First Responder - St John Youth · signs acquisition, 3- lead ECG acquisition and IMIST- AMBO...

First ResponderStudent workbook

January 2014

CLINICAL DEVELOPMENT

First Responder Facilitator manual - Youth version

MAY 2014 - PILOT

FIRST RESPONDER FACILITATOR MANUAL2

Contents

DAY 1 Sessions 1 - 10 4

Session 1: Introduction and Overview 5

Session 2: Role of the First Responder 8

Session 3: Terminology and communication 13

Session 4: The primary survey 26

Session 5: The secondary survey 31

Session 6: Vital signs 35

Session 7: 3 lead ECG acquisition 56

Session 8: Patient questioning 63

Session 9: Handovers 66

Session 10: Knowledge Check 73


Session 1: Airway management 79

Session 2: Basic resuscitation 87

Session 3: Automated external defibrillation (AED) 93

Session 4: Full resuscitation 99

Session 5: Oxygen therapy 105

Session 6: Shock and trauma 113

Session 7: Haemorrhage control 122

Session 8: Fractures and dislocations 131

Session 9: Thermal problems 143

Session 10: Head and spinal injuries 147Session 11: Caring for yourself and your patient 159

Additional Considerations 162

Important Information 169

Issued by: Daniel Ohs, Head of Clinical PracticeAuthorised by: Norma Lane, Clinical and Community Programmes Director

Facilitator manual Issue No: 01Issue Date: April 2014

Document No: CDT450Review Date: March 2015

FIRST RESPONDER

FIRST RESPONDER 2 FACILITATOR MANUAL

FIRST RESPONDER Facilitator manual 3


Session 1: Recap 171

Session 2: Pain relief 173

Session 3: Respiratory emergencies and anaphylaxis 183

Session 4: Cardiac chest pain 204

Session 5: IM injections in other circumstances 209

Session 6: Other medical conditions 219

Session 7: Stretchers and carry chairs 226

Session 8: Knowledge check 233


Session 1: Knowledge check 238

Session 2: Full resuscitation simulation, burns simulation and skills station 241

Session 3: Anaphylaxis scenario, spinal injury scenario and skills station 249

Session 4: Hypoglycaemia scenario, motor vehicle accident scenario and skills station 257

Glossary 265

3FIRST RESPONDER FACILITATOR MANUAL


Day one: The basics

Timetable (approximate):

0830 Session 1 - Introduction and overview

0900 Session 2 - Role of the First Responder

0930 Session 3 - Terminology and communication

1030 Morning Tea

1045 Session 4 - The primary survey

1130 Session 5 - The secondary survey

1215 Lunch

1245 Session 6 - Vital signs

1445 Afternoon tea

1500 Session 7 - 3 lead ECG acquisition

1520 Session 8 - Patient questioning

1600 Session 9 - Handovers

1630 Session 10 - Knowledge Check



Lesson plan: Introduction and overview

Day one: Session one (30 minutes)

Learning objectives

The student will:

� Understand the structure of the First Responder course

� Understand expectations and standards of the First Responder course, including an explanation of any assessment and scenario based learning activities

� Understand the ground rules for the duration of the course relating to teamwork, integrity, professionalism and empathy

� Understand the health and safety procedures of the venue

Required equipment � First Responder facilitator manual

� First Responder student workbook

� FR Day One PowerPoint

� Projector & laptop

Suggested way to teach1 Discuss the health and safety features (fire evacuation, earthquake etc.) unique

to the environment you are presenting in (5 minutes)

2 Introduce yourself to the class and hand out the First Responder student workbook (5 minutes)

3 Have the students introduce themselves to the group stating a few facts about themselves and what they expect to gain from the course (10 minutes)

4 Run through the Introduction and role section of the FR Day One PowerPoint ensuring to explain the course structure and course objectives (10 minutes)



Introduction and overview

Day one: Session one

Course overviewWelcome to the St John First Responder Course. It is the foundation clinical course within St John. This workbook contains much of the essential information you will need to operate safely at First Responder level. To complete this course you are required to complete all activities throughout this workbook. At the end of the course, your tutor will check that this workbook is complete. Provided you have attended and fully engaged in all elements of the course, you will then be allocated your First Responder Course Certificate.

You should keep this workbook as a record of your learning, and as a point of reference for future revision.

Clinical GovernanceSt John and New Zealand Fire Service First Responders fall within the St John clinical governance structure. This means that provided treatment provision occurs in line with the principles taught on this First Responder course, responsibility for the treatment falls on St John (specifically the St John Medical Director). Where treatment provision occurs outside of the principles being taught on this course, the responsibility for that treatment rests with the individual. If the individual is in doubt, they should have a low threshold for seeking clinical advice.

It should be noted that some of the techniques taught on this course are different from what you may have been taught on other courses, specifically First Aid and Advanced First Aid courses. These differences are not clinically significant, and the differences are to allow First Responders to link more closely with the practice of the ambulance crews they will be working with.



Course scheduleThe approximate timetables for each day are listed at the start of each section. Some skills learnt during this course have a certain degree of clinical risk associated with them, and for this reason their teaching are reserved for Day Three and Four. The following provides an overview for each day:

� Day one - The Basics: This initial day covers the context and role of a First Responder, basics of patient assessment, status codes, identification of a ‘chief complaint’, communication and calling for help (including use of the Clinical Desk). Skills taught on this day will include primary and secondary surveys, vital signs acquisition, 3- lead ECG acquisition and IMIST- AMBO handovers.

� Day Two – This second day focuses on resuscitation, and basic trauma management, to include haemorrhage control, spinal management and fracture management. Skills taught on this day include manual airway manipulation, oropharyngeal airways (OPAs), bag mask ventilation, cardiopulmonary resuscitation (CPR), oxygen therapy, Automated External Defibrillation (AED), use of suction, dressings, Combat Application Tourniquets (CATs), cervical collar application and application of a Kendrick Extrication Device (KED).

� Day Three – The third day has more of a medical focus, overviewing common medical pathologies. Extrication and pain relief will also be covered. Skills taught on this day include FAST assessment, intramuscular injection, setting up of nebulised medication, administration of pain relief, and use of rigid lifting boards and other extrication devices as needed.

Day Four – Bringing It All Together: This final day brings together all skills taught over the previous three days with practical, scenario based application of skills learnt. Each scenario will be formally debriefed as a group. Scenarios include a full resuscitation, burns, anaphylaxis, spinal injury, hypoglycaemia and motor vehicle accident scenario.



Lesson plan: Role of the First Responder

Day one: Session two (30 minutes)

Learning objectives � Understand the role of the First Responder

� Discuss scope of practice

� Understand that First Responders do not have a delegated scope of practice

� State what skills a First Responder can use without supervision

� State what skills can be used out of scope

� Have an understanding of other ambulance clinical practice levels





� Whiteboard and whiteboard markers

Suggested way to teach1 Begin by brainstorming the student’s thoughts on their role as a First Responder

(5 minutes)

2 Referencing the First Responder facilitator manual, present the second part of the Introduction and role section of the FR Day One PowerPoint. This PowerPoint should be presented in an interactive way. Students should reference the First Responder student workbook during the presentation (15 minutes)

3 Depending on the apparent level of understanding from the class emerging from this presentation, ask the students questions to test their understanding. Have students place First Responder student workbooks on the desk while asking questions from the PowerPoint and workbook content (10 minutes).



Role of the First Responder

Day one: Session twoThe primary role of a First Responder is to identify and respond to immediately life threatening abnormalities in the community. This predominantly involves the First Responder providing good basic life support measures until support arrives from an ambulance, or supporting an ambulance officer with a higher clinical practice level to transport the patient to a medical facility.

This involves always:

� identifying problems with the primary survey

� providing immediate treatment for any deficits found with the primary survey

� recognising patient severity and calling for appropriate help.

And as appropriate

� identifying problems with the secondary survey and vital signs

� providing appropriate treatment within the limits of your knowledge and scope

� providing a succinct handover to the transporting ambulance crew or other appropriate medical professional

Scopes of practiceSt John and NZFS personnel do not have the legal authority to independently administer or supply controlled drugs or prescription medicines to patients. They may only do so using the St John Clinical Procedures and Guidelines (CPGs) under the delegated authority of the St John Medical Director. This is facilitated via the Standing Orders Regulations, 2002.

Personnel may only use the CPGs if they have been granted individual Authority to Practice (ATP). The St John Medical Director grants ATP to individual personnel at a specified practice level. Each practice level has a delegated scope of practice that lists the drugs and medicines that may be independently administered by personnel at that practice level. Delegated scopes of practice are listed in the introduction section of the CPGs.

First Responders are not allocated an individual ATP. This is an important concept for First Responders to understand with reference to administering medicines. There are two circumstances that First Responders are permitted to administer medicines These are:

1 The medication being administered is a general sale (over the counter) medication. In this circumstance the First Responder may advise the patient that they may choose to consume that medicine in line with the manufacturer’s instructions. Examples of this include paracetamol and aspirin.



2 The medication being administered is a specific prescription medicine (these are listed in the front of the CPGs). In this circumstance the First Responder must ensure:

• they have been formally taught, and are competent to administer that medicine

• they have permission to administer that medicine from the Clinical Advisor at the St John Clinical Desk (discussed specifically in Session Three), or a Medical Doctor at the scene of an incident.

We understand that this may be confusing to you at this stage of your course. Further details and clarification are available in the introduction section of the St John CPGs, and we will be discussing this in greater depth as the course progresses.

What skills can a First Responder use independently?

� 3 lead ECG acquisition

� Automated External Defibrillation

� Bag mask ventilation

� Combat Action Tourniquet (CAT)

� Dressings

� Kendrick Extrication Device (or equivalent)

� Limb realignment

� Manual airway manipulation

� Oropharyngeal Airway (OPA)

� Oxygen therapy

� Primary survey

� Secondary survey

� Splinting

� Suction

� Traction splint(s)

� Vital signs (respiratory rate, heart rate, blood pressure, SpO2, temperature, blood glucose levels, level of consciousness).

What skills can a First Responder use under direction (consultation)?

� Inhaled entonox

� Inhaled methoxyflurane

� Intramuscular adrenaline

� Intramuscular ceftriaxone

� Intramuscular glucagon

� Nebulised adrenaline

� Nebulised ipratropium

� Nebulised salbutamol

� Sublingual glyceryl trinitrate (GTN).



How do the St John Clinical Practice levels work?

There are four primary practice levels within St John, these are:

� First Responder: As discussed earlier this is the base clinical practice level within St John. There are currently three primary ways of achieving First Responder.

1 St John Operations: Complete the St John Operations Induction Course and the First Responder Course

2 St John Youth: Complete the St John Operations Induction Course (minus Ambulance Driving) and the two First Responder Course modules (note: upon joining Operations an Ambulance Driving Course must be completed)

3 New Zealand Fire Service First Response Brigades (as defined in the NZFS St John Memorandum of Understanding): Complete a New Zealand Fire Service ‘Recruit Course’ and the St John First Responder Course (note if that firefighter intends to join St John, a St John Operations Induction Course must be completed).

� Emergency Medical Technician (EMT): This is the first level to be issued with an ATP, thus this is the first level that is individually able to administer prescription medicines. There are currently three primary ways of achieving EMT:

1 Complete the National Diploma Course. This is a vocational course facilitated by St John, and consists of approximately 1200 hours of learning.

2 Complete the first 18 months of the Bachelor of Health Science in Paramedicine at Auckland University of Technology (AUT) or Whitireia Community Polytechnic. This is approximately 1800 hours of learning.

3 Negotiate recognition of current competency with the St John Clinical Development Team. This is usually reserved for people with professional qualifications and experience in a medical or pre-hospital equivalent field.

� Paramedic: This is the first level that is able to administer controlled drugs. There are currently two primary ways of achieving Paramedic:

1 Complete a Bachelor of Health Science in Paramedicine. In New Zealand this is facilitated by Auckland University of Technology (AUT) and Whitireia Community Polytechnic. This undergraduate degree is now the minimum requirement to achieve Paramedic in New Zealand. This is approximately 3600 hours of learning.

2 Negotiate recognition of current competency with the St John Clinical Development Team. This is usually reserved for people with professional qualifications and experience in a medical or pre-hospital equivalent field.



� Intensive Care Paramedic (ICP): ICPs are the top clinical level of Ambulance Officer within St John; they have a broad range of advanced pharmacology, invasive skills and clinical reasoning. There are currently two primary ways of achieving ICP:

1 Complete a recognised post graduate paramedic qualification. These are available through both Auckland University of Technology (AUT) and Whitireia Community Polytechnic. Post graduate studies are now the minimum qualifications needed to achieve ICP in New Zealand. This is approximately 600 hours of learning (plus 3600 hours until Paramedic level).

2 Negotiate recognition of current competency with the St John Clinical Development Team. This is usually reserved for people with professional qualifications and experience in a medical or pre-hospital equivalent field. This method of successfully gaining ICP ATP is now rare within St John.

Additional information:

� In order to gain an ATP at EMT, Paramedic or ICP, the student must be a member of St John

� For further information regarding what each specific practice level is able to do, see the St John CPGs.

Want further information?

� Contact us at [email protected]

� Check out the tertiary provider websites at:

http://www.aut.ac.nz/study-at-aut/study-areas/health-sciences/paramedic-and-emergency-management/paramedic

http://www.whitireia.ac.nz/courses/Pages/BachelorofHealthScience(Paramedic).aspx



Lesson plan: Terminology and communication

Day one: Session three (60 minutes)

Learning objectives � Understand what response priorities are allocated to ambulance incidents and

how those response priorities are determined

� Understand what the St John status codes mean and how to allocate these

� Discuss what a chief complaint is and how to identify these

� Identify the critical elements of a situation report for ambulance incidents

� Understand how to communicate directly with a St John Ambulance Communication Centre and Clinical Desk if required




� Vomiting and Chest Pain 111 Call

� Cardiac Arrest 111 Call


Suggested way to teach1 This lesson introduces key terminology to help students understand content

through the rest of the course materials. It is important to emphasize that while this new terminology may be confusing initially, it will become clearer as the course progresses.

2 Referencing the First Responder facilitator manual, present the Terminology and communication section of the FR Day One PowerPoint. This PowerPoint should be presented in an interactive way. Students should reference the First Responder student workbook during the presentation (60 minutes including the exercises described below).



3 During the PowerPoint presentation, you will be referred to two 111 call audios which should be played for students. During the audio calls you should make reference to the following (note we have deliberately removed names, addresses and identifiers from the audio files as these are real incidents):

• Vomiting and Chest Pain 111 Call:

- This is a normal 111 call that was randomly selected

- Initially the incident sounds like it is very unlikely to be life threatening, but it is very difficult to know whether the caller is actually comprehending questions from the call taker or not.

- Later it is revealed that the patient appears to have chest pain. It is at this point that ProQa latches onto the complaint (a potential threat to the primary survey). This incident triggered an urgent (red) response as a result of the chest pain.

- Acknowledge that communications center staff have one of the most difficult jobs within St John. This is a good example of an incident where it is extremely difficult to gain a true account of how unwell the patient is likely to be – so the balance of risk is in favour of ensuring this incident receives an urgent response.

• Cardiac Arrest 111 Call (this can be stopped after 3-4 minutes)

- The caller is very calm, this is very typical of the majority of 111 calls that are made to ambulance communications (irrespective of the circumstance). It is actually relatively uncommon to have a caller scream down the phone.

- The call taker is calm, and the quality of the instructions she is delivering are good.

- Notice how the call taker attempts to accelerate interventions for the patient, while maintaining control of the call

- Note how long it takes to actually start chest compressions. Reassure students that it is uncommon for it to take this long to start compressions.

- Remind students that there is a lot occurring concurrently during this call (incident is sent to dispatch, the dispatcher sends the closest resource, closest advanced life support, fire, and conducts an ‘all informed broadcast’, this is covered in more detail later in this session.

• Nancy is a 23 year old female who has called today because she has nonspecific abdominal pain, associated with transient shortness of breath (but not short of breath at the moment), the patients primary survey and vital signs are unremarkable.

• Phillip is a 63 year old male complaining of toothache. Your assessment of Phillip and his medical history is unremarkable



• Mike is a 48 year old cyclist who has come off a track and slid approximately 30 metres down a bank. The bank is 45 degrees and you have trouble getting down to him. When you arrive you discover that Mike has a bruised abdomen, painful pelvis, grossly factured femur (thigh bone), he is screaming and appears to be agitated (you cannot tell if this is owing to pain or a possible head injury.Additionally during the PowerPoint presentation, you will be referred to three exercises that the students need to complete, these are:

• Exercise 1: What status are the following patients? (5-10 minutes)

• Exercise 2: What chief complaint do the following patients have? (5-10 minutes)

• Exercise 3: Situation reports (5-10 minutes). Note the information for the sitreps is below:

4 Note: Students are welcome to work in small groups or in pairs during these exercises. Answers should be placed into the student workbook as evidence of completion. Model answers are in the facilitator manual under the questions.

5 All material must be completed prior to students being released for morning tea.



Terminology and Communication

Day one: Session threeBefore we get into the ‘nitty gritty’ hands on elements of being a First Responder, there are a number of elements that are important to understand, including:

� What happens when a 111 call comes in to the Ambulance Communications Centre

� How response codes are allocated and what these are

� What the ambulance sector status codes are and how these are allocated

� What a chief complaint is and how these are allocated

� What information needs to be passed to the Communications Centre

� Who and how to call for help

� What the Clinical Desk within Ambulance Communications is

� How to contact the Ambulance Communications Centre and/or the Clinical Desk.

Process for 111 calls:When a person dials 111 they will initially be connected with Telecom who ask the question ‘111 emergency, Fire, Ambulance or Police’? If the caller is after an ambulance they will be transferred to the next available call taker within an Ambulance Communications Centre. When available the system will automatically select an available call taker within the closest appropriate Ambulance Communications Centre. If no call takers are available in that Centre the call will divert to another Ambulance Communications Centre in another part of New Zealand. Currently there are three Ambulance Communications Centres in Auckland, Wellington and Christchurch.



DeterminantsOnce a call taker has been allocated, they answer the call and ask a series of scripted and prescribed questions using the Advanced Medical Priority Dispatch System (AMPDS). You will commonly hear this referred to as ProQa which is the electronic tool that runs AMPDS. The system will then identify a response determinant based on what appears to be the most life threatening or serious medical problem the patient is experiencing. There are 32 common response determinants and a number of specialised ones. The main response determinants include:

1 Abdominal Pain

2 Allergy

3 Animal attack

4 Assault

5 Back pain

6 Breathing problems

7 Burns or explosions

8 Carbon dioxide poisoning / Hazardous materials

9 Cardiac / respiratory arrest or death

10 Chest pain

11 Choking

12 Convulsions / seizures

13 Diabetic problem

14 Drowning / diving or SCUBA accident

15 Electrocution / lightning

16 Eye problems

17 Fall

18 Headache

19 Heart problems

20 Heat / cold exposure

21 Haemorrhage / laceration

22 Inaccesssible incident or other entrapments (non- vehicle)

23 Overdose / poisoning

24 Pregnancy / birth

25 Psychiatric / self-harm

26 Sick person

27 Stab / gunshot

28 Stroke

29 Transportation / traffic accident

30 Traumatic injuries

31 Unconscious / fainting

32 Unknown

It is important to understand that these are the main categories of determinants; there are literally hundreds of additional determinants that form subgroups of this main set. This determinant is determined by the information given to the call taker within Ambulance Communications. Each individual code has a predetermined response colour.



Response coloursResponse colours determine which incident a dispatcher is required to dispatch first, and whether an ambulance crew is required to respond under lights and sirens to an incident. The ambulance sector in New Zealand currently has five primary response colours; these are outlined in the table below.

Colour What it is for What happens in Comms

PURPLE

Respond under lights and siren

Immediately life threatening

emergencies

Examples:

� Cardiac arrest

� Hanging

1 Dispatch closest resource immediately

2 Dispatch PRIME, First Response Unit and FIRE as appropriate

3 Dispatch closest Intensive Care Paramedic (if not already responding)

4 Tone stations

5 Complete all informed broadcast

RED

Respond under lights and siren

Potentially immediately life

threatening

Examples:

� Heart problems

� Seizures

1 Dispatch closest resource immediately

2 Dispatch PRIME and First Response Unit as appropriate

3 Dispatch closest Intensive Care Paramedic if appropriate

4 Tone stations

ORANGE

Crew determines

response priority

Urgent but not immediately life

threatening

Examples:

� Abdominal pain

� Broken arm

1 Dispatch most appropriate resource immediately

2 Dispatch Ambulance First Response Unit (not FIRE First Response Units) as appropriate



Colour What it is for What happens in Comms

GREEN

Road speed response

Not medically urgent

Examples:

� Twisted ankle

� Generally unwell

1 Dispatch most appropriate resource when available

GREY

Clinical telephone

advice

Not medically urgent

Example:

� Toothache

� Catheter problems

1 Have a clinician ring back the address and provide advice. Send resource if advised to do so by the clinician

2 If no clinician is available treat the incident as GREEN



Status codesStatus codes are a numerical representation of how unwell or unstable a patient is. These are allocated individually to a patient by the most senior clinician at an incident. They are qualitative, require clinical judgement and are allocated to patients after taking into account their illness or injuries, their vital signs and the potential threat to their life. These status codes are standard across the ambulance sector in New Zealand, and are outlined in the table below:

Status What it is for Triage tag colour

ZERO Dead Black / White

ONE Immediate threat to life

Example:

� Obstructed airway

� Cardiac arrest

Red

TWO Potential threat to life

Example:

� Multi-system trauma

� Stroke < 3.5hrs

Orange / Yellow

THREE Unlikely threat to life

Example:

� Broken long bone

� Nausea and vomiting

Green

FOUR No threat to life

Example:

� Cuts with little bleeding

� Sprains and strains

Green



What does this mean for me as a First Responder?

Recognising how unwell a patient is and passing this back to Ambulance Communications is essential for resource management. Reporting that a patient is status four may allow a Rapid Response unit or PRIME to stand down, allowing that resource to be available for other patients. Conversely reporting that a patient is status one will ensure that resource is mobilised towards you.

EXERCISE 1: What status are the following patients?1 17 year old male who has been fitting for the past ten minutes (still fitting now)

Status one

2 75 year old female who has had a fall and has a hip fracture

Status three

3 45 year old male, sudden onset one sided paralysis (possible stroke)

Status two

4 23 year old intoxicated male with a twisted ankle

Status four

5 18 year old male motorcyclist who has been decapitated

Status zero

6 13 year old female with an open fracture of the wrist (bone poking through wrist)

Status three

7 39 year old male in cardiac arrest who you are resuscitating

Status one

8 39 year old male in cardiac arrest after you have stopped resuscitation

Status zero

9 25 year old female with asthma not responding to her own medication

Status two

10 53 year old female who has rolled her car but appears uninjured

Status four



The chief complaintFirst Responders are not expected to diagnose a patient’s condition. This does not prohibit you from doing so however if the diagnosis is very obvious (for example if a patient is short of breath and wheezy and tell you they have asthma, it is okay to call the patients chief complaint asthma).

First Responders are expected to identify the patient’s chief complaint. Where a problem has been identified with the patient’s primary survey (response, airway, breathing or circulation) then this is the patient’s chief complaint. Where there is no problem with the primary survey the problem that the patient is complaining of the most is the patient’s chief complaint, for example:

� If a patient has abdominal pain and shortness of breath, the patient’s chief complaint is ‘shortness of breath’. This is because there is a problem with the primary survey (breathing).

� If a patient has abdominal pain and vomiting, but the problem they are complaining of the most is abdominal pain, the patient’s chief complaint is ‘abdominal pain’. This is because there is no problem with the primary survey.

� If that same patient started vomiting blood, and was still complaining of abdominal pain, the patient’s chief complaint is ‘vomiting blood’. This is because there is a problem with the primary survey (circulation).

In the next session we cover the primary survey and identifying problems with the primary survey in greater detail.

EXERCISE 2: What chief complaint do the following patients have?

1 4 year old female who has fallen off a trampoline and her leg was caught in the springs on the way down. The patient has an ‘egg’ on her head and a grossly fractured femur (the bone in the upper leg).

Fractured (broken) femur

2 35 year old female who has been playing senior netball and torn her achilles tendon. Following the excessive pain in her leg she has developed stressed induced angina pains (cardiac chest pain).

Cardiac chest pain (this could threaten the patient’s circulation)

3 26 year old male cyclist who has fallen off his cycle on a track. The patient has grazed knees and elbows, a fractured collar bone, neck stiffness and a bruise on his right hip. The patient is complaining of severe pain in the fractured collar bone.

Fractured clavicle (collar bone)



Situation reportsAs we have already alluded to, the information you pass back to Ambulance Communications is extremely important for resource management. For your safety, and for the safety of the patient, you need to give a situation report (SITREP) within 5 minutes of locating at an incident. The following information is necessary when passing a SITREP:

� Age: The patient’s age

� Sex: The patient’s biological sex at birth

� Status: The patient’s status as described previously

� Chief complaint: The patient’s chief complaint

� Resources: Additional or specialist resources required

This needs to be stated as a sentence rather than announcing each section for example:

� “One 45 year old female, status three, abdominal pain, ambulance required at road speed for transport”

� One 15 year old male, status two, stab wound to abdomen, Intensive Care Paramedic required”

EXERCISE 3: Situation ReportsUsing the scenarios read to you by your tutor, write out three SITREPs which you could give based on the information provided

1. “One 23 year old female, status three, abdominal pain”, ambulance required at road speed for transport”(consider pain relief)

2. “One 63 year old male, status four, toothache, keep ambulance coming howeverat this stage it is unlikely transport will be required”

3. “One 48 year old male, status two, multi- system trauma, requesting an ICP owing to injuries, and Fire (or a helicopter if appropriate to patient’s location)to assist with extrication.”



Calling for helpWhen you are learning it is sometimes difficult to understand who to call for help. As a First Responder you should always be working with or backed up by an ambulance crew with a higher clinical practice level, however if your patient has specific needs then you need to ensure that the right help is mobilised at the earliest possible opportunity. The St John Clinical Procedures and Guidelines contain some guidance specific to particular conditions, however in general:

� Status one patients need an Intensive Care Paramedic or PRIME

� Status two patients need a Paramedic (minimum)

� Status three and status four patients can be handled by an Emergency Medical Technician (minimum)

Sometimes a patient may need a specific skill, in this instance unless you know which practice level has that skill within their scope you should either:

� Call for an Intensive Care Paramedic, these staff have the broadest scope of practice so will be able to meet the needs of your patient or

� Contact the Clinical Desk within Ambulance Communications

Clinical DeskEach of the Ambulance Communications Centres has a Clinical Desk. This is staffed by a Clinical Advisor (usually an Intensive Care Paramedic). Clinical Advisors are subject matter experts who are able to discuss any patient with you and provide guidance as to the best course of action. They are also able to authorise you to use the skills you can administer under direction (already discussed in the ‘Role of a First Responder’ session). In exceptional circumstances, the Clinical Advisor may put you through to a St John Doctor for additional specialist support.

When you contact the Clinical Desk you will be required to give the following information:

� Your name, clinical practice level and station (or organisation)

� The location and type of incident you are attending (this is so they can look the incident up and enter appropriate notes during your discussion)

� The reason for your call, along with a summary of the question or problem you have

� A full list of your patients vital signs (a must if you are wishing to discuss the treatment regime for your patient, or are seeking permission to give a medicine or do a skill under direction).



Contacting Ambulance Communications and the Clinical DeskThe most appropriate way to contact Ambulance Communications for general communication and operational activity is:

� Via the radio for St John First Responders

� Via your normal processes for NZFS First Responders (this is normally via radio and through the relevant Fire Communications Centre (FIRECOM)

� Via 0800 AMBCOM (262266) if you do not have a radio or the information you wish to share is not appropriate for the radio.

If you wish to talk to the Clinical Desk you will need to talk to them via phone. The most appropriate numbers are:

� 0800 244 111 (preferred) or

� 0800 AMBCOM

First Responders in the North Island should select the ‘NorthComm’ desk. First Responders in the South Island should select ‘SouthComm’ desk – although you may be transferred to any Clinical Desk in the country automatically if the desk you have selected is not available.

In extreme situations when you need immediate attention and a radio is not immediately available it is acceptable to dial 111 and ask for ambulance.

Our recommendation is that you take a moment now to enter the two 0800 numbers supplied above if you have not done so already.



Lesson plan: The primary survey

Day one: Session four (45 minutes)

Learning objectives � State when and why we perform a primary survey

� List the elements of a primary survey

� Evaluate the safety of an environment and apply risk mitigation strategies as necessary

� Demonstrate methods of performing a primary survey

� Discuss the rationale for repeating the primary survey as part of reassessment

Required equipment � Blankets (one between two) for students to lie on

� First Responder facilitator manual


� FR D1S4 Primary Survey Demonstration video


� Gloves (one full box S, M, L, XL)

� Projector, laptop and speakers



Suggested way to teach1 Referencing the First Responder facilitator manual, present the first part of

the the first half of the Primary survey section in the FR Day One PowerPoint. This PowerPoint should be presented in an interactive way. Students should reference the First Responder student workbook during the presentation (10 minutes).

2 Play the FR D1S4 Primary survey demonstration video (5 minutes)

3 Divide students into pairs and give each group a blanket. Instruct students to find some clear space and place their blanket on the floor. Following this:

• One student should lie on the blanket whilst the other one conducts a primary survey. Once the primary survey has been completed the students should swap. Repeat this for two cycles (so each student has performed a primary survey twice) (10 minutes)

• Next have the student who is lying on the blanket position himself or herself in a difficult position, then have the second student conduct a primary survey. Once the primary survey has been completed the students should swap. Repeat this for two cycles (so each student has performed a difficult primary survey twice) (10 minutes)

• If students appear to have mastered the concepts of the primary survey, the facilitator may choose to line up students and time how fast it takes each team to concurrently perform primary surveys (remember it should take less than a minute). If students do not appear to have mastered the concepts of a primary survey, have students continue practicing for the remainder of the session (10 minutes)

• During this time the facilitator should be moving around the class providing focused support and guidance as needed. Ensure each student has completed a full primary survey.



The Primary Survey

Day one: Session four

OverviewThe primary survey is a rapid assessment of immediate threats to life and should take less than one minute. When an immediate threat to life is found it must be corrected on before moving on to the next aspect of the survey. The primary survey is important for all patients; not just those suffering from trauma. It contains seven parts:

� Safety (described in some texts as ‘danger’)

� Response (described in some texts as ‘level of consciousness’ or ‘LOC’)

� Airway

� Breathing

� Circulation

� Disability (described in some texts as ‘deformity’)

� Exposure, examination and environmental considerations.

Description of the primary survey � Assessing the safety of a scene is essential. Any time you feel that your safety is

at risk you should withdraw and make a plan to mitigate the safety concern. This may involve simply making all responders aware of the concern, or may involve leaving the scene until another service arrives to mitigate the risk. You should assess the safety first, the safety of your crew and other responders second, then the safety of the patient and bystanders

� Checking the patient’s response (level of consciousness) involves assessing AVPU (whether they are Alert, responding to Voice, responding to Pain, or are Unresponsive).

� The airway check involves examining for and establishing an adequate airway. Look at and listen to the airway. Consider immobilising the cervical spine, but leave this until the beginning of the secondary survey if there are more immediate life threatening abnormalities obvious. If immobilising the cervical spine makes it difficult to look after an obstructed airway then it is appropriate not to formally immobilise it.

� The breathing check involves examining for and establishing adequate breathing. Look at and feel chest movement.



� The circulation check involves examining for and establishing an adequate circulation. Feel the pulse noting rate and strength, look at and feel peripheral perfusion/capillary refill and physically check the patient for significant external bleeding using the ‘blood sweep’ technique. The blood sweep involves touching areas that you are unable to see skin (for example the head or patients clothing) then pausing to check your gloves for evidence of bleeding. Focus on areas where blood is likely to pool without you noticing it (for example under the small of the patients back, or inside a patients boots – particularly gum-boots).

� The disability check involves a brief examination looking for major abnormalities. Re-check the response (level of consciousness) using either AVPU (Alert, responds to Voice, responds to Pain, or Unresponsive) or the motor score of GCS (note GCS is not formally taught at First Responder level although First Responders are not prohibited from using it. Look for unilateral (one sided) weakness: ask the patient to show you their teeth, squeeze hands and wiggle toes.

� The exposure, examination and environmental control aspect is the transition zone between the primary and secondary survey. Appropriately expose and examine the patient but keep them warm. Any deterioration in the patient’s condition must prompt a reassessment of the primary survey looking for a cause.

Variations on the primary surveyPre-hospital medicine is a relatively young and rapidly evolving discipline. If you search the internet you can find any number of variations on the material in this book – including the primary survey. One very common variation is to conduct a ‘major haemorrhage’ check (our variation of a blood sweep) very early on in a primary survey, There is good evidence emerging from the Iraq and Afghanistan wars to support this approach in major trauma patients (particularly those injured due to an explosion or penetrating trauma). The reason we have not taken this approach is because the majority of the patients we see have not experienced such trauma. Where major haemorrhage is obvious it is acceptable to address this early in the primary survey, for all other patients the SRABCDE method is required.

It is also important to realise that your primary survey will be different if your patient does not have an altered level of consciousness. Response, airway and breathing can be determined within seconds if they are alert and talking to you.

It is inappropriate to conduct a secondary survey if there are unresolved problems within the primary survey.



Special considerations in young children

Children’s general appearance is an important consideration when determining how severe the illness or injury is, the need for treatment, and the response to therapy. The paediatric assessment triangle (PAT) is a form of assessment that can be used to help determine the severity of illness or injury. The PAT involves an assessment of activity, breathing and circulation and is performed at the same time as the primary survey.

The Paediatric Assessment Triangle (PAT)

Activity(movement, interaction, tone)

Circulation(heart rate, perfusion)

Breathing(respiratory rate, work of breathing)

Abnormal: Inactive, lethargic,

abnormal or absent cry or speech,

failure to interact with people or

objects, floppy

Normal: Active, normal cry

or speech, interacts with

people and objects, good muscle tone.

Abnormal: Tachypnoea, nasal

flaring, indrawing, use of

accessory muscles, grunting.

Normal: Normal regular

breathing without

accessory muscle use

or audible sounds.

Abnormal: Tachycardia, mottled skin, pale, cold, slow capillary refill time.

Normal: Normal heart rate, normal skin colour, warm, fast capillary refill time.

A B

C



Lesson plan: The secondary survey

Day one: Session five (45 minutes)

Learning objectives � State when and why to perform a secondary survey

� List the components of a head to toe assessment

� Demonstrate a comprehensive secondary survey

� Re-examine the definition and identification of a chief complaint

� Bring together the elements of both the primary and secondary survey

Required equipment � Blankets (one between two) for students to lie on




� FR D1S5 Secondary survey demonstration video


� Projector, laptop and speakers

Suggested way to teach1 Referencing the First Responder facilitator manual, present the second part of

the Secondary survey section of the FR Day One PowerPoint. This PowerPoint should be presented in an interactive way. Students should reference the First Responder student workbook during the presentation (10 minutes).

2 Play the FR D1S4 Secondary survey demonstration video (5 minutes)

3 Using the pairs and blankets from the primary survey practical session:

• One student should lie on the blanket whilst the other one conducts a secondary survey. Once the secondary survey has been completed the students should swap. Repeat this for two cycles (so each student has performed a secondary survey twice) (10 minutes)

• Next have the student who is lying on the blanket position himself or herself into a difficult position, then have the second student conduct a



secondary survey. Once the secondary survey has been completed the students should swap. Repeat this for two cycles (so each student has performed a difficult secondary survey twice) (10 minutes)

• Finally have one student lie on the blanket, while the other student conducts both a primary and secondary survey on their partner. Once this is completed the students should swap. This should continue until the end of the session, or until it is clear that the students have mastered both the primary and secondary survey (at which time the facilitator may elect to move on to lunch).

• For NZFS, have the students complete a secondary survey on a patient who is in level two gear with/without breathing apparatus.

• During this time the facilitator should be moving around the class providing focused support and guidance as needed. Ensure each student has completed a full secondary survey.

4 All of this material must be completed prior to students being released for lunch



The Secondary Survey

Day one: Session five

Overview:The secondary survey follows the primary survey and is a head to toe and front to back, systematic examination which should take less than two minutes. The purpose of the secondary survey is to discover significant injuries in the setting of trauma or significant problems in the setting of illness that will alter what you do to the patient before they reach hospital. The secondary survey is just as important in the medical patient as it is in the trauma patient.

Description of the secondary survey1 Central nervous system (the brain and spine): If the patient is conscious, check

they can talk normally, move their face and move and feel all four limbs.

2 Head and face: Look and feel for deformity, tenderness and bleeding. Re-check the airway. Look at eyes for pupil asymmetry and reaction to light.

3 Neck: Look and feel for deformity and tenderness. Immobilise cervical spine if indicated and not already done (c spine immobilisation covered on day three).

4 Chest: Look, feel and listen for symmetry of air entry, auscultate breath sounds, tenderness and crepitus. Remember that the back is part of the chest.

5 Abdomen and pelvis: Look and feel for tenderness. The abdomen should be examined with the patient recumbent. Palpate the four quadrants of the abdomen ensuring any areas of pain or tenderness are palpated last. The pelvis should be firmly palpated to assess for pain and tenderness (note we do not want the pelvis ‘sprung’ anymore).

6 Extremities: Look and feel for wounds, fractures, colour, capillary refill, gross sensation and movement.

7 Back: Look and feel for tenderness and deformity.

Following the secondary survey, appropriate vital signs must be acquired and documented.

Any deterioration in the patient’s condition must prompt a reassessment of the primary survey, then secondary survey

looking for a cause.



What if the patient is fully awake and alert?If the patient is fully awake and alert, it may be appropriate to do what is referred to as a ‘modified secondary survey’. This is where the secondary survey is completed by asking a series of focused questions relevant to the patient’s chief complaint. These questions should aim to elicit the same information as above, in a structured and methodical way. Areas of vulnerability or uncertainty should be examined as per the above. Patient’s with a significant mechanism of injury should receive a full secondary survey, regardless of whether they are conscious or not.

Focused patient questioning is covered in more depth later on the First Responder Course and in this booklet.

Notes



Lesson plan: Vital signs

Day one: Session six (120 minutes)

Learning objectives � Define what a vital sign is.

� Demonstrate vital signs acquisition to include heart rate, respiratory rate, blood pressure, capillary refill time, level of consciousness, blood glucose level, temperature and SpO2.

� Discuss the normal parameters for vital signs.

� Discuss the importance of reassessing vital signs.





� Blood pressure cuff (one between two)

� Defibrillator / Monitor OR standalone unit with SpO2 capability (one between 6)


� Glucometer and test strips (one between two)

� Stethoscopes (one between two)

� Tympanic thermometer (one between four)

Suggested way to teach1 Referencing the First Responder facilitator manual, and the level of consciousness

slide in the Vital signs section of the FR Day One PowerPoint, define what level of consciousness is, then explain what this means for the First Responder. Following this, demonstrate how you would ascertain the level of consciousness in a patient. Note there is no activity associated with this.



2 Referencing the First Responder facilitator manual, and the respiratory rate slide in the Vital signs section of the FR Day One PowerPoint, define what level of consciousness is, then explain what this means for the First Responder. Following this, demonstrate how you would obtain a respiratory rate in a patient. Have students practice acquiring a respiratory rate on each other (10 minutes).

3 Repeat this process as above for respiratory rate, heart rate, capillary refill time, blood pressure (palpated and auscultated), oxygen saturation level, blood glucose level, and temperature ensuring all students participate in practice and complete the activities in the First Responder student workbook where required (15 minutes for each).

4 End the lesson by briefly discussing the appropriateness of vital signs reassessment as per the First Responder facilitator manual (5 minutes).



Vital SignsDay one: Session six

Overview:A vital sign is both a sign of life, and indication of a patient’s physical condition. In this session we will be learning how to determine a patient’s vital signs including:

� Level of consciousness (LOC)

� Respiratory rate (RR)

� Heart rate (HR)

� Capillary refill time (CRT)

� Blood pressure (BP)

� Oxygen saturation level (SpO2)

� Blood glucose level (BGL)

� Temperature

When you are first starting out it can take a while to get proficient at acquiring vital signs. For this reason, if you are starting out, we strongly suggest you take every opportunity and take these vital signs as often as possible. Often the best way to do this is to pick up the gear next time you’re on station and assess a colleague’s vitals.

Level of consciousness (LOC)

What is LOC?

LOC is a measure of how responsive a patient is to stimuli from their environment. There are two tools we use to measure an LOC, these are:

� AVPU: Alert, voice, pain, unresponsive and

� GCS: Glascow Coma Score.

At First Responder level we are promoting the use of AVPU, as it is easy to apply and easy to remember. You are able to use GCS if you are confident in doing so however we do not talk about it here and it is not mandatory at First Responder level.



What does the patient’s LOC tell me?

For the majority of patients, the further they get down the scale, the sicker they are. For example being ‘alert’ is very good, being ‘unresponsive’ is very poor. For some groups of patients this may indeed be their normal state, however unless you know the patient you should treat them like this is a new presentation until you can confirm otherwise. A normal patient should present as alert,

How do I assess the patient’s LOC?

� The patient is alert if they are alert and able to converse with you from the moment you engage with them. This involves engaging with them in normal conversation with no additional effort.

� The patient is responsive to voice if they only respond to you in response to verbal stimuli. This involves a concerted effort to have the patient respond to your normal stimuli. Use of the patient’s name is an effective way to do this, for example ‘John can you hear me?’ The patient’s response could be a coherent verbal reply, or could be as subtle as a grunt, moan, or movement of a limb.

� The patient is responsive to pain if they only respond to you after you apply painful stimuli. This involves you squeezing the patient’s trapezius (preferred) or applying pressure to the patient’s nailbed. As previous, the patient’s response could be a coherent verbal reply, or could be as subtle as a grunt, moan, or movement of a limb.

� The patient is unresponsive (sometimes referred to as unconscious) if the patient gives no response

Some helpful hints:

� You may occasionally come across a patient who appears to be unresponsive but is not. There are various methods of attempting to verify that the patient is actually awake, these all carry a degree of risk. At First Responder level our expectation is that you will simply treat the patient as being unresponsive until a senior clinician arrives to explore this further.



Respiratory rate:

What is a RR?

A RR is the number of breaths (including inhalation and exhalation) that a patient takes during one full minute. Whilst you are taking a RR you should note the depth of respiration and observe the patients overall work of breathing.

What does taking a RR tell me?

The RR helps you build a picture of overall how unwell a patient is. A very slow RR can indicate that your patient is about to arrest, whereas a very fast RR can indicate that your patient is in pain and or significantly distressed. In general, respiratory rates in adults range between 12 and 20 per minute.

How do I calculate the RR?

1 Observe the number of breaths a patient takes over one full minute OR

2 Observe the number of breaths a patient takes over 30 seconds and multiply that by two.

Some helpful hints

� Avoid telling the patient you are taking their RR. This is because we have voluntary control over our RR, and a patient’s RR may vary if you tell them first.

� If the patient has an oxygen mask on, measure their RR by observing the misting of the mask as the patient exhales.

PRACTICAL: Respiratory ratesObserve the respiratory rate of at least two of your class mates and record these in this workbook

Name: Time: RR:Name: Time: RR:Name: Time: RR:Name: Time: RR:



Heart rate:

What is a HR?

A HR is the number of times that the heart beats and generates a pulse that you are able to feel during one full minute. Whilst you are taking a HR you should note whether the pulse is strong, normal, weak or thready.

What does taking a HR tell me?

The HR is one of the most useful vital signs for understanding whether the body is under stress. Slow heart rates (less than 40/min for adults) are uncommon and can indicate that the patient is having a heart problem or has overdosed on medication. Fast heart rates (greater than 100/min for adults) are common and are an early indicator that the patient is under stress. This may be as simple as the patient getting a fright, or may be more sinister such as indicating that the patient is in shock. In general, heart rates in adults range between 60 and 80 per minute.

How do I calculate the HR?

1 First you need to identify a pulse. There are two primary sites that we use to take a pulse:

• Radial pulse: so named owing to its proximity to the radius bone, the radial pulse is found by first identifying the radius. The easiest way to do this if you are unsure is to ask the patient to do a ‘thumbs up’, the radius is the bone in the wrist on the same side as the patient’s thumb. While the patient maintains a ‘thumbs up; position, run your fingers down the top of the thumb to the wrist until you come across the bony prominence on the top of the radius. Move your fingers down this bony prominence to the inside of the wrist and push in lightly with your middle and index finger. You should be able to feel the patient’s pulse. The radial pulse should be used as your primary pulse site unless the patient is very unwell or unconscious.



• Carotid pulse: is found by first identifying the patients ‘adams apple’ (laryngeal prominence). This is usually relatively easy in males, but is more difficult in females. If it is not obvious then you should run your fingers from the chin down the front of the neck until you find the most prominent protrusion, this should be the ‘adams apple’. Once identified move your fingers either side of the ‘adams apple’ and if nothing is felt, push in lightly with your middle and index finger until a pulse is felt. The carotid pulse should be used as your primary pulse if the patient is very unwell or unconscious.

2 Once you have found a pulse

• Count the number of palpable pulsations over one full minute OR

• Count the number of palpable pulsations over fifteen seconds then multiply that by four

Some helpful hints:

� Avoid using your thumb to take a pulse, this is because there is good blood flow in the thumb and often with gentle pressure you can confuse the patient’s pulse with your own.

� Wait several seconds before determining you cannot feel a pulse. You need to be still in order to feel a pulse, and if the patient’s HR is very slow or irregular it is very easy to miss the patient’s pulse.

� If you have access to an electrocardiogram (ECG) you still need to check the patients HR. This is because an ECG measures electrical activity in the heart. whereas a HR measures mechanical output from the heart. It is possible for the rate on the monitor to be faster than the palpable pulse.

� If the patient has a very irregular pulse, you will need to calculate the heart rate by feeling the pulse over one full minute.



PRACTICAL: Heart ratesObtain a heart rate from at least one of your class mates and record it in this student workbook:

Name: Time: HR:

Have that class mate go for a brisk walk around the building and then measure the heart rate again to see how this has changed

Name: Time: HR:

Notes



Capillary refill time (CRT):

What is a capillary refill?

Capillary refill time is the time taken for colour to return to an external capillary bed after pressure is applied to cause blanching (whitening) as a result of blood being pushed out of the capillary.

What does a patient’s CRT tell me?

Normal capillary refill is 2 seconds or less (that is the time from when pressure is released until colour returns). A delayed CRT can be indicative of shock, or decreased peripheral blood flow.

How do I assess a CRT?

This is a very simple assessment. It can be measured by pressing your thumb on an area of skin until it turns white, then releasing taking note of the time needed for the colour to return once pressure is released.

CRT should be assessed both peripherally (for example on a limb) and centrally (for example on the patient’s forehead or sternal notch).

Some helpful hints:

� A CRT that is delayed peripherally but not centrally indicates either that the patient is cold, that blood flow to the limb is compromised, or that the patient is becoming shocked as the body redirects blood flow to the central organs

� A CRT that is delayed centrally is usually a sign that the patient is very unwell, have a low threshold for getting backup from a Paramedic or Intensive Care Paramedic in such instances, especially where the patient is a child.

PRACTICAL: Capillary refill timeTake a capillary refill (both peripheral and central) on at least two of your class mates and record these in this workbook:

Name: Time: CRT central:Name: Time: CRT central:Name: Time: CRT central:Name: Time: CRT central:



Blood pressure:

What is a BP?

A blood pressure is a measure of the amount of pressure applied to blood vessel walls when the heart beats (the ‘top’ recording known as the ‘systolic’ reading), and when the heart is at rest (the ‘bottom’ reading known as the ‘diastolic’ reading). It is measured in millimetres of mercury (mmHg)

What does the blood pressure tell me?

The blood pressure gives you an indication of how well the heart is working (as a pump), and how well the blood vessels are working as a circuit. A blood pressure that is too low will result in blood not getting to vital organs. A blood pressure that is too high may put stress on the heart causing it to fail, or the blood vessels causing them to rupture. In adults, the radial pulse requires a systolic blood pressure of approximately 80mmHg to be palpable, whereas the carotid pulse requires a systolic blood pressure of approximately just 60mmHg to be palpable. In general a normal blood pressure in adults is thought to be around 120/80.

How do I take a blood pressure?

There are two primary methods for taking a blood pressure, these are ‘palpated’ and ‘auscultated’.

1 Palpated blood pressures: Should be the method of choice for patients who are in a noisy environment (such as a moving ambulance, or in a car where the Fire Service is working to actively disentangle the patient with hydraulic tools operating). Using this method will only give you a systolic (top) reading. The method for this is:

• Apply the blood pressure cuff (medical name is sphygmomanometer) to the arm you intend to use to take the palpated blood pressure. Ensure the cuff is applied the correct way, and that the lower edge of the cuff is approximately 1cm above the crease of the elbow. There is usually identifying marks on the cuff as shown.

• Find the radial pulse on the same arm that you have applied the cuff to.



• Inflate the cuff until you are no longer able to feel the radial pulse.

• Looking at the blood pressure gauge, slowly deflate the cuff until you can again feel the radial pulse, pause here and note the pressure at which the radial pulse is felt.

• Deflate the gauge and remove the blood pressure cuff from the patient’s arm (unless you intend to go on and auscultate as below, noting that you do not need to palpate a blood pressure every time you wish to auscultate, or vice versa).

• Record the patient’s pressure as [pressure at which you felt the radial pulse]/P. The ‘P’ here is used to represent that the blood pressure has been taken by palpation.

For example your patient’s palpated blood pressure might be 120/P.



PRACTICAL: Palpated blood pressureTake a palpated blood pressure on at least two of your class mates and record these in this workbook:

Name: Time: BP: /PName: Time: BP: /PName: Time: BP: /PName: Time: BP: /P

2 Auscultated blood pressures: Should be the method of choice for patients who are in a quiet environment. Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope. Using this method will give you both a systolic (top) reading and a diastolic (bottom) reading. The method for this is:

• Apply the blood pressure to the arm you intend to use to take the auscultated blood pressure. Ensure the cuff is applied the correct way, and that the lower edge of the cuff is approximately 1cm above the crease of the elbow. There is usually identifying marks on the cuff as shown.

• Place the diaphragm (large end) of the stethoscope over the ‘brachial artery area’ in the crease of the elbow as shown.

Note: previous teaching and some texts have asked that the brachial artery is identified prior to placing a stethoscope. We are no longer mandating this as the overwhelming majority of auscultated blood pressures may be auscultated without the need to identify this artery.

• Place the ear tips of the stethoscope into your ears (ensure these are angled forward where applicable).

• Inflate the cuff past 100 mmHg until you are no longer able to hear the first korotkoff sound (this is the medical term for the sound generated by a pulse which is heard when auscultating a blood pressure).



• Looking at the blood pressure gauge, slowly deflate the cuff until you can again hear the korotkoff sounds, pause here and note the pressure at which the korotkoff sounds are heard. This is the systolic (top) reading.

• Continue to slowly deflate the cuff until you are no longer able to hear the korotkoff sounds, pause here and note the pressure at which the korotkoff sounds are no longer heard. This is the diastolic (bottom) reading.

• Deflate the gauge and remove the blood pressure cuff from the patient’s arm.

• Record the patient’s pressure as [pressure at which you first heard the korotokoff sounds]/[pressure at which the korotokoff sounds disappeared].

This equates to systolic reading/diastolic reading.

For example your patient’s auscultated blood pressure might be 120/80.

PRACTICAL: Auscultated blood pressureTake an auscultated blood pressure on at least two of your class mates and record these in this workbook:

Name: Time: BP: Name: Time: BP: Name: Time: BP: Name: Time: BP:



Some helpful hints:

� You may need to inflate and deflate the cuff several times to get an accurate palpated or auscultated recording. This is okay and encouraged. It is acceptable to re-inflate the cuff a little in order to facilitate this while you are taking the blood pressure.

� Auscultating but nothing heard? Some stethoscopes that have a bell (small end) and diaphragm (big end) have a head that can be twisted around. This directs the sound up one end of the stethoscope and avoids noise from being transferred up the other. Look at the ‘hole’ in the middle of the bell or diaphragm, nothing should be visible. If it appears obstructed (usually by a metallic object) then you need to turn the head around to allow sound to be transferred through that side.

� Your first blood pressure must always be either a palpated or auscultated one. It can be tempting if you have an automated blood pressure cuff to just use that, but some devices can give inaccurate readings if the patient’s blood pressure is very high or very low. Don’t fall into this trap!



Oxygen saturation (SpO2):

What is an SpO2?

An SpO2 is a measure of how well oxygenated a patient is. More specifically it is a measure of how much oxygen is bound to circulating red blood cells. This is represented as a percentage (the maximum percentage being 100%). Oxygen saturation is measured using an SpO2 meter which may be stand alone or attached to a monitor defibrillator. These units may also provide you with a heart rate (noting that this must be verified by checking a patient’s pulse).

What does an SpO2 tell me?

The patient’s SpO2 reading will help guide your decision to administer or withhold oxygen. Often it is difficult to tell if a patient needs oxygen by looking at them and the early signs of low oxygen levels can be subtle. More often than not you will be surprised at who does not need oxygen. The St John Clinical Procedures and Guidelines provide an excellent summary of who should and who should not receive oxygen. It is also covered later in this First Responder Course. A well patient will typically have an oxygen saturation of 97% or greater.

How do I assess a patient’s SpO2?

The exact steps here are largely dependent on what type of unit you are operating, but in general the steps are:

1 Place the SpO2 probe on the patient’s digit and switch the unit on

2 Wait for the recording to display. If your unit has a pleth wave ensure this is tall and regular. A tall and regular pleth wave indicates that the SpO2 reading is accurate. A short or irregular pleth wave indicated that the SpO2 reading is inaccurate and the probe should be moved and troubleshooted.



Some helpful hints:

� Excessively dirty skin, black nail polish, cold skin and poor blood flow are barriers to attaining an effective SpO2 reading

� It can be difficult to get an SpO2 on children with very small digits. Try holding the probe on the patient’s big toe, or even on a fleshy part of the ear if you are having difficulty getting a reading

� Carbon monoxide (CO) binds better to red blood cells than oxygen does. SpO2 units are unable to differentiate between CO and O2. For this reason oxygen saturation should be ignored in patients with CO poisoning and the patient administered oxygen regardless of the SpO2 reading

� Oxygen is not a routine or acceptable treatment for every patient, there must be a specific reason to give oxygen. There are in fact many groups of patients where the administration of oxygen can make outcomes worse, however, where an SpO2 probe is unavailable and you are unsure, the balance of risk is in favour of administering oxygen if it appears to be clinically indicated.

PRACTICAL: Oxygen saturationTake an SpO2 from at least two of your class mates and record these in this workbook:

Name: Time: SpO2:Name: Time: SpO2:Name: Time: SpO2:Name: Time: SpO2:



Blood glucose level (BGL):

What is a BGL?

The BGL is the amount of glucose (sugar) present in the blood stream. Glucose is the primary source of energy for the body’s cells. It is measured in millimoles per litre (mmol/L) using a glucometer (blood glucose meter).

What does the patient’s BGL tell me?

Extreme variations in blood glucose levels can be life threatening. It is generally accepted that most healthy adults will have a BGL between 4 mmol/L and 9 mmol/L, (noting that there are many factors that can influence BGL).

If the patient’s BGL is very low (medical term is hypoglycaemia) the patient can suffer a reduced level of consciousness and may become agitated, have seizures, or become unconscious. First Responders can treat patients who have a BGL that is less than 3.5 mmol/L with either oral glucose, or intramuscular glucagon in consultation with the St John Clinical Desk (more on this in the Medical section).

If the patient’s BGL is very high (medical term is hyperglycaemia) the patient can suffer a reduced level of consciousness (as above) and may develop life threatening shock as the body attempts to dump the excess glucose in the blood stream. Paramedics and Intensive Care Paramedics will generally administer intravenous fluids to patients who have a BGL greater than 20 mmol/L and shock. First Responders should request a Paramedic (or higher) in these groups of patients.

BGL recordings should be taken routinely from diabetics and persons with an unexplained medical collapse. For all other circumstances clinical judgement is required.

How do I assess a patient’s BGL?

1 Prepare the lancets, sharps container, and glucometer. Ensure a test strip has been placed into the glucometer.



2 Select a site to take blood from. In adults and large children the best site is usually the side of a fingertip. In infants and small children the best site is usually the heel of the foot. If the site is visibly dirty it should be cleaned.

3 Select the depth on the side of the lancet by turning the head of the lancet to the corresponding depth and pull off the safety cap.

4 Push the lancet firmly against the skin at the selected site and press the trigger button.

5 Place the lancet immediately into the sharps container.



6 If necessary, lightly squeeze the site to encourage blood from the site.

7 Dip the end of the test strip into the blood, the unit will beep after a few seconds and the BGL reading will be displayed. The test strip may then be removed from the glucometer and discarded in a biohazard bag or sharps container.

8 Apply a plaster to the site if needed.

Some helpful hints:

� If you choose to clean the skin, ensure you let it dry as some products may alter the BGL reading

� Remember blood can carry infectious disease, therefore you should use gloves when acquiring a BGL.

PRACTICAL: Blood glucose levelTake a BGL from at least one of your class mates and record it in this workbook:

Name: Time: BGL: Name: Time: BGL:



Temperature:

What is a temperature?

When we refer to a temperature we are referring to the patient’s approximate body temperature. In New Zealand we measure this in degrees Celsius (ºC). The average body temperature in humans is considered to be approximately 37ºC.

What does the patient’s temperature tell me?

There are many factors that can contribute to a variation in the patient’s temperature. Most commonly variations in temperature can be caused by environmental exposure, the presence of infection, or extremes in physical activity.

Fundamentally we become concerned when the patient has a temperature lower than 35ºC or higher than 38ºC.

How do I assess the patient’s temperature?

The most common method for assessing temperature is via the use of a tympanic thermometer, to use this device:

1 Place a new / clean probe cover on the thermometer. The thermometer should turn on automatically

2 Wait for the ready ‘beep’

3 Angling the thermometer forward (to align it with the natural shape of the ear canal), place the thermometer snuggly’ into the ear canal then push/release the ‘START’ button

4 The indicator light will flash when probe is correctly positioned and a temperature is being acquired. Once a temperature is obtained, there will be a long ‘beep’ and the indicator light will be on with the temperature displayed.



Some helpful hints:

� A tympanic thermometer may fail to operate if it has been stored at low temperatures. This is a relatively common problem in winter if it has been stored inside a cold ambulance or in the locker of a fire appliance. It may take a few minutes to warm and begin operating in these circumstances

� You should reassess the patient’s temperature after 20 minutes if they have been swimming or bathing recently, or exposed to extreme variations in temperature.

� If you obtain an abnormal temperature from the first reading, take the temperature again in the other ear to eliminate the possibility that the reading is an outlier.

PRACTICAL: TemperatureTake a temperature from at least two of your class mates and record these in this workbook:

Name: Time: Temp: ºCName: Time: Temp: ºCName: Time: Temp: ºCName: Time: Temp: ºC

Reassessment of vital signsIt is more important to focus on the trend of a set of vital signs than on one specific set. A single set of vital signs will provide you with a baseline. To establish a trend, vital signs need to be reassessed. The decision to reassess vital signs is one that requires clinical judgement. In general it is appropriate to reassess vital signs every ten minutes for status one and status two patients, and every thirty minutes for status three and status four patients. It is worth noting that some specific treatments require vital signs are taken as a prerequisite to treatment. At First Responder level all of these medicines require consultation with the Clinical Desk.



Lesson plan: 3 lead ECG acquisition

Day one: Session seven (20 minutes)

Learning objectives � Identify the indications for 3 lead acquisition

� Describe what information can be obtained via an ECG

� Demonstrate how to apply or assist in applying a three lead ECG

� Identify causes and how to minimise artefact on an ECG

� Competently print a 6 second strip



� Defibrillator / Monitor OR AED with ECG capability (one between 4, where possible use the same type of defibrillator as the one used by the students operationally)


Suggested way to teach1 Referencing the First Responder facilitator manual, and with students

referencing the First Responder student workbook discuss:

• What information is obtained via an ECG

• Why 3 lead acquisition is being covered on this course (5 minutes)

2 Demonstrate the application of ECG leads and acquisition of a 3 lead ECG, and where possible print a six second strip with reference to the model of defibrillator you are using. Discuss methods for minimising artefact referencing the First Responder facilitator manual (5 minutes)

3 Have students practice taking ECGs on each other for the remainder of the session. Ensure students place a six second strip from one other classmate in their student workbook (where available) (20 minutes).



3 lead ECG acquisition

Day one: Session sevenThis short session is to introduce you to basic electrocardiogram (ECG) acquisition. First Responders are required to understand how to acquire a 3 lead ECG and print a six second strip. It is worth noting that we are not covering 12 lead acquisition or ECG interpretation on this course.

First Responders are not required to acquire 12 lead ECGs or understand how to interpret an ECG, however they are not prohibited from doing so if they have a good understanding in this area (for example those who have a background as a Registered Nurse or an ECG technician). If you routinely work with an Emergency Medical Technician, Paramedic or Intensive Care Paramedic, and have access to a 12 lead defibrillator/monitor, we recommend that you work with a senior officer to learn to acquire 12 leads on your own. You may also wish to learn how to interpret ECGs in your own time following this course. If you elect to do so we recommend Basic Arrhythmias by Gail Walraven as a good self-directed learning tool. This is available from any good medical book store or off the internet.

What is an ECG?Muscles require a stimulus to contract. In the heart the stimulus for contraction is miniscule electrical signals transmitted through a tiny electrical circuit. Electrical stimulus is generated near the top of the heart in the atria causing the top of the heart to pump, and then runs through the middle of the heart to the bottom (and up the sides) in the ventricles causing the bottom of the heart to pump. We can see this minute transmission of electrical impulses on an ECG.

Right atriumLeft atrium

Right ventricle

Left ventricle



The first part of the ECG (known as the P wave) represents electrical conduction through the atria (top of heart). The second part of the ECG (known as the QRS) represents electrical conduction through the ventricles (bottom of heart). The QRS is much larger than the P wave, because the ventricles are much larger than the atria.

This diagram represents what a relatively normal looking complex on an ECG looks like. There are multiple variations to this caused by problems to the electrical conduction through the heart. We will look at a couple of these when we cover cardiac arrest on day two of this First Responder course.

It is good to verify that the number of complexes on the ECG correlates with the pulse. This is because the ECG is looking at electrical signals not mechanical output. A good example of this is a motor crash victim who has suffered massive trauma and ‘bled out’. The ECG of these patients can look normal for several minutes as the electrical circuit within the heart has remained intact, even though there may be no blood for the heart to pump, so no pulse is generated. Conversely if there is no electrical output, there cannot possibly be a pulse generated as there are no electrical impulses to stimulate the heart muscle to contract.

Why is ECG acquisition important?As a First Responder you may have access to a defibrillator/monitor. Acquiring an ECG and printing a six second strip will allow the crew backing you up to see a snapshot of what the patient’s heart was doing when you arrived. It is not uncommon for patients to have a heart rhythm that makes them feel very unwell, and unless it is persistently occurring or constant, your ECG may be the only indication to the transporting ambulance crew and hospital staff that something sinister is occurring.



If you do not have access to a defibrillator/monitor then understanding how to acquire an ECG is still important as if your patient is very unwell, you can assist the transporting crew by acquiring an ECG while they get the handover and/or administer more advanced interventions to the patient. If you do not have access to a defibrillator/monitor, we encourage you to practice acquiring an ECG where possible when the transporting ambulance crew arrives.

How do you acquire an ECG?Acquiring an ECG is simple to remember and simple to do, and the process is the same irrespective of what type of defibrillator/monitor you are using.

Indications:

Patients with the following should routinely have an ECG acquired:

� An apparent collapse or faint

� Cardiac history

� Chest pain

� Decreased level of consciousness

� Diabetes

� Elderly

� Anyone else where you think taking an ECG could add value

Process:

1 If the patient is conscious, gain informed consent

Explain that you would like to take an ECG to give you a better idea what their heart is doing and ask their permission. If you need to uncover the patient to acquire the ECG you will need to gain permission for this also (only uncover the patient as little as needed to acquire the ECG).

2 Turn on your defibrillator/monitor and apply ECG dots to the 3 lead cables

Depending on the configuration of your defibrillator you may have a three, four or five lead configuration on your ECG leads (referring to the number of leads available for routine patient monitoring). The leads we are interested in are the right arm (RA), left arm (LA), left leg (LL) and right leg (RL) where fitted. Some units may have a fifth lead labelled V1 or C1, this lead can be left off for the purpose of a 3 lead ECG.



3 Apply the ECG electrodes

Fortunately the leads are labelled RA, LA, RL and LL which gives you a good indication of where the leads need to be placed. The arm leads can be placed anywhere from the patient’s chest just under the shoulder to the patient’s wrist. The leg leads can be placed anywhere from the patient’s abdomen just above the pelvis to the ankle.

Remember, it is the patient’s right and left, not yours!

The lead should be placed on the side corresponding with the label on the lead (left or right); arm and leg leads should be in the same place as the other arm or leg lead, and bony prominences should be avoided.

RA = white LA = black

LL = red

3 electrode system

4 Press the print button and print a six second strip

To do this you can count out loud for six seconds, alternatively you will note that the top (or sometimes bottom) of the ECG paper has vertical lines occurring at regular intervals. The gap between these is one second. Therefore seven of these lines (or six gaps) is six seconds. A six second strip is preferred as it is easy to calculate the heart rate from this (multiply the number of complexes by ten), and it is accepted as the minimum length necessary to diagnose the rhythm.

5 Troubleshoot if needed

Occasionally you will find that there is too much artefact (electrical interference) which means the ECG quality is poor. In these situations you should do the following to minimise or eliminate artefact:

� Ensure anything that might cause electromagnetic interference is switched off (electric blankets being the most common).

� Pull over briefly if you are in a moving vehicle

� Ensure the ECG electrodes have had time to warm to room temperature (the conductive gel needs to be at room/body temperature to work correctly)



� Ensure there is good connectivity between the electrodes and the patients skin (most commonly the patient will be very sweaty or hairy)

� Remove any stress or tension from the ECG cable (i.e. being pulled too tight)

� Ensure leads are correctly connected

� If necessary change over the ECG dots.

You should verify that the number of complexes on the ECG correlates with the pulse.

Notes



PRACTICAL: ECG AcquisitionAcquire a 3 lead ECG off one of your class mates and place it here:

Name: Time:

Notes



Lesson plan: Patient questioning

Day one: Session eight (40 minutes)

Learning objectives � Understand the importance of patient questioning

� Utilise open questions to elicit important information

� Use common pneumonics to gather and organise information




Suggested way to teachReferencing the First Responder facilitator manual, while having students reference their First Responder student workbooks:

1 Introduce patient questioning (2 minutes)

2 Explain what is meant by ‘open questions’ and closed questions (3 minutes)

3 Discuss the SAMPLE and OPQRST pneumonics (5 minutes)

4 Pair the students up. Allocate one student from each pair an illness from the following:

• Abdominal pain and vomiting

• Chest pain and shortness of breath

• Headache

• Back pain

Have one student from each pair play the role of a patient with one of these conditions, have the other practice acquiring information and history gathering, then have the students swap. Continue this for the rest of the session. Reassure students that there will be more time to practice these skills as the course progresses. Note: It is not necessary for students (or yourself ) to get hung up on the clinical detail or accuracy of the student’s condition (20 minutes).



Patient questioning

Day one: Session eightBy ‘patient questioning’ we are referring to the process of communicating with your patient to gather information and history that may be relevant to their current condition. Like many skills in the pre-hospital environment it takes time to become proficient at patient questioning. The concepts are introduced here, and while there are additional opportunities to practice these skills during this course, true consolidation of patient questioning will require practical application of these skills.

Open versus closed questionsPatient questioning requires that you start with a broad set of questions, and then focus questioning depending on the problems identified. The best way to do this process is through the use of open questions. A closed question is one that can only elicit a yes or no response. An open question is one that could elicit a wide array of responses. An example of a closed versus open question is:

� Closed: Did you call us because you have chest pain?

� Open: Could you tell me why you called us today?

Useful mnemonicsThere are two widely used mnemonics which are useful for assisting you to gather information, these are SAMPLE and OPQRST

SAMPLE is a useful tool to help ensure you cover all the main topics when gathering information, and refers to:

� Signs and symptoms - what signs (physical findings) and what symptoms (things the patient is complaining of ) does the patient have?

� Allergies – what allergies does the patient have (both medicines and others)?

� Medications – what medications is the patient currently prescribed? Has the patient been taking their medicines? Has the patient taken any medicines they are not prescribed? Have there been any recent changes to the patient’s medication?

� Past history – have you had this problem before, if so when? What other medical problems do you have? Last hospital admission? Last visit to the doctor? Once you have this information you need to determine what is relevant (for example the patient’s screw in their knee 10 years ago probably is not relevant to their chest pain today)

� Last oral intake – when was the last time you had any food or drink? What did you have?

� Events prior – what were you doing prior to this illness or injury?



OPQRST is a useful tool when gathering information about a patient’s pain, and refers to:

� Onset – What were you doing when the pain started?

� Provokes – Does anything make the pain worse?

� Quality – What does the pain feel like (dull, achy, sharp, heavy etc)?

� Radiates/region – Where is the pain? Does it travel anywhere?

� Severity – How bad is your pain on a scale of zero to ten (zero being no pain and ten being the worst pain imaginable)?

� Timing – What time did the pain start? Is the pain always there or does it come and go?

Notes



Lesson plan: Handover

Day one: Session nine (30 minutes)

Learning objectives � Understand the importance of handover

� Differentiate between subjective and objective information

� Identify and explain the importance of a comprehensive handover

� Demonstrate an effective handover using the IMIST AMBO method.

� Identify general principles regarding the importance of documentation



� Patient Report Form (PRF) Pads


Suggested way to teachReferencing the First Responder facilitator manual, and having students reference the First Responder student workbook:

1 Discuss the importance of the patient handover and introduce the IMIST-AMBO method for patient handover. Emphasise that the use of IMIST-AMBO is still relatively new for St John, and that while we acknowledge that it is still being embedded and is not yet widely adopted, it is mandatory that students use this in their practice. Our expectation (and challenge) is that this new generation of First Responders drives change from the ground up (5 minutes)

2 Encourage students to read examples of handovers in the student workbook, there is a trauma handover and a medical handover example (5 minutes).



3 Have students develop their own IMIST-AMBO as per Exercise 4 in their First Responder student workbook. Ask two of the students to share their answer. If necessary read the model answer in the First Responder facilitator manual (10 minutes).

4 Hand around the St John PRF and discuss the general principles to be adhered to when completing a written handover or PRF as per the First Responder facilitator manual. Reassure the students that we do not expect them to be proficient in PRF writing post this course. The First Responder Course has a ‘hands on’ focus. General principles of documentation are briefly summarised in the First Responder student workbook. Note: Learning how to write a comprehensive PRF is something that is best learned via practical application at station level relevant to the role of the individual First Responder (10 minutes).



Handovers

Day one: Session nineHandover is a fundamental part of patient care. Multiple studies have shown that loss of important information during handover impacts negatively on the care of the patient. The handover is where you have an opportunity to summarise the pertinent information you have acquired during your patient assessment.

Verbal Handovers: IMIST - AMBOOriginally developed by the New South Wales Ambulance Service the IMIST- AMBO handover provides a structured approach that is well recognised within healthcare. You should use the IMIST AMBO handover when handing over a patient to another healthcare provider (including an ambulance crew):

� Identification (the patients name and age)

� Mechanism of injury or the medical complaint

� Injuries identified or information related to the medical complaint

� Signs and symptoms (what you have found)

� Treatment and trends (what you have done and its effect)

� Allergies

� Medicines (that the patient is prescribed)

� Background (medical background / past medical history)

� Other (for example family and social situation)

Prior to handover you should review the details so that they can be delivered in a proficient manner. Determining what information to include is important because important information can be lost amongst large volumes of irrelevant information. Aim to deliver the handover in approximately 60 seconds.

When handing over to a team at a hospital, it is preferable to provide the handover before moving the patient off the ambulance stretcher otherwise vital information can be missed. Pause at the end of the handover and ask if there are any questions.



Example of IMIST - AMBO for a trauma patient � I - This is David Prichard. He is 64 years old.

� M - He has fallen approximately 2 metres off a ladder on to concrete.

� I - He appears to have injuries to his neck, left chest and left wrist.

� S - His primary survey was normal. On secondary survey he has severe pain in the left chest. His respiratory rate is 25 and his SpO2 on air is 96%. His circulation has been normal with a blood pressure of 140/80, a heart rate of 90 and a peripheral capillary refill time of one second. He has been alert throughout.

He has midline lower neck tenderness with normal peripheral sensation and movement. He has a closed fracture of the left wrist with normal distal perfusion, sensation and movement in his left hand. The rest of his secondary survey is normal.

� T - He has been placed in a cervical collar and has had paracetamol for the pain.

� A - He is allergic to ibuprofen.

� M - He is on aspirin.

� B - There is no significant previous history.

� O - His wife has been notified and is expected to arrive soon.

Example of IMIST - AMBO for a medical patient: � I - This is Mary Christie. She is 52 years of age.

� M - She has had onset of chest pain approximately 60 minutes ago.

� I - The chest pain appears to be cardiac in nature. It is central, dull and radiating to her neck.

� S - She has a blood pressure of 120/70, a heart rate of 70 and a peripheral capillary refill time of two seconds. The rest of her vital signs and her secondary survey are normal.

� T - She has received 300 mg of aspirin and two doses of 0.4 mg of GTN. There has been no change in her symptoms with the GTN and no change in her blood pressure.

� A – She has no allergies

� M - She is taking medication for blood pressure but cannot recall what it is called.

� B - She has previously had surgery and chemotherapy for cancer of the left breast.

� O - We have been unable to contact her husband.



EXERCISE 4: IMIST - AMBOYou are called to a 16 year old female who has arrived home from the school ball inebriated and is claiming to have had her drink ‘spiked’. She is responsive to voice and is claiming to have had no alcohol (although there is a strong odour of wine when she vomits. At times she appears to become unresponsive however wakes up and tells you to ‘go away’ when you apply painful stimuli. She is unwilling to talk to you except to say that she has not been drinking and ‘her drink has been spiked’, then she projectile vomits.

Airway, breathing and circulation seem okay. Secondary survey reveals some superficial cuts (that look deliberate) all the way up her right arm stretching from her elbow to her wrist. The patient refuses to let you take vitals, but you manage to get a respiratory rate which is 22. You place a dressing on the arm and await the transporting ambulance.

In discussion with the mother the patient ‘Jacinda Smith’ was last seen at 1800hrs when she was picked up in a limousine. The patient was then dropped home by the police at 2300hrs. Unimpressed with her daughter, the mother has no intention of going with her daughter to hospital. You are unable to gain any other history or useful information. The transporting ambulance crew has arrived.

As an individual, or working with those around you, complete an IMIST-AMBO handover for this patient. You may be asked to share your answer with your classmates:

� Identification: This is Jacinda Smith, she is 16 years old.

� Mechanism of injury or the medical complaint: She claims her drink has been spiked this evening while at a school ball.

� Injuries identified or information related to the medical complaint:Airway, breathing and circulation are ok, there is a strong odour of wine despiteher claims that she has had no alcohol tonight.

� Signs and symptoms:She is responsive to voice most of the time, and always responds to painful stimuliwhen unresponsive to voice. She has been vomiting, and also has superficial cutson her right arm from her elbow to wrist.



� Treatment and trends: Patient is reasonably uncooperative, and we have only been able to dress thecuts on her arm, and get her RR of 22. Patient was last seen at 1800hrs leavingthe house, and police dropped her off at 2300 hrs.

� Allergies:Unknown

� Medicines:Unknown

� Background:Unable to ascertain any PMHx

� Other: Patients mother is on scene, and has no intention of taking Jacinda to thehospital. The cuts on her arm look deliberate.

Written handoversThe extent to which you will need to write a formal handover is very dependent on your role as a First Responder. It is generally not necessary to write a full patient report form (PRF) unless you are part of a transporting ambulance crew. For the most part it is appropriate to note down the patient’s vitals and any treatments (for accuracy) and utilise the IMIST- AMBO mnemonic when handing over to the transporting ambulance crew.



Learning how to write a comprehensive PRF is something that is best learned via practical application at station level. For First Responders who form part of a transporting ambulance crew, the general principles for completion of a paper St John PRF are as follows:

� Treating the patient always takes priority over completing documentation

� Write clearly and legibly

� Start with information which is difficult to remember should you need to stop writing the PRF and provide the patient with treatments. It is generally harder to recall the treatment and observation detail (part D) and patient’s personal details (part D) accurately off the top of your head. It is generally easy to remember the patient information (part C)

� The patient information section should consist of the following:

• History (Hx) – a succinct summary of the history of the complaint as it pertains to this event

• On arrival (O/A) – a succinct statement that describes what you saw and how the patient was presenting when you first arrived.

• On examination (O/E) – a detailed summary of what you found when you examined the patient. Space is limited so keep it pertinent, succinct, and avoid ‘waffle’

• Past medical history (PMHx) – a list of the patient’s past medical history. Where this is extensive limit it to the most pertinent or the most relevant to the patient’s current complaint.

� Be objective not subjective with what you write (i.e. write concrete, tangible observations – not opinion or assumption).

Notes



Lesson plan: Knowledge check

Day one: Session ten (30 minutes)

Learning objectives � Revise knowledge learnt throughout the course of day one.

� Ensure key learning outcomes from day one have been achieved

� Replicate skills learned on day one



� Blood pressure cuff (one between two)

� Stethoscopes (one between two)

Suggested way to teach1 Divide students into pairs and give each group a blanket. Instruct students to

find some clear space and place their blanket on the floor. Following this have one student lie on the blanket, while the other student conducts both a primary and secondary survey on their partner. Once this is completed the students should swap. Encourage the students to focus on completing a thorough and accurate primary and secondary. During this time the facilitator should be moving around the class providing focused support and guidance as needed (10 minutes).

2 In pairs have students take a full set of vitals on one another; these vitals should be written in their First Responder student workbook. Let students know that you will randomly check the vitals that have been acquired. Randomly check the vitals of at least 2 students in the class focusing on blood pressures (10 minutes).

Note: taking a BGL on each other is not a priority if some students feel uncomfortable doing so. They should set up the unit and work through the process however



3 Ask students the knowledge check questions, with the students silently writing their answers in their First Responder student workbook. Once all questions have been asked, work through the answers with the students self-marking their answers:

Question one: Name three medicines a First Responder can administer upon consultation with the Clinical Desk:

Answer should consist of three from:

� Entonox (inhaled)

� Intramuscular adrenaline

� Intramuscular ceftriaxone

� Intramuscular glucagon

� Methoxyflurane (inhaled)

� Nebulised adrenaline

� Nebulised ipratropium

� Nebulised salbutamol

� Sublingual GTN

Question two: What information should be included in a SITREP?

Answer:

� Age: The patient’s age

� Sex: The patient’s biological sex at birth

� Status: The patients status as described previously

� Chief complaint: The patients chief complaint

� Resources: Additional or specialist resources required



Question three: List the five status codes and briefly describe what they mean:

Answer:

� Status zero: dead

� Status one: immediate threat to life

� Status two: potential threat to life

� Status three: unlikely threat to life

� Status four: no threat to life

Question four: What does OPQRST stand for?

Answer:

� Onset

� Provokes

� Quality

� Radiates/region

� Severity

� Timing



Knowledge check

Day One: Session tenDuring the knowledge check you will be asked to complete some tasks and answer some questions, you should record these here:

Vital signs:

RR: HR:BP: CRT:LOC: SpO2

BGL: Temp:

Question one:

Question two:



Question three:

Question four:



Day Two

Timetable (approximate):

0830 Session 1 - Airway management

0930 Session 2 - Basic resuscitation

1015 Session 3 - Automated external defibrillation (AED)

1100 Morning tea

1115 Session 4 - Full resuscitation

1200 Session 5 - Oxygen therapy

1230 Session 6 - Shock and trauma

1300 Lunch

1330 Session 7 - Haemorrhage control

1400 Session 8 - Fractures and dislocations

1500 Session 9 - Thermal problems

1530 Afternoon tea

1545 Session 10 - Head and spinal injuries

1645 Session 11 - Caring for yourself and your patient



Lesson plan: Airway management

Day two: Session one (60 minutes)

Learning objectives � Understand the importance of airway management

� Demonstrate competency in manual airway manipulation, bag mask ventilation, and the placement of basic airway adjuncts at First Responder level

� Overview the principles of ventilation

� Understand the role of suction in basic airway management

Required equipment � Blankets (one between two)




� Oxygen set (one between four)

� Resusci-Anne (CPR-D) manikin (one between four)

� St John First Response (Resus) Kit (one between four)

� Suction unit with hard/rigid and soft catheters (one between four)

Suggested way to teachReferencing the First Responder facilitator manual:

1 Demonstrate manual airway manipulation techniques to include optimising head position, head tilt chin lift and the jaw thrust. Following this have students split into pairs, place a blanket on the floor, and practice these techniques (15 minutes).

2 Demonstrate bag mask ventilation techniques, to include the single-handed mask hold and the two-handed mask hold. Following this, in groups of four (maximum), using a CPR-D and a resuscitation kit, have students practice these techniques (15 minutes)



3 Demonstrate the insertion of basic airway adjuncts, to include the oropharyngeal and nasopharyngeal airways. Emphasise that nasopharyngeal airways are outside the scope of First Responders; however they are able to use them upon consultation with the St John Clinical Desk. Following this, in groups of four (maximum), using a CPR-D and a resuscitation kit, have students practice these techniques (10 minutes).

4 Briefly discuss the principles of ventilation and demonstrate suctioning. Following this allow students to practice airway management (including suctioning) within their groups of four (20 minutes).

If it appears that students are competent in airway management, and do not appear to be practicing airway management, it is appropriate to move on to the next session.



Airway management

Day two: Session one The following is a list of techniques that the First Responder can utilise when performing airway management. These are not unique to cardiac arrest and can be applied to any situation that requires airway management.

In general these will be used on patients who are unresponsive, however occasionally you may need to use some of these techniques on patients who are alert, responsive to voice or responsive to pain. Usually these patients have injuries, or a medical condition that have left them unable to maintain their own airway without support.

In general if a patient is unwell enough that they require airway support, they need an Intensive Care Paramedic, therefore you must request backup for all patient’s whom you are providing airway support to.

Manual airway manipulationOften an airway can be effectively managed without the support of any adjuncts whatsoever. Sometimes all that is required is positioning of the airway.

One common misconception is that spinal alignment must be maintained at all costs, this is incorrect. Correcting a problem with the airway must always take precedence over any problem (actual or potential) with the spine.

Optimising head positionThe aim of optimising head position is to place the patient’s airway into the position which is anatomically most appropriate to maximise air flow. This technique varies by age, and is designed to align the ‘axis of the airway’.



� Adults: Known as the ‘sniffing position’, and often described as ‘sniffing the morning air’, this is best achieved by tilting back the patient’s head, and or placing a pillow or folded towel under the patient’s head.

� Children: Should not need any form of propping up, and as such should be in a relatively ‘neutral’ position. It may be appropriate to tilt their head back.

� Toddlers and infants (less than 2 years): Need their shoulders elevated with nothing below their head. This is best achieved by placing a folded towel (preferred) or pillow from their shoulders along the length of their body.

Head tilt, chin lift:

This quick and easy technique is useful when examining that a patient’s airway is clear. It is also a good technique to use when it is apparent the patient is not completely unresponsive.

Using two hands extend the patient’s neck and open their airway. One hand is used to apply downward pressure to the patient’s forehead, while the tips of the index and middle finger of the other hand lift the jaw.

Jaw thrust

This technique is useful when the patient is deeply unconscious. It is uncommon for this technique to be effective on patients who are not unconscious as it is painful for the patient and difficult to achieve unless the jaw is flaccid.

It is achieved by placing both thumbs on the patient’s chin encouraging it forward, while simultaneously tucking both middle fingers behind the angle of the jaw, thrusting it forward.

The ‘head tilt, chin lift’ and ‘jaw thrust’ are both designed to bring the tongue forward to prevent it obstructing the patient’s airway.

Additional informationIf there is a foreign object or material in the mouth that could be obstructing the airway or impeding adequate ventilation, an OPA can be used to sweep it out of the mouth.



Bag mask ventilation

Single handed mask hold

Place your non-dominant hand on the mask, using the distal pads of your thumb and index finger to hold the mask in situ, rock it gently from side to side to achieve a seal. Use your remaining fingers to pull the patient’s jaw up into the mask to keep the airway open.

If a seal is not easily achieved, a common tendency is to pinch the body of the mask with the thumb and index finger. This makes leaks worse, and should be avoided.

The single handed mask hold works well for experienced responders with large hands, but is difficult for inexperienced responders or those with small hands. In any case, it is notoriously difficult to do effectively for long periods.

Two handed mask hold

This is the most effective method for opening the airway whilst achieving a mask seal. It is the method of choice in the emergency situation where two responders are present. This technique mandates that its one responders responsibility to maintain an effective airway by simultaneously using both hands to open the airway and achieve an effective mask seal.

In this method both hands are placed parallel on the mask with the thumbs pointing inferiorly, executing gentle downward pressure to achieve a seal. The fingers can be used to achieve a jaw thrust manoeuvre, either by placing the middle fingers under the angle of the jaw, or hooking all fingers underneath the jaw to thrust it forward.

Whilst one responder maintains this position, the other ventilates as appropriate

Note: the oxygen flow rate for BVM is 10-15 litres/ minute



Basic airway adjuncts

Oropharangeal airway (OPA)

The OPA is a semi-circular plastic airway designed to follow the curvature of the mouth. It holds the base of the tongue away from the back of the throat, thus preventing it from obstructing breathing.

OPAs should be routinely placed in patients requiring airway support unless there is a good reason not to.

OPAs should not be placed in patients who are conscious or semiconscious who have a gag reflex as this may cause vomiting.

The advantages of an OPA are:

� Easy to place using proper technique

� Helps prevent obstruction by teeth and lips

� Helps manage unconscious patients who are breathing spontaneously or need mechanical ventilation

� Serves as a bite block in case of seizure or to protect more advanced airways.

The disadvantages of an OPA are:

� Vomiting may occur if gag reflex is present

� If the OPA is too large, it can close the glottis

� Cannot be inserted if trismus (lockjaw) is present

� Easily dislodged

� Does not isolate the windpipe or prevent aspiration.

Sizing

Measure the OPA from the corner of the mouth to the bottom of the ear.

Insertion

In adults, the airway is then inserted into the person’s mouth upside down. Once the tip reaches the back of the throat it is rotated 180° until it comes to rest over the tongue.

In small children and infants, the airway is inserted the right way up.



Nasopharyngeal airway (NPA)

The NPA is a soft rubber tube that follows the natural curvature of the nasal cavity. It enters the nostrils and extends to the back of the throat sitting just below the base of the tongue.

NPAs are within the delegated scopes of Emergency Medical Technicians; however First Responders may be permitted to insert them upon consultation with the St John Clinical Desk.

The advantages of an NPA are:

� It can be rapidly inserted

� It is able to be used in patients with a gag reflex, damage to the oral cavity, or trismus (lockjaw)

� You can suction through it.

The disadvantages of an NPA are:

� Small diameter

� Can cause bleeding

� Can kink due to its soft rubber

� May pass into the cranial vault if a skull fracture is present (caution only).

Sizing

It is measured from the nostril to the ear lobe.

Insertion

First, size the airway, then lubricate, select the biggest nostril and insert the NPA. Slowly slide it in, aiming for the back of the head. It is likely you will encounter resistance and this is normal. If resistance is felt, gently rotate the NPA and push again (never force). It is rare that an NPA will not slip into place by doing this two or three times.



Principles of ventilation: � Avoid hyperventilation: Ventilating too fast for the patient and supplying too

much oxygen decreases blood flow to the brain and interferes with the flow of blood during CPR. Adults should only be ventilated at a maximum rate of 8-10, and children at a maximum rate of 12-14.

For many people this involves making the conscious decision to take their hand off the bag and counting to seven, then ventilating.

� Avoid over inflation: A bag mask will deliver much higher volumes than a normal breath. A healthy adult normally breathes in approximately 500 ml of air, whereas an adult bag mask is capable of delivering 1600 ml of air. Over inflation risks delivering air into the food pipe (oesophagus) and making the patient regurgitate. It also interferes with the flow of blood during CPR.

Adults only require a one third to half squeeze on the bag to receive adequate ventilation.

� Stay focused: It is easy for the person ventilating to become distracted on other tasks during a busy resuscitation. It is not uncommon for ventilation to be interrupted as the patient is transferred to the ambulance – stay focused!

Suctioning

Airway suctioning is indicated for the physical removal of secretions in order to maintain a patient’s airway to ensure a path for adequate ventilation. Suctioning is reserved for fluid that is interfering with your ability to maintain ventilation. It is not indicated for the clearance of small amounts of saliva or blood that are not interfering with ventilation. Vomiting or regurgitation is the most common fluid that requires suctioning.

Irrespective of the type of suction unit you are using, the principles of suctioning are the same:

� Where copious or solid debris and fluids are present, manual clearance should be attempted using an OPA

� Suction catheters have a hole which must be occluded to allow suction to occur

� Only suction for as far as you can see

� Rigid suction catheters must not be used in a moving vehicle

� Only suction when withdrawing the catheter (not while inserting)

� Suctioning should only occur for 8-10 seconds (maximum) at a time

� Minimum personal protection is gloves

� Ensure that the suction unit remains upright (especially with compact suction units). Many suction units if placed on their side will fail to operate (owing to debris clogging the filters).



Lesson plan: Basic resuscitation

Day two: Session two (45 minutes)

Learning objectives � Understand what a cardiac arrest is

� Emphasise the importance of chest compressions in resuscitation

� Understand how to maximise the effectiveness of chest compressions

� Demonstrate effective chest compressions on an adult patient; including effective rate, depth and positioning during chest compressions

� Demonstrate effective CPR, including airway management but excluding defibrillation.



� St John Clinical Procedures and Guidelines Pocket Edition (four per class for student reference)








Suggested way to teach1 Referencing the First Responder facilitator manual, and having students

reference the First Responder student workbook, summarise the importance of chest compressions in resuscitation, and discuss the steps that the First Responder can take to maximise the effectiveness of chest compressions to include:

• Starting compressions early

• Minimising interruptions

• Maintaining an adequate rate

• Compressing an appropriate depth

• Allowing full chest recoil

• Changing at two minute intervals (15 minutes).

2 In the same groups of four from the last session, have students demonstrate effective CPR on the manikins. Ensure each person in each group performs at least two rounds of two minutes effective chest compressions.

Once groups appear proficient at chest compressions, pause the class and referencing the First Responder facilitator manual, introduce ventilation and airway management in relation to the cardiac arrest algorithm.

Have students continue resuscitation, swapping at two minute intervals for the remainder of the session (30 minutes).



Basic resuscitation

Day two: Session two A patient is in cardiac arrest when they are unconscious and have no palpable pulses, or no signs of life. In New Zealand more than 1200 people suffer from cardiac arrest out of hospital every year and only approximately 10% survive to hospital discharge. Some countries overseas have rates approaching 35% (or higher).

Resuscitation is one of the most prescriptive and algorithm driven types of incidents we deal with, and for the most part the science behind resuscitation is clear. Strict adherence to the algorithm, techniques and principles of resuscitation saves lives – it’s that simple.

The chain of survival refers to a series of actions that reduces the mortality rate of cardiac arrest patients when applied. As with any chain, it is only as strong as its weakest link. The links in the chain of survival are prevention, early recognition, early access, early CPR, early defibrillation and early advanced care.

The overwhelming majority of viable cardiac arrests that we attend are primary cardiac arrests. This means that the cause of the arrest is likely to be the failure of the heart to pump. Secondary cardiac arrests, those caused by a problem that is not directly related to the heart (for example trauma or asthma) are not as common a cause of viable cardiac arrest. Because the majority of arrests we attend are primary, this makes chest compressions incredibly important, as chest compressions act as the artificial pump (in place of the heart) until a definitive treatment can be delivered.



What are the important aspects of chest compressions?

1 Start compressions early: Early and effective CPR with an emphasis on chest compressions can increase survival from a witnessed arrest by almost 50%. With every minute that passes, the chances of survival without CPR rapidly decrease by 7-10% per minute. However, with quick recognition and good CPR the survival rates decrease less rapidly at 3-4% per minute.

Blood carries oxygen. It is likely that a patient who has recently suffered a cardiac arrest will still have reserves of oxygen within their blood; it just is not getting to vital organs as the heart is not pumping it there. Therefore in early cardiac arrest it is appropriate to start compressions at the earliest opportunity.

2 Minimise interruptions: It takes up to 30 compressions to get good blood flow from compressions, but flow drops off rapidly when compressions cease. For this reason there should be minimal time off the chest and maximum time on the chest. Pauses for ventilations should be no more than three seconds, and if the person ventilating is not able to deliver two ventilations within three seconds compressions should be continued for another full cycle.

Minimising interruptions also minimises distension of the heart, which distends during cardiac arrest. This distension reduces the likelihood that defibrillation will be successful, and it reduces the ability of the heart to contract if defibrillation is successful. Chest compressions, particularly uninterrupted chest compressions reduce this distension.

Pulse checks should not be performed unless there are obvious signs of life (such as the patient moving or waking up). This is because you will do no harm by performing chest compressions on a beating heart, however spending time finding a pulse can result in significant loss of blood supply to the brain.

3 Maintain an adequate rate: A rate of approximately 100 per minute maximises blood flow, noting that in general we compress too fast. Rates faster than 100 yield little in the way of improved blood flow as the heart does not have enough time to fill. Additionally you will tire quicker at faster rates, contributing to poor technique.

4 Compress at an appropriate depth: Effective compressions need to be approximately one third the depth of the chest, in adults this is approximately five centimetres.

Good positioning is key to ensure that you are able to compress the chest with enough force. The best position is to kneel at the side or at the head of the patient with your knees spread shoulder width apart and shoulders directly above the hands. The heel of the hand should be placed between the nipple line and the other hand placed on top of the first hand with fingers interlocked. During compressions the elbows must be locked straight.



5 Allow chest recoil: During chest compressions, it is both physical compression of the heart, and the changing positive (while pushing down) and negative (while allowing the chest to recoil) pressure within the chest that generates flow. For these changing pressures to be fully effective, the rescuer needs to ensure they allow the chest to fully recoil.

6 Change at two minute intervals: Quality compressions are difficult to maintain as they are physically demanding, for this reason we recommend changing every 2 minutes, or when you are tired (whatever comes first).

Ensure you

1 Start compressions early

2 Minimise interruptions (no more than 3 seconds without compressions)

3 Maintain an adequate rate (100 per minute)

4 Compress at an appropriate depth (one third of the chest depth)

5 Allow chest recoil

6 Change at two minute intervals

How do ventilations fit in during cardiac arrest? � For an adult the CPR compression to ventilation ratio is 30:2 (chest

compressions to ventilations) for those receiving ventilation via a bag and mask. This ratio prioritises chest compressions on the basis that an adult is most likely to have had a primary cardiac arrest. If an adult has clearly had a cardiac arrest secondary to asphyxiation or to respiratory failure, alter the ratio to 15:2.

� For a child the CPR compression to ventilation ratio is 15:2 for those receiving ventilation via a bag mask (exception – the ratio is 3:1 for a neonate). The 15:2 ratio reduces the priority of chest compressions on the basis that a child is most likely to have had a cardiac arrest secondary to respiratory failure.

� Some senior clinicians may insert an airway that allows for continuous compressions with concurrent ventilation. During continuous chest compressions ventilate an adult with 8-10 breaths per minute and a child with 12-14 breaths per minute. Ventilation rates higher than these must be avoided as they reduce the blood flow achieved during CPR.



Cardiac arrest algorithm in the absence of a defibrillator:

Perform continuous chest compressions

Place an OPA and setup bag mask

Continue compressions at ratio 30:2 (adult)

Do not stop until directed to do so

*Remember to rotate the person doing chest compressions every 2 minutes

Additional considerations:

� Resuscitation should start unless there is a clear reason not to. Clear reasons for not starting resuscitation include:

• Signs of rigor mortis or post-mortem lividity

• A clear advance directive not to receive resuscitation for cardiac arrest

• Scenarios where resuscitation is either futile or clearly not in the best interest of the patient (for example a patient who is dying from cancer).

� If there is doubt regarding the appropriateness of a resuscitation attempt, then resuscitation should begin while further information is gained.

� Family members do not have the right to either demand or decline resuscitation in the event of cardiac arrest, but their opinion of what the patient would want must be taken into consideration.

� Once started, resuscitation should be continued until you are directed to stop (unless you become too physically exhausted to continue). This may be from a senior clinician, or upon consultation with the St John Clinical Desk

� Even if you have been sent to a cardiac arrest, it is important to confirm that a patient is in cardiac arrest at the earliest opportunity. This ensures the ambulance communication centre is sending you the most appropriate help, or can free up resources to help another patient if it is not a cardiac arrest.

� You will sometimes hear the term ROSC used. This is return of spontaneous circulation (ROSC), and is the presence of a palpable pulse, or clear signs of spontaneous circulation in the absence of on-going CPR.



Lesson Plan: Automated external defibrillation (AED)

Day two: Session three (45 minutes)

Learning objectives � Discuss (in simple terms) how defibrillation works

� Explain and demonstrate the procedure for safe defibrillation; including pad placement and verbally and visually clearing prior to shocking

� Describe the sequence of actions and skills required to use an AED in conjunction with basic principles of resuscitation

� Explain problem solving techniques if a problem is encountered in a cardiac arrest situation.



� FR Day Two PowerPoint


� Defibrillator / Monitor OR AED with ECG capability (one between 4, where possible use the same type as defibrillator as the one used by the students operationally)


� Resusci-Anne (CPR-D) manikin (one between four).



Suggested way to teach1 Referencing the First Responder facilitator manual present the Automated

external defibrillation section of the FR Day Two PowerPoint. This PowerPoint should be presented in an interactive way. Students should reference the First Responder student workbook during the presentation (10 minutes).

2 Using a Resusci-Anne (CPR-D) manikin, demonstrate how to defibrillate a patient using an AED, emphasise that:

• The defibrillators actually shock the manikin so they need to be treated as live, and metal contacts on the manikin must not be touched. Attaching the defib and pushing analyse takes priority over other interventions, including compressions and airway management if attaching the defib and doing these things cannot be done concurrently

• The patient must not be touched during the analysis

• It is the responsibility of the responder operating the AED to ensure the safety of all personnel when delivering a shock

• As soon as a shock has been delivered the responder(s) should resume/start compressions at the earliest opportunity. Following this, set the manikins to a shockable rhythm, and have the students practice safe defibrillation in the absence of other interventions (30 minutes).

3 Finally, referencing the final information slide on the Automated external defibrillation section of the FR Day Two PowerPoint, briefly discuss the key actions that need to be taken if a defibrillator fails during a cardiac arrest (5 minutes).



Automated external defibrillationDay two: Session three You will recall from the ECG acquisition section that the heart is reliant on electrical stimulus to initiate contraction. Electrical stimulus is generated near the top of the heart in the atria causing the top of the heart to pump, and then runs through the middle of the heart to the bottom (and up the sides) in the ventricles causing the bottom of the heart to pump.

If this electrical circuit malfunctions, multiple and sometimes chaotic electrical impulses throughout the heart mean the heart muscle is unable to respond and contract in a coordinated fashion – this is referred to as fibrillation. In this setting a larger than usual electrical impulse can stop this malfunction and allow the normal electrical circuit of the heart to resume – this is referred to as defibrillation. It is worth noting that not all rhythms that result in cardiac arrest can be defibrillated. For example, in trauma if the electrical circuit is intact but the heart is empty, defibrillation will not work. Likewise if there is no electrical activity in the heart (flat line) then defibrillation will not work.

Automated external defibrillators (AEDs) are designed to analyse the patient’s ECG and determine whether the patient has a rhythm that will respond to defibrillation. If there is an appropriate rhythm the AED will charge so you can deliver a shock. If there is not an appropriate rhythm the AED will direct you to continue CPR and will analyse every two minutes until it has been turned off.

Example of shockable rhythms:

Ventricular fibrillation

Ventricular tachycardia



Example of non-shockable rhythms:

Sinus rhythm if the patient has a pulse OR PEA if the patient does not

have a pulse

Asystole

How to use an AEDThere are a number of different AEDs in service with St John and allied emergency services throughout New Zealand. Irrespective of the type of AED, using the defibrillator is as easy as 1, 2, 3.

1 Turn the defibrillator on and apply the pads

2 Analyse the rhythm

3 Deliver the shock

Attach and use a defibrillator as soon as possible. Defibrillation must not be delayed by performing other interventions.

1 Turn the defibrillator on and apply the pads

Depending on the type of AED you are using, you may need to turn the defibrillator on or the defibrillator may turn on automatically when you open the case. When using a Phillips MRx, ensure that the dial on the defibrillator has been switched to ‘On AED’.

Next apply the defibrillation pads. One will need to be applied under the patient’s right collarbone, the other under their left armpit. In the heat of the moment the easiest thing to do is to follow the instructions on the diagrams attached to the defibrillator pad packaging. Avoid placing pads over monitor leads (if applied) or jewellery. If there is excessive hair you will need to shave the patient’s chest.

Once the defibrillation pads have been applied the AED will verbalise instructions. There are some older defibrillators in circulation that may contain variations in algorithm. In this setting ensure you follow the instructions as directed by the AED.



2 Analyse the rhythm

Push the analyse button when directed to do so. You will be prompted to stop CPR and to avoid touching the patient. This is important as it may interfere with the ability of the AED to analyse the rhythm. You will need to pull over to analyse in a moving vehicle.

3 Deliver the shock

Verbally announce ‘shock advised, stand clear’, visually sweep the scene to ensure everyone is clear, place your finger on the shock button, look at the patient and push the shock button if it is safe to do so.

The patient ‘jumping’ and cessation of the audible warning tone signals that the shock has been delivered.

Additional considerations

� Move the patient away from oxygen rich or flammable environments prior to defibrillating. It is safe to defibrillate on metal surfaces or in wet environments.

� Defibrillators in advisory (automatic) mode should be used on children if a defibrillator in manual mode is not immediately available.

Attach and use the defibrillator as soon as possible.

Defibrillation must not be delayed by performing other interventions.

TroubleshootingRarely you may encounter a problem with your defibrillator at a cardiac arrest. This is a serious situation as failure of the defibrillator could contribute to patient death. The following checklist should be used in the event that your defibrillator fails. We strongly advocate that this checklist is placed into the pocket of your defibrillator for quick reference. It is also in both the comprehensive and pocket editions of your Clinical Procedures and Guidelines.



Defibrillator failure checklist:Use this checklist if a defibrillator fails and there is not another defibrillator (including an AED) immediately available. At each defibrillator intervention, pause briefly to determine if the problem has been fixed.

� Task specific personnel to focus on resuscitating the patient.

� Task specific personnel to focus on troubleshooting the defibrillator.

� Call Comms and ensure another vehicle is responding.

� Ensure the pads are attached and connected.

� Ensure the ECG leads are attached.

� Change the lead shown on the screen so that the rhythm is visible.

� Turn the defibrillator off for thirty seconds and turn it back on again.

� Remove and replace the batteries, utilising the spare battery.

� Attach and connect a new set of pads.

� If in manual mode switch to automatic mode.

� Turn the defibrillator off for thirty seconds and turn it back on again.

Report as an adverse incident if you reach the point of turning the defibrillator off for thirty seconds.



Lesson plan: Full resuscitation

Day two: Session four (45 minutes)

Learning objectives � Understand the importance of gear placement at a cardiac arrest

� Evaluate the full cardiac arrest algorithm

� Understand the idiosyncrasies of single, double and multiple rescuer resuscitation

� Demonstrate full and effective resuscitation of a patient in cardiac arrest.



� FR D2S4 Rapid Response Cardiac Arrest video

� FR D2S4 Full Resuscitation Single Responder video

� FR D2S4 Full Resuscitation Double Responder video

� FR D2S4 Full Resuscitation Multiple Responder video



� Defibrillator / Monitor OR AED with ECG capability (one between 4, where possible use the same type of defibrillator as the one used by the students operationally)








Suggested way to teach1 Using the Full resuscitation section of the FR Day Two PowerPoint, and

referencing the First Responder facilitator manual, introduce students to the cardiac arrest algorithm with an AED. It is worth noting that older defibrillators may not follow this algorithm. In this setting responders should follow the instructions given by the AED (5 minutes).

2 Watch the single, double and multiple FR D2S4 Full resuscitation videos and discuss the idiosyncrasies of each referencing the First Responder facilitator manual (10 minutes).

3 In groups of four, have students practice full cardiac arrest scenarios utilising all the skills learned today. During this time walk around the class toggling the manikins between shockable and non-shockable rhythms (or have students do this if appropriate). Students should be instructed to start the cardiac arrest from arriving on scene, and may perform single, double or multiple responder resuscitation relevant to their role (noting that our preference is for St John staff to focus on double responder and NZFS staff to focus on multiple rescuer CPR, but be guided by the students as to what is most relevant for them). It may be useful to leave the PowerPoint slide showing the cardiac arrest algorithm displayed during this time (30 minutes).

4 In closing before lunch, play the FR D2S4 Rapid Response Cardiac Arrest video.



Full resuscitationDay two: Session four Now that we have looked at all the critical elements of resuscitation we need to bring all the elements together. In doing so it is important to recognise that while we set our standards high, every situation is different, and there is no such thing as a perfect resuscitation!

Cardiac arrest algorithm in the presence of a defibrillator:

Perform continuous chest compressions

Attach defib, *place OPA, setup bag mask

Analyse rhythm shock advised?

Check safety of team and bystanders

Single shock Immediate compressions at 30:2

Obvious signs of life (moving, waking up)?

*Note attaching the defib and

analysing takes priority over

airway management if these

cannot be done concurrently

YES NO

2 minutes


� Deliver a pre-cordial thump if cardiac arrest occurs in the presence of personnel and a defibrillator is not attached.

� Minimise the post-shock pause by resuming chest compressions immediately following a shock, without checking for a pulse. Ideally post-shock pauses should be less than 3 seconds.

� Once cardiac arrest has been confirmed, only check for a pulse if there are obvious signs of life (such as the patient moving or waking up)

� If space is at a premium, it is appropriate to move the patient to an area where resuscitation can be performed safely and effectively



� Consider your gear placement carefully; gear must be close enough to be easily accessible, but far enough away that it does not clutter the scene. Remember that your backup will bring more equipment. Where practicable keep one side of the patient free so that there is room for your backup to set up their equipment and access the patient.

Single responder resuscitation:Performing single responder resuscitation is challenging and there is no single correct method for managing such a situation. In short if you are faced with this situation you will just need to do the best you can, attempting to adhere to the following principles:

� Perform a primary survey and confirm cardiac arrest

� Utilise bystanders to perform chest compressions and confirm cardiac arrest if available. Only engage in compressions where necessary to ensure quality of compressions

� Attach and use the defibrillator at the earliest opportunity. If bystanders are present be especially mindful of safety during defibrillation as the danger is likely to be unfamiliar to them

� Insert an OPA and stay on the airway if possible. From here you can see the whole scene and operate the defibrillator

� Attempt to keep an eye on time and the number of shocks delivered if possible.

Notes



Double responder resuscitation:This is the most likely situation for a responding ambulance or ambulance first response crew. In this setting the algorithm can largely be adhered to, noting that the first two minutes are likely to be very demanding. Ideally concurrent actions would occur as per the following table:

Action number Responder one Responder two

1 Performs a primary survey Places equipment

2 Confirms cardiac arrest with comms

Performs continuous chest compressions

3 Turns on the defibrillator and attaches pads


4 Analyses the rhythm Opens the first response pack and prepares the airway gear

5 Waits for defib to charge Performs continuous chest compressions

6

Confirms that a shock is advised, tells bystanders to stand clear

Opens the first response pack and prepares the airway gear until command is given to stand clear

7 Delivers shock Stands clear

8Inserts basic airway adjunct and prepares to deliver a breath


9Confirms airway is inserted and that they are ready to deliver two breaths


10 Delivers two breaths Pauses

11Examines the scene and encourages chest compressions

Performs 30 compressions stating the last five out loud

12 Delivers two breaths Pauses

Once the responders are at this point it is appropriate to continue this cycle until the AED prompts the next analysis. At that point the responders should swap so the rested officer can perform CPR, and the cycle should continue.



Multiple responder resuscitation:Occasionally multiple responders may be available, this is ideal as tasks can be quickly divided up leading to a very effective resuscitation scene. This is most likely at events or in the case of New Zealand Fire Service First Responders where multiple responders are common. Concurrent actions should occur as per the algorithm but with broad division of responsibility.

Responder one: Should perform a primary survey, confirm arrest, then stand back and manage the scene. This should be a senior First Responder or ranking officer.

Responder two: Should focus solely on uninterrupted chest compressions.

Responder three: Should focus on attaching the defibrillator, analysing and shocking as appropriate.

Responder four: Should focus solely on airway management.

At each analysis, responders two, three and four should rotate to ensure that there is always someone performing chest compressions.

Notes



Lesson plan: Oxygen therapyDay two: Session five (30 minutes)

Learning objectives

� Demonstrate how to change an oxygen cylinder and a bodok seal.

� Discuss the importance of correct oxygen delivery.

� Identify and discuss the correct use of different oxygen delivery devices; including nasal cannula, simple mask, reservoir mask and nebuliser masks.

� Identify circumstances (in line with CPG’s) when oxygen should be administered.




Suggested way to teachAllocate the students into groups of four and give each an oxygen set. Then, referencing the First Responder facilitator manual, and with students referencing their First Responder student workbooks:

1 Introduce oxygen administration emphasizing that oxygen is not a one size fits all treatment for patients who are unwell. Then demonstrate:

• How to identify an oxygen cylinder

• How to change an oxygen cylinder

• How to change a Bodok seal

Encourage students to replicate this using their group oxygen set. Following this briefly discuss the safety considerations when using oxygen (5 minutes).

2 Run through the indications for oxygen administration with reference to the special considerations for high risk patients (5 minutes)

3 Walk through each type of oxygen delivery device. Demonstrate the application and use of each and encourage students to replicate this using their oxygen set (10 minutes)

4 As a class, work through Exercise 5: Oxygen administration. This brief exercise is designed to get students thinking about who should and shouldn’t receive oxygen (10 minutes).



Oxygen therapy

Day two: Session fivePreviously oxygen was the mainstay of treatment for nearly every patient attended by ambulance and first response services. Over the past few years much research has occurred around which patients require oxygen and which do not. Curiously, this research has revealed that there were a number of patients to whom we were giving oxygen, and probably harming in doing so. Examples of this include stroke and cardiac chest pain, both of which large volumes of oxygen has been shown to actually make those conditions worse. The following session introduces oxygen and provides guidance as to which patients should receive it.

The oxygen cylinder, regulator and Bodok sealOxygen cylinders are identified by being black in colour right up to the cylinders neck, or by being white in colour right up to the cylinders neck with a black ‘N’ printed on the outside near the neck. The latter colour is relatively new, and is occurring as a result of gas suppliers to bringing their colour coding into line with international standards.

Oxygen cylinders have a standard fitting, although there are several different types of regulators. Attached to the oxygen regulator is a ‘Bodok seal’. The Bodok seal is a specialised washer that ensures a tight seal between the regulator and the cylinder. Attachment and detachment of oxygen cylinders, combined with constant exposure to high pressures can make Bodok seals break down, thus they are a common culprit if the oxygen cylinder is leaking. Bodok seals should be replaced if they appear to be breaking down or are leaking.



Safety when administering oxygenWhile oxygen is generally a safe gas to use, it should be noted that it increases the likelihood and intensity of combustion. Thus administration of oxygen should be avoided in areas which are not well ventilated, where fire is a risk or a reality. It is worth noting that materials not normally considered combustible may ignite in oxygen rich environments. Therefore oil, grease and lubricants should not come into contact with oxygen.

Oxygen should be lay flat when in use (not left standing). It is common for cylinders to be inadvertently kicked, or for cylinders to tip over in wind which may damage the oxygen regulator.

Oxygen should only be taken into rescue and extrication situations when absolutely necessary. It is common for responders to trip over cylinders and tubing to get snagged.

Indications for oxygen administrationOxygen is not a one size fits all or routine treatment, it should only be administered if clinically indicated. You should administer oxygen if the patient has:

� An SpO2 less than 94% on air or

� Airway obstruction or

� Respiratory distress or

� Shock or

� Inability to obey commands from traumatic brain injury (TBI) or

� Carbon monoxide poisoning or

� Smoke inhalation or

� Decompression (diving) illness.

High risk patientsThere are some patients in the community who have chronic respiratory problems. Patients in this category include patients with chronic obstructive respiratory disorder (CORD), morbid obesity, and those on home oxygen.

For these patients oxygen flow rates should be titrated to the patient’s normal SpO2 if this is known. If it is not known, titrate the oxygen flow rate to an SpO2 of 88-92% (even if they are presenting with respiratory distress). If you do not have a pulse oximeter then give the lowest volume of oxygen possible to ease the patient’s distress until a pulse oximeter arrives.



Identifying these patients is important (they will usually be able to tell you) as for a small number of patients high volumes of oxygen can inhibit their respiratory drive. If you are unsure you should administer oxygen and contact the St John Clinical Desk.

See the notes on CORD for further information.

Oxygen delivery devicesThere is an array of oxygen delivery devices which are used depending on the volume of oxygen required, and whether the patient requires nebulised medications and/or support with their ventilation. There is no strict rule on which one is best as every circumstance and clinical presentation is different. Use the simplest device and lowest flow rates to achieve the desired SpO2. If pulse oximetry is unreliable or unavailable, give oxygen as appropriate for the patient’s clinical condition.

Nasal prongsNasal prongs are carried and used on adults and older children only. We do not carry nasal prongs for small children as usually when children require oxygen they require high volumes. Use nasal prongs where a mild increase in oxygen levels is required.

To apply nasal prongs:

� Turn the oxygen on at a flow rate of 1-4 litres/minute

� Place the prongs in the patient’s nose

� Loop each end around the ears

� Tighten the tubing under the patient’s chin



Simple mask:Simple masks are carried for both adults and children. Use a simple mask where a moderate increase in oxygen levels is required.

To apply a simple mask � Turn the oxygen on at a flow rate of 6-8 litres/minute

� Place the mask on the patient’s face

� If necessary adjust the nose plate and tighten the straps

� Condensation in the mask indicates that the oxygen flow rate is too low and needs to be increased



Nebuliser maskNebuliser masks are carried for both adults and children. Use a nebuliser mask where a nebulised medicine needs to be administered.

To apply a nebulised mask:

� Remove the lid from the nebuliser bulb and place medicine around the outside of the inner casing

� Replace the lid and attach the nebuliser bulb to the mask

� Turn the oxygen on at a flow rate of 8 litres/minute



� The nebuliser should begin to mist

� Condensation in the mask indicates that the oxygen flow rate is too low and needs to be increased



Reservoir maskReservoir masks are carried for both adults and children. Use a reservoir mask where a rapid and significant increase in oxygen levels is required.

To apply a simple mask:

� Turn the oxygen on at a flow rate of 10-15 litres/minute



� Condensation in the mask or a deflated reservoir bag indicates that the oxygen flow rate is too low and needs to be increased

Bag mask (manual ventilation bag)Bag masks are carried for both adults and children. Use a bag mask where a rapid and significant increase in oxygen levels is required in conjunction with support for the patient’s ventilation. Reservoir masks are preferred wherever feasible as they do not tie up a responder like a bag mask does. The flow rate for a manual ventilation bag is 10-15 litres/minute. A deflated reservoir bag indicates that the oxygen flow rate is too low and needs to be increased. Techniques for application are as per those covered in the airway management session.



EXERCISE 5: Administering oxygenFor the following patients decide whether oxygen is indicated. If indicated state the type of device you will use and its flow rate

1 56 year old male with acute chest pain and an SpO2 of 90%

Indicated? YES Device? Nasal prongs Flow rate? 1-4 L/min

2 75 year old CORD patient with moderate distress and an SpO2 of 95%

Indicated? NO Device? None Flow rate? None

3 45 year old male, sudden onset one sided paralysis (possible stroke), SpO2 not available but no signs of respiratory distress

Indicated? NO Device? None Flow rate? None

4 32 year old intoxicated male with a head injury who is unable to obey commands, his SpO2 is 99%.

Indicated? YES Device? Simple mask Flow rate? 6-8 L/min

5 6 year old male with mild respiratory distress and no available SpO2

Indicated? YES Device? Simple mask Flow rate? 6-8 L/min

Notes



Lesson plan: Shock and trauma

Day two: Session six (30 minutes)

Learning objectives � Define trauma

� Discuss common causes of trauma (mechanism of injury)

� Discuss common injuries of trauma situations (index of suspicion)

� Discuss the types of shock and severity of shock

� Recognise the shocked patient

� Discuss the management of the shocked patient





Suggested way to teach1 Referencing the First Responder facilitator manual present the Shock and trauma

section of the FR Day Two PowerPoint. This PowerPoint should be presented in an interactive way. Students should reference the First Responder student workbook during the presentation (30 minutes)

2 During the PowerPoint presentation, you will be referred to two exercises that the students need to complete, these are:

• Exercise 6: Mechanism of injury (5 minutes)

• Exercise 7: Recognising shock (5 minutes)

Students are welcome to work in small groups or in pairs during these exercises. Answers should be placed into the student workbook as evidence of completion.



Shock and trauma

Day two: Session six In this session you will overview some of the basic principles of trauma and shock. Be reassured that in some ways dealing with trauma patients is easier because in general it is easier to understand what is wrong, and apply treatment accordingly. For example, it is much more difficult to treat a patient who is non-specifically unwell with abdominal pain, than it is to treat a patient with a broken leg.

What is trauma?

Trauma occurs when there is an injury as a result of an external force being applied to the body. It is the presence of an external force which differentiates a traumatic injury from a medical problem.

Mechanism of injury:

The mechanism of injury (MOI) refers to how the injury occurred. It is an assessment of the forces applied in trauma to assist you to gain an index of suspicion (IOS) about what injuries may have occurred. With experience you will eventually be able to zero in on the most likely injuries depending on the MOI.

For example, if you attend an incident where the sole occupant driver has been ‘T boned’ in the driver’s door, we can ascertain that extreme forces have been applied to the body from the side. This should give you a strong IOS that the patient may have cervical (neck), right chest, right abdominal and right pelvic injuries.

You will still need to perform a full patient assessment, but you may do so with reference to the more likely sites of injury. As the adrenaline wears off and the patient becomes sore, you can also reassess the patient with reference to these areas if initially they appeared to be uninjured.



EXERCISE 6: Mechanism of injury

Circle the joints you think would be affected as a result of this person landing on the ground after jumping from a 1 metre height.

Which parts of the body do you think will be affected as a result of the impact on these joints?

Ligaments and tendons associated with these joints, muscles associated with these joints, bones associated with these joints, pressure from landing could travel up the spine.

Bearing the above in mind, what injuries do you think this patient might sustain?

Given that the height the person is landing from is minimal the chance that thisperson will sustain any serious injuries is also minimal. You could still considertissue damage to muscle, ligaments, tendons or cartilage associated with thejoints e.g. sprains/ strains/ tears/ ruptures. Fractures of the bones involved,dislocations of joints affected, or slipped discs in the spine. From a small height,internal organ damage is unlikely.



What differences in injuries would you expect to see if the patient was landing from a second story balcony?

As the fall is higher, the impact will be larger, and so will the correspondinginjuries. Injuries suspected could be similar to above, but more extensive e.g.fractures could be larger, transfer of more energy up the spine, resulting in ahigher chance of back/ neck injury. The patient is also likely to land differentlywhen jumping from a higher height- this could mean the initial impact is in adifferent area, which would alter your IOS for particular injuries. You would haveto start considering the possibility of internal organ damage too, as the fall issignificant and has the potential to cause significant damage as a result.

Significant mechanism of injury:

The following are a list of circumstances which have a high MOI. You should have a high IOS that your patient has serious injuries if any of the following mechanisms have been identified:

� Car versus pedestrian > 30 km/h

� Death of other vehicle occupant

� Explosion

� Fall more than twice the patient’s height

� Intrusion more than 0.3m into a passenger compartment

� Intrusion more than 0.5m into an engine compartment

� Motor vehicle crash > 60 km/h

� Object fallen on patient from >5 metres

� Patient ejected from motor vehicle

� Patient in vehicle rollover

� Trapped for more than 30 minutes.

You should have a low threshold for recommending transport to patients with these mechanisms of injury irrespective of how well they appear to be.

It is worth noting that MOI is a useful tool for predicting injuries that may have occurred as the result of a particular trauma. It is not a useful indicator of patient status. For example, a patient who has been in a vehicle rollover, but upon full assessment you are unable to identify any injuries, and their vital signs are normal, the patient is status four.



In some scenarios with a particular MOI, there are predictable patterns of injury that aid in formulating your index of suspicion. For example, pedestrians who have been struck by a motor vehicle:

With adults, the bumper of the vehicle will hit the lower leg first (resulting in lower leg fractures), and as the lower segment of the body is pushed forwards with the vehicle, the upper and side of the body is hit by the hood (causing chest, femur and upper extremity fractures). The patient will then hit the windshield (causing neck and head trauma). Additional injuries will be sustained when the patient is thrown to the ground.

With children, as they are shorter, the initial impact of the bumper impacts the pelvis and/or femur (resulting in fractures in these areas). Due to their smaller size and lower centre of gravity, they are commonly thrown in front of the vehicle, and land on their head (as this is proportionally larger than in adults), resulting in head injuries.

Mechanism of injury should not be considered when determining a patient status

Notes



ShockIt is not uncommon for people to report that a patient is in ‘shock’ when calling for help. This is owing to the common misconception amongst novice responders and first aiders that shock is a form of severe fright or psychological trauma.

Shock is in fact a physical problem that results in decreased and inadequate blood flow, and supply of vital nutrients to the vital organs. Shock can be caused by a number of different problems, these are briefly summarised next.

Causes of shock

� Anaphylactic shock is caused by mediators released in response to an allergic reaction. The most common causes are ingestion of antibiotics, nuts or seafood.

� Cardiogenic shock is caused by low blood flow from the heart as a result of a heart problem. This can be seen following a ‘heart attack’ and may occur with or without cardiac chest pain.

� Hypoadrenal shock is caused by inadequate levels of certain hormones. Patients with congenital problems have this and will usually have information with or on them which will tell you about this condition.

� Hypovolaemic shock is caused by inadequate circulating blood volume. You might see this in someone who has had a large bleed, or someone who is very dehydrated.

� Obstructive shock is caused by an inability of blood to flow due to a physical obstruction near the heart. This can be caused by a blood clot in the lung, or physical compression of the heart resulting from trauma.

� Septic shock is caused by mediators released in response to severe infection. We mainly see this in elderly patients with severe chest or urinary infections.

� Spinal shock is caused by loss of blood vessel tone (the vascular space gets so big there is not enough blood volume to fill it) following spinal cord injury. Remember very simple injuries on the right angle can cause spinal injury.

The term distributive shock is sometimes used to describe shock states associated with dilated and leaky blood vessels. This is particularly associated with anaphylactic shock and septic shock.



Recognising the shocked patient:

Irrespective of what is causing the shock there are some common symptoms to watch out for which indicate the patient may have some form of shock, these are:

� Hypotension (low blood pressure)

� Absent or weak pulse

� Tachycardia (fast heart rate)

� Cool extremities

� Agitation (an early sign of decreasing LOC)

� Decreased LOC

� Delayed capillary refill time (longer than 2 seconds)

If your patient has signs of shock you must call for a Paramedic or Intensive Care Paramedic.

What do I do if my patient is shocked?

Management of shock is specific to its cause, some of which we have covered already (for example septic shock and anaphylaxis). The general principles that can be applied to all types are:

� Reassure the patient

� Lie the patient flat with legs raised

� Administer oxygen if the patient has an SpO2 equal to or less than 94%

� Seek backup from a Paramedic or Intensive Care Paramedic

� Transport without delay

� Have a low threshold for contacting the Clinical Desk

In addition to the above, if you are able to identify what is causing the shock, you should attempt to treat the underlying cause if possible. For example we have already identified:

� Anaphylactic shock: IM adrenaline and nebulised medicines under consultation

� Septic shock: IM ceftriaxone under consultation

Some are covered in the following sessions:

� Hypovolaemic shock: compress external bleeding, allow the patient to drink fluids as appropriate.

� Spinal shock: careful immobilisation and maintenance of neutral alignment (this will not fix the problem but it will help stop making it worse).



If your patient has shock, call for backup from a Paramedic or Intensive Care Paramedic

Have a low threshold for contacting the St John Clinical Desk

EXERCISE 7: Recognising shockYou respond to a 63 year old male, who is a diabetic and has a high blood glucose level. He tells you that he is extremely thirsty, and has been urinating large volumes frequently. His vital signs are as follows:

HR: 135 CRT: 4 secondsRR: 28 SpO2: 93%BP: 125/80 Pain: 0/10

Does this patient have shock? Why/Why not?

This patient has shock. His heart rate is elevated, as is his respiratory rate. His CRTis slow- indicating inadequate perfusion to his peripheries. From the historyprovided by the patient, he has lost a lot of fluids recently, which has led tohypovolemic shock.

You respond to a 23 year old male who has been involved in a motorcycle accident. Upon assessment you find that both his femurs are grossly fractured and he has significant pain in his pelvis. His vital signs are as follows:


Does this patient have shock? Why/Why not?

This patient is in shock. He has a high heart rate, a high respiratory rate, a verylow blood pressure, and is obviously not very well perfused due to his lowoxygen saturations and slow CRT. Despite not seeing a lot of blood, thispatient may be bleeding into his pelvis, causing hypovolaemic shock.



You respond to a 16 year old female who has been involved in a low speed nose-to-tail motor vehicle accident. The primary survey reveals no life- threatening abnormalities. Her vital signs are as follows:


Does this patient have shock? Why/ why not?

This patient is not in shock. She has been involved in an accident, which is verylow speed, and the IOS is very low for any injuries. She is young, anxious, andlikely shaken by the experience. Her elevated heart rate and increased respiratoryrate is likely to be due to her anxiety rather than an indicator of shock. Her blood pressure is normal, and her oxygen saturations and CRT indicate that she is well perfused.

Notes



Lesson plan: Haemorrhage control

Day two: Session seven (30 minutes)

Learning objectives � Define haemorrhage

� Discuss differences between capillary, venous and arterial bleeds

� Discuss injuries that produce haemorrhage; including but not limited to abrasions, lacerations, incisions, avulsions, impaled objects, amputations and puncture wounds.

� Describe and identify the correct dressings and bandages to manage the haemorrhage patient; including but not limited to sterile/non sterile dressings, wet/dry dressings, crepe bandages.

� Describe possible complications of an incorrectly applied dressing or bandage

� Discuss management of the haemorrhage patient; including but not limited to elevation and CAT



� Whiteboard and whiteboard pens

� Combat Application Tourniquets (CATs) (one between two)

� Various bandages (crepe and triangular)

� Various dressings (combine)




1 Define haemorrhage and discuss the types of bleeding. Next define the different types of open wounds, drawing these on the whiteboard if required (5 minutes).

2 Summarise the key points of the management of open wounds (including application of a butterfly stitch), then have the students replicate application of a dressing and bandage - both on a limb and scalp (10 minutes)

3 Discuss the rationale for, and demonstrate the method for CAT application (including mention of amputation management). Following this, have students practice CAT application in pairs (15 minutes).



Haemorrhage control

Day two: Session sevenHaemorrhage refers to the escape of blood from a blood vessel, and is commonly referred to as bleeding. Control of external bleeding is one of the simplest skills that can be performed by the First Responder; unfortunately it is also one of the areas which it is easy to get wrong if the wrong type of controls are put in place.

Types of bleedingBleeding can be classified as capillary, venous or arterial depending on the type of blood vessel that has been ruptured. This is important to understand as the type of bleeding is also a factor in determining what type of controls to apply.

Blood exiting the heart is carried by high pressure arteries, these feed oxygenated blood and nutrients to the low pressure capillaries within the skin, organs and tissues, before veins collect the deoxygenated blood and waste products which are returned to the heart.

Arterial, capillary and venous bleeding has the following characteristics:

Arterial: Because these blood vessels are carrying blood directly from the heart, they are under high pressure. As such these are the blood vessels that produce a pulse, and blood will appear to squirt out at the same time as the patient’s heart beats. Often blood can squirt several metres. Because blood is oxygenated it appears to be bright red. Arterial bleeds are notoriously difficult to control with dressings, and these bleeds usually require focal pressure (for example with a gloved finger) or a dressing with focal pressure to control bleeding. Arterial bleeds require immediate intervention.

Capillary: These are the smallest blood vessels which form the body’s microcirculation, and allow nutrient and gas exchange to take place. These are the blood vessels usually contained within the upper layers of the skin. They are low pressure and do not produce a pulse. Pressure within the capillaries is low, and these wounds ‘ooze’ blood continuously until they scab over. Capillary bleeds are rarely life threatening unless large surface areas are involved. Capillary bleeds are very easy to control with basic dressings. These bleeds usually do not need immediate treatment and it is easy to become distracted by them.

Venous: Because these blood vessels are carrying blood back to the heart from the capillaries, they are low pressure because they are reliant on passive pressure generated by the heart that has already been through the arteries and capillaries to push blood back to the heart. They are low pressure and do not produce a pulse. Because blood is deoxygenated it appears dark red. The passive pressure through the veins is relatively constant and as such venous bleeding appears constant. While not as spectacular as an arterial bleed, these vessels are high volume and bleeds from veins can be life threatening. Bleeding from a vein is usually easy to control with focal pressure followed by application of a standard dressing.



Types of open wounds � Abrasions (grazes): are caused by friction over the surface of the skin

� Amputation: are when a limb or digit is completely severed. Sometimes the term partial-amputation is used to described partially severed limbs

� Avulsion: where the skin is forcibly detached from the underlying structured. May be a skin flap (minor) or a de-gloving (moderate to severe)

� Incision: clean cut caused by a sharp object

� Laceration: irregular tear caused by blunt trauma

� Penetrating wound: caused by an object entering the skin (you cannot tell how much damage has occurred to the underlying structures)

� Puncture wound: caused by an object piercing the skin (e.g. a needle or nail)

These wounds often do not occur in isolation, and have any combination of arterial, capillary or venous bleeding.

Management of open wounds

Easily controlled bleeding, or bleeding stopped:

1 Examine: inspect the wound for foreign matter

2 Clean: irrigate the wound with saline or tap water

3 Close: apply a dressing appropriate to the size and type of wound. Ensure the dressing is applied damp (not soaking).

4 Reassess: if bleeding continuous, refer below.

Difficult to control bleeding, or bleeding continuous:

1 Apply pressure: using a damp gauze dressing (a gloved finger or balled dressing may be appropriate).

2 Elevate: above the height of the heart (especially for venous bleeds)

3 Close: apply a dressing appropriate to the size and type of wound (use the smallest dressing possible to maximise pressure). Ensure the dressing is applied damp (not soaking).

4 Reassess: if bleeding continuous, remove dressing and apply direct pressure with a gloved hand until support arrives.



Other considerations:

� Ensure the dressing is not soggy, as long term contact with the wound can cause the tissue to absorb water and may make closure more difficult.

� Use an appropriate sized bandage that will provide numerous applications to the site and extend beyond wound edges.

� Apply a crepe bandage with sufficient pressure to stem the bleeding but not so tight as to restrict circulation.

� Work from slightly below the wound up, this shunts blood away from the wound to prevent venous congestion and further bleeding.

� Once applied check the limb baselines at regular intervals

� If blood leaks through the dressing then haemorrhage is not controlled.

� Haemorrhage may be controlled by bringing the edges of the wound together.

� Use saline moistened gauze balls under bandages if additional direct pressure is needed.

Don’t forget elevation for non-arterial bleeds. It works!



Applying a ‘butterfly stitch’When a thin adhesive strip is applied to a wound to close it this is commonly referred to as a ‘butterfly stitch’. The most common thin adhesive strip used by St John is the Steri-strip brand. These are useful when attempting to close a laceration or incision when bleeding has been controlled. To apply these:

1 Clean and dry the skin around the site

2 Starting from the centre of the wound, apply one half of the adhesive strip to one side of the wound margin and press firmly in place

3 Using a gloved hand, bring the wound edges as close together as possible

4 Take the free end of the adhesive band and push down firmly on the other side of the wound

5 Repeat this along the wound allowing a 3 mm gap between adhesive strips

Determining if a wound needs suturingIn general it is very easy to tell if a wound will need suturing or gluing, and if in doubt you should refer the patient to a medical facility for suturing. Some indications for suturing include:

� A deep wound (> 6mm) with bone or fatty tissue exposed

� Large avulsions

� Wounds that are in areas subject to a lot of movement

� Jagged wounds that cannot be pulled together

� Open surgical wounds



Amputations

Irrespective of the type of amputation, the principles to manage it are the same:

� Control bleeding and administer pain relief

� Dress the wound ensuring that dressings being applied to the amputated area are moist but not wet

� If possible, get the amputated limb or digit and place this into a plastic bag

� Place the plastic bag into ice (if available) ensuring that the limb or digit stays dry, and does not come into direct contact with the ice

� If ice is not available, put the bag containing the limb or digit into a cool place

� Transport without delay, if possible direct to a hospital with surgical facilities.

Combat Application Tourniquet (CAT)

Application of a CAT is indicated when:

� Bleeding from a limb is uncontrolled despite usual methods

� Bleeding is immediately life threatening

� You cannot get to the bleeding site, such as when a lower limb is trapped in a vehicle

How to apply a CAT to an arm:

1 Take the CAT out of the packaging – it is ready to be used on an arm, with the self-adhering band passing through the outside slit of the buckle - slide the band over the arm

2 Position the CAT 5 cm proximal to the wound (approx. 3 fingers)

3 Pull the self-adhering band VERY TIGHT and securely fasten the band back on itself



4 Rotate the windlass rod until the bleeding has stopped and there is no distal pulse (this should be ≤ 3 complete rotations)

5 Lock the windlass rod in place in the windlass clip

6 Check again for bleeding – if bleeding is not controlled consider re-applying

7 Secure the rod inside the clip with the rod securing strap. If there is enough self-adhering band still free secure it around the end of the windlass rod and fasten back on itself as an additional securing method for the rod

8 Record the time of application on the securing strap – an alternative, if CAT is covered in blood, is to write on patient’s limb / chest / forehead in vivid marker



How to apply a CAT to a leg:1 Take the CAT out of the packaging and undo the strap from the buckle. Pass the

self-adhering band around the leg and then pass the tip of the band through the inside slit of the friction buckle.

2 Pass the tip of self-adhering band back through the outside slit of the friction buckle. The friction buckle will lock the band in place.

3 Position the CAT 5 cm (approx. 3 fingers) proximal to the wound site

4 Pull the band until it is VERY TIGHT and securely fasten the band back on itself. To gain purchase to tighten, push on the C-clip with one hand whilst pulling the self-adhering band with the other

5 Rotate the windlass rod until the bleeding has stopped and there is no distal pulse (this should be ≤ 3 complete rotations)

6 Lock the windlass rod in place in the windlass clip

7 Check again for bleeding – if bleeding is not controlled consider re-applying

8 Secure the rod inside the clip with the rod securing strap

If there is enough self-adhering band still free secure it around the end of the windlass rod and fasten back on itself as an additional securing method for the rod

9 Record the time of application on the securing strap – an alternative, if CAT is covered in blood, is to write on patient’s limb / chest / forehead in vivid marker.

Post CAT application checks: � Check that the blood flow has stopped

� Check distally for pulse – this should be absent

� Check skin colour to assess circulation – it should be pale

� Check that you have written an application time on the tourniquet or the patient



Lesson plan: Fractures and dislocations

Day two: Session eight (60 minutes)

Learning objectives � Discuss the different types of musculoskeletal injury; including but not limited to

fractures (open and closed), dislocations, sprains and strains

� Describe techniques for assessing musculoskeletal injuries

� Discuss the implications of an incorrectly applied splint/bandage

� Discuss the benefits of splinting

� Discuss methods of managing the musculoskeletal injured patient; including but not limited to cardboard splints, slings and assisting with traction devices.



� Blankets

� Cardboard splints

� Crepe bandages

� Gloves (all sizes)

� Pillows

� Sager Traction Splint

� Towels

� Transpore Tape

� Triangular bandages

� FR D3S8 Patella Dislocation video




1 Discuss the signs and symptoms that indicate the presence of a fracture. Emphasise that if students are at all unsure whether there is a fracture or not, the site should be treated as if a fracture is present (5 minutes).

2 Using a volunteer from the students, demonstrate the acquisition and importance of limb baselines. Following this, have students split into pairs and acquire limb baselines on each other (10 minutes).

Using all facilitators:

3 Set up two work stations- one for sling application and box splinting and one for use of a Sager splint. Split the class into two groups, with each group spending 20 minutes at each station. Note: for St John Youth members, box splinting and sling application should be a refresher.

4 Briefly discuss dislocation recognition and management (10 minutes)

5 Play the FR D3S8 Patella Dislocation Video (5 minutes).



Fractures and dislocations

Day two: Session eight A fracture is simply a break in the continuity of the bone, and is often referred to as having a broken bone. There are 206 bones in the body of an adult, and every one of them has the ability to break if force is applied at the right angle. Fractures are categorised according to whether or not the fracture has broken the continuity of the skin, with those that have not termed ‘closed fractures’ and those that have termed ‘open fractures’.

How to recognise a fracture:

The following are the signs and symptoms of a fracture.

� Pain and tenderness

� Deformity (compare with uninjured side if possible)

� Swelling

� Decreased ability to move limb

� Patient felt or heard bone snap

� Crepitus (grating of bone)

In the absence of conclusive symptoms, or if you are unsure, the patient should be treated as though they have a fracture.

General principles of fracture management:

� Reassure the patient

� Administer pain relief (covered in the next session)

� Immobilise joints above and below the fracture

� Assess limb baselines before and after splinting

� Realignment of the limb is acceptable (move it back to its normal position)

� Don’t bandage directly over the fracture site.



Limb baselines

What are limb baselines?

� Limb baselines are a series of basic assessments that evaluate blood flow to the extremity of a limb

� Limb baselines include the assessment of colour, sensation, warmth, movement, pulses and capillary refill

Why are they important?

� Limb baselines can indicate whether blood flow to a limb is being compromised

� Poor limb baselines before splinting may indicate an angulated limb needs to be urgently straightened

� Deteriorating limb baselines after splinting can indicate the splint or bandage is too tight and restricting blood flow

When are limb baselines assessed?

� Anytime you are assessing a limb for potential injury

� Before and after splinting an orthopaedic (or soft tissue) injury

Splinting:

In the following session we will discuss:

� Application of a sling (elevation and broad arm)

� Box splinting

� Application of a Sager splint

If it is an open fracture:

� Compress any external bleeding

� Cover the open wound with a damp sterile dressing

� Apply a bandage over the wet dressing

� Splint around the open wound



Elevation sling

Indications

1 Fracture or soft tissue injury to the clavicle, shoulder, humerus

2 Haemorrhage control in the affected limb

Applying an elevation sling

1 Expose and examine the affected limb or joint2 Provide analgesia as appropriate3 Assess limb baselines (colour, sensation, warmth, movement, pulses, capillary

refill)4 Prepare triangular bandage5 Support the patient to place the affected limb across the chest with their fingers

touching the opposite shoulder

6 Place the point of the triangular bandage at the elbow and drape one end of the bandage over the arm, extending one end over the uninjured shoulder

Step 6

7 Sweep the lower end of the triangular bandage under the arm

Step 7

8 Bring the lower end of the bandage up around the patient’s back to meet the other end

9 Tie the two ends in a knot at the nape of the neck on either side of the spine

Step 9



10 Twist the loose point of the bandage so that it fits closely around the elbow and either tuck it in or use a safety pin to secure it

11 Adjust as required for comfort12 Reassess limb baselines

Broad arm (fracture) sling

Indications

� Fracture injury to the hand, wrist or forearm

Applying a broad arm sling:

1 Expose and examine the affected limb2 Provide analgesia as appropriate3 Assess limb baselines (colour, sensation, warmth, movement, pulses, capillary

refill)4 Prepare a triangular bandage5 Support the patient to hold the affected arm at 90 degrees against their

abdomen

6 Place the triangular bandage between the injured arm and the patient’s chest, with the elbow resting on the apex of the sling

Step 6

7 Place the free lower end of the triangular bandage up over the patient’s shoulder on the injured side

Step 7

8 Place the other end of the sling over the shoulder on the uninjured side



9 Tie the two ends in a knot at the nape of the neck on the uninjured side

Step 9

10 Adjust as required for comfort11 Reassess limb baselines

Box splinting

Indications:

Indicated for fractures or dislocations of the:

� Ankle

� Tibia and/or fibula (lower leg)

� Patella (including fractures around the knee joint)

� Hand, wrist, radius or ulnar (lower arm)

� Elbow

Applying a box splint:

1 Expose and examine the affected limb2 Provide analgesia as appropriate (noting that splinting will help with the pain)3 Prepare equipment – cardboard splint(s), towels, triangular bandages4 Assess limb baselines (colour, sensation, warmth, movement, pulses, capillary

refill)

5 Pad the inside of splint with towels

Step 5



6 Position splint under limb. For long bone fractures, ensure the splint extends past the joint above and below the fracture site

Step 6

7 Pad any natural hollows under the limb

Step 7

8 Fold cardboard splint around limb

9 Secure splint to the limb with bandages above and below the fracture site

Step 9

10 If splinting an ankle, secure splint to the ankle in a figure of 8 pattern with a bandage

Step 10

11 Reassess limb baselines



Notes



Sager splint

Indications

� Significant mechanism of injury affecting the proximal third or mid-shaft femur

� Moderate or worse pain to the proximal third or mid-shaft femur

� Swelling or deformity to the proximal third or mid-shaft femur

� Reduced or painful movement in the affected leg

Contraindications

� Suspected fracture of the distal third of the femur

� Fractured pelvis or a suspected fracture to any other part of the affected limb (for example fractures of the tibia or ankle)

How to apply a Sager splint

1 Expose and examine the affected limb2 Provide analgesia as appropriate (noting that splinting will help with the pain)3 Prepare equipment – Sager splint and straps4 Assess limb baselines (colour, sensation, warmth, movement, pulses, capillary

refill)5 Straighten affected limb if necessary

6 Position the splint between the patient’s legs, resting the perineal cushion (top of the splint) against the ischial tuberosity (inner leg of the affected limb)

Step 6

7 Apply the ischial strap around the upper thigh of the injured limb

Step 7

8 Lift the button latch and extend the inner shaft until the crossbar rests adjacent to the patient’s heels

Step 8



9 Fit the ankle harness (malleolar support) and fasten the harness snuggly to the crossbar

Step 9

10 Grasp the splint shaft with one hand and the traction bar with the other and gently extend the inner shaft until the appropriate amount of traction is applied (10% of body weight to a maximum of 7)

Step 10

11 Slide the elastic straps under the hollow of the knee and attach them over the middle of the thigh, below the knees and above the ankles

Step 11

12 Apply the figure of 8 strap around the feet13 Reassess limb baselines


If you have a patient with bilateral femur fractures, and the use of a Sager splint is not contraindicated, you may apply traction to both limbs. In this scenario, the appropriate amount of traction is applied at 20% of the body weight to a maximum of 14.



DislocationsA dislocation is where there is a separation where two bones should meet at a joint. First Responders are generally encouraged to manage dislocations in the same way as fractures, although they may attempt realignment of dislocations if they:

� Have competence and experience doing so

� Liaise with the Clinical Desk to discuss the technique and options for pain relief

� Only attempt realignment once.

There is one type of dislocation which is very safe to realign which we are encouraging First Responders to consider treating, that being knee cap (patella) dislocations.

How to recognise a dislocated patella

Patella dislocations are obvious; the patella of the affected leg will be lateral (outward) from its normal anatomical position. If you are unsure then compare the patella to the other leg. The leg is usually bent and the patient will not want to move it.

What do I do if my patient has a dislocated patella?

1 Assess limb baselines and obtain a full set of vitals

2 Contact the Clinical Desk

3 Administer inhaled pain relief (if the Clinical Desk has authorised it)

4 Distract the patient

5 Bend the knee 45 degrees if it is not already

6 Grasp the patella with the hand and push it medially while simultaneously straightening the knee

How to tell if the patella has realigned

Successful realignment will result in:

� Relief of pain

� Return of a normal knee shape

� Return of improved range of motion of the knee joint



Lesson plan: Thermal problems

Day two: Session nine (30 minutes)

Learning objectives � Overview the definition and incidence of hypothermia and hyperthermia

� Discuss the key principles in the treatment of hypothermia and hyperthermia

� Understand the different types of burns and how to recognise them

� Demonstrate burn management

� Understand how to estimate burn depth and area



� Cling film (glad wrap)

� Crepe bandages

� Transpore tape

Suggested way to teachReferencing the First Responder Facilitator manual

1 Discuss the recognition and treatment of hypothermia and hyperthermia (10 minutes)

2 Discuss the different types of burns, and the recognition of these (5 minutes)

3 Discuss the method for estimating burn size and depth. Remind students that the calculation for burn depth and area only includes partial thickness and full thickness burns (5 minutes)

4 Demonstrate the application of cling film to a burn on the arm. Emphasise that cling film should not be applied circumferentially and that it should only be draped over the burn. Close by highlighting the importance of cooling over any other treatment (in the absence of problems with the primary survey) (10 minutes)



Thermal problems

Day two: Session nine In this session we overview:

� Hypothermia (low temperatures)

� Hyperthermia (high temperature)

� Burn injury (including chemical)

HypothermiaHypothermia is a condition where the body’s temperature drops below that which is necessary for normal function. Onset of true hypothermia starts from 35ºC, and can result from a decrease in heat production, increase in heat loss, or combination of the two.

How to recognise a patient has hypothermia:

Mild 34-36ºC – shivering, hypertension (high blood pressure), tachycardia (fast heart rate), increased respiratory rate.

Moderate 30-34ºC – lethargy, lack of coordination, slow and laboured movements, agitation, lips, ears, fingers and toes may become blue.

Severe <30ºC – no shivering, hypotension (low blood pressure), bradycardia (low heart rate), decreased respiratory rate, decreased LOC (eventually unconscious), eventually cardiac arrest will occur.

What do I do if my patient has hypothermia?

� Take a history, and full set of vitals

� Remove the patient from the environment by getting them out of the elements (particularly wind) and removing any wet clothing

� Passively re-warm the patient by wrapping them up warm and giving them a warm drink (where available). If a thermal blanket is available this should only be used while the patient is in a cold environment as thermal blankets keep heat out as well as it will keep heat in.

� Move the patient carefully if they have moderate to severe hypothermia. Sudden or violent movement can cause cardiac arrest.

� Seek backup from a Paramedic or Intensive Care Paramedic if the patient has an altered level of consciousness.



HyperthermiaHyperthermia is an elevated body temperature due to failed thermoregulation that occurs when a body produces or absorbs more heat than it dissipates. Onset of hyperthermia starts from 37.5ºC.

How to recognise a patient has hyperthermia:

Mild (heat cramps 37.5-39ºC) – sweating, brief intermittent or severe cramps, tachycardia (fast heart rate).

Moderate (heat exhaustion 39-41ºC) – irritability, poor judgement, dizziness, sweating, nausea, headache, delayed capillary refill.

Severe (heat stroke >41ºC) – this is where regulatory mechanisms have broken down entirely, and manifests as absent sweating, significantly delayed capillary refill time, decreased LOC, increased respiratory rate.

What do I do if my patient has hyperthermia?


� Remove the patient from the heat source if possible

� Passively cool the patient, remove clothing (down to underwear), encourage ingestion of cool drinks. If able fan skin and keep it wet.

� Seek backup from a Paramedic or Intensive Care Paramedic if the patient has an altered level of consciousness.

Burn injuryThere are three types of burns which can be caused by thermal or chemical injury, these are:

Superficial: painful, red and dry burns resulting from the superficial layer of skin (epidermis) being destroyed.

Partial thickness: painful, weepy, blistered burns resulting from the top layer of skin (dermis) being destroyed

Full thickness: painless, white, leathery or charred burns resulting from all skin and nerves being destroyed (down to muscle or bone)



What do I do if the patient has burns?

� Administer oxygen if the patient has probable smoke inhalation.

� Cool burns for at least 20 minutes:

• This should be at the scene unless there is an immediately life threatening problem in the primary survey.

• Remove all clothing (leaving underwear on) and decontaminate the patient if the burns are due to chemical exposure.

� Irrigate chemical burns to the eye for at least 30 minutes.

� Estimate burn depth and size.

� Cover burns with cling film after cooling.


� A patient with suspected airway burns must be transported to an appropriate hospital without delay as airway swelling may require early intubation, or possibly surgical intervention. Suspect airway burns if there are any of the following:

• Burn injury around the lips

• Loss of nasal hair

• Visible swelling or burns in the mouth

• Hoarse voice

• Stridor

• Black sputum

� Burns are preferably cooled using cool (not ice cold) running water

� Beware of hypothermia during cooling, particularly in small children and in patients with large burns.

� Estimate burn depth only after cooling is complete:

• Use a piece of paper the same size as the patient’s hand (including their fingers).

• This represents 1% of the patient’s body size.

• Do not include superficial burns in the estimate of burn size.

• It is very easy to overestimate burn size.



Lesson plan: Head and spinal injuries

Day two: Session ten (60 minutes)

Learning objectives � Discuss various head injuries; including but not limited to skull fractures and

traumatic brain injury (TBI)

� Recognise the patient with head injury

� Discuss management techniques for the head injury patient

� Recognise the patient with spinal injury

� Describe management of the spinal injured patient; including the use of C-collars, head blocks and extrication devices such as KED’s.

� Discuss implications of incorrect treatment of the head and spinal injured patient.

Required equipment � Clinical Procedures and Guidelines (four per class for student reference)



� Blankets

� C-collars (one between two)

� KED or equivalent (one between four)


� Towels




1 Discuss, in simple terms, the types of traumatic brain injury (TBI), then, (with Student Workbooks closed) brainstorm with the class the signs and symptoms of TBI. Briefly discuss the management of TBI emphasising that:

• A patient with a head injury should always be assessed by someone with a higher clinical practice level, and if a First Responder is going to treat and discharge a patient with TBI at scene, we strongly encourage consultation with the Clinical Desk to ensure all bases are covered.

• A severe TBI is one where the patient is unable to obey commands – in this setting the First Responder should call for an Intensive Care Paramedic (preferably one who is RSI capable) (10 minutes).

2 Demonstrate the correct technique for applying a C collar. Following this have students practice applying a C - collar (20 minutes).

3 With a patient sitting in a chair, demonstrate the application of a KED. Following this, have students practice applying a KED (30 minutes).



Head & spinal injuries

Day two: Session ten

Traumatic brain injury

There are two broad categories of traumatic brain injury (TBI), these are:

� Diffuse: affecting the whole brain, these can range from mild concussion (‘brain shake’) to severe tearing and shearing of communication pathways within the brain.

� Focal: affecting one part of the brain, these are caused by a rupture of a blood vessel within or outside the substance of the brain itself.

Identifying a TBI

To identify a TBI there must be a mechanism of injury which suggests TBI and any or all of the following symptoms:

� Headache

� Nausea / vomiting

� Light headed / unsteady

� Feeling ‘groggy, hazy or foggy’

� Amnesia / memory loss

� Disorientation

� Reduced attention or concentration

� Delay when answering questions

� Reduced level of consciousness / inability to obey commands

What do I do if the patient has TBI?

� Take a history and full set of vitals

� Administer oxygen if the patient has an SpO2 equal to or less than 94% or if they are unable to obey commands. Low levels of oxygen in patients with TBI have a poorer prognosis as it can contribute to secondary brain injury. For this reason, oxygen is administered irrespective of a patient’s oxygen saturations.

� Manage the patient’s cervical spine (covered next)

� If the patient is unable to obey commands, call for backup from an Intensive Care Paramedic. In this setting the patient may require sedation and or specialist airway management – this can be facilitated by an Intensive Care Paramedic.



Spinal injury‘True’ spinal injury, that is injuries to the spinal cord causing an interruption to the signals that are sent back and forth along the spine, is relatively uncommon. However spinal injuries are such that they are notoriously difficult to confidently rule out in the pre-hospital setting (especially if the patient has painful, emotional or distracting injuries). As a result management of the cervical spine remains one of the cornerstones of emergency pre-hospital trauma management.

One of the little recognised facts of spinal management is that good spinal management will not make the patient better; it can however prevent the patient’s injury from getting any worse if it is done well. Poor spinal management however has been demonstrated to make outcomes from spinal injury significantly worse.

Cervical spine immobilisation

Indications:

If the patient has a mechanism of injury that could injure the cervical spine and any of the following signs or symptoms, they should have their cervical spine immobilised:

� Tenderness at the posterior midline of the cervical spine or

� Focal neurological deficit or

� A decreased level of alertness or

� Evidence of intoxication or

� Clinically apparent pain or other factors that might distract the patient from the pain of a cervical spine injury.

Applying a cervical collar:

1 Advise the patient not to move their head

2 If required, remove any helmet (which requires two people to minimise neck manipulation) and jewellery around the patient’s neck

3 If the patient is not already, log roll them into the supine position (onto their back), with an officer carefully supporting the head and neck during the roll

4 Kneel at the patient’s head and stabilise the cervical spine by supporting the lower jaw with your fingers and the head with your palms

5 Carefully move the patient’s head into a neutral alignment. If the patient’s head cannot be moved into a neutral alignment, do not force it



6 Size the cervical collar

• Count the number of fingers from where the trapezius muscle joins the shoulder to the jaw line

• Place your fingers on the side of the cervical collar, with your small finger to the bottom edge of the plastic and the correct number of fingers to the closest marker pin

• Clip the collar into place at the level of the appropriate marker pin

7 Fit the collar

• Manoeuvre the flat end of the collar under the patient’s neck until it can be seen on the other side

• Bring the chin cup of the collar around onto the patient’s chin

• Bring the opposite end of the collar up towards the chin cup and join the Velcro edges together

8 Place 3-4cm of padded towels under the head (more towels may be required in an elderly patient due to curvature of the spine)




� Immobilisation must not impair the maintenance of an adequate airway, breathing or circulation.

� The most important part of immobilisation is the application of a correctly sized, well fitted hard collar. Getting the size and the fit right is important.

� Clinical judgement is required if the patient is uncooperative. If attempts to immobilise the cervical spine result in the patient becoming agitated and/or uncooperative, it is sufficient to verbally discourage them from moving.

� The head and shoulders must not be independently immobilised. If the head and shoulders are immobilised, the entire body must be immobilised as well.

� An immobilised patient will require full body immobilisation with:

• A well fitted cervical collar and

• The head and body firmly restrained to the device and

• Rolled towels or blocks placed alongside the head.

No spinal injury management is better than poor spinal injury management



Full body immobilisation

Indications:

� Suspected spinal cord injury or

� Cervical or thoracic pain associated with peripheral numbness, or abnormal skin sensations (such as tingling, itching or burning) or

� Loss of sensation or

� Cervical neck pain and anticipated transport over rough terrain

Fully immobilising a patient:

1 Carefully bring the head and neck into neutral alignment

2 Immobilise the cervical spine with a well fitted collar

3 Assess the function of each extremity

4 Place 3-4cm of padded towels under patient’s head

5 Place the patient onto a scoop stretcher or combi-carrier by placing the device under the patient from both sides

6 Ensure the patient is centred on the device

7 Secure the patient’s upper torso to the device

Step 7



8 Secure the pelvis and upper legs, using padding as needed between the knees and ankles

Step 8

9 Immobilise the patient’s head by positioning rolled towels or blocks on each side of the head

10 Secure the head by placing tape across the forehead, and across the cervical collar just under the chin

Step 10

11 Check and readjust straps as needed to ensure that the entire body is tightly immobilised

12 Reassess the function of each extremity.


� Scoop stretchers and combi-carriers are primarily lifting and carrying devices.

� These devices carry the risk of creating pressure injuries if the patient is on them for longer than 30 minutes. If this is expected to be the case, the patient should be removed from the device prior to beginning transport whenever feasible, and immobilised again on the ambulance stretcher.

� If the patient is transported on such a device, it should be removed as soon as possible after arrival at hospital.



Kendrick Extrication Device (and like products):

The Kendrick Extrication Device (KED) is a device that is used to remove patients with suspected spinal injury from vehicles and other spaces, where that extrication could pose a risk to the spinal cord (especially where significant lateral movement is anticipated).

Indications:

� Immobilising a patient with suspected spinal cord injury

� Immobilising a patient when a difficult extrication is anticipated

Applying a KED (and like devices):

1 Explain the procedure and gain informed consent2 Manually stabilise the cervical spine from behind

the patient and apply a cervical collar3 Prepare the KED, in particular run the leg straps

along the front of the KED and use the Velcro patches to secure these to the rear of the KED

4 Carefully lean the patient forward in their seat and slide the KED down the back of the patient

Step 4



5 Detach the Velcro patches from the rear of the KED and pull the leg straps down across the front of the KED on the associated side until they are resting by the patient’s lateral hip on the same side

Step 5

6 Clip in and tighten the middle (yellow) then bottom (red) abdominal straps

Step 6

Step 6

7 Attach the leg straps (black) by sliding each one from its resting location near the lateral hip, under the opposite knee (as far as it will go), before feeding it back under the knee and attaching it to the clip above the thigh and tightening the strap



8 Slide the green padding between the back of the patient’s head and the KED

Step 8

9 Attach the forehead strap by placing the padded portion over the forehead and attaching both Velcro ends to the KED

Step 9

10 Attach the chin strap by placing the padded portion over the patient’s chin and attaching both Velcro ends to the KED

Step 10

11 Clip in and tighten the green (top) abdominal strap.

Step 11

12 Extricate the patient as required



13 Once on the stretcher, detach the leg straps. The KED should remain in place provided this does not interfere with patient care.

You can use a mnemonic to help remember the order in which the straps are applied (middle, bottom, legs, head, top): My Black Labrador Has a Tail or My Bandaged Leg Hurts Today

Notes



Caring for yourself and your patient

Day two: Session eleven

Caring for yourselfAs a First Responder you will experience situations that you find difficult to cope with. We all have these experiences and it is important to find a way to deal with your emotions and thoughts. This is a normal part of learning to be a First Responder.

Stress and grief are real emotions and we know that this job can be stressful. That’s why we select staff carefully and that’s why we invest in your education. We believe that you can do this job and we will assist you along the way. But you must also take responsibility for your own well-being, and that of your colleagues.

Recognising stress in ourselves and others is important to make sure we are looking after each other. Stress can affect us behaviourally, physically and psychologically. Over time as you gain more experience you will develop your own coping mechanisms. These could include finding a particular person you like talking to, a friend, family member, or colleague.

Signs of stressEmotional - panic, depression, excessive anger, negativism, hostility, defensiveness, mood swings, feelings of worthlessness, fear, denial, confusion, crying, hyperactivity, suicidal.

Physical - chest pain, difficulty breathing, persistent exhaustion, headaches, gastrointestinal distress, dizziness, heart problems, lethargy and nausea.

Behavioural - over/under eating, increased alcohol or drug use, grinding teeth, inability to make judgements or decisions, loss of motivation, chronic forgetfulness, loss of objectivity, flashbacks and distressing dreams.



How to unwindTalking to people close to you - you may find it helpful talking to people that are close to you, such as a friend, family member or colleague.

Being happy and finding things that make you laugh - don’t forget about or ignore those things that generally make you happy or laugh, such as the company of family and friends or hobbies or other activities outside St John / NZFS.

Peer Support - this is a confidential, professional, safe and empathetic support from trained colleagues who understand the unique work you do.

The purpose of the Peer Support is

� to provide support to all staff, who may be, or have been, affected by an incident/s to ensure early recovery

� to promote staff self-awareness and enhance personal and professional development within a confidential and safe environment

� to ascertain the nature of the staff person’s stress/distress and arrange referral to appropriate services if/as required.

These are available through your line manager / Station Manager, or can be contacted through Comms.

There are additional support services available within your organisation. You should talk to your line manager / Station Officer to learn more

Caring for your patientAs you know there are many things that you can do to care for your patient, but caring for your patient is more than just assessing your patient or applying a treatment, it is about being aware of the generic principles and standards that all patients we respond to can expect. As a First Responder you are a health provider, and as such you are bound by the Code of Health and Disability Services Consumers’ Rights

Code of Health and Disability Services Consumers’ RightsThese guide all those who are providing health care to the rights that patients have, along with the standards patients have, these are:

Right one: right to be treated with respect – every patient has the right to be treated with respect, this includes respecting privacy, and taking into account (within reason) the patient’s beliefs, values and culture.

Right two: right to freedom from discrimination, coercion, harassment, and exploitation - every consumer has the right to be free from discrimination, coercion, harassment, and sexual, financial or other exploitation.



Right three: right to dignity and independence - every consumer has the right to have services provided in a manner that respects the dignity and independence of the individual.

Right four: right to services of an appropriate standard – this means services that are provided with reasonable care, skill and quality.

Right five: right to effective communication – every consumer has the right to effective communication in a form, language, and manner that enables the consumer to understand the information provided.

Right six: right to be fully informed - every consumer has the right to the information that a reasonable consumer, in that consumer’s circumstances, would expect to receive,

Right seven: right to make an informed choice and give informed consent – your patient has the right to consent or refuse treatment. Informed consent in its essence is gaining permission from the patient before you perform an assessment or treatment. It is expected that if the patient is alert, you will gain informed consent. This is as simple as:

� We need to (tell the patient what you need to do)

� Because (why you need to do it)

� The benefits are (state benefits)

� The risks are (state risks)

� Is that okay?

This is much simpler to apply in reality, especially with practice!

Right eight: right to support – every consumer has the right to have one or more support persons of his or her choice present, except where safety may be compromised.

Right nine: rights in respect of teaching or research – these rights extend to those involved in teaching and/or research.

Right ten: right to complain – every consumer has the right to complain about a provider in any form appropriate to the consumer.

Remember: The Code of Health and Disability Services Consumers’ Rights are there to protect you and your patient



Additional ConsiderationsThis section contains important safety considerations which are discussed, but not specifically allocated a section during this course. It is included here for your reference and reading. You need to ensure you are familiar will the content. If you have questions ask your tutor, or drop us a line at [email protected].

Scene ManagementThere are three elements you should consider while approaching the scene of an incident:

� Scene safety

� Incident type

� Scene characteristics

Your first priority is to ensure your own personal safety. Examination gloves are considered the minimum personal protection required for all patient contact. The other equipment that may be available to you are hard hats, protective glasses, reflectorized clothing, wet weather clothing, ear protection and face shields. This equipment will be needed to maintain personal safety at particular types of incidents. Ensure you or someone with you has a radio or cell phone at all times, to ensure you have the ability to call for assistance quickly.

Determining hazards

One of your primary responsibilities is scene control. You need to assess the scene well and remember that the scene is always changing. The initial information you receive when you are being dispatched to a callout provides you with indications of what you may find at the scene.

The way you approach the scene can make a big impact.

Assess scene safety

� Driving past the scene to have a good look at the environment you are going into

� Identifying access and egress from the scene

� Look for signs of violence, weapons of any kind, signs or sounds of intoxication or drug use.

� You should be on alert as soon as you see something unusual. If you are attending the job at night, is there enough light to see hazards such as dogs, offenders, agitated relatives or bystanders?



Positioning your vehicle

� Is the vehicle visible to the other traffic?

� If in an ambulance, do not waste time backing into a driveway when arriving at an address. Park on the street initially if the house is close, and carry in your gear from there.

Determining priorities

� Equipment- what is the incident? What area are you going to? What equipment might you need to take in?

� Nature of illness- judging from the information received from the initial call, what kind of illnesses do you expect? Will you want to take in more protective gear?

� Will you possibly need backup or extra resources?

If you feel uncertain, call for assistance and don’t enter the scene



HelicoptersThere are a number of patients that may meet the criteria for helicopter transport. The following information may be helpful to you if you ever need to request a helicopter response for your patient.

How to summon a helicopter

� Contact Comms by radio (cell phone may be used if coverage is poor)

� Give a clear reason why you require a helicopter

� Locate an appropriate site

� Inform Comms of the exact location of the landing site, and potential hazards for the helicopter.

Helicopter landing zone

� Choose a large area (i.e. field) that is clear, flat, and away from trees, debris and power lines

� Clear or secure all loose items and debris (including clothing)

� Close all windows and doors on the ambulance

� Ensure all unnecessary personnel/ members of the public are removed from the site.

� The designated person directing the aircraft stands with their back to the wind and their arms raised and pointing to the landing zone.

� At night, use a torch and wave it up and down. Never point it directly at the helicopter or this can cause problems for the pilot.



� Make use of vehicles or strobes to mark the site. Note how the lights from vehicles are not facing the aircraft that might affect visibility.

wind

� Never assume the pilot of crew are aware of immediate hazards

What you see from the ground: What the crew see from above:

Helicopter hazards

� Main rotor can flex very low

� Tail rotor- almost invisible

� High frequency aerials- they can burn

� Loose debris

� Dust

� Engine exhaust

� Rotor wash

� Noise

Before approaching the helicopter

� Do not approach until all the rotors have stopped

� Stay outside of the area of the rotor blades

� Establish visual contact with the pilot

� Wait for confirmation to proceed



Approaching the helicopter

� Only when directed by the crew

� Walk, do not run

� Stay together as a group

� Approach (or exit) from the downside of the hill only

� Be very cautious in confined areas

� If dust or debris blinds you, stop. Do not walk if you cannot see.

� Carry equipment horizontally and below the waist

� Don’t throw pieces of equipment

� Let the pilot or crew stow any equipment

� Do not chase after any equipment



Management of the agitated patientAssociated legislation

Crimes Act 1961, Section 43

Everyone is justified in using such force as may be reasonably necessary in order to prevent the commission of suicide, or the commission of an offence which would be likely to cause immediate and serious injury to the person or property of any one, or in order to prevent any act being done which he believes, on reasonable grounds, would, if committed, amount to suicide or to any such offence.

Mental Health (Compulsory Assessment and Treatment) Act 1992

Allows for compulsory intervention of the mental health problem

General Principles:

� Clearly identify yourself

� Express the intent to provide help

� Friendly but neutral approach

� Do not engage anger or aggression

� Speak frankly and openly with the patient and bystanders

� Be tactful and firm in your recommendations

� Watch for violence

� If the patient is hallucinating: do not tell them ‘its not there’, do not talk to hallucinations, and reassure the patient they are safe.

Safety considerations:

� Remain at a safe distance

� Do not allow the patient between you and the exit

� Do not be left alone with the patient

De-escalation:

� Remain calm and in control

� Listen to the other person and respond empathetically

� Use the patient’s name

� Respect personal space

� Maintain and open stance

� Appropriate eye contact and facial expression

� Utilise friends and/ or family if appropriate



Physical restraint:

It is exceptionally rare that a First Responder would be expected to physically restrain a patient. This is not our role, however we recognise that there are circumstances where the patient may pose an immediate risk to their safety, or the safety of others, where this may be necessary. In these circumstances:

� Look for reversible causes, blood glucose fluctuations, lack of oxygen supply and head injury are common causes of the patient being non-compliant

� Call for help, this may be the Clinical Desk, an Intensive Care Paramedic, a manager, and/or the police as required

� If you cannot deescalate the situation, and physical restraint is the ONLY option left, use the following principles to do this:

• Request the police

• Nobody is to be restrained prone

• No weight on the chest

• Minimum of 4 officers (can include other emergency services), each responsible for a limb. It is useful if someone controls the patient’s head. At this point, all limbs should be tied for sedation or physical restraint.

• All forms of restraint must be documented

• Monitor ABCs.

• Blankets fully encapsulating the patient are appropriate where a patient is unlikely to require interventions en route to the emergency department. The patient’s arms should be by their side and their legs together. If possible having the patient lie on the area where the ends of the blanket meet is useful (relevant to transport time) as the patients weight will help ensure that the blanket does not come apart. Straps are applied on the outside of the blanket.


FIRST RESPONDER Facilitator manual 169169FIRST RESPONDER FACILITATOR MANUAL

Important informationIt is absolutely acceptable to read the content in the following pages at your own leisure if you have only completed Day One and Two. This however, does not allow you to implement the skills taught in the following pages.

It is imperative to understand that there are skills taught in Day Three and Day Four that carry a degree of clinical risk and you must not put them into practice unless you have been formally taught Day Three and Four.

If you have any questions regarding this, please do not hesitate to ask your Manager.


Day Three:Timetable (approximate):0830 Session 1 - Recap

0930 Session 2 - Pain relief

1000 Morning tea

1015 Session 3 - Respiratory emergencies and anaphylaxis

1145 Session 4 - Cardiac chest pain

1215 Lunch

1245 Session 5 - IM injections in other circumstances

1330 Session 6 - Other medical conditions

1415 Afternoon tea

1430 Session 7- Stretchers and carry chairs

1530 Session 8- Knowledge check



Lesson plan: Recap

Day Three: Session one (60 minutes)

Learning objectivesThe student will:

� Revise knowledge learnt throughout the course of day one and two.

� Replicate skills chosen by the tutor that they have learn on day one and two.



� St John First Response (Resus) kit (one between four)

� Defibrillator (one between four)

� Resuci- Ann (CPR-D) manikin (one between four)


Suggested way to teach1 Welcome the students back for day three of the First Responder course, and briefly

run through the day three timetable referencing the First Responder facilitator manual.

2 The time allocated for this session can be used to recap information and skills covered during day one and two of the First Responder course. This time was inserted with the knowledge that some St John Youth students may have had a considerable length of time between finishing day one and two, and starting day three and four.

3 The students will have been asked to read over the content in their First Responder student workbook before coming to class, with any questions prepared.

4 Allow time for the students to ask any questions they have about skills learnt or information provided in day one and two.

5 If students want to revisit any practical skills, this is the session in which to do this.

6 Should the students appear relatively content, and have no questions, the facilitator may ask students to do any of the following:



� Obtain a full set of vital signs on a partner

� Demonstrate a complete primary and secondary survey on a partner or a manikin

� Present them with a scenario, and ask them to provide a SITREP for that patient

� Write on the whiteboard what SAMPLE, OPQRST and IMIST AMBO stand for

� Demonstrate appropriate ventilation and/or chest compressions on a manikin

� Discuss the different oxygen masks and what they are used for

� Run through the full resuscitation algorithm

� Demonstrate application of a CAT

� Discuss the management of a dislocated patella

� Discuss the management of a burns patient

� Describe the different types of shock, and what they as First Responders are able to do for these patients

� Discuss the difference between mechanism of injury and index of suspicion



Lesson plan: Pain relief

Day three: Session two (30 minutes)

Learning objectives � Discuss drugs that the First Responder can administer without direction

� Discuss drugs that the First Responder can administer under direction; including methoxyflurane and entonox

� Discuss general principles of drug administration; including right drug, right dose, ,right person, right route and expiry date

� Discuss specific administration principles for specific drugs; including indications, contraindications, and administration techniques.

Required equipment � Clinical Procedures and Guidelines (four per class for student reference)




� Entonox, filter, mouth piece and demand valve (one between four)

� Methoxyflurane, charcoal filter and inhaler (one between two)


1 Identify which pain relieving medicines First Responders can administer provided they follow the instructions on the packaging, and which they can administer provided they consult the Clinical Desk (include the rationale for this – being that as First Responders they do not have an Authority to Practice (5 minutes)

2 Walk students through the components of an entonox set; demonstrate how to put this together (include changing of the cylinder) and what to tell the patient before administering entonox. Following this allow students to practice setting up the entonox set (15 minutes)



3 Walk students through the components of a methoxyflurane set; demonstrate how to set this up and what to tell the patient before administering methoxyflurane. Following this allow students to practice setting up the methoxyflurane. Emphasise the importance of ensuring patients breathe through the charcoal filter to avoid the crew being affected by the methoxyflurane (10 minutes).

4 Close with students working through Exercise 8: Pain relief. This brief exercise is designed to help students administer adequate pain relief, and do so by the appropriate means.



Pain relief

Day three: Session two Pain is a very subjective phenomenon. There are many examples of patients whom have significant injuries whom have very little pain, and patients who have relatively insignificant injuries who have a lot of pain. We rely on our patients to tell us how much pain they are in as we have no other way of objectively measuring it.

Pain relief is best achieved through a combination of positioning, splinting and medicines. A combination of pain relieving medicines has been shown to work better than one single pain reliever alone.

At First Responder level there are two forms of pain relief in tablet form that you are able to administer provided you follow the instructions on the packaging, these are:

� Paracetamol

� Ibuprofen

There are two forms of pain relief you may administer in consultation with the St John Clinical Desk, these are:

� Entonox

� Methoxyflurane

Most First Responders will have access to one of these forms of inhaled pain relief. We will focus on inhaled pain relief here since the instructions for administering both paracetamol and ibuprofen are available on the packaging.



Entonox

How it works

Entonox is a combination of 50% nitrous oxide and 50% oxygen. Entonox is absorbed through the lungs where it is distributed through the body to achieve its affect (the exact mechanism by which entonox works is unknown). It is indicated for moderate or severe pain.

Contraindications:

� Is unable to obey commands or

� Has a suspected pneumothorax (collapsed lung) or

� Has a suspected bowel obstruction or

� Has been SCUBA diving in the last 24 hours, or has a diving related emergency

� Permission not obtained from the Clinical Desk (First Responder level only)

Administration:

1 Gather the equipment needed to administer entonox (entonox set, mouthpiece and inline filter)

Step 1



2 Assemble the entonox set. If the entonox has been stored in a very cold environment invert the cylinder three times to mix the gases

Step 2

3 Explain to the patient that they will have to breathe on the mouthpiece in the same way that they would a diving mask (this takes some effort). Advise that after several breaths they may feel light headed and euphoric – that is normal

Step 3

4 Hand them the entonox hose, and mouthpiece and allow them to self-administer (the patient MUST self-administer)

Step 4

5 Continue to allow the patient to breathe on the entonox for as long as they are in pain and feel the entonox is needed.




� The effects of entonox come on very quickly, and wear off very quickly. For this reason patients should be encouraged to continuously breathe on the entonox.

� Patient’s with chest or abdominal pain may find it difficult to inhale if this provokes their pain

� The nitrous oxide in entonox expands gas filled spaces in the body. This is the reason for many of its contraindications.

� Entonox is not contraindicated in a patient with chest injury, but is contraindicated if a pneumothorax is suspected. Entonox administration should be discontinued if it is associated with worsening respiratory distress in a patient with chest injury.

� Entonox is not contraindicated in a patient with abdominal pain, but is contraindicated if a bowel obstruction is suspected. Bowel obstruction most commonly presents with vomiting and abdominal discomfort. Abdominal distension and reduced frequency of bowel motions/passing of gas may be present.

� In general only one form of inhalational pain relief (either entonox or methoxyflurane) should be used, but it is acceptable to swap from one to the other if there is a good indication to do so.



Methoxyflurane

How it works

Methoxyflurane is absorbed through the lungs where it is distributed through the body to achieve its affect (the exact mechanism by which methoxyflurane works is unknown). It is indicated for moderate or severe pain.

Contraindications:

� Is unable to obey commands or

� Has a personal or family history of malignant hyperthermia or

� Has known renal (kidney) impairment or

� Has received methoxyflurane within the last week or

� Permission not obtained from the Clinical Desk (First Responder level only).

Use with caution if the patient:

� Has toxaemia of pregnancy or

� Is in labour with known signs of foetal distress.



Methoxyflurane whistle

Administration:

1 Gather the equipment needed to administer methoxyflurane (methoxyflurane kit with 3ml bottle of liquid methoxyflurane)

Step 1

2 Check the methoxyflurane with your partner (drug, dose, expiry date, bottle intact)

Step 2

3 Assemble the methoxyflurane whistle by placing the activated charcoal chamber onto the top of the plastic inhaler

Step 3



4 Hold the methoxyflurane whistle (with inhaler down), open the methoxyflurane bottle and tip the contents from this bottle into the area around the outside of the oxygen connector

Step 4

5 Explain to the patient that they will have to breathe through the whistle. They must inhale and exhale through their mouth so that the fumes are filtered by the activated charcoal table. The methoxyflurane itself has a strong chemical smell – this is normal.

Step 5

6 Hand them the methoxyflurane whistle, place strap around wrist, and allow them to self- administer (the patient MUST self- administer)

Step 6

7 Continue to allow the patient to breathe on the methoxyflurane for as long as they are in pain and feel the methoxyflurane is needed. You may need to continually coach the patient to ensure they continue to exhale through their mouth and into the whistle.




� In small spaces, responders have been known to be affected by the fumes from methoxyflurane, which is why you must insist that the patient breathes through the filter.

� Malignant hyperthermia is a rare, inherited disorder of muscle metabolism. When exposed to methoxyflurane the patient may develop life threatening hyperthermia. A patient with malignant hyperthermia (or a family history of it) will usually be aware of it so will be able to tell you.

� Renal failure with dialysis and kidney stones are not contraindications to methoxyflurane administration.

� Place the inhaler in a closed zip lock bag if the methoxyflurane has not been fully used. It may be subsequently reused by the same patient.

Remember, pain relief is achieved by more than just medication- don’t underestimate the power of positioning, distraction and reassurance

EXERCISE 8: Pain reliefYou are responded to an 18 year old female patient who has fractured her humerus after falling while playing netball. There are no life- threatening abnormalities in the primary survey, and no abnormalities other than deformity in the humerus in the secondary survey. Her vitals are as follows:


What are the steps you will take to treat this patient?

This patient has clinically significant pain and this needs to be controlled.Reassure the patient

Tell the patient that you have ibuprofen and paracetamol that they can take ifthey would like (ensure they follow the manufacturers instructions)

Place the arm in a sling, or alternatively, allow the patient to adopt the positionthat is most comfortable for them, and provide support.

If positioning is proving difficult or pain persists, call the Clinical Desk and askfor permission to administer an inhaled analgesic.



Lesson plan: Respiratory emergencies and anaphylaxis

Day three: Session three (90 minutes)

Learning objectives � Identify when a patient is suffering from CORD, asthma, stridor or anaphylaxis.

� Overview the management for a patient suffering from CORD, asthma, stridor or anaphylaxis.

� Explain when a First Responder can administer out of scope skills.

� Understand when to seek help from the Clinical Desk.

� Recognise the medicines used in the treatment of CORD, asthma, stridor or anaphylaxis.

� Demonstrate techniques for the administration of nebulised medicines and IM adrenaline.



� FR Day Three PowerPoint

� FR D3S3 Rapid Response Asthma video

� Adrenaline ampoules (two each minimum)

� Alcohol wipes (one each minimum)

� Blunt drawing up needles (one each minimum)

� Gauze pads (one each minimum)

� IM needles (one each minimum)

� Manikins, IM training arms OR oranges for IM injection as appropriate (one between four)

� Ipratropium ampoules (one each minimum)



� Salbutamol ampoules (one each minimum)

� Sharps container (one between four)

� Syringes (one each minimum of 1mL and 3 or 5mL)



Suggested way to teachUsing the Respiratory emergencies and anaphylaxis section of the FR Day Three PowerPoint, and referencing the First Responder facilitator manual:

1 Introduce the session; explain that we are covering four different conditions in which the treatment and pathology overlap. Emphasise that while rationale for treatments have been included, the important thing at First Responder is recognition and treatment. That is to say that our aim is to allow the First Responder to recognise the condition, initiate basic cares, and contact the Clinical Desk who may, or may not allow them to deliver additional treatments. It is also worth emphasising at this point that use of the Clinical Desk for such treatments is not a substitute for calling for appropriate backup. Calling the Clinical Desk and seeking appropriate backup should occur concurrently (5 minutes)

2 Briefly discuss CORD emphasising that CORD is the only condition that we routinely maintain sats 88-92%. Also acknowledge that there will be some First Responders that do not have immediate access to a pulse oximeter. In this circumstance it is appropriate to use clinical judgment to determine whether oxygen administration is appropriate. If it is administered, give the minimum amount necessary to relieve respiratory distress. Discuss ipratropium and salbutamol. Distribute a nebuliser mask, one salbutamol ampoule and one ipratropium ampoule to each student. Have the students follow each step (as it is demonstrated) with their own equipment of how to place the salbutamol and ipratropium in a nebuliser and and make up the nebuliser mask. Emphasise that ipratropium is only administered once, so should further nebulisers be authorised by the Clinical Desk, these will be salbutamol only (20 minutes).



3 Discuss asthma, noting that whilst the pathology of asthma and CORD are similar, asthma is largely reversible, CORD is not. Play the FR D3S3 Rapid Response Asthma video so students can see for themselves what a patient with severe asthma looks like. (5 minutes) Discuss IM adrenaline and run through the equipment and consumables needed for IM adrenaline, and IM injections. Ensure each student has an adrenaline ampoule, 1ml syringe, drawing up needle and IM safety needle. Demonstrate the steps for drawing up 0.5 mg of adrenaline and have students replicate this concurrently. This will be an area of anxiety for some students, and it it is important to have the other tutors amongst the students whilst they draw up the adrenaline, providing extra guidance. Following this, with the class watching on, demonstrate the method for administering an IM injection. Students should then come through and demonstrate the administration of IM adrenaline with the facilitator watching. Students who have completed this should be encouraged to draw up more adrenaline and practice on the manikins, IM training arms or oranges as appropriate (30 minutes).

4 Discuss stridor, emphasising that stridor is not a medical condition in its own right, but a symptom of other medical conditions. Ensure each student has at least one ampoule of adrenaline, a nebuliser mask, a drawing up needle, and a 3 or 5 ml syringe. Demonstrate the drawing up of 5 ampoules of adrenaline and placing them into a nebuliser and have the students do it concurrently with their equipment. Note: the students are not required to all draw up 5 ampoules of adrenaline- just ensure it is at least one ampoule in order to practice the skill (15 minutes).

5 Discuss anaphylaxis, noting that the respiratory symptoms can be a combination of those seen in both asthma and stridor. Emphasise that in general our threshold for giving adrenaline has been too high in the past, and we want First Responders to have a low threshold for seeking advice. (10 minutes)

6 Review the treatments that can be administered under direction for respiratory emergencies and anaphylaxis (5 minutes). If there is time left at the end of the session, allow students to practice running nebulisers or administering IM adrenaline as appropriate.



Respiratory emergencies and anaphylaxisDay three: Session three This session covers the following conditions:

� CORD

� Asthma

� Stridor

� Anaphylaxis

While it must be acknowledged that these are different conditions, we have placed these together as the skills needed to treat each overlap. Within this section you will also find generic instructions describing how to administer an intramuscular (IM) injection.

Chronic obstructive respiratory disorder (CORD)CORD is a term used to encompass chronic inflammatory and destructive diseases within the lung, including chronic bronchitis and emphysema. The symptoms of CORD are not completely reversible, and many patients with CORD are short of breath even when they are well. It is most commonly seen in patients who have been long term smokers or have had some industrial exposure to substances that damage the lungs.

Identifying CORD

The easiest way to identify CORD is to ask the patient if they have it. If the patient is very short of breath it is appropriate to ask closed questions that enable the patient to nod or shake their head. Additional signs that will help you identify a CORD patient include:

� Productive cough

� Wheeze, crackles or quiet chest on auscultation

� Tripod positioning and pursed lips

� Respiratory distress with accessory muscle usage

� Bluish tinge to skin



If you suspect that a patient has CORD and they are presenting with an exacerbation it is appropriate to briefly pause to understand how bad the patient’s condition is for them. Because patients with CORD are short of breath even when well, it is easy to over-estimate the severity of their CORD. If possible, ask how their shortness of breath compares with their usual state.

What do I do if the patient has an exacerbation of their CORD?

� Take a history, full set of vitals and ECG (where available)

� Administer oxygen if the patient has an SpO2 less than 88% - titrate the oxygen flow to maintain an SpO2 of 88-92%. If you do not have a pulse oximeter then give the lowest volume of oxygen possible to ease the patient’s distress until a pulse oximeter arrives.

� Administer the patient’s own medications via metered dose inhaler (MDI) or spacer if available and the patient is status three or status four – many patients have a spacer through which they deliver their inhaled medications. Medications administered via a spacer are very effective for the majority of patients if their exacerbation is mild to moderate.

If the patient has mild or moderate CORD, it is preferable to administer their own bronchodilator via MDI and spacer (commonly 1 puff, with 6 breaths to empty the spacer after each puff, repeated 6 to 12 times), rather than administering nebulised medicines

� Contact the St John Clinical Desk if spacers are ineffective or inappropriate – there are two potential treatments that may be administered under consultation, these are:

• Nebulised ipratropium

• Nebulised salbutamol

Notes



Ipratropium

How it works:

Ipratropium blocks receptors that cause constriction and mucus secretion within the lung, thus increasing air flow within the lungs

Contraindications:

There are no specific contraindications other than known serious allergy

Administration:

� The 0.5 mg in 2.5 ml ampoule of ipratropium should be placed into the nebuliser bulb with salbutamol (discussed next).

� For CORD patients, to avoid over oxygenating the patient the nebuliser should be administered five minutes on, five minutes off.


Ipratropium is only administered once, you may be instructed to administer other nebulised medicines continuously.



Salbutamol

How it works:

Salbutamol stimulates receptors that cause dilation within the lung, thus increasing air flow within the lungs

Contraindications:

There are no specific contraindications other than known serious allergy

Administration:

� The 5 mg in 2.5 ml ampoule of salbutamol should be placed into the nebuliser bulb with ipratropium.

� For CORD patients to avoid over oxygenating the patient the nebuliser should be administered five minutes on, five minutes off.


Salbutamol causes smooth muscle dilation of the uterus and thus should be avoided in late term pregnancy

Remember: symptoms of CORD are not completely reversible, so check how their shortness of breath

compares with their usual state



AsthmaAsthma is a common inflammatory disease of the airways characterised by acute swelling, plugging and constriction of the airways. The symptoms of asthma are completely reversible, and patients with asthma are symptom free between attacks. It is caused by a combination of genetic and environmental factors.

Airways

Muscle

MuscleMuscle

Airway wall

Narrowed airway (limited air flow)

Tightened muscles constrict airway

Tightened muscles constrict airway

Inflamed thickened airway wall

Mucus

MucusAirway wall

Airway x-section

Lungs

Identifying asthma

The easiest way to identify asthma is to ask the patient if they have it. If the patient is very short of breath it is appropriate to ask closed questions that enable the patient to nod or shake their head. Additional signs that will help you identify an asthma attack may include:

� Wheeze or quiet chest on auscultation

� Tripod positioning

� Respiratory distress

� Accessory muscle usage

� Anxiety

� Reduced words per breath

� Cough

� Blue lips or fingernails



� Fatigue

Identifying how unwell an asthma patient is:

� Patients that are status three or status four have moderate or mild asthma. They are usually short of breath, but are moving air and able to speak sentences with each breath. They do not have significant chest or neck indrawing.

� Patients that are status two have severe asthma. They are very short of breath, but are moving air and usually able to speak more than two words per breath. They usually have chest or neck indrawing.

� Patients that are status one have immediately life threatening asthma. They are extremely short of breath, not moving much air and usually unable to speak more than two words per breath. They usually have marked indrawing (unless exhausted) and may not be moving enough air to create wheeze.

� Patients with a falling level of consciousness or exhaustion are high risk and must be treated aggressively.

What do I do if the patient is suffering from an asthma attack?


� Administer oxygen if the patient has an SpO2 equal to or less than 94% - this is a transient treatment at First Responder level as we look to administer the patient’s own spacer, or contact the St John Clinical Desk to give additional medicines.

� Administer the patient’s own medications via metered dose inhaler or spacer if available and the patient is status three or status four – many patients have a spacer through which they deliver their inhaled medications. Medications administered via a spacer are very effective for the majority of patients if their exacerbation is mild to moderate.

If the patient has mild or moderate asthma, it is preferable to administer their own bronchodilator via MDI and spacer (commonly 1 puff, with 6 breaths to empty the spacer after each puff, repeated 6 to 12 times), rather than administering nebulised medicines

� Contact the St John Clinical Desk if spacers are ineffective or inappropriate – there are three potential treatments that may be administered under consultation, these are:

• Nebulised ipratropium

• Nebulised salbutamol

• Intramuscular adrenaline



Ipratropium

The notes on ipratropium can be found in the section on CORD. The mechanisms by which this medicine works for asthma are the same as for CORD.

Salbutamol

The notes on salbutamol can be found in the section on CORD. The mechanisms by which this medicine works for asthma are the same as for CORD.

Intramuscular (IM) injectionsAs the name suggests, an intramuscular injection is an injection which is delivered into muscle. The principles contained within this section are the same for all IM injections. It is worth emphasising at this point that First Responders must gain permission from the St John Clinical Desk before giving any IM injection.

1 If the patient is alert, gain informed consent – this involves talking to the patient about what you want to do, and asking permission to do so.

2 Select a site – the two sites used for IM injections within St John are the upper arm and lateral thigh. The lateral thigh is always preferred as blood flow through the site enhances absorption.

3 Prepare the site – swab the site with an alcohol and chlorhexidine wipe and allow it to dry.



4 Draw up the medicine you will be injecting – this is dependent on the type of medicine you are delivering.

5 Prepare to inject – hold the syringe with your dominant hand and pull the cover off with your other hand. Place the syringe between your thumb and first finger. Let the barrel of the syringe rest on your second finger.

6 Hold the skin around where you will give the injection – with your free hand, gently press on and pull the skin so that it is slightly tight.

7 Insert the needle into the muscle – hold the syringe barrel tightly and use your wrist to inject the needle through the skin and into the muscle at a 90 degree angle.

8 Check for blood in the syringe – let go of the skin with your other hand. Hold the syringe so it stays pointed straight in. Pull back on the plunger a little to make sure you did not hit a blood vessel. If blood comes back, remove the needle immediately and try another site. Do not inject the medicine.



9 Inject the medicine – if no blood has come back into the syringe, push down on the plunger to inject the medicine. Do not force the medicine by pushing hard. Some medicines hurt. You can inject the medicine slowly to reduce the pain.

10 Remove the needle – once the medicine is injected, remove the needle at the same angle as it went in. If the syringe is fitted with a safety needle, trigger this mechanism. Immediately place the used needle into a sharps container.

11 Massage the site and apply gauze – gentle massaging of the site assists with absorption. A gauze swab should be applied to the site and held in place with tape.

Adrenaline – IM for asthma

How it works:

Adrenaline stimulates receptors that cause dilation within the lung, thus increasing air flow within the lungs, similar to nebulised salbutamol. Unlike nebulised medicines, which can be ineffective if air flow is so reduced in the lungs that the medication is unable to reach its target organ, IM adrenaline is absorbed into the circulation via the muscles, where it is transported to the lungs to have its affect.

Contraindications:

There are no specific contraindications to adrenaline in the setting of life threatening asthma



Administration:

1 Prepare the patient and intramuscular injection site

2 Bring together the necessary consumables for administration of IM adrenaline. This includes an ampoule of 1 mg adrenaline in 1 ml, a 1 ml syringe, drawing up needle, and IM safety needle

3 Put the drawing up needle on the end of the 1 ml syringe

4 Check the adrenaline with your partner (drug, dose, date, ampoule intact)

5 Facing the white dot on the adrenaline ampoule towards you, place your dominant hand on the top of the adrenaline ampoule, and your non dominant hand on the bottom of the adrenaline ampoule. Assertively break the top off the ampoule by moving it away from you. Immediately discard the top into a sharps container.



6 Withdraw the adrenaline from the ampoule by placing your drawing up needle in the ampoule. Withdraw the entire contents.

7 Remove the drawing up needle from the 1 ml syringe and place this immediately into a sharps container. Place the IM safety needle on the 1ml syringe.

8 Remove the safety cap from the IM injection needle and depress the syringe plunger until you have the correct dose of adrenaline as directed by the St John Clinical Desk.

9 Inject the adrenaline into the chosen site (as per the instructions on IM injections next)


Intramuscular adrenaline often makes the patient look and feel unwell. Do not automatically take this as a worsening of their symptoms. It is common for the patient to develop shakes, nausea, anxiety and an elevated heart rate post adrenaline.



StridorStridor is an abnormal high pitched noise created when air is moving through a narrowed upper airway. It is a clinical sign associated with a number of complaints and not a diagnosis or a disease.

Stridor is predominantly inspiratory, but it may have an expiratory component too (biphasic stridor). The adult wind pipe (trachea) is well supported by cartilage which prevents airway collapse and reduces stridor. Children are at higher risk of airway obstruction than adults because they have narrower airways with less cartilaginous support.

Stridor is predominantly caused by medical conditions such as croup or anaphylaxis, which can cause the trachea to swell or constrict. Less commonly it is caused by other medical conditions or foreign body airway obstruction.

Identifying stridor

Stridor is usually immediately obvious and usually does not require a stethoscope to be heard (although occasionally a stethoscope is needed). It is high pitched, and can sound like a creak or grating noise. Because anatomically stridor occurs in the upper airway, stridor can be confirmed by auscultating the upper third of the front of the patient’s chest. If the noise is localised to the upper chest it is likely to be stridor. Stridor is normally worse if air is being forced through the affected area (for example if the patient is upset)

What do I do if the patient has stridor?

� Take a history and full set of vitals – pay particular attention to whether the stridor has been caused by a medical problem, or something else such as a foreign body airway obstruction.

� Administer oxygen if the patient has an SpO2 equal to or less than 94% - this is a transient treatment at First Responder level as we look to contact the St John Clinical Desk to give additional medicines.

� Contact the St John Clinical Desk if the stridor appears to be from infection or swelling – there is one potential treatment that may be administered under consultation, this is:

• Nebulised adrenaline



Adrenaline - nebulised

How it works:

Adrenaline stimulates cells within the wind pipe (trachea) to constrict, thus reducing swelling and constriction of the trachea. Adrenaline also stimulates receptors that cause dilation within the lung, thus increasing air flow within the lungs via the same mechanism as salbutamol.

Contraindications:

There are no specific contraindications to adrenaline in the setting of stridor or respiratory distress.

Administration:

1 Bring together the necessary consumables for administration of nebulised adrenaline, this includes five ampoules of 1 mg adrenaline in 1 ml, a 5 ml syringe, drawing up needle, and nebuliser mask

2 Put the drawing up needle on the end of the 5 ml syringe

3 Check the adrenaline with your partner (drug, dose, date, ampoule intact).

4 Facing the white dot on the adrenaline ampoule towards you, place your dominant hand on the top of the adrenaline ampoule, and your non dominant hand on the bottom of the adrenaline ampoule. Assertively break the top off the ampoule by moving it away from you. Immediately discard the top into a sharps container.



5 Withdraw the adrenaline from the ampoule by placing your drawing up needle in the ampoule. Withdraw the entire contents.

6 Repeat steps 3 and 4 until all five ampoules have been drawn up.

7 Remove the drawing up needle from the 5 ml syringe and place this immediately into a sharps container. The contents of the 5 ml syringe should now be injected into the nebuliser bulb.

8 Nebulised adrenaline can now be administered

Remember: stridor is a clinical sign, and not a diagnosis or disease


It is important to keep children with stridor as calm as possible, because stridor will usually get worse if they become upset or cry. Young children are more likely to remain calm if they are kept in the arms of a parent, provided this is safe and feasible.



AnaphylaxisAnaphylaxis is a rapid onset, multiple-organ, generalised hypersensitivity (allergic) syndrome. It is usually characterised by skin features plus the involvement of the respiratory, cardiovascular or gastrointestinal system.

Exposure to an allergen results in the release of inflammatory mediators which causes the signs and symptoms described above. While there are a number of mediators, histamine is the most widely recognised.

Anaphylaxis can be triggered by almost anything, but most commonly it is caused by exposure to venom (particularly wasps and bees), food (particularly eggs, peanuts and shellfish) or medications.

A patient with stings and only localised swelling, redness or pain does not have anaphylaxis.

Identifying anaphylaxis

It is common for patients with anaphylaxis to know they have it, therefore it is appropriate to ask. Patients with severe anaphylaxis often have an epipen and or medic alert bracelet which can aid in identification of anaphylaxis.

A patient has anaphylaxis if they have skin symptoms such as itch, flushing, swollen lips and/or tongue and symptoms from any of the following groups:

� The respiratory system: difficulty breathing, chest or throat tightness, wheeze or stridor.

� The cardiovascular system: low blood pressure (hypotension), delayed capillary refill, fainting, collapse or altered level of consciousness.

� The gastrointestinal system: severe nausea, vomiting, abdominal pain or diarrhoea.

To have anaphylaxis a patient must have signs of systemic involvement. Skin features alone are insufficient. A very small proportion of patients do not have obvious skin features initially, particularly if the onset is sudden and severe.

Consider the possibility of anaphylaxis in any patient with unexplained wheeze, respiratory distress or shock.



What do I do if the patient has anaphylaxis?


� If the patient has an epipen, this should be administered immediately. It is not uncommon for people to have prescribed epipens if they have a history developing anaphylaxis after exposure to particular antigens (e.g. shellfish, bee stings, nuts etc). There are many different types of epipens out in the community, and they all operate with the same general principles. The instructions for administration will be found on the outside of the epipen, usually with images to aid this.

� Administer oxygen if the patient has an SpO2 equal to or less than 94% - this is a transient treatment at First Responder level as we look to contact the St John Clinical Desk to give additional medicines.

� Contact the St John Clinical Desk – there are two potential treatments that may be administered under consultation, these are:

• Intramuscular adrenaline

• Nebulised adrenaline

Adrenaline – IM for anaphylaxis

How it works:

Adrenaline has a number of effects in anaphylaxis, these include:

� Decreased release of inflammatory mediators

� Dilation within the lung, thus increasing air flow within the lungs

� Increased blood pressure

Contraindications:

There are no specific contraindications to adrenaline in the setting of life threatening anaphylaxis

Administration:

The notes on the administration of IM adrenaline can be found in the section on asthma. The method for drawing up and administering IM adrenaline in asthma is the same as for anaphylaxis.


The most crucial treatment in anaphylaxis is the early administration of adrenaline. The risk of death is raised in a patient whose need for adrenaline (or repeat adrenaline) is under-recognised. Have a low threshold for seeking permission to administer adrenaline from the St John Clinical Desk if anaphylaxis is suspected, even if it is not immediately life threatening. Have a low threshold for seeking permission to administer repeat adrenaline if the patient is not rapidly improving



Adrenaline - nebulisedThe notes on nebulised adrenaline can be found in the section on stridor. The mechanisms by which this medicine works for stridor are the same as for anaphylaxis. Stridor is a symptom of anaphylaxis.

Summary table – conditions and treatments:

CORD Asthma Stridor Anaphylaxis

Oxygen to maintain SpO2 88-92% POxygen to maintain SpO2 >94% P P POwn MDI or spacer P PNebulised ipratropium P PNebulised salbutamol P PIntramuscular adrenaline P PNebulised adrenaline P POwn epipen P



Lesson Plan: Cardiac chest pain

Day three: Session four (30 minutes)

Learning objectives � Discuss what cardiac chest pain is.

� Describe how to recognise cardiac chest pain.

� Describe the procedure for managing cardiac chest pain.

� Administer aspirin to patients with cardiac chest pain.

� Explain when a First Responder can administer GTN to a patient with cardiac chest pain.



� Aspirin tablets

� GTN metered dose spray (one between 4)

Suggested way to teach1 Referencing the First Responder facilitator manual, and having students

reference the First Responder student workbook, discuss what cardiac chest pain is and how to identify it (10 minutes).

2 Discuss the treatment of cardiac chest pain. Hand out aspirin and GTN, overview how each of these drugs work and how to administer them. Specifically demonstrate the administration of GTN, including the importance of explaining the possible side effects. Finally emphasise that GTN can be dangerous if used improperly. It is therefore important to use it with reference to its contraindications and strictly follow the instructions of the Clinical Desk.



Cardiac chest pain

Day three: Session fourThe heart muscle itself relies on a good supply of blood, carrying oxygen and other essential nutrients to the heart muscle. This is facilitated via the coronary circulation, which is a complex network of blood vessels which supply the heart. If there is a narrowing or blockage of these vessels, that can manifest itself as cardiac chest pain. Fortunately there are some interventions you can provide as a First Responder which reduce damage to the heart caused by such a blockage and ease discomfort.

Plaque in coronary artery

Insufficient blood flow to the heart muscle from narrowing of a coronary

artery may cause chest pain

Identifying cardiac chest painCardiac type chest pain is identified by clinical examination, focusing on OPQRST assessment. Typical findings that would indicate cardiac chest pain in the OPQRST assessment include:

� Onset – cardiac chest pain can come on at any time, while doing any activity, although it is generally more likely if the patient was, or had just undergone strenuous physical activity.

� Provokes – cardiac pain is generally a constant pain, that does not change with movement or inhalation, although exercise may increase pain.

� Quality – usually described as dull, achey or heavy. It is rare for cardiac chest pain to be described as sharp.

� Radiates/region – Often it is described as central, difficult to pin down. Commonly it radiates into the patients jaw, arm and shoulder blade (typically on



the left which is the same side of the heart.

� Severity – Cardiac chest pain can vary from 1-10. Pain scoring itself is a poor indicator of how unwell someone is with their pain. All chest pain, irrespective of score is serious until proven otherwise.

� Timing – Cardiac chest pain is usually always there, and is constant. It does not come and go in waves.

Physical findings consistent with cardiac chest pain include:

� Significant anxiety, including a feeling of ‘impending doom’

� A slow, fast or irregular pulse

� Sudden weakness or fatigue

� Sweating and or clammy (cold sweats)

� Shortness of breath

It is becoming increasingly common for patients to have unusual presentations of cardiac pain, this is especially the case in diabetics. Have a low threshold for seeking advice if you are unsure.

What do I do if I think my patient has cardiac chest pain?

� Provide reassurance - reducing anxiety in such patients is important as anxiety speeds up the nervous system and increases stress on the heart

� Take a history, full set of vitals and ECG (where available)

� If you suspect cardiac chest pain, offer the patient 300 mg aspirin (one tablet) - because you do not have an authority to practice you should allow the patient to self-administer it with reference to the instructions on the packaging.

� Contact the St John Clinical Desk – there are two potential treatments that may be administered under consultation, these are:

• Sublingual glyceryl trinitrate (GTN)

• Inhaled entonox (where available). Note – entonox is discussed in further depth on day three of this First Responder Course.



Aspirin

How it works:

Aspirin helps inhibit the formation or growth of blockages in the blood vessels that feed the heart muscle. Research has demonstrated a reduction in mortality by 25-30% with aspirin alone.

Contraindications:

There are no specific contraindications to aspirin other than known serious allergy

Administration:

Aspirin should be chewed then swallowed, this aids rapid absorption


If the patient has taken aspirin already on the advice of the ambulance communication centre then it is appropriate to withhold aspirin. Some patients have enteric coated aspirin, which takes several hours to be absorbed. Check that these tablets have been crushed prior to being swallowed. If they have not been absorbed it is appropriate to repeat the dose of aspirin.



Glyceryl trinitrate (GTN)

How it works:

GTN reduces blood pressure, this in turn reduces the workload of the heart, which reduces the heart muscles demand for oxygen and nutrients.

Contraindications:

� Do not have permission to administer GTN from the St John Clinical Desk

� Life threatening or known serious allergy

� Blood pressure less than 100 mmHg systolic

� Heart rate less than 40, or greater than 130 beats per minute

Administration:

If the patient has not had GTN before, let the patient know that the GTN will drop their blood pressure, and as such they might feel light headed, dizzy, flushed and have a headache for a short time post administration.

Ensure the patient is sitting or lying down before administration. The patient should be instructed to place their tongue on the roof of their mouth, and the GTN should be sprayed under the tongue. Each spray delivers 0.4 mg sublingual GTN. The St John Clinical Desk will advise whether to give one or two sprays.


Many patients with a history of cardiac problems have GTN prescribed for them. It is acceptable to advise the patient to continue to use their own GTN as per their Doctor’s instructions if they are comfortable in doing so.

If the patient is not normally prescribed GTN, or you are directing the patient to take GTN, you need permission from the St John Clinical Desk prior to administration.



Lesson plan: IM injections in other circumstances

Day three: Session five (45 minutes)

Learning objectives � Discuss in broad terms what septic shock is

� Understand how to identify and treat septic shock

� Demonstrate how to draw up and administer ceftriaxone

� Understand how to identify meningococcal septicaemia

� Discuss in broad terms what diabetes is

� Understand how to identify and treat hypoglycaemia

� Demonstrate how to draw up and administer glucagon



� 5 ml syringes (one each minimum)

� 10 ml saline ampoules (one each minimum)

� Ceftriaxone vials (one each minimum)

� Drawing up needles (one each minimum)

� FR D3S5 Rapid Response Hypoglycaemia video

� Glucagon kits (one between two minimum)

� IM safety needle (one each minimum)

� Manikins, IM training arms OR oranges for IM injection as appropriate (one between four)



Suggested way to teachReferencing the First Responder facilitator manual, and having the students reference their First Responder student workbooks:

1 Discuss what septic shock is, how to identify it and how to treat it. Hand out ceftriaxone vials, drawing up needles, 5 ml syringes, 10ml saline ampoules and IM safety needles. Then demonstrate how to dilute, draw up and administer ceftriaxone. Have students replicate this, and allow students to inject their ceftriaxone into a manikin, IM training arm or orange as appropriate. Overview what meningococcal septicaemia is, and the importance of aggressive treatment upon recognition (20 minutes)

2 Briefly overview what diabetes is, then discuss what hypoglycaemia, how to identify it and how to treat it. Hand out glucagon kits, and then demonstrate how to dilute, draw up and administer glucagon. Have students replicate this, and allow students to inject their glucagon into a manikin, IM training arm or orange as appropriate. (20 minutes). Finally, play the FR D3S5 Rapid Response Hypoglycaemia video.



IM injections in other circumstances

Day three: Session fiveThis session covers the two circumstances, other than asthma and anaphylaxis, that a patient may administer an intramuscular (IM) injection under direction, these are:

� Septic shock (ceftriaxone)

� Diabetic emergencies (glucagon).

Septic ShockShock is a global reduction in blood flow (perfusion) to the tissues and organs of the body. Septic shock is a medical condition which results from severe infection. The infection spreads to the blood stream causing the blood vessels to expand and leak. The result is that there is not enough blood to fill the blood vessels, resulting in a drop in blood pressure and an inability for blood to be delivered to vital organs.

Identifying septic shock

Diagnosing septic shock requires two things:

� A source of infection – this means you must have a high index of suspicion or objective evidence of infection. This may be as obvious as an infected wound, or more subtle such as a chest or urinary infection. Typically patients with infection have a temperature below 36ºC, or greater than 38ºC and

� Shock – as evidenced by a high heart rate, fast breathing and a low blood pressure.

Additional signs and symptoms of septic shock include:

1 Decreased urine output

2 Confusion

3 Diarrhoea

4 Nausea and vomiting

5 Aching muscles or joints.

What do I do if my patient has septic shock?



� Call for Paramedic or Intensive Care Paramedic support – patients with septic shock require urgent support from a Paramedic (or preferably Intensive Care Paramedic) for fluids and possibly adrenaline



� Contact the St John Clinical Desk if it will be more than 30 minutes until the patient reaches hospital – there is one potential treatment that may be administered under consultation, this is:

• Intramuscular ceftriaxone

Ceftriaxone

How it works:

Ceftriaxone is a broad spectrum antibiotic which interferes with the cell walls of bacteria causing them to rupture.

Contraindications:

There are no specific contraindications to ceftriaxone other than known serious allergy

Administration:

1 Prepare the patient and intramuscular injection sites on the lateral thighs. Note that for this particular treatment two injections are necessary and these must be the lateral thighs owing to the volumes involved

2 Bring together the necessary consumables for administration of IM ceftriaxone, this includes two vials of 1 gram ceftriaxone as a powder, two 3 ml syringes, three drawing up needles, one 10 ml prefilled saline syringe, and two IM safety needles.

3 Check the ceftriaxone and prefilled saline syringe with your partner (drug, dose, date, ampoule intact).



4 Place a drawing up needle on the end of the prefilled syringe and remove the lids from the ceftriaxone vials

5 Carefully insert the drawing up needle into the soft area at the top of the ceftriaxone vials and inject 2 ml saline into each vial.

6 Remove the needle and gently shake the vials until the powder appears to have dissolved

7 Place a drawing up needle on each of the 3 ml syringes

8 Carefully insert the drawing up needle attached to a 3 ml syringe into the soft area at the top of one of the ceftriaxone vials and draw out the 2ml ceftriaxone. Repeat this with the second 3 ml syringe and ceftriaxone vial



9 Inject the ceftriaxone into the chosen sites of each lateral thigh


Ceftriaxone can also be administered under direction from the Clinical Desk if the patient has meningococcal septicaemia (irrespective of the distance from hospital). This disease (widely described in the media as meningitis, although it is in fact a different disease) has a high mortality (death) rate. Early antibiotics can help prevent death or disability from this disease.

Meningococcal septicaemia is difficult to diagnose in the early stages as the symptoms resemble influenza. To administer ceftriaxone there must be objective signs of meningococcal septicaemia such as petechiae or purpura:

� Petechiae are small spots about the size of the tip of a pen. They are due to bleeding from small capillaries in the skin. They can be seen anywhere and the patient should be examined fully to exclude them. They often develop over minutes and if the diagnosis is being considered, the patient’s skin should be re-examined every 10 to 15 minutes looking for new petechiae.

� Purpura are larger spots that look like bruises. They result from a combination of bleeding and ischaemia of the skin. They are usually very obvious.

Finding petechiae or purpura should trigger immediate consultation with the St John Clinical Desk.

Purpura Petechiae



Diabetic emergencies Diabetes describes a group of diseases which disrupt the body’s ability to process and control the level of glucose (sugars) within the blood stream. Some diabetics are highly reliant on medications and careful diet to control their sugar levels. Extreme variations in blood glucose levels can be life threatening. It is generally accepted that most healthy adults will have a BGL between 4 mmol/L and 9 mmol/L, (noting that there are many factors that can influence BGL).

If the patient’s BGL is very low (medical term is hypoglycaemia) the patient can suffer a reduced level of consciousness and may become agitated, have seizures, or become unconscious. First Responders can treat patients who have a BGL that is less than 3.5 mmol/L with either oral glucose, or intramuscular glucagon in consultation with the St John Clinical Desk (more on this in the Medical section). This is discussed in further depth below.

If the patient’s BGL is very high (medical term is hyperglycaemia) the patient can suffer a reduced level of consciousness (as above) and may develop life threatening shock as the body attempts to dump the excess glucose in the bloodstream. Paramedics and Intensive Care Paramedics will generally administer intravenous fluids to patients who have a BGL greater than 20 mmol/L and shock. First Responders should request a Paramedic (or higher) in these groups of patients.

Identifying hypoglycaemia

The primary indicator of hypoglycaemia is a blood glucose level less than 3.5 mmol/L.

Physical findings consistent with hypoglycaemia can include:

� Agitation, acting abnormally or unreasonably

� Reduced level of consciousness, possibly seizures

� Profuse sweating

What do I do if my patient has hypoglycaemia?

� Take a history, and full set of vitals (including BGL if not already done)

� Administer glucose orally (or food) - only if the patient is conscious and able to swallow. Most oral glucose gels contain 10-20 g of glucose per dose and can be administered to adults and children aged 2 years and over.

� Contact the St John Clinical Desk if unable to swallow – there is one potential treatment that may be administered under consultation, this is:

• Intramuscular glucagon



Glucagon

How it works:

Glucagon is a naturally occurring hormone which stimulates the release of stored glucose in the liver and skeletal muscle. It also stimulates the conversion of fats and acids to glucose. The cumulative effect of this is to raise blood sugars.

Contraindications:

There are no specific contraindications to glucagon other than known serious allergy to the synthetic version of glucagon (exceptionally uncommon).

Administration:

1 Prepare the patient and intramuscular injection site

2 Check the container of the glucagon kit is sealed

3 Open the kit, pick up the vial and remove the lid



4 Pick up the syringe and remove the safety cap

5 Carefully insert the needle into the soft area at the top of the vial

6 Inject the entire volume of sterile water within the syringe into the vial

7 Leaving the needle in the vial, invert the syringe and vial and shake carefully until the solution becomes clear



8 With the syringe and vial still inverted, draw back on the plunger until the desired volume is within the syringe (0.5 or 1.0 ml at the direction of the Clinical Desk)

9 Withdraw the needle from the vial and inject the glucagon into the chosen site


Glucagon takes time to work (up to 15-20 minutes). It may not be effective if the patient has already consumed their glucagon stores (as can be seen in patients who have undergone strenuous physical exercise or patients with severe infection). If glucagon does not work the patient will require a Paramedic or Intensive Care Paramedic to administer intravenous glucose.

Extreme variations in BGL can be life- threatening and will require treatment



Lesson plan: Other medical conditions

Day three: Session six (45 minutes)

Learning objectives � Discuss the basic pathology of stroke and assessment techniques and

assessment findings indicative of a stroke.

� Discuss the management of a patient who is presenting with a stroke.

� Demonstrate the FAST assessment

� Briefly discuss the pathology, identification and treatment of seizure

� Briefly discuss the management of normal birth




� FR D3S6 Birth video


Suggested way to teach1 Present the Other medical conditions section of the FR Day Two PowerPoint with

reference to the First Responder facilitator manual. Run through stroke, pausing to demonstrate the FAST assessment, then in pairs have the students practice the FAST assessment on each other. (20 minutes).

2 Briefly review the pathology, presentation and treatment of seizure (10 minutes).

3 Overview the actions that a First Response crew is expected to take if they come across a birth. Spend some time on this, as it is a high area of anxiety (particularly amongst New Zealand Fire Service First Responders). Emphasise that there are no particular medical procedures that need to be performed, and in the event of complication, if they ring the Clinical Desk they will be talked through what to do next. Following this, play the FR D3S6 Birth video, noting that people who are not comfortable watching it are welcome to avert their gaze (15 minutes).



4 As this is the last session today, close the course for the day:

• Thank students for their participation and hard work

• Reassure the students that it is normal to feel overwhelmed with the volume of information they are receiving, and that the important thing is to get out there and apply it

• Advise the students that there is a ‘knowledge check’ first up in the morning and invite them to take their First Responder facilitator manual home to review their notes (they MUST bring it back tomorrow)

• If necessary run through the timetable for the following day, and confirm the start and approximate finish times

• Answer any questions; invite students to ask questions after the class.



Other medical conditions

Day three: Session six This session overviews three medical conditions which are either common, or create significant anxiety at First Responder level, these are:

� Stroke

� Seizures

� Pregnancy and childbirth

There are no specific interventions or medicines that you need to consult with the Clinical Desk to use in this session.

StrokeStroke is characterised by the sudden loss of circulation to an area of the brain, resulting in a corresponding loss of brain function. Strokes are classified as either ischaemic or haemorrhagic, of which approximately 80% are ischaemic:

� Ischaemic stroke refers to stroke caused by a blockage occluding the blood flow in the brain resulting in cell death.

� Haemorrhagic stroke occurs when a blood vessel in part of the brain ruptures, which reduces cerebral blood flow and causes bleeding into the brain tissue.

Ischaemic Stroke Haemorrhagic Stroke

Area deprived of blood

Area of bleeding

Weakened vessel wall ruptures, causing bleeding in the brain

Obstruction blocks blood flow to part of the brain



Signs and symptoms

Ischaemic stroke

Patients with an ischaemic stroke have signs and symptoms that relate to the part of the brain that has lost its blood supply. Most commonly, these include a new onset of any combination of the following:

� One sided weakness in the patient’s face, arm or jaw

� Speech disturbance

� Visual disturbance.

Haemorrhagic stroke

Patients with an ischaemic stroke are usually able to obey commands on their ‘good side’. If they cannot, it is unlikely they have had an ischaemic stroke.

Patients with a haemorrhagic stroke typically present with sudden onset of severe headache with signs and symptoms – including all of those listed above – that relate to the part of the brain in which the bleed has occurred. Patients with a haemorrhagic stroke are less likely to be able to obey commands than a patient with an ischaemic stroke.

It is not possible to clinically distinguish between an ischaemic stroke and a haemorrhagic stroke with a high degree of confidence without a CT scan.

FAST assessment

The FAST assessment should be performed for all conscious patients who are possibly having a stroke. Patients with new onset of abnormalities, as detected by the FAST assessment, are having a stroke until proven otherwise.

� Face - Look for new onset of unilateral facial weakness. Ask the patient to smile and show all of their teeth/gums.

� Arms – Look for new onset of one sided arm or leg weakness:

Ask the patient to raise their arms (to 90 degrees from the body) with their palms facing upward. Look for inability to raise one arm, or for one arm that drifts downward.

Ask the patient to walk. Look for abnormalities.

� Speech - Look for new onset of abnormal speech:

Ask the patient to repeat a sentence. Look for slurring of words.

Show the patient several common objects and ask them to name them. Look for difficulty or inability to name objects.



� Time – Note the time of onset of symptoms. This is defined as the time that the patient was last seen to be normal. If the patient has woken up with the signs or symptoms, then the time of onset of symptoms is the time that the patient went to sleep.

Transient ischaemic attack (TIA)TIA is defined as stroke symptoms or signs that completely resolve within 24 hours. Patients who have had a TIA are at increased risk of subsequently developing a stroke.

Some districts use a form of scoring known as an ABCD2 score to determine whether the patient can be referred to a formal TIA pathway. This table is able to be viewed in the CPGs. Canterbury District does not have a TIA pathway at this time. All patients presenting with a suspected TIA must receive a firm recommendation that they are transported to an Emergency Department.

What do I do if the patient has had a stroke?

� Take a history, full set of vitals and do a FAST assessment

� Transport without delay if the patient can reach hospital within 3.5 hours of onset of symptoms – this involves ensuring you give an early SITREP if you are unable to transport yourself. Provision of a SITREP allows the responding crew to respond under lights (if responding at road speed), and the ambulance communications centre to consider alternative transport options in conjunction with the Clinical Desk if the patient is a significant distance from transport

There are no specific pre-hospital treatments for stroke other than recognition and rapid transport (with early hospital notification).

It is impossible to accurately differentiate between an ischaemic or haemorrhagic stroke prehospitally, but the

treatment remains the same for both



SeizuresSeizures result from the massive discharge of electrical signals within the brain. Externally this can manifest with the patient losing consciousness and exhibiting violent and rhythmic twitching. It is not uncommon for patients to lose bowel and bladder control during a seizure. After the seizure there is commonly a post seizure period where the patient will appear confused, tired, lethargic, and may exhibit unreasonable, aggressive or argumentative behaviour.

Identifying a seizure

If the patient is still fitting identification of a seizure is very easy. If the patient is no longer fitting they will commonly present as confused, tired and lethargic as above.

What do I do if my patient is having a seizure?

� Ensure the patient is safe – move dangerous objects away from the patient, or move the patient away from objects that may hurt the patient as they are fitting.

� Take a history, and full set of vitals – pay particular attention to the patient’s blood glucose level, as very low or very high blood glucose level can cause seizures. If the patient has a low BGL ensure you treat this as this may stop the seizure.


� Call for Paramedic or Intensive Care Paramedic support – patients having prolonged seizures require urgent support from a Paramedic (or preferably Intensive Care Paramedic) so they can give medicines to stop the seizure.


There is a useful memory jogger called AEIOU-TIPS you may wish to remember when attempting to identify a cause for the patient’s seizure, which can also be applied to any patient with a decreased level of consciousness.

� Alcohol

� Epilepsy

� Insulin (diabetes)

� Overdose

� Underdose

� Trauma / temperature / tumor

� Infection

� Psychiatric / poisoning

� Stroke / shock



Pregnancy and childbirthBoth pregnancy and childbirth are an area of high anxiety for First Responders, and it need not be. The principles for treating a pregnant patient, and those giving birth are very simple.

Pregnant patients:

At First Responder level, the principles for treating pregnant patients are exactly the same as for any other patient noting that:

� Some of the medicines that you may give under consultation may be refused by the Clinical Desk

� In general pregnant patients should always be transported for assessment unless there is a very good reason not to

� You should keep the patient’s Lead Maternity Carer (typically a midwife) in the loop where possible

Normal birth:

When attending a birth it is important to recognise that there are literally millions of births each year, safely delivered by people who have no medical education whatsoever. Birth is a natural process and despite the media hype it is relatively uncommon for complications during delivery. If there are any complications, or you are unsure you should ring the Clinical Desk who can walk you through what to do.

What do I do if the patient is giving birth?

� Support the patient to adopt the position they prefer.

� Support the baby’s head and shoulders as they appear without applying traction.

� Dry the baby.

� Place the baby ‘skin to skin’ with the mother (baby to breast)

� Place a hat on the baby if one is available and cover them both with a blanket. Continue to observe the baby’s activity and breathing.

� Clamping and cutting the cord is not urgent unless the baby is requiring resuscitation. In the absence of urgency, clamp and cut the cord 5 cm from the baby 2-3 minutes after birth

� Allow the placenta to deliver spontaneously, without applying traction. This may take up to 30 minutes.

� Following delivery of the placenta, feel for the uterus at approximately umbilical level and rub it using a circular motion until it feels firm.

Normal birth is a natural process and is not a medical emergency



Lesson plan: Stretchers and carry chairs

Day three: Session seven (60 minutes)

Learning objectives � Discuss stretchers and carry chairs within St John

� Describe the safe manual handling techniques for lifting/carrying patients and equipment

� Demonstrate safe use of the stretcher and carry chair in various situations; in/out of the vehicle, up/down stairs/flat surfaces

� Discuss general guidelines for using stretchers and carry chairs



� Ambulance with Stryker and York Stretcher (where possible)

� Combi carrier

� Scoop stretcher

� Ferno 2042 carry chair



Suggested way to teachThis session will vary depending on the audience you are engaging. It is designed to either:

� Allow students from St John Youth or the NZFS to familiarise themselves with equipment that they do not normally have access to, but may come across in the course of their normal duties

� Allow students from St John Operations to solidify concepts of manual handling utilising the various extrication devices within St John

If you have students who are already competent with these devices, it is appropriate to move onto the next session sooner.

1 Introduce the lesson by emphasising the importance of safe lifting to include:

• Keep the stretcher as close as possible to the officers’ body (centre of gravity)

• Avoid bending and twisting

• Keep back straight and knees bent

• Always seek additional assistance to lift the stretcher if required (5 minutes)

2 Referencing the First Responder facilitator manual, demonstrate the technique for full patient immobilisation using a scoop stretcher or combi carrier (15 minutes)

3 Set up skill stations for the use of devices relevant to equipment that students are normally exposed to. Ensure students have a basic understanding of using these devices safely. Where students are clearly proficient in using these devices, challenge them to use them whilst moving a patient who has a spinal injury (40 minutes).



Stretchers and carry chairs

Day three: Session sevenIn this session we overview:

� Drop leg stretchers

� York stretchers

� Combi Carriers

� Scoop stretchers

� Carry chairs

Safety considerations when using stretchers and carry chairs:

� Keep the stretcher as close as possible to the officers’ body (centre of gravity)

� Avoid bending and twisting

� Keep back straight and knees bent

� Always seek additional assistance to lift the stretcher if required

Drop leg stretchersThe primary drop leg stretcher utilised by ambulance services in New Zealand is the Stryker M1. This is a drop leg stretcher which means it can be pushed into, and pulled out of an ambulance with the legs collapsing or dropping as required, instead of the crew needing to manually lift the stretcher. The maximum loading capacity of an M1 Stryker is 228 kg



Safety considerations specific to the Stryker M1:

� The Stryker has a two stage system for the front legs as a safety feature. Do not press the green button and green left-hand lever until the front legs make contact with the ramp. If the front legs of the stretcher hit a bump before the Stryker ramp, they may collapse.

� A second officer must be present to ensure the front legs fully extend when the stretcher is unloaded. Collapsed stretchers are a main cause of injury to patients and responders.

� For heavy patients, two officers can work together at each end to lower one end at a time.

� Ensure the side rails stay up and the patient’s seatbelt remains fastened during this process.

This is used when loading the stretcher into the ambulance in the final stages, when the last set of legs are to be collapsed. It is also used when lowering/raising the stretcher.

These are used simultaneously when loading the stretcher into the ambulance, to allow for collapse of the first set of legs.



York stretchersThe York stretcher remains a prominent stretcher within ambulance services in New Zealand, although these stretchers are now primarily used as a bench seat and spare stretcher. Some areas with earlier models of ambulances may still operate the York as their primary lifting device. There are two models of York in circulation, the York 2 (does not lift) and the York 4 (does lift). The maximum loading capacity of a York Stretcher is 180 kg. The York stretcher needs to be manually lifted into and out of the ambulance:

Combi CarriersThe Combi Carrier is one of the primary extrication devices used within ambulance services, which combines many of the benefits of a scoop stretcher or backboard. The Combi Carrier can be split in the middle so it is able to be ‘scissored’ or slid under the patient. Once placed onto a Stryker of York it can be split to facilitate easy transfer. The maximum loading capacity of a Combi Carrier is 205 kg.



Scoop stretchersAlthough the scoop stretcher is no longer routinely purchased by ambulance services, in New Zealand, they remain a common and effective device. The scoop stretcher can be split in the middle so it is able to be ‘slid under the patient. Once placed onto a Stryker of York it can be split to facilitate easy transfer. The maximum loading capacity of a scoop stretcher is 159 kg.



Carry chairsThere are several types of carry chairs utilised by ambulance services. Carry chairs are used to move patients through tight spaces or up and down stairs. One of the most common carry chairs is the Ferno 2042. This simple but robust carry chair has a maximum loading of 160 kg.

Remember:

� Keep the carry chair as close as possible to the officers’ body (centre of gravity)

� Avoid bending and twisting

� Keep back straight and knees bent

� Always seek additional assistance to lift the stretcher if required




Day three: Session eight (30 minutes)

Learning objectives � Revise knowledge learnt throughout the course of day one and two

� Ensure key learning outcomes from day one have been achieved

� Replicate skills learned on day one and two



� Defibrillator / Monitor OR AED with ECG capability (one between 4, where possible use the same type as defibrillator as the one used by the students operationally)






Suggested way to teachThis session involves running a simulation with some students participating and others observing:

� Having a patient with cardiac chest pain which students are required to fully assess

� The student asking the Clinical Desk for advice, at which time they will be instructed to administer GTN

� Approximately two minutes after the patient receives GTN they will VF arrest



� After two shocks the students will get ROSC. The patient will remain unconscious with a GCS 3 and no breathing

� A backup crew will arrive and an IMIST-AMBO handover will occur.

Note: As this scenario is heavily reliant on the facilitator being present, only one scenario should be run per facilitator that is present. Some students will be involved in the simulation; others will watch and be involved in debriefing.

1 Ask for four volunteers to be part of the simulation, three to be responders and one to be the patient. Send the three responders out of the room to check their equipment (resus kit, oxygen kit, suction and resus kit). The remaining student will be the patient, and should be briefed to have chest pain as per the following symptoms:

• Onset – at rest.

• Provokes –constant pain that does not change with movement or inhalation.

• Quality – heavy.

• Radiates/region – Often it is described as central, difficult to pin down, with a little in the jaw.

• Severity – 7/10

• Timing – Constant

All other history should be as per their medical conditions (if they are comfortable) or with the history made up (no medications or problems, if not).

Excess students should be asked to watch and observe things that could be done differently, and think about a possible IMIST-AMBO handover (5 minutes).

2 Bring the responders in. Allow them to fully assess the patient. Allow them to ‘call the Clinical Desk’ (you) and give them permission to administer GTN. Allow them to continue assessing the patient until 2 minutes after GTN is administered or until the assessment has been going for ten minutes (whichever comes sooner). At this time the patient should collapse, and you should switch to the manikin (10 minutes)

3 With the manikin in VF, the crew should immediately start CPR, apply pads, and administer a shock. After two minutes of CPR, and a second shock, the patient will have ROSC but remains unconscious and not breathing (5 minutes)

4 You should step in as the backup crew and ask for a handover, this should be delivered using the IMIST-AMBO format. If the students that have been involved in the resuscitation have been too flustered, use the observers to put together the IMIST-AMBO handover (5 minutes)

• Identification (the patients name and age)

• Mechanism of injury or the medical complaint



• Injuries identified or information related to the medical complaint

• Signs and symptoms (what you have found)

• Treatment and trends (what you have done and its effect)

• Allergies

• Medicines (that the patient is prescribed)

• Background (medical background / past medical history)

• Other (for example family and social situation).

5 Finally debrief the scenario as a class:

• Applaud the bravery of the patient and responders

• Ask the patient and responders for feedback as to what they feel they did well, and what they could have done better

• Ask the observers if there are any other points that have been missed

• Give feedback using the positive, learning point, positive feedback technique (5 minutes).



Knowledge check

Day three: Session eight During the knowledge check you will be asked to either participate in a simulation, or observe a simulation. You should record your observations here:

Things done well – what happened that went particularly well?

Learning points – what happened that you and your class can learn from?

IMIST-AMBO – formulate a handover for the simulation you are watching here:

I -

M -

I -

S -

T -

A -

M -

B -

O -



Day Four: Bringing it all togetherTimetable (approximate)

0830 Session 1 - Knowledge check

1000 Morning tea

1015 Session 2 - Full resuscitation simulation, burns simulation and skills station

1200 Lunch

1230 Session 3 - Anaphylaxis scenario, spinal injury scenario and skills station

1400 Afternoon tea

1415 Session 4 - Hypoglycaemia scenario, motor vehicle accident scenario and skills station

1545 Debrief and presentations




Day four: Session one (90 minutes)

Learning objectivesThe student will:

� Revise knowledge learnt throughout the course of day three

� Ensure key learning outcomes from day three have been achieved

� Replicate skills learned on day three



� Access to extrication devices (KED, scoop stretcher, combi carrier, spinal board, Ferno 2042 carry chair)

� Access to splints (cardboard and Sager), roller bandages, triangular bandages and towels

� Access to cervical collars

� Access to entonox (including mouth piece and demand valve) and methoxyflurane (including charcoal filter and inhaler).

Suggested way to teach1 Welcome the students back for the final day of the First Responder course,

and run through today’s timetable referencing the First Responder facilitator manual(10 minutes).

2 Ask students the following questions and discuss the answers as a class, but encourage the students to write in the correct answers in their student workbook (35 minutes):

Question one: What does MOI and IOS stand for? Answer: Mechanism of injury and Index of suspicion



Question two: What is the difference between MOI and IOS? Answer: MOI is how the injury occurred, whereas IOS is how seriously an injury is being considered as a possibility, based on the MOI.

Question three: What kind of injuries would you suspect in a patient who has been hit by a motor vehicle while walking? Answer: If the patient was an adult: femur fractures, intra- thoracic or intra- abdominal injuries and head injury

Question four: Define shock Answer: A state in which there is decreased and inadequate blood flow, and supply of vital nutrients to the vital organs.

Question five: What kind of shock is a patient most likely to be in if they have lost a lot of blood? Answer: Hypovolaemic shock- as this is defined as shock due to inadequate circulating blood volume.

Question 6: How would you define obstructive shock? Answer: Shock caused by an inability of blood to flow due to a physical obstruction.

Question 7: List some signs and symptoms of shock Answer: Hypotension, absent or weak pulse, tachycardia, cool extremities, agitation, decreased LOC, delayed CRT.

Question 8: You have a patient who is in anaphylactic shock after ingesting some peanuts. Outline your treatment. Answer: Reassure the patient, call for backup, ask the patient if they have their own prescribed epipen, and if so administer this. If this is not possible, recognise that the priority for this patient is adrenaline and immediately call the Clinical Desk for permission to administer IM adrenaline (if the patient has a wheeze, also request you administer nebulised adrenaline), continuously monitor the patient’s vital signs.

Question 9: List some types of open wounds Answer: Abrasions, amputation, avulsion, incision, laceration, penetrating, puncture.

Question 10: How would your treatment differ between a patient with a partial amputation of the leg, and a patient with multiple deep lacerations to the leg? Answer: With the amputation, a CAT would be applied due to the disruption of some major blood vessels in the leg. This would not necessarily occur with deep lacerations alone. Treatment for the lacerations would depend on the degree to which the patient was bleeding, and whether or not there was significant arterial involvement. Pain may differ in these two scenarios, and therefore so would the pain relief administered. Other than those considerations, treatment would follow the same principles.



Question 11: List the limb baselines Answer: Colour, sensation, temperature, movement, pulses, capillary refil

Question 12: What are the contraindications for entonox? Answer: If the patient is unable to obey commands If the patient has a suspected bowel obstruction If the patient has a suspected pneumothorax If the patient has been SCUBA diving in the last 24 hours, or has a diving related emergency Permission from the Clinical Desk has not been obtained

Question 13: What would be the difference in presentation between a patient with mild hypothermia, and a patient with severe hypothermia? Answer: A patient with mild hypothermia will be shivering, have hypertension, tachycardia and an increased respiratory rate. In contrast, a patient with severe hypothermia will not be shivering, have hypotension, bradycardia, decreased respiratory rate and decreased LOC.

Question 14: What types of burns do you take into consideration when estimating the burn size on a patient? Answer: Partial thickness and full thickness

Question 15: What are some signs and symptoms of a TBI? Answer: Headache, N + V, light- headed, amnesia, disorientation, reduced attention or concentration, reduced LOC. Severe TBI can manifest as an inability to obey commands, agitation and/or combativeness.

Pick three students from the class to be patients, and split the rest of the class up into three groups. Each group has a patient who has: a fractured right humerus, a fractured left clavicle, a left midshaft femur fracture, a fractured right ankle, cervical spine pain, but no time- critical injuries. Inform each group they are to treat their patient, and transfer them from the classroom to another area (this will change depending on venue) (30 minutes).

Before morning tea, tidy up and pack away all the equipment used.



Lesson plan: Full resuscitation scenario, burns scenario and skills station

Day four: Session two (105 minutes)

Learning objectives

The student will:

� Demonstrate effective patient management in a full resuscitation scenario.

� Demonstrate effective patient management in a burns scenario.

� Replicate skills learned over the last three days at the skill station



� Access to any equipment used in the last three days of learning

Suggested way to teach1 Discuss with the class the way the scenarios and skills stations are going to be

run during Day Four (15 minutes):

• highlight the fact that these sessions are a good time to put into practice everything that they have learnt over the last three days.

• emphasise that these scenarios should be treated as real- life situations, and they should act accordingly (acknowledging that the concept of scenarios may be new and daunting for some students)

• allow students to ask any questions regarding scenarios.



2 Split the class into three groups. These groups will rotate every 20 minutes between the burns scenario, the full resuscitation scenario, and the skills station. A tutor will be stationed at each activity (60 minutes):

• The skills station is a time for the students to practice what they are not confident doing, and to ask the tutor any questions.

• The burns scenario and full resuscitation scenarios are found on the following pages.

• Ideally, you would have no more than four people involved in one scenario. There are times where class size may require more than one of the same scenario to be set up in order to achieve this.

3 Once there has been a full rotation of the groups, bring the class back together for a debrief. Go through each scenario and discuss what was done well, what they could have done better, and the ideal treatment for that particular patient. Encourage students to write these points down in their student workbook (30 minutes).



Full Resuscitation Scenario Outline

OverviewFirst Responders will have 20 minutes to work through this scenario.

They will have the following equipment with them to use:

� Resus kit

� AED

� Handheld radio

� Oxygen

� Suction

The First Responders are dispatched to an address where the patient has been complaining of chest pain this morning. Upon arrival of the First Responders, they will find the patient has collapsed, is not breathing and has no pulse. They will be required to perform resuscitation.

Objectives � Demonstrate logical and sequential management of a patient in cardiac arrest

� Demonstrate competence in performing interventions with appropriate equipment at First Responder level

Critical performance elements � Scene size-up

� Patient assessment

� Early call for back up

� Immediate continuous CPR of good quality

� Appropriate airway care

� Safe and effective use of AED

� Crew communication



Information to students

You are called to a private residence where a 68 year old patient who lives with his wife has been complaining of chest pain this morning. The patient has since collapsed and requires immediate attention.

If the First Responders investigate further, the wife will give the following information:

S - Chest pain, shortness of breath, nausea prior to collapse

A - Nil

M - GTN, Aspirin, Betaloc

P - Angina, Hypertension

L - Breakfast at approximately 0800

E - Patient got up for breakfast, was sitting on the sofa watching TV when chest pain developed suddenly. He got up to go to the toilet and collapsed on the floor.

O - Sitting on the sofa watching TV when pain came on

P - Pain was constant in nature, nothing made the pain better or worse

Q - Described as being ‘like an elephant sitting’ on patients chest

R - Chest, no other information known

S - Severe, no other information known

T - 40 minutes ago, collapsed 2 minutes before ambulance arrival

Manikin preparation � Dressed as a 68 year old patient

� Collapsed on the floor



Manikin Parameters

Breathing Circulation Other information

Sounds None Rate 0 / min Pain N/A

RR 0 Rhythm VT GCS 3

Volume 0 BP - Temp 36.0

Sp02 - Cap. Refill >3 seconds BGL 5 mmol/L

Debrief pointsIt is important to ensure that all students understand that this is a safe learning environment and any feedback given must be given in a constructive manner.

� Give students the opportunity to state things they did well

� Give students the opportunity to recognise areas for improvement

� Feedback should focus on critical performance elements

• Scene size-up; safe approach

• Patient assessment- logical, sequential and timely

• Placement of equipment logical and workable

• Early and appropriate SITREP

• Immediate continuous CPR of good quality- rate, depth, method, ratio

• Appropriate airway care- OPA measurement and insertion, correct and effective BVM technique

• Safe and effective use of AED- correct pad placement, verbal and visually clears, follows prompts

• Effective crew communication with one another, bystanders, and the patient.



Burns Scenario OutlineTutors have the option of using themselves as the patient in this scenario, or to simulate the scenario with a manikin.

OverviewFirst Responders will have 20 minutes to work through this scenario.

They will have the following equipment with them to use:

� Resus kit

� AED

� Handheld radio

� Oxygen

The First Responders are dispatched to an address where the patient has sustained partial thickness burns to their right arm. Upon arrival, they find the patient running their arm under water.

Objectives � Identification of hazards and mitigation/ minimisation of these

� Demonstrate logical and sequential management of a patient with superficial and partial thickness burns.

� Demonstrate competence in performing interventions with appropriate equipment at first responder level

Critical performance elements � Scene size-up


� Early and appropriate SITREP

� Continuation of cooling the burn

� Effective patient and bystander questioning

� Appropriate pain management

� Appropriate burn wound management post- cooling




Information to students You are called to a private residence where a 45 year old male has fallen onto a BBQ and sustained burns to his arm.

If the First Responders investigate further, the wife will give the following information:

S - Superficial and partial thickness burns to the patients right arm (upper and lower areas)

A - Penicillin

M - Nil

P - Nil

L - Lunch approimately 4 hours ago

E - Patient was walking toward the BBQ, tripped over the garden hose and fell onto the BBQ. Patient immediately began running the burn under cold water.

O - When the patient fell onto the BBQ

P - Pain is constant- nothing makes it worse, and cold water relieves it somewhat.

Q - ‘Burning’/ ‘stinging’ pain

R - Right arm, no radiation

S - Described as ‘very sore’ by the patient, 7/10

T - 15 minutes ago

Manikin/ Patient Parameters


Sounds Vesicular Rate 100 / min Pain 7/10

RR 26 Rhythm Sinus GCS 15

Volume 6 BP 135/80 Temp 36.5

Sp02 100 % Cap. Refill 1 second BGL 5 mmol/L



Debrief pointsIt is important to ensure that all students understand that this is a safe learning environment and any feedback given must be given in a constructive manner.




• Scene size-up; safe approach, hazard identification

• Patient assessment- logical, sequential and timely

• Placement of equipment logical and workable

• Appropriate patient questioning

• Appropriate patient treatment - including burn cooling, burn dressing, and adequate pain relief.




Lesson plan: Anaphylaxis scenario, spinal injury scenario and skills station Day four: Session three (90 minutes)

Learning objectives

The student will:

� Demonstrate effective patient management in an anaphylaxis scenario

� Demonstrate effective patient management in a spinal injury scenario







Suggested way to teach1 Split the class into three groups. These groups will rotate every 20 minutes

between the anaphylaxis scenario, the spinal injury scenario, and the skills station. A tutor will be stationed at each activity (60 minutes):

• The skills station is a time for the students to practice what they are not confident doing, and to ask the tutor any questions.

• The anaphylaxis scenario and spinal injury scenarios are found on the following pages.


2 Once there has been a full rotation of the groups, bring the class back together for a debrief. Go through each scenario and discuss what was done well, what they could have done better, and the ideal treatment for that particular patient. Encourage students to write these points down in their student workbook (30 minutes).



Anaphylaxis Scenario Outline

OverviewFirst Responders will have 20 minutes to complete this scenario.

They will have the following equipment with them:

� Resus kit

� AED

� Handheld radio

� Cell-phone

The First Responders are dispatched to a rural farm where they encounter a patient who is suffering from anaphylaxis secondary to a bee sting. The First Responder will be expected to recognise the patient is in anaphylaxis, assess the patient, call the Clinical Desk and administer IM adrenaline.

Objectives � Correctly recognise a patient in anaphylaxis

� Effectively manage a patient in anaphylaxis

� Effectively monitor the patient for any deterioration in condition

Critical performance elements � Scene size up


� Early and appropriate SITREP

� Recognition of anaphylaxis

� Early call to Clinical Desk


� Correct procedure for drawing up and administering adrenaline (both IM and nebulised)

� Effective monitoring of the patient is conducted



Information to studentsYou are called to rural farm, approximately 20 minutes from your nearest back up. You have come across a patient who has been outside gardening today. The patient’s friend meets you at the letterbox and states the patient is allergic to bees and has just been stung.

Upon approaching the patient, the first responders will note that the patient is severely short of breath, has stridor, presents with a rash, swollen lips and tongue and is flushed.

If the First Responders investigate further, the following information can be given:

S - Severe shortness of breath, stridor, rash, swollen lips, swollen tongue, flushed, anxious

A - Bee stings

M - Epipen, but she left it at home this morning, ventolin inhaler

P - Anaphylaxis to bees, asthma

L - Breakfast at 0830

E - Gardening

Manikin Vital signs


Sounds Stridor Rate 130 / min Pain 0 / 10

RR 28 Rhythm Regular GCS 14

Volume Shallow BP 90 / 60 Temp 36.7

SpO2 88 % on air Cap. Refill < 3 secs BGL 5.6 mmol / L

Development of scenarioIf adrenaline is not administered quickly, the patient’s condition will deteriorate.



Debrief points It is important to ensure students understand that this is a safe learning environment and any feedback given must be in a constructive manner.


� Give students the opportunity to recognise areas they need to work on


• Scene size up; safe approach

• Patient assessment; timely, logical, sequential, focussed

• Early call for back up; recognition of severity, identifies themselves correctly, appropriate level of back up requested

• Recognises anaphylaxis; promptly and decides on management plan

• Early call to Clinical Desk; portrays all relevant information

• Correct procedure for drawing up and administering adrenaline: preparation of equipment, drug check, draws up correct dose, prepares patient adequately, locates site of administration, insertion technique.

• Effective monitoring of the patient’s condition




Spinal Injury Scenario

Overview Tutors can chose whether they use a manikin for this scenario, or themselves as the patient.

First Responders will have 20 minutes to complete this scenario.


� Resus kit

� AED

� Handheld radio

� Cell-phone

� C-Collar

� Scoop stretcher

The First Responders are dispatched to a 23 year old male who has been fixing the roof of his house when a gust of wind made him lose his balance resulting in him falling from the ladder. The First Responder will be expected to recognise the patient has a potential spinal injury and immobilise the patient appropriately. They may attempt to extricate the patient using appropriate means.

There will be three hazards the crew need to identify and mitigate if possible:

� Ladder (trip hazard)

� Loose roof materials (potentially hazardous on a windy day)

� Nails on the ground

Objectives � Identify and mitigate/minimise hazards in a scene

� Recognise a potential spinal injury

� Effectively immobilise a spinal injured patient

� Use interventions with competence

� Effectively extricate a spinal injured patient



Critical performance criteria � Scene size up

� Patient assessment and questioning

� Early call for back up

� Recognition of a potential spinal injury


� Effective immobilisation

� Adequate handover to transporting crew

Information to studentsYou are called to a 23 year old male who has been fixing the roof of his house when a gust of wind made him lose his balance resulting in him falling from the ladder. He has landed on the grass area outside his house.

He is complaining of pain in his lumbar region, has altered sensations in his lower legs and has a loss of movement in the lower legs. The patient is distressed. No other injuries are found upon a secondary survey.

S - Pain to the lumbar region, altered sensations in lower legs, loss of movement in both legs

A - No known allergies

M - No regular medications

P - Patient is normally fit and healthy

L - Morning tea at 1000hrs

E - Was fixing the gutter of the roof when a gust of wind made him loose his balance

O - pain came on soon after landing on the ground

P - Pain is constant, movement and palpation makes it worse

Q - Sharp, constant pain

R - Lumbar region

S - Moderate at rest- severe upon movement and palpation

T - 5 minutes ago



Manikin/ Patient Vital signs


Sounds Vesicular Rate 96 / min Pain Moderate


Volume Normal BP 120 / 80 Temp 36.3

SpO2 98% on air Cap. Refill < 2 seconds BGL 6.1 mmol / L

Debrief points It is important to ensure that all students understand that this is a safe learning environment and any feedback given must be given in a constructive manner.




• Scene size up; safe approach, hazard identification, clues at the scene, height of fall

• Patient assessment; timely, logical and sequential, including patient questioning

• Early call for back up; correct information portrayed, correct status, timely

• Recognition of a potential spinal injury; recognition of signs and symptoms

• Effective crew communication with one another, bystanders, and the patient

• Effective immobilisation; manual in line stabilisation, C-Collar

• Effective handover to transporting crew



Lesson plan: Hypoglycaemia scenario, motor vehicle accident scenario, and skills stationDay four: Session four (90 minutes)

Learning objectives

The student will:

� Demonstrate effective patient management in a hypoglycaemia scenario

� Demonstrate effective patient management in a motor vehicle accident scenario





Suggested way to teach1 Split the class into three groups. These groups will rotate approximately every

20 minutes between the hypoglycaemia scenario, the motor vehicle accident scenario, and the skills station. Each tutor will be stationed at each scenario (60 minutes):

• The skills station is a time for the students to practice what they are not confident doing, and to ask the tutor any questions

• The anaphylaxis scenario and spinal injury scenario are found on the following pages.


2 Once there has been a full rotation of the groups, bring the class back together for a debrief. Go through each scenario and discuss what they each did well, what they could have done better, and the ideal treatment for that particular patient. Encourage students to write these points down in their workbook (30 minutes).



Hypoglycaemia Scenario Outline

Overview The First Responder will have 20 minutes to complete this scenario.


� Resus kit

� AED

� Handheld radio

� Cell phone

The First Responders are dispatched to a diabetic patient who is suffering from a hypoglycaemic event. They will be expected to assess the patient, decide on the diagnosis and effectively manage the patient using skills under the scope of a first responder.

Objectives � Effectively assess a medical patient

� Effectively question bystanders to gain a better history

� Accurately diagnose a patient as being hypoglycaemic

� Effectively manage the hypoglycaemic patient

Critical performance elements � Scene size up


� Correct status classification


� Effective history acquisition using family members

� Communication with patient

� Effective management of the patient and their condition



Information to studentsYou are called to a patient who is a diabetic. The family member states their blood sugars are usually well controlled but today the patient has been doing significantly more exercise than normal and has collapsed and is unable to be roused.

If the First Responder investigates further, the following information may be given:

S - Not responsive, otherwise primary and secondary survey are normal

A - No known allergies

M - Insulin

P - Diabetic

L - Hasn’t eaten much today

E - Started doing marathon training today

Vital signs


Sounds Vesicular Rate 96 Pain 0


Volume Normal BP 110 / 60 Temp 37.0

Sp02 97 % Cap. Refill < 2 seconds BGL 3.0 mmol / L



Debriefing pointsIt is important to ensure students understand that this is a safe learning environment and any feedback given must be in a constructive manner.




• Scene size up- safe approach, environmental clues

• Patient assessment - appropriate, logical, timely, sequential

• Recognition of hypoglycaemia; good thorough history taking


• Effective management of patient and their condition - administration of glucose and follow up with complex carbohydrate



Motor Vehicle Accident Scenario Outline

Overview The tutor can decide whether manikins are used for this scenario, or if they pose as one of the ‘patients’- or a combination of both.

The First Responder will have 20 minutes to complete this scenario.


� Resus kit

� AED

� Handheld radio

� Cell phone

� Cervical collar

� Access to extrication devices

� Splinting equipment

The First Responders are dispatched to an MVA (car vs. pole) There will be two occupants in the vehicle, one of which has injuries inconsistent with life and the other who is unconscious but alive. They will be expected to triage appropriately, and attend to the patient who is not status zero.

There will be three hazards the crew need to identify and mitigate if possible:

� Powerlines potentially down

� Car engine running

� Glass on the ground

Objectives � Effectively triage patients involved in a motor vehicle accident

� Effectively manage the patient who is alive



Critical performance elements � Scene size up- hazard identification and subsequent mitigation/ minimisation of

these

� Appropriate triage- correct status classification

� Call for back-up

� Assessment of an unconscious trauma patient


� Communication with patient (after regaining consicousness)

� Effective management of the patient and their injuries

� Successful extrication

Information to studentsYou have been called to a witnessed MVA- car versus pole. Your response time was very short. Upon arrival you find two patients in the vehicle.

The passenger (32 year old male) has injuries inconsistent with life, and should be classified at status zero.

The driver of the vehicle (30 year old male) is unconsicous, but airway, breathing, circulation and life- threatening hamorrhage are all fine. The patients head has obviously come into contact with the windscreen.

Vital signs - passenger


Sounds None Rate 0 Pain n/a

RR 0 Rhythm n/a GCS 3

Volume n/a BP 0 Temp 36.0

Sp02 0 Cap. Refill n/a BGL 7.0 mmol / L



Vital signs - driver


Sounds Vesicular Rate 94 Pain n/a


Volume Normal BP 125/70 Temp 37.0

Sp02 96 % Cap. Refill 3 seconds BGL 7.0 mmol / L

Scenario developmentSecondary survey findings: should detect a fractured right ankle, fractured right clavicle, lacerations and contusion to forehead.

Sometime during the secondary survey, this patient will start to regain consciousness- at which point, the crew will begin communicating with, and questioning the patient:

S - Confusion, pain in head, cervical spine tenderness, pain and deformity in right ankle, pain in right clavicle, retrograde amnesia, anxiety.

A - Nil

M - Nil

P - Unable to acertain.

L - Unknown.

E - Patient cannot recall anything prior to accident



Debriefing pointsIt is important to ensure students understand that this is a safe learning environment and any feedback given must be in a constructive manner.




• Scene size up- safe approach, environmental clues

• Appropriate triage

• Patient assessment- Appropriate, logical, timely, sequential

• Early and appropriate SITREP

• Recognition of increase in patient’s consciousness ; good patient questioning.

• Effective crew communication with one another, bystanders, and the patient



Glossary � Advance directive - a means by which a patient indicates their choices

regarding possible future treatments. These only apply when the patient is no longer competent to make, or communicate, decisions for themselves.

� AED - Automatic External Defibrillator

� Anaphylaxis - rapid onset, multiple organ, generalised hypersensitivity (allergic) syndrome.

� Angina - a heart condition marked by cardiac chest pain

� Atria - the two upper cavities of the heart

� Artery - blood vessel that carries oxygenated blood from the heart to the rest of the body

� Aspirin - a medication administered as part of the treatment for cardiac chest pain

� Asthma - a respiratory condition characterised by wheeze, mucus production and shortness of breath.

� Asystole - when the heart ceases to beat.

� Auscultation - the action of listening to sounds from the heart, lungs, or other organs with a stethoscope.

� Bilateral - both sides e.g. bilateral femur fractures (left and right femur fractures)

� Bodok seal - a specialised washer that ensures a tight seal between a gas cylinder and its regulator.

� Bowel obstruction - a mechanical or functional obstruction of the intestines, preventing the normal movement of the products of digestion.

� Bradycardia - slow heart rate

� Bronchitis - inflammation of the mucous membranes of the bronchial tubes

� Capillary refill - the rate at which blood fills empty capillaries.

� Cardiogenic - originating from the heart; caused by normal or abnormal function of the heart.

� Cardiovascular - relating to the heart and blood vessels

� Ceftriaxone - broad spectrum antibiotic

� Cervical spine - the top seven vertebrae of the spine.

� Clavicle - collar bone



� CORD - Chronic Obstructive Respiratory Disease

� Coronary - relating to or denoting the arteries which surround and supply the heart.

� CPR - Cardiopulmonary resuscitation

� Crackles - an abnormal respiratory sound consisting of discontinuous bubbling noises when auscultating the lungs.

� Crepitus - a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone

� Electrocardiogram - a record or display of a patient’s heart

� Emphysema - a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness.

� Entonox - a form of inhaled pain relief

� Femur - thigh bone

� Fibrillation - twitching of individual muscle fibres acting without coordination.

� Fibula - the outer and usually smaller of the two bones between the knee and the ankle.

� Gastrointestinal - relating to the oesophagus, stomach, small and large intestine, rectum and anus.

� Glottis - the part of the larynx consisting of the vocal cords and the slit- like opening between them.

� GTN (glyceryl trinitrate) - a medication administered as part of the treatment for cardiac chest pain

� Haemorrhage - bleeding/ the escape of blood from a ruptured blood vessel.

� Humerus - the bone of the upper arm, between the shoulder and the elbow joint.

� Hyperglycaemia - abnormally high levels of sugar in the blood

� Hypertension - high blood pressure

� Hyperthermia - high body temperature

� Hyperventilation - fast respiratory rate

� Hypoglycaemia - abnormally low levels of sugar in the blood

� Hypotension - low blood pressure

� Hypothermia – low body temperature

� Hypovolaemia - low circulating blood volume



� Ibuprofen - an anti- inflammatory medication administered for mild pain

� Intramuscular - into muscle tissue

� Intranasal - into the nose/ nasal passage

� Intravenous - into the vein

� IOS (index of suspicion) - a phrase used to indicate how seriously a particular injury is being entertained as a diagnosis, based on mechanism of injury.

� Ipratropium - a medication administered as part of the treatment for moderate to severe asthma.

� Ischaemia – inadequate blood supply to an organ or part of the body.

� KED (kendrick extrication device) - device used to remove patients with suspected spinal injury from vehicles and other spaces, where that extrication could pose a risk to the spinal cord.

� Lividity (post- mortem) - settling of blood in the lower portion of the body, causing a purplish red discolouration of the skin.

� Malignant hyperthermia - a rare, inherited disorder in which certain anaesthetics cause high body temperatures and muscle rigidity.

� Malleolus - either of the two body protuberances on each side of the ankle.

� Methoxyflurane - a form of inhaled pain relief

� MDI (metered dose inhaler) - aka, spacer. A device that delivers a specific amount of medication to the lungs.

� MOI (mechanism of injury) - how the injury occurred.

� Multi-system trauma - a term describing the condition of a person who has been subjected to multiple traumatic injuries, such as a serious head injury in addition to burns.

� Nebuliser - a dispenser that turns liquid into a fine mist

� Oesophagus - the part of the gastrointestinal tract that connects the throat to the stomach.

� Palpation - the act of inspecting a particular body part, feeling for size, shape, firmness or location.

� Paracetamol - a form of oral pain relief

� PEA (pulseless electrical activity) - a cardiac arrest situation in which a heart rhythm observed on the ECG should be producing a pulse, but is not.

� Petechiae - a small red or purple spot caused by bleeding into the skin.

� Placenta - a flattened circular organ in the uterus of pregnant women, which nourishes the foetus through the umbilical cord.



� Pneumothorax - collapsed lung

� Postictal - the period of time following a seizure in which the patient can have an altered level of consciousness, with drowsiness, confusion, agitation or amnesia.

� Precordial thump - a single blow of the fist to the middle of a patient’s sternum.

� Pulse oximeter - a device that measures the percentage of oxygenated haemoglobin in the blood.

� Purpura - a rash of purple spots on the skin caused by internal bleeding from small blood vessels.

� Radius - the thicker and shorter of the two bones in the human forearm.

� Respiratory - relating to or affecting breathing or the organs of breathing.

� Rigor mortis - stiffening of the joints and muscles of a body over a few hours after death, usually lasting from one to four days.

� Salbutamol - a medication administered as part of the treatment for asthma.

� Scapula - shoulder blade

� Septic shock - sepsis (systemic infection) with signs of shock

� Shock - global reduction in blood flow to the tissues and organs of the body.

� Sinus rhythm - normal beating of the heart, as measured by an ECG.

� SITREP (situation report) - an update on the current situation

� Sputum - a mixture of saliva and phlegm coughed up from the respiratory tract.

� Stridor - an abnormal, high pitched noise created when air is moving through a narrowed upper airway. It is a clinical sign and not a diagnosis or a disease.

� Stroke - rapid loss of brain function due to disturbance in the blood supply of the brain.

� Sublingual - under the tongue

� Syncope - temporary loss of consciousness aka faint.

� Tachycardia - fast heart rate

� TIA (transient ischaemic attack) - signs and symptoms of a stroke that have completely resolved within 24 hours.

� Tibia - the inner and usually larger of the two bones between the knee and the ankle.

� Trachea - windpipe

� Trismus - spasm of the jaw muscles, causing the mouth to remain tightly closed.



� Ulna - the thinner and longer of the two bones in the human forearm, on the side opposite to the thumb.

� Vascular - relating to, affecting, or consisting of a blood vessel.

� Ventricular fibrillation - an irregular heart rhythm caused by rapid, uncoordinated, fluttering movement of the ventricles, which does not allow the blood to be pumped effectively around the body.

� Ventricular tachycardia - when the ventricles of the heart are beating so fast that they do not have time to refill properly.

� Wheeze - high pitched whistling sound that occurs when air is moving through narrowed airways.



Notes


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First Responder - St John Youth · signs acquisition, 3- lead ECG acquisition and IMIST- AMBO...

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