e-Study Guide for Paramedics

Paramedic Study Guide Audio Format

Finally a solution for your Emt needs. It's 100+ page Quick Study Guide for persons either currently in Emt school or preparing for the Nremt Emt-B exam. As you have certainly heard, the Nremt Emt exam is no joke. This is one of the most difficult exams you will ever take and often times, your career depends on you passing it. Nremt Paramedic Exam Study Guide is the Most Condensed Paramedic Study Guide Ever Created! Study Only Nremt exam tested material. No fluff or other information you dont need to know to pass. Over 8 hours of audio study material available as downloadable MP3 ready for your iPod or other MP3 player. Topics include: Legal & Ethics, Airway Management, Cardio, Trauma, Burns, Many More. Perfect if you dont study well by reading. No books to read or classes to attend. Rewind and replay over and over at your discretion. Plus: The 37 most tested Paramedic On-Board Drugs and their Actions, Indications, Contraindications, Dosages, Etc.

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Spinal Immobilization

Carrying boarded patients takes a heavy toll on the backs of EMTs and paramedics. Evaluation of the boarded patient is expensive and time-consuming in the emergency department because of the need to clear the spine. Not all trauma victims require spinal immobilization for transport. The medical director should develop protocols or guidelines to avoid unnecessary field immobilization. 18 For example, a patient with no neck pain or tenderness (neck pain must be defined liberally and includes stiffness or feels funny), not in the extremes of age (below 10 or above 65), with no altered sensorium (no drugs or alcohol present and no head injury), and with no distracting injuries (e.g., long bone fracture or abdominal or chest injury) does not routinely require immobilization because there is an extraordinarily low probability of neck injury. Ideal guidelines for prehospital personnel necessarily would have virtually 100 percent sensitivity with acceptable specificity for cervical spine...

Crew Configuration and Training

The medical crew on a rotor-wing craft can be configured in multiple ways nurse-paramedic, nurse-nurse, nurse-physician, or nurse-respiratory therapist. The literature suggests that the addition of a physician to the crew does not add a significantly higher level of care to that already rendered by a flight nurse or flight medic, although there is a minority view that on-board physicians do improve patient care. 45 The most frequently used crew is nurse-paramedic because of their complementary skills. Since rotor-wing missions vary on the spectrum between scene flights and interfacility transports, a broad skill basis is essential in the medical crew. A comprehensive curriculum guide developed by a number of national air medical organizations under contract from the U.S. Department of Transportation is available to use for training medical flight crews.6 This curriculum covers all aspects of air medical care and is intended for use by paramedics, nurses, and physicians.

Clinical Use of Helicopters

Helicopters are fast ambulances, cruising at 125 to 175 mph, depending on the aircraft. They are not limited by traffic or road quality. The usual flight range for a helicopter is 150 to 200 mi. Helicopters bring sophisticated medical care to areas that otherwise might have only basic life support (BLS) ground ambulance service. The air medical crews bring tertiary critical care and transfer patients back to the tertiary center at two to three times the speed of a ground ambulance. The two major types of helicopter missions are trauma medical scene responses and interfacility transfers. Mission patterns vary widely among flight programs, with the national average in 1997 for scene and interfacility flights being 30 and 70 percent, respectively. 1

Scene Helicopter Response

National guidelines (Table.i3 1) have been developed to assist in making decisions for trauma scene responses.13 Clinical information such as mechanism of injury, severity of injury, vital signs, and level of consciousness are one part of the equation. Emergency medical technicians on the scene are very accurate at defining which patients are critical and need air medical transport to the trauma center.14

Conduct Of A Transport

A collaborative decision must also be made regarding who will assume the responsibility for transporting the patient. There are usually four options private automobile, local ambulance service, local ambulance with personnel from the referring hospital, or service provided by the receiving hospital. The selection should be based on the appropriate balance between the needs of the patient and the resources of each type of provider. Cost should be a consideration only when more than one provider can satisfy the patient's needs.

Reception of Patients

All available litters and wheelchairs should be taken to the ambulance ramp immediately on announcement of the disaster status. Patients from the disaster site are met at the receiving area by hospital escorts, who assist the emergency medical technicians in transferring patients to wheelchairs or stretchers.

Medical Care during Disaster Situations

The approach to patient evaluation and treatment is quite different under disaster situations resulting in large numbers of casualties. While some principles of medical care are unchanged in a mass-casualty incident, other principles must be altered to achieve the best outcome for the largest number of patients rather than concentrating resources on a single patient. There is no role for advanced life support resuscitation at triage care should be limited to manual opening of airways and control of external hemorrhage. Routine emergency department care is also modified patients in cardiac arrest do not usually receive advanced life support and cardiopulmonary resuscitation in order that other seriously injured patients with a better chance of survival can be treated with available resources radiologic and laboratory studies are used only if they will provide critical information patients are hospitalized only when necessary nurses have increased autonomy and paramedics operate under...

Health Core Value Propositions

An additional core value proposition often cited as a rationale for adopting an e-health paradigm is user empowerment through tele-education and e-learning. Videoconferencing and on-line health learning and Web-based educational technologies, for instance, may assist long-distance medical training and permit tele-educational and multimedia educational dialogues among doctors, nurses, mental health and other specialists, and residents. The same videoconferencing and associated Web-based Internet training technology may be used for long-distance radiological consultations, remote medical consultations among doctors and specialists, and e-consultations by qualified doctors on emergency treatments that must be carried out by paramedics. Other e-health initiatives for tele-education and e-learning include on-line kiosks to provide software games and instructional materials for consumer education. Such e-health preventive initiatives, promoted to an entire population, can lead to huge cost...

Prehospital Treatment

There has also been debate over the efficacy of prehospital line placement and fluid resuscitation. Proponents of field resuscitation state that skilled paramedics are able to place intravenous lines with little or no delays in transport. 9 Opponents state that since blood loss cannot be controlled in the field, any delay in definitive treatment is excessive. Clinical studies have shown that the amount of fluid infused en route is usually minimal as compared with the total fluid requirement, and one randomized study of victims of penetrating trauma has failed to show any benefit associated with preoperative fluid therapy. 10 Prehospital fluid therapy probably does not affect outcome in the vast majority of cases, but it may be valuable given a specific combination of hemorrhage severity and distance from the hospital. Until conclusive data for a particular position can be obtained, it is reasonable to place intravenous lines once en route to the hospital whenever possible. This...

The EHealth Paradigm Shift

Approaches to health care and service delivery. In traditional health care systems, the focus is on caring for the sick rather than promoting wellness in e-health systems, the focus is on preventive care and ubiquitous health care services. The traditional health care system transports the sick and those in need of treatment and healing to the doctors and specialists the e-health care system moves or transmits key data, information, knowledge, and even products and services to the e-consumers and anyone who needs the data, information, knowledge, products, or services, including paramedics, nurses, and general practitioners. In essence, transforming the way in which health care information, data, knowledge elements, products, or services are transmitted from a physical mode to a digital mode completely changes the way health care business can be conducted. At least in theory, e-consumers or their intermediaries (for example paramedics) will be able to access evidence-based medicine....

Prognosis of hospital treated infarction

The two major advances in treatment which have changed the natural history of hospital treated infarction over the last 30 years are resuscitation from cardiac arrest and restoration of flow to the infarct related coronary artery by thrombolytic drugs or primary angioplasty. It has been estimated that thrombolysis saves about 30 lives per thousand patients treated,15 although the benefit may be doubled for those treated within the golden hour after the onset of symptoms.16 Reduction in delay in giving thrombolytic treatment has been a major goal for hospitals in recent years, and various strategies for fast track administration either in accident and emergency departments or in coronary care units have been proposed. Pre-hospital treatment on a large scale has so far proved impracticable, and emphasis is placed on reduction in patient delay and use of ambulance paramedics rather than medical practitioners in providing early resuscitation and transport to hospital. Delay is inevitable...

Assessment and Management of the Trauma Patient

In the United Kingdom, pre hospital management of severely injured patients is performed mainly by paramedics. These personnel are trained in advanced airway management (including intubation), intravenous cannulation, fluid resuscitation, the provision of analgesia and spinal immobilisation. Paramedics are trained to consider the Golden Hour' and minimise on scene time a prolonged time to definitive care will increase mortality. The receiving hospital must be given advanced warning of the impending admission of a severely injured patient. Ideally, the ambulance officer at the scene should be able to communicate directly with accident department staff via a talk through link. Concise and essential information on the patient's condition and estimated time of arrival must be given. Accident department staff can then decide whether to alert individual specialists or, depending on hospital policy, the trauma team.

Emergency Cardiac Care

These findings have lead a number of physicians to train FRs or EMT-Bs, who usually arrive first at the scene of an emergency, to recognize and treat VF. Systems in King County, Washington, and in Iowa have documented that this approach improves survival from cardiac arrest if the interval between collapse and defibrillation is short. That observation has lead to the wide proliferation of automated external defibrillators (AEDs). The American Heart Association has identified AED defibrillation as the standard of care for vehicles that respond to emergencies and transport patients. However, there is conflicting evidence concerning whether equipping FRs or EMT-Bs with AEDs incrementally improves survival in an existing EMS system with paramedics.2 Clearly, a cost-benefit analysis should be undertaken in individual systems, and, if implementation of AEDs by police or fire FRs can significantly decrease the time to defibrillation in a system, this modality should be part of the system....

Specific Injuries Of Importance

Traumatic Arrests In most emergency medical systems, paramedics transport patients without vital signs to a hospital while cardiopulmonary resuscitation (CPR) is initiated (unless obvious signs of death are present). On arrival to the Emergency Department (ED), a critical decision must be made regarding the level of intervention. A recently published large series analyzing 862 patients undergoing ED thoracotomy at a regional trauma center yields interesting information. 12 There were 385 patients (45 percent) with blunt trauma, 147 (17 percent) with stab wounds, and 330 (38 percent) with gunshot wounds. The overall number of neurologically intact survivors was 34 (3.9 percent), and the series was large enough and sufficiently equally divided among mechanisms of injury to permit subgroup analysis. There were 259 patients with blunt trauma and no vital signs in the field. There were no survivors in this group. This is a consistent finding among other series, and clearly ED thoracotomy...

Emergency Department

HISTORY A careful history is important for all patients with TBI. For the unconscious patient, the past medical history and the patient's baseline mental status must be obtained from the paramedics, bystanders, or the family. Important historical points include the mechanism of injury, the patient's condition before and after the trauma, the past medical history and the recent use of drugs or alcohol. Important information regarding the condition after the injury includes the length of the loss of consciousness, vomiting and if seizure activity occurred. A history of anticoagulant use or a coagulopathy must be determined for all patients. Potential for associated unidentified injuries conditions should be sought. These include entities such as hypothermia, inhalation injuries, and toxic exposures including carbon monoxide.

Expected deterioration in a patient known to the service

In the community good instructions should be left in the home (for example to prevent ambulance paramedics feeling obliged to initiate CPR if they are called out by someone unfamiliar with the plan). National laws vary, but it is sensible to have necessary drugs, including opioids, already in the home so that there is no need to contact unfamiliar out-of-hours services to prescribe drugs which relatives then have to travel to obtain leading to substantial delays and suffering for the patient.

And Etiological Profile in Developing Countries

Recent studies have shown that the administration of benzodiazepines by paramedics is an effective and safe means of treating status epilepticus in adults58 and children.5960 In the prehospital setting. These studies also suggest prehospital therapy shortens the duration of status epilepticus and simplifies subsequent management in the emergency department. It is reasonable to extend these conclusions to the treatment of acute symptomatic clusters and prolonged seizures since rapid, maximal control is desired. In developing countries poor health care delivery systems and logistic difficulties in transporting patients to a center with adequate facilities, make prehospital administration of benzodiazepines by paramedics a viable option. The potential benefits of such approach include the prevention of systemic and neurologic sequelae of prolonged convulsive seizures. Rectal diazepam is effective in aborting seizures and preventing febrile seizures.61 Prehospital intravenous and rectal...

VT related to regions of scar

Referred to as clinical tachycardias. Those that are induced in the electrophysiology laboratory, but have not been previously observed, are sometimes referred to as nonclinical tachycardias. However, a nonclinical VT may occur later, after ablation of the clinical VT. In addition the ECG of spontaneous VTs terminated by an implanted defibrillator or emergency medical technicians is often not available. Thus the distinction between clinical and non-clinical is often uncertain.

Status Epilepticus in Developing Countries An Account

Status epilepticus is typically encountered in the prehospital environment. Potential benefits of out-of-hospital treatment of status epilepticus include the prevention of systemic and neurologic sequelae. Several recent studies found that intravenous benzodiazepines are safe and effective when administered by paramedics for the treatment of out-of-hospital status epilepticus in both children33,34 and adults.35 Rectal and intravenous diazepam was effective in terminating status epilepticus in 81 and 100 of children respectively. Only two children treated with intravenous diaz-epam and none treated with rectal diazepam needed intubation prior to arrival in the emergency department.33 Prehospital rectal or intravenous diazepam was associated with status epilepticus of shorter duration, and reduced likelihood of recurrent seizures in the ED.34 In adults both lorazepam (59.1 ) and diazepam (42.6 ) were found safe and effective in terminating status epilepticus when compared to placebo,...

TABLE 2163 Contraindications to Fibrinolytic Therapy

Trials of prehospital fibrinolysis for AMI using bolus therapy (anistreplase) suggests that paramedic-initiated fibrinolytic therapy might be delivered earlier than hospital-initiated fibrinolysis without increased complications. 24 However, no mortality rate difference has been demonstrated. Very early fibrinolytic therapy (i.e., within 70 min of symptom onset), whether paramedic- or hospital-initiated, resulted in markedly diminished in-hospital mortality rates and infarct size. The American College of Emergency Physicians has stated that prehospital fibrinolytic therapy for AMI is still investigational, but in rural and remote communities, such therapy seems medically reasonable when excessive delays (> 30 min) until arrival at the hospital may occur. 25 Special paramedic training in the clinical evaluation and treatment of AMI must be done on a continuing basis.

Vascular Access Equipment

Ambulances, IV access is used for fluid resuscitation and administration of drugs. In general, vascular access is obtained for drug administration as soon as possible after the patient is assessed and it is determined that pharmacologic intervention is required. Paramedics are very adept at rapid IV placement. 11 For fluid resuscitation, usually in trauma patients, vascular access is usually started en route to the hospital after the patient is immobilized, unless there is prolonged scene time due to extrication difficulties. Obtaining IV access should not prolong scene times in a trauma patient, especially when LOAD AND GO criteria are present. Prehospital fluid administration may make little difference in the patient's outcome.12 First, the amount of fluid that can be administered during transport in most urban and suburban EMS systems is modest and may not be physiologically significant. Second, there is evidence that prehospital (and emergency department) fluid administration to...

Transport Team Personnel

A variety of personnel might serve as attendants during pediatric transport including physicians, nurses, nurse practitioners, respiratory therapists, physician assistants, and paramedic-emergency medical technicians.10 Practical issues such as availability, salary costs, and the requirement for training most often govern the selection of a particular professional group. Although it would be desirable to have a physician with expertise in pediatric emergency medicine in attendance during each transport, this is rarely practical. Utilizing physicians in training is an alternative, but the competition between transport activities and other aspects of their training often makes this an unattractive alternative. An increasing number of programs now utilize specially trained nonphysician personnel exclusively.

Automatic And Implantable Defibrillators

AEDs are most effective in tiered emergency medical services systems where AED-equipped first responders reach the patient rapidly and are backed up by the later arrival of paramedics with full advanced life-support capabilities.15 There is ongoing interest in making AEDs available for widespread use by nonmedical personnel and the lay public.1 17

Airway and Cervical Spine

It should be assumed that every patient sustaining significant blunt trauma (particularly above the clavicles) has a cervical spine injury, until proven otherwise. Properly trained paramedics will have applied cervical spine immobilisation at the accident scene (Figure TT.3). The most effective method comprises a combination of an appropriately sized semi rigid cervical collar (e.g. Nec-Loc or Stiffneck), and bilateral sandbags or blocks joined with tape or straps across the forehead. Use of a long spine board will minimise movement at the thoraco cervical junction. This combination will virtually eliminate neck flexion, although 30 of normal extension is still possible. If the patient has an unstable cervical spine injury, further movement may result in permanent injury to the cord. Thus, all airway manoeuvres must be performed carefully, and without moving the neck. Mask ventilation can produce at least as much displacement of the cervical spine as that produced by oral intubation....

Pharmaceutical Equipment

Drugs carried by ALS services are more extensive, but it must be emphasized that out-of-hospital pharmaceutical interventions are limited to a few that will make a real difference before the patient gets to the hospital. The drugs that can make a real difference when administered by a paramedic include oxygen for hypoxia glucose for hypoglycemia nitroglycerin for chest pain and pulmonary edema inhaled beta-adrenergic agonists for bronchospasm naloxone for suspected narcotic overdose morphine for pain benzodiazepines for seizures, delirium, or intubation furosemide for fluid overload epinephrine for cardiac arrest and anaphylaxis and lidocaine, magnesium, bretylium, and perhaps amiodarone for cardiac arrest. Adenosine and diltiazem are useful for rate control of tachycardia, but most patients would be able to wait until arrival in the emergency department for treatment. Sodium bicarbonate is helpful for suspected or known hyperkalemia but probably not for cardiac arrest. Calcium may...

Death Investigation and Forensic Nursing in the United States and Canada

The practice arena included registered nurses, physicians, physician's assistants, paramedics, and emergency medical technicians. It also included community service professionals (e.g., police officers, court officials, and attorneys) interacting with victims. These professionals were expected to be able to recognize the problems in the existing system and alert other trained personnel to potential solutions. To this end, it was believed necessary to establish and train professionals in the philosophy of living forensics, beginning with emergency interventions. Lynch37 believed many cases of death encountered in the clinical setting fell within the jurisdiction of the medical examiner or coroner and believed it vital for clinicians to be skilled in the documentation and preservation of evidence related to those cases. Nurses, particularly emergency room nurses, often were the first personnel to come in contact with the victim and the evidence even before the police were notified that...

Medical Control

On-line medical control is the provision of direct medical communication to personnel in the field either in person or by radio or phone communication. The EMS medical director delegates this authority to other physicians who understand the protocols under which paramedics administer care. Also, the medical director may allow ambulance personnel to carry out certain standing orders when timely contact with the controlling physician is not feasible.

Adult Medical Care

The management of airway obstruction and respiratory arrest is an important function of the EMS system. Airway control by endotracheal and nasotracheal intubation is readily achieved by paramedics with a high success rate and an acceptable complication rate. Early advanced airway measures for upper airway obstruction from burns, trauma, foreign body, or allergic causes may be lifesaving. Some EMS systems have shown that neuromuscular paralytic agents, such as succinylcholine, may be safely used by paramedics in the field with appropriate instruction and close medical oversight. Paramedics are commonly called to evaluate patients with altered mental status. Glucose is frequently given to hypoglycemic patients and naloxone to patients with suspected narcotic overdose. Similarly, control of seizures with diazepam and airway support for status epilepticus are important EMS functions.

Pediatric Care

With the development of pediatric emergency care as an area of interest, experts and organizations have started to review the care of children in EMS systems. 14 It is estimated that 5 to 10 percent of a system's volume consists of pediatric cases, and the most common pediatric emergencies are trauma, respiratory emergencies, and seizures.15 Cardiac arrest in children is rare (approximately 1 per 10,000 children per year in the United States) usually with a dismal outcome. The ability of paramedics to perform procedures to treat pediatric cardiac arrest, respiratory emergencies, and trauma is extremely variable and age dependent. For most age groups, endotracheal intubation success rates are comparable to those for adults. As would be expected, endotracheal intubation and intravenous access are performed with poor success in infants. In a large regional study of pediatric intubation, Gausche and others have shown no change in patient outcome after field endotracheal intubation.16 The...

Defibrillators

Defibrillators used by ALS personnel are more sophisticated, with monitoring screens, printout units, manual defibrillation ability, and synchronized cardioversion capability. Defibrillation is often done with combination pads (as with the AED) rather than with paddles. These pads provide better contact with the skin, resulting in decreased resistance and allowing for more current to be delivered with a higher success rate for conversion. Such pads are also safer for the operator, who does not have direct contact with the patient when the shock is delivered. The monitor screen is used by the paramedics for initial interpretation of rhythms, ongoing monitoring of patients' rhythms, synchronizing a countershock for rhythms other than ventricular fibrillation, and pacing bradycardiac rhythms. The ALS defibrillators will soon be equipped with the technology to monitor blood pressures, pulse oximetry, and end tidal CO 2. The ALS personnel will use these machines for monitoring very ill...

Chapter References

White RD, Asplin BR, Bugliosi TF, Hankins DG High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 28 480-485, 1996. 7. Bradley JS, Billows GL, Olinger ML, et al Prehospital oral endotracheal intubation by rural basic emergency medical technicians. Ann Emerg Med 32 26-32, 1998.

Helicopter Transport

The first hospital-based civilian program began in 1972 in Denver. Currently, there are 385 air medical service providers identified by the Association of Air Medical Services (AAMS), 362 domestic and 23 international.1 Most of these programs are run by hospitals or groups of hospitals. Helicopters are expensive, ranging from 750,000 to 5 million. Because of the high cost of purchase, maintenance, and pilot training, most programs lease their helicopters from aircraft vendors. In this arrangement, the air medical program provides the medical personnel (paramedics, nurses, physicians, and dispatchers) and medical supplies, while the aircraft vendor supplies the helicopters, pilots, and maintenance personnel. The annual cost of operating a rotor-wing service typically exceeds 2 million.

Patient Care Path

Once a response team has been dispatched, they should respond and initiate patient care. This is best accomplished by the rapid extrication of the patient from the crowd to the nearest space (e.g., a tunnel or open entryway) isolated by security personnel. At this point, treatment can be initiated by protocol or with on-line medical direction. The amount of treatment provided at this time depends on the medical condition of the patient and the layout of the facility. Transport to a designated treatment site or ambulance should occur as soon as possible so that a specialist can provide care at the highest level appropriate to definitive treatment. Ideally, direct supervision by the medical director should be available. Staffing of the treatment facility can be variable, including nurses, physician assistants, emergency medical technicians, paramedics, Red Cross volunteers, medical students, or first responders.

Early Defibrillation

The best survival is attained in EMS systems that can provide early defibrillation to a large percentage of patients. In most cases, this is most cost-effectively accomplished by a tiered response system, in which large numbers of rapid first-response firefighters or emergency medical technicians (EMTs) are trained and equipped to provide first aid, CPR, and early defibrillation using an AED. Unfortunately, not all communities in the United States have yet implemented a comprehensive, tiered EMS system. Many systems, particularly in suburban or rural areas, have EMTs who are neither trained nor equipped to defibrillate. For such areas, adding rapid defibrillation capability offers a cost-effective alternative that can significantly improve survival from out-of-hospital VF or pulseless VT. The American Heart Association advocates the widespread implementation of rapid defibrillation programs throughout the nation in its belief that all emergency personnel should be trained and...

Early ACLS

Physicians provide prehospital ACLS by staffing specially equipped ambulances in many countries (e.g., western Europe, Scandinavia, and Canada). In the United States, intermediate-level EMTs or paramedics provide most prehospital ACLS intervention (e.g., defibrillation or synchronized cardioversion, endotracheal intubation, intravenous fluid therapy, or drug administration). Intermediate EMTs (often called cardiac technicians) typically receive several hundred hours of training paramedics usually receive 1000 or more hours. Adding field ACLS capability appears to affect survival from out-of-hospital cardiac arrest favorably, although the degree of benefit is relatively minimal compared to the powerful effect of early defibrillation. 8

Prehospital Care

Treatment of near drowning begins at the scene with rapid, cautious removal of the victim from the water (T.a.ble , 193.-1). Spinal precautions should be observed if the mechanism of injury, such as diving or surfing, raises suspicion of such injury. The vast majority of spinal injuries are to the lower cervical spine after diving. Clues to spinal injury may be paradoxical respiration (abdominal breathing without movement of intercostal muscles), flaccidity, priapism, or unexplained hypotension or bradycardia. Lifeguards and emergency medical technicians should maintain spinal precautions during rescue if possible. Initial history may be unreliable, and the physician should have a low threshold for obtaining cervical spine x-rays.

Resuscitation

The evaluation and management of patients in the resuscitation phase are guided by the accepted standards of Advanced Trauma Life Support (ATLS) protocols. This phase begins when the patient is first evaluated in the field by emergency medical technicians and paramedics and should be well under way when the patient arrives in the emergency room (ER). It concludes when the patient is hemodynami-cally stable. A trauma patient's airway competency, ability to breathe, and circulatory stability, known as the ABCs, are assessed and treated. The ABCs remain the cornerstone for prevention of early death following trauma.

Suicide

Negative attitudes toward the suicide attempter have been documented among all types of emergency personnel paramedics, nurses, and emergency physicians. A negative attitude intensifies a patient's already low self-esteem, thus increasing the risk of subsequent suicide and making it difficult to establish a therapeutic relationship.

Trauma Care

There is less agreement on what therapy should be given by EMS providers to trauma victims in the field and en route. 1 1 Some early literature documented a decreased survival rate if patients received ALS (intravenous fluid administration and intubation) at the scene instead of immediate transport to the hospital presumably this occurred because of the delay to definitive care. More recent studies have found that paramedics may secure an airway, establish an intravenous line, and infuse significant volumes of fluid rapidly without delaying transport of the patient. While the value of providing a secure airway is unarguable, the value of prehospital intravenous fluid administration has been challenged. Thought-provoking work from Houston found that, for hypotensive victims of penetrating truncal trauma who required surgical repair, withholding fluid and blood in both the prehospital and emergency department phases until arrival in the operating room improved survival rates, reduced...

Training

Some communities use a dual-response system consisting of first responders (FRs) followed by ambulance personnel. The FRs may be firefighters, police, park rangers, or citizen volunteers. The DOT National Highway Traffic Safety Administration (NHTSA) was initially given the responsibility of developing training curricula for EMS providers. The use of these curricula was tied to receipt of federal EMS grants, and the training programs were widely accepted and utilized nationally. Although their use is no longer required, DOT training standards are the de facto national standard for EMS education. Training for FRs may include the DOT FR course (which encompasses 60 h of classroom training) or similar courses developed by the American Red Cross or American Heart Association. The training for ambulance personnel usually requires completion of an emergency medical technician (EMT) course. Although various levels of EMT training have evolved in various states, there are three nationally...