Chapters 2 - 8 Flashcards
EMS
coordinated network of personnel and resources designed to provide emergency medical care and, when indicated, transport patients to an appropriate higher level of care; also expected to serve a role in the larger public health system through public education and prevention efforts
Timeline of EMS
- origin
- accomplishments beginning in 1960s
Originated in funeral homes bc they were the only ones to operate ambulances – however, conflicting ideals and inadequate patient care created demand for a new field to emerge
1966 National Academy of Science publishes “Accidental Death and Disability: the Neglected Disease of Modern Society” aka THE WHITE PAPER – marked the birth of modern EMS as it spotlighted inadequacies of prehospital care in the US, particularly related to trauma
Early 1970s, the US Dept of Transportation develops the first EMT National Standard Curriculum (and later, also the first paramedic NSC)
1980s, American Heart Assoc dramatically increases its emphasis on cardiovascular disease prevention, science, and education – this adds levels of training to the existing EMT / paramedic curriculum BUT there is a lack of unity in training from state to state
1990s, NREMT advocates for a national training curriculum; public access defibrillation and layperson training on the use of AEDs significantly increases survival of out-of-hospital cardiac arrest
2000s, four new levels of EMS licensure / certification are created. National standard implemented.
Components of the EMS system (5)
Clinical care: outlines the scope of practice and associated equipment
Medical direction: physician oversight of patient care
Integrated health services: prehospital service providers work cooperatively w hospital personnel to ensure continuity of care
Research: move toward EMS care based on evidence-based medicine
Legislation and regulation: ensures the EMS system conforms to various local, state, and federal requirements
Levels of training (4)
EMR (Emergency Medical Responder): provides basic, immediate care, incl bleeding control, CPR, AED, airway obstruction, and emergency childbirth
EMT (Emergency Medical Technician): incl all EMR skills + advanced oxygen and ventilation skills, pulse oximetry, non-invasive blood pressure monitoring, and administration of certain medications
AEMT (Advanced EMT): incl all EMT skills + advanced airway devices, intravenous and intraosseous access, blood glucose monitoring, and administration of additional medications
Paramedic: incl all preceding training levels + advanced assessment and management skills, various invasive skills, and extensive pharmacological interventions → highest level of prehospital care
Medical director
- online
- offline
physician responsible for providing medical oversight; oversees quality improvement
Online: direct contact btwn the physician and EMT via phone or radio
Offline: written guidelines and protocols
Quality improvement
continuous audit and review of all aspects of the EMS system to identify areas of improvement
EMT Roles and Responsibilities (12)
Equipment preparedness Emergency Vehicle Operations Establish and maintain scene safety Patient assessment and treatment Lifting and moving Strong verbal and written communication skills Patient Advocacy Professional development Quality improvement Illness and injury prevention Maintain certification and licensure
Patient Safety in “High Risk” Activities Conducted by EMTs (5)
Transfer of patient care Lifting and moving patients Transporting the patient in an ambulance; safety is the priority, not speed Spinal precautions Administration of medications
Scene Safety priorities
(in declining priority status): yourself, your partner(s), patients, and bystanders
Incl addressing scene-specific hazards, appropriate infection control precautions, and safe lifting and moving techniques
EMT Wellness
- physical
- mental
Physical: maintain a certain level of physical conditioning, get adequate sleep, and eat a healthy diet
Mental: stress management via recognizing the signs, balancing demands, addressing risk factors, and seeking out relaxing activities
CISM
Critical Incident Stress Management
formalized process to help emergency workers deal w stress; team is made of trained peer counselors and mental health experts → participants can, but are not required to, share their feelings
Meant to facilitate the process of dealing with critical incident stress; not as a critique of patient care or any other type of performance evaluation → information shared during a CISM session is confidential
Defusing sessions: within 4 hours of incident
Debriefing sessions: btwn 24 and 72 hours of incident
3 Types of Stress
Acute: immediate physiological and psychological reaction to a specific event; triggers the body’s “fight or flight” response
Delayed: stress reaction that develops after a stressful event; does not interfere w the EMT’s ability to perform during the stressful event → eg. PTSD
Cumulative: result of exposure to stressful situations over a prolonged period of time; can lead to burnout
Stages of Grief
Death always brings definite acceptance
Denial Anger Bargaining Depression Acceptance
Infectious diseases
caused by invading pathogen; can be transmitted through direct contact (eg. person-to-person) or indirect contact through a mediating object (eg. doorknob)
Bacterial: usually respond to prescription antibiotics → eg. strep throat
Viral: resistant to antibiotics → eg. flu
OSHA
Occupational Safety and Health Administration
oversees regulations concerning workplace safety, incl infectious disease precautions
Employers provide the necessary equipment / training for infection control, exposure reporting, and blood-borne pathogens; they also implement and reinforce infection control policies
Standard precautions
aka universal precautions / body substance isolation precautions; implemented for all patient contacts and are based on the assumption that all body fluids pose the risk of infection
Immediately reporting exposures to the designated infection control officer
Handwashing: most effective way at preventing the spread of infection; soap and water will always be preferred over hand sanitizer
PPE
PPE
personal protective equipment; vary based on exposure risk
Minimum: gloves and eye protection
Expanded: disposable gown and mask for significant contact w any body fluid; HEPA (high-efficiency particulate air) mask or N-95 respirator for suspected airborne disease exposure
Additional infection control guidelines (4)
Contaminated medical waste should be enclosed in special “biohazard” bags and disposed of according to local and federal guidelines
Disposable supples are intended for SINGLE PATIENT USE, thus reducing risk of exposure and are usually preferred to reusable equipment
Reusable equipment (eg stretchers and BP cuffs) must be properly cleaned w an approved disinfectant after every use
“Sharp” (eg needles) are placed in designated puncture-proof containers; should NOT be recapped before placing in an approved sharps container
Recommended Immunizations and Vaccines (6)
Regular Tuberculosis (TB) testing – at least annually
Hepatitis B vaccination series
Tetanus shot – every ten years
Flu vaccine – annual
MMR (measles, mumps, rubella) vaccine – as needed
Varicella vaccine – as needed
Upon encountering a hazardous materials (hazmat) incident, the EMT should … (5)
Maintain a safe distance and attempt to keep others out
Call for specially trained Hazmat responders
Look for placards without entering the scene, and utilize the Emergency Response Guidebook (ERG) to determine evacuation distance
Not enter a hazmat scene until cleared by a hazmat specialist
Not begin emergency until patients have been decontaminated or otherwise cleared by hazmat crews
Upon encountering a crime scene, the EMT should … (4)
Not enter a crime scene unless law enforcement has determined it is safe
Maintain a safe distance away until cleared by law enforcement; aka “Staging for PD”
Avoid any unnecessary disturbance of the scene
Remember and note the position of patient(s) and anything else touched at the scene during treatment
Upon encountering a sexual assault scene, the EMT should … (2)
Discourage patients from changing clothes or showering
Try to get a same-sex provider to assist with the patient care
Upon encountering a scene that requires special responses, the EMT should … (2)
Prepare for extrication situations by wearing highly reflective traffic safety vests when working on roadways, around traffic, or at an accident scene
These scenarios incl: downed power lines, fire situations, etc; terrorism; high angle rescue, swift water rescue, confined space rescue, etc
Safe lifting techniques
Power lift: keep object close to body; use the LEGS to lift, not the back (ie legs bent, back straight); use a power grip with PALMS UP and fingers wrapped around the object
Position the stretcher to reduce the height of the lift
Preplan the lift to reduce distance and avoid problems
Get enough help
define the following:
- emergency moves
- urgent move
- non-urgent moves
Emergency moves: used when the scene is dangerous and the patient must be moved PRIOR to providing patient care → incl the armpit-forearm drag, shirt drag, blanket drag
Urgent move: used when the patient has potentially life threatening injuries or illness and must be moved quickly for evaluation and transport
– Rapid extrication: used for patients in a motor vehicle; requires multiple rescuers and a long backboard → patient is rotated onto a backboard w manual cervical spine precautions and removed from the vehicle
Non-urgent moves: used when there are no hazards and no life threatening conditions apparent
Incl direct ground list, extremity lift, direct carry method, and draw sheet method
Log Roll Technique
commonly used to place a patient on a backboard or assess the posterior
Can be done while maintaining manual cervical spine precautions
Should have at least three trained personnel → person controlling manual cervical spine protection (ie at head of patient) should direct the log roll
Equipment for patient movement
- wheeled stretcher
- portable stretcher
- scoop stretcher
Wheeled stretcher: stretcher that secures in the ambulance for transport and is usually the safest way to move a patient; can accommodate at least 300 pounds
Portable stretcher: lightweight and compact stretcher that allows more accessibility than wheeled stretchers
Scoop stretcher: can be disassembled; allows for easy positioning with minimal patient movement, thus good for reducing patient discomfort vs other techniques
Equipment for patient movement
- stair chair
- backboard
- neonatal isolette
Stair chair: excellent for staircases, small elevators, etc; does not allow for manual cervical spine protection or artificial ventilation
Backboard: used primarily for cervical spine immobilization; lightweight and allows for CPR and artificial ventilation; requires a four person lift
Neonatal isolette: designed to keep neonatal patients warm during transport; requires specialized training to operate
Patient packaging for air medical transport (5)
If there is a hazardous material exposure, patient must be decontaminated before being loaded into the aircraft
Notify air medical crew ASAP of any special circumstances → eg. large patient, cardiac arrest patient, traction splint applied, combative patient, or unstable airway
Secure all loose equipment before approaching a running aircraft
Never approach the aircraft without pilot or air medical crew authorization
Never approach a rotor wing aircraft from the rear; never back up
Special consideration patients (3)
Bariatric / obese patients: increased risk to providers during lifting and movement; know what your equipment and team can handle; request additional assistance
Skeletal abnormalities: may pose a challenge to transportation without special equipment → eg. patients w unusual curvature of the spine (eg kyphosis or lordosis) may not be capable of lying supine without special padding
Pregnant patients: patients in the later stages of pregnancy SHOULD NOT be placed supine due to the risk of supine hypotensive syndrome; instead, place her on her left side
– If the patient has potential cervical spinal trauma, tilt backboard to the left about 20 degrees
Medical restraint
last resort; only forcibly restrain a patient if they pose a significant, immediate threat to you, your partner(s), or others
Anticipate and plan; request law enforcement assistance; know your local protocols; contact medical direction when possible
Use of force doctrine: the EMT must act reasonably to prevent harm to a patient being forcibly restrained; the use of force must be protective, not punitive
Guidelines of Medical restraint (7)
At least four people is recommended, so request additional help whenever possible
Use the MINIMUM amount of force necessary to protect yourself, the patient, and others
Secure the patient as supine, w a backboard if available – do NOT secure the patient in a prone position
Use soft, padded restraints – avoid handcuffs, flexi-cuffs, etc
Monitor the patient’s level of consciousness, airway, and distal circulation (below points of restraints) continuously
Thoroughly document the reason for restraining the patient, the method of restraint, the duration of restraint, and frequent reassessment of the patient while restrained
Do NOT ever restain a patient in the prone position, hogtie a patient, or leave a restrained patient unsupervised
Medical and Legal considerations
EMS providers operate under the license of their physician medical director(s).
EMS protocols have been based on practices and guidelines handed down by higher medical authorities and informed by EMS research (aka evidence-based medicine).
define the following:
- scope of practice
- standard of care
Scope of practice: outlines the actions a provider is legally allowed to perform based on his or her licensure or certification level – thus, not based on individual’s knowledge or experience
Standard of care: degree of care a reasonable person with similar training would provide in a similar situation; requires EMTs to competently perform the indicated assessment and treatment within their scope of practice
Sources that help establish the standard of care
National EMS education standards
State protocols and guidelines
Medical direction
EMS agency’s policies and procedures
Reputable textbooks
Care considered acceptable by similarly trained providers in the same community
Consent
- informed
- expressed
Informed: required from all patients who are alert and competent → patient must be informed of your care plan and associated risks of accepting or refusing care and transport
Expressed: also requires that the patient be alert and competent to give expressed consent; can be given verbally or nonverbally → not usually as in depth as informed consent; usually obtained for more basic assessments or procedures
Consent
- implied
- minor
- involuntary
Implied: allows assumption of consent for emergency care from an unresponsive or incompetent patient
– Special case: can be used to treat a patient who initially refused care but later loses consciousness or becomes otherwise incapacitated
Minor consent: minors are not competent to accept or refuse care; consent is required from a parent or legal guardian, but implied consent can be used if they cannot be reached and treatment is needed
Involuntary consent: used for mentally incompetent adults or those in custody of law enforcement; obtained from the entity with the appropriate legal authority
Advance directives
- DNRs
- living will
written instructions, signed by the patient, specifying their wishes regarding treatment and resuscitative efforts
DNR (do not resuscitate): do not affect treatment prior to the patient entering cardiac arrest
Living will: broader than DNRs; address health-care wishes prior to entering cardiac arrest, incl use of advanced airways, ventilators, feeding tubes, etc
Requirements for a legally recognized advance directive vary by state
EMT liability
- good samaritan laws
- criminal liability
- civil liability
Good samaritan laws: designed to protect someone who renders care as long as they are not being compensated and gross negligence is not committed
Criminal liability: involves a government entity taking legal action against a person
- Assault: intent to inflict harm; physical contact is not required
- Battery: physically touching another person without their consent
Civil liability: in a civil law, an individual (plaintiff) sues an EMT (defendant) for a wrongful act involving injury or damage → usually seeking monetary compensation
EMT liability
- negligence
- gross negligence
- one more
Negligence: most common reason EMS providers are sued civilly; plaintiff has the burden of proof, not the EMT → w negligence, the EMS provider is accused of unintentional harm to the plaintiff
Gross negligence: exceeds simple negligence bc it involves an indifference to, and violation of, a legal responsibility → incl reckless patient care
Hospital destination
EMT liability
- abandonment
- false imprisonment
- patient refusals
Abandonment: once care is initiated, EMS providers cannot terminate care without the patient’s consent; also incl the termination of care without transferring the patient to an EQUAL OR HIGHER medical authority
False imprisonment: incl transporting a competent patient without consent
Patient refusals: competent patients may refuse treatment regardless of the severity of their condition → in this case, an AMA (against medical assistance) form
What does the plaintiff have to provide as the “burden of proof” against the defendant? (4)
Duty to act: EMT had an obligation to respond and provide care
Breech of duty: EMT failed to assess, treat, or transport patient according to the standard of care
Damage: plaintiff experienced damage or injury recognized by the legal system as worthy of compensation
Causation: aka proximate cause; injury to plaintiff was, at least in part, directly due to the EMT’s breech of duty
What factors go into choosing a hospital destination? (5)
Patient’s request or medical direction → when in doubt, consult medical direction
Closest appropriate facility or specialty facility
Written protocols or triage guidelines
Hospital diversion or bypass
Note: a patient’s ability to pay should NOT factor into where a patient is transported; remember to thoroughly document why the destination was chosen
What defines the “competency” of a patient?
What is competency affected by?
ANO4; alert and oriented on four levels
Person: knows their own name
Place: knows where tehy are
Time: knows the date and time
Event: knows their present circumstance → ie “why are you here”
–
Age → are they of legal age for their event
Mental impairment by illness, injury, drugs, alcohol
Communication barriers, either in language, sight, or hearing
What information about a patient can an EMT release?
Most cases, cannot release patient info without written consent
Special cases:
- -When information is necessary for continuity of care or for billing services
- When a valid subpoena is received
- When required to report possible crimes, abuse, assault, neglect, certain injuries, or communicable disease
HIPAA
Health Insurance Portability and Accountability Act
est in 1996; improved privacy protection of patient health care records by giving patients greater control on how their records are used and transferred
COBRA + EMTALA
COBRA (Consolidated Omnibus Budget Reconciliation Act) + EMTALA (Emergency Medical Treatment and Active Labor Act)
incl federal regulations guaranteeing public access to emergency care; also intended to stop the inappropriate transfer of patients (aka “patient dumping”)
Interfacility transports guidelines (4)
Obtain a patient report from the transferring facility before departing
Confirm the exact destination location, incl department or admitting physician
Make sure the patient’s condition does not exceed scope of practice
Obtain consent from the patient or guardian
Death determination
Protocols vary; when in doubt, consult medical direction
Signs of death can be presumptive or definitive:
- Presumptive: not dead yet but without intervention, will be → indicates a need to begin resuscitation and incl unresponsiveness, pulselessness, and apnea (lack of breathing)
- Definitive: aka obvious signs of death; indicate that intervention efforts do not need to be initiated
Four types of definitive death
Decomposition: physical decay of the body’s components
Rigor mortis: stiffening of the body after decay
Dependent lividity: settling of blood within the body
Decapitation: patient’s head is no longer attached to the body
For what situations do you inform law enforcement or medical examiners? (6)
Any scene where the patient is DOA (dead on arrival) Suicide atempts Assault or sexual assault Child abuse or elder abuse Suspected crime scene Childbirth
EMS communication
- therapeutic
- interpersonal
relate to mobile-based communications w dispatch, medical direction, other EMS workers, etc
Therapeutic: refers to interactions with the patient and ability to obtain clinical information
Interpersonal: ability to send and receive information btwn at least two people
Devices used in communication
- base station
- repeater
Base station: transmitter / receiver in a fixed location that is in contact w all other components in the radio system
Repeater: type of base station that receives low power transmissions from portable or mobile radios and rebroadcasts at higher power to improve range
Devices used in communication
- portable radios
- mobile radios
Portable radios: hand-held transmitter / receiver w a very limited range, unless used w a repeater
Mobile radios: vehicle-mounted transmitters and receivers; greater range than portable radios but distance is still limited unless used w a repeater
Devices used in communication
- mobile data computers
- cellular phones
Mobile Data computers (MDCs): relay digital information instead of voice transmissions; can display the address of the call and routing information; allow digital communication w dispitach and other responding units; reduce the volume of routine radio traffic
Cellular phones: quickly replacing radios; good for easy, clear, and inexpensive means of communication BUT incl potential unreliability in communication during peak demands or a mass casualty incident
FCC
Federal Communications Commission
regulates all radio operations in the US and has allocated specific frequencies for EMS use only
Guidelines for Radio Communication
specifically, Communication w dispatch
Confirm receipt of dispatch → “copy”
Notify dispatch when en route to call, on scene, en route to hospital, and at the hospital
Do’s and don’ts of radio communication
DO …
- Make sure you are on the correct frequency
- Ensure there is no other radio traffic before transmitting
- Depress the transmit button and WAIT ONE SECOND BEFORE SPEAKING
- Identify who you are talking to first, THEN who you are → eg. “Dispatch, this is Medic 1”
- Use clear text, not radio codes unless approved locally
- Use affirmative / negative rather than yes / no
- Always “echo” orders from medical direction to confirm accuracy
DO NOT …
- Use unnecessary verbiage (eg please, thank you)
- Relay protected information (eg patient’s name)
Communication w Medical Direction
Requires strong verbal communication skills bc details matter and mutual understanding is critical – you will be relaying a lot of information in a very short period of time
Objective information only – no subjective opinions
order of relaying info to medical direction
Relay patient information from high to low priority order → as follows:
Unit designation, certification level, destination, estimated time of arrival
> Patient’s age, sex, and chief complaint
> Patient’s level of consciousness
> History of present illness or mechism of injury
> Any associated symptoms or pertinent negatives
> Patient’s vitals
> Patient’s physical examination
> Patient’s history, medications, and allergies
> Treatment provided and response to treatment
> Any requests for additional interventions
> Echo any orders provided by medical direction
transfer of care
recall that it must be to an EQUAL OR HIGHER medical authority
Verbal report: provide all relevant information as a radio report, incl any chances since the radio report
Written copy of patient care report must also be provided
Establishing rapport w the patient
Introduce yourself Ask for the patient’s name and USE IT Make eye contact with the patient Be HONEST, not kind Use age appropriate techniques Be aware of special needs of the patient Respect cultural differences
Guidelines to questioning patients
LISTEN
Ask patients the most important questions first
Open ended questions are preferred to close ended ones bc they can yield more information about the patient’s situation → eg. “Can you tell us what’s wrong today” instead of “are you having chest pain”
Close ended ones are only when you need specific information or the patient is unable to provide longer answersAvoid judgemental or biased questions
Components of Therapeutic Communication
the 5 C’s Compassion Competence Confidence Conscience Commitment
PCR
+ purpose
patient care report; legal document that becomes a part of the patient’s permanent medical record
Purposes of PCR: -- Continuation of care -- Legal documentation Billing -- Research and continuous quality improvement
PCR rules 1-5
Rule #1: If you did it, write it down; if you didn’t do it, then don’t write it down and definitely DON’T write down that you did.
Rule #2: It is much better to document well than to explain later why you didn’t.
Rule #3: Accurate timing and relevant documentation is one of the best defenses for an EMT defendant in court.
Rule #4: Document objectively, not subjectively
Rule $5: Spelling counts; if there are more than two errors in a handwritten PCR, start over if time permits.
Minimum Data Set
identifies the information that should be incl on every PCR
Times: of dispatch, en route to call, arrival to call, patient contact, en route to hospital, arrival to hospital, transfer of care
Patient information: age, sex, chief complain, level of consciousness, minimum of TWO sets of vital signs, all assessments completed on patient, all treatments provided and the patient’s responses to that treatement
Administrative information: address of call, date of call, unit designation, name or identifying number and certification level of all EMS providers on the call
Narrative: where the EMT “paints a picture” of what happened; first place readers will go to in order to begin understanding the nature of a call
FACT Documentation
Factual
Accurate
Complete
Timely
objective vs subjective documentation + example
Objective documentation: based on facts, findings, or observations that are highly difficult to dispute
Subjective documentation: based on opinions or perceptions and can be easily disputed → subjective information from the patient should be documented in quotations
Eg. Objective “Patient states he drank two beers this evening” vs. Subjective “Patient intoxicated”
associated symptoms vs pertinent negative signs
Associated symptoms: patient complaints in addition to the chief complaint → eg. Chief complain is chest pain, but the patient also complains of mild difficulty breathing
Pertinent negative signs: signs or symptoms you have reason to suspect but the patient denies having → eg. patient has experienced trauma but denies neck pain
Errors and Falsifications in a PCR
+ 2 types of errors
Draw a single line through the middle of any mistake(s); initial it and make the correction
Intentional falsification of a PCR jeopardizes patient care and are grounds for termination
Errors of omission: something that should’ve been incl was left out of PCR
Errors of commission: something incorrect was incl on the PCR
what do you do when a patient refuses care?
Document patient’s competency, your assessment, any treatment given to the patient (and their response), at least two sets of vitals, your recommendation of the patient to be treated / transported, your discussion about the possible risks of refusing treatment (and their understanding), your discussion with medical direction, your recommendation to the patient to call again if they change their mind or their condition worsens, their signature on the refusal form, a witness signature on the refusal form (cannot be a fellow EMS provider)
Electronic PCRs
Advantage: improvement of data storage and retrieval; improved ability to use PCR information for CQI and research; now the standard of EMS
Cons: software design can sometimes not be user-friendly or detailed enough to capture all necessary information; transfer of e-PCRs during transfer of care can be challenging
Special reporting situations
Mass casualty incidents → may result in triage tag being the only documentation of patient care
Suspected cases of abuse or criminal activity
Animal bites
define the following:
- anatomy
- physiology
- pathophysiology
- homeostasis
- anatomical position
Anatomy: study of the body’s structure
Physiology: study of the body’s function
Pathophysiology: study of disease
Homeostasis: state of balance or equilibrium within the body
Anatomical position: body is in standing position w the arms at the side and palms forward (ie thumbs on the outside)
planes of the body (3)
Midline divides the body into left and right
Transverse: divides the body into top and bottom at the level of the umbilicus (belly button)
Frontal plane: divides the body into anterior and posterior
paired directional terms (4)
Anterior / ventral (front) vs posterior / dorsal (back)
Superior (top) vs inferior (bottom)
Proximal (closer to point of attachment) vs distal (farther)
Medial (close to midline) vs lateral (far)
Terms of movement
Abduction: movement away from the midline
Adduction: towards
Extension: straightening the joint (increasing the angle of the joint)
Flexion: bending the joint (decreasing)
body positions (4)
Supine: lying on your back, face up
Prone: lying on your stomach, face down
Fowler: seated w the head elevated
Recovery: lying on the left or right side
Abdominal quadrants
Based on the intersection of the midline and transverse line; left and right are always in reference to the PATIENT’s left and right
what organs / structures does the LUQ contain
Left upper quadrant (LUQ): left portion of the liver, the larger portion of the stomach, the pancreas, left kidney, spleen, portions of the transverse and descending colon, and parts of the small intestine
what organs / structures does the RUQ contain
Right upper quadrant (RUQ): right portion of the liver, gallbladder, right kidney, a small portion of the stomach, portions of the ascending and transverse colon, and parts of the small intestin
what organs / structures does the LLQ contain
Left lower quadrant (LLQ): majority of the small intestine, some of the large intestine, the left female reproductive organs, and the left ureter
what organs / structures does the RLQ contain
Right lower quadrant (RLQ): cecum, appendix, part of the small intestines, the right female reproductive organs, and the right ureter
define the following:
- skeletal system
- axial skeleton
- appendicular skeleton
Skeletal system: provides shape, allows movement, and protects the internal organs → there are 206 bones in the human body Incl tendons (connect bone to muscle), ligaments (connect bond to bone), and cartilage (connective tissue that allows smooth movement in joints)
Axial skeleton: primarily consists of the skull, spinal column, and rib cage (thoracic cavity)
Appendicular skeleton: incl the bones of the arms, legs, and pelvis
Skull bones (9)
Frontal Bone: aka forehead
Parietal bone: top of head, btwn frontal and occipital bones
Occipital bone: posterior portion of the skull
Temporal bone: lateral bones, above the cheekbones
Maxillae: forms the upper jaw, above the upper teeth
Mandible: movable portion of the lower jaw
Zygomatic bone: cheekbones
Nasal bone: nose
Foramen magnum: opening in the occipital bone where the brain connects to the spinal cord
Spinal column
central supporting structure; protects the spinal cord; consists of 33 vertebrae (9 of which are fused)
Cervical spine: C1 thru 7 = 7 total Thoracic spine: T1 thru 12 = 12 total Lumbar spine: L1 thru 5 = 5 total Sacrum: 5 fused Coccyx: 4 fused
Thoracic cavity
houses the heart, lungs, trachea, esophagus, and great vessels
Sternum: breastbone
Manubrium: upper portion of sternum
Body: middle portion of the sternum
Xiphoid process: inferior tip of the sternum
shoulder girdle
formed by the clavicle (collarbone), scapula (shoulder blade), and humerus (upper arm)
arm bones
Humerus: upper arm Radius: lateral bone of the forearm (thumb side) Ulna: medial bones of the forearm Carpal bones: wrist Metacarpals: base of the fingers Phalanges: fingers
Pelvis
ring shaped structure formed by three bones
Illium: upper portion of the pelvis
Ischium: lower
Pubis: anterior
leg bones
Femur: thigh bones; strongest bone in the body
Patella: kneecap; not found in babies bc formed during crawling stage
Tibia: medial bone of the lower leg; aka shinbone
Fibula: lateral bone of the lower leg
Tarsal bones: ankle
Metatarsal: base of the toes
Phalanges: toes
Joints
exists where two long bones come together
Symphysis: joint w limited motion
Ball and socket joint: joint where the distal end is capable of free motion → eg. shoulder
Hinge joint: joint where bones can only move uniaxially → eg. knee
Three types of muscle
Smooth: involuntary muscle located within the blood vessels and digestive tract
Skeletal: voluntary muscle that attaches to the skeleton
Cardiac: heart muscle; involuntary
Types of skeletal muscle
Biceps: anterior humerus Triceps: posterior humerus Pectoralis: anterior chest Latissimus dorsi: posterior chest Rectus abdominis: abdominal muscles Quadriceps (four muscles): anterior femur Biceps femoris: posterior femur; part of the hamstring muscle Gluteus (three muscles): buttocks
Respiratory system
- upper airway components
- lower
provides the body w adequate oxygen and eliminates waste products (eg CO2); helps regulate pH levels to assist in maintain homeostasis
Upper airway: nose, mouth, nasopharynx (upper part of throat behind the nose), oropharynx (behind the mouth), larynx (voice box), epiglottis (valve that protects the opening of the trachea)
Lower airway: trachea, carina (where the trachea ends and bronchi begin), left and right mainstem bronchi (primary brances of the trachea leading to the left and right lungs), bronchioles (smaller branches of the bronchi), alveoli (only place for gas exchange bc alveoli are in contact w pulmonary capillaries), surfactant (keeps the alveoli from collapsing)
EMT considerations for diff parts of the airway
Most of the manual airway techniques and mechanical airway adjuncts used by the EMT are designed to clear and protect the upper aiway
Foreign-body airway obstruction (FBAO) is a concern for the EMT bc the rongue is by far the most common cause of upper airway obstruction
Muscles of breathing
Diaphragm: primary muscle of respiration; separates the thoracic cavity from the abdominal cavity; usually under involuntary control, but can also be controlled voluntarily; Esophagus and great vessels pass thru the diaphragm→ dome shaped until it contracts during inhalation
Intercostal muscles: located btwn the ribs; contract during inhalation to expand the thoracic cage
Lung expansion
Pleura: two thin, smooth layers of tissue w thin film of fluid in btwn to allow frictionless movement across one another
- Visceral: lines the outer surface of the lungs
- Parietal pleura: lines the inside surface of the best cavity
During inhalation, the diaphragm contracts and moves down, pulling the parietal pleura and thus also pulling the visceral pleura, thus pulling the lungs and increasing its volume; this causes the pressure in the lungs to be less than the environmental air pressure, causing environmental air to rush in → aka negative pressure inhalation
– During exhalation, the diaphragm and muscles relax, contracting the thoracic cage, increasing the pressure and expelling air
define the following:
- inhalation
- exhalation
Inhalation: Active process and requires energy → Atmospheric air contains 21% oxygen
Exhalation: Passive process and does not require energy → Exhaled air contains 16% oxygen
define the following:
- external respiration
- internal respiration
- cellular respiration
External respiration: exchange of oxygen and CO2 btwn the alveoli and the pulmonary capillaries
Internal Respiration: gas exchange btwn the body’s cells and the systemic capillaries
Cellular respiration: aka aerobic metabolism; uses oxygen to break down glucose to create energy
Carbon Dioxide drive vs hypoxic drive
CO2 drive: primary mechanism of breathing control for most people bc brainstem monitors CO2 levels in the blood and the cerebrospinal fluid → high CO2 levels will stimulate an increase in respiratory rate and tidal volume
Hypoxic drive: backup system to the CO2 drive based off specialized sensors in the brain, aorta, and carotid arteries that monitor oxygen levels → low oxygen levels stimulate breathing but is generally less effective than CO2 drive
Lung volumes
- tidal volume
- residual volume
- reserves
- dead space
- minute volume
Tidal volume: amount of air inhaled or exhaled in one breath
Residual volume: amount of air in the lungs after completely exhaling; this volume keeps the lungs open
Inspiratory and expiratory reserve volume: amount of air you can still inhale or exhale after a normal breath, respectively
Dead space: amount of air in the respiratory system not incl the alveoli
Minute volume: respiratory rate times tidal volume
Normal breathing
non-labored, regular rhythm, clear and equal breath sounds bilaterally (ie in each lung); normal rate and tidal volume
For adults: 12 to 20 breaths per minute (bpm)
For pediatric patients (kids): 15 to 30 bpm
For infants: 25 to 50 bpm
Abnormal breathing
- info + 5
abnormal rate or tidal volume; labored breathing; abnormal skin color; abnormal, diminished or absent lung sounds; unequal rise / fall of the chest
Muscle retractions: intercostal (btwn the ribs), supraclavicular (above the clavicles), use of abdominal muscles
Tripod position: seated, leaning forward, and using the arms to help breath
Agonal breaths: dying gasps; slow and shallow; will not move air into alveoli
Nasal flaring: enlargement of the nostrils during breathing
Apnea: no breathing at all
Heart
muscular organ w two pumps (one on either side), divided by a septal wall
Left: receives oxygenated blood from the lungs and sends it throughout the body; stronger of the two pumps bc has a greater workload than the right (ie has to pump blood through entire body vs just to the lungs that are adjacent to the heart)
Right: receives deoxygenated blood from the body and sends it to the lungs in order to drop off CO2 and pick up oxygen on its way to the left heart
Heart receives its blood flow from the coronary arteries, which branch off of the aorta → Heart is extremely intolerant of a lack of oxygen
Four layers of the heart
Endocardium: smooth, thin lining on the inside of the heart
Myocardium: thick muscular wall of the heart
Epicardium: outermost layer of the heart and innermost layer of the pericardium
Pericardium: fibrous sac surrounding the heart
Chambers of the heart
Atria: upper chambers; receives blood from the body (right) or the lungs (left); pumps blood into the ventricles just before the latter contracts, providing the “atrial kick” that helps to increase cardiac output
Ventricles: lower chambers; larger than atria; send blood to the lungs (right) or the body (left); usually generates a palpable pulse
Cardiac conduction system
- 3 diff electrical impulse origins
heart has its own electrical system that generates electrical impulses to stimulate contraction of the heart muscle
Sinoatrial (SA) node: primary pacemaker; normally generates 60 to 100 impulses per minute in the adult (thus yielding a heart rate of 60 to 100 beats per minute)
Atrioventricular (AV) junction: backup pacemaker; generates 50 to 60 impulses per minute
Bundle of His: final pacemaker that usually receives impulses from the other two to transmit through the ventricular heart muscles; otherwise, generates impulses at only 20 to 40 impulses per minute
Cardiac output / circulation will cease if the heart is unable to generate electrical impulses or if the heart muscle is too damaged to respond to the impulses
Myocardial contractility
- preload
- afterload
heart’s ability to contract → adequate contractility requires adequate blood volume and muscle strength
Preload: precontraction pressure based on the amount of blood RETURNING to heart → increased preload leads to increased stretching of the ventricles and increased myocardial contractility
Afterload: resistance the heart must overcome during ventricular contraction to EXPEL blood from the heart → increased afterload leads to decreased cardiac output
Pathway of blood
oxygen rich blood leaves heart via right semilunar valve and aorta
> aorta branches off into arteries, then arterioles, then capillaries
> capillaries are location of gas exchange, thus blood becomes oxygen poor here
> capillaries feed into venules, then veins
> oxygen poor blood enters the heart via the superior or inferior vena cava
> passes through the right atrium, right tricuspid valve, right ventricle
> expelled to the lungs via right semilunar valve and the pulmonary artery
> lungs are location of gas exchange, thus blood becomes oxygen rich again here
> return to the heart via the pulmonary vein
> passes through the left atrium, left tricuspid valve, and left ventricle
> expelled into the aorta to begin cycle once more
functions of arteries and veins
Artery for blood moving AWAY from heart; veins for blood moving TOWARD the heart
Pulmonary artery is the only artery to carry deoxygenated blood
Pulmonary vein is the only vein to carry oxygenated blood
Systemic vascular resistance
resistance to blood flow throughout the body, excluding the pulmonary system → determined by the size of blood vessels
Constriction: reduced diameter of blood vessels; increases SVR and can cause an increase in blood pressure
Dilation: increased diameter … decreases SVR … decrease in BP
Arterial pulses
- central (2)
- peripheral (3)
Central pulses:
- Carotid: can be felt by palpating the carotid artery in the neck during contraction of the left ventricle
- Femoral: femoral artery in the groin area
Peripheral pulses:
- Radial pulse: palpated in the wrist on the radial (thumb) side
- Brachial pulse: medial portion of the upper arm, beneath the biceps muscle; can also be felt on the anterior medial area of the arm where the humerus meets the forearm (elbow area)
- Dorsalis pedis: palpated on top of the foot
Components of blood (4)
Plasma: liquid component of blood; made mostly of water
Red blood cells: aka erythrocytes; oxygen carrying component of blood
White blood cells (leukocytes): fight infection by defending against invading organisms
Platelets: essential for clot formation to stop bleeding
define the following:
- blood pressure
- perfusion
Blood pressure: measurement of the pressure exerted against the walls of the arteries
- Systolic: blood pressure exerted during contraction of the left ventricle
- Diastolic: BP in btwn contractions
Perfusion: flow of blood throughout the body
- Adequate perfusion means blood flow is adequate to all the tissues and organs in the body
- Inadequate perfusion (hypoperfusion or shock) means blood flow has been compromised to the point that the entire body is at risk
Central nervous system
- definition and function
- cerebrum
- cerebellum
- brain stem
- spinal cord
incl brain and spinal cord; command and control portion of the nervous system; brain receives information from the peripheral nervous system, makes decisions, and sends orders back
Cerebrum: largest part of the brain; controls thought, memory, and the senses
Cerebellum: coordinates voluntary movement, fine motor function, and balance
Brain stem: incl midbrain, pons, and medulla; controls essential body functions, such as breathing and consciousness
Spinal cord: communication bridge btwn the brain and PNS; contains cerebrospinal fluid (CSF), which is a clear fluid in and around brain and spinal cord; cushions the CNS and filters contaminants
Peripheral nervous system
incl all other nervous system structures outside of CNS, incl cranial and peripheral nerves; sends info to the CNS and carries out orders from it
Sensory division: sends sensory info to the CNS
Motor division: receives motor commands from the CNS
- Somatic: voluntary portion of the PNS
- Autonomic: involuntary
- —– Sympathetic: FIGHT OR FLIGHT; exerts greater control in times of stress or danger
- —– Parasympathetic: REST AND DIGEST; exerts greater control in times of rest, digestion, or reproduction
Integumentary system
aka SKIN
Epidermis: outermost later; two layers
- Germinal layer: produces new cells and pushes them to the surface; the cells die en route to the surface
- Stratum corneal layer: top epidermal layer and consists of dead skin cells
Dermis: contains blood vessels, nerve endings, sweat glands, and hair follicles
Subcutaneous tissue: fatty tissue; deepest layer of the integumentary system, just above the muscle layer
Abdominal cavity
- definition
contains numerous organs of digestion and excretion; separated fr thoracic cavity by the diaphragm and continues inferiorly into the pelvic cavity (thus the two continuous cavities are sometimes referred to as the abdominopelvic cavity)
Abdominal cavity
- esophagus
- stomach
Esophagus: collapsible digestive structure running from mouth to stomach; resides posterior to the trachea
Stomach: hollow digestive organ in the LUQ; receives food, begins breaking it down, and sends it to the small intestine
Abdominal cavity
- liver
- gall bladder
Liver: solid organ that occupies the most of RUQ; helps to bread down facts, filter toxins, and produce cholesterol
Gall bladder: hollow organ positioned beneath the liver; collects and stores bile from the liver and releases it into the intestine for use in digestion
Abdominal cavity
- small intestine
- large
Small intestine: hollow organ that absorbs nutrients and water → duodenum, jejunum, ileum
Large intestine: hollow organ, incl the colon and rectum; occupies the outer border of the abdomen; absorbs water and forms fecal matter → cecum, the ascending (right) colon, the transverse (across) colon, the descending (left) colon and the sigmoid colon, which connects to the rectum
Abdominal cavity
- appendix
- spleen
- kindyes
Appendix: hollow organ in the RLQ; can become easily obstructed, causing inflammation, rupture, and life-threatening infection
Spleen: solid organ w little protection in the LUQ; filters the blood thus has a rich blood supply and can be the source of severe internal bleeding
Kidneys: solid organ that is part of the urinary system; control fluid balance, filter waste, and control pH balance
endocrine system
system of glands that secrete hormones into the blood to help regulate body functions; responsible for insulin production and regulation of blood glucose levels
Urinary system
filters waste from the blood thru the kidneys; controls fluid balance in the body; also controls pH (acid-base balance) to maintain homeostasis
Ureters are tubes connecting each kidney to the bladder → thus, urine moves from the kidneys thru the ureters to the bladder, then thru the urethra and out of the bod
structures involved in reproductive system
Males: testicles, penis, sperm, prostate gland
Females: ovaries, fallopian tubes, and vagina
Cellular energy and metabolism
- aerobic
- anaerobic
ATP (Adenosine triphosphate): the body uses oxygen to convert nutrients into cellular energy; aerobic respiration generates more energy than anaerobic
Aerobic metabolism: most efficient method of energy production; heart and brain will cease to function without oxygen, and the lungs / kidneys are also very sensitive to a lack of oxygen → waste products are water and carbon dioxide, which are removed from the body via the respiratory and urinary system
Anaerobic metabolism: creation of energy without adequate oxygen supply; most of the body has the capacity to “switch over” to this when necessary as the body will triage the oxygen supply to supply more critical areas → byproducts are lactic acid, which take longer to be removed from the body and cannot be completed without a return to aerobic processes
Anatomical differences btwn children and adults (5)
Pediatric tongue is larger in proportion to the airway
Pediatric airway is more easily obstructed
Pediatric head is large in proportion to the body
Lungs are smaller in children, thus tidal volume during artificial ventilation is reduced and risk of gastric distension is higher
Oxygen reserves in children / infants are lower than adults; they also have a higher metabolic rate → thus hypoxia and bradycardia are more common
Normal physiology of neonates
Typical newborn weight is about 6 to 8 pounds (3 to 3.5 kilograms) → will typically double by six months and triple by about one year
Newborn’s head makes up about 25% of the body and is a significant source of heat loss
– Fontanelles (soft spots) will be fully fused by 18 months → depressed fontanelles may be indicative of hypovolemia (decreased volume of circulating blood)
Infants are often nose breathers and can develop respiratory distress easily → rapid breathing can lead to fluid and heat loss; hyperventilation of infants present significant risk of barotrauma (injury caused by a change in air pressure, esp of the ear or lung)
Neonates typically have …
Startle reflex: open arms wide, spreading fingers
Grip reflex: grips when something placed in palm
Rooting reflex: turns toward a touch to the cheek
Sucking reflex: stimulated by touching the lips
Infants at 6 vs 12 months typically ….
@ 6 months: typically begin teething, can sit upright, and track objects visually
@ 12 months: typically know their name, recognize parents or caregivers, walk w assistance, and speak a few words; however, still communicate distress primarily thru crying
Physiology of toddlers → infants
As the immune system develops, children at this age typically experience a number of minor colds / viruses / flu like symptoms / respiratory infections / etc
Fine motor skills improve and brain grows rapidly in size
Recommendations when dealing w toddlers / preschool patients
vs. School age
vs. Adolescents
toddlers / preschool patients:
- Separation anxiety is common; allow the child to stay w the caregiver when possible
- Communicate directly w the child, not just the caregivers
- Choose your words carefully → they will probably be taken literally
- DO NOT LIE
Vs. School age children:
- Communicate in understandable terms but do not talk down to them
- Respect the privacy rights for this age group
Vs. Adolescents:
– For sensitive matters, talk w them without caregivers present when possible
Adult demographic things to know (4)
Accidental trauma is the leading cause of death in the young adult age
Mild physical decline typically develops in the middle age group → Continued physical and mental decline is common in late adulthood
Women typically experience menopause during middle adulthood
Older adults frequently have extensive medical histories and are on multiple medications
Years for each age group
Neonate / newborns: newborn from birth to one month of age
Infant: one month to one year of age
Toddlers: one to three years old
Preschoolers: three to six years old
School-age children: six to twelve years old
Adolescents: twelve to eighteen years old
Adulthood: eighteen years old onwards
- Early: 20 to 40 years of age
- Middle: 40 to 60
- Late: 60+
Respiration Rate for each age group
Neonate / newborns: 30 to 60 bpm Infant: 25 to 50 bpm Toddler: 20 to 30 bpm Preschoolers: 20 to 25 bpm School-age children: 15 to 20 bpm Adolescents: 12 to 20 bpm Adulthood: 12 to 20 bpm
Heart Rate for each age group
Neonate / newborns: 140 to 160 bpm Infant: 100 to 140 bpm Toddler: 90 to 140 bpm Preschoolers: 80 to 130 bpm School-age children: 70 to 110 bpm Adolescents: 60 to 100 bpm Adulthood: 60 to 100 bpm
Blood Pressure for each age group
Neonate / newborns: 70 systolic Infant: 90 systolic Toddler: 80 to 90 systolic Preschoolers: 90 to 110 systolic School-age children: 90 to 120 systolic Adolescents: 100 to 120 systolic Adulthood: 110/70 to 130/90 ;; systolic / diastolic ratio
