Operations Study Guide for the EMT Test

Patient Identification

Avoid making assumptions or letting the information you obtained pigeonhole your thinking. Use the scene size-up to gather baseline information regarding the incident onset, and the pattern and duration of signs and symptoms.

During any incident, but especially one where multiple patients are involved, it is crucial to ensure accurate treatment, tracking, and transport. This concept is initiated with the prompt identification of patients and can be facilitated by simple commands making distinction more simple. These commands may include asking victims to raise their hands or if they’re able to move to a designated area. Once this process has begun, patients can be uniquely identified by markers and triage can begin. This will help to determine the severity of each patient’s condition.

Triage

The goal of triage is to sort patients into categories by injury severity and try and do the most good for the most patients. Triage tags are usually used to quickly sort injured into red, yellow, green, and black to aid in organizing their movement to the appropriate treatment area.

Here are some concepts to know:

primary triage—the initial rapid assessment of patients at a scene to quickly determine the severity of their injuries to prioritize treatment and transport
secondary triage—a more detailed patient assessment performed after the primary triage when the patient has been moved from the scene to a treatment area or is en route to the hospital; allows for reassessment of the patient’s condition to adjust treatment or transport decisions if necessary
START triage—acronym for “simple triage and rapid treatment”; a rapid assessment system used to categorize patients during mass casualty incidents based on assessment findings, including respiration, perfusion, and mental status; findings used as basis for assigning a color-coded priority (see categories below)
JumpStart triage—the pediatric version of the START triage system; designed to be adaptive for children under the age of eight or weighing less than one hundred pounds; categories still include breathing, perfusion, and mental status; metrics are modified for children
triage categories—color-coded patient classifications utilized during mass casualty incidents to prioritize patient care based on severity.
- red—immediate (Priority 1): life threatening injuries requiring urgent intervention
- yellow—delayed (Priority 2): serious injuries that can tolerate short delay
- green—minor (Priority 3): walking wounded or minor injuries; treatment can be delayed
- black—deceased/expectant (Priority 4): dead or injuries are not compatible with life
triage tags—color-coded labels or forms used during mass casualty incidents to identify a patient’s category and track their information during the incident
disaster—a catastrophic event, either natural or man-made, resulting in widespread damage that overwhelms local resources
casualty collection point—a designated location in close proximity to the scene of an incident where patients are gathered and stabilized before being moved again

Additional Resources

Some emergency calls can be handled by just the original responders to the call or the ambulance crew. Other situations require additional specialized skills, and you should know when additional resources are necessary for optimal care.

A Team Approach

Modern healthcare is based on a team approach. Care will be transferred to other members of the broader healthcare team. Effective communication and collaboration are essential. Transferring information about a patient is necessary for care. This takes place both in person or verbally over a radio or phone and also in written documentation records.

Team Types

Different types of teams can exist. They can include regular teams, temporary teams, and speciality teams, such as those for special events. Teams are typically multidisciplinary and need to focus on a common goal.

Here are some concepts to know:

continuum of care—the ongoing, coordinated efforts of care beginning with the initial emergency response ranging through hospital treatment

Example: EMTs arrive then pass care off to the paramedics who treat the patient and transfer care to the hospital staff after transport.

community paramedicine—a type of healthcare model in which paramedics provide expanded services that range beyond emergency response, including preventive care, chronic disease monitoring, and follow-up visits to improve community health and reduce hospital visits
mobile integrated healthcare (MIH)—a type of healthcare model in which EMS providers deliver non-emergent healthcare services in the community; often coordinated with primary care providers

Group Versus Team

A group is made up of individual healthcare providers who all are working to take care of a patient, but typically do so independently. A modern approach to healthcare consists of a team of healthcare providers who are interdependent and have clear roles.

Here is a concept to know:

team leader—individual responsible for coordinating a group of EMS personnel at a scene; ensures that tasks are assigned, care is prioritized, and communication is maintained

Types of Groups

Different types of groups can exist. Common types can include dependent groups which rely on one leader for direction. In independent groups, each member has an area of responsibility, and interdependent groups represent true teams. Groups can also be organized according to the Incident Command System (ICS).

Here are some concepts to know:

dependent group—individuals who depend on assistance from others to evacuate, move, or receive care during an emergency
independent group—individuals who are self-sufficient, do not require assistance evacuating or moving, and can care for themselves
interdependent group—individuals who can function and move safely when assisted by others; rely on teamwork and support

Team Performance

Effective teams have a shared goal with clear roles and responsibilities. The team leader monitors and facilitates team performance, and all team members are encouraged to provide input and speak up if they recognize a problem.

Here is a concept to know:

crew resource management—a set of strategies that revolve around communication, teamwork, and decision making used by responders to maximize safety and efficiency during incidents

Transferring Patient Care

Transfers of care present a point for critical errors to occur. Transfers should be minimized and conducted in a standardized format to ensure proper transfer of care. Critical information needs to be passed on to the next team member and responsibilities clearly transferred.

Here are some concepts to know:

minimal interference—little to no disruption in ongoing operation; patient care transfer and hand-off report conducted in a location where there are minimal distractions
uninterrupted critical care—the seamless transition of lifesaving care, such as chest compressions being taken over during transfer of patient care
common priorities—key assessment findings that are pertinent to both the team member giving them as well as the team member receiving patient reports
common terminology—the use of clear, plain language that is universally understood; allows for effective communication across different agencies

BLS and ALS Care

Basic Life Support (BLS) and Advanced Life Support (ALS) care exist together, and often BLS care continues as part of the addition of ALS care. In some states, BLS care may be blended with some ALS procedures. EMTs may still need to assist with ALS skills, such as vascular access and advanced airways.

Here are some concepts to know:

endotracheal intubation—an advanced airway procedure where a tube is placed through the mouth into the trachea to maintain airway patency, protect against aspiration, and facilitate mechanical ventilation
oxygenation—the process of adding oxygen to the blood and body tissues; occurs through breathing or ventilatory assistance
preoxygenation—the process of giving a patient extra oxygen before an airway procedure is performed; increases the body’s oxygen reserves and prevents patients from becoming hypoxic while undergoing the procedure
apneic oxygenation—the delivery of oxygen to a patient who is not breathing on their own; often done through ventilation with a bag-valve-mask device
direct laryngoscopy—a procedure during which an advanced-level provider places an endotracheal tube by utilizing a laryngoscope blade to directly visualize the vocal cords, ensuring that the tube moves through the glottic opening and into the trachea
video laryngoscopy—an airway procedure that uses a laryngoscope with a camera and a screen attached; provides an indirect view of the glottic opening, allowing for an endotracheal tube to be passed
gum elastic bougie—a thin, flexible assistive device used during intubation; when the glottic opening is small or difficult to visualize, it can be inserted through the vocal cords first and used as a guide for the endotracheal tube to follow
esophageal intubation—an improper placement of the endotracheal tube resulting from a failed intubation attempt; occurs when the tube is accidentally placed in the esophagus instead of the trachea; can lead to air entering the stomach and not the lungs
vascular access—the process of gaining entry directly into a patient’s circulatory system through their veins, allowing for the administration of medications, fluids, and blood products
saline locks—a type of intravenous setup where the catheter that is placed in a vein is capped with a small plug when fluid or medications are not being administered

Team Conflict Troubleshooting

While effective teams have minimized conflicts, conflict will still occur. When conflict occurs, the patient must always come first. Other troubleshooting techniques can include keeping calm, waiting until after the incident to address, focusing on the behavior, and choosing your battles.

Special Situations

Many kinds of special rescue situations exist that require unique skills. Technical rescue can include water rescue, building collapses, fires, search and rescue, and SWAT situations. Special situations can present unique hazards and communication and safety are paramount.

Here are some concepts to know:

technical rescue situation—an emergency scenario that requires specialized skills, equipment, and training to safely rescue patients from hazardous environments, such as rescue from a confined space or high-angle, trench, water, or vehicle extrications
specialized weapons and tactics team (SWAT)—a specialized law enforcement team trained to handle high risk incidents; occasionally may employ EMS personnel to work closely alongside these law enforcement teams.
tactical situation—an emergency scenario, usually involving law enforcement or special operations, where there may be an active threat present
structure fire—a fire occurring in a building or enclosed structure posing risk to property, victims, and responders; may require coordinated medical efforts to ensure the safety of all involved
self-contained breathing apparatus (SCBA)—a portable tank device that provides breathable air to responders who must operate in IDLH (immediately dangerous to life or health) environments

Medical Supervision During AED Use

There are ongoing outcome-based studies and quality improvements related to cardiac survival rates of patients where early intervention is implemented. It is important to include appropriate medical supervision in the protocols, procedures, and guidelines related to AED use. Ideally, after each time the AED is used, the emergency team should have a debriefing/review session that includes a description of the situation, what went well, and what can be improved in the future.

Here are concepts to know:

role of the medical director in AED use—While not directly involved in the application or use of the AED, the medical director provides oversight, guidance, and protocols for the use of the AED. This ensures that responders are utilizing the device properly when necessary.
quality improvement goals with AED—The main function of the AED is to provide lifesaving electrical shocks which will convert the heart into a rhythm that is compatible with life. In order to improve the chances of this occurring, the goals of care are early and proper application of the AED as well as early defibrillation.

The Role of ALS

The role of the Advanced Life Support (ALS) team is invaluable to the community. Ensure open, clear, and concise communication with this team to support the best measures for patient care. In situations where ALS has not arrived or is not available, act in the patient’s best interests by beginning the use of the AED as soon as possible. If the patient is in ventricular fibrillation, time is of the essence, so follow the AED instructions.

Here is a concept to know:

difference in scope of practice between EMT and ALS team—The main difference between the EMT and ALS scopes of practice pertain to their level of intervention and skill. EMTs are responsible for performing basic life support interventions including CPR, AED use, oxygen administration, basic airway management, and bleeding control. ALS providers are responsible for performing advanced interventions to manage life threatening conditions. These include advanced airway management (endotracheal intubation), IV access, medication administration, and cardiac monitoring.

Legal Issues

There is a lot of liability (legal responsibility) associated with emergency services. It is for this reason that understanding legal issues is important. EMTs will encounter many legal components pertaining to their job ranging from protocols to documentation and so on. The law defines your responsibilities as an EMT, as well as helps to protect patients’ rights and your rights as a provider. Every patient care report that is written for each patient contact is a legal document which is filed and stored for a minimum of seven years. Other legal documents you may encounter include refusal of care forms, and patient confidentiality (HIPAA).

Mental Health Situations

When a patient is mentally incompetent, there are some legal considerations. Patients who are mentally unstable cannot give consent for medical care. If a patient is not mentally competent, law enforcement may place the person in protective custody, which allows you to provide treatment. In situations where mental competency is a consideration, always have law enforcement involved.

Here are some terms to know:

acute psychosis—a sudden disturbance in the way a person is thinking or perceiving reality; can often cause hallucinations, delusions, confusion, or unorganized and irrational behavior
schizophrenia—a chronic mental disorder that affects the way a person thinks, feels, or behaves; can cause symptoms like hallucinations, auditory disturbances, and difficulty distinguishing reality from imagination
organic brain syndrome—a condition in which the brain does not function properly due to a physical issue such as injury, illness, or drug induction; can cause confusion, memory problems, or unusual behavior
excited delirium—a sudden state of extreme agitation or aggression often related to drug use or mental illness; has the potential to lead to worse patient conditions and should be considered a true medical emergency
post-traumatic stress disorder (PTSD)—A mental health condition that can develop after experiencing or witnessing a traumatic event, with common signs including flashbacks, anxiety, nightmares, and avoidant behavior

Law Enforcement Assistance for Specific Cases

In certain emergency situations, you should contact law enforcement if they are not already at the scene. This contact is not only helpful, but is often legally required.

Child Neglect or Abuse

You as a provider are responsible for reporting suspected child neglect or abuse. It is important to observe the scene where you believe a child is in danger of abuse for any concerning findings. These may include ripped or dirty clothes, uninhabitable living conditions, full/unchanged dirty diapers, injury patterns inconsistent with explanations, child hesitation around guardian, or any other observations of note. All findings should be documented and reported to the authorities and or child protective services.

Rape and Sexual Abuse

If your patient reports to you during your assessment that they have been raped or sexually abused, it is your responsibility to document and report this to the proper authorities. Some victims may be hesitant to speak about their assault and will not be forthcoming with this information. It is your responsibility to assess for and report any concerning physical findings leading you to believe a patient may have been assaulted. This may include genital trauma, bruising, ripped or torn clothing, and any other signs of note.

Elder Abuse

Elder abuse is a common but minimally reported incident. It is the responsibility of the EMT to report any suspicions of this type of abuse to the proper authorities. Some signs to look for may include unexplained bruising or other injury, signs of neglect (poor hygiene, malnutrition), fearfulness, and sudden loss of money.

Wounds from Weapons

Injury patterns on any patient are important to assess and report however this is especially necessary when a weapon is involved. Proper assessment, documentation and reporting of injury patterns from a weapon may assist law enforcement in their investigation as well as allow for prompt definitive medical treatment at the hospital. Examples include assessing for bullet hole entry and exit wounds, shell casings, stab wound patterns, burn marks or bruising, etc.

Air Operations

Fixed-wing and helicopter aircraft are used as ambulances. Helicopters can be called directly to scenes; the decision to do so must be based on patient condition and transport considerations. Once called, a landing zone will need to be secured and safety around the helicopter ensured.

Here are some concepts to know:

air ambulances—a helicopter or fixed-wing aircraft equipped like an ambulance with a crew of medical providers and tools, used to transport patients quickly between scenes or hospitals
medevac—a quick air extraction, typically by helicopter, of a patient from a remote location to a hospital
landing zone—a fixed or remote location, typically 100 by 100 feet, where medical helicopters can take off and land safely to pick up or drop off patients