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EBOOK Advanced Emt A Clinical Reasoning Approach 2Nd Edition Ebook PDF Download Full Chapter PDF Kindle
EBOOK Advanced Emt A Clinical Reasoning Approach 2Nd Edition Ebook PDF Download Full Chapter PDF Kindle
vii
viii Detailed Contents
Anatomy and Physiology Review 369 Health Care Provider CPR 433
Physiology of Air Movement 369 Scene Size-Up and Primary Assessment 433
Upper Airway 370 Chest Compressions 435
Lower Airway 372 Airway and Ventilations 436
Gas Exchange 373 Integrating Advanced Airway Devices 436
Ventilation373 Defibrillation437
Pathophysiology of the Airway, Ventilation, and Intravenous Access and Medications 441
Oxygenation373 Resuscitation Outcomes and Postresuscitation
Upper Airway Problems 373 Care441
Lower Airway Problems 374 CPR in Infants and Children 441
Ventilation Problems 375 Secondary Assessment and History Taking
in Resuscitation 442
Assessment of the Airway, Ventilation, and
Oxygenation375 Ethical and Legal Considerations 443
Scene Size-Up 375 Return of Spontaneous Circulation 443
Primary Assessment 376 Management of Body Temperature 444
Secondary Assessment and Reassessment 381
Airway Management 385 18 Vital Signs and Monitoring
Positioning and Manual Maneuvers 386 Devices447
Removing Foreign Bodies and Fluids from Introduction450
the Airway 387
Prioritizing Information Collection 450
Airway Adjuncts 393
Vital Signs 450
Ventilation398
Assessing the Pulse 450
Positive Pressure Ventilation 399
Assessing Blood Pressure 454
Bag-Valve-Mask Ventilations 399
Orthostatic Vital Signs 458
Manually Triggered Ventilation Device and
Assessing Respirations 459
the Automatic Transport Ventilator 402
Assessing Body Temperature 461
Continuous Positive Airway Pressure 403
Assessing the Skin 462
Oxygenation403
Oxygen as a Medication 404 Assessing the Pupils 463
Oxygen Equipment 404 Monitoring Devices 464
Oxygen Safety 407 Pulse Oximetry 465
Oxygen Delivery Devices 407 End-Tidal Carbon Dioxide Monitoring 465
Blood Glucose Level 466
Section 5 Medical Emergencies 505 Clinical Reasoning and Decision Making 573
Reassessment573
20 Respiratory Disorders 506 Specific Neurologic Disorders 573
Altered Mental Status 573
Introduction508
Syncope574
Anatomy and Physiology Review 508
Stroke575
The Need for Oxygen 508
Seizures578
Structure and Function of the Lungs 510
Headache581
Ventilation510
Dementia and Delirium 582
General Assessment and Management 512
Vertigo583
Scene Size-Up 514
Nontraumatic Back and Neck Pain 583
Primary Assessment 515
Central Nervous System Infections 583
Secondary Assessment 515
Other Neurologic Disorders 584
Clinical-Reasoning Process 515
Treatment515 23 Endocrine Disorders 590
Reassessment515
Introduction592
Specific Respiratory Disorders 516
Anatomy and Physiology Review 592
Chronic Obstructive Pulmonary
Disease516 The Pancreas and Blood Glucose Level 594
Asthma519 The Thyroid Gland and Metabolism 596
Pulmonary Embolism 521 The Adrenal Glands 596
Pulmonary Edema 522 Assessment596
Spontaneous Pneumothorax 523 Scene Size-Up 596
Hyperventilation Syndrome 524 Primary Assessment 597
Infectious Respiratory Diseases 525 Secondary Assessment 597
Lung Cancer 528 Reassessment598
Cystic Fibrosis 528 Common Endocrine Disorders 598
Diabetes and Diabetic Emergencies 598
21 Cardiovascular Disorders 531 Thyroid Disorders 602
Adrenal Disorders 603
Introduction533
Anatomy and Physiology Review
Coronary Circulation
533
534
24 Abdominal Pain and
Gastrointestinal Disorders 607
The Vascular System and Blood 535
Perfusion, Cardiac Output, Introduction608
and Blood Pressure 536 Anatomy and Physiology Review 609
Cardiac Electrophysiology 538 Stomach and Intestines 610
General Assessment of Cardiovascular Accessory Organs of Digestion 611
Complaints541 Assessment and Management 612
Specific Cardiovascular Conditions 544 Scene Size-Up 612
Acute Coronary Syndrome 544 Primary Assessment 613
Signs and Symptoms 546 Secondary Assessment 613
Heart Failure 552 Clinical-Reasoning Process 614
Cardiogenic Shock 557 Treatment614
Hypertension557 Reassessment614
Aortic Aneurysm and Dissection 558 General Abdominal Complaints 614
Heart Rate Disturbances 560 Abdominal Pain 614
Nausea and Vomiting 616
22 Neurologic Disorders 564 Specific Abdominal Problems 616
Introduction566 Disorders of the Esophagus 616
Anatomy and Physiology Review 566 Disorders of the Stomach and Intestines 617
Assessment568 Pancreatitis621
Scene Size-Up 568 Liver Disease 621
Primary Assessment 568 Cholecystitis622
Secondary Assessment 569 Other Causes of Abdominal Pain 623
Detailed Contents xiii
xix
Letter to Students
Welcome, students!
You are beginning an exciting learning experience, and this textbook will help you. We have designed
it to help you learn facts, principles, and concepts in EMS. But we have gone beyond simply presenting
facts, principles, and concepts. This textbook contains features that will help you learn critical thinking
and problem solving, which are essential skills in the health care professions. The process of using criti-
cal thinking to solve patient care problems is called clinical reasoning. The clinical-reasoning process is
a cornerstone of safe, excellent patient care, and we have made it a foundation of this textbook.
We, as authors, educators, and clinicians, are excited about the unique focus of our textbook on
clinical reasoning. Each chapter begins with a case study that includes problem-solving questions. Each
case study frames the material in the chapter in a way that establishes its importance. Beginning each
chapter with a specific problem in mind helps you read the chapter for deeper understanding of how
the material can be applied in your real-life Advanced EMT practice. After the chapter material is pre-
sented, the case study wrap-up with an accompanying clinical-reasoning process helps you understand
how the Advanced EMTs in the case study determined and solved the problems. This approach provides
you with a model for transferring what you have learned from the classroom to the work environment.
melalexander1@gmail.com
rbelle2024@yahoo.com
sweiss@salud.unm.edu
xx
Preface
A
dvanced EMT: A Clinical-Reasoning Approach, 2nd an updated description of the approach to patients with
Edition, was developed to assist you in success suspected cervical-spine injury. Chapter 17 now offers in-
fully completing the Advanced EMT course and formation on tranexamic acid in hemorrhagic shock and on
ultimately obtaining licensure. The National EMS Education systemic inflammatory response (SIRS) and the potential
Standards serve as the foundation of the text, and special role of prehospital serum lactate measurement. It also has
care was taken to ensure that the most up-to-date evidence- expanded information on topical hemostatics, common
based patient care has been included. Specifically, content prescription anticoagulants, teamwork in resuscitation,
that has been added or updated for Advanced EMT: A Clinical- and end-of-life care terminology related to physician’s or-
Reasoning Approach, 2nd Edition, includes the following. ders for life-sustaining treatment (POLST). Chapter 18 clar-
ifies the uses and limitations of estimating blood pressure
What’s New in Section 1: Preparing by palpation and pulse oximetry waveform methods, and
offers additional information on temporal artery-scanning
for Advanced Emergency Medical thermometers. Chapter 19 now includes anatomic and
Technician Practice systems-based frameworks in the discussion of the clinical-
New to Chapter 1 is an expanded section on professionalism reasoning approach. Where appropriate, the chapters in
and social media use, and added emphasis on self-directed this section reflect the newest American Heart Associa-
learning as a professional characteristic. Chapters 1 and 2 tion’s 2015 guidelines.
also include new content on mobile integrated health care
(MIH) and community paramedicine (CP). Chapter 3 has What’s New in Section 5: Medical
expanded the information on National Health Goals, and Emergencies
the section on EMS provider mental health now includes
shift-work disorder. Chapter 4 now includes an updated Chapter 20 now includes guidelines for administering
concept of decision-making capacity, and physician’s or- oxygen to patients with advanced COPD, and new infor-
ders for life-sustaining treatment (POLST). Chapter 5 now mation on MERS and the importance of obtaining a travel
offers updated information on the anticipated replacement history. Additional emphasis has been added to reflect the
of the DOT’s specifications for ambulance design. importance of pneumococcal vaccine for susceptible popu-
lations, and the information on asthma and lung cancer has
been updated. Chapter 21 has been reorganized to enhance
What’s New in Section 2: Human clinical reasoning, focusing on pertinent positives and neg-
Development, Health, and Disease atives for specific cardiovascular emergencies. Chapter 22
In Chapter 8, the In the Field features have been expanded now includes an updated list of medications prescribed for
and updated to highlight the importance of understanding neurological disorders. Chapter 23 now includes hyperos-
anatomy and physiology. molar hyperglycemic state (HHS) in the discussion on dia-
betes. Chapter 24 has added information on chronic opioid-
induced constipation and on pediatric abdominal pain and
What’s New in Section 3: foreign body ingestion. Chapter 26 offers an updated list
Pharmacology of medications that affect blood clotting. Chapter 28 now
Chapters 11 and 12 now include discussion of obesity and provides information on the special concerns related to
weight-based medication calculations. Chapter 12 also has pregnant women and fetuses, updates the discussion of in-
new information on medications administered via auto- fectious diseases of global concern, and lists resources for
injector. infectious disease information. Chapter 31 adds new em-
phasis to addiction as a mental illness and now includes in-
What’s New in Section 4: Assessment formation on mental illness among EMS personnel. Chap-
ter 32 provides updated information on the public health
and Initial Management crisis related to increased abuse of opiates and opioids, on
Chapter 14 expands the first edition’s discussion of diagno- the use of synthetic cannabinoids and vaping, and on de-
sis and differential diagnosis in EMS, and it offers updated signer drugs.
xxi
xxii Preface
What’s New in Section 6: Trauma ting to attending every scheduled class and putting in
your clinical experience time, you must be ready to com-
Information on the American College of Surgeons Commit-
mit substantial time outside class to prepare. You must
tee on Trauma Level V Trauma Center has been added to
have good time management and organizational skills.
Chapter 33, as has a discussion on the SALT triage system.
You also must develop learning habits that give the best
Chapter 34 now addresses quinary blast injuries. Chapter 40
results for your time and effort. As a general rule for
has been updated to reflect new research on the use of spi-
learning required content, students must spend three
nal motion restriction and current trends that deemphasize
hours outside class for every hour in lecture. But often
the use of long backboards.
students either wait until just before the first exam or,
worse, until finding out they did not do well on the exam
What’s New in Section 7: Special to ask their instructor, “What is the best way to study for
Patient Populations the test?”
The best way to study for any test is not to study for the
Chapter 43 has been updated with new information on the
test but instead to study for understanding. Understanding
use of suctioning in the neonate.
can only develop incrementally over time, not in the last
days and hours before a test. You must spend time every
What’s New in Section 8: Rescue day immersing yourself in the course content in order to
and Special Operations build understanding. This is where your excitement comes
in: It gives you the motivation and energy required to keep
Chapter 47 now incorporates new information on safety
going even when you might feel somewhat discouraged or
procedures when working with hybrid and electric
anxious. Beyond motivation, though, there are a number of
vehicles.
concrete actions and tools that will help you organize the
content for understanding.
What’s New in the Appendixes Because time is at a premium for everyone, you should
Ketamine has been added to Appendix 4 as a sedative for use your study time to your best advantage. The follow-
endotracheal intubation and in patients with excited de- ing sections offer you some basic information about how
lirium, and tranexamic acid has been included for reducing learning occurs; to what degree learning styles play a role
internal bleeding in trauma patients. in how you should approach studying; and some specific
skills, tips, and tools you can use to help yourself acquire
the knowledge and problem-solving skills needed to com-
An Introduction to Your plete your course successfully.
priorities, whether the current time is the right time for segments. For example, you might study for 20 to 50
you, and how you can allow sufficient time not only to minutes and take a five-minute break before resuming
attend class but to commit the time needed outside class study. Take some time to reflect on what study environ-
in order to succeed. You must bring time and effort to the ment works for you. Some people prefer to study with a
learning situation. Your instructor cannot provide these partner or in a group, while others prefer to study alone.
for you. Create a comfortable place as free from distractions as
possible. Many of the specifics of these factors depend
on individual preference.
Learning Styles
Learning styles include visual, auditory, and kinesthetic
(hands-on). The most important thing to know about The Nature of Learning
them is that they are no more than preferences for the Not only must you learn for the short-term goals of test-
way people take in and process information. In truth, ing, but you also must be able to transfer knowledge and
everyone can and does learn by all of those means. The skills to the job. This requires learning in three domains:
most effective way to learn something has more to do cognitive (facts, concepts, thinking, and problem solving),
with what is being learned than how people prefer to psychomotor (hands-on skills), and affective (values and
learn it. Most complex concepts have components that professionalism). The main focus of this preface is the cog-
are better learned in one way than another. For example, nitive domain.
the concepts behind measuring blood pressure are best Knowledge is arranged in hypothetical mental
learned through reading and lecture, often with accom- structures called schemas. A schema is a collection of
panying figures and diagrams. However, the skill of taking related information that helps in making sense of what
a blood pressure is best learned by demonstration and we see, hear, read, and experience in other ways. When
hands-on practice. you can relate new information to an existing schema,
learning is easier and more effective. A schema provides
Study Habits a context and framework for interpreting and storing
There are many prescriptions for effective study habits. information. Much of the rest of the information in this
Some of the key ideas behind them include being organ- preface takes advantage of how schemas work and the
ized, planning study time, and having an environment ideas that learning occurs in small increments over time,
that is conducive to focusing and learning. An example and with repetition.
of being organized is making sure that everything you
need, such as a pen or pencil, paper, computer, textbook, Graphic Organizers
and perhaps a beverage or snack are readily at hand. Graphic organizers are learning tools that help arrange
This prevents an interruption in your thinking process information in ways that make it easier for you to pro-
to retrieve needed items. Commit to study time. Block cess and learn. You are most likely familiar with graphic
out specific time in your schedule to study (Figure 1). For organizers, even if you have not heard them called by
the period of time you are taking your Advanced EMT this name. Tables, flowcharts, and Venn diagrams are
course, consider your study time a necessary appoint- common types of graphic organizers (Figures 2 and 3).
ment with yourself. Depending on your work schedule Graphic organizers are powerful learning tools because
and lifestyle, the time that works best for you to study they allow you to see how information is organized in
may vary. Intervals between classes, or between work a way that goes beyond words. By using graphic organ-
and class, or even 20 minutes in the car spent waiting izers, you can better understand overall relationships be-
to pick up your child from school can serve as planned tween concepts and ideas.
study time. Learning occurs best when you study This textbook contains many graphic organizers to
for short periods of time with a small break between help structure your learning process. However, creating
• May develop
• Onset at young age hypoglycema • Onset in middle age
• Insulin-dependent • Prone to infection, • Non-insulin dependent
• Develops diabetic cardiovascular • Develops non-ketotic
ketoacidosis disease, kidney hyperosmolar coma
disease
Figure 2 Venn diagrams are used to compare and contrast the features of two or three related items. The organization of overlapping circles
allows information to be organized according to what features are unique to each item and which features are shared. The example here shows a
Venn diagram for type I and type II diabetes.
Signs and symptoms Weight gain in the trunk, often Hyperpigmentation of the skin
with thin extremities. “Moon face” and gums, fatigue, weakness,
appearance, accumulation of and weight loss.
fat in the upper back (“buffalo
hump”). Thin, easily bruised
skin. Delayed wound healing.
Development of facial hair in
women.
Emergencies Increased risk of MI, stroke, and Adrenal crisis (Addisonian crisis).
infection. May be present with hypo-
glycemia, hypotension, and
cardiac rhythm disturbances due
to electrolyte abnormalities.
Figure 3 Tables can be used to organize and summarize information for side-by-side comparison. This example compares the features of two
adrenal-gland disorders.
your own graphic organizers as part of your study process A variety of configurations can be used to create mind
adds even more to your learning power. For example, KWL maps or webs, cause–effect diagrams, processes, time lines,
(know, want, learn) charts are effective because they help and other ways of summarizing and representing informa-
identify what you do not yet know (Figure 4). This is criti- tion (Figures 6, 7, and 8). If you prefer to use computer-
cal because learning cannot take place until you recognize based tools rather than drawing those structures in your
the boundaries of your current knowledge. (A variation of notes, Microsoft Word has a number of graphic organizer
a KWL chart is shown in Figure 5.) templates in its online resources.
Preface xxv
Figure 4 KWL Chart. KWL stands for know, want, learn. Information is organized by what you already know, what you want to know, and
what you then learned.
• History of modern EMS began in 1966 with • What are the specific goals of the EMS
the White Paper Agenda for the Future?
• Much of what is known about prehospital
care is based on military experience
• The EMS Agenda for the Future outlines
goals for EMS system development
4. What I Learned
3. How I Learned About EMS Systems
About EMS Agenda Goals
Figure 5 The KWHL chart is a variation of the KWL chart that includes a “how” section for listing references for information.
Note Taking have on a slide. Writing word for word is rote, requires
Taking notes on both your assigned reading and your little thinking, and interferes with listening for mean-
instructor’s lectures is a way of creating study materi- ing. Mentally summarizing what is said and writing in
als for later use. An effective method is Cornell note your own words helps you develop understanding. Ap-
taking, which is explained later in this section (Figure 9). proaching note taking in this way helps you listen for
When taking notes in class, do not write word for meaning as you translate your instructor’s words into
word what your instructor is saying or what he might your own.
xxvi Preface
Vocabulary Sheet
Chapter 1
Advanced life support (ALS) Complex patient care Advanced EMTs provide basic
assessments and and limited advanced life support.
interventions that require
in-depth training.
Figure 7 A variety of charts and graphs can illustrate the steps in a process, such as a skill, or the steps of a physiological or pathophysiological
process. The example here shows the main steps in patient assessment.
Pathophysiology of Asthma
Inflammation and constriction narrow the bronchioles. It requires more work to move air past
the obstruction, especially on exhalation. Oxygen and carbon dioxide exchange are impaired.
Figure 8 A pathophysiology and presentation graphic such as this can be used to show the relationship between disease pathophysiology and
the signs and symptoms it causes in the patient.
Preface xxvii
Summary
Figure 9 Cornell note taking is a system that allows for effective organization of information and recognition of key points.
An effective way of preparing for class is discussed in Three Time Frames for
the following section. As you listen to your instructor, write
only what you do not already have in your reading notes,
Learning Activities
or anything that bears special emphasis. If you have not Learning for each concept in the course can be divided into
prepared for class and are being exposed to the material three time frames: preparation for class, time in class, and
for the first time, you will not be able to determine what review and reinforcement after class (Figure 10). None of
to write and will likely attempt to write down everything. these three time periods can be sacrificed. The use of all
Attempting to write down everything causes you to fall be- three underscores the importance of repetition in learning.
hind the pace of the lecture and miss a great deal of infor- It is rarely possible, even with simpler concepts, to grasp a
mation. Don’t do it. concept fully on first exposure. Each time you are exposed
Instead, use the Cornell note-taking method. Cornell to the same concept, you will pick up additional under-
note taking is a simple, effective and widely used note-taking standing of it. Repetition allows you to correct misconcep-
structure that you can use to take notes while reading tions, fill in gaps in knowledge, and develop deeper and
and during class. The steps are to divide, document, write, more sophisticated understanding of concepts.
review and clarify, summarize, and study. First, divide The variety of different ways in which you are exposed
your paper as shown in Figure 9. Write the course name to a concept through repetition also enriches your under-
and the date at the top of the page. Write your notes in the standing of it. Just reading about vital signs will not give
main section of the paper. Learn to use abbreviations and you a complete understanding. You will learn more by
symbols to help you write your notes more quickly and also hearing your instructor talk about vital signs, working
concisely. (Once you have read Chapter 7, “Medical Termi- on case studies in which patients’ vital signs have differ-
nology,” you will have an ample supply of symbols and ab- ent meanings, seeing your lab instructor demonstrate the
breviations at your disposal.) Review and clarify the notes skills, practicing hands-on skills in lab, seeing other health
by pulling out main concepts and key ideas and writing care providers perform the skill, and incorporating the
them in the cue column on the left side of the paper. Also skills into practice scenarios and clinical experience. Being
write any questions you have in that column. Summarize exposed to the same concept in various settings helps you
your notes at the bottom of the page, and then study from transfer learning from one context to another (such as from
the page. in the classroom to on the job).
xxviii Preface
Preparation
Preread, Read for Review, Summarize Test Knowledge, Fill-
Understanding in Knowledge Gaps
Class Time
Prepare for Class reading. Reading for answers is an effective way of reading
Preparation provides a framework for making sense of the for meaning.
information that will be provided when you are in class
Read for Understanding Begin a chapter by read-
(recall the concept of schema introduced earlier). Prepa-
ing the case study. The case studies and questions that
ration allows you to be an active and therefore a more
accompany them are specifically designed to prime your
effective learner. It also allows you to participate fully, both
thinking to read for understanding and problem solving.
mentally and in interactions with your instructor and class-
Read for meaning by looking for material that answers
mates. Coming to class prepared with questions, for exam-
each of the questions posed by the objectives, key terms,
ple, helps focus your attention during lecture so that you
and subject headings. Take notes on your reading.
can begin to fill in gaps in understanding. At a minimum,
preparation consists of completing assigned reading and Review and Summarize Review the assigned chap-
reviewing your notes. Effective reading of assigned material ter by reading again the introduction, the subject headings,
requires prereading, reading for understanding, review, and summary. Then summarize the chapter in your own
summarization, testing to identify gaps in knowledge, and words. It helps to do this in writing, but you can also do it
filling gaps in knowledge. The design of this textbook helps mentally or by talking with a classmate or mentor.
you in these activities.
Test Your Knowledge and Identify Learn-
Preread the Assigned Text Chapter Begin pre- ing Gaps Test your knowledge by changing each of
reading the chapter by reading the chapter introduction the objectives and subject headings into questions and
and summary. Next, review the objectives, key terms, and then answering them. Use the review questions at the
subject headings. Each of these chapter features serves as a end of the chapter to test your knowledge further. Iden-
preview of the content to come and helps you prepare tify gaps in knowledge by noting anything that you were
mentally to receive the information. The features are not able to answer. Go back and read for the answer.
turned into even more powerful learning tools when you Before class, write any questions you have from your
phrase each of them as a question to be answered. For reading in the Cues column of a fresh page of notes to be
example, when you see a chapter learning objective that used in class. Listen for the answers to those questions,
says “After reading this chapter, you should be able to and ask for clarification if you do not hear the answers to
identify signs and symptoms of stroke,” turn it into a ques- your questions.
tion to be answered in your reading, “What are the signs
and symptoms of stroke?” If one of the key terms in the Time in Class
chapter is aphasia, ask yourself, “What is aphasia?” If a Your time in class allows repetition and explanation of key
subject heading is “Pathophysiology of Type I Diabetes,” information and is an opportunity for your instructor to
turn it into a question, “What is the pathophysiology of elaborate on concepts and give examples. It is also an op-
type 1 diabetes?” Read each of the chapter review ques- portunity for critical thinking and asking questions. Creat-
tions to get an idea of the answers you will look for in your ing and taking advantage of those opportunities is a joint
Preface xxix
responsibility between you and your instructor. To do your improves performance. However, performance declines
part, begin by attending class prepared and well rested. Be when anxiety levels are high. At high levels of anxiety, you
ready to focus and engage fully with the instructor, con- may have difficulty reading and understanding test in-
tent, and your classmates. An important step in doing this structions and test items. You may experience the phenom-
is to avoid distractions. If your instructor does not have a enon of drawing a blank on a test item, only to remember
policy regarding phone calls, texting, and Internet use dur- it as soon as you turn in your test. Some factors that lead
ing class, avoid those temptations voluntarily. The ability to test anxiety are under your immediate control. Under-
to multitask effectively is a myth. When two tasks are un- standing the material well enough to recall it when you are
dertaken simultaneously, both tasks suffer. under stress is a key way to decrease test anxiety. This kind
Take the perspective of cooperation rather than com- of understanding develops over time. Putting off reading
petition in learning with your classmates. Form working and studying until the night before the exam is a sure way
relationships with them because it is important for your to increase your anxiety level.
learning and theirs. Also form a good working relationship To decrease anxiety during the test, focus on one item
with your instructor. Mutual trust and respect are key com- at a time. Do not worry about how many questions you
ponents in a successful learning experience. Keep an open have answered or how many questions you still need to
mind about the information you receive. Ideas that seem answer. Do not entertain thoughts about poor performance
to be in conflict often can be reconciled. At earlier levels of on the exam and do not worry about how long it takes
learning, complex concepts can be presented very simply. other people to finish the exam. There is little correlation
When presented at a more complex level, there can at first between test performance and how long it takes to com-
seem to be a contradiction when, in reality, there is not. It plete the test. In general, do not change your answers on
is helpful to ask your instructor how your previous under- multiple-choice items. If you are not sure of the answer,
standing of the concept relates to the current explanation. stay with your first choice. Change your response only if
you mismarked the answer or you misread the question or
Review and Reinforcement one or more of the responses to it.
After class, while the lecture is still fresh, review or rewrite If possible, first answer the questions you find easiest,
your notes to fill in any gaps. Use graphic organizers to and then come back to the more difficult ones. This makes
summarize and clarify information. As you study your the most efficient use of the limited time you have to take
notes on a daily basis, focus more and more on the main a test. However, a drawback is the possibility of skipping a
ideas in the Cues column, moving back to the detailed question or mismarking the answer. Whether you answer
notes or the text when you are unable to fully explain the questions in order or not, take a few minutes at the end
main ideas to yourself or a study partner. Prior to quizzes of the exam to check your answers. Make sure you have
and tests, repeat your prereading of the chapter, answering answered all the questions and that you have marked your
each of the questions developed from objectives, key terms, answer sheet correctly.
and headings. For anything that you are not able to answer, Test anxiety is reduced and mental performance is en-
go back and reread that section of the chapter. hanced by taking good care of yourself. Get a full night’s
sleep prior to the exam. Eat nutritious foods and avoid
Testing and Practice Testing excess sugar and caffeine.
xxxi
xxxii Acknowledgments
We wish to thank the following reviewers for providing M. Allen McCullough, PhD, Fire Chief/Director of
invaluable feedback and suggestions in preparation of the Public Safety, Department of Fire and Emergency
first edition of Advanced EMT: A Clinical-Reasoning A
pproach. Services, Fayetteville, GA
Deborah Poskus Medley, RN-BC, MSN, CCRN, Excela
Jeffrey L. Barnes, EMT-P, Instructor, Operation’s Man-
Health Westmoreland, Greensburg, PA
ager, Firefighter, Haz Mat Tech, Weatherly, PA
Elizabeth E. Morgan, EMT, Mt. Hood Community
Lauri Beechler, RN, MSN, CEN, EMT, Loyola University
College, Gresham, OR
Medical Center, Maywood, IL
Tom Nevetral, BS, NRP, ALS Training Coordinator, Vir-
George Blankinship, EMT-FP, Flight Paramedic, Moraine
ginia Department of Health Office of Emergency Medi-
Park Technical College, Fond du Lac, WI
cal Services, Glen Allen, VA
David Bryant, BS, EMT-P, Associate Professor, Health
Steve Nguyen, MS, NRP, Tulsa Technology Center,
Related Professions, Northeast State Community
Tulsa, OK
College, Blountville, TN
Mark Podgwaite, NREMT-I, NECEMS I/C, Training
David Burdett, NRP, Training Officer/Clinical Coordi-
Coordinator, VT EMS District 6, Berlin, VT
nator, Hamilton County EMS and Chattanooga State
Warren J. Porter, MS, BA, LP, NRP, Director, Clinical and
Community College, Chattanooga, TN
Education American Medical Response-South Region,
Rebecca Burke, BS, RN, NRP, Wallace Community
Arlington, TX
College, Dothan, AL
Barry Reed, MPA, RN, EMTP, CCRN, CEN, CCEMTP,
Helen T. Compton, NRP, Mecklenburg County Rescue
EMS, Fire, AHA Programs Director, Northwest Florida
Squad, Clarksville, VA
State College, Niceville, FL
Steve Creech, BA, MMin (NC), EMT-P, National
Douglas P. Skinner, BS, NRP, NCEE, Training Officer,
Director, Nazarene Disaster Response, Lenexa, KS
Loudoun County Fire Rescue, Leesburg, VA
Lyndal M. Curry, MA, NRP, University of South Ala-
Dale Trusty, EMT-P, Paramedic/Instructor, North
bama, Mobile, AL
Georgia Technical College, Clarkesville, GA
Glenn Faught, AAS, BS, MS, Program Chair and
Rebecca Valentine, BS, CCEMT-P, I/C, EMS Instructor,
Associate Professor, Emergency Medical Technology,
Natick, MA
SW Tennessee CC, Memphis, TN
Kelly Weller, MA, GN, LP, EMS-C, EMS Program
James W. Fogal, MA, NRP, EMS Instructor, Opelika, AL
Coordinator, Lone Star College-Montgomery, Conroe,
David C. Harrington, AS, NRP, City of Oak Ridge Fire
TX
Department, Oak Ridge, TN
Randy Williams, NRP, Instructor of Paramedic
James F. Jones, NRP, Program Director, Southeastern
Technology/EMS Programs Coordinator, Bainbridge
Technical College, Vidalia, GA
College, Bainbridge, GA
Kevin F. Jura, NRP, Lead ALS Instructor, DC Fire & EMS,
Washington, DC
Deb Kaye, EMT, BS Health Education, Physical
Education, Director/Instructor Dakota County Technical
Photo Advisors
We wish to thank the following for their valuable assis-
College, EMT–Sunburg Ambulance, Lakes Area Rural
tance on the photo program: Michael J. Grant, President &
Responders, Rosemount, MN
CEO, Alan J. Skavroneck, VP & COO, and Debbie Har-
Robin Kinsella, NECEM I/C, Mad River Valley Ambu-
rington, BS, EMT, Director, Community Relations, Ambi-
lance Service, Waitsfield, VT
trans Medical Transport, Inc., Punta Gorda, FL. Thanks
Peggy Lahren, NRP, Regional EMS Coordinator, Arizona
also to medical advisors Skippi Farley, EMT-P, and Rodney
Bureau of EMS and Trauma System, Phoenix, AZ
VanOrsdol, FF/EMT-P, and for photography, Maria Lyle
Jim Massie, BS, NRP, Instructor, EMS Program, College
Photography, Sarasota, FL.
of Southern Idaho, Twin Falls, ID
About the Authors
xxxiii
xxxiv About the Authors
Medical Editor in New Mexico. Over 20 years working in EMS, he has been
a medical director of numerous EMS services and EMS
Steven Weiss, MD, MS, training programs. During his time in Tennessee, he was
the State EMS medical director.
FACEP, FACP Dr. Weiss has been involved in training residents, phy-
sicians, and EMTs in EMS concepts and practice. He has
Dr. Weiss was first
published over 30 articles related to EMS and presented
drawn to EMS as a
over 20 abstracts at national meetings. He spent four years
working EMT in the
as the medical director for the EMS Academy in Albuquer-
mountains of Colorado.
que, which trains all levels of EMS providers throughout
After completing medi-
the state. Most recently, he helped to start the Critical Care
cal school, he trained
Paramedic program with Albuquerque Ambulance and
and received board cer-
has acted as the program medical director for five years.
tifications in both Emer-
Presently, Dr. Weiss is a tenured professor of Emergency
gency and Internal Med-
Medicine at the University of New Mexico, where he works
icine at Charity Hospital
as a research director with the EMS fellows and with the
in New Orleans. He is a
ambulance services. He is on the editorial board of Prehos-
fellow of the American
pital and Emergency Care. He is married to Amy Ernst, a
College of Emergency
fellow emergency physician with an interest in injury pre-
Physicians and the American College of Physicians. In
vention and intimate partner violence. His only daughter
2016, he became boarded in EMS medicine. His career has
has worked as an Intermediate EMT and is interested in
spanned a great diversity of emergency medicine and EMS
pursuing a career in health sciences.
systems including Louisiana, Tennessee, California, and now
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.