient’s nose and mouth.Exhaust ports expel excess oxygen and permit
entry of outside air on inhalation. Oxygen
concentration of 60% at 8-10 L/min.
• 1 Non-rebreather O2 mask • Delivers high concentrations of oxygen from
reservoir. Oxygen concentration of 90-95% at
10 L/min. Used in treating smoke inhalation,
gas inhalation, or carbon monoxide poisoning.
1.2:Identify the equipment
contained in the FirstResponder kit
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First Responder kit
20 FIRST RESPONDER STUDENT MANUAL LEVEL III
Item Function
• 1 Pocket mask with 1-way valve • May be used for mouth-to-mask or bag-to-mask
ventilation, as an oxygen delivery mask
delivering oxygen concentration of 50-60% at
10 L/min. Used for CPR-on-the-move or whenregular resuscitation mask from BVM does not
create an effective seal.
• 1 Litre saline or sterile water • For cooling thermal burns.
• 1 Burn pack • Used to prepare the stretcher and cover the
burn patient. Helps to maintain a sterile field.
Paper sheets and pillow cases should not be
placed directly onto the burned area.
• Four 12″ × 12″ polygauze
One 18″ × 18″ polygauze
One 24″ × 24″ polygauze
• Used primarily for burn injuries. Size depends
on size of wound.
• 1 Alcare foamed alcohol • An in-field solution to degerm hands and
forearms. For use when FRs do not have
access to soap, water, and wash basins.
• 2 face shields, particulate masks and
goggles
• To protect FR’s eyes, mouth, and nose.
COMPARTMENT B
• 2 Pressure dressings • Gauze with straps that can be wrapped and tied
to create direct pressure on a wound.
• Three 8″ × 10″ abdominal pads
Three 6″ × 8″ abdominal pads
• Large sterile pads used to hold sterile dressings
(e.g., 4″ × 4″ gauze pads) in place, and toabsorb blood and other body fluids.
• One 10″ × 30″ multi-trauma • For use with large wounds.
• Three 3″ cling • To hold dressings in place.
• Three 3″ crepe • To hold dressings in place.
• One 1″ cloth tape • To secure cling or crepe ends, or to hold
dressings in place.
• One 1″ transpor tape • May be used instead of cloth tape if patient is
allergic to tape or you do not want to cause
further damage to a wound.
• 1 Package 4″ × 4″ gauze
10 Sterile 4″ × 4″ gauze
5 Sterile 3″ × 5″ gauze
• Dressing wounds.
• Four 3″ × 5″ telfa pads • Small wound care, burns.
• 1 Esmarch • May be used as a tourniquet as a last resort.
Section may be used to cover open chest
injuries.
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First Responder kit
PARAMEDIC ACADEMY / MARCH 2001 UNIT 1: ROLE OF THE FIRST RESPONDER 21
Item Function
COMPARTMENT C
• 1 Ring pad • To protect an embedded object.
• 6 Triangular bandages • To secure large dressings and immobilizelimbs.
• 2 Hot packs • For treatment of hypothermia.
• 2 Cold packs • For treatment of fractures, swelling, and pain if
circulation to the affected area is adequate.
• SAM splints • For splinting of fractures/head immobilization.
• Speed straps • To secure dressings and immobilize limbs.
• 1 Head Immobilization Device • For head immobilization.
COMPARTMENT D
• 4 Pairs non-sterile surgical gloves • To protect the FR from body fluids duringassessment and treatment.
• 2 Pairs sterile surgical gloves • To protect the FR and the patient from
transmission of disease, bacteria.
• 6 Tongue depressors • For examining the oral cavity and applying the
contents of a Glucopak.
• 2 Glucopaks • For applying in the oral cavity (under tongue,
against inside of cheek) in unconscious patients
with history of diabetes.
COMPARTMENT E
• 1 Pair scissors • To cut patient clothing so that injuries can be
assessed; to cut tape, dressings and bandages
as required.
• 1 Pen light • To assess pupil response; to visualize oral
cavity.
• 4 Savlodil • To cleanse small wounds.
• PRESEPT™ tablets • To sterilize FR equipment (masks, etc.).
EXTERNAL EQUIPMENT
• 4 Sandbags • To immobilize a patient’s head and neck; to
immobilize limbs.
• 1 Oxygen tank and regulator • Pressurized oxygen storage with flow regulator.
To increase oxygen concentration to the
patient.
• 1 Blanket • To keep patient warm (prevent shock) and dry;
to support limbs. For patient comfort.
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First Responder kit
22 FIRST RESPONDER STUDENT MANUAL LEVEL III
Item Function
• FR report forms • To record patient assessment and treatment
provided, and any changes to patient’s
condition.
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Unit 2:
Patient Assessment
When you arrive at the scene of an accident, disaster, or
other emergency, there may be a multitude of things
competing for your attention. Without a structured and
uniform patient assessment model to follow, you would
probably end up overlooking many steps that are vital to a
patient’s survival.
The patient assessment model you are about to learn will help
you evaluate the patient systematically, starting with the
highest priorities and continuing to the less urgent ones.
Your goal will be to discover and manage hidden injuries and
other potentially life-threatening conditions that may not be
immediately obvious. By following the model consistently,
you can be sure of doing everything you should for your
patient.
First Responders with different levels of training andequipment can all use this model. Because Firefighters may
carry more equipment than other First Responders, they may
be able to treat patients more extensively, but the model does
not change from one level to the next.
Fo l l ow t he pa t i e n t a s ses sm en t m odel w heneve r y ou r espond
t o a n y em er g en c y .
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24 FIRST RESPONDER STUDENT MANUAL LEVEL III
The model has four components:
1. scene assessment
2. primary survey
3. secondary survey
4. reporting of data
Let’s now take a look at each of these in greater detail. By
the time you complete this unit, you should be able to
accomplish the following objectives:
2.1 Perform a scene assessment.
2.2 Perform a primary survey.
2.2a Assess level of consciousness (LOC) using the
AVPU method.
2.2b Manage a delicate spine.
2.2c Open and maintain the airway.2.2d Assess and manage the patient’s breathing.
2.2e Assess and manage the patient’s circulation.
2.2f Perform a rapid body survey (RBS).
2.3 Perform a secondary survey.
2.3a Establish the chief complaint and history of chief
complaint.
2.3b Record and monitor the patient’s LOC, pulse,
respirations, and skin colour and temperature.
2.4 Report data accurately to ambulance personnel.
2.5 Describe the principles of triage.
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Scene assessment
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 25
Make a quick assessment of the overall situation at an accident scene.
Concentrate on the “big picture.” Consider three things:
1. environment
2. hazards
3. mechanisms of injury
Watch out for danger from traffic, fire, smoke, gasoline vapours, fallen
power lines, and and other hazards that may be present at the scene.
Consider whether the environment will allow you to treat the patient
safely.
Find out what caused the injury. The mechanism of injury can
alert you to the possibility that certain types of injuries may be
present. For example, fractured bones are usually associated with falls
and motor vehicle accidents; burns with fires and motor vehicle
accidents; and soft tissue injuries with gunshot wounds. Remember,
however, that for every obvious injury, there may be a number of
hidden injuries.
If any of the following factors are present, the patient
should be considered unstable and must be transported to
hospital by ambulance immediately:
• fall from a height greater than 5 metres
• severe deceleration accident
• ejection from a vehicle
• pedestrian struck by a vehicle
• motorcyclist with blunt abdominal trauma or chest injury
• penetrating injuries of the head, neck, chest, and abdomen
• amputation of extremities
• trauma patients older than 65 or younger than five
• evidence of shock
• respiratory distress
• serious head injury
You should be able to describe the patient’s injury. Confirm that theEmergency Medical System (EMS) has been activated, and be
prepared to provide treatment based on the mechanism of injury. In
later units, you will learn how to recognize and treat specific
emergencies.
2.1:Perform a scene
assessment
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Scene assessment
26 FIRST RESPONDER STUDENT MANUAL LEVEL III
Read the following case study and answer the questions about it.
Compare your answers with those provided in Appendix B.
Case A
One January night, you respond to the scene of a motor vehicle
accident on the Upper Levels Highway. Car A has struck Car B,
throwing it against a power pole at the side of the highway. The
impact has knocked down a power line, which lies across the roof of
Car B. Car A has gone off the road too, and smoke is rolling from
under its hood.
1. As you observe the two cars, you do a quick scene assessment. List
10 things you should note during this assessment.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Case B
You respond to an incident where the victim has suffered a gunshot
wound to the head. The bullet creased the scalp but did not penetrate
the skull.
2. Given the mechanism of injury, what other injury might you
suspect?
____________________________________________
Case Study 2.1
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Primary survey
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 27
The primary survey is conducted once dangers at the scene have
been neutralized. It is the first step in the physical assessment of the
patient and consists of the following:
• check the level of consciousness (LOC) as you approach the
patient
• check the DABC (Delicate spine, A irway, Breathing, and
Circulation)
• performs a rapid body survey (RBS) to check for external
blood loss and deformities
While conducting the primary survey, you may discover life-
threatening emergencies such as obstructed airways, respiratory
difficulties, external bleeding, and obvious shock. Treat these
problems immediately.
For your safety, always wear personal protective equipment.
To perform a primary survey, you must be able to do the following:
2.2a Assess level of consciousness (LOC) using the AVPU method.
2.2b Manage a delicate spine.
2.2c Open and maintain the airway.
2.2c(1) Clear obstructions from the patient’s mouth, using a
tongue jaw lift or crossed-over finger technique to do
a visual check.
2.2c(2) Open the airway.
2.2c(3) Measure and insert a correctly sized oral airway for
unconscious patients.2.2c(4) Suction the mouth cavity if required.
2.2c(5) Place unconscious patients and patients with
compromised airways in the recovery position and
monitor breathing.
2.2d Assess and manage the patient’s breathing.
2.2d(1) Determine when a patient is not breathing
adequately.
2.2d(2) Use a pocket mask to ventilate patients with
inadequate breathing.
2.2d(3) Ventilate a pediatric patient (infant or child) with
inadequate breathing using a bag-valve-mask-oxygen reservoir unit.
2.2d(4) Use the bag-valve-mask-oxygen reservoir unit to
ventilate adult patients with inadequate breathing.
2.2e Assess and manage the patient’s circulation.
2.2f Perform a rapid body survey (RBS).
2.2f(1) Perform a rapid body survey.
2.2:Perform a primary
survey
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28 FIRST RESPONDER STUDENT MANUAL LEVEL III
2.2f(2) Give oxygen at high flow (10 L/min) with a standard
face mask.
2.2f(3) Describe the pathophysiology of hypoxic drive and
the management of a COPD patient.
Check for level of consciousness as you approach the patient. Thisinformation is important for other emergency personnel when they
take over patient care. A change in the level of consciousness is often
the first sign of a brain injury or other serious medical condition.
THE AVPU METHOD IS A SHORT AND SIMPLE WAY TO ASSESS THE LOC:
A – patient is Alert
V – patient responds to Verbal stimuli
P – patient responds to Pain
U – patient is Unresponsive to your approach and to verbal and painful stimuli
The best way to administer a painful stimulus is to squeeze the
patient’s trapezius muscle, which lies over the shoulder blades
(trapezoidal squeeze).
Always assume that the patient has a neck or spine injury ( de l i ca te
s p i n e ). You may rule it out a f t e r considering the mechanism of
injury, but always check for a delicate spine if the patient must be
moved. If you do not do this, you may seriously damage the patient’s
spinal cord and cause permanent paralysis.
If you suspect that the patient has a delicate spine, do the following:
1. Approach the patient from the head.
2. Tell the patient, “If you can hear me, don’t move.”
3. Stabilize the head in the position found using manual or
temporary stabilization.
4. Do not move the patient unless absolutely necessary to maintain
an open airway or to remove the patient from an immediate
hazard.
Airway management involves three things:
1. opening the airway
2. maintaining the open airway
3. helping the patient breathe effectively (ventilation)
2.2a: Assess level of
consciousness (LOC)using the AVPU method
2.2b:Manage a delicate spine
2.2c:Open and maintain the
airway
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 29
You will learn about opening and maintaining the airway under this
objective, and about ventilating the patient under Objective 2.2d.
Look, listen, and feel for the movement of air at the mouth or nose.
After an injury, a patient’s airway may become closed or blocked by
broken teeth, the tongue, or foreign objects.
Before taking steps to open the airway, make sure you have ruled
out a delicate spine or protected the neck. The technique you use will
depend on whether or not the mechanism of injury indicates a
delicate spine.
To manage the airway, you must be able to do the following:
2.2c(1) Clear obstructions from the patient’s mouth, using a tongue
jaw lift or crossed-over finger technique to do a visual check.
2.2c(2) Open the airway.
2.2c(3) Measure and insert a correctly sized oral airway for
unconscious patients.
2.2c(4) Suction the mouth cavity if required.
2.2c(5) Place unconscious patients and patients with compromised
airways in the recovery position and monitor breathing.
2.2c(1): Clear obstructions from the patient’s mouth, using a tongue
jaw lif t or crossed-over finger technique to do a visual check
Make sure your patient’s airway is clear before trying to open it.Remove foreign materials such as broken teeth, vomitus, loose-fitting
dentures, fluid, and mucus before attempting any further treatment.
Use an appropriate technique to open the patient’s mouth, and do a
visual check.
CROSSED-OVER FINGER TECHNIQUE
Do the following:
1. Place thumb on
upper front teeth andfirst finger on lower
front teeth.
2. Spread the mouth
open using a scissor
movement.
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30 FIRST RESPONDER STUDENT MANUAL LEVEL III
3. Visually check for foreign objects, then do a simple finger sweep to
remove any foreign objects. Be especially careful to protect the
patient’s neck if you suspect
a neck injury. Moving the
neck might seriously damage
the patient’s spinal cord.2.2c(2): Open the airway
Open the airway after clearing foreign materials from the mouth. The
tongue can easily act as a lid, closing down onto the back of the throat
and making breathing impossible. To open your patient’s airway, you
must lift the tongue up and off the back of the throat.
The technique you use will depend on whether or not the mechanism
of injury indicates a delicate spine. Assume that a neck injury is
present if the mechanism of injury suggests that neck trauma may
have occurred.
NO NECK INJURY: HEAD-TILT/CHIN-LIFT METHOD
Wa r n i n g : Do not use this procedure on any patient with neck or
spinal injuries.
Do the following:
1. Place one hand (A) on the patient’s forehead.
2. Place the first three fingers of the other hand (B) under the
patient’s chin and the thumb above the chin.
3. Keep fingertips on the bony part of the chin. Do not compress the
soft tissues that are under the lower jaw.
4. Gently push downward
with hand A. At the same
time, lift the chin and bringit to a point where the lower
teeth are almost touching
the upper teeth.
5. Do not allow the mouth to
close.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 31
NECK INJURY SUSPECTED: MODIFIED JAW THRUST METHOD
If you suspect a neck injury, take care not to move the neck.
Do the following:
1. Kneel on the groundabove the patient’s head
with your elbows on theground, before takingcontrol of the head.
2. Place your hands on
either side of the patient’s
head so that your thumbs
are on the zygomas
(cheek bones) and your
middle and index fingersgrasp the angle of the
jaw.
3. Ensure the patient’s head
remains stable during all
procedures.
4. Use your index and
middle fingers to displace
the patient’s jaw upwards
to open the airway.
2.2c(3): Measure and insert a correctly sized oral airway for
unconscious patients
The techniques for opening the mouth to insert an airway are:
• tongue/jaw lift
• crossed-over finger technique
Once the airway passage is clear and open, you must keep it open,
especially if the patient is unconscious and cannot do it himself or
herself. The oropharyngeal airway , a hard plastic tube, is the ideal
tool for this. Inserted correctly, it prevents the tongue from falling
back and blocking the airway. A number of sizes are available, ranging
from size 00 (smallest) to size 6 (the largest) (metric sizes 5 – 12).
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32 FIRST RESPONDER STUDENT MANUAL LEVEL III
Never reuse an airway. Always use a new one foreach patient.
There are three steps in theuse of an oral airway.
1. SELECTION OF AIRWAY
Always use a correctly sized airway. If the airway is too short, it will
not lift the tongue off the back of the throat. If it is too long, it may
occlude the airway, cause damage to the structures of the upper
airway, or protrude from the mouth, complicating the use of the BVM.
Do the following to select the correct airway size for your patient:1. Look at the patient from one side.
2. Estimate the distance from the corner of the mouth (point A in the
diagram) to the angle of the jaw (point B).
3. Select an airway that looks to be the correct size. Measure it by
placing it against the side of the patient’s face (points A to B).
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 33
2. INSERTION OF AIRWAY
1. Open mouth using an
acceptable method (tongue- jaw lift, crossed over finger
technique).
2. Put the airway in the mouth,
and point its tip towards the
roof of the mouth.
3. Glide the tip carefully along
the roof of the mouth until it
reaches the soft palate. Be
careful not to damage the
mouth or force the tongue
back into the airway. 4. Rotate the airway 180°.
5. Insert the rest of the airway until the ridge meets the patient’s lips.
6. To prevent aspiration (a situation in which the patient inhales
vomitus), the patient must be placed in the ¾ prone or recovery
position, if possible. (You will learn about this under Objective
2.2c[5].) Patients left on their back must be monitored
continuously to ensure that they are breathing, have a pulse, anddo not aspirate.
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34 FIRST RESPONDER STUDENT MANUAL LEVEL III
3. REMOVAL OF AIRWAY
If the patient is regaining consciousness, he or she will start to gag,
swallow, or make sounds. The patient may also try to push the airway
out with the tongue. You can help the patient by gently pulling it
outward and slightly downward, following the natural shape of the
mouth.
Remove the airway as soon as the patient starts gagging.
If the patient is still unconscious and you have to change the airway
(such as when it becomes plugged), follow these steps:
1. Open the mouth with an appropriate technique.
2. Lift the oropharyngeal airway slightly.
3. Then remove it from the patient’s mouth, allowing it to follow its
normal curve as it comes out.
This minimizes damage to tissues. Because the patient may vomit
when you remove the airway, make sure suctioning equipment is
available.
2.2c(4): Suction the mouth cavity if required
Suctioning the mouth cavity is another procedure used to keep the
airway clear. Secretions and other debris are removed by applying
negative pressure through a hollow tube. If you do not remove the
debris, you may force it into the patient’s lungs during ventilation.
V-Vac or Yankauer suction tips are routinely advised for suctioning
but any rigid suction tip should suffice.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 35
To operate the suction unit, follow these steps:
• Ensure that the new cartridge is in place.
• Remove the protective cap from the intake valve.
• Adjust the stroke (suction pressure) if required.
• Follow the general guidelines for suctioning.
After use:
• Replace the protective cap.
• Ensure the intake valve cover is closed.
• Keep the intake valve above the level of the cartridge fluids;
otherwise, suctioned material may flow out the intake valve.
• Remove the cartridge for ambulance crews to take to hospital, or
dispose of the cartridge in an approved container.
• Clean the handle as necessary.
• Install a new cartridge.
Prepare to suction the following:
• unconscious patients
• conscious patients who are having trouble with secretions, blood,
or vomitus
While preoxygenation for two to three minutes is desirable, in the
prehospital setting you will rarely have the opportunity to do this.
When you need to suction, suctioning takes priority .However, be aware that the suction is removing air as well as fluid.
Suction only as long as you need to in order to clear the airway, and
reoxygenate the patient as soon as possible after suctioning. If you are
assisting respirations or ventilating the patient, consider
hyperventilating the patient after suctioning is complete.
2.2c(5): Place unconscious patients and patients with compromised
airways in the recovery posit ion and monitor breathing
Patients who are unconscious or whose airways are compromised by
fluid or foreign objects should be placed in the ¾ prone or
recovery position. This will protect the airway in case the patient
vomits while unconscious or semi-conscious.
The technique you use for placing the patient in the recovery position
will depend on whether or not the mechanism of injury indicates a
delicate spine. Assume that a neck injury is present if the mechanism
of injury suggests that neck trauma may have occurred.
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36 FIRST RESPONDER STUDENT MANUAL LEVEL III
Moving patients
A general principle for First Responders is that patients should be
cared for in the position found. This principle is based on the
assumption that certain conditions or injuries (such as a neck fracture
in an unconscious patient) may be hidden and therefore missed
during the initial assessment. Unnecessary movement of the patientmay make the situation worse. In such cases, all repositioning should
be done by the most experienced persons on scene, who will also be
responsible for complete immobilization and transport.
In practice, however, there are three situations in which you, the First
Responder, will have to move the patient:
• repositioning the patient to manage immediate ABCs
• moving patients as quickly as possible out of hazardous areas
• rescuing and transporting patients
REPOSITIONING THE PATIENT TO MANAGE IMMEDIATE ABCs
Many patients are found in unusual or difficult positions. It may be
necessary to move them in order to effectively assess or manage their
ABCs by doing such things as:
• maintaining an open airway
• effectively ventilating the patient
• controlling life-threatening bleeding
• providing CPR
If you must move a patient, follow these principles:
• Moves are best done with the help of two or more people.
• Although managing the ABCs is always a priority, try to minimize
movement during urgent repositioning.
• Movement of the neck and spine is potentially more dangerous
than moving an extremity.
• In a conscious patient, increased pain caused by movement should
limit the amount of repositioning you carry out.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 37
Procedure
If time and personnel allow, the suggested procedure is as follows:
1. Manually immobilize the patient’s head.
2. Direct a helper to place a hand on the patient’s shoulder and the
other hand on the patient’s hip. An additional helper may hold thepatient’s legs. If you are alone, support the patient’s head with one
hand, and place your other hand on the patient’s hip.
3. Roll the patient as a unit far enough to manage any life-
threatening problems.
MOVING THE PATIENT AS QUICKLY AS POSSIBLE OUT OF HAZARDOUS AREAS
Often a patient ends up in a precarious position, in which his or her
immediate health is threatened and simple care cannot be given.Examples include:
• a patient found in a fire or in a place where there is danger of fire
• a patient injured in an area where there are explosives or other
hazardous materials
• a patient who has fallen halfway down a staircase
• a patient who has to be moved from a car so that rescuers can
reach a more seriously injured patient trapped inside
In these situations, your job as First Responder is:
• to move the patient as quickly as necessary to an area where
further treatment can be done, and
• to protect the patient from further injury during the move, in the
best manner possible
Move the patient to the closest secure area for assessment and
treatment. Urgent moves such as these require quick decisions and
action, but the principles outlined earlier still apply. If a spine board
or similar rigid board is available, you may log-roll the patient onto
the board with help from assistants. If no board is available, you may
have to lift or drag the patient to a safe area.
The moves should be done in a way that minimizes spinal movement.
If spinal injury is not suspected, you may use the fore-and-aft lift.
(See section 8.2 for a detailed description of this procedure.)
A patient who does not need to be moved should not be moved, but
should be cared for in the position found.
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38 FIRST RESPONDER STUDENT MANUAL LEVEL III
RESCUING AND TRANSPORTING PATIENTS
First Responders are often called upon to move a patient who has to
be rescued. Examples of such situations include:
• embankment rescues
• hazardous terrain rescues
• rescues from heights
• confined space rescues
In these situations, you are expected to perform full spinal
immobilization (as taught in the Management of Spinal Injuries
Module for First Responders). You should then move the patient to
the nearest secure area for treatment and eventual transfer of care to
ambulance personnel.
The role of the First Responder does not include transporting
patients. If, because of extenuating circumstances, you are called
upon to transport injured patients, you should perform full spinal
immobilization. You should make specific arrangements in advance,
in cooperation with the BC Ambulance Service and the medical
coordinator, for these rare instances.
COMPLEX SITUATIONS
When you treat injured patients, you will face conditions that requirecomplex management. Although you may have to improvise, the
principles stay the same:
• Do no harm.
• Concentrate on ABCs first.
• Avoid unnecessary movement.
Airway Management
In a patient with an altered level of consciousness (LOC) or facial
trauma, your primary concern may be managing the airway and
aiding ventilation. These are difficult skills to perform without spinal
movement, but they obviously take precedence over any otherprocedures. The preferred manoeuvre for opening the airway is the
modified jaw-thrust; review this technique with your instructor. If
possible, have a partner keep the head stable while procedures are
being done.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 39
Vomiting
Vomiting is a common problem in injured patients and may change a
simple situation into a crisis. If suctioning or drainage is not adequate
in the position that the patient is in, placing the patient in the lateral
or ¾ prone (recovery) position may solve the problem. If possible,
keep the cervical spine in a neutral position (either manually or withhelp) during repositioning.
Awkward Positions
There is no limit to the number of inconvenient positions that you will
find patients in, but no situation is totally unmanageable. Again,
concentrate on the principles, and do the best with the problems you
encounter.
Infants and Children
Although rare, 5% of all spinal cord injuries occur in the pediatric age
group. The principles are unchanged; however, children have
relatively larger heads and tend to flex their necks when lying supine.Improvise when necessary.
Difficult Patients
Sometimes because of anxiety, injuries, or intoxication, a patient may
not cooperate with you. Never try to immobilize the patient by force if
the struggle will possibly worsen injuries. Patients suffering from
altered LOC, other painful injuries, or intoxication may not even
notice the pain of a spinal injury. Reassure them, and minimize
movement in the best manner available.
Unstable Patients
A patient with critical injuries requires constant monitoring andinterventions. Stabilize the head and neck in the best manner
possible, and reassess ABCs and injuries frequently. Ambulance
attendants may sometimes make the difficult decision to rapidly
transport these patients before they can be fully immobilized. Manual
stabilization is always a reasonable option.
In summary, patients should be moved only in specific instances
where it is in the best interest of the patient’s care. Focus your
attention on ABCs, reassuring the patient, and making him or her
comfortable.
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40 FIRST RESPONDER STUDENT MANUAL LEVEL III
Positioning the patient
In most cases, positioning of the patient is determined by patient
comfort. If possible, the patient should be left in the position found
until ambulance personnel arrive. However, if moving the patient
results in better patient care, consider the following options:
• semi-sitting shortness of breath; obese
patients; chest pain
• supine suspected neck injuries; patients
with no radial pulse; hip fractures
• ¾ prone or recovery position all unconscious patients with no
suspected neck injury; all patients
with airway problems that cannot
be controlled by suctioning
Placing the patient in the recovery position
NO NECK INJURY
Do the following:
1. Kneel at the patient’s side and bring the far leg towards you so that
the patient’s ankles are crossed.
2. Place the arm and hand nearest you along the patient’s side. Place
the other arm across the chest.
3. Position your knee close to the person. Place one hand under the
head to support it, then grasp the pants or belt at the hip on the
side away from you.
4. Roll the patient towards you in one smooth but firm motion,
bringing the chest and abdomen to rest on your thighs. Protect the
head and neck during the roll.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 41
5. Bend the patient’s upper knee towards you to prevent the body
from rolling forward. To maintain an open airway, position the
head so that the neck is extended.
6. Bend the arm nearest you at the elbow to support the upper body.Position the patient’s other arm along his/her side to prevent the
patient from rolling back.
7. Always check that the patient is still breathing and has a pulse
after being put in the recovery position. Monitor the level of
consciousness until medical help arrives.
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42 FIRST RESPONDER STUDENT MANUAL LEVEL III
NECK INJURY SUSPECTED
If the mechanism of injury indicates a possible spinal injury, the
patient is lying on his or her back, and the airway is compromised by
large volumes of vomitus or other secretions that cannot be managed
by suctioning, you must place the patient in the recovery position.
This is a two-person manoeuvre. The FR at the patient’s lower
body performs the same steps as for an unconscious patient who is not
suspected of having a spinal injury. The FR at the patient’s head must
support the head in the position found, and ensure that the head and
body travel as a unit as the patient is turned.
Do the following to immobilize the head:
1. Grasp the patient’s trapezius muscles (trapezoid squeeze).
2. Wedge the patient’s head between your forearms.3. Do not stop supporting the head until you are relieved.
Placing a patient with a suspected spinal injury in the recovery
position might seem contrary to the principles of patient care. Realize,
however, that you are managing priorities. If the patient is not
breathing, he or she will die. Thus, draining the airway and
maintaining it should be the top priority.
A patient may be breathing on his or her own but not doing so
adequately. Do not wait for respiratory arrest before ventilating the
patient.
To assess and manage the patient’s breathing, you must be able to do
the following:
2.2d(1) Determine when a patient is not breathing adequately.
2.2d(2) Use a pocket mask to ventilate patients with inadequate
breathing.
2.2d(3) Ventilate a pediatric patient (infant or child) with inadequate
breathing using a bag-valve-mask-oxygen reservoir unit.
2.2d(4) Use the bag-valve-oxygen reservoir unit to ventilate adult
patients with inadequate breathing.
2.2d:
Assess and manage thepatient’s breathing
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 43
2.2d(1): Determine when a patient is not breathing adequately
A patient is not breathing adequately if he or she has fewer than 10
respirations per minute and/or shows any of the following signs of
hypoxia (low oxygen level in the blood):
• agitation
• irritability
• drowsiness
• headache
• decreased level of consciousness
• rapid pulse
• laboured breathing
• abdominal breathing
• bluish skin colour
• irregular heartbeat
2.2d(2): Use a pocket mask to ventilate patients with inadequate
breathing
The pocket mask is designed to help you give assisted ventilations to
patients who need them. You can give mouth-to-mask ventilations
through a port on the mask. Always use a one-way valve with the
pocket mask.
The pocket mask provides several advantages:
• It reduces the effort required to keep the patient’s airway open.
• It allows you to ventilate the patient without touching his or her
mouth and nose (reducing the chances of contamination).
• You can use both hands to maintain the head in the position found
and still hold the mask firmly in place.
• It is easy to keep a good seal between the mask and the patient’s
face.
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44 FIRST RESPONDER STUDENT MANUAL LEVEL III
To provide mouth-to-mask ventilations, follow these steps:
1. Position yourself at the patient’s head.
2. Open the patient’s airway and clear it if necessary.
3. Position the mask on the patient’s face so that the apex (upper tip
of the triangle) is over the bridge of the nose and the base is between the lower lip and the projection of the chin.
4. Clamp the rest of the mask to the patient’s face, keeping both of
your thumbs along the sides of the mask.
5. With your fingers, grasp the patient’s jaw below the angles. Pull
gently upward to maintain the backward tilt of the head.
6. Breathe into the mask port once every 3-5 seconds. This will force
your breath into the patient’s lungs.
7. Monitor the patient’s breathing by watching the rise and fall of the
chest.
2.2d(3): Ventilate a pediatric patient (infant or child) with inadequate
breathing using a bag-valve-mask-oxygen reservoir unit.
Reference: The First Responder Pediatric BVM multi-media CD-
ROM lesson plan. Contact your Training Officer to view the disc or
contact the Justice Institute’s Callcentre at 604-528-5690.
ntroduct ion
You are called for a 9-month old boy who was left unattended in a
bathtub. Dispatch informs you the infant may by in respiratory arrest.When you arrive you are met by a very distraught mother who is
holding a baby that is obviously cyanotic. The mother frantically
passes you the baby and begs you to do something. You quickly
assess the baby’s respirations and pulse – the infant is in respiratory
arrest.
There is nothing more challenging for a First Responder than dealing
with a pediatric patient in a life-threatening situation. The rescue
scene may be emotionally charged and chaotic with reactions ranging
from quiet withdrawal and depression to shock, anger, and frustration.
And this is just from the caregivers. Pediatric patients are quitedistinctive from their adult counterparts. As such, your approach and
interactions with the patient will need to be modified. Unlike adults
who are usually glad to see the arrival of First Responders, children
may be afraid and withdraw from your presence. Let’s begin by
looking at a few of the unique characteristics of pediatric patients.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 45
Unique Characteristics and Tips for ssessment of the Pediatric
Patient
“Pediatrics” refers to infants and children. For the purposes of this
lesson, infants will be defined as newborns up to one-year of age or
approximately 7 kgs or less. Children will be defined from one-year to
eight-years of age or approximately 30 kgs or less.
Infants
• Infants less than 2 months of age spend most of their time eating
and sleeping.
• Infants between 2 and 6 months are more alert and begin to make
eye contact. They will recognize their caregivers. They normally
will be actively moving their extremities. If upset they will cry
vigorously.
• Infants 6 – 12 months begin to babble, put objects in their mouth,
and sit on their own. Around 1 year they begin to crawl or stand
with support. Infants at this age may be very afraid of strangers or
being separated from their caregivers.
• Infants are nose breathers for the first few months of life.
• Infant’s chest muscles are not fully developed so they will appear
to “belly breath”.
• Approach an infant slowly and at eye level. Avoid sudden
movements and loud noises. Leave the infant with the caregiver if
possible.
• If crying, a toy or pacifier may calm the baby.
Toddlers
• By about 1 ½ years of age children can run, play, and
communicate with others.
• They may be scared of the First Responders.
• They are opinionated and self-centered.
• They still use their abdominal muscles to breath.
• When assessing the toddler allow them to remain with the
caregiver if possible.
• Use toys as a form of distraction.
• Approach the toddler slowly and at eye level.
• Praise tends to get cooperation.
• Ask the caregiver for assistance.
Preschoolers
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46 FIRST RESPONDER STUDENT MANUAL LEVEL III
• Many preschoolers have misconceptions about injury and bodily
functions.
• Use simple statements to explain what you are going to do.
• Ask the child for his/her help.
• Praise tends to get cooperation.
• Use toys or games as a form of distraction.
• Attention span is short.
• Pre-school age children fear separation from their caregivers.
School age
• They need explanations and privacy.
• They do not like to talk about their feelings.
• Peers are becoming important.
• Try and speak directly to the child.
• Explain to the child what you are going to do.
• Reassurance is important.
Indications for Assisting Ventilations of an Infant or Child
There are two indications for the use of the Pediatric BVM:
1. Ventilating a non-breathing infant or child (as determined in
the Primary Survey)
2. Ventilating an infant or child with inadequate breathing.
Determining if a pediatric patient is ventilating adequately is not a
simple task and requires special consideration. Always follow theLook, Listen, and Feel method for assessing breathing:
o Observation skills are critical in assessing a pediatric
patient. Even as you approach the infant or child, look for
signs of respiratory distress. Does the patient make eye
contact, are they crying, are they moving their extremities,
do they appear to be struggling to breath, and what does
their skin colour look like. A child who is vigorously
crying, pink, and thrashing about probably won’t need
respiratory assistance. However, a child who is listless,
with rapid noisy breathing, and noticeable cyanosis may
require immediate respiratory assistance.
o Normal respiratory rates vary considerably with pediatric
patients with rates of 30 – 60 being normal for infants (0
– 1 year of age) and rates of 20 – 30 being normal for
children (1 – 8 years of age). Respiratory rate alone is not
a good indicator to determine whether or not the pediatric
patient is breathing adequately but a First Responder
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 47
must be ready to intervene if the patient’s respiratory rate
is significantly below or above the normal expected rate.
o Closely linked to respiratory rates is the character of
breathing. How hard is the pediatric patient working to
breath and are there any abnormal respiratory noises?Normal respirations should be effortless and quiet in any
position. If you hear snoring, grunting, wheezing, or high-
pitched sounds along with signs that the child or infant is
working hard to breath (nasal flaring, abnormal
positioning or using accessory muscles to breath) the First
Responder must be ready to intervene and assist the
patient’s breathing. Using accessory muscles is defined
when the patient is using muscles other than the
diaphragm and intercostals muscles to assist with
breathing – usually the muscles in the neck.
Contraindications and Cautions for Assisting Ventilationson an Infant or Child
Contraindications
The only contraindication for assisting ventilations of an infant or
child is complete airway obstruction. The airway obstruction
must be removed prior to being able to ventilate the patient. Follow
the Canadian Heart and Stroke CPR guidelines for dealing with an
obstructed airway.
Cautions
Infants:
o Infants have very delicate airway structures so the First
Responder must be cautious to prevent injury while inserting
an oropharyngeal airway and using the BVM.
o Head to body size is proportionately greater in the infant than
the older child and this can make effective positioning more
difficult.
o The infant’s airway is very soft and collapsible –
hyperextension of the head during ventilation can close off the
airway.
o Abdominal muscles are the main muscles of respiration in
infants.
o Infants are more prone to airway obstruction from foreign
material or swelling due to very small airway size.
Children:
o It is very difficult to assist a child with inadequate respirations
as they are scared and unable to understand what you are
trying to do. A calm reassuring approach will assist with this.
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48 FIRST RESPONDER STUDENT MANUAL LEVEL III
Selecting the proper Pediatric BVM
The Pediatric BVM must be sized appropriately for the patient. The
First Responder may use age or weight as a guideline:
o Infants (0-1 year of age) use the Infant BVM.
o Children (1 –8 years of age) use the Child BVM.o Children/Adults (over 8 years of age) use the Adult BVM.
o Infants (under 7 kilograms) use the Infant BVM.
o Children (between 7 and 30 kilograms) use the Child BVM.
o Children/Adults (over 30 kilograms) use the Adult BVM.
Mask size is critical. Measure the mask on the patient and ensure the
mask extends from the bridge of the nose to the cleft of the
chin. Proper mask selection will ensure a good seal to facilitate
effective positive pressure ventilation.
Ensure the Pediatric BVM has an attached oxygen reservoir bag and is
connected to an oxygen tank with the flow meter adjusted to 15 litersper minute.
Procedure for Using the Pediatric BVM
As with all patient assessment the First Responder must follow an
established routine.
• RSE: Conduct a Rescue Scene Evaluation.
• PPE: Wear personal protective equipment.
• LOC: Assess patient’s Level of Consciousness.
• D: Take spinal precautions as required.
• A: Open the patient’s Airway.
o Medical Patient – use a Head-Tilt/Chin-Lift maneuver.
o Trauma Patient – use a Jaw Thrust maneuver.
o Insert oropharyngeal airway as required. Important note –
When inserting an oropharyngeal airway in an infant (0-1 year
of age) complete the following procedure:
a. Measure the oropharyngeal airway the same as for
an adult or child.
b. Open and visualize the infant’s mouth.
c. Using a tongue depressor, gently depress the
tongue to the floor of the mouth so that you can
visualize the back of the oral cavity.
d. Insert the oropharyngeal airway directly into
position. Do not rotate the airway as you
would in a child or adult.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 49
e. If a tongue depressor is not available you can
insert an oropharyngeal airway in an infant in the
traditional manner but extreme care must be
taken, as the upper palate of an infant is delicate
and easily damaged.
• B: Assess patient’s Breathing.
o Intervene as required……
The following steps outline the specific use of the Pediatric BVM:
1. Ensure Neutral positioning of the pediatric patient’s airway:
o For an infant the head is positioned in the neutral position by
placing a roll or pad under the baby’s shoulders. Use caution
to not place an item that is too large, as hyperextension will
result in airway collapse and the inability to ventilate
effectively.
2. Begin Ventilation.
o Apply appropriately sized mask to face and get an airtight seal
using the C-clamp grip.
o Failure to provide a good seal between the mask and face will
result in ineffective ventilations.
o Avoid putting any pressure on the soft tissues under the chin
as this could result in airway collapse.
o Think of pulling the lower jaw up into the mask rather than
pushing the mask onto the face.
o Squeeze the bag and watch for the chest to rise, as soon as
chest rise is visually detected release the bag.
o Assess effectiveness of ventilation. You should see the chest
rise and fall on each ventilation. The patient’s skin colour
should improve. Cyanosis, if it was previously present, should
improve. Watch the abdomen for signs of enlargement during
ventilation. If enlargement is noted reposition the airway and
observe chest rise carefully, squeeze the bag o n l y until chest
rise is detected.
o Ventilate at a rate 30/minute for infants.
o Ventilate at a rate of 20/minute for children.
2.2d(4): Use the bag-valve-mask-oxygen reservoir unit to ventilate
adult patients with inadequate breathing
The bag-valve-mask-oxygen reservoir (BVM) unit allows you to
ventilate an adult patient by moving enriched, oxygenated air into the
lungs and removing carbon dioxide. The unit consists of the following:
• Oxygen reservoir
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50 FIRST RESPONDER STUDENT MANUAL LEVEL III
• A bag
• A non-return valve (to prevent rebreathing)
• An anesthetic-type mask available in various sizes (the pocket
mask may also be used with this unit)
• An inlet for oxygen delivery
When using the BVM with oxygen, ensure the oxygen tubing is
connected to the bag-valve mask and the oxygen flow rate is set at a
minimum of 15L/min.
If the patient will accept an oropharyngeal airway, the FR must
ensure the OPA is in place when using the BVM with an unconscious
patient.
Do the following:
1. Place the narrow end of the mask on the bridge of the patient’s
nose and in the groove between the lower lip and the chin.
2. Make sure you are directly behind the patient’s head, not slanted
to one side or the other.
3. Place the apex of the mask over the bridge of the patient’s nose.
4. Place the base of the mask into the groove between the lower lip
and the chin.
5. Extend the head and neck if no neck injury is present.
6. Place the thumb and first finger of one hand in a C-shape on top of
the mask, and grip the rim of the lower jaw with the remaining
fingers.
7. Grip tightly to complete the seal around the mask. Make sure the
seal is tight. If you cannot get a tight seal, you can either
• switch to a pocket mask, or
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 51
• if help is available, have one person apply even pressure
around the mask using both hands
8. Place four fingers of the other hand on top of the bag and the
thumb under it.
9. Squeeze the bag as completely as possible. (If your hands aresmall, try pressing the bag against your thigh.)
10. Ventilate the patient at 12 to 20 ventilations per minute.
11. Check for adequate ventilation by
• watching for an even rise and fall of the chest
• feeling for an even resistance from the bag
For a skilled operator, the BVM unit is a useful tool. However, because
it is easier to maintain the skills required to use a pocket mask, the
pocket mask is the preferred tool for ventilating a patient.
2.2e: Assess and manage the
patient’s circulation
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52 FIRST RESPONDER STUDENT MANUAL LEVEL III
After managing a delicate spine, opening and maintaining the airway,
and assisting patient breathing, you must check for adequate
circulation.
Do the following:1. Check the patient’s pulse.
2. If the carotid pulse is absent, begin CPR.
NOTE: CPR should be started only if no pulse is found and the
patient is unconscious. Check both carotid arteries separately if you are unsure about the presence of a pulse.
3. If the radial pulse is absent but the carotid pulse is present , the
patient may be in shock and is therefore unstable. (You will learn
how to manage shock in Unit 4).
Radial pulse
Carotid pulse
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 53
The rapid body survey will help you to locate and expose injury
sties, stabilize fractures, and control bleeding. Firefighters carry
oxygen and should administer it to trauma and medical patients.
You should be able to accomplish the following objectives:
2.2f(1) Perform a rapid body survey.
2.2f(2) Give oxygen at high flow (10 L/min) with a standard face
mask.
2.2f(3) Describe the pathophysiology of hypoxic drive and the
management of a Chronic Obstructive Pulmonary Disease
(COPD) patient.
2.2f(1): Perform a rapid body survey
Do the following:
1. Check for bleeding, deformity, and your patient’s response to pain
by systematically running your hands over and under the
following:
• head and neck
• chest and abdomen
• back
• lower extremities
• upper extremities
2. Ask your partner and/or a bystander to bring appropriate
equipment as needed.
3. Control bleeding using direct or indirect pressure, elevation, or a
tourniquet, as described in Unit 4.
4. Stabilize possible fractures, as described in Unit 4.
You should take no more than 30 seconds to perform a rapid body
survey. It should be interrupted only long enough to provide
intervention for life-threatening injuries.
Ambulance personnel will transport unstable patients to the hospital
after the rapid body survey. They will continue with a secondary
survey en route to the hospital.
2.2f(2): Give oxygen at high flow (10 L/min) with a standard face mask
As a First Responder, you should use a standard face mask to give
oxygen at 10 L/min to:
• all trauma patients
• all patients with a medical or respiratory emergency
REGARDLESS of a history of COPD
2.2f:Perform a rapid body
survey (RBS)
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This includes:
– All trauma patients
– Medical emergencies including:
• All unconscious patients
• All suspected heart attacks
• All chest pain• All strokes
• All overdose patients with altered LOC
• All seizure patients
• All patients in shock
– Respiratory emergencies including:
• Patients complaining of SOB
• Laboured or noisy breathing
• Increased respiratory rate
• Cyanosis
Oxygen therapy for the non-traumatic COPD patient is 6 L/min
through a standard adult oxygen mask (see Objective 2.2f[3]).
The standard face mask delivers a high concentration of oxygen to
short of breath patients. There are two sizes, adult and child. Try to fit
the patient as best you can. The mask can sometimes appear very
threatening, so explain to the patient how it will help him or her.
Some patients might resist wearing the mask. In this case, you or the
patient could hold the mask inches from the patient’s face.
Clean used oxygen equipment to avoid spreading infection from
patient to patient or to yourself and others. Follow the procedure
described in Objective 7.4, Decontaminating Equipment, in Unit 7.
Your oxygen supply will be found in a small, portable tank that you
can carry with you to the emergency scene.
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 55
Make sure your tank always has enough oxygen. Replace it when
there is less than 500 PSI.
Do the following:
BEFORE AN EMERGENCY
1. Hold the oxygen tank upright securely, and position yourself to
the side.
2. “Crack” the valve open with the wrench: slowly open and quickly
close it. This blows away any loose debris.
3. Make sure the main valve is equipped with a new gasket.
4. Tightly fit the oxygen (= pressure) regulator onto the main valve
stem.
DURING AN EMERGENCY
1. Make sure the litre control valve is off, then open the main
cylinder valve slowly. Bring it one-half turn past the point where
pressure begins to register on the regulator.
2. Open the litre control valve to the desired flow and lay the cylinder
down.
3. Explain the use of oxygen to the patient before fitting the mask
over the patient. Attach the tubing to the mask and the oxygen
tank. Determine whether the patient has a history of chronic
lung disease and set the appropriate flow rate (see
Objective 2.2f[3]).
4. When finished, turn the control valve off until the litre flow is
zero.
5. Turn off the main cylinder valve.
6. Bleed all pressure from the regulator by shutting the cylinder
valve but leaving the litre control valve open until the oxygen has
escaped.
2.2f(3): Describe the pathophysiology of hypoxic drive and the
management of a COPD patient
In normal people, the breathing reflex is triggered by high levels of
carbon dioxide (CO2) in the blood. Patients with emphysema, chronic
bronchitis, and chronic asthma may have a condition known as
Chronic O bstructive Pulmonary Disease (COPD). They retain CO2
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56 FIRST RESPONDER STUDENT MANUAL LEVEL III
and thus have a chronically high level of this gas. Their breathing
reflex is triggered only when the oxygen level in their blood is low.
This mechanism is known as hypoxic drive. COPD patients who rely
on hypoxic drive rarely deteriorate as a result of the administration of
high flow oxygen. First Responders rarely experience this situation,
provided that BCAS arrival is less than 10-15 minutes. Generallyspeaking, it requires several minutes for high flow oxygen to inhibit
hypoxic drive and cause a patient to be drowsy, thus reducing their
ventilation. All First Responders should closely monitor the rate and
depth of breathing in all cases where oxygen is administered and be
prepared to assist ventilations with a BVM.
Give the patient with COPD 6 L/min through a standard adult oxygen
mask, if there are no signs of medical, respiratory or traumatic
emergencies. In reality, patients requiring low flow oxygen should
make up less than 5% of calls.
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Read the following case study and answer the questions about it.
Compare your answers with those provided in Appendix B.
You are called to a local bar where a 40-year-old man has been
injured. When you arrive, you find him lying motionless on his back, with a small amount of blood trickling from the corner of his mouth.
His skin is bluish.
“What happened here?” you ask the people standing around. “Sam’s
been drinking all day,” they reply. “He was sitting on the bar stool
when he fell backwards and hit his head on the table.”
1. List the six major steps you would take to treat this patient before
the ambulance arrives.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
2. You call loudly to the man, “Hello, sir! Can you hear me?” He
doesn’t respond to this or to a trapezoidal squeeze. How would
you rate the man’s level of consciousness?
____________________________________________
3. Should you be concerned about a neck injury? Why?
____________________________________________
____________________________________________
4. The ________________________________ technique isused to open a patient’s mouth before making a visual check.
5. What method would you use to open the patient’s airway? Why?
____________________________________________
____________________________________________
Case Study 2.2
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6. What tool would you use to maintain an open airway in this
patient?
____________________________________________
____________________________________________
7. From what you know of the patient so far, what signs indicate that
he may not be breathing adequately?
____________________________________________
____________________________________________
8. You can use the _____________________________to give
the patient mouth-to-mask ventilations through a port on the
mask.
9. Is it important to find out whether this patient has COPD before
giving supplemental oxygen?
____________________________________________
____________________________________________
10. When you check the patient’s circulation, you find that both radial
and carotid pulses are absent. What should you do?
____________________________________________
____________________________________________
11. When should this patient be transported to the hospital? Who
should transport him?
____________________________________________
____________________________________________
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PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 59
The purpose of a secondary survey is to identify problems that,
while not immediately life-threatening, may threaten the patient’s
survival if left undetected. The secondary survey consists of the:
• medical history
• vital signs• head-to-toe physical examination
The information you gather here will be vital for the patient’s care.
You should be able to report it accurately and concisely to ambulance
personnel when they arrive (see Objective 2.4).
To perform a secondary survey, you must be able to do the following:
2.3a Establish the chief complaint and history of chief complaint.
2.3b Record and monitor the patient’s LOC, pulse, respirations, and
skin colour and temperature.
If time permits, perform a head-to-toe examination, which is really a
more thorough rapid body survey. Constantly monitor the patient’s
level of consciousness and DABCs also.
Begin the secondary survey by establishing what is wrong with the
patient.
Chief complaint
The chief complaint is what the patient says is wrong with him orher. Record and report it using the patient’s own words. This will help
you to avoid interpreting what the patient has said, which may
obscure or change the nature of the problem.
Most chief complaints are characterized by pain or abnormal function.
Find out what is bothering the patient most. For example, patient in a
motor vehicle accident may have an obvious leg fracture but his chief
concern may be, “I can’t breath.” This may help you discover an
unsuspected chest injury.
History of the chief complaint
The history of the chief complaint examines the chief complaint
in greater detail. Get a description of the events that caused the chief
complaint. If pain is the chief complaint, use the PQRST mnemonic
to help you organize your questioning.
2.3:Perform a secondary
survey
2.3a:Establish the chief
complaint and history ofchief complaint
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Secondary survey
60 FIRST RESPONDER STUDENT MANUAL LEVEL III
HISTORY OF CHIEF COMPLAINT: PQRST MNEMONIC
P Position of the pain
Where is it located? Can you point to it?
Q Quality of the painWhat does it feel like? Is it sharp, dull, throbbing, or crushing?
R Radiation of the pain
Does it radiate anywhere?
Does it stay in one place or move around?
Does anything relieve it? What makes it worse?
S Severity
How would you rate the pain on a scale of 1 to 10 (10 being the worst)?
T Timing of the pain
When did it start? What brought it on? Does it have a time pattern? Have you
had it before? How long does it last?
Follow these guidelines when interviewing a patient:
• Allow the patient to answer in his or her own words.
• Avoid suggesting answers. (“What provoked the pain?” not “Does
the pain come after exertion?”)
• Use open-ended questions. Avoid asking questions that can be
answered with a yes or no.
• To pinpoint responses, give the patient alternatives. (“Does the
pain stay in one place or does it move around?”)
• Use an empathetic tone, and reassure the patient frequently.
Avoid a rapid-fire interrogation. It will only increase the patient’s
anxiety.
Other information
If time permits, ask the patient about:
• past medical problems
• medications
• allergies
• patient’s identity (name, age, and address)
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Secondary survey
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 61
Baseline vital signs are one of the most important aspects of
patient assessment. They are taken after the primary survey and the
medical history. Based on them, ambulance personnel and receiving
hospital staff can tell whether or not the patient’s condition is
deteriorating.
As a First Responder you should record the following:
• LOC (using the AVPU method; see Objective 2.2a)
• Pulse – rate, rhythm, and strength
• Respirations – rate, rhythm, and volume
• Skin – colour and temperature
Monitor the LOC, take the pulse, and count the respirations every
five minutes. Check whether the patient’s skin is:
• cool or warm
• moist or dry
• cyanotic (blue), pale, or normal in colour
When patients are suffering from life-threatening conditions,
treating conditions found in the primary survey is more urgent than
taking vital signs.
2.3b:Record and monitor the
patient’s LOC, pulse,respirations, and skin
colour and temperature
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Secondary survey
62 FIRST RESPONDER STUDENT MANUAL LEVEL III
Read the following case study and answer the questions about it.
Compare your answers with those provided in Appendix B.
As you drive by a bus stop, you see a crowd gathered around an elderly
man sitting on the bench. He is clutching at his chest in obviousdistress. You stop the vehicle and quickly walk over. As you approach,
you hear the man gasping, “Can’t breathe…pain’s killing me!”
Working efficiently you complete the primary survey.
1. In what order would you perform the following steps of the
secondary survey?
a) Record pulse, respirations, condition of skin; take a history;
perform more thorough rapid body survey.
b) Take a history; perform more thorough rapid body survey;
record pulse respirations, condition of skin.
c) Take a history; record pulse, respirations, condition of skin;
perform more thorough rapid body survey.
2. This patient’s chief complaint is chest pain. Which of the following
sets of questions should you ask in order to get the history of the
chief complaint?
a)
1. Can you show me where the pain is, sir?
2. What type of pain is it?
3. Does this pain stay in one place or does it go somewhere
else?4. On a scale of 1 to 10, with 10 being the worst, how would
you rate this pain
5. Has this ever happened to you before?
b)
1. Have you ever had a heart attack?
2. What were you doing when this happened?
3. Do you feel nauseated?
4. On a scale of 1 to 10, with 10 being the worst, how would
you rate this pain?
5. Does this pain go into your left arm?
c)
1. Is the pain in the middle of your chest, sir?
2. Does this pain feel sharp?
3. When did you first feel this pain?
4. Did you feel dizzy before this occurred?
5. Has this ever happened to you before?
Case Study 2.3
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Secondary survey
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 63
3. If a patient was shot in the chest, what additional, possibly hidden,
injury might you detect?
____________________________________________
____________________________________________
____________________________________________
____________________________________________
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Recording and reporting data
64 FIRST RESPONDER STUDENT MANUAL LEVEL III
Recording and reporting data is the final major component of the
patient assessment model. Your report will help guide the ambulance
personnel and hospital staff in treating the patient.
It is critical that the record of your findings be as thorough, complete,
and accurate as possible. Besides being useful to medical staff, yourfindings form a crucial record of the patient’s initial conditions, your
assessment, and your treatment that can be subpoenaed at a later date
during a legal inquiry. If patient condition, assessment, and treatment
are not documented, a court may well conclude that the missing items
were not performed or completed as required by your First Responder
licence.
Report your findings orally to responding ambulance personnel. Your
oral report should include the following:
• mechanism of injury
• chief complaint
• history of chief complaint
• LOC, pulse, respirations, and skin colour and temperature
• treatment given
• all relevant physical findings
Follow up your oral report with a completed copy of the First
Responder Report. If you are unable to complete this form before the
ambulance crew departs, forward your copy to the receiving hospital
within 24 hours of the incident. The First Responder Report forms
part of the patient’s permanent medical record.
2.4:Record data and
report it accurately toambulance personnel
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Principles of triage
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 65
During a disaster, casualties may stretch available facilities, supplies,
equipment, and personnel. Triage is the sorting of multiple patients
according to their need for emergency treatment and evacuation. The
first aid team does primary triage at the disaster site to determine
the order in which patients are brought to the secondary triage
area. In the secondary triage area, stretcher-borne and more seriouslyinjured patients are assessed, sorted into priorities, and stabilized
before further treatment and eventual evacuation.
The general rules of triage are as follows:
1. Injuries threatening life take priority over injuries threatening
limbs.
2. Injuries threatening function, such as those to the respiratory or
cardiovascular systems, take priority over injuries causing
anatomical defects, such as a fractured leg or a skull fracture in a
conscious patient.
3. Criteria for grouping patients will vary with the situation, the
backlog of patients awaiting medical care, and the capabilities of
the emergency services at the scene. As much as possible,
however, patients should be sorted into the following categories
for medical care:
• Urgent category
Patients whose lives are in immediate and serious jeopardy
and who require urgent treatment and evacuation.
• Delayed category
These are patients whose lives or limbs are not in serious
jeopardy although a limb or organ may have sustained acrippling injury. The physical condition of such patients may
be relatively stable for the moment. They are evacuated as
transportation becomes available.
• Minor injuries/walking wounded category
These patients may be managed at a temporary first aid
facility and do not require hospitalization.
4. Airways in unconscious patients can become obstructed at any
time. Noisy respirations indicate partial obstruction.
5. Patients in shock or with a reduced blood volume tolerate
transportation poorly. Ambulance personnel should start
intravenous fluid replacement before evacuation and continue itduring the process if possible.
6. NEVER DELAY URGENT TREATMENT FOR
DOCUMENTATION.
7. Assess patients periodically. A patient may deteriorate at any time
and may have to placed in a more urgent category.
2.5:Describe the
principles of triage
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Principles of triage
66 FIRST RESPONDER STUDENT MANUAL LEVEL III
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Principles of triage
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 67
Answer the following questions and compare your answers with
those provided in Appendix B. Review this section if you make any
mistakes.
1. Define triage.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
2. Patients at a disaster site are sorted into three categories for
medical care. What are these categories?
____________________________________________
____________________________________________
____________________________________________
3. Injuries threatening ____________________________
take priority over injuries causing anatomical defects.
Self-Test 2.5
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Summary 2
68 FIRST RESPONDER STUDENT MANUAL LEVEL III
You have just studied the patient assessment model that you should
follow whenever you respond to an emergency. Take a few moments
now to complete the following narrative. Check your work against
the full version that follows. If you made any mistakes, review the
appropriate sections of this unit.
The patient assessment model will help you evaluate patients
systematically. The model has four components:
__________________, _________________________,
__________________________, and
_________________________.
In performing a __________________, concentrate on the “big
picture.” Consider the environment, hazards, and
______________________.
The _____________________ is the first step in the physical
assessment of the patient. In this step, you should check the ________________________ and DABC, and perform a rapid
body survey. For your protection, always wear
___________________.
The AVPU method is a short and simple way to assess the
______________________. “A” means the patient is alert, “V”
means the patient responds to __________________________
stimuli, “P” means the patient responds to
___________________, and “U” means the patient is
_____________________.
Always assume that the patient has a _____________________spine, especially if the mechanism of injury suggests that neck trauma
may have occurred. Stabilize the neck in the position found.
Airway management involves opening the airway, maintaining the
open airway, and helping the patient breathe effectively. Make sure
the patient’s mouth is clear before trying to open the airway. Use the
_______________________ method to open the airway if there
is no neck injury. If you suspect a neck injury, use only the
__________________ method.
Once the airway is open, you must keep it open, especially if the
patient is ____________________. An ________________
airway is useful for this. _____________________ the mouth
cavity is another way to keep the airway clear by removing secretions
and other debris through a catheter. Patients who are unconscious or
whose airways are compromised by fluid or foreign objects should be
placed in the ____________________ or
____________________. The technique you use for this will
Summary 2
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Summary 2
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 69
depend on whether or not the mechanism of injury indicates a
__________________________.
A patient is not breathing adequately if he or she has fewer than
________ respirations per minute or shows signs of
_______________. You can use the ________________________ to give mouth-to-mask
ventilations to patients who need them. The _________________
unit consists of a bag, reservoir, non-return valve, mask, and inlet for
oxygen delivery.
Trauma patients and medical patients require oxygen at a flow of
_________________. In patients with __________________,
the breathing reflex is triggered only by a low oxygen level in the
blood. This mechanism is known as
_______________________.
In assessing the patient’s circulation check the ___________________ and _______________________
pulses. If both are absent, begin _____________________ to
force blood and oxygen through the heart and lungs and into the blood
vessels.
You should take no more than 30 seconds to perform a
____________.
The ______________________________ consists of the
medical history, __________________________, and
________________________. The
_________________________ is what the patient says is wrong with him or her. The ______________ mnemonic will help you
question the patient about pain.
The ____________________ vital signs are the first set of vital
signs taken after the primary survey and the medical history. As a
First Responder you should take the pulse and count the respirations
every _______ minutes. You should also check the condition of the
skin.
___________________________________ is the last major
component of the patient assessment model. Remember that your
report will guide the ambulance personnel and hospital staff in their
treatment of the patient.
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Summary 2
70 FIRST RESPONDER STUDENT MANUAL LEVEL III
Summary 2 – Answers
The patient assessment model will help you evaluate patients
systematically. The model has four components: scene assessment,
primary survey, secondary survey, and reporting of data.
In performing a scene assessment, concentrate on the “big picture.”
Consider the environment, hazards, and mechanism of injury .
The primary survey is the first step in the physical assessment of
the patient. In this step, you should check the level of
consciousness and DABC, and perform a rapid body survey. For
your protection, always wear personal protective equipment.
The AVPU method is a short and simple way to assess the level of
consciousness (LOC). “A” means the patient is alert, “V” means the
patient responds to verbal stimuli, “P” means the patient responds to
pain, and “U” means the patient is unresponsive.
Always assume that the patient has a delicate spine, especially if the
mechanism of injury suggests that neck trauma may have occurred.
Stabilize the neck in the position found.
Airway management involves opening the airway, maintaining the
open airway, and helping the patient breathe effectively. Make sure
the patient’s mouth is clear before trying to open the airway. Use the
head-tilt/chin-lift method to open the airway if there is no neck
injury. If you suspect a neck injury, use only the modified jaw
thrust method.
Once the airway is open, you must keep it open, especially if the
patient is unconscious. An oral airway is useful for this.
Suctioning the mouth cavity is another way to keep the airway clear
by removing secretions and other debris through a catheter. Patients
who are unconscious or whose airways are compromised by fluid or
foreign objects should be placed in the ¾ prone or recovery
position. The technique you use for this will depend on whether or
not the mechanism of injury indicates a delicate spine.
A patient is not breathing adequately if he or she has fewer than
10 respirations per minute or shows signs of hypoxia. You can use
the pocket mask to give mouth-to-mask ventilations to patients who
need them. The bag-valve-mask (BVM) reservoir unit consists of
a bag, reservoir, non-return valve, mask, and inlet for oxygen delivery.
Trauma patients and medical patients require oxygen at a flow of
10 L/min. In patients with chronic obstructive pulmonary
disease (COPD), the breathing reflex is triggered only by a low
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Summary 2
PARAMEDIC ACADEMY / MARCH 2001 UNIT 2: PATIENT ASSESSMENT 71
oxygen level in the blood. This mechanism is known as hypoxic
drive.
In assessing the patient’s circulation check the radial and carotid
pulses. If both are absent, begin CPR to force blood and oxygen
through the heart and lungs and into the blood vessels.
You should take no more than 30 seconds to perform a rapid body
survey .
The secondary survey consists of the medical history, vital signs,
and head-to-toe physical examination. The chief complaint is
what the patient says is wrong with him or her. The PQRST
mnemonic will help you question the patient about pain.
The baseline vital signs are the first set of vital signs taken after the
primary survey and the medical history. As a First Responder you
should take the pulse and count the respirations every five minutes. You should also check the condition of the skin.
Recording and reporting data is the last major component of the
patient assessment model. Remember that your report will guide the
ambulance personnel and hospital staff in their treatment of the
patient.
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