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Milford Ambulance Service Field Training Program Situations Manual - BASIC Table of Contents Introduction Protocols and policies Medical / legal issues Ambulance equipment IV establishment Trauma case study Main streets and back roads exam Page 1 of 19 FTP Situations Manual – Basic 2 3 7 10 11 13 16 January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC Introduction This manual has been developed to assist the new ambulance member with his or her transition into the service by providing them with various situations that can or have occurred during the tenure of the Milford Ambulance Service. The situations in this manual are designed to engage the trainee in problem solving and conversation with FTO’s. It is our hope that trainees will take this opportunity to exercise their decision-making abilities and apply them to the scenarios in this manual. By working through each situation with an FTO and obtaining what the service considers to be an “appropriate” response or answer to each, it will better prepare the trainee for future scenarios they may be faced by during the course of their duty. This manual address situations involving violations of policy, law, and questions on protocols. It is important to understand that there may be more than one correct answer to the situation, as with any incident in the EMS field, and the explanations contained here within are to be used as a guideline. As a new trainee to the service we welcome you and encourage you to ask questions not just of your FTO’s but also of all service members alike. It is also up to you, the attendant, to help make yourself a vital and respected member of the Milford Ambulance team. Page 2 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC Protocols / Policies 1. You are a basic EMT and riding with a partner who is an EMT-I. You are on 20A2, the second ambulance, and the paramedic is all ready out of town on another call. A tone goes out for a person who is in and out of consciousness at the middle school. You and your partner respond and meet the school nurse in the office. She is there with a male child who is 13 years of age. She tells you that he has a history of diabetes. He has taken some medication this morning but has not had anything to eat. He is only semiconscious at this time and will need some assistance in maintaining his airway. You take the patient’s vital signs and your partner checks the blood sugar with the glucometer. It shows a reading of 40. Your partner wants to start an IV and give D50. You are not sure if he should do that since this patient is under the age of 18 and not an adult. Your partner tells you that this is an emergency and that the patient may die if he does not get the D50 right away. What should you do in this situation to help guide your partner and the ultimate treatment of this patient? ANSWER: All though this is an emergency, your partner should not establish an IV line on a pediatric patient. Any patient that is under the age of fifteen (15) years old is considered to be a “pediatric” according to MAS and SNHMC protocols. There are two options that are available to you and your partner. You can either run the patient to the Milford Medical Center to be stabilized or call for a paramedic intercept. Otherwise, continue to support the patient with vitals, oxygen, monitoring, and transport. 2. You and your basic partner are toned to the Pillsbury home for a 75 year old female who is experiencing difficulty breathing. Upon your arrival you find the patient sitting in their bedroom with distress. They are unable to speak in full sentences and have a history of asthma. You listen to lung sounds and determine that there are wheezes in all fields. The paramedic is all ready out on a call and unable to respond to your location. One of the “care givers” at the facility states that the patient does have a prescribed inhaler but that it ran out yesterday. The inhaler medication is albuterol. The “caregiver” further states that she also has asthma and has an albuterol inhaler of the same dose. She states that she has given the inhaler to your patient before in the past, and hands you the inhaler. You look at the patient again and decide that she Page 3 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC is in severe distress and that this is the only medication that you can give. What should you do? ANSWER: All though the patient has an inhaler and prescription for albuterol, the fact remains that the medication has run out. It is not appropriate to administer someone else’s medication to this patient. If the patient were to have some sort of a reaction to the medication the liability would rest with the ambulance crew. This patient should be taken to the Milford medical center in town, a paramedic intercept form another community should be called, or an EMT-I intercept from Milford should be toned. EMT-I’s, per protocol, area able to asses the patient and administer albuterol nebulizer treatments. 3. You and your intermediate partner respond to a call for a possible fractured leg at the football field. Upon your arrival you find a 16year-old male who is sitting in the middle of the field. The coach tells you that he was running with the ball when he was struck from behind and fell to the ground. A “snap” was heard and the patient’s right leg shows deformity in the tib/fib area. The patient is splinted but complains of severe pain. He states that it is a 9 on a 1-10 scale. As a basic you have no medications that you can give this patient. What facility should you go to with this injury and what else could you do to provide the patient with comfort or other medications to help with the pain? ANSWER: The best location for the patient is the Milford medical center in town. They can administer the pain medications and, if necessary, can have the patient transported down to a hospital in Nashua for further treatment and follow-up care. Provide splinting care and treatment to include O2, Vitals, and transport in the interim. 4. You and your basic partner are toned to a residence in town for a woman in her 30’s having a seizure. Upon your arrival you find a 30ish female on the floor unresponsive. Her husband states that she had a violent shaking episode at least two times within the last five minutes. She never regained consciousness in between the episodes. He further states that she has a history of seizures but has not had one in the past 2 years. You begin your assessment and determine that the patient is no longer violently jerking around but that her pinky finger on her left had is “twitching” back and fourth. As a basic what does this mean to you and what kind of medical condition is the patient suffering from? Page 4 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC ANSWER: This would indicate that seizure activity is still active and – present in the patient. This would classify as a “status epileptics” patient. The fact that the patient’s finger is still twitching indicates that they are still having a generalized seizer or grand maul seizure. Their muscles have become too tired to keep up the full body jerking movement. This is a life threatening condition and could result in brain injury. 5. You and your intermediate partner have been toned to an industrial location for a report of a possible electrocution. Upon your arrival you find a 50ish year old male sitting on the floor conscious and breathing. He states to you that he as working on an overhead fluorescent light and though the power was off. He made contact with a “live” portion of the light with his metal screwdriver and felt a jolt that knocked him off his aluminum ladder. He did not hit his head nor did he fall from any height greater than his own. He never lost consciousness and complains of no head, neck, or back injury. His vitals are all within normal ranges but he does complain of a burn to his right thumb and index finger. Upon inspection you see a third degree burn to those area where he was holding onto the screwdriver. What should your treatment be of this patient? ANSWER: This patient is suffering from an electrocution injury and should be considered for full spinal immobilization, O2, Vitals, IV therapy, and transport to the nearest trauma center. A trauma team activation should be considered also due to the internal damage that may have been caused by the electrical current to many body systems and organs. 6. You and your basic partner are toned to a motor vehicle accident on Rte. 101A. Upon your arrival you find a 16-year-old female who was the driver of a 1996 dodge spirit. It is a minor accident with minimal front-end damage. The patient was wearing a seatbelt. There is no spidering of the windshield. The patient was traveling around 30mph when she struck the back of a stopped motor vehicle. She complains of no injuries and no pain. She did not lose consciousness. He vitals signs are all within normal limits and she has no past medical history. She is not on any medications. She is 16 years old and with a friend of her’s who is 22 years old. She states that she does not want to be transported to the hospital. You are unable to speak with her mother at the scene. What should you do? Page 5 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC ANSWER: Although it may be possible to clear the c-spine with the cspine clearance protocol, this patient will still need to be transported to the nearest and appropriate medical facility until such time as a parent or legal guardian can be notified and respond to sign the refusal form. As a person who is under the age of eighteen (18) years old, this patient is considered to be a juvenile and thus cannot sign or enter into any type of contract in New Hampshire. Page 6 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC Medical / Legal situations 7. You and your intermediate partner are toned to respond to a residence for a report of a patient having chest pains. Upon your arrival you find a 70-year-old patient who is describing chest pain and pressure under the sternum. They are pale and diaphoretic. The patient’s pulse is increased and respirations are labored and difficult. The patient has vomited. The patient wants you to transport them to the hospital but does not want an IV or any medications such as nitro, O2, or aspirin. As hard as you try you cannot convince the patient to take any treatment other than transport and the heart monitor. What should you do? ANSWER: All though you know that the most appropriate treatment would be to provide the above medications and skills, you cannot force first aid or treatment upon anyone. The best thing to do is to continue with informing the patient of the benefits of the treatments in hopes that they will give you informed consent to provide such skills and medications. Otherwise, provide the care that you can, transport to the nearest and appropriate facility and document everything that occurred. 8. You and your basic partner are toned to a home residence for a report of a child having seizures. Upon your arrival you find a 17month-old female infant who is unresponsive from an apparent seizure. The airway is secure and clear, the infant is breathing on their own and vital signs are within normal ranges at this time. The mother states that the child went unresponsive and began “twitching” for about 30 to 60 seconds. That is when she called. The infant is on no medications. When you suggest transporting the child to the hospital the mother refuses transport. She states that she only wanted you to respond to see if the infant was “ok” and does not want any further treatment or transport. What should you do? Page 7 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC ANSWER: If you believe that the infant is in imminent danger and that further injury will occur if there is no transport or that transport is delayed, you should contact the police department and request an officer to respond to the scene. The officer can take the child into protective custody and allow you to transport the child to the nearest and appropriate medical facility. Otherwise, the mother is the child’s legal guardian and we cannot transport the child against the wishes of the mother. You should make your best attempts to inform the mother of the severity of the condition and attempt to get an informed consent from her. 9. You and your intermediate partner are toned for a report of a motorcycle accident on Rte. 13 north. Upon your arrival you find a 23-year-old male who was involved in a crash at a speed of about 50 mph. The patient was not wearing a helmet and has a swollen area on his forehead. Further more you detect that the patient has consumed some alcohol. The patient’s vital signs are within normal ranges but you detect slurred speech and a total lack of coordination. The police ask you if you can check the patient out because they would like to check him for DWI. While assessing the patient he refuses transport to the hospital. What should you do? ANSWER: Since there is a positive mechanism for injury to the head, neck, or back and since the signs and symptoms that are presenting can either be taken for intoxication or a closed head injury, you must inform the police that the patient must be transported to the hospital. The patient cannot refuse care at this time due to the potential for the head injury, which indicates that he is incapable of making a solid judgment that is rational and of sound mind. You will inform the patient of the same and may use force to restrain the same. 10. You and your basic crew, which consists of 2 other attendants, have been toned to a home residence for a report of an unresponsive person. Upon your arrival you find a 25-year-old male who is indeed unresponsive lying on their side. The patient has vomited once and your partner is assessing vitals at this time. You are obtaining a medical history and another male witness at the scene states that they were experimenting with acid and LSD. He feels as though the patient may have overdosed or gotten some “bad stuff”. The witness is very worked up and slightly hostile. You call for the police to respond. Upon their arrival the single officer is speaking with the witness. The witness becomes agitated and the officer escorts him out of the immediate room that you are your patient are in. As you and your partners are working on the patient, securing the airway and establishing an IV, you hear a Page 8 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC small scuffle taking place in the other room. You get up and see that the officer is struggling with the witness and attempting to handcuff him in the other room. The witness clearly does not want to be cuffed and continues to struggle. What should you do? ANSWER: It must be understood that you are at the scene as an ambulance attendant and not a police officer. You should not get involved with the situation unless the officer specifically requests your assistance. This is with the understanding that assistance can refer to calling for back up on the radio to get other police officers on scene. You primary goal is patient safety and care. Page 9 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC Ambulance equipment 11. While performing the morning rig check of the ambulance you note that the heart monitor fails the self-test. What should you do? ANSWER: The director should be notified ASAP and the monitor may have to be taken out of service until such time as it has been repaired. This should also be noted on the daily rig check sheet and documented. 12. While doing the morning rig check, of the ambulance, you begin checking the first in bag. You have noted that there are only 4 band-aids in the kit and all though that is all the check sheet calls for you feel as though there should be more in the kit in case you need them. What should you do? ANSWER: What you personally feel should be on the ambulance may differ from what others think should be there. The rig check sheet has been set up with minimum requirements that are in accordance with the State of New Hampshire EMS checklist requirements. By adding more equipment to the ambulance, MAS will lose the standardization and uniformity between the two ambulances. 13. You and your basic partner have been toned to the scene of a minor motor vehicle accident. You have the patient loaded and you are driving the patient to the Milford Medical Center. As you are backing up you bump another vehicle behind you. It is parked and the owner is nowhere around. There is only very minimal damage to the ambulance and a scratch on the bumper of the vehicle that you struck. What should you do? ANSWER: You must not leave the scene of an accident. You can contact the local police department to report the accident and, if it is not severe and no injury, the police may release you from the scene to continue transporting to the hospital. Otherwise, contact the second ambulance and have them respond to the scene to take and transport to the hospital. Page 10 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC IV establishment 14. You are an intermediate and are toned for a 40-year-old female patient who has a possible fractured leg. The patient was hiking in the woods and slipped and fell. She thought she heard a snap. Her vital signs are stable and no other significant history or injuries are noted. Should you establish an IV? ANSWER: Yes. Due to the possibility that there is a fracture, an IV would be warranted. There may be a lengthy extrication as well as pain medications that can be given. 15. You are an intermediate and you are toned for a person who has a history of stroke. Upon your arrival you find a 50-year-old male whose only complaint was that he could only look to the right side. This condition came on suddenly within the past hour. He has had a history of TIA’s but not for the past 2 years. The patient’s vital signs are within normal ranges and there is not SOB or difficulty breathing. Should you establish an IV? ANSWER: Yes. This could be a sign of another TIA, that could worsen within the next few moments or hours. There is no way of telling, thus an IV would be warranted in case the patient takes a turn for the worse or needs a port for medication administration. Bloods can also be drawn for this patient. 16. You are an intermediate and are toned for a female patient who has fallen off her back deck. She is 45 years old and she has been consuming alcohol. She states that she only has a minor headache and no other complaints. She has positive csm’s in all extremities and states that she did lose consciousness for a few minutes prior to the ambulance arriving. Should you start an IV? ANSWER: Yes. Due to the possibility that the patient has a closed head injury and the loss of consciousness, an IV would be warranted. Bloods can also be drawn for this patient. 17. You are an intermediate and toned to a home residence for a subject sitting on the front porch complaining of feeling dizzy and light headed. Upon your arrival you find a 58-year-old male who tells you that he was driving himself to the hospital because he was feeling lightheaded. As he was driving he began feeling dizzy and pulled over at this residence. His vital signs are within normal ranges but he just does not feel right. He has a history of cardiac Page 11 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC issues and stroke. He has no paralysis and no chest pain. He is not short of breath. Should you start an IV? ANSWER: Yes. Due to the fact that the patient has a history of stroke and is feeling ill, an IV would be warranted to provide a medication port for medication administration, blood draw access, and a fluid bolus depending on what the patient’s blood pressure is. Further examination would be required to see if there are other medical issues present with the patient that would further warrant the IV. 18. You are an intermediate and have been toned to the scene of a minor motor vehicle accident. Upon your arrival you find a 17year-old male who was operating a small sports car (red with two white racing stripes) and lost control of the vehicle when it hydroplaned into a banking off the side of the road. There is damage to the vehicle and the male was not wearing a seat belt. He slid forward in the seat and struck his chest on the steering wheel. He complains of only minor pain to the area and slight SOB. His vital signs are within normal ranges. He denies any loss of consciousness. Should you start an IV? ANSWER: Yes. Due to the nature of the injury and the impact to the chest, an IV would be warranted for the potential internal injuries or chest injuries. Since the patient is still relatively young, his body may be compensating well and the true severity of the injuries may not be readily apparent at this time. Page 12 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC Trauma Case Study 20A1 and the medic are returning from Nashua, from a chest pain call when 20A2 and the police are dispatched to the scene of an attempted suicide with shots fired. Apparently a family member who was called by the patient threatening to do harm to himself with a handgun received the call. The police arrive moments before you and advise that the scene is secure (safe) and that you should respond directly to the scene, which is a private home. Upon arrival, you find a 45-year old male lying prone with his face in a pool of blood. He is moaning and his chest and abdomen appear to be moving as he breathes. After donning protective gloves, mask, and goggles, both you and your partners carefully provide manual stabilization of the neck and log roll the patient onto a long board. What you reveal is a mandible and tongue that are severely lacerated and the mouth and nose are bubbling with blood as the patient attempts to breathe. 19. How should you open the airway of this patient? ANSWER: You would open the airway with the modified jaw thrust due to the potential for a head or neck injury. 20. Does this patient need to be suctioned? ANSWER: Yes, in order to maintain the airway properly and keep from moving the head excessively, suctioning must be performed. 21. If so, what is the maximum amount of time to accomplish this procedure? ANSWER: No more than fifteen (15) seconds. 22. Should an airway adjunct be used on this patient? ANSWER: Yes, both an oral and nasal adjunct should be used. 23. Page 13 of 19 If so, what is your 1st choice and then your 2nd choice for a patient who has a gag reflex? FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC ANSWER: The oral airway and then the nasal. Once the patient’s airway is opened and cleared, you need to oxygenate this patient. He has no other obvious injuries, yet you are treating him for a possible spinal injury due to the impact of the bullet and his backward fall from his desk chair during the incident. The police think that this is why he shot his chin instead of his brain during the suicide attempt. You evaluate the patient’s breathing rate as 28 shallow and labored and his pulse as 120 weak and regular. 24. What device should be used to administer oxygen to this patient? ANSWER: A BVM with 100 percent oxygen. 25. What is the proper liter flow to set the regulator? ANSWER: 15 to 25 lpm 26. Your portable D cylinder was full at the beginning of the shift and this is your first call. How many liters are in the tank? ANSWER: 2000 27. How much pressure is in the tank? ANSWER: 2000psi 27. As you prepare to transport the patient, you continue to suction him making sure not to exceed ____ seconds per attempt. ANSWER: 15 seconds. 29. This is because as you suction you are also removing ______. ANSWER: Oxygen 30. Which would be better to use, a Yankauers tip or a whistle tip catheter? ANSWER: Yankauers. Page 14 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC 31. What is the difference between a Yankauers and whistle tip catheter? ANSWER: The Yankauers is a rigid tipped suction device where as the whistle tip is a soft tip device used for small mucus. 32. The patient has a BP of 100/70 so you decide his priority is [high or low?] ANSWER: High priority. 33. The major problem with this patient is his _______. ANSWER: His airway management. 34. He should be transported [right away or in a few minutes]. ANSWER: Right away. 35. He should be brought to [MMC or trauma team in Nashua?} ANSWER: If the airway can be properly secured and the patient is oxygenating well, you should go to Nashua, otherwise you should go to MMC to stabilize the patient. 36. What ALS treatment might be helpful to this patient if the paramedic in 20A1 can intercept you on his return from Nashua? ANSWER: Endotracheal intubation. 37. What should you do if you hear hissing or bubbling around the mask as you ventilate? ANSWER: Reposition the mask and get a better seal around the airway. Page 15 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC Milford Ambulance Service Field Training Program Main Streets and Back Roads of Milford Exam Trainee Name: _________________________________________________ 1. What a. b. c. d. landmark is closest to Capron Road? Burger King Good day café The oval Hampshire Hills 2. What a. b. c. d. landmark is located on Buxton Road? China Star restaurant School bus company State gas pumps None of the above 3. What a. b. c. d. road is Great Brook Road located off from? West Street North Street Ridgefield Drive Mason Road 4. What a. b. c. d. road is River Way West located off from? Elm Street Nashua Street West Street Westchester Drive 5. What a. b. c. d. road is the Milford Police Department located on? Nashua Street Elm Street South Street Mont Vernon Street 6. What a. b. c. d. road is Primary Care of Milford located on? Franklin Street Nashua Street Jones Road None of the above Page 16 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC 7. What a. b. c. d. road are the Granite Square Apartments located on? Bridge Street South Street North River Road Nashua Street 8. What a. b. c. d. road is the town’s transfer station located on? River way East Mont Vernon Street North River Road Capron Road 9. What a. b. c. d. road is the Heron Pond School located off? Elm Street Mason Road Iris Road Whitten Road 10. a. b. c. d. Where is Dr. Diagastino’s office located? At 161 Bridge Street in the basement At 28 Jones Road in the back of the building At the Granite bank on the top floor At the Milford Medical Center on Nashua Street a. b. c. d. What road is Key’s Field located on? Elm Street Noon’s Quarry Road Purgatory Road Franklin Street a. b. c. d. What road is the Pillsbury Home located on? Franklin Street High Street Bridge Street Buxton Road a. b. c. d. What road is Crestwood nursing home located on? Elm Street Crosby Street North Street Both A and B 11. 12. 13. Page 17 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC 14. a. b. c. d. What is the address of the town hall? 1 Mason Road 1 Elm Street 1 Union Square 1 Middle Street a. b. c. d. What road leads to Brookline, NH? Mont Vernon Street Jones Road Perry Road South Street a. b. c. d. Summer Street runs off from what road? Amherst Street Mont Vernon Street High Street Armory Road a. b. c. d. The Hitchcock Clinic is located on which road? Federal Hill Road Ponemah Hill Road Willow street Armory Road a. b. c. d. Hampshire Hills is located on what road? Ponemah Hill Road Emerson Road Boxwood Circle Wellesley Street 15. 16. 17. 18. 19. If you were dispatched to County Stores what road would it be on? a. Alder Street b. Emerson Road c. Nashua Street d. Annanad Street 20. What would be the fastest way to get to the town center of Amherst from the Milford Ambulance bay? a. Nashua Street b. Amherst Street c. North River Road d. Farley Road Page 18 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition Milford Ambulance Service Field Training Program Situations Manual - BASIC 21. If you were dispatched mutual aid to Mont Vernon to the Mont Vernon Inn, what road would you take to get there the fastest? a. Purgatory Road b. Amherst Street c. Chappell Drive d. Mont Vernon Street 22. a. b. c. d. What is the closest landmark to the Milford High School? Cumberland Farms Highland Estates Heritage Estates Woodland Heights a. b. c. d. What road is Woodland Heights located on? Powers Street Purgatory Road West Street Clinton Street a. b. c. d. What road is Westchester Heights located off? Westchester Drive Elm Street Both A and B Joslin Road a. b. c. d. What road is the MCAA athletic fields located on? Stable Road Sunset Circle North River Road Clark Road 23. 24. 25. Page 19 of 19 FTP Situations Manual – Basic January 1, 2004 Second Edition