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Teaching the IPPSS - Primary

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A presentation for use in teaching the International Paramedic Primary Survey. For more information about this please visit www.paramedicine.com

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Teaching the IPPSS - Primary

  1. 1. The International Paramedic Primary Survey Marc Colbeck Teaching Workshop
  2. 2. © Marc Colbeck and Paramedicine.com, used by permission of the author. See: https://creativecommons.org/licenses/by-nc-sa/4.0/ Maintaining this note in the file is sufficient attribution of authorship as per the author.
  3. 3. Background • 2016: No evidence-based research on either the primary or secondary survey found in the literature • Formation of an international team of senior paramedic academics and clinicians • Systematic review of all CPGs from: Australasia, the UK, Ireland, South Africa, Qatar, United Arab Emirates, and of evidence-based exemplar CPGs from the USA.
  4. 4. Background • Resulted in the first (and only!) evidence-based, peer- reviewed and published, primary and secondary surveys for paramedicine. • Two mnemonics came from the study • 1o Survey: Safety FIRST GET ABCDEs • 2o Survey: I See I HAD Vitals Assessed and Treated • “For paramedic students … memorising over 100 unique concepts to practice in order and without omission, under novel and stressful conditions, is a daunting proposition. It is the author groups’ hope that this work will assist them in that effort”.
  5. 5. The International Primary and Secondary Survey Open Access article in the Irish Journal of Paramedicine Colbeck, M. A., Maria, S., Eaton, G., Campbell, C. B., Batt, A. M., & Caffey, M. R. (2018). International Examination and Synthesis of the Primary and Secondary Surveys in Paramedicine. Irish Journal of Paramedicine, 3(2), 1–9. https://doi.org/10.32378/ijp.v3i2.91
  6. 6. Make sure you know the sentence… “Safety FIRST GET ABCDE’s”
  7. 7. Layout of this workshop First: Explanation of the topic Second: What to say (sample scripts) Third: Reinforcement activity (for some topics) S F I R S T G E T A B C D E Follow along!
  8. 8. Safety “Safety” Means biological safety. Wear your gloves & goggles. Wear helmets and footwear. S F I R S T G E T A B C D E http://cache.daylife.com/imageserve/0a6HdEh1q593B/610x.jpg April 2008
  9. 9. To the Scenario Director • “I’m wearing my gloves and goggles” S F I R S T G E T A B C D E To the Patient Safety
  10. 10. Fear Is there anything that you’re worried could endanger the safety of you or your team? S F I R S T G E T A B C D E http://www.27east.com/assets/news.Article/232449/main1747.jpg February 2018
  11. 11. To the Scenario Director • “I don’t see anything that makes me feel unsafe” [or] • “I’m concerned about ______ and would address that by ______ before entering the scene” S F I R S T G E T A B C D E To the Patient Fear
  12. 12. • Discus some examples of safety concerns on things we should fear while on the job with another student? • How many can you think of? • Share as a class S F I R S T G E T A B C D E Safety and Fear
  13. 13. Incident What is the nature of the incident? Specifically, is it traumatic or medical? S F I R S T G E T A B C D E http://img.coxnewsweb.com/C/00/29/29/image_3429290.jpg April 2008
  14. 14. To the Scenario Director • “This seems to be a traumatic/non- traumatic incident” (pick one) • “I’m considering the mechanism of injury” [or] • “I’m considering the nature of illness” S F I R S T G E T A B C D E To the Patient Incident
  15. 15. • What are some examples of traumatic vs medical scenarios and what are some considerations with this? • How many can you think of? • Share as a class S F I R S T G E T A B C D E Incident
  16. 16. numbeR How many patients are involved? Look for clues that someone is missing. Look at any bystanders – do they need help? Keep an eye on your team. S F I R S T G E T A B C D E http://elkgrovetribune.com/wp-content/uploads/2016/12/exercise3.jpg February 2018
  17. 17. To the Scenario Director • “There appears to be only one patient” [or] • “I see more than one patient, there are ______ patients” • “I see one patient is there anyone else I need to be concerned about” S F I R S T G E T A B C D E To the Patient numbeR
  18. 18. • What are some situations where patients could be missed? • How many can you think of? • Share as a class S F I R S T G E T A B C D E numbeR
  19. 19. Send for help Do you need any help to manage the scene? S F I R S T G E T A B C D E http://www.lifemedems.com/images/IMG_1581.JPG April 2008 April 2008
  20. 20. To the Scenario Director • “No need to send for help at this point” [or] • “I’m going to request ______ for help because of ______” S F I R S T G E T A B C D E To the Patient Send for help
  21. 21. • Class discussion – who can we call for help? • What can they do for us? • How many can you think of? • Share as a class S F I R S T G E T A B C D E Send for help
  22. 22. Triage? Trauma? If there is more than one patient do you need to prioritise the most sick? (perform ‘triage’) If there is only one patient, do you need to worry about trauma to their c-spine? S F I R S T G E T A B C D E https://upload.wikimedia.org/wikipedia/commons/thumb/e/ea/Wounded_Triage_France_WWI.jpg/1200px-Wounded_Triage_France_WWI.jpg February 2018
  23. 23. To the Scenario Director • “I’m ruling in C-spine – partner can you immobilise” [or] • “I’m ruling out C-spine – no need to immobilise” • “There’s only 1 patient so no need to triage” [or] • “There are multiple patients so I will begin triaging” S F I R S T G E T A B C D E To the Patient Triage? Trauma?
  24. 24. General impression – Single Patient 1. Age 2. Sex 3. Position found* 4. Location 5. Level of distress* S F I R S T G E T A B C D E http://vkool.com/wp-content/uploads/2016/05/asthma.jpg February 2018 Supine Prone Left/right lateral High/low fowlers Tripod Mild (fine) Severe (REALLY sick) Moderate (anything else)
  25. 25. To the Scenario Director • “I see a 50-year-old male standing upright in a classroom in no apparent distress” S F I R S T G E T A B C D E To the Patient General impression
  26. 26. S F I R S T G E T A B C D E General impression • Practice making up some situations and describing the scene to another student using the five items mentioned – in order. • Have each student describe their own current general impression
  27. 27. METHANE update • Major Incident Declared • Exact location • Type of incident • Hazards • Access • Number and type of casualties • Emergency services present and required General Impression S F I R S T G E T A B C D E
  28. 28. To the Scenario Director • “I’m notifying dispatch that I am declaring a major incident, • Our exact location is: ______________ • The type of incident is:______________ • Be aware of the following hazards:______________ • Best access and egress are: ______________ • We have the following casualties: ______________ • On scene we have ______________, and I am requesting ______________ S F I R S T G E T A B C D E General impression – Multicausality Incident
  29. 29. S F I R S T G E T A B C D E General impression • Practice making up some situations and describing the scene to another student using the METHANE mnemonic.
  30. 30. Estimate levels of awareness AVPU Alert Verbal Pain Unresponsive S F I R S T G E T A B C D E https://www.virtual-college.co.uk/-/media/virtual-college/news/virtual-college/guides/what-to-do-if-someone-is- unconscious.ashx?h=288&la=en&mh=288&mw=512&w=512&hash=6CB6D638ACB8564916D5A9FEE2393180C73BEEFE February 2018
  31. 31. To the Scenario Director • “The patient appears to be alert, is visually tracking me, and is responding to verbal with normal verbal” [or] • “Patient is responding to loud verbal by moaning” [or] • “Patient is responding to pain by …” [or] • “Patient is responding to _____ by _____” S F I R S T G E T A B C D E To the Patient • “Hi, my name is ______ and I’m a paramedic, are you ok?” Estimate LOA’s
  32. 32. S F I R S T G E T A B C D E Estimate LOA’s • Have each student describe several patient presentations to each other using the structure … “The patient is responding to _____ by _____”
  33. 33. Threats POPE People Objects Places Environment S F I R S T G E T A B C D E http://www.abc.net.au/news/image/7288144-3x2-700x467.jpg February 2018 Includes “life threatening bleeding” in your patient
  34. 34. To the Scenario Director • “There are no POPE threats to myself, my team, my patient, or bystanders” • There is no life threatening bleeding in my patient. S F I R S T G E T A B C D E To the Patient Threats
  35. 35. The ABCDE’s S F I R S T G E T A B C D E • Are done in sequence • Experienced paramedics might vary the sequence, or do them all simultaneously • Are done using a ‘Find-it, Fix-it, Move-forward’ approach
  36. 36. Airway S F I R S T G E T A B C D E http://cursoenarm.net/UPTODATE/contents/images/f5/60/6095.myextj?title=Endotracheal+intubation+ant February 2018 Assess: • Is the airway patent? • Does it need clearing? • Are there current, or impending, obstructive difficulties? Consider: • Positioning • Suctioning • Foreign Body Airway Obstruction removal (Magill forceps/laryngoscope/back blows/chest thrusts) • Basic airway adjuncts (oro/nasopharyngeal airways, supraglottic airway device) • Advanced airway adjuncts (endotracheal intubation +/- pharmacological assistance) • Surgical airway (for the “can’t intubate-can’t ventilate” patient) Clear Poor Absent Treat from the ‘outside→in’ Ask: ‘Do I need to go ‘in’ to the patient?
  37. 37. To the Scenario Director • “Airway is clear/poor/absent” • “I’m going to attempt to ventilate the patient to see if the airway is clear” [or] • “Patient does/does-not require advanced airway support” S F I R S T G E T A B C D E To the Patient • “How’s your breathing, is it ok?” • Explain to the patient what you are doing • (Be sure to get consent!) Airway
  38. 38. • Have students explain the airway approach to each other • Have students perform the entire primary survey up to this point S F I R S T G E T A B C D E Airway
  39. 39. Breathing S F I R S T G E T A B C D E https://www.news-medical.net/image.axd?picture=2016%2F1%2Fman_has_difficulty_getting_his_breath.jpg February 2018 Assess: • Look, listen, feel for breathing and assess respiratory effort • Consider rapid 4-point auscultation (if appropriate) • Consider oxygen saturation (SpO2) and end tidal carbon dioxide (EtCO2) measurement (prn) Consider: • Establishing breathing using a bag valve mask • Initiating oxygen administration (mask, nasal cannula, bag valve mask) for hypoxemia • Chest Needle Decompression or Finger Thoracotomy (prn for life threatening tension pneumothorax, or hemo-pneumothorax) Clear Poor Absent Treat from the ‘outside→in’ Ask: ‘Do I need to go ‘in’ to the patient?’
  40. 40. To the Scenario Director • “Patient’s breathing is clear/poor/absent” • “I’m going to apply a non-rebreather mask @ 15L per minute” [or] • “I’m going to apply a nasal cannula @ 2L per minute” [or] • “I’m going to ventilate with a BVM” S F I R S T G E T A B C D E To the Patient • Explain to the patient what you are doing • (Be sure to get consent!) Breathing
  41. 41. • Have students explain it to each other • Have students PERFORM the AB assessments • Then have students perform the Safety FIRST GET AB assessment S F I R S T G E T A B C D E Breathing
  42. 42. Circulation S F I R S T G E T A B C D E http://co.cheshire.nh.us/hoc/Images/cpr3.jpg April 2008. Assess: • If there is a pulse or not • Pulse rate, strength, and regularity • Perfusion estimation - adequate vs inadequate • For uncontrolled external haemorrhaging • Skin condition (colour, temperature, diaphoresis) Consider: • Direct pressure/tourniquet for uncontrolled haemorrhage • Cardiopulmonary resuscitation if vital signs absent • Electrocardiogram determination prn • Intravenous initiation Clear Poor Absent Ask: ‘Do I need to go ‘in’ to the patient?
  43. 43. To the Scenario Director • “There is a strong radial/carotid pulse” [or] • “There is no carotid pulse” • “Patient appears well/poorly perfused” • “Skin is pink (pale, mottled), warm (cool, cold) and dry (clammy, wet)” S F I R S T G E T A B C D E To the Patient • Explain to the patient what you are doing • (Be sure to get consent!) Circulation
  44. 44. • Have students summarise our approach to Circulation to each other • Have students PERFORM the Circulation assessment • Then have students perform the Safety FIRST GET ABC assessment S F I R S T G E T A B C D E Circulation
  45. 45. Decision/Disability S F I R S T G E T A B C D E https://cihparamed.files.wordpress.com/2016/10/920x920.jpg February 2018 Medical: B: Benzo/Seizures or Aggression A: Adrenaline/Anaphylaxis N: Narcan/Opioid OD G: Glucose/Hypoglycaemia Zap: Defib pulseless patients Push: IV fluid push for hypovolemic hypotensive Trauma: Bad breaks and bleeding
  46. 46. To the Scenario Director • “I’m assessing for medical disabilities” • “No treatment required at this point” [or] • “I want to give Midazolam for seizures” [or] • “I want to give Adrenaline for anaphylaxis” [or] • “I want to give Narcan for opioid overdose” [or] • “I want to give Glucose/Glucagon for hypoglycaemia” S F I R S T G E T A B C D E To the Patient • Explain to the patient what you are doing • (Be sure to get consent!) Decision: Medical
  47. 47. To the Scenario Director • “I’m assessing for trauma disabilities” • “The patient has an uncontrolled bleed/or break – this is a load and go situation” [or] • “Patient appears to be stable” S F I R S T G E T A B C D E To the Patient • Explain to the patient what you are doing • (Be sure to get consent!) Decision: Trauma
  48. 48. Learn “BANG, Zap, Push” • Have students stand and repeat • Explain to each other • Then have students perform the Safety FIRST GET ABCD assessment S F I R S T G E T A B C D E Decision
  49. 49. Extrication S F I R S T G E T A B C D E http://rafah.virtualactivism.net/newsphotos/06/november/6/palestinian%20medical%20work ers%20carrying%20the%20body%20of%20one%20of%20the%20victims.jpg April 2008 Assess: • Current environmental conditions (e.g. heat, cold, wind, rain, direct sun, impending danger) • Egress route to transportation (manual handling considerations, obstacles, dangers) Consider: 1. Time Criticality: • Escape (if unsafe scene) • ASAP (‘load and go’) • Normal (non-critical patients) • Prolonged (may require shelter) 2. Getting help: • Requesting additional assistance 3. Where are you going, How will you get there? • Appropriate transport method (e.g. bariatrics, air transport) • Appropriate transport destination (e.g. cardiac or trauma bypass, paediatric centre, neuro centre, etc.)
  50. 50. To the Scenario Director • “This patient requires immediate extrication” [or] • “This patient is a load and go” [or] • “This patient can be extricated normally” [or] • “This is going to be a prolonged extrication, and I’m going to consider _____” • “I’m going to request _______ to assist in extrication” • “I’m going to request _______ to assist in patient care” • “I’m going to request _______ for transport” • “I’m going to transport the patient to _____” S F I R S T G E T A B C D E To the Patient • Explain to the patient what you are doing • (Be sure to get consent!) Extrication
  51. 51. 1. What are the four levels of time criticality? (exact words aren’t important, just explain the idea. • Have students explain the above to each other, forwards and backwards 2. Brainstorm possible destinations and why you would choose those over another 3. Have students brainstorm alternate transport teams S F I R S T G E T A B C D E Extrication
  52. 52. S F I R S T G E T A B C D E Scenario Time! Have the students do the following scenario: • 50 year old male walking in the park, bystanders saw him sit on a bench, then slump over gently. He didn’t respond when they tried to wake him up, so they called for help. There is no evidence of trauma to the patient.
  53. 53. S F I R S T G E T A B C D E The International Paramedic Primary Survey Questions?
  54. 54. About this presentation 1. This work is shared under a Attribution-NonCommercial-ShareALike 4.0 International (CC BY-NC-SA 4.0) Creative Commons License. 2. See: https://creativecommons.org/licenses/by-nc-sa/4.0/ 3. This work is authored by Marc Colbeck, based on the following work: Colbeck, M. A., Maria, S., Eaton, G., Campbell, C. B., Batt, A. M., & Caffey, M. R. (2018). International Examination and Synthesis of the Primary and Secondary Surveys in Paramedicine. Irish Journal of Paramedicine, 3(2), 1–9. https://doi.org/10.32378/ijp.v3i2.91 4. Maintaining and showing the second and last slide (in their entirety) in the presentation, is considered a sufficient statement of authorship under the License. You may add the presenters name to the first slide of the presentation. 5. Please visit www.paramedicine.com for more information. 6. You are not obligated to, but we would appreciate hearing about where this work was used in order to give us an idea of where it is spreading to. Feedback is greatly appreciated!

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