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EMT:Basic PracticalExaminationLJsers Guide

Developedby The National Registry of EmergencyMedical Technicians

as The artwork on the front cover of the PracticalExaminationtJsersGuide is available a full color, l8 x 24 poster. To obtain a poster,senda written requestand $15.00 to:

Medical Technicians of NationalRegistry Emergency P.O.Box 29233 Ohio 43229 Columbus,

FORE\TORD

of This manual was developed as a result of the National Registry'scontinued awareness the need for standardized and uniform criteria for pracrical examinations. The evolution of practical examinations has been guided by many changeswithin emergenry medical servicesin the United Srates. VAen EMT training began in the earlv 1970t, there were relatively few people with an inmedical care,limired rypesof equipmenr and one training srandard. Since then, deprh knowledgeof the spectrum of emergency siruarions have changed and thus standardization is becoming more difficulr to attain. Emergency medical care has evolved into a recognizedbody of knowledge and skill, multiple approachesfor accomplishing a task have been advocaredin peer journals and a of variery of methods for rhe use of standard equipment have been suggested equipment manufacturers. Because this situation by thereare currently multiple ways to perform a skill, conduct a practicalexaminationand define competency.Therefore standardiza, tion has becomemore difficult in the assessment psychomotorskills. of and In rhe spring of 1993, the Narional Regisrry conveneda meeringof its EMT-Basic Practical ExaminarionCommirtee to revierv revise current practicalexaminationskiil instrumentsusedto assess competency the EMT-Basic level. In conjunction witl-r the skill at and pilot tesringof of the developmen, th. 1994 EMT-Basic National Srandard Curriculum, rhe Naiional Regisrry beganpeerrevierv the proposed skill sheets. Irollowing the review and revision process,the staff of the National Registry was directed to develop a Examination User'sGuide which would reflectrhe scopeof practiceidentified in the 1994 EMT-Basic revisedEMT-Basic Practical Narional StandardCurriculum and the National ElvlS Educationirnd PracticeBlueprint and would include up-to date skill evaluation instrumenrsas well as criteria Forconducting a practicalskills examination. This manual presents structured,organizedapproech to conducting a practicalexanrination. It is irnportant to note that this a m a n u a li s o n l y a g u i d e . L o c a lm e d i c a l i r e c t i o n o r s r r t e E M S o F f i c i a l s m a y c h o o s e r o a l r e r t l ' r e { : o r m a t o r d e s i g n o f t h e e x a m i n a r i o n o r d in rhe performance skill sheers order ro meet local constraint.s placedon the tesringagency.The National Registrywill continue ro in acceptsrate-approved the criteriapresented this usert guide. practicalexaminarions provided they meer or exceed lf rhe examination is being given lror the purposeof fulfilling National Regi'rr1'entrv requirements, candid:rces must be deemed competent in the nrandatorystlrions and the random skill station. 'We would like to thank the lollowing membersof the Narional RegistryEM'l--Brsicl'racticalExaminationConrmittee for the many hours o[expert work which they provided for this project:Liae Burrill, NH; Alex Butman, OH; Lou,[ordan, MD; Jon Policis, NY; 'We and Mike Smirh, VA. also extend a specialthank you to Walr Sroy and Tom Platt of the Center of EnrergencyMedicine rn Pittsburgh,l'A fbr their help during this project.Addirionally,we would like to acknowledge tin.re and expertise the provided by the National RegistryStandards and Examination Committee and its chairpersonMarilyn Gifford, MD, FACEP Dr. Gifford and the Con-rmittee provided extensivemedical and editorial review relativeto the skill evaluarioninstruments and their accompanying Finallv,rve extend comrnendations the more than 350 outside leviervers essays. to from across the entire countrv who provided the initial peerreviewof the documents.'I-hese individual reviewers were instrumentalin ensuringthat the practicalexaminationis truly a national EMS project. Philip Dickison, NRL,MT BasicLevel Coordinator should be recognized coordinatingand seeingthis for extensive projecr through to completion. -l-he National Registryis dedicatedto rhe goal of-esrablishing srandarclized, valid practicalexaminarionrhat can be utilized across a the nation. As we work toward this goal,w'ewelcomeyour comnrentsconcerningthis examinationand its lrormar.Please addre.ss all comments to the National Registryof Ernerge Medical Tbchnicians, ncy IlO. Ilox 29233, Columbus, Ohio 43229.

TABLE OF CONTENTS Forward Part I

. t O r g a n i z i n gh eI n f o r m a t i o n. . . . . . . . . . . . . . . . . n A . E x a m i n a t i oS t a t i o n s B .S e l e c t i oo f T e s t a c i l i t y . . . . . . . . . . . . . . . . . . . F . n C . S e l e c t i oo f E x a m i n a t i oS t a f f . n n D . R e s p o n s i b i l i t io fs x a m i n a t i oS t a f f . . . . . . . . . . . . . . eE n . E .E c l u i p m e n t F .B u c i g e t h C . C ) r i e n t i ntg eS k i l lS t a t i o n x a m i n e ra sa C r o u p E s H. C)ricnting Candidates a Clroup the as I . O r i c n t i n gh eI n d i v i d u a.l. . . . . . . . . . . . . . . . . . . . t

...................... 1 . . . . . . . . . . 1. . . . ..............2 . . . . . . . . . . . . . . . 2. . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . .3. . ................ 3 . . . . . . . . . .3. . . . ........... 3 . . . . . . . . .3 . . . .

D e t e r m i n i n ca F i n . r IG r a d c - . . . . . . . . . . . . . .

A s s u r i n g t l r eS t a n d a r d i z a t i o n n d Q u a l i t y 'C o n t r o l a Part II

. . . . . . . . . . . . . . . . . .4. . . . . .

S a m p l eO r i e n t a t i o nS c r i p t / C e n e r a lI n s t r u c t i o n s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . .5 . . . . . . . . P r o g r a m m i n gt h e P a t i e n t . . . . . . . . . . . . . . . 6. . . . . E M T - B a s i c r a c t i c a l x a m i n a t i o nQ u a l i t y C o n t r o l C h e c k l i s t P E ................................7 E M T - B a s i c r a c t i c a E x a m i n a t i o nR e 1 . r s F 1 r n r . . . . . . . . . . . . . P l 1o . . . . . . . . . . . . . .8 . . . . P r a c t i c a E x a m i n a t i o nO r i e n t a t i o nt o S k i l l S t a t i o nE x a m i n e r ' s l . . . . . . . . . . . . . . . . . . . . . .9 . . . . . . . E q u i p m e n tL i s t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0 . . . . . Irrstructionsto the PracticalSkills Examiner PatientAssessment/ManagementTrauma .......10 Instructions to the PracticalSkills Examiner Patient Assessment/ManagementMedical ......12 Sample Medical Scenarios ............14-17 lnstructions to the PracticalSkills Examiner CarcliacArrest/Management AED .................... 18 Instructions to the PracticalSkills Examiner Airway, Oxygen, Ventilation Skills

Bag-Valve-Mask-Apneic Pulse with 19 Instructions the Practical to SkillsExaminer Spinallmmobilization-Seated Patient 79 lnstructions the Practical to SpinalImmobilization-Supine SkillsExaminer Patient 20 lnstructions the Practical to SkillsExaminer Splinting Ski1ls.............. 21 lnstructions the Practical to SkillsExaminer Bleeding ZJ Control/Shock Management.............. Instructions the Practical Airway,Oxygen, to SkillsExarlirrer Ventilation Skills UpperAirway Adjunctsand Suction ZJ Instructious the Practical to Skills ExaminerAirway, Oxygen,VentilationSkills aA Mouth-to-Mask with Supplemental ....... Oxygen Instructions the Practical to Airway,Oxygen, Ventilation SkillsExaminer Skills aA Supplemental OxygenAdministration ....................

INTRODUCTION Deparrment ofTiansportarion released ln l994,the United Srates a revisedversionof the EMT-Basic Narional StandardCurricuof lum. In expectationof release this new curriculum and in conjunction with its development,the Board of Directorsof the National Regisrrvinstrucred the National Registry staFfro revise Examination Usert Guide. The Board of irs EMT-Basic Practical its Directors continued to srress goal of developinga practical while continuing to asexaminationthat would be cost effective of sure protection of the public through adequatemeasurentent minimal skill competencv. In January 1993, the EMT-Basic PracticalExamination Commirtee conveneda meeting in Columbus Ohio to begin revision Practical Examinarion Userls of the EM'l--Basic Cuide. Prelirlinarv discussions centeredaround rhe fbrnrat olr the evalultion insrrumentsand accompanyingessavs, well as the concept of as 'l'he individtraltesring. decisionof rhe con.rgroup resringversus nritreewls ro rerrin rhe existingfbrmat of the crlrrentet alu,rtion which acconrprr)\, tl-rose evalultion instrumenrsand rhe essavs the commirree decided to insrrumenrs. After some discussion, inclividuallv conrinue with the conccprof evllrratingcrrndidares in each sration. The underlying premise fbr this decisionw,as is nse :r thar rhe L,MT-Basic issuecl certificatc/lice ro rvork r.r'irhin a on and efl'ective stareba^secl his/herability ro providesaf'e prtient care. It rvasthc conce of this cornn-rirtee rn that u'hile teanr testverih'comperence ,r relrr, it failsto ensr,rre ing nral'adequarelv of competencyof e,rchinclividuelrncrlber of thrt tcrnr.

The committee identifiedthe follorvingcriteriathat must be rnet for a performanceexaminationto be used narionwide: a. Each taskon rhe evaluationinsrrumentmusr be scored as a seParare task. b. All irems criricalro parient/limb outcome must be identified on the skill sheer. must be considc . Sequencing tasks in some instances of ered critical behavior. d . Overall competencymust be achievedas defined in this mantral. -l-he cvaluarioninstrumentsprovided in this User\ (luide were d e v e l o p c ttlo n r c e tr h c a b o v e . r i r e r i l . -lechnician Medical wasse nNational Regisrrv Enrergency of sirive to input receivedrequesringthe National Registryto develop an adnrinistrarivelv f-easible cost cFfective and practicalex-I'he :rnrination, EMl--Ba-sicPracticalExanrinarionCommittee and tl'reNational RegistryIlorrd of Directorsconsidered fblthe lowing factorswhen developingand approving this practicalexanrin:rtion user's guicle: '['he y e . I ) r o t e c r i o n f t h e p u b l i c i s t h e p r i m a r y r e s p o n s i b i l i to f o 'fechniciens of the N;rrionalRegisrrv ErnergencyMedical l n . l . r l li e r r i h ' i n ga g c r r c i c s . b . T h e c u r r c n r D O T E M l - t r r r i n i n gc u r r i c u l u m c o n r l i n s scheduled rrrrrcrical skilis llboratories. 'I-hc have been using c. National Regisrrvand many states linrireclrandom skill oerltormance stationswith success and lr;rvelbund thrrt ihey red,,cecost without reducing r h c , l L r e l i no i r h c c x a n t i t t riro r t . ' t 'lirrining for cl. progrirmsare resp<-rnsible assuringconrpetenc of candidates scekingNarional Registration.Cand i d l t e s d e e n r e di n c o n r p e t e n tb y t h e t r a i n i n g p r o g r r m s h o u l d n o r b e p e r m i t t e dt o r a k e t h i s p r a c t i c a e x a n r i n a l tion. not verification agencies inclividuals direcrly or c. C)r-rtsitle bv r u s s o c i a t e ci lt h t h e t r a i n i n g p r o g r a n rm u s r b e a c c o m w plishedin orclerto assure protection of the public.

lircusecl Aficr estlblishing rhe exanrinationforrn.rr,cliscussions o n w h i c h o f t h e s k i l l si n t h e c u r r e n t e x a r t r i n a r i on- re d e dt o b e re A i r r c l u d e dn t h e r e v i s c d x r t m i n : r r i o r t . d d i t i o n r l l v ,t h e c o r r t m i t i e proiectecl rvhich of the ncw skills and srrb-skills fbr tee cliscussecl curriculunr needcdto be ininclusion in the revisedlrlr,lT-Basic c l u d e d i n t h e u r a c t i c a l x a m i n a r i o n .T h e c o m n r i t t e er e v i e w e c l e each skill in relationshipto thc fiequencv of use b1,the F.lr4'lB a s i ci n d a y - r o - d a 1 , p r e - h o s p ica lr ea s . v e l la s t h e c r i t i c a l i t vo f ta the skill in rclationshipto prrblic salen' rrnd parient care. J-hc f o l l o w i n g 1 3 s k i l l sw e r e i d e n t i f i e da s b e i n g t h e m i n r m u r l n u n r items th:rtshould be included in everypr.rctiber of perfbrmance l-he sarnplepracticalcxamination presented this user'.s in guide calexamination. contrins six (6) skill stations. A totally random skill practical ^lirruma PatientAssessnrent examinarionis not rcceotableand does fulfill all of the criteria /Menirgemer)t listed above. Vhen using this sampleprucricalexaminationfor ParientA-ssessment Mlnagement - Nledical Narional Registrarion, the restingagency must ensure that the CardiacArresr Mrnrgcrnent/AED Bag-Valverrainirrgprogram measures and documentsthe candidate's comlvlaskApne'icPrrient Spinal Immobiliz"rtion- Supine Parient perencyin all skills included in the mandatory and random skill P stirtions.This must bc accomplished S o i n a lI m m o b i l i z a t i o n S e a t e d r t i c n r prior ro allowing a candiI - o n gB o n e I n j u r v l n r m o b i l i z a t i o n date ro atrempt the practicalexaminationusedfor regisrrarion. Joint Injury Immobilization Traction Solint Imnrobilization Organizing the Examination BleedingControl/Sl.rock Management Upper Airway Adjuncrs and Suction A. ExaminationStations Mouth-ro-N{askwith Supplemental Oxygen Supplemenral Oxygen Adminisrrarion The practicalexaminationconsists six (6) starions five of (5) mandatorystarions and one (l ) random skill sration.The Theseskills reflecrperformance'items thar are directly relatedto mandatory and random skill srationsconsistof both skill the lossoFlife or limb. Therefore,rhe maior focusof rhe examibrsed and scenariobasedtesting. The random ski[[ starion narion is on airway, breathing, circulation and immobilization is conductedso rhe candidateis totally unawareof the skill skills. until he/shearrivesat the test site. to be resred

will be testedindividually in eachstationand The candidare will be expectedto direcr the actionso{ranyassistant EMT.s who mav be oresenrin the station. The candidateshould passor fail the examinationbasedsolelyon his/her acnons and decisions. The following is a list of rhe stationsand their established b t i m e l i m i t s . T h e m a x i m u m t i m e i sd e t e r n r i n e d y t h e n u m ber and difficulry of tasksto be conipleted. Maximum Skill to be Tbsted Time Limit Station l: PatientAssessr-nent Manngement- Trauma l0 rnin Station 2: l'atient Assessment Manasenrent- Medical l0 nrin Station 3: CardiacArrcst M:.rnrgement/AED l5 nrin Station 4: Bag-Valve-M:rsk Aprreic l);rtienr l0 rnin S t a t i o n5 : S p i n a ll m m o b i l i z a t i o nS t l t i o r . r S p i n a lI m m o b i l i ; r a r r o - S u p r i n e a t i e n r n P S p i n a ll m m o b i l i z e t i o n- S e a t c d ) a t i c n t l Station 6: Rrndonr tlasicSkill \trificrrion l0 nrin I0 nrin

iry should havea waiting arealargeenough to accommodate the number of candidates scheduledro aftemDt the examination. The waiting areashould havechairsoi ben.hes, ".cessto restrooms and water fountains as well as adequare storagespacefor examinationsupplies. ArrangementsFor mealsand other breaksfor staff members and candidares is an additionaconsiderarion. l C o n r n r u n i t y f a c i l i t i e sw i r h r v a i l a b l e s p a c e m a y i n c l u d e schools,ofllce buildings, hospitals,fire stations and other structurewhich meet the critcria described above. Selection of the Examination Staff One of the nrajor consideratior-rs the selectionof examiin nation staff membersis rhcir er-rthusiasm interestin rhe and e x a m i n a t i o nT h e e x a n r i n a r i o p r o c e d u r es d em a n d i n ga n c i . n i -l'herefbre, ing. t i nre-consum w,i thout f ull cooperarionfrorn rs, the strrfFrnembe it rvill be difflcult to conduct the reperted cvalultions neccss:ir'|' :r Iergegrotrp of c:rndidates. lor \(hcnever possible, is reconrmended form a core group it to -fhis o r r c g u l a re x a m i n a t i o rp e r s o n n e l . r will help pronrote te:rnrrvork lncl consistency unrong the exanrinationstafl. lt hes been our expericncerhar the more freqtrentlya group rvorks together,the nrore snloorhly and elfecrivelythe exarnination runs. I'robably not lll core exarninationDerson'l r r c lw i l l b c a v : r i l . r h lfc r e . . r . e x , r n r i r r : r r i o r rs s i o u . h e r e o se fore, there should bc backup rnembers who can parricil'tl1s 'l'hese fionr tinre to tir))els rclit-fpcrsonnel. should persons be firlly awareof their responsibilirics skill stationexrrnrrrres ers and rsked periodicallyto relicveregularstaff members. Skill station exanriners should be recruited from the local FIMScornnrunity.You shouldonly consicler inclivicluals who arc currently licenscdor ccrtificd to perforrn the skill 1'ou rvish thenr ro evirluirre.Careful attention must be plid ro avoid possible conflictsol-inrerest, local political dispures or any pre-existing condirions which could bias thc porential skill exanrinerrowardsa piirticuLlr individual or group of individuals. In no instanceshould a primary instructor serve as a skill station examiner. Casualrnembers the insrrucof tor stafFmay be utilized, if necessary, provided there is no of evidence biasand rhev do not evalurteany skillsfbr rvhich they servedas the prinrarv lnstructor. EveryeFfbrtshould be made ro select who are fair, examiners consisrent,objective, respecrful,reliable and impartirl in conduct and evaluation.Examiners should be selected based on their expertisein the skill to be evaluated. Examiners must understand rva1, that there is more than one acceptable ro perform a skill and should not indicate a bias thar prenrerhods. You should work to obrain skill cludesacceotable station examinerswho ar noc acouaintedwith the candidate if possible.All examiners workshould haveexperience ing with EMTi, teachingor formal evaluarion pre-hospiof tal care. A minimum examinationsraffshould consistof one (l ) exlour aminarion coordinator,six (6) skill station examiners, (4) programmedparients, rhree (3) EMT assistanrs one and make-up personto conduct the pracricalexaminarion.

[)ependen t on theskill

Long Boneln.;urv 5 ntin lnjury 5 rnin Joint T i a c t i o nS p l i n t l0 nrin t s l e e d i n g o n t r o l / S h o c kN h n r g e m e n r C l0 nrin UppcrAirwayAtljrrncts nd Strction a 5 nrin M o u t h - t o - N I : r sr v i r h S t r p p l c m c n t a l x y g c n 5 n r i n k O S u p p l c m e n t aC ) x y g c n d m i n i s t r a t i o n l A 5 nrin 'l he randornskill srationshould bc conducreci rfrarthe candiso darc is complctely unawareof tlrc skill to be testeduntil he/she entersthe skill station. A methociof acconrplishing rhis is ro list t l t e r a n d o ms k i l l si n d i v i d u a l l y r r c a r d s .A s t h e c a r r d i d a te n t e r s , o e -I'he he/shewill draw a card. skill thar is lisredon rhe carclis the skillro be tested. A n o t h e rn o s s i b l e e r h o d i s t o h l v e t h e e x a n r i n r t i o n o o r c l i n l t o r m c :rnd rhe physicianmedicaldirecror ro randonrll,selecr skill rher r will be restedby all candidates enreringthe rrrndomskill srrrion. 'l'his will reducethe amount of cquipmenr r-reeded rhis sr:rtion. et A c o m p l i c a r i o n F t h i s m e r h o d i s t h a r c a n d i d a r er e s r i n g a t e ri n o l s the day rnay be inforrned by earliercandidates abour the skill to be rested. If this merhod is used, great care should be taken t<r elinrinatethis unfair advanrage. Advancedairwav evaluationinstnrmentsarre include in Append i x L T h e e v a l u a r i o nn s t r u m e t s a r en o r a r e q u i r e d o m p o n e n r i n c of the nrinimal skill competencyof rhe ENlT-Ba.sic defined by a.s t h e 1 9 9 4N r t i o n a l S t a n d a r d u r r i c u l u m . \ 7 e a r ei n c l u d i n gt h e s e C skill evaluation instruments a service rhosesrates who choose as ro ro follow rhe recommendrtion of the Narional EMS Educarion and Practice Blueprint asa part of the advance airwal,module of the 1994 EMT-Basic National SrandardCurriculum. B. Selection of a Test Faciliry It is important that the resrstarionsare serup in such a wav Io prevenrcandidares From observingrhe patienr managem e n t p r o b l e m s r i o r r o r h e t i m e o [ r h e i r r e s r i n g .T h e f a c i l p

D.

Responsibilities of the Examination Staff \X4rile it is not essential have a physician medical director to in artendance all examinationsessions, is highly desirat it able. The skills to be tested and the acceptablelevelsof performanceshould always determinedwith physicianmedibe cal director input.

F.

Budget The Fundsrequired ro conduct an examination will vary. The exact cosr will depend on rhe availabilityof volunreersro staff the examination and the degreeof other communiry support such as donations of spaceand supplies. Equipment can usuallybe borrowed from local rescue agencies or hospitals. Orienting the Skill Station Examiners as a Group An important component in ensurethe examinationopratessmoothly is orienting the skill stationexaminers their to role and responsibilities during the examinationprocess.In order to ensure the consistent oerformance of examiners throughout the day,the examineisshould be assembled a as group prior to rhe start of the examinationand instructedin the procedures the examinationaccordingto a standardof izedorientation script. (Appendix F.) Orienting the Candidates as a Group An important aspectof the examinationis thc initial meeting and orientation of the candidates. Once all candidates havebeen registered the examination,they should be mfor sembledas r group and instructed in the procedureof the examinationaccordingto a standardorientation script (Ap'A"). During this period, the candidates should be pendix given clerr and completedirectionsas to whar is expected oI thcm during the examination. However, special effort should be made to put the candidates ease. It is during this peat riod that questions regarding the examinations should be solicited and answered. During this orientarion session, candidates should also be instructed leave testingareaimmediatelyupon completo the tion of their examination and to not discussthe examrnation with thosecandidates waiting to be tesred. Orienting the Individual Followingthe group orientation,candidates will wait for directionsto report to a specifictestingarea. Prior to entering theseareas,the candidaresare greeted by the examiner and read the "lnstructions to the Candidare" as rhey appearar the end oFeachpracticalskills essay provided by the examination coordinator.To assure consistency and fairness, these instructionsshould be readto eachcandidate exacrly writas ten. Each candidateshould then be ouestionedas to his/her understanding the instruction and provided with clarifiof cation as required. Caution must be used to avoid lengthy quesrionsor attempts by the candidate to obtain answersto questionswhich have no bearingon the examination. Examinersshould be courteousand professional all conversations in wirh candidates. Evaluating the Candidate

The examination coordinator is responsible the overall for , o G. p l a n n i n g ,i m p l e m e n t a r i o nq u a l i r yc o n t r o la n d v a l i d a t i o n f Specificdutiesinclude orientation the examinationprocess. and skill starion examiners of the candidates and reporting results the National Registry Emergency of examinarion to of Medical Technicians. observecandidateoerformanceand Skill station examiners instrumenrs.Vith inpur f:rompro, completeskill evaluarion grammed patienrs,they also make an inirial evaluarion a of candidatet Derformance.In the interestof Fairness oband jectivity,insirucrors should not examinetheir own students. E x a m i n e r s u s t m a i n t a i na p r o f e s s i o n a ln d i m p a r t i a la r t i - H . m a tude at all times. This not only creates environment of an fairnessto the candidate,it also a.ssisrs crelring a nrore in realistic atmosphere. Examiners rnaybe selected from a fairly wide rangeof resources. example, For localphysiciens, nurscs, and EM'ls providepotentialexamiparamedics, experienced nation staffing. AssistantEMTs should be knowledgerblein the skill that they are assisting.They are required ro perform as trained EMS professionals would in an actrrelfield situation. They should follow the direction of the EMT candidare and may not coach the cantlidaterelativero rhe Derformance any of skill. The programmedpatient's is irnperformance alsoextremely portant. A lack of uniformity in perforrnar.rce a proby grammed parient may causea variancein rhe candidate's abiliry to identiS and treat an injury correcrly.ln addition, an informed programmedpatienrfrequenrlyis ableto evalu, I . ate certain aspects a candidare'.s of proficiency nor readily observed rhe examine by r. Attempts should be made ro ensurerhat programmed parient's experienced are EMTs, paramedics and/or other allied healrh personnel. The advantages ofthis approachare that prior patient contact enablesrhe programmed patienr to re-enacrinjuries more accurarely and ro evaluare appropriateor inappropriate behavior/technique the candidate. by Make-up personnelare responsible realistically For simulating wounds. This realismhas a great deal of influenceon the candidatesactions during the examination. Virrually any rype of wound can be realisrically reproducedwith makeup by using the right materials,common sense and a lirrle practice. E. Equipment The suppliesand equipment neededto prepareeach of the six (6) examinarionsrationsare lisredin Appendix F. Each examinerwill need a warch and a supply of evaluarioninstruments to scoreeach candidate'sperformance.

A.

Examiner's Role It is stressed again that the examinersmusr be objective and fair in their scoring. In smallercommunities, it may be ex-

rremely difficult to avoid the potential problem of EMTBasicinstructorsexamining their own students.This problem may be avoidedif communitiescan join togetherto conduct the examinations.

tion resultsonto the PracticalExamination Report Form (Appendix D). The PracticalExamination Report Form is then used to determine and record the overall score of the practicalexamination.

B.

Using the Skill Evaluation Instruments consists the examinerat eachsraof The evaluationprocess and recordingit tion observingthe candidate's performance o n a s r a n d a r d i z e d k i l l e v a l u a t i o ni n s t r u m e n t s . T h e s and recorderof role becomesthat of an observer examiner's events. Skill evaluation instruments have been developed for eachof the six (6) stationsand are included in Apperrdix I'1. Additionally, essays explainingeach skill evaluationinthe skill starion exstrument have been develooedto assist aminer with the appropriate use oF rhe instrument. l'hese are essays included in Appendix G Exceptto start or stop a candidate's to performance, deliver .l00/40; is necessary cues(e.g.,"The patient's blood pressure pulseis 120 and thready.")or to ask for clarificarionthe examiner should not speak to the candid:rteduring his/her eiperformance. Similarly,the examinershould not re.rct, to or negatively, anything the candidateslvs :1.j1::',''.'t

B.

Reporting the Score If the practicalexaminationis being given for the purposeof and it gainingNational Registration, must be state-approved equal or exceed the criteriaestablished this manual. in Successful completion of the practicalexaminationmust be reportedto the Narional Registryby compleringthe reverse side of rhe National RegistryEMT-Basic application. This is rhe resoonsibiliry rhe examinationcoordinatorand the of physicianmedical direcror of rhe testing institution, or an agent or assignee the physician medical director. The o[ phvsicianmedical director should use the PracticalExamination Report Form (Appendix D) to veri$, the applicantt practicalex:rminationperformanceprior to completing the N : r t i o n e lR r g i s t r va p p l i c e t i o r r .

C . Reporting Examination Results to the Candidate

The examin:rtion fbr coordinatoris responsible reportingthe results the individual candidate.At to practicalexaminatiorr no time should rhe skill station examinernotifr the candidate of practicalexamination results. Notifring candidates of Failing rformances pe prior to completionof the entirepractical rnayhavean adverse afFect their performancein subon sequentstations. The resultso{rthe practicalexamination should be reported as a pass/failof the skill station. The candid:rteshould not receivea detailed critique of his/her skill performrnceon any skill or a copy of their performance sheets. Idenrifuing errors is not only contrary to the principlesof this rype of examination,it could resultin the canw d i d l t e " l e a r n i n g " h e e x a m i n a t i o n h i l e s t i l l n o t b e i n gc o m t skills. petent in the necessary It is recommendedthat candidates notified in writing of be Examinatheir examinationresults.A copy of the Practical tion Report Form could be usedfor this purpos. Additionally,a copv oFthe Practical Examination Report Form must file. be kept in the training program's

C. Programmed Patient's Role

The programmedpatient is responsible an accurate [or and consistent for portrayalas the victim in the scenario the station. The programmed patier-rt's comments concerningthe rse candidate's rformanceshould be noted on the reve side pe of the performanceskill sheet. These cornmentsshould be so asbriefand asobjectiveas possible they can be usedin the final scoringof the candidate's performance. SeeAppendix B for more information on the programnringof a patient and the use of moulase in the skill strtion.

Determining a Final Grade A. Scoring

As mentioned earlier,the six (6) skill station examiners observe the candidate'soerformance and record rhe observations on the skill evaluarioninsrrumenrs.These skill sheets Assuring Standardization and Q""liry Control arecollectedby the examinationcoordinatorand aregraded according to the pass/Fail criteria provided by the tesring To be reliable,a pracricalexamination must be conducted acagency. To obtain a copy of the minimal pass/fail criteria, cording to a uniform set of criteria. These control criteria must contact rhe National Registryof EmergencyMedical please be rigidly applied to all aspects the examination iI impartial, of Technicians. objectiveand standardized scoring is to be assured. In most cases, pass/fail will be easily the determined. If, however,the pass/fail determination is not easilyidentified,the physicianmedicaldirecror,examinarioncoordinatorand the stationexaminershould reviewthe situationasa committee beforecoming to a final decision.The programmedpatient's comments, rhe examiner's comments and the documentation on the skill evaluationinstrument should all be consideredwhen determining the final grade. Once the individual skill sheers havebeenscored, examithe nation coordinatorshould transcribe the individual skill staand qualTo assist examinarioncoordinaror in standardizarion rhe iry control, a qualiry conrrol checklistis included in Appendix C. This form can be used as an internal checklist for evaluatins the examinationprocess. Sample Orientation Script

This standardized orientation script is an exampleof the rype of after scriot which should be read before eachexamination session the candidatehave registered the examination and before they for are sent to the examinationstations. The script is normally read

by the examination coordinator, who should maintain a Friendly and professionalatritude. General Instructions 'Welcome to the EMT-Basic practical examination. I'm name and completing this examination processand By successfirlly ritle. receiving subsequentcertificarion you will have proven to yourself andihe m.dical communiry rhat you have achievedthe level qualiry pre-hosof competency assuringthat the public receives Pltat care. I will now read the roster, for attendance PurPoses,before we identifr yourselfwhen )'our name is begin the orientation. Please called.

of appropriatemanagement the patient. Do not leelobligaredto use all the equipmenr. If you brought any of your own equ.ipment, I -uti inrp.., and approve it before vou enter the skill station. fu you progressthrough the practical examination, eachskill staand recordingyour performance' tion examiier will be observing influenceyour Pernot let his/her documentarion Practices Do formance in the station. There is no correlation berweenthe and the qualiry of your perforvolume of his/herdoctrmenration to mance. You are encouraged explain the things you are doing during your perlormancein the station.

If the station has an overalltime limit, the examinerwill inform you of this during the reading oF the instructions' !?hen you will inform you to ,.".h the time limit, the skill sltion exarniner because stop your perFormance.However, i[ you complete the station The skill starion examinersutilized today were selected the examiner that you are finin of their expertise the particularskill starion' Skill station ex- before rhe'allotredtime, inform appropriate ished. You may be askedro removeequipment from the patient ofyour expecred and recorders aminersareobservers rhe skill starion. actions. They record your performancein relationshipto rhe beforeleavirrg by criteria listed on the evaluation instrument developed any specificdetailsof any sraYou are not permitted to discuss be tion with each other at any time. Please courteousto the noiseto a miniwho are testingby keepingall excess The skitl stxtion examinerwill catl you into the stationwhen it is candidares mum. Be prompt in reporring to each srrtion so that we may prepared For testing. No candidate, at any time, is pern.rittedto tinre period' reasonable ieniain in the restingareawhile waiting Forhis/her next sration' completethi, .*a,.tin"tion within a wait outside the testing areauntil the stltion is open You must (3) or lessskill stationsentitlesyou to a sameday and you are called. You are not permitted ro take any books, Failureof three retest of those skills firiled. Failureof four (4) or more skill stapamphlets,brochuresor other study material into the station' examinarion,rea of You ar. not permitted to make anv copiesor recordings any tions constirutes failureoFthe entire Practical you enter the quiring a retestof the entire practicalex-amination'Failureof a examinerwill greetyou a.s station. The skill sration ....-Joy retestentitles)/ou to a retestof thoseskillsfailed' This him/ assist skill station. The examinerwill askyour name. Please site with a different at her in spellingyour name so that your resultsmay be.reported retestmust be accomplished a different examiner. Failureof the retestat the different site constitutesI readaloud "ln,..ur"r.ly. Each skill station examinerwill then and you.will bc structionsto the Candidate"exactlyasprinted on the instruc(ioll complete failure of the practicalexamination, examination. A candidateis providedto them by the examinationcoordinaror.The informa- ,.quir.d to retestrhe entirepractical of three (3) times before tion is readto eachcandidatein the slme manner to ensurecon- allowedto test a singleskill a maximum he musr retestthe entire practical examinarion. Any retestof the sistencyand fairness. enrirepracticalexaminationrequiresthe candidateto documenr skills before re-attemptingrhe examias Itlease pay closeattenrion to the instrtlctions, they co.rrespond ,emedial training over all to disparch informarion you might receiveon a similar emer- nation. gency'call and give you valuable information on what will be are reported asa pass/fail of expected you during the skill sration. The skill station exam- The resultsof the practical examination a detailedcritique of your offer to repeir the instructionsand will ask you if the of the skill station. You will not receive inir will examinarememberthat today'.s on insrructions*.r. und.r.tood. l)o not ask for additional infor- perFormance any skill. Please and was not designedto assist iion is a formal verification process as mation not containedwithin the instructions, the skill station oFthis examinationis to examineris nor permitted to give this information. Candidates with teachingor learning. The purpose after the competencies are compiain that skill itation examincrs abrupt, cold verifi achieviment of the minimal DOT sometimes has been completed. Identifuing errors and educationalcomPonent or appear unfriendly. No one is here to add ro the stress of this rype of examination' anxieryyou may alreadyfeel. It is important to understandthe would be contrary to the principle conversation and could resultin the candidate"learning" the examinationwhile examiners have been told they must avoid casual skill. It is recommended to with candidares. This is necessary assurefair and equal rreat- still not being competenr in the necessary institution for remedialtraining i[ ment of all candidatesrhroughout the examination. W'e have that you.oni.., your teaching in you are unsuccessful a skill station' instructedthe skill station examitlersnot to indicate to you in skill stain your performance the any way a judgement regarding remark asan indica- If you feel you havea complaint concerningthe practicalexamirion. Do not int.rpt.t any o[the examiners rhe ski[l sta- nation, a formal comPlaint proceduredoesexist. You must inirecognize tion ofyour oue.ailpetfo.mance. Please and simply tiate any complaint with me today' Complaints will not be vaiid and objective, attitude asprofessional tion examiner's *ill not be accePtedif they are issuedafter you after today perform the skills ro the best of your abilitv "nd learn of your resultsor leavethis site. You may file a complaint for only rwo (2) reasonsi Each skill station is supplied with severalrypes of equipment fbr You wiil be given time ar the beginning^of the your selecrion. for skill station to survey and selectthe equipment necessary the

5

l. You feel you have been discriminated against. Any situation in that can be documentedin which you feel an unfair evaluationof your abiliriesoccurredmay be considered discriminatory. t an equipment problem or malfunction in your ]l;:.":IFyou feeleither oFtheserwo things occurred,you musr contacr me immediatelyto initiate the complaint process. You must subm i t t h e c o m p l a i n ti n w r i r i n g . T h e e x a m i n a t i o n o o r d i n a t o a n d c r the medicaldirector will reviewyorrr conce rns. I am heretoday to assure that fair, objective, and impartial evaluationsoccur in accordance with the guidelinescontainedin this guide. If you have any concerns,noti$, me immediatelyto discussyour concerns. I will be visiring all skill srarions throughour the examinationro verifr adherence theseguidelines. l)lease ro r e m e m b e r h a t i f y o u d o n o r v o i c ey o u r c o n c e r n s r c o m p l a i n r s t o today before you leavethis site or belore I inform you of your results, your cornplaintswill not be accepted. The skill station examiner does not know or play a role in the establishment of pass/fail criteria, but is merely an observer and recorder of your actions in the skill sration. This is an examination experience,not a teaching or learning experience. Doesanyonehaveany quesrions concerningrhe pracrical examination at this tinrc? Points to Remember

how he/she personally reactsro pain. The programmed patienr should work with the medical personnel until he/she has fully developed the proper reacrionsand responses.Medical personnel should alwaysuselay terms in programmingthe patient,and the patient should alwaysrespondin lay terms ro any quesrions from the candidate. After the patienr has been fully "programmed," it is essentialthat he/she stay in characrer,regardless of what goeson around him/her. Input from the programmedpatientwith respect the way canro didateshandlehim/her is important in the scoringprocess. This should be strongly emphasized the programmedpatient. to Moulage Make-up of simulatedpatientsis important if rhe tesringagency is expectingcandidates identifr wounds readily. The sample to pracricalexamination only requiresmoulage in the PatientAsscssnrent/Management srations. Alrhough thearricalmoulageis ideal,comnrercially available moulagekits areacceprable alertin ing the candidateto the presence injuries on rhe simulated oF r P a t e nt . R e g r r d l e so f t h c q u a l i r vo f n - r o u l a g e x a m i n e r s u s rc o m m u n i s , m catcrvith the canclidare concerninginformarion on wound presence and apperrance. Candidareswill need to distinguish berweenvenousand arterialbleeding,paradoxical chestmovement, obsrruction oFrheairwly and any other injury thar a programmed patientcannotrealistically simr,rlate. candidates If complainabout the qualirv of moulage,the examinarioncoordinatorshould objectivelyre-examine the quality of the moulage.If the quality of the moulage is deemed ro be nrirrginaland does not accurately represent wound, rhe examinarion the coordinator shouldinsrrucr the skill station exrnriner to alert candidates rhe exacrnarure ro of the iniury.

l. Follow instructionsfrom the sraff. the examinarion,move only to areas directedby the staff. 3 . Cive your name as you arriveat eachsrarion. 4 . Listencarefullyasthe tesringscenario explained each is at statiolt. 'l'he skill stationexaminershould do this only a{:ter candidate rhe 5. Ask questionsif the instructionsare not clear. hasassessed areaof rhe wound a.s the would be done in an actual 6. During the examination,do not ralk about the exlminefield situation. tion with anyone orher rhan the skill starion examiner, programmed parient and, when applicable, rhe EMT to asslstant. qualiry 7. Be aware of the time limit, bur do not sacrifice performance for speed. 8. Equipment will be provided. Selectand use only that which is necessary care for your patient adequately. to

2 . During

Progamming the Patient Patientprogramming involvesrwo essenrial elements: acting and medicalinput as to rhe rype of injury, rype of pain, generalreaction and what should and should nor be accomplishedby rhe EMT candidate. It is not necessary have professionalactors as programmed paro tients. Almosr anyone with the proper morivation can do an job. The basicskillsare believingand concenrration.If excellent the programmed parienr really believesin rhe scenario,it will becomebelievable orhers. ro Once the programmed parienr has receivedthe medical information on rhe rype oFinjury or illness, he/sheshould concenrrare on

o

MedicalTechnicians The NationalRegistry Emergency of

EMT-Basic PracticalExamination

for The purposeof this checklistis to help the examinationcoordinatorestablisha quality control process standardization of the examinationand to provide the testingagencywith a meansof helping to assure must personally practicalexaminations.To achievethis, the examinationcoordinator, designee, or in of or oversee observethe variouscomponents the examinationas presented this checklist. As each placedin the space provided. If a check is not placedin a control criterion is completed, checkshouldbe sideof provided,an explanation why that criterionwas not met shouldbe listed on the reverse the space this checklist.This checklistshouldbe completedand signedby the examinationcoordinatorbeforean for examination accepted credit by the testingagency. is

E x a m i n a t i oS i t e : n Date Examination

OF A. ORGANIZATION THE EXAMINATION a of skill fl fstantished minimum six (6) examination stations examiners the numberof qualified skillstation E ScneOuled appropriate in candidates assureeligibility participate the examination to to Registered and identified E qualification skillstation priorto the examination examiners of E Reviewed B . F A C I L IT IE S had adequate roomto conduct examination the withoutinterference E Sfittstations Equipment was in workingorder fl varietyof equipment was provided n nn adequate C: SKILL STATIONEXAMINERS process theirrole in the examination and understood E ReaO performance objective recording in each candidate's E Remained extraneous elementsintothe skill station n OiOnot introduce SkillsCandidate" each individual to tested the to D ReaO "lnstructions the Practical for OiOnot show preference towardany agencyor individual any reason n OF AND SKILL STATIONEXAMINERS D. ORIENTATION CANDIDATES and completely the orientation scriptclearly n ReaO standardized questions the to concerning examination adequate time for candidates ask D Rttowed programmed patients as and EMT assistance required D Oriented E. CANDIDATES retestpolicy examination the concerning practical E Were instructed for complaint the concerning process filingan official E Were instructed F . S C O R IN G H E P E R F OR MA NCE T propercriteria determining finalgradeof the candidate for the I UseO gradeon the Practical Examination ReportForm Recorded overall the E

B), virtue oJ tny signature and conpletion of this checklist, I attest lo thefacl lhat lhis examination v'as organized and administered according to slandards by esrablished

Coordinator Examination Signature

SignaturoMediclDirector

ExaminationAttempt

nitial Attempt lst Retest Retest

The NationalRegistryof Emergency MedicalTechnicians

Overall Score

Pass Fail Retest

EMT-Basic Practical ReportForm Examination

Name

Middle lnitial

Address

City Stato Zip Gode

ExamSite: Station#l Station#2 Station#3 Station#4 Station#5 Station#6 - Trauma Patient Assessment/lVlanagement - Medical Patient Assessment/lVlanagement Cardiac Arrest Management/AED Bag-Valve-MaskApneic Patient Spinal Immobilization (speciryy Seated/Supine

Random Skill Verification (Speciry)

Date: Pass Pass Pass Pass Pass Pass Fail Fail Fail Fail Fail Fail

Examination Coordinator:

Physician Medical Director:

Signatu16

Candidates failing three (3) or less stationsare eligible for a sameday retestof the skills failed. Failing a sameday retestwill require the candidateto retestonly those skills failed at a different site with a different examiner. Failure of the retestattempt at a different site and with a different examiner constitutesa complete failure of the practical examination. A candidateis allowed to test a single skill a maximum of three (3) times before he/shemust retestthe entire practical examination. Failing four (4) or more stations,constitutesa complete failure of the practical examination.Any complete failure of the practical examination will require the candidateto documentremedial training over all skills before re-attemptingall stationsof the practical examination.

Remarks:

ORJENTATION PP"ACTICAI EXAMINATION STATION EXAMINERS

TO SKILL

inspected and that you are Familiar with irs useprior to evaluatir ing the candidate.

As the candidatebegins rhe performance,document the time I Good (morning, afternoon,evening).My name is-. on instrument. As the candidate progresses administeringthis examination. started the evaluiirion wilI be the starerepresentative thc station,fill out the evaluationform in the following On behalf of rhe stateof , I would like to thank you [or All to servingasa skill stationexaminer. data relative a candidate's *::::l and obserperfbrmanceis basedupon your objective recordings a. Place point or points awardedin the approprirresp,rce the ofyour vations.You were chosenas an examiner today because ar the time eachitem is completed. station and abilirv to lairll'rtttd lccuexpertisein the assigned b. Onlv whole points mry be awardedfor those srepsperratelyobserveand document variousperfortnances.All perforformed in an acceptablemanner. You are not permitted degreeof objectiviry mancesmust be reportedwith the greatest to award fractions of a point. possible. The skill evaluationinstrtrmentsvou are usirrgtodrrv c. l)lacea zero in the "l)oints Awlrdecl" colunrn for rny step evaluating canrhe havebeendesigned lssisryou in objectivelv to which r.'",as conrpleredor was perfbrnredin ln unacnot didates. resultor ceptable nrrnner (inappropriate non-sequential i n g i n e x c e s s i v e d d e t r i m e n t ad e l a y ) . l rn veriflcation Let nre enrphasize tlrat this exanrinarionis l forn-ral for i s train- A l l e v a l u a t i o nn s r r u r n e n ts h o u l db e f l l l e do u t i n a m a n n e rw h i c h procedureiot designed teaching,coachingor renredial ing. Thereforcyou arenot pernritted to giveany indicationwhat- prohibits the candidarcfrom directly observingthe poirrrsvou yorr soever ofsatisf,rctory unsatisfactor]. or perfornrence :rnycancii- awardor rhe cornrrrents nrry note. Do not become disrracted to on instrunot rnv s;-rr'cific fbr darear any rinre. You nrr,rst disctrss pcrformancc by searching the speciticst:rterncr)rs the cvalu.rtior-t . with anyone orher than rnyself. If you rrreunsure of scoring a ment u,he you shoultlbe observingthe candidatc's n performance i noti$r nre rs soon rs Possible. [)o not I d e a l l y o u s h o u l db e f r r m i l i a w i t h t h e s e n s t r u n r e n t s ,u t i f I r o t , r b v particular perfcrrmance, ar-ry anv tprestiorrs over and concisclvrecord the etttit-c sign or conrplete evalultion fornr iiyou hrrve nt simoly turn the insrrunrcrrt all, until we havediscussed performance. the o.rFor,,-,",r." the back side. After ,l'," ."ndid"," finishcsrhe on conrpleterhe fiont sidc of the evaluationinstruprerfurnr,rnce, Please You should f,ct in a professional nrlnner at all times, p.r)'ingp.rr- rnent in lccordancervith the documcnted oerfornrance. , l c ticular ettention to the m:rnncr in which 1'ou,rddress canclidates. r r n r e r r r b etrh c r r r o sirl c c u r : r tr n e r h o .o f L r i r l ye ' l l u a r i n gJ n ) ( J n You must be consistenr, fair and respecrfill clrrving our I'our didate is one in which your attention is devotedentirely to the in The satest apl.roechis to limit your duties es a formal examiner. perfbrnrrnceof the candidate. rnlrerill onlr'. Be cerefulof tlre di,rlogueto examination-relared manr)erin which you address candidrteses nrany will interpret You must obsene and enfbrce all tinre linrits lor the stations. stop thc candidatc'.s perremarks someinclicltion of rheir perfirrmlnce. You shoulcl Vhen the tinre lirnit has been reached, your as rhroughoutrheir perfbrrnance fornuncc promprlv and direcr thc candidateto move on to his/ dcvelopa dialoguewirh cencliclatcs and should ask cluestions clariflcationpurposcs. fbr These ques- her next station, nraking sure that no candidaretakesany trotes of tions should not be leacling but should be rsked rvhenadditional or recordings the station. If the candidateis in the middle oFa stepwhen the rirne limit is reached, pernrit him/her to conrplete r e q u i r e d .F o r e x a r n p l e i,i ' r r c a n d i d a t c t r r e s" l U c l a r i f l c a t i o ns i s 'l'he onlv rhar sreo. candidateshould not bc allowed to start annow rrpplyhigh f)ow ox),gen,"your approprilte response might "stopwatchwalcher" and try not ro add be; "l)lease explainhow you would do that." Do not ask Foraddi- other srep. Dont be a one or several additionalminutes to rhe station. You should then tional informarion beyond tl.rescopeof the skill, such rs having "l'oints Arvarded"column for any stepswhich t h e c a n d i d a r c e x p l a i n r h e F i O 2 d e l i v e r e d b y t h e d e v i c e , placer zero in the contraindicationsto the use of the device or other knowledge- were not compleredwithin the allotted time. rype information. You may also haveto stimulatea candidateto "lil do a quick assessperform some action. If a candidarestates menr of the legs,"you must respondby asking rhe crndidare ro actuallyperfornr the assessment heishewould in a fielclsituaas tior-r. After all points havebeenav"arded, you must toral them and enrer the rotal in rhe .rppropriate space rhe evalultionform. Next, on reviewall "Critical Criteria"st:lte nts printed on the evaluatior-t me ltorm and check any that apply to the performanceyou just observed. You must factually document, on the reverseside of the evaluation fornr, your rationale for checking any "Critical CriWe suggest you introduce yourselfto eachcandidateas you call teria" statement. Do nor be vagueor contradicroryand do not them into the station. No candidate, any time, is permitted to at simply rewrite the statemenrrvhich you havechecked. Factually r e m e i ni n t h e t e s t i n ga r e r w h i l e r v a i r i n gf o r h i s / h e rn e x r s t a n o r r . caused you to checkany document the carididate's actionsr.r,hich Take a few moments to clcarlvurinr the candidate's firsr and lasr You may alsowish to document, in the same of rhese statemenrs. narneon the evaluationfbrm'ai well as your name, the date and way,eachstepof the skill in rvhich zero points were awarded. Be scenarionumber. We suggestyou use an ink pen and follow sure to sign the evaluationinstrumenr in the appropriatesplce good rr.redical-legal docunrentaiion practiceswl.rencompleting and then preparerhe station for the next candidate. theseforms. \bu should readaloud the "lnstructionsto rhe Candidate" exactlyas printed ar rhe end ofyour essays. You rnay not You are responsiblefbr the securiry of all evaluation material add or detract from theseinstrucrionsbut nray repearanv por- throughout the day and must return all material to me befbre tion as requested.The instructionsmust be read to eachcandi- you leave rhis examinationsire. Ifyou needto takea break,please date in the samemanner to assure and fairness.Give inf:orm me and secure evaluationinstrumentswhich were isconsistency all the candidatetime ro inspectthe equipment if necessary ex- sued to 1,ou. and of plain any specificdesignfeatures rhe equipmenr if you areasked. If the candidatebrings his/her own equipment, be sure I have

After you receiveyour marerials for today's examination, you may proceed to your station and check the props, equipment and .r | | I r . L- c - - - ^ . - , , (ne | ror moulage to assure sKlllstauon ls PrePareo (ne' rlrst canol. I

Bag-Valrc-N{a*ApneicParientwidrhls E_-b x a m i n a t i o ng l o v e s

r, | | D^_ \r r t:l::t, 1"9 e e n t a n k , r e g u l a t o r a ,,d t^o w m e t e r -",1"-:1Y1":l (Jxy l n

c l a t e ,I o u s h o u l d o f l e n t a n y v l c t l m s a n o a s s t s t a n t s o v e r t n e l r r o l e s , | | .' f l e n t w o u l o l n a f l e l o s r t u a i l o n a n o t n e a s s l s t a n t ss n o u l o p e r r o r m

in todayt examination. The victimsshouldact asa similarpa-

connecringtubing Please emphasize ,h;l;fi;;;:; as trained EMS professionals. |ri"tt' i l a r i o n a n n e q u i n( c a p a b l e f r e c o r d i n g . o Venr m . . I r . n.r' o.u gL _ u.t , - _." n o . _ ; - t o t t n e l r c o n s l s t e n ta n d p r o i e s s l o n a P e r l o r m a n c el \ r - , .l : . - L -^ _ ^ _ ^ ^ r ' o . , ^ * ' t v e n t i l a r i o n o|l u m e s ) v by lighror graph,800ml , , , , ._ lntodavs examrnatlon. Iou must reao tnrougn tne essavano , : ,tr',,.tionr, brief your assistantsand simula"tedp",i.,'ti, and re- c-:-^rr* . . . SpindlrnmobilizationSkills(Searedard$rpinePuiar0 , , I r | v l e w t n e e v a l u a t l o nn s t r u m e n tD e r o r e v a l u a u n g._..-_-;,r-- o a t e . e anycanor l Please wait until I have inspected your station and answered any Examinationgloves your first candidate. of your specificquestionsbeforeevaluating Short spineimmobilization device(shortspineboard, KED, etc.) Are there any questions? Long spine immobilization device(i.e. long spine board) Cervicalcollar EquipmentList Head immobilizer (commercialor improvised) Padding(i.e. towel, cloths) nakrtese"srrntftdamgilnentflrarmardMdkaD Patientsecuringstraps Roller gauzeor cravats Examinationgloves lape Pen Light Blood pressure cuff RandomSkillStation Stethoscope Moulage kit [,xarnirration gloves Gndirenes IttamgemenUeEO E1,e goggles of Ventilation mannequin (capable recording, by light or graph, 800 ml ventilation volumes) Oxygen tank, regulatorand flowmeter Oxl,gen connectingtubing Nasal Cannula ma-sk and with rcservoir Non-rebreather I)ocket ma.skwith one-way valve Oropharyngealairways(varioussizes) airwlys (varioussizes) Nasopharvngeal Airway lubricant 'lbngue blades Intubation mannequin (must be anatomicallyaccurate) 'Iiacrion splint and associated equipment Sling and swarhe Rigid splinting material (varioussizes) Ilield dressings and bandages

Exarninationgloves Full body CI)R mannequin Auromated externaldefibrillator Bag-valve-mask device Pocketmask or demanclvalve Oropharyngeal airway tank, regulatorand flowmeter Oxyger-r Oxygen connectingtubing I'ortable suction Rigid tip suction catheter Backboard or CPR board Ambulance cot Patientsecuringstraps

or EXAMINERwhich you are uncertainofthe areas functions being assessed, TO INSTRUCTIONS THE PMCTICALSKILTS you must immediately ask rhe candidateto explain his/her acTRAUMA PATIENTASSESSMENT/MANAGEMENT abiliry to integrate This station is designedto test the candidate's and parientassessment interventionskillson a victim with multisystems rrauma. Sincethis is a scenariobasedstation, it will require some dialogue berweenthe examiner and the candidate. The candidate will be required to physically accomplish all assessmenr stepslistedon the evaluationinstrumenr, However,all interventioni should be spoken insreadof physicallyaccomplished, a Because rhe limitations of moulage,you must establish diaof logue with the candidatethroughour rhis station. If a candidate or quickly inspects,assesses palpatesthe patienr in a manner in at tions. For example,if the candidatesrares the patient'sface, to you must ask what he/sheis assessing preciselydetermine iF he/shewas checking the eyes,facial injuries or skin color. Any information pertainingto sight,sound, touch, smell,or an injury moulagedbut would be immediately that can not be realistically evident in a real patient encounter,must be supplied by the exor that area of aminer as soon as the candidate exDoses assesses the patient. the presence a simulatedtrauma vicof This skill station requires rim. The victim should be briefed on his/her role in this station

t0

by as well as how to respond throughout the assessment the candidate. Additionally,the victim should havereadthoroughly the "lnstructions to the SimulatedTiauma Victim." Tiauma moulage should be used as appropriate. Moulage may range from commercially prepared moulage kits to thearrical moulage. Exuse oF moulage must not interfere wirh the cessive/dramatic abiliry to exposethe victim for assessment. candidate's with a minimum of an airway,breathing, The vicrim will present circulatory problem and one associated injury or wound. The mechanismand location of the injury may vary, as long as the that once a guidelineslisted above are followed. It is essential for scenariois established a specifictest site. it remainsthe same being testedat thar sire. This will ensureconfor all candidates of for sistency the examinationprocess all candidates.

Due to the scenario format and voiced treatments. a candidate may forgec what he/she has already done to the patienr. This may result in the candidare arrempting to do assessmenr/inrervention steps on the patienr that are physically impossible. For example, the candidate may have voiced placemenr of a cervical collar in the initial assessmenr rhen later,in the derailedphysiand cal examination, attempr to evaluarethe integriry of the cervical spine. Since this cannot be done without removing the collar, you, as an examiner,should remind the candidarerhar previous rrearmenr prevenrsassessing area. This same situarion may the occur with splintsand bandages.

Eachcandidateis requiredto completea detailedphysicalexaminarion of the parient.The candidatechoosing to transport the victim immediatelyafterthe initial assessment musr be instructed to continue the detailedphysicalexaminationenroutero rhe hosCandidatesare required to conduct a scenesize-upjust as they pital. You should be aware rhar rhe candidatemay accomplish would in a field setting.'When a.sked abour the safety the scene, portions of the detailed physicalexamination during the rapid of the examinermust indicarerhe sceneis safeto enter. IIrhe can- traLlma assessment. example,the candidatemusr inspecrrhe For didate does not assess saferyof the scenebeFore the beginning neck prior to placenrent ofa cervicalcollar. Ifthe candidatefails patient car,no points should be awarded lor the task "Derer- to assess body areaprior to coveringthe areawith a parientcare a mines the sceneis safe". device,no points should be awardedfor the rask. However,if a candidate rernovesthe device, a*ssesses area and reolacesthe rhe An item of some discussion where ro placvir:rlsignswithin a devicewithout compromising parienrcare,full points -should is be pre-hospitalparient assessment.Obtaining preciseagreemenr awirrded for the specific rask. among variousEMT textsand progran.rs virtually impossible. is Viral signshave been place in the focusedhisrory and physical. NOTE: J'he rrreferredmethod ro evaluarea candidate is to write l'his should not be construedrs the only place rhar vital signs the exact..qu.n.. the candidatefollowsdurine the srarionas ir is may be accomplished. It is merell, tl'reearliestpoint in a pre- perForrnecl.You may then use rhis documenta-"rion fill out the ro hospitalassessment they may be acconrplished. that evaluation instrumentsheetafter rhe candidare comoletes stathe tion. This documenrationmay then be usedto validatethe score Once rhe scenesize-upand initial assessmenr complered,rhe on the evaluationinstrument if questionsshould ariselater. are ex;rctlocation of: vital signs wirhin a pre-hospitalassessmenr is dependcnt upon the patient'scondition. As an examiner,you INSTRUCTIONS THE SIMUTATED TO TRAUMAUCNM should award one point for vital signsas lor-rg they are accomas plishedaccordingto the patienr's condirion. The scenario lrormar The following should be reviewedby rhe skill srarion examiner of a rnulti-trauma assessment/management re.sting srarionreqrri res w i t h r h e p e r s o n e r v i n g . s i c r i n r . s a v the examinerto providerhe candidatewith essenrial information throughout the examination process. Since this srarion usesa NOTE: In order to ensurea fair examinarionenvironmenr for simulatedpatient,the examinermust supply all information per- eachcandidate, the simulatedvicrim should be an adult of avertaining to sighr,sound,smell or touch rhat can not be adequarely age height and weight. For example,the use of very small chi[porrrayedwith the useoltmoulage.. This information should be drerris discouraged rhis srarion. in given to the candidatewhen the area of the patienr is exposedor 'When assessed. serving as a victim for the scenario roday make every artempt to be consistentwith every candidate in presenringthe The candidatemay direct an EMT assistant obrain parienr appropriate symptoms. The level of respiratorydisrress ro acredour vital signs. The examiner musr provide the candidarewith rhe by you and the degree oFpresenration pain at injury siresmus! of patients pulserare,respiratoryrareand blood pressure when asked. be consistent all candidates.As the candidare for wirh progresses -fhe examiner must give vital signs rhar are appropriarefor the rhe examinationbe awareo[anv oeriod in which he/shetouches patienrand rhe rrearmenr rhat hasbeenrendered.In other words, a simulatedinjured area. If the'scenario indicares rhat you are ro iI a candidare has accomplished correcr rreatmenr for respond with deep painful stimuli and the candidate lightly hypoperfusion, not offer viralsignsrhardeteriorare parient's touchesthe area, not respond. Only respondaccordingro rhe do rhe do condition. This may causerhe candidarero assumehe/shehas situation as you feel a real victim would in a multiple rrauma renderedinadequare inappropriarecare. Likewise,if a candi- situation. Do not give the candidate any clues while you are or datefailsto accomplish appropriaterrearmenr hypoperfusion, acting asa victim. For example,it is inappropriatero moan thar for do not offer viral signsrhar improve rhe patient's condition. This your wrist hurrs after you become aware rhar rhe candidare has may causethe candidate ro assumehe/shehas provided adequare not found that injury. Pleaseremember what areashave been care. The examinershould not offer information that overly imassessed treared because may need ro discussrhe candidare's and we provesor deteriorares patienr. Overly improving a parienr ina after he/she leavesrhe room. perFormance vitesthe candidateto disconrinuerrearmenrand may lead ro rhe candidatefailing rhe examinarion. Overly deterioratingthe pa- The skill station examinermay use information provided by rhe tient may leadro rhe candidateinitiaring C.PR. This srarionwas trained and well coachedvictim asdara in derermining rhe awardnot desisnedro resrC.P.R. ing of points for specificstepson the evaluationinsrrument.

ll

INSTRUCTIONS TO THE CANDIDATE PATIENT ASSESSMENT/MANAGEMENT TMUMA This station is designedto tesr ),our abiliq, to perForma parienr assessment a victim of multi-sysrenls of trauma and "voice" trear all conditions and injuries discovered. You must conduct your a s s e s s m e a s y o u w o u l d i n r h e f i e l d i n c l u d i n gc o n r m u n i c a r i n g nt rvith vour patient. \bu rnay removc rhe parient's clothing down ro shorrsor srvimsuirif you fe'elir is neces.san'. vou conducr As your assessment, should state everythingyor.lirre assessing. vou C l i n i c a li n f o r m a t i o r r o t o b r a i n a b l e l , v i s u a lo r p h v s i c ailn s p e c n b tion rvill be givcn to you alrter you demonstrarte ht',*,;,ou would n o r n r r r l l l ' g a i t h a t i n f o r n n r i o n . \ b u r n a ya . s s u mte l r 1 , o u a v e n h h n v o l . M - l s u , o r k i n g* ' i t l r y o u a n d r h a r r h e ya r ec o r r e c t l y a r r l , i n g c ( o u r t h c v e r b a lr r c a r n r e n ry o r . r n d i c a t e . Y o u l ' r e v c 1 0 ) r e n n i i n s i tutcs corn;rlete to this skill srarion. [)o 1,ouhaveanv quesrions?

7. neck veins flat 8. oelvissrable 9. op.n injury of rhe left lemur rvith capillarvbleeding Vital Signs 1 . I n i t i a l V i t a l S i g n s- B I P 7 2 1 6 0 , P 1 4 0 , RR 28 2. Upon recheck - if appropriarerrearm e n r : B / P 8 6 1 7 4 ,P 1 2 0 , R R 2 2 rrear3. Upon recheck of inappropriare m e n t : B / P 6 4 1 4 8 , P1 3 8 ,R R 4 4

INSTRUCTIONS TO THE PRACTICAI- SKILTS EXAMINER PATI ENT ASSESSMENT/MANAGEMENT MEDICAL

This strrtionis clesigncd resrthc candidate's to abiIity to use rppropriatecltresrioning techniquesro rrssessparienrwirh a chicf a conrplaintoFa nredicalnatureand ro vcrbalize approlrri:rre inrerSAM I'LE TRAUMA SCENARIO ventionsblsed on the assessnrenr flndinss.This is a scenario based s t i r t i o n n d r v i l l r c q u i r ee x r e n s i vd i . r l o [ u eb e n v e e n h e e x a m i n e r a c r 'l'he follorving is an exarnirlcof rrn ucceirrlblcsccnariofbr rhis a n . l t l r e c : r r r d i d e t eA . s i m u l l r e d n e d i c a r ) r r i e n r u i l l a n s w e rr h e . r l r s s t n t i o n .I t i s n o t i n r c n c l e do b c r h eo n l r , p o s s i b ls c c n n l i o b r r h i s ( l u e s t i o nr s k e db v t h e c l n t l i . l r r eb r r e t lo n r h . ' : c e n a r i o e i n gu t i e t f b -l'hc s t a t i o n . V a r i a r i o n .o f r h e s c c n a r i or r r ep o s s i b l e r n d s h o u l c lb e lizcd. . r c:rndidare rvill be reqtrirecl pl.rysically ro accomplishall uscclto rccluccthe possibilitvof firture c:rntlitl:rre's knorving the llssessnre stcpslisrcclon rhe skill shecr. However,all inrervennt s c c r t e r i o c f i r r ec n t e l i n g t h e s t a t i o n . I f t h e s c e n l r i oi s c h a n g c d , t i o n s s h o u l db c s p o k e ni n s r c a d f p h y s i c a l l v c c o n r p l i s h e d . o u b o a Y t h c f b l l o r v i n g u i d c l i n c s r L r sb c L r s e t l . g n t n r u s tc s t u b l i s la d i a l o g u e i t h r h c c i r n d i d a r r h r o u g h o u r h i s s r a r w e t t i o n . A r r v i n t o r n u r t i o n r c r r a i n i nrg s i g h t ,s o u n d ,r o u c h ,o r s r n e l l p o I . A c l e e r l y c f l n e dr n e c h a n i s ro r i r rj u r y n r u s tb c i n c l u d e d . that cennot bc sccn but w,ould bc evidcr-rr d rf irnnrediarely a rell in -l-hc nrccharrisnr inirrlt rnurr in.li..rrc rhc nccclfor the prrtientcr)cor.lntcr, oi nrusr be supplied by the cxanriner. candiclarc perfornr a r:rpid tr:rrrrnrassessn)ent. ro 'l-hcre -fhc 2. n r u s rb c e m i n i n r r i n )o f r r n a i r r v l r , b r e e r h i n g n d , a scenarioshoulclprovide enolrgh ir-rformation enablerhe to circulatorr,problcrn. clndirl:rrctr>f,rrrnrrgeneralinrpres.sion rhe paricnrls of condition. 3 . ' l h e r em r r s tb c r r na d d i t i o n . r.lr s s o c i r r rs olf i r i s s u c r r n u s - Additionrrllr,, prrrienrin thc sceneriomusr b awakeand able ct o rhc 'l.he cr-rloskelctaljury. in to t:rlk. metlic:rlconc'lition the patient u,ill vary dependof 4. Viral signsrirustbe given firr rhe iniriel cfrcckanclone re- ing upon tlie scenrrrio uriliz.ecl the st:rtion. lt is essential in rhat chcck. once a sccnariois est:rblished l specifictesrsite,ir remainsthe For f s r r r n eo r a l l c r r n d i r l l r eL r e i n s e s r e d . l r h a r \ i r c . T h i s w i l l e n s u r e s r c o n s i s tn c v o i t h c c x u n r i n . l ( i o l[ r r o i e s f o r e l l c : r n d i d a t e s . e \ ) his skill stirtion rcquiresrhe presence a simulared medical of paticnt. \'ou, or rhe sirnularedrledical parienr,should nor alrer t h e l r a t i c n ti n f o r n r a r i o n r o v i d e di n r h c s c e n a r i o n d s h o u l dp r o p a Mechanism of Injury \bu arc cellcd ro rhc.sccnc a nrotor ve- r'ideonly tlre iniornrrrion rhrrtis specificallv askedfbr b1,rhecanof hiclc crrsh rvherevou find a victinr rvho did:rte. Infbrrnation perrainingco vital signsshould nor be pro, was rhrown from rhe car. \'orr flnd severe vided until the candidrreactuallyperformsthe srepsnecessary ro -l'he grin such infornretion. ln order to verily rhat rhe simulatedpadln.rlge ro the fiont end of rhe car. t i e n t i s f a n r i l i a r* . i t h h i s / h e r r o l e d u r i n g r h e e x r m i n a t i o n ,y o u vicrirn is fbund lying in a field 30 f'eer fiom should ensure he/she readsrhe "lnsrructior)sro rhe Simulared r h e u p r i g h rc a r . Medical Parient"provided ar the end of rhis essal'.You should 'l'he Injuries nr rvirh the follow- alsorole play rhe sclected scenario parie u,ill presenr with him/her grriorto rhe firsr ing in juries. All injuriesw,illbe moulagecl. candidateenreringthe skill srarion. Each exrrniner should progrirnr the pa'fhe scenesize-upshould be lccomplished once rhe candidare rienr ro resl>ond appropriatell'rhroughout the assessntent assure and rhe yicrim entersthe testing starion. Brief quesrionssuch as "ls rhe scene h a s r e a d r h e " l n s r r u c t i o n s o S i m u l a r e d safe?"should be asked bv the candidate. V4ren rhe candidare t 'Irauma Victim" that havebee provided. attempts to derermine rhe narure of the illness,you should ren spond based the scenario on being utilized,i.e.: Respirarory, Cardiac, Altered Mental Status,Poisoning/Overdose, L unresponsive EnvironmenL l e f t s i d ef l a i l c h c s r tal E,mergency, or Obsrerrics, Behavioral. breath sounds,left side 3. decreased For the purposeo[this sration,rhereshould be only one parienr, 4 . c o o l ,c l a m m v s k i n ; n o d i s t a lp u l s e s no addirional help is available and cervicalspine stabilizarion is 5. distendedabdomen not indicated. The candidatemust verbalize 6. pupils equal the generalimpression of the parient after hearing rhe scenario. The remainderof VTRAUMASITUATION#I I'A'I'I ENT ASSESSM [,N'I'/MANAGF,M T.-NT 'l

I2

and rhe fothe possiblepoinrs relativeto the initial assessment examinarionarelisredin the individual cusedhistoryand physical scenarios. The ooint for "lntervenrions" should be awarded based on the candidatesabiliry to verbalizeappropriate trearmenr for the medidescribed the scenario. For example;if the pain cal emergency tient is complaining of breathing difficulry the point for intervenrionsshould be awardedif the candidateverbalizes administ r a r i o no f o x v g e n r o t h e p a t i e n t . rhe Vhen assessing signsand symproms of the patient, the candidate musr gather the appropriate information by asking the 'fhe number of questionsrequestionslisted on the skill sheet. ouired ro be asked differs basedon the scenarioand the chief complair.rt. The poinr fbr "signs and Symptoms (Assess history of presentillness)" is awardedbasedon the followirrgcriteria: Respiratorv asked, arvard one iroint. 5 or more questiorls 4 or lessquesrions asked,arvardno point. lward one point. 5 or nrorequestions;rsked, asked,arvardno point. 4 or lessquesrions

NOTE: In order to ensurea fair examinationenvironment for height eachcandidate, the simulatedvictim should be of average and weight for the scenario being used. For example,the useoI very small children is discouraged this starion unlessrhe scein nario specifically indicares pediarricpatient. a The examination today will require you ro role play a patient ex;reriencingan acute medical mergency. You should act as an actual patient would in the real situ:rtion. You must answerthe candidare's questionsusing only the inFormation contained in rhe scenario providedro you by the examinerfor this srarion. Do nor overact or add signsor symptomsro rhe scenario provided. It and the is inrportant thlt you be very familiar with the scenirrio 'When required parient responses. serving as a patient for the scenariotoclaymake everl' attempt to be consistentwirh every candidarein presenting the appropriatesymptoms. The levelof responsiveness, distress, etc.,actedout by you anxiery respiratory nrust be consistent all candidates.Do not givc the cantlitlare {:or a n v c l u c sr v h i l e y o u l r e a c t i r t ga s l v i c t i m . F o r e x a m p l e ,i t i s you becorne "l inrppropriateto sar, rrn allergic ro penicillin" afic-r awlre that the candidatehas not remenrbered rsk that quesro rion during the SAMI'[.E history. I'leaseremembcr wlrrr qucsbetions you have answeredand what areashlve been ass.'ssed efter causewe rnay need ro discussthe candidare's perform,rnce he/sheleaves the room. The skill station examinerma\r use information provided by thc trrined and well coachcdvictint :rsdata in determining the awarcling of points Forspccificstepsin rhe evaluationinstrumenr. INSTRUCTIONS TO THE CANDIDATE PATIENT ASSESSMENT/MANAG EMENT MEDICAI'fhis

Crrdiac

Alteretl Mental Sratus

6 or more questions askecl, aw:rrd one point. point. 5 or lessquestionsasked,award r-ro 4 or more questions asked, awardone point. arvardno point. 3 or lessquestions:rsked,

Allergic Reaction

l'oisoning/Overdose 5 or more quesrions l.sked, awardone point. 4 or lessqrrestions asked,award no point. Environmental Emergencv

station is designedto test your abiliry to perform a parient assessment a patienr wirh a chieFcomplaint of a rnedicalnaof ture and "voice" treat all c<lnditions discovered.You must conduct your assessment you would in the field including comas with your parienr.You may removethe patient's clothObstetrics asked, awardone point. mr-rnicating 5 or more <luestions As ing down to shortsor swinrsuitif you feel it is necessary. you 4 or lessquestionsasked,award no point. conducr your assessment, you should state everwhing you are Behavioral 4 or more questions asked, awardone point. assessing. Clinical informarion not obtainableby visualor physical inspectionwill be given to you after you demonstratehow 3 or lessquestionsasked,award no point. that you would normally gain rhat information. You may assume Each candidateis requiredto completea full patient assessment. you haverwo EMTi working with you and that they arecorrectly The candidatechoosingto rransporrthe victim immediarelyaf- carrying out the verbal rrearments you indicate. You have (10) ter the initial assessment must be instructedto continue the Fo- minures to complete rhis skill station. Do you have any quescusedhisrory and physicalexaminationand ongoing assessment t i o n s ? enroureto the hospital. 4 or more quesrions asked, awardone point. 3 or lessquestionsasked,lrvard no point. NOTE: The oreferred method to evaluarea candidate is to write the the exactsequence candidare followsduring the srationasit is performed. You may then userhis documentarionto fill out rhe evaluationinsrrument after the candidatecompleres rhe station. This documentarion may rhen be used to validatethe scoreon the evaluationinstrument if quesrionsshould ariselater. INSTRUCTIONS TO THE SIMUIATED MEDICAL

PATIENT

The following should be reviewedby the skill station examiner with the personservingas patient.

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SAMPLE MEDICAL SCENARIOS

RESPIRATORY You arriveat a home and find an elderly male patient who is receivingoxygen through a nasalcannula. The patienr is 65 yearsold and appears overweight. He is sitting in a chair in a "tripod" position. You seerapid respirations and rhere is ryanosisaround the lips, fingersand capillarybeds. INITIAL ASSESSMENT Chief " l ' m h a v i n ga h a r d t i m e b r e a r h i n g n d I n e e d Complaint: a to go to the hospital." Apperent LifeThrertr: Respirrroryconlpromi\e.

CARDIAC where 57 year man is complainYouarrive thescene on a old ing of chesr pain. He is paleand sweary. INITIAL ASSESSMENT Chief "My chesr Complainr: really hurts. have I angina this bur thananyI have ever before." felt painisworse Apparent Life Threats: Levelof

Responsiveness: Arvakeand alerr. Ainvav: Breathing: (lircuIrtion: -liansport l)ecision: Lnmediare. Patent. 24 and shallow. N o b l e e d i n g p u l s e1 2 4 a n d w e a k ,s k i n c o o l , and clammy.

Cardiac conrpromise.

Level o[ Responsiveness: Patientis only ableto speak shortsenrences in interrupted b1'coughing. Airw,ay: Brerthing: (lircrrlation: I)atent. 28 and tleep,rhrough pursedlips. No bleeding, Tl'rere pulserare120 rnd srrong. i s c y r n o s i s r o u n d t h e l i p s ,f i n g e r s n d c a p i l r a larybcds.

lransport Decisior-r:

FOCUSED HISTORY AN D PHYSICAI, EXAMINATION ()nset: "The pain woke rne u1> lrronrnry afrernoon naP. l)rovokes: "lt hurts reallv brd anclr.rothing do makes I the pain go away." "lt srartedour like indigesrionbur ha.s gotten a lot worse. It feelslike .r big weight is pressing againstrny chest. Ir makesit hard to bre:rth." "lvlv shoulclcrs j:rwsstarted and hurting about tetr nrinutes before you got here, but the worst pain is in the middle oF my chest. -l'hut's w h y I c a l l e dy o u . " Severitv': 'J'irne: "-fhis is the worsr pain I have ever felt. I c a n ' ts t a n di t . " " l ' t , eh a d r h i s p a i n f o r a b o u ra n h o u r , b u t i t seenrs like days."

In-rmediate trrlrsport.

FOCUSE,D HIST'ORY AN D PI IYSICAL FXAM INATION "l've had c-rnpl-r1'sema the pl.sr terl Onsct: tor )'ears, but rny breathinghasbeengertingworsethe past corrpleof days." I)rovokes: "\Whcnever go rrp or dou,n steps,ir gersre, I .rlli bad." Qualiw: "l dont have any pain, l'm just rvorried beir cau.se is so hard ro brearh. I can'r seenrro catch my breath." " l d o n t h a v e: t n y p a i n . " " l c i r n ' t r o p c o r r g h i n gI. t h i n k I ' m d v i n g . " s "l woke up abour three hours ago. I haven'r b c e na b l et o b r e a t hr i g h t s i n c et h e n . "

Quelirr':

llrrdi:ite:

Radilte: Severity: -I'ime:

Interventions: "l turned up rhe flow ofmv oxvgenabout an hour ago." Allergies: Medications; Pasrlr{edical History: La.st lvleel: I'enicillin and bee stings. C)xvgenand a handheld inhaler.

Inrerventions: "l rook my nirroglycerinabour l5 minure.s ago but it didnt make any difference.Nitro alwaysworked before. Am l having a heart anack?" Allergies: Medications: None. Nitroglycerin.

Jieated for emphysema rhe past l0 years. for "l ate breakFa.st nrorning." rhi.s

l'ast Medical Hisrory: Last Meal:

Diagnosedwith anginarwo yearsago. "l had soupand a sandwich about threehours ago."

EvenrsLeading "l gor worse a couple o[davs ago.1-heday to lllness: it gor reallycold and rained all day. Todav, I've just felt bad since I got our of bed." Focused phvsical examinarion: Auscultarebrearh.sound.s. Vitals: RR28, P 120, BP 140/88.

l4

Evenrs Leading "l w'as sleepingwhen painwokemeup." jus to lllness: fie Focused physical vital examination: Assesses baseline signs. Vitals: R 2 4 , P 1 2 4 , 8 1 '1 4 4 1 9 2 .

SAMPLE MEDICAI SCENARIOS

AIIERED MENTAL STATUS AILERGIC REACTION

'Xtren you arrive on the scene you are mer by a 37 year old male who sayshis wife is a diabetic and isnt acting normal. INITIAL ASSESSMENT Chief "My wife just isn't acring right. I cani get Complainr: her to stay :rwake. She onlv opens her eyes then goesright back to sleep." Apparent Life Threats:

You arriveto find a 37 yearold male who reportseatingcookieshe purchased a bakesale. He hasaudiblewheezing, and at is scratchingred, blotchy areason his abdomen, chest and

central nervoussystem,respir.rrory Depressed conrpronrise.

INITIAL ASSESSMENT Chief "l'm havinganallergic Complaint: reactiorr thosecookro ies I ate." Apparent LifeThreirts:

Level of Responsiveness: Opens evesin response being sl'raken. to Airway: Brearhing: Circulation: -lransport L)ecision: Patenr. l4 and shrllow. 120and weak.

Respiratoryandcirculatorl'comprornise.

Levelof Rcsponsiveness: Au'eke,verv anxiousand restless. Air*,ay: Breathing: (--ircularion: Patent. 26, rvheezing and deep. No bleeding,pulse 120 and w.'ak, cold and cllmmy skin.

Irnmcdiarc. Transport L)ccision:

FOCUSED HISTORY AN D PHYSICAI- EXAMINATION f)cscription "My rvife took her insulin this nrorning like o[ Episode: any other n'rorningbut she l-ra.s hld rhe flu a n d h a sb e e nv o n r i t i n g . " Onset: "lt happenedso quicklv. She was just ralking to me aud then shejust went to sleep. I haventreallybeenableto wakeher up since." "She'beenthis way for about I 5 minutes now,. I calledyou right away. I was reallyscared." Associated

I n r m c c l i a tt r r r ) s p o r t . e

FOCUSED I IISTORY AN D PHYSICAL [,XAM INATION H i s t o r yo f "Ycs.I'n'rallcrgicto pealruts.' allergies: \{/hen ingested: "l ate cookiesabour 20 mirrutesago and began itching all over abotrtfir'enrinuteslarer." Hou,nrtrch ingestec.l: L,lfects: "l only .ltc rwo cookies" "l'm having trouble breathing and I Feel lightheaded antl dizzy." "My wheezingis worse. Now I'nr sweating reallybad."

Duration:

svmPloms: JH;',I,iln:'ili::liiili;hft:'"

Evidence of trauma: "Sheclidnt FJl. Shew:rsju^st siningon rhecouch and lell asleep.I havent trieclro move her." Inrerventions: "l haven'tdone anything bur crll you gu)'s. I k n o w s h er o o k h e r i n s u l i n t h i s m o r n i n g . " Se izures: Fever: None. Low grade fever. Pe nicillin. Insulin.

Progression:

I ntervenrions: "l havemy epi-pen upstairs but I'm afiaid to stick myselL" Allergies: Medicarions: PasrMedical I I isrory: l'eanuts nd penicillin. a None. "l had ro spend rwo days in the hospital the lasrtime this happened." "J'he last thing I ate were rhosecookies."

Ailergies: Medications: PastMedical History: L:st N4ea[:

Last Meal:

Insulindependent diaberic since21 ye.rnof age. "My wile are breakfast rhis morning."

EventsLeading "None, exceprI ate thosecookies." to Illness:

Focused physical (award examination: Nor indicated point). Vitals: R R 2 6 , P 1 2 0 ,B P 9 0 / 6 0 .

Events Leading "My wife has had rhe flu and beenvomiting to lllness: for the pasr 24 hours." Focusedphysical examination: C-ompleresrapidassessment ruleout trauma. a to Vitals: RR 14, P 120,BP 110172.

r5

SAMPLE MEDICAL SCENARIOS

POISONING/OVERDOSE You arriveon the scene where a 3 year old girl is sitting on her mother's lap. The child appearsvery sleepyand doesn'rlook ar you as you aPProacn. INITIAL ASSESSMENT Chief "l rhink my baby hasswallowed Complaint: someof my sleepingpills. Please dont let her diel" Apparent Life Threats: Depressedcenrral nervous sysremand respirlrory compromise.

EI.I\4RO NM ENTAL EM ERGENCIES You arriveon rhe scene rescuers pullinga l6 yearold as are fenrale from an icecovered creek.The teen"ger beenmoved has out of.the creekonto dry land, is completely soaked and apqrowsy. Pears INITTAL ASSESSMENT Chief "l sawsomething thewarer Complaint: in below ice. che Vtren I rried ro get it our, the icebroke." Appare nt LifeThrears: Generalized hyporhermia.

Level of Responsiveness: Respond.s slowly to verbal commands. Airway: Breathing: Circulation: liansporr L)ecision: I'atent. l8 and deep. .l20 and srrong.

Levelof Re.sponsiveness: Respon-sive, slowto speak. but Airway: Breathing: Circularion:

'liansport Decision: lmmediare rransporr.

l)arenr. 26 andshallow. No bleeding; pulse l0 andstrong; , wet I pale skinstillcovered wer clorhing. in

Immediate.

FOCUSED HISTORY AND PHYSICAL EXAMINATION "My baby rook my .sleeping Subsrance: pill-s. I don't know what kind rhey are. They jusr help me sleepar night." V/hen ingesred: "l think she must have got them abour an hour agowhen I was in the shovver. Her older sisterwas supposedro be watching her." How much ingested: "My prescriptionwas almost empty. There couldnt have been more rhan four or five pills left. Now rhey'reall gone. l)leasedo something." "She jusr isn't aoing like herself. She'.s usua l l y r u n n i n g a r o u n d a n d g e r t i r r gn r o e v e r y i thing."

FOCUSED HISTORY AN D PHYSICAL FXAMINATION

Source: "l fell in the creek when the ice broke. I rried ro ger out bur rhe currenr wasro strong. Thank Cod you came." "The waterwasup ro my neck. I could stand up, but I couldn'rger our of rhe warer." "l think I was in the water for ten minures before rhey pulled me our. lr felr like an hou r."

Environmenr:

Duration:

Loss of consciousne.ss: "l feel sick, bur I never passedout." Effects: Lowered body remperature,slow speechpatterns, "l can'r srop shivering." None. None.

Effects:

Progressions: "Shejust seems get sleepier sleepier ro and b y t h em i n u t e . " Interventions: "l didnt know whar to do, so I just called you. Can'tyou do somerhing her." for Allergies: None.

Allergies: Medications: PastMedical Hisrory: Last Meal:

None. "l ate lunch at schoolthree hours ago."

Medications: None. Past Medical History: LastMeal: None. "Shearebreakfasr morning." this

Events Leading "l thoughr rhe ice would hold me." to lllness: Focusedphysical examination: Completes a rapid assessmenr rule our to trauma. Vitals: RR 26, P I l0 and srrong, BP 120/80.

Events Leading "She to Illness: swallowed pills." rhe .just Focused physical examinarion: Completesrapidrrauma a assessmenr ro rule

out trauma.

Virals:

RR 18,P t20,BP90t64.

16

SAMPLE MEDICAL SCENARIOS

OBSTETRICS

You arriveon the scene where a 26 yearold femaleis layingon saying,"The baby is coming and rhe pain is killing *:,:"t.n INITTAL ASSESSMENT Chief "l'm nine months pregnanrand the baby is Complaint: c o m i n gs o o n . " Apparent Life Threars:

BEHAVIORAL You arrive on rhe scenewhere you Ftnda 45 year old male in the custodyof the police. He is unableto stand and smellsoI beer. He appearsto be dirry and 1'ou norice nunrerousnps and rearsin his clothes. INITIAL ASSESSMENT Chiel: "Nothing is wrong with me excepr Complainr: these cops won't leaveme alone. I only drank rwo " beers. Apparent Life Threars:

None.

Level of Responsiveness: Awake and alert. Airway: Breathing: Circularion: Transporr Decision: Parent. Panting,rapidbrearhingduringcontracrions. N o b l e e d i n g , u l s e 1 2 0 ,s k i n i s p a l e . p Unknowrr.

None.

Level of Responsiveness: Responds slowly bal questions. Airway: Brearhing: Circulation: I)eten t. l6 rrndeffortless. Notleeding, pulse

slurredspeechto ver,

warm skin rnd red

FOCUSED HISTORY AN D PHYSICAL EXAMINATION Are you See chief complainr (award point if menPregnant: tioned in generalimpression). How long Pregnant: Pain or contrlcrions: S e ec h i e f c o m p l a i n t ( a w a r dp o i n t i f m e n rioned in gener;rl impression). "My pain is every2-3 minutes and it lasts23 minutes." None.

Delayed.

FOCUSEDHISTORY AN D PHYSICAL EXAM INATION Hou,do "l'm a little sick, otherwise,I just war)rro go you f-eel:

" to sleep.

Suicidal tendencies: Threarro

otners:

"No, I

goingto kill myself."

Bleedingor discharge :

man, I ain't never hurr anyone in my

Do you feel the "Yes,every rime the pain begins." needto push: Crowning: (awardpoinr if idenrifiedin focused Presenr physicalexam). None. None. "This is my rhird baby." "l are breakfasttoday."

Is there a medical "My wif-e problem: says I'm an alcoholic, bur what does she know?" Interventions: "Yeah,I rook rhree aspirinsbecause know I I'm going to have one heck ofa headache in the morning." Allergies: lvledications: I)astMedical Hisrory: None. None. "l've been in the hospital four times with thoseD'Is." "Man, ] haven't eaten since yesrerday."

Allergies: Medications: PastMedical History: Last Meal:

EventsLeading "The conrracrionsstarted a few hours ago to lllness: and havenor stopped." Focusedphysical examination: fusessfor crowning, bleedingand discharge. Vitals: R R 4 0 d u r i n g c o n r r a c r i o n s , 1 2 0 ,B P 1 4 0 / P

Last Meal:

EvenrsLeading "l don'rcare to Illness: whar these copssay, didnt fall I

80.

lo*n.,, nome .

I wasjust takinga nap beforegoing

Focused physical examinarion: Complerea rapid assessmenr rule our ro trauma. Vitals: R R 1 6 ,P 1 0 0 ,B P 9 0 / 6 0 .

t7

INSTRUCTIONS TO THE PRACTICAL SKILTS EXAMINER CARDIAC ARREST MANAGEMENT/AED -fhis abiliry to effecstation is designedto test the candidate's tively managea pre-hospitalcardiac arrestby integrating CI)R skills,defibrillation,airway adjuncts,and patientiscene management skills. This includesthe integration of peopleand equipmenr commonly associated with an ambulancerespondingro a cardiacarrestscenein a basic life support scenario. The candidate will arriveat the sceneand encountera cardiacarresrsiruarion rvith CPR being perfornredby a firsr respronder. The candi, datc will be requiredro imnrediately apply an auromrted external defibrillatorend deliverappropriateshocks.

INTEGRATION: In this segmenr the candidatemusr inregrare the useofan oropharyngeal airwayand a ventilationadjunct into the CPR scenario that i.s alreadyin progress. voices The candidare that he/shewould mea-sure insert the oropharvngeal and airway. He/she tlren musr vent;lateor direcr the ventilarion of the pat i e n t u s i n ga d j u n c t i v e q u i p m e n t . I n r e r r u p r i o n I C P R s h o u l d e o not exceed seconds measuring fbr and placingthe airway.The 30 cendidatemay chooseto usea pocket mask, flow restricted oxygen pou'e ventilariondeviceor a bag-valve red maskdevicero vent i l a r et h e p a r i e n r .

Yorr should not indicate disolea.strre with the candidatels choice o f v e n t i l a t o r y d . j u n cs i n c er h i s s r . r r i o ns t e s r i n g h e c a n d i d a t e ' s a t i t abiliry. inregrate to adjuncrive equipn-renr r cardiac ir.rro arresr scene 'l-he current Anrerican Red Cross and American Heart Associa- a n d n o t l o c a lp r o t o c o l s r v l r i . r t i o n s n e q u i p n r e n r . e g a r d l e s s o i R of t i o n C I ) R c o u r s e sn s r r u c ts r u d c n t si n r h e t e c h n i q u c s f C I ) R , t h e d e v i c e h o s e n , t i s e s s e n r i a h a t r h e c a n d i d a r e o n n e c ti r r o i o c i tl c however, they do nor instrucrthe srudcnt in the userrnci inregrl- s u p p l e m e n t rh i g h p e r c e t l g e o x v g e n .A l t e r e s t l b l i s h i n g e n t i l a l v n t i o n o I a d j u n c t i v e r l u i p m e n t i,n c l u c l i n g E I ) , o r h o r vt o p r e p l r e t i o n u s i n g t h e a d j u n c t i v ee q u i p n r e n t , h e c a n d i d a t e n u s r p e r e A t r t h e p a t i e n tf b r t r a n s p o r t a t i o n s h e / s h e i l l b e r e q L r i r etc l d o i n e w o forrn two rcscue CPR with the aid of the l.MT rssisrant one r for a n a c t u a lf i e l d s i t u a t i o n . S i n c et h i s s t a r i o nr e s t s h c c a n d i c l a r e ' s rninute. The cirndidrterhen nrust re-evaluarc patienr,dere r rhc r:rbiliry to integrlte CPR skills irrto cardiac:lrresrsccnemlrniige- tnine the rrbsetrce a pulse:rrrdrepertthe defi[.rill.rr'on of scgucncc. m e n t , i t i s r e q u i r e d h a t b e l o r cen t e r i n gt h i s s r ; r r i o nl r ec a n c l i . l a t e You shoLrld r r infbrnr the clndidate that there is "rro rrulse" on anv presntdocumentationof srrccessfirl conrpletion (cardor certifi- p u l s ec h c c k . -I-he cate)of a currel)t CI)ll course. courscmusr nlccr, or exceed, rhe crirerie .\erforrh irr the Arnerican Herirr A.ssociarionls Basic T R A N S P O R ' I A I I O N : I n t h i ss c g r r e n r h c c a n d i d a r e r e q u i r e d is Life Support Coursc "BasicLife Supporr fbr Health Care I)rovid- to verbaliz-e nroving rhe pnticnt orrto a long spinc board or onto a ers"or the Arnerican Red (lross equivalent C P R b o r r d / s p i n e o a r dl n d a n a m b u h n c ec o r . b 'l'he The skill sheet is divided into for.rrclistinctsegnrnrs:Assesssupplies/eqr.ripment needecl this station include an auroFor -lrarrsportution. r n e n t , ' lr i r n s i t i o n l,n t c g r a t i o n a n d , mated externrrl deflbrilhror, a bag-valve-rnask, pocket mask or a a denrendvalvc,strpplenrcrrtal oxvgenset up, oxygenc()nnection ASSESSMF.NT: Jn this sesrnent rhe c:rndidarernusr denron- tubing, portable suction equipnrer.rt, Thc supplementaloxygen strateeflectivehistory garheiing skillr l.v oht.rining infbrmrtion :rnd portablesucrionc<lrripment nrey be nrock set-ups.Thc canabour the eventsle:rdingup ro, and during, the crrdiac rrrrest. didate rnustbe infbnned of the nrock ser-ups and whar rhey indiW h e n g a t h e r i n gh e h i s t o r yt h e c a n d i d a t e u s t a s k , . r m i n i n r u m , clte beforest;lrting the proceclures.Note: The candidatcmay t m r rhe Followi clue.stiorrs: ng c h o o s e o b r i n g h i s / h e ro s , r re t l r r i P n r e n r u s c i n r h i s s t a t i o n . r ro . . Horv long has the victinr been in arrest? llow long has CI)R bccn in progrcs.s? (rhe This skill station requircsthe prescnce an L,MT assistant of exanrirrer nra),lct as the l'.MT as.sisrrnr), fir.sr re'sponder, a e and deflbrillationmannequin. Candidatesare to be restedindividually with the EM-f assistlntand rhe first responder acring as ass i s t l n t s h o p r o v i d e o i n p u t i n r h ea p p l i c a t i o n f s k i l l s r e q u i p w n o o 'l'he ment. EMT assistant and firsr resoonder should be rold not to speakbut to follow the conrnrrndsof the c,rndidare. Errorsof onrissionor cornmissionbv the flrst resoonderor a*ssisrant can not resultin farilure the candidat. unl.i, they were improperly of instrucrecl rhe candidate. by

Due to the extra individuals involved in rhis skill station, ir is es.\enrial you ob.serve rctions of rhe candidirre all times. that ar the Do not be distracred the actionsof the flrst respondcror rhe by EMT assisrant because rhey should do only as instructedby the candidate. As vou observerhe candidarevenrilatingrhe parienr, rememberthar the abiliry to venrilarerhe patienr niith .i.qurt. TRANSITION: In rhis segmenrrhe candidaremusr direct the volumesof air is nor being evaluated. Adequateventilation of a Elr4T assistant and the firsr responderto iniriate rwo (2) rescuer mannequin is evaluatedin the "Bag Valve Mask Apneic Patienr CPR. Also during rhis segmenr, rhe candidatemusr preparerhe with Pulse". You are evaluatingscene/situation control, integraainval'and venrilationadjuncrsto be usedin rhe inregrationseg- t i o n s k i l l s , n d d e c i s i o n a k i n g a b i l i r y . a m menr. The candidateshould arremprro garheradditional information from bysranders abour the evenrsleading ro rhe cardiac arrest. When askedquesrions abour the event,you should indicate that bysranders did not seethe victim collapse and are unawareof an,,, associared medical problems.

Although gathering r historv on the cardiac arresrevenr is rn assssmen( item, ir should not be construedrhar ir overrides the needfor resuscitation. The current srandards Cl)R should be for a d h e r e d o a t a l l t i m e sd u r i n g t h i s s t a r i o n T h e c a n d i d a t e u s r t m assess rhe presence for ofa spont:rneous pulse and be inlornred, by you, rhat there is no sponraneous pulse. The candidatemust direct the resumprionof Cl'R bv the assisrant EMI- or rhe first responder while he/sheprepares defibrillaror[or use. rhe The candidate must, within one minute of arrival ar rhe patient'.s side, rpplv rhe automatedexternaldefibrillarorto rhe -rnn.qr-rjn and initiate the first shock.The candidareshould deliver the entire threeshocksequence. You should inFormthe candidare rhar there is "no pulse" on .ny pulsecheck.

l8

TO INSTRUCTIONS THE CANDIDATE CARDIACARREST MANAGEMENT

This srationis designedto tscyour abiliry to managea pre-hospital cardiacarresrby integratingCPR skills,defibrillation,airway adjunctsand patient/scene management skil[s.The re will be an EMT assistant this station. The EMT assistant only do in rvill as you instruct him/her. A.syou arriveon the scene you will enbe countera parientin cardiac arrest.A first responderwill present performing singlerescuer CPR. You musr immediatelyesrablish conrrol oF the sceneand begin resuscitarion the patient wirh of :rn auromatedexrernaldefibrillator. At the appropriatetime, the ainvay must be controlled and you nrust ventilareor parienr's direct the ventilationof the patient using adjunctiveequipment. You may useany of rhe supplies available this room, You have in (15) fifteen minutes to complete this skill station. L)o you have any questions? INSTRUCTIONS TO THE PRACTICAL SK]LTS EXAMI N ER AI R\TAY, OXYC EN. VEN TI TAI'I ON SKI LLS BAG.VAL\TF,.MASK-APN EIC \fI'I H PULSE

secondrof ventilation,you should advisehim that rhe parienris being ventilatedproperlyand he should integratehigh florv oxvgen at this point in the procedure. You should observe the candidatevenrilatingthe mannequin lor a p e r i o d o F 3 0 s e c o n d s .D u r i n g r h i s t i m e y o u s h o u l d p a v c l o s e arrenrionro volumes.The volumesshould be in the rangeoF800 ml - 1200 ml per breath. lf you observeone or lessventilation e r r o r i n 3 0 s e c o n d s o u s h o u l d a w a r do n e ( l ) p o i n t . N o p o i n t y should be awardediFyou observerwo or more ventilation errors in ,10 seconds. After successfully dernonstratingsingle rescuer you useof a bag-valve-mask will inform the candidatthar a sec'l'he ond rescuer present. is secondrescuer will be instructedto ventilatethe patient while the candidateconrrols the mask and the eirwal'. You may serveas the second rescuer. INSTRUCTIONS TO THE CANDIDAI'E AIRWAY, SKILLS OXYGEN, VENTILATION BAG.VAL\TE-MASK-APN EIC W'II'H PULSE 'l'his

s t a t i o ni s d e s i g n c d o t e s ty o u r a b i l i t y t o v e n t i l a t e p l t i c n r t a usinga bag-valve-mask. you entcr the stationyou will find an As 'fhis station is designetlto test the candidate's abiliry ro effec- ;rirncicparient rvith a palpablecc'ntralpulse. There are no bytively initiatc and continue venrilarionof ar.r apr.reic and anificial ventilarionhasnot beeninitiated. The only parienru\ing standers a bag-valve-n-rask is and ventilirdevice. Tfrc station was developed sinrulate patient nr:rn;rgernent ro re'quired airrvaymanagelnent a realisticsituation that an [,Nl'l- nrisht lace in the field. l-he t o r y s u p p o r t .Y o u m u s t i n i t i a l l yv e n r i l a r eh e p a t i e n rf o r a m i n i t c a n d i d a t e i l l e n t e rt h e s t a r i t r nr n df l n d r n e p n e i cp a t i e n tw i r h a nrunr of -]0 seconds.You will be evaiu:rred thc approprietew . on centralpulse.l'here are no bvstanders palpable and artificialven- nessof ventilatorvolumes. I will rhen inform vou rhat a second rilation has not becn initi:rted. The candid;rre nrusrimmediarely resclie'r arril'ed and will instrucr yorr th.rt vou -ur, control has open the patienr'.s airway and initiere venrilation using a bag- the rirwly and the mask sealwhile rhe secondrescuerprovides valve-nrask.After esteblishing 1>atent a airwly and venrilaring v c n t i l . r t i o n .Y o u m a y u s e o n l y t h e e q u i p m e n ra v a i l a b l en t h i s i the parient For30 seconds longer,the candidatemusr inregrilre room. You have five (5) minutes to complete this station. I)o or supplemental high flow oxygeninto the procedure. lf the candi- vou haveany questions? date chooses set up high flow oxygen prior ro establishing to a INSTRUCTIONS TO THE PRACTICAL SKILTS patent airway and ventilation, he/shehas f'ailedro immedirrtely - SEAIED PANENT ventilatean apneicparienr. EXAMINI,R SPINAL IMMOBIUZAIION \Whenventilating,the candidate must providea minimum of 800 ml volume per breath. This equalsthe current standards establishedfor appropriaterescue brearhingvolumesduring ba.sic and advanced lifc support. This station requires mannequin that is capable being ventia of lared with volumes o[ 800 ml or more. Ir must also have rhe successful capabiliryo[ registering lung inflations of 800 nrl to 1200 ml per breath. fhis may be accomplished using a sysby tem rhat lights up when successful volumesare reached a sysor tem thar graphssuccessful volumes. The mannequin must be life size,possess anatomicallycorrectairwaystructures, and meet rhe criterialistedabove.The mannequin may be an inrubarionhead, however,it should be life sizeand have anaromically correctairway structures. Additionally this stationrequires bag-valve-mask a deviceand oxygenconnectingtubing. The supplemenral oxygen systemshould be functional, however for restingpurposes,rhe rank may be empry aslong as rhe equipment and suppliesnecessary for it to function are presnr. fu the candidateentersthe station thev are reouiredto immediarely open rhe patient'sairway and ventilatethe patient using a bag-valve-mask device. If the candidarebeginsvenrilarionusing a mou(h-to-mouth technique,you should advisethe candidate thar he is requiredto usea bag-valve-mask deviceForall venrilation in this sration. After rhe candidatecompletesrhe initial 30 -fh,s station is designedto test the candidate's ability to provide s p i n l l i m m o b i l i z a t i o n n r p a t i e n tu s i n ga s h o r ts p i n ei m m o b i l i o zation device The candidateis testedon his/herability ro imme. diatelyprotectand immobilize the patienr'sspineby using a rigid half soine immobilization device. l'he candidatewill be advised that the scenesize-up,initial assessment focusedassessmenr and havebeencompletedand no condition requiring further resuscitati.ln or urgenr transportarionare present. The patient will presentseatedin an armlesschair, sitring upright with his/her back loose touching rhe back of the chair. The patientwill not lv nt wereslumpedover the steerprese slumpedForwrrdasif he/slre ing rvheel.The position oFthe patienr should be identicalfor all candidates. The candidatewill be ret.rired to treat the specific,isolated,problem cf an unstable ;f spine. Inirial and ongoing assessmenr rhe parienr's airway,brearhingand central circulation are nor required in this testingstation.The candidatewill be requiredto check motor, sensory and circulatoryfi:nction in eachexrremiryat the proper times throughour this station.Once rhe candidarehasimmobilizrd victim ro the halFspinedevice,ask the candidateto exthe seated plain all key stepshe/shewould complerervhile moving the patient ro the long backboard.The candidaremay check moror, sensory and circulatoryfrrnction at anytime during the procedure withour a loss of points; however,if he/she fails to check motor, sensoryor circulatory fi.inctionin all extremiriesafter verbalizingrhat the pa-

19

This skill stationrequires presence a simularedvicrim. The the of victim should be briefed on his/her role in this stationand acr as a calm oarient would if this were a real situa(ion. The victim Y o u s h o u l dh a v ev a r i o u s a l f s p i n ei m m o b i l i z a t i o n e v i c e s v a i l - should be an adult oF ave h d a rage height and weight. You may use able at rhis testing station. The devicesshould represenr those comments from rhe simulatedvictim about soinalmovementand you with the eraluarionprocess half spine immobilization dcvicesused in the local Elr4Ssy.stem overallcareto assist afrerthe can( a h a l f s p i n e b o a r d , K E D , X P - 1 , O S S , K a n s a s o a r d o r o t h e r didate completeshis/her performanceand exits the tesringstab acceprable devices).It is requiredthat at leasta rigid wooden or cion. immobilizaplastichalf spine board and a commercialvest-rype t i o n d e v i c ew i t h a l l o r h e r a s s o c i a t eid m o b i l i z a t i o n q u i p m e n r m e INSTRUCTIONS TO THE CANDIDATE SPINAL be availablein this station. You are responsible ensuringall for IMMOBILIZATION SKILIS - ST-{-TED PATIENT e q u i p m e n ti n t h i s s t a t i o ni s p r e s e n a n d i n p r o p e rw o r k i n g c o n t 'l-his dition. The candidare may choo.se bring a devicewhich he/she to strtion is designedto resrvour abiliry ro provide spinal imi s f a m i l i a rw i t h t o u s ei n t h i s s t a t i o n . Y o u m u s t b e f a m i l i a rw i t h m o b i l i z a t i o n n a p a t i e n tu s i n ga h a l F s p i n e m m o b i l i z a t i o n e o i d rhe deviceand its proper use be[oreany ev:rluarion the candi- t,ice. Ybu and an EMT as^.sisrant of arrive on the sceneof an auto'1'he datc may take place. You must not indicateclispleasure with the mobile crash. The sceneis safeand rhere is only one parienr. 'l'he cendidate'.s choiceof immobilizationdcvice. E,MT hascornpleredrhe initial assessment no criricrndidateshould :t-ssistrtnt and be evaluatedon how well he/she imnrobilizesnncl protecrsrhe cal conclitionrequiring intcrvenrionwasfound. For the purpose spine, not on what immobiliz-ation parient'.s deviccis used. o f t h i s s t a r i o n ,r h e p a t i e n r ' s i t a l s i g n sr e m a i n s t a b l e . Y o u a r e v reqLrired trert the specific, to isolared spine problemofan unstable -fhe skill stationinstrumcnt wasdesigned be gcnericso ir could using a half-spineimmobilizrrion device.You arc responsible to fbr be utiliz.ed evaluatethc canditlare'.s to of pcrfbrrnenccregardle.s.s thc dircctionend subseoucr)r lcrions of rhe EMTrr.s.sistenr. Tian.sthe hrl lt-spi i m nrolriliz-atio deviceLrti ne n lized. Al I nranufacttr rer's f-erring arrdirnrnobilizing patientto rhe long backboard the should instructionsdescribevliriousorders in rvhich srreosand buckles be ecconrprlisheclrballv.Yorrhave(10) ten minuresro complere ve a r c t o b c a p p l i e dw h e n s e c u r i n g h c r o r s or o r l r ei m n r o b i l i z a t i o n t h i s s k i l l s t r r r i o n .[ ) o v o r r h a v ea n y q u e s t i o n s ? t devices. This station is not clesigned specificallv eachirrdiro test vidual devicebut to "gene rically"verifl,a crurdidate's compere nce INSTRUCTIONS TO THE PRACTICAL SKILTS securinga sus'ected ttnst:rble s;rinei. a EXAM IN ER SPINAL IMMOBI I,IZATION-SUPINE PATI ENT ::::f'J":l*:ffectively This station is designedto rest the candidate's abiliry to provide -fherefore o i , while the specificor.ler oIplacing enclse.rrringsrr.rps s p i n a li n r n r o b i l i a r t i o n n a p a t i e n tu s i n ga l o n g . s p i n em m o b i l i a n d b u c k l e s s n o r c r i t i c a l , r i s i n r p e n i t i v eh r t r h e p a t i e n t ' s c a d zrtion clevice.'l-he i i t h candidareis testedon his/herabiliry to immebc secured the halflspinc inrnrobilizationdevicconly aftcr rhe c{iatclv ro prorcctrnd immobilize the parient'.s spineby using a rigid 'I'he deviceh;rsbeen secured the torso. This seqtrential to order most long spinalinrnrobilization will be inlormed device. candidate defensiblyminimizes potential c:rvical s;rinccompromisear.rd is that a scettesizc-up, ir-ritial assessment and fbcusedassessment rhe mo.st*,idcll,acceptedand defendcd order of applicarionro havebcen conrl'tlered and no conditior-r requiring furrher resusci, 'l'he dlte regardless the device usecl. Placenrent of ofan approprilte tation exisrs. lying on his/he back,arms r patientrvill presenr cervicalcollar is irlsorequiredwith any tvpe o[half-spine immosrreightdc,rvnat his/hcr side,wirh leer rogerher.Candidares should bilization device. not have to be concernedu,irh clisrractors such as limb realignnlent, prone position, or other posirionsnot coveredin rhe maA rrainedEM-I'assisrant will be presenr rhe srarionro assist in the j o r i t y o f E M T b r r s i c u r r i c u l a . h e p o s i t i o no f t h e p a t i c n rs h o u l d T c a n d i d a t e y a p p l y i n gm r n u a l i n - l i n e s r . r b i l i z e r i oo F r h e h e a d he identicalfor all candioares. b n and cen,icalspine onlv upon rhe candidare's conrmantl. The as'be sistantmust be briefed to fbllow only rhe commandsof the can- The candidate will requiredto trearthe specific, isolated probdidare,as the candiclare responsible direcringrhe actionsof is [or lem of an unstablespine. Initial and ongoing assessment airof the L,MT assistant. \X4rer.r directed, the EMI' assisranr must way, breathing,and circulation are not required at this resting n r a i n r a i n a n u a li n - l i n ei m m o b i l i z a r i o n sa t r a i n e d[ , M T w o u l d station. The candidatewill be requiredto check moror, sensory m a in the field. No unnecessary movemenr of the herd or other and circulatory function in each exrremiry at rhe proper rimes "tricks" should be toleratedand are nor meanrto be a oart of this throughor,rt this station. IF the candidate lails to check motor, examinationstation. However,if rhe assisrant direcredro pro- sensory is and circulatory lruncrion,a zero should be placedin the vide inrpropercare,points on the evaluationFormrelatingro rhis points awardedcollrmn Forrhoseitems. inrpropercareshouldbe deductedand docunrenred.For example; ifthe candidare directsrhe assistant let go ofrhe head prior ro l'here arevariouslong spineimmobilization devices usein the to in its mechanical inrmobilization,rhe candidarehasfailed ro main- EMS community. The skill sheetwas designedco be genericso t a i n m a n u a ln e u t r a li n - l i n e i m m o b i l i z a t i o n .Y o u m u s rc h e c kt h e that it could be used to evaluatethe candidateregardless ofthe relatedstatementunder "Crirical Criteria" and docun.rent your immobilization deviceused. You should havevariouslong spine rationale. On the orher hand, iFthe assisranr accidentlyreleases immobilizarion devices available this testing station-specifiat immobilization without an order,yorr should direcr the assistant cally long spine immobilizarion devicesused in the local EMS ro again rake manual in-line immobilizarion. Immediateli., ins]'srem, long spine board, and a scoop srrercher.The candidate form the candidare that rhis acrion will nor affecrhis/herevalua- may chooseto bring a devicehe/sheis familiar with to usein this rion. At no rime should you allow rhe candidareor assistant station. This devicemust be approvedby the examinarioncoorEMT to perform a procedure that would acuall)'injure the simu- dinator and you musr be familiar with its proper use before the lated parient candidatemay use it during the examination. You should not

tienr is moved to a Iong backboard,a zero should be placedin the "points awarded"column for that items.

)n

with the candidate's indicate disoleasure choice of immobilization device. The candidateshould be evaluated how well he/ on she immobilizes and protects the patienr'sspine, not on what immobilization deviceis used.

The candidatemust, with the help of an EMT assistant and the evaluator, move the parienr from'the ground onto a long spinal immobilization device. There arevariousacceptable ways ro move a patient from the ground onto a long spinal immobilization device, (i.e. logroll, straddleslide, direcr parient lift). You should not advocateone method over any others. All merhodsshould be considered acceptable long as spinal integriry rs nor comas INSTRUCT'IONS TO THE PRACTICAL SKILIJ promised. Regardless the method used, the EMI' assistant of EXAMINER SPLINTING SKILTS should control the head and cervicalsoine n,hile rhe candidate and evaluaror move the patient on the direcrionofthe candidate. This srationis designed test the candidate's ro abiliry to usevarious splints and splinring materialsto properly immobilize speIrnmobilizarionof the lower spine/pelvis line wirh the torso is cific musculoskeleral juries.This station will be testedas three in in required. Lateral movemenrof rhe legswill causeangulationof separate skills. tach candidatewill be requiredto splint a long the lower spine and should be avoided. Additionally, tilring rhe b o n e i n j u r y u s i n g a r i g i d . ^ p l i n t a s h o u l d e ri n j u r y u s i n g a s l i n g , backboardwhen tl'repelvis and upper legs zrrenor securedwill and swathe, a mid-shahlemur def:ormiry or usinga tractionsplinr. ultimatelycause moverne of the legsand engulation the spine. nt of IMMOBII,IZATION SKILL - LONG BONE A rrainedEN,[Tassistanr be presenr rhe srarionro assist will in the 'l c a n d i d a t e v r p p l y i n g m a n u a ll n - l i r r e s t a b i l i z a t i o n f t h e h e r d b o h e c a n d i d a t es t e s t e d n h i s / h e ra b i l i r yt o p r o p e r l yi m m o b i l i z e i o 'l'he and cervicalspine only upon the candidrte's command. :rs- a swollen,deformed exrremiry using a rigid splinr. The candisistantmust be briefed to follow only rhe commandsof tl'recan- date will be advisedthat a scenesize-uDand initial assessment didate,as the candidateis responsible directingthe actionsof For have been completedon the victim and rhar during the focused the EMT assistanr. When direcred, the EM-l' assisrerrr musr :lssessmentdeformiry of a long bone was derected.The victim a m a i n t a i nm a n u a li n - l i n ei m m o b i l i z a t i o n sa t r l i n e d E M T r v o u l d *'ill preserrt a wirh a non-angulated,closed,long bone injury of in the field. No unnecessary movemenr of rhe head or other rhc upper or lower extremiry- specifically injurv of rhe radius, an " r r i c k s " h o u l db e r o l e r : r t e r n d . r r e n o r m e i r n rr . r b c ' l o l r r o f r h i s u l n a . t i b i a .o r f i b u l a . s d examinationstation. Ilowever, if the a.ssist:rnrdireciedro pro, is vide improper care,points on rhe evaluarion form relatingro this The candidatewill then be requiredto rrearthe specific, isolared impropercareshouldbe deducred and documenred.For example, extremiryinjury. Initial and ongoing assessmenr the patienr! of if the candidare direcrsthe a*ssistanr ler go of rhe head prior to ro airway,breathingand centralcirculationare not requiredat this its mechanical immobilization, the candidarehas failed to nrain- restingstation. The candidatewill be requiredro motor, sensory tain manual neutral in-line immobilization. You must checkthe :rnd circulatoryfunction in the injured exrremiryprior to splint relatedstatemenrunder "Critical Crireria" and documenr vour application and alier completing the splinting process. Addirationale. On the other hand, if the assisranr accidentlyreleases rionally, the useof rractionsplinrs,pneumaticsplints,and vacuum immobilization withour an order,you should direct rhe assistlnt not permitted and thesesplintsshould nor be available to again take nranual in-linc immobilizarion. Immediately,in;ll'r;::.'r form the candidatethat this action will nor affecthis/herevaluation. At no rime should you allow the candidateor assisranr The candidateis requiredto "secure entire injured extremiry"afEMI' to perform a procedr.rre which would actually injure rhe ter the splint has been applied. There are various methods of simulatedparient accomplishing this particulartask. Long bone injuriesof rhe upby per extremirymay be secured tying the exrremiryto the rorso -fhe This skill station requires prese of a simulatedvictim. the nce afier a splint is applied. Long bone injuriesoI the lower extremvictinr should be briefed on his/her Lolein this srarionand acr as iry may be secured placingthe victim properlyon a long spine bv a calm patient would if this were a real situation. The victin.r board or applying a rigid long board splint berweenthe victims should Le an adult of average height and weighr. You may use legsand then securingthe legstogether. Any of thesemethods commentsfrom the simulatedvicrim about spinalmovemenrand should be considered acceptable and points should be awarded overall careto assisr you with rhe evaluarion process after the can- accordingly. didate compleres rheir performanceand exirsrhe tesringsrarion. \X/hensplinting the upper extremiry the candidareis requiredto INSTRUCTIONS THE CANDIDATE TO SPINAL immobilize the hand in the posirion of function. A position that IMMOBILIZATION.SUPINPATIENT E is to be avoidedis the hand secured with the palm flatrenedand rhe fingersextended. the palm should never'beflattened. The This station is designedro tesryour abiliw ro providespinal imwrist should be dorsiflexedabout 20 to 30 degrees and all the mobilization on a patient using a long spine immobilizarion de- fingers should be slightly flexed. vice. You arriveon the scenewith an EMT assistant. The assistant EMT has completed rhe scenesize-upas well as the initial Vften splinting the lower extremiry, the candidate is required ro assessment no critical condition was found which would re- immobilize the foot in a position of funcrion. Two positionsto and quire intervention. For rhe purpose of this restingsrarion,rhe be avoidedare grossplanrar flexion and grossplanrar extension.

patient'svital signsremain stable. You are requiredto rrearrhe specific problem of an unstable spine usinga long spine immobilization device.\X/henmoving the parient ro the device,you should use the help of the assistant EMT and the evaluaror.The assistant EMTihould conrrol rhe head and cervicalspine of the patient while you and rhe evaluatormove the parienrto the immobilizariondevice.You are resDonsible the direcrionand subsefor q u e n t a c r i o no f t h e E M T r r r i r , r n , . Y o u m a y u s ea n y e q u i p m e n r available this room. You have ren (10) minutes to complete in this skill srarion. Do you haveany questions?

2l

in-line traction musr be applied prior to elevaringthe leg for splint insertion. V4rile using the bipolar splint, manual traction may IMMOBILIZATION SKILTS - JOINT INJURY be applied immediatelyupon detectionof a mid-shaft femur injury beFore applicationof the ankle hitch. An alternaremerhod The candidateis testedon his/her abiliry to properly immobilize while using a bipolar rracrion splint is ro supporr the injury site a shoulderinjury usinga sling and swarhe.The candidate will be while the leg is on rhe ground, apply the ankle hirch and rhen advised that a scene size-up and initial assessmenr beencom- applv manual rracrionbeforeelevaring leg to inserrrhe splint. have the pleted and rhar during the focusedassessmenr shoulderinjury Thesevariationsin applying manual rracrionwhile using a bipo, a is detected. The victim will presentwith the upper arm posi- lar deviceare equally acceptable and should be awardedpoints tioned at his sidewhile supporting the lower arm ar a 90 degree accordinglv. The rwo methods describedfor applying manual angleacross his/her chestwirh the uninjured hand. For this sta- traction while using a bipolar rracrion splint are also acceprable tion, the injured arm should not be positioned away from rhe when using a unipolar rracrion device. body, behind the body, or any position thar could not be imnrob i l i z e db y a s i m p l es l i n ga n d s w a r h e . A d d i t i o n a l l y , t h e i r p p l i c a t i o n o f c e r t a i n u n i p o l a r ( S a g a ro r K e n d r i c k s )t r a c t i o n s p l i n t s d o n o r r e q u i r e r h e a p p l i c a t i o no f The candidatewill be requiredto treat only rhe specific,isolated mantraltracrion sinceelevationo[rhe leg is nor required. Vith shoulderinjury. Initial and ongoing assessmenr rhe parient's these of devices, deformedsireis supportedwirhout manualrracthe airway,breathingand centralcirculation are nor requiredat this tion until the device is in place and mechanicaltracrion is aptestingstation. l-he candidarewill be requiredto check motor, plied. In this insrance, candidare the should receive point for the sensory " a p p l i e d n d m a i n t a i n e d a n u a lr r a c r i o n . " and circulatory[unction in the injured exrrenrity prior to a m . s p l i n ta p p l i c a t i o na n d r f t e r c o m p l e r i n g t h e s p l i n r i n g p r o c e s s . A d d i t i o n a l l yt,h e o n l y s p l i n ra v a i l a b l e : r r i s s r a r i o n s a s l i n ga n d This skill requires th i that au assistanr EMT be presenrduring resrs w a t h e . A n y o t h e r s p l i n t , i n c l u d i n g a l o n g s p i n eb o a r d , i s n o t ing. Candidares ro be testedindividually.All assisring are EMI't permitted ar this starion. should be told not to speakbut to follow rhe commands of the candidate. l-he candidateis responsible rhe conduct of rhe for It should be noted thar the useofa long spine board is an accepr, a.ssisting L,NIT. If rhe assisting I-MT is instructedto provide ima b l em e t h o do f s p l i n r i n gt h i s i n j u r y s i n c ea l o n g s p i n eb o a r dw i l l proper carc,i.lrers rhe scoresheerrelaringto rhar careshould on effectivcly splint every bone in rhe body. Ifrhe crndidatc elecrs be decluctcd. At no rime should you allow rhe candidareor mto avoid individual splinring and responds thar he/shewill usea sisting F-M'f ro 1>erform procedurerhat would actually injure a long spine board, rhe examinershould respond,"that is an ac- t h e s i r n u l a t e d i c r i n r . v ceptable procedure,however,in this srarionyou are being tested on yoLrrability ro apply a simple sling and swarheto immobilize INSI'RUCTIONS'I'O THE CANDIDATE the injury." The examinershould reser/resrarr rime clock afrhe IMMOBII-IZATION SKILLS - LONG BONE ter this explanarion. 'l'his station is designedro resryour abiliry ro properly immobiIMMOBILIZATION SKII-I-S - TRACl-tON SPLIN-T lize a closed,non-angulared Iong bone injury. You are required to treat only rhe specif.ic, isolatedinjury ro the extremiry. The 'l'he candidateis testedon his/herability to properly immobilize scenesize-up and inirial assessmenr have been completed and a mid-shaft femur injury using a rracrion splinr. The candidate during the focusedassessmenr closed,non,angularedinjury of a will be advised rhar a scene size,upand initial assessme hasbeen the (radius, nr ulna,tibia,flbula) derecred. was completedand that during ,r focured rs\es\me a mid-shaft fe- Ongoing assessmenr the patient'sairway,brearhing,and cennr of mur injury was detected. The vicrim will presentwirh a closed, tral circulation is nor necessary.You may use any equipment non-angulated, mid-shaftfemur injury. l'he vicrim will be Found available this room. You have(5) five minutesto complerethis in laying supine with borh legs fully extended. The femur defor- skill station. Do you haveany quesrions? miry should be an isolatedinjury with no complicating facrors rhat would concern or distractthe candidare. INSTRUCTIONS TO T'HE CANDIDATE IMMOBILIZATION SKILTS . JOINT INJURY The candidare will be requiredro rreatonly the specific,isolared -l'his femur injury. Inirial and ongoing assessnrent the patient's of air, station is designedro resryour abiliry to properly inrmobiway breathingand cenrralcirculationarenor requiredat this rest- lize a non-complicated shoulderinjury. You are requiredro rrear ing starion. The candidare will be requiredro check moror, sen- only the specific,isolatedinjury to rhe shoulder.'fhe scenesizesory and circularory function in the injured extremiry prior ro up and initial assessmenr have been accomplished the victim on splint applicationand aFter complering rhe splinting process. and during the focusedassessme a shoulder injury was derecred. nr Ongoing assessmenr rhe patienrt airway,brearhingand cenof There should be various rypes of rracrion splints ar rhis resting tral circulation is not necessary.You may use any equipment station-specifically rraction splinrscommonly usedin the local available this room. You have (!) five minutes to complererhis in EMS system,a bipolar tracrion splint, and a unipolar rracrion skill station. Do you haveany quesrions? splint. Carefully nore rhe comments lisredon the evaluarionform Forunipolar versus bipolar splint application. INSTRUCTIONS TO THE CANDIDAIE

No points should be awardediFthesepositionsare used.

IMMOBILIZATION SKILTS- TRACTION SPLINTING

One conrroversy encounrered using rracrionsplintsis when ro in apply manual rracrion. \X/hen using a bipolar (Hare) rraction splint, elevarionof rhe injured leg is required,rhereforemanual

This station designed resr is ro your abiliryro properly immobilizea mid-shaft femurin.f with a traction ury splint.Youwill have

22

to an EMT assistant help you in the applicationof the deviceby applying manual traction when directed to do so. You are reinjury to the femur. The quired to rreatonly the specific,isolated on havebeen accomplished scenesize-upand initial assessment a the victim and during the focusedassessment mid-shaft femur Ongoing assessment the patient's of airdeformity was detected. You may way, brearhing, and central circulation is not necessary. use any equipment availablein this room. You have (10) ten minutes to complete this skill starion. Do you have anv questions? INSTRUCTIONS TO THE PRACTICAL SKILI,S EXAMINER BLEEDING CONTROL/SHOCK MANAGEMENT This srarionis designed tesrthe candidate's abiliry to treata lifb to hypoperfusion. l-his stathreatening hemorrhage and subsequent tion will be scenariobasedand will require some dialogue berweenyou and the candidate. The candidatewill be requiredto properly treat a lif'ethreateninghemorrhage. The victim will presentwith an arterialbleed From a severe llceration of the exiremiry. You will prompr the acrionsof rhe canintervalsas indicatedon the skill sheet. didate ar oredetermined -l'he candidatewill be requiredto provide the appropriercinrervention at eachintervalwhen the patient'.s condition changes.lt is essential, due to the purposeof this station, that the patier-rt's condition not deteriorateto a ooint where CPR would be initia t e d . T h i s s t a t i o ni s n o r d e s i g n e do t e s tC l ) R . t 'fhe equipment and suppliesneededat this station includc field dressings bandages, blanket,an oxygendelivery and a system(rnav be a mock-up) and a non-rebreather mask.

are for this level of shock (example:cool clammv skin, restlessn e s sB P I 1 0 / 8 0 ,P 1 1 8 ,R 3 0 ) . , Controversyexistsin rhe national EMS communiry concerning the removal of dressings EMTi when controlling hemorrhage. by This station does not require the EMT to removeany dressing once applied.lf the candidatechooses removethe initial dressto ing to apply direct finger tip pressure, should awardthe point you lor "applies an additional dressing to the wound" since this is an acceptable alternativemerhod to control bleedingwhen the apdressingfails to stop the flow of plication ofan initial pressure blood. 'l'he -l'his victim. skill stationrequires presence a sirnulated the of v i c t i m m a y b e a n a p p r o p r i a t e a n n e q u i no r a l i v e p e r s o n . I f m accuused,the mannequin must be a hard shelland anaromically

INSTRUCTIONS TO THE CANDIDATF, BI-EEDING CONTROL/SHOCK MANAG EM ENT 'l'his station is designedto test your abiliry to control hemorrhagc.This is a scen:rrio basedtesting starion. As you progress through the scenario, you will bc given varioussignsand symptonrs:r;rpropriate the patient'.s for condition. You will be required to managethe patient basedon thesesigns and symptoms. A scenlrio will be read aloud to you and you will be given rn ophowever, about the scen:rrio, portunity ro askclari$,ingquestions you will not receiveanswersto any questionsaborrt the acttral stepsof the procedures be performed. You may useany of the to s u p p l i e s n d e q u i p m e n ta v a i l a b l en t h i s r o o m . Y o u h a v e ( 1 0 ) a i haveany questen minutesto completethis skill station. Do yor.r tions?

l'he scenario is providedin this essay an exampleof an acceprable SCENARIO (SAMPLE) BLEEDING CONTROL/SHOCK scenario this station. It is not intendedto be rhe onlv oossible for MANAGEIUENT scenarioFor this station. Variationsof the scenario.r. iro..il'rl. and should be utilized in order to reducethe possibiliry r c.rn- You respondto a stabbingand find a 25 year old male victim. of didate knowing the scenariobeforeentering the test. lf the sce- Upon examination you find a rwo (2) inclr stab wound to the (antecubital nario is to be changed,the following guidelinesmust be used: inside ofthe right arm at the anterior elbow crease fascia).Bright red blood is spurting from the wound. The scene . An isolatedlace and alert. His airway is open ration to arnextremiryproducing rn .lrte- is safeand the patient is responsive rial bleed must be presenr. and he is breathingadequately. yoLrhaveany quesrions? Do . 'fhe scenemusr be'safe. . As the scenariocontinues the victim must presentiigns INSTRUCTIONS TO THE PRACTICAL SKILTS and symptoms of hypoperfusion. EXAMINER AIR\rAY, OXYGEN, VENTITATION SKILLS

UPPERAIRWAYADJUNCTS AND SUCTION

It is essential is for that once a scenario established a soecifictest. it remain the same for all candidates being testedon that date. This will ensureconsistencv the examination orocess of for all candidates tested. Due to the scenarioformat of this station, you are required to prompt the candidateat varioustimes during the exam. Vhen the bleeding is initially managedwith a pressure dressingand bandage, you should inform the candidatethat rhe wound is still bleeding. Ifrhe candidateplacesa secondpressure over dressing the first, you should again inform him/her that the wound continues to bleed. After the candidateusesan appropriatearterial pressure poinr ro conrrol the hemorrhage,you should inform him/ her that the bleeding is controlled. Once the bleeding is controlled, you should indicateto the candidatethat the victim is in a hypoperfusedstateby indicating signsand symproms appropri-

abiliryto properly This station designed resr candidaret is to the measure insertan oropharyngeal airway, nasopharyngeal a and suctiona patient's airway.This stationis airwayand properly will comprise three of separate skills.The candidate be required and insert, and remove oropharyngeal a nasophaan to measure, upperairway. ryngeal airwayaswell suctionthe patienr's airwayand sucrion The oropharyngeal airway,nasopharyngeal not for only. It should be arein oneskillstation scoring purposes nor connecinferred, arewe implying, that thereis a sequential rhe rion berween threeskills. You should not test theseas seisolated skills. skills but asthreedisrincr, quenrial an The rechnique openinga patientt mourh and inserting for oropharyngeal airwayvariesfrom text to text, i.e. - 90 degree

rotation, direct insertion. Sinceconcernfor rorarion,180 degree spinal immobilization is not requiredat this station,the ultimate mourh and insertopening the patient's crireriafor appropriately airway should be that the tongue is not ing rhe oropharyngeal pushed posteriorly. The equipment neededat this station includesvarious sizesof oropharyngealand nasopharyngealairways and a suction device (manual or battery operateddevice). Additionally, this station requiresthe presence a mannequin that can acceptthe inserof tion o[an oropharyngeal and nasopharyngeal airway. The mannequin may be an intubation head,howeverit should be life size a n d h a v ea n a t o m i c a l l c o r r e c ta i r w r y s r r u c r u r e s . y Once the candidatehas the oropharyngeal airway in place,you should adviserhe candidarethat the patient is gagging. If: the candidate failsto immediatelyrernovethe oropharyngeal airway, placea zeroin the "points awarded"column. Once the candidate hasfinished the procedurefor oropharyngealairway insertion and removal,you should direct him/her to demonstratethe proper procedurefor suctioning a patient'supper airway. Finally the candidate should be instructedto inserta nasopharyngeal airway into the mannequin.

however, it should be life sizeand have anatomically correct airway structures.Additionally, this srarionrequiresa ventilator mask with a one way vdve and oxygenconnectingtubing. The supplemenral oxygen system should be funcrional, however, for testing purposes, an empry tank may be used as long as all accessory for equipment and suppliesnecessary a functional oxygen system are Present. Due to the natureof rhis station,infectioncontrol measures must be enforced. You should Follow the current infection control measures by for established the American HearrAssociation mannequin disinfection. You should observe the candidateventilatingthe mannequin for a period of 30 seconds. During this time you should pay close attention to volumes. The volumesshould be in the rangeof 800 ml - 1200 ml per breath. If you observeone ventilarionerror or (volume only) you should awardone (1) point. lessin 30 seconds No points should be awardedifyou observe rwo or more ventilation errorsin 30 seconds. INSTRUCTIONS TO THE CANDIDATE AIR\TAY.

OXYG VENTITATIONSKILTS EN, MOUTH-TO.MASK W]TH SUPPLEMENTAIOXYGEN

l-his station is designedto test your abiliry to ventilarea patient This with supplenrental oxygenusinga mouth-to-mask technique. is an isolatedskills test. You may assumethat mouth-to-barrier This station is designedto test your abiliry to properly measure, deviceventilationis in progress and that the patient hasa central insert and remove an oropharyngealand a nasopharyngeal air- pulse The only patient managementrequired is ventilator sup. way m well a.s suction a patient's upper airway. This is an isolated port using a mouth-ro-maskrechniquewith supplementaloxyskillstestcomprisedof threeseparate skills.You may useany equip- gen. Yor-r must ventilatethe patient Forat least30 seconds.You ment available this room. You have five (5) minutes ro com- will be eveluated the appropriateness ventilatoryvolumes. in on of You may uselny equipment available this room. You havefive plete this station. Do you heveany questions? in (5) minutes to complete this station. Do you have any quesINSTRUCTIONS TO THE PRACTICAL SKILLS tions? EXAM INER AI RVAY, OXYGEN, VENTI IATI ON SKI T,I,S MOUTH-TO-MASK WITH SUPPLEM EN-IALOXYCEN INSTRUCTIONS TO THE PRACTICAL SKILIS EXAMINER AIR\fAY, OXYGEN, VENTITATION SKILIS This station is designedto test the candidate's abiliry to effecSUPPLEMENTAL OXYGEN ADMINISTRATION tively ventilatea patient using a mouth-to-masktechnique.This station is testingan isolatedskill. The candidatewill be advised This station is designed test the candidate's to abiliry to correctly that rhe patient is being ventilared,mouth-to-barrier,by a first assemble equipment neededto administersupplemental the oxyresponder.Upon enteringthe skill srarion,the candidatewill be gen in the pre-hospital setting. The candidatewill be requiredto requiredto connect the mask to oxygenand ventilatethe parient assemble oxygen delivery system,administercorrect oxygen the using a mouth-to-mask technique. The candidaremay assume lirer flow to a patient using a non-rebreather mask. The candithat the patienrhasa centralpulseand that the only parie man- date will be informed that the patienr does not toleratea nonnr agementrequiredis ventilation with high concnrrarion oxy- rebreather of mask and will be instructedto administeroxygenusgen. ing a nasal cannula.The candidatewill be required to disconfrom the tinue oxygen therapy including relieving all pressure When ventilatingthe patienr rhe candidaremusr providea minioxygentank regulator. mum of 800 ml volume per breath. This equalsthe currenrstandardsestablished appropriaterescuebreathingvolumesdur- As the candidareenters the station he will be instructed to asfor ing basicand advancedlife support. semblethe oxygendeliverysysremand administeroxygento the simulatedparienrusing a non-rebreather mask. During this proThis station requires mannequin rhat is capable being venti- cedure,the candidatemust check for tank/regulatorleaks. If a a of lated with volumes of 800 ml or more. It must also have the leak is found and not corrected,you should subtracrone point capabiliryof registering successful lung inflarions oF 800 ml to for this step. If a leak is found but is corrected, there should be 1200 ml per breath. This may be accomplished using a sys- no points deducted. by tem that lights up when successful volumesare reachedor a system that graphssuccessFul volumes. The mannequin must be life Oxygen liter flow rales are normally establishedaccording to rhe size,possess anatomicallycorrecrairway srructures, and meet the parient history and patient condition. Since this is an isolated criterialistedabove.The mannequin may be an intubation head, skillstest, liter flow ratesof qreaterthan l2liters/minute for rhe

INSTRUCTIONS THE CANDIDAIts TO AIR\SAY. OXYGEN. VEN]'I[{I'ION SKILLS UPPER AIR\OTAY ADJUNCTS D SUCTION AN

24

non-rebreather and less than six (6) liters/minute for the nasal cannula are acceptable. Afrer rhe candidate has applied the non-rebreather mask to the patient and establishedan oxygen liter flow, you must inform the candidate that the Datient can nor roleratethe mask and instruct him to continue oiyg.n administration using a nasal cannula. Once the oxygen flow rate has been adjusted for the nasal cannula, instruct the candidareto discontinue oxygen administration. The equipment neededat this station includes an oxygen tank, a regulator with a flow meter, a non-rebreather mask, and a nasal cannula.The oxygen tank at this station must be fuily pressurized (air or oxygen) and rhe regularor/flow merer musr be [unctional. The simularedpatient for this starion may be a live person or a mannequin. If a mannequin, is used it musr have anatomically correctears,noseand mouth. INSTRUCTIONS TO THE CANDIDATE AIRWAY, OXYGEN, VEN'TIIATION SKILLS SUPPLEMENTAL OXYGEN ADMINISTRATION This station is designedto test your abiliry to correctly assemble the equipmenr neededto administersupplemental oxygenin the pre-hospitalsetting. This is an isolatedskills tesr. You will be required to assemblean oxygen rank and a regularor and administer oxygen to a patient using a non-rebreather mask. At this point you will be instructed to discontinueoxygen administration by the non-rebreathe mask and start oxygenadministration r using a nasalcannula becauserhe patient can not toleratethe mask. Once you have initiated oxygen administration using a nasalcannula,you will be instructedto discontinueoxygen administration completely.You may useonly the equipment available in this room. You have five (5) minutes to complete rhis station. Do you haveany questions?

?q

PatientAssessment/ManagementTrauma

Start Time: Stop Time:

Candidate's Name: Evaluator's Name: T a k e s , o r v e r b a l i z e s ,b o d y s u b s t a n c e i s o l a t i o n p r e c a u t i o n s

Points Possible

Points Awardod

Date:

1

SCENE SIZE.UP

Determinesthe scene is safe Determinesthe mechanism of injury Determinesthe number of oatients Requestsadditional help if necessary C o n s i d e r ss t a b i l i z a t i o no f s p i n e

,| ,|

1 1 1 1 1 1

Assessment Initiates appropriate oxygen therapy Assures adequate ventilation Injury management Assesses/controls major bleeding Assesses oulse Assesses skin (color, temperature and condition)

INITIAL ASSESSMENT

i,/erbalizes eneral impression of the patient g D e t e r m i n e s r e s p o n s i v e n e s s / l e v e lo f c o n s c i o u s n e s s Determineschief complaint/apparent life threats Assesses airway and breathing

1 1 1 1 I 1 1 1 1

1

{ssesses circulation dentifies priority patients/makes transport decision

:OCUSED HISTORY AND PHYSICAT EXAM]NATION/RAPID TBAUMA ASSESSMENT

ielects appropriate assessmenl lfocused or rapid assessment) Jbtains, or directs assistance to obtain, baseline vital signs ) b t a i n s S . A . M . P . L . E .h i s t o r v

1

nspects and palpates the scalp and ears \ssesses the eyes \ssesses the facial areas includinq oral and nasal areas nspects and palpates the neck A s s e s s e sf o r J V D { s s e s s e s f o r t r a c h a e ld e v i a t i o n

)ETAILED PHYSICAL EXAMINATION

A s s e s s e st h e h e a d

1 1 1 1 1 1 1 1 1 1 1 1

4

\ssesses the neck

Assessesthe chest

nspecrs )alpates \ u s c ul t a t e s

\ssesses the abdomen \ssesses the oelvis /erbalizes assessment of genitalia/perineumas needed 'l point for each extremity includes inspection, palpation, and assessment of motor, sensory and crrculatory function Assesses thorax Assesses lumbar

Assesses the abdomen/oelvis

Assesses the extremities Assessesthe Dosterior

1 1 1 1

Manages secondary injuries and wounds appropriately 1 point for appropriate management of the secondary injury/wound V e r b a l i z e sr e - a s s e s s m e n t o f t h e v i t a l s i g n s

CriticalCriteria p Did not take. or verbalize. uro not taKe, or verDattze, ody sur bodv substance b isolation r e c a u t r o n s orecautions _

_ Did not determine scene safety D i d n o t a s s e s sf o r s p i n a l p r o t e c t i o n

Total:

40

_ _ _ _ _

Did not providefor spinalprotectionwhen indicated Did not providehigh concentration oxygen of D i d n o t f i n d , o r m a n a g e p r o b l e m s s s o c i a t ew i t h a i r w a y ,b r e a t h i n gh e m o r r h a go r s h o c k( h y p o p e r f u s i o n ) , a d , e patient'sneed for transportation Did not differentiate versuscontinued assessment the scene at physical Did other detailed examination beforeassessing airway,breathing the and circulation D i d n o t t r a n s p o rp a t i e n tw i t h i n ( 1 0 ) m i n u t et i m e l i m i t t

26

PatientAssessment/ManagementMedical

Start Time: Stop Time:

Candidate's Name:

Date:

Evaluator's Name: precautions Takes,or verbalizes, body substance isolation SCENE SIZE-UP Determines sceneis safe the

Determinesthe mechanism of injury/nature of illness

Points Po3!ible

rotntS Awa.dd

1 1 1 1 1 1 1 1

1

Determines numberof oatients the

Requests additional help if necessary Considers stabilizationof spine

NITIALASSESSMENT

V e r b a l i z e sg e n e r a l i m p r e s s i o n o f t h e p a t i e n t D e t e r m i n e s r e s p o n s i v e n e s s / l e v e lo f c o n s c i o u s n e s s Determines chief complaint/apparent life threats Assesses airway and breathing

Assessment appropriate Initiates oxygentherapy ventilation Assuresadeouate

Assesses/controls major bleeding Assesses pulse Assesses skin (color, temperature and condition)

Assesses circulation d e n r i fi e s p r i o r i t v p a t i e n t s / m a k e s t r a n s p o r t d e c i s i o n

1 1 1 1 I 1 1

'l

:OCUSED AND PHYSICAL HISTORY EXAMINATION/RAPID ASSESSMENT

Signs and symptoms (,4ssess history of present illness) Cardiac Altelod Montal Status rDescription of the episode. rOnset? r Duration? 'Associated Symptoms? rEvidence of Trauma? l lnterventions? r Seizures? r Fever {llergies Vledicalaons )ast pertinent historv l - a s to r a l i n t a k e Event leading to present illness (rule out trauma) )erforms focused physical examination (assesses affected body part/system or, if indicated, completes rapid assessment) yitafs (obtans baseline vital signs) nterventions Transport (obtains medical direction or verbalizes standing order for medication interventions and verbalizes proper additional intervention/treatment) ( r e - e v a l u a t e s t h e t r a n s p o r td e c i s i o n )

Respiratory

Allergic Reaction

'History of allergies? *What were you exposed to? rHow were you e x p o s e d? r Effects ? +P r o g r e s s i o n ? r Interventions?

Poisoning/ Ovardosa r S u b s t a n c e? rWhen did you ingest/become exposed? lHow much did you ingest? rOver what time p e r i o d? r Interventions? r Estimated weight?

Environmantal Emergency

Obstotrics

Eehavioral rHow do you feel? I Determine suicidal tendencies. lls the palient a threat to self or o t h e r s? rls there a medical problem? r Interventions?

i Onset? rOnset? 'Provokes? r Provokes? * Ouality? r O u a l i t y? 'Radiates? r Radiates? * Severity? 'Severity ? 'Time? iTime? * InterventionsT I n t e r v e n t i o n s ? l

r Source? rAre you pregnant? r Environmenl? ' H o w l o n g h a v e y o u r Duration? been pregnant? * Lossof iPain or ? consciousness c o n t r a c t i o n s ? rEffects rBleeding or general or d i s c h a r g e? rDo you feel the local?

need to push? rLast menstrual period?

1

I

,|

1 1 1 1 1 1 1 1 1 1

Total:

V e r b a l i z e st h e c o n s i d e r a t i o n f o r c o m p l e t i n g a d e t a i l e d p h y s i c a l e x a m i n a t i o n

(verbalized) ONGOING ASSESSMENT Repeats initialassessment Repeats vital signs patientcomplaintor injuries Repeats focusedassessment regarding

Critical Criteria

_ _ _ _ _ _ _ _ _ precautions Did not take, or verbalize, isolation when necessary body substance Did not determine scenesafety Did not obtainmedicaldirectionor verbalize standingordersfor medicalinterventions Did not providehigh concentration oxygen of with airway,breathing, hemorrhage shock (hypoperfusionl or Did not find or manageproblemsassociated patient'sneedfor transportation versuscontinuedassessment the scene at Did not differentiate the and circulation or examination beforeassessing airway,breathing Did detailed focusedhistory/physical Did not ask questions about the presentillness intervention Administered dangerous inappropriate a or

30

27

Cardiac Arrest Management/AED

Start Time: Stop Time:

Candidate'sName:

Date:

Name: Evaluator's ASSESSMENT precautions body substance isolation Takes,or verbalizes, questions the rescuerabout arrestevents Briefly

D i r e c t s r e s c u e rt o s t o p C P R

POTnIS

Possible 1

1

POtnls Awarded

1 1 1 1 1

1 1

pulse (skillstationexaminer of states "no pulse") Verifies absence spontaneous Directsresumption CPR of

f u r n s o n d e f i b r i l l a t o rp o w e r A t t a c h e s a u t o m a t e d d e f i b r i l l a t o rt o t h e p a t i e n t D i r e c t s r e s c u e r t o s t o p C P R a n d e n s u r e s a l l i n d i v i d u a l sa r e c l e a r o f t h e p a t i e n t I n i t i a t e sa n a l y s i s o f t h e r h y t h m D e l i v e r ss h o c k ( u p t o t h r e e s u c c e s s i v e s h o c k s )

1

1

pulse (skillstationexaminer states "no pulse") Verifies absence spontaneous of TRANSITION

Directs resumption of CPR G a t h e r sa d d i t i o n a l i n f o r m a t i o n a b o u t a r r e s t e v e n t ( v e n t i l a t i o na n d c o m p r e s s i o n s ) Confirms effectivenessof CPR

'l

1 1

INTEGRATION Verbalizes directsinsertion a simpleairway adjunct (oral/nasal airway) or of

V e n t i l a t e s ,o r d i r e c t s v e n t i l a t i o n o f , t h e p a t i e n t A s s u r e s h i g h c o n c e n t r a t i o n o f o x y g e n i s d e l i v e r e dt o t h e p a t i e n t

1

1 I

Assures interruption CPRcontinues without unnecessary/prolonged

p R e - e v a l u a t e s a t i e n t / C P Ri n a p p r o x i m a t e l y o n e m i n u t e R e p e a t s d e f i b r i l l a t o rs e q u e n c e

1 1

1

TRANSPORTATION

V e r b a l i z e st r a n s p o r t a t i o n o f p a t i e n t

1

Total: Critical Criteria

precautions isolation Did nottake,or verbalize, bodysubstance the use Did not evaluate needfor immediate of theAED at appropriate times. of ventilation/compressions Did not directinitiatiorVresumption shock delivering each wereclearof patient before all Did not assure individuals to shock) Did not operate AED properly(inability deliver the indicated shocks stacked Prevented defibrillator the from delivering

21

28

BAG.VALVE.MASK APNEIC PATIENT

StartTime: StopTime:

Candidate'sName:

Date:

Name: Evaluator's

Points Points Possible Awarded

1 1 ,l 1 ,l

precautions isolation fakes,or verbalizes, substance body

y'oices the opening airway y'oices inserting airwayadjunct an Selects appropriately sized mask

a mask-to-face Creates proper seal

patient no lessthan 800 ml volume Ventilates at (The examiner must wifness for at leasf 30 seconds) reservoir Connects and oxygen

1

1

1 Adjusts flowto 15 liters/minute greater liter or The examiner indicates arrival of a second EMT. The second EMT is instructed to ventilatethe patientwhile the candidatecontrols the maskand the airway

Voicesre-opening airway the a Creates propermask-to-face seal

1 1 1

per Instructs assistant resume to ventilation proper at volume breath (The examiner must wifness for at leasf 30 seconds/

Total:

11

CriticalCriteria precautions Didnottake,or verbalize, bodysubstance isolation Didnotimmediately ventilate patient the Interrupted ventilations morethan20 seconds for Didnotprovide highconcentrationoxygen of proper volume/breath Didnot provide, direct or assistant provide, to

per (2) (morethantvvo ventilations minuteare below800ml)

exhalation Didnotallow adequate

29

SPINAL IMMOBILIZATION SEATED PATIENT

StartTime: StopTime:

Candidate'sName:

Date:

Evaluator's Name:

Points Points Possible Awarded 1 1

1 1 1 1 1 1 I 1 1 1

precautions Takes, verbalizes, substance or body isolation position Directs assistant place/maintain in the neutral to head in-line Directs to manual assistant maintain immobilization head of the Reassesses motor, and in sensory circulatory function eachextremity Applies appropriately sizedextrication collar Positions immobilization the device behind patient the

Secures deviceto the patient's the torso Evaluates torso fixationand adjustsas necessary Evaluates and pads behindthe patient's headas necessary Securesthe patient'shead to the device

Verbalizes moving patient a longboard to the Reassesses motor, sensory circulatory and function eachextremity in

Total: Critical Griteria Did not immediately direct,or take,manualimmobilization the head of

12

Released, orderedrelease manualimmobilization or of, beforeit was maintained mechanicall

potential Patient manipulated, moved or excessively, causing spinal compromise Device moved excessively down,leftor righton the patient's up, torso Headimmobilization allows excessive for movement Torso fixation inhibits chestrise,resulting respiratory in compromise position Upon completion immobilization, is notin the neutral of head Didnotassess function eachextremity aftervoicing motor, sensory circulatory in and immobilization longboard to the lmmobilized headto the boardbefore securing torso the

30

SPINAL IMMOBILIZATION SUPINE PATIENT

StartTime: StopTime:

Candidate'sName:

Date:

Name: Evaluator's

Points Points Possible Awarded

1 1 1 1 1 1 1

precautions fakes,or verbalizes, isolation bodysubstance position Directs head in-line assistant place/maintain in the neutral to

Directs manualimmobilization the head assistant maintain to of

Reassesses motor, sensory circulatory and function eachextremity in Applies sizedextrication appropriately collar

Positions immobilization deviceappropriately the Directs movementof the patientonto the devicewithoutcompromising rheintegrity the spine of paddingto voids betweenthe torso and the boardas necessary Applies mmobilizes patient's the torso to the device valuates and pads behindthe patient's headas necessary lmmobilizes patient's the headto the device Secures patient'slegs to the device the

1 1 1 1 1 1 1

Secures patient's the armsto the device Reassesses motor, sensory circulatory and function eachextremity in Total:

Critical Griteria

14

Didnotimmediately direct, take,manual or immobilization head of the Released, ordered immobilization or release manual of, before was maintained it mechanicall potential Patient manipulated, moved or excessively, causing spinal compromise Patient moves excessively down,leftor righton the patient's up, torso Headimmobilization for movement allows excessive position Uponcompletion immobilization, is notin the neutral of head Didnotassess function eachextremity in motor, and afterimmobilization sensory circulatory to the device lmmobilized the headto the boardbefore securing torso

3l

IMMOBILIZATION SKILLS LONGBONEINJURY

StartTime: StopTime:

Candidate'sName: Evaluator'sName:

Date:

Points Points Possible Awarded

,, 1

precautions isolation fakes, or verbalizes, body substance of Directs of application manualstabilization the injury

1 function the injured in extremity Assesses motor, sensory circulatory and fVote.' examiner acknowledges "motor, sensory and circulatory function are The presentand normal"

Measures splint the Applies splint the mmobilizes joint abovethe injurysite the lmmobilizes joint belowthe injurysite the

1 1 1 1 1 1

Secures entireinjured the extremity

lmmobilizes hand/foot the position function in of the

function the injured in Reassesses motor, sensory circulatory and extremit' 1 Mote,' examiner acknowledges"motor,sensory and circulatory function are The presentand normal"

Total:

10

Critical Criteria moves injured Grossly the extremity site the andthejointbelow injury the Didnotimmobilize jointabove extremity function the injured in and sensory circulatory Didnot reassess motor, andaftersplinting before

1)

IMMOBILIZATION SKILLS JOINTINJURY

StartTime: StopTime:

Candidate'sName:

Date:

Evaluator's Name:

Points Points Possible Awarded

precautions 1 Iakes,or verbalizes, substance isolation body 1 injury Directs of application manual of stabilization the shoulder 1 function the injured in extremity Assesses motor, and sensory circulatory Mofe.' The examiner acknowledges"motor, sensory and circulatory function are present and normal."

Selects propersplinting the material

1 1

lmmobilizes siteof the injury the joint lmmobilizes boneabove injured the the

joint lmmobilizes bone belowthe injured the

1

1

Reassesses function the injured in extremit' 1 motor, sensory circulatory and t\lote.'The examiner acknowledges"motor, sensory and circulatory function are present and normal." Total:

8

CriticalCriteria weight the Didnotsupport jointso thatthejointdid notbeardistal site the the andbelow injured Didnotimmobilize boneabove before extremity function the injured in motor, sensory circulatory and Didnot reassess andaftersplinting

33

IMMOBILIZATION SKILLS TRACTION SPLINTING

StartTime: StopTime:

Candidate'sName:

Date:

Evaluator's Name:

Points Points Possible Awarded 1

1 1

precautions body isolation l-akes, verbalizes, substance or

of leg Directs application manualstabilization the injured of Directs application manualtraction the of

,l in extremity Assesses motor, sensory circulatory and function the injured Mofe.' The examiner acknowledges "motor, sensory and circulatory function are presentand normal"

Prepares/adjusts splintto the properlength Positions splintnext to the injuredleg the Applies proximal the securing device(e.9.. ischial strap) Applies distalsecuring the device(e.g..anklehitch) Applies mechanical traction

1 1 1 1 1 1 1

Positions/secures support the straps

Re-evaluates proximal/distal the securingdevices

Reassesses motor, sensory circulatory and in extremity 1 function the injured Note:Theexaminer acknowledges"motor, sensoryand circulatory function are presentand normal"

Mofe: The examiner must ask the candidate how helshe would prepare the p atient fo r tra ns po rtati o n Verbalizes securing torsoto the longboardto immobilize hip the the Verbalizes securing splintto the longboardto prevent the movement the splint of

1 I

Total:

CriticalCriteria

14

Lossof traction anypointafterit was applied at Didnot reassess motor, sensory circulatory and function the injured in before extremity andafter splinting Thefootwas excessively aftersplint was applied rotated extended or Didnotsecure ischial the strapbefore taking traction leg rotation the injured of Final lmmobilization to support femur prevent failed the or mechanical traction Secured legto the splint the before applying

Note:lf the Sagar splint or the KendricksTraction Deviceis used without elevating the patient'sleg, applicationof manualtraction is not necessary. Thecandidateshould be awardedone (1) point as if manual traction were applied. Note:lf the legis elevatedat all, manual traction must be applied beforeelevating the leg. Theankle hitch may be appliedbeforeelevating legand usedto providemanualtraction. the

1q

BLEEDING CONTROUSHOCK MANAGEMENT

StartTime: StopTime:

Candidate'sName:

Date:

Evaluator's Name:

Points Points Possible Awarded

precautions Takes, verbalizes, or bodysubstance isolation I Applies 1 directpressure the wound to Elevates extremity the 1 Note: The examiner must now inform the candidatethat the wound continues fo bleed. Applies additional an dressing thewound to 1 Note: The examiner must now inform the candidate that the wound still continues to bleed. Ihe second dressingdoes not control the bleeding. pressure appropriate pressure point Locates applies and to arterial 1 Note:Theexaminer must now inform the candidatethat the hleedingis controlled

Bandages wound the

1

lVofe.' The examiner must now inform the candidate the patient is now showing srgns and symptoms indicative of hypopertusion positions patient Properly the Applies concentration high oxygen Initiates stepsto prevent heatlossfromthe patient

lndicates need for immediate the transportation

1 1 1 1

Total:

Gritical Griteria

10

precautions Didnottake,or verbalize, isolation bodysubstance Didnotapplyhighconcentration oxygen of Applied tourniquet a attempting othermethods bleeding of control before Didnotcontrol in manner hemorrhage a timely Didnot indicate needfor immediate a transportation

35

AIRWAY, OXYGEN ANDVENTILATION SKILLS AIRWAY ADJUNCTS ANDSUCTION UPPER

StartTime: StopTime:

Name: Gandidate's Evaluator'sName:

Date:

OROPHARYNGEAL AIRWAY precautions Takes, verbalizes, body substance isolation or Selects appropriately sizedairway

Points Points Possible Awarded 1 1 1 1

Measures airway pushing tongue posteriorly without the Inserts airway

Note:The examiner must advisethe candidatethat the patientis gagging and becomingconscious the ainruay Removes oropharyngeal 1

SUCTION Alofe;The examiner must advise the candidate to suction the patient's airway

device Turns on/prepares suction

presence mechanical Assures of suction

1 1 1 1

Inserts suction without suction the tip Applies suction the oropharynx/nasopharynx to NASOPHARYNGEAL AIRWAY

lVofe;The examiner must advisethe candidafeto rnserta nasopharyngeal airway

appropriately Selects sizedairway

1 1 ,l 1

airway Measures

Verbalizes lubrication the nasalairway of Fullyinserts ainruay the bevelfacingtowardthe septum the with

Total:

13

CriticalCriteria

precautions Didnottake,or verbalize, isolation bodysubstance Didnotobtain patent a airway withthe oropharyngeal airway Didnotobtain patent a airuay withthe nasopharyngeal airuuay Didnotdemonstrate acceptable technique an suction Inserted adjunct a manner any in dangerous the patient to

TO MOUTH MASKWITHSUPPLEMENTAL OXYGEN

StartTime: StopTime:

Gandidate'sName: Evaluator'sName: Points Points Possible Awarded

Date:

precautions Takes,or verbalizes, isolation bodysubstance

1 1 1 1 ,l

one-wav valveto mask Connects patient's patient's is Opens airway confirms or airway open (manually withadjunct) or

Establishes maintains propermaskto face seal and a

Ventilates patient the proper the volume at and rate

(800-1200 per breath/l0-20 breathsper minute) ml

Connects maskto highconcentration oxygen the of

Adjustsflow rate to at least 15 litersper minute ventilation the patient the propervolumeand rate Continues of at

(800-1200ml per breath/l0-20 breathsper minute\

1 1 1

Nofe.'The examiner must ryitness ventilations for at least 30 seconds

Total: Critical Criteria 8

precautions isolation Didnottake,or verbalize, bodysubstance per Didnot adjustliterflowto at least15 liters minute proper per Didnotprovide volume breath

(more than 2 ventilationsper minute were below 800ml)

per breaths minute Didnotventilate patient a ratea 10-20 at the Didnotallow complete for exhalation

37

OXYGEN ADMINISTRATION

StartTime: StopTime:

Candidate'sName: Evaluator'sName: Points Possible 1 1 1 1 1 ,l 1 1

,l

Date:

Points Awarded

precautions body substance isolation fakes, or verbalizes,

Assembles regulator thetank the to

Cpensthe tank Checksfor leaks Checkstank pressure Attaches non-rebreather mask to oxygen Prefills reservoir

per liter Adjusts flowto 12liters minute greater or

Applies and adjusts the maskto the patient's face

Note: The examiner must advise the candidate that the patient is not tolerating the non-rebreather mask. The medical director has ordered you to apply a nasal cannula to the patient. Attaches nasal cannulato oxygen

1 1 1

per Adjusts flowto six (6)liters minute less liter or

nasalcannula the patient Applies to

Note:The examinermust advisethe candidate discontinueoxygentherapy to fromthe patient Removes nasal 1 the cannula

Shutsoff the regulator Relieves pressure the withinthe regulator Total:

1 I

15

Critical Criteria precautions Didnottake,or verbalize, bodysubstance isolation without Didnot assemble tankand regulator leaks the Didnot prefill reservoir the bag mask liter Didnotadjust device the correct flowfor the non-rebreather to the

(12liters minute greater) per or

liter Didnot adjust device the correct flowfor the nasalcannula the to

(6 liters minuteor /ess/ per

38

Start Time: Stop Time:

Candidate's Name: Evaluator's Name:

VENTILATORY MANAGEMENT ENDOTRACHEAL BATION INTU

Date:

Note: /f a candidatee/ecfs lo initially ventilate the patient with a BVM attached to a reservoir and oxygen, full credit must be awarded for steps denoted by " " " provided the first ventilationis delivered within the initial 30 seconds

Points Points Possible Awarded

precautions Takes verbalizes isolation bodvsubstance of

Spensthe airwaymanually

1 1

(oropharyngeal/nasopharyngeal Elevates patient's the tongue inserts simple a airuayadjunct ainray) 1 and Note:Theexaminer must now inform the candidate"no gag reflex is presentand the patient accepfs the airway adjunct."

" Ventilates patientimmediately the usinga BVM deviceunattached oxygen to ,l 1

** Hyperventilates patient roomair the with

Note:Theexaminermust now inform the candidatethat ventilationis beingproperly pertormed without difficulty Attaches oxygen the reservoir the BVM to 1

Attachesthe BVM to high flow oxygen (15 liter per minute) Ventilates patientat the propervolumeand rate (800-1200ml/breathand 10-20breaths/minute) the 1 1

Note: After30 seconds, the examiner must auscultatethe patient'schesf and inform the candidate that breath sounds are presentand equalbilaterally and medical direction hasordered endotrachealintubation. Theexaminer must now take over ventilationof the patient.

Directs to assistant hyper-oxygenate patient the ldentifies/selects properequipment endotracheal the for intubation Checks equipment 3hecksfor cuff leaks Sheckslaryngoscope operation and bulbtightness 1 1 1 1

Note:Theexaminer must remove the OPAand move out of the way when the candidateis prepared to intubatethe patient.

Positions patient'shead properly the Inserts laryngoscope the mouthwhiledisplacing patient's the bladeintothe patient's tonguelaterally Elevates patient's the mandible with the laryngoscope Introduces endotracheal the tube and advances tubeto the properdepth the nflatesthe cuff to the properpressure Disconnects syringefrom the cuff inlet port the Directs assistant ventilate oatient to the 1 ,l 1 1 I 1 1 1 1

proper placement theendotracheal by auscultation Confirms of bilaterally overtheepigastrium and tube Note:Theexaminermusf as& "lf you had proper placement,what would you expectto hear?"

Securesthe endotracheal tube (may be verbalized)

2',1 Critical Griteria Total: precautions Didnottakeor verbalize whennecessary bodysubstance isolation gloves interrupts ventilations greater Didnotinitiate or for than30 ventilation within seconds 30 after applying seconds anytime at (15 Didnotvoice provide oxygen or or high concentrations liter/minute greater) per Didnotventilate patient a rateof at least10breaths minute the at per permissible) per (maximum 2 errors minute of Didnotprovide adequate volume breath prior intubation Didnothyper-oxygenate patient the to intubate patient the within attempts 3 Didnotsuccessfully patient's fulcrum Usedthe teethas a proper over Didnotassure by bilaterally eachlungand overtheepigastrium tubeplacement auscultation (if tube the Thestylette used) extended beyond endof theendotracheal in that to Inserted adjunct a manner wasdangerous thepatient any portafterinflating cuff the fromtheinlet disconnect syringe the Didnotimmediately 39

VENTILATORY MANAGEMENT DUALLUMEN DEVICE INSERTION FOLLOWING AN UNSUCCESSFUL ENDOTRACHEAL INTUBATION ATTEMPT StartTime: Stop Time:

Name: Candidate's

Date: Pornts Points Possible Awarded

1

Name: Evaluator's precautions isolation Continues substance body

is ventilated 3onfirms patient beingproperly the with highpercentage oxygen Directsthe assistant hyper-oxygenate patient to the hecks/prepares airwaydevice the Lubricates distaltip of the device (may be verbalized) the

1

1 1 1

Note:The examinershould remove the OPAand move out of the way when the candidateis preparedto insert the device Positions patient's the headproperly 1

Performs tongue-jaw a lift 1

-

USES COMBITUBE

THEPTL E USES

Inserts devicein the mid-line the untilthe bite blockflangeis at the levelof the teeth Securesthe strap Blowsintotube#1 to adequately inflate both cuffs 1 1 1

Inserts devicein the mid-line and to the depthso ring is at the levelof the teeth thatthe printed Inflates pharyngealcuff the with the propervolume and removes syringe the Inflates distalcuff with the propervolumeand the removes syringe the

placement)lumen ventilates {ttaches/directs attachment BVM to the first(esophageal of and 1 placement Sonfirms and ventilation throughthe correctlumenby observing chestrise, 1 auscultation the epigastrium over and bilaterally over each lung Note: The examiner states, "You do not see rise and fall of the chesf and hear sounds only over the epigastrium." placement) Attaches/directs attachment BVM to the second(endotracheal of lumerr and ventilates placement Sonfirms and ventilatron throughthe correctlumenby observing chestrise, 1 auscultatron the epigastrium over and bilaterally over each lung Note: The examiner states, "You see rise and fall of the chest, there are no sounds over the epigastrium and breathsounds are equal over each lung." Secures deviceor confirms that the deviceremainsproperly secured 1

I

Total: CriticalCriteria

15

precautions Didnottakeor verbalize bodysubstance isolation Didnotinitiate ventilations within seconds 30 Interrupted ventilations more for than30 seconds anytime at Didnothyper-oxygenate patient prior placement theduallumen the to of airway device per permissible) Didnotprovide (maximum errors/minute volume breath adequate 2 per Didnotventilate patient a rateof at least10 breaths minute the at place Didnotinsert duallumen the within attempts airway device a proper at depth at theproper or 3 Didnotinflate bothcuffsproperly Combitube Didnotremove syringe immediately following inflation eachcuff the of the - Didnotsecure strapprior cuffinflation PTL the to Didnotconfirm, observing over over that by rise and chest andauscultation theepigastrium bilaterally eachlung, theproper lumen thedevice of wasbeing usedto ventilate patient the Inserted adjunct a manner wasdangerous thepatient in any that to

40

MANAGEMENT VENTILATORY NG ESOPHAG EAL OBTURATORAIRWAY INSERTIONFOLLOWI ENDOTRACHEAL INTUBATION ATTEMPT AN UNSUCCESSFUL

StartTime: StopTime:

Gandidate'sName:

Date:

Evaluator's Name:

Points Points Possible Awarded

1 1 1 1 1 1 1 ,l

precautions isolation body Continues substance

the high percentage oxygen Confirms patientis beingventilated

the to the Directs assistant hyper-oxygenate patient of ldentifies/selects proper equipment insertion EOA for the

Assembles EOA the Teststhe cuff for leaks

lnflates mask the

Lubricatesthe tube (may be verbalized)

Note:The examinershould removethe OPAand move out of the way when the is candidate prepared insertthe device to

Positions head properly the with the neckin the neutral slightly or position flexed

1 1 1 1 1 1

and the tongue Grasps elevates patient's andmandible

Inserts tube in the same direction the curvature the pharynx the as of Advances tube untilthe mask is sealedagainstthe patient's face the

Ventilates patient whilemaintaining tightmask-to-face a seal the

Directsconfirmation placement EOA by observing chest rise and of of for and overeach lung auscultation overthe epigastrium bilaterally

Alofe.'The examinermust acknowledgeadequatechest rise, bilateralbreathsounds and absenfsounds over the epigastrium pressure 1 nflates cuffto the proper the 1 )isconnects syringe fromthe inletport the 1 ventilation the patient of 3ontinues

CriticalCriteria precautions isolation Didnottakeor verbalize bodysubstance 30 Didnotinitiate within seconds ventilations at for than30 seconds anytime Interrupted ventilations more prior placement theEOA of to of the Didnotdirect hyper-oxygenation patient placethe EOAwithin3 attempts Didnotsuccessfully per Didnotventilate a rateof at least10breaths minute at permissible) per (maximumerrors/minute 2 Didnotprovide volume breath adequate placement auscultation proper bilaterally overtheepigastrium and by Didnotassure tube the Didnotremove syringe afterinflating cuff the ventilate patient the Didnotsuccessfully per (15 or high Didnotprovide flowoxygen liters mtnute greater) to in that Inserted adjunct a manner wasdangerous thepatient any

4t

Total:

17

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