Prehospital Emergency Care 11th

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 vi Detailed Contents

PART 4 Bag-Valve-Mask Ventilation 253

Flow-Restricted, Oxygen-Powered Ventilation Device
Life Span Development 204
(FROPVD) 257
9 Life Span Development 204 Automatic Transport Ventilator (ATV) 258
Introduction 205 Ventilation of the Patient Who Is Breathing Spontaneously 259
Life Span Development 205 Continuous Positive Airway Pressure (CPAP) 260
Neonates and Infants 205 Hazards of Overventilation 263
Toddlers and Preschool-Age Children 208 Special Considerations in Airway Management and
School-Age Children 209 ­Ventilation 263
Adolescence 210 A Patient with a Stoma or Tracheostomy Tube 263
Early Adulthood 211 Infants and Children 265
Middle Adulthood 211 Patients with Facial Injuries 265
Late Adulthood 212 Foreign Body Airway Obstruction 266
Dental Appliances 266
Oxygen Therapy 266
PART 5
Oxygen Cylinders 266
Airway Management, Artificial Ventilation, Safety Precautions 267
and Oxygenation 216
Pressure Regulators 267
10 Airway Management, Artificial Ventilation, Oxygen Humidifiers 268
and ­Oxygenation 216 Clinical Decision Making Regarding Oxygen Administration 268
Introduction 218 Indications for Oxygen Administration 269
Respiration 218 Variations in SpO2 Goals for Medical, Trauma, and Other S­ pecial
Respiratory System Review 218 Consideration Patients 269
Anatomy of the Respiratory System 219 Hazards of Oxygen Administration 270
Mechanics of Ventilation (Pulmonary Ventilation) Review 221 Oxygen Administration Procedures 270
Respiratory Physiology Review 223 Terminating Oxygen Therapy 270
Pathophysiology of Pulmonary Ventilation and External and Transferring the Oxygen Source: Portable to On-Board 271
Internal Respiration 225 Oxygen Delivery Equipment 271
Airway Anatomy in Infants and Children 226
Airway Assessment 227 PART 6
Airway Functions and Considerations 228
Assessment 284
Abnormal Upper Airway Sounds 228
Opening the Mouth 229 11 Vital Signs, Monitoring Devices, and History ­Taking 286
Opening the Airway 229 Introduction 287
Suctioning 233 Gathering Patient Information 287
Airway Adjuncts 235 Vital Signs 288
Assessment of Breathing 239 Respiration 288
Relationship of Volume and Rate in Breathing Assessment 239 Pulse 290
Assessing for Adequate Breathing 240 Skin 293
Adequate Breathing 242 Pupils 294
Inadequate Breathing 243 Blood Pressure 296
Deciding whether or not to Assist Ventilation 244 Testing Orthostatic Vital Signs 299
Techniques of Artificial Ventilation 245 Vital Sign Reassessment 299
Differences Between Normal Spontaneous Ventilation and Monitoring Equipment 299
­Positive Pressure Ventilation 245 Pulse Oximeter: Oxygen Saturation Assessment 299
Basic Considerations 246 Noninvasive Blood Pressure Monitor 301
Mouth-to-Mouth Ventilation 249 Capnometry (EtCO2 Monitor) 302
Mouth-to-Mask and Bag-Valve Ventilation: General Preparing to take the History 303
­Considerations 249 Gain Control of the Scene 303
Mouth-to-Mask Ventilation 251 Achieve a Smooth Transition of Care 303

Reduce the Patient’s Anxiety 303
Maintain Control 304
Taking the History 305
Statistical and Demographic Information 305
Current Health Status 305
Techniques for Taking a Patient History 305
Standardized Approach to History Taking 306
Sensitive Topics or Special Challenges 308
12 Scene Size-Up 314
Introduction 315
Violence toward EMS Personnel 316
Take the Necessary Standard Precautions and other
Personal Protection Precautions 316
Determine Scene Safety 317
Consider Dispatch Information 317
Consider the Need for Additional or Specialized
Resources 318
Consider Scene Characteristics 318
Protect the Patient 324
Protect Bystanders 325
Control the Scene 325
Maintain Situation Awareness 326
Determine the Nature of the Problem 326
Determine the Mechanism of Injury 326
Determine the Nature of the Illness 328
Determine the Number of Patients 329
13 Patient Assessment 333
Introduction 335
Form a General Impression of the Patient 336
Introduction to Spine Motion Restriction 338
Determine Whether the Patient Is Injured or Ill 339
Obtain the Chief Complaint 340
Identify Immediate Life Threats During the General
­Impression 341
Perform Spine Motion Restriction 341
Position the Patient for Assessment 342
Assess Level of Consciousness (Mental Status) 342
Assess the Level of Responsiveness 342
Assess the Airway 345
Determine Airway Status 345
Open the Airway 345
Assess Breathing 346
Assess Rate and Quality of Breathing 347
Assess Oxygenation 349
Oxygen Therapy in the Patient with Adequate
Breathing 349
Detailed Contents vii
Assess Circulation 349
Assess the Pulse 350
Identify Major Bleeding 351
Assess Perfusion 351
Establish Patient Priorities 353
Overview of Secondary Assessment: Anatomic
and Body ­Systems Approaches, Vital Signs,
and History 357
Performing the Secondary Assessment: An Anatomic
­Approach 357
Performing the Secondary Assessment: A Body Systems
­Approach 366
Assess Vital Signs 367
Obtain a History 367
Reevaluate the Mechanism and Injury 368
Significant Mechanisms of Injury 368
Rapid Secondary Assessment: Trauma Patient with ­
Significant Mechanism of Injury, Altered Mental Status,
Multiple ­Injuries, or Critical Finding (Unstable) 370
Continue Spine Motion Restriction 370
Consider an Advanced Life Support Request 370
Reconsider the Transport Decision 370
Reassess Mental Status 370
Perform a Rapid Secondary Assessment 372
Assess Vital Signs 382
Obtain a History 384
Prepare the Patient for Transport 385
Provide Emergency Care 386
Trauma Score 388
Modified Secondary Assessment: Trauma Patient with No
Significant Mechanism of Injury, Altered Mental Status,
Multiple Injuries, or Critical Finding (Stable) 388
Perform a Modified Secondary Assessment 388
Obtain Vital Signs and History 390
Perform a Rapid Secondary Assessment if Indicated 390
Medical Patient who is not Alert or is Disoriented, is
­Responding Only to Verbal or Painful Stimuli, or is
­Unresponsive 392
Perform a Rapid Secondary Assessment for the Medical
Patient 392
Assess Vital Signs 395
Position the Patient 396
Obtain a History 397
Provide Emergency Care 398
Make a Transport Decision 398
Responsive Medical Patient who is Alert and Oriented 398
Assess Patient Complaints: OPQRST 399
Complete the History 399
Perform a Modified Secondary Assessment 399
Assess Vital Signs 399
 viii Detailed Contents

Provide Emergency Care 399
Make a Transport Decision 399
Purposes of the Reassessment 400
Detect Any Change in Condition 401
Identify Any Missed Injuries or Conditions 401
Adjust the Emergency Care 401
Repeat the Primary Assessment 402
Reassess Mental Status 402
Reassess the Airway 402
Reassess Breathing 402
Reassess Oxygenation 402
Reassess Circulation 402
Reestablish Patient Priorities 403
Complete the Reassessment 403
Reassess and Record Vital Signs 403
Repeat Components of the Secondary Assessment for
Other Complaints 403
Check Interventions 403
Note Trends in the Patient’s Condition 403
PART 7
General Pharmacology and
Medication Administration 419
14 General Pharmacology and Medication ­Administration 419
Introduction 420
Administering Medications 420
Medications the EMT Commonly Administers 421
Medications 421
Medication Names 426
Routes of Administration 427
Medication Forms 428
Essential Medication Information 429
Indications 429
Contraindications 429
Dose 429
Administration 429
Actions 429
Side Effects 429
Key Steps in Administering Medications 430
Obtain an Order from Medical Direction 430
Select the Proper Medication 430
Verify the Patient’s Prescription for Patient-Assisted
­Administration 430
Check the Expiration Date 431
Check for Discoloration or Impurities 431
Verify the Form, Route, and Dose 431
Medication Administration: The Five “Rights” 431
Documentation 431
Reassessment Following Administration 432
Sources of Medication Information 432
PART 8
Shock and Resuscitation 435
15 Shock and Resuscitation 435
Introduction 436
Shock 436
Etiologies of Shock 437
Categories of Shock 440
Specific Types of Shock 443
The Body’s Response to Shock 445
Stages of Shock 446
Shock Assessment 449
Age Considerations in Shock 451
General Goals of Prehospital Management
of Shock 451
Resuscitation in Cardiac Arrest 452
Pathophysiology of Cardiac Arrest 452
Terms Related to Out-of-Hospital Cardiac Arrest (OHCA)
­Resuscitation 453
Withholding a Resuscitation Attempt 453
The 2015 AHA Chain of Survival 453
Automated External Defibrillation and Cardiopulmonary
­Resuscitation 454
Types of Defibrillators 455
Analysis of Cardiac Rhythms 456
When and When Not to Use the AED 458
Recognizing and Treating Cardiac Arrest 458
Assessment-Based Approach: Cardiac Arrest 458
Performing Defibrillation 460
Cardiac Arrest in a Pregnant Patient 461
Transporting the Cardiac Arrest Patient 462
Post-Resuscitation Care 463
Providing for Advanced Cardiac Life Support 463
Summary: Assessment and Care 463
Special Considerations for the AED 463
Safety Considerations 463
AED Maintenance 464
Training and Skills Maintenance 466
Medical Direction and the AED 466
Cardiac Pacemakers 466
Automatic Implantable Cardioverter Defibrillators 466
Automated Chest Compression Devices 467
 Detailed Contents ix

PART 9 Assessment and Care: General Guidelines 542

Assessment-Based Approach: Cardiac Compromise and
Medical 472
Acute Coronary Syndrome 542
16 Respiratory Emergencies 472
Summary: Assessment and Care 546
Introduction 473
Respiratory Anatomy, Physiology, and Pathophysiology 473
Normal Breathing 474 18 Altered Mental Status, Stroke, and Headache 555
Abnormal Breathing 474 Introduction 556
Respiratory Distress 475 Altered Mental Status 556
Pathophysiology of Conditions that Cause Respiratory Assessment-Based Approach: Altered Mental Status 557
­Distress 477 Stroke 559
Obstructive Pulmonary Diseases 478 Neurologic Deficit Resulting from Stroke 559
Other Conditions That Cause Respiratory Acute Stroke 560
Distress 483 Pathophysiology of a Stroke 561
Metered-Dose Inhalers and Small-Volume Nebulizers 492 Types of Stroke 562
Using an MDI 493 Stroke or Transient Ischemic Attack 565
Using an SVN 493 Assessment-Based Approach: Stroke and Transient
Advair: Not for Emergency Use 496 Ischemic Attack 568
Age-Related Variations: Pediatrics and Geriatrics 496 Summary: Assessment and Care 577
Pediatric Patients 497 Headache 577
Respiratory Distress or Failure in the Pediatric Patient: Types of Headache 577
­Assessment and Care 497 Assessment 579
Geriatric Patients 499 Emergency Medical Care 579
Respiratory Distress or Failure in the Geriatric Patient: Stroke 580
­Assessment and Care 499
Assessment and Care: General Guidelines 500 19 Seizures and Syncope 584
Assessment-Based Approach: Respiratory Distress 500 Introduction 585
Summary: Assessment and Care 510 Seizures 585
Pathophysiology of Seizures 586
17 Cardiovascular Emergencies 520 Types of Seizures 587
Introduction 521 Assessment-Based Approach to Seizure Activity 592
Review of the Circulatory System Anatomy, Physiology, Summary: Assessment and Care for Seizures 596
and Pathophysiology 521 Syncope 598
The Circulatory System 521
The Electrocardiogram 528 20 Acute Diabetic Emergencies 603
Blood Pressure 529 Introduction 604
Inadequate Circulation 529 Understanding Diabetes Mellitus 604
Cardiac Compromise and Acute Coronary Syndrome 529 Glucose (Sugar) 604
Arteriosclerosis and Atherosclerosis 529 Hormones That Control Blood Glucose Levels 605
Acute Coronary Syndrome 530 Normal Metabolism and Glucose Regulation 606
The Dangers of Administering Too Much Oxygen in ­Acute Checking the Blood Glucose Level 608
­Coronary Syndrome 534 Diabetes Mellitus 608
Other Causes of Cardiac Compromise 535 Acute Diabetic Emergencies 610
Cardiac Arrest 538 Hypoglycemia 610
Nitroglycerin 538 Hyperglycemia 614
Age-Related Variations: Pediatrics and Geriatrics 539 Hyperglycemic Condition: Diabetic Ketoacidosis 614
Pediatric Considerations 539 Hyperglycemic Condition: Hyperglycemic Hyperosmolar
Geriatric Considerations 539 ­Syndrome 618
 x Detailed Contents
Assessment-Based Approach: Altered Mental Status in
A ­Diabetic Emergency 620
Scene Size-Up and Primary Assessment 620
History and Secondary Assessment 620
Emergency Medical Care 622
Reassessment 622
Summary: Assessment and Care 622
21 Allergic and Anaphylactic Reactions 629
Introduction 630
Allergic and Anaphylactic Reactions 630
Pathophysiology of Allergic Reaction 630
Pathophysiology of Anaphylactic Reaction 631
Assessment-Based Approach to Anaphylactic
Reaction 634
Summary: Assessment and Care 640
Epinephrine 640
22 Toxicologic Emergencies 650
Introduction 651
Poisons and Poisonings 651
Poisons and Routes of Exposure 651
Managing the Poisoning Patient 653
Antidotes 653
Ingested Poisons 653
Assessment-Based Approach: Ingested Poisons 653
Activated Charcoal 656
Inhaled Poisons 658
Assessment-Based Approach: Inhaled Poisons 658
Injected Poisons 660
Assessment-Based Approach: Injected Poisons 660
Absorbed Poisons 661
Assessment-Based Approach: Absorbed Poisons 662
Summary: Assessment and Care 663
Specific Types of Poisoning 666
Food Poisoning 666
Carbon Monoxide Poisoning 666
Cyanide 667
Acids and Alkalis 668
Hydrocarbons 669
Methanol (Wood Alcohol) 669
Isopropanol (Isopropyl Alcohol) 670
Ethylene Glycol 670
Poisonous Plants 671
Suicide Bags and Chemical Suicide by Toxic Gas
Inhalation 671
Poison Control Centers 672
Drug and Alcohol Emergencies 672
Assessment-Based Approach: Drug and Alcohol
­Emergencies 674
Summary: Assessment and Care 678
Managing a Violent Drug or Alcohol Abuse Patient 678
Specific Substance Abuse Considerations 682
Drug Withdrawal 682
The Alcoholic Syndrome 682
The Withdrawal Syndrome 684
Opioids 684
PCP, Cocaine, Amphetamines, Methamphetamines, PABS,
and MDMA 688
Tetrahydrocannabinol 689
Medication Overdose 690
Huffing 691
23 Abdominal, Hematologic, Gynecologic, Genitourinary,
and Renal Emergencies 696
Introduction 697
Acute Abdomen 697
Abdominal Structures and Functions 697
Abdominal Pain 699
Conditions That Can Cause Acute Abdominal Pain 701
Considerations in Special Populations with Abdominal
Pain 706
Assessment-Based Approach: Acute Abdomen 707
Summary: Assessment and Care 710
Hematologic Emergencies 710
Common Hematologic Conditions 710
Gynecologic Emergencies 714
Female Reproductive Structures and Functions 714
Gynecologic Conditions 714
Assessment-Based Approach: Gynecologic
Emergencies 717
Genitourinary/Renal Emergencies 719
Genitourinary/Renal Structures and Functions 719
Genitourinary/Renal Conditions 720
Assessment-Based Approach: Genitourinary/Renal
­Emergencies 723
24 Environmental Emergencies 728
Introduction 729
Heat and Cold Emergencies 729
Regulation of Temperature 729
Exposure to Cold 732
Generalized Hypothermia 732
Pathophysiology of Generalized Hypothermia 733
Nonfreezing Cold Injury 736
Freezing Cold Injury 737
Pathophysiology of Freezing Cold Injury 737
Assessment-Based Approach: Cold-Related
Emergency 737
Summary: Assessment and Care—Cold Emergency 745
 Detailed Contents xi

Exposure to Heat 745 Dealing with Psychiatric Emergencies 796

Hyperthermia 745 Basic Principles 796
Pathophysiology of Heat-Related Emergencies 745 Techniques for Treating Psychiatric Emergency Patients 797
Assessment-Based Approach: Heat-Related Assessment-Based Approach: Psychiatric Emergencies 798
Emergency 750 Summary: Assessment and Care 801
Summary: Assessment and Care—Heat Emergency 753 Restraining a Patient 801
Exercise-Associated Hyponatremia 753 Legal Considerations 805
Bites and Stings 755 Consent 805
Snakebite 755 Refusal of Care 805
Insect Bites and Stings 757 Using Reasonable Force 805
Assessment-Based Approach: Bites and Stings 758 Police and Medical Direction 806
Marine Life Bites and Stings 760 False Accusations 806
Lightning Strike Injuries 760
Pathophysiology of a Lightning Strike Injury 761 PART 10
Assessment of the Lightning Strike Patient 762
Trauma 810
Emergency Care for the Lightning Strike Patient 763
High-Altitude Sickness 763 27 Trauma Overview: The Trauma Patient and
Acute Mountain Sickness 763 the Trauma System 810
High-Altitude Pulmonary Edema 764 Introduction 811
High-Altitude Cerebral Edema 764 The Kinetics of Trauma 811
Mass and Velocity 811
Acceleration and Deceleration 812
25 Submersion Incidents: Drowning and Diving
Energy Changes Form and Direction 812
­Emergencies 768
Impacts 812
Introduction 769
Mechanisms of Injury 813
Water-Related Emergencies 769
Vehicle Collisions 813
Definitions 769
Falls 822
Incidence of Drowning 770 Penetrating Injuries 822
Prognostic Predictors 770 Blast Injuries 825
Pathophysiology of Drowning 770 The Multisystem Trauma Patient 825
Diving Emergencies 772 The Golden Period and Platinum 10 Minutes 826
Safety Measures in Water-Related Emergencies 772 The Trauma System 827
Possible Spine Injury 773 Golden Principles of Prehospital Trauma Care 828
Resuscitation 774 Special Considerations in Trauma Care 828
Assessment-Based Approach: Drowning and Water-Related
Emergencies 774 28 Bleeding and Soft Tissue Trauma 833
Summary: Assessment and Care 777 Introduction 834
Scuba or Deepwater Diving Emergencies 778 External Bleeding 834
Basic Laws of Physics Related to Scuba or Deepwater Severity 834
Diving Emergencies 780 Types of Bleeding 835
Decompression Sickness 780 Methods of Controlling External Bleeding 836
Assessment-Based Approach: External Bleeding 840
26 Psychiatric Emergencies 785 Bleeding from the Nose, Ears, or Mouth 841
Introduction 786 Internal Bleeding 841
Psychiatric Problems and Emergencies 786 Severity 841
Behavioral Changes: Psychiatric or Physical? 787 Assessment-Based Approach: Internal Bleeding 842
Psychiatric Problems 789 Factors that Increase Bleeding 844
Violence 794 Hemorrhagic Shock 844
Mini Assessment for Common Psychiatric Assessment-Based Approach: Hemorrhagic Shock 845
Emergencies 795 Summary: Assessment and Care 846
 xii Detailed Contents

Soft Tissue Trauma 847 Injuries to Bones and Joints 900

The Skin 847 Types of Injuries 900
Closed Soft Tissue Injuries 849 Mechanism of Injury 902
Contusions 849 Critical Fractures: The Femur and the Pelvis 903
Hematomas 849 Assessment-Based Approach: Bone or Joint Injuries 904
Crush Injuries 849 Summary: Assessment and Care 907
Assessment-Based Approach: Closed Soft Tissue Basics of Splinting 907
­Injuries 849 General Rules of Splinting 907
Open Soft Tissue Injuries 850 Splinting Equipment 908
Abrasions 850 Hazards of Improper Splinting 911
Amputations 852 Splinting Long Bone Injuries 912
Penetrations/Punctures 852 Splinting Joint Injuries 912
Crush Injuries 853 Traction Splinting 912
Other Soft Tissue Injuries 853 Splinting Specific Injuries 913
Assessment-Based Approach: Open Soft Tissue Pelvic Fracture 913
Injuries 854 Compartment Syndrome 914
Dressings and Bandages 857 Nontraumatic Fractures 914
Dressings 857
Bandages 857 31 Head Trauma 927
Pressure Dressings 858 Introduction 928
General Principles of Dressing and Bandaging 858 Anatomy of the Skull and Brain 928
Summary: Assessment and Care 859 The Skull 928
The Brain 928
29 Burns 873 Head Injury 930
Introduction 874 Scalp Injuries 930
Review of the Anatomy of the Skin 874 Skull Injuries 930
Pathophysiology of Burns 875 Brain Injuries 930
Circulatory System 875 Pathophysiology of Traumatic Brain Injury 930
Respiratory System 875 Types of Head and Brain Injuries 931
Renal System (Kidneys) 875 Assessment-Based Approach: Head Injury 934
Nervous and Musculoskeletal Systems 876 Summary: Assessment and Care 942
Gastrointestinal System 876
Classification of Burns 876 32 Spinal Injury and Spine Motion Restriction 947
Classifying Burns by Depth 876 Introduction 948
Classifying Burns by Severity 877 Anatomy and Physiology of Spinal Injury 948
Types of Burns 881 The Nervous System 948
Causes of Burns 881 The Skeletal System 948
Assessment-Based Approach: Burns 883 Common Mechanisms of Spinal Injury 950
Chemical Burns 886 Spinal Column Injury Versus Spinal Cord Injury 952
Electrical Burns 887 Emergency Care for Suspected Spinal Injury 954
Summary: Assessment and Care 888 Assessment-Based Approach: Spinal Injury 954
Summary: Assessment and Care 961
30 Musculoskeletal Trauma and Nontraumatic Guidelines for Spine Motion Restriction 961
­Fractures 896 Historical Perspective: Spinal Immobilization Versus Spine
Introduction 897 ­Motion Restriction 961
Musculoskeletal System Review 897 Tools for SMR 966
The Muscles 897 Spine Motion Restriction Techniques 968
Tendons and Ligaments 897 The Ambulatory Patient 968
Cartilage 897 The Patient Found Supine or Prone 969
The Skeletal System 898 The Patient Seated in a Vehicle 970

Special Considerations 972
Helmets 972
SMR in Infants and Children 974
33 Eye, Face, and Neck Trauma 998
Introduction 999
Anatomy of the Eye, Face, and Neck 999
The Eye 999
The Face 1000
The Neck 1000
Eye, Face, and Neck Injuries 1001
Assessment-Based Approach: Eye, Face, and Neck
Injuries 1001
Specific Injuries Involving the Eye, Face, and Neck 1002
Injuries to the Eye 1002
Injuries to the Neck 1010
34 Chest Trauma 1020
Introduction 1021
The Chest 1021
Anatomy of the Chest 1021
General Categories of Chest Injuries 1023
Specific Chest Injuries 1024
Assessment-Based Approach: Chest Trauma 1030
Summary: Assessment and Care—Chest Trauma 1035
35 Abdominal and Genitourinary Trauma 1041
Introduction 1042
The Abdomen 1042
Anatomy of the Abdominal Cavity 1042
Abdominal Injuries 1044
Assessment-Based Approach: Abdominal Trauma
Summary: Assessment and Care—Abdominal
Trauma 1047
Genital Trauma 1048
36 Multisystem Trauma and Trauma in Special
Patient ­Populations 1053
Introduction 1054
Multisystem Trauma 1054
Golden Principles of Prehospital Multisystem Trauma
Care 1054
Trauma in Special Patient Populations 1056
Trauma in Pregnant Patients 1056
Trauma in Pediatric Patients 1057
Trauma in Geriatric Patients 1059
Trauma in Cognitively Impaired Patients 1060
Assessment-Based Approach: Multisystem Trauma and
Trauma in Special Patient Populations 1061
Scene Size-Up 1061
Detailed Contents xiii
Primary Assessment 1061
Secondary Assessment 1062
Emergency Medical Care 1062
Reassessment 1063
PART 11
Special Patient Populations 1066
37 Obstetrics and Care of the Newborn 1066
Introduction 1067
Anatomy and Physiology of the Obstetric Patient 1067
Anatomy of Pregnancy 1068
Menstrual Cycle 1069
Prenatal Period 1069
Physiologic Changes in Pregnancy 1070
Antepartum (Predelivery) Emergencies 1070
Antepartum Condition Causing Severe Vomiting,
Dehydration, and Electrolyte Imbalance: Hyperemesis
Gravidarum 1070
Antepartum Conditions Causing Hemorrhage 1071
Summary: Assessment and Care—Antepartum (Predelivery)
Emergency 1080
Labor and Normal Delivery 1081
Labor 1081
Assessment-Based Approach: Active Labor and Normal
­Delivery 1086
Abnormal Delivery 1091
Assessment-Based Approach: Active Labor with Abnormal
Delivery 1091
Intrapartum Emergencies 1092
Summary: Assessment and Care—Active Labor and
1044 ­Delivery 1100
Postpartum Complications 1100
Care of the Newborn 1102
Assessment-Based Approach: Care of the Newborn 1102
38 Pediatrics 1116
Introduction 1117
Dealing with Caregivers 1117
Dealing with the Child 1118
Developmental Characteristics 1118
Anatomic and Physiologic Differences 1120
Assessment-Based Approach to Pediatric Emergencies 1124
Scene Size-Up 1124
Primary Assessment 1124
Secondary Assessment 1129
Special Considerations for the Physical Exam 1129
Special Considerations for Assessing the Vital Signs 1132
Special Considerations for Taking a History 1132
Reassessment 1133
 xiv Detailed Contents

Airway and Respiratory Problems in Pediatric Patients 1133 The Gastrointestinal System 1186
Early Respiratory Distress 1133 The Endocrine System 1186
Decompensated Respiratory Failure 1134 The Musculoskeletal System 1186
Respiratory Arrest 1136 The Renal System 1187
Airway Obstruction 1136 The Integumentary System 1187
Signs and Symptoms of a Respiratory Emergency 1137 Special Geriatric Assessment Findings 1187
Emergency Medical Care—Respiratory Emergencies 1137 Assessment Finding: Chest Pain or Absence of Chest
Emergency Medical Care—Foreign Body Airway Pain 1187
­Obstruction 1140 Assessment Finding: Shortness of Breath (Dyspnea) 1189
Specific Pediatric Respiratory and Cardiopulmonary Assessment Finding: Altered Mental Status 1191
­Conditions 1143 Assessment Finding: Signs of Trauma or Shock 1195
Croup 1143 Assessment Finding: Gastrointestinal Bleeding 1196
Epiglottitis 1143 Assessment Finding: Environmental Temperature
Asthma 1144 ­Extremes 1197
Bronchiolitis 1146 Elder/Geriatric Abuse 1197
Pneumonia 1146 Assessment-Based Approach: Geriatric Patients 1198
Congenital Heart Disease (CHD) 1148 Scene Size-Up 1199
Shock 1148 Primary Assessment 1200
Cardiac Arrest 1149 Secondary Assessment 1202
Summary: Pediatric Respiratory and Cardiopulmonary Emergency Medical Care and Reassessment 1204
­Emergencies 1150
Other Pediatric Medical Conditions and Emergencies 1150 40 Patients with Special Challenges 1209
Seizures 1150 Introduction 1210
Altered Mental Status 1154 Recognizing the Patient with Special Challenges 1211
Drowning 1156 Sensory Impairments 1211
Fever 1157 Hearing Impairment 1211
Meningitis 1157 Vision Impairment 1211
Gastrointestinal Disorders 1158 Speech Impairment 1212
Poisoning 1159 Accommodations for Patients with Sensory
Brief Resolved Unexplained Events 1159 Impairments 1212
Sudden Infant Death Syndrome 1160 Cognitive and Emotional Impairments 1212
Pediatric Trauma 1162 Mental or Emotional Impairments 1212
Trauma and the Pediatric Anatomy 1162 Developmental Disabilities 1213
Infant and Child Car Seats in Trauma 1164 Autism and EMS 1213
Four-Point Spine Motion Restriction of an Infant or Child 1167 Accommodations for Patients with Mental, Emotional, or
Injury Prevention 1167 ­Developmental Impairments 1214
Child Abuse and Neglect 1168 Brain-Injured Patients 1215
Emergency Medical Care Guidelines for Child Abuse 1169 Accommodations for Brain-Injured Patients 1215
Special Care Considerations 1169 Paralysis 1216
Emergency Medical Services for Children 1169 Accommodations for Paralyzed Patients 1216
Family-Centered Care 1170 Obesity 1217
Taking Care of Yourself 1170 Accommodations for Obese Patients 1218
Homelessness and Poverty 1219
39 Geriatrics 1181 Accommodations for Patients Who Are Homeless or Poor 1220
Introduction 1182 Abuse 1221
Effects of Aging On Body Systems 1182 Human Trafficking 1221
The Cardiovascular System 1182 The Human Trafficking Victim 1221
The Respiratory System 1184 EMS Management for a Suspected Human Trafficking
The Neurologic System 1184 ­Victim 1222
 Detailed Contents xv

Domestic Violence 1223 Signature Wounds of the Combat Veteran 1249

The Domestic Violence Victim 1223 TBI Versus PTSD: Signs and Symptoms 1250
EMS Management for a Victim of Domestic Abuse or Assessing and Providing Emergency Care to Combat Veterans:
­Violence 1224 Recommendations for EMTs 1251
Technology Dependence 1225
Airway and Respiratory Devices 1226 PART 12
Medical Oxygen 1227
EMS Operations 1255
Apnea Monitors 1227
Pulse Oximetry 1228 42 Ambulance Operations and Air Medical Response 1255
Tracheostomy Tubes 1228 Introduction 1256
CPAP and BiPAP 1229 Culture of Safety in EMS 1256
Home Mechanical Ventilators 1230 Crew Resource Management 1257
Accommodations for Patients with Airway or Respiratory Driving the Ambulance 1259
Devices 1231 Laws, Regulations, and Ordinances 1259
Vascular Access Devices 1233 Driving Excellence 1259
Central Intravenous Catheters 1233 Warning Devices 1263
Central Venous Lines 1233 Colors and Markings 1263
Implanted Ports 1233 Warning Lights and Emergency Lights 1263
Accommodations for Patients with Vascular Access Using Your Siren 1263
­Devices 1233 Using Your Air Horn 1264
Ventricular Assist Device 1234 Roadway Incident Scene Safety 1264
Special Assessment Considerations for Patients with an High-Visibility Apparel 1264
­Implanted VAD 1234 Safety Benchmarks 1265
Accommodations for Patients with an Implanted Phases of an Ambulance Call 1265
VAD 1234 Daily Prerun Preparation 1265
Vagus Nerve Stimulator 1235 Dispatch 1266
Accommodations for Patients with a VNS 1235 En Route to the Scene 1267
Renal Failure and Dialysis 1235 At the Scene 1267
Accommodations for Patients on Dialysis 1236 En Route to the Receiving Facility 1269
Gastrointestinal and Genitourinary Devices 1236 At the Receiving Facility 1270
Feeding Tubes 1236 En Route to the Station or Response Area 1270
Ostomy Bags 1237 Post Run 1271
Urinary Tract Devices 1238 Air Medical Transport 1272
Accommodations for Patients with Gastrointestinal and When to Request Air Medical Transport 1272
­Genitourinary Devices 1238 Requesting Air Medical Transport 1273
Intraventricular Shunts 1239 Additional Considerations for Air Medical Transport 1273
Accommodations for Patients with Intraventricular Setting Up a Landing Zone 1273
Shunts 1239 Security and Safety 1275
Terminally Ill Patients 1240 Operational Security Measures 1275
Accommodations for Terminally Ill Patients 1241 Carbon Monoxide in Ambulances 1276

41 The Combat Veteran 1244 43 Gaining Access and Patient Extrication 1282
Introduction 1245 Introduction 1283
The Psychophysiology of Stress Response 1246 Planning Ahead 1283
Combat Veterans 1246 Dispatch 1283
The Nature of PTSD 1246 Location 1283
Associated Signs and Symptoms of PTSD 1248 Motor Vehicle Collisions 1284
Alcohol and Drug Use 1248 Sizing up the Scene 1284
Danger to Self or Other 1249 Perform a 360-Degree Assessment 1284
 xvi Detailed Contents
Evaluate the Need for Additional Resources 1284
Personal Protective Equipment 1284
Scene Safety 1285
Locate All Patients 1286
Vehicle Safety 1288
Gaining Access 1288
Residential Access 1288
Motor Vehicle Access 1289
Extrication 1290
The Role of the EMT 1290
Caring for the Patient 1291
Specialized Stabilization, Extrication, and Disentanglement
Techniques 1291
Stabilizing a Vehicle 1291
Extricating a Patient 1293
44 Hazardous Materials 1300
Introduction 1301
Identifying Hazardous Materials 1301
What Is a Hazardous Material? 1301
Placards and Shipping Papers 1305
Using Your Senses 1307
Resources 1308
Training Required by Law 1309
Guidelines for Hazardous Materials Rescues 1310
General Rules 1310
Decontamination 1311
Incident Management 1311
Emergency Procedures 1314
Radiation Emergencies 1315
Criminal Use of Hazardous Materials 1317
Terrorist Attacks 1318
45 Multiple-Casualty Incidents and Incident
­Management 1322
Introduction 1323
Multiple-Casualty Incidents 1323
National Incident Management System 1323
Incident Command System 1325
Triage 1326
Primary and Secondary Triage 1326
START Triage System 1328
JumpSTART Pediatric Triage System 1329
SALT Triage 1331
Patient Tagging 1331
Treatment 1333
Staging and Transport 1333
Communications 1334
Follow-Through 1334
Reducing Posttraumatic and Cumulative Stress
Disaster Management 1335
Requirements of Effective Disaster Assistance 1336
Warning and Evacuation 1336
Disaster Communications Systems 1336
The Psychological Impact of Disasters 1337
46 EMS Response to Terrorist Incidents 1340
Introduction 1341
Weapons of Mass Destruction 1341
Prehospital Response to Terrorism Involving WMD 1343
Supplies and Equipment 1343
Medical Direction 1343
Provider Preparation 1343
Responding to the Scene 1344
Issues of Scene Safety 1344
Role of the EMT at the Terrorist Incident Involving
WMD 1345
Conventional Explosives and Incendiary Devices 1345
Explosives 1345
Primary, Secondary, Tertiary, and Quaternary Effects 1346
Body Position 1346
Types of Injuries 1346
Incendiary Devices 1347
Chemical Agents 1347
Properties of Chemical Weapons 1347
Types of Chemical Agents 1348
Biological Agents 1351
Specific Biological Agents 1352
Emergency Medical Care for Biological Agents 1353
Nuclear Weapons and Radiation 1353
Radiation 1353
Blast Injuries 1354
Thermal Burns 1354
Radiological Dispersal Devices/Radiological Exposure
­Devices 1354
Improvised Nuclear Device 1355
Assessment and Care for Nuclear Detonation and Radiation
Injuries 1355
Personal Protection and Patient Decontamination 1356
Active Shooter Incident 1356
Tactical EMS 1356
Cyberterrorism 1357
Appendix 1 ALS-Assist Skills 1359
Appendix 2 Advanced Airway Management 1366
Appendix 3 Agricultural and Industrial
­Emergencies 1398
Answer Key 1407
Glossary 1445
1335 Index 1461

Assessment Summaries
Cardiac Arrest 464
Respiratory Distress 510
Cardiac Compromise and Acute Coronary
Syndromes 548
Stroke 578
Seizures 597
Acute Diabetic Emergency: Suspected
Hypoglycemia 623
Anaphylactic Reaction 640
Poisoning Emergency 663
Emergency Care Protocols
Cardiac Arrest 464
Respiratory Distress 511
Cardiac Compromise and Acute Coronary
Syndromes 549
Stroke 579
Seizures 598
Acute Diabetic Emergency 624
Anaphylactic Reaction 641
Poisoning Emergency 664
Drug or Alcohol Emergency 680
Acute Abdominal Pain 711
Generalized Hypothermia Emergency 747
Heat Emergency 755
Drowning 778
Emergency Care Algorithms
Automated External Defibrillation 465
Respiratory Distress/Failure/Arrest 512
Cardiac Compromise 550
Stroke 580
Seizures 599
Acute Diabetic Emergency 625
Anaphylactic Reaction 642
Poisoning Emergency 665
Drug or Alcohol Emergency 681
Acute Abdominal Pain 712
Key Features
Drug or Alcohol Emergency 679
Acute Abdominal Pain 711
Generalized Hypothermia Emergency 746
Heat Emergency 754
Drowning 777
Behavioral Emergency 802
Bleeding and Hemorrhagic Shock 846
Soft Tissue Trauma 860
Burn Emergency 889
Musculoskeletal Injury 908
Behavioral Emergency 803
Bleeding and Hemorrhagic Shock 847
Soft Tissue Trauma 861
Burn Emergency 890
Musculoskeletal Injury 909
Head Injury 943
Spine Injury 962
Eye Injury 1007
Facial Injury 1011
Neck Injury 1012
Chest Trauma 1037
Abdominal Trauma 1048
Antepartum (Predelivery) Obstetric
Emergency 1081
Cold Emergency 748
Heat Emergency 756
Drowning Emergency 779
Psychiatric Emergency 804
Bleeding and Shock 848
Open Soft Tissue Trauma 862
Burn Emergency 891
Musculoskeletal Injury 910
Head Injury 944
Spine Injury 963
Head Injury 942
Spine Injury 961
Chest Trauma 1036
Abdominal Trauma 1047
Antepartum (Predelivery) Obstetric
­Emergency 1080
Obstetric Emergency—Active Labor and
Delivery 1101
Respiratory or Cardiopulmonary Emergency
in the Pediatric ­Patient 1151
Obstetric Emergency—Active Labor
and Delivery 1102
Newborn Infant 1109
Pediatric Shock 1149
Respiratory or Cardiopulmonary Emergency
in the Pediatric Patient 1152
Pediatric Seizures 1155
Pediatric Altered Mental Status 1156
Pediatric Drowning 1157
Pediatric Fever 1158
Pediatric Poisoning 1160
Sudden Infant Death Syndrome 1161
Pediatric Trauma 1168
Pediatric Abuse and Neglect 1170
Chest Trauma 1038
Abdominal Trauma 1049
Antepartum (Predelivery) Obstetric
­Emergency 1082
Obstetric Emergency—Active Labor and
Delivery 1103
Newborn Care and Resuscitation 1110
Respiratory or Cardiopulmonary Emergency
in the Pediatric Patient 1153
xvii
 xviii Key Features

Drug Profiles
The Drug Profiles are intended to provide additional information about the medications and their administrations.
Beta2 agonist Metered-Dose Inhaler (MDI)/ Aspirin 547 Activated Charcoal 657
Small-Volume Nebulizer (SVN) 494–496 Oral Glucose 613 Naloxone 687
Nitroglycerin 540 Epinephrine 643
 EMT Skills
Safe Glove Removal 41 Bleeding Control by Direct Pressure 863
Power Lift 119 Application of a Tourniquet 864
Direct Ground Lift 120 Controlling a Nosebleed 865
Extremity Lift 121 Emergency Care for Shock 865
Direct Carry 121 Soft Tissue Injuries 866
Draw Sheet Method 122 Gunshot Wounds 867
Loading the Roll-In Wheeled Stretcher 122 Stabilizing an Impaled Object 867
Bariatric Stretchers 123 Bandaging 868
Moving a Patient on a Stair Chair 123 The Self-Adhering Roller Bandage 870
Applying the Scoop Stretcher 124 Superficial and Partial-Thickness Burns 892
Suctioning Technique 274 Full-Thickness Burns 892
Inserting an Oropharyngeal Airway 275 Electrical Burn 893
Inserting a Nasopharyngeal Airway 276 General Splinting Rules 915
Patient Has Breathing Difficulty: When and How to Intervene 277 Applying a Vacuum Splint 916
Spine Motion Restriction During Bag-Valve Ventilation 278 Splinting a Long Bone 917
Continuous Positive Airway Pressure (CPAP) Procedure 279 Splinting a Joint 918
Initiating Oxygen Administration 280 Applying a Bipolar Traction Splint 918
Taking Blood Pressure by Auscultation 310 Applying a Unipolar Traction Splint 920
Taking Blood Pressure by Palpation 310 Applying a Sling and Swathe 921
Taking Orthostatic Vital Signs 311 Splinting Specific Injuries 922
Pulse Oximetry 311 Neurologic Assessment of Motor and Sensory Function 975
Scene Characteristics 330 Establish Manual In-Line Motion Restriction 977
Log Rolling from a Prone to a Supine Position When Spinal Injury Is Cervical Collars 977
Suspected 404 Sizing a Cervical Collar 978
Assessing Capillary Refill in Children and Infants 404 Applying a Cervical Collar to a Seated Patient 979
The Secondary Assessment: Anatomic Approach 405 Applying a Cervical Collar to a Supine Patient 979
Common Signs of Trauma 408 Applying an Adjustable Collar to a Seated Patient 980
The Rapid Secondary Assessment for the Trauma Patient 410 Applying an Adjustable Collar to a Supine Patient 981
The Rapid Secondary Assessment for the Medical Patient 412 Four-Rescuer Log Roll and Spine Motion Restriction Using a
The Reassessment 414 ­Backboard 982
Using a Semiautomated AED Ideally, at Least Two EMTs Securing a Patient to a Long Board 983
Should be Present—One to Operate the AED and the Other Three-Rescuer Log Roll 984
to Perform CPR. 468 Two-Rescuer Log Roll 985
Auscultating the Chest 513 Examples of Spine Motion Restriction Devices 985
Administering Medication by Metered Dose Inhaler 514 Assessment for Spinal Injury in an Ambulatory Patient 986
Administering a Metered-Dose Inhaler with a Valved Holding Spine Motion Restriction in an Ambulatory Patient 987
Chamber 515 Spine Motion Restriction in Self-Extrication from a Motor
Administering Nebulized Medications 516 ­Vehicle 988
Assisting a Patient with Prescribed Nitroglycerin 551 Spine Motion Restriction of a Seated Patient with a Ferno K.E.D.
Testing the Blood Glucose Level with a Glucose Meter 626 Extrication Device 989
Administering an Epipen Epinephrine Auto-Injector 646 Rapid Extrication 990
Routes of Exposure 692 Helmet Removal 991
Administering Activated Charcoal 693 Helmet Removal—Alternative Method 992
Restraining the Combative Patient 807 Removing a Football Helmet Face Mask 993

xix
 xx EMT Skills
Extrication from a Child Safety Seat 994
Removal of Foreign Object—Upper Eyelid 1013
Emergency Care—Impaled Object in the Eye 1013
Injuries to the Face 1014
Injuries to the Mouth, Jaw, Cheek, and Chin 1014
Injuries to the Nose 1015
Injuries to the Ear 1015
Injuries to the Neck 1016
Emergency Care—Severed Blood Vessel of the Neck
Dressing an Abdominal Evisceration 1050
Childbirth 1111
Neonatal Resuscitation 1112
Pediatric Primary Assessment 1171
Checking Capillary Refill 1172
The Pediatric Physical Exam 1173
Oropharyngeal Airway 1176
Nasopharyngeal Airway 1176
A Pediatric Spine Motion Restriction System 1177
Child Abuse and Neglect 1178
Spine Motion Restriction for a Patient with Kyphosis 1206
Elements of the Daily Vehicle Inspection 1277
En Route to the Receiving Facility 1277
Post Run 1279
Breaking an Automobile Window 1295
Stabilizing a Vehicle on its Side 1295
1016 Extricating an Entangled Patient 1296
Extricating a Patient from a Vehicle on Its Side 1298
Hazardous Materials Protective Equipment 1319
Assisting with IV Administration 1363
ECG 3-Lead Placement 1364
ECG 12-Lead Placement 1364
Orotracheal Intubation 1394
Orotracheal Suctioning 1395
Nasogastric Intubation 1396
 Preface
Congratulations on your decision to undertake an EMT
education program. The field of emergency medical ser-
vices is extremely rewarding and will provide you with
experiences you will find both challenging and gratifying.
Be Prepared
As an EMT student, you have a few pressing concerns.
You want to be prepared:
• To pass your course exams
• To pass the credentialing exam that allows you to
practice as an EMT
• To treat patients to the best of your ability
• To do well in all aspects of your job
As the authors, we want to assure you that Prehospital
Emergency Care, 11th Edition, is written to help you
achieve those goals.
It All Makes Sense
The key to the above goals—passing your exams, pro-
viding excellent patient care, and doing well in your
job—is understanding how everything fits together:
• A basic understanding of anatomy, physiology, and
pathophysiology will allow you to better understand
signs, symptoms, and emergency care.
• An anatomical and body systems approach to the
physical exam will link conditions to assessment
findings.
• Knowledge of the presentations of common medical
conditions and traumatic injuries encountered in the
prehospital environment will enable you to perform
efficient and accurate assessments.
• A diagnostic-based approach to patient assessment
will allow you to form a differential field impression
of the condition or injury.
• An assessment-based approach to patient assess-
ment will allow you to identify and provide immedi-
ate emergency care for life-threatening conditions or
injuries.
• You will learn how to provide the most efficient and
effective emergency care.
The good news is that—although what you have to
learn may seem daunting in the beginning—it all makes
sense. In fact, that is the philosophy behind this text-
book. Our purpose has been to show you at every step
of your EMT education program how:
It all makes sense!
Features
All of the features in this textbook are designed to help
you navigate the anatomy, physiology, pathophysiology,
assessment findings, medical conditions, traumatic inju-
ries, and emergency care to best prepare you to provide
excellent emergency medical services to the patient—
beginning with the dispatch of the call, followed by as-
sessment and management of the patient and delivery
to the medical facility, through writing your prehospital
care report. In addition to the many new photographs
and illustrations, in the “clinical” chapters (on airway
care, the medical chapters, and the trauma chapters)
you will find:
• Assessment Tips
• Pathophysiology Pearls
• Drug Profiles
• Assessment Summaries
• Emergency Care Protocols
• Emergency Care Algorithms
• Pathophysiology notes within the Case Study Follow-
Ups to explain the “why” of what you observe about
the patient
And a special feature that appears throughout Chapter 13,
“Patient Assessment”:
• Critical Findings,
which explains, at every step of the assessment, critical
conditions/signs/symptoms you may find . . . what might
be causing them . . . and specifically what you should do
when your assessment of the patient reveals one of these
critical findings.
EMTs are often taught WHAT signs and symp-
toms they should expect to see in certain conditions
and WHAT should be done; however, the WHY of
assessment and emergency care is often not well
addressed. Three of the features, “Pathophysiology
Pearls,” “Assessment Tips,” and the new pathophysiol-
ogy notes in the clinical-chapter Case Study Follow-
Ups —in addition to expanded discussion within the
chapters—provide you with a basic understanding so
that you can better comprehend WHY you are see-
ing signs and symptoms and WHY you are providing
specific emergency care.
The Assessment Summaries, Emergency Care Proto-
cols, Emergency Care Algorithms, and Critical Thinking
features provide the most up-to-date strategies for pro-
viding competent care. These features and the entire text
have been updated to conform to the latest American
Heart Association guidelines.
xxi
 xxii Preface
In Your EMS Career
In your EMS career, you will respond to a variety of calls
in uncontrolled environments requiring confidence, com-
passion, and a high degree of competence. As an EMT,
you will be put to the test to think critically and respond
instantaneously. The foundation for these skills will be
provided in your education program; you will learn fur-
ther and gain better clinical insight through patient con-
tact, continuing education, and experience. Once you
have read this textbook and complete your EMT program,
you will have only begun your educational experience as
an EMT. Every day you should strive to learn something
new that may enhance your emergency patient care. Be-
cause of the dynamic nature of emergency medical ser-
vices, you will become a lifelong learner.
Pathophysiology
As an EMT, you will be required to learn about many pa-
tient conditions and injuries that you will encounter in the
prehospital environment. Identifying these conditions and
injuries is most often based on the recognition of specific
signs and symptoms and history findings. Not only is it
difficult to memorize the myriad of signs and symptoms
for each condition or injury, it is not desirable, because
not every patient presents with just one condition or in-
jury or all of the same signs and symptoms. A good basic
foundation of pathophysiology helps you to understand
and explain the “why” behind the patient presentation.
There is no need to memorize when you understand and
can explain why each sign or symptom is occurring. Put-
ting this together with a fundamental understanding of
the pathophysiology of the conditions and a thorough ap-
proach to patient assessment will allow you to quickly
recognize immediate life threats and provide excellent
emergency care. Don’t memorize, but understand. This is
the foundation to making “it all make sense!”
The Importance of Patient
Assessment
Patient assessment is one of the most important skills
that an EMT performs, requiring good practical ability
and also the capability to think critically. You must take
each finding from the assessment, determine if an im-
mediate life-saving intervention is required, store the
information learned in the back of your mind as you
continue with the assessment, and finally put all the
pieces of the assessment together to provide effective
emergency medical care. The challenge is similar to
putting a puzzle together. You start out with individual
pieces of the puzzle that have to be connected to form a
meaningful picture. The pieces of the puzzle correlate to
signs, symptoms, and other findings of the assessment.
You must take the findings, consider them individually,
and then put them together to form a whole picture of
your patient. Specific findings are meaningless without
fitting them into the entire picture.
Prehospital Emergency Care, 11th Edition, provides
a strong, comprehensive approach to patient assessment,
which is reinforced at several points in the chapters—in
the Case Study, chapter text, Assessment-Based Approach,
Assessment Summaries, and Algorithms. This approach rein-
forces assessment information and also provides an alterna-
tive learning method. You will find the necessary clinical
information integrated into the assessment approach for
each section, unlike other sources that integrate the assess-
ment information into the clinical information.
This textbook uses a two-tiered approach to teaching
emergency medical care: assessment based and diagnostic
based. An assessment-based approach to patient injuries
and illnesses teaches you to identify life-­threatening con-
ditions and provide immediate interventions to reverse
those problems. An assessment-based approach to acute
patient care is followed no matter what level of care is
provided. Once you have managed life-threatening condi-
tions, you will then move to the next level of assessment,
the diagnostic-based approach. The d ­ iagnostic-based
approach entails putting the signs, symptoms, and other
assessment findings together to come to a probability
of what conditions the patient may be suffering from.
Many EMS providers refer to this as their “differential field
impression.” Prehospital Emergency Care, 11th Edition,
presents the necessary information to move naturally,
successfully, and effectively from the assessment-based
approach to the diagnostic-based approach.
Using Medical Terminology
As you progress through your education program, you will
learn a new system of communication that involves the
use of appropriate medical terminology. It is important to
establish a basic understanding of medical terminology so
that you may communicate effectively, both orally and in
writing, with other members of the medical team. Prehos-
pital Emergency Care, 11th Edition, addresses medical ter-
minology in Chapter 7, “Anatomy, Physiology, and Medi-
cal Terminology,” and has integrated a basic foundation
of medical terminology into each chapter (see the terms
in bold type and the glossary at the end of the book) that
will help you to enhance your professional image and
communication skills. You should expand your medical
terminology base as you continue your education.
As You Begin Your EMS Career
We wish you the best of luck as you begin your career in
emergency medical services. Our best piece of advice to
you is to provide the best emergency care possible and al-
ways do what is right for the patient. This will allow you to
contribute to the mission of emergency medical services.
Good luck and best wishes!
Joseph J. Mistovich and Keith J. Karren
 What’s New in the 11th Edition?
Prehospital Emergency Care, 11th Edition, continues to meet
the National EMS Education Standards published by the Na-
tional Highway Traffic Safety Administration in 2009 and to re-
flect the latest and best medical knowledge and practices in
emergency medical services in the United States. Recognizing,
as well, that equipment, standards, and practices vary from one
state and local EMS service to another, the statement “follow lo-
cal protocols” appears in numerous places throughout the text.
The content of Prehospital Emergency Care, 11th Edition,
is summarized here, with emphasis on “what’s new” in this
edition. The text’s table of contents is organized to follow the
National EMS Educational Standards.
Part 1: Preparatory and Public Health
The chapters that fall under the first two standards, “Prepara-
tory” and “Public Health,” set the foundation for the chapters
that follow with such basic topics as EMS systems; research;
public health; workforce safety and wellness; medical, legal,
and ethical issues; documentation; communication; and lifting
and moving patients.
What’s New?
• Chapter 1, “Emergency Medical Care Systems, Research, and
Public Health,” includes new and updated information on
types of EMS services, medical oversight of EMS, and
EMS research. New sections on evidence-based guide-
lines (EBG), mobile integrated healthcare (MIH), and
community paramedicine (CP) have been added.
• Chapter 2, “Workforce Safety and Wellness of the EMT,”
includes new information on emergency infectious dis-
eases (EID), including new sections on Ebola virus and
zika virus disease. A new discussion of clandestine
drug labs is included.
• Chapter 3, “Medical, Legal, and Ethical Issues,” regarding a
patient’s ability to consent to or refuse care, includes a new
explanation of the terms competence and capacity —
noting that while EMS personnel cannot judge a patient’s
competence (a legal judgment that can only be made in a
court of law), EMS and other medical personnel can judge
a patient’s capacity (a medical assessment) to understand
and make rational decisions.
• Chapter 4, “Documentation,” has a new list of documen-
tation goals and expanded information on mandatory
reporting.
• Chapter 5, “Communication,” has a new information and
new sections on new and advanced communications tech-
nology, including FirstNet, a nationwide public safety
broadband, land mobile radio systems (LMRS), as well
as telemetry and land mobile satellite communications.
• Chapter 6, “Lifting and Moving Patients,” places new
emphasis on spine motion restriction and self restric-
tion to replace former emphasis on immobilization of
patients with suspected spinal injury, on the basis that
total “immobilization” of the spine is impossible, and that
“immobilization” to a hard spine board has been found in
many instances to worsen injuries. (The complete explana-
tion of spine motion restriction is in Chapter 32, “Spinal
Trauma and Spine Motion Restriction.”
Part 2: Anatomy, Physiology, and
Medical Terminology
These standards are covered in a single chapter, Chapter 7,
“Anatomy, Physiology, and Medical Terminology.” This chap-
ter has no significant changes from the prior edition.
Part 3: Pathophysiology
This standard is covered in one chapter, Chapter 8, “Patho-
physiology.” This chapter is largely unchanged from the prior
edition.
Part 4: Life Span Development
This standard is covered in one chapter, Chapter 9, “Life Span
Development.”
What’s New?
• Chapter 9, “Life Span Development,” presents a table of
vital signs revised from the prior edition in accordance
with the values included American Heart Association
and American Academy of Pediatric Life Support
Pediatric Advanced Life Support 2016. (Vital signs
values throughout the text have been revised to be con-
sistent with these.).
Part 5: Airway Management, Artificial
Ventilation, and Oxygenation
This standard is covered in one chapter, “Airway Management,
Artificial Ventilation, and Oxygenation.”
What’s New?
• Chapter 10, “Airway Management, Artificial Ventilation, and
Oxygenation,” includes revised information on cricoid pres-
sure to reflect contraindications and modified recommenda-
tions for its use. The CPAP section is revised to explain uses
to overcome PEEP and auto-PEEP (exhalation difficulties)
and possible uses of CPAP in children. Importantly, there are
updated recommendations for oxygen administration in
medical patients and trauma patients to reflect current
recommendations of the American Heart Association and
the American College of Surgeons (and revised through-
out the text to be consistent with these).
Part 6: Assessment
The chapters that fall under the “Assessment” standard are
those that detail vital signs, monitoring devices, and history
taking as well as scene size-up and the process of patient
­assessment.
xxiii
Another random document with
no related content on Scribd:
she assumed the charge of the paper, she printed it with her own
motto as the heading, Vox Populi Vox Dei.
William Goddard drifted to Philadelphia, where he published the
Pennsylvania Chronicle for a short season, and in 1773 he removed
to Baltimore and established himself in the newspaper business
anew, with only, he relates, “the small capital of a single solitary
guinea.” He found another energetic business woman, the widow
Mrs. Nicholas Hasselbaugh, carrying on the printing-business
bequeathed to her by her husband; and he bought her stock in trade
and established The Maryland Journal and Baltimore Advertiser. It
was the third newspaper published in Maryland, was issued weekly
at ten shillings per annum, and was a well-printed sheet. But William
Goddard had another bee in his bonnet. A plan was formed just
before the Revolutionary War to abolish the general public post-
office and to establish in its place a complete private system of post-
riders from Georgia to New Hampshire. This system was to be
supported by private subscription; a large sum was already
subscribed, and the scheme well under way, when the war ended all
the plans. Goddard had this much to heart, and had travelled
extensively through the colonies exploiting it. While he was away on
these trips he left the newspaper and printing-house solely under the
charge of his sister Mary Katharine Goddard, the worthy daughter of
her energetic mother. From 1775 to 1784, through the trying times of
the Revolution, and in a most active scene of military and political
troubles, this really brilliant woman continued to print successfully
and continuously her newspaper. The Journal and every other work
issued from her printing-presses were printed and published in her
name, and it is believed chiefly on her own account. She was a
woman of much intelligence and was also practical, being an expert
compositor of types, and fully conversant with every detail of the
mechanical work of a printing-office. During this busy time she was
also postmistress of Baltimore, and kept a bookshop. Her brother
William, through his futile services in this postal scheme, had been
led to believe he would receive under Benjamin Franklin and the new
government of the United States, the appointment of Secretary and
Comptroller of the Post Office; but Franklin gave it to his own son-in-
law, Richard Bache. Goddard, sorely disappointed but pressed in
money matters, felt forced to accept the position of Surveyor of Post
Roads. When Franklin went to France in 1776, and Bache became
Postmaster-General, and Goddard again was not appointed
Comptroller, his chagrin caused him to resign his office, and naturally
to change his political principles.
He retired to Baltimore, and soon there appeared in the Journal an
ironical piece (written by a member of Congress) signed Tom Tell
Truth. From this arose a vast political storm. The Whig Club of
Baltimore, a powerful body, came to Miss Goddard and demanded
the name of the author; she referred them to her brother. On his
refusal to give the author’s name, he was seized, carried to the
clubhouse, bullied, and finally warned out of town and county. He at
once went to the Assembly at Annapolis and demanded protection,
which was given him. He ventilated his wrongs in a pamphlet, and
was again mobbed and insulted. In 1779, Anna Goddard printed
anonymously in her paper Queries Political and Military, written
really by General Charles Lee, the enemy and at one time
presumptive rival of Washington. This paper also raised a
tremendous storm through which the Goddards passed triumphantly.
Lee remained always a close friend of William Goddard, and
bequeathed to him his valuable and interesting papers, with the
intent of posthumous publication; but, unfortunately, they were sent
to England to be printed in handsome style, and were instead
imperfectly and incompletely issued, and William Goddard received
no benefit or profit from their sale. But Lee left him also, by will, a
large and valuable estate in Berkeley County, Virginia, so he retired
from public life and ended his days on a Rhode Island farm. Anna
Katharine Goddard lived to great old age. The story of this
acquaintance with General Lee, and of Miss Goddard’s connection
therewith, forms one of the interesting minor episodes of the War.
Just previous to the Revolution, it was nothing very novel or
unusual to Baltimoreans to see a woman edit a newspaper. The
Maryland Gazette suspended on account of the Stamp Act in 1765,
and the printer issued a paper called The Apparition of the Maryland
Gazette which is not Dead but Sleepeth; and instead of a Stamp it
bore a death’s head with the motto, “The Times are Dismal, Doleful,
Dolorous, Dollarless.” Almost immediately after it resumed
publication, the publisher died, and from 1767 to 1775 it was carried
on by his widow, Anne Katharine Green, sometimes assisted by her
son, but for five years alone. The firm name was Anne Katharine
Green & Son: and she also did the printing for the Colony. She was
about thirty-six years old when she assumed the business, and was
then the mother of six sons and eight daughters. Her husband was
the fourth generation from Samuel Green, the first printer in New
England, from whom descended about thirty ante-Revolutionary
printers. Until the Revolution there was always a Printer Green in
Boston. Mr. Green’s partner, William Rind, removed to Williamsburg
and printed there the Virginia Gazette. At his death, widow
Clementina Rind, not to be outdone by Widow Green and Mother
and Sister Goddard, proved that what woman has done woman can
do, by carrying on the business and printing the Gazette till her own
death in 1775.
It is indeed a curious circumstance that, on the eve of the
Revolution, so many southern newspapers should be conducted by
women. Long ere that, from 1738 to 1740, Elizabeth Timothy, a
Charleston woman, widow of Louis Timothy, the first librarian of the
Philadelphia Library company, and publisher of the South Carolina
Gazette, carried on that paper after her husband’s death; and her
son, Peter Timothy, succeeded her. In 1780 his paper was
suspended, through his capture by the British. He was exchanged,
and was lost at sea with two daughters and a grandchild, while on
his way to Antigua to obtain funds. He had a varied and interesting
life, was a friend of Parson Whitefield, and was tried with him on a
charge of libel against the South Carolina ministers. In 1782 his
widow, Anne Timothy, revived the Gazette, as had her mother-in-law
before her, and published it successfully twice a week for ten years
till her death in 1792. She had a large printing-house, corner of
Broad and King Streets, Charleston, and was printer to the State;
truly a remarkable woman.
Peter Timothy’s sister Mary married Charles Crouch, who also was
drowned when on a vessel bound to New York. He was a sound
Whig and set up a paper in opposition to the Stamp Act, called The
South Carolina Gazette and Country Journal. This was one of the
four papers which were all entitled Gazettes in order to secure
certain advertisements that were all directed by law “to be inserted in
the South Carolina Gazette.” Mary Timothy Crouch continued the
paper for a short time after her husband’s death; and in 1780 shortly
before the surrender of the city to the British, went with her printing-
press and types to Salem, where for a few months she printed The
Salem Gazette and General Advertiser. I have dwelt at some length
on the activity and enterprise of these Southern women, because it
is another popular but unstable notion that the women of the North
were far more energetic and capable than their Southern sisters;
which is certainly not the case in this line of business affairs.
Benjamin and James Franklin were not the only members of the
Franklin family who were capable newspaper-folk. James Franklin
died in Newport in 1735, and his widow Anne successfully carried on
the business for many years. She had efficient aid in her two
daughters, who were quick and capable practical workers at the
compositor’s case, having been taught by their father, whom they
assisted in his lifetime. Isaiah Thomas says of them:—
A gentleman who was acquainted with Anne Franklin and
her family, informed me that he had often seen her daughters
at work in the printing house, and that they were sensible and
amiable women.
We can well believe that, since they had Franklin and Anne
Franklin blood in them. This competent and industrious trio of
women not only published the Newport Mercury, but were printers
for the colony, supplying blanks for public offices, publishing
pamphlets, etc. In 1745 they printed for the Government an edition of
the laws of the colony of 340 pages, folio. Still further, they carried on
a business of “printing linens, calicoes, silks, &c., in figures, very
lively and durable colors, and without the offensive smell which
commonly attends linen-printing.” Surely there was no lack of
business ability on the distaff side of the Franklin house.
Boston women gave much assistance to their printer-husbands.
Ezekiel Russel, the editor of that purely political publication, The
Censor, was in addition a printer of chap-books and ballads which
were sold from his stand near the Liberty Tree on Boston Common.
His wife not only helped him in printing these, but she and another
young woman of his household, having ready pens and a biddable
muse, wrote with celerity popular and seasonable ballads on passing
events, especially of tragic or funereal cast; and when these ballads
were printed with a nice border of woodcuts of coffins and death’s
heads, they often had a long and profitable run of popularity. After
his death, Widow Russel still continued ballad making and monging.
It was given to a woman, Widow Margaret Draper, to publish the
only newspaper which was issued in Boston during the siege, the
Massachusetts Gazette and Boston News Letter. And a miserable
little sheet it was, vari-colored, vari-typed, vari-sized; of such poor
print that it is scarcely readable. When the British left Boston,
Margaret Draper left also, and resided in England, where she
received a pension from the British government.
The first newspaper in Pennsylvania was entitled The American
Weekly Mercury. It was “imprinted by Andrew Bradford” in 1719. He
was a son of the first newspaper printer in New York, William
Bradford, Franklin’s “cunning old fox,” who lived to be ninety-two
years old, and whose quaint tombstone may be seen in Trinity
Churchyard. At Andrew’s death in 1742, the paper appeared in
mourning, and it was announced that it would be published by “the
widow Bradford.” She took in a partner, but speedily dropped him,
and carried it on in her own name till 1746. During the time that
Cornelia Bradford printed this paper it was remarkable for its good
type and neatness.
The Connecticut Courant and The Centinel were both of them
published for some years by the widows of former proprietors.
The story of John Peter Zenger, the publisher of The New York
Weekly Journal, is one of the most interesting episodes in our
progress to free speech and liberty, but cannot be dwelt on here. The
feminine portion of his family was of assistance to him. His daughter
was mistress of a famous New York tavern that saw many
remarkable visitors, and heard much of the remarkable talk of
Zenger’s friends. After his death in 1746, his newspaper was carried
on by his widow for two years. Her imprint was, “New York; Printed
by the Widow Cathrine Zenger at the Printing-Office in Stone Street;
Where Advertisements are taken in, and all Persons may be
supplied with this Paper.”
The whole number of newspapers printed before the Revolution
was not very large; and when we see how readily and successfully
this considerable number of women assumed the cares of
publishing, we know that the “newspaper woman” of that day was no
rare or presumptuous creature, any more than is the “newspaper-
woman” of our own day, albeit she was of very different ilk; but the
spirit of independent self-reliance, when it became necessary to
exhibit self-reliance, was as prompt and as stable in the feminine
breast a century and a half ago as now. Then, as to-day, there were
doubtless scores of good wives and daughters who materially
assisted their husbands in their printing-shops, and whose work will
never be known.
There is no doubt that our great-grandmothers possessed
wonderful ability to manage their own affairs, when it became
necessary to do so, even in extended commercial operations. It is
easy to trace in the New England coast towns one influence which
tended to interest them, and make them capable of business
transactions. They constantly heard on all sides the discussion of
foreign trade, and were even encouraged to enter into the discussion
and the traffic. They heard the Windward Islands, the Isle of France,
and Amsterdam, and Canton, and the coast of Africa described by
old travelled mariners, by active young shipmasters, in a way that
put them far more in touch with these far-away foreign shores, gave
them more knowledge of details of life in those lands, than women of
to-day have. And women were encouraged, even urged, to take an
active share in foreign trade, in commercial speculation, by sending
out a “venture” whenever a vessel put out to sea, and whenever the
small accumulation of money earned by braiding straw, knitting
stockings, selling eggs or butter, or by spinning and weaving, was
large enough to be worth thus investing; and it needed not to be a
very large sum to be deemed proper for investment. When a ship
sailed out to China with cargo of ginseng, the ship’s owner did not
own all the solid specie in the hold—the specie that was to be
invested in the rich and luxurious products of far Cathay.
Complicated must have been the accounts of these transactions, for
many were the parties in the speculation. There were no giant
monopolies in those days. The kindly ship-owner permitted even his
humblest neighbor to share his profits. And the profits often were
large. The stories of some of the voyages, the adventures of the
business contracts, read like a fairy tale of commerce. In old letters
may be found reference to many of the ventures sent by women.
One young woman wrote in 1759:—
Inclos’d is a pair of Earrings. Pleas ask Captin Oliver to
carry them a Ventur fer me if he Thinks they will fetch
anything to the Vally of them; tell him he may bring the effects
in anything he thinks will answer best.
One of the “effects” brought to this young woman, and to hundreds
of others, was a certain acquaintance with business transactions, a
familiarity with the methods of trade. When the father or husband
died, the woman could, if necessary, carry on his business to a
successful winding-up, or continue it in the future. Of the latter
enterprise many illustrations might be given. In the autumn of 1744 a
large number of prominent business men in Newport went into a
storehouse on a wharf to examine the outfit of a large privateer. A
terrible explosion of gunpowder took place, which killed nine of them.
One of the wounded was Sueton Grant, a Scotchman, who had
come to America in 1725. His wife, on hearing of the accident, ran at
once to the dock, took in at a glance the shocking scene and its
demands for assistance, and cutting into strips her linen apron with
the housewife’s scissors she wore at her side, calmly bound up the
wounds of her dying husband. Mr. Grant was at this time engaged in
active business; he had agencies in Europe, and many privateers
afloat. Mrs. Grant took upon her shoulders these great
responsibilities, and successfully carried them on for many years,
while she educated her children, and cared for her home.
A good example of her force of character was once shown in a
court of law. She had an important litigation on hand and large
interests at stake, when she discovered the duplicity of her counsel,
and her consequent danger. She went at once to the court-room
where the case was being tried; when her lawyer promptly but vainly
urged her to retire. The judge, disturbed by the interruption, asked
for an explanation, and Mrs. Grant at once unfolded the knavery of
her counsel and asked permission to argue her own case. Her
dignity, force, and lucidity so moved the judge that he permitted her
to address the jury, which she did in so convincing a manner as to
cause them to promptly render a verdict favorable to her. She
passed through some trying scenes at the time of the Revolution
with wonderful decision and ability, and received from every one the
respect and deference due to a thorough business man, though she
was a woman.
In New York the feminine Dutch blood showed equal capacity in
business matters; and it is said that the management of considerable
estates and affairs often was assumed by widows in New
Amsterdam. Two noted examples are Widow De Vries and Widow
Provoost. The former was married in 1659, to Rudolphus De Vries,
and after his death she carried on his Dutch trade—not only buying
and selling foreign goods, but going repeatedly to Holland in the
position of supercargo on her own ships. She married Frederick
Phillipse, and it was through her keenness and thrift and her
profitable business, as well as through his own success, that
Phillipse became the richest man in the colony and acquired the
largest West Indian trade.
Widow Maria Provoost was equally successful at the beginning of
the eighteenth century, and had a vast Dutch business
correspondence. Scarce a ship from Spain, the Mediterranean, or
the West Indies, but brought her large consignments of goods. She
too married a second time, and as Madam James Alexander filled a
most dignified position in New York, being the only person besides
the Governor to own a two-horse coach. Her house was the finest in
town, and such descriptions of its various apartments as “the great
drawing-room, the lesser drawing-room, the blue and gold leather
room, the green and gold leather room, the chintz room, the great
tapestry room, the little front parlour, the back parlour,” show its size
and pretensions.
Madam Martha Smith, widow of Colonel William Smith of St.
George’s Manor, Long Island, was a woman of affairs in another
field. In an interesting memorandum left by her we read:—
Jan ye 16, 1707. My company killed a yearling whale made
27 barrels. Feb ye 4, Indian Harry with his boat struck a whale
and called for my boat to help him. I had but a third which was
4 barrels. Feb 22, my two boats & my sons and Floyds boats
killed a yearling whale of which I had half—made 36 barrels,
my share 18 barrels. Feb 24 my company killed a school
whale which made 35 barrels. March 13, my company killed a
small yearling made 30 barrels. March 17, my company killed
two yearlings in one day; one made 27, the other 14 barrels.
We find her paying to Lord Cornbury fifteen pounds, a duty on “ye
20th part of her eyle.” And she apparently succeeded in her
enterprises.
In early Philadelphia directories may be found the name of
“Margaret Duncan, Merchant, No. 1 S. Water St.” This capable
woman had been shipwrecked on her way to the new world. In the
direst hour of that extremity, when forced to draw lots for the scant
supply of food, she vowed to build a church in her new home if her
life should be spared. The “Vow Church” in Philadelphia, on
Thirteenth Street near Market Street, for many years proved her
fulfilment of this vow, and also bore tribute to the prosperity of this
pious Scotch Presbyterian in her adopted home.
Southern women were not outstripped by the business women of
the north. No more practical woman ever lived in America than Eliza
Lucas Pinckney. When a young girl she resided on a plantation at
Wappoo, South Carolina, owned by her father, George Lucas. He
was Governor of Antigua, and observing her fondness for and
knowledge of botany, and her intelligent power of application of her
knowledge, he sent to her many tropical seeds and plants for her
amusement and experiment in her garden. Among the seeds were
some of indigo, which she became convinced could be profitably
grown in South Carolina. She at once determined to experiment, and
planted indigo seed in March, 1741. The young plants started finely,
but were cut down by an unusual frost. She planted seed a second
time, in April, and these young indigo-plants were destroyed by
worms. Notwithstanding these discouragements, she tried a third
time, and with success. Her father was delighted with her enterprise
and persistence, and when he learned that the indigo had seeded
and ripened, sent an Englishman named Cromwell—an experienced
indigo-worker—from Montserrat to teach his daughter Eliza the
whole process of extracting the dye from the weed. Vats were built
on Wappoo Creek, in which was made the first indigo formed in
Carolina. It was of indifferent quality, for Cromwell feared the
successful establishment of the industry in America would injure the
indigo trade in his own colony, so he made a mystery of the process,
and put too much lime in the vats, doubtless thinking he could
impose upon a woman. But Miss Lucas watched him carefully, and in
spite of his duplicity, and doubtless with considerable womanly
power of guessing, finally obtained a successful knowledge and
application of the complex and annoying methods of extracting
indigo,—methods which required the untiring attention of sleepless
nights, and more “judgment” than intricate culinary triumphs. After
the indigo was thoroughly formed by steeping, beating, and washing,
and taken from the vats, the trials of the maker were not over. It must
be exposed to the sun, but if exposed too much it would be burnt, if
too little it would rot. Myriads of flies collected around it and if
unmolested would quickly ruin it. If packed too soon it would sweat
and disintegrate. So, from the first moment the tender plant
appeared above ground, when the vast clouds of destroying
grasshoppers had to be annihilated by flocks of hungry chickens, or
carefully dislodged by watchful human care, indigo culture and
manufacture was a distressing worry, and was made still more
unalluring to a feminine experimenter by the fact that during the
weary weeks it laid in the “steepers” and “beaters” it gave forth a
most villainously offensive smell.
Soon after Eliza Lucas’ hard-earned success she married Charles
Pinckney, and it is pleasant to know that her father gave her, as part
of her wedding gift, all the indigo on the plantation. She saved the
whole crop for seed,—and it takes about a bushel of indigo seed to
plant four acres,—and she planted the Pinckney plantation at
Ashepoo, and gave to her friends and neighbors small quantities of
seed for individual experiment; all of which proved successful. The
culture of indigo at once became universal, the newspapers were full
of instructions upon the subject, and the dye was exported to
England by 1747, in such quantity that merchants trading in Carolina
petitioned Parliament for a bounty on Carolina indigo. An act of
Parliament was passed allowing a bounty of sixpence a pound on
indigo raised in the British-American plantations and imported
directly to Great Britain. Spurred on by this wise act, the planters
applied with redoubled vigor to the production of the article, and
soon received vast profits as the rewards of their labor and care. It is
said that just previous to the Revolution more children were sent
from South Carolina to England to receive educations, than from all
the other colonies,—and this through the profits of indigo and rice.
Many indigo planters doubled their capital every three or four years,
and at last not only England was supplied with indigo from South
Carolina, but the Americans undersold the French in many European
markets. It exceeded all other southern industries in importance, and
became a general medium of exchange. When General Marion’s
young nephew was sent to school at Philadelphia, he started off with
a wagon-load of indigo to pay his expenses. The annual dues of the
Winyah Indigo Society of Georgetown were paid in the dye, and the
society had grown so wealthy in 1753, that it established a large
charity school and valuable library.
Ramsay, the historian of South Carolina, wrote in 1808, that the
indigo trade proved more beneficial to Carolina than the mines of
Mexico or Peru to old or new Spain. By the year of his writing,
however, indigo (without waiting for extermination through its modern
though less reliable rivals, the aniline dyes) had been driven out of
Southern plantations by its more useful and profitable field neighbor,
King Cotton, that had been set on a throne by the invention of a
Yankee schoolmaster. The time of greatest production and export of
indigo was just previous to the Revolution, and at one time it was
worth four or five dollars a pound. And to-day only the scanty records
of the indigo trade, a few rotting cypress boards of the steeping-vats,
and the blue-green leaves of the wild wayside indigo, remain of all
this prosperity to show the great industry founded by this remarkable
and intelligent woman.
The rearing of indigo was not this young girl’s only industry. I will
quote from various letters written by her in 1741 and 1742 before her
marriage, to show her many duties, her intelligence, her versatility:—
Wrote my father on the pains I had taken to bring the
Indigo, Ginger, Cotton, Lucern, and Casada to perfection and
had greater hopes from the Indigo, if I could have the seed
earlier, than any of ye rest of ye things I had tried.
I have the burthen of 3 Plantations to transact which
requires much writing and more business and fatigue of other
sorts than you can imagine. But lest you should imagine it too
burthensome to a girl in my early time of life, give me leave to
assure you I think myself happy that I can be useful to so
good a father.
Wont you laugh at me if I tell you I am so busy in providing
for Posterity I hardly allow myself time to eat or sleep, and
can but just snatch a moment to write to you and a friend or
two more. I am making a large plantation of oaks which I look
upon as my own property whether my father gives me the
land or not, and therefore I design many yeer hence when
oaks are more valuable than they are now, which you know
they will be when we come to build fleets. I intend I say two
thirds of the produce of my oaks for a charity (Ill tell you my
scheme another time) and the other third for those that shall
have the trouble to put my design in execution.
I have a sister to instruct, and a parcel of little negroes
whom I have undertaken to teach to read.
The Cotton, Guinea Corn, and Ginger planted was cutt off
by a frost. I wrote you in a former letter we had a good crop of
Indigo upon the ground. I make no doubt this will prove a
valuable commodity in time. Sent Gov. Thomas daughter a
tea chest of my own doing.
 I am engaged with the Rudiments of Law to which I am but
a stranger. If you will not laugh too immoderately at me I’ll
trust you with a Secrett. I have made two Wills already. I know
I have done no harm for I conn’d my Lesson perfect. A widow
hereabouts with a pretty little fortune teazed me intolerably to
draw a marriage settlement, but it was out of my depth and I
absolutely refused it—so she got an able hand to do it—
indeed she could afford it—but I could not get off being one of
the Trustees to her settlement, and an old Gentⁿ the other. I
shall begin to think myself an old woman before I am a young
one, having such mighty affairs on my hands.
I think this record of important work could scarce be equalled by
any young girl in a comparative station of life nowadays. And when
we consider the trying circumstances, the difficult conditions, in
which these varied enterprises were carried on, we can well be
amazed at the story.
Indigo was not the only important staple which attracted Mrs.
Pinckney’s attention, and the manufacture of which she made a
success. In 1755 she carried with her to England enough rich silk
fabric, which she had raised and spun and woven herself in the
vicinity of Charleston, to make three fine silk gowns, one of which
was presented to the Princess Dowager of Wales, and another to
Lord Chesterfield. This silk was said to be equal in beauty to any silk
ever imported.
This was not the first American silk that had graced the person of
English royalty. In 1734 the first windings of Georgia silk had been
taken from the filature to England, and the queen wore a dress made
thereof at the king’s next birthday. Still earlier in the field Virginia had
sent its silken tribute to royalty. In the college library at Williamsburg,
Va., may be seen a letter signed “Charles R.”—his most Gracious
Majesty Charles the Second. It was written by his Majesty’s private
secretary, and addressed to Governor Berkeley for the king’s loyal
subjects in Virginia. It reads thus:—
Trusty and Well beloved, We Greet you Well. Wee have
received wᵗʰ much content ye dutifull respects of Our Colony
 in ye present lately made us by you & ye councill there, of ye
first product of ye new Manufacture of Silke, which as a
marke of Our Princely acceptation of yoʳ duteys & for yoʳ
particular encouragement, etc. Wee have been commanded
to be wrought up for ye use of Our Owne Person.
And earliest of all is the tradition, dear to the hearts of Virginians,
that Charles I. was crowned in 1625 in a robe woven of Virginia silk.
The Queen of George III. was the last English royalty to be similarly
honored, for the next attack of the silk fever produced a suit for an
American ruler, George Washington.
The culture of silk in America was an industry calculated to attract
the attention of women, and indeed was suited to them, but men
were not exempt from the fever; and the history of the manifold and
undaunted efforts of governor’s councils, parliaments, noblemen,
philosophers, and kings to force silk culture in America forms one of
the most curious examples extant of persistent and futile efforts to
run counter to positive economic conditions, for certainly physical
conditions are fairly favorable.
South Carolina women devoted themselves with much success to
agricultural experiments. Henry Laurens brought from Italy and
naturalized the olive-tree, and his daughter, Martha Laurens
Ramsay, experimented with the preservation of the fruit until her
productions equalled the imported olives. Catharine Laurens
Ramsay manufactured opium of the first quality. In 1755 Henry
Laurens’ garden in Ansonborough was enriched with every curious
vegetable product from remote quarters of the world that his
extensive mercantile connections enabled him to procure, and the
soil and climate of South Carolina to cherish. He introduced besides
olives, capers, limes, ginger, guinea grass, Alpine strawberries
(bearing nine months in the year), and many choice varieties of
fruits. This garden was superintended by his wife, Mrs. Elinor
Laurens.
Mrs. Martha Logan was a famous botanist and florist. She was
born in 1702, and was the daughter of Robert Daniel, one of the last
proprietary governors of South Carolina. When fourteen years old,
she married George Logan, and all her life treasured a beautiful and
remarkable garden. When seventy years old, she compiled from her
knowledge and experience a regular treatise on gardening, which
was published after her death, with the title The Garden’s Kalendar.
It was for many years the standard work on gardening in that locality.
Mrs. Hopton and Mrs. Lamboll were early and assiduous flower-
raisers and experimenters in the eighteenth century, and Miss Maria
Drayton, of Drayton Hall, a skilled botanist.
The most distinguished female botanist of colonial days was Jane
Colden, the daughter of Governor Cadwallader Colden, of New York.
Her love of the science was inherited from her father, the friend and
correspondent of Linnæus, Collinson, and other botanists. She
learned a method of taking leaf-impressions in printers’ ink, and sent
careful impressions of American plants and leaves to the European
collectors. John Ellis wrote of her to Linnæus in April, 1758:—
This young lady merits your esteem, and does honor to
your system. She has drawn and described four hundred
plants in your method. Her father has a plant called after her
Coldenia. Suppose you should call this new genus Coldenella
or any other name which might distinguish her.
Peter Collinson said also that she was the first lady to study the
Linnæan system, and deserved to be celebrated. Another tribute to
her may be found in a letter of Walter Rutherford’s:—
From the middle of the Woods this Family corresponds with
all the learned Societies in Europe. His daughter Jenny is a
Florist and Botanist. She has discovered a great number of
Plants never before described and has given their Properties
and Virtues, many of which are found useful in Medicine and
she draws and colours them with great Beauty. Dr. Whyte of
Edinburgh is in the number of her correspondents.
N. B. She makes the best cheese I ever ate in America.
The homely virtue of being a good cheese-maker was truly a
saving clause to palliate and excuse so much feminine scientific
knowledge.
 CHAPTER III.
“DOUBLE-TONGUED AND NAUGHTY WOMEN.”

I am much impressed in reading the court records of those early

days, to note the vast care taken in all the colonies to prevent lying,
slandering, gossiping, backbiting, and idle babbling, or, as they
termed it, “brabling;” to punish “common sowers and movers”—of
dissensions, I suppose.
The loving neighborliness which proved as strong and as
indispensable a foundation for a successful colony as did godliness,
made the settlers resent deeply any violations, though petty, of the
laws of social kindness. They felt that what they termed “opprobrious
schandalls tending to defamaçon and disparagment” could not be
endured.
One old author declares that “blabbing, babbling, tale-telling, and
discovering the faults and frailities of others is a most Common and
evill practice.” He asserts that a woman should be a “main store
house of secresie, a Maggazine of taciturnitie, the closet of
connivence, the mumbudget of silence, the cloake bagge of rouncell,
the capcase, fardel, or pack of friendly toleration;” which, as a whole,
seems to be a good deal to ask. Men were, as appears by the
records, more frequently brought up for these offences of the tongue,
but women were not spared either in indictment or punishment. In
Windsor, Conn., one woman was whipped for “wounding” a neighbor,
not in the flesh, but in the sensibilities.
In 1652 Joane Barnes, of Plymouth, Mass., was indicted for
“slandering,” and sentenced “to sitt in the stockes during the Courts
pleasure, and a paper whereon her facte written in Capitall letters to
be made faste vnto her hatt or neare vnto her all the tyme of her
sitting there.” In 1654 another Joane in Northampton County, Va.,
suffered a peculiarly degrading punishment for slander. She was
“drawen ouer the Kings Creeke at the starne of a boate or Canoux,
also the next Saboth day in the tyme of diuine seruis” was obliged to
present herself before the minister and congregation, and
acknowledge her fault, and ask forgiveness. This was an old Scotch
custom. The same year one Charlton called the parson, Mr. Cotton,
a “black cotted rascal,” and was punished therefor in the same way.
Richard Buckland, for writing a slanderous song about Ann Smith,
was similarly pilloried, bearing a paper on his hat inscribed Inimicus
Libellus, and since possibly all the church attendants did not know
Latin, to publicly beg Ann’s forgiveness in English for his libellous
poesy. The punishment of offenders by exposing them, wrapped in
sheets, or attired in foul clothing, on the stool of repentance in the
meeting-house in time of divine service, has always seemed to me
specially bitter, unseemly, and unbearable.
It should be noted that these suits for slander were between
persons in every station of life. When Anneke Jans Bogardus (wife of
Dominie Bogardus, the second established clergyman in New
Netherlands), would not remain in the house with one Grietje van
Salee, a woman of doubtful reputation, the latter told throughout the
neighborhood that Anneke had lifted her petticoats when crossing
the street, and exposed her ankles in unseemly fashion; and she
also said that the Dominie had sworn a false oath. Action for slander
was promptly begun, and witnesses produced to show that Anneke
had flourished her petticoats no more than was seemly and tidy to
escape the mud. Judgment was pronounced against Grietje and her
husband. She had to make public declaration in the Fort that she
had lied, and to pay three guilders. The husband had to pay a fine,
and swear to the good character of the Dominie and good carriage of
the Dominie’s wife, and he was not permitted to carry weapons in
town,—a galling punishment.
Dominie Bogardus was in turn sued several times for slander,—
once by Thomas Hall, the tobacco planter, simply for saying that
Thomas’ tobacco was bad; and again, wonderful to relate, by one of
his deacons—Deacon Van Cortlandt.
Special punishment was provided for women. Old Dr. Johnson
said gruffly to a lady friend: “Madam, there are different ways of
restraining evil; stocks for men, a ducking-stool for women, pounds
for beasts.” The old English instrument of punishment,—as old as
the Doomsday survey,—the cucking-stool or ducking-stool, was in
vogue here, was insultingly termed a “publique convenience,” and
was used in the Southern and Central colonies for the correction of
common scolds. We read in Blackstone’s Commentaries, “A
common scold may be indicted and if convicted shall be sentenced
to be placed in a certain engine of correction called the trebucket,
castigatory, or cucking-stool.” Still another name for this “engine”
was a “gum-stool.” The brank, or scold’s bridle,—a cruel and
degrading means of punishment employed in England for “curst
queans” as lately as 1824,—was unknown in America. A brank may
be seen at the Guildhall in Worcester, England. One at Walton-on-
Thames bears the date 1633. On the Isle of Man, when the brank
was removed, the wearer had to say thrice, in public, “Tongue, thou
hast lied.” I do not find that women ever had to “run the gauntelope”
as did male offenders in 1685 in Boston, and, though under another
name, in several of the provinces.
Women in Maine were punished by being gagged; in Plymouth,
Mass., and in Easthampton, L. I., they had cleft sticks placed on their
tongues in public; in the latter place because the dame said her
husband “had brought her to a place where there was neither gospel
nor magistracy.” In Salem “one Oliver—his wife” had a cleft stick
placed on her tongue for half an hour in public “for reproaching the
elders.” It was a high offence to speak “discornfully” of the elders and
magistrates.
The first volume of the American Historical Record gives a letter
said to have been written to Governor Endicott, of Massachusetts, in
1634 by one Thomas Hartley from Hungar’s Parish, Virginia. It gives
a graphic description of a ducking-stool, and an account of a ducking
in Virginia. I quote from it:—
The day afore yesterday at two of ye clock in ye afternoon I
saw this punishment given to one Betsey wife of John Tucker,
who by ye violence of her tongue had made his house and ye
neighborhood uncomfortable. She was taken to ye pond
where I am sojourning by ye officer who was joyned by ye
 magistrate and ye Minister Mr. Cotton, who had frequently
admonished her and a large number of People. They had a
machine for ye purpose yᵗ belongs to ye Parish, and which I
was so told had been so used three times this Summer. It is a
platform with 4 small rollers or wheels and two upright posts
between which works a Lever by a Rope fastened to its
shorter or heavier end. At the end of ye longer arm is fixed a
stool upon which sᵈ Betsey was fastened by cords, her gown
tied fast around her feete. The Machine was then moved up
to ye edge of ye pond, ye Rope was slackened by ye officer
and ye woman was allowed to go down under ye water for ye
space of half a minute. Betsey had a stout stomach, and
would not yield until she had allowed herself to be ducked 5
severall times. At length she cried piteously Let me go Let me
go, by Gods help I’ll sin no more. Then they drew back ye
machine, untied ye Ropes and let her walk home in her
wetted clothes a hopefully penitent woman.
I have seen an old chap-book print of a ducking-stool with a “light
huswife of the banck-side” in it. It was rigged much like an old-
fashioned well-sweep, the woman and chair occupying the relative
place of the bucket. The base of the upright support was on a low-
wheeled platform.
Bishop Meade, in his Old Churches, Ministers, and Families of
Virginia, tells of one “scolding quean” who was ordered to be ducked
three times from a vessel lying in James River. Places for ducking
were prepared near the Court Houses. The marshal’s fee for ducking
was only two pounds of tobacco. The ducking-stools were not kept in
church porches, as in England. In 1634 two women were sentenced
to be either drawn from King’s Creek “from one Cowpen to another
at the starn of a boat or kanew,” or to present themselves before the
congregation, and ask forgiveness of each other and God. In 1633 it
was ordered that a ducking-stool be built in every county in
Maryland. At a court-baron at St. Clements, the county was
prosecuted for not having one of these “public conveniences.” In
February, 1775, a ducking-stool was ordered to be placed at the
confluence of the Ohio and Monongahela Rivers, and was doubtless
used. As late as 1819 Georgia women were ducked in the Oconee
River for scolding. And in 1824, at the court of Quarter Sessions, a
Philadelphia woman was sentenced to be ducked, but the
punishment was not inflicted, as it was deemed obsolete and
contrary to the spirit of the times. In 1803 the ducking-stool was still
used in Liverpool, England, and in 1809 in Leominster, England.
One of the last indictments for ducking in our own country was that
of Mrs. Anne Royall in Washington, almost in our own day. She was
a hated lobbyist, whom Mr. Forney called an itinerant virago, and
who became so abusive to congressmen that she was indicted as a
common scold before Judge William Cranch, and was sentenced by
him to be ducked in the Potomac. She was, however, released with a
fine.
Women curst with a shrewish tongue were often punished in
Puritan colonies. In 1647 it was ordered that “common scoulds” be
punished in Rhode Island by ducking, but I find no records of the
punishment being given. In 1649 several women were prosecuted in
Salem, Mass., for scolding; and on May 15, 1672, the General Court
of Massachusetts ordered that scolds and railers should be gagged
or “set in a ducking-stool and dipped over head and ears three
times,” but I do not believe that this law was ever executed in
Massachusetts. Nor was it in Maine, though in 1664 a dozen towns
were fined forty shillings each for having no “coucking-stool.” Equally
severe punishments were inflicted for other crimes. Katharine Ainis,
of Plymouth, was publicly whipped on training day, and ordered to
wear a large B cut in red cloth “sewed to her vper garment.” In 1637
Dorothy Talbye, a Salem dame, for beating her husband was
ordered to be bound and chained to a post. At a later date she was
whipped, and then was hanged for killing her child, who bore the
strange name of Difficulty. No one but a Puritan magistrate could
doubt, from Winthrop’s account of her, that she was insane. Another
“audatious” Plymouth shrew, for various “vncivill carriages” to her
husband, was sentenced to the pillory; and if half that was told of her
was true, she richly deserved her sentence; but, as she displayed
“greate pensiveness and sorrow” before the simple Pilgrim
magistrates, she escaped temporarily, to be punished at a later date