2019 EMT Refresher Instructor Manual

Emergency Medical Technician Refresher Manual

EMT Refresher Curriculum Manual

Version: 2019.01 Review Date(s): 1/19

On The Content of This Course

Less Stress Instructional Services’ EMT refresher has been designed to meet the following requirements:

- NJ Department of Health’s A, B, C topic format - NREMT’s Skills Verification for EMT Renewal - NREMT’s NCCP National Requirements for education topics

Due to the specifics of the design and the various compliance requirements involved, instructors are not permitted to deviate from the prescribed format. This includes:

- Utilizing only the provided AV presentations - Running the exact labs specified in this document - Running the exact scenarios in this document - Using only the designated exams for this class

Specifically the NCCP requirements require that specific amounts of time be spent on various topics in class. This program has been painstakingly designed though didactic content, video presentation, lab work, and scenarios to spend the designated amount of time necessary on each topic to meet NCCP requirements.

Please no not deviate from the enclosed format.

On Testing During EMT Refresher

Students in EMT refresher frequently have expectations that they simply need to attend refresher to renew their EMT cards. While students who fail refresher are rare, some competency must be demonstrated by students to complete the program. This at times can more complicated than in the EMT Initial program as students are already certified by OEMS and failure to pass refresher does not preclude them from practicing as an EMT (until perhaps they expire and cannot renew). Some EMTs also think very highly of their skills set – particularly those with lots of EMS experience or those who work in high-volume urban areas. They may come in with a negative attitude about training and their need to demonstrate skills. Practical stations should be repeated until the instructor feels it has been performed competently. Where an EMT performs poorly or refuses to participate, the instructor should politely inform him or her that completing the program requires that they be signed off on all the skills of the program and that until the skill is performed to satisfaction they will not be signed off. Written examinations were designed to be difficult. Instructors should expect students to fail at the first attempt at the pretest. This reinforces the notion that EMTs don’t know everything – even if they are experienced or work in high-volume environments. It also serves to demonstrate to EMTs in the course that they learned something when they complete the post-test successfully. Proceed with the lecture and eventually the skills components. You should see students identify correct answers as they progress through the course. Do not blatantly give them answers or drop hints that answers are on specific slides, but you can remind them to look for answers in the course and that they need at least a 70% to get credit for the class. This should convince them that this is not a course where their simple presence in the room will get them credit. At the end, give them the post-test (it is not the same exam). They should not be doing a group exam at that point. If they previously discussed questions during lunch or a skills session that is fine, but they should not be cooperating on the exam at the end. Administer the pre-test when the class starts. Grade the pretest and make sure the student has both his exam sheet and the question booklet for the rest of the day.

Have them turn in exams and grade them. Students scoring less than 70% should be held for remediation while the others are dismissed.

EMT Refresher Program – Airway Module A Airway and Patient Assessment

Outline: 00:00-00:30 00:30-01:20

Introduction and Pretest

Lecture - Airway management and physiology - Respiratory assessment – adequate vs. abnormal breathing, respiratory assessment - Respiratory devices and clinical presentations

01:20-04:00

Lecture - VAD Devices (25 minutes)

- Cardiac Arrest Management (adult) (55 minutes) - Cardiac Arrest Management (pediatric) (55 minutes) - Post Resuscitation care (25 minutes)

04:00-04:30 04:30-05:25 05:25-06:20 06:20-07:10 07:10-08:00 08:00-08:30

Lunch

Stations: A.1 series (50 minutes) Stations: A.2 series (50 minutes) Stations: A.3 series (50 minutes) Stations: A.4 series (50 minutes)

Post Test

Class Materials Needed:

Lesson Type:

Combined Lecture/Skill Lab

Lecture Sections:

Lecture Ratio:

1: ~

- EMT Refresher A Presentation - Computer - Display (LCD TV or projector)

Skills Ratio:

1: 6 1:10 with an aide

Master Equipment List: -

Airway management torso (1)

EMT Airway Manikin (1)

- - - - - - -

Suction Unit (1)

Cohort Bag (1 per 6 students) Airway Special Procedures Bag Autopulse with battery (1)

Child Manikin (1) Infant Manikin (1)

- AED trainer with adult & peds pads (1)

Student Materials Needed: -

EMT Refresher Skills Sheet 1/ student

Course evaluation 1/student

- -

Saline “bullets” for nebulizer 1/student

A.1.A – BVM Apneic Patient (~16 minutes)

Station: BVM Apneic Patient

This station will test the candidate’s ability to:

1. Demonstrate the steps in performing the head tilt–chin lift maneuver.

2. Demonstrate how to assist a patient with ventilations using the bag-mask device for one and two rescuers.

Set-up: Airway management torso Suction unit Cohort bag with 3 OPA, 3 NPA, BVM, and oxygen system

Instructions: Read the scripted lines on the skills sheet and observe for good technique

Precautions: Do not lead the student or correct performance. This is a testing station and no feedback should be offered.

Please note the following:

- Students should be encouraged to ventilate patients from the cephalic position at all times as it generally improves airway opening and mask seals. Lateral position is taught for pocket mask (but no other device) since a student may one day be doing 1-Rescuer CPR with a pocket mask and be forced to operate from the patient’s side. - Have students run through the station performing the scripted scenario on the skills sheet. Students should suction, insert an OPA or NPA, and ventilate, then attach to oxygen.

A.1.A - Bag-Valve Mask Apneic Patient

Takes appropriate BSI Checks responsiveness Checks breathing NOTE: After checking responsiveness and breathing for at least 5 but no more than 10 seconds, examiner informs the candidate, “The patient is unresponsive and apneic.” Requests additional EMS assistance Checks pulse for at least 5 but no more than 10 seconds NOTE: The examiner must now inform the candidate, “You palpate a weak carotid pulse at a rate of 60.” Opens airway properly NOTE: The examiner must now inform the candidate, “The mouth is full of secretions and vomitus.” Prepares rigid suction catheter Turns on power to suction device or retrieves manual suction device Inserts rigid suction catheter without applying suction Suctions the mouth and oropharynx NOTE: The examiner must now inform the candidate, “The mouth and oropharynx are clear.” Opens the airway manually Inserts oropharyngeal airway NOTE: The examiner must now inform the candidate, “No gag reflex is present and the patient accepts the airway adjunct.” **Ventilates the patient immediately using a BVM device unattached to oxygen [**Award this point if candidate elects to ventilate initially with BVM attached to reservoir and oxygen so long as first ventilation is delivered within 30 seconds.] NOTE: The examiner must now inform the candidate that ventilation is being properly performed without difficulty. Re-checks pulse for at least 5 but no more than 10 seconds Attaches the BVM assembly to oxygen [15 L/minute] Ventilates the patient adequately -Proper volume to make chest rise (1 point) -Proper rate [10 – 12/minute but not to exceed 12/minute] (1 point) NOTE: The examiner must now ask the candidate, “How would you know if you are delivering appropriate volumes with each ventilation?”

Critical Criteria: ___ After suctioning the patient, failure to initiate ventilations within 30 seconds or interrupts ventilations for greater than 30 seconds at any time ___ Failure to take or verbalize body substance isolation precautions

___ Failure to suction airway before ventilating the patient ___ Suctions the patient for an excessive and prolonged time ___ Failure to check responsiveness and breathing for at least 5 seconds but no more than 10 seconds ___ Failure to check pulse for at least 5 seconds but no more than 10 seconds ___ Failure to voice and ultimately provide high oxygen concentration [at least 85%] ___ Failure to ventilate the patient at a rate of at least 10/minute and no more than 12/minute ___ Failure to provide adequate volumes per breath [maximum 2 errors/minute permissible] ___ Insertion or use of any adjunct in a manner dangerous to the patient ___ Failure to manage the patient as a competent EMT

___ Exhibits unacceptable affect with patient or other personnel ___ Uses or orders a dangerous or inappropriate intervention

A.1.B – Automatic Transport Ventilator (ATV) (~16 minutes)

AUTOMATIC TRANSPORT VENTILATOR Objectives: Demonstrate the use of an automatic transport ventilator to assist in delivering artificial ventilation to the patient. (p 361) Setup: - Oxygen system with ATV device - Good quality BLS manikin (Resusci-Anne or equivalent with good chest rise) or EMT airway manikin Instructions to be read to students: “I am going to demonstrate how to set up an automatic transport ventilator” Precautions: Do not let the station deteriorate into chatter. Continue rotating them through one at a time until everyone has set up the ATV Please note the following: This station is about setting up an automatic transport ventilator. Is it mostly a skills lab with little scenario action, but you MUST emphasize that BVM ventilation should precede the ATV use. Have students being ventilating (2 rescuer BVM is ideal) and have a third student se up and use the ATV. Rotate positions until every student has set up the ATV. You must confirm the manikin you selected has a good lung capacity and produces easily visible chest rises. DO NOT use a cheaper 1:1 ratio CPR manikin such as Prestan.

ATV Takes appropriate BSI Assemble ATV, selects appropriate mask Makes effective seal – delivers manually triggered breath and confirms chest rise Sets size-appropriate volume on ATV (6-7ml/kg) Sets size-appropriate rate on ATV (adults 10-12/minute; peds 12-20/minute) Maintains effective seal for > 6 breaths Critical Criteria: ____ Did not take, or verbalize, BSI procedures ____ Did not correctly assemble ATV ____ Utilized incorrect rate or volume on ATV

A.1.C – Continuous Positive Airway Pressure (CPAP) (~16 minutes)

Objectives: Demonstrate the use of CPAP. (pp 363–364, Skill Drill 9-9)

Setup: - Oxygen system: Oxygen tank, regulator, CPAP system - Good quality manikin such as AMBU PAL or RESUSCI ANNE

Instructions to be read to students: “I am going to demonstrate assembling and administering CPAP.” ‘ Precautions: Do not let the station deteriorate into chatter. Continue rotating them through assemblies until time is up.

Please note the following:

- Demonstrate the assembly of the CPAP system in use. Do not take more than 5 minutes. Review indications and contra-indications for the device.

- Make sure students turn the gas on and check the device is administering before applying it to the manikin.

- Make sure students understand that the device only works if the seal is intact. Leaks will decrease CPAP efficiency, so the device must be on snugly

- It is good practice to explain the device to the patient first, then hold it against their face to get them acclimated to it, then put the straps on once it is not so unfamiliar to the patient.

- Students should reevaluate the patient’s breathing frequently, including:

o Rate of respiration

o Work of breathing

o Breath sounds

o Pulse oximetry

CPAP Takes appropriate BSI

Connect the circuit to the CPAP generator. Connect the face mask to the circuit tubing.

Confirm that the device is on before you apply it to the patient’s face. Place the mask over the patient’s mouth and nose or allow the patient to hold it to his or her mouth and nose. Coach the patient to breathe through the CPAP. Use the strapping mechanism to secure the CPAP to the patient’s head. Make sure there is a tight seal. Adjust the PEEP valve and the FIO2 accordingly to maintain adequate oxygenation and ventilation. Reassess the patient.

Critical Criteria: ____ Did not take, or verbalize, BSI procedures

____ Fails to check airflow from device before application ____ Incorrectly applies or assembles mask or straps ____ Incorrectly adjusts PEEP or FIO2

A.2.A – Humidifier, simple mask, venturi mask (~16 minutes)

Objectives: Demonstrate the use of a humidifier, simple mask, and venturi mask

Setup:

- Oxygen system: Oxygen tank, regulator, (TWO OR MORE SYSTEMS IS IDEAL) - Humidifier, simple mask, venturi mask, nebulizer - CPR Manikin for mask placement

Instructions to be read to students: “I am going to demonstrate assembling and utilizing various oxygenation devices.” ‘ Precautions: Do not let the station deteriorate into chatter. Continue rotating them through assemblies until time is up.

Please note the following:

- Demonstrate each device in use. Do not take more than 5 minutes. Review indications each device.

Humidifier – Explain that humidification may play a small role in street EMS with short transport times, but in medical transportation where patients might have been on oxygen for days or hours it is much more relevant to prevent mucous membrane drying.

Simple Mask – This device provides an intermediary concentration of oxygen (more than cannula and less than NRB) and is not uncommon in medical facilities. It might be encountered in medical transportation.

Venturi Mask– This device provides a precise amount of oxygen using various blenders. Ask the student in the lab to deliver a precise percentage of oxygen (25%, 31%, 35%, 40%) and have the student find the correct liter flow and blender to deliver that amount of oxygen.

Takes appropriate BSI Places SPO2 probe on patient finger Correlates heart rate with radial pulse Connects simple mask and sets O2 to 6-10 lpm Connects venturi mask to oxygen

Critical Criteria: ____ Did not take, or verbalize, BSI procedures ____ Attached SPO2 without radial pulse correlation ____ Selected incorrect venturi jet for FiO2 desired ____ Could not state ideal SPO2 range ____ Could not attach humidifier to circuit correctly

Examiner informs the candidate the transport order calls for the administration of 28% oxygen

Selects correct jet to administer 28% FiO2

Examiner informs the candidate the transport order calls for the administration of 40% oxygen Selects correct jet to administer 40% FiO2 Examiner asks the candidate what would be the ideal range for titrating oxygen delivery Candidate states “> 95% SPO2” Examiner Informs the candidate the transport will be over an hour long Candidate attaches humidifier to oxygen delivery system

A.2.B - Nebulizer / NRB / SPO2 (~13 minutes)

Objectives: Demonstrate the use of a non-rebreathing mask, nebulizer, and pulse oxymeter

Setup: - Oxygen system with NRB, nebulizer, fake albuterol ‘bullets’ - Good quality BLS manikin - ET3 (ideal) or pulse oxymeter

Instructions to be read to students: “I am going to demonstrate how to assemble a nebulizer and run you through a quick vignette on using them”

Precautions: Do not let the station deteriorate into chatter. Continue rotating them through one at a time until everyone has done the scenario.

Please note the following:

This station is about demonstrating NRB competency and administering albuterol by nebulizer (new skill!).

Nebulizer– This device aerosolizes medication, and EMTs can continue a nebulizer treatment the patient has already begun prior to EMS arrival. Have the EMTs assemble the nebulizer and place the contents of an “albuterol” bullet in the medication tray to create vapor so the EMTs can see it. The limitations of this intervention is that the patient must already be diagnosed with COPD or asthma and have shortness of breath.

“Your patient is 32 years-old and is short of breath with moderate distress. Please administer oxygen to this patient.”

Takes appropriate BSI Gathers appropriate equipment Cracks valve on oxygen tank Assembles regulator to the oxygen tank Opens tank valve / Checks oxygen pressure

Critical Criteria: ____ Did not take, or verbalize, BSI procedures ____ Did not correctly assemble nebulizer ____ Delivers incorrect dose of abuterol

Attaches non-rebreather mask to correct oxygen port Turns on liter flow to 10+ lpm and prefills reservoir bag Attaches mask to patient’s face and adjusts snugly

Places SPO2 probe on patient finger Correlates heart rate with radial pulse Examiner informs the candidate that the patient is dyspneic, wheezing and has a history of asthma Assembles nebulizer system Empties one albuterol 2.5mg ampule into nebulizer chamber Attaches nebulizer to oxygen delivery system and sets oxygen to 6 lpm Places device on patient’s face Examiner asks candidate what reassessments would be indicated in this scenario Candidate states he/she would reassess breath sounds and breathing difficulty

A.2.C – Ventilation Patient Scenarios 1

Objectives: As identified in scenario sheet.

Setup: -

Cohort Bag CPAP device Suction Unit

- -

- EMT-level manikin with OPA/NPA capability – an airway torso is ideal. - ET3 if available.

Scope: Students should treat the patient’s respiratory condition in mini-vignettes – six of them are provided for this station. They should take 1-2 minutes per student. Do not allow the students to verbalize their way through this station as they are expected to perform hands-on skills. Deployment: DO NOT LECTURE – your students should be working hands-on within 5 minutes of arriving Deploy your students as one team – identify a team leader. That person has the final decision-making responsibility.

Debriefing: Utilize the notes at the end of the scenario for debriefing. .

v A.2.C - Respiratory Arrest 1

A.2.C - Respiratory Arrest 2

A.2.C – Choking 1

The patient is an 84-year-old who has collapsed after being confused and having slurred speech for 20 minutes. He has a pulse, but is not breathing. The patient will have a continue having a pulse as long as he is ventilated. Without ventilations the SPO2 will be 84%, but will climb to 96% if ventilated with oxygen. The patient will tolerate an oral airway. Force students to bag with 2- person technique, and to develop timing and hand dexterity.

The patient is a 32-year-old dragged out of a vat at a chemical plant. He was cleaning the vat when the chemical fumes in the container overcame him and he is not apneic. The patient will have a continue having a pulse as long as he is ventilated. Without ventilations the SPO2 will be 68%, but will climb to 93% if ventilated with oxygen. The patient will tolerate an oral airway, but will reject it 2 minutes after being bagged. Force students to bag with 2- person technique, and to develop timing and hand dexterity. The patient will become responsive after a total of 4 minutes of ventilation and only need a NRB mask after that. Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds Fails to insert adjunct Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2 Does not provide NRB to responsive patient Debriefing Points: Were ventilations promptly provided? Were monitoring devices placed before critical care was provided? Discuss the significance of aggressive respiratory care in this case The patient is 19 year old who is responsive only to pain and breathing 4 snoring breaths per minute. There is obvious heroin use paraphernalia on the scene and the pupils are pinpoint. The patient will need BVM ventilations and an adjunct. He will not tolerate an oral adjunct. After about 6 breaths, the patient will vomit and require suctioning. ALS will arrive 5 minutes into the scenario and administer Narcan. The patient will vomit again, then begin breathing 22 bpm and begin responding but be confused and agitated. Does not open airway manually Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds Fails to insert adjunct Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2 Does not provide NRB to responsive patient Debriefing Points: Were ventilations promptly provided? What caused this scenario? What specific indications were there for Narcan? Critical Criteria Does not open airway manually A.2.C - Respiratory Failure 2 Critical Criteria

The patient is 42 year old who is collapsed. The family thinks he took a heart attack during dinner.

The patient is unresponsive will be obstructed at the first attempt to give breaths. One round of airway maneuvers will remove a large piece of beef from the airway. The patient will then vomit and need suctioning. The patient will then remain apneic and require an airway adjunct and continuous ventilation.

Critical Criteria

Critical Criteria

Does not perform unc FBAO / CPR Places oxygen on patient before clearing airway Fails to identify open airway Fails to ventilate patient @ 1 breath / 5-6 seconds

Does not open airway manually Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds Fails to insert adjunct

Unable to create visible chest rise Does not connect device to oxygen

Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2

Debriefing Points:

Were choking maneuvers performed promptly? Why did the patient vomit after the object was relieved? Why was the patient not breathing after the choking was relieved?

Debriefing Points:

Were ventilations promptly provided? Were monitoring devices placed before critical care was provided?

A.2.C - Respiratory Failure 1

A.2.C – Respiratory Failure 3

The patient is an 18 year old who had fallen from a skateboard and is unresponsive.

The patient is a 22 year old who is wheezing and short of breath. The patient tripoding and working hard to breathe. The patient will require a NRB mask. She will SPO2 @ 94% and not do any better than that. After a minute have the person playing the patient display fatigue, slouching, increased work of breathing, rales and grimacing. If the students do not pick up on the patient’s getting tired, state “your patient appears to be tiring from breathing so hard”. The students should transition her to CPAP. Despite CPAP, this patient will tire and become unresponsive, and breathe at 4bpm. This patient will require BVM ventilations and an airway adjunct. Does not connect device to oxygen Does not identify fatigue in patient Does not transition patient to CPAP Does not identify respiratory failure in patient Does not transition patient to BVM Did not insert airway adjunct Does not apply appropriate monitoring device Debriefing Points: Was NRB and SPO2 applied promptly? What were the signs/symptoms that made the students transition to CPAP? What were the signs/symptoms that made the students transition to BVM? Could the CPAP have been left of to improve the 4bpm’s? Critical Criteria Does not apply NRB mask

The patient will need BVM ventilations and an adjunct. He will tolerate either adjunct. After about 20 breaths, he will vomit. The patient will need suctioning and resumed ventilation with an adjunct. After about 5 minutes, ALS will arrive and intubate the patient, and ask you to connect him to your ATV so you can help backboard him.

Critical Criteria Opens the airway w, Head Tilt/Chin Lift Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds Fails to insert adjunct

Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2

Does not appropriately connect to ATV

Debriefing Points: Were ventilations promptly provided? What caused this scenario? Why not use head-tilt/chin-lift?

A.2.D – Ventilation Patient Scenarios 2

Objectives: As identified in scenario sheet.

Setup: -

Cohort Bag CPAP device Suction Unit

- -

- EMT-level manikin with OPA/NPA capability – an airway torso is ideal. - Child manikin and BVM - ET3 if available. - ET Tube; NG Tube if available

Scope: Students should treat the patient’s respiratory condition in mini-vignettes – six of them are provided for this station. They should take 1-2 minutes per student. Do not allow the students to verbalize their way through this station as they are expected to perform hands-on skills. Deployment: DO NOT LECTURE – your students should be working hands-on within 5 minutes of arriving Deploy your students as one team – identify a team leader. That person has the final decision-making responsibility.

Debriefing: Utilize the notes at the end of the scenario for debriefing. .

v A.2.D - Respiratory Failure 1

A.2.D - Respiratory Failure 2

A.2.D – Choking 1

The patient is 70 year old with an unknown complaint. You find him sitting on his chair responsive only to pain. He is breathing 3 bpm, and is pale and sweaty. The patient will need BVM ventilations and an adjunct. He will not tolerate an oral adjunct. After about 12 breaths, the patient will have gastric distension, but will not vomit. The person who is bagging should be told that bag compliance is poor and that it’s increasing hard to ventilate. The SPO2 will stay at 91%. ALS will arrive and intubate the patient. The person who is bagging should be told that bag compliance is poor and that it is still hard to ventilate. The SPO2 will stay at 91%. ALS will insert an NG tube and the stomach will decompress. The EMT should be told that his effort at ventilation is now easier and the SPO2 has increased to 97%. Critical Criteria Does not open airway manually

The patient is a 50 year old who stabbed in the stomach. A bystander controlled his bleeding, and he is responsive to pain only, and breathing at 34 bpm. He is pale and sweaty. The patient will need BVM ventilations and an adjunct. He will tolerate either adjunct. The patient will continue in this situation for the rest of the scenario. The SPO2 will read “NO READING”.

The patient is 72 year old who is wide-eyed and clutching her throat. Her family insists she is choking on her daughter’s meatloaf. The patient will clutch her throat for another minute until she collapses unresponsive. The patient will expel one object after one round of unconscious obstructed airway maneuvers / CPR, but continue to be obstructed. The patient will expel a second object during the 2 nd round of maneuvers/CPR. The patient will have a brief period of apnea, for which the students must ventilate her. After about 30 seconds of rescue breathing, the patient will become responsive to verbal stimulus and breathe at 14 bpm and transition to a NRB mask. Critical Criteria Does not perform Heimlich maneuver Does not perform unc FBAO / CPR Places oxygen on patient before clearing airway Fails to identify open airway Fails to ventilate patient @ 1 breath / 5-6 seconds Unable to create visible chest rise Does not connect device to oxygen Does not transition patient to NRB mask Debriefing Points: Were choking maneuvers performed promptly? Why didn’t breaths go in when the object came out? Why was the patient not breathing after the choking was relieved?

Critical Criteria

Does not open airway manually Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds Fails to insert adjunct

Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2

Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds Fails to insert adjunct

Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2

Debriefing Points: Were ventilations promptly provided?

What caused this scenario? Why did the SPO2 not read?

Debriefing Points: Why were the ventilations hard to perform? Why didn’t the ET tube help? Why did the stomach decompression help?

A.2.D – Medical Transportation 1

A.2.D – Pediatric Trauma

A.2.D – Respiratory Failure 3

The patient is 24-year-old with a brain tumor that requires 2 lpm of oxygen by nasal canula. The students should set up the canula and SPO2 monitor and transport the patient. Initial SPO2 reading will be 98%. The patient will have a seizure during transport and become apneic. Students should ventilate the patient via BVM and insert an adjunct. The patient will reject the oral airway but tolerate the nasal. If the patient does not get ventilated promptly, make the SPO2 decrease gradually to 80%.

The patient is a 3-year-old who has been hit by a car. The mother tells you he was tossed 10 feet and hit his head on the pavement. There is a large laceration to the head. The patient will have a continue having a pulse as long as he is ventilated. Without ventilations the SPO2 will be 84%, but will climb to 96% if ventilated with oxygen. The patient will tolerate an oral airway. Force students to bag with 2- person technique, and to develop timing and hand dexterity.

The patient is 68 year old with CHF. She is breathing at 22 bpm, with accessory muscle use.

The patient will need a NRB mask @ 15lpm and upright positioning. She will SPO2 at 95%. After a minute have the person playing the patient display fatigue, slouching, increased work of breathing, rales and grimacing. If the students do not pick up on the patient’s getting tired, state “your patient appears to be tiring from breathing so hard”. The students should transition her to CPAP. If they do not, the patient will breathe at 6bpm and the SPO2 will drop to 87%. If CPAP is applied early, the patient will maintain an SPO2 of 96% with little effort.

Critical Criteria

Critical Criteria

Does not open airway manually Opens the airway with head-tilt

Does not appropriately set up oxygen Does not monitor SPO2 Selects inappropriate ventilation device Fails to ventilate at 1 breath / 5-6 seconds

Critical Criteria

Selects inappropriate ventilation device Fails to ventilate at 1 breath / 3-5 seconds Fails to insert adjunct

Does not apply NRB mask Does not connect device to oxygen Does not identify fatigue in patient Does not transition patient to CPAP Does not apply appropriate monitoring device

Unable to create visible chest rise Does not connect device to oxygen

Unacceptable adjunct technique Unable to create visible chest rise Does not connect device to oxygen Does not monitor SPO2

Debriefing Points:

Debriefing Points:

Were ventilations promptly provided? What would other acceptable devices for this scenario include? What caused this scenario?

Debriefing Points:

Was NRB and SPO2 applied promptly? What were the signs/symptoms that made the students transition to CPAP? Could BVM have been used instead of CPAP? Why not wait until SPO2 drops to apply CPAP?

Were ventilations promptly provided? Were monitoring devices placed before critical care was provided? Discuss the need for spinal precautions in this case.

A.3.A - Mechanical CPR (~17 minutes) Takes or verbalizes appropriate BSI Determines the scene/situation is safe Attempts to question bystanders about arrest events Checks patient responsiveness NOTE: The examiner must now inform the candidate: “The patient is unresponsive Assesses pt for signs of breathing, determines absence of abnormal breathing (gasping or agonal); Checks carotid pulse (no more than 10 seconds) NOTE: The examiner must now inform the candidate: “The patient is apneic and pulseless” Rescuer 1: Immediately begins chest compressions (adequate depth and rate, allows the chest to recoil completely) Rescuer 2: Immediately begins applying AED electrodes and analyzes NOTE: The examiner must set AED to “Shockable” Rescuer 2: Clears the patient and presses “Shock” button; resumes compressions Rescuer 1: Immediately begins applying AutoPulse device Places device at head of the patient; insures band is open; presses power Cuts clothing off back of patient while Rescuer 2 picks up torso Slides device behind patient; lowers torso on board Closes band over lower sternum Presses START – insures device is set to 30:2 Provides 2 breaths when device pauses compressions NOTE: After 4 cycles, the examiner should advise rescuers that ALS has intubated the patient Switches device to CONTINUOUS mode. Insures patient is ventilated 1 breath every 6 seconds NOTE: After 40 seconds of CPR, prompts students to transport patient Insures appropriate ventilation interval (1 breath every 6 seconds) Stops mechanical compressions during analysis of patient INSTRUCTOR: DEBRIEFS STUDENTS

A.3.A Mechanical CPR (~17 minutes) Adult VF Cardiac Arrest Instructor Guidance

Objectives: Demonstrate how to reposition an unconscious adult for airway management. (pp 417–418, Skill Drill 11-1) Demonstrate how to check for a pulse at the carotid artery in an unresponsive patient. (p 417) Demonstrate how to perform external chest compressions in an adult. (pp 419–420, Skill Drill 11-2) Demonstrate how to perform a head tilt–chin lift maneuver on an adult. patient. (pp 419–421) Demonstrate how to perform one-rescuer adult CPR. (pp 424–426, Skill Drill 11-3) Demonstrate how to perform rescue breathing on an adult.. (pp 432– 433) Demonstrate how to perform two-rescuer adult CPR. (pp 424–428, Skill Drill 11-4) Demonstrate how to use AEDs and perform CPR. (pp 551–553, Skill Drill 14-2) Demonstrate how to utilize a mechanical compressor such as Autopulse

Setup: •

Cohort Bag AED Trainer

• • • •

Suction

EMT Level Full Body Manikin

Autopulse with battery

Deployment: DO NOT LECTURE – your students should be working hands-on within 5 minutes of arriving

This is a lab – not a scenario. Quickly show them how to apply the Autopulse, then have them do several rotations.

Debriefing: Give students feedback on the scenario at the end. Some points to discuss: - Did they assess the patient and perform compressions by hand? - Did they apply the AED as quickly as possible? - Did they place the autopulse on AFTER the steps above? - Did they switch to CONTINOUS after the patient is intubated? Scenario:

“Your patient is a 58-year-old collapsed on the ground. He was witnessed to collapse a few minutes ago.”

Make sure he is pulseless and apneic.

A.3.B Resuscitation Scenario 1 Adult VF Cardiac Arrest Instructor Guidance

Objectives: Demonstrate how to reposition an unconscious adult for airway management. (pp 417–418, Skill Drill 11-1) Demonstrate how to check for a pulse at the carotid artery in an unresponsive patient. (p 417) Demonstrate how to perform external chest compressions in an adult. (pp 419–420, Skill Drill 11-2) Demonstrate how to perform a head tilt–chin lift maneuver on an adult. patient. (pp 419–421) Demonstrate how to perform one-rescuer adult CPR. (pp 424–426, Skill Drill 11-3) Demonstrate how to perform rescue breathing on an adult.. (pp 432–433)

Demonstrate how to perform two-rescuer adult CPR. (pp 424–428, Skill Drill 11-4) Demonstrate how to use AEDs and perform CPR. (pp 551–553, Skill Drill 14-2)

Setup: •

Cohort Bag AED Trainer

• • •

Suction

EMT Level Full Body Manikin

Deployment: DO NOT LECTURE – your students should be working hands-on within 5 minutes of arriving

Deploy your students in one team – one student or the instructor should be patient, the rest rescuers. You can make one student be the son doing CPR if you like. Have them transition through the scenario on the back of this sheet like any other scenario from a scenario lab day.

Debriefing: Give students feedback on the scenario at the end. Some points to discuss:

- Did they quickly solicit a history from the family?

Did they apply quickly begin CPR?

-

Did they quickly try to shock the patient?

-

- Were they weary to not put the AED pads on the device?

- What had to fail for this guy to be in arrest (internal defibrillator)?

- Make sure they understand the joules delivered by an internal defibrillator are so few that it represents no hazard to rescuers doing CPR. It is also unlikely to fire at this point.

VF Arrest

Situation: 68 years old – lying on floor at home, getting bystander CPR from family

A.3.B

Scene Size-up: Safety:

Safe

BSI:

Gloves

Patients: 1 Mechanism/Nature: NOI Resources: ALS

Implanted Defibrillator

Primary Assessment: General Impression: Adult getting CPR from son Mental Status: Unresponsive Airway: Patent Breathing: Not breathing Circulation:

pulseless, warm/dry, no bleeding

Desired Response: Primary then resuscitation

Physical Exam: Head:

Unremarkable

Neck:

Unremarkable

Chest :

Unremarkable

Abdomen:

Unremarkable

Pelvis:

Unremarkable

Extremities:

Unremarkable 5 seconds

Posterior :

Unremarkable

Vitals: 1

2

OPQRST: O:

SAMPLE: S:

N/A N/A N/A N/A N/A N/A

Unresponsive

Pulse: 0

0

P: Q: R:

A:

None

M:

Aspirin, Plavix

BP:

0

0

P: L: E:

Bypass, pacemaker/defibrillator

Resp:

0

0

S: T:

Meatloaf 4 hours ago

Sleeping in bed with parents and was found unresponsive

SPO2: 0

0

OTHER: AED will be shockable

A.3.C Resuscitation Scenario 2 Traumatic Arrest Instructor Guidance

Objectives: Demonstrate how to reposition an unconscious adult for airway management. (pp 417–418, Skill Drill 11-1) Demonstrate how to check for a pulse at the carotid artery in an unresponsive patient. (p 417) Demonstrate how to perform external chest compressions in an adult. (pp 419–420, Skill Drill 11-2) Demonstrate how to perform a head tilt–chin lift maneuver on an adult. patient. (pp 419–421) Demonstrate how to perform one-rescuer adult CPR. (pp 424–426, Skill Drill 11-3) Demonstrate how to perform rescue breathing on an adult.. (pp 432–433)

Demonstrate how to perform two-rescuer adult CPR. (pp 424–428, Skill Drill 11-4) Demonstrate how to use AEDs and perform CPR. (pp 551–553, Skill Drill 14-2)

Setup: •

Cohort Bag AED Trainer

• • •

Suction

EMT Level Full Body Manikin

Deployment: DO NOT LECTURE – your students should be working hands-on within 5 minutes of arriving

Deploy your students in one team – one student or the instructor should be patient, the rest rescuers. You can make one student be the son doing CPR if you like. Have them transition through the scenario on the back of this sheet like any other scenario from a scenario lab day.

Debriefing: Give students feedback on the scenario at the end. Some points to discuss:

- Did they quickly solicit a history from the family?

Did they apply quickly begin CPR?

-

Did they quickly try to shock the patient?

-

- What are some likely causes for this arrest (Pneumothorax)

- Make sure they understand the joules delivered by an internal defibrillator are so few that it represents no hazard to rescuers doing CPR. It is also unlikely to fire at this point.

Traumatic Arrest

Situation: 39 years old – lying on ground outside building

A.3.C

Scene Size-up: Safety:

Safe

BSI:

Gloves

Patients: 1 Mechanism/Nature: Bystanders state he fell out of a 3 rd floor window Resources: ALS

Left sided crepitus Absent breath sounds Diminished chest rise

Primary Assessment: General Impression: Patient crumpled on ground Mental Status: Unresponsive Airway: Patent Breathing:

Not breathing (patient will be hard to ventilate)

Circulation:

pulseless, pale/sweaty, no bleeding

Desired Response: Primary then resuscitation

Physical Exam: Head:

Unremarkable

Neck:

JVD, tracheal deviation

Chest : Crepitus to left chest, asymmetric chest rise that is diminished on left, absent breath sounds on left.

Abdomen:

Unremarkable

Pelvis:

Unremarkable

Extremities:

Unremarkable 5 seconds

Posterior :

Unremarkable

Vitals: 1

2

OPQRST: O:

SAMPLE: S:

N/A N/A N/A N/A N/A N/A

Unresponsive Unresponsive Unresponsive Unresponsive Unresponsive` Unresponsive

Pulse: 0

0

P: Q: R:

A:

M:

BP:

0

0

P: L: E:

Resp:

0

0

S: T:

SPO2: 0

0

OTHER: AED will be non shockable

A.4.A Resuscitation Child Scenario Child Arrest Instructor Guidance

A.4.1 Resuscitation Child Scenario

Takes or verbalizes appropriate BSI Determines the scene/situation is safe Attempts to question bystanders about arrest events Checks patient responsiveness NOTE: The examiner must now inform the candidate: “The patient is unresponsive Assesses pt for signs of breathing, determines absence of abnormal breathing (gasping or agonal); Checks carotid pulse (no more than 10 seconds) Utilize length-based resuscitation tape to determine appropriate specifics for this age The examiner must now inform the candidate: “The patient is apneic and pulseless” Rescuer 1: Immediately begins chest compressions (adequate depth and rate, allows the chest to recoil completely) Rescuer 2: Immediately begins applying AED electrodes and analyzes NOTE: The examiner must set AED to “Shockable” Rescuer 2: Clears the patient and presses “Shock” button; resumes compressions Pit Crew CPR After 1 minute of CPR, examiner states “the patient has vomited” Suctions patient’s oropharynx with rigid catheter Resumes CPR at a ratio of 15:2 After 1 minute of CPR, examiner states “the patient hand appears to be moving slightly” Assesses patient’s pulse and breathing Examiner states” Patient has a pulse but is not breathing” Resumes rescue breathing at 12-20 breaths per minute Performs post-resuscitation care such as BP and pulse oxymetry INSTRUCTOR: DEBRIEFS STUDENTS

Objectives: Demonstrate how to reposition an unconscious adult for airway management. (pp 417–418, Skill Drill 11-1) Demonstrate how to check for a pulse at the carotid artery in an unresponsive patient. (p 417) Demonstrate how to perform external chest compressions in an adult. (pp 419–420, Skill Drill 11-2) Demonstrate how to perform a head tilt–chin lift maneuver on an adult. patient. (pp 419–421) Demonstrate how to perform one-rescuer adult CPR. (pp 424–426, Skill Drill 11-3) Demonstrate how to perform rescue breathing on an adult.. (pp 432–433) Demonstrate how to perform two-rescuer adult CPR. (pp 424–428, Skill Drill 11-4) Demonstrate how to use AEDs and perform CPR. (pp 551– 553, Skill Drill 14-2)

Setup: •

Cohort Bag AED Trainer

• • •

Suction

Child Manikin

Deployment: DO NOT LECTURE – your students should be working hands- on within 5 minutes of arriving Deploy your students in one team – one student or the instructor should be patient, the rest rescuers. You can make one student be the son doing CPR if you like. Have them transition through the scenario on the back of this sheet like any other scenario from a scenario lab day. Debriefing: Give students feedback on the scenario at the end. Some points to discuss:

- Did they quickly solicit a history from the family?

- Did they quickly suction the airway after vomit?

Did they quickly begin CPR?

-

Did they try to shock the patient?

-

Did they use pediatric AED pads?

-

Pediatric Arrest

Situation: 5 years old – lying on ground in living room

A.4.A

Scene Size-up: Safety:

Safe

BSI:

Gloves

Patients: 1 Mechanism/Nature: Bystanders state he ran into the room and collapsed Resources: ALS

Primary Assessment: General Impression: Patient collapsed and prone in living room Mental Status: Unresponsive Airway: Patent Breathing: Not breathing Circulation: pulseless, pale/sweaty, no bleeding

Small round burn mark

Desired Response: Primary then resuscitation

Physical Exam: Head:

Unremarkable

Neck:

Unremarkable

Chest :

Unremarkable

Abdomen:

Unremarkable

Pelvis:

Unremarkable

Extremities:

Unremarkable 5 seconds

Posterior :

Unremarkable

SAMPLE: S:

Unconscious

Vitals: 1

2

OPQRST: O:

A:

Peanuts

N/A N/A N/A N/A N/A N/A

Pulse: 0

132

M:

None None

P: Q: R:

P: L: E:

BP:

0

76/50

None `

Was playing in kitchen, the lights flickered

Resp:

0

0

S: T:

and ran in and collapsed

SPO2: 0

88

OTHER: AED will be shockable ; patient will recover after one shock and get his pulse back

A.4.B Resuscitation Child Scenario Child Arrest Instructor Guidance

A.4.B Resuscitation Child Scenario

Takes or verbalizes appropriate BSI Determines the scene/situation is safe Attempts to question bystanders about arrest events Checks patient responsiveness NOTE: The examiner must now inform the candidate: “The patient is unresponsive Assesses pt for signs of breathing, determines absence of abnormal breathing (gasping or agonal); Checks carotid pulse (no more than 10 seconds) Utilize length-based resuscitation tape to determine appropriate specifics for this age The examiner must now inform the candidate: “The patient is apneic and pulseless” Rescuer 1: Immediately begins chest compressions (adequate depth and rate, allows the chest to recoil completely) Rescuer 2: Immediately begins applying AED electrodes and analyzes NOTE: The examiner must set AED to “Shockable” Rescuer 2: Clears the patient and presses “Shock” button; resumes compressions Pit Crew CPR After 1 minute of CPR, examiner states “the patient hand appears to be moving slightly” Assesses patient’s pulse and breathing Examiner states” Patient has a pulse but is not breathing” Resumes rescue breathing at 12-20 breaths per minute Performs post-resuscitation care such as BP and pulse oxymetry INSTRUCTOR: DEBRIEFS STUDENTS

Objectives: Demonstrate how to reposition an unconscious adult for airway management. (pp 417–418, Skill Drill 11-1) Demonstrate how to check for a pulse at the carotid artery in an unresponsive patient. (p 417) Demonstrate how to perform external chest compressions in an adult. (pp 419–420, Skill Drill 11-2) Demonstrate how to perform a head tilt–chin lift maneuver on an adult. patient. (pp 419–421) Demonstrate how to perform one-rescuer adult CPR. (pp 424–426, Skill Drill 11-3) Demonstrate how to perform rescue breathing on an adult.. (pp 432–433) Demonstrate how to perform two-rescuer adult CPR. (pp 424–428, Skill Drill 11-4) Demonstrate how to use AEDs and perform CPR. (pp 551– 553, Skill Drill 14-2)

Setup: •

Cohort Bag AED Trainer

• • •

Suction

Child Manikin

Deployment: DO NOT LECTURE – your students should be working hands- on within 5 minutes of arriving Deploy your students in one team – one student or the instructor should be patient, the rest rescuers. You can make one student be the son doing CPR if you like. Have them transition through the scenario on the back of this sheet like any other scenario from a scenario lab day. Debriefing: Give students feedback on the scenario at the end. Some points to discuss:

- Did they quickly solicit a history from the family?

Did they quickly begin CPR?

-

Did they try to shock the patient?

-

Did they use pediatric AED pads?

-

Pediatric Arrest

Situation: 6 years old – lying in bed

A.4.B

Scene Size-up: Safety:

Safe

BSI:

Gloves

Patients: 1 Mechanism/Nature: Bystanders state he has been sick for two days Resources: ALS

Primary Assessment: General Impression: Patient lying quietly in bed Mental Status: Unresponsive Airway: Patent Breathing: Not breathing Circulation:

pulseless, hot and sweaty, no bleeding

Desired Response: Primary then resuscitation

Physical Exam: Head:

Unremarkable

Neck:

Unremarkable

Chest :

Unremarkable

Abdomen:

Unremarkable

Pelvis:

Unremarkable

Extremities:

Unremarkable 5 seconds

Posterior :

Unremarkable

Vitals: 1

2

OPQRST: O:

SAMPLE: S:

N/A N/A N/A N/A N/A N/A

Has been feverish for a two days

Pulse: 0

118

P: Q: R:

A:

None

M:

Tylenol

BP:

0

82/48

P: L: E:

None prior to this Broth 3 hours ago Just lying in bed

Resp:

0

0

S: T:

SPO2: 0

88

OTHER: AED will be non-shockable ; patient will recover after one shock and get his pulse back