1.Chapter 35Lifting and MovingPatients

2. National EMS EducationStandard CompetenciesEMS OperationsKnowledge of operational roles andresponsibilities to ensure patient, public, andpersonnel safety. 3. Introduction In the course of a call, EMTs move patients. To move patients without injury, you need tolearn proper techniques. Correct body mechanics, grips, and devicesare important. 4. Moving and Positioning thePatient (1 of 3) When you move a patient, take care thatinjury does not occur: To you To your team To the patient Many EMTs are injured lifting and movingpatients. 5. Moving and Positioning thePatient (2 of 3) Training and practice are required. Special lifting and moving techniques arenecessary for: Patients with head injury, shock, spinal injury Pregnant patients Obese patients 6. Moving and Positioning thePatient (3 of 3) 7. Body Mechanics (1 of 12) In lifting: Shoulder girdle should be aligned over pelvis. Hands should be held close to legs. Force then goes essentially straight down spinal column. Very little strain occurs. 8. Body Mechanics(2 of 12) 9. Body Mechanics (3 of 12) This is the correct way to lift. 10. Body Mechanics (4 of 12) You may injure your back: If you lift with your back curved If you lift with your back straight but bentsignificantly forward at the hips 11. Body Mechanics (5 of 12) This is an incorrect method of lifting. 12. Body Mechanics (6 of 12) Power lift Legs should be spread about 15 apart (shoulder width). Place feet so center of gravity is balanced. With your back held upright, bring your upper body down by bending the legs. Grasp the patient/stretcher. 13. Body Mechanics (7 of 12) Power lift (contd) Lift patient by raising your upper body and arms and straightening your legs until standing. Keep the weight close to your body. See Skill Drill 35-1. 14. Body Mechanics (8 of 12) 15. Body Mechanics (9 of 12) Power grip gets maximum force fromhands. Palms up Hands about 10 apart All fingers at same angle Fully support handle on curved palm 16. Body Mechanics (10 of 12) 17. Body Mechanics (11 of 12) To lift a patient by a sheet or blanket: Center the patient. Tightly roll up excess fabric on the sides. Use the cylindrical handle to grasp fabric and lift patient. 18. Body Mechanics (12 of 12) 19. Weight and Distribution (1 of 9) Whenever possible, use a device that canbe rolled. When a wheeled device is not available, abackboard must be used. 20. Weight and Distribution (2 of 9) More of the patients weight rests on thehead half of the device than on the foot half. Diamond carry and the one-handed carryuse one EMT at head and foot, and one oneach side of patients torso. See Skill Drill 35-2 and Skill Drill 35-3. 21. Weight and Distribution (3 of 9) 22. Weight and Distribution (4 of 9) Always secure patient to backboard orstretcher. So patient cannot slide significantly whenstretcher is at an angle 23. Weight and Distribution (5 of 9) Wheeled ambulance stretcher weighs 40145 lb. Generally too heavy for use on stairs 24. Weight and Distribution (6 of 9) If you must use a backboard or wheeledstretcher on stairs, see Skill Drill 35-4. 25. Weight and Distribution (7 of 9) A stair chair can be used to bring aconscious patient down to stretcher(see Skill Drill 35-5). 26. Weight and Distribution (8 of 9) 27. Weight and Distribution (9 of 9) Backboardshould be usedinstead forpatient: In cardiac arrest Who must bemoved in supineposition Who must beimmobilized 28. Directions and Commands(1 of 3) Team actions must be coordinated. Team leader Indicates where each team member should be Rapidly describes sequence of steps to performbefore lifting 29. Directions and Commands (2 of 3) Preparatory commands are used. Example: Team leader says, All ready to stop, to getteams attention. Then team leader says, Stop! in louder voice. Countdowns are also used. 30. Directions and Commands(3 of 3) Estimate patients weight before lifting Adults often weigh 120220 lb. Two EMTs should be able to safely lift this weight. If patient weighs over 250 lb, use fourrescuers. Place strongest EMT at head end. 31. Principles of Safe Reachingand Pulling (1 of 4) Body drag When you use a body drag, same principlesapply as when lifting and carrying. Keep back locked and straight. Kneel. Extend arms no more than 1520 in front ofyou. 32. Principles of Safe Reaching and Pulling (2 of 4) Log rolling Log roll the patient onto his or her side toplace a patient on a backboard. 33. Principles of Safe Reaching and Pulling (3 of 4) Log rolling (contd) Kneel as close to the patients side as possible. Keep your back straight. Roll the patient without stopping. 34. Principles of Safe Reaching and Pulling (4 of 4) Rolling the stretcher Stretcher should be fully elevated. Push the stretcher from the head end. Never push with arms fully extended. 35. General Considerations Move a patient in orderly, planned,unhurried manner. Carefully plan ahead. Select methods that will involve leastamount of lifting and carrying. 36. Emergency Moves (1 of 5) Use when there is potential for dangerbefore assessment and management. Examples: fire, explosives, hazardous materials Use when you cannot properly assesspatient or provide immediate care becauseof patients location or position. 37. Emergency Moves (2 of 5) If you are alone, use a drag to pull patientalong long axis of body. Use techniques to help prevent aggravationof patient spinal injury. Clothes drag Blanket drag Arm drag Arm-to-arm drag 38. Emergency Moves (3 of 5) 39. Emergency Moves (4 of 5) To remove unconscious patient fromvehicle alone: First move legs clear of pedals. Rotate patient so back is toward open car door. Place arms through armpits and support headagainst your body. Drag patient from seat to a safe location. 40. Emergency Moves (5 of 5) 41. Urgent Moves (1 of 2) Necessary to move patient with: Altered level of consciousness Inadequate ventilation Shock Rapid extrication technique requires team ofknowledgeable EMTs. See Skill Drill 35-6. 42. Urgent Moves (2 of 2) Rapid extrication technique is an urgentmove and should only be used if urgencyexists. Patient can be moved within 1 minute. Technique increases damage if patient hasspinal injury. Look at all options before using technique. 43. Nonurgent Moves (1 of 5) Used when both scene and patient arestable Carefully plan how to move the patient. Team leader should plan the move. Personnel Obstacles identified Equipment Path 44. Nonurgent Moves (2 of 5) Choose between: Direct ground lift (Skill Drill 35-7) For those with no suspected spinal injury who are supine. Patient will need to be carried distance. EMTs stand side by side to lift/carry. 45. Nonurgent Moves (3 of 5) Choose between (contd): Extremity lift (Skill Drill 35-8) For those with no suspected spinal injury who are supine or sitting Helpful when patient is in small space One EMT at patients head and the other at patients feet Coordinate moves verbally. 46. Nonurgent Moves (4 of 5) To transfer a patient from bed to stretcher,use: Direct carry (see Skill Drill 35-9) Move supine patient from the bed to stretcherusing a direct carry method. Draw sheet method Move patient from bed to stretcher using asheet or blanket. Scoop stretcher (see Skill Drill 35-10) 47. Nonurgent Moves (5 of 5) 48. Geriatrics (1 of 2) Most patients transported by EMS aregeriatric patients. Skeletal changes cause brittle bones, andspinal curvatures present specialchallenges. Allay patients fears with sympathetic andcompassionate approach. 49. Source: Dr. P. Marazzi/Photo Researchers, Inc.Kyphosis Geriatrics (2 of 2)Spondylosis 50. Bariatrics (1 of 2) Refers to management of obese people 100 million adults in the US are overweightor obese. Approximately 20% to 25% of children areoverweight or obese. Back injuries account for the largest numberof missed days of work. 51. Bariatrics (2 of 2) Stretchers and equipment are beingproduced with higher capacities. Does not address danger to EMTs of carryingever-heavier weights Mechanical ambulance lifts are uncommon inUnited States. 52. Patient-Moving Equipment(1 of 3) Stretcher is available in many models withvarious features. General features Head and foot end Strong metal frame (to push, pull, lift) Hinges at center allow for elevation ofhead/back. Guardrail prevents patient from rolling out. 53. Patient-Moving Equipment (2 of 3) General features (contd) Undercarriage frame allows adjustment to anyheight. Stretcher has locking mechanism when controlsare not activated. Controls are located at the foot end and at oneor both sides of most stretchers. 54. Patient-Moving Equipment(3 of 3) 55. Types of Stretchers (1 of 19) Wheeledambulancestretcher Also calleda stretcheror gurney Mostcommonlyuseddevice 56. Types of Stretchers (2 of 19) Wheeled ambulance stretcher (contd) Patient may be secured directly to stretcher Or, patient may be secured to backboard first if: Suspected spinal injury or multisystemtrauma Patient is in need of CPR 57. Types of Stretchers (3 of 19) Bariatric stretcher Specialized for overweight or obese patients Wider wheel base for increased stability Source: Courtesy of Stryker Medical 58. Types of Stretchers (4 of 19) Bariatric stretcher (contd) Some have tow package with winch. Rated to hold 850900 lb Regular stretcher rated for 650 lb max. 59. Types of Stretchers (5 of 19) Pneumatic andelectronic-poweredwheeled stretcher Battery operatedelectronic controls toraise/lowerundercarriage This increases the weight of stretcher.Source: Courtesy of Stryker Medical Hazardous for uneven terrain or stairs 60. Types of Stretchers (6 of 19) Loading a wheeled stretcher into an ambulance Ensure the frame is held firmly between two hands so it does not tip. 61. Types of Stretchers (7 of 19) Loading a wheeled stretcher into anambulance (contd) Newer models are self-loading, allowing you topush the stretcher into ambulance. Other models need to be lowered and lifted tothe height of the floor of ambulance. Clamps in ambulance hold stretcher in place. See Skill Drill 35-11. 62. Types of Stretchers (8 of 19) Portable/folding stretcher Strong, rectangular tubular metal frame with fabric stretched across it 63. Types of Stretchers (9 of 19) Portable/folding stretcher (contd) Some models have two wheels. Some can be folded in half. Used in areas difficult to reach Weigh less then wheeled stretchers 64. Types of Stretchers (10 of 19) Flexible stretcher Can be rolled into atubular package Excellent for storage andcarrying Conform around apatients sides Useful for confinedspaces Uncomfortable, butprovides support andimmobilization 65. Types of Stretchers (11 of 19) Backboard Long, flat, and made of rigid rectangularmaterial (mostly plastic) Used to carry and immobilize patients withsuspected spinal injury or other trauma 66. Types of Stretchers (12 of 19) Backboard (contd) Commonly used for patients found lying down 6 to 7 long Holes serve as handles and a place to securestraps. 67. Types of Stretchers (13 of 19) Backboard (contd) Short backboardsor half-boards areused to immobilizeseated patients Example: the KED vest-type device 68. Types of Stretchers (14 of 19) Basket stretcher Rigid stretcher alsocalled a Stokeslitter Used for remotelocationsinaccessible by avehicle, includingwater rescues andtechnical roperescues 69. Types of Stretchers (15 of 19) Basket stretcher (contd) If spinal injury, secure patient to backboard andplace inside basket stretcher to carry patient outof location. When you return to ambulance, lift thebackboard out of basket stretcher and place onwheeled stretcher. 70. Types of Stretchers (16 of 19) Scoop stretcher Also called orthopaedic stretcher 71. Types of Stretchers (17 of 19) Scoop stretcher (contd) Splits into two or four pieces Pieces fit around patient who is lying on flat surface and reconnect Both sides of patient must be accessible. Patient must be stabilized and secured onscoop stretcher. 72. Types of Stretchers (18 of 19) Stair chair Folding aluminum frame chairs with fabric stretched across to form a seat and back Most have rubber wheels in the back 73. Types of Stretchers (19 of 19) Neonatal isolette Also called an incubator Neonates cannot be transported on a wheeledstretcher. Isolette keeps neonate warm, protects fromnoise, draft, infection, excess handling. Isolette may be secured to wheeled ambulancestretcher or freestanding. 74. Decontamination Decontaminate equipment after use. For your safety For the safety of the crew For the safety of the patient To prevent the spread of disease 75. Medical Restraints (1 of 2) Evaluate for correctible causes ofcombativeness. Head injury, hypoxia, hypoglycemia Follow local protocols. Restraint requires five personnel. Restrain patient supine. Positional asphyxia may develop in proneposition. 76. Medical Restraints (2 of 2) Apply restraint to each extremity. Assess circulation after restraints are applied. Document all information. 77. Personnel Considerations (1 of 2) Questions to ask before moving patient: Am I physically strong enough to lift/move thispatient? Is there adequate room to get the proper stanceto lift the patient? Do I need additional personnel for liftingassistance? 78. Personnel Considerations (2 of 2) Remember, an injured rescuer cannot helpanyone. 79. Summary (1 of 13) The first key rule of lifting is to always keepyour back in an upright position and liftwithout twisting. The power lift is the safest and mostpowerful way to lift. 80. Summary (2 of 13) Pushing is better than pulling. If you do not have a proper hold, you willnot be able to bear your share of the weight,or you may lose your grasp and possiblycause a lower back injury to one or moreEMTs. 81. Summary (3 of 13) It is always best to move a patient on adevice that can be rolled. You must constantly coordinate yourmovements with those of the other teammembers and make sure that youcommunicate with them. 82. Summary (4 of 13) Ideally, members of the lifting team shouldalso be of similar height and strength. If you must carry a loaded backboard orstretcher up or down stairs or other inclines,be sure that the patient is tightly secured tothe device to prevent sliding. 83. Summary (5 of 13) Carry the backboard or stretcher foot endfirst, so that the patients head is elevatedhigher than the feet. Directions and commands are an importantpart of safe lifting and carrying. 84. Summary (6 of 13) You and your team must anticipate andunderstand every move and execute it in acoordinated manner. The team leader is responsible forcoordinating the moves. You should try to use four rescuerswhenever resources allow. 85. Summary (7 of 13) You should know how much you cancomfortably and safely lift and not attemptto lift more than this amount. Rapidly summon additional help to lift andcarry a weight that is greater than you areable to lift. 86. Summary (8 of 13) The same basic body mechanics apply forsafe reaching and pulling as for lifting andcarrying. Keep you back locked and straight, andavoid twisting. Do not hyperextend your back whenreaching overhead. 87. Summary (9 of 13) For a nonurgent move, move the patient inan orderly, planned, and unhurried manner,selecting methods that involve the leastamount of lifting and carrying. At times, you may have to use anemergency move to maneuver a patientbefore providing assessment and care. 88. Summary (10 of 13) You should perform an urgent move if apatient has an altered level ofconsciousness, inadequate ventilation, orshock, or in extreme weather conditions. 89. Summary (11 of 13) The wheeled ambulance stretcher is themost commonly used device to move andtransport patients. Other devices include portable stretchers,flexible stretchers, backboards, basketstretchers, scoop stretchers, and stairchairs. 90. Summary (12 of 13) Whenever you are moving a patient, youmust take special care so that neither you,your team, nor the patient is injured. 91. Summary (13 of 13) You will learn the technical skills of patientpackaging and handling through practiceand training. Training and practice are required to use allthe equipment that is available to you. 92. Review1. What is the first rule of lifting?A. Twist slowly when you liftB. Keep your back in a straight positionC. Bend at the waist to pick something upD. Use your arms to do most of the lifting 93. ReviewAnswer: BRationale: The first rule of lifting is to alwayskeep your back in a straight, upright, positionand use the powerful muscles of your thighs.Never twist while lifting. 94. Review1. What is the first rule of lifting?A. Twist slowly when you lift Rationale: You should never twist your back.B. Keep your back in a straight position Rationale: Correct answerC. Bend at the waist to pick something up Rationale: You should never bend at the waist. Your back should be properly maintained in an upright position.D. Use your arms to do most of the lifting Rationale: Use your leg muscles since they are well developed and very strong. 95. Review2. When lifting a stretcher using the power lift, you should: A. bend at the hips, knees, back, and arms. B. bend at the waist and keep your back straight. C. place your hands palms up on the litterhandle. D. place your hands palms down on the littersside bars. 96. ReviewAnswer: CRationale: When lifting any heavy object,your hands should be facing palms up; thisprovides better lifting power and is not asstressful on the wrists. 97. Review (1 of 2)2. When lifting a stretcher using the power lift, you should: A. bend at the hips, knees, back, and arms.Rationale: When lifting, keep your back andarms straight. Always bend at the knees. B. bend at the waist and keep your back straight.Rationale: When lifting, always keep yourback straight. Never bend at the waist. 98. Review (2 of 2)2. When lifting a stretcher using the power lift, you should: C. place your hands palms up on the litterhandle.Rationale: Correct answer D. place your hands palms down on the littersside bars.Rationale: Your hands have the greateststrength when your palms are facing up. 99. Review3. It is impractical to apply a vest-style extrication device on a critically-injured patient to remove him or her from a wrecked vehicle because it: A. takes too long to correctly apply. B. does not fully immobilize the spine. C. cannot be used on patients who are in theircar. D. does not provide adequate c-spinestabilization. 100. ReviewAnswer: ARationale: It takes several minutes to correctlyapply a vest-style extrication device. This is toomuch time to waste when treating a critically-injured patient. A long spine board would be moreappropriate. Vest-style immobilization devices,when applied correctly, provide adequate spinalmotion restriction and are ideal to use in stablepatients who need to be removed from theirvehicle. 101. Review (1 of 2)3. It is impractical to apply a vest-style extrication device on a critically-injured patient to remove him or her from a wrecked vehicle because it: A. takes too long to correctly apply.Rationale: Correct answer B. does not fully immobilize the spine.Rationale: When applied correctly, the vestprovides adequate restriction of the spine. 102. Review (2 of 2)3. It is impractical to apply a vest-style extrication device on a critically-injured patient to remove him or her from a wrecked vehicle because it: A. cannot be used on patients who are in their car.Rationale: When a patient is stable, the vest isa beneficial device for vehicle extrications. B. does not provide adequate c-spine stabilization.Rationale: The vest provides adequaterestriction of the spine. 103. Review4. Proper guidelines for correct reaching include all of the following, EXCEPT: A. avoiding twisting your back. B. avoiding hyperextension of your back. C. keeping the back in a locked-in position. D. reaching no more than 30 in front of yourbody. 104. ReviewAnswer: DRationale: When reaching, you should keepyour back in a locked-in position, and avoidtwisting or hyperextending your back. Do notreach more than 15" to 20" in front of yourbody. 105. Review (1 of 2)4. Proper guidelines for correct reaching include all of the following, EXCEPT: A. avoiding twisting your back.Rationale: Never twist your back whilereaching or lifting. B. avoiding hyperextension of your back.Rationale: Never bend or hyperextend yourback. 106. Review (2 of 2)4. Proper guidelines for correct reaching include all of the following, EXCEPT: C. keeping the back in a locked-in position.Rationale: Always keep your back straight ina locked position. D. reaching no more than 30" in front of yourbody.Rationale: Correct answer 107. Review5. An injured hang glider is trapped at the top of a large mountain and must be evacuated to the ground. The terrain is very rough and uneven. Which of the following devices would be the safest and most appropriate to use? A. Stair chair B. Stokes basket C. Scoop stretcher D. Long spine board 108. ReviewAnswer: BRationale: A basket stretcher, also called astokes basket, should be used to carrypatients over rough or uneven terrain that isinaccessible by ambulance. Its closed-endedsides protect the patient from falling out of thedevice. 109. Review (1 of 2)5. An injured hang glider is trapped at the top of a large mountain and must be evacuated to the ground. The terrain is very rough and uneven. Which of the following devices would be the safest and most appropriate to use?A. Stair chair Rationale: This is used to transfer a patient up and down stairs.B. Stokes basket Rationale: Correct answer 110. Review (2 of 2)5. An injured hang glider is trapped at the top of a large mountain and must be evacuated to the ground. The terrain is very rough and uneven. Which of the following devices would be the safest and most appropriate to use?C. Scoop stretcher Rationale: This is designed to split into 2 or 4 pieces. It must have access to both sides of patient and the patient should be lying on a relatively flat surface.D. Long spine board Rationale: There is no protection for the patient from falling off or out of the device. 111. Review6. When two EMTs are lifting a patient on a long backboard, they should: A. lift the patient from the sides of the board. B. make every attempt to lift with their backs. C. position the strongest EMT at the foot of theboard. D. position the strongest EMT at the head of theboard. 112. ReviewAnswer: DRationale: Since more than half of thepatients weight is distributed to the head endof a backboard or stretcher, you shouldalways ensure that the strongest EMT is atthat position. This will reduce the risk of injuryto less stronger personnel as well as the riskof dropping the patient. 113. Review (1 of 2)6. When two EMTs are lifting a patient on a long backboard, they should: A. lift the patient from the sides of the board.Rationale: This may cause the backboard totip since the upper torso is heavier. B. make every attempt to lift with their backs.Rationale: Never lift with your back. Alwaysuse your legs. 114. Review (2 of 2)6. When two EMTs are lifting a patient on a long backboard, they should: C. position the strongest EMT at the foot of theboard.Rationale: The strongest EMT should be atthe patients head, where the patients weightis greater. D. position the strongest EMT at the head of theboard.Rationale: Correct answer 115. Review7. Which of the following techniques is considered to be an emergency move? A. Extremity lift B. Supine transfer C. Firefighters drag D. Direct ground lift 116. ReviewAnswer: CRationale: The firefighters drag is a one-person technique that is used when a patientmust be removed from a life-threateningsituation immediately. 117. Review7. Which of the following techniques is considered to be an emergency move? A. Extremity liftRationale: This is a nonurgent move, helpful innarrow spaces. B. Supine transferRationale: This is not considered to be anemergency move. C. Firefighters dragRationale: Correct answer D. Direct ground liftRationale: This is a nonurgent move, used to carry apatient long distances to the cot. 118. Review8. To extract a patient from the basement of a building, you must transport the patient up a flight of stairs. In doing this, you must ensure that: A. the elevated head of the backboard goes first. B. the backboard with the elevated foot end goesfirst. C. the backboard is slightly tilted to the left todistribute weight. D. the patients feet are higher than his or herhead, whichever end is carried first. 119. ReviewAnswer: ARationale: When you carry a patient upstairsor up an incline, you must ensure that theelevated head of the backboard or stretchergoes first. This will help to equally distributethe weight. 120. Review (1 of 2)8. To extract a patient from the basement of a building, you must transport the patient up a flight of stairs. In doing this, you must ensure that: A. the elevated head of the backboard goes first.Rationale: Correct answer B. the backboard with the elevated foot end goesfirst.Rationale: Always try to carry the head higherto distribute the weight. 121. Review (2 of 2)8. To extract a patient from the basement of a building, you must transport the patient up a flight of stairs. In doing this, you must ensure that:C. the backboard is slightly tilted to the left to distribute weight. Rationale: Backboards are designed to carry a patient flat and the weight is best distributed when the head is slightly elevated.D. the patients feet are higher than his or her head, whichever end is carried first. Rationale: Carries are easier with the patients head first and elevated for distribution of the patients weight. 122. Review9. If an injured patient needs to be moved but is not in immediate danger from fire or building collapse, you should first: A. order the equipment you need for extrication. B. check the patients airway, breathing, andcirculation. C. remove the patient with the rapid extricationtechnique. D. determine the number of people you will needto move the patient. 123. ReviewAnswer: BRationale: The only time your attentionshould be directed away from the primaryassessment of the patient is when thepatients life or your life is in immediatedanger. 124. Review (1 of 2)9. If an injured patient needs to be moved but is not in immediate danger from fire or building collapse, you should first: A. order the equipment you need for extrication.Rationale: This is not the first thing youshould do. B. check the patients airway, breathing, andcirculation.Rationale: Correct answer 125. Review (2 of 2)9. If an injured patient needs to be moved but is not in immediate danger from fire or building collapse, you should first:C. remove the patient with the rapid extrication technique. Rationale: The patient is not in immediate danger, so this is not needed.D. determine the number of people you will need to move the patient. Rationale: After the ABCs have been checked, then the EMT can determine the safest method of extrication. 126. Review10. The rapid extrication technique is a: A. nonurgent move to remove a patient from avehicle. B. technique used to transfer a patient from abed to a stretcher. C. technique used to lift a patient with nosuspected spinal injury onto a stretcher. D. technique used to quickly remove a patientfrom a vehicle and onto a backboard. 127. ReviewAnswer: DRationale: By using the rapid extricationtechnique, a seriously injured patient can bemoved from a sitting position in a vehicle to asupine position on a backboard whileprotecting the spine at the same time. 128. Review (1 of 2)10. The rapid extrication technique is a: A. nonurgent move to remove a patient from avehicle.Rationale: This is considered to be anurgent move. B. technique used to transfer a patient from abed to a stretcher.Rationale: This is used to move a patientfrom a vehicle to a backboard. 129. Review (2 of 2)10. The rapid extrication technique is a: C. technique used to lift a patient with nosuspected spinal injury onto a stretcher.Rationale: This is not a lifting technique.The patient is placed on a backboard andnot a stretcher. D. technique used to quickly remove a patientfrom a vehicle and onto a backboard.Rationale: Correct answer 130. Credits Background slide image: Jones & BartlettLearning. Courtesy of MIEMSS.