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AEA (Intermediate Life Support) Osce Booklet
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16 Terrace Road, Eastleigh Ridge, EdenvalePO Box 8808, Edenglen, 1613Tel: +27 0(86) 101-HELP ( 4357) Fax: +27 0(86) 514-9267 Cell:+27 0(82) 338-2847
Emergency Tel: (ER24 Emergency Medical Care) E-mail: info@helpemt.co.zaWebsite: www.helpemt.co.za
084 124
Members:D J Taylor (Btech EMC), M J Taylor (A11SA)
Human Emergency Life Programme (Gauteng) cc
Human Emergency Life Programme
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Human Emergency Life Programme
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Human Emergency Life ProgrammeGAUTENG Reg. No. CK 1996/019225/23VAT Reg. No. 4530226622
AMBULANCE EMERGENCY ASSISTANT COURSE
OSCE SKILL SHEETS
There will be eight random OSCE skill stations in your final examinations. Those eight will come from the OSCE
skills contained in this booklet.
The pass mark for the practical component of the AEA course is 100%. This means that you are not able to be
assessed as “NOT YET COMPETENT” for any of the OSCE skills. Should you not attain 100% for your OSCE
skills, you will not gain entrance into your final patient simulation examination.
There are thirty-four OSCE skills in this booklet, and they are, in order:
1) Suctioning of the Mouth and Pharynx
2) Use of an Oxygen Cylinder
3) OP Tube and BVM Ventilation
4) Nebulisation
5) Use of ENTONOX
6) Vital Signs: Pulse, Respirations and BP
7) Determination of Blood Glucose Levels
8) Examination of an Unconscious Patient – Medical
9) Examination of an Unconscious Patient – Trauma
10) Application of a Field Dressing
11) Use of Pressure Points
12) Application of a Padded Board Splint – Arm Fracture
13) Application of a Padded Board Splint – Leg Fracture
14) Trauma Traction Splint
15) Log-roll of a Patient onto a Long Spine Board
16) Extrication of a Patient from a Vehicle
17) Normal Vaginal Delivery
18) Breech Delivery
19) Intravenous Therapy
20) Administration of 50% Dextrose
21) Use of an ECG Monitor
22) Use of a Pulse Oximeter
23) Defibrillation
24) Needle Cricothyrotomy
25) Upper Airway Obstruction – with Equipment
26) Needle Thoracentesis
27) Pneumatic Anti-Shock Garment (MAST Suit)
28) One-Man Megacode
29) Adult 1-Rescuer CPR
30) Adult 2-Rescuer CPR
31) Adult FBAO in Responsive Patient (and Responsive Patient who becomes Unresponsive)
32) Child 1-Rescuer CPR
33) Integrated Child FBAO (Responsive and Unresponsive Patient; CPR and Rescue Breathing)
34) Infant 1-Rescuer CPR
35) Integrated Infant FBAO (Responsive and Unresponsive Patient; CPR and Rescue Breathing)
36) CPR and the Use of an AED
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: _____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – SUCTIONING OF THE MOUTH AND PHARYNX
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
PREPARATION Candidate ensures that the patient is in the lateral
position. *
Candidate prepares all required equipment:
- Suction Unit
- Suction tubing
- Suction catheter (yankauer)
*
*
*
Candidate turns suction unit on, blocks the flow to check
suction pressure, and turns the unit off. *
Candidate connects suction catheter to suction tubing,
ensuring that it is kept clean. *
SUCTIONING Candidate turns the suction unit on. *
Candidate inserts catheter correct distance into the
oropharynx (only as far as candidate can see). *
Candidate blocks the suction catheter opening at the
coupling member. *
Candidate ensures that airway is suctioned clear – while
avoiding hypoxic delay. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCTIONING
CONT. Candidate only suctions on the way out. *
Candidate ensures that patient is placed back on oxygen
after the airway is clear. *
Candidate flushes suction unit system after use. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: _________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – USE OF AN OXYGEN CYLINDER
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PREPARATION OF
O2 CYLINDER
Candidate opens the main valve slowly until an audible
rush of oxygen is heard. *
Candidate closes the main valve rapidly *
APPLICATION OF
THE REGULATOR
Candidate checks that the regulator is the correct one for
the cylinder and that the O-ring seal is present. *
Candidate applies the regulator correctly. *
Candidate opens the cylinder valve slowly, keeping
his/her face clear of the gauges. *
Candidate listens for and notes any leaks.
CONNECTION OF
DELIVERY
DEVICE
Candidate selects the correct oxygen delivery device.
Candidate connects oxygen tubing to the cylinder and to
the delivery device.
*
FLOW
ADJUSTMENT
Candidate opens the flow regulator *
Candidate selects the correct flow rate for the chosen
delivery device *
Candidate correctly applies the delivery device to the
patient, after explaining the procedure. *
TERMINATION OF
O2 THERAPY
Candidate removes the delivery device from the patient.
Candidate turns off the flow meter *
Candidate closes the main cylinder valve. *
Candidate opens the flow meter to bleed the system of
trapped oxygen. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
TERMINATION OF
O2 THERAPY
CONT…
Candidate closes the flow meter
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – OP TUBE and BVM VENTILATION
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness. *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Ensures that adequate ventilation and
oxygenation are in progress.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
OP TUBE
INSERTION
Candidate measures airway from the corner of the mouth
to the angle of the jaw. *
Candidate opens the patient’s mouth. *
Candidate depresses patient’s tongue with tongue
depressor. *
Candidate inserts airway with tip facing downward, and
slides it over the tongue. *
Candidate ensures that the patient’s tongue is not
displaced posteriorly into the oropharynx. *
Candidate ensures that the flange of the OPT is against
the patient’s lips. *
Candidate removes tongue depressor. *
If a gag reflex is present, candidate does not re-insert OP
tube. *
If patient rejects the OP tube, candidate does not re-insert
it. *
VENTILATION Candidate correctly checks and assembles BVMR
Candidate correctly and snugly fits mask to patient’s
face. *
Candidate ventilates patient until chest rises. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
OXYGEN Candidate attaches O2 tubing to O2 cylinder. *
Candidate attaches O2 tubing to BVMR. *
Candidate opens O2 cylinder and adjusts flow rate to 12-
15 litres/min. *
Candidate resumes ventilations. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – NEBULISATION
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Ensures adequate oxygenation.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
COMPLETION OF
RESPIRATORY
ASSESSMENT
Candidate determines the need for B2 Stimulant
nebulisation and rules out contra-indications. *
PREPARATION
Candidate correctly checks and assembles all equipment
required for nebulisation:
- Nebuliser
- Oxygen with tubing
- Syringe and needle
- B2 Stimulants
*
*
*
*
Candidate checks drug for:
- Correct drug
- Expiry date
- Cloudiness and leaks
- Dosage of drug.
*
*
*
*
Candidate calculates dose required. *
Candidate injects required drug/s into nebuliser and
connects to oxygen source. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
NEBULISATION Candidate connects nebuliser to oxygen source. *
Candidate selects an oxygen flow rate of 4-6 litres/min
and ensures that the nebuliser mask is misting
appropriately.
*
Candidate securely fits nebuliser mask to patient’s face. *
Candidate instructs patient to take slow, deep breaths. *
REASSESSMENT Candidate assesses the patient for effectiveness or side-
effects of nebulisation. *
Candidate monitors the patient’s vital signs, including
noting the patient’s blood sugar level 5 minutes post
nebulisation.
*
Candidate records drug administration correctly. *
Candidate repeats administration of B2 stimulant
nebulisation as required, and as per protocol. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – USE OF ENTONOX
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PREPARATION OF
ENTONOX
CYLINDER
Candidate opens the main valve slowly until an audible
rush of ENTONOX is heard. *
Candidate closes the main valve rapidly *
APPLICATION OF
THE REGULATOR
Candidate checks that the regulator is the correct one for
the cylinder and that the O-ring seal is present. *
Candidate applies the regulator correctly. *
Candidate opens the cylinder valve slowly, keeping
his/her face clear of the gauges. *
Candidate listens for and notes any leaks.
EXPLANATION OF
PROCEDURE
Candidate ensures that the patient understands how to
use the ENTONOX by demonstrating the procedure and
ensuring that the demand valve is functional
*
Candidate ensures that the face-mask fits the patient
snugly. *
Candidate indicates that the ENTONOX will produce its
peak effect in 3 to 4 minutes *
TERMINATION OF
ENTONOX
THERAPY
Candidate removes the delivery device from the patient.
*
Candidate turns off the flow meter *
Candidate closes the main cylinder valve. *
Candidate presses the orange purge button to bleed the
system of trapped ENTONOX. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – VITAL SIGNS: PULSE, RESPIRATIONS and BP
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PULSE
MEASUREMENT
Candidate correctly locates a palpable pulse at the radial
artery. *
Candidate palpates pulse with fingertips and not with the
thumb. *
Using a watch with a second hand, or with a countdown
display, candidate times the pulse for 15 or 30 seconds. *
Candidate reports the pulse rate, rhythm and strength. *
Candidate is accurate in his/her assessment of the pulse
(examiner please to check) *
RESPIRATION
MEASUREMENT
Candidate observes the rise and fall of the patient’s chest
(may do so while holding the patient’s arm to their chest) *
Using a watch with a second hand, or with a countdown
display, candidate times the respirations for 30 seconds. *
Candidate reports the respiratory rate, rhythm and depth. *
Candidate is accurate in his/her assessment of the
respirations (examiner please to check) *
BLOOD PRESSURE
MEASUREMENT
Candidate explains the procedure to the patient
Candidate snugly attaches the BP cuff in the correct
position *
Candidate inflates the cuff to just above the point at
which the radial pulse disappears (systolic BP) or
approximately 160mmHg.
*
Candidate places the diaphragm of the stethoscope over
the brachial artery (medial aspect of the arm) *
Candidate slowly deflates the cuff, observing the gauge
and listening for Korotkoff sounds. *
Candidate is accurate in his/her assessment of the BP
(examiner please to chech – within 10mmHg either side
of the actual measurement)
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – DETERMINATION OF BLOOD GLUCOSE LEVELS
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
EXAMINER STATES THAT THE PRIMARY AND
SECONDARY SURVEYS HAVE BEEN
PERFORMED
PREPARATION
Candidate selects the correct equipment for the
procedure:
* Glucose test strips
* Blood Lancets
*Gauze swabs
* Watch with second hand/countdown display
* Gloves
* Alcohol swab (not essential)
*
*
*
*
*
Candidate checks the expiry date of the glucose test
strips. *
PROCEDURE Candidate selects a glucose test strip and closes the
container lid soon after removing the strip. *
Candidate explains the procedure to the patient.. *
Candidate safely, and ensuring sterility, opens the blood
lancet. *
Candidate milks the finger chosen for finger-prick.
Candidate pricks the finger at the tip and on the side of
the chosen finger – squeezing the finger at the same
time.
*
Candidate obtains a suitably sized drop of blood. *
Candidate places the drop of blood on the reagent strip of
the glucose test strip without touching the patient’s
finger excessively on the reagent strip.
EVALUATION Candidate waits 60 seconds *
Candidate blots the blood carefully, yet firmly off the
test strip. *
Candidate waits a further 60 seconds. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
EVALUATION
CONTINUED…
Candidate compares the colour reagent strip to the colour
blocks on the test strip bottle. *
Candidate obtains a reading in mg/% or mmol/L. *
Candidate is accurate in his/her assessment of the HGT
(examiner please to check) *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – EXAMINATION OF AN UNCONSCIOUS PATIENT
(Medical)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate determines that the patient is unresponsive. *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Checks patient’s mouth for foreign material
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
GENERAL
APPEARANCE
Candidate assesses patient’s skin colour, temperature and
condition. *
HEAD-TO-TOE
SURVEY Candidate assesses for facial symmetry. *
Candidate checks patient’s pupils for size, equality and
reaction to light. *
Candidate examines the patient’s neck for distended
neck veins. *
Candidate examines for use of accessory muscles of
breathing. *
Candidate observes patient’s respiratory excursion, and
auscultates for equal air entry and breath sounds. *
Candidate examines patient’s chest for any implantable
devices. *
Candidate examines patient’s chest for any unusual
markings or bruising – including surgical scars. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
HEAD-TO-TOE
SURVEY CONT.
Candidate palpates the patient’s abdomen, and examines
for distension, tenderness, guarding and rigidity. *
Candidate examines patient’s abdomen for any unusual
markings or bruising – including surgical scars. *
Candidate examines patient for signs of incontinence. *
Candidate inspects the patient’s torso for signs of
oedema. *
Candidate examines the patient’s limbs for signs of
oedema. *
Candidate examines patient’s limbs for neurovascular
patency. *
Candidate checks motor function in the patient’s limbs. *
Candidate inspects patient for presence of medical
identification. *
Candidate turns the patient and examines the patient’s
back for any unusual markings or bruising – including
surgical scars.
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – EXAMINATION OF AN UNCONSCIOUS PATIENT
(Trauma)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate determines that the patient is unresponsive. *
Candidate ensures an open airway – using the head-tilt
chin-lift or jaw thrust techniques. *
BREATHING
Candidate:
- Checks patient’s mouth for foreign material
- Look, listen and feel for breathing
*
*
If breathing is absent or inadequate, candidate gives the patient 2 slow breaths (2 seconds
per breath), ensuring that there is adequate chest rise, and that he allows for exhalation
between breaths.
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
GENERAL
APPEARANCE
Candidate assesses patient’s skin colour, temperature and
condition. *
HEAD-TO-TOE
SURVEY Candidate notices obvious wounds and deformities. *
Candidate examines patient’s scalp for injury and
bruising. *
Candidate checks the patient’s nose and ears for injury
and discharge. *
Candidate examines the patient’s eyes for signs of injury. *
Candidate checks patient’s pupil size, equality and
reaction to light. *
Candidate examines patient’s facial bones and jaw for
deformity and stability. *
Candidate smells patients breathe for abnormal odours. *
Candidate examines the patient’s neck for wounds and
deformity. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
Candidate checks for tracheal deviation and distended
neck veins. *
Candidate correctly applies a cervical collar *
Candidate examines patient’s chest for wounds and
stability. *
Candidate observes patient’s respiratory excursion, and
auscultates for equal air entry and breath sounds. *
Candidate examines patient’s chest for any implantable
devices. *
Candidate examines patient’s chest for any unusual
markings or bruising – including surgical scars. *
Candidate palpates the patient’s abdomen, and examines
for wounds, distension, tenderness, guarding and
rigidity.
*
Candidate examines patient’s abdomen for any unusual
markings or bruising – including surgical scars. *
Candidate examines patient’s pelvis for wounds,
stability, signs of incontinence, and priapism (in males). *
Candidate examines the patient’s limbs for wounds and
deformity. *
Candidate examines patient’s limbs for neurovascular
patency. *
Candidate checks motor function in the patient’s limbs. *
Candidate inspects patient for presence of medical
identification. *
Candidate logrolls the patient and examines his back for
wounds and deformity.
Candidate examines the patient’s back for any unusual
markings or bruising – including surgical scars. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
__________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – APPLICATION OF A FIELD DRESSING
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
The Examiner states that the patient is conscious and has a wound – Examiner to point out
the wound site
PATIENT
ASSESSMENT 1O
SURVEY
Candidate verbally indicates that a primary survey
should be done.
If profuse bleeding is present, Candidate is to state that
immediate direct pressure needs to be applied.
Candidate verbally indicates that a secondary survey
should be done.
Candidate checks pulse distal to the wound. IF the
wound is to a limb (preferred site) *
WOUND CARE Candidate checks the wound for presence of foreign
bodies. *
OPENING OF
DRESSING
Candidate opens the dressing packaging without causing
contamination and removes the dressing. *
Candidate unrolls the short end of the bandage until the
dressing is free.
Candidate keeps the wound contact service of the
dressing folded-in on itself. *
APPLICATION OF
THE DRESSING
Candidate opens the wound contact surface of the
dressing and immediately applies it to the wound. *
Candidate uses the bandage to secure the dressing in
place. *
Candidate covers both open ends of the dressing. *
Candidate ensures that the dressing is not so tight as to
restrict circulation. *
Candidate checks pulses distal to the wound. *
Candidate evaluates the injured part where possible.
Candidate assesses whether or not the bleeding is
controlled. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – USE OF PRESSURE POINTS
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access.
Candidate attaches ECG monitor to patient
PATIENT
ASSESSMENT
Candidate indicates that primary and secondary surveys
have been performed. *
The Examiner is to state which pressure point is to be used by giving examples of bleeding
sites
TEMPORAL Candidate correctly locates pulse point *
Candidate uses the side of his/her thumb to compress the
artery *
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)
*
FACIAL Candidate correctly locates pulse point *
Candidate uses the side of his/her thumb to compress the
artery *
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
BRACHIAL Candidate correctly locates pulse point *
Candidate uses his/her fingertips to compress the artery *
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)
*
FEMORAL Candidate correctly locates pulse point *
Candidate sits at the patients’ side opposite to the side of
the injury *
Candidate places his/her fist on the artery (on the injured
side) and uses his/her body weight to compress the artery *
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – APPLICATION OF A PADDED BOARD SPLINT
(ARM FRACTURE)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
PATIENT
ASSESSMENT
Candidate indicates that primary and secondary surveys
have been performed. *
Candidate exposes arm with suspected fracture without
unnecessary movement. *
Candidate assesses:
- Radial pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
*
*
*
*
*
Candidate assesses wrists, elbow and shoulder for
associated injuries.
SPLINTING Candidate explains the procedure to the patient. *
Candidate requests that partner applies steady
longitudinal traction and realign the limb as necessary.
Candidate evaluates for the presence of a radial pulse
following the application of longitudinal traction.
Candidate aligns a padded board splint under or
alongside the injured limb. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SPLINTING CONT. Candidate ensures that the padded splint extends from
the hand to the mid-humerus. *
Candidate ensures that any natural hollows between the
splint and the patients’ limb are filled with gauze or
similar material.
Candidate secures the padded splint to the patients’ arm
with roller bandages, ensuring to cover the entire length
of the splint.
*
Candidate performs the splinting procedure with minimal
movement of the injured limb. *
Candidate requests that partner releases longitudinal
traction if applied.
Candidate re-assesses:
- Radial pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
*
*
*
*
*
Candidate elevates the splinted arm.
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – APPLICATION OF A PADDED BOARD SPLINT
(LEG FRACTURE)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
PATIENT
ASSESSMENT
Candidate indicates that primary and secondary surveys
have been performed. *
Candidate exposes leg with suspected fracture without
unnecessary movement. *
Candidate assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
*
*
*
*
*
Candidate assesses ankle, knee and hip for associated
injuries.
SPLINTING Candidate explains the procedure to the patient. *
Candidate requests that partner applies steady
longitudinal traction and realign the limb as necessary.
Candidate evaluates for the presence of a pedal pulse
following the application of longitudinal traction.
Candidate aligns a padded board splint under or
alongside the injured limb. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SPLINTING CONT. Candidate ensures that the padded splint extends from
the foot to the mid-thigh. *
Candidate ensures that any natural hollows between the
splint and the patients’ limb are filled with gauze or
similar material.
Candidate secures the padded splint to the patients’ leg
with roller bandages, ensuring to cover the entire length
of the splint.
*
Candidate performs the splinting procedure with minimal
movement of the injured limb. *
Candidate requests that partner releases longitudinal
traction if applied.
Candidate re-assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
*
*
*
*
*
Candidate elevates the splinted leg.
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P.
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – TRAUMA TRACTION SPLINT
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
PATIENT
ASSESSMENT
Candidate indicates that primary and secondary surveys
have been performed. *
Candidate exposes leg with suspected fracture without
unnecessary movement. *
Candidate removes the patient’s shoes and socks. *
Candidate assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
*
*
*
*
*
SPLINTING Candidate explains the procedure to the patient. *
Candidate fastens ankle stirrup strap. *
Candidate correctly measures traction splint against
patient’s uninjured leg. *
Candidate requests partner to grasp the patient’s ankle
and apply gentle longitudinal traction. *
Candidate slides traction splint into position. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SPLINTING CONT.
Candidate ensures that the splint is seated correctly
against the ischial tuberosity, and ensures that the splint
is not pressing against the patient’s genitals.
*
Candidate secures the ischial strap of the splint. *
Candidate attaches ankle strap to traction mechanism,
and starts pulling mechanical traction. *
Candidate requests that partner releases his grip slowly
as the traction splint takes over traction. *
Candidate re-assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
*
*
*
*
*
Candidate adjusts traction as necessary. *
Candidate secures traction splint to patient’s leg –
ensuring not to strap over the fracture site. *
Candidate elevates the foot of the splint. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – LOGROLL OF A PATIENT ONTO A LONG SPINE
BOARD
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
C-SPINE
IMMOBILISATION Candidate instructs the patient not to move. *
Candidate requests partner to place himself at the
patients’ head.
Candidate explains procedure to the patient. *
Candidate requests that partner maintains support of the
patient’s head and neck in alignment with the patient’s
body.
*
Candidate correctly applies a cervical collar and
instructs partner to maintain manual stabilisation of the
patient’s head and neck.
*
PREPARATION
FOR LOGROLL
Candidate prepares equipment:
- Spine Board
- Base Plate
- Head Blocks
- Spider Harness/straps
Candidate positions him/herself at the patients’ side,
kneeling at the patients’ shoulders.
Candidate requests a third persons to kneel at the
patients’ buttocks on the same side
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PREPARATION
FOR LOGROLL
CONT.
Candidate ensures that he/she has a proper grasp by
placing one hand on the patients’ furthermost shoulder
and another hand at the patients’ hip.
Candidate ensures that third person places one hand at
the patients’ buttocks and the other hand at the patients’
mid-thigh.
LOGROLL
Candidate instructs the person maintaining manual
stabilisation of the patients’ head to be in control of the
logroll procedure.
*
On the count of the person at the patients’ head, the
patient is rolled onto his/her side as a unit whilst the
patients’ head and neck remains in alignment with the
rest of the patients’ body.
*
Candidate requests that spine board is pulled under and
aligned with the patient. *
On the count of the person at the patients’ head, the
patient is lowered, as a unit, onto the spine board. *
SECURING THE
PATIENT TO THE
SPINE BOARD
Candidate adequately secures the patient to the spine
board by placing straps over the patients’ chest, thighs
and knees (or by securing a full spider harness over the
patient).
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – EXTRICATION OF A PATIENT FROM VEHICLE
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
C-SPINE
IMMOBILISATION
Candidate requests partner to place himself behind the
patient. *
Candidate explains procedure to the patient. *
Candidate requests that partner maintains support of the
patient’s head and neck in alignment with the patient’s
body.
*
Candidate correctly applies a cervical collar and
instructs partner to maintain manual stabilisation of the
patient’s head and neck.
*
HEAD-TO-TOE
SURVEY Examiner states that there are no obvious injuries.
Candidate states that vital signs would also be checked. *
PREPARATION
FOR EXTRICATION
Candidate correctly positions extrication device behind
patient. *
Candidate correctly secures patient to extrication device. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PREPARATION
FOR
EXTRICATION
CONT.
Candidate places padding between the patient’s neck and
the extrication device – as required.
Candidate secures the patient’s head to the extrication
device. *
Candidate requests that partner release manual
stabilisation of the patient’s head and neck. *
EXTRICATION Candidate supervises partner to assist him in positioning
the patient onto a long spine board. *
Candidate, with assistance, places the spine board onto
the ground.
Candidate secures patient to spine board. *
Candidate removes patient, on spine board, to a safe
place. *
SECONDARY
SURVEY
Candidate performs a full secondary survey on the
patient, and re-records a full set of vital signs. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – NORMAL VAGINAL DELIVERY
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
PREPARATION Candidate positions mother with buttocks at the edge of
the bed with knees flexed. *
Candidate prepares all required equipment:
- Cord clamps.
- Scissors/blade
- Pads
- Warm blanket
- Mucous extractor
- Resuscitation equipment
*
*
*
*
*
*
DELIVERY Candidate places gentle pressure on the baby’s head to
prevent it from delivering too quickly. *
Candidate protects the perineum from tearing. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
DELIVERY CONT.
Once the baby’s head is delivered, candidate removes
mucous and blood from the baby’s mouth and nose, and
suctions gently if necessary.
*
Candidate checks for the umbilical cord around the
baby’s neck:
a. If present, slip it over the baby’s head.
b. If it is too tight to slip over the baby’s head, it
must be double clamped and cut between the
clamps.
*
*
Candidate allows restitution to take place. *
Candidate places palms on either cheek to apply gentle
downward traction to deliver the anterior shoulder. *
Candidate applies gentle upward traction on the head to
deliver the posterior shoulders. *
Candidate grasps the baby firmly as it delivers. *
Candidate holds the infant’s head down to allow fluid to
drain from its airway. *
Candidate places the infant in the lateral position and
clears the airway if necessary. *
Candidate double clamps the umbilical cord and cuts the
cord between the clamps. *
Candidate cleans and dries the infant. *
Candidate takes the APGAR score one minute after birth
of the infant. *
Candidate inspects the cord for bleeding. *
Candidate wraps the infant in a warm blanket and gives
it to the mother. *
DELIVER OF THE
PLACENTA
Candidate applies gentle pressure over, and massages the
uterus. *
Candidate encourages the mother to push. *
Candidate does not pull on the umbilical cord. *
When the placenta delivers, candidate places it in a
plastic bag and takes it with to hospital. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
DELIVER OF THE
PLACENTA CONT.
Candidate continues to massage the uterus. *
Candidate allows only 20 minutes for the delivery of the
placenta.
Candidate cleans the mother appropriately.
Candidate notes time of delivery of baby and placenta.
Candidate administers post natal care to the mother and
baby. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – BREECH DELIVERY
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
Candidate establishes IV access. *
Candidate attaches ECG monitor to patient. *
PREPARATION Candidate positions mother with buttocks at the edge of
the bed with knees flexed. *
Candidate prepares neonatal resuscitation equipment. *
Candidate allows the foetus’ legs, buttocks and trunk to
deliver spontaneously (don’t pull!). *
Candidate supports baby’s weight on left forearm.
Candidate checks for the umbilical cord around the
baby’s neck. *
LOVESET
MANOEUVRE Candidate grasps baby’s pelvis with both hands. *
Candidate rotates baby 90o until anterior arm is freed. *
If arm not free, locate arm and free it from under the
symphysis pubis, by gently pulling down across the face
and the chest.
*
Candidate gently rotates baby to the opposite side. *
Candidate re-performs steps of Loveset manoeuvre to
free second arm. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
MAURICEAU-
SMELLIE-VEIT
MANOEUVRE
Candidate straddles baby on left forearm, with palm
facing upward. *
Candidate inserts middle finger on baby’s occiput. *
Candidate places index and ring finger on either side of
the baby’s neck. *
Candidate lifts the baby’s body upwards. *
Candidate flexes baby’s head by applying traction on jaw
and pressure on occiput. *
Candidate slowly extracts baby’s head upward when
fully flexed. *
Candidate checks for umbilical cord around baby’s neck
and removes if present. *
Candidate administers post natal care to the mother and
baby. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P.
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – INTRAVENOUS THERAPY
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
DETERMINE NEED
FOR IV THERAPY
Candidate obtains the patient’s vital signs and
determines the need for IV therapy.
PREPARATION Candidate explains the procedure to the patient.
Candidate selects appropriate fluid. *
Candidate checks vacolitre for cloudiness, leaks and
expiry date. *
Candidate selects correct administration set and attaches
correctly to vacolitre. *
Candidate fills the administration set chamber halfway
and flushes the tubing, ensuring the line is free of air. *
Candidate closes the line clamp and recovers the tubing
tip. *
Candidate selects correct cannula. *
Candidate places BP cuff on patient’s arm and inflates to
just below the systolic BP. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
VENIPUNCTURE Candidate selects suitable vein and cleans site with
alcohol swab.
Candidate stabilises vein with non-dominant hand.
Candidate inserts needle through the skin, bevel facing
upward, into a vein. *
Candidate advances needle until backflow is seen. *
Candidate slides the catheter over the needle into the
vein and withdraws the needle. *
Candidate attaches IV administration set to catheter and
deflates the BP cuff. *
Candidate opens the flow clamp wide open, and checks
the placement and checks the patient’s arm for swelling
indicating infiltration of the tissue.
*
Candidate adjusts the flow rate as desired. *
Candidate secures cannula and tubing with appropriate
strapping. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – ADMINISTRATION OF 50% DEXTROSE
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
COMPLETION OF
SECONDARY
SURVEY
Candidate determines the need for 50% dextrose
administration and rules our contra-indications. *
PREPARATION
Candidate checks drug for:
- Correct drug
- Expiry date
- Cloudiness and leaks
- Dosage of drug.
*
*
*
*
Candidate calculates dose required. *
Candidate draws up correct dose into syringe and
eliminates excess air. *
ADMINISTRATION Candidate establishes IV access. *
Candidate cleans the administration site with alcohol
swab. *
Candidate ensures a free-flowing IV line. *
Candidate slowly administers desired dose of 50%
dextrose. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
REASSESSMENT Candidate assesses the patient for effectiveness or side-
effects of 50% dextrose administration. *
Candidate monitors the patient’s vital signs, especially
noting the patient’s blood sugar level 5 minutes post
dextrose administration.
*
Candidate records drug administration correctly. *
Candidate repeats administration of 50% dextrose as
required, and as per protocol. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – USE OF AN ECG MONITOR
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
COMPLETION OF
PRIMARY SURVEY
Candidate determines the need for ECG monitoring. *
PREPARATION
Candidate checks patient for:
- Dry skin for application of ECG electrodes
- Skin area free of excess hair for application of
ECG electrodes (shaves if necessary)
Candidate prepares the following equipment:
- Appropriate number of ECG electrodes (for
monitor)
- ECG electrode wires CONNECTED to ECG
monitor
- Pre-placement of ECG electrodes onto ECG
electrode wires.
*
*
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
APPLICATION
(EUROPEAN ECG
MONITOR)
Candidate places ECG electrodes as follows:
- Red electrode to the right shoulder (infra-
clavicular)
- Yellow electrode to the left shoulder (infra-
clavicular)
- Green electrode to the left mid-axillary line at
base of costal margin.
If black electrode present:
- Black electrode to the right mid-axillary line at
base of costal margin.
*
*
*
*
APPLICATION
(AMERICAN ECG
MONITOR)
Candidate places ECG electrodes as follows:
- White electrode to the right shoulder (infra-
clavicular)
- Black electrode to the left shoulder (infra-
clavicular)
- Red electrode to the left mid-axillary line at base
of costal margin.
If green electrode present:
- Green electrode to the right mid-axillary line at
base of costal margin.
*
*
*
*
Candidate ensures that the monitor is turned to “lead II”
for monitoring purposes. *
INTERPRETATION Candidate prints a six second (30 big block) strip of
“lead II”. *
Candidate assesses the rhythm strip and accurately notes
the following features:
- Rhythm (in terms of regularity)
- Rate (as calculated from the strip and not
monitor)
- ECG diagnosis (as per ILS rhythm strips)
*
*
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – USE OF A PULSE OXIMETER
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
COMPLETION OF
PRIMARY SURVEY
Candidate determines the need for pulse oximetry. *
PREPARATION
Candidate checks patient for:
- Signs and symptoms of profound shock
- Pulse/ perfusion on the limb being used
- Clean finger (for finger probe)
- Presence of nail varnish (even clear coat)
- Recent use of intravenous dyes (methylene blue,
etc)
- Cold extremities
- History of Sickle Cell Disease (underestimate
SaO2 by 8%)
- Toxic Inhalations (carboxyhaemoglobinaemia &
methaemglobinaemia)
*
*
*
*
*
*
*
*
APPLICATION Candidate places finger probe snugly over the patient’s
finger. *
Candidate ensures that there is not excessive ambient
light affecting the probe (may show “poor signal”) *
Candidate ensures that patient is not excessively moving
his/her hand with probe attached to finger. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
ASSESSMENT Candidate checks that pulse oximeter shows adequate
signal generation. *
Candidate checks that an adequate waveform is seen on
pulse oximeter screen (if available).
Candidate notes pulse oximeter reading. *
Candidate is aware of the difference between a “false
positive” and “false negative” pulse oximetry reading,
and the causes thereof.
*
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – DEFIBRILLATION
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate opens patient airway (Head-Tilt/Chin Lift or
Jaw Thrust) *
BREATHING Candidate assesses patient’s breathing for maximum of
10 seconds. *
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
CIRCULATION Candidate assesses patient’s carotid pulse for a
maximum of 10 seconds. *
If the arrest was not witnessed, candidate is to perform 2 minutes (5 cycles) of CPR prior to
defibrillation. If the collapse was witnessed, immediate defibrillation is to be done.
PREPARATION Set monitor to 360 Joules (monophasic) or to 150/200
Joules (biphasic) (adult) or 2J/kg (child) *
Ensure “Sync” button switched off
DEFIBRILLATION Defibrillator gel to be placed on paddles. *
Determine correct paddle position and press down with
at least 20kg force to reduce trans-thoracic impedance. *
Check rhythm on monitor (Quick Look Paddles or lead
II) *
If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, continue with
defibrillation.
Charge monitor to 360 Joules (monophasic) or to
150/200 Joules (biphasic) (adult) or 2J/kg (child) *
Ensure that all persons are clear of the patient (I’m
Clear, You’re Clear, Oxygen clear, Everybody’s Clear). *
1 Candidate depresses both discharge buttons at the same
time to deliver shock, and observes ECG rhythm. *
After defibrillation, the candidate is to proceed with CPR starting with chest compressions.
Candidate performs 2 minutes (5 cycles) or CPR,
pushing hard and fast at a rate of at least 100
compressions a minute using the 30:2 compression-to-
ventilation ratio.
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
ALS ASSISTANCE Candidate establishes ALS back-up.
DEFIBRILLATION
CONTINUED…
Candidate assesses cardiac rhythm through paddles. If
the rhythm remains unchanged, candidate is to continue
with defibrillation.
Candidate is only to check the patient’s pulse if the rhythm displayed on paddle check is an
organised rhythm. If the presenting rhythm is not organised and not shockable, the
candidate is to continue with CPR.
Charge monitor to 360 Joules (monophasic) or to 150
Joules (biphasic) (adult) or 4J/kg (child) *
Ensure that all persons are clear of the patient (I’m
Clear, You’re Clear, Oxygen clear, Everybody’s Clear). *
2 Candidate depresses both discharge buttons at the same
time to deliver shock. *
After defibrillation, the candidate is to proceed with CPR starting with chest compressions.
Candidate performs 2 minutes (5 cycles) or CPR,
pushing hard and fast at a rate of at least 100
compressions a minute using the 30:2 compression-to-
ventilation ratio.
*
Candidate repeats cycles of defibrillation and CPR as
necessary and continues until ALS arrives, or until
return of spontaneous circulation.
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: __________________ Name: _________________
Qualific: _____________________ Qualific: ____________________
Signature: _____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – NEEDLE CRICOTHYROTOMY
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene
safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING Candidate:
- Look, listen and feel for breathing
*
*
CIRCULATION Candidate:
- Assesses patient’s pulse and perfusion.
*
*
VENTILATION Candidate attempts to ventilate the patient. *
Candidate repositions the patient’s airway and
reattempts ventilation. *
All other methods (e.g. abdominal thrust) fail to remove
obstruction. *
CRICOTHYROTOMY Candidate correctly assembles and checks equipment.
Candidate places the patient in a supine position. *
Candidate cleans the anterior neck with alcohol swab.
Candidate correctly locates the cricothyroid membrane. *
Candidate stabilises the thyroid cartilage. *
Candidate punctures the skin midline directly above the
cricothyroid membrane with a 14G Jelco with a 20mL
syringe attached (saline in syringe for bubbling to
occur).
*
Candidate inserts needle into cricothyroid membrane
and directs needle 45o caudally, applying a negative
pressure to the syringe, and advancing until air is
aspirated.
*
Candidate withdraws the needle while simultaneously
advancing the 14G cannula into position. *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
VENTILATION
Candidate attaches a 3-way tap to oxygen tubing, as well
as to the cannula:
a. Open all taps in all directions on the 3-way tap.
b. Set oxygen flow rate at 1 lire per minute per year
of age (up to a maximum of 8 litres/minute).
c. Occlude the open 3-way tap hole for 1 second,
and release (open) it for 4 seconds.
d. Watch for chest rise.
*
Candidate secures the cannula and tap to the patient’s
neck. *
Candidate ventilates the patient, auscultates the chest and
epigastrium for adequate ventilation. *
IF A CRITICAL POINT IS OMITTED, THE FINAL RESULT IS AUTOMATICALLY NOT YET
COMPETENT!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – UPPER AIRWAY OBSTRUCTION (with equipment)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness. *
Candidate opens the patient’s airway. *
BREATHING
Candidate:
- Look, listen and feel for breathing
- Attempts finger sweep if obstruction visible.
*
*
VENTILATION Candidate attempts ventilation. *
Candidate repositions the patient’s airway and re-
attempts ventilation. *
If obstruction still visible and not removed by finger
sweep, candidate prepares equipment:
- Tongue depressor
- Magills forceps
*
*
REMOVAL OF
OBSTRUCTION
Candidate depresses patient’s tongue with tongue
depressor. *
Under direct vision, candidate inserts Magills forceps
into patient’s airway and removes obstruction. *
If obstruction can not be removed, attempt manual
manoeuvres. *
MANUAL
MANOEUVRES
For adults, children and infants, perform 2 minutes (5
cycles) of CPR using the appropriate compression-to-
ventilation ratio
*
*
Candidate re-attempts removal of obstruction with
Magills forceps under direct visualisation. *
If still unsuccessful after 2 attempts, candidate performs
needle cricothyroidotomy in the adult patient.
In the child or infant patient, candidate is to continue
with CPR and removal attempts.
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
If effective, candidate assesses patient’s circulation. *
Candidate resumes ventilations as necessary. *
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – NEEDLE THORACENTESIS
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
HELLO Candidate assesses patient’s responsiveness *
ABC
Only if the candidate suspects the patient to be clinically
dead:
A- Open
B- Look, listen and feel
C- Pulse check
*
PATIENT
ASSESSMENT
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
a. Administers high flow O2 prn
b. Assesses respiratory status e.g. trachea, neck
veins, breath sounds
c. Diagnoses tension pneumothorax
*
*
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
DECOMPRESSION
Candidate prepares equipment:
a. 14G IV cannula
b. Alcohol swab
c. Syringe with saline and air-space (for air
bubbling)
Candidate locates 2
nd intercostals space, mid-clavicular
line on the side of the tension pneumothorax *
Candidate cleans the intended area of centesis.
Candidate inserts the 14G IV cannula just over the 3
rd
rib. *
Candidate punctures the parietal pleura. *
Candidate watches for air bubbles in saline.
Candidate removes syringe and listens for sudden
escape of air-relief from tension pneumothorax. *
Using the Seldinger technique, candidate fully advances
the catheter to the hub and then removes the needle. *
Candidate leaves the catheter in place as a marker.
Candidate reassesses the patient’s respiratory status. *
Candidate assesses the patient’s circulation:
- assess pulse and perfusion
- treat accordingly
*
IF A CRITICAL POINT IS OMITTED, THE FINAL RESULT IS AUTOMATICALLY NOT YET
COMPETENT!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
__________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – PASG
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate assesses patient’s responsiveness *
Candidate ensures an open, maintained and protected
airway. *
BREATHING
Candidate:
- Assesses patient’s respiratory status
- Administers oxygen as necessary.
*
*
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
CIRCULATION
Candidate:
- Assesses patient’s pulse and perfusion.
- Arrests life-threatening haemorrhage.
*
*
DETERMINE NEED
FOR PASG
Candidate obtains the patient’s vital signs and
determines the need for PASG (now or following IV
fluids).
*
PREPARATION Candidate establishes an IV line. *
Candidate attaches the ECG monitor. *
Candidate explains the procedure to patient (if patient
conscious)
Candidate prepares PASG on spineboard.
Candidate attaches the foot-pump and closes the
stopcock valves. *
Candidate places patient onto PASG.
Candidate removes the patient’s shoes and socks.
Candidate removes all objects from the patient’s pockets *
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
Candidate secures leg and abdominal sections to the
patient by means of Velcro fasteners.
USE OF PASG
If used for haemorrhage control, candidate inflates
required sections sequentially, starting with the legs (legs
only for ILS), to approximately 5mmHg above the
systolic BP, or otherwise inflate to 40mmHg.
*
Candidate closes stopcock valves after successful
inflation of each chosen section. *
Once inflated, do not deflate pre-hospitally unless an
urgent need exists. *
Candidate continually reassesses:
- respiration
- air entry
- pulse
- blood pressure
*
*
*
*
Candidate transports the patient to hospital.
* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT: COMPETENT ______ NOT YET COMPETENT ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – ONE MAN MEGACODE
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
RESPONSE Candidate determines that the patient is unresponsive and
activates the emergency response system. *
Candidate notes absent breathing or breathing which is not
normal (only gasping) *
CIRCULATION
Candidate:
- Checks for carotid pulse, and
- Checks for other signs of circulation. (no longer than
10 seconds)
*
*
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate begins 30
chest compressions (rate of at least 100 compressions per
minute)
*
AIRWAY Candidate opens the patient’s airway using the head-tilt chin-
lift manoeuvre (or jaw thrust if trauma) *
BREATHING Candidate delivers 2 breaths over 1 second each – each with
enough volume to make the chest rise. *
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations – if defibrillator available, use as soon as possible.
DEFIBRILLATION Defibrillator gel to be placed on paddles. *
Determine correct paddle position and press down with at
least 12kg force to reduce trans-thoracic impedance.
*
Check rhythm on monitor (Quick Look Paddles) *
If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, continue with
defibrillation.
Charge monitor to 360 Joules (monophasic) or to 150 Joules
(biphasic) or 4 J/kg (paediatrics)
*
Ensure that all persons are clear of the patient (I’m Clear,
You’re Clear, Oxygen Clear, Everybody’s Clear).
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
1 Candidate depresses both discharge buttons at the same time
to deliver shock.
*
After defibrillation, the candidate is to immediately resume chest compressions.
ALS ASSISTANCE Candidate establishes ALS back-up while continuing with
CPR.
*
CIRCULATION
After 2 minutes (approximately 5 cycles) of 30:2
compression-to-ventilation CPR, the candidate re-evaluates
presenting rhythm. If the rhythm has not changed then the
candidate continues with defibrillation. Candidate is only to
check for a pulse is the rhythm has changed to one that looks
like an organised cardiac rhythm.
*
If there is a rhythm change to an organised cardiac rhythm, candidate is to check for a
pulse, and continue with the rhythm management as per protocol.
DEFIBRILLATION
CONTINUED…
Charge monitor to 360 Joules (monophasic) or to 150 Joules
(biphasic) or 4 J/kg (paediatrics)
*
Determine correct paddle position and press down with at least
12kg force to reduce trans-thoracic impedance.
*
Ensure that all persons are clear of the patient (I’m Clear,
You’re Clear, Oxygen clear, Everybody’s Clear).
*
2 Candidate depresses both discharge buttons at the same time
to deliver shock.
*
After defibrillation, the candidate is to immediately resume chest compressions.
CIRCULATION
After 2 minutes (approximately 5 cycles) of 30:2
compression-to-ventilation CPR, the candidate re-evaluates
presenting rhythm. If the rhythm has not changed then the
candidate continues with defibrillation. Candidate is only to
check for a pulse is the rhythm has changed to one that looks
like an organised cardiac rhythm.
*
ECG MONITOR Candidate is to place the ECG leads on patient’s chest *
Candidate switches ECG monitor from “Paddles” to “Lead II” *
If there is a rhythm change to an organised cardiac rhythm, candidate is to check for a
pulse, and continue with the rhythm management as per protocol.
DEFIBRILLATION Charge monitor to 360 Joules (monophasic) or to 150 Joules
(biphasic) or 4 J/kg (paediatrics)
*
Determine correct paddle position and press down with at least
12kg force to reduce trans-thoracic impedance.
*
Ensure that all persons are clear of the patient (I’m Clear,
You’re Clear, Oxygen clear, Everybody’s Clear).
*
3 Candidate depresses both discharge buttons at the same time
to deliver shock.
*
After defibrillation, the candidate is to immediately resume chest compressions.
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
CIRCULATION
After 2 minutes (approximately 5 cycles) of 30:2
compression-to-ventilation CPR, the candidate re-evaluates
presenting rhythm. If the rhythm has not changed then the
candidate continues with defibrillation. Candidate is only to
check for a pulse is the rhythm has changed to one that looks
like an organised cardiac rhythm.
*
If the initial presenting rhythm has not changed (i.e. remained in Ventricular Fibrillation
or Pulseless Ventricular Tachycardia) the candidate is to continue with defibrillation
according to protocol.
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
BASIC LIFE SUPPORT – ADULT 1-RESCUER CPR
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
RESPONSE Candidate determines that the patient is unresponsive
and activates the emergency response system. *
Candidate notes absent breathing or breathing which is
not normal (only gasping) *
CIRCULATION
Candidate:
- Checks for carotid pulse, and
- Checks for other signs of circulation. (no longer
than 10 seconds)
*
*
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate begins 30
chest compressions (rate of at least 100 compressions per
minute)
*
AIRWAY Candidate opens the patient’s airway using the head-tilt
chin-lift manoeuvre (or jaw thrust if trauma) *
BREATHING Candidate delivers 2 breaths over 1 second each – each
with enough volume to make the chest rise. *
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
PATIENT
REASSESSMENT
After 5 cycles of compressions and ventilations (30:2
ratio, about 2 minutes), candidate rechecks the patient’s
carotid pulse and signs of circulation.
*
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions.
*
If signs of circulation are present, but breathing is absent
or inadequate, candidate continues rescue breathing (1
breath every 5 to 6 seconds or about 10 to 12
breaths/minute).
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCCESSFUL CPR If the patient is breathing, or resumes adequate breathing,
place in recovery position. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – ADULT 2-RESCUER CPR
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
RESPONSE Candidate determines that the patient is unresponsive
and activates the emergency response system. *
Candidate notes absent breathing or breathing which is
not normal (only gasping) *
CIRCULATION
Candidate 1:
- Checks for carotid pulse, and
- Checks for other signs of circulation (no more
than 10 seconds)
*
*
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate 2 begins
30 chest compressions (rate of at least 100 compressions
per minute).
*
AIRWAY Candidate 1 opens the patient’s airway using the head-
tilt chin-lift manoeuvre (or jaw thrust if trauma) *
BREATHING Candidate 1 delivers 2 breaths over 1 second each – each
with enough volume to make the chest rise. *
Candidates continue with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
PATIENT
REASSESSMENT
After 5 cycles of compressions and ventilations (30:2
ratio, about 2 minutes), candidate 1 delivers 2 rescue
breaths and rechecks the patient’s carotid pulse and signs
of circulation.
*
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions, until an AED or EMS team
arrives.
*
If signs of circulation are present, but breathing is absent
or inadequate, candidate continues rescue breathing (1
breath every 5 to 6 seconds or about 10 to 12
breaths/minute).
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCCESSFUL CPR If the patient is breathing, or resumes adequate breathing,
place in recovery position. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – ADULT FBAO IN RESPONSIVE PATIENT
(and RESPONSIVE PATIENT WHO BECOMES UNRESPONSIVE)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate determines that the patient is responsive and
indicating universal distress signal. *
ABDOMINAL
THRUSTS
Candidate gives abdominal thrusts with proper hand
position (chest thrusts for patient who is obese or
pregnant), avoiding compressions over the lower
sternum (xiphoid).
*
Candidate repeats thrusts until the object is expelled
(obstruction relieved) or the patient becomes
unresponsive.
*
Adult FBAO – Patient becomes unresponsive
PERFORMANCE Candidate activates the emergency response system. *
Candidate opens the patient’s airway with a tongue-jaw-
lift; & performs a finger sweep if the foreign object is
visible.
*
Candidate opens the patient’s airway and attempts to
ventilate; if it is still obstructed (chest does not rise),
reopen the airway (reposition the head and chin) and try
to ventilate again.
*
If ventilation is unsuccessful, candidate starts CPR by
giving 30 chest compressions on the lower half of the
patient’s sternum in the midline between the nipples.
*
Continue with CPR until ALS arrives or patient begins
breathing normally.
SUCCESSFUL If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – CHILD 1-RESCUER CPR
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
RESPONSE Candidate determines that the patient is unresponsive
and activates the emergency response system. *
Candidate notes absent breathing or breathing which is
not normal (only gasping) *
CIRCULATION
Candidate:
- Checks for carotid pulse, and
- Checks for other signs of circulation. (no longer
than 10 seconds)
*
*
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 3 to 5 seconds, about 12 to 20 breaths/minute)
If no signs of circulation are present, or heart rate is less
than 60 bpm with signs of poor perfusion, candidate
begins 30 chest compressions (typically 1-hand
compression technique, rate of at least 100 compressions
per minute)
*
AIRWAY Candidate opens the patient’s airway using the head-tilt
chin-lift manoeuvre (or jaw thrust if trauma) *
BREATHING Candidate delivers 2 breaths over 1 second each – each
with enough volume to make the chest rise. *
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
PATIENT
REASSESSMENT
After about two minutes of rescue support, candidate
rechecks the patient’s carotid pulse and signs of
circulation.
*
If candidate is alone, candidate now activates the
emergency response system. *
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions.
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PATIENT
ASSESSMENT
CONT.
If signs of circulation are present, but breathing is absent
or inadequate, candidate continues rescue breathing (1
breath every 3 to 5 seconds or about 12 to 20
breaths/minute).
*
SUCCESSFUL CPR If the patient is breathing, or resumes adequate breathing,
place in recovery position. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – INTEGRATED CHILD FBAO
(RESPONSIVE and UNRESPONSIVE PATIENT; CPR and RESCUE BREATHING)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate determines that the patient is responsive and
indicating universal distress signal. *
Candidate asks “Are you choking?” (YES), if yes,
candidate asks “Can you speak?” (NO). If no, candidate
tells the child that he is going to help.
*
ABDOMINAL
THRUSTS
Candidate stands or kneels behind the child, with his
arms encircling the child’s abdomen. *
Candidate gives abdominal thrusts using the proper hand
position (avoid xiphoid) and supports the child’s body. *
Candidate repeats until the object is expelled or the
patient becomes unresponsive.
Child FBAO – Patient becomes unresponsive
PERFORMANCE If a second rescuer is available, candidate sends that
rescuer to activates the emergency response system. *
Candidate opens the patient’s airway with a tongue-jaw-
lift; and removes any foreign objects that can be seen (no
object seen = no finger sweeps).
*
Candidate opens the patient’s airway and attempts to
ventilate; if it is still obstructed (chest does not rise),
reopen the airway (reposition the head and chin) and try
to ventilate again.
*
If ventilation is unsuccessful, candidate starts CPR
beginning with chest compressions *
Continue with CPR until ALS arrives or patient begins
breathing normally.
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCCESSFUL If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – INFANT 1-RESCUER CPR
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
RESPONSE Candidate determines that the patient is unresponsive
and activates the emergency response system. *
Candidate notes absent breathing or breathing which is
not normal (only gasping) *
CIRCULATION
Candidate:
- Checks for brachial pulse, and
- Checks for other signs of circulation. (no longer
than 10 seconds)
*
*
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 3 to 5 seconds, about 12 to 20 breaths/minute)
If no signs of circulation are present, or heart rate is less
than 60 bpm with signs of poor perfusion, candidate
begins 30 chest compressions (typically 2-finger
compression technique, rate of at least 100 compressions
per minute)
*
AIRWAY Candidate opens the patient’s airway using the head-tilt
chin-lift manoeuvre (or jaw thrust if trauma) *
BREATHING Candidate delivers 2 breaths over 1 second each – each
with enough volume to make the chest rise. *
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
PATIENT
REASSESSMENT
After about two minutes of rescue support, candidate
rechecks the patient’s carotid pulse and signs of
circulation.
*
If candidate is alone, candidate now activates the
emergency response system. *
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions.
*
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
PATIENT
ASSESSMENT
CONT.
If signs of circulation are present, but breathing is absent
or inadequate, candidate continues rescue breathing (1
breath every 3 to 5 seconds or about 12 to 20
breaths/minute).
*
SUCCESSFUL CPR If the patient is breathing normally, or resumes adequate
breathing, place in recovery position. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE: __________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – INTEGRATED INFANT FBAO
(RESPONSIVE and UNRESPONSIVE PATIENT; CPR and RESCUE BREATHING)
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
AIRWAY Candidate determines that the patient is responsive. *
Candidate confirms severe or complete airway
obstruction (signs of serious breathing difficulty,
ineffective cough, no strong cry).
*
BACK
BLOWS/CHEST
COMPRESSIONS
Candidate gives up to 5 forceful back blows with the
heel of the hand, and 5 forceful chest compressions using
the 2-finger compression technique (no abdominal
thrusts).
*
Candidate repeats until the object is expelled or the
patient becomes unresponsive.
Infant FBAO – Patient becomes unresponsive
PERFORMANCE If a second rescuer is available, candidate sends that
rescuer to activates the emergency response system. *
Candidate opens the patient’s airway with a tongue-jaw-
lift; and removes any foreign objects that can be seen (no
object seen = no finger sweeps).
*
Candidate opens the patient’s airway and attempts to
ventilate; if it is still obstructed (chest does not rise),
reopen the airway (reposition the head and chin) and try
to ventilate again.
*
If ventilation is unsuccessful, candidate starts CPR
beginning with chest compressions *
Continue with CPR until ALS arrives or patient begins
breathing normally.
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SUCCESSFUL If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________
Examiner One: Examiner Two:
Name: ____________________ Name: __________________
Qualific: ____________________ Qualific: __________________
Signature: ____________________ Signature: __________________
H.E.L.P. EMERGENCY MEDICAL TRAINING
CANDIDATE EXAM NUMBER: _____________________ DATE:
_____________________
COURSE: FULL TIME _______ PART TIME _______
INTERMEDIATE LIFE SUPPORT – CPR AND THE USE OF THE AED
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
SAFETY Candidate assesses the area with regards to scene safety. *
RESPONSE
Candidate determines that the patient is unresponsive
and activates the emergency response system – calling
for an AED
*
Candidate notes absent breathing or breathing which is
not normal (only gasping) *
CIRCULATION
Candidate:
- Checks for carotid pulse, and
- Checks for other signs of circulation. (no longer
than 10 seconds)
*
*
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate begins 30
chest compressions (rate of at least 100 compressions per
minute)
*
AIRWAY Candidate opens the patient’s airway using the head-tilt
chin-lift manoeuvre (or jaw thrust if trauma) *
BREATHING Candidate delivers 2 breaths over 1 second each – each
with enough volume to make the chest rise. *
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
AED USE Candidate places the AED next to the patient as soon as
it is available and proceeds with AED use.
Candidate puts the AED on by pushing the “POWER
ON” button *
Candidate attached the electrode pads in the proper
position (as pictured on each of the AED electrodes)
sternum and apex, with proper contact and no
overlapping of the electrodes.
*
Candidate “clears” the patient for analysis (automated) *
The AED will analyse and will advise a shock and will charge the electrodes
ACTIVITY
CRITICAL PERFORMANCE
DONE/
NOT
DONE
AED USE CONT. Candidate “clears” the patient and presses the “SHOCK”
button. *
The AED will only deliver one shock and will then instruct the candidate to continue with
CPR starting with chest compressions. The internal AED timer will now also commence
timing for 2 minutes.
CPR Candidate continues with CPR until ALS arrives or until
the patient begins breathing normally *
Pulse, breathing, coughing and movement are present
PATIENT CARE Candidate continues to monitor breathing and signs of
circulation until ALS arrives. *
If trauma is not suspected, candidate placed the patient in
the recovery position with the AED attached. *
* If a critical point is omitted, the final result is automatically unsatisfactory!
FINAL RESULT: SATISFACTORY ______ UNSATISFACTORY ______
COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One: Examiner Two:
Name: ____________________ Name: ____________________
Qualific: ____________________ Qualific: ____________________
Signature: ____________________ Signature: ____________________
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