Prehospital Emergency Care.

(11th
Edition ) 11th Edition
Visit to download the full and correct content document:
https://ebookmass.com/product/prehospital-emergency-care-11th-edition-11th-edition
/
 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
 xxiv What’s New in the 11th Edition?
What’s New?
• Chapter 11, “Vital Signs, Monitoring Devices, and History
Taking,” has updated vital signs values as recommended
by the AHA and American College of Surgeons (as was
noted for Chapter 9). Chaper 11 includes an increased
emphasis on early pulse oximeter use.
• Chapter 12, “Scene Size-Up,” has a new section, “Violence
Toward EMS Personnel” (what to anticipate; how to pro-
tect yourself). Also included is new information on the
dangers of calls to clandestine drug labs (and how to
protect yourself).
• Chapter 13, “Patient Assessment,” includes new spine
motion restriction recommendations (more fully
explained in Chapter 32 “Spinal Trauma and Spine Motion
Restriction”). There are updated guidelines for oxygen
therapy goals for medical patients (as recommended
by AHA) and for trauma patients (as recommended by
the American College of Surgeons). A new section has
been added on naloxone (Narcan) administration for
opioid overdose.
Part 7: General Pharmacology and
Medication Administration
This standard is covered in one chapter, “General P
­ harmacology
and Medication Administration.”
What’s New?
• Chapter 14, “General Pharmacology and Medication
Administration,” contains several new elements, including
distinguishing two ways EMTs may administer medica-
tion: EMT medication administration and patient-
assisted medication administration. There are new
cautions regarding administration of oxygen (which
can be harmful in some circumstances). The chapter
includes new information on manual administration
of epinephrine for anaphylactic reaction (in lieu of
expensive auto-injectors). There is also a new section
on intranasal administration of naloxone using a
mucosal atomizer device (MAD).
Part 8: Shock and Resuscitation
This standard is covered in one chapter, “Shock and
­Resuscitation.”
What’s New?
• Chapter 15, “Shock and Resuscitation,” now identifies just
two stages of shock: compensatory and decompensa-
tory (“irreversible shock” is no longer identified as a stage
of shock). There is an extensive new section on sepsis
and septic shock, a major cause of death in the United
States. There is expanded information on multiple organ
dysfunction syndrome (MODS), and there are new sec-
tions on cardiac arrest in the pregnant patient and on
post resuscitation care after return of spontaneous
circulation (ROSC) from cardiac arrest.
Part 9: Medical
The chapters within the “Medical” standard are those on res-
piratory and cardiovascular emergencies; altered mental status,
stroke, and headache; seizures and syncope; acute diabetic
emergencies; allergic and anaphylactic reactions; toxicologic
emergencies; abdominal, hematologic, gynecologic, genitouri-
nary, and renal emergencies; and environmental, submersion
(drowning and diving), and psychiatric emergencies.
What’s New?
• Chapter 16, “Respiratory Emergencies,” has been exten-
sively revised and updated. Included are expanded infor-
mation on respiratory distress, respiratory failure, and
respiratory arrest; on forms of obstructive pulmonary
disease: asthma, emphysema, and chronic bronchitis;
on pulmonary embolism, pulmonary edema, and cys-
tic fibrosis; and on the use of metered-dose inhalers
and small-volume nebulizers.
• Chapter 17, “Cardiovascular Emergencies,” features
expanded information on dangers of administering too
much oxygen and expanded information on evaluating
hypertension associated with a cardiac emergency.
• Chapter 18, “Altered Mental Status, Stroke, and Head-
ache” has been extensively revised and updated. New or
expanded information is included on the AHA Stroke
Chain of Survival; the FAST mnemonic (facial droop,
arm drift, speech difficulty, time to call 911) for identify-
ing a stroke; the ischemic penumbra (area of afflicted
brain cells that can be restored to full function by prompt
emergency care); new information on atrial fibrillation
as a cause of stroke and on atriovenous malformation
(AVM), a tangle of malformed vessels that can rupture
and cause a stroke. There is expanded information on
transient ischemic attack (TIA) and a new section on
cryptogenic stroke (unidentifiable cause). New sections
introduce two newer stroke screening tools: MENDS
(Miami Emergency Neurologic Deficit) and RACE
(rapid arterial occlusion evaluation) scale and asso-
ciated information on large vessel occlusion (LVO) in
addition to retaining information on the Los Angeles and
Cincinnati stroke screening tools.
• Chapter 19, “Seizures and Syncope,” includes information
on differentiating a primary seizure (unprovoked, as
from a condition like epilepsy) from a secondary sei-
zure (provoked; caused by an insult to the body such as
infection, drug withdrawal, brain disease, or other). New
definitions of prolonged seizure and status epilepticus
from the American Epilepsy Society are included, and there
is an updated classification and discussion of generalized
seizures and partial seizures.
• Chapter 20, “Acute Diabetic Emergencies,” includes gen-
eral updates throughout the chapter and a new section on
intranasal glucagon.
• Chapter 21, “Allergic and Anaphylactic Reactions,” has
expanded information on the causes of anaphylactic
and anaphylactoid reactions. There is new information
on the use of manual epinephrine injection to control
an anaphylactic reaction and a new section on biphasic
anaphylactic reactions (that seem normalized but then
return in life-threatening form).

• Chapter 22, “Toxicologic Emergencies,” puts new emphasis
on opioid drug abuse and overdose and on administra-
tion of naloxone to reverse an opioid overdose. Expanded
information is included on suicide bags and suicide by
toxic gas inhalation. There are new sections on the sub-
stances methylenedioxymethamphetamine (MDMA)
and tetrahydrocannabionl (THC). There is also a new
section on cannabinoid hyperemesis syndrome.
• Chapter 23, “Abdominal, Hematologic, Gynecologic, Geni-
tourinary, and Renal Emergencies,” introduces new sections
on considerations regarding abdominal pain in pediatric,
geriatric, immunocompromised, and bariatric surgery
patients.
• Chapter 24, “Environmental Emergencies,” introduces the
concept of two systems, behavioral and physiologic,
to regulate body temperature. There is new informa-
tion on immersion hypothermia to include cold shock
response, cold incapacitation, and nonfreezing cold
injury. A new term, freezing cold injury replaces the
former term local cold injury. There is a new section on
exercise-associated hyponatremia (EAH).
• Chapter 25, “Submersion Incidents: Drowning and Div-
ing Emergencies,” has general updates throughout but no
major changes from the prior edition.
• Chapter 26, “Psychiatric Emergencies,” (formerly titled
“Behavioral Emergencies”) has been extensively revised to
emphasize distinguishing psychiatric from physical
causes of behavior changes, including a mental status
exam and a new section, “Mini Assessment for Com-
mon Psychiatric Emergencies.” There are updated def-
initions, based on the Diagnostic and Statistical Manual
(DSM-5), and detailed discussion of psychiatric prob-
lems including anxiety; bipolar disorder; depression; neu-
rocognitive disorders; schizophrenia spectrum and other
psychotic disorders; substance abuse and addictive disor-
ders; trauma/stressor-related disorders; and extrapyrami-
dal symptoms (involving involuntary movement). There
is expanded discussion of violence (including suicide
and violence to others), and there is an expanded and
updated dicsussion of principles, techniques, and legal
considerations in dealing with psychiatric emergencies.
Part 10: Trauma
The chapters within the “Trauma” standard include a trauma
overview and chapters on bleeding and soft tissue trauma;
burns; musculoskeletal trauma and nontraumatic fractures;
trauma to the head, spinal column and spinal cord, eye, face,
neck and chest; abdominal and genitourinary trauma; multi-
system trauma; and trauma in special patient populations.
The chapters in the Trauma Section of this edition
­include many new photos of exceptional quality illus-
trating types of trauma and trauma care techniques.
What’s New?
• Chapter 27, “Trauma Overview: The Trauma Patient and the
Trauma System,” is largely unchanged from the prior edition
but, in the Vehicle Collisions section, includes added infor-
mation about vehicle telemetry data predictive of injury.
• Chapter 28, “Bleeding and Soft Tissue Trauma,” newly
includes The Prehospital External Hemorrhage
What’s New in the 11th Edition? xxv
Control Protocol from the American College of Sur-
geons Committee on Trauma. There is new and expanded
information on tourniquet application and hemostatic
impregnated gauze dressings. There is a new section
on junctional bleeding control (where extremities or the
head meet torso or core body) and expanded information
on emergency care for nosebleed.
• Chapter 29, “Burns,” includes new information on fluid
shifts from burns causing edema that occludes the
airway. There is a new section, “Toxin-Induced Lung
Injury,” and the Lund-Browder burn classification
chart is newly included. The chapter includes expanded
information on burn dressings, burn center referral
criteria, and treatment of chemical burns.
• Chapter 30, “Musculoskeletal Trauma and Nontraumatic
Fractures,” has expanded information on assessment and
care of pelvic fracture and new information on use of
the full-body vacuum mattress as a full-body splint.
Information on the pneumatic antishock garment (PASG)
has been deleted from the chapter as this device is no
longer recommended.
• Chapter 31, “Head Trauma,” includes a new discussion of
the pathophysiology of primary brain injury, second-
ary brain injury, and brain herniation. There is new
emphasis on spine motion restriction (rather than sta-
bilizaiton or immobilization) and expanded information
on establishing and maintaining adequate breathing
in head trauma.
• Chapter 32, “Spinal Trauma and Spine Motion Restriction,”
(formerly titled Spinal Column and Spinal Cord Trauma”)
reflects a critical change in care for spinal trauma: spine
motion restriction rather than immobilization. (This con-
cept is discussed in some prior chapters, but the principal
discussion is presented in this chapter.) The chapter recog-
nizes that the neck and spine cannot truly be immobilized
and that evidence has shown that immobilization can actu-
ally worsen an injury. Use of soft or rigid cervical collars (no
longer called cervical spine immobilization collars) to remind
the patient to restrict head motion as well as techniques of
spine motion restriction by EMTS as well as self-restriction by
the patient are discussed. The emphasis on spine motion
restriction rather than immobiliation is a major change
throughout the text whenever spinal (column or cord)
injury is suspected or possible.
Photo sequences in Chapter 32, many new to this
­edition, clearly illustrate techniques of assessment for
spinal injury and techniques of spine motion restric-
tion for supine, ambulatory, and seated patients—
including self-extrication techniques and traditional
techniques of extrication with a Kendrick Extrication
Device and rapid extrication from a vehicle.
• Chapter 33, “Eye, Face, and Neck Trauma,” now includes
emphasis on spine motion restriction and includes a
new section on corneal injury.
• Chapter 34, “Chest Trauma,” introduces a new concept: the
cardiac box – the rectangular area of the anterior chest to
which any penetrating or blunt injury increases the likeli-
hood of cardiac or great vessel injury. There is updated
information on care of an impaled object, emphasis on
spine motion restriction (noting that immobilizing a
patient to a hard board can impede chest excursion), and
expanded information on use of a commercial vented
occlusive dressing such as Asherman, Halo, or Bolin.
 xxvi What’s New in the 11th Edition?
• Chapter 35, “Abdominal and Genitourinary Trauma,” now
emphasizes spine motion restriction in care of the
abdominal trauma patient.
• Chapter 36, “Multisystem Trauma and Trauma in Spe-
cial Patient Populations,” includes expanded information
on assessment of trauma in a pregnant patient, new
information on cervical spine injury in the pediatric
patient, and emphasis on spine motion restriction.
Part 11: Special Patient Populations
The chapters that fall under the “Special Patient Populations”
standard are chapters on obstetrics and newborn care, pediat-
rics, geriatrics, and patients with special challenges.
What’s New?
• Chapter 37, “Obstetrics and Care of the Newborn,” has
extensive revisions and updates throughout. There is new
and expanded information on the effects of abruptio
placentae on mother and fetus; hypertensive emergen-
cies; assessing contractions; assessment for prehospital
delivery and delivery at the scene; benefits of delayed
cord clamping; abnormal deliveries; types of breech
presentation and breech delivery; and shoulder dysto-
cia. Included are the AHA guidelines for newborn care;
obtaining the Apgar score; and meconium present at
birth. New sections have been added on the predelivery
emergency hyperemesis gravidarum (extreme and pro-
longed morning sickness); estimating gestational age
based on fundal height; face, chin, brow, and com-
pound presentations; and a new list of assessment trig-
gers and immediate interventions.
• Chapter 38, “Pediatrics,” has a new section on “Brief
Resolved Unexplained Events” – events in an infant or
child that, though brief, concerned the parent or caregiver,
such as a period of cyanosis or a change in breathing or
level of consciousness. There is also a new discussion of
spine motion restriction in the pediatric patient.
• Chapter 39, “Geriatrics,” has a new section on “Cognitive
Impairment” and a new discussion of spine motion
restriction in the geriatric patient.
• Chapter 40, “Patients with Special Challenges,” includes
an extensive new section, “Autism and EMS,” based on
facts for EMS personnel provided by the Autism Spectrum
Disorder Foundation. There are extensive new sections
on “Human Trafficking” and “Domestic Violence.” The
section on ventricular assist devices (VADs) has been
extensively revised, and there is a new section, “Vagus
Nerve Stimulator” about an implanted device found in
some patients with seizure disorder.
• Chapter 41, “The Combat Veteran,” has no significant
changes from the prior edition.
Part 12: EMS Operations
The chapters within the “EMS Operations” standard are chap-
ters on ambulance and air medical operations; gaining access
and patient extrication; hazardous materials; multiple-casualty
incidents and incident management; and EMS response to
­terrorist incidents.
• Chapter 42, “Ambulance Operations and Air Medical
­ escue,” includes two new sections: “Culture of Safety
R
in EMS” (based on recommendations of the National
Emergency Medical Services Advisory Council) and “Crew
Resource Management” (based on recommendations of
the International Association of Fire Chiefs).
• Chapter 43, “Gaining Access and Patient Extrication,” has
many updates and added details throughout the ­chapter
and new information on gaining access to a home
through an unlocked upper story window.
• Chapter 44, “Hazardous Materials,” has revised sections
on safety data sheets (SDS) [no longer called mate-
rial safety data sheets (MSDS)]; the 2016 Emergency
Response Guidebook.; and decontamination. There
is a new ­section. on the Wireless Information System for
Emergency Responders (WIZER) app from the National
Library of Medicine providing access to extensive medical
information. There is also a new section on “Criminal Use
of Hazardous Materials” that includes information on
clandestine drug labs.
• Chapter 45, “Multiple-Casualty Incidents and Incident
Management,” provides a reference and URL/link to
training and certification in the incident command
system, provided free of charge on the Federal
Emergency Management Agency (FEMA) website.
A new section is included on the SALT Field Triage
System formulated by the American College of Surgeons
Committee on Trauma.
• Chapter 46, “EMS Response to Terrorist Incidents,” has
new information and/or new sections on improvised
explosive devices (IED); radiological exposure
­
devices (RED); improvised nuclear devices (IND)’
active shooter incidents and the use of tactical EMS;
and cyberterrorism.
We Want to Hear from You
Many of the best ideas for improving our text books and train-
ing for future EMTs come from the instructors and students
who use our books and ancillary materials. If you have ideas
to offer us or questions to ask, you can reach us at the ad-
dresses listed below.
Contact Joseph Mistovich at:
jjmistovich@ysu.edu
Visit the Brady website at:
http://www.bradybooks.com
 Acknowledgments
We wish to thank the following groups
of people for their assistance in devel-
oping the 11th Edition of Prehospital
­Emergency Care.
Medical Editor
Our special thanks to Howard A. ­Werman,
MD, Professor and Vice Chair of Aca-
demic Affairs, Department of Emergen-
cy Medicine, The Ohio State Univer-
sity, ­Columbus, Ohio, and to Dr. Ashley
Larrimore, MD, Assistant Professor and
­ Combat Medic – Vietnam (1967–1968)
Medical Director, Center for EMS, De-
partment of Emergency Medicine, The
Ohio State University, Columbus, Ohio.
Dr. Werman and Dr. Larrimore reviewed
the entire manuscript to ensure that the
highest degree of medical accuracy was
attained. Their insight and expertise was
invaluable to the d
­ evelopment of the text.
Contributing Writers
We would like to express special appre-
ciation to the following specialists who
contributed to chapter development in
the 11th Edition.
Tom Brazelton, MD, MPH, FAAP
Professor of Pediatrics
University of Wisconsin School of
­Medicine and ­Public Health
Madison, Wisconsin
Chapter 38 – Pediatrics
Benjamin J. Esposito, EMT-P
Lieutenant/Hazardous Materials ­Specialist
Youngstown Fire ­Department
Youngstown, Ohio
Chapter 2 – Workforce Safety and
Wellness of the EMT
Chapter 43 – Gaining Access and Patient
Extrication
Chapter 44 – Hazardous Materials
Chapter 45 – Multiple Casualty ­Incidents
and Incident Command
Chapter 46 – EMS Response to ­Terrorist
Incidents
Thomas Gifford, DO, MS, FACOEP
Director, Emergency Medicine Residency
Program
St Elizabeth Boardman Hospital
Boardman, Ohio
Chapter 15 – Shock and Resuscitation
Chapter 17 – Cardiovascular Emergencies
A02_MIST4456_11_SE_FM.indd 27
Janet M. Gorsuch, RN, MS, CRNP
Nurse Practitioner Akron Children’s
Reviewers
Hospital The following reviewers of 11th Edition
Boardman, OH material provided invaluable feedback
Chapter 38 – Pediatrics and suggestions.
Brandt S. Lange, BA, CEP/EMT-P
Engineer/Paramedic
Joey Brand
Paramedic Instructor
Chandler Fire ­Department Atlanta Fire ­Department
Chandler, Arizona Atlanta, GA
Chapter 41 – The Combat Veteran Amy Eisenhauer
EMT
James D. Lange, PhD RWJBH
New Jersey
Mesa, Arizona
Chapter 41 – The Combat Veteran Gregory Helmuth
Emergency Medical Services, Program
Matthew Ozanich, MHHS, NRP Advisor
Director of Pre-Hospital Care Hawkeye Community College
Trumbull Memorial Hospital Waterloo, IA
Warren, Ohio David J. Kuchta, BSAS,RN, NRP
Chapter 38 – Pediatrics Emergency Medical Technology
Amanda L. Roby, MHHS, RRT, RPSGT Program Director
Assistant Professor, Director of ­Clinical Northwest Mississippi Community
Education for Respiratory Care and College
Senatobia, Mississippi
Polysomnography
Department of Health Professions Kelly Miyashiro, EMT
Youngstown State University Senior EMS Instructor
Youngstown, Ohio American ­Medical Response
Chapter 10 – Airway Management, Tukwila, WA
­Artificial Ventilation, and Oxygenation Aaron Nafziger, BS, NRP
Appendix 2 – Advanced Airway Higher-Ed Instructor
­Management Hewitt Trussville High School
Trussville, AL
Jessica Wallace, PhD, AT, ATC
Assistant Professor Jack Pearsull, BA
Master of Athletic Training Program Emergency Medical Services, ­Instructor
Director Massasoit Community College
Youngstown State University ­Brockton, MA
Youngstown, Ohio Timothy Steele, PhD, MT (ASCP)
Chapter 32 – Spinal Injury and Spine Microbiology and Immunology,
Motion Restriction ­Professor and Chair
Kristyn Woodward, MSW, LISW-S Des Moines ­University
Outpatient Mental Health Clinician Des Moines, IA
PsyCare Greg West, MEd, EMT I/C
Boardman, Ohio Human Services and Emergency
Chapter 26 – Psychiatric Emergencies ­Response Pathways, Instructor
­Northshore Community College
Mary Yacovone, MEd, RRT ­Danvers, MA
Associate Professor, Director of
­Respiratory Care
Department of Health Professions Photo
Youngstown State ­University
Youngstown, Ohio
­Acknowledgments
Chapter 16 – Respiratory Emergencies All photographs not credited adjacent to
Appendix 2 – Advanced Airway the photograph were photographed on
­Management assignment for Brady/Pearson.
xxvii
21/08/18 7:04 AM
 xxviii Acknowledgments

Organizations models, props, and locations for our

photos:
Lisa Sedillo
Brandon Smith
We wish to thank the following organi- Odis P. Smith
zations for their assistance in creating Rodney Van Orsdol, EMT-P Taylor Smith
the photo program for this edition: Dustin Martinez, EMT-P Jordan Tuttle
Skippi Farley, EMT-P Mark Tuttle
Suncoast Technical College Mark Tuttle, EMT-P Ashley Uhran
(Sarasota, FL) Rodney VanOrsdol
Scott Kennedy, ARNP – Health and Deborah Williams
Public Safety Program Mgr.
Brian ­Kehoe, EMT-P – EMS Program MODELS Photographers:
­Director. Thanks to the following people who por- Michal Heron
Mark Tuttle, EMT-P – ­Human ­Simulation trayed patients and EMS providers: Maria Lyle, Maria Lyle Photography
Coordinator/Lead EMT ­Instructor.
Ed Effron
Dustin Martinez, EMT-P – EMT Instructor Amber Lee Albritton Kevin Link
Sarah Albritton
Sarasota County Fire Department Cody Alsip
(Sarasota, FL) Photographers Assistants:
Monica Amaya Monica Amaya
Chief Michael Regnier Karen Arango Karen Arango
COMPANIES: Eric Austin Eric Austin
We wish to thanks the following compa- Timothy Scott Ball Mark Burelle
nies for their assistance in providing medi- Stephen E. Bledsoe, II
cal devices for the photo p ­ rogram for this Jeffrey Bolger
project: Addyson Brown
Jake Nyhart, Account Manager, Phillips Aubrey Brown
North America Ava Brown
Rob Williams, Cardiac Science Jude Brown
Korrell Butler
Jonathan Chu
Omarrie Cook
PHOTO COORDINATORS/ Fay Donaldson
SUBJECT MATTER Skippi Farley
Ryan Felts
EXPERTS Isaac Ferrell
Landon Ginter
Thanks to the following for valuable Dustin Anthony Martinez
assistance directing the medical accu- Dwayne McKeaver
racy of the shoots and coordinating Britta Saemann
 About the Authors
Joseph J. Mistovich, MEd, NRP
Joseph Mistovich is Chairperson of the Department of Health
Professions and a Professor at Youngstown State University
in Youngstown, Ohio. He has more than 33 years of experi-
ence as an educator in emergency medical services.
Mr. Mistovich received his Master of Education
degree in Community Health Education from Kent State
University in 1988. He completed a Bachelor of Science
in Applied Science degree with a major in Allied Health
in 1985, and an Associate in Applied Science degree in
Emergency Medical Technology in 1982 from Youngstown
State University.
Mr. Mistovich is an author or coauthor of numerous EMS books and journal articles
and is a frequent presenter at national and state EMS conferences.

Keith J. Karren, PhD, EMT-B

Keith J. Karren is Professor Emeritus and former Chair
of the Department of Health Science at Brigham Young
University in Provo, Utah. He has been a professional
Health Science and EMS educator and author for 40 years.
Dr. Karren received his Bachelor of Science and Mas-
ter of Science degrees from Brigham Young University
in 1969 and 1970 and his PhD in Health Science from
­Oregon State University in 1975. Dr. Karren was one of
the e­ arliest-certified EMTs in Utah and helped found
­SAVERS, a community volunteer EMS ambulance asso-
ciation in Utah. Dr. Karren co-founded the Prehospital
Emergency Care and Crisis Intervention Conference, held annually in Salt Lake City
for 36 years, one of the premier EMS conferences in North America. Dr. Karren is the
author or coauthor of numerous books on prehospital emergency care and health,
including First Aid for Colleges and Universities, First Responder: A Skills Approach
and Mind/Body Health.

xxix
 This page intentionally left blank

A01_THOM6233_05_SE_WALK.indd 9 1/13/17 6:50 PM

 Welcome to

PREHOSPITAL
EMERGENCY
CARE
11th Edition
 A Guide to Key Features
Standards and Competencies
Listed at the opening of each chapter is the
­Education Standard (or Standards) around which
the chapter is written.
CHAPTER
12
Also listed is the Competency (or Scene Size-Up
Competencies) that identifies fundamental The following items provide an overview to the purpose and content of this chapter. The Standard and Competency are
knowledge as well as patient assessment and from the National EMS Education Standards.
STANDARDS • Assessment (Content Area: Scene Size-Up)
management skills for the chapter. COMPETENCY • Applies scene information and patient assessment findings (scene size-up, primary and secondary
assessment, patient history, and reassessment) to guide emergency management.

OBJECTIVES • After reading this chapter, you should be able to:

Objectives 12-1. Define key terms introduced in this chapter.
12-2. Explain the purposes and goals of performing a scene
may present with potential hazards to EMS, patients,
or bystanders.
size-up on every EMS call. 12-6. Discuss measures necessary to protect the patient,
Objectives form the basis of each chapter and 12-3. Understand the importance of recognizing violence
toward EMS personnel whether on-scene or in the
protect bystanders, control the scene, and maintain
situation awareness.

were developed around the Education Standards ambulance.

12-4. Discuss how to use dispatch information and informa-
tion gained upon arrival at the scene to assess scene
12-7. Identify factors involved in determining the nature of
the problem based on a mechanism of injury (MOI) or
nature of illness (NOI).
and Instructional Guidelines. safety.
12-5. Identify situations that may require a call for addi-
12-8. Identify factors involved in determining the number of
patients.
tional or specialized resources, including those that

KEY TERMS • Page references indicate the first major use in this chapter. For complete definitions, see the Glossary at the
Key Terms back of this book.
index of suspicion p. 327 nature of the illness (NOI) p. 328 scene size-up p. 315
mechanism of injury (MOI) p. 326 personal protective equipment (PPE) p. 316 trauma p. 326
Page numbers identify where each key term first medical p. 326 scene safety p. 317

appears in the chapter.

Case Study and Follow-Up

Each chapter opens with a case study relevant to
the chapter topic. The case draws students into
the subject and creats a link between the text and
real-life situations and experiences.
436 PART 8 • Shock and Resuscitation 314

KEY TERMS • Page references indicate the first major use in this chapter. For complete definitions, see the Glossary at the 470 PART 8 • Shock and Resuscitation
back of this book.
anaphylactic shock p. 444 hemorrhagic shock p. 443 sepsis p. 444 M12_MIST4456_11_SE_C12.indd 314 9/13/17 5:45 AM
asystole p. 457
automated external defibrillator
hypoperfusion p. 436
hypovolemic shock p. 440
sepsis syndrome p. 444
septic shock p. 444 Case Study Follow-Up
(AED) p. 455 metabolic shock p. 442 shock p. 436
burn shock p. 443 multiple organ dysfunction syndrome sudden death p. 452 Scene Size-Up log roll the patient to place him on a backboard. As you
cardiac arrest p. 452 (MODS) p. 448 survival p. 453 do so, you quickly cut away the clothing to the back and
You have been dispatched for a 26-year-old male patient
cardiogenic shock p. 441 neurogenic shock p. 445 total downtime p. 453 inspect and palpate for any other injuries. You place the
who has been stabbed in the leg and is bleeding profusely.
chain of survival p. 453 nonhemorrhagic hypovolemic shock p. 443 unwitnessed cardiac arrest p. 453 patient on the backboard and cover him with blankets.
compensatory shock p. 448 obstructive shock p. 441 vasogenic shock p. 445
You are directed into the house by a police officer. You find
the patient lying supine on the floor with a large pool of While your partner prepares the patient for transport to the
decompensatory shock p. 448 pulseless electrical activity (PEA) p. 457 ventricular fibrillation (VF or V-Fib) p. 456 stretcher, you obtain a set of vital signs. His blood pressure
defibrillation p. 454 respiratory shock p. 442 ventricular tachycardia (VT or V-Tach) blood around his right thigh.
is 72/58 mmHg. (The narrow pulse pressure of less
distributive shock p. 441 resuscitation p. 436 p. 457 Primary Assessment than 30 mmHg is an indication that the cardiac out-
downtime p. 453 return of spontaneous circulation witnessed cardiac arrest p. 453 put is dropping and the systemic vascular resistance
As you approach the patient, he is not alert and doesn’t
hemorrhagic hypovolemic shock p. 443 (ROSC) p. 453
respond when you call his name. He also appears to be is increasing. The cardiac output is dropping because
very pale. The patient moans when you pinch and twist his of the volume loss, which decreases the preload and
trapezius muscle. You open the airway using a jaw thrust stroke volume. The systemic vascular resistance
and inspect inside the oral cavity. The mouth is clear of any is increasing as the vessels constrict to increase
obstructions. You assess the rate and depth of breathing the blood pressure. The systolic blood pressure is
by listening for air movement and watching the chest rise. a measure of the cardiac output and the diastolic
The respirations are rapid and the tidal volume is adequate. blood pressure is a measure of the systemic vascu-
(Tachypnea is a response by the body to supply more lar resistance. As the cardiac output drops, the SBP
oxygen to the hypoxic cells and to compensate for decreases. As the SVR increases, the DBP increases.
an increasing metabolic acidosis from the shift from This creates the narrow pulse pressure as the differ-
Case Study aerobic to anaerobic metabolism. The cells are likely
hypoxic from a lack of available hemoglobin to trans-
ence between the SBP and DBP becomes smaller.)
His heart rate is 132 bpm. (CO = HR : SV. When the
port the oxygen. As the cells become more hypoxic, stroke volume is decreasing because of a decreas-
The Dispatch floor with a large pool of blood around his right thigh. His the respiratory rate will continue to increase.) You ing preload, one way to try to raise the cardiac output
EMS Unit 102—respond to 46 Hillman Street. You have a pant leg is completely soaked in blood. The patient is not is to raise the heart rate. As the patient continues to
instruct your partner to apply a nonrebreather mask at 15
26-year-old male patient who has been stabbed in the leg alert and doesn’t respond when you call out to him. He bleed and the preload and stroke volume continue
lpm because shock and poor perfusion are suspected and
and is bleeding profusely. Law enforcement is en route. appears to be extremely pale. to decrease, the heart rate will continue to increase.)
to apply the pulse oximeter to attempt to get an SpO2 read-
Time out is 2102 hours. ing. The radial pulse is barely palpable (The radial pulse is Respirations are 26/minute with a good tidal volume, and
How would you proceed to assess and care for this patient?
Upon Arrival weak because of a decrease in blood pressure. Blood his skin is pale, cool, and clammy. Once the patient is
During this chapter, you will learn about assessment and
loss will cause a drop in preload, which will lower secured to the stretcher, you quickly move him to the back
You and your partner arrive at the scene and are directed emergency care for a patient suffering from shock and
the stroke volume and cardiac output. If the cardiac of the ambulance and begin rapid transport to the level 1
into the house by a police officer. He leads you into the those needing resuscitation. Later, we will return to the case
output decreases, the blood pressure will decrease, trauma center.
basement where you find the patient lying supine on the and apply the procedures learned.
resulting in weak or absent pulses. In addition, There was no one at the scene from whom you could
extreme peripheral vasoconstriction in the body’s have gathered a history. You did not note any medical iden-
attempt to increase the blood pressure by increasing tification items on his body. The patient remains responsive,
SVR will also contribute to a weak or absent periph- but only to a painful stimulus. (The decrease in men-
eral pulse.) and the skin is pale, cool, and clammy. (Pale, tal status is from inadequate perfusion of oxygen-
cool and clammy skin results from the sympathetic ated blood to the brain. The brain cells are shifting
INTRODUCTION Resuscitation is the emergency care process that response to constrict the peripheral vessels to raise to anaerobic metabolism and producing very small
attempts to restore lost vital functions. It focuses on man- the blood pressure. The skin becomes pale and cool amount of ATP—not enough for all the brain cells to
Shock is a critical condition that results in the inadequate aging the airway, oxygenation, ventilation, and circula- function normally. The result you see clinically is a
as the red, warm blood is shunted to the core of the
The Case Study Follow-Up at the end of each
perfusion of cells, tissue, and organs, leading to cel-
lular and organ dysfunction. It carries a high morbidity
tion. Resuscitation is most often associated with cardiac
arrest; however, it is also performed in cases of respira-
body. The hormones epinephrine and norepinephrine
stimulate the alpha receptors in the vessels, causing
decrease in mental status.) Thus, he is not able to pro-
vide any history.
and mortality if it is allowed to progress. If shock is not
chapter emphasizes key concepts learned and in-depth
managed effectively, it eventually leads to cell injury,
organ dysfunction, multisystem organ failure, and even
tory failure, respiratory arrest, shock, and many other
conditions.
a sustained vasoconstriction. The alpha 1 receptors
in the sweat glands are also stimulated, causing them
to produce and secrete sweat.) You quickly expose the
Reassessment
En route to the hospital, you reassess the mental sta-
resolution. Case Study Follow-Ups in the clinical
death. Every cell, tissue, organ, and organ system can be
affected by shock. In a shock state, the body attempts to
SHOCK
leg and find a steady flow of blood coming from the wound.
You apply direct pressure. You instruct your partner to cut
tus, airway, ventilation, oxygenation, and circulation. You
check the pressure dressing on the leg to be sure there
restore homeostasis through a response of the nervous is no additional bleeding. You obtain another set of vital
chapters include pathophysiology
Shock is defined notes
system and release of hormones, which causes many of to perfusion
as the inadequate
the signs and symptoms seen in the shock patient. There
explain
tissue, and organs with oxygen and other nutrients
of cells, the
the clothing to expose the remainder of the body.
Secondary Assessment
signs. You contact the trauma center and provide a radio
report of the assessment findings, your emergency care,

“why” of what you observe resulting

about the patient.
are many different etiologies and types of shock. Deter-
in cell, tissue, and organ dysfunction. It is also
often referred to as hypoperfusion. During a shock
mining the underlying cause is important to providing
You recognize the signs the patient is exhibiting to be con-
sistent with hypovolemic shock so you elect to do a rapid
and the ETA.
Upon arrival to the emergency department, the trauma
effective emergency care. state, inadequate amounts of oxygen and glucose are secondary assessment. You begin at the head and move surgeon meets you to bring the patient into the trauma
systematically down to the toes inspecting and palpating for bay. You provide an oral report and transfer the care of
any other life-threatening injuries. You auscultate the breath the patient. You then prepare your written report as your
sounds and find them to be equal and clear bilaterally. You partner cleans and prepares the ambulance for another call.

xxxii
M15_MIST4456_11_SE_C15.indd 436 9/13/17 5:48 AM

M15_MIST4456_11_SE_C15.indd 470 9/13/17 5:48 AM

 CHAPTER 16 • Respiratory Emergencies 477

TABLE 16-2 Categorization, Assessment, and Management of a Respiratory Disturbance

Category Assessment Emergency Care

Respiratory Distress Adequate tidal volume and adequate respiratory 614 PART 9 •supplemental
Provide Medicine oxygen to maintain and
rate that produces an adequate
CHAPTER minute
16 • Respiratory and alveolar
Emergencies 487 SpO2 794%.
ventilation. intranasally (IN) using a mucosal atomizer device (MAD)
breathing is present, provide positive pressure ventilation. Assessment Tips Pathop
Respiratory Failure Inadequate tidal volume, or an inadequate respiratory and
Positive pressure ventilation in a patient suffering from syringe. Intranasal administration of glucagon has
Immediately begin positive pressure ventilation with The na
a These suggestions offer clinical oxygen
insights
a pneumothorax must be performed with great care
rate, or both. been shown to have effectiveness
bag-valve-mask device with comparable
supplemental to that of
because the pneumothorax could easily be converted in the c
IMcav-and SQconnected
into a tension pneumothorax (air entering the pleural glucagon
into patient
to administration.
the assessment
device. that EMTs learn
ity that cannot escape, eventually causing lung collapse). typicall
Although protocols vary, intranasal glucagon should
over timebegin
through
positive experience.
Use the most minimal tidal volume necessary to ventilate
Respiratory Arrest No tidal volume and no respiratory
If cyanosis,rate. The patient Immediately equate
the patient effectively. hypotension, be administered
signifi- to a patient withpressure ventilation with
a severe
toaltered mental
may have agonal respirations in which there is a sudden a bag-valve-mask devicethe
Lung begins to collapsecant resistance to ventilation, and severely decreased to They enable withEMT more
supplemental oxygen amount
gasping
absent breath sounds to one hemithorax occur, suspect
respiration with a longThe period
status who has a BGL
accurately less than
to theconduct
70 mg/dL, especially
device. an assessment and
in
Ruptured bleb
a tension pneumothorax. pulse of apnea.
oximeter reading connected low blo
the patient where aspiration is a concern with the admin-
also declines severely with the development of a tension
pneumothorax. ALS can provide life-saving decompres-
interpret the findings.
istration of oral glucose. Intranasal glucagon is typically
body ar
sion of the chest in a tension pneumothorax; therefore, equate
consider an ALS backup or rendezvous if a long transport administered as a 2-mg dose via MAD and syringe with
of the b
time is expected. Follow your local protocol. 1 mg administered in each nostril. In one study, when
CPAP is contraindicated in a patient with a suspected The cel
in respiratory distress. Typically, a patient in respira-
pneumothorax regardless of the complaint of dyspnea if not properly
administered manageditsbecause
intranasally onset of of a lack
action wasofreported
oxygen
and evidence of respiratory distress. The positive pres- collects
tory distress has a normal minute ventilation from com-
sure can increase the size of the pneumothorax and delivery
to to the brain
be between 13 andand 16 heart.
minutes. Following glucagon
This
■ ■ FIGURE 16-8 Apensation in theareatidal volume (breathing deeper) and/or Whether breathing
administration, difficulty
after the patient is caused
is alert enough bytotrauma
swallow, or
ruptured bleb, or weakened
worsen the hypoxia.
of lung tissue,
causes a spontaneous pneumothorax in which air enters the pleural tion and
cavity and travels the respiratory
upward, rate
beginning the collapse of the(breathing
lung from faster). Because the tidal a medical condition,
administration your priority
of oral glucose may beisnecessary
to determineto raiseif the
the
the top. Hyperventilation Syndrome Firs
volume and respiratory rate are still adequate, the patient patient
BGL is infor
enough respiratory
the patientdistress
to become andalertin need of only
and oriented.
Hyperventilation syndrome is frequently encountered in glucose
Assessment. is compensating.
A key finding in spontaneous Because pneu- there are signs
the prehospital setting. It of respira-
is commonly associatedoxygen
with therapy, or if he is in respiratory failure or respi-
mothorax is tory situations in which the patient is emotionally upset or drawin
a suddendistress,
onset of however,
shortness of breath supplemental
excited. Patientsoxygen should
suffering “panic attacks”be
also sufferratory
from arrest in which he needs immediate ventilatory
begins
Hyperglycemia
without any evidence of trauma to the chest and with
decreased breath administered. A nasal
sounds to one hemithorax cannula
upon assess- at 2 lpm
hyperventilation can
syndrome. be used
Although to assistance
hyperventilation with a bag-valve mask or other ventilation
ment. Remember, if the patient is seated, the decreased syndrome is most often associated with an anxious patient, glucose
breath soundsincrease will be heardor maintain
in the apex (top) ofthe SpOrecognize
the lung 2 reading at 94% or syndrome
that hyperventilation higher.can be Hyperglycemia
device and supplemental
caused
is the term oxygen.
for a high blood glucose level
by a serious medical problem. Therefore, always consider water a
because of gravity Oxygen causing administration
the air to rise. The signsshouldand be based on the patient’s (hyper = high, glyco = glucose, emia = blood) and is
symptoms of a spontaneous pneumothorax follow: an underlying medical cause of hyperventilation syndrome tion in t
oxygenation status as measured and primarily
when assessing guidedmedicaldefined
and providing emergency care.
as a blood glucose level greater than 200 mg/dL.
• Sudden onset of shortness of breath It is extremely important to point out that EMS per- other t
• Sudden onset by ofthe sharppulse
chest painoximeter
or shoulder pain instead of often
sonnel using predetermined
overlook significant and potentially Any life- hyperglycemic ASSESSMENT
episode in a diabetic TIPS patient should
• Decreaseddevices breath sounds to one side of the chest glucose
(most often heard first at and flow
the apex, rates
or top, for allthreatening
of lung) patients. The patient
conditions, who embolism
especially pulmonary
and myocardial infarction, because they become prompt the EMT to assess for an infection, acute medical
fixated cose fro
• Subcutaneous presents
emphysema with(can moderate
be found) to severe respiratory
on hyperventilation distress
syndrome. why categorizingRespiratory distress patients have an adequate chest rise
That isand
• Tachypnea illness, recent cocaine use, or medication
patient as hyperventilation syndrome must be done(tidal volume) and an adequate respiratory rate. Because noncompliance. and sig
• Diaphoresis who is awake and alert canawith benefit fromandcontinuous
extreme caution only after all other potentialUnlike hypoglycemia, which is characterized by the
• Pallor positive pressure ventilation causes is also extremely impor-both the tidal volume and respiratory rate are adequate, the
pancrea
(CPAP). A
have been patient
ruled out. Itpresent-
presence
• Cyanosis (can be seen late and in a large or tension tant to do a thorough assessment and reassessments andpatientof hasinsulin
adequate and a lackand
breathing of isglucose
in need ofinonly
thesupple-
blood, request
pneumothorax) ing with a severely decreasedstay SpO 2 reading
vigilant for a and
deterioration obvious
in the patient’s condition.
in hyperglycemic conditions there is a lack of insulin
• SpO2 6 94% Pathophysiology. The hyperventilation syndromemental oxygen. A patient in respiratory failure has inadequate level is
signs of severe hypoxia may benefit from higher concen- and tidal an volume
excessiveor anamount
inadequateofrespiratory
glucoserate in (too
thehigh
blood.
or tooIn request
patient is often anxious and experiences the feeling
trations of oxygen delivered by a nonrebreather
of not being able to catch his mask at patienthypoglycemic
breath. The then
ASSE SSME NT TI PS begins to breathe faster and deeper, causing many oflow) or both.conditions, the brain is starved of
If either tidal volume or respiratory rate is inad- glucose. into glu
15 lpm. The SpO2 of pregnant patients
the signs who ofpresent
and symptoms in to In
hyperventilation hyperglycemic conditions, the brain has more glucose
occur.
If a patient presents with a sudden onset of shortness of
The true hyperventilation syndrome patient begins toequate, the respiratory status is inadequate and the patient erbates
breath withrespiratory distress should
the chest be maintained at the highest
“blow off” excessive amounts of carbon dioxide.than A cer- it knows what to do with.
decreased breath sounds to one side of
needs immediate ventilation. Respiratory failure and respira- conseq
level possible to maintain adequate
and no evidence of trauma, you should suspect a possible
tain level ofoxygenation of thefor the bodyAs
carbon dioxide is necessary
to function normally. When too much carbon dioxidetorynoted earlier, two theconditions
same way, that may result from Sec
spontaneous pneumothorax. ■
fetus. These patients must receive a high concentration arrest are treated with positive pressure
has been eliminated through rapid breathing, the extreme patient hyperglycemia are diabetic ketoacidosis (DKA) and the live
Emergency of Medical
oxygen Care.via a nonrebreather
Administer oxygen to beginsmask regardless
to experience of the
worsened signs and symptoms ofventilation and supplemental oxygen. ■
maintain an SpO2 of 94% or greater if the patient pres- hyperventilation syndrome. The patient becomeshyperglycemic more hyperosmolar syndrome (HHS). HHS is also to meta
ents with signs SpO 2 reading.
of respiratory distress, chest pain, or any anxious because of the symptoms and breathesknown even as nonketotic hyperosmolar state (NKHS) or hyper- produc
other indicators for The oxygen patient isIf said to be inOne respiratory failure
PATHOPHYSIOLOGY OF(HHNS). DKA
administration. inadequate faster. result is that the amount of calcium in the
glycemic hyperosmolar nonketotic syndrome of a stro
when the tidal volume or respiratory rate is inadequate is more commonly seen in the type 1 diabetic, whereas
HHS CONDITIONS
is more common in the THAT CAUSE levels in
and no longer can provide an adequate oxygenation of type 2 diabetic. In both condi- (acidosi
the cells. If the tidal volume decreases or the respira- tions,RESPIRATORY
M16_MIST4456_11_SE_C16.indd 487

tory rate increases or decreases significantly, you must

9/14/17 4:02 AM
the blood glucose level increases DISTRESS drastically. The
lead to
provide immediate positive pressure ventilation and oxy- Many conditions can cause a patient to experience respi-
and can
genation with a bag-valve-mask device or other venti- ratory distress, PAT Hrespiratory
O PH YSI Ofailure,L O GY or PErespiratory
ARL S arrest.
to dehy
lation device. Supplemental oxygen must be delivered Even though disease processes differ, the assessment
Pathophysiology Pearls
through the ventilation device. If a patient with inad- andHyperglycemic
emergency patientscare are havebasically
too much the same.
glucose in theItblood
is not
develop
This feature offers snapshots Becaus
equate breathing is notoftreated pathology
promptly, it is likely that yourand responsibility to diagnose
not enough insulin. The cellsthe in thespecific
body arecondition
starving, or
considerations of the
he will students
deteriorate will to encounter
respiratory arrest. in the field. disease causing
even though thethebloodrespiratory
glucose level distress; however,high
can be extremely you
sympto
It highlights Respiratory the body processes arrest is that
thelead to medical
complete cessation of are because
responsible
there isfor
notidentifying
enough insulin theto signs
move the andglucose
symptoms,
into
eral day
conditions breathing
found in effort or the patient
patients. experiences
Understanding bodyagonal breath- determining
the cells. Atwhether
the same time,the breathing
however, theisbrain adequate
is gettingormore
inad-
In t
ing. Agonal breathing
processes aids in making the right treatment decisions occurs when the brainstem reflex equate,than anticipating
an adequate deterioration
amount of glucose. in■ the patient’s status,
the follo
for them.causes a gasping breath in an otherwise apneic patient. and providing immediate intervention as necessary to
Respiratory arrest can lead to cardiac arrest in minutes, support adequate respiration.
Hyperglycemic Condition: Diabetic Factors
in the D
Ketoacidosis • The
In this section, we explore the pathophysiology of DKA, tract
the resulting assessment findings, and emergency care lin an
M16_MIST4456_11_SE_C16.indd 477 for this condition. 9/14/17 4:02 AM
debil

xxxiii
Another random document with
no related content on Scribd:
 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

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.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN