SOLDIER'S MANUAL AND TRAINER'S GUIDE - Fort Drum
SOLDIER'S MANUAL AND TRAINER'S GUIDE - Fort Drum
SOLDIER'S MANUAL AND TRAINER'S GUIDE - Fort Drum
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STP 8-91W15-SM-TG<br />
SOLDIER’S <strong>MANUAL</strong><br />
<strong>AND</strong> TRAINER’S <strong>GUIDE</strong><br />
MOS 91W<br />
HEALTH<br />
CARE<br />
SPECIALIST<br />
SKILL LEVELS 1/2/3/4/5<br />
HEADQUARTERS, DEPARTMENT OF THE ARMY<br />
DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited.
STP 8-91W15-SM-TG<br />
* SOLDIER TRAINING HEADQUARTERS<br />
PUBLICATION<br />
DEPARTMENT OF THE ARMY<br />
No. 8-91W15-SM-TG Washington, DC, 10 October 2001<br />
<strong>SOLDIER'S</strong> <strong>MANUAL</strong> and <strong>TRAINER'S</strong> <strong>GUIDE</strong><br />
MOS 91W<br />
Soldier's Manual, Skill Levels 1/2/3/4/5 and Trainer's Guide,<br />
MOS 91W, Health Care Specialist<br />
Skill Levels 1, 2, 3, 4 and 5<br />
TABLE OF CONTENTS<br />
PAGE<br />
Table of Contents .........................................................................................................................................i<br />
Preface.........................................................................................................................................................vi<br />
Chapter 1. Introduction.......................................................................................................................... 1-1<br />
1-1. General .......................................................................................................................... 1-1<br />
1-2. Battle Focused Training................................................................................................. 1-1<br />
1-3. Relationship of Soldier Training Publications (STPs) to Battle Focused Training......... 1-1<br />
1-4. Task Summaries............................................................................................................ 1-1<br />
1-5. Soldier's Responsibilities ............................................................................................... 1-2<br />
1-6. NCO Self-Development and the Soldier's Manual ........................................................ 1-2<br />
1-7. Trainer's Responsibilities ................................................................................................ 1-3<br />
1-8. Training Tips for the Trainer .......................................................................................... 1-5<br />
1-9. Training Support ............................................................................................................ 1-6<br />
Chapter 2. Trainer's Guide..................................................................................................................... 2-1<br />
2-1. General .......................................................................................................................... 2-1<br />
2-2. Part One, Section I. Subject Area Codes ..................................................................... 2-3<br />
2-3. Part One, Section II. Duty Position Training Requirements ......................................... 2-4<br />
2-4. Part Two. Critical Tasks List ......................................................................................... 2-5<br />
* DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited.<br />
*This publication supersedes STP 8-91B15-SM-TG, 3 October 1995 and STP 8-91C25-SM-TG, 17 July<br />
1990.<br />
i
STP 8-91W15-SM-TG<br />
Chapter 3. MOS/Skill Level Tasks......................................................................................................... 3-1<br />
Skill Level 1<br />
Subject Area 1: Vital Signs<br />
081-831-0010 MEASURE A PATIENT'S RESPIRATIONS............................................................. 3-1<br />
081-831-0011 MEASURE A PATIENT'S PULSE............................................................................ 3-3<br />
081-831-0012 MEASURE A PATIENT'S BLOOD PRESSURE...................................................... 3-6<br />
081-831-0013 MEASURE A PATIENT'S TEMPERATURE ............................................................ 3-9<br />
081-833-0164 MEASURE A PATIENT'S PULSE OXYGEN SATURATION................................ 3-12<br />
Subject Area 2: Emergency Medical Treatment<br />
081-831-0018 OPEN THE AIRWAY ............................................................................................. 3-14<br />
081-831-0019 CLEAR AN UPPER AIRWAY OBSTRUCTION..................................................... 3-16<br />
081-831-0046 ADMINISTER EXTERNAL CHEST COMPRESSIONS......................................... 3-19<br />
081-831-0048 PERFORM RESCUE BREATHING....................................................................... 3-23<br />
081-833-0161 CONTROL BLEEDING .......................................................................................... 3-27<br />
081-833-0167 PLACE A PATIENT ON A CARDIAC MONITOR .................................................. 3-30<br />
081-833-3027 MANAGE CARDIAC ARREST USING AED.......................................................... 3-32<br />
Subject Area 3: Basic Medical Care<br />
081-831-0007 PERFORM A PATIENT CARE H<strong>AND</strong>WASH ........................................................ 3-35<br />
081-831-0008 PUT ON STERILE GLOVES.................................................................................. 3-37<br />
081-831-0033 INITIATE A FIELD MEDICAL CARD ..................................................................... 3-40<br />
081-833-0076 APPLY RESTRAINING DEVICES TO PATIENTS................................................ 3-42<br />
081-833-0006 MEASURE A PATIENT'S INTAKE <strong>AND</strong> OUTPUT................................................ 3-45<br />
081-833-0007 ESTABLISH A STERILE FIELD............................................................................. 3-48<br />
081-833-0010 CHANGE A STERILE DRESSING ........................................................................ 3-50<br />
081-833-0012 PERFORM A WOUND IRRIGATION .................................................................... 3-54<br />
081-833-0021 PERFORM ORAL <strong>AND</strong> NASOPHARYNGEAL SUCTIONING OF A<br />
PATIENT .............................................................................................................. 3-57<br />
081-833-0059 IRRIGATE AN OBSTRUCTED EAR...................................................................... 3-61<br />
081-833-0145 DOCUMENT PATIENT CARE USING SUBJECTIVE, OBJECTIVE,<br />
ASSESSMENT, PLAN (SOAP) NOTE FORMAT................................................. 3-64<br />
081-833-0165 PERFORM PATIENT HYGIENE............................................................................ 3-66<br />
081-835-3007 OBTAIN AN ELECTROCARDIOGRAM................................................................. 3-71<br />
Subject Area 4: Respiratory Dysfunction/Airway Management<br />
081-833-0016 INSERT AN OROPHARYNGEAL AIRWAY (J TUBE)........................................... 3-78<br />
081-833-0018 SET UP AN OXYGEN TANK................................................................................. 3-80<br />
081-833-0142 INSERT A NASOPHARYNGEAL AIRWAY ........................................................... 3-86<br />
081-833-0158 ADMINISTER OXYGEN ........................................................................................ 3-88<br />
081-833-0169 INSERT A COMBITUBE........................................................................................ 3-91<br />
081-833-3006 PERFORM A NEEDLE CRICOTHYROIDOTOMY................................................ 3-93<br />
081-833-3007 PERFORM NEEDLE CHEST DECOMPRESSION ............................................... 3-96<br />
Subject Area 5: Venipuncture and IV Therapy<br />
081-833-0032 OBTAIN A BLOOD SPECIMEN USING A VACUTAINER..................................... 3-99<br />
081-833-0033 INITIATE AN INTRAVENOUS INFUSION........................................................... 3-104<br />
081-833-0034 MANAGE A PATIENT WITH AN INTRAVENOUS INFUSION............................ 3-109<br />
081-835-3025 INITIATE A SALINE LOCK .................................................................................. 3-114<br />
ii
STP 8-91W15-SM-TG<br />
Subject Area 6: Casualty Management<br />
081-831-0035 MANAGE A CONVULSIVE <strong>AND</strong>/OR SEIZING PATIENT................................... 3-118<br />
081-833-0045 TREAT A CASUALTY WITH AN OPEN ABDOMINAL WOUND......................... 3-121<br />
081-833-0046 APPLY A DRESSING TO AN IMPALEMENT INJURY........................................ 3-123<br />
081-833-0048 MANAGE AN UNCONSCIOUS CASUALTY....................................................... 3-125<br />
081-833-0049 TREAT A CASUALTY WITH A CLOSED CHEST WOUND................................ 3-128<br />
081-833-0050 TREAT A CASUALTY WITH AN OPEN CHEST WOUND.................................. 3-132<br />
081-833-0052 TREAT A CASUALTY WITH AN OPEN OR CLOSED HEAD INJURY............... 3-135<br />
081-833-0070 ADMINISTER INITIAL TREATMENT FOR BURNS ............................................ 3-139<br />
081-833-0103 PROVIDE CARE FOR A SOLDIER WITH SYMPTOMS OF BATTLE<br />
FATIGUE ............................................................................................................ 3-144<br />
081-833-0116 ASSIST IN VAGINAL DELIVERY ........................................................................ 3-147<br />
081-833-0143 TREAT A POISONED CASUALTY...................................................................... 3-151<br />
081-833-0144 TREAT A DIABETIC EMERGENCY.................................................................... 3-154<br />
081-833-0155 PERFORM A TRAUMA CASUALTY ASSESSMENT.......................................... 3-157<br />
081-833-0156 PERFORM A MEDICAL PATIENT ASSESSMENT............................................. 3-163<br />
081-833-0159 TREAT A CARDIAC EMERGENCY .................................................................... 3-167<br />
081-833-0160 TREAT A RESPIRATORY EMERGENCY........................................................... 3-169<br />
081-835-3030 DETERMINE A PATIENT'S LEVEL OF CONSCIOUSNESS USING THE<br />
GLASGOW COMA SCALE ................................................................................ 3-171<br />
Subject Area 7: Eye Injuries<br />
081-833-0054 IRRIGATE EYES.................................................................................................. 3-174<br />
081-833-0056 TREAT FOREIGN BODIES OF THE EYE........................................................... 3-176<br />
081-833-0057 TREAT LACERATIONS, CONTUSIONS, <strong>AND</strong> EXTRUSIONS OF THE EYE.... 3-178<br />
081-833-0058 TREAT BURNS OF THE EYE ............................................................................. 3-181<br />
Subject Area 8: Skeletal Dysfunction<br />
081-831-0044 APPLY A PNEUMATIC SPLINT TO A CASUALTY WITH A SUSPECTED<br />
FRACTURE OF AN EXTREMITY ...................................................................... 3-183<br />
081-833-0060 APPLY A ROLLER B<strong>AND</strong>AGE............................................................................ 3-185<br />
081-833-0062 IMMOBILIZE A SUSPECTED FRACTURE OF THE ARM OR DISLOCATED<br />
SHOULDER........................................................................................................ 3-190<br />
081-833-0064 IMMOBILIZE A SUSPECTED DISLOCATED OR FRACTURED HIP................. 3-193<br />
081-833-0092 TRANSPORT A CASUALTY WITH A SUSPECTED SPINAL INJURY............... 3-196<br />
081-833-0141 APPLY A TRACTION SPLINT............................................................................. 3-201<br />
081-833-0154 PROVIDE BASIC EMERGENCY TREATMENT FOR A PAINFUL,<br />
SWOLLEN, DEFORMED EXTREMITY.............................................................. 3-208<br />
Subject Area 9: Environmental Injuries<br />
081-831-0038 TREAT A CASUALTY FOR A HEAT INJURY..................................................... 3-210<br />
081-831-0039 TREAT A CASUALTY FOR A COLD INJURY..................................................... 3-213<br />
081-833-0031 INITIATE TREATMENT FOR ANAPHYLACTIC SHOCK.................................... 3-217<br />
081-833-0072 TREAT A CASUALTY FOR INSECT BITES OR STINGS................................... 3-219<br />
081-833-0073 TREAT A CASUALTY FOR SNAKEBITE............................................................ 3-223<br />
iii
STP 8-91W15-SM-TG<br />
Subject Area 10: Chemical Agent Injuries<br />
081-833-0083 TREAT A NERVE AGENT CASUALTY IN THE FIELD....................................... 3-226<br />
081-833-0084 TREAT A BLOOD AGENT (HYDROGEN CYANIDE) CASUALTY IN THE<br />
FIELD.................................................................................................................. 3-230<br />
081-833-0085 TREAT A CHOKING AGENT CASUALTY IN THE FIELD .................................. 3-232<br />
081-833-0086 TREAT A BLISTER AGENT CASUALTY (MUSTARD, LEWISITE,<br />
PHOSGENE OXIME) IN THE FIELD ................................................................. 3-234<br />
081-833-0095 DECONTAMINATE A CASUALTY ...................................................................... 3-237<br />
Subject Area 11: Shock<br />
081-833-0047 INITIATE TREATMENT FOR HYPOVOLEMIC SHOCK ..................................... 3-244<br />
081-833-3011 APPLY PNEUMATIC ANTI-SHOCK GARMENT................................................. 3-246<br />
Subject Area 12: Urinary Catheterization<br />
081-833-3017 INSERT A URINARY CATHETER....................................................................... 3-250<br />
081-835-3010 MAINTAIN AN INDWELLING URINARY CATHETER......................................... 3-253<br />
Subject Area 13: Gastric Intubation<br />
081-833-3022 INSERT A NASOGASTRIC TUBE....................................................................... 3-256<br />
081-835-3005 PERFORM A GASTRIC LAVAGE ....................................................................... 3-259<br />
Subject Area 14: Triage and Evacuation<br />
071-334-4001 <strong>GUIDE</strong> A HELICOPTER TO A L<strong>AND</strong>ING POINT................................................ 3-262<br />
071-334-4002 ESTABLISH A HELICOPTER L<strong>AND</strong>ING POINT................................................. 3-269<br />
081-833-0080 TRIAGE CASUALTIES ON A CONVENTIONAL BATTLEFIELD........................ 3-272<br />
081-833-0082 TRIAGE CASUALTIES ON AN INTEGRATED BATTLEFIELD .......................... 3-276<br />
081-833-0151 LOAD CASUALTIES ONTO GROUND EVACUATION PLATFORMS................ 3-278<br />
081-833-0171 LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD VEHICLES, 1 1/4 TON, 4X4,<br />
M998................................................................................................................... 3-286<br />
081-833-0172 LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD VEHICLES, 2 1/2 TON, 6X6<br />
OR 5 TON, 6X6, CARGO TRUCK ..................................................................... 3-289<br />
081-833-0173 LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD VEHICLES, 5 TON M-1085,<br />
M-1093, 2 1/2 TON M-1081................................................................................ 3-291<br />
Subject Area 15: Medication Administration<br />
081-833-0088 PREPARE AN INJECTION FOR ADMINISTRATION ......................................... 3-294<br />
081-833-0089 ADMINISTER AN INJECTION (INTRAMUSCULAR, SUBCUTANEOUS,<br />
INTRADERMAL)................................................................................................. 3-299<br />
081-833-0174 ADMINISTER MORPHINE .................................................................................. 3-304<br />
081-835-3001 ADMINISTER ORAL MEDICATIONS.................................................................. 3-306<br />
081-835-3020 ADMINISTER TOPICAL MEDICATIONS ............................................................ 3-309<br />
081-835-3021 ADMINISTER RECTAL OR VAGINAL MEDICATIONS ...................................... 3-312<br />
081-835-3022 ADMINISTER MEDICATED EYE DROPS OR OINTMENTS.............................. 3-315<br />
Subject Area 16: Force Protection/Risk Assessment<br />
081-831-0037 DISINFECT WATER FOR DRINKING................................................................. 3-318<br />
Skill Level 2<br />
Subject Area 17: Advanced Procedures (SL 2)<br />
081-833-0170 PERFORM ENDOTRACHEAL SUCTIONING OF A PATIENT........................... 3-320<br />
081-835-3024 PROVIDE TRACHEOSTOMY CARE .................................................................. 3-323<br />
081-835-3031 PROVIDE NURSING CARE FOR A PATIENT WITH A WATERSEAL<br />
DRAINAGE SYSTEM......................................................................................... 3-326<br />
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STP 8-91W15-SM-TG<br />
Skill Level 3<br />
Subject Area 18: Advanced Procedures (SL 3)<br />
081-830-3016 INTUBATE A PATIENT........................................................................................ 3-333<br />
081-833-0093 SET UP A CASUALTY DECONTAMINATION STATION ................................... 3-339<br />
081-833-0168 INSERT A CHEST TUBE..................................................................................... 3-343<br />
081-833-3005 PERFORM A SURGICAL CRICOTHYROIDOTOMY.......................................... 3-345<br />
081-833-3014 PERFORM A NEUROLOGICAL EXAMINATION ON A PATIENT WITH<br />
SUSPECTED CENTRAL NERVOUS SYSTEM (CNS) INJURIES .................... 3-348<br />
081-835-3000 ADMINISTER BLOOD ......................................................................................... 3-352<br />
081-835-3002 ADMINISTER MEDICATIONS BY IV PIGGYBACK ............................................ 3-357<br />
081-833-3208 SUTURE A MINOR LACERATION...................................................................... 3-360<br />
Appendix A ..............................................................................................................................................A-1<br />
Appendix B ..............................................................................................................................................B-1<br />
Glossary ......................................................................................................................................Glossary-1<br />
Supporting References..........................................................................................................References-1<br />
v
STP 8-91W15-SM-TG<br />
PREFACE<br />
This publication is for skill level 1, 2, 3, 4, and 5 soldiers holding military occupational specialty<br />
(MOS) 91W and for trainers and first-line supervisors. It contains standardized training<br />
objectives, in the form of task summaries, to train and evaluate soldiers on critical tasks that<br />
support unit missions during wartime. Trainers and first-line supervisors should ensure soldiers<br />
holding MOS/SL 91W1/2/3/4/5 have access to this publication. This STP is available for<br />
download from the Reimer Digital Library (RDL).<br />
This manual applies to both Active and Reserve Component soldiers.<br />
The proponent of this publication is HQ, TRADOC. Send comments and recommendations on<br />
DA Form 2028 (Recommended Changes to Publications and Blank Forms) directly to Academy<br />
of Health Sciences, ATTN: MCCS-HLD, 2250 Stanley Road, STE 326, <strong>Fort</strong> Sam Houston, TX<br />
78234-6130.<br />
vi
STP 8-91W15-SM-TG<br />
CHAPTER 1<br />
Introduction<br />
1-1. General<br />
This manual identifies the individual MOS training requirements for soldiers in MOS 91W.<br />
Commanders, trainers, and soldiers should use it to plan, conduct, and evaluate individual<br />
training in units. This manual is the primary MOS reference to support the self-development<br />
and training of every soldier.<br />
Use this manual with Soldier's Manuals of Common Tasks (STP 21-1-SMCT and STP 21-24-<br />
SMCT), Army Training and Evaluation Programs (ARTEPs), and FM 25-101, Battle Focused<br />
Training, to establish effective training plans and programs which integrate soldier, leader, and<br />
collective tasks.<br />
1-2. Battle Focused Training<br />
As described in FM 25-100, Training the Force, and FM 25-101, Battle Focused Training, the<br />
commander must first define the mission essential task list (METL) as the basis for unit training.<br />
Unit leaders use the METL to identify the collective, leader, and soldier tasks which support<br />
accomplishment of the METL. Unit leaders then assess the status of training and lay out the<br />
training objectives and the plan for accomplishing needed training. After preparing the longand<br />
short-range plans, leaders then execute and evaluate training. Finally, the unit's training<br />
preparedness is reassessed, and the training management cycle begins again. This process<br />
ensures that the unit has identified what is important for the wartime mission, that the training<br />
focus is applied to the necessary training, and that training meets established objectives and<br />
standards.<br />
1-3. Relationship of Soldier Training Publications (STPs) to Battle Focused Training<br />
The two key components of enlisted STPs are the Trainer's Guide (TG) and Soldier's Manual<br />
(SM). The TG and SM give leaders important information to help in the battle focused training<br />
process. The TG relates soldier and leader tasks in the MOS and SL to duty positions and<br />
equipment. It provides information on where the task is trained, how often training should occur<br />
to sustain proficiency, and who in the unit should be trained. As leaders go through the<br />
assessment and planning stages, they should use the TG as an important tool in identifying<br />
what needs to be trained.<br />
The execution and evaluation of soldier and leader training should rely on the Armywide training<br />
objectives and standards in the SM task summaries. The task summaries ensure that soldiers<br />
in any unit or location have the same definition of task performance and that trainers evaluate<br />
the soldiers to the same standard.<br />
1-4. Task Summaries<br />
Task summaries contain information necessary to conduct training and evaluate soldier<br />
proficiency on tasks critical to the MOS. A separate task summary is provided for each critical<br />
task. These task summaries are, in effect, standardized training objectives which ensure that<br />
1-1
STP 8-91W15-SM-TG<br />
soldiers do not have to relearn a task on reassignment to a new unit. The format for the task<br />
summaries included in this manual is as follows:<br />
• Task Title. The task title identifies the action to be performed.<br />
• Task Number. A 10-digit number identifies each task or skill. Include this task number,<br />
along with task title, in any correspondence relating to the task.<br />
• Conditions. The task conditions identify all the equipment, tools, references, job aids,<br />
and supporting personnel that the soldier needs to perform the task in wartime. This section<br />
identifies any environmental conditions that can alter task performance, such as visibility,<br />
temperature, and wind. This section also identifies any specific cues or events that trigger<br />
task performance.<br />
• Standards. The task standards describe how well and to what level you must perform a<br />
task under wartime conditions. Standards are typically described in terms of accuracy,<br />
completeness, and/or speed.<br />
• Performance Steps. This section includes a detailed outline of information on how to<br />
perform the task.<br />
• Evaluation Preparation (when used). This subsection indicates necessary modifications<br />
to task performance in order to train and evaluate a task that cannot be trained to the<br />
wartime standard under wartime conditions. It may also include special training and<br />
evaluation preparation instructions to accommodate these modifications and any instruction<br />
that should be given to the soldier before evaluation.<br />
• Performance Measures. This evaluation guide identifies the specific actions that the<br />
soldier must do to successfully complete the task. These actions are listed in a GO/NO-GO<br />
format for easy evaluation. Each evaluation guide contains a feedback statement that<br />
indicates the requirements for receiving a GO on the evaluation.<br />
• References. This section identifies references that provide more detailed and thorough<br />
explanations of task performance requirements than that given in the task summary<br />
description.<br />
Additionally, some task summaries include safety statements and notes. Safety statements<br />
(danger, warning, and caution) alert users to the possibility of immediate death, personal injury,<br />
or damage to equipment. Notes provide a small, extra supportive explanation or hint relative to<br />
the performance measures.<br />
1-5. Soldier's Responsibilities<br />
Each soldier is responsible for performing individual tasks which the first-line supervisor<br />
identifies based on the unit's METL. The soldier must perform the tasks to the standards listed<br />
in the SM. If a soldier has a question about how to do a task or which tasks in this manual he or<br />
she must perform, it is the soldier's responsibility to ask the first-line supervisor for clarification.<br />
The first-line supervisor knows how to perform each task or can direct the soldier to the<br />
appropriate training materials.<br />
1-6. NCO Self-Development and the Soldier's Manual<br />
Self-development is one of the key components of the leader development program. It is a<br />
planned progressive and sequential program followed by leaders to enhance and sustain their<br />
military competencies. It consists of individual study, research, professional reading, practice,<br />
and self-assessment. Under the self-development concept, the NCO, as an Army professional,<br />
1-2
STP 8-91W15-SM-TG<br />
has the responsibility to remain current in all phases of the MOS. The SM is the primary source<br />
for the NCO to use in maintaining MOS proficiency.<br />
Another important resource for NCO self-development is the Army Correspondence Course<br />
Program (ACCP). Refer to DA Pamphlet 350-59 for information on enrolling in this program and<br />
for a list of courses, or write to: AMEDDC&S, ATTN: MCCS-HSN, 2105 11TH STREET SUITE<br />
4191, FORT SAM HOUSTON TX 78234-5064.<br />
Unit learning centers are valuable resources for planning self-development programs. They can<br />
help access enlisted career maps, training support products, and extension training materials.<br />
A life cycle management diagram for MOS 91W soldiers is on page 1-4. You can find more<br />
information and check for updates to this diagram at http://das.cs.amedd.army.mil/ooc.htm<br />
(scroll down to LIFE CYCLE MANAGEMENT, select ENLISTED, and find the appropriate tab<br />
along the bottom.) This information, combined with the MOS Training Plan in Chapter 2, forms<br />
the career development model for the MOS.<br />
1-7. Trainer's Responsibilities<br />
Training soldier and leader tasks to standard and relating this training to collective missionessential<br />
tasks is the NCO trainer's responsibility. Trainers use the steps below to plan and<br />
evaluate training.<br />
• Identify soldier and leader training requirements. The NCO determines which tasks<br />
soldiers need to train on using the commander's training strategy. The unit's METL and ARTEP<br />
and the MOS Training Plan (MTP) in the TG are sources for helping the trainer define the<br />
individual training needed.<br />
• Plan the training. Training for specific tasks can usually be integrated or conducted<br />
concurrently with other training or during "slack periods." The unit's ARTEP can assist in<br />
identifying soldier and leader tasks which can be trained and evaluated concurrently with<br />
collective task training and evaluation.<br />
• Gather the training references and materials. The SM task summary lists all references<br />
which can assist the trainer in preparing for the training of that task.<br />
• Determine risk assessment and identify safety concerns. Analyze the risk involved in<br />
training a specific task under the current conditions at the time of scheduled training. Ensure<br />
that your training preparation takes into account those cautions, warnings, and dangers<br />
associated with each task.<br />
• Train each soldier. Show the soldier how the task is done to standard, and explain stepby-step<br />
how to do the task. Give each soldier one chance to do the task step-by-step.<br />
• Emphasize training in mission-oriented protective posture (MOPP) level 4 clothing.<br />
Soldiers have difficulty performing even the very simple tasks in an NBC environment. The<br />
combat effectiveness of the soldier and the unit can degrade quickly when trying to perform in<br />
MOPP 4. Practice is the best way to improve performance. The trainer is responsible for<br />
training and evaluating soldiers in MOPP 4 so that they are able to perform critical wartime<br />
tasks to standards under NBC environment conditions.<br />
1-3
MOS 91W<br />
Health Care Specialist<br />
CAREER/TRAINING LIFE CYCLE<br />
RANK<br />
AMEDD Course<br />
NR<br />
TRAINING LENGTH LOCATION<br />
ATTENDANCE<br />
REQUIREMENT<br />
Self-Development<br />
Course NR<br />
SELF-DEVELOPMENT LENGTH LOCATION<br />
ATTENDANCE<br />
REQUIREMENT<br />
E1 - E5 Basic Combat Training Course 9 wks<br />
Ft. LW<br />
Ft. Sill<br />
Ft. Jackson<br />
Ft. Benning<br />
IET<br />
TC-8-800 (Semi-Annual Combat Medical Skills<br />
Validation Test)<br />
Unit Training<br />
Semi-Annual<br />
300-91W10 Health Care Specialist 16 wks FSH, TX IET Army Correspondence Course Program<br />
SEE ASI<br />
N3, N9, P1, P2, P3, M6, Y6<br />
MD0010 Basic Medical Terminology Correspondence Optional<br />
PLDC 4 wks Multiple sites Leadership MD1010 91B10 Initial Unit Training Package Unit Training<br />
300-F6 Flight Medical Aidman 4 wks USASAM SQI-F /optional MD1014<br />
Exportable Sustainment Training/<br />
Recertification Training Package<br />
Unit Training Sustainment<br />
MD1273 91B Rapid Train-Up Unit Training Just in Time<br />
6-8-C40 BNCOC 17 wks, 1 day FSH, TX Leadership MD1290 ASMART Unit Training Sustainment<br />
300-91W(Trauma<br />
AIMS)<br />
Transition Training 081-91W10 Medical Academic Preparatory Course Correspondence Preparatory<br />
Prepares Soldiers<br />
Transition Training MOS Health Care<br />
holding Primary MOS<br />
68 Hrs Multiple sites<br />
Specialist, Trauma Aims<br />
91B for transition to<br />
081-91W10 Medical Specialist Sustainment Correspondence Sustainment<br />
MOS 91W<br />
Transition Training MOS Health Care<br />
300-<br />
Specialist, Advanced Pre-Hospital Life<br />
91W(PHTLS)(ADV)<br />
Support<br />
300-91W(EMT<br />
BRIDGE)<br />
300-<br />
91W(BTLS)(ADV)<br />
300-91W(EMT-B)<br />
Transition Training MOS Health Care<br />
Specialist, EMT Bridge<br />
Transition Training MOS Health Care<br />
Specialist, Advanced Basic Trauma<br />
Life Support<br />
Transition Training MOS Health Care<br />
Specialist, EMT Basic<br />
20 Hrs Multiple sites<br />
60 Hrs Multiple sites<br />
24 Hrs Multiple sites<br />
120 Hrs Multiple sites<br />
Prepares Soldiers<br />
holding Primary MOS<br />
91B for transition to<br />
MOS 91W<br />
Prepares Soldiers<br />
holding Primary MOS<br />
91B for transition to<br />
MOS 91W<br />
Prepares Soldiers<br />
holding Primary MOS<br />
91B for transition to<br />
MOS 91W<br />
Prepares Soldiers<br />
holding Primary MOS<br />
91B for transition to<br />
MOS 91W<br />
081-91W20/30 Medical NCO Sustainment Correspondence Sustainment<br />
Combat Life Saver (CLS) Unit Training Just in Time<br />
E6 - E9 Instructor Courses 300-A0704 75/71 Personnel/Retention Legal/EO 4 days SA,TX Just in Time<br />
5K-F3/520-F3 Instructor Training Course 10 days AHS, FSH, TX Just in time SQI-H 340-A0715 MEDCOM CSM/SGM NCO Short Course 4 days SA, TX Leadership<br />
5K-F6/520-F6 Small Group Instruction Training 5 days AHS, FSH, TX Just in Time 340-A0743 CSM/SGM SR NCO Course 4 days Landstuhl, Germany Leadership<br />
Battle Staff 6 wks, 2 days USASMA Just in time - ASI 2S 6A-300/A0130 Emergency Med on the Riverwalk 5 days SA, TX Just in Time<br />
Recruiter 6 wks USAREC Just in time 6E-300/A0502 Field Medicine Short Course 5 days Ft Bragg, NC Just in Time<br />
Master Fitness Trainer 2 wks Multiple sites Just in time ASI-P5 6H-300/A0406 Sperandio POITS Short Course 5 days Dallas, TX Just in Time<br />
Drill Sgt School 9 wks Multiple Sites Just in Time SQI-X<br />
6-8-C42 ANCOC (SL4) 6 wks FSH, TX Leadership Specialty Courses<br />
First Sergeant Course 5 wks USASMA Just in time SQI-M 5K-F7/520-F7(PILOT) Advanced Instructor Training<br />
1 Wk, 3<br />
Days<br />
<strong>Fort</strong> Sam Houston, TX<br />
SGM Course 9 months USASMA Just in time MEL-A 5K-F8/520-F8(PILOT) Education and Training for the 21st Century 4 Weeks <strong>Fort</strong> Sam Houston, TX<br />
CSM Course 1 wk USASMA Just in time/leadership<br />
NOTE: Must maintain EMT Certification.<br />
PPSCP<br />
1- 4
STP 8-91W15-SM-TG<br />
• Check each soldier. Evaluate how well each soldier performs the tasks in this manual.<br />
Conduct these evaluations during individual training sessions or while evaluating soldier<br />
proficiency during the conduct of unit collective tasks. This manual provides an evaluation<br />
guide for each task to enhance the trainer's ability to conduct year-round, hands-on evaluations<br />
of tasks critical to the unit's mission. Use the information in the MTP as a guide to determine<br />
how often to train the soldier on each task to ensure that soldiers sustain proficiency.<br />
• Record the results. The leader book referred to in FM 25-101, appendix B, is used to<br />
record task performance and gives the leader total flexibility on the method of recording training.<br />
The trainer may use DA Forms 5164-R (Hands-On Evaluation) and 5165-R (Field Expedient<br />
Squad Book) as part of the leader book. The forms are optional and locally reproducible. STP<br />
21-24-SMCT contains a copy of the forms and instructions for their use.<br />
• Retrain and evaluate. Work with each soldier until he or she can perform the task to<br />
specific SM standards.<br />
1-8. Training Tips for the Trainer<br />
Prepare yourself.<br />
• Get training guidance from your chain of command on when to train, which soldiers to<br />
train, availability of resources, and a training site.<br />
• Get the training objective (task, conditions, and standards) from the task summary in this<br />
manual.<br />
• Ensure you can do the task. Review the task summary and the references in the<br />
reference section. Practice doing the task or, if necessary, have someone train you on the task.<br />
• Choose a training method.<br />
• Prepare a training outline consisting of informal notes on what you want to cover during<br />
your training session.<br />
• Practice your training presentation.<br />
Prepare the resources.<br />
• Obtain the required resources identified in the conditions statement for each task.<br />
• Gather equipment and ensure it is operational.<br />
• Coordinate for use of training aids and devices.<br />
• Prepare the training site according to the conditions statement and evaluation preparation<br />
section of the task summary, as appropriate.<br />
1-5
STP 8-91W15-SM-TG<br />
Prepare the soldiers.<br />
• Tell the soldier what task to do and how well it must be done. Refer to the standards<br />
statement and evaluation preparation section for each task as appropriate.<br />
• Caution soldiers about safety, environment, and security.<br />
• Provide any necessary training on basic skills that soldiers must have before they can be<br />
trained on the task.<br />
• Pretest each soldier to determine who needs training in what areas by having the soldier<br />
perform the task. Use DA Form 5164-R and the evaluation guide in each task summary to<br />
make this determination.<br />
NOTE: Deficiencies noted in soldiers' ability to perform critical tasks taught in schools or by<br />
extension training materials should be reported to the proponent school.<br />
Train the soldiers who failed the pretest.<br />
• Demonstrate how to do the task or the specific performance steps to those soldiers who<br />
could not perform to SM standards. Have soldiers study the appropriate materials.<br />
• Have soldiers practice the task until they can perform it to SM standards.<br />
• Evaluate each soldier using the evaluation guide.<br />
• Provide feedback to those soldiers who fail to perform to SM standards and have them<br />
continue to practice until they can perform to SM standards.<br />
Record results in the leader book.<br />
1-9. Training Support<br />
This manual includes the following information which provides additional training support<br />
information.<br />
• Appendix A, DA Form 5165-R (Field Expedient Squad Book). This appendix provides an<br />
overprinted copy of DA Form 5165-R for the tasks in this MOS. The NCO trainer can use this<br />
form to set up the leader book described in FM 25-101, appendix B.<br />
• Appendix B contains information that is used in performing drug dosage calculations.<br />
• Glossary. The glossary, which follows the last appendix, is a single comprehensive list of<br />
acronyms, abbreviations, definitions, and letter symbols.<br />
• References. This section contains two lists of references, required and related, which<br />
support training of all tasks in this SM. Required references are listed in the conditions<br />
statement and are required for the soldier to do the task. Related references are materials<br />
which provide more detailed information and a more thorough explanation of task performance.<br />
1-6
STP 8-91W15-SM-TG<br />
CHAPTER 2<br />
Trainer's Guide<br />
2-1. General. The MOS Training Plan (MTP) identifies the essential components of a unit<br />
training plan for individual training. Units have different training needs and requirements based<br />
on differences in environment, location, equipment, dispersion, and similar factors. Therefore,<br />
the MTP should be used as a guide for conducting unit training and not a rigid standard. The<br />
MTP consists of two parts. Each part is designed to assist the commander in preparing a unit<br />
training plan which satisfies integration, cross training, training up, and sustainment training<br />
requirements for soldiers in this MOS.<br />
Part One of the MTP shows the relationship of an MOS skill level between duty position and<br />
critical tasks. These critical tasks are grouped by task commonality into subject areas.<br />
Section I lists subject area numbers and titles used throughout the MTP. These subject areas<br />
are used to define the training requirements for each duty position within an MOS.<br />
Section II identifies the total training requirement for each duty position within an MOS and<br />
provides a recommendation for cross training and train-up/merger training.<br />
• Duty Position column. This column lists the duty positions of the MOS, by skill level, which<br />
have different training requirements.<br />
• Subject Area column. This column lists, by numerical key (see Section I), the subject areas<br />
a soldier must be proficient in to perform in that duty position.<br />
• Cross Train column. This column lists the recommended duty position for which soldiers<br />
should be cross trained.<br />
• Train-up/Merger column. This column lists the corresponding duty position for the next<br />
higher skill level or MOSC the soldier will merge into on promotion.<br />
Part Two lists, by general subject areas, the critical tasks to be trained in an MOS and the type<br />
of training required (resident, integration, or sustainment).<br />
• Subject Area column. This column lists the subject area number and title in the same order<br />
as Section I, Part One of the MTP.<br />
• Task Number column. This column lists the task numbers for all tasks included in the<br />
subject area.<br />
• Title column. This column lists the task title for each task in the subject area.<br />
• Training Location column. This column identifies the training location where the task is first<br />
trained to soldier training publications standards. If the task is first trained to standard in the<br />
unit, the word “Unit” will be in this column. If the task is first trained to standard in the training<br />
base, it will identify, by brevity code (ANCOC, BNCOC, etc.), the resident course where the<br />
task was taught. Figure 2-1 contains a list of training locations and their corresponding<br />
brevity codes.<br />
2-1
STP 8-91W15-SM-TG<br />
AIT<br />
UNIT<br />
BNCOC<br />
Advanced Individual Training<br />
Trained in the Unit<br />
Basic NCO Course<br />
Figure 2-1. Training Locations<br />
• Sustainment Training Frequency column. This column indicates the recommended<br />
frequency at which the tasks should be trained to ensure soldiers maintain task proficiency.<br />
Figure 2-2 identifies the frequency codes used in this column. Tasks designated "SA" must<br />
be sustained to support the Semi-Annual Combat Medic Skills Validation Test (SACMS-VT)<br />
to be conducted IAW TC 8-800.<br />
BA - Biannually<br />
AN - Annually<br />
SA - Semiannually<br />
QT - Quarterly<br />
MO - Monthly<br />
BW - Bi-weekly<br />
WK - Weekly<br />
Figure 2-2. Sustainment Training Frequency Codes<br />
• Sustainment Training Skill Level column. This column lists the skill levels of the MOS for<br />
which soldiers must receive sustainment training to ensure they maintain proficiency to<br />
soldier’s manual standards.<br />
2-2
STP 8-91W15-SM-TG<br />
2-2. Part One, Section I. Subject Area Codes.<br />
Skill Level 1<br />
1 Vital Signs<br />
2 Emergency Medical Treatment<br />
3 Basic Medical Care<br />
4 Respiratory Dysfunction/Airway Management<br />
5 Venipuncture and IV Therapy<br />
6 Casualty Management<br />
7 Eye Injuries<br />
8 Skeletal Dysfunction<br />
9 Environmental Injuries<br />
10 Chemical Agent Injuries<br />
11 Shock<br />
12 Urinary Catheterization<br />
13 Gastric Intubation<br />
14 Triage and Evacuation<br />
15 Medication Administration<br />
16 Force Protection/Risk Assessment<br />
Skill Level 2<br />
17 Advanced Procedures (SL 2)<br />
Skill Level 3<br />
18 Advanced Procedures (SL 3)<br />
2-3
STP 8-91W15-SM-TG<br />
2-3. Part One, Section II. Duty Position Training Requirements.<br />
DUTY POSITION<br />
SUBJECT<br />
AREAS<br />
CROSS<br />
TRAIN<br />
TRAIN-UP/<br />
MERGER<br />
SL 1 Health Care Specialist 1-16 NA 91W2 Health Care Specialist<br />
SL 2 Health Care Specialist 1-17 NA 91W3 Health Care Specialist<br />
SL 3 Health Care Specialist 1-18 NA NA<br />
SL 4 Health Care Specialist 1-18 NA NA<br />
SL 5 Health Care Specialist 1-18 NA 91Z5 Chief Medical NCO<br />
2-4
STP 8-91W15-SM-TG<br />
2-4. Part Two. Critical Tasks List.<br />
MOS TRAINING PLAN<br />
91W15<br />
CRITICAL TASKS<br />
Subject<br />
Area<br />
Task Number Title Training<br />
Location<br />
Sust<br />
Tng<br />
Freq<br />
Sust<br />
Tng SL<br />
Skill Level 1<br />
1. Vital Signs 081-831-0010 MEASURE A PATIENT'S RESPIRATIONS AIT SA 1-5<br />
081-831-0011 MEASURE A PATIENT'S PULSE AIT SA 1-5<br />
081-831-0012 MEASURE A PATIENT'S BLOOD PRESSURE AIT SA 1-5<br />
081-831-0013 MEASURE A PATIENT'S TEMPERATURE AIT SA 1-5<br />
081-833-0164 MEASURE A PATIENT'S PULSE OXYGEN<br />
SATURATION<br />
AIT AN 1-5<br />
2.<br />
Emergency<br />
Medical<br />
Treatment<br />
081-831-0018 OPEN THE AIRWAY AIT SA 1-5<br />
081-831-0019 CLEAR AN UPPER AIRWAY OBSTRUCTION AIT SA 1-5<br />
081-831-0046 ADMINISTER EXTERNAL CHEST<br />
COMPRESSIONS<br />
AIT SA 1-5<br />
081-831-0048 PERFORM RESCUE BREATHING AIT SA 1-5<br />
081-833-0161 CONTROL BLEEDING AIT SA 1-5<br />
081-833-0167 PLACE A PATIENT ON A CARDIAC MONITOR AIT AN 1-5<br />
081-833-3027 MANAGE CARDIAC ARREST USING AED AIT SA 1-5<br />
3. Basic<br />
Medical Care<br />
081-831-0007 PERFORM A PATIENT CARE H<strong>AND</strong>WASH AIT SA 1-5<br />
081-831-0008 PUT ON STERILE GLOVES AIT SA 1-5<br />
081-831-0033 INITIATE A FIELD MEDICAL CARD AIT AN 1-5<br />
081-833-0006 MEASURE A PATIENT'S INTAKE <strong>AND</strong><br />
OUTPUT<br />
AIT AN 1-5<br />
081-833-0007 ESTABLISH A STERILE FIELD AIT AN 1-5<br />
081-833-0010 CHANGE A STERILE DRESSING AIT AN 1-5<br />
081-833-0012 PERFORM A WOUND IRRIGATION AIT AN 1-5<br />
081-833-0021 PERFORM ORAL <strong>AND</strong> NASOPHARYNGEAL<br />
SUCTIONING OF A PATIENT<br />
AIT SA 1-5<br />
2-5
STP 8-91W15-SM-TG<br />
CRITICAL TASKS<br />
Subject<br />
Area<br />
Task Number Title Training<br />
Location<br />
Sust<br />
Tng<br />
Freq<br />
Sust<br />
Tng SL<br />
081-833-0059 IRRIGATE AN OBSTRUCTED EAR AIT AN 1-5<br />
081-833-0076 APPLY RESTRAINING DEVICES TO<br />
PATIENTS<br />
081-833-0145 DOCUMENT PATIENT CARE USING<br />
SUBJECTIVE, OBJECTIVE, ASSESSMENT,<br />
PLAN (SOAP) NOTE FORMAT<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
081-833-0165 PERFORM PATIENT HYGIENE AIT AN 1-5<br />
081-835-3007 OBTAIN AN ELECTROCARDIOGRAM AIT AN 1-5<br />
4.<br />
Respiratory<br />
Dysfunction/<br />
Airway<br />
Management<br />
081-833-0016 INSERT AN OROPHARYNGEAL AIRWAY (J<br />
TUBE)<br />
AIT SA 1-5<br />
081-833-0018 SET UP AN OXYGEN TANK AIT SA 1-5<br />
081-833-0142 INSERT A NASOPHARYNGEAL AIRWAY AIT SA 1-5<br />
081-833-0158 ADMINISTER OXYGEN AIT SA 1-5<br />
081-833-0169 INSERT A COMBITUBE AIT SA 1-5<br />
5.<br />
Venipuncture<br />
and IV<br />
Therapy<br />
081-833-3006 PERFORM A NEEDLE<br />
CRICOTHYROIDOTOMY<br />
081-833-3007 PERFORM NEEDLE CHEST<br />
DECOMPRESSION<br />
081-833-0032 OBTAIN A BLOOD SPECIMEN USING A<br />
VACUTAINER<br />
AIT AN 1-5<br />
AIT SA 1-5<br />
AIT AN 1-5<br />
081-833-0033 INITIATE AN INTRAVENOUS INFUSION AIT SA 1-5<br />
081-833-0034 MANAGE A PATIENT WITH AN<br />
INTRAVENOUS INFUSION<br />
AIT SA 1-5<br />
081-835-3025 INITIATE A SALINE LOCK AIT AN 1-5<br />
6. Casualty<br />
Management<br />
081-831-0035 MANAGE A CONVULSIVE <strong>AND</strong>/OR SEIZING<br />
PATIENT<br />
081-833-0045 TREAT A CASUALTY WITH AN OPEN<br />
ABDOMINAL WOUND<br />
081-833-0046 APPLY A DRESSING TO AN IMPALEMENT<br />
INJURY<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
081-833-0048 MANAGE AN UNCONSCIOUS CASUALTY AIT AN 1-5<br />
2-6
STP 8-91W15-SM-TG<br />
CRITICAL TASKS<br />
Subject<br />
Area<br />
Task Number Title Training<br />
Location<br />
081-833-0049 TREAT A CASUALTY WITH A CLOSED<br />
CHEST WOUND<br />
Sust<br />
Tng<br />
Freq<br />
Sust<br />
Tng SL<br />
AIT AN 1-5<br />
081-833-0050 TREAT A CASUALTY WITH AN OPEN CHEST<br />
WOUND<br />
081-833-0052 TREAT A CASUALTY WITH AN OPEN OR<br />
CLOSED HEAD INJURY<br />
081-833-0070 ADMINISTER INITIAL TREATMENT FOR<br />
BURNS<br />
081-833-0103 PROVIDE CARE FOR A SOLDIER WITH<br />
SYMPTOMS OF BATTLE FATIGUE<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
081-833-0116 ASSIST IN VAGINAL DELIVERY AIT AN 1-5<br />
081-833-0143 TREAT A POISONED CASUALTY AIT AN 1-5<br />
081-833-0144 TREAT A DIABETIC EMERGENCY AIT AN 1-5<br />
081-833-0155 PERFORM A TRAUMA CASUALTY<br />
ASSESSMENT<br />
081-833-0156 PERFORM A MEDICAL PATIENT<br />
ASSESSMENT<br />
AIT SA 1-5<br />
AIT SA 1-5<br />
081-833-0159 TREAT A CARDIAC EMERGENCY AIT AN 1-5<br />
081-833-0160 TREAT A RESPIRATORY EMERGENCY AIT AN 1-5<br />
081-835-3030 DETERMINE A PATIENT'S LEVEL OF<br />
CONSCIOUSNESS USING THE GLASGOW<br />
COMA SCALE<br />
AIT AN 1-5<br />
7. Eye<br />
Injuries<br />
081-833-0054 IRRIGATE EYES AIT AN 1-5<br />
081-833-0056 TREAT FOREIGN BODIES OF THE EYE AIT AN 1-5<br />
081-833-0057 TREAT LACERATIONS, CONTUSIONS, <strong>AND</strong><br />
EXTRUSIONS OF THE EYE<br />
AIT AN 1-5<br />
081-833-0058 TREAT BURNS OF THE EYE AIT AN 1-5<br />
8. Skeletal<br />
Dysfunction<br />
081-831-0044 APPLY A PNEUMATIC SPLINT TO A<br />
CASUALTY WITH A SUSPECTED FRACTURE<br />
OF AN EXTREMITY<br />
AIT AN 1-5<br />
081-833-0060 APPLY A ROLLER B<strong>AND</strong>AGE AIT AN 1-5<br />
081-833-0062 IMMOBILIZE A SUSPECTED FRACTURE OF<br />
THE ARM OR DISLOCATED SHOULDER<br />
081-833-0064 IMMOBILIZE A SUSPECTED DISLOCATED<br />
OR FRACTURED HIP<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
2-7
STP 8-91W15-SM-TG<br />
CRITICAL TASKS<br />
Subject<br />
Area<br />
Task Number Title Training<br />
Location<br />
081-833-0092 TRANSPORT A CASUALTY WITH A<br />
SUSPECTED SPINAL INJURY<br />
Sust<br />
Tng<br />
Freq<br />
Sust<br />
Tng SL<br />
AIT SA 1-5<br />
081-833-0141 APPLY A TRACTION SPLINT AIT SA 1-5<br />
081-833-0154 PROVIDE BASIC EMERGENCY TREATMENT<br />
FOR A PAINFUL, SWOLLEN, DEFORMED<br />
EXTREMITY<br />
AIT AN 1-5<br />
9.<br />
Environmental<br />
Injuries<br />
081-831-0038 TREAT A CASUALTY FOR A HEAT INJURY AIT AN 1-5<br />
081-831-0039 TREAT A CASUALTY FOR A COLD INJURY AIT AN 1-5<br />
081-833-0031 INITIATE TREATMENT FOR ANAPHYLACTIC<br />
SHOCK<br />
081-833-0072 TREAT A CASUALTY FOR INSECT BITES OR<br />
STINGS<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
081-833-0073 TREAT A CASUALTY FOR SNAKEBITE AIT AN 1-5<br />
10. Chemical<br />
Agent<br />
Injuries<br />
081-833-0083 TREAT A NERVE AGENT CASUALTY IN THE<br />
FIELD<br />
081-833-0084 TREAT A BLOOD AGENT (HYDROGEN<br />
CYANIDE) CASUALTY IN THE FIELD<br />
081-833-0085 TREAT A CHOKING AGENT CASUALTY IN<br />
THE FIELD<br />
081-833-0086 TREAT A BLISTER AGENT CASUALTY<br />
(MUSTARD, LEWISITE, PHOSGENE OXIME)<br />
IN THE FIELD<br />
AIT SA 1-5<br />
AIT SA 1-5<br />
AIT SA 1-5<br />
AIT SA 1-5<br />
081-833-0095 DECONTAMINATE A CASUALTY AIT AN 1-5<br />
11. Shock 081-833-0047 INITIATE TREATMENT FOR HYPOVOLEMIC<br />
SHOCK<br />
AIT SA 1-5<br />
081-833-3011 APPLY PNEUMATIC ANTI-SHOCK GARMENT AIT AN 1-5<br />
12. Urinary<br />
Catheterization<br />
081-833-3017 INSERT A URINARY CATHETER AIT AN 1-5<br />
081-835-3010 MAINTAIN AN INDWELLING URINARY<br />
CATHETER<br />
AIT AN 1-5<br />
13. Gastric<br />
Intubation<br />
081-833-3022 INSERT A NASOGASTRIC TUBE AIT AN 1-5<br />
081-835-3005 PERFORM A GASTRIC LAVAGE AIT AN 1-5<br />
2-8
STP 8-91W15-SM-TG<br />
CRITICAL TASKS<br />
Subject<br />
Area<br />
14. Triage<br />
and<br />
Evacuation<br />
Task Number Title Training<br />
Location<br />
071-334-4001 <strong>GUIDE</strong> A HELICOPTER TO A L<strong>AND</strong>ING<br />
POINT<br />
Sust<br />
Tng<br />
Freq<br />
Sust<br />
Tng SL<br />
AIT AN 1-5<br />
071-334-4002 ESTABLISH A HELICOPTER L<strong>AND</strong>ING POINT AIT AN 1-5<br />
15.<br />
Medication<br />
Administration<br />
081-833-0080 TRIAGE CASUALTIES ON A CONVENTIONAL<br />
BATTLEFIELD<br />
081-833-0082 TRIAGE CASUALTIES ON AN INTEGRATED<br />
BATTLEFIELD<br />
081-833-0151 LOAD CASUALTIES ONTO GROUND<br />
EVACUATION PLATFORMS<br />
081-833-0171 LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD<br />
VEHICLES, 1 1/4 TON, 4X4, M998<br />
081-833-0172 LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD<br />
VEHICLES, 2 1/2 TON, 6X6 OR 5 TON, 6X6,<br />
CARGO TRUCK<br />
081-833-0173 LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD<br />
VEHICLES, 5 TON M-1085, M-1093, 2 1/2 TON<br />
M-1081<br />
081-833-0088 PREPARE AN INJECTION FOR<br />
ADMINISTRATION<br />
081-833-0089 ADMINISTER AN INJECTION<br />
(INTRAMUSCULAR, SUBCUTANEOUS,<br />
INTRADERMAL)<br />
AIT SA 1-5<br />
AIT SA 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
081-833-0174 ADMINISTER MORPHINE AIT SA 1-5<br />
081-835-3001 ADMINISTER ORAL MEDICATIONS AIT AN 1-5<br />
081-835-3020 ADMINISTER TOPICAL MEDICATIONS AIT AN 1-5<br />
081-835-3021 ADMINISTER RECTAL OR VAGINAL<br />
MEDICATIONS<br />
081-835-3022 ADMINISTER MEDICATED EYE DROPS OR<br />
OINTMENTS<br />
AIT AN 1-5<br />
AIT AN 1-5<br />
16. Force<br />
Protection/<br />
Risk<br />
Assessment<br />
081-831-0037 DISINFECT WATER FOR DRINKING AIT AN 1-5<br />
2-9
STP 8-91W15-SM-TG<br />
CRITICAL TASKS<br />
Subject<br />
Area<br />
Task Number Title Training<br />
Location<br />
Sust<br />
Tng<br />
Freq<br />
Sust<br />
Tng SL<br />
Skill Level 2<br />
17.<br />
Advanced<br />
Procedures<br />
(SL 2)<br />
081-833-0170 PERFORM ENDOTRACHEAL SUCTIONING<br />
OF A PATIENT<br />
UNIT AN 2-5<br />
081-835-3024 PROVIDE TRACHEOSTOMY CARE UNIT AN 2-5<br />
081-835-3031 PROVIDE NURSING CARE FOR A PATIENT<br />
WITH A WATERSEAL DRAINAGE SYSTEM<br />
UNIT AN 2-5<br />
Skill Level 3<br />
18.<br />
Advanced<br />
Procedures<br />
(SL 3)<br />
081-830-3016 INTUBATE A PATIENT BNCOC AN 3-5<br />
081-833-0093 SET UP A CASUALTY DECONTAMINATION<br />
STATION<br />
BNCOC AN 3-5<br />
081-833-0168 INSERT A CHEST TUBE BNCOC AN 3-5<br />
081-833-3005 PERFORM A SURGICAL<br />
CRICOTHYROIDOTOMY<br />
081-833-3014 PERFORM A NEUROLOGICAL<br />
EXAMINATION ON A PATIENT WITH<br />
SUSPECTED CENTRAL NERVOUS SYSTEM<br />
(CNS) INJURIES<br />
BNCOC AN 3-5<br />
BNCOC AN 3-5<br />
081-833-3208 SUTURE A MINOR LACERATION BNCOC AN 3-5<br />
081-835-3000 ADMINISTER BLOOD BNCOC AN 3-5<br />
081-835-3002 ADMINISTER MEDICATIONS BY IV<br />
PIGGYBACK<br />
BNCOC AN 3-5<br />
2-10
STP 8-91W15-SM-TG<br />
CHAPTER 3<br />
MOS/Skill Level Tasks<br />
Skill Level 1<br />
Subject Area 1: Vital Signs<br />
MEASURE A PATIENT'S RESPIRATIONS<br />
081-831-0010<br />
Conditions: Necessary materials and equipment: a watch and appropriate forms.<br />
Standards: Counted a patient's respirations for 1 full minute. Identified any abnormalities in<br />
respiration rate, depth, rhythm, pattern, and quality.<br />
Performance Steps<br />
1. Count the number of times the chest rises in 1 minute. Normal respirations for each age<br />
group are as follows:<br />
NOTE: The patient should not be aware that respirations are being counted. If the patient is<br />
aware, he or she often becomes tense, and an accurate count becomes extremely difficult.<br />
a. Adult and adolescent (11-14 years old) = 12-20.<br />
b. School age (6-10 years old) = 15-30.<br />
c. Preschooler (3-5 years old) = 20-30.<br />
d. Toddler (1-3 years old) = 20-30.<br />
e. Infant (6-12 months old) = 20-30.<br />
f. Infant (0-5 months old) = 25-40.<br />
g. Newborn = 30-50.<br />
2. Evaluate the respirations.<br />
a. Depth.<br />
(1) Normal--deep, even movement of the chest.<br />
(2) Shallow--minimal rise and fall of the chest and abdomen.<br />
(3) Deep--the rib cage expands fully, and the diaphragm descends to create a<br />
maximum capacity.<br />
b. Rhythm and pattern.<br />
(1) Healthy--exhalations are twice as long as inhalations.<br />
(2) Irregular.<br />
(3) Hypoventilation--slow and shallow respirations.<br />
(4) Hyperventilation--sustained increased rate and depth of respiration.<br />
(5) Sigh--deep inhalation followed by a slow audible exhalation.<br />
(6) Apnea--temporary absence of breathing.<br />
(7) Tachypnea--increased respiration rate, usually 24 or more breaths per minute.<br />
c. Quality.<br />
(1) Normal--effortless, automatic, regular rate, even depth, noiseless, and free of<br />
discomfort.<br />
(2) Dyspnea--difficult or labored breathing.<br />
(3) Wheezing or whistling sound.<br />
(4) Rattling or bubbling.<br />
3-1
STP 8-91W15-SM-TG<br />
Performance Steps<br />
3. Check for the physical characteristics of abnormal respirations.<br />
a. Appearance--the casualty may appear restless, anxious, pale, ashen, or cyanotic.<br />
b. Position--the casualty may alter his or her position by leaning forward or may be<br />
unable to lie flat.<br />
c. Cough.<br />
(1) Acute--comes on suddenly.<br />
(2) Chronic--has existed for a long time.<br />
(3) Dry--coughs without sputum.<br />
(4) Productive--coughs which expel sputum.<br />
(a) Normal sputum--clear, semiliquid mucus which may appear watery, frothy, or<br />
thick.<br />
(b) Abnormal sputum--may be green, yellow, gray, or blood-tinged, and may<br />
have a foul or sweetish smell.<br />
4. Record the rate of respirations and any observations noted on the appropriate forms.<br />
5. Report any abnormal respirations to the supervisor immediately.<br />
Evaluation Preparation:<br />
Setup: You must count the rate with the soldier. If you are using a simulated patient, you may<br />
test step 2 by having him or her purposely exhibit abnormal breathing characteristics. A<br />
tolerance of plus or minus two counts will be allowed.<br />
Brief soldier: Tell the soldier to count, evaluate, and record a patient's respirations.<br />
Performance Measures GO NO<br />
GO<br />
1. Counted the number of times the chest rose in 1 minute. —— ——<br />
2. Evaluated the respirations. —— ——<br />
3. Checked for the physical characteristics of abnormal respirations. —— ——<br />
4. Recorded the rate of respirations and any observations noted on the<br />
appropriate forms.<br />
—— ——<br />
5. Reported any abnormal respirations to the supervisor immediately. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-2
STP 8-91W15-SM-TG<br />
MEASURE A PATIENT'S PULSE<br />
081-831-0011<br />
Conditions: Necessary materials and equipment: a watch, stethoscope, and appropriate<br />
forms.<br />
Standards: Counted a patient's pulse for 1 full minute. Identified any abnormalities in the pulse<br />
rate, rhythm, and strength.<br />
Performance Steps<br />
1. Position the patient so that the pulse site is accessible.<br />
2. Palpate the pulse site.<br />
a. Place the tips of your index and middle fingers on the pulse site.<br />
NOTE: You must use a stethoscope to monitor the apical site.<br />
b. Press the fingers, using moderate pressure, to feel the pulse.<br />
3. Count for 1 full minute and evaluate the pulse.<br />
NOTE: To detect irregularities, you must count for 1 full minute.<br />
a. Pulse rate.<br />
(1) Normal adult rate--60 to 100 beats per minute.<br />
(2) Infants and Children<br />
(a) Adolescent 11-14 years--60 to 105<br />
(b) School age 6-10 years-- 70 to 110<br />
(c) Preschooler 3-5 years-- 80 to 120<br />
(d) Toddler 1-3 years-- 80 to 130<br />
(e) Infant 6-12 months--80 to 140<br />
(f) Infant 0-5 months-- 90 to 140<br />
(g) Newborn--120 to 160<br />
(3) Bradycardia--less than 50 beats per minute.<br />
WARNING: Patient presenting with bradycardia, medic must consider physical condition of<br />
patient. For example, the patient is and athlete an their normal at-rest pulse rate is between 40<br />
to 50 beats per minute.<br />
(4) Tachycardia--more than 100 beats per minute.<br />
b. Pulse rhythm.<br />
(1) Regular.<br />
(a) Usually easy to find.<br />
(b) Has a regular rate and rhythm.<br />
(c) Varies with the individual.<br />
(2) Irregular/intermittent--any change from a regular beating pattern.<br />
NOTE: If a peripheral pulse is irregular or intermittent, you should take a second pulse at the<br />
carotid, femoral, or apical site. (See Figure 3-1.)<br />
3-3
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-1<br />
c. Pulse strength.<br />
(1) Strong or full pulse.<br />
(a) Easy to find.<br />
(b) Has even beats with good force.<br />
(2) Bounding.<br />
(a) Easy to find.<br />
(b) Exceptionally strong heartbeats which make the arteries difficult to compress.<br />
(3) Weak/thready<br />
(a) weak and thin<br />
(b) difficult to find<br />
4. Record the rate, rhythm, strength, and any significant deviations from normal on the<br />
appropriate forms.<br />
5. Report any significant pulse abnormalities to the supervisor immediately.<br />
3-4
STP 8-91W15-SM-TG<br />
Evaluation Preparation:<br />
Setup: While the soldier is palpating a pulse site, you must palpate the corresponding site.<br />
Specify which site the soldier is to palpate. If the apical site is chosen, either a double<br />
stethoscope or separate stethoscopes may be used. A tolerance of plus or minus two beats will<br />
be allowed.<br />
Brief soldier: Tell the soldier to count, evaluate, and record the patient's pulse.<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the patient so that the pulse site is accessible. —— ——<br />
2. Palpated the pulse site. —— ——<br />
3. Counted for 1 full minute and evaluated the pulse. —— ——<br />
4. Recorded the rate, rhythm, strength, and any significant deviations from<br />
normal on the appropriate forms.<br />
5. Reported any significant pulse abnormalities to the supervisor<br />
immediately.<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-5
STP 8-91W15-SM-TG<br />
MEASURE A PATIENT'S BLOOD PRESSURE<br />
081-831-0012<br />
Conditions: Necessary materials and equipment: sphygmomanometer, clean stethoscope,<br />
and appropriate forms.<br />
Standards: Measured a patient's blood pressure and recorded the measurement on the<br />
appropriate forms.<br />
Performance Steps<br />
1. Explain the procedure to the patient, if necessary.<br />
a. The length of time the procedure will take.<br />
b. The site to be used.<br />
c. The physical sensations the patient will feel.<br />
2. Select the proper size of sphygmomanometer cuff.<br />
NOTE: The cuff width should be two-thirds of the upper arm length if using the brachial artery<br />
and two-thirds of the upper leg if using the popliteal artery.<br />
3. Check the equipment.<br />
a. Ensure that the cuff is deflated completely and fully retighten the thumbscrew.<br />
b. Ensure the sphygmomanometer gauge reads zero.<br />
NOTE: Steps 2, 3, and 4 describe the procedure for taking the blood pressure at the brachial<br />
site. If the brachial site cannot be used, measure the blood pressure using a larger cuff applied<br />
to the thigh. The patient should be lying down (preferably on the stomach; otherwise, on the<br />
back with one knee flexed). Apply the cuff at mid-thigh, and place the stethoscope over the<br />
popliteal artery. The remainder of the procedure is the same as for the brachial artery site.<br />
4. Position the patient.<br />
a. Place the patient in a relaxed and comfortable sitting, standing, or lying position.<br />
NOTE: A reading obtained from a standing position will be slightly higher.<br />
b. Place the patient's arm palm up at approximately heart level. Support the arm so that<br />
it is relaxed.<br />
5. Place the cuff at the brachial artery site.<br />
a. Place the cuff so the lower edge is 1 to 2 inches above the elbow and the bladder<br />
portion is over the artery.<br />
b. Wrap the cuff just tightly enough to prevent slippage.<br />
c. If applicable, clip the gauge to the cuff in alignment with the palm.<br />
6. Position the stethoscope, if used.<br />
a. Palpate for the brachial pulse.<br />
b. Place the diaphragm of the stethoscope over the pulse site.<br />
7. Inflate the cuff until the gauge reads at least 140 mm Hg or 10 mm Hg higher than the<br />
usual range for that patient, if known.<br />
NOTE: If a pulsation is heard when the gauge reaches 140 mm Hg, continue to inflate the cuff<br />
10 mm Hg beyond the point at which the last pulsation was heard.<br />
CAUTION: The cuff should not remain inflated for more than 2 minutes.<br />
3-6
STP 8-91W15-SM-TG<br />
8. Determine the blood pressure.<br />
a. If a stethoscope is used, complete the following steps:<br />
(1) Rotate the thumbscrew slowly in a counterclockwise motion, allowing the cuff to<br />
deflate slowly.<br />
(2) Watch the gauge and remember the reading when the first distinct sound is heard<br />
(systolic pressure).<br />
(3) Continue to watch the gauge and remember the reading where the sound<br />
changes again and becomes muffled or unclear (diastolic pressure).<br />
(4) Release the remaining air.<br />
b. If a stethoscope is not used, complete the following steps:<br />
(1) Palpate for the radial pulse.<br />
(2) Rotate the thumbscrew slowly in a counterclockwise motion, allowing the cuff to<br />
deflate slowly.<br />
(3) Watch the gauge and remember the point at which the pulse returns (systolic<br />
pressure).<br />
NOTES: 1. The diastolic pressure cannot be determined using this method. 2. If the<br />
procedure must be repeated, wait at least 1 minute before repeating steps 6 through 8.<br />
9. Record the blood pressure on the appropriate forms.<br />
a. Record the systolic reading over the diastolic reading, for example 120/80.<br />
b. Record the readings in even numbers.<br />
10. Evaluate the blood pressure reading by comparing it with one of the following:<br />
a. The patient's previous reading.<br />
b. An average of the patient's previous readings.<br />
c. The normal range: 100-140/60-90 for males and 90-130/50-60 for females.<br />
11. Report abnormal readings to the supervisor.<br />
Evaluation Preparation:<br />
Setup: A double stethoscope should be used if available. A tolerance of ± 4 mm Hg will be<br />
allowed. If other methods are used, such as independent measurements on different sites or at<br />
different times, the evaluator must apply discretion in applying the ± 4 mm Hg standard. You<br />
will allow the soldier to retake the blood pressure at least once if the soldier feels that it is<br />
necessary to obtain an accurate reading. You will use discretion in allowing additional<br />
repetitions based upon the difficulty of obtaining a reading on the patient.<br />
Brief soldier: Tell the soldier to take a patient's blood pressure. Tell the soldier that the blood<br />
pressure may be retaken, if necessary, to obtain an accurate reading.<br />
Performance Measures GO NO<br />
GO<br />
1. Explained the procedure to the patient, if necessary. —— ——<br />
2. Selected the proper size of sphygmomanometer cuff. —— ——<br />
3. Checked the equipment. —— ——<br />
4. Positioned the patient. —— ——<br />
3-7
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Placed the cuff just tightly enough to prevent slippage. —— ——<br />
6. Positioned the stethoscope, if used. —— ——<br />
7. Inflated the cuff until the gauge read at least 140 mm Hg or 10 mm Hg<br />
higher than the usual range for that patient, if known.<br />
—— ——<br />
8. Determined the blood pressure. —— ——<br />
9. Recorded the blood pressure on the appropriate forms. —— ——<br />
10. Evaluated the blood pressure. —— ——<br />
11. Reported any abnormal readings to the supervisor. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-8
STP 8-91W15-SM-TG<br />
MEASURE A PATIENT'S TEMPERATURE<br />
081-831-0013<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: disinfected mercury oral and rectal thermometers or an electronic thermometer,<br />
canisters marked "used," water soluble lubricant, gauze pads, a watch, and appropriate forms.<br />
Standards: Recorded the patient's temperature to the nearest 0.2° F.<br />
Performance Steps<br />
1. Determine which site to use.<br />
a. Take an oral temperature if the patient is a conscious adult or a child who can follow<br />
directions, and can breathe normally through the nose.<br />
CAUTION: Do not take an oral temperature when the patient--<br />
1. Has had recent facial or oral surgery.<br />
2. Is confused, disturbed, or heavily sedated.<br />
3. Is being administered oxygen by mouth or nose.<br />
4. Is likely to bite down on the thermometer.<br />
5. Has smoked, chewed gum, or ingested anything hot or cold within the last 15 to 30 minutes.<br />
b. Tympanic method can be used with conscious or unconscious patients and is<br />
preferred temperature if the patient has recently had something to eat or drink.<br />
CAUTION: Do not take a tympanic temperature if the patient has had recent facial or aural<br />
surgery, or has cerumen (ear wax).<br />
c. Take a rectal temperature if the oral or tympanic site is ruled out by the patient's<br />
condition.<br />
CAUTION: Do not take a rectal temperature on a patient with a cardiac condition, diarrhea, a<br />
rectal disorder such as hemorrhoids, or recent rectal surgery. Do not take a rectal temperature<br />
on an infant unless directed to by medical guidance.<br />
d. Take an axillary temperature if the patient's condition rules out using the other<br />
methods.<br />
2. Select the proper thermometer.<br />
a. Tympanic thermometer.<br />
b. An oral thermometer has a blue tip and may be labeled "Oral."<br />
c. A rectal thermometer has a red tip and may be labeled "Rectal."<br />
d. Axillary temperatures are taken with oral thermometers.<br />
3. Explain the procedure and position the patient.<br />
a. Take a tympanic temperature with the patient s head turned toward side so that the<br />
ear canal is easily viewed.<br />
b. Take an oral temperature with the patient seated or lying face up.<br />
c. Take a rectal temperature with the patient lying on either side with the top knee flexed.<br />
d. Take an axillary temperature with the patient lying face up with the armpit exposed.<br />
4. Measure the temperature.<br />
a. Shake the thermometer down to below 94° F.<br />
b. Place the thermometer at the proper site.<br />
(1) If you are taking an oral temperature, place the thermometer in the heat pocket<br />
under the tongue and tell the patient to close his or her lips and not to bite down.<br />
(2) If you are taking a rectal temperature on an adult, insert the thermometer 1 to 2<br />
inches into his or her rectum.<br />
3-9
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Lubricate the tip prior to insertion. Hold the thermometer in place.<br />
(3) If you are taking a tympanic temperature, pull the ear pinna back, up, and out;<br />
insert the speculum into the ear canal snugly to make a seal, pointing toward the<br />
nose.<br />
(4) If you are taking an axillary temperature, pat the armpit dry and then place the<br />
bulb end in the center with the glass tip protruding to the front of the patient's<br />
body. Place the arm across his or her chest.<br />
c. Leave the thermometer in place for the required time.<br />
(1) Oral--at least 3 minutes.<br />
NOTE: Leave digital thermometers in place until testing is complete. The unit will normally<br />
have an audible tone.<br />
(2) Rectal--at least 2 minutes.<br />
(3) Tympanic--until an audible signal occurs and the patient's temperature appears on<br />
the digital display.<br />
(4) Axillary--at least 10 minutes.<br />
5. Remove the thermometer and wipe it down with a gauze square or discharge the protective<br />
plastic sheath.<br />
6. Read the scale.<br />
7. Put the thermometer in the proper "used" canister or dispose of the plastic sheath as<br />
appropriate.<br />
8. Record the temperature to the nearest 0.2° F on the appropriate forms and report any<br />
abnormal temperature change immediately to the supervisor.<br />
NOTES: 1. The normal temperature range is--Oral - 97.0° to 99.0° F; Rectal - 98.0° to<br />
100.0° F; Axillary - 96.0° to 98.0° F. 2. Record an axillary temperature with an "A" on the<br />
patient's record. Record a rectal temperature with an "R" on the patient's record.<br />
Evaluation Preparation:<br />
Setup: To test step 1 for evaluation purposes, create a scenario in which the patient's condition<br />
will dictate which site the soldier must choose.<br />
Brief soldier: Tell the soldier to measure, evaluate, and record a patient's temperature.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined which site to use. —— ——<br />
2. Selected the proper thermometer. —— ——<br />
3. Explained the procedure and positioned the patient. —— ——<br />
4. Measured the temperature. —— ——<br />
5. Removed the thermometer and wiped it down with a gauze square. —— ——<br />
6. Read the scale. —— ——<br />
7. Placed the thermometer in the proper "used" canister or disposed of the<br />
plastic sheath as appropriate.<br />
—— ——<br />
3-10
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
8. Recorded the temperature to the nearest 0.2° F on the appropriate forms<br />
and reported any abnormal temperature change immediately to the<br />
supervisor.<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-11
STP 8-91W15-SM-TG<br />
MEASURE A PATIENT'S PULSE OXYGEN SATURATION<br />
081-833-0164<br />
Conditions: You encounter a patient showing signs of respiratory distress and have determined<br />
the need to measure the pulse oxygen saturation. You have taken body substance isolation<br />
precautions. Necessary materials and equipment: pulse oximetry monitor, oximetry sensors,<br />
and alcohol wipes.<br />
Standards: Measured a patient's pulse oxygen saturation.<br />
Performance Steps<br />
1. Select a sensor appropriate to the patient's size.<br />
2. Select the appropriate sensor location.<br />
a. For adults, adhesive sensors and finger tip sensors can be placed on the index,<br />
middle, or ring finger.<br />
b. All adhesive sensors can be placed on the toe unless the patient has decreased<br />
circulation to the lower extremities.<br />
c. Earlobe clip and neonate adhesive sensors for the foot are available for infants and<br />
newborns.<br />
3. Wipe the site with alcohol to ensure the site is clean and dry.<br />
NOTE: Remove any fingernail polish or acrylic nails on the finger to be used, if applicable.<br />
4. Place the sensor so that the emitting light is directly opposite to the detector.<br />
5. Attach the sensor cable to the machine and turn it on.<br />
6. Notify the MD or PA if the digital readout is below the prescribed parameters.<br />
NOTE: Usually, the goal is to maintain the patient's oxygen saturation at 95% or better.<br />
7. Document the oximeter reading, the location of the device, and the amount of oxygen being<br />
delivered (if applicable).<br />
8. Take appropriate measures for continuous monitoring, if applicable.<br />
a. Ensure the alarms are on before leaving the patient.<br />
NOTE: Monitors come with preset limits. These limits can be changed per physician's order.<br />
b. Move clip sensors every 2 hours. Move adhesive sensors every 4 hours.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected the appropriate size of sensor. —— ——<br />
2. Selected the appropriate sensor location. —— ——<br />
3. Cleaned and dried the site. —— ——<br />
4. Applied the sensor. —— ——<br />
5. Attached the sensor cable to the monitor and turned it on. —— ——<br />
6. Notified the MD or PA of abnormal readings. —— ——<br />
3-12
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
7. Documented the oximeter reading, the location of the device, and the<br />
amount of oxygen being delivered.<br />
—— ——<br />
8. Performed measures for continuous monitoring. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-13
STP 8-91W15-SM-TG<br />
Subject Area 2: Emergency Medical Treatment<br />
OPEN THE AIRWAY<br />
081-831-0018<br />
Conditions: You are evaluating a casualty who is not breathing. You are not in an NBC<br />
environment.<br />
Standards: Completed all of the steps required to open the casualty's airway without causing<br />
unnecessary injury.<br />
Performance Steps<br />
1. Roll the casualty onto his or her back if necessary.<br />
a. Kneel beside the casualty.<br />
b. Raise the near arm and straighten it out above the head.<br />
c. Adjust the legs so that they are together and straight or nearly straight.<br />
d. Place one hand on the back of the casualty's head and neck.<br />
e. Grasp the casualty under the arm with the free hand.<br />
f. Pull steadily and evenly toward yourself, keeping the head and neck in line with the<br />
torso.<br />
g. Roll the casualty as a single unit.<br />
h. Place the casualty's arms at his or her sides.<br />
2. Establish the airway using the head-tilt/chin-lift or jaw thrust method.<br />
a. Head-tilt/chin-lift method.<br />
CAUTION: Do not use this method if a spinal or neck injury is suspected.<br />
NOTE: Remove any foreign material or vomitus seen in the mouth as quickly as possible.<br />
(1) Kneel at the level of the casualty's shoulders.<br />
(2) Place one hand on the casualty's forehead and apply firm, backward pressure<br />
with the palm of the hand to tilt the head back.<br />
(3) Place the fingertips of the other hand under the boney part of the casualty's lower<br />
jaw, bringing the chin forward.<br />
CAUTIONS: 1. Do not use the thumb to lift the lower jaw. 2. Do not press deeply into the soft<br />
tissue under the chin with the fingers. 3. Do not completely close the casualty's mouth.<br />
b. Jaw thrust.<br />
CAUTION: Use this method if a spinal or neck injury is suspected.<br />
(1) Kneel at the top of the casualty's head.<br />
(2) Rest the elbows on the surface on which the casualty is lying.<br />
(3) Place one hand on each side of the casualty's lower jaw at the angle of the jaw,<br />
below the ears.<br />
(4) Stabilize the casualty's head with your forearms.<br />
(5) Use index fingers to push the angles of the patient's lower jaw forward.<br />
(6) Use thumb to keep the casualty's mouth open, if necessary.<br />
CAUTION: Do not tilt or rotate the casualty's head.<br />
3. Check for breathing within 3 to 5 seconds. While maintaining the open airway position,<br />
place an ear over the casualty's mouth and nose, looking toward the chest and stomach.<br />
a. Look for the chest to rise and fall.<br />
b. Listen for air escaping during exhalation.<br />
c. Feel for the flow of air on the side of your face.<br />
3-14
STP 8-91W15-SM-TG<br />
Performance Steps<br />
4. Take appropriate action.<br />
a. If the casualty resumes breathing, maintain the airway and place the casualty in the<br />
recovery position.<br />
(1) Roll the casualty as a single unit onto his or her side.<br />
(2) Place the hand of the upper arm under his or her chin.<br />
(3) Flex the upper leg.<br />
NOTE: Check the casualty for other injuries, if necessary.<br />
b. If the casualty does not resume breathing, perform rescue breathing. (See task 081-<br />
831-0048.)<br />
Evaluation Preparation:<br />
Setup: Place a CPR mannequin or another soldier acting as the casualty face down on the<br />
ground. For training and evaluation, you may specify to the soldier whether the casualty has a<br />
spinal injury to test step 2, or you may create a scenario in which the casualty's condition will<br />
dictate to the soldier how to treat the casualty. After step 3 tell the soldier whether the casualty<br />
is breathing or not and ask what should be done.<br />
Brief soldier: Tell the soldier to open the casualty's airway.<br />
Performance Measures GO NO<br />
GO<br />
1. Rolled the casualty onto his or her back, if necessary. —— ——<br />
2. Established the airway using the head-tilt/chin-lift or jaw thrust method. —— ——<br />
3. Checked for breathing within 3 to 5 seconds. —— ——<br />
4. Took appropriate action. —— ——<br />
5. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-15
STP 8-91W15-SM-TG<br />
CLEAR AN UPPER AIRWAY OBSTRUCTION<br />
081-831-0019<br />
Conditions: You are evaluating a casualty who is not breathing or is having difficulty breathing,<br />
and you suspect the presence of an upper airway obstruction.<br />
Standards: Completed, in order, all the steps necessary to clear an object from a casualty's<br />
upper airway. Continued the procedure until the casualty could talk and breathe normally or<br />
until relieved by a qualified person.<br />
Performance Steps<br />
1. Clear the airway.<br />
a. Conscious casualty.<br />
(1) Determine whether or not the casualty needs help. Ask the casualty whether he<br />
or she is choking.<br />
(a) If the casualty has good air exchange (is able to speak, coughs forcefully, or<br />
wheezes between coughs), do not interfere except to encourage the casualty.<br />
(b) If the casualty has poor air exchange (weak, ineffective cough; high-pitched<br />
noise while inhaling; increased respiratory difficulty; and possible cyanosis),<br />
continue with step 1a(2).<br />
(c) If the casualty has a complete airway obstruction (is unable to speak,<br />
breathe, or cough and may clutch the neck between the thumb and fingers),<br />
continue with step 1a(2).<br />
(2) If the casualty is lying down, bring him or her to a sitting or standing position.<br />
(3) Apply abdominal or chest thrusts.<br />
NOTE: Use abdominal thrusts unless the casualty is in the advanced stages of pregnancy, is<br />
very obese, or has a significant abdominal wound.<br />
(a) Abdominal thrusts.<br />
1) Stand behind the casualty and wrap your arms around his or her waist.<br />
2) Make a fist with one hand and place the thumb side of the fist against the<br />
casualty's abdomen in the midline slightly above the navel and well below the<br />
tip of the xiphoid process.<br />
3) Grasp the fist with your other hand and press the fist into the casualty's<br />
abdomen with quick backward and upward thrusts.<br />
4) Continue giving thrusts until the blockage is expelled or the casualty<br />
becomes unconscious.<br />
NOTE: Make each thrust a separate, distinct movement given with the intent of relieving the<br />
obstruction.<br />
(b) Chest thrusts.<br />
1) Stand behind the casualty and encircle his or her chest with your arms just<br />
under the armpits.<br />
2) Make a fist with one hand and place the thumb side of the fist against the<br />
middle of the casualty's breastbone.<br />
3) Grasp the fist with your other hand and give backward thrusts.<br />
4) Continue giving thrusts until the blockage is expelled or the casualty<br />
becomes unconscious.<br />
3-16
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Do not position the hand on the xiphoid process or the lower margins on the rib<br />
cage.<br />
NOTES: 1. Administer each thrust with the intent of relieving the obstruction. 2. If the casualty<br />
becomes unconscious, position the casualty on his or her back, perform a finger sweep (see<br />
step 1b(2)), open the airway (see task 081-831-0018), and then start rescue breathing<br />
procedures (see task 081-831-0048).<br />
b. Unconscious casualty.<br />
NOTE: Perform abdominal or chest thrusts on the unconscious casualty only after attempts to<br />
open the airway and ventilate the casualty indicate that the airway is obstructed.<br />
(1) Apply abdominal or chest thrusts.<br />
NOTE: Use abdominal thrusts unless the casualty is in the advanced stages of pregnancy, is<br />
very obese, or has a significant abdominal wound.<br />
(a) Abdominal thrusts.<br />
1) Kneel astride the casualty's thighs.<br />
2) Place the heel of one hand against the casualty's abdomen in the midline<br />
slightly above the navel and well below the tip of the xiphoid process.<br />
3) Place the other hand directly on top of the first.<br />
4) Press into the abdomen with quick upward thrusts up to five times.<br />
(b) Chest thrusts.<br />
1) Kneel close to either side of the casualty's body.<br />
2) With the middle and index fingers of the hand nearest the casualty's legs,<br />
locate the lower margin of the casualty's rib cage on the side nearest you.<br />
3) Move the fingers up the rib cage to the notch where the ribs meet the<br />
sternum in the center of the lower part of the chest.<br />
4) With the middle finger on this notch, place the index finger next to it on the<br />
lower end of the sternum.<br />
5) Place the heel of the other hand on the lower half of the sternum next to<br />
the index finger of the first hand.<br />
6) Remove the first hand from the notch and place it on top of the hand on<br />
the sternum so that the hands are parallel to each other.<br />
NOTE: You may either extend or interlace your fingers but keep the fingers<br />
off the casualty's chest.<br />
7) Lock your elbows into position, straighten your arms, and position your<br />
shoulders directly over your hands.<br />
8) Press straight down depressing the sternum 1.5 to 2 inches and then<br />
release the pressure completely without lifting the hands from the chest.<br />
9) Repeat the chest thrust up to five times.<br />
NOTE: Make each thrust a separate, distinct movement given with the intent of relieving the<br />
obstruction.<br />
(2) Perform a finger sweep.<br />
(a) Open the casualty's mouth by grasping both the tongue and lower jaw with<br />
your thumb and fingers and lifting.<br />
(b) Insert the index finger of your other hand down along the inside of the cheek<br />
and deeply into the throat to the base of the tongue.<br />
(c) Use a hooking motion to attempt to dislodge the foreign body and maneuver<br />
it into the mouth for removal.<br />
CAUTION: Do not force the object deeper into the airway.<br />
(3) Attempt to ventilate. If the airway is still not clear, repeat the sequence of thrusts,<br />
finger sweep, and attempt to ventilate until the airway is cleared or you are<br />
relieved by qualified personnel.<br />
3-17
STP 8-91W15-SM-TG<br />
Performance Steps<br />
2. When the object is dislodged, check for breathing. Perform rescue breathing, if necessary<br />
(see task 081-831-0048) or continue to evaluate the casualty for other injuries.<br />
Evaluation Preparation:<br />
NOTE: Only the procedure for clearing an airway obstruction in a conscious casualty will be<br />
evaluated. The procedure for an unconscious casualty can be evaluated as a part of task 081-<br />
831-0048.<br />
Setup: You will need another soldier to play the part of the casualty.<br />
Brief soldier: Describe the symptoms of a casualty with good air exchange, poor air exchange,<br />
or a complete airway obstruction. Ask the soldier what should be done and score step 1 based<br />
on the answer. Then, tell the soldier to clear an upper airway obstruction. Tell the soldier to<br />
demonstrate how to position the casualty, where to stand, and how to position his or her hands<br />
for the thrusts. The soldier must tell you how they should be done and how many thrusts should<br />
be performed. Ensure that the soldier understands that he or she must not actually perform the<br />
thrusts. After completion of step 5, ask the soldier what must be done if the casualty becomes<br />
unconscious.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined whether the casualty needs help. —— ——<br />
2. Moved the casualty to a sitting or standing position, if necessary. —— ——<br />
3. Stood behind the casualty. —— ——<br />
4. Positioned arms and hands properly to perform the thrusts. —— ——<br />
5. Stated how to perform the thrusts and how many should be performed. —— ——<br />
6. Stated that the following actions would be taken if the casualty becomes<br />
unconscious.<br />
a. Reposition the casualty.<br />
b. Perform a finger sweep.<br />
c. Open the airway.<br />
d. Perform rescue breathing procedures.<br />
—— ——<br />
7. Completed all necessary steps in order. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-18
STP 8-91W15-SM-TG<br />
ADMINISTER EXTERNAL CHEST COMPRESSIONS<br />
081-831-0046<br />
Conditions: You are treating a casualty who is not breathing and has no pulse. The airway is<br />
open and is clear. Another soldier who is CPR qualified may be available to assist or may arrive<br />
while you are performing one-rescuer CPR. You are not in an NBC environment.<br />
Standards: Continued CPR until the pulse was restored or until the rescuer(s) were relieved by<br />
other qualified persons, stopped by a physician, or too tired to continue.<br />
Performance Steps<br />
Perform one-rescuer CPR.<br />
1. Ensure that the casualty is positioned on a hard, flat surface.<br />
2. Position the hands for external chest compressions.<br />
a. With the middle and index fingers of the hand nearest the casualty's feet, locate the<br />
lower margin of the casualty's rib cage on the side near the rescuer.<br />
b. Move the fingers up the rib cage to the notch where the ribs meet the sternum in the<br />
center of the lower part of the chest.<br />
c. With the middle finger on the notch, place the index finger next to it on the lower end of<br />
the sternum.<br />
d. Place the heel of the other hand on the lower half of the sternum, next to the index<br />
finger of the first hand.<br />
e. Remove the first hand from the notch and place it on top of the hand on the sternum<br />
so that both hands are parallel to each other.<br />
NOTE: You may either extend or interlace your fingers but keep the fingers off the casualty's<br />
chest.<br />
3. Position your body.<br />
a. Lock your elbows with the arms straight.<br />
b. Position your shoulders directly over your hands.<br />
4. Give 15 compressions.<br />
a. Press straight down to depress the sternum 1.5 to 2 inches.<br />
b. Come straight up and completely release pressure on the sternum to allow the chest to<br />
return to its normal position. The time allowed for release should equal the time<br />
required for compression.<br />
CAUTION: Do not remove the heel of your hand from the casualty's chest or reposition your<br />
hand between compressions.<br />
c. Give 15 compressions in 9 to 11 seconds (at a rate of 100 per minute).<br />
5. Give two full breaths.<br />
a. Move quickly to the casualty's head and lean over.<br />
b. Open the casualty's airway. (See task 081-831-0018.)<br />
c. Give two full breaths (1.5 to 2 seconds each).<br />
6. Repeat steps 2 through 5 four times.<br />
7. Assess the casualty.<br />
a. Check for the return of the carotid pulse for 3 to 5 seconds.<br />
(1) If the pulse is present, continue with step 7b.<br />
(2) If the pulse is absent, continue with step 8.<br />
3-19
STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Check breathing for 3 to 5 seconds.<br />
(1) If breathing is present, monitor breathing and pulse closely.<br />
(2) If breathing is absent, perform rescue breathing only. (See task 081-831-0048.)<br />
8. Resume CPR with compressions.<br />
9. Recheck for pulse every 3 to 5 minutes.<br />
10. Continue to alternate chest compressions and rescue breathing until--<br />
a. The casualty is revived.<br />
b. You are too tired to continue.<br />
c. You are relieved by competent person(s).<br />
d. The casualty is pronounced dead by an authorized person.<br />
e. A second rescuer states, "I know CPR," and joins you in performing two-rescuer CPR.<br />
NOTE: A qualified second rescuer joins the first rescuer at the end of a cycle after a check for<br />
pulse by the first rescuer. The new cycle starts with one ventilation by the first rescuer, and the<br />
second rescuer becomes the compressor. Two-rescuer CPR is then initiated.<br />
11. Perform two-rescuer CPR, if applicable.<br />
a. Compressor: Give 15 chest compressions at the rate of 100 per minute.<br />
Ventilator: Maintain an open airway and monitor the carotid pulse occasionally for<br />
adequacy of chest compressions.<br />
b. Compressor: Pause.<br />
Ventilator: Give two full breaths (over 2 seconds).<br />
c. Compressor: Continue to give chest compressions until a change in positions is<br />
initiated.<br />
Ventilator: Continue to give ventilations until the compressor indicates that a change is<br />
to be made.<br />
d. Compressor: Give a clear signal to change positions.<br />
Ventilator: Remain in the rescue breathing position.<br />
e. Compressor: Give the 15th compression.<br />
Ventilator: Give two breaths following the 15th compression.<br />
f. Compressor and ventilator simultaneously switch positions.<br />
g. New Ventilator: Check the casualty's carotid pulse for 5 seconds.<br />
* If present state, "There is a pulse," and perform rescue breathing.<br />
* If not present state, "No pulse." Tell the new compressor to give chest<br />
compressions.<br />
New compressor: Position the hands to begin chest compressions as directed by the<br />
ventilator.<br />
h. Ventilator: Continue to give two breaths on each 15th upstroke of chest compressions<br />
and ensure that the chest rises.<br />
Compressor: Continue to give chest compressions at the rate of 100 per minute.<br />
NOTE: If signs of gastric distension are noted, do the following: 1. Recheck and reposition the<br />
airway. 2. Watch for the rise and fall of the chest. 3. Ventilate the casualty only enough to<br />
cause the chest to rise.<br />
CAUTIONS: 1. Do not push on the abdomen. 2. If the casualty vomits, turn the casualty on<br />
the side, clear the airway, and then continue CPR.<br />
NOTE: If the patient is intubated, the ratio of breaths to compressions becomes asynchronous.<br />
Give 100 compressions per minute with a ventilation rate of approximately 10 to 12 per minute.<br />
12. Continue to perform CPR as stated in the task standard.<br />
3-20
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: The rescuer doing rescue breathing should recheck the carotid pulse every 3 to 5<br />
minutes.<br />
13. When the pulse and breathing are restored, continue to evaluate the casualty. If the<br />
casualty's condition permits, place him or her in the recovery position. (See task 081-831-<br />
0018.)<br />
CAUTION: During evacuation, CPR or rescue breathing should be continued en route if<br />
necessary. When pulse and breathing are restored, the casualty should be watched closely.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation a CPR mannequin must be used. Place the mannequin face<br />
up on the floor. One-rescuer CPR, two-rescuer CPR, or a combination of both (see NOTE after<br />
step 10e) can be evaluated. If two soldiers are involved, they will be designated as "rescuer #1"<br />
and "rescuer #2." Rescuer #1 will start in the chest compression position and will be the only<br />
one scored during performance of the task. The evaluator will ensure that all aspects of the<br />
task are evaluated by indicating whether pulse is present and when the rescuers should change<br />
positions.<br />
Brief soldier: If two soldiers are involved, tell them about their roles as rescuer #1 and #2. Ask<br />
rescuer #1 on what kind of surface the casualty should be positioned. Then, tell the soldier(s) to<br />
perform one-rescuer or two-rescuer CPR, as appropriate.<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the casualty on a hard flat surface. —— ——<br />
2. Properly positioned the hands during chest compressions. —— ——<br />
3. Administered the correct number of chest compressions. —— ——<br />
4. Gave the chest compressions at the rate of 80 to 100 per minute. —— ——<br />
5. Administered the correct number of breaths. —— ——<br />
6. Gave the breaths at the correct rate. —— ——<br />
7. Checked the carotid pulse for about 5 seconds approximately 1 minute<br />
after starting CPR.<br />
—— ——<br />
8. Rechecked the carotid pulse every 3 to 5 minutes. —— ——<br />
9. Performed the transition to two-rescuer CPR correctly, if applicable. —— ——<br />
10. Changed positions during two-rescuer CPR correctly, if applicable. —— ——<br />
11. Continued CPR as stated in the task standard. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
3-21
STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-22
STP 8-91W15-SM-TG<br />
PERFORM RESCUE BREATHING<br />
081-831-0048<br />
Conditions: You are treating a casualty who is unconscious and is not breathing. You are not<br />
in an NBC environment.<br />
Standards: Completed, in order, all the steps necessary to restore breathing. Continued the<br />
procedure until the casualty started to breathe or until relieved by another qualified person,<br />
stopped by a physician, required to perform CPR, or too exhausted to continue.<br />
Performance Steps<br />
1. Position yourself at the casualty's head.<br />
2. Open the airway (see task 081-831-0018).<br />
a. Head-tilt/chin-lift when no trauma is suspected.<br />
b. Jaw thrust when trauma is suspected.<br />
3. Ventilate the casualty using the mouth-to-mouth, mouth-to-nose, mouth-to-mask, bagvalve-mask,<br />
or flow-restricted oxygen-powered ventilation device (FROPVD or demandvalve),<br />
as appropriate.<br />
a. Mouth-to-mouth method.<br />
(1) Maintain the chin-lift while pinching the nostrils closed using the thumb and index<br />
fingers of the hand on the casualty's forehead.<br />
(2) Take a deep breath and make an airtight seal around the casualty's mouth with<br />
your mouth.<br />
(3) Blow one full breath (1.5 to 2 seconds) into the casualty's mouth, watching for the<br />
chest to rise and fall and listening and feeling for air to escape during exhalation.<br />
(4) If the chest rises and air escapes--<br />
(a) Give a second full breath.<br />
(b) Go to step 6.<br />
(5) If the chest does not rise or air does not escape, go to step 4.<br />
b. Mouth-to-nose method.<br />
NOTE: The mouth-to-nose method is recommended when you cannot open the casualty's<br />
mouth, there are jaw or mouth injuries, or you cannot maintain a tight seal around the casualty's<br />
mouth.<br />
(1) Maintain the head-tilt with the hand on the forehead while using the other hand to<br />
lift the casualty's jaw and close the mouth.<br />
(2) Take a deep breath and make an airtight seal around the casualty's nose with<br />
your mouth.<br />
(3) Blow one full breath (1.5 to 2 seconds) into the casualty's nose while watching for<br />
the chest to rise and fall and listening and feeling for air to escape during<br />
exhalation.<br />
NOTE: It may be necessary to open the casualty's mouth or separate the lips to allow air to<br />
escape.<br />
(4) If the chest rises--<br />
(a) Give a second full breath.<br />
(b) Go to step 6.<br />
(5) If the chest does not rise, go to step 4.<br />
c. Mouth-to-mask.<br />
3-23
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: The face mask is an important part of infection control to the rescuer. Rescuer breaths<br />
are delivered to the casualty through the one-way valve of the mask. There is no direct contact<br />
with the casualty's mouth.<br />
(1) Insert an airway adjunct as necessary (see tasks 081-831-0016 and 081-833-<br />
0142).<br />
(2) Place the mask on the casualty.<br />
(a) Position the apex of the mask on the bridge of the nose.<br />
(b) Place the base of the mask at the chin between the lower lip and the chin<br />
prominence.<br />
(3) Create a seal while maintaining the airway.<br />
(a) Place your thumbs over the top half of mask.<br />
(b) Place your index and middle fingers over the bottom half of the mask.<br />
(c) Use your fourth and fifth fingers to bring the jaw toward the mask.<br />
(4) Take a deep breath and exhale into the mask.<br />
NOTES: 1. Remove your mouth from the valve to allow for exhalation. 2. Some masks have<br />
oxygen inlets. Providing supplemental oxygen significantly increases the concentration of<br />
oxygen delivered to the patient. Oxygen concentrations can reach 50% when the flow is set to<br />
15 LPM.<br />
(a) If the breath goes in, give a second breath and go to step 6.<br />
(b) If the breath fails to go in, go to step 4.<br />
d. Bag-valve-mask (BVM).<br />
NOTE: Supplemental oxygen can be given while using the BVM to increase oxygen<br />
concentration levels to 50%. When BVM systems have a reservoir supply, oxygen<br />
concentrations can reach almost 100%.<br />
(1) Insert an airway adjunct as needed.<br />
(2) Select the proper size of mask.<br />
(3) Position the mask on the casualty's face.<br />
(4) Form a "C" around the ventilation port. Use the third, fourth, and fifth fingers<br />
under the casualty's jaw to hold the mask in place.<br />
NOTE: The most difficult part of performing rescue breathing using a BVM is maintaining an<br />
adequate seal. The American Heart Association recommends two rescuer BVM ventilation. In<br />
this method, one rescuer maintains a two-hand seal while the other rescuer squeezes the bag.<br />
(5) Squeeze the bag.<br />
(6) Release pressure from the bag and allow the patient to exhale passively.<br />
(a) If the chest rises and air goes in, squeeze the bag again to give a second<br />
breath and then go to step 6.<br />
(b) If the chest fails to rise, go to step 4.<br />
e. Flow-restricted oxygen-powered ventilation device.<br />
CAUTION: Use caution when using the FROPVD on patients with chest injuries. Be careful not<br />
to force excess air into the stomach instead of the lungs. This may cause gastric distention and<br />
vomiting. Do not use on children.<br />
(1) Follow the same steps to position and seal the mask as with the BVM.<br />
(2) Push the trigger on the device once.<br />
(a) If the chest rises, push the button again and proceed to step 6<br />
(b) If the chest fails to rise, go to step 4.<br />
4. Reposition the head to ensure an open airway and attempt the breath again.<br />
NOTE: When using a BVM or FROPVD, it is also important to check the mask seal.<br />
a. If the chest rises, give another breath and go to step 6.<br />
b. If the chest does not rise, continue with step 5.<br />
3-24
STP 8-91W15-SM-TG<br />
Performance Steps<br />
5. Clear an airway obstruction, if necessary (see task 081-831-0019). When the obstruction<br />
has been cleared, continue with step 6.<br />
6. Check the carotid pulse for 5 to 10 seconds.<br />
a. While maintaining the airway, place the index and middle fingers of your hand on the<br />
casualty's throat.<br />
b. Slide the fingers into the groove beside the casualty's Adam's apple and feel for a<br />
pulse for 5 to 10 seconds.<br />
c. If a pulse is present, go to step 7.<br />
d. If a pulse is not found, begin CPR (see task 081-831-0046).<br />
7. Continue rescue breathing.<br />
a. Ventilate the casualty at the appropriate rate.<br />
(1) Adult - 10-12 per minute.<br />
(2) Adolescent - 15 per minute.<br />
(3) Children greater than a year of age - 20 per minute (mouth-to-mouth or mouth-tonose).<br />
(4) Children less than one year of age - 40 per minute (mouth-to-nose).<br />
b. Watch for rising and falling of the chest.<br />
c. Recheck for pulse and breathing after every 12 breaths.<br />
NOTE: Although not evaluated, continue rescue breathing as stated in the task standard.<br />
When breathing is restored, watch the casualty closely, maintain an open airway, and check for<br />
other injuries. If the casualty's condition permits, place him or her in the recovery position. (See<br />
task 081-831-0018.)<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, a CPR mannequin must be used. Position the mannequin<br />
on its back. To test step 3, you may specify to the soldier whether to use the mouth-to-mouth or<br />
mouth-to-nose method, or you may create a scenario in which the casualty's condition dictates<br />
which method is to be used. You may determine how much of the task is tested by telling the<br />
soldier whether the airway is clear or a pulse is found as the soldier proceeds through the task.<br />
However, you should ensure that the soldier is routed through the task far enough to continue<br />
rescue breathing after checking the carotid pulse.<br />
Brief soldier: Tell the soldier to perform rescue breathing.<br />
Performance Measures GO NO<br />
GO<br />
1. Opened the airway —— ——<br />
2. Ventilated the casualty using the mouth-to-mouth, mouth-to-nose, mouthto-mask,<br />
BVM, or FROPVD method, as appropriate.<br />
3. Repositioned the head to ensure an open airway and repeated ventilation<br />
attempt, if necessary.<br />
—— ——<br />
—— ——<br />
4. Cleared an airway obstruction, if necessary. —— ——<br />
5. Checked the carotid pulse for 5 to 10 seconds. —— ——<br />
3-25
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
6. Continued rescue breathing. —— ——<br />
7. Completed all necessary steps in order. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-26
STP 8-91W15-SM-TG<br />
CONTROL BLEEDING<br />
081-833-0161<br />
Conditions: You have encountered a casualty who is bleeding externally and may also be<br />
bleeding internally. Body substance isolation precautions have been taken, as appropriate.<br />
Necessary materials: field dressings, cravats, gauze pads, gauze roller bandage, and materials<br />
for a tourniquet.<br />
Standards: Controlled bleeding without further harming the casualty.<br />
Performance Steps<br />
1. Determine if the bleeding is external or internal.<br />
a. External bleeding (go to step 2).<br />
b. Internal bleeding (see tasks 081-833-0047, 081-833-0062, 081-833-0064, and 081-<br />
833-0154).<br />
(1) Large bruises on the trunk or abdomen indicating injury to underlying organs.<br />
(2) Painful, swollen or deformed extremities indicating underlying fractures.<br />
(3) Rigid and/or tender abdomen.<br />
(4) Bleeding from the mouth, rectum, or other body orifice.<br />
(5) Vomiting bright red or dark (like coffee grounds) blood.<br />
(6) Bloody stool that is dark and tarry or bright red.<br />
2. Apply direct pressure to the wound with a gauze pad or field dressing.<br />
NOTE: If bleeding is profuse, apply direct pressure to the wound with your gloved hand. Do not<br />
waste time looking for a dressing.<br />
3. Elevate the affected extremity above the level of the heart.<br />
CAUTION: Do not elevate if there are suspected musculoskeletal injuries, impaled objects in<br />
the extremity, or spinal injury.<br />
4. Apply additional dressings if the wound continues to bleed.<br />
CAUTIONS: 1. Never remove a dressing once it has been applied to a wound. Removing the<br />
dressing may destroy any clotting that has begun, thus causing further injury to the site. In<br />
some cases, leaving the blood soaked dressing in place allows more bleeding. In this instance,<br />
remove the dressing and redress once to be sure direct pressure is being placed on the wound.<br />
2. Once bleeding has been controlled it is important to check a distal pulse to make sure that<br />
the dressing has not been applied too tightly. If a pulse is not palpable, adjust the dressing to<br />
reestablish circulation.<br />
NOTE: If using gauze pads or similar material to dress a wound, bandage the dressing in place.<br />
5. Locate and apply pressure to the appropriate arterial pressure point, if the wound continues<br />
to bleed.<br />
NOTE: Pressure points may not be effective if the wound is at the distal end of the limb. Blood<br />
is being sent to these areas from many smaller arteries.<br />
a. Brachial artery--used to control bleeding from the distal end of an upper extremity.<br />
(1) Hold the casualty's arm out at a right angle to his or her body with the palm facing<br />
up.<br />
NOTE: Do not use force to raise the arm if the movement causes pain.<br />
(2) Locate the groove between the humerus and the biceps muscle.<br />
(3) Hold the upper arm in the palm of your hand with your fingers positioned in the<br />
medial groove.<br />
3-27
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) Press your fingers into the groove to compress the artery against the underlying<br />
bone.<br />
NOTE: If pressure is applied properly, the radial pulse will not be palpable.<br />
b. Femoral artery--used to control bleeding of a lower extremity.<br />
(1) Locate the femoral artery on the medial side of the anterior thigh, just below the<br />
groin.<br />
(2) Place the heel of your hand over the site and apply pressure toward the bone.<br />
NOTE: More pressure is needed to compress the femoral artery than the brachial artery due to<br />
the amount of tissue and muscle in the thigh. Greater force is needed for obese and muscular<br />
individuals. If pressure is applied properly, a distal pulse will not be palpable.<br />
6. Consider other conjunctive therapies to slow bleeding if necessary.<br />
a. Splinting (see task 081-831-0044).<br />
NOTE: Airsplints are effective in controlling venous and capillary bleeding. They are not<br />
usually effective in high pressure arterial bleeds. Airsplints are effective, however, in<br />
maintaining pressure once other manual methods, such as pressure dressings, have been<br />
applied.<br />
b. Cold application.<br />
NOTE: Cold minimizes swelling and constricts blood vessels.<br />
CAUTION: Never apply icepacks directly to the skin. Always wrap cold packs in cloth before<br />
applying to the skin. Do not apply ice for more than 20 minutes at a time.<br />
c. Pneumatic anti-shock garments (PASG) (see task 081-833-3011).<br />
NOTE: Though controversial, PASG can be useful in controlling bleeding to lower extremities.<br />
Refer to local SOP for guidance on application.<br />
CAUTION: Never inflate only the abdominal section. PASG are contraindicated in chest<br />
injuries.<br />
7. Apply a tourniquet if the wound continues to bleed. See task 081-833-0047.<br />
CAUTION: A tourniquet is a last resort for life-threatening injuries. Tourniquets cut off blood<br />
flow to and from the extremity and are likely to cause permanent damage to vessels, nerves,<br />
and muscles. Never loosen or remove the tourniquet after it has been applied.<br />
NOTE: A blood pressure cuff can provide a temporary tourniquet to control bleeding until a<br />
pressure dressing is applied. Place the cuff above the wound and inflate it to 150 mm Hg.<br />
Deflate the cuff slowly once a bandage has been applied.<br />
8. Initiate treatment for shock as needed (see task 081-833-0047).<br />
9. Assess the need for evacuation.<br />
10. If the source of bleeding was due to a traumatic amputation--<br />
a. Wrap the amputated part in a sterile dressing.<br />
b. Wrap or bag the amputated part in plastic.<br />
c. Label the bag or plastic.<br />
d. Transport the amputated part in a cool container with the patient.<br />
CAUTION: Do not place the amputated part directly on ice. Do not submerge it directly in<br />
water. Do not allow the part to freeze.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined the type of bleeding (internal or external). —— ——<br />
3-28
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
2. Performed measures to control external bleeding. —— ——<br />
a. Applied direct pressure to the wound.<br />
b. Elevated the extremity.<br />
c. Applied additional dressings to the wound, if needed.<br />
d. Located and applied pressure to the appropriate arterial pressure<br />
point, if needed.<br />
e. Applied a tourniquet, if needed.<br />
3. Initiated treatment for shock. —— ——<br />
4. Assessed the need for transport. —— ——<br />
5. Performed measures for continuous monitoring. —— ——<br />
6. Caused no further injury. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-29
STP 8-91W15-SM-TG<br />
PLACE A PATIENT ON A CARDIAC MONITOR<br />
081-833-0167<br />
Conditions: You have a conscious patient requiring continuous cardiac monitoring. Necessary<br />
equipment and materials: cardiac monitor, leads, and electrodes.<br />
Standards: Correctly connected the patient to the monitor.<br />
Performance Steps<br />
1. Identify the patient.<br />
a. Have the patient state his or her name.<br />
b. Check the patient's arm band, if one is available.<br />
c. Explain the procedure to the patient.<br />
2. Prepare the equipment.<br />
a. Turn the power switch to the on position. Make sure the cord is connected to a power<br />
source.<br />
b. Attach the lead cable to the monitor and observe for flat line on the monitor.<br />
c. Check for the presence of recording paper and replace it as needed.<br />
d. Turn the lead selection knob to the Lead II position, if so equipped.<br />
3. Attach the patient to the monitor.<br />
a. Place an electrode on the right anterior superior chest just inferior to the clavicle (right<br />
arm lead).<br />
b. Place a second electrode on the left anterior superior chest just inferior to the clavicle<br />
(left arm lead).<br />
c. Place a third electrode on the left lateral aspect of the abdomen (this electrode may<br />
also be placed on the left upper leg).<br />
d. Attach the cable from the monitor to the corresponding electrodes.<br />
e. Observe the monitor and note the type of pattern.<br />
f. Set the monitoring and alarm parameters IAW with local SOP.<br />
4. Document the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the patient. —— ——<br />
2. Prepared the equipment. —— ——<br />
3. Attached the patient to the monitor. —— ——<br />
4. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
3-30
STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-31
STP 8-91W15-SM-TG<br />
MANAGE CARDIAC ARREST USING AED<br />
081-833-3027<br />
Conditions: You and an assistant arrive at a scene where an adult patient is in ventricular<br />
fibrillation or pulseless ventricular tachycardia and is receiving basic cardiac life support from a<br />
rescuer. You have already taken the necessary body substance isolation. Necessary materials<br />
and equipment: automatic external defibrillator (AED), oropharyngeal airway, bag-valve-mask,<br />
nonrebreather mask, and oxygen tank set up.<br />
Standards: Completed all the steps necessary to perform cardiac defibrillation with an<br />
automatic external defibrillator in order.<br />
Performance Steps<br />
1. Briefly question the rescuer about the arrest event.<br />
a. How long has the patient been in arrest?<br />
b. How long has CPR been in progress?<br />
c. Do you know two man CPR?<br />
2. Direct the rescuer to stop CPR.<br />
NOTE: Allow the rescuer to complete the current cycle.<br />
3. Determine whether the patient is a candidate for an AED.<br />
NOTE: If the patient has sustained trauma before collapse, do not attach the AED. Continue<br />
CPR and transport immediately.<br />
a. Unresponsive.<br />
b. Apneic.<br />
c. Pulseless.<br />
4. Direct the rescuer to resume CPR.<br />
5. Turn the automatic external defibrillator on.<br />
6. Attach the monitoring-defibrillation pads to the cables if the pads aren't attached.<br />
7. Attach the AED to the patient.<br />
a. Place the top right pad below the right mid-clavicular.<br />
b. Place the lower pad over the lower left ribs.<br />
8. Direct the rescuer to stop CPR.<br />
9. Ensure all individuals are standing clear of the patient.<br />
a. Give the order, "ALL CLEAR."<br />
b. Visually check to ensure that no one is in contact with the patient.<br />
c. Visually check to ensure no one is in direct contact with any electrically conductive<br />
material touching the patient, such as IV lines, monitor wires, or the bed frame.<br />
10. Initiate analysis of rhythm.<br />
a. Press the analysis button.<br />
b. Wait for the machine to analyze the rhythm.<br />
11. Press the button to deliver shock if advised by the defibrillator.<br />
3-32
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Do not defibrillate if anyone is touching the patient or the patient is wet (dry the<br />
patient), touching metal (move away from metal), or wearing a nitroglycerin patch (remove the<br />
patch with a gloved hand).<br />
a. If shock is indicated, proceed to step 12.<br />
b. If no shock is indicated--<br />
NOTE: The patient may be in asystole or pulseless electrical activity (PEA) which are not<br />
shockable rhythms.<br />
(1) Check the pulse.<br />
(2) If none, perform CPR for 1 minute.<br />
(3) Press the analyze button.<br />
(4) If no shock is indicated, repeat steps 11b(1)-(3).<br />
(5) If no shock is still indicated, check the pulse. If none, start CPR and transport.<br />
12. Repeat steps 9 through 11 until three shocks have been delivered.<br />
13. Check for pulse.<br />
14. If no pulse, direct the assistant and rescuer to resume CPR.<br />
15. Check the pulse during CPR to confirm effectiveness of CPR.<br />
16. Insert an airway adjunct (see task 081-833-0016).<br />
17. Ventilate the patient.<br />
18. After 1 minute of CPR, repeat steps 9 through 12.<br />
19. Check for pulse.<br />
a. If the patient has a pulse--<br />
(1) Check the patient's breathing.<br />
(a) If breathing is adequate, provide oxygen via nonrebreather mask.<br />
(b) If breathing is inadequate or absent, ventilate the patient using a bag-valvemask.<br />
(2) Transport.<br />
NOTE: If a resuscitated patient arrests during transport, repeat steps 9 through 18 until six<br />
shocks have been given or the patient regains a pulse.<br />
b. If the patient is pulseless--<br />
(1) Resume CPR.<br />
(2) Transport.<br />
20. Perform ongoing assessment.<br />
Performance Measures GO NO<br />
GO<br />
1. Questioned the rescuer about the arrest event. —— ——<br />
2. Directed the rescuer to stop CPR. —— ——<br />
3. Determined whether the patient was a candidate for an AED. —— ——<br />
4. Directed the rescuer to resume CPR. —— ——<br />
5. Turned the AED on. —— ——<br />
3-33
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
6. Attached the monitoring-defibrillation pads to the cables, if necessary. —— ——<br />
7. Attached the AED to the patient. —— ——<br />
8. Directed the rescuer to stop CPR. —— ——<br />
9. Ensured all individuals were standing clear of the patient. —— ——<br />
10. Initiated analysis of rhythm. —— ——<br />
11. Pressed the button to deliver shock if advised by the AED. —— ——<br />
12. Repeated steps 9 through 11 until three shocks were delivered. —— ——<br />
13. Checked for pulse. —— ——<br />
14. Directed the assistant and rescuer to resume CPR if no pulse was found. —— ——<br />
15. Checked the pulse during CPR to confirm effectiveness. —— ——<br />
16. Inserted an airway adjunct. —— ——<br />
17. Ventilated the patient. —— ——<br />
18. Repeated steps 9 through 12 after 1 minute of CPR. —— ——<br />
19. Checked for pulse. —— ——<br />
a. If the patient had a pulse, checked for breathing.<br />
(1) If the patient was breathing, provided oxygen via nonrebreather<br />
mask.<br />
(2) If breathing was inadequate or absent, ventilated the patient<br />
using a bag-valve-mask.<br />
b. If the patient was pulseless, resumed CPR.<br />
20. Performed ongoing assessment. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-34
STP 8-91W15-SM-TG<br />
Subject Area 3: Basic Medical Care<br />
PERFORM A PATIENT CARE H<strong>AND</strong>WASH<br />
081-831-0007<br />
Conditions: You are about to administer patient care or have just had hand contact with a<br />
patient or contaminated material. Necessary materials and equipment: running water or two<br />
empty basins, a canteen, a water source, soap, towels (cloth or paper), and a towel receptacle<br />
or trash can.<br />
Standards: Performed a patient care handwash without recontaminating the hands.<br />
Performance Steps<br />
1. Remove wristwatch and jewelry, if applicable.<br />
NOTE: Rings should not be worn. If rings are worn, they should be of simple design with few<br />
crevices for harboring bacteria. Fingernails should be clean, short, and free of nail polish.<br />
2. Roll shirt sleeves to above the elbows, if applicable.<br />
3. Prepare to perform the handwash.<br />
a. If using running water, turn on the warm water.<br />
b. If running water is not available, set up the basins and open the canteen.<br />
4. Wet your hands, wrists, and forearms.<br />
a. If using running water, hold your hands, wrists, and forearms under the running water.<br />
b. If running water is not available, fill one basin with enough water to cover your hands<br />
and refill the canteen.<br />
5. Cover your hands, wrists, and forearms with soap.<br />
NOTE: For routine patient care, use regular hand soap. For an invasive procedure such as a<br />
catheterization or an injection, use antimicrobial soap.<br />
6. Wash your hands, wrists, and forearms.<br />
a. Use a circular scrubbing motion, going from the fingertips toward the elbows for at<br />
least 15 seconds..<br />
b. Give particular attention to creases and folds in the skin.<br />
c. Wash ring(s) if present.<br />
7. Rinse your hands, wrists, and forearms.<br />
a. If using running water.<br />
(1) Hold your hands lower than the elbows under the running water until all soap is<br />
removed.<br />
(2) Do not touch any part of the sink or faucet.<br />
b. If not using running water.<br />
(1) Use a clean towel to grasp the canteen with one hand.<br />
(2) Rinse the other hand, wrist, and forearm, letting the water run into the empty<br />
basin. Hold your hands lower than the elbows.<br />
(3) Repeat the procedure for the other arm.<br />
(4) Do not touch any dirty surfaces while rinsing your hands.<br />
8. Dry your hands, wrists, and forearms.<br />
3-35
STP 8-91W15-SM-TG<br />
Performance Steps<br />
a. Use a towel to dry one arm from the fingertips to the elbow without retracing the path<br />
with the towel.<br />
b. Dispose of the towel properly without dropping your hand below waist level.<br />
c. Repeat the process for the other arm using another towel.<br />
9. Use a towel to turn off the running water, if applicable.<br />
10. Reinspect your fingernails and clean them and rewash your hands, if necessary.<br />
Evaluation Preparation:<br />
Setup: None<br />
Brief soldier: Tell the soldier to perform a patient care handwash. You may specify which<br />
method to use. The soldier need not perform both.<br />
Performance Measures GO NO<br />
GO<br />
1. Removed wristwatch and jewelry, if applicable. —— ——<br />
2. Rolled shirt sleeves to above the elbows, if applicable. —— ——<br />
3. Prepared to perform the handwash. —— ——<br />
4. Wet the hands, wrists, and forearms. —— ——<br />
5. Covered the hands, wrists, and forearms with soap. —— ——<br />
6. Washed the hands, wrists, and forearms. —— ——<br />
7. Rinsed the hands, wrists, and forearms. —— ——<br />
8. Dried the hands, wrists, and forearms. —— ——<br />
9. Used a towel to turn off the running water, if applicable. —— ——<br />
10. Reinspected the fingernails and cleaned them and rewashed the hands, if<br />
necessary.<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-36
STP 8-91W15-SM-TG<br />
PUT ON STERILE GLOVES<br />
081-831-0008<br />
Conditions: Necessary materials and equipment: handwashing facilities, sterile gloves, and a<br />
flat, clean, dry surface.<br />
Standards: Put on and removed sterile gloves without contaminating self or the gloves.<br />
Performance Steps<br />
1. Select and inspect the package.<br />
a. Select the proper size of glove.<br />
b. Inspect the package for possible contamination.<br />
(1) Water spots.<br />
(2) Moisture.<br />
(3) Tears.<br />
(4) Any other evidence that the package is not sterile.<br />
2. Perform a patient care handwash.<br />
3. Open the sterile package.<br />
a. Place the package on a flat, clean, dry surface in the area where the gloves are to be<br />
worn.<br />
b. Peel the outer wrapper open to completely expose the inner package.<br />
4. Position the inner package.<br />
a. Remove the inner package touching only the folded side of the wrapper.<br />
b. Position the package so that the cuff end is nearest you.<br />
5. Unfold the inner package.<br />
a. Grasp the lower corner of the package.<br />
b. Open the package to a fully flat position without touching the gloves.<br />
6. Expose both gloves.<br />
a. Grasp the lower corners or designated areas on the folder.<br />
b. Pull gently to the side without touching the gloves.<br />
7. Put on the first glove.<br />
a. Grasp the cuff at the folded edge and remove it from the wrapper.<br />
b. Step away from the table or tray.<br />
c. Keeping your hands above the waist, insert the fingers of the other hand into the glove.<br />
d. Pull the glove on touching only the exposed inner surface of the glove.<br />
NOTE: If there is difficulty in getting your fingers fully fitted into the glove fingers, make the<br />
adjustment after both gloves are on.<br />
8. Put on the second glove.<br />
a. Insert the fingertips of the gloved hand under the edge of the folded over cuff.<br />
NOTE: You may keep the gloved thumb up and away from the cuff area or may insert it under<br />
the edge of the folded over cuff with the fingertips.<br />
b. Keeping your hands above the waist, insert the fingers of the ungloved hand into the<br />
glove.<br />
c. Pull the glove on.<br />
d. Do not contaminate either glove.<br />
3-37
STP 8-91W15-SM-TG<br />
Performance Steps<br />
9. Adjust the gloves to fit properly.<br />
a. Grasp and pick up the glove surfaces on the individual fingers to adjust them.<br />
b. Pick up the palm surfaces and work your fingers and hands into the gloves.<br />
c. Interlock the gloved fingers and work the gloved hands until the gloves are firmly on<br />
the fingers.<br />
NOTE: If either glove tears while putting them on or adjusting the gloves, remove both gloves<br />
and repeat the procedure.<br />
10. Remove the gloves.<br />
a. Grasp one glove at the heel of the hand with the other gloved hand.<br />
b. Peel off the glove, retaining it in the palm of the gloved hand.<br />
c. Reach under the cuff of the remaining glove with one or two fingers of the ungloved<br />
hand.<br />
d. Peel off the glove over the glove being held in the palm.<br />
e. Do not contaminate yourself.<br />
CAUTION: Do not "snap" the gloves while removing them.<br />
11. Discard the gloves IAW local SOP.<br />
12. Perform a patient care handwash.<br />
Evaluation Preparation:<br />
Setup: If performance of this task must be simulated for training and evaluation, the same<br />
gloves may be used repeatedly as long as they are properly rewrapped after each use. You<br />
may give the soldier a torn or moist glove package to test step 1.<br />
NOTE: If the soldier does not know his or her glove size, have several different sizes available<br />
to try on to determine the correct size.<br />
Brief soldier: Tell the soldier to put on and remove the sterile gloves.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected and inspected the package. —— ——<br />
2. Performed a patient care handwash. —— ——<br />
3. Opened the sterile package. —— ——<br />
4. Positioned the inner package. —— ——<br />
5. Unfolded the inner package. —— ——<br />
6. Exposed both gloves. —— ——<br />
7. Put on the first glove. —— ——<br />
8. Put on the second glove. —— ——<br />
9. Adjusted the gloves to fit properly. —— ——<br />
10. Removed the gloves. —— ——<br />
3-38
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
11. Discarded the gloves IAW local SOP. —— ——<br />
12. Performed a patient care handwash. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-39
STP 8-91W15-SM-TG<br />
INITIATE A FIELD MEDICAL CARD<br />
081-831-0033<br />
Conditions: You have treated a casualty and must record the treatment given. Necessary<br />
materials and equipment: DD Form 1380 (Field Medical Card) and a pen or pencil.<br />
Standards: Completed, as a minimum, blocks 1, 3, 4, 7, 9, and 11. Completed blocks 2, 5, 6,<br />
8, 10, 12, 13, 14, 15, 16, and 17 as appropriate. Completed other blocks as time permits.<br />
Performance Steps<br />
1. Remove the protective sheet from the carbon copy.<br />
2. Complete the minimum required blocks.<br />
a. Block 1. Enter the casualty's name, rank, and complete social security number (SSN).<br />
If the casualty is a foreign military person (including prisoners of war), enter his or her<br />
military service number. Enter the casualty's military occupational specialty (MOS) or<br />
area of concentration for specialty code. Enter the casualty's religion and sex.<br />
b. Block 3. Use the figures in the block to show the location of the injury or injuries.<br />
Check the appropriate box(es) to describe the casualty's injury or injuries.<br />
NOTES: 1. Use only authorized abbreviations. Except for those listed below, however,<br />
abbreviations may not be used for diagnostic terminology.<br />
Abr W--Abraded wound.<br />
Cont W--Contused wound.<br />
FC--Fracture (compound) open.<br />
FCC--Fracture (compound) open comminuted.<br />
FS--Fracture (simple) closed.<br />
LW--Lacerated wound.<br />
MW--Multiple wounds.<br />
Pen W--Penetrating wound.<br />
Perf W--Perforating wound.<br />
SL--Slight.<br />
SV--Severe.<br />
2. When more space is needed, attach another DD Form 1380 to the original. Label the<br />
second card in the upper right corner "DD Form 1380 #2." It will show the casualty's name,<br />
grade, and SSN.<br />
c. Block 4. Check the appropriate box.<br />
d. Block 7. Check the yes or no box. Write in the dose administered and the date and<br />
time that it was administered.<br />
e. Block 9. Write in the information requested. If you need additional space, use Block<br />
14.<br />
f. Block 11. Initial the far right side of the block.<br />
3. Complete the other blocks as time permits. Most blocks are self-explanatory. The<br />
following specifics are noted:<br />
a. Block 2. Enter the casualty's unit of assignment and the country of whose armed<br />
forces he or she is a member. Check the armed service of the casualty, that is, A/T =<br />
Army, AF/A = Air Force, N/M = Navy, and MC/M Marine.<br />
b. Block 5. Write in the casualty's pulse rate and the time that the pulse was measured.<br />
c. Block 6. Check the yes or no box. If a tourniquet is applied, you should write in the<br />
time and date it was applied.<br />
3-40
STP 8-91W15-SM-TG<br />
Performance Steps<br />
d. Block 8. Write in the time, date, and type of IV solution given. If you need additional<br />
space, use Block 9.<br />
e. Block 10. Check the appropriate box. Write in the date and time of disposition.<br />
f. Block 12. Write in the time and date of the casualty's arrival. Record the casualty's<br />
blood pressure, pulse, and respirations in the space provided.<br />
g. Block 13. Document the appropriate comments by the date and time of observation.<br />
h. Block 14. Document the provider's orders by date and time. Record the dose of<br />
tetanus administered and the time it was administered. Record the type and dose of<br />
antibiotic administered and the time it was administered.<br />
i. Block 15. The signature of the provider or medical officer is written in this block.<br />
j. Block 16. Check the appropriate box and enter the date and time.<br />
k. Block 17. This block will be completed by the United Ministry Team. Check the<br />
appropriate box of the service provided. The signature of the chaplain providing the<br />
service is written in this block.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation have another soldier act as a casualty and have him or her<br />
respond to the soldier's questions on personal data.<br />
Brief soldier: Tell the soldier to complete the FMC by asking appropriate questions of the<br />
casualty. Tell the soldier being tested any necessary information such as the nature of the<br />
wound and the treatment given. To test step 2, you may either have the soldier complete the<br />
minimum required blocks, or you may require the completion of all blocks. After step 2 ask the<br />
soldier what must be done with each copy of the FMC.<br />
Performance Measures GO NO<br />
GO<br />
1. Removed the protective sheet from the carbon copy. —— ——<br />
2. As a minimum, completed blocks 1, 3, 4, 7, 9, and 11. —— ——<br />
3. Made proper distribution of the FMC copies. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None AR 40-66<br />
3-41
STP 8-91W15-SM-TG<br />
APPLY RESTRAINING DEVICES TO PATIENTS<br />
081-833-0076<br />
Conditions: You have identified the patient and explained the procedure. An assistant is<br />
available. Necessary materials and equipment: a bed, wrist and ankle restraining devices, ABD<br />
pads, padding materials, litters, flexible gauze (Kerlix/Kling), rifle slings, web belts, elastic<br />
bandages, bandoleers, cravats, and sheets.<br />
Standards: Applied restraining devices to a patient without causing injury to the patient or<br />
yourself.<br />
Performance Steps<br />
NOTE: In a field environment, the need for restraints may be your own decision, especially in<br />
the absence of senior medical personnel.<br />
1. Apply wrist and ankle restraints.<br />
NOTE: If you apply ankle restraints, also apply wrist restraints.<br />
WARNINGS: 1. Do not attempt to apply restraining devices by yourself. Get adequate help.<br />
2. A patient who is depressed or has an altered level of consciousness should be positioned on<br />
the stomach with the head turned to the side. 3. Position restraints to avoid causing further<br />
injury to a wound or interfering with IV lines, catheters, and tubes.<br />
a. Adjustable limb holders (cuff and strap).<br />
(1) Clean and powder the skin around the wrists and ankles, if possible.<br />
(2) Pad the limb with ABD pads or similar material.<br />
(3) Position the restraint cuff over the padded limb.<br />
(4) Thread the strap through the loop on the cuff. Pull the straps snugly enough to<br />
restrict free movement of the limb.<br />
NOTE: If two fingers can be comfortably inserted under the cuff, the restraint is snug enough.<br />
The patient, however, must not be able to wiggle his or her hand out of the cuff.<br />
(5) Wrap the strap around the bedframe.<br />
(6) Lock the buckle and position it facing the outside of the bedframe for quick<br />
access.<br />
(7) Repeat steps 1a(2) through 1a(6) for each limb.<br />
NOTE: The keys to the locked restraints must be readily available.<br />
b. Improvised restraints.<br />
(1) Clean and powder the skin around the wrists and ankles, if possible.<br />
(2) Pad the limb with any soft cloth such as towels, gauze, cravats, clean<br />
handkerchiefs, or clothing.<br />
(3) Secure the restraining material (gauze or roller bandage) to the limb with a clove<br />
hitch.<br />
(4) Pull the knot to fit the limb snugly.<br />
(5) Using a bow knot, tie both free ends to the bedframe in a location inaccessible to<br />
the patient.<br />
(6) Repeat steps 1b(2) through 1b(5) for each limb.<br />
2. Apply mitt restraints.<br />
a. Place the patient's hand in a naturally flexed position.<br />
b. Place a soft rolled dressing or similar material in the patient's hand and close the hand.<br />
c. Wrap the entire hand snugly with a flexible gauze bandage (Kerlix, Kling).<br />
d. Secure the bandage with tape, not clips.<br />
3-42
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Remove and replace mitts at least every 8 hours. Clean the skin and perform<br />
range-of-motion exercises.<br />
3. Apply sheet restraints.<br />
NOTE: This procedure requires the assistance of another person.<br />
a. Litter or stretcher.<br />
(1) Unfold a sheet. Hold it at opposite corners and fold it lengthwise.<br />
(2) Twirl the sheet into a tight roll.<br />
(3) Place the patient on his or her stomach on a litter. Turn the head to the side.<br />
WARNING: Check the patient frequently because he or she may suffocate while in the prone<br />
position.<br />
(4) Place the middle of the rolled sheet diagonally across the patient's upper back<br />
and one shoulder.<br />
(5) Bring both ends of the sheet under the litter, cross the ends, and bring the ends<br />
up over the other shoulder and upper back. Tie snugly in the middle of the upper<br />
back.<br />
(6) Secure one wrist to the litter, parallel to the thigh, using a wrist restraint.<br />
(7) Secure the other wrist above the head by attaching it to the nearest litter handle<br />
using a wrist restraint.<br />
CAUTION: Use litter or stretcher restraints only as a temporary restraint for a patient who is<br />
combative or uncontrollable.<br />
b. Bed.<br />
(1) Fold a sheet in half lengthwise.<br />
(2) Tuck approximately 2 feet of one end of the sheet under one side of the mattress<br />
at the patient's chest level.<br />
(3) Bring the other end of the sheet over the patient's chest, keeping the sheet over<br />
the arms. Tuck the free end of the sheet snugly under the other side of the<br />
mattress.<br />
(4) If further restriction is necessary, apply sheets in the same manner at the level of<br />
the patient's abdomen, legs, knees, and ankles.<br />
NOTE: Use this method of restraint only for limiting movement. It is not a secure method of<br />
restraining a violent patient.<br />
4. Apply field expedient restraints.<br />
NOTE: Field expedient restraints should not be used for long periods of time and should be<br />
replaced with regular restraining devices as soon as possible.<br />
a. Mixed equipment. Restraints may be improvised from such items as rifle slings, web<br />
belts, bandoleers, or cravats.<br />
(1) Restrain the patient's arms and legs tight enough to restrict movement but not so<br />
tight as to restrict circulation.<br />
(2) Lay the patient on the ground.<br />
b. Double litters.<br />
(1) Place the patient on his or her stomach on a litter. Turn the head to the side.<br />
(2) Place the patient's hands alongside the thighs and secure them to the litter with<br />
wrist restraints.<br />
(3) Place the other litter, carrying side down, on top of the patient.<br />
(4) Bind the litters together with two or more litter straps.<br />
(5) Place the litter strap buckles in a location inaccessible to the patient.<br />
5. Check the patient at least once every half hour for signs of distress and security of<br />
restraints.<br />
3-43
STP 8-91W15-SM-TG<br />
Performance Steps<br />
WARNING: The use of restraints has the following hazards: 1. Tissue damage under the<br />
restraints. 2. Development of pressure areas. 3. Nerve damage. 4. Injury or death in case of<br />
fire or other emergencies. 5. Inability to effectively resuscitate a patient. 6. Possibility of<br />
shoulder dislocations in combative patients or those with seizure activity.<br />
6. Change the patient's position at least once every 2 hours, day and night. Exercise the<br />
limbs through normal range-of-motion activities.<br />
7. Evacuate the patient, if necessary.<br />
Performance Measures GO NO<br />
GO<br />
1. Applied wrist and ankle restraints, as applicable. —— ——<br />
2. Applied mitt restraints, as applicable. —— ——<br />
3. Applied sheet restraints, as applicable. —— ——<br />
4. Applied field expedient restraints, as applicable. —— ——<br />
5. Checked the patient. —— ——<br />
6. Changed the patient's position. —— ——<br />
7. Evacuated the patient, if necessary. —— ——<br />
8. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-44
STP 8-91W15-SM-TG<br />
MEASURE A PATIENT'S INTAKE <strong>AND</strong> OUTPUT<br />
081-833-0006<br />
Conditions: You have a physician's orders and have performed a patient care handwash.<br />
Necessary materials and equipment: DD Form 792, SF 511, or other appropriate forms,<br />
calibrated graduated container, gloves, common serving items, urinal, bedpan, urinary drainage<br />
bag, emesis basin, and nasogastric drainage container.<br />
Standards: Accurately measured and recorded the patient's fluid intake and output on<br />
appropriate forms.<br />
Performance Steps<br />
1. Explain the procedure to the patient.<br />
a. Inform the patient of the length of time during which the intake and output will be<br />
measured and the purpose of taking the measurements.<br />
b. Tell the patient of any physician's orders on fluid intake, such as forcing fluids or<br />
restricting the amount of intake.<br />
2. Tell the patient what types of items require intake and/or output measurement.<br />
a. Intake measurement.<br />
(1) Items that are naturally fluid at room temperature such as jello, ice cream, ice, and<br />
infant cereals.<br />
(2) Fluids consumed with and between meals, such as water, coffee, tea, broth, juice,<br />
milk, milk shakes, and carbonated beverages.<br />
(3) IV infusion fluids and blood.<br />
(4) Oral liquid medications.<br />
(5) Irrigating solutions that are not returned.<br />
b. Output measurement.<br />
(1) Urine.<br />
(2) Liquid stool.<br />
(3) Vomitus.<br />
(4) Drainage from wounds and suction devices.<br />
3. Tell the patient to use specified containers, such as a bedpan or urinal, to save all fluid<br />
output.<br />
4. Measure the intake.<br />
a. Calculate the oral fluid intake.<br />
NOTE: Check the water pitcher at the beginning and end of each shift. Check the meal tray for<br />
the amount of liquids consumed before removing it from the room.<br />
(1) Note the type and size of the oral fluid containers.<br />
(2) Check the container to find the fluid capacity.<br />
(3) Check the "Equivalents Table" on DD Form 792.<br />
NOTE: If an unmarked container is not listed on DD Form 792, fill it with water and pour its<br />
contents into a graduate to check its capacity.<br />
b. Calculate the amount of IV solution or blood given.<br />
c. Calculate the amount of any irrigating solutions that are not returned, if applicable.<br />
(1) Subtract the amount of solution returned from the known amount used for the<br />
irrigating procedure.<br />
(2) Record the difference as intake.<br />
3-45
STP 8-91W15-SM-TG<br />
Performance Steps<br />
5. Record, in cubic centimeters (cc), the fluid intake under the appropriate heading on DD<br />
Form 792.<br />
NOTE: To convert ounces to cc, multiply the number of fluid ounces by 30. Example: 12 fluid<br />
ounces multiplied by 30 equals 360 cc. One milliliter (ml) is approximately equal to one cc.<br />
6. Measure the output.<br />
a. Put on gloves.<br />
b. Record the level of output (urine, liquid stool, or emesis) in a graduated container.<br />
NOTE: If it is not possible to weigh or measure liquid stool, estimate the amount IAW local<br />
SOP. Estimate the amount of solid stool IAW local SOP.<br />
c. Estimate the amount of wound drainage, if present, IAW local SOP.<br />
d. Estimate any output not in a container, such as on the floor, skin, or sheets, IAW local<br />
SOP.<br />
e. Observe characteristics of the output.<br />
(1) Color and odor of urine.<br />
(2) Color, odor, and consistency of stool.<br />
(3) Color and consistency of nasogastric drainage.<br />
7. Remove gloves and perform a patient care handwash.<br />
8. Record in cc, the amount and characteristics of output under the appropriate headings on<br />
DD Form 792.<br />
NOTE: If no output was available to measure, enter this information in the "Remarks" section of<br />
DD Form 792.<br />
9. Compute accumulated intake and output totals at the end of the 24-hour period and record<br />
on the appropriate forms IAW local SOP.<br />
Evaluation Preparation:<br />
Setup: If the performance of this task must be simulated for training and evaluation,<br />
premeasure at least two fluid items into common serving utensils. The soldier will use them as<br />
the remains of a patient's simulated intake. You may also partially empty a bag or bottle of<br />
intravenous (IV) solution and have the soldier calculate the amount of intravenous intake. Have<br />
at least two premeasured containers of simulated waste fluid to use for simulated output. Have<br />
the soldier explain steps 1 through 3 to you.<br />
Brief soldier: Tell the soldier to measure and record the intake and output of a specified patient.<br />
Performance Measures GO NO<br />
GO<br />
1. Explained procedures to the patient. —— ——<br />
2. Told the patient what types of items require intake and/or output<br />
measurement.<br />
3. Told the patient to use specific containers, such as a bedpan or urinal, to<br />
save all fluid.<br />
—— ——<br />
—— ——<br />
4. Measured the intake. —— ——<br />
3-46
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Recorded, in cubic centimeters (cc), the fluid intake. —— ——<br />
6. Measured the output. —— ——<br />
7. Removed gloves and performed a patient care handwash. —— ——<br />
8. Recorded, in cc, the amount and characteristics of output under the<br />
appropriate headings on DD Form 792.<br />
9. Computed accumulated intake and output totals at the end of the 24-hour<br />
period and recorded on the appropriate forms IAW local SOP.<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-47
STP 8-91W15-SM-TG<br />
ESTABLISH A STERILE FIELD<br />
081-833-0007<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: sterile packs, sterile drapes and towels, small solution basin, sterile liquids, sterile<br />
needles and syringes, sterile gloves, and a flat, clean, dry surface.<br />
Standards: Established a sterile field. Added items and liquids without violating aseptic<br />
technique.<br />
Performance Steps<br />
1. Obtain sterile equipment and supplies IAW local SOP.<br />
2. Select a flat, clean, dry surface.<br />
NOTE: Choose a surface away from drafts, if possible.<br />
3. Create a sterile field with a double-wrapped sterile package.<br />
a. Lift the top flap of the sterile pack away from the body without crossing the hand or<br />
arm over the sterile field.<br />
b. Lift the remaining flaps, one at a time, away from the center without crossing the hand<br />
or arm over the sterile field.<br />
4. Add sterile items to the sterile field.<br />
NOTE: The outer one-inch border of the sterile field is considered contaminated. Items that fall<br />
in that area are considered contaminated and should not be used. If an item rolls from the oneinch<br />
border onto the sterile field, the sterile field is considered contaminated and the procedure<br />
must be stopped immediately. The procedure must be repeated using a new sterile pack.<br />
a. Commercially prepacked items.<br />
(1) Keeping the hands on the outside of the sterile wrapper, grasp the opening edge<br />
of the package.<br />
(2) Carefully fold each end of the wrapper back toward the wrist.<br />
(3) Without contaminating the contents, drop them onto the sterile field.<br />
NOTE: If the wrapper has been punctured or torn, the item is no longer sterile.<br />
b. Centralized Material Section (CMS) items (wrapped in double muslin wrappers).<br />
(1) Remove the outer wrapper.<br />
(2) Grasp the edge of the item being unwrapped, keeping the hand on the outside of<br />
the inner wrapper.<br />
(3) Fold each edge of the wrapper slowly back over the wrist of the hand holding the<br />
item.<br />
(4) Drop the item onto the sterile field.<br />
5. Open sterile liquids.<br />
NOTES: 1. Liquids prepared in CMS are considered sterile if a vacuum release sound is heard<br />
when the bottle is opened. If there is no sound, the bottle is considered unsterile, and a new<br />
bottle must be obtained before continuing the procedure. 2. Some commercially prepared<br />
bottles of sterile solution may not make a vacuum release sound.<br />
a. Remove the outer protective bottle seal, if necessary, and remove the cap.<br />
b. Hold the cap in one hand, or place the cap so the top rests on the table.<br />
3-48
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: The bottle rim and inside of the cap are considered sterile.<br />
CAUTION: Discard the sterile solution under any of the following conditions: 1. Anyone<br />
touches the bottle rim. 2. The lip of the bottle touches nonsterile items. 3. Someone touches<br />
the inside of the cap, or the part of the cap that touches the container is placed on the table.<br />
6. Pour sterile liquids.<br />
a. Hold the bottle with the label against the palm.<br />
b. Pour a small amount of the liquid from the bottle into a waste receptacle.<br />
c. Hold the bottle about 6 inches above the container into which the liquid is to be<br />
poured.<br />
d. Slowly pour a steady stream to avoid splashing, thus preventing contamination.<br />
e. Replace the cap without contaminating the bottle.<br />
f. Write the date and time the bottle was opened and your initials on the label. Return<br />
the bottle to the storage area or discard it IAW local SOP.<br />
NOTE: If the sterile field is contaminated at any time, the procedure must be stopped<br />
immediately. Repeat all steps using new sterile equipment.<br />
Performance Measures GO NO<br />
GO<br />
1. Obtained sterile equipment and supplies IAW local SOP. —— ——<br />
2. Selected a flat, clean, dry surface. —— ——<br />
3. Created a sterile field with a double-wrapped sterile package. —— ——<br />
4. Added sterile items to the sterile field. —— ——<br />
5. Opened sterile liquids. —— ——<br />
6. Poured sterile liquids. —— ——<br />
7. Did not violate aseptic technique. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-49
STP 8-91W15-SM-TG<br />
CHANGE A STERILE DRESSING<br />
081-833-0010<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: protective pad, scissors, forceps, gloves, basin, sponges, face mask, swabs,<br />
towels, tape, dressings, sterile cleaning solution, adhesive solvent, and handwashing facilities.<br />
Standards: Removed the dressing on a wound and cleaned and recovered the wound with a<br />
secure, sterile dressing without violating aseptic technique.<br />
Performance Steps<br />
1. Identify the patient.<br />
2. Gather the equipment.<br />
3. Prepare the patient.<br />
a. Explain the procedure to the patient.<br />
b. Expose the wound by moving the patient's clothing and folding the bed linens away<br />
from the wound area, if necessary.<br />
c. Position the patient to provide maximum wound exposure.<br />
d. Place a protective pad under the patient.<br />
4. Prepare the work area.<br />
a. Clear the bedside stand or table.<br />
b. Cut the required tape strips and attach them where they are accessible.<br />
5. Put on a mask and exam gloves.<br />
6. Remove the outer dressing.<br />
a. Loosen the ends of the tape by peeling toward the wound while supporting the skin<br />
around the wound.<br />
WARNING: Do not peel the tape away from the wound.<br />
b. Grasp the edge of the dressing and gently remove it from the wound.<br />
c. Note any drainage, color, and odor associated with the dressing.<br />
d. If the dressing is grossly saturated, discard the dressing and the gloves in a<br />
contaminated waste container otherwise, dispose of in regular trash.<br />
7. Perform a patient care handwash.<br />
8. Establish a sterile field. (See task 081-833-0007.)<br />
a. Open and place all sterile equipment and supplies on the sterile field.<br />
b. Pour the sterile cleaning solution into a basin.<br />
9. Put on a mask and sterile gloves.<br />
10. Remove the inner dressings.<br />
a. Using forceps, remove the dressings one at a time.<br />
b. Note any drainage, color, and odor associated with the dressings.<br />
c. Discard the dressings in a contaminated waste container.<br />
d. Drop the forceps on the glove wrap.<br />
11. Check the wound for the following conditions.<br />
a. Redness, swelling, foul odor, and/or bleeding.<br />
3-50
STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Drainage that contains blood, serum, or pus (usually yellow but may be blood-tinged,<br />
greenish, or brown).<br />
CAUTION: Notify the supervisor if any of the above conditions are present.<br />
c. If drainage is present, seek permission from the physician to irrigate the wound. (See<br />
task 081-833-0012.)<br />
12. Clean the wound with sterile gauze soaked with a sterile cleaning solution.<br />
a. Linear wound.<br />
(1) First stroke. Clean the area directly over the wound with one wipe and discard the<br />
gauze.<br />
(2) Second stroke. Clean the skin area on one side next to the wound with one wipe<br />
and discard the gauze.<br />
(3) Third stroke. Clean the skin area on the other side next to the wound with one<br />
wipe and discard the gauze.<br />
(4) Continue the procedure alternating sides of the wound, working away from the<br />
wound until the area is cleaned.<br />
b. Circular wound.<br />
(1) First stroke. Start at the center of the wound, wipe the wounded area with an<br />
outward spiral motion, and then discard the gauze.<br />
(2) Second stroke. Clean the skin area next to the wound using an outward spiral<br />
motion, approximately one and one half revolutions, and then discard the gauze.<br />
(3) Using successive outward, spiral strokes of approximately one and one half<br />
revolutions, clean the entire area around the wound.<br />
13. Change gloves.<br />
14. Remove adhesive from around the wound, if necessary.<br />
a. Using a solvent-soaked cotton tipped applicator or gauze pad, rub gently over the<br />
adhesive residue.<br />
b. Observe the skin for signs of irritation.<br />
15. Apply a sterile dressing.<br />
a. Lay the first dressing over the wound so that it extends over the edge.<br />
b. Overlap the first dressing with a second dressing.<br />
c. Overlap the second dressing with a third dressing.<br />
d. Cover all of the dressings with a large outer dressing.<br />
NOTE: If the wound has a drain inserted, cut the dressing halfway through and position it<br />
around the drain.<br />
16. Remove sterile gloves and face mask.<br />
17. Secure the dressing with tape.<br />
NOTE: The tape should not form a constricting band around the wound.<br />
a. Apply tape to the edge of the dressing with half of the tape on the dressing and the<br />
other half on the skin.<br />
b. Write the date and time the dressing was changed on a piece of tape, initial it, and<br />
secure the tape to the dressing.<br />
18. Dispose of contaminated materials in a contaminated waste container.<br />
19. Perform a patient care handwash.<br />
3-51
STP 8-91W15-SM-TG<br />
Performance Steps<br />
20. Record the procedure on the appropriate form.<br />
a. Enter the date and time of the dressing change.<br />
b. Enter a description of the wound's appearance.<br />
(1) Type and amount of drainage, if any.<br />
(2) Characteristics of the wound before and after cleaning.<br />
Evaluation Preparation:<br />
Setup: If the performance of this task must be simulated for training or evaluation, have another<br />
soldier act as the patient. A moulage kit or similar materials may be used to simulate an injury.<br />
Apply a dressing to the patient.<br />
NOTE: For testing purposes, the dressing may be reused.<br />
Brief soldier: Tell the soldier to change the patient's sterile dressing.<br />
Performance Measures GO NO<br />
GO<br />
NOTE: Under combat conditions, dressings are not normally changed but are<br />
reinforced. The second dressing is labeled "Reinforcement." The date and<br />
time and the medic's initials are written on the dressing.<br />
1. Identified the patient. —— ——<br />
2. Gathered the equipment. —— ——<br />
3. Prepared the patient. —— ——<br />
4. Prepared the work area. —— ——<br />
5. Put on a mask and exam gloves. —— ——<br />
6. Removed the outer dressing. —— ——<br />
7. Performed a patient care handwash. —— ——<br />
8. Established a sterile field. —— ——<br />
9. Put on a mask and sterile gloves. —— ——<br />
10. Removed the inner dressings. —— ——<br />
11. Checked the wound. —— ——<br />
12. Cleaned the wound with sterile gauze soaked with a sterile cleaning<br />
solution.<br />
—— ——<br />
13. Changed gloves. —— ——<br />
14. Removed adhesive from around the wound, if necessary. —— ——<br />
15. Removed sterile gloves and face mask. —— ——<br />
16. Applied a sterile dressing. —— ——<br />
3-52
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
17. Secured the dressing with tape. —— ——<br />
18. Disposed of contaminated materials in the appropriate waste container. —— ——<br />
19. Performed a patient care handwash. —— ——<br />
20. Recorded the procedure on the appropriate form. —— ——<br />
21. Did not violate aseptic technique. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-53
STP 8-91W15-SM-TG<br />
PERFORM A WOUND IRRIGATION<br />
081-833-0012<br />
Conditions: You have verified a physician's order to irrigate a wound. You have performed a<br />
patient care handwash. Necessary materials and equipment: protective pads, irrigating<br />
syringe, sterile gloves, mask, prescribed irrigating solution, sterile dressing, catch basin, sterile<br />
gauze sponges, and a sterile solution basin.<br />
Standards: Irrigated the wound without violating aseptic technique or causing further injury to<br />
the patient.<br />
Performance Steps<br />
1. Identify the patient.<br />
2. Explain the procedure to the patient.<br />
3. Provide privacy, if possible, and position the patient to provide maximum wound exposure.<br />
4. Place a protective pad directly under the wound area.<br />
5. Prepare the irrigation equipment.<br />
a. Establish a sterile field using the wrapper of the sterile solution basin.<br />
b. Open and place all other sterile equipment and supplies on the sterile field.<br />
c. Verify the prescribed irrigating solution and pour it into the sterile basin.<br />
6. Put on a mask and exam gloves.<br />
7. Remove the soiled outer dressing.<br />
8. Remove the exam gloves.<br />
9. Place a catch basin on the protective pad, against the body, to collect the used solution.<br />
10. Put on sterile gloves.<br />
11. Use sterile forceps to remove the inner dressings.<br />
12. Irrigate the wound.<br />
a. Fill the irrigating syringe with solution from the sterile basin.<br />
b. Hold the tip of the syringe as close to the wound as possible without touching it.<br />
Depress the bulb or plunger, directing the flow of solution to all parts of the wound in a<br />
slow, steady stream.<br />
c. Repeat steps 12a and 12b until all of the solution is used, or the wound is clear of<br />
debris and/or drainage.<br />
d. Observe the drainage for blood or characteristics such as unusual color, odor, or<br />
consistency.<br />
CAUTION: Use extra care when irrigating a wound in which an abscess has formed. Check all<br />
internal surfaces of the wound to inspect for "sinus tract" (resembles tunnels in which pus may<br />
be collected). This may require using the gloved hand or a sterile object to gently pull back the<br />
flesh. Be careful not to tear healing tissue.<br />
13. Dry the wound and apply a sterile dressing.<br />
a. Pat the wound dry with sterile gauze sponges.<br />
(1) Start at the center of the wound.<br />
3-54
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(2) Move outward toward the wound edges.<br />
b. Apply a sterile dressing to the wound. (See task 081-833-0010.)<br />
c. Remove the catch basin and protective pad, if they are still in place.<br />
14. Remove the mask and gloves.<br />
15. Reposition the patient for comfort, if necessary.<br />
16. Clean and store the equipment IAW local SOP.<br />
17. Perform a patient care handwash.<br />
18. Record the procedure on the appropriate form.<br />
Evaluation Preparation:<br />
Setup: If the performance of this task must be simulated for training or evaluation, have another<br />
soldier act as the patient. Designate a wound site or use a moulage kit or similar material to<br />
simulate an injury. Prepare a physician's order specifying the type and amount of solution to be<br />
used.<br />
Brief soldier: Give the soldier the physician's order and tell the soldier to irrigate the wound.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the patient. —— ——<br />
2. Explained the procedure to the patient. —— ——<br />
3. Provided privacy, if possible, and positioned the patient to provide<br />
maximum wound exposure.<br />
—— ——<br />
4. Placed a protective pad directly under the wound area. —— ——<br />
5. Prepared the irrigation equipment. —— ——<br />
6. Put on a mask and exam gloves. —— ——<br />
7. Removed the soiled outer dressing. —— ——<br />
8. Removed the exam gloves. —— ——<br />
9. Placed a catch basin on the protective pad, against the body, to collect the<br />
used solution.<br />
—— ——<br />
10. Put on sterile gloves. —— ——<br />
11. Used sterile forceps to remove the inner dressings. —— ——<br />
12. Irrigated the wound. —— ——<br />
13. Dried the wound and applied a sterile dressing. —— ——<br />
14. Removed the mask and gloves. —— ——<br />
15. Repositioned the patient for comfort, if necessary. —— ——<br />
3-55
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
16. Cleaned and stored the equipment IAW local SOP. —— ——<br />
17. Performed a patient care handwash. —— ——<br />
18. Recorded the procedure on the appropriate form. —— ——<br />
19. Did not violate aseptic technique. —— ——<br />
20. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-56
STP 8-91W15-SM-TG<br />
PERFORM ORAL <strong>AND</strong> NASOPHARYNGEAL SUCTIONING OF A PATIENT<br />
081-833-0021<br />
Conditions: A patient requires suctioning. You have identified the patient, explained the<br />
procedure, and performed a patient care handwash. Necessary materials and equipment:<br />
suction apparatus, suction catheter and tubing, "Y" adapter/connector, sterile saline, sterile<br />
solution basin, and sterile gloves.<br />
Standards: Performed oral or nasopharyngeal suctioning without violating aseptic technique or<br />
causing injury to the patient.<br />
Performance Steps<br />
1. Position the patient in the semi-Fowler's (semi-sitting) position.<br />
NOTE: In some cases, such as spinal injuries, the patient will have to remain in whatever<br />
position he or she is in at the time.<br />
2. Check the pressure on the suction apparatus.<br />
a. Turn the unit on, place a thumb over the end of the suction connecting tube, and<br />
observe the pressure gauge.<br />
b. Ensure that the pressure reading is within the limits specified by local SOP and the<br />
recommendations of the equipment manufacturer.<br />
c. Notify the supervisor if the pressure is not within the recommended limits.<br />
d. Turn the unit off after verifying the correct pressure.<br />
WARNING: If the suction pressure is too low, the secretions cannot be removed. If the<br />
pressure is too high, the mucous membranes may be forcefully pulled into the catheter opening.<br />
3. Prepare the materials.<br />
NOTE: Many disposable kits have all the items needed for suctioning if you are using a soft tip<br />
catheter.<br />
a. Open the solution basin package.<br />
b. Pour saline solution into the basin.<br />
c. Open the suction catheter package to expose the suction port of the catheter.<br />
4. Explain to the patient the reason for suctioning.<br />
5. Oxygenate the patient.<br />
a. If the patient is on oxygen therapy, increase the oxygen to 100% for 1 minute.<br />
b. Monitor the patient's pulse oximeter reading during the entire procedure. (See task<br />
081-833-0164.)<br />
c. If the patient is not on oxygen therapy, have him or her take a minimum of five deep<br />
breaths or administer them with a bag-valve-mask.<br />
NOTE: After each suctioning attempt or suctioning period, reoxygenate the patient.<br />
6. Remove the catheter from the package using the dominant hand.<br />
7. Grasp the suction connecting tubing with the other hand. Attach the tubing to the catheter.<br />
8. Test the patency of the catheter.<br />
a. Turn the suction unit on with the nondominant hand.<br />
b. Insert the catheter tip into the sterile saline solution using the dominant hand.<br />
c. Place the nondominant thumb over the suction port to create suction. Observe the<br />
saline entering the drainage bottle.<br />
3-57
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: If no saline enters the bottle, check the suction unit and/or replace the catheter and<br />
retest for patency.<br />
9. Suction the patient.<br />
a. Oral route.<br />
(1) Rigid pharyngeal tip.<br />
(a) Instruct a conscious patient to cough to help bring secretions up to the back<br />
of the throat.<br />
(b) If the patient is unconscious, use the cross finger method of opening the<br />
airway (see task 081-831-0019).<br />
(c) Place the convex side of the rigid tip against the roof of the mouth and insert<br />
to the base of the tongue.<br />
NOTE: A rigid tip does not need to be measured. Only insert the tip as far as you can see it.<br />
Be aware that advancing the catheter too far may stimulate the patient's gag reflex and cause<br />
him to vomit.<br />
(d) Apply suction by placing the thumb of the nondominant hand over the suction<br />
port.<br />
(e) Suction no longer than 15 seconds removing secretions from the back of the<br />
throat, along outer gums, cheeks and base of tongue.<br />
(f) Clear the secretions from the tip between suctions by inserting tip into the<br />
saline solution and suction the solution through the catheter until the catheter<br />
is clear of secretions.<br />
(g) Repeat steps 9a(1)(a) - (g) until all secretions have been removed or until the<br />
patient's breathing becomes easier. Noisy, rattling or gurgling sounds should<br />
no longer be heard.<br />
(h) Place the catheter in a clean, dry place with suction turned off for reuse at a<br />
later time.<br />
NOTE: It may also be placed within the patient's reach if the patient is conscious and is taught<br />
how to use it correctly.<br />
(2) Flexible catheter.<br />
(a) Measure the catheter from the patient's earlobe to the corner of the mouth or<br />
the center of the mouth to the angle of the jaw.<br />
(b) Insert the catheter into the patient's mouth, without suction applied.<br />
NOTES: 1. Hold the catheter with the sterile hand. Manipulate the suction connecting tubing<br />
and suction port with the non sterile hand. 2. If an oropharyngeal airway is in place, insert the<br />
catheter alongside the airway and then back into the pharynx.<br />
(c) Place the thumb of your nondominant hand over the suction control port on<br />
the catheter.<br />
(d) Apply intermittent suction by moving your thumb up and down over the<br />
suction control port.<br />
(e) Suction for no longer than 15 seconds removing secretions front the back of<br />
the throat, along outer gums, cheeks, and base of tongue.<br />
(f) Slowly and gently rotate the catheter between the thumb and index finger of<br />
your sterile hand as you withdraw the catheter.<br />
WARNINGS: 1. Advancing the catheter too far into the back of the patient's throat may<br />
stimulate the gag reflex. This could cause vomiting and the aspiration of stomach contents. 2.<br />
Do not continue suctioning for more than 10 to 15 seconds because it removes oxygen as well<br />
as secretions. Longer periods of continuous suctioning may cause oxygen deprivation.<br />
3-58
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(g) Clear the secretions from the catheter between suctionings by inserting the<br />
tip into the saline solution and suction the solution through the catheter until<br />
the catheter is clear of secretions.<br />
(h) Repeat steps 9a(2)(a) through 9a(2)(g) until all secretions have been<br />
removed or until the patient's breathing becomes easier. Noisy, rattling, or<br />
gurgling sounds should no longer be heard.<br />
(i) Allow the patient to rest between each suctioning.<br />
NOTE: If the patient is uncooperative, or oral entry is not possible due to injuries,<br />
nasopharyngeal suctioning may be required.<br />
b. Nasopharyngeal route.<br />
(1) Measure the catheter from the tip of the earlobe to the nose.<br />
(2) Lubricate the catheter by dipping the tip into the saline solution.<br />
(3) Insert the catheter into one nostril without suction applied. If an obstruction is met,<br />
try the other nostril. If both are obstructed, seek assistance.<br />
(4) Quickly and gently advance the catheter 3 to 5 inches.<br />
(5) Perform steps 9a(2)(c) through 9a(2)(h) to suction secretions.<br />
10. Observe the patient for hypoxemia.<br />
WARNING: Discontinue suctioning immediately if severe changes in color or pulse rate occur.<br />
a. Color change.<br />
b. Increased or decreased pulse rate.<br />
11. Disconnect the catheter and remove the gloves.<br />
a. Hold the catheter in one hand.<br />
b. Remove that glove by turning it inside out over the catheter to prevent the spread of<br />
contaminants.<br />
c. Remove the other glove.<br />
d. Discard them in contaminated trash.<br />
12. Make the patient comfortable.<br />
13. Discard, or clean and store, used items.<br />
14. Record the procedure on the appropriate form.<br />
a. Date and time.<br />
b. Respirations (rate and breath sounds before and after suctioning).<br />
c. Type of suction performed.<br />
d. Type and size of suctioning catheter used.<br />
e. Type and amount of secretions.<br />
f. Patient's toleration of the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the patient. —— ——<br />
2. Checked the pressure on the suctioning apparatus. —— ——<br />
3. Prepared the materials. —— ——<br />
4. Explained the procedure to the patient. —— ——<br />
3-59
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Oxygenated the patient, if necessary. —— ——<br />
6. Removed the catheter from the package. —— ——<br />
7. Attached the suction connecting tube to the catheter. —— ——<br />
8. Tested the patency of the catheter. —— ——<br />
9. Suctioned the patient (10-15 seconds). —— ——<br />
10. Observed the patient for hypoxemia. If patient suctioning needed to be<br />
performed again, reoxygenated the patient.<br />
—— ——<br />
11. Disconnected the catheter and removed the gloves. —— ——<br />
12. Made the patient comfortable. —— ——<br />
13. Discarded, cleaned, or stored used items. —— ——<br />
14. Recorded the procedure on the appropriate form. —— ——<br />
15. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-60
STP 8-91W15-SM-TG<br />
IRRIGATE AN OBSTRUCTED EAR<br />
081-833-0059<br />
Conditions: You have a physician's order to irrigate an obstructed ear. Necessary materials<br />
and equipment: irrigating syringe, catch basin, irrigating solution, towels, gauze sponges, and<br />
otoscope set.<br />
Standards: Irrigated the obstructed ear until the obstructing material was removed from the<br />
external ear or until the prescribed amount of solution was used. Performed the procedure<br />
without causing further injury to the patient.<br />
Performance Steps<br />
1. Gather the irrigation equipment.<br />
NOTE: Common solutions used to irrigate the ear include water, normal saline, hydrogen<br />
peroxide and water, and prescribed medication solution. Alcohol may be used to shrink<br />
vegetable matter (associated with pediatric patients) and make it easier to expel. Oil may be<br />
used for other foreign bodies to make them slippery.<br />
2. Perform a patient care handwash (081-831-0007).<br />
3. Warm and test the solution.<br />
a. Warm the solution to about body temperature (95° to 105° F) by placing the solution<br />
container in a container of warm water.<br />
b. Test the temperature of the solution by running a small amount of it on the inner wrist.<br />
CAUTION: Cold solutions are not only uncomfortable but may cause dizziness or nausea as a<br />
result of stimulation of the equilibrium sensors in the semicircular canals.<br />
4. Identify the patient and explain the procedure.<br />
a. Tell the patient that some discomfort may be experienced when the solution is instilled.<br />
b. Emphasize to the patient that he or she must remain as still as possible.<br />
CAUTION: If the patient moves when the solution is instilled, the syringe may damage the ear<br />
canal or tympanic membrane.<br />
5. Insert the otoscope speculum into the external ear canal.<br />
a. Position the patient to allow a good view into the ear.<br />
b. Tilt the patient's head toward the shoulder opposite the ear to be irrigated.<br />
c. Straighten the external ear canal by gently pulling the outer ear upward and backward<br />
for an adult or downward and backward for a child.<br />
NOTE: Use the largest speculum that will fit comfortably in the patient's ear.<br />
d. Turn on the otoscope light and insert the speculum just inside the opening of the ear.<br />
NOTE: To avoid causing pain, the speculum should be inserted gently and not too far into the<br />
ear canal.<br />
e. View the ear canal by looking through the lens of the otoscope.<br />
6. Check for abnormalities.<br />
a. Check the external ear canal for redness, swelling, drainage, or foreign bodies.<br />
b. Check the tympanic membrane for any abnormal conditions.<br />
NOTE: A normal eardrum is slightly cone-shaped, shiny, translucent, and pearly grey.<br />
(1) A blue, yellow, amber, red, or pink eardrum indicates disease or infection.<br />
(2) A bulge in the eardrum indicates possible pus or fluid in the middle ear.<br />
(3) A hole or tear indicates rupture of the tympanic membrane.<br />
3-61
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: If an abnormal condition of the tympanic membrane is suspected, do not irrigate the<br />
ear. To do so could cause pain and carry debris or infectious discharge into the middle ear.<br />
Report the condition to the supervisor immediately.<br />
7. Position the patient sitting or lying with the head slightly tilted toward the affected side.<br />
NOTE: Do not tilt the head toward the unaffected side, as this interferes with the return of the<br />
irrigating solution.<br />
8. Drape the patient's shoulder and upper arm area under the affected ear.<br />
9. Clean the external ear and the entrance to the ear canal with 4 x 4 gauze sponges slightly<br />
moistened with the irrigating solution.<br />
WARNING: If a cotton-tipped applicator is used to clean the ear, make sure it does not stick far<br />
enough into the ear to rupture the tympanic membrane.<br />
10. Fill the irrigating syringe.<br />
11. Test the flow of solution from the syringe by expelling a small amount back into the solution<br />
container.<br />
12. Position the catch basin firmly against the neck just under the affected ear.<br />
13. Straighten the external ear canal by gently pulling the outer ear upward and backward for<br />
an adult or downward and backward for a child.<br />
14. Irrigate the patient's ear.<br />
a. Place the tip of the irrigating syringe just inside the ear, with the tip directed toward the<br />
roof of the ear canal.<br />
WARNING: Never allow the syringe to completely block the ear canal. If space is not left<br />
around the tip, the solution will not be able to return, and undue pressure will build up in the<br />
canal.<br />
b. Depress the bulb or plunger of the syringe.<br />
(1) Direct a slow, steady stream of solution against the roof of the ear canal.<br />
(2) Repeat the procedure until the foreign body is removed, the solution returns free<br />
of wax or debris, or the proper amount of solution has been used.<br />
15. Remove the catch basin and dry the external ear with a gauze sponge.<br />
16. Instruct the patient to continue tilting the head toward the affected side for a few minutes to<br />
allow any remaining solution to drain from the ear.<br />
17. Remove the drapes from the patient.<br />
18. Dispose of, or clean and store, the equipment.<br />
19. Perform a patient care handwash.<br />
20. Document the procedure on the appropriate forms IAW local SOP.<br />
a. Type and amount of solution used.<br />
b. Nature of return flow.<br />
3-62
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Gathered the irrigation equipment. —— ——<br />
2. Performed a patient care handwash. —— ——<br />
3. Warmed and tested the solution. —— ——<br />
4. Identified the patient and explained the procedure. —— ——<br />
5. Inserted the otoscope speculum into the external ear canal. —— ——<br />
6. Checked for abnormalities. —— ——<br />
7. Positioned the patient. —— ——<br />
8. Draped the patient's shoulder and upper arm area under the affected ear. —— ——<br />
9. Cleaned the external ear and the entrance to the ear canal. —— ——<br />
10. Filled the irrigating syringe. —— ——<br />
11. Tested the flow of solution. —— ——<br />
12. Positioned the catch basin. —— ——<br />
13. Straightened the external ear canal. —— ——<br />
14. Irrigated the patient's ear. —— ——<br />
15. Removed the catch basin and dried the external ear. —— ——<br />
16. Instructed the patient to continue tilting the head toward the affected side. —— ——<br />
17. Removed the drapes from the patient. —— ——<br />
18. Disposed of, or cleaned and stored, the equipment. —— ——<br />
19. Performed a patient care handwash. —— ——<br />
20. Documented the procedure on the appropriate forms IAW local SOP. —— ——<br />
21. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-63
STP 8-91W15-SM-TG<br />
DOCUMENT PATIENT CARE USING SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN<br />
(SOAP) NOTE FORMAT<br />
081-833-0145<br />
Conditions: You are treating a patient and must record the treatment given. Necessary<br />
materials: documentation forms (as specified by local SOP) and a black ink pen.<br />
Standards: Recorded patient care using SOAP note format.<br />
Performance Steps<br />
1. Record the patient's name, rank, SSN, date, and time.<br />
NOTE: An addressograph card can be used on the patient identification block.<br />
2. Write subjective data.<br />
a. Chief complaint.<br />
b. The patient's statements regarding the illness or injury history to include OPQRST.<br />
3. Write objective data.<br />
a. Observations by the medic to include sight, sound, touch, and smell.<br />
b. Physical assessment data.<br />
c. Lab and radiology results.<br />
4. Write the assessment/analysis (conclusions reached based upon the data).<br />
5. Write the plan.<br />
a. Course of action to resolve the problem.<br />
(1) Treatments made.<br />
(2) Profiles.<br />
(3) Medications.<br />
b. Follow-up appointment or referral.<br />
NOTE: Some treatment facilities use SOAPE format. The E stands for evaluation.<br />
6. Correct recording errors, if applicable.<br />
a. Draw a single line through the error.<br />
b. Write the word error above it.<br />
c. Initial next to the error.<br />
d. Record the note correctly.<br />
7. Finish the entry with your signature, rank, and title.<br />
Performance Measures GO NO<br />
GO<br />
1. Recorded patient information. —— ——<br />
2. Documented subjective data. —— ——<br />
3. Documented objective data. —— ——<br />
4. Wrote the assessment. —— ——<br />
5. Wrote the plan. —— ——<br />
3-64
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
6. Signed the entry. —— ——<br />
7. Corrected errors, if applicable. —— ——<br />
8. Made legible entries (typed or handwritten). —— ——<br />
9. Used black or blue-black ink. —— ——<br />
10. Did not skip lines or leave space between lines. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-65
STP 8-91W15-SM-TG<br />
PERFORM PATIENT HYGIENE<br />
081-833-0165<br />
Conditions: A patient requires assistance with personal hygiene. Necessary materials and<br />
equipment: washcloths, towels, bath blanket or cover sheet, toiletry items, clean hospital gown,<br />
gloves, wash basin, toothbrush or toothettes, emesis basin, suction equipment, water soluble<br />
lubricant, brush, comb, shampoo, razor, shaving cream, orange stick nail file, sheets, and<br />
waterproof pads.<br />
Standards: Performed patient hygiene to the level indicated without causing further injury to the<br />
patient.<br />
Performance Steps<br />
1. Verify the activity with doctor's orders or nursing care plan.<br />
2. Explain the procedure to the patient.<br />
NOTE: Some of the following steps may be omitted based upon the client's condition. Patients<br />
should be encouraged to participate in self care to the extent that they are able.<br />
3. Provide a bedbath.<br />
a. Provide privacy.<br />
(1) Close the door and draw a curtain around the patient.<br />
(2) Expose only the areas being bathed.<br />
b. Raise the entire bed to comfortable working height.<br />
c. Place the bath blanket or sheet over the patient and remove top covers without<br />
exposing the patient.<br />
d. Remove the patient's gown.<br />
(1) If the patient has an IV, remove the gown from the arm without the IV first. Move<br />
the IV bag and the tubing through the sleeve and rehang the bag.<br />
NOTE: If an IV pump is used, turn off the pump, clamp the tube, and then remove it as<br />
described above. Unclamp the tube, reinsert it into the pump, turn on the pump, and adjust the<br />
rate.<br />
(2) If the patient has an injured extremity, remove the sleeve from the unaffected side<br />
first.<br />
e. Place a towel under the patient's head.<br />
f. Wash the face.<br />
(1) Wash the patient's eyes from inner to outer canthus, using a clean part of the<br />
cloth for each eye.<br />
NOTE: If the patient is unconscious, clean the eyes as above. Instill prescribed eye drops or<br />
ointment, if applicable (see task 081-835-3022). If the patient does not have a blink reflex, keep<br />
the eyelids closed and cover with a patch. Do not tape the eyelid.<br />
(2) Wash, rinse, and dry the forehead, cheeks, ears, nose, and neck with plain warm<br />
water.<br />
NOTES: 1. Soap tends to dry the face. 2. Men may want to be shaved (see step 6).<br />
g. Wash the upper body.<br />
(1) Remove the bath blanket from over the arm. Place a towel under the arm.<br />
(2) Bathe the arm using long firm strokes from distal to proximal end.<br />
(3) Lift the arm above the head if possible and wash and dry the axilla completely.<br />
(4) Repeat steps 3f(1) through 3f(3) on other arm.<br />
(5) Apply powder or deodorant to the axilla if applicable.<br />
3-66
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(6) Bathe and dry the chest.<br />
NOTE: Take special care to wash the skin under a female's breasts. Lift the breasts upward if<br />
necessary. Clean and dry thoroughly.<br />
h. Wash the lower body.<br />
(1) Place a bath towel over the chest and abdomen. Fold the blanket down to just<br />
above the patient's pubic region.<br />
(2) Wash, rinse, and dry the abdomen paying attention to the umbilicus and the skin<br />
folds of the abdomen and groin.<br />
(3) Wash and dry the leg nearest you.<br />
(a) Place a towel under the leg.<br />
(b) Support the leg at the knee and place the foot flat on the bed.<br />
NOTE: The patient's foot may be placed in the basin to soak while the leg is being washed.<br />
However, soaking feet is NOT recommended for patients with diabetes mellitus or peripheral<br />
vascular disease.<br />
(c) Wash and dry the leg using long firm strokes. Wash from ankle to knee and<br />
then from knee to thigh.<br />
CAUTION: Avoid massaging the legs when the client is at risk for thrombosis or emboli.<br />
(d) Wash and dry the foot completely.<br />
(e) Move to the opposite side and repeat steps 3g(3)(a) through 3g(3)(d) for the<br />
other leg.<br />
NOTE: Always raise the side rail for safety.<br />
i. Change bath water and gloves.<br />
j. Wash the perineum.<br />
(1) Place the client in a side lying position and keep the patient covered with a bath<br />
blanket as much as possible.<br />
(2) Wash the buttocks and anus from front to back.<br />
NOTE: If feces is present, wrap it in underpad fold and remove as much as possible with<br />
disposable wipes first. Use as many wash cloths as necessary to clean completely. Ensure to<br />
cleanse the gluteal folds.<br />
(3) Dry the area and replace the underpad with a clean one.<br />
k. Wash the genitals.<br />
(1) Female.<br />
(a) Position the patient supine with a waterproof pad beneath the buttocks.<br />
Drape the patient with a bath blanket to maintain privacy.<br />
(b) Wash the labia majora and then gently pull back the labia majora to wash the<br />
groin from perineum to rectum.<br />
(c) Clean the pubic area from front to back.<br />
NOTE: Clean around an indwelling catheter if applicable without pulling tension on it. Ensure<br />
the catheter is secured to the upper thigh or positioned over the thigh (not under it).<br />
(2) Male.<br />
(a) Gently grab the penis. Retract the foreskin if uncircumcised.<br />
(b) Wash the tip of the penis and urinary meatus cleansing away from the<br />
meatus. Use a circular motion.<br />
(c) Clean the penial shaft, scrotum, and underlying folds.<br />
(d) Rinse and dry.<br />
l. Change bath water and gloves.<br />
m. Wash the back.<br />
(1) Place the patient on his or her side.<br />
(2) Clean and dry the back from neck to buttocks using long firm strokes.<br />
n. Apply lotion to the skin if needed.<br />
3-67
STP 8-91W15-SM-TG<br />
Performance Steps<br />
o. Replace the gown.<br />
4. Provide oral care.<br />
a. Place the casualty in a side-lying position with a towel under the chin. Have an emesis<br />
basin available.<br />
b. Separate the upper and lower teeth.<br />
NOTE: Oral suction must be available, especially if the patient has no gag reflex.<br />
c. Clean the mouth using a toothbrush, moistened 4 x 4 gauze, or toothette with water.<br />
Ensure the tongue, roof of mouth, inside cheeks, and tooth surfaces have been<br />
cleaned.<br />
NOTE: The toothbrush should be soft bristled. Angle the brush at 45 degrees to clean the<br />
teeth. Avoid using glycerine or lemon swabs.<br />
d. Rinse with a clean toothette and water.<br />
NOTE: Use as little water as possible to avoid aspiration.<br />
e. Suction the oral cavity as secretions accumulate if the patient is unable to remove<br />
them.<br />
f. Apply lip balm or water-soluble jelly to the lips.<br />
5. Provide hair care.<br />
a. Shampoo the hair.<br />
(1) Place a towel and waterproof pad under the head.<br />
(2) Comb or brush the patient's hair to release any tangles.<br />
(3) Position the patient supine with a plastic trough under the head.<br />
(4) Pour warm water over the head until completely wet.<br />
NOTES: 1. Protect the patient's face and eyes by placing a towel or washcloth over them. 2.<br />
If hair is matted with blood, apply hydrogen peroxide to dissolve it, and then rinse with saline or<br />
water.<br />
(5) Apply shampoo and lather.<br />
(6) Massage gently starting at the hairline and working toward the back of the scalp.<br />
(7) Rinse the hair.<br />
(8) Apply conditioner if needed.<br />
(9) Dry the hair.<br />
(10) Complete styling of the hair as necessary.<br />
NOTE: Braids may be helpful to prevent tangling of long hair.<br />
b. Shave the beard.<br />
(1) Position the patient into a sitting position if possible. Place a towel over the chest.<br />
(2) Place a moist, warm washcloth over the patient's face.<br />
(3) Apply shaving cream.<br />
(4) While pulling the skin taut, angle the razor to 45 degrees. Shave in the direction of<br />
hair growth.<br />
NOTE: Ask the patient to direct you on his usual technique.<br />
(5) Rinse and dry the face. Apply aftershave if patient desires.<br />
6. Perform foot and nail care.<br />
a. Using an orange stick, gently clean under the patient's nails.<br />
b. Clip the nails straight and even with the digits. File the nails to shape and smooth<br />
rough edges.<br />
CAUTION: Never cut the toenails. A patient with diabetes or hypertrophy should be referred to<br />
a podiatrist.<br />
c. Push the cuticle back gently with an orange stick.<br />
d. Apply lotion.<br />
3-68
STP 8-91W15-SM-TG<br />
Performance Steps<br />
7. Change the patient's linen (make an occupied bed).<br />
a. Raise the entire bed to a comfortable working height.<br />
b. Lower the head of the bed, if tolerated by the patient.<br />
c. Remove the bedspread or blanket. Leave a sheet covering the patient.<br />
d. Roll the patient to a side-lying position on the far side of the bed.<br />
NOTE: Make sure any tubing is not pulled.<br />
e. Roll the bottom sheet, draw sheet, and underpad toward the patient as far as possible.<br />
f. Place a clean bottom sheet on the bed.<br />
(1) The sheet may be fitted.<br />
(2) Flat sheet. Center the sheet on the bed, and pull the bottom hem toward the foot<br />
of the bed. Open the sheet toward the patient. Tuck and miter the top under the<br />
head of the bed.<br />
g. Place draw sheets or waterproof pads on the center of the bed. Fan-fold toward the<br />
patient.<br />
h. Cover the unoccupied side of bed with the linen. Tuck the draw sheet under the<br />
mattress.<br />
i. Assist the patient to logroll over all the linen toward the other side of the bed.<br />
j. Raise the bed rail on the side facing the patient. Go to the other side and lower the<br />
bed rail.<br />
k. Remove soiled linens. Place them on the floor or in the hamper.<br />
CAUTION: Never leave the patient alone with the side rails down.<br />
l. Pull clean linen toward you. Straighten the linen out.<br />
m. Tuck and miter the corners.<br />
n. Tuck in the draw sheet.<br />
o. Straighten the waterproof pads.<br />
p. Assist the patient to a supine position.<br />
q. Place a clean top sheet and blanket over the patient.<br />
r. Remove the original cover sheet.<br />
s. Tuck the bottom of the covers under the mattress making a modified miter. Loosen<br />
the linen at the feet for comfort.<br />
t. Change the patient's pillowcase.<br />
8. Assist the patient to a position of comfort and place needed items within reach.<br />
9. Raise the side rails and lower the bed.<br />
10. Remove soiled supplies.<br />
11. Document what was performed and the patient's response. Inability to tolerate a procedure<br />
should be documented.<br />
Performance Measures GO NO<br />
GO<br />
1. Verified the activity with doctor's orders or nursing care plan. —— ——<br />
2. Provided a bedbath. —— ——<br />
3. Provided oral care. —— ——<br />
4. Provided hair care. —— ——<br />
3-69
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Provided foot and nail care. —— ——<br />
6. Changed the patient's linen. —— ——<br />
7. Assisted the client to a position of comfort and placed needed items within<br />
reach.<br />
—— ——<br />
8. Raised the siderails and lowered the bed. —— ——<br />
9. Removed soiled supplies. —— ——<br />
10. Documented the procedures and the patient's response. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored a GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-70
STP 8-91W15-SM-TG<br />
OBTAIN AN ELECTROCARDIOGRAM<br />
081-835-3007<br />
Conditions: You have verified a physician's orders to obtain an electrocardiogram on a patient.<br />
You have identified the patient and explained the procedure. A patient care handwash has<br />
been performed. Necessary materials and equipment: an EKG machine, electrodes, alcohol<br />
prep pads, towels, tape, OF 520, and the patient's clinical record.<br />
Standards: Obtained an electrocardiogram in accordance with the physician's orders.<br />
Performance Steps<br />
1. Prepare the equipment.<br />
a. Read the manufacturer's instructions for the proper use of the equipment on hand.<br />
b. Plug in the machine and turn it on.<br />
c. Allow it to perform its self-checks, if computerized, or warm up for 5 minutes if not<br />
computerized.<br />
d. Obtain any other necessary materials.<br />
2. Prepare the patient.<br />
a. Provide for the patient's privacy.<br />
b. Provide a female chaperon, if necessary, for female patients.<br />
c. Ask or assist the patient to remove wristwatch, shoes, socks or hose, and all clothing<br />
from the waist up.<br />
d. Provide a chest drape for female patients.<br />
e. Ask or assist the patient to lie supine on the bed or examination table.<br />
f. Ensure that the patient's body is not in contact with any metal objects, and that all<br />
limbs are firmly supported.<br />
NOTE: Some metal objects, watches, or jewelry may interfere with the accurate recording of<br />
the electrical impulses.<br />
g. Instruct the patient to relax and breathe normally throughout the entire procedure.<br />
3. Apply limb electrodes.<br />
a. Clean the site for electrode placement by wiping with an alcohol prep pad to remove<br />
dead skin and oils as needed.<br />
NOTE: An area of broken down or irritated skin should not be used for the electrode<br />
connection.<br />
b. Position the electrode.<br />
(1) Secure the leg electrodes on the medial or lateral aspect of the calf.<br />
(2) Secure the arm electrodes on the arm or forearm, ensuring that the connections<br />
are not on, or adjacent to, an IV site.<br />
(3) Ensure that all the connections are made over a fleshy area, not over bone, as<br />
bone may interfere with conduction of the electrical impulse to the electrode.<br />
NOTE: Make the usual electrode connection to a fleshy part of the stump if the patient is<br />
missing a limb. Secure the electrode with tape if necessary.<br />
4. Apply the chest electrodes.<br />
a. Clean the sites for electrode placement by wiping with an alcohol prep pad to remove<br />
dead skin and oils as needed.<br />
b. Position the electrodes, being careful to place them over the intercostal spaces and<br />
not directly over the ribs (see Figure 3-2).<br />
3-71
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-2<br />
(1) V1: 4th intercostal space at the right sternal border.<br />
(2) V2: 4th intercostal space at the left sternal border.<br />
(3) V3: Halfway between V2 and V4.<br />
(4) V4: 5th intercostal space at the left midclavicular line.<br />
(5) V5: 5th intercostal space at the left anterior axillary line.<br />
(6) V6: 5th intercostal space at the left midaxillary line.<br />
NOTE: The standard EKG machine utilizes 12 "leads". These leads represent paths of<br />
electrical activity, and are designated as leads I, II, III, AVR, AVL, AVF, V1, V2, V3, V4, V5, and<br />
V6. Do not confuse these 12 leads with the 10 electrodes (sometimes referred to as "leads")<br />
that are attached to the patient.<br />
5. Obtain the EKG tracing.<br />
a. Operate the equipment in accordance with the manufacturer's operating instructions.<br />
b. Ensure a complete and readable EKG tracing.<br />
6. Observe and assess the EKG tracing as it is printed and take appropriate action.<br />
a. Observe the tracing for the presence of the normal waves in each heartbeat.<br />
NOTE: Each heartbeat is normally represented as 5 major waves: P, Q, R, S, and T. The Q, R,<br />
and S waves all represent the same portion of the heartbeat and are referred to as a unit: QRS<br />
complex. Occasionally, a 6th wave will appear. It is referred to as the U wave. Although it<br />
does not always appear, its presence is perfectly normal (see Figure 3-3).<br />
3-72
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-3<br />
b. Observe for irregularities that are a result of artifact, interference, or equipment<br />
malfunction.<br />
(1) Check the patient's position.<br />
(2) Check the placement of the electrodes.<br />
(3) Obtain new equipment if necessary.<br />
(4) Repeat the EKG.<br />
c. Observe for irregularities of the heart's rhythm.<br />
(1) Notify the charge nurse or physician IMMEDIATELY if you note the presence of<br />
any of the life-threatening ventricular arrhythmias.<br />
NOTE: Ventricular arrhythmias are characterized by an ectopic (out of place) focus in the wall<br />
of the ventricle which initiates ventricular contraction. A distorted and prolonged QRS complex<br />
occurs as a result of the aberrant conduction pathway.<br />
(a) Ventricular Fibrillation. V-Fib is an irregular and chaotic ventricular<br />
arrhythmia characterized by a rapid rate and disorganized conduction of<br />
impulses throughout the ventricular myocardium. Death will occur within<br />
minutes without immediate defibrillation or initiation of CPR (see Figure 3-4).<br />
3-73
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-4<br />
(b) Ventricular Tachycardia. V-Tach is a ventricular arrhythmia characterized by<br />
broad QRS complexes and a regular rate that falls between 100 to 200 beats<br />
per minute. Immediate correction is essential, as V-Tach may lead to V-Fib<br />
(see Figure 3-5).<br />
Figure 3-5<br />
(c) Premature Ventricular Contractions (PVCs). PVCs occur when an ectopic<br />
focus in one of the ventricles initiates contraction of the ventricles. When this<br />
occurs, there will be no atrial contraction associated with that beat, and no P<br />
wave will be seen in front of the QRS complex. A PVC usually has a tall,<br />
broad QRS complex. PVCs that come from different focal points in the<br />
ventricle will have different shapes on the EKG. PVCs may be harmless, but<br />
they may also be the forerunners of V-Tach and V-Fib. For this reason, even<br />
occasional PVCs should be considered important. PVCs are considered life<br />
threatening when they are frequent (more than 6 per minute), when they<br />
occur in groups of two or more (back-to-back), when they are multi-focal, and<br />
when they occur in a pattern of every other beat or every third beat<br />
(bigeminy, trigeminy) (see Figure 3-6).<br />
3-74
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-6<br />
(2) Notify the charge nurse or physician of any other irregularities of the heart's<br />
rhythm after you have completed the tracing, but before you remove the<br />
electrodes from the patient. (A second tracing may be ordered.)<br />
7. Calculate the heart rate and report any abnormalities.<br />
a. Time is measured on the horizontal axis of the EKG graph paper (see Figure 3-7).<br />
Figure 3-7<br />
(1) Each small box = 0.04 seconds.<br />
(2) Each large box = 5 small boxes = 0.20 seconds.<br />
(3) 5 large boxes = 1.0 second = 1 inch of graph paper.<br />
(4) 300 large boxes = 60 seconds = 1 minute.<br />
3-75
STP 8-91W15-SM-TG<br />
b. Calculate the heart rate using one of the following methods:<br />
(1) Count the number of large boxes between any two R waves and divide that<br />
number into 300. Example: 300 divided by 5 large boxes = 60.<br />
(2) Count the number of R waves in a 6 second strip and multiply by 10. Example: 6<br />
R waves X 10 = 60.<br />
c. Notify the nurse of irregularities.<br />
(1) Bradycardia--less than 60 beats per minute.<br />
(2) Tachycardia--more than 100 beats per minute.<br />
NOTE: Paper speed must be set on the normal (25 mm/sec) setting.<br />
8. Remove the electrodes.<br />
a. Remove all the chest and limb electrodes.<br />
b. Wipe the patient's skin with a damp towel to remove the excess electrode paste.<br />
NOTE: Instruct the patient to wash with soap and water as soon as convenient to avoid skin<br />
irritation from the EKG paste.<br />
9. Ask or assist the patient to dress.<br />
10. Prepare the report.<br />
a. Remove the EKG tracing from the machine.<br />
b. Mark the EKG tracing printout with the patient's identification.<br />
c. Attach the completed OF 520 to the EKG tracing printout.<br />
d. Make proper distribution of the report as directed by the physician's orders or IAW<br />
local SOP.<br />
11. Store the equipment.<br />
a. Dispose of used electrodes IAW local SOP.<br />
b. Restock the machine with EKG paper, electrodes, alcohol prep pads, towels, and<br />
drapes, as necessary.<br />
c. Store the machine in the area and manner directed by local policy.<br />
12. Document the procedure and significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
Performance Measures GO NO<br />
GO<br />
1. Prepared the equipment. —— ——<br />
2. Prepared the patient. —— ——<br />
3. Applied the limb electrodes. —— ——<br />
4. Applied the chest electrodes. —— ——<br />
5. Obtained the EKG tracing. —— ——<br />
6. Assessed the EKG tracing. —— ——<br />
7. Calculated the heart rate. —— ——<br />
8. Removed the electrodes. —— ——<br />
9. Asked or assisted the patient to dress. —— ——<br />
3-76
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
10. Prepared the report. —— ——<br />
11. Stored the equipment. —— ——<br />
12. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-77
STP 8-91W15-SM-TG<br />
Subject Area 4: Respiratory Dysfunction/Airway Management<br />
INSERT AN OROPHARYNGEAL AIRWAY (J TUBE)<br />
081-833-0016<br />
Conditions: You are assessing an unconscious casualty who requires insertion of an<br />
oropharyngeal airway. Necessary materials and equipment: three sizes of oropharyngeal<br />
airways, gloves, and gauze pads or tongue blades.<br />
Standards: Inserted the correct size of oropharyngeal airway and made it functional without<br />
causing further injury to the casualty.<br />
Performance Steps<br />
WARNING: Use an oropharyngeal airway for an unconscious casualty only. Do not use it on a<br />
conscious or semiconscious casualty because he or she may still have a gag reflex.<br />
1. Select the correct size of airway.<br />
a. Position the casualty's jaw in a normal closed mouth position.<br />
b. Place the airway beside the outside of the casualty's jaw.<br />
c. Ensure that the airway reaches from the corner of the casualty's mouth to the ear lobe.<br />
NOTE: The measurement from the ear lobe to the corner of the casualty's mouth is equivalent<br />
to the depth of insertion in the airway.<br />
2. Perform head-tilt/chin-lift to open the airway. (See task 081-831-0018.)<br />
WARNING: If a neck or spinal injury is suspected, use the jaw thrust method to open the<br />
airway.<br />
3. Open the casualty's mouth.<br />
WARNING: Wear gloves for self-protection against transmission of contaminants whenever<br />
handling body fluids.<br />
a. Place the crossed thumb and index finger of one hand on the casualty's upper and<br />
lower teeth at the corner of the mouth.<br />
b. Use a scissors motion to pry the casualty's teeth apart.<br />
NOTE: If the teeth are clenched, wedge the index finger behind the casualty's back molars to<br />
open the mouth.<br />
4. Insert the airway.<br />
a. Place the tip end of the airway into the casualty's mouth over the tongue.<br />
b. Point the tip up toward the roof of the mouth.<br />
c. Slide the J tube along the roof of the mouth. Follow the natural curvature of the tongue<br />
past the soft palate.<br />
d. Rotate the airway 180° as the tip reaches the back of the tongue.<br />
NOTE: The airway may be difficult to insert. If so, use a gauze pad to pull the tongue forward<br />
or a tongue blade to depress the tongue.<br />
e. Gently advance the airway and adjust it so the flange rests on the casualty's lips.<br />
NOTES: 1. The tip of the airway should rest just above the epiglottis. 2. If the flange of the<br />
airway did not seat correctly on the lips or if the casualty gags, the airway may be the wrong<br />
size. Repeat the procedure using a different airway.<br />
WARNING: If the casualty starts to regain consciousness and gags or vomits, remove the<br />
airway immediately.<br />
3-78
STP 8-91W15-SM-TG<br />
Performance Steps<br />
5. Evacuate the casualty.<br />
NOTE: The airway may need to be taped or tied in place to avoid dislodgement during<br />
evacuation. If so, the casualty must be constantly monitored for the return of consciousness.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, use a CPR mannequin capable of accepting an<br />
oropharyngeal airway.<br />
Brief soldier: Tell the soldier that the simulated casualty is unconscious and breathing. Tell the<br />
soldier to insert an oropharyngeal airway.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected the correct size of airway. —— ——<br />
2. Performed head-tilt/chin-lift. —— ——<br />
3. Opened the casualty's mouth. —— ——<br />
4. Inserted the airway. —— ——<br />
5. Evacuated the casualty. —— ——<br />
6. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-79
STP 8-91W15-SM-TG<br />
SET UP AN OXYGEN TANK<br />
081-833-0018<br />
Conditions: A patient care handwash has been performed. Necessary materials and<br />
equipment: full oxygen cylinders, nonsparking cylinder wrench, cylinder regulators, flowmeters<br />
for E and M tanks, yoke attachment, humidifier, sterile water, administration device, and warning<br />
signs.<br />
Standards: Set up the oxygen tank without violating safety precautions or endangering patients<br />
or oneself.<br />
Performance Steps<br />
1. Obtain the necessary equipment.<br />
a. Oxygen tank (cylinder). (See Figure 3-8.)<br />
Figure 3-8<br />
NOTE: Check the oxygen cylinder tag to determine whether the tank is "FULL", "IN USE"<br />
(partially full), or "EMPTY". (See Figure 3-9.)<br />
CAUTION: Always ensure that the tank selected contains oxygen and not some other gas.<br />
United States oxygen tanks are color coded (painted) green. The international color code is<br />
white.<br />
3-80
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-9<br />
b. Cylinder regulator with flowmeter. (See Figure 3-10.)<br />
Figure 3-10<br />
NOTES: 1. When the cylinder regulator pressure gauge reads 200 psi or lower, the oxygen<br />
tank is considered empty. 2. The pressure-compensated flowmeter is affected by gravity and<br />
must be maintained in an upright position. The Bourdon gauge flowmeter is not affected by<br />
gravity and can be used in any position.<br />
c. Humidifier.<br />
d. Sterile water.<br />
e. Nonsparking cylinder wrench.<br />
f. Oxygen tank transport carrier and/or stand.<br />
g. Oxygen delivery device ordered by the physician (nasal cannula or mask).<br />
h. Warning signs.<br />
(1) "NO SMOKING.<br />
(2) "OXYGEN IN USE".<br />
3-81
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Because of the extreme pressure in oxygen tanks, they should be handled with<br />
great care. Do not allow tanks to be banged together, dropped, or knocked over.<br />
2. Secure the oxygen cylinder.<br />
a. Upright position or IAW local SOP.<br />
b. Secured with straps or in a stand.<br />
c. Away from doors and areas of high traffic.<br />
3. Remove the cylinder valve cap.<br />
NOTE: The cylinder valve cap may be noisy or difficult to remove. However, the threads of the<br />
cylinder cap should never be oiled.<br />
5. Use either the handwheel or a nonsparking wrench to "crack" (slowly open and quickly<br />
close) the cylinder to flush out any debris.<br />
6. Attach the regulator to the cylinder.<br />
a. M cylinder.<br />
(1) Hold the gauge in an upright position.<br />
(2) Insert the cylinder regulator inlet into the oxygen cylinder's threaded outlet in an<br />
upright position.<br />
(3) Hand-tighten the inlet nut, located on the cylinder regulator, and then completely<br />
tighten the inlet nut with a nonsparking wrench. (See Figures 3-11 and 3-12.)<br />
Figure 3-11<br />
3-82
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-12<br />
(4) Open the valve to test for leaks, and then close it.<br />
NOTE: If there is a leak, check the regulator connection and obtain a new regulator and/or tank,<br />
if necessary.<br />
b. D or E cylinder.<br />
(1) Locate the three holes on the oxygen cylinder stem and ensure that an "O" ring is<br />
present. (See Figure 3-13.)<br />
Figure 3-13<br />
NOTE: If the "O" ring is not present, an oxygen leak will occur.<br />
(2) Examine the yoke attachment and locate the three corresponding pegs on the<br />
yoke attachment. (See Figure 3-14.)<br />
3-83
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-14<br />
(3) Slide the yoke attachment over the cylinder stem, ensuring that the pegs are<br />
seated in the proper holes.<br />
(4) Turn the vise-like screw on the side of the yoke attachment to secure it.<br />
(5) Open the valve to test for leaks, and then close it.<br />
NOTES: 1. If there is a leak, check the regulator connection and obtain a new regulator and/or<br />
tank, if necessary. 2. When in-wall oxygen is available, the flowmeter will be attached to the<br />
oxygen outlet as follows: a. Turn the flow adjusting valve of the flowmeter to the OFF position.<br />
b. Insert the flowmeter adapter into the opening outlet and press until a firm connection is<br />
made.<br />
7. Fill the humidifier bottle to the level indicated (about two-thirds full) with sterile water.<br />
8. Attach the humidifier to the flowmeter.<br />
NOTE: If an oxygen tube connector adapter is present, remove it from the flowmeter by turning<br />
the wing nut.<br />
a. Attach the humidifier to the flowmeter with the wing nut on the humidifier.<br />
NOTE: Not all humidifiers have "wing style nuts. Some have regular "bolt" style nuts.<br />
b. Secure the nut by hand-tightening it.<br />
NOTE: Humidifiers and tubing should be changed at least once every 24 hours (or more often<br />
IAW local SOP).<br />
10. Post warning signs.<br />
CAUTION: "OXYGEN" and "NO SMOKING" signs should be posted in the areas where oxygen<br />
is in use or stored.<br />
12. Report and/or record completion of the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Obtained the necessary equipment. —— ——<br />
2. Secured the oxygen cylinder. —— ——<br />
3-84
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
3. Removed the cylinder valve cap. —— ——<br />
4. Used either the handwheel or a nonsparking wrench to "crack" (slowly<br />
open and quickly close) the cylinder to flush out any debris.<br />
—— ——<br />
5. Attached the regulator to the cylinder. —— ——<br />
6. Filled the humidifier bottle to the level indicated (about two-thirds full) with<br />
sterile water.<br />
—— ——<br />
7. Attached the humidifier to the flowmeter. —— ——<br />
8. Attached the oxygen administration device. —— ——<br />
9. Posted warning signs. —— ——<br />
10. Reported and/or recorded completion of the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-85
STP 8-91W15-SM-TG<br />
INSERT A NASOPHARYNGEAL AIRWAY<br />
081-833-0142<br />
Conditions: You encounter a casualty with a reduced level of consciousness who requires an<br />
airway adjunct. The casualty has a gag reflex. Body substance isolation precautions have<br />
been taken. Necessary materials and equipment: gloves, nasopharyngeal airway, and waterbased<br />
lubricant.<br />
Standards: Inserted a nasopharyngeal airway without causing further injury to the casualty.<br />
Performance Steps<br />
1. Place the casualty supine with the head in a neutral position.<br />
CAUTION: Do not use the nasopharyngeal airway if there is clear fluid (cerebrospinal fluid -<br />
CSF) coming from the ears or nose. This may indicate a skull fracture.<br />
2. Select the appropriate size of airway using one of the following methods:<br />
a. Measure the airway from the patient's nostril to the earlobe.<br />
b. Measure the airway from the patient's nostril to the angle of the jaw.<br />
NOTE: Choosing the proper length ensures appropriate diameter. Standard adults sizes are<br />
34, 32, 30, and 28 French.<br />
3. Lubricate the tube with a water-based lubricant.<br />
CAUTION: Do not use a petroleum-based or non-water-based lubricant. These substances<br />
can cause damage to the tissues lining the nasal cavity and pharynx thus increasing the risk for<br />
infection.<br />
4. Insert the airway.<br />
a. Push the tip of the nose upward gently.<br />
b. Position the tube so that the bevel of the airway faces toward the septum.<br />
NOTE: Most nasopharyngeal airways are designed to be placed in the right nostril.<br />
c. Insert the airway into the nostril and advance it until the flange rests against the nostril.<br />
CAUTION: Never force the airway into the patient's nostril. If resistance is met, pull the tube<br />
out and attempt to insert it in the other nostril.<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the casualty. —— ——<br />
2. Measured and selected the appropriate size of airway. —— ——<br />
3. Lubricated the nasal airway. —— ——<br />
4. Fully inserted the airway —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
3-86
STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-87
STP 8-91W15-SM-TG<br />
ADMINISTER OXYGEN<br />
081-833-0158<br />
Conditions: You have a patient requiring oxygen therapy. Necessary materials and equipment:<br />
oxygen tank, pressure gauge, flowmeter, water, extension tubing, nonrebreather mask, and<br />
nasal cannula.<br />
Standards: Administered oxygen therapy using a nonrebreather mask or nasal cannula to<br />
assist patient breathing without causing further injury to the patient. Calculated the duration of<br />
flow of the oxygen cylinder.<br />
Performance Steps<br />
1. Explain the procedure to the patient.<br />
2. Prepare the equipment.<br />
a. Open the tank.<br />
b. Check for leaks.<br />
c. Check tank pressure.<br />
NOTE: The safe residual level is the level of the oxygen at which the tank should be replaced.<br />
The level has been established to be 200 pounds per square inch (psi).<br />
3. Position the casualty in the position of comfort in order to facilitate breathing unless<br />
contraindicated by the mechanism of injury.<br />
4. Determine the delivery device.<br />
NOTE: Humidifiers can be connected to flowmeters to provide moisture to dry oxygen. Oxygen<br />
can dry out mucous membranes with prolonged use. Humidified oxygen is usually more<br />
comfortable to patients and is particularly helpful for children and those patients who have<br />
COPD.<br />
a. A nonrebreather mask is the delivery system of choice for patients with signs of<br />
inadequate breathing, or who are cyanotic, have cool clammy skin, chest pain, severe<br />
injuries, or altered mental status. Go to step 5.<br />
b. Nasal cannula is appropriate for patients unable to tolerate the nonrebreather mask.<br />
Go to step 6.<br />
5. Apply the nonrebreather mask.<br />
a. Select the correct size of mask.<br />
NOTE: The apex of the mask should fit over the bridge of the patient's nose and extend to rest<br />
on the chin thereby covering the mouth and nose completely. Nonrebreather masks come in<br />
different sizes for adults, children, and infants.<br />
b. Attach the tubing to the regulator.<br />
c. Start the oxygen flow and adjust it to the prescribed rate of 12 liters/minute or greater.<br />
NOTE: The minimum flow is 8 liters/minute.<br />
d. Prefill the reservoir bag using your fingers to cover the connection between the mask<br />
and the reservoir, if applicable.<br />
e. Place the mask on the patient and adjust the straps.<br />
f. Instruct the patient to breathe normally.<br />
6. Apply the nasal cannula.<br />
a. Attach the tubing to the regulator.<br />
b. Adjust the oxygen flow to the prescribed rate of 6 liters/minute or less.<br />
3-88
STP 8-91W15-SM-TG<br />
Performance Steps<br />
c. Position the cannula so that the tips comfortably sit in the patient's nose.<br />
d. Adjust the nasal cannula to hold in place.<br />
7. Continue to assess the patient for confusion, restlessness, level of consciousness, color, or<br />
changes in vital signs.<br />
8. Check the equipment for security of tubing connections and administration device, oxygen<br />
flow, and humidifier water level as indicated.<br />
NOTE: Change the delivery device and tubing every 24 hours or more often IAW local SOP.<br />
Humidifier water should be changed every shift. The water reservoir can become a breeding<br />
ground for harmful bacteria.<br />
9. Calculate the duration of flow of the oxygen cylinder.<br />
a. Determine the remaining pressure in the tank by reading the regulator gauge.<br />
b. Determine the safe residual level of the oxygen tank.<br />
NOTE: The safe residual level is the level of oxygen at which the tank should be replaced. This<br />
level has been established to be 200 pounds per square inch (psi).<br />
c. Determine the available cylinder pressure by subtracting the safe residual level from<br />
the remaining pressure. Example: 2000 psi remaining pressure minus 200 psi safe<br />
residual level = 1800 psi available pressure.<br />
d. Determine the conversion factor for the oxygen cylinder in use.<br />
NOTE: Each type of oxygen cylinder, depending on its size, employs a specific conversion<br />
factor.<br />
(1) D size oxygen cylinder--0.16.<br />
(2) E size oxygen cylinder--0.28.<br />
(3) G size oxygen cylinder--2.41.<br />
(4) H size oxygen cylinder--3.14.<br />
(5) M size oxygen cylinder--1.56.<br />
e. Determine the available liters by multiplying the conversion factor by the amount of<br />
available pressure. Example: A "D" size cylinder is being used. A .16 conversion<br />
factor x 1800 psi available pressure = 288 liters of oxygen available for use.<br />
f. Determine the flow rate as prescribed by the physician's order.<br />
g. Determine the duration of the oxygen by dividing the available liters by the flow rate.<br />
Example: 288 available liters divided by the prescribed flow rate of 10 LPM = 28.8 (29)<br />
minutes duration of oxygen flow.<br />
10. Follow safety precautions.<br />
a. Post "OXYGEN" and "NO SMOKING" signs wherever oxygen is used or stored.<br />
b. Inform the patient and visitors about the restrictions.<br />
WARNING: The chief danger in using oxygen is fire. The presence of oxygen in increased<br />
concentrations makes all materials more combustible. Things that burn slowly in ordinary air<br />
will burn violently and even explosively in the presence of oxygen.<br />
c. Use only nonsparking wrenches on tanks.<br />
d. Ensure all electrical equipment is properly grounded.<br />
e. Position oxygen cylinders away from doors and high traffic areas.<br />
f. Do not use oil or grease around oxygen fittings.<br />
g. Secure oxygen cylinders in an upright position.<br />
3-89
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Explained the procedure to the patient. —— ——<br />
2. Prepared the equipment. —— ——<br />
3. Positioned the patient. —— ——<br />
4. Selected the proper delivery device. —— ——<br />
5. Applied the delivery device. —— ——<br />
6. Monitored the patient. —— ——<br />
7. Checked the equipment. —— ——<br />
8. Calculated the duration of flow of the oxygen cylinder. —— ——<br />
9. Followed safety precautions. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-90
STP 8-91W15-SM-TG<br />
INSERT A COMBITUBE<br />
081-833-0169<br />
Conditions: An unconscious, nonbreathing casualty requires the insertion of an esophageal<br />
tracheal Combitube. An assistant is performing resuscitative measures. No cervical spine<br />
injury is present. Necessary materials and equipment: Combitube, 50 cc syringe, 10 cc<br />
syringe, gloves, eye protection, suction equipment, stethoscope, and bag-valve-mask (BVM).<br />
Standards: Inserted the Combitube within 20 seconds and successfully ventilated the casualty<br />
without causing further injury.<br />
Performance Steps<br />
1. Oxygenate the casualty.<br />
a. Instruct the assistant to oxygenate the casualty using the BVM.<br />
b. Instruct the assistant to count aloud for 20 seconds while intubation is performed.<br />
c. At the end of 20 seconds, the assistant should immediately resume resuscitation if<br />
intubation is unsuccessful.<br />
2. Prepare the Combitube.<br />
a. Inspect the tube for breaks or cracks.<br />
b. Attach the large syringe to the pharyngeal (proximal) cuff and inflate it with 100 cc of<br />
air. Check for leaks and then deflate completely.<br />
c. Attach the small syringe to the tracheal (distal) cuff and inflate it with 15 cc of air.<br />
Check for leaks and then deflate completely.<br />
NOTE: If a leak is present, replace the tube.<br />
3. Put on gloves.<br />
4. Kneel just above the casualty's head facing the casualty's feet.<br />
NOTE: If casualty's neck has been hyperextended to open the airway, return it to a neutral<br />
position.<br />
5. Insert the tube.<br />
a. Have the assistant give the casualty two breaths and start counting for 20 seconds.<br />
b. Lift the jaw and tongue straight upward without hyperextending the neck.<br />
c. Pass the tube blindly following the pharyngeal curvature until the teeth are between<br />
the two black lines on the tube.<br />
CAUTION: Do not force the tube at any time.<br />
d. Use the large syringe to inflate the pharyngeal cuff with 100 cc of air. The device will<br />
seat itself in the posterior pharynx behind the hard palate.<br />
e. Use the small syringe to inflate the distal cuff with 10 to 15 cc of air.<br />
6. Ventilate the casualty and check tube placement.<br />
a. Attach the BVM device to the esophageal connector (marked #1).<br />
b. Attempt to ventilate and listen for the presence of breath sounds in the lungs and<br />
absence of sounds from the epigastrium.<br />
c. If there is an absence of breath sounds and presence of sounds in the epigastrium, the<br />
tube is in the trachea.<br />
d. Attach the BVM to the tracheal connector (marked #2) and ventilate the casualty.<br />
e. Listen for the presence of breath sounds.<br />
f. Continue to ventilate the casualty every 3 to 5 seconds.<br />
3-91
STP 8-91W15-SM-TG<br />
Performance Steps<br />
7. Remove the Combitube if the casualty regains consciousness or regains a gag reflex.<br />
a. Oxygenate the casualty with two slow breaths.<br />
b. Turn the casualty to one side.<br />
c. Deflate both cuffs.<br />
d. Withdraw the tube in one quick motion following the curve of the pharynx.<br />
e. Immediately clear the casualty's airway of any vomitus.<br />
NOTE: Suction should be readily available when removing a Combitube.<br />
Performance Measures GO NO<br />
GO<br />
1. Oxygenated the casualty. —— ——<br />
2. Prepared the tube. —— ——<br />
3. Put on gloves. —— ——<br />
4. Kneeled at the casualty's head. —— ——<br />
5. Inserted the tube within 20 seconds. —— ——<br />
6. Ventilated the casualty and checked placement. —— ——<br />
7. Removed the tube. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-92
STP 8-91W15-SM-TG<br />
PERFORM A NEEDLE CRICOTHYROIDOTOMY<br />
081-833-3006<br />
Conditions: You are in a field environment. A casualty has a total upper airway obstruction.<br />
The casualty's airway cannot be opened using manual methods or an endotracheal (ET) tube.<br />
Necessary materials and equipment: blanket, poncho, two large bore needles (10 to 14 gauge),<br />
povidone-iodine, 5 to 10 cc syringe, cannula-over-needle device (optional), gloves, and tape.<br />
Standards: Established an emergency airway without causing unnecessary injury to the<br />
casualty. Completed steps 3 through 8 in order.<br />
Performance Steps<br />
1. Hyperextend the casualty's neck.<br />
WARNING: Do not hyperextend the casualty's neck if a cervical injury is suspected.<br />
a. Place the casualty in a supine position.<br />
b. Place a blanket or poncho rolled up under the casualty's neck or between the shoulder<br />
blades so the airway is straight.<br />
2. Put on gloves, if available.<br />
3. Locate the cricothyroid membrane.<br />
a. Place a finger of the nondominant hand on the thyroid cartilage (Adam's apple) and<br />
slide the finger down to the cricoid cartilage.<br />
b. Palpate for the "V" notch of the thyroid cartilage.<br />
c. Slide the index finger down into the depression between the thyroid and cricoid<br />
cartilages.<br />
d. Prep the casualty's neck with povidone-iodine. Clean a 3 to 4 inch area using a<br />
circular motion, starting from the center and working outward.<br />
4. Stabilize the larynx.<br />
a. Place the thumb and index finger of the nondominant hand on each side of the larynx.<br />
b. Apply enough pressure to keep the larynx in place.<br />
WARNING: Holding the larynx too long or too tightly could cause the larynx to spasm or swell.<br />
5. Insert a large bore needle (10 to 14 gauge) into the cricothyroid membrane.<br />
a. Hold the needle with the point directed 45 degrees caudally.<br />
b. Insert the needle through the cricothyroid membrane until no resistance is met.<br />
CAUTIONS: 1. This procedure is more risky on a casualty with a large thick neck or one who<br />
has a tendency to bleed readily. 2. If resistance is met after having passed through the<br />
cricothyroid membrane, the needle has punctured the other side of the tracheal cartilage.<br />
c. Once the needle has penetrated the cricothyroid membrane, direct the needle inside<br />
the larynx downward and posteriorly to avoid penetration of the esophagus.<br />
NOTE: This procedure may be varied by using a cannula-over-needle device. The catheter is<br />
advanced into the larynx.<br />
6. Listen and feel for free airflow through the needle.<br />
7. Insert a second needle, if necessary, and recheck for air flow. (If the airway formed by the<br />
first needle is not sufficient, a second needle may be inserted next to the first one following<br />
the procedure in step 5.)<br />
NOTE: If air does not flow through the cricothyroidotomy needles, a surgical cricothyroidotomy<br />
must be performed. (See task 081-833-3005.) No more than two needles will be inserted.<br />
3-93
STP 8-91W15-SM-TG<br />
Performance Steps<br />
8. Stabilize the needle(s).<br />
a. Wrap a 6 to 8 inch strip of tape around the needles one time where they exit the skin.<br />
b. Press the ends of the tape to the skin so they do not come off and so the needles are<br />
held in place.<br />
NOTE: Adequate ventilation of the casualty cannot be maintained simply by establishing an<br />
airway through the use of a needle cricothyroidotomy. The plunger of a syringe may be<br />
removed and mouth to barrel ventilation may be used. If equipment is available, the casualty<br />
can be ventilated using an ambu bag or oxygen. Approximately 12 respirations per minute<br />
should be administered.<br />
9. Keep the casualty's head immobilized.<br />
NOTE: If an airway needs to be artificially maintained for a prolonged period of time, and<br />
endotracheal intubation is not possible, perform a surgical cricothyroidotomy or tracheostomy.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, use a mannequin or have another soldier act as the<br />
casualty. Under no circumstances will the needle be inserted in another soldier. Have the<br />
soldier demonstrate and explain what he or she would do.<br />
Brief soldier: Tell the soldier to perform a needle cricothyroidotomy.<br />
Performance Measures GO NO<br />
GO<br />
1. Hyperextended the casualty's neck. —— ——<br />
2. Put on gloves, if available. —— ——<br />
3. Located the cricothyroid membrane. —— ——<br />
4. Stabilized the larynx. —— ——<br />
5. Inserted a large bore needle into the cricothyroid membrane. —— ——<br />
6. Listened and felt for free airflow through the needle. —— ——<br />
7. Inserted a second needle, if necessary and rechecked for air flow. (If the<br />
airway formed by the first needle is not sufficient, a second needle may be<br />
inserted next to the first one following the procedure in step 5.)<br />
—— ——<br />
8. Stabilized the needle(s). —— ——<br />
9. Completed steps 3 through 8 in order. —— ——<br />
10. Kept the casualty's head immobilized. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
3-94
STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-95
STP 8-91W15-SM-TG<br />
PERFORM NEEDLE CHEST DECOMPRESSION<br />
081-833-3007<br />
Conditions: You have a conscious, breathing casualty with chest trauma who requires needle<br />
chest decompression. Necessary materials and equipment: stethoscope, large bore needle (10<br />
to 14 gauge), 35 to 60 cc Luer-Lock syringe with 3-way stopcock, povidone-iodine swab, sterile<br />
gloves, and Field Medical Card.<br />
Standards: Completed all the steps necessary to perform a needle chest decompression in<br />
order, without causing unnecessary injury to the casualty.<br />
Performance Steps<br />
NOTE: Pneumothorax is defined as the presence of air within the pleural space. Air may enter<br />
the pleural cavity either from the lungs through a rupture, laceration, or from the outside through<br />
a sucking chest wound. Trapped air in the pleural space compresses the lung beneath it.<br />
Unrelieved pressure will push the contents of the mediastinum in the opposite direction, away<br />
from the side of the tension pneumothorax. This, in turn, will compromise venous return to the<br />
heart and interfere with respiration.<br />
1. Verify the presence of tension pneumothorax by checking for indications of the condition.<br />
WARNING: Correct assessment is essential. Insertion of a needle into the pleural space of a<br />
nonaffected person will result in pneumothorax.<br />
a. Question a conscious casualty about difficulty in breathing, pain on the affected side,<br />
or coughing up blood.<br />
b. Observe a bared anterior chest and upper abdomen for respiratory rate and depth.<br />
c. Look for mediastinal shift manifested as a tracheal deviation and/or jugular distension.<br />
d. Look and listen for gasping for air (dyspnea) and progressive respiratory distress.<br />
NOTE: Dyspnea may be, but is not always, an indication of pneumothorax.<br />
e. Look at and feel the patient's chest for signs of subcutaneous emphysema.<br />
f. Check for lack of chest excursion.<br />
(1) Observe the rising and falling of the chest on respiration.<br />
(2) Compare chest excursion bilaterally.<br />
g. Look for unilateral distension.<br />
(1) Place one hand on the affected side.<br />
(2) Place the other hand on the unaffected side.<br />
(3) Observe the height of each hand.<br />
(4) Determine if the height of the hand on the affected side is greater during<br />
expiration than the height of the hand on the unaffected side.<br />
h. Use a stethoscope to listen to breath sounds.<br />
(1) Compare the sides for equality.<br />
(2) Auscultate both sides of the chest.<br />
(3) If breath sounds are unequal, percuss both sides to determine the difference in<br />
tone.<br />
NOTE: Breath sounds will be diminished or absent on the affected side.<br />
i. Check for progressive distension of the abdomen that is not relieved by gastric<br />
aspiration and endotracheal intubation.<br />
j. Look for deep cyanosis.<br />
k. Look for signs and symptoms of shock.<br />
3-96
STP 8-91W15-SM-TG<br />
Performance Steps<br />
2. Locate the insertion site. Locate the second intercostal space (between the second and<br />
third ribs) at the midclavicular line (approximately in line with the nipple) on the affected<br />
side of the patient's chest.<br />
3. Thoroughly cleanse a 3 to 4 inch area around the insertion site. Begin in the center and<br />
work outward using a circular motion.<br />
4. Insert a large bore (10 to 14 gauge) needle with attached syringe.<br />
a. Place the needle tip, bevel up, on the insertion site (2nd intercostal space,<br />
midclavicular line).<br />
b. Lower the proximal end of the needle to permit the tip to enter the skin just above the<br />
third rib margin.<br />
c. Firmly insert the needle into the skin over the third rib, until the pleura has been<br />
penetrated, as evidenced by feeling a "pop" as the needle enters the pleural space.<br />
WARNING: Proper positioning of the needle is essential to avoid puncturing blood vessels<br />
and/or nerves.<br />
5. Decompress the affected side by aspirating as much air as is necessary to relieve the<br />
patient's acute symptoms.<br />
NOTES: 1. If you are using a catheter-over-needle, hold the needle still and push the catheter<br />
into the plural space until resistance is felt. Withdraw the needle along the angle of insertion<br />
while holding the catheter still. 2. If you are using a three-way stopcock, additional air can be<br />
aspirated from the plural cavity by turning the stopcock lever to allow expulsion of the air from<br />
the syringe.<br />
6. Initiate closed chest drainage with underwater seal, if available. Proceed to step 7 if<br />
improvisation is required.<br />
7. If an underwater seal drainage is not available, use a commercial one-way flutter valve or<br />
improvise one.<br />
a. Cut a finger casing from a sterile glove.<br />
b. Cut off the finger tip.<br />
c. Tie or tape the finger casing to the needle hub.<br />
d. Check the operation of the improvised flutter valve.<br />
(1) Ensure that air passes through the needle-valve assembly and improvised flutter<br />
valve on expiration.<br />
(2) Ensure that the flutter valve collapses against itself on inspiration.<br />
NOTE: This will prevent air from entering the pleural cavity.<br />
8. Secure the needle or catheter to the chest.<br />
9. Record the treatment on the Field Medical Card.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, use a mannequin or have another soldier act as the<br />
casualty. Under no circumstances will the needle be inserted. Have the soldier demonstrate<br />
and explain what he or she would do.<br />
Brief soldier: Tell the soldier to perform needle chest decompression.<br />
3-97
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Verified the presence of tension pneumothorax. —— ——<br />
2. Located the insertion site. —— ——<br />
3. Thoroughly cleaned the area. —— ——<br />
4. Inserted a large bore needle. —— ——<br />
5. Decompressed the affected chest. —— ——<br />
6. Initiated closed chest drainage or applied a flutter valve. —— ——<br />
7. Secured the needle or catheter to the chest. —— ——<br />
8. Recorded the treatment on the Field Medical Card. —— ——<br />
9. Completed all steps in order. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-98
STP 8-91W15-SM-TG<br />
Subject Area 5: Venipuncture and IV Therapy<br />
OBTAIN A BLOOD SPECIMEN USING A VACUTAINER<br />
081-833-0032<br />
Conditions: Necessary materials and equipment: blood specimen tubes, constricting band,<br />
vacutainer adapter, vacutainer needles, disinfectant pads, sterile 2 x 2 gauze sponges, betadine<br />
or alcohol, adhesive bandage strips, protective pad, labels, and gloves.<br />
Standards: Obtained a blood specimen without causing injury to the patient or violating aseptic<br />
technique.<br />
Performance Steps<br />
1. Verify the request to obtain a blood specimen. Select the proper blood specimen tube for<br />
the test to be performed.<br />
2. Label the blood specimen tube with the information necessary to identify the patient.<br />
3. Perform a patient care handwash.<br />
WARNING: Gloves should be worn for self-protection against transmission of contaminants<br />
whenever handling body fluids.<br />
4. Assemble the vacutainer adapter, the needle, and the blood specimen tube.<br />
a. Inspect the needle for nicks or barbs. Replace the needle if it is flawed or dull.<br />
b. Insert the rubber stoppered end of the specimen tube into the vacutainer holder and<br />
advance the tube until it is even with the guideline.<br />
NOTE: The needle is now partially imbedded into the stopper. If the tube is pushed beyond the<br />
guideline, the vacuum of the tube may be broken.<br />
5. Identify the patient.<br />
a. Ask the patient his or her name and compare the name to the bed card and<br />
identification band or tags.<br />
b. If the specimen is being obtained from an outpatient, identify the patient by asking his<br />
or her name and comparing the name with the medical records or the laboratory<br />
request.<br />
NOTE: Ask the patient about allergies to such things as iodine or alcohol.<br />
6. Explain the procedure and purpose for collecting the blood specimen to the patient.<br />
7. Position the patient.<br />
a. Assist the patient into a comfortable sitting or lying position.<br />
WARNING: Never attempt to draw blood from a standing patient.<br />
b. The patient should be positioned so the arm is well supported and stabilized by using a<br />
pillow, table, or other flat surface.<br />
c. Place a protective pad under the elbow and forearm.<br />
8. Expose the area for venipuncture.<br />
9. Select and palpate one of the prominent veins in the bend of the arm (antecubital space).<br />
a. The first choice is the median cubital vein. It is well supported and least apt to roll.<br />
b. The second choice is the cephalic vein.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
c. The third choice is the basilic vein. Although it is often the most prominent, it tends to<br />
roll easily and makes venipuncture difficult.<br />
WARNINGS: 1. Avoid veins that are infected, irritated, injured, or have an IV running distal to<br />
the proposed venipuncture site. 2. Do not use the vacutainer to draw blood from small or<br />
fragile veins, because this can cause the vein walls to collapse. Use a needle and syringe<br />
instead.<br />
10. Prepare the sponges for use.<br />
a. Open the betadine or alcohol and 2 X 2 gauze sponge packages.<br />
b. Place them within easy reach (still in the packages).<br />
11. Apply the constricting band with enough pressure to stop venous return without stopping<br />
the arterial flow (a radial pulse will be present).<br />
a. Wrap latex tubing around the limb approximately 2 inches above the proposed<br />
venipuncture site.<br />
b. Stretch the tubing slightly and pull one end so that it is longer than the other.<br />
c. Form a loop with the longer end and draw the loop under the shorter end so that the<br />
tails of the tubing are turned away from the proposed site.<br />
NOTE: If a commercial band is used, wrap it around the limb as in step 11a and then secure<br />
the band by overlapping the Velcro ends.<br />
d. Instruct the patient to form a fist, clench and unclench several times, and then hold the<br />
fist in a clenched position.<br />
12. Palpate the selected vein lightly with the index finger, moving an inch or two in either<br />
direction so that the size and direction of the vein can be determined. The vein should feel<br />
like a spongy tube.<br />
13. With a disinfectant soaked pad, cleanse the area around the puncture site using an<br />
outward circular motion.<br />
CAUTION: After cleansing the skin, do not repalpate the area.<br />
WARNING: Do not leave the constricting band on for more than 2 minutes.<br />
14. Prepare to puncture the vein.<br />
a. Grasp the vacutainer unit and remove the protective needle cover.<br />
b. Position the needle directly in line with the vein. Using the free hand, grasp the<br />
patient's arm below the expected point of entry.<br />
c. Place the thumb of the free hand approximately 1 inch below the expected point of<br />
entry and pull the skin taut toward the hand.<br />
15. Puncture the vein.<br />
a. Place the needle, bevel up, in line with the vein and pierce the skin at a 15 to 30<br />
degree angle.<br />
b. Decrease the angle until the needle is almost parallel to the skin surface. Direct it<br />
toward the vein and pierce the vein wall.<br />
NOTE: A faint "give" will be felt when the vein is entered and blood will appear in the hub of the<br />
needle.<br />
(1) If the venipuncture is unsuccessful, pull the needle back slightly (not above the<br />
skin surface) and attempt to pierce the vein again.<br />
CAUTION: If the needle is withdrawn above the skin surface, quickly release the constricting<br />
band and stop the procedure. Begin again with a new needle.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(2) If the venipuncture is still unsuccessful, release the constricting band, place a<br />
gauze sponge lightly over the site, quickly withdraw the needle, and immediately<br />
apply pressure to the site.<br />
(3) Notify the supervisor before attempting to enter another vein.<br />
c. Instruct the patient to unclench the fist.<br />
16. Collect the specimen.<br />
a. Single specimen sample.<br />
(1) With the dominant hand, hold the vacutainer unit and the needle steady.<br />
(2) Place the index and middle fingers of the free hand behind the flange of the<br />
vacutainer and ease the tube as far forward as possible. Blood will enter the tube.<br />
WARNING: If the unit and needle are not held steady while pushing in the tube, the needle<br />
may either slip out of the vein or puncture the opposing vein wall.<br />
(3) After the tube is approximately two-thirds full of blood or the flow of blood stops,<br />
prepare to withdraw the needle.<br />
b. Multiple specimen samples (multiple tubes).<br />
(1) Follow steps 16a(1) and 16a(2) for collecting a single specimen.<br />
(2) Remove the first tube and insert another tube into the vacutainer.<br />
(3) Repeat this procedure until the desired number of tubes are filled or blood stops<br />
flowing.<br />
(4) Release the constricting band using the nondominant hand.<br />
(5) After the last tube is approximately two-thirds full of blood or the flow stops,<br />
prepare to withdraw the needle.<br />
NOTE: If the blood flow starts to slow down between samples, remove the constricting band.<br />
17. Withdraw the needle.<br />
a. Release the constricting band by pulling on the long, looped end of the tubing or<br />
pulling the Velcro fasteners open.<br />
WARNING: Never withdraw the needle prior to removing the constricting band because this will<br />
cause blood to be forced out of the venipuncture site with resulting blood loss and/or hematoma<br />
formation.<br />
b. Place a gauze sponge lightly over the venipuncture site.<br />
c. Keeping the patient's arm fully extended, withdraw the needle smoothly and quickly.<br />
Immediately apply firm manual pressure over the venipuncture site with the sponge.<br />
d. Instruct the patient to elevate the arm slightly and keep the arm fully extended.<br />
Continue to apply firm manual pressure to the site for 2 to 3 minutes.<br />
18. Remove the specimen tube from the vacutainer.<br />
a. Replace the protective cover over the needle.<br />
NOTE: Dispose of the uncapped needle IAW local SOP.<br />
WARNING: If accidentally punctured by a used needle, force the puncture site to bleed, wash it<br />
thoroughly, and report the incident to your supervisor immediately.<br />
b. Pull the tube from the vacutainer.<br />
c. If the tube contains an anticoagulant, gently invert the tube several times to mix it with<br />
the blood.<br />
19. Apply an adhesive bandage strip to the venipuncture site after the bleeding has stopped.<br />
Adhesive bandage strips do not take the place of pressure and therefore, are not applied<br />
until the bleeding has stopped.<br />
20. Provide for the patient's safety and comfort.<br />
a. Remove the protective pad.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Assist the patient to assume a comfortable position.<br />
21. Dispose of and/or store the equipment.<br />
a. Collect all the equipment and remove it from the area.<br />
b. Place the used gauze sponge, alcohol or betadine sponge, and the protective pad in<br />
the trash receptacle.<br />
c. Store the constricting band and vacutainer adapter IAW local SOP and dispose of the<br />
needle and syringe IAW local SOP.<br />
22. Remove the gloves.<br />
23. Perform a patient care handwash.<br />
24. Complete the laboratory request.<br />
a. Patient identification.<br />
b. Requesting physician's name.<br />
c. Ward number, clinic, or dispensary.<br />
d. Date and time of specimen collection.<br />
e. Test(s) requested.<br />
f. Specimen source--blood.<br />
g. Remarks. Write in the admission diagnosis or the type of surgery in this section.<br />
h. Complete the "urgency" box. (Routine, today, preop, STAT, or ASAP.)<br />
NOTE: There are many lab request slips which are used for requesting specific blood tests. All<br />
slips must be checked for the minimum information, as given.<br />
25. Forward the specimen to the laboratory.<br />
a. Attach the lab request to the specimen tube(s) with a rubber band or paper clip.<br />
NOTE: Ensure that the lab requests and blood tubes are appropriately labeled with infectious<br />
warning labels IAW local SOP.<br />
b. Arrange for the specimen to be sent to the lab or transport the specimen to the lab<br />
IAW local SOP.<br />
26. Perform a patient care handwash.<br />
27. Record the procedure on the appropriate form.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected the proper blood specimen tube. —— ——<br />
2. Labeled the blood specimen tube. —— ——<br />
3. Performed a patient care handwash. —— ——<br />
4. Assembled the vacutainer unit, needle, and blood specimen tube. —— ——<br />
5. Identified the patient. —— ——<br />
6. Explained the procedure and purpose for collecting the blood. —— ——<br />
7. Positioned the patient. —— ——<br />
8. Exposed the venipuncture site. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
9. Selected and palpated the vein. —— ——<br />
10. Prepared sponges for use. —— ——<br />
11. Applied the constricting band. —— ——<br />
12. Palpated the selected vein. —— ——<br />
13. Cleaned the venipuncture site. —— ——<br />
14. Prepared to puncture the vein. —— ——<br />
15. Punctured the vein. —— ——<br />
16. Collected the specimen. —— ——<br />
17. Withdrew the needle. —— ——<br />
18. Removed the specimen tube from the vacutainer. —— ——<br />
19. Applied an adhesive bandage strip to the site. —— ——<br />
20. Provided for the patient's safety and comfort. —— ——<br />
21. Disposed of and/or stored equipment. —— ——<br />
22. Removed the gloves. —— ——<br />
23. Performed a patient care handwash. —— ——<br />
24. Completed the laboratory request. —— ——<br />
25. Forwarded the specimen to the laboratory. —— ——<br />
26. Performed a patient care handwash. —— ——<br />
27. Recorded the procedure on the appropriate form. —— ——<br />
28. Did not violate aseptic technique. —— ——<br />
29. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-103
STP 8-91W15-SM-TG<br />
INITIATE AN INTRAVENOUS INFUSION<br />
081-833-0033<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: IV injection set, IV solution, needle or catheter-over-needle, constricting band,<br />
antiseptic sponges, 2 x 2 gauze sponges, tape, IV stand or substitute, armboard, and gloves.<br />
Standards: Initiated an intravenous infusion without causing further injury or unnecessary<br />
discomfort to the patient. Did not violate aseptic technique.<br />
Performance Steps<br />
1. Identify the patient and explain the procedure.<br />
a. Ask the patient's name.<br />
b. Check the identification band against the patient's chart, as appropriate.<br />
c. Explain the reason for IV therapy.<br />
d. Explain the procedure and caution the patient against manipulating the equipment.<br />
e. Ask about any known allergies to such things as betadine or medication.<br />
f. Reassure the patient that this is a common procedure.<br />
2. Select and inspect the equipment for defects, expiration date, and contamination.<br />
a. IV fluid of choice (check doctor's orders, as appropriate). Discard containers that have<br />
cracks, scratches, leaks, sedimentation, condensation, or fluid which is not crystal<br />
clear and colorless.<br />
b. IV injection set.<br />
(1) Spike, drip chamber, tubing, and needle adapter. Discard them if there are cracks<br />
or holes or if any discoloration is present.<br />
(2) Tubing clamp. Ensure that the clamp releases and catches.<br />
(3) Needle or catheter-over-needle. Discard them if they are flawed with barbs or<br />
nicks.<br />
NOTE: Place the stand to the side of the patient and close to the IV site.<br />
3. Prepare the equipment.<br />
a. Clamp the tubing 6 to 8 inches below the drip chamber.<br />
b. Remove the protective covers from the spike and from the outlet of the IV container.<br />
CAUTION: Do not touch the spike or the outlet of the IV container.<br />
c. Insert the spike into the container.<br />
(1) If using a bag, push the spike firmly into the container's outlet tube.<br />
(2) If using a bottle, push the spike firmly through the container's diaphragm.<br />
CAUTION: If no vacuum release sound is heard when puncturing bottled solution, discard the<br />
solution. Bagged solution makes no vacuum release sound.<br />
d. Hang the container at least 2 feet above the level of the patient's heart, if possible.<br />
NOTE: An IV bag container may be placed under the patient's body if there is no way to hang<br />
it.<br />
e. Squeeze the drip chamber until it is half full of the IV fluid.<br />
f. Prime the tubing.<br />
NOTE: Ensure that all air is expelled from the tubing.<br />
(1) Hold the tubing above the level of the bottom of the container.<br />
(2) Loosen the protective cover from the needle adapter to allow the air to escape.<br />
(3) Release the clamp on the tubing.<br />
3-104
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) Gradually lower the tubing until the solution reaches the end of the needle<br />
adapter.<br />
(5) Clamp the tubing.<br />
(6) Retighten the needle adapter's protective cover.<br />
(7) Loop the tubing over the IV stand or holder.<br />
g. Cut several pieces of tape and hang them in a readily accessible place.<br />
4. Select the infusion site.<br />
a. Put on gloves for body substance isolation.<br />
b. Choose the most distal and accessible vein of an uninjured arm or hand.<br />
c. Avoid sites over joints.<br />
d. Avoid veins in infected, injured, or irritated areas.<br />
e. Use the nondominant hand or arm, whenever possible.<br />
CAUTION: Do not use an arm that may require an operative procedure.<br />
f. Select a vein large enough to accommodate the size of needle/catheter to be used.<br />
5. Prepare the infusion site.<br />
a. Apply the constricting band.<br />
NOTE: When applying the constricting band, use soft-walled latex tubing about 18 inches in<br />
length.<br />
(1) Place the tubing around the limb, about 2 inches above the site of venipuncture.<br />
Hold one end so that it is longer than the other, and form a loop with the longer<br />
end.<br />
(2) Pass the looped end under the shorter end of the constricting band.<br />
NOTE: When placing the constricting band, ensure that the tails of the tubing are turned away<br />
from the proposed site of venipuncture.<br />
(3) Apply the constricting band tight enough to stop venous flow but not so tightly that<br />
the radial pulse cannot be felt.<br />
(4) Tell the patient to open and close his or her fist several times to increase<br />
circulation.<br />
CAUTION: Do not leave the constricting band in place for more than 2 minutes.<br />
b. Select a prominent vein.<br />
NOTES: 1. Wet the area with germicide to facilitate palpation of the vein with the fingertips.<br />
Touch the distended vein with the fingertips and estimate tissue support. 2. If the vein rolls,<br />
select another vein.<br />
c. Tell the patient to close his or her fist and keep it closed until instructed to open the<br />
fist.<br />
d. Clean the skin over the selected area with 70% alcohol or betadine, using a firm<br />
circular motion from the center outward.<br />
e. Allow the skin to dry and discard the gauze.<br />
f. Put on gloves for self-protection against transmission of contaminants.<br />
6. Prepare to puncture the vein.<br />
a. Pick up the assembled needle and remove the protective cover with the other hand.<br />
(1) Ensure the needle is bevel up.<br />
(2) Place the forefinger on the needle hub to guide it during insertion through the skin<br />
and into the vein.<br />
b. Position yourself so as to have a direct line of vision along the axis of the vein to be<br />
entered.<br />
7. Puncture the vein.<br />
3-105
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Keep the needle at the same angle to prevent through-and-through penetration of<br />
the vein walls.<br />
NOTE: You may position the needle directly above the vein or slightly to one side of the vein.<br />
a. Draw the skin below the cleaned area downward to hold the skin taut over the site of<br />
venipuncture.<br />
b. Position the needle point, bevel up, parallel to the vein and about 1/2 inch below the<br />
site of venipuncture.<br />
c. Hold the needle at a 20 to 30 degree angle and insert it through the skin.<br />
d. Decrease the angle of the needle until it is almost parallel to the skin surface and direct<br />
it toward the vein.<br />
e. Move the needle forward about 1/2 inch into the vein.<br />
8. Confirm the puncture.<br />
NOTE: A faint "give" will be felt as the needle enters the lumen of the vein.<br />
a. Check for blood in the flash chamber. If successful, proceed to step 9.<br />
b. If the venipuncture is unsuccessful, pull the needle back slightly (not above the skin<br />
surface) and attempt to pierce the vein again.<br />
c. If the venipuncture is still unsuccessful, release the constricting band and tell the<br />
patient to open and relax his or her clinched fist.<br />
(1) Place a sponge lightly over the site and quickly withdraw the needle.<br />
(2) Immediately apply pressure to the site.<br />
d. Notify your supervisor before attempting a venipuncture at another site.<br />
9. Advance the needle or the catheter.<br />
a. Grasp the hub and advance the needle into the vein up to the hub.<br />
b. If using the catheter-over-needle, grasp the hub and with a slight twisting motion fully<br />
advance the catheter.<br />
c. While continuing to hold the hub, press lightly on the skin over the needle or catheter<br />
tip with the fingers of the other hand.<br />
NOTE: This prevents the backflow of blood from the hub.<br />
d. If using a catheter-over-needle, remove the needle from inside the catheter.<br />
10. Remove the protective cover from the needle adapter on the tubing. Quickly and tightly<br />
connect the adapter to the catheter or needle hub.<br />
WARNING: Do not allow air to enter the blood stream.<br />
11. Tell the patient to unclench the fist, and then release the constricting band.<br />
12. Unclamp the IV tubing and adjust the flow rate to keep the vein open (TKO or KVO).<br />
NOTE: A rate of about 30 cc per hour, or 7 to 10 drops per minute using standard drip tubing, is<br />
adequate to keep the vein open.<br />
13. Check the site for infiltration. If it is painful, swollen, red, cool to the touch, or if fluid is<br />
leaking from the site, stop the infusion immediately.<br />
14. Secure the site IAW local SOP.<br />
a. Apply a sterile dressing over the puncture site, leaving the hub and tubing connection<br />
visible.<br />
b. Loop the IV tubing onto the extremity and secure the loop with tape.<br />
c. Splint the arm loosely on a padded splint, if necessary, to reduce movement.<br />
15. Readjust the flow rate.<br />
a. Determine the total time over which the patient is to receive the dosage.<br />
3-106
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Example: The patient is to receive the dosage over a 3 hour period.<br />
b. Determine the total IV dosage the patient is to receive by checking the doctor's orders.<br />
Example: The patient is to receive 1000 cc of IV fluid.<br />
c. Check the IV tubing package to determine the number of drops of IV fluid per cc the<br />
set has been designed to deliver.<br />
Example: The set is designed to give 10 drops of IV fluid per cc (10 gtts/cc).<br />
d. Multiply the total hours (step 15a) by 60 minutes to determine the total minutes over<br />
which the IV dosage is to be administered.<br />
Example: 3 hours X 60 min = 180 min.<br />
e. Divide the total IV dosage (step 15b) by the total minutes over which the IV dosage is<br />
to be administered (step 15d) to determine the cc of fluid to be administered per<br />
minute.<br />
Example: 1000 cc / 180 min = 5.5 cc/min.<br />
f. Multiply the cc/min (step 15e) by the number of drops of IV fluid per cc delivered by the<br />
tubing (step 15c) to determine the number of drops per minute to be administered.<br />
Example: 5.5 cc/min X 10 drops/cc = 55 drops/min.<br />
NOTE: Always round drops per minute off to the nearest whole number. If drops per minute<br />
equal .5, round up to the next whole number.<br />
16. Prepare and place the appropriate label.<br />
a. Dressing.<br />
(1) Print the information on a piece of tape.<br />
(a) Date and time the IV was started.<br />
(b) Initials of the person initiating the IV.<br />
(2) Secure the tape to the dressing.<br />
b. IV solution container.<br />
(1) Print the information on a piece of tape.<br />
(a) Patient's identification.<br />
(b) Drip rate.<br />
(c) Date and time the IV infusion was initiated.<br />
(d) Initials of the person initiating the IV.<br />
(2) Secure the tape to the IV container.<br />
c. IV tubing.<br />
(1) Wrap a strip of tape around the tubing, leaving a tab.<br />
(2) Print the date and time the tubing was put in place and the initials of the person<br />
initiating the IV.<br />
NOTE: Place disposable items in an appropriate receptacle and clean and store equipment<br />
IAW local SOP.<br />
17. Recheck the site for infiltration.<br />
18. Perform a patient care handwash.<br />
19. Record the procedure on the appropriate form.<br />
a. Date and time the IV infusion was initiated.<br />
b. Type and amount of IV solution initiated.<br />
c. Drip rate and total volume to be infused.<br />
d. Type and gauge of needle or cannula.<br />
e. Location of the infusion site.<br />
f. Patient's condition.<br />
g. Name of the person initiating the IV.<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Inspected the equipment. —— ——<br />
2. Prepared the equipment. —— ——<br />
3. Identified the patient and explained the procedure. —— ——<br />
4. Selected the infusion site. —— ——<br />
5. Prepared the infusion site. —— ——<br />
6. Prepared to puncture the vein. —— ——<br />
7. Punctured the vein. —— ——<br />
8. Confirmed the puncture. —— ——<br />
9. Advanced the needle or the catheter. —— ——<br />
10. Connected the tubing to the catheter or needle hub. —— ——<br />
11. Released the constricting band. —— ——<br />
12. Unclamped the IV tubing and adjusted the flow rate TKO. —— ——<br />
13. Checked the site for infiltration. —— ——<br />
14. Secured the site. —— ——<br />
15. Readjusted the flow rate. —— ——<br />
16. Prepared and placed the appropriate labels. —— ——<br />
17. Rechecked the site for infiltration. —— ——<br />
18. Performed a patient care handwash. —— ——<br />
19. Recorded the procedure on the appropriate form. —— ——<br />
20. Did not violate aseptic technique. —— ——<br />
21. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-108
STP 8-91W15-SM-TG<br />
MANAGE A PATIENT WITH AN INTRAVENOUS INFUSION<br />
081-833-0034<br />
Conditions: Necessary materials and equipment: dressings, antiseptic swabs, sterile gauze, IV<br />
tubing, IV solution, tape, antimicrobial ointment, and exam gloves.<br />
Standards: Properly managed a patient with an IV infusion, accurately documented the IV<br />
therapy, properly assessed for the complications of IV therapy, and initiated appropriate<br />
interventions when necessary. Did not violate aseptic technique and did not cause further injury<br />
to the patient.<br />
Performance Steps<br />
1. Assess for signs and symptoms of IV therapy complications.<br />
a. Infiltration is an accumulation of fluids in the tissue surrounding an IV needle site. It is<br />
caused by penetration of the vein wall by the needle/catheter or later dislodgement of<br />
the needle/catheter.<br />
(1) Solution flows sluggishly or not at all.<br />
(2) Discoloration or cool feeling around the infusion site.<br />
(3) Swollen extremity.<br />
(4) Fluid leaking from the infusion site.<br />
(5) Patient complains of pain, tenderness, irritation, or burning at the infusion site.<br />
b. Phlebitis is an inflammation of the wall of the vein. It is caused by injury to the vein<br />
during puncture, from later needle movement, or from irritation to the vein caused by<br />
long term therapy, incompatible additives, or use of a vein that is too small to handle<br />
the amount or type of solution.<br />
(1) Swelling, redness, and/or tenderness around the venipuncture site.<br />
(2) Sluggish flow rate.<br />
c. Infection is a yellowish, foul-smelling discharge (pus) from the venipuncture site.<br />
d. Air embolism is the obstruction of a blood vessel by air carried via the bloodstream<br />
(usually occurring in the lungs or heart). It is caused by conditions such as air bubbles<br />
in the IV tubing, a solution container that has run dry, or disconnected IV tubing.<br />
(1) Abrupt drop in blood pressure.<br />
(2) Chest pain.<br />
(3) Weak, rapid pulse.<br />
(4) Cyanosis.<br />
(5) Loss of consciousness.<br />
e. Circulatory overload is an increased blood volume that is caused by excessive IV fluid<br />
infused too rapidly into the vein (overhydration).<br />
(1) Elevated blood pressure.<br />
(2) Distended neck veins.<br />
(3) Rapid breathing, shortness of breath, tachycardia.<br />
(4) Fluid intake is much greater than urine output.<br />
2. Perform the nursing interventions for IV therapy complications.<br />
a. Infiltration.<br />
(1) Stop the infusion.<br />
(2) Notify your supervisor.<br />
(3) Record observations and action taken.<br />
b. Phlebitis.<br />
(1) Stop the infusion.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(2) Report observations to your supervisor.<br />
(3) Record observations and actions taken.<br />
c. Infection.<br />
(1) Report observations to your supervisor.<br />
(2) Record observations and actions taken.<br />
d. Air embolism.<br />
(1) Report observations to your supervisor.<br />
(2) Record observations and actions taken.<br />
e. Circulatory overload.<br />
(1) Slow the infusion rate to TKO.<br />
(2) Place the patient in the semi-Fowler's position.<br />
(3) Notify the physician or supervisor.<br />
(4) Record observations and actions taken.<br />
3. Document the IV therapy.<br />
a. Frequency.<br />
(1) When the IV is initiated.<br />
(2) Each time any part of the IV equipment is changed.<br />
b. Label the dressing.<br />
(1) Cut adhesive tape and place it on a flat surface.<br />
NOTE: Never write on the tape after it has been placed on the dressing.<br />
(2) Record the information on the piece of tape.<br />
(a) The gauge of the catheter/needle.<br />
(b) The time and date the dressing was applied.<br />
(c) Your initials.<br />
(3) Place the labeled tape over the dressing.<br />
c. Label the solution container.<br />
(1) Cut adhesive tape and place it on a flat surface.<br />
(2) Record the information on the piece of tape.<br />
(a) The patient's name.<br />
(b) The patient's identification number and room/ward number, as appropriate.<br />
(c) The infusion rate.<br />
(d) The time and date the solution container was hung.<br />
(e) Your initials.<br />
(3) Place the label on the solution container.<br />
(4) Prepare the timing label.<br />
(a) Place a strip of adhesive tape vertically along the length of the solution<br />
container.<br />
(b) Determine how long the solution container will last. (See task 081-833-0033.)<br />
(c) Write on the tape the approximate times at which the solution level will reach<br />
the volume markings on the solution container.<br />
(d) At the bottom of the label write the approximate time the solution container<br />
will be empty.<br />
d. Label the tubing.<br />
(1) Place a strip of adhesive tape around the tubing, leaving a tab.<br />
(2) Write on the tab the date and time the tubing was changed.<br />
e. Record the information on the appropriate forms (Nursing Notes/Field Medical Card).<br />
(1) The date and time the IV was initiated.<br />
(2) The amount and type of solution.<br />
(3) The infusion rate.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) The type and gauge of the needle/catheter.<br />
(5) The insertion site.<br />
(6) The patient's condition.<br />
(7) Your name.<br />
f. Record the amount of infusion on DD Form 792, if applicable.<br />
4. Replace the solution container (only).<br />
NOTE: Change the solution container every 24 hours when running a slow infusion in which the<br />
container may not be depleted in 24 hours.<br />
a. Perform a patient care handwash.<br />
b. Select or prepare the new solution. (See task 081-833-0033.)<br />
c. Clamp the IV tubing shut.<br />
d. Remove the used container from the IV hanger.<br />
e. Remove the spike from the used container.<br />
f. Insert the IV spike into a new IV container.<br />
CAUTION: The old tubing is still connected to the catheter or needle. Use care to maintain<br />
sterility. To prevent backflow of blood, keep the spike and tubing elevated.<br />
g. Hang the new container.<br />
h. Adjust the infusion rate.<br />
i. Label the solution container and prepare a timing label.<br />
j. Record the amount of solution received from the previous container, and the time,<br />
type, and amount of new solution.<br />
5. Change the dressing.<br />
NOTE: Change the dressing every 24 hours or IAW local SOP.<br />
a. Perform a patient care handwash.<br />
b. Remove the tape and the old dressing without dislodging the catheter/needle.<br />
NOTE: Tubing should remain taped in place to reduce the chance of accidental dislodgement<br />
of the catheter or needle.<br />
c. Clean the area around the infusion site IAW local SOP.<br />
d. Examine the site for infiltration.<br />
e. Cover the infusion site with sterile gauze and secure with tape, or dress IAW local<br />
SOP.<br />
f. Secure the dressing to the site without encircling the wrist or arm.<br />
g. Label the dressing.<br />
6. Replace the solution container and tubing.<br />
NOTE: Change the tubing every 48 hours or IAW local SOP. Time the tubing change to<br />
coincide with the time the solution container will be changed.<br />
a. Perform a patient care handwash.<br />
b. Spike the new tubing into a new solution container and hang it from the IV pole.<br />
c. Prime the tubing and clamp it.<br />
d. Clamp the old tubing shut.<br />
e. Connect the new tubing to the needle hub.<br />
WARNING: Wear gloves for self-protection against transmission of contaminants whenever<br />
handling body fluids.<br />
(1) Loosen the tape on the old tubing without dislodging the catheter and needle.<br />
(2) Place a sterile gauze pad under the catheter or needle hub to provide a small<br />
sterile field for the needle hub.<br />
(3) Grasp the new tubing between the fingers of one hand.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) Grasp the catheter or needle hub with a sterile gauze pad between the thumb and<br />
index finger and carefully disconnect the old adapter.<br />
(5) Press the fingers over the catheter or needle tip to help prevent dislodgement and<br />
backflow of blood.<br />
(6) Remove the protective cap from the new tubing adapter and quickly connect it to<br />
the catheter or needle hub.<br />
CAUTION: Do not remove the protective cap with your teeth.<br />
(7) Remove the pressure over the catheter or needle tip.<br />
(8) Remove the gauze pad from under the needle hub and clean the site, if<br />
necessary.<br />
(9) Secure the tubing to the arm and reinforce the dressing, as necessary.<br />
(10) Adjust the infusion rate.<br />
7. Discontinue the infusion.<br />
a. Perform a patient care handwash.<br />
b. Put on exam gloves.<br />
c. Clamp the IV tubing.<br />
d. Remove the tape and dressing without dislodging the needle and catheter.<br />
e. Place a sterile gauze pad over the injection site.<br />
f. Smoothly pull out the needle, following the course of the vein.<br />
WARNING: Do not twist, raise, or lower the needle.<br />
g. Apply pressure to the site with the gauze.<br />
h. Examine the needle or catheter to ensure that it was removed intact.<br />
i. Apply an adhesive bandage to the site, if necessary.<br />
j. Dispose of the used equipment IAW local SOP.<br />
8. Record the procedure on the appropriate form.<br />
NOTE: Ensure that the fluids received have been recorded on the appropriate form(s).<br />
Evaluation Preparation:<br />
Setup: If the performance of this task must be simulated for training or evaluation, assemble the<br />
IV materials and equipment as indicated in task 081-833-0033. It is not necessary to have the<br />
catheter or needle inserted into a person. A simulated arm or other material may be used.<br />
Brief soldier: Tell the soldier to manage a patient with an intravenous infusion.<br />
Performance Measures GO NO<br />
GO<br />
1. Assessed for signs and symptoms of IV therapy complications. —— ——<br />
2. Performed the nursing interventions for IV therapy complications. —— ——<br />
3. Documented the IV therapy. —— ——<br />
4. Replaced the solution container, as necessary. —— ——<br />
5. Changed the dressing, as required. —— ——<br />
6. Replaced the solution container and tubing, as necessary. —— ——<br />
7. Discontinued the infusion, as required. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
8. Recorded the procedure on the appropriate form. —— ——<br />
9. Did not violate aseptic technique. —— ——<br />
10. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-113
STP 8-91W15-SM-TG<br />
INITIATE A SALINE LOCK<br />
081-835-3025<br />
Conditions: You have a physician's orders to establish and maintain a saline lock for<br />
intermittent infusion therapy. Necessary materials and equipment: an intermittent infusion<br />
needle or an IV catheter and a saline lock adapter plug, sterile saline for injection, needles,<br />
syringes, antiseptic wipes, tourniquet, antiseptic ointment, tape, sterile 2 X 2 gauze, nonsterile<br />
gloves, and the patient's clinical record.<br />
Standards: Established a saline lock and maintained it in accordance with the physician's<br />
orders and without causing further injury to the patient.<br />
Performance Steps<br />
1. Prepare to establish a saline lock.<br />
a. Verify the physician's orders.<br />
b. Assemble the necessary equipment.<br />
(1) An intermittent infusion needle, or an IV catheter and a saline lock adapter plug (if<br />
you are inserting a new IV for the saline lock).<br />
(2) A saline lock adapter plug (if you are converting an existing IV site into a saline<br />
lock).<br />
(3) A syringe filled with 5 cc of sterile saline for injection.<br />
(4) Sterile dressing materials.<br />
(5) A tourniquet, if necessary.<br />
c. Identify the patient by asking his or her name and by checking the identification on the<br />
wristband.<br />
d. Explain the procedure and the purpose of the saline lock to the patient.<br />
e. Place the patient in a comfortable position with the arms supported.<br />
2. Insert a saline lock using an intermittent infusion needle.<br />
a. Perform a patient care handwash and put on gloves.<br />
b. Clean the rubber diaphragm on the end of the intermittent infusion needle with an<br />
antiseptic wipe.<br />
c. Uncap the needle of the prefilled saline syringe and insert the needle into the rubber<br />
diaphragm.<br />
d. Perform the venipuncture.<br />
e. Aspirate with the saline syringe and check for a blood return.<br />
f. Slowly inject the saline, and then remove the needle and syringe.<br />
g. Tape the needle securely in place.<br />
h. Apply a dressing to the site in accordance with local SOP.<br />
3. Insert a saline lock using an IV catheter and adapter plug.<br />
a. Perform a patient care handwash and put on gloves.<br />
b. Perform the venipuncture.<br />
c. Using aseptic technique, remove the metal stylet after advancing the plastic catheter<br />
into the vein.<br />
d. Quickly uncap and insert the male end of the adapter plug into the hub of the needle.<br />
e. Tape the needle securely in place.<br />
f. Clean the rubber diaphragm of the plug with an antiseptic wipe.<br />
g. Uncap the needle of the saline syringe and insert it into the rubber diaphragm.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
h. Aspirate with the saline syringe to remove all air from the adapter plug and check for a<br />
blood return.<br />
i. Remove the needle and syringe and expel all of the air from the syringe.<br />
j. Rewipe the diaphragm, reinsert the needle of the saline syringe, and inject the sterile<br />
saline. Remove the needle and syringe.<br />
k. Rewipe the diaphragm, uncap the needle of the saline syringe, and insert the needle<br />
into the diaphragm.<br />
l. Inject the saline, and then remove the needle and syringe.<br />
m. Apply a dressing to the site in accordance with local SOP.<br />
4. Convert an existing IV to a saline lock.<br />
a. Perform a patient care handwash and put on gloves.<br />
b. Clean the junction of the tubing and IV catheter with an antiseptic wipe.<br />
c. Close the roller clamp on the IV tubing.<br />
d. Loosen the tubing from the hub of the needle.<br />
e. Using aseptic technique, quickly remove the tubing from the needle and insert the<br />
male end of the adapter plug securely into the hub of the needle.<br />
f. Clean the rubber diaphragm on the plug with an antiseptic wipe.<br />
g. Inject 1-5 cc of saline into the lock and apply a dressing to the site by following steps<br />
3g through 3m.<br />
5. Maintain the saline lock.<br />
NOTE: When the saline lock is not being used at regular intervals for administration of<br />
medication or IV solution, it must be flushed with saline to maintain patency. This is normally<br />
done once per shift (every 8 hours). When used for administration of medication or IV fluids, the<br />
saline lock is normally flushed after each administration. Follow the local SOP for your facility to<br />
determine when to flush the saline lock.<br />
a. Assemble the necessary equipment and take it to the patient's bedside.<br />
(1) Antiseptic wipes.<br />
(2) Syringe of sterile saline for injection.<br />
b. Identify the patient and explain the procedure.<br />
c. Place the patient in a comfortable position with the arms supported and the saline lock<br />
site exposed.<br />
d. Wipe the rubber diaphragm with an antiseptic wipe.<br />
e. Uncap the needle of the saline syringe and insert it into the rubber diaphragm.<br />
f. Aspirate to check for IV patency.<br />
NOTE: Blood return, or "flashback", should be evident.<br />
g. Inject the saline, and then remove the needle and syringe.<br />
h. Discard the used equipment in the appropriate receptacles.<br />
NOTE: Document the administration of a saline flush by initialing the appropriate box on the<br />
patient's care sheet IAW local SOP.<br />
6. Maintain the IV site.<br />
a. Change the dressing and inspect the IV site once every 24 hours. Assess for redness,<br />
swelling, warmth, tenderness, and drainage. Apply fresh sterile dressings and<br />
antiseptic ointment as directed by the local policy in your facility.<br />
NOTE: It is a good habit to take a look at the IV site each time you encounter the patient. A<br />
quick glance is all that is necessary to observe for redness or swelling.<br />
b. Assess the IV site for evidence of subcutaneous infiltration each time the saline lock is<br />
used or flushed.<br />
c. Investigate any patient complaint of discomfort at the IV site.<br />
3-115
STP 8-91W15-SM-TG<br />
Performance Steps<br />
d. IV needles should generally be replaced every 72 hours. This will vary with local<br />
policy and the physician's orders. Follow the local SOP for your facility when a specific<br />
physician's order has not been written.<br />
7. Remove the saline lock.<br />
a. Verify the physician's orders.<br />
b. Assemble the sterile dressing material.<br />
c. Identify the patient and explain the procedure.<br />
d. Perform a patient care handwash and put on gloves.<br />
e. Carefully remove all tape and lift off the dressing. Discard it into the appropriate<br />
receptacle.<br />
f. Note the condition of the puncture site and surrounding area.<br />
g. Loosen or remove the tape securing the catheter.<br />
h. Place a sterile 2 X 2 gauze square over the puncture site, applying slight pressure.<br />
i. Withdraw the IV catheter, apply more pressure to the site, and elevate the extremity.<br />
j. Examine the IV catheter to ensure that it was removed intact.<br />
k. Lower the extremity to a supported position and apply a sterile dressing to the<br />
puncture site.<br />
8. Convert the saline lock to a continuous infusion IV.<br />
a. Verify the physician's order.<br />
b. Assemble the necessary equipment.<br />
(1) Sterile dressing materials.<br />
(2) A container of the prescribed IV solution with primed tubing and a syringe filled<br />
with 5 cc of sterile saline for injection.<br />
c. Identify the patient and explain the procedure.<br />
d. Perform a patient care handwash and put on gloves.<br />
e. Clean the rubber diaphragm of the saline lock with an antiseptic wipe.<br />
f. Uncap the needle on the saline syringe, insert it into the rubber diaphragm, and<br />
aspirate to assess patency of the IV. (Blood return should be evident.)<br />
NOTE: If the IV is not patent, do not continue with the conversion. Remove the saline lock and<br />
establish a new IV site.<br />
g. Carefully remove the tape and loosen the adapter plug from the hub of the needle.<br />
h. Using aseptic technique, quickly remove the adapter plug and insert the end of the IV<br />
tubing securely into the needle hub.<br />
i. Set the roller clamp on the IV tubing to the prescribed rate and observe the site to<br />
ensure that normal flow is occurring.<br />
j. Apply a fresh sterile dressing over the IV site IAW local SOP.<br />
9. Document the procedure and significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
a. The type and size of needle inserted.<br />
b. The location of the venipuncture site.<br />
c. The date and time of insertion.<br />
d. The date and time an existing IV was converted to a saline lock.<br />
e. An assessment of the condition of the venipuncture site.<br />
f. Date and time of each saline lock flush administered.<br />
g. Date and time the saline lock was removed.<br />
h. Date and time the saline lock was converted to a continuous infusion IV and the type<br />
and amount of IV solution hung.<br />
i. The patient's reaction to the procedure.<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Prepared to establish a saline lock. —— ——<br />
2. Established a saline lock. —— ——<br />
3. Maintained a saline lock. —— ——<br />
4. Maintained the IV site. —— ——<br />
5. Removed or converted a saline lock. —— ——<br />
6. Documented all procedures on the appropriate forms IAW local SOP. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-117
STP 8-91W15-SM-TG<br />
Subject Area 6: Casualty Management<br />
MANAGE A CONVULSIVE <strong>AND</strong>/OR SEIZING PATIENT<br />
081-831-0035<br />
Conditions: You have already taken the appropriate body substance isolation precautions.<br />
Necessary materials and equipment: None.<br />
Standards: Completed all steps to manage a convulsive and/or seizing patient without allowing<br />
or causing unnecessary injury to the patient.<br />
Performance Steps<br />
1. Identify the type of convulsions and/or seizures based upon the following characteristic<br />
signs and symptoms:<br />
a. Petit mal.<br />
(1) Brief loss of concentration or awareness without loss of motor tone.<br />
(2) Found chiefly in children and rarely an emergency.<br />
b. Focal.<br />
(1) No loss of consciousness.<br />
(2) Tingling, stiffening, or jerking in just one part of the body (arm, leg or face).<br />
(3) May rapidly progress to generalized convulsions.<br />
c. Grand mal (generalized).<br />
(1) May be preceded by an aura.<br />
(2) Has three distinct phases.<br />
(a) Tonic phase--characterized by rigidity and stiffening of the body.<br />
(b) Colonic phase--characterized by jerking about violently, foaming at the<br />
mouth, drooling, and cyanosis around the face and lips.<br />
(c) Postictal phase--begins when convulsions stop. The patient may regain<br />
consciousness and enter a state of drowsiness and confusion or remain<br />
unconscious for several hours.<br />
(3) May involve incontinence, biting of the tongue (rare), cyanosis, or mental<br />
confusion.<br />
CAUTION: Never place anything in the mouth of a seizing patient.<br />
d. Status epilepticus.<br />
(1) Two or more seizures without an intervening period of consciousness.<br />
(2) A dire medical emergency, if untreated it may lead to--<br />
(a) Aspiration of secretions.<br />
(b) Cerebral or tissue hypoxia.<br />
(c) Brain damage or death.<br />
(d) Fractures of long bones.<br />
(e) Head trauma.<br />
(f) Injured tongue from biting.<br />
NOTE: Mentally note the aspects of seizure activity for recording after the seizure.<br />
2. Place the patient on his or her side, if possible.<br />
a. Observe the patient to prevent aspiration and suffocation.<br />
b. The patient's mouth and throat should be suctioned by trained personnel, if possible.<br />
CAUTIONS: 1. Do not elevate the patient's head. 2. Do not restrain the patient's limbs during<br />
seizures.<br />
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Performance Steps<br />
3. Prevent injury to tissue and bones by padding or removing objects on which the patient<br />
may injure himself or herself.<br />
4. Manage the patient after the convulsive state has ended.<br />
a. Place the patient on his or her side, if necessary.<br />
b. Continue to maintain the patient's airway.<br />
NOTE: A patient who has just had a grand mal seizure will sometimes drool and will usually be<br />
drowsy so you must be prepared to suction, if equipment is available.<br />
c. Administer supplemental oxygen, if available, via nonrebreather mask or bag-valvemask<br />
as appropriate.<br />
d. If possible, place the patient in a quiet, reassuring atmosphere.<br />
CAUTION: Sudden, loud noises may cause another seizure.<br />
5. Record the seizure activity.<br />
a. Duration of the seizure.<br />
b. Presence of cyanosis, breathing difficulty, or apnea.<br />
c. Level of consciousness before, during, and after the seizure.<br />
d. Whether preceded by aura (ask the patient).<br />
e. Muscles involved.<br />
f. Type of motor activity.<br />
g. Incontinence.<br />
h. Eye movement.<br />
i. Previous history of seizures, head trauma, and/or drug or alcohol abuse.<br />
6. Evacuate the patient.<br />
a. Position the patient on his or her side.<br />
b. Arrange for the administration of oxygen or suction, if available and necessary.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as a patient.<br />
Brief soldier: Tell the soldier to manage the patient.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the type of convulsions and/or seizures. —— ——<br />
2. Maintained the airway of a patient exhibiting tonic-clonic movement. —— ——<br />
3. Placed the patient on his or her side, if possible. —— ——<br />
4. Prevented injury to tissue and bones by padding or removing objects on<br />
which the patient may injure himself or herself.<br />
—— ——<br />
5. Managed the patient after the convulsive state ended. —— ——<br />
6. Recorded the seizure activity. —— ——<br />
7. Evacuated the patient. —— ——<br />
8. Did not cause further injury to the patient. —— ——<br />
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STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-120
STP 8-91W15-SM-TG<br />
TREAT A CASUALTY WITH AN OPEN ABDOMINAL WOUND<br />
081-833-0045<br />
Conditions: All other more serious injuries have been treated. You are not in an NBC<br />
environment. Necessary materials and equipment: field dressings, cravats, scissors, gauze,<br />
saline solution, and intravenous (IV) equipment.<br />
Standards: Treated an open abdominal wound, minimized the effects of the injury, and<br />
stabilized the casualty without causing additional injury.<br />
Performance Steps<br />
1. Treat for shock. (See task 081-833-0047.)<br />
WARNING: The most important concern in the initial management of abdominal injuries is<br />
shock. Shock may be present initially or develop later. Neither the presence or absence of a<br />
wound, nor the size of the external wound are safe guidelines for judging the severity of the<br />
wound.<br />
a. Ensure the casualty has a patent airway.<br />
b. Initiate two large bore (16 gauge) IVs if the casualty is exhibiting signs and symptoms<br />
of shock.<br />
2. Position the casualty.<br />
a. Place the casualty on his or her back (face up).<br />
b. Flex the casualty's knees.<br />
c. Turn the casualty's head to the side and keep the airway clear if vomiting occurs.<br />
3. Expose the wound.<br />
CAUTION: Do not attempt to replace protruding internal organs or remove any protruding<br />
foreign objects.<br />
4. Stabilize any protruding objects. (See task 081-833-0046.)<br />
5. Apply a sterile abdominal dressing.<br />
NOTE: Protruding abdominal organs should be kept moist to prevent the tissue from drying out.<br />
A moist, sterile dressing should be applied if available.<br />
a. Using the sterile side of the dressing, or other clean material, place any protruding<br />
organs near the wound.<br />
b. Ensure that the dressing is large enough to cover the entire mass of protruding organs<br />
or area of the wound.<br />
c. If large enough to cover the affected area, place the sterile side of the plastic wrapper<br />
directly over the wound.<br />
d. Place the dressing directly on top of the wound or plastic wrapper, if used.<br />
e. Tie the dressing tails loosely at the casualty's side.<br />
CAUTION: Do not apply pressure on the wound or expose internal parts.<br />
f. If two dressings are needed to cover a large wound, repeat steps 5a through 5e.<br />
Ensure that the ties of additional dressings are not tied over each other.<br />
g. If necessary, loosely cover the dressings with cravats. Tie them on the side of the<br />
casualty opposite that of the dressing ties.<br />
6. Do not cause further injury to the casualty.<br />
a. Do not touch any exposed organs with bare hands.<br />
b. Do not try to push any exposed organs back into the body.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
c. Do not tie the dressing tails tightly or directly over the dressing.<br />
d. Do not give the casualty anything by mouth (NPO).<br />
NOTE: Continue to assess the casualty, if necessary.<br />
7. Prepare the casualty for evacuation.<br />
a. Place the casualty on his or her back (face up) with the knees flexed.<br />
b. If evacuation is delayed, check the casualty for signs of shock every 5 minutes.<br />
8. Record the treatment given on the Field Medical Card.<br />
Performance Measures GO NO<br />
GO<br />
1. Treated for shock. —— ——<br />
2. Positioned the casualty. —— ——<br />
3. Exposed the wound. —— ——<br />
4. Stabilized any protruding objects. —— ——<br />
5. Applied a sterile abdominal dressing. —— ——<br />
6. Prepared the casualty for evacuation. —— ——<br />
7. Recorded the treatment given on the Field Medical Card. —— ——<br />
8. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-122
STP 8-91W15-SM-TG<br />
APPLY A DRESSING TO AN IMPALEMENT INJURY<br />
081-833-0046<br />
Conditions: The casualty you are assessing has an impalement injury. All other more serious<br />
injuries have been treated. You are not in an NBC environment. Necessary materials and<br />
equipment: field dressings, cravats, bandages, gauze, scissors, splinting equipment, and<br />
oxygen delivery device.<br />
Standards: Immobilized the impaled object and minimized the effect of the injury without<br />
causing further injury to the casualty.<br />
Performance Steps<br />
WARNING: Do not exert any force on or attempt to remove the impaled object unless the<br />
object is impaled in the cheek and both ends of the object can be seen or unless the object is<br />
blocking the airway. Severe bleeding or nerve and muscle damage may result.<br />
1. Prepare the casualty.<br />
a. Tell the casualty to remain still and not to move the impaled object.<br />
b. Expose the injury by cutting away or removing clothing or equipment around the<br />
wound site.<br />
c. If the impalement injury is on an extremity, check the pulse distal to the injury site.<br />
d. If the impalement is found in the cheek and both ends of the object can be seen.<br />
(1) Remove the object in the direction it entered the cheek.<br />
(2) Position the patient to allow for drainage and be prepared to suction the patient.<br />
e. If both ends of the object in the cheek cannot be seen, go to step 2.<br />
2. Immobilize the impaled object.<br />
NOTE: If an assistant is available, one person should immobilize the object while the other<br />
applies the dressings and bandages.<br />
a. If necessary, apply direct pressure using gloved hands on either side of the object.<br />
WARNING: Do not exert force on the impaled object.<br />
b. Place several layers of bulky dressing around the injury site so that the dressings<br />
surround the object.<br />
c. Use additional bulky materials or dressings to build up the area around the object.<br />
3. Apply the support bandages.<br />
a. Apply the bandage over the bulky support material to hold it in place.<br />
b. Apply the bandage tightly but not so tight as to impair circulation or breathing.<br />
WARNING: Do not anchor the bandage on or exert pressure on the impaled object.<br />
c. Check the circulation after applying the support bandages.<br />
NOTE: If a pulse was palpated in step 1c and it cannot be palpated after the bandage has been<br />
applied, the bandage must be loosened until a pulse can be palpated.<br />
4. Immobilize the affected area with a splint or sling, if applicable.<br />
WARNINGS: 1. Do not anchor a splint or sling to the impaled object. 2. Avoid undue motion<br />
of the impaled object when applying a splint.<br />
5. Check for a pulse distal to the injury site.<br />
6. Provide oxygen.<br />
7. Treat for shock, if necessary.<br />
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Performance Steps<br />
8. Record the treatment on the Field Medical Card.<br />
9. Evacuate the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. Use a moulage<br />
set or similar materials to create a simulated impalement injury. You may also have another<br />
soldier assist in immobilizing the object.<br />
Brief soldier: Tell the soldier to treat the casualty for an impalement injury and to direct the<br />
actions of the assistant, if applicable.<br />
Performance Measures GO NO<br />
GO<br />
1. Prepared the casualty. —— ——<br />
2. Immobilized the impaled object. —— ——<br />
3. Applied the support bandages. —— ——<br />
4. Immobilized the affected area with a splint or sling, if applicable. —— ——<br />
5. Checked for a pulse distal to the injury site. —— ——<br />
6. Provided oxygen. —— ——<br />
7. Treated for shock, if necessary. —— ——<br />
8. Recorded the treatment on the Field Medical Card. —— ——<br />
9. Evacuated the casualty. —— ——<br />
10. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-124
STP 8-91W15-SM-TG<br />
MANAGE AN UNCONSCIOUS CASUALTY<br />
081-833-0048<br />
Conditions: You have an unconscious casualty in a field environment. You are not in an NBC<br />
environment. Necessary materials and equipment: blanket, field jacket, poncho, Ringer's<br />
lactate, and Field Medical Card.<br />
Standards: Managed and stabilized an unconscious casualty and arranged prompt evacuation.<br />
Performance Steps<br />
1. Establish unresponsiveness.<br />
2. Establish and maintain an open airway.<br />
CAUTION: Maintain C-spine control. Suspect C-spine injury with trauma involving the head<br />
and neck, motor vehicle accidents (MVAs), falls, and diving accidents.<br />
a. Open the airway. (See task 081-831-0018.)<br />
b. Clear any upper airway obstruction. (See task 081-831-0019.)<br />
c. Insert an oropharyngeal airway, if necessary, to maintain the airway. (See task 081-<br />
833-0016.)<br />
d. Perform artificial respiration if breathing is absent. (See task 081-831-0048.)<br />
3. Assess the casualty.<br />
4. Position the casualty.<br />
a. Place the casualty on his or her side or face down, if the injury permits, to prevent<br />
aspiration of vomitus.<br />
b. Maintain good body alignment by using padding for head and limb support. Use a<br />
folded or rolled blanket, field jacket, or poncho.<br />
c. In extended care situations, turn the casualty from side to side every hour.<br />
NOTE: Protect the casualty against extremes of heat or cold.<br />
5. Observe the casualty.<br />
a. Check for drainage of blood or cerebrospinal fluid (CSF) from the ears and nose.<br />
WARNING: Do not attempt to control cerebrospinal/bloody drainage with a dressing. The<br />
dressing may cause increased pressure on the brain and collection of fluids between the brain<br />
and skull.<br />
b. Take the vital signs.<br />
NOTE: Check the vital signs every 15 to 20 minutes and record the data on the Field Medical<br />
Card.<br />
c. Assess the casualty's level of consciousness using the AVPU scale.<br />
(1) A--alert. The casualty responds spontaneously to stimuli and is able to answer<br />
questions in a clear manner.<br />
(2) V--verbal. The casualty does not respond spontaneously, but is responsive to<br />
verbal stimuli.<br />
(3) P--pain. The casualty does not respond spontaneously or to verbal stimuli, but is<br />
responsive to painful stimuli.<br />
(4) U--unresponsive. The casualty is unresponsive to any stimuli.<br />
NOTE: Even if the casualty is unresponsive, assume the casualty can hear you, and explain<br />
the procedures.<br />
d. Assess the casualty's pupils.<br />
(1) Observe the size of each pupil.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: A variation of pupil size may indicate a brain injury. In a very small percentage of<br />
people, unequal pupil size is normal.<br />
(2) Shine a light into each eye to observe the pupillary reaction to light.<br />
NOTE: The pupils should constrict promptly when exposed to bright light. Failure of the pupils<br />
to constrict may indicate brain injury.<br />
e. Check movement of the extremities.<br />
NOTE: Record which movements are spontaneous and which are stimulus related.<br />
f. Observe for seizure activity.<br />
6. Obtain the casualty's history, if possible.<br />
a. Events immediately preceding current condition.<br />
b. Recent illness or infection.<br />
c. History of epilepsy, diabetes, or other medical conditions.<br />
d. Prior periods of unconsciousness.<br />
e. Drug or alcohol abuse (evacuate any medications with the casualty).<br />
7. Initiate an IV of Ringer's lactate and run it slowly to keep the vein open (TKO). (See task<br />
081-833-0033.)<br />
8. Administer supplemental oxygen without pressure, if available.<br />
9. Record the treatment on the Field Medical Card.<br />
10. Evacuate the casualty.<br />
NOTE: An unconscious casualty should have an artificial airway inserted prior to evacuation<br />
and must be constantly monitored during evacuation.<br />
Performance Measures GO NO<br />
GO<br />
1. Established unresponsiveness. —— ——<br />
2. Established and maintained an open airway. —— ——<br />
3. Assessed the casualty. —— ——<br />
4. Positioned the casualty. —— ——<br />
5. Observed the casualty. —— ——<br />
6. Obtained the casualty's history. —— ——<br />
7. Initiated an IV. —— ——<br />
8. Administered oxygen, if available. —— ——<br />
9. Recorded the treatment. —— ——<br />
10. Evacuated the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
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STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-127
STP 8-91W15-SM-TG<br />
TREAT A CASUALTY WITH A CLOSED CHEST WOUND<br />
081-833-0049<br />
Conditions: All other more serious injuries have been treated. Necessary materials and<br />
equipment: cravats, field jacket, poncho, blanket, or similar material, and oxygen.<br />
Standards: Treated a closed chest wound, minimizing the effects of the injury, without causing<br />
additional injury to the casualty.<br />
Performance Steps<br />
1. Check the casualty for signs and symptoms of closed chest injuries.<br />
a. Pleuritic pain that is increased by or occurs with respirations and is localized around<br />
the injury site.<br />
b. Labored or difficult breathing.<br />
c. Diminished or absent breath sounds.<br />
d. Cyanotic lips, fingertips, or fingernails.<br />
e. Rapid, weak pulse and low blood pressure.<br />
f. Coughing up blood or bloody sputum.<br />
g. Failure of one or both sides of the chest to expand normally upon inhalation.<br />
h. Paradoxical breathing--the motion of the injured segment of a flail chest, opposite to<br />
the normal motion of the chest wall.<br />
i. Enlarged neck veins.<br />
j. Bulging tissue between the ribs and above the clavicles.<br />
k. Tracheal deviation--shift of the trachea from the midline toward the unaffected side due<br />
to pressure buildup on the injured side.<br />
l. Mediastinal shift--shift of the heart, great vessels, trachea, and esophagus from the<br />
midline to the unaffected side due to pressure buildup on the injured side.<br />
WARNING: Evidence of mediastinal shift indicates excessive pressure within the chest cavity.<br />
Compression of the heart and great vessels will impair blood flow through the heart. Immediate<br />
relief of the pressure (chest decompression) must be accomplished by trained medical<br />
personnel or death will result.<br />
2. Determine the type of injury.<br />
a. Rib fracture--generally caused by a direct blow to the chest or compression of the<br />
chest. Severe coughing can also cause rib fracture.<br />
(1) Signs and symptoms.<br />
(a) Pain is aggravated by respirations and coughing.<br />
(b) Crepitus is present.<br />
(c) The casualty will take a defensive posture to protect the injury.<br />
(2) Complications.<br />
(a) Internal bleeding (hemothorax).<br />
(b) Shock.<br />
(3) Treatment.<br />
(a) Use a sling and swathe to immobilize the affected side.<br />
(b) Administer oxygen as necessary.<br />
NOTE: The broken rib may puncture the lung or the skin.<br />
WARNING: Do not tape, strap, or bind the chest.<br />
b. Flail chest involves three or more ribs fractured in two or more places or a fractured<br />
sternum.<br />
(1) Signs and symptoms.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(a) Sever pain at the site.<br />
(b) Rapid shallow breathing.<br />
(c) Paradoxical respirations.<br />
(2) Complications.<br />
(a) Respiratory insufficiency.<br />
(b) Traumatic asphyxia.<br />
(3) Treatment.<br />
(a) Establish and maintain an airway.<br />
(b) Administer oxygen.<br />
(c) Assist the casualty's respirations, if necessary.<br />
(d) Monitor the casualty for signs of hemothorax or tension pneumothorax, as<br />
necessary.<br />
(e) Stabilize the flail segment using one of the following methods:<br />
1) Apply manual pressure.<br />
2) Tape a pillow, folded blanket, field jacket, or poncho in place.<br />
3) Place the casualty on the injured side.<br />
WARNING: Do not wrap the casualty's chest with tape. This will interfere with the casualty's<br />
ability to breathe.<br />
c. Hemothorax is caused by the bleeding from lacerated blood vessels in the chest cavity<br />
and/or lungs. It results in the accumulation of blood in the chest cavity but outside the<br />
lungs.<br />
(1) Signs and symptoms.<br />
(a) Hypotension due to blood loss.<br />
(b) Shock.<br />
(c) Cyanosis.<br />
(d) Tightness in the chest.<br />
(e) Mediastinal shift may produce deviated trachea away from the affected side.<br />
(f) Coughing up frothy red blood.<br />
(2) Complications.<br />
(a) Possibility of hypovolemic shock.<br />
(b) Frequently accompanies a pneumothorax.<br />
(3) Treatment.<br />
(a) Establish and maintain an airway.<br />
(b) Administer oxygen.<br />
(c) Assist the casualty's breathing, as necessary.<br />
d. Injuries to the back of the chest can result from a direct blow on the back of the chest.<br />
Contusions or rib fractures may occur.<br />
WARNING: Spinal injury should be suspected.<br />
(1) Signs and symptoms.<br />
(a) Rib fracture.<br />
(b) Lacerations on the back.<br />
(c) Muscle strain.<br />
(d) Fractured scapula.<br />
(e) Spinal injury.<br />
(f) Respiratory distress.<br />
(2) Complications.<br />
(a) Spinal injury.<br />
(b) Hemothorax.<br />
(c) Pneumothorax.<br />
(3) Treatment.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: The main concern with this injury is the spine.<br />
(a) Establish and maintain an airway.<br />
NOTE: Use the jaw thrust technique if a spinal injury is suspected.<br />
(b) Administer oxygen.<br />
(c) Assist the casualty's respirations, if necessary.<br />
(d) Treat suspected spinal injuries. (See task 081-833-0092.)<br />
e. Tension pneumothorax.<br />
(1) Condition in which air enters the chest cavity (pleural space) through a hole in the<br />
lung(s), expanding the space with every breath the casualty takes.<br />
(2) The air becomes trapped and cannot escape.<br />
(3) Increased pressure in the chest causes the lung(s) to collapse.<br />
(4) May result from the laceration of the lung by a broken rib or by spontaneous<br />
rupture of a bleb or lesion on the lung.<br />
(5) Position the casualty for evacuation.<br />
(a) Conscious--in a comfortable position.<br />
(b) Unconscious--on the injured side.<br />
(6) Treatment.<br />
(a) Establish and maintain an airway.<br />
(b) Administer oxygen.<br />
(c) Assist the casualty's respirations, as necessary.<br />
(d) Monitor the casualty for evidence of a mediastinal shift.<br />
3. Treat the casualty for shock.<br />
4. Record the care provided on the appropriate form.<br />
5. Evacuate the casualty.<br />
NOTE: Continue to assess the casualty, if necessary.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. To test step 1,<br />
have the soldier tell you the signs of a closed chest wound.<br />
Brief soldier: Tell the soldier to treat a casualty with a closed chest wound. Tell the soldier<br />
whether the wound involves a simple rib fracture, a flail chest, a compression injury, an injury to<br />
the back of the chest, a pneumothorax, or a hemothorax.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the casualty for signs and symptoms of closed chest injuries. —— ——<br />
2. Determined the type of injury. —— ——<br />
3. Initiated treatment for a closed chest injury. —— ——<br />
4. Treated the casualty for shock. —— ——<br />
5. Recorded the care provided on the appropriate form. —— ——<br />
6. Evacuated the casualty. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
7. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-131
STP 8-91W15-SM-TG<br />
TREAT A CASUALTY WITH AN OPEN CHEST WOUND<br />
081-833-0050<br />
Conditions: All other more serious injuries have been treated. Necessary materials and<br />
equipment: scissors, adhesive tape, field dressings, padding, ace bandage, and cravats.<br />
Standards: Treated an open chest wound, minimizing the effects of the injury. Sealed the entry<br />
and exit wounds.<br />
Performance Steps<br />
1. Check the casualty for signs and symptoms of an open chest wound.<br />
a. A "sucking" or "hissing" sound when the casualty inhales.<br />
b. Difficulty breathing.<br />
c. A puncture wound of the chest.<br />
d. An impaled object protruding from the chest.<br />
e. Froth or bubbles around the injury.<br />
f. Coughing up blood or blood tinged sputum.<br />
g. Pain in the chest or shoulder.<br />
2. Expose the wound.<br />
a. Cut or unfasten the clothing that covers the wound.<br />
b. Disrupt the wound as little as possible.<br />
NOTE: Do not remove clothing stuck to the wound.<br />
CAUTION: Do not remove protective clothing in a contaminated environment. Mask the<br />
casualty. Cut back protective clothing so that the wound is exposed and the dressing can be<br />
applied.<br />
3. Check for an exit wound.<br />
a. Feel and/or look at the casualty's chest and back.<br />
b. Remove the casualty's clothing, if necessary.<br />
4. Seal the wound(s), covering the larger wound first.<br />
NOTE: All penetrating chest wounds should be treated as if they were sucking chest wounds.<br />
a. Cut the dressing wrapper on one long and two short sides and remove the dressing.<br />
NOTE: In an emergency, any airtight material can be used. It must be large enough so it is not<br />
sucked into the chest cavity.<br />
b. Apply the inner surface of the wrapper to the wound when the casualty exhales.<br />
c. Ensure that the covering extends at least 2 inches beyond the edges of the wound.<br />
d. Seal by applying overlapping strips of tape to three sides of the plastic covering to<br />
provide a flutter-type valve.<br />
e. Cover the exit wound in the same way, if applicable.<br />
NOTE: Assess the effectiveness of the flutter valve when the casualty breathes. When the<br />
casualty inhales, the plastic should be sucked against the wound, preventing the entry of air.<br />
When the casualty exhales, trapped air should be able to escape from the wound and out the<br />
untaped side of the dressing.<br />
5. Dress the wound.<br />
a. Place the field first aid dressing over the seal and tie the ends directly over the wound.<br />
(See Figure 3-15.)<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-15<br />
b. Use padding material and another dressing for additional pressure and stability, if<br />
required.<br />
c. Dress the exit wound in the same way, if applicable.<br />
CAUTION: Ensure that the dressings are not tied so tightly that they interfere with the breathing<br />
process or the flutter-type valve.<br />
6. Place the casualty on the injured side.<br />
7. Monitor the casualty.<br />
a. Monitor breathing and the wound seal.<br />
b. Assess the effectiveness of the flutter valve.<br />
c. Check vital signs.<br />
d. Observe for signs of shock.<br />
8. Record the treatment on the appropriate form.<br />
NOTE: Continue to assess the casualty, if necessary. The casualty should be evacuated by<br />
the most expedient means.<br />
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STP 8-91W15-SM-TG<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have a mannequin or another soldier act as the casualty.<br />
Use a moulage kit or similar materials to simulate entry and exit wounds. To test step 1, have<br />
the soldier tell you the signs and symptoms of an open chest wound.<br />
Brief soldier: Tell the soldier to treat a casualty for an open chest wound.<br />
NOTE: Do not tell the soldier whether an exit wound exists.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the casualty for signs and symptoms of an open chest wound. —— ——<br />
2. Exposed the wound. —— ——<br />
3. Checked for an exit wound. —— ——<br />
4. Sealed the wound(s), covering the larger wound first. —— ——<br />
5. Dressed the wound. —— ——<br />
6. Placed the casualty on the injured side. —— ——<br />
7. Monitored the casualty. —— ——<br />
8. Recorded the treatment on the appropriate form. —— ——<br />
9. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-134
STP 8-91W15-SM-TG<br />
TREAT A CASUALTY WITH AN OPEN OR CLOSED HEAD INJURY<br />
081-833-0052<br />
Conditions: The casualty you are assessing has a head injury. All other more serious injuries<br />
have been treated. Necessary materials and equipment: field dressings, cravats, stethoscope,<br />
sphygmomanometer, oxygen tank set up, oropharyngeal airway, nonrebreather, bag-valvemask,<br />
and intravenous (IV) setup.<br />
Standards: Treated a head injury, minimizing the effects of the injury, and stabilized the<br />
casualty without causing additional injury.<br />
Performance Steps<br />
WARNING: Treat casualties with any type of traumatic head injury or loss of consciousness as<br />
if they have a spinal injury<br />
1. Take appropriate body substance isolation precautions.<br />
2. Check for the signs and symptoms of head injuries.<br />
a. Superficial wound.<br />
(1) Lacerated, torn, ragged, or mangled skin tissue.<br />
(2) Copious bleeding, possible exposed skull.<br />
WARNING: Do not manipulate the wound to observe the skull.<br />
b. Closed head injury--caused by a direct blow to the head.<br />
WARNING: Brain injury, leading to a loss of function or death, often occurs without evidence of<br />
a skull fracture or scalp injury. Because the skull cannot expand, swelling of the brain or a<br />
collection of fluid pressing on the brain can cause pressure. This can compress and destroy the<br />
brain tissue.<br />
(1) Deformity of the head.<br />
(2) Clear fluid or blood escaping from the nose and/or ear(s).<br />
(3) Periorbital discoloration (raccoon eyes).<br />
(4) Bruising behind the ears, over the mastoid process (battle sign).<br />
(5) Lowered pulse rate if the casualty has not lost a significant amount of blood.<br />
(6) Signs of increased intracranial pressure.<br />
(a) Headache, nausea, and/or vomiting.<br />
(b) Possible unconsciousness.<br />
(c) Change in pupil size or symmetry.<br />
(d) Lateral loss of motor nerve function--one side of the body becomes<br />
paralyzed.<br />
NOTE: Lateral loss may not happen immediately but may occur later.<br />
(e) Change in the casualty's respiratory rate or pattern.<br />
(f) A steady rise in the systolic blood pressure if the casualty hasn't lost<br />
significant amounts of blood.<br />
(g) A rise in the pulse pressure (systolic pressure minus diastolic pressure).<br />
(h) Elevated body temperature.<br />
(i) Restlessness--indicates insufficient oxygenation of the brain.<br />
c. Concussion--caused by a violent jar or shock.<br />
NOTE: A direct blow to the skull may bruise the brain.<br />
(1) Temporary unconsciousness followed by confusion.<br />
(2) Temporary, usually short term, loss of some or all brain functions.<br />
(3) The casualty has a headache or is seeing double.<br />
(4) The casualty may or may not have a skull fracture.<br />
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Performance Steps<br />
d. Contusion--an internal bruise or injury. It is more serious than a concussion. The<br />
injured tissue may bleed or swell. Swelling may cause increased intracranial pressure<br />
that may result in a decreased level of consciousness and even death.<br />
e. Open head injury.<br />
(1) Penetrating wound--an entry wound with no exit wound.<br />
(2) Perforating wound--the wound has both entry and exit wounds.<br />
(3) Visibly deformed skull.<br />
(4) Exposed brain tissue.<br />
(5) Possible unconsciousness.<br />
(6) Paralysis or disability on one side of the body.<br />
(7) Change in pupil size.<br />
3. Direct manual stabilization of the casualty's head.<br />
4. Check the casualty's vital signs.<br />
5. Assess the casualty's level of consciousness using the AVPU scale.<br />
a. A--alert. The casualty responds spontaneously to stimuli and is able to answer<br />
questions in a clear manner.<br />
b. V--verbal. The casualty does not respond spontaneously but is responsive to verbal<br />
stimuli.<br />
c. P--pain. The casualty does not respond spontaneously or to verbal stimuli but is<br />
responsive to painful stimuli.<br />
d. U--unresponsive. The casualty is unresponsive to any stimuli.<br />
6. Assess the casualty's pupil size.<br />
a. Observe the size of each pupil.<br />
NOTE: A variation of pupil size may indicate a brain injury. In a very small percentage of<br />
people, unequal pupil size is normal.<br />
b. Shine a light into each eye to observe the pupillary reaction to light.<br />
NOTE: The pupils should constrict promptly when exposed to bright light. Failure of the pupils<br />
to constrict may indicate brain injury.<br />
7. Assess the casualty's motor function.<br />
a. Evaluate the casualty's strength, mobility, coordination, and sensation.<br />
b. Document any complaints, weakness, or numbness.<br />
NOTE: Progressive loss of strength or sensation is an important indicator of brain injury.<br />
8. Treat the head injury.<br />
a. Treat a superficial head injury.<br />
(1) Apply a dressing.<br />
(2) Observe for abnormal behavior or evidence of complications.<br />
b. Treat a head injury involving deep trauma.<br />
(1) Maintain a patent airway using the jaw thrust maneuver (see task 081-831-0018).<br />
(2) If the patient is unconscious, insert an oropharyngeal airway without<br />
hyperextending the neck (see task 081-833-0016).<br />
(3) Administer high concentration oxygen by nonrebreather mask and evaluate the<br />
need for artificial ventilations with supplemental oxygen.<br />
NOTE: If the casualty shows signs of brain injury (increased pulse, decreased blood pressure,<br />
and an decreased level of consciousness), hyperventilate the patient with supplemental oxygen<br />
at a rate of at least 25 ventilations per minute.<br />
(4) Apply a cervical collar (see task 081-833-0092).<br />
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Performance Steps<br />
(5) Dress the head wound(s).<br />
(6) Control bleeding.<br />
WARNING: Do not apply pressure to or replace exposed brain tissue.<br />
(7) Treat for shock.<br />
(8) Monitor the casualty for convulsions or seizures. (See task 081-831-0035.)<br />
(9) Position the casualty with the head elevated 6 inches to assist with the drainage<br />
of blood from the brain.<br />
CAUTION: Do not give the casualty anything by mouth.<br />
9. Continue to monitor the casualty and check and record the following at 5 minute intervals.<br />
a. Level of consciousness.<br />
b. Pupillary responsiveness and equality.<br />
c. Vital signs.<br />
d. Motor functions.<br />
10. Record the treatment on the appropriate form.<br />
11. Evacuate the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. Use a moulage kit<br />
or similar materials to simulate a head wound. To test steps 2 and 7, coach the simulated<br />
casualty on how to answer the soldier's questions regarding such symptoms as headache. Tell<br />
the soldier what signs, such as changes in pupil size, the casualty is exhibiting.<br />
Brief soldier: Tell the soldier to identify the type of head injury and treat the casualty for a head<br />
injury.<br />
Performance Measures GO NO<br />
GO<br />
1. Took appropriate body substance isolation procedures. —— ——<br />
2. Checked for the signs and symptoms of head injuries. —— ——<br />
3. Directed manual stabilization of the casualty's head. —— ——<br />
4. Checked the casualty's vital signs. —— ——<br />
5. Assessed the casualty's level of consciousness using the AVPU scale. —— ——<br />
6. Assessed the casualty's pupil size. —— ——<br />
7. Assessed the casualty's motor function. —— ——<br />
8. Treated the head injury. —— ——<br />
9. Continued to monitor the casualty at 5 minute intervals. —— ——<br />
10. Recorded the treatment on the appropriate form. —— ——<br />
11. Evacuated the casualty. —— ——<br />
12. Did not cause further injury to the casualty. —— ——<br />
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Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-138
STP 8-91W15-SM-TG<br />
ADMINISTER INITIAL TREATMENT FOR BURNS<br />
081-833-0070<br />
Conditions: You are in a field environment. Necessary materials and equipment: field<br />
dressings, sterile dressings, Ringer's lactate or normal saline, and an intravenous (IV) setup.<br />
You are not in an NBC environment..<br />
Standards: Administered initial treatment IAW the type and extent of the casualty's burns.<br />
Stabilized the casualty without causing further injury to the casualty or injuring self.<br />
Performance Steps<br />
1. Determine the cause of the burns.<br />
a. Assess the scene.<br />
b. Question the casualty and/or bystanders.<br />
c. Determine if the casualty has been exposed to smoke, steam, or combustible<br />
products.<br />
d. Determine if the cause was open flame, hot liquid, chemicals, or electricity.<br />
e. Determine whether the casualty was struck by lightning.<br />
NOTE: If the burn was caused by an explosion or lightning, the casualty may also have been<br />
thrown some distance from the original spot of the incident. He or she may, therefore, have<br />
associated internal injuries, fractures, or spinal injuries.<br />
2. Stop the burning process.<br />
a. Thermal burns.<br />
(1) Have the casualty STOP, DROP, and ROLL.<br />
(a) Do not permit the casualty to run, as this will fan the flames.<br />
(b) Do not permit the casualty to stand, as the flames may be inhaled or the hair<br />
ignited.<br />
(c) Place the casualty on the ground or floor and roll the casualty in a blanket or<br />
in dirt, and/or splash with water.<br />
(2) Remove all smoldering clothing and articles that retain heat, if possible.<br />
(3) Cut away clothing to expose the burned area.<br />
CAUTIONS: 1. Do not remove clothing that is stuck to the burned area. If the clothing and<br />
skin are still hot, immerse in clean, cold water or cover with a wet dressing, if available. Do not<br />
immerse the burned area for more than 10 minutes. Prolonged cold water immersion,<br />
particularly of an extensive burn, can cause hypothermia (loss of body heat). 2. Immerse third<br />
degree burns only if they are still burning. Infection is the greatest danger of a third degree<br />
burn. Immersion other than to stop the burning may increase the risk of infection.<br />
b. Electrical burns.<br />
(1) Turn off the current, if possible.<br />
(2) If the current cannot be turned off, stand on a dry surface and move the casualty<br />
with nonconductive material such as rubber gloves or a wooden pole.<br />
WARNING: Do not directly touch a casualty receiving a shock. To do so will conduct the<br />
current to you.<br />
(3) If necessary and/or possible, remove the electrical source from the casualty.<br />
WARNING: Electrical shock may cause the casualty to go into cardiac arrhythmia or arrest.<br />
Initiate CPR as appropriate. Casualties of lightning strikes may require prolonged CPR and<br />
extended respiratory support.<br />
c. Chemical burns.<br />
WARNING: A chemical will burn as long as it is in contact with the skin.<br />
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Performance Steps<br />
(1) Flush the area of contact immediately with water. Do not delay flushing by<br />
removing the casualty's clothing first.<br />
NOTE: If a solid chemical, such as lime, has been spilled on the casualty, brush it off before<br />
flushing. A dry chemical is activated by contact with water and will cause more damage to the<br />
skin.<br />
(2) Flush with cool water for 10 to 15 minutes while removing contaminated clothing<br />
or other articles.<br />
NOTES: 1. Flush longer for alkali burns because they penetrate deeper and cause more<br />
severe injury. 2. Many chemicals have a delayed reaction. They will continue to cause injury<br />
even though the casualty no longer feels pain.<br />
WARNING: Do not use a hard blast of water. Extreme water pressure can add mechanical<br />
injury to the skin.<br />
d. White phosphorus burns.<br />
NOTE: White phosphorus (WP) will stick to the skin and continue to burn until it is deprived of<br />
air. WP burns are usually multiple and deep, usually producing second and third degree burns.<br />
(1) Deprive the WP of oxygen.<br />
(a) Splash with a nonpetroleum liquid (such as water, mud, or urine).<br />
(b) Submerge the entire area.<br />
(c) Cover the affected area with a moistened cloth, if available, or mud.<br />
(2) Remove the WP particles from the skin by brushing with a wet cloth or using<br />
forceps, stick, or knife.<br />
WARNING: Do not use any type of petroleum product to smother the WP. This will cause it to<br />
be more rapidly absorbed into the body.<br />
3. Maintain an open airway, if necessary. (See task 081-831-0018.)<br />
NOTE: As long as 30 to 40 minutes may elapse before edema obstructs the airway and<br />
respiratory distress is noted.<br />
a. Check for signs and symptoms of inhalation injury.<br />
(1) Facial burns.<br />
(2) Singed eyebrows, eyelashes, and/or nasal hairs.<br />
(3) Carbon deposits and/or redness in the mouth and/or oropharynx.<br />
(4) Sooty carbon deposits in the sputum.<br />
(5) Hoarseness, noisy inhalation, brassy sounding cough, or dyspnea.<br />
b. Check for signs and symptoms of carbon monoxide poisoning.<br />
(1) Dizziness, nausea, and/or headache.<br />
(2) Cherry-red colored skin and mucous membranes.<br />
(3) Tachycardia or tachypnea.<br />
(4) Respiratory distress or arrest.<br />
c. Administer humidified oxygen at a high flow rate. (See tasks 081-833-0018 and 081-<br />
833-0019.)<br />
4. Determine the percent of body surface area (BSA) burned.<br />
a. Cut the casualty's clothing away from the burned areas.<br />
b. Determine the percentage of BSA burned using the Rule of Nines. (See Figure 3-16.)<br />
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Performance Steps<br />
Figure 3-16<br />
5. Determine the degree of the burns.<br />
a. First degree.<br />
(1) Superficial skin only.<br />
(2) Red and painful, like a sunburn.<br />
b. Second degree.<br />
(1) Partial thickness of the skin.<br />
(2) Penetrates the skin deeper than first degree.<br />
(3) Blisters and pain.<br />
(4) Some subcutaneous edema.<br />
c. Third degree.<br />
(1) Damage to or the destruction of a full thickness of skin.<br />
(2) Involves underlying muscles, bones, or other structures.<br />
(3) The skin may look leathery, dry, and discolored (charred, brown, or white).<br />
(4) Nerve ending destruction causes a lack of pain.<br />
(5) Massive fluid loss.<br />
(6) Clotted blood vessels may be visible under the burned skin.<br />
(7) Subcutaneous fat may be visible.<br />
CAUTIONS: 1. Check for entry and exit burns when treating electrical burns and lightning<br />
strikes. 2. The amount of injured tissue in an electrical burn is usually far more extensive than<br />
the appearance of the wound would indicate. Although the burn wounds may be small, severe<br />
damage may occur to deeper tissues. (High voltage can destroy skin and muscles to such as<br />
extent that amputation may eventually be necessary.)<br />
6. Treat for shock those casualties who have second or third degree burns of 20% BSA or<br />
more.<br />
a. Initiate treatment for hypovolemic shock. (See task 081-833-0047.)<br />
b. Keep the casualty flat.<br />
c. Initiate an IV. (See task 081-833-0033.)<br />
(1) Use Ringer's lactate, if available. Normal saline is the second fluid of choice.<br />
(2) Use a large gauge (#16 or #18) needle.<br />
(3) Initiate the IV in an unburned area, if possible.<br />
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Performance Steps<br />
(4) Use a large peripheral vein.<br />
NOTE: The presence of overlying burned skin should not deter the use of an accessible vein.<br />
The upper extremities are preferable to lower extremities.<br />
d. Infuse fluids for a casualty based on fluid replacement calculations.<br />
(1) Calculate the casualty's body weight in kilograms (kg).<br />
(a) Determine or estimate the casualty's body weight in pounds.<br />
(b) Divide the casualty's body weight by 2.2. For example, the casualty weighs<br />
about 165 pounds. 165/2.2 = 75 kg.<br />
(2) Calculate the amount of fluid to infuse per hour for the next 8 hours.<br />
(a) Determine the percentage of BSA burned (see step 4b). For example, the<br />
casualty's BSA burned is 36%.<br />
(b) Multiply 1 milliliter of fluid (1.00 cc) by the percentage of BSA burned. For<br />
example, 1.00 cc X 36 = 36 cc.<br />
(c) Multiply the above figure by the casualty's weight, found in step 6d(1). For<br />
example, 36 cc X 75 kg = 2700 cc. The casualty will require this much fluid<br />
over the next 8 hours.<br />
(d) Divide the above figure by 8 to determine the amount of fluid to give per hour.<br />
For example, 2700/8 = 337.5, rounded to 338 cc of fluid per hour (cc/hr).<br />
e. Assess the circulatory blood volume.<br />
NOTE: Urine output is a reliable guide to assess circulating blood volume.<br />
(1) Measure the casualty's urine output in cc per hour.<br />
(2) Adjust the IV fluid flow to maintain 30 to 50 cc of urine output per hour.<br />
7. Stabilize the casualty and perform a secondary assessment.<br />
a. Measure and record the casualty's vital signs.<br />
b. Assess the casualty for associated injuries. (See task 081-833-0151)<br />
c. Check the distal circulation by checking pulses in all extremities.<br />
8. Remove potentially constricting items such as rings and bracelets.<br />
CAUTION: The swelling of burns on extremities can cause a tourniquet-like effect, and the<br />
swelling of a burned throat can impair breathing.<br />
9. Apply cold soaks, if applicable.<br />
a. Use for casualties with second degree burns of 10% BSA or less only.<br />
b. Apply the soaks for 10 to 15 minutes only.<br />
CAUTION: Do not immerse or apply cold water to a casualty with extensive burns.<br />
10. Dress the burns.<br />
a. Apply a dry sterile dressing to the burns.<br />
CAUTION: Do not put ointment on the burns and do not break blisters.<br />
b. Cover extensive burns with a sterile sheet, if available, or clean linen.<br />
11. Administer oxygen, if available. (See task 081-833-0019.)<br />
12. Record the treatment given.<br />
13. Evacuate the casualty.<br />
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Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. You may use a<br />
moulage kit or similar material to simulate burns on the casualty, or you may describe to the<br />
soldier the area(s) of the body burned. Create a scenario which describes the cause and depth<br />
of the burns. For step 2, have the soldier describe what actions should be taken to prevent<br />
further injury. To test step 5, describe the depth of the burns and have the soldier tell you if they<br />
are first, second, or third degree. When testing step 6, have the soldier describe what actions<br />
should be taken when administering IV therapy, if necessary. When testing step 7, have the<br />
soldier describe what action is taken.<br />
Brief soldier: Tell the soldier to determine the extent of the casualty's burns and the treatment<br />
required.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined the cause of the burns. —— ——<br />
2. Stopped the burning process. —— ——<br />
3. Maintained the airway, if necessary. —— ——<br />
4. Determined the percent of BSA burned. —— ——<br />
5. Determined the degree of the burns. —— ——<br />
6. Treated the casualty for shock, if necessary. —— ——<br />
7. Stabilized the casualty and performed a secondary assessment. —— ——<br />
8. Removed potentially constricting items. —— ——<br />
9. Applied cold soaks, if applicable. —— ——<br />
10. Dressed the burns. —— ——<br />
11. Administered oxygen, if available. —— ——<br />
12. Recorded the treatment given. —— ——<br />
13. Evacuated the casualty. —— ——<br />
14. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-143
STP 8-91W15-SM-TG<br />
PROVIDE CARE FOR A SOLDIER WITH SYMPTOMS OF BATTLE FATIGUE<br />
081-833-0103<br />
Conditions: A soldier in a combat environment displays signs and symptoms of battle fatigue.<br />
Standards: Classified the degree of battle fatigue and treated the soldier accordingly.<br />
Performance Steps<br />
NOTE: Battle fatigue refers to combat stress symptoms and reactions which may manifest as<br />
emotional and/or physical conditions. The soldier's mission performance may not be affected.<br />
Battle fatigue is considered a "normal" condition which could occur in anyone subjected to the<br />
physical and emotional stress of combat.<br />
1. Identify contributing causes of battle fatigue.<br />
NOTE: These are factors that have been historically identified as contributors to increasing<br />
battle fatigue rates.<br />
a. Sudden exposure to the intense fear, stimuli, and life/death consequences of battle.<br />
b. Cumulative exposure to dangers, responsibilities, and consequences of combat,<br />
including repeated grief and guilt over loss of comrades, friends, or patients.<br />
NOTE: This may lead to the sense that one's own luck, skill, and courage have been used up.<br />
c. Physical stressors.<br />
(1) Sleep loss.<br />
(2) Lack of food and/or water.<br />
(3) Physical exhaustion or excessive physical demands.<br />
(4) Inclement weather.<br />
(5) Lack of facilities for personal hygiene.<br />
(6) Environmental illnesses.<br />
(7) Cumulative exposure to combat conditions (noise, odor, and discomfort).<br />
d. Psychosocial factors.<br />
(1) Worry about family members and friends.<br />
(2) Homefront worries (debts, " Dear John" letters, and family illness/death).<br />
(3) Lack of confidence in oneself, leaders, comrades, and/or equipment.<br />
2. Check the casualty for signs and symptoms of battle fatigue.<br />
a. Simple fatigue.<br />
(1) Loss of initiative.<br />
(2) Tiredness.<br />
(3) Indecisiveness.<br />
(4) Inattention.<br />
b. Anxiety.<br />
(1) Marked startle response.<br />
(2) Tremors.<br />
(3) Sweating.<br />
(4) Insomnia with terror dreams.<br />
(5) Rapid heartbeat.<br />
c. Depression.<br />
(1) Self-doubt.<br />
(2) Self-blame.<br />
(3) Hopelessness.<br />
(4) Grief.<br />
(5) Bereavement.<br />
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Performance Steps<br />
d. Memory loss.<br />
(1) Ranges from inability to remember recent instructions to loss of memory of well<br />
learned skills.<br />
(2) Loss of memory of a traumatic event or period of time.<br />
(3) Total amnesia or fugue state (soldier leaves his post, forgets his own past, goes<br />
somewhere else, and may assume a new identity).<br />
e. Physical function disturbance.<br />
NOTE: These symptoms are not due to a physical cause and may have a clear symbolic<br />
relationship to a specific trauma or conflict of motivation.<br />
(1) Motor functions.<br />
(a) Weakness or paralysis of hands, limbs, or body.<br />
(b) Gross tremors.<br />
(c) Sustained contractions of muscles.<br />
(2) Sensory functions.<br />
(a) Visual symptoms--tunnel vision or total blindness.<br />
(b) Auditory symptoms--dizziness, ringing in the ears, or deafness.<br />
(c) Tactile changes--loss of sensations or abnormal sensations.<br />
(d) Speech--stuttering, hoarseness, or muteness.<br />
3. Classify battle fatigue cases.<br />
NOTE: Classification labels are based on where the soldiers can be treated and therefore,<br />
depend as much on the situation of the unit as on the symptoms of the soldier. The<br />
classification has only transient significance due to the quickly changing nature of the battle<br />
fatigue symptoms.<br />
a. Duty--can be treated within the small unit while remaining on duty status.<br />
b. Rest--treated in a nonmedical support unit on a limited duty status for 1 to 2 days.<br />
c. Hold--requires holding for restorative treatment in the medical unit where the soldier is<br />
being evaluated.<br />
d. Refer--requires transfer to the next echelon medical facility for further evaluation.<br />
4. Use basic treatment principles for battle fatigue.<br />
NOTE: The acronym "PIES" is a method of remembering how to treat soldiers with battle<br />
fatigue.<br />
a. Proximity. Treat as close to the soldier's unit and the battle as possible to reduce<br />
overevacuation.<br />
b. Immediacy. Treat immediately, without delay.<br />
c. Expectancy. Express positive expectation of a full, rapid recovery.<br />
d. Simplicity. Use simple, brief methods to restore physical well-being and selfconfidence,<br />
and use nonmedical terminology and techniques with the soldier.<br />
5. Perform appropriate treatment interventions for battle fatigue.<br />
a. Maintain a military atmosphere.<br />
(1) Have the soldier dress in a field uniform.<br />
(2) Have the soldier maintain his or her field equipment.<br />
(3) Keep the soldier busy with physical exercise, useful work details, and military<br />
training.<br />
(4) Maintain appropriate military rank distinctions and courtesies.<br />
b. Encourage the soldier to--<br />
(1) Sleep or rest.<br />
(2) Eat and drink to replenish lost fluids.<br />
(3) Shower and clean up, if possible.<br />
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Performance Steps<br />
c. Reassure the soldier that other soldiers have had the same experience and symptoms<br />
and have recovered and returned to duty.<br />
d. Encourage the soldier to talk about what has happened and about his or her emotions<br />
and unacceptable feelings.<br />
(1) Maintain an accepting attitude.<br />
(2) Assist the soldier in finding a more adaptive perspective to what has happened.<br />
(3) Focus on lessons learned and alternative methods of coping.<br />
e. Recognize that some physical or mental illnesses may resemble battle fatigue.<br />
(1) Hypothermia.<br />
(2) Blunt trauma injury.<br />
(3) Substance abuse.<br />
(4) Laser eye injury.<br />
(5) Nerve agent or atropine poisoning.<br />
(6) Psychiatric and personality disorders.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified contributing causes of battle fatigue. —— ——<br />
2. Checked the soldier for signs and symptoms of battle fatigue. —— ——<br />
3. Classified the battle fatigue case. —— ——<br />
4. Used basic treatment principles for battle fatigue. —— ——<br />
5. Performed appropriate treatment interventions for battle fatigue. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 8-10<br />
3-146
STP 8-91W15-SM-TG<br />
ASSIST IN VAGINAL DELIVERY<br />
081-833-0116<br />
Conditions: You encounter a pregnant female who is in labor. Necessary materials and<br />
equipment: sterile obstetric kit (if kit is not available, you will need clean sheets and towels,<br />
heavy flat twine or new shoelaces, plastic bag, and clean, unused gloves).<br />
Standards: Assisted with cephalic vaginal delivery<br />
Performance Steps<br />
1. Assist with the first stage of labor assessment.<br />
NOTES: 1. All scene size-up, initial assessment, focused history, examination, detailed<br />
physical examination, ongoing assessment, and evacuate assessment steps must be taken to<br />
ensure that injury(ies) or illness is/are not over looked resulting in further injury to the patient. 2.<br />
Evacuate an expecting mother unless delivery is expected within a few minutes.<br />
a. Interview the pregnant woman. Request health history.<br />
(1) Present pregnancy history: Is this your first pregnancy? Has there been<br />
complications during your pregnancy?<br />
(2) Medical history: History of diabetes, hypertension, or chronic diseases?<br />
(3) Obstetric history: How many times have you been pregnant?<br />
b. Assess general appearance and behavior.<br />
c. Check vital signs: monitor blood pressure.<br />
d. Assess the labor pattern status.<br />
(1) Contractions: initial onset, frequency, and duration.<br />
(2) Discomfort or pain.<br />
e. Assess fetal status: Apply monitor for fetal heart tones.<br />
f. Assess amniotic membranes status: Inquire if the patient has experienced constant<br />
leakage or rupture of vaginal fluid.<br />
2. Assist with the second stage of labor assessment.<br />
a. Monitor continuously:<br />
(1) Fetal heart rate and interval.<br />
(2) Contractions.<br />
(3) Patient's response.<br />
(4) Patient's comfort or pain.<br />
(5) Vital signs of the patient between contractions. If hypertension occurs, place the<br />
patient on her left side, administer oxygen (if available), and notify health care<br />
provider immediately.<br />
b. Maintain intravenous fluids.<br />
c. Assist to provide safety and position of comfort to the patient.<br />
3. Assist with the third stage of labor assessment.<br />
a. Recognize precautions.<br />
(1) Use body substance isolation.<br />
(2) Do not let the mother go to bathroom.<br />
(3) Do not hold the mother's legs together.<br />
b. Assist with delivery of the infant as directed by health care provider.<br />
NOTE: If the medic is in an isolated environment and is unable to evacuate the patient, the<br />
medic will deliver the infant.<br />
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Performance Steps<br />
(1) Determine if the umbilical cord is around the infant's neck as the infant is being<br />
born. Slip over the shoulder.<br />
(2) Support the head after the infant's head is born.<br />
(3) Suction the mouth two or three times and the nostrils. Avoid contact with the back<br />
of the mouth.<br />
(4) Support the infant with both hands as the torso and full body are born.<br />
(5) Wipe blood and mucus from the mouth and nose with sterile gauze. Suction the<br />
mouth and nose again.<br />
(6) Clamp, tie, and cut the umbilical cord (between the clamps) as pulsation cease<br />
approximately four finger widths from the infant.<br />
(7) Wrap the infant in a warm blanket and place on its side, head slightly lower than<br />
trunk.<br />
(8) Observe for delivery of the placenta while preparing the mother and infant for<br />
evacuation.<br />
(9) Place a sterile pad over the vaginal opening and lower patient's legs.<br />
(10) Record the time of delivery and evacuate the mother, infant, and placenta to the<br />
hospital.<br />
4. Assist with the fourth stage of labor assessment.<br />
a. Provide care to the mother.<br />
(1) Complete assessment for the following every 15 minutes:<br />
(a) Fundus.<br />
(b) Lochia.<br />
(c) Perineum.<br />
(d) Vital signs.<br />
(e) Pulse.<br />
(f) Bladder extension.<br />
(g) Deep tendon reflexes, if needed.<br />
(2) Assess and provide for comfort and emotional response.<br />
(3) Maintain intravenous fluids.<br />
b. Provide initial care for the newborn.<br />
(1) Position, dry, wipe, and wrap the newborn in a blanket and cover the head.<br />
(2) Assessment findings<br />
(a) Appearance--color: no central (trunk) cyanosis.<br />
(b) Pulse--greater than 100/min.<br />
(c) Grimace--vigorous and crying.<br />
(d) Activity--good motion in extremities.<br />
(e) Breathing effort--normal, crying.<br />
5. Monitor for complications during labor.<br />
a. Identify prolapsed cord.<br />
(1) Pulsating, protruding cord from vagina.<br />
(2) Abnormal fetal heart rate and pattern.<br />
b. Identify abruptio placentae.<br />
(1) Vaginal bleeding may be dark red.<br />
(2) Amniotic fluid may be red in color.<br />
(3) Firm, rigid abdomen.<br />
(4) Pain: mild to severe.<br />
(5) Associated complications.<br />
(a) Hypovolemic shock.<br />
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Performance Steps<br />
(b) Fetal distress.<br />
c. Identify placenta previa.<br />
(1) Painless, bright-red uterine bleeding.<br />
(2) Non-tender uterus: soft abdomen while in labor.<br />
6. Identify additional gynecological emergencies.<br />
a. Ectopic pregnancy.<br />
(1) Assessment findings.<br />
(a) Acute abdominal pain.<br />
(b) Vaginal bleeding.<br />
(c) Rapid and weak pulse.<br />
(d) Low blood pressure.<br />
(2) Consider immediate transport.<br />
(3) Treat for shock if indicated.<br />
b. Miscarriage and abortion.<br />
(1) Assessment status.<br />
(a) Cramping abdominal pains.<br />
(b) Vaginal bleeding ranging from moderate to severe.<br />
(2) Save all tissues expelled.<br />
(3) Provide emotional support.<br />
(4) Consider immediate transport.<br />
Performance Measures GO NO<br />
GO<br />
1. Assisted with the first stage of labor assessment. —— ——<br />
a. Interviewed the pregnant woman.<br />
b. Assessed general appearance and behavior.<br />
c. Checked vital signs.<br />
d. Assessed the labor pattern status.<br />
e. Assessed fetal status.<br />
f. Assessed amniotic membranes status.<br />
2. Assisted with the second stage of labor assessment. —— ——<br />
a. Monitored continuously.<br />
b. Maintained intravenous fluids.<br />
c. Assisted to provide safety and positions of comfort to the patient.<br />
3. Assisted with the third stage of labor assessment. —— ——<br />
a. Recognized precautions.<br />
b. Assisted with delivery of infant as directed by health care provider.<br />
4. Assisted with the fourth stage of labor assessment. —— ——<br />
a. Provided care to the mother.<br />
b. Provided initial care for the newborn.<br />
5. Monitored for complications during labor. —— ——<br />
a. Identified prolapsed cord.<br />
b. Identified abruptio placentae.<br />
c. Identified placenta previa.<br />
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Performance Measures GO NO<br />
GO<br />
6. Identified additional gynecological emergencies. —— ——<br />
a. Ectopic pregnancy.<br />
b. Miscarriage and abortion.<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-150
STP 8-91W15-SM-TG<br />
TREAT A POISONED CASUALTY<br />
081-833-0143<br />
Conditions: You have taken body substance isolation precautions. You have performed an<br />
initial assessment. Necessary materials and equipment : activated charcoal, airway adjuncts,<br />
oxygen, IV catheter, IV tubing, .9 percent normal saline, water source, and suction equipment.<br />
Standards: Determined the type of poisoning and provided treatment, minimizing the effects of<br />
the poisoning, without causing further injury to the casualty.<br />
Performance Steps<br />
1. Determine the type of poisoning.<br />
CAUTION: If determination cannot be made to the type of poisoning, the patient should be<br />
treated by the symptoms presented.<br />
a. Ingested poisons.<br />
(1) Altered mental status.<br />
(2) Nausea/vomiting.<br />
(3) Abdominal pain.<br />
(4) Diarrhea.<br />
(5) Chemical burns around the mouth.<br />
(6) Unusual breath odors.<br />
b. Inhaled poisons.<br />
(1) Carbon monoxide.<br />
(a) Headache.<br />
(b) Dizziness.<br />
(c) Dyspnea.<br />
(d) Nausea/vomiting.<br />
(e) Cyanosis.<br />
(f) Coughing.<br />
(2) Smoke Inhalation.<br />
(a) Dyspnea.<br />
(b) Coughing.<br />
(c) Breath that has a smoky smell or the odor of chemicals involved at the scene.<br />
(d) Black residue in any sputum coughed up by the patient.<br />
(e) Nose-hairs singed from super-heated air.<br />
c. Injected poisons.<br />
(1) Uppers.<br />
(a) Excitement.<br />
(b) Tachycardia.<br />
(c) Tachypnea.<br />
(d) Dilated pupils.<br />
(e) Sweating.<br />
(2) Downers.<br />
(a) Sluggish.<br />
(b) Sleepy typical coordination of body and speech.<br />
(c) Pulse and breathing rates are low, often to the point of a true emergency.<br />
(3) Hallucinogens.<br />
(a) Tachycardia.<br />
(b) Dilated pupils.<br />
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Performance Steps<br />
(c) Flushed face.<br />
(d) Often sees or hears things, has very little concept of time.<br />
(4) Narcotics.<br />
(a) Reduced rate of breathing.<br />
(b) Dyspnea.<br />
(c) Low skin temperature.<br />
(d) Muscles relaxed.<br />
(e) Pinpoint pupils.<br />
(f) Very sleepy and doesn't want to do anything.<br />
d. Absorbed poisons.<br />
(1) Liquid or powder on the patient's skin.<br />
(2) Burns.<br />
(3) Itching.<br />
(4) Irritation.<br />
(5) Redness.<br />
2. Administer emergency care.<br />
a. Ingested poisons.<br />
(1) Maintain the airway.<br />
(2) Gather all information about the type of ingested poisoning.<br />
(3) Initiate IV therapy.<br />
(4) Administer activated charcoal.<br />
CAUTION: Activated charcoal is contraindicated for patients that have an altered mental status,<br />
that you suspect have swallowed acids or alkalis, or that are unable to swallow.<br />
NOTE: Be prepared to provide oral suctioning if the patient starts to vomit. All vomitus must be<br />
saved.<br />
(a) Adults and children: 1 gram of activated charcoal/kg of body weight.<br />
(b) Usual adult dose: 25 - 50 grams.<br />
(c) Usual pediatric dose: 12.5 - 25 grams.<br />
(5) Record the name, dose, and time of administration of medication.<br />
(6) Transport to the nearest medical treatment facility.<br />
b. Inhaled poisons.<br />
(1) Remove the patient from the unsafe environment.<br />
(a) Maintain the airway.<br />
(b) Administer high concentrations of oxygen.<br />
NOTE: This is the most important treatment for inhalation poisoning.<br />
(c) Transport to the nearest medical treatment facility.<br />
(d) Document interventions.<br />
c. Absorbed poisons.<br />
(1) Remove the patient from the source.<br />
(2) Remove contaminated clothing.<br />
(3) Brush off any powders from the patient's skin.<br />
(4) Flush the skin with large amounts of water for at least 20 minutes.<br />
NOTE: Flushing the skin with water may be contraindicated with some dry chemicals. Water<br />
may actually activate the chemical.<br />
d. Injected poisons.<br />
(1) Maintain the airway and be prepared to provide assisted ventilations.<br />
(2) Initiate IV therapy.<br />
(3) Look for gross soft tissue damage ("tracks").<br />
(4) Protect the patient from harming self and others.<br />
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Performance Steps<br />
NOTE: Be prepared to use restraints.<br />
(5) Transport to the nearest medical treatment facility.<br />
3. Document procedures (see tasks 081-831-0033 and 081-833-0145).<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty.<br />
Brief soldier: Tell the soldier that the patient has an ingested or inhaled poison. Have the<br />
soldier state what actions should be taken when an IV infusion is initiated.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined the type of poisoning. —— ——<br />
2. Maintained the airway. —— ——<br />
3. Initiated an IV. —— ——<br />
4. Administered proper medical intervention. —— ——<br />
a. Ingested poisons - administered activated charcoal.<br />
b. Absorbed poisons - brushed off powder and flushed, if appropriate.<br />
c. Inhaled poisons - administered high concentration of oxygen.<br />
5. Provided suctioning, if necessary. —— ——<br />
6. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
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TREAT A DIABETIC EMERGENCY<br />
081-833-0144<br />
Conditions: You have taken body substance isolation precautions. You have performed an<br />
initial assessment, focused history, and physical exam. Necessary materials and equipment:<br />
oral glucose and a tongue depressor.<br />
Standards: Initiated treatment for hypoglycemia or hyperglycemia, stabilized the casualty, and<br />
minimized the effects without causing further injury to the casualty.<br />
Performance Steps<br />
1. Identify the signs and symptoms of a diabetic emergency.<br />
a. Hypoglycemia. (Low blood sugar)<br />
NOTE: Hypoglycemia is the most common of all diabetic emergencies.<br />
(1) Rapid onset of altered mental status.<br />
NOTE: This is especially so after missing a meal, vomiting, or an unusual amount of physical<br />
exertion.<br />
(2) Intoxicated appearance, staggering, slurred speech, or unconsciousness.<br />
(3) Elevated heart rate.<br />
(4) Cold, clammy skin.<br />
(5) Hunger.<br />
(6) Seizures.<br />
(7) Uncharacteristic behavior.<br />
(8) Anxiety.<br />
(9) Combativeness.<br />
b. Hyperglycemia. (High blood sugar)<br />
(1) Slow onset.<br />
(2) Warm, red, dry skin.<br />
(3) Sweet, fruity breath odor (acetone).<br />
(4) Deep, rapid breathing.<br />
(5) Dry mouth.<br />
(6) Intense thirst.<br />
(7) Abdominal pain.<br />
(8) Nausea and vomiting.<br />
2. Administer the appropriate treatment.<br />
NOTE: If you are unsure whether the patient has hyperglycemia or hypoglycemia, it is safer to<br />
treat the patient for hypoglycemia.<br />
a. Hypoglycemia.<br />
(1) If conscious, administer oral glucose in accordance with local protocol.<br />
NOTE: Give it only if the patient has a history of diabetes, the patient has an altered mental<br />
status, and the patient is awake enough to swallow.<br />
(a) Apply glucose to a tongue depressor and place it in the patient's mouth<br />
between the cheek and gum.<br />
(b) Or if the patient is able, let the patient squeeze the glucose from the tube<br />
directly into his or her mouth.<br />
(2) Monitor the patient for complications.<br />
(3) If unconscious--<br />
(a) Secure the airway and administer oxygen, if necessary.<br />
(b) Start an IV at TKO rate.<br />
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Performance Steps<br />
(c) Place the patient in the recovery position.<br />
(d) Transport to the nearest medical treatment facility.<br />
b. Hyperglycemia.<br />
(1) Maintain an open airway and administer oxygen, if necessary.<br />
(2) Start an IV at TKO rate.<br />
(3) Place the patient on a cardiac monitor, if available.<br />
(4) Transport to the nearest medical treatment facility.<br />
3. Document all treatment given.<br />
NOTE: Document the patient's mental status using the AVPU throughout the contact. A<br />
change in mental status may indicate an alteration in the patient's blood sugar level.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty and exhibit signs<br />
and symptoms of hyperglycemia or hypoglycemia.<br />
Brief Soldier: Tell the soldier to state the signs and symptoms of hypoglycemia or<br />
hyperglycemia, and then treat the casualty.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the type of diabetic emergency (hypoglycemia or<br />
hyperglycemia).<br />
—— ——<br />
2. Administered appropriate treatment for hypoglycemia (conscious patient). —— ——<br />
a. Administered oral glucose.<br />
b. Monitored the patient for complications.<br />
3. Administered appropriate treatment for hypoglycemia (unconscious<br />
patient).<br />
a. Secured the airway and administered oxygen, if necessary.<br />
b. Started an IV at TKO rate.<br />
c. Placed the patient in a recovery position.<br />
d. Documented all treatment given.<br />
e. Transported the patient to the nearest medical treatment facility.<br />
—— ——<br />
4. Administered appropriate treatment for hyperglycemia. —— ——<br />
a. Maintained an open airway and administered oxygen, if necessary.<br />
b. Started an IV at TKO rate.<br />
c. Placed the patient on a cardiac monitor, if available.<br />
d. Documented all treatment given.<br />
e. Transported the patient to the nearest medical treatment facility.<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
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References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-156
STP 8-91W15-SM-TG<br />
PERFORM A TRAUMA CASUALTY ASSESSMENT<br />
081-833-0155<br />
Conditions: You find a casualty with multiple injuries. You are not in an NBC environment.<br />
You have available the necessary materials and equipment.<br />
Standards: Assessed the casualty, identified all life threatening injuries, and treated them<br />
appropriately without causing further injury. Performed the assessments in the correct order.<br />
Performance Steps<br />
1. Take body substance isolation precautions.<br />
2. Perform a Scene Assessment.<br />
a. Determine the safest route to access the casualty.<br />
b. Determine the mechanism of injury.<br />
c. Determine the number of casualties.<br />
d. Request additional help, if necessary.<br />
e. Consider stabilization of the spine.<br />
NOTE: If the mechanism of injury is significant, direct other soldiers to provide in line<br />
stabilization of the cervical spine.<br />
3. Perform an Initial Assessment.<br />
NOTE: Life threatening injuries should be treated as they are identified.<br />
a. Verbalize a general impression of the patient and of the patient's environment.<br />
b. Assess the patient's mental status using the AVPU scale.<br />
(1) A - Alert and oriented.<br />
(2) V - Responsive to verbal stimuli.<br />
(3) P - Responsive to painful stimuli.<br />
(4) U - Unresponsive (see task 081-833-0048).<br />
c. Determine the chief complaint.<br />
d. Assess the airway.<br />
(1) Perform appropriate maneuver to open and maintain the airway (see task 081-<br />
831-0018).<br />
(2) Insert an appropriate airway adjunct, if necessary. (See tasks 081-833-0016,<br />
081-833-0142, and 081-833-0169. If skill level 30, see task 081-830-3016 also.)<br />
e. Assess breathing.<br />
(1) Determine the rate, rhythm, and quality of breathing.<br />
(2) Administer oxygen if necessary using the appropriate delivery device (see tasks<br />
081-833-0158 and 081-831-0048).<br />
f. Assess circulation.<br />
(1) Skin color, condition, and temperature.<br />
(2) Assess the pulse for rhythm and force.<br />
(a) Check the radial pulse in adults.<br />
(b) Check the radial pulse and capillary refill in children.<br />
(c) Check the brachial pulse and capillary refill in infants.<br />
(3) Check for major bleeding.<br />
(4) Control major bleeding (see tasks 081-833-0161 and 081-833-0046).<br />
(5) Treat for shock (see task 081-833-0047).<br />
g. Identify patient priority and make a transport decision (load and go or stay and play).<br />
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Performance Steps<br />
NOTE: High priority conditions that require immediate transport include poor general<br />
impression, unresponsive, responsive but not following commands, difficulty breathing, shock,<br />
complicated childbirth, chest pain with systolic blood pressure less than 100, uncontrolled<br />
bleeding, and severe pain.<br />
4. If the mechanism of Injury is significant, perform a Rapid Trauma Assessment.<br />
NOTE: Significant mechanisms of injury include ejection from a vehicle, death in the same<br />
passenger compartment, falls of more than 15 feet or three times the patient's height, roll over<br />
of vehicle, high-speed vehicle collision, vehicle-pedestrian collision, motorcycle crash,<br />
unresponsive or altered mental status, and penetrations of the head, chest, or abdomen (e.g.,<br />
stab and gunshot wounds). Additional significant mechanisms of injury for a child include falls<br />
from more than 10 feet, bicycle collision, and vehicles in medium speed collision.<br />
a. Head.<br />
(1) Inspect for deformities, contusions, abrasions, punctures or penetration, burns,<br />
tenderness, lacerations, swelling (DCAP-BTLS).<br />
(2) Inspect for crepitus.<br />
b. Neck.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Palpate spine step-offs.<br />
(3) Inspect for jugular vein distention (JVD).<br />
(4) Inspect for tracheal deviation.<br />
(5) Apply a cervical collar, if necessary<br />
c. Chest.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for crepitus.<br />
(3) Inspect for paradoxical motion.<br />
(4) Inspect breath sounds (absent/present, equal).<br />
d. Abdomen.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for tenderness.<br />
(3) Inspect for rigidity.<br />
(4) Inspect for distention.<br />
e. Pelvis.<br />
NOTE: If a conscious patient complains of pain or if an unconscious patient responds as if in<br />
pain at anytime during the assessment, do not continue the exam. Treat for pelvic fracture.<br />
CAUTION: Do not log roll patients suspected of having a pelvic fracture.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Gently compress to detect instability and crepitus.<br />
(3) Determine the level of pain.<br />
(4) Inspect for priapism.<br />
f. Extremities.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Check the distal pulse.<br />
(3) Check distal motor function.<br />
(4) Check distal sensation.<br />
g. Posterior.<br />
NOTE: The patient must be log rolled to do this portion of the assessment. If necessary, the<br />
patient should be placed on a long spine board after assessment. If PASGs were deemed<br />
necessary, they should be positioned on the long spine board before patient placement. If a<br />
patient has a suspected pelvic fracture, place in a scoop litter and then assess the posterior.<br />
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Performance Steps<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for rectal bleeding.<br />
5. If there is no significant mechanism of injury, perform a Focused History and Physical<br />
Exam.<br />
a. Based on chief complaint.<br />
b. Focus on the areas that the patient tells you are painful or that you suspect may be<br />
painful due to the mechanism of injury.<br />
6. Obtain baseline vital signs (see tasks 081-831-0013, 081-831-0011, 081-831-0010, and<br />
081-831-0012).<br />
7. Obtain a SAMPLE history.<br />
NOTE: A SAMPLE history is obtained by questioning the patient. If the patient is unable to<br />
answer, search the scene or ask bystanders and/or family members for information.<br />
a. Signs/Symptoms.<br />
(1) Ask the patient what's wrong.<br />
(2) Observe the patient.<br />
b. Allergies.<br />
(1) Ask the patient if there are any allergies to medications, foods, or environmental.<br />
(2) Look for a medical identification tag.<br />
c. Medications.<br />
(1) Ask the patient if he or she is taking any medications (prescription, over the<br />
counter, or illegal).<br />
(2) Ask a female patient if she is taking birth control pills.<br />
(3) Search for an identification tag with medications on it or medications in the area.<br />
d. Pertinent past history.<br />
(1) Ask the patient if there are any medical problems (past and present).<br />
(2) Ask the patient if he or she has been feeling ill.<br />
(3) Ask the patient about recent surgery or injuries.<br />
(4) Ask the patient if he or she is currently seeing a doctor and, if so, what is the<br />
doctor's name.<br />
e. Last oral intake.<br />
(1) Ask the patient when his or her last meal or drink was.<br />
(2) Ask the patient what he or she drank or ate.<br />
f. Events leading to the injury or illness.<br />
(1) If the patient is unable to answer, search the scene for anything that may help.<br />
(2) Ask about the sequence of events that led up to the current problem.<br />
8. Perform a Detailed Physical Examination<br />
NOTE: This is done only if time permits during evacuation or while waiting for evacuation. Do<br />
not delay evacuation to perform this exam.<br />
a. Assess the scalp and cranium.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for crepitation.<br />
b. Assess the ears.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for drainage.<br />
(a) Blood.<br />
(b) Clear fluid.<br />
c. Assess the face for DCAP-BTLS.<br />
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Performance Steps<br />
d. Assess the eyes.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for discoloration.<br />
(3) Inspect for unequal pupils.<br />
(4) Inspect for foreign bodies.<br />
(5) Inspect for blood in anterior chamber.<br />
e. Assess the nose.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for drainage of blood and/or clear fluid.<br />
f. Assess the mouth.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for loose or broken teeth.<br />
(3) Inspect for objects that could cause obstruction.<br />
(4) Inspect for swelling or laceration of the tongue.<br />
(5) Inspect for unusual breath odor.<br />
(6) Inspect for discoloration.<br />
g. Assess the neck.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for jugular vein distention (JVD).<br />
(3) Inspect for tracheal deviation.<br />
(4) Inspect for crepitation.<br />
h. Reassess the chest.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Palpate.<br />
(3) Auscultate breath sounds.<br />
(4) Assess for flail chest.<br />
i. Reassess the abdomen.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for tenderness.<br />
(3) Inspect for rigidity.<br />
(4) Inspect for distention.<br />
j. Reassess the pelvis.<br />
NOTE: If pain, instability, or crepitus was noticed in the rapid trauma assessment, ensure the<br />
pelvis is properly stabilized and do not reassess.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for instability.<br />
(3) Inspect for crepitation.<br />
(4) Determine the level of pain.<br />
k. Reassess the extremities.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect motor function.<br />
(3) Check sensation.<br />
(4) Check circulation.<br />
l. Reassess the posterior.<br />
NOTE: If the patient is secured to a long spine board, do not remove from the board. Reassess<br />
the flanks and as much of the spine as you can without moving the patient.<br />
(1) Inspect for DCAP-BTLS.<br />
(2) Inspect for rectal bleeding.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
m. Manage secondary injuries and wounds appropriately (see tasks 081-831-0044, 081-<br />
833-0045, 081-833-0046, 081-833-0049, 081-833-0050, 081-833-0052, 081-833-0056,<br />
081-833-0057, 081-833-0058, 081-833-0060, 081-833-0062, 081-833-0064, 081-833-<br />
0154, and 081-833-3011.<br />
n. Reassess vital signs.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty or use a trauma<br />
manikin. Describe a general scenario to the soldier. The casualty must have more than one<br />
injury or condition. Wounds may be simulated using moulage or other available materials. A<br />
"conscious" casualty can be coached to show signs of such conditions as shock, and to respond<br />
to the soldier's questions about the location of pain and other symptoms of injury. The evaluator<br />
will cue the soldier during the assessment of an "unconscious" casualty as to whether the<br />
casualty is breathing, and describe such conditions as shock to the soldier as he or she is<br />
making the checks.<br />
Brief soldier: Tell the soldier to tell you what action he or she would take for each wound or<br />
condition identified.<br />
Performance Measures GO NO<br />
GO<br />
1. Took body substance isolation precautions. —— ——<br />
2. Performed a Scene Assessment. —— ——<br />
3. Assessed for spinal protection. —— ——<br />
4. Performed an Initial Assessment. —— ——<br />
5. Administered high concentration of oxygen, if necessary. —— ——<br />
6. Managed problems associated with the airway, breathing, hemorrhage, or<br />
shock (hypovolemic).<br />
7. Differentiated the patient's need for transportation versus continued<br />
assessment at the scene.<br />
8. If the mechanism of injury was significant, performed a Rapid Trauma<br />
Assessment.<br />
9. If there was no significant mechanism of injury, performed a Focused<br />
History and Physical Exam.<br />
—— ——<br />
—— ——<br />
—— ——<br />
—— ——<br />
10. Obtained baseline vital signs. —— ——<br />
11. Obtained the SAMPLE history. —— ——<br />
12. Performed a Detailed Physical Exam. —— ——<br />
13. Performed the assessments in order. —— ——<br />
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STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-162
STP 8-91W15-SM-TG<br />
PERFORM A MEDICAL PATIENT ASSESSMENT<br />
081-833-0156<br />
Conditions: You have a patient with a complaint that is medical in nature and no significant<br />
mechanism of injury. You have available the necessary materials and equipment to treat or<br />
stabilize the patient.<br />
Standards: Assessed the patient and identified and treated the present illness without causing<br />
further injury.<br />
Performance Steps<br />
1. Take body substance isolation precautions.<br />
2. Perform scene size-up.<br />
a. Determine the safest route to access the casualty.<br />
b. Determine the mechanism of injury/nature of illness.<br />
c. Determine the number of patients.<br />
d. Request additional help if necessary.<br />
e. Considers stabilization of the spine.<br />
3. Perform an Initial Assessment.<br />
a. Verbalize general impression of the patient and the patient's environment.<br />
b. Assess the patient's mental status using the AVPU scale.<br />
(1) A - Alert and oriented.<br />
(2) V - Responsive to verbal stimuli.<br />
(3) P - Responsive to painful stimuli.<br />
(4) U - Unresponsive (see task 081-833-0048).<br />
c. Determine the chief complaint/apparent life threatening condition.<br />
d. Assess the airway.<br />
(1) Perform an appropriate maneuver to open and maintain the airway if necessary<br />
(see task 081-831-0018).<br />
(2) Insert an appropriate airway adjunct, if necessary. (See tasks 081-833-0016,<br />
081-833-0142, and 081-833-0169. If skill level 30, see task 081-830-3016 also.)<br />
e. Assess breathing.<br />
(1) Determine the rate, rhythm, and quality of breathing.<br />
(2) Administer oxygen if necessary using the appropriate delivery device (see tasks<br />
081-833-0158 and 081-831-0048).<br />
f. Assess circulation.<br />
(1) Skin color and temperature.<br />
(2) Assess the pulse for rhythm and force.<br />
(a) Check the radial pulse in adults.<br />
(b) Check the radial pulse and capillary refill in children under 6 years old.<br />
(c) Check the brachial pulse and capillary refill in infants.<br />
(3) Check for major bleeding.<br />
(4) Control major bleeding (see tasks 081-833-0161 and 081-833-0046).<br />
(5) Treat for shock (see task 081-833-0047).<br />
g. Identify priority patients and make a transport decision (load and go or stay and play).<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: High priority conditions that require immediate transport include poor general<br />
impression, unresponsive, responsive but not following commands, difficulty breathing, shock,<br />
complicated childbirth, chest pain with systolic blood pressure less than 100, uncontrolled<br />
bleeding, and severe pain.<br />
4. Conduct a rapid physical exam if the patient is unconscious. Inspect each of the following<br />
areas for deformities, contusions, abrasions, punctures or penetration, burns, tenderness,<br />
lacerations, swelling (DCAP-BTLS).<br />
a. Assess the head.<br />
b. Assess the neck.<br />
c. Assess the chest.<br />
d. Assess the abdomen.<br />
e. Assess the pelvis.<br />
f. Assess the extremities.<br />
g. Assess the posterior.<br />
5. Gather a SAMPLE history from the patient.<br />
NOTE: If the patient is unable to give you this information, gather as much information about<br />
the SAMPLE history as you can from the patient's family and/or bystanders.<br />
a. Signs and symptoms. Gather history of the present illness (OPQRST) from the<br />
patient.<br />
(1) RESPIRATORY.<br />
(a) Onset - When did it begin?<br />
(b) Provocation - What were you doing when this came on?<br />
(c) Quality - Can you describe the feeling you have?<br />
(d) Radiation - Does the feeling seem to spread to any other part of your body?<br />
Do you have pain or discomfort anywhere else in your body?<br />
(e) Severity - On a scale of 1 to 10, how bad is your breathing trouble (10 is<br />
worst, 1 is best)?<br />
(f) Time - How long have you had this feeling?<br />
(g) Interventions - Have you taken any medication to help you breathe? Did it<br />
help?<br />
(2) CARDIAC.<br />
(a) Onset - When did it begin?<br />
(b) Provocation - What were you doing when this came on?<br />
(c) Quality - Can you describe the feeling you have?<br />
(d) Radiates - Does the feeling seem to spread to any other part of your body?<br />
Do you have pain or discomfort anywhere else in your body?<br />
(e) Severity - On a scale of 1 to 10, how bad is your breathing trouble (10 is<br />
worst, 1 is best)?<br />
(f) Time - How long have you had this feeling?<br />
(g) Interventions - Have you taken any medication to help you? Did it help?<br />
(3) ALTERED MENTAL STATUS.<br />
(a) Description of the episode - Can you tell me what happened? How did the<br />
episode occur?<br />
(b) Onset - How long ago did it occur?<br />
(c) Duration - How long did it last?<br />
(d) Associated symptoms - Was the patient sick or complaining of not feeling well<br />
before this happened?<br />
(e) Evidence of trauma - Was the patient involved in falls or accidents recently?<br />
3-164
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(f) Interventions - Has the patient taken anything to help with this problem? Did<br />
it help?<br />
(g) Seizures - Did the patient have a seizure?<br />
(h) Fever - Did the patient have a fever? What was the patient's temperature?<br />
(4) ALLERGIC REACTION.<br />
(a) History of allergies - Do you have any allergies?<br />
(b) What were you exposed to - Is there any chance that you were exposed to<br />
something that you may be allergic to?<br />
(c) How were you exposed - How did you come into contact with ___________<br />
(whatever the patient is allergic to)?<br />
(d) Effects - What kind of symptoms are you having? How long after you were<br />
exposed did the symptoms start?<br />
(e) Progression - How long after you were exposed did the symptoms start? Are<br />
they worse now than they were before?<br />
(f) Interventions - Have you taken anything to help? Did it help?<br />
(5) POISONING/OVERDOSE.<br />
(a) Substance - What substance was involved?<br />
(b) When did you ingest/become exposed - When did the exposure/ingestion<br />
occur?<br />
(c) How much did you ingest - How much did the patient ingest?<br />
(d) Over what time period - Over how long a period did the ingestion occur?<br />
(e) Interventions - What interventions did the family or bystanders take?<br />
(f) Estimated weight - What is the patient's estimated weight?<br />
(6) ENVIRONMENTAL EMERGENCY.<br />
(a) Source - What caused the injury?<br />
(b) Environment - Where did the injury occur?<br />
(c) Duration - How long were you exposed?<br />
(d) Loss of consciousness - Did you lose consciousness at any time?<br />
(e) Effects (general or local) - What signs and symptoms are you having? What<br />
effect did being exposed have on the patient?<br />
(7) OBSTETRICS.<br />
(a) Are you pregnant?<br />
(b) How long have you been pregnant?<br />
(c) Are you having pain or contractions?<br />
(d) Are you bleeding? Are you having any discharge?<br />
(e) Do you feel the need to push?<br />
(f) When was your last menstrual period?<br />
(8) BEHAVIORAL.<br />
(a) How do you feel?<br />
(b) Determine suicidal tendencies - Do you have a plan to hurt yourself or<br />
anyone else? .<br />
(c) Is the patient a threat to self or others?<br />
(d) Is there a medical problem?<br />
(e) Interventions?<br />
b. Allergies.<br />
c. Medications.<br />
d. Past pertinent history.<br />
e. Last oral intake.<br />
f. Event(s) leading to present illness.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
6. Perform a focused physical examination on the affected body part/system.<br />
7. Obtain baseline vital signs (see tasks 081-831-0013, 081-831-0011, 081-831-0010, and<br />
081-831-0012).<br />
8. Provide medication interventions and treatment as needed (see tasks 081-831-0035, 081-<br />
833-0103, 081-833-0116, 081-833-0143, 081-833-0144, 081-833-0159, 081-833-0160,<br />
081-833-0163, 081-833-0166, 081-833-0054, 081-831-0038, 081-831-0039, 081-833-0031,<br />
081-833-0073, and 081-833-3206) .<br />
9. Reevaluate the transport decision.<br />
10. Consider completing a detailed physical examination.<br />
11. Perform Ongoing Assessment.<br />
a. Repeat the initial assessment.<br />
b. Repeat vital signs.<br />
c. Repeat the focused assessment regarding the patient's complaint or injuries.<br />
Performance Measures GO NO<br />
GO<br />
1. Took body substance isolation precautions. —— ——<br />
2. Performed a scene size up. —— ——<br />
3. Obtained medical direction or used standing orders for medical<br />
interventions.<br />
—— ——<br />
4. Provided high concentration of oxygen. —— ——<br />
5. Found and managed problems associated with the airway, breathing,<br />
hemorrhage, or shock.<br />
6. Differentiated the patient's need for transportation versus continued<br />
assessment at the scene.<br />
7. Performed a detailed or focused history/physical examination before<br />
assessing the airway, breathing, and circulation.<br />
—— ——<br />
—— ——<br />
—— ——<br />
8. Asked questions concerning the present illness. —— ——<br />
9. Administered appropriate interventions. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-166
STP 8-91W15-SM-TG<br />
TREAT A CARDIAC EMERGENCY<br />
081-833-0159<br />
Conditions: You have a conscious patient who is complaining of chest pain. You have already<br />
taken the appropriate body substance isolation precautions. You have already done the initial<br />
patient assessment, focused history, and physical. Necessary materials and equipment:<br />
oxygen tank setup, nonrebreather mask, and IV materials.<br />
Standards: Completed all necessary steps to manage a patient with a cardiac emergency,<br />
without causing any further injury.<br />
Performance Steps<br />
1. Identify the signs and symptoms of cardiac emergency or compromise.<br />
a. Pain, pressure, or discomfort in the chest or upper abdomen (epigastrium).<br />
b. Dyspnea.<br />
c. Palpitations.<br />
d. Sudden onset of sweating with nausea or vomiting.<br />
e. Anxiety (feeling of impending doom or irritability).<br />
f. Abnormal pulse (arrhythmia).<br />
(1) Bradycardia (less than 60 beats per minute).<br />
(2) Tachycardia (greater than 100 beats per minute).<br />
g. Abnormal blood pressure.<br />
(1) Hypotensive (systolic pressure less than 90).<br />
(2) Hypertensive (systolic pressure greater than 150).<br />
h. Pulmonary edema.<br />
(1) Shortness of breath.<br />
(2) Dyspnea.<br />
(3) Rales upon auscultation.<br />
(4) Blood tinged sputum.<br />
i. Pedal edema.<br />
2. Administer the appropriate treatment.<br />
a. Place the patient in a position of comfort.<br />
NOTE: This is usually in the Fowler's position.<br />
b. Apply a high concentration of oxygen via a nonrebreather mask.<br />
c. Assist the patient in taking nitroglycerin, if available.<br />
NOTE: Administer the nitroglycerin only if ALL of the following conditions are met:<br />
1. Patient complains of chest pain.<br />
2. Patient has a history of cardiac problems.<br />
3. Patient has a current prescription for nitroglycerin.<br />
4. Patient has the nitroglycerin with him or her.<br />
5. Patient's systolic blood pressure is greater than 100.<br />
(1) Check the five rights.<br />
(2) Remove the oxygen mask.<br />
(3) Ask the patient to open his or her mouth and lift his or her tongue.<br />
(4) Place the tablet or spray (if using mist) under the tongue with a gloved hand.<br />
CAUTION: Avoid contacting the nitroglycerin tablet or mist with bare skin. The vasodilation<br />
affects could cause unconsciousness.<br />
(5) Have the patient close his or mouth and hold the tablet under the tongue.<br />
(6) Replace the oxygen mask.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(7) Recheck the blood pressure within 2 minutes.<br />
NOTE: If the blood pressure falls below 100, treat the patient for shock and transport<br />
immediately.<br />
d. If the patient experiences no relief, repeat step 2c every 5 minutes until the patient has<br />
taken a total of three tablets.<br />
e. If the patient experiences no relief after three nitroglycerin tablets or their condition<br />
worsens, initiate an IV at TKO rate (see task 081-833-0033) or establish a saline lock,<br />
if available (see task 081-835-3025).<br />
3. Transport promptly to the nearest medical treatment facility.<br />
4. Perform an ongoing assessment while en route.<br />
5. Document all interventions.<br />
Evaluation Preparation:<br />
Setup: Have one soldier be the patient while the soldier being tested administers treatment.<br />
Tell the soldier who is acting as the patient the signs and symptoms he should exhibit and how<br />
to answer the questions asked by the soldier being tested.<br />
Brief soldier: Tell the soldier to treat the patient for a cardiac emergency.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the signs and symptoms of cardiac emergency or compromise. —— ——<br />
2. Administered the appropriate treatment. —— ——<br />
3. Transported promptly to the nearest medical treatment facility. —— ——<br />
4. Performed an ongoing assessment while en route. —— ——<br />
5. Documented all interventions. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-168
STP 8-91W15-SM-TG<br />
TREAT A RESPIRATORY EMERGENCY<br />
081-833-0160<br />
Conditions: You have a conscious casualty experiencing trouble breathing. You are not in an<br />
NBC environment. Necessary equipment and materials: stethoscope, pulse oximeter, oxygen<br />
tank, nasal cannula, oxygen mask and tubing, hand held metered dose inhaler (MDI) with<br />
spacer, nebulizer set up, and medicated solution and normal saline for inhalation therapy.<br />
Standards: Correctly identified and treated a respiratory emergency without causing further<br />
harm to the casualty.<br />
Performance Steps<br />
1. Examine the casualty.<br />
a. Assess the airway and open it, if necessary. (See task 081-831-0018.)<br />
CAUTION: A casualty experiencing respiratory distress can rapidly progress to full arrest.<br />
Always be prepared to move quickly to a more definitive step such as intubation.<br />
(1) Ask the casualty a question requiring more than a yes or no answer.<br />
(2) Note whether or not the casualty can speak in full sentences.<br />
(3) Look for the presence of drooling that may indicate a partial or complete airway<br />
obstruction.<br />
b. Assist with artificial ventilations if respiratory effort and rate are inadequate.<br />
(1) Look for the rise and fall of the chest during inspiration and expiration.<br />
(2) Listen for the presence of noisy respirations (e.g., stridor, wheezing).<br />
c. Apply supplemental oxygen by mask or nasal cannula.<br />
NOTE: Any casualty complaining of difficulty breathing should receive supplemental oxygen.<br />
d. Place the casualty in the position of comfort.<br />
NOTE: Most casualties experiencing difficulty breathing prefer to remain in a seated position.<br />
e. Obtain a complete set of vital signs to include pulse oximetry, if available.<br />
2. Perform a focused physical examination.<br />
a. Listen to the anterior and posterior lung fields with the stethoscope.<br />
b. Look at the chest and abdomen and note the presence of any retractions.<br />
c. Check the skin for the presence of cyanosis.<br />
d. Check the lower extremities for the presence of edema. This could indicate heart<br />
failure.<br />
3. Obtain a focused history.<br />
a. Ask the casualty if there is an existing condition such as asthma.<br />
b. Ask the casualty if he or she is taking any medications.<br />
c. Question the casualty about allergies to medications.<br />
d. Ask the casualty if difficulty breathing was of sudden or gradual onset.<br />
4. Assist the casualty in using a metered dose inhaler.<br />
a. Perform the five rights of medication usage.<br />
b. Have the casualty exhale deeply.<br />
c. Have the casualty place his or her lips around the opening and press the inhaler to<br />
activate the spray as he or she inhales deeply.<br />
d. Instruct the casualty to hold his or her breath as long as possible before exhaling.<br />
e. Repeat steps 4b through 4d.<br />
5. Administer a nebulizer treatment.<br />
3-169
STP 8-91W15-SM-TG<br />
Performance Steps<br />
a. Set up the nebulizer per manufacturer's guidelines.<br />
b. Instill the appropriate medicine IAW with local SOP.<br />
c. Connect the nebulizer to an oxygen source.<br />
NOTE: Compressed air can be used but it doesn't supply the casualty with supplemental<br />
oxygen.<br />
d. Turn on the flow of oxygen and check for the formation of mist (smoke).<br />
e. Have the casualty place his or her lips on the mouth piece and slowly inhale and<br />
exhale the mist.<br />
f. Monitor the casualty's vital signs every 5 minutes. If available, attach the casualty to a<br />
pulse oximeter.<br />
6. Document the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Examined the casualty. —— ——<br />
2. Performed a focused physical examination. —— ——<br />
3. Obtained a focused history. —— ——<br />
4. Assisted the casualty in using a metered dose inhaler. —— ——<br />
5. Administered a nebulizer treatment. —— ——<br />
6. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored a GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-170
STP 8-91W15-SM-TG<br />
DETERMINE A PATIENT'S LEVEL OF CONSCIOUSNESS USING THE GLASGOW COMA<br />
SCALE<br />
081-835-3030<br />
Conditions: You have a patient who is in an altered state of consciousness. Necessary<br />
materials and equipment: the patient's clinical record, stethoscope, blood pressure cuff, and a<br />
watch with a second hand.<br />
Standards: Accurately determined and recorded a patient's level of consciousness in<br />
accordance with the standardized response scale.<br />
Performance Steps<br />
1. Determine best eye response in accordance with the following response grading scale.<br />
a. Eyes open spontaneously--4 points.<br />
b. Eyes open in response to speech--3 points.<br />
c. Eyes open in response to painful stimuli--1 point.<br />
2. Determine best verbal response in accordance with the following response grading scale.<br />
a. The patient is oriented to person, place, and time--5 points.<br />
b. The patient is not oriented (is confused), but is able to communicate--4 points.<br />
c. The patient speaks in a disorganized manner (inappropriate speech)--3 points.<br />
d. The patient responds with moaning or groaning sounds (incomprehensible sounds)--2<br />
points.<br />
e. The patient has no verbal response--1 point.<br />
3. Determine best motor response in accordance with the following response grading scale.<br />
a. The patient obeys commands appropriately and is able to move all extremities equally<br />
and spontaneously--6 points.<br />
b. The patient is still able to obey commands, but exhibits weakness (for example, drifting<br />
of an upper extremity)--5 points.<br />
c. The patient attempts to withdraw from the source of the painful stimulus (flexor<br />
withdrawal)--4 points.<br />
d. The patient flexes an extremity abnormally--3 points.<br />
e. The patient extends an extremity abnormally--2 points.<br />
f. The patient has no motor response to painful stimuli (flaccid)--1 point.<br />
4. Determine the total consciousness level score by adding the points determined in steps 1<br />
through 3. (See Figure 3-17.)<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-17<br />
5. Record and/or graph the patient's response.<br />
6. Report any changes in level of consciousness to the charge nurse immediately.<br />
7. Document significant nursing observations on the appropriate forms IAW local SOP.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined best eye response. —— ——<br />
2. Determined best verbal response. —— ——<br />
3. Determined best motor response. —— ——<br />
4. Determined the total consciousness level score by adding the points<br />
determined in steps 1 through 3.<br />
—— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Recorded and/or graphed the patient's response. —— ——<br />
6. Reported any changes in level of consciousness to the charge nurse<br />
immediately.<br />
7. Documented significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-173
STP 8-91W15-SM-TG<br />
Subject Area 7: Eye Injuries<br />
IRRIGATE EYES<br />
081-833-0054<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: draping materials, catch basin, light source, gauze or cotton balls, irrigating syringe<br />
or similar equipment, gloves, and irrigating solution (normal saline, water, or other prescribed<br />
solution).<br />
Standards: Irrigated the eyes without contaminating or injuring the eyes.<br />
Performance Steps<br />
1. Identify the casualty and explain the procedure.<br />
2. Verify the type, strength, and expiration date of the medication, as appropriate.<br />
CAUTION: Do not irrigate an eye that has an impaled object.<br />
3. Ask the casualty to remove contact lenses or glasses, if necessary.<br />
4. Position the casualty.<br />
a. If lying on the back, tilt the head slightly to the side that is to be irrigated.<br />
b. If seated, tilt the head slightly backward and to the side that is to be irrigated.<br />
5. Position the equipment.<br />
a. Drape the areas of the casualty that may be splashed by the solution.<br />
b. Place a catch basin next to the face on the affected side.<br />
c. Position the light so that it does not shine directly into the casualty's eyes.<br />
6. Put on gloves.<br />
WARNING: Wear gloves for self-protection against transmission of contaminants whenever<br />
handling body fluids.<br />
7. Clean the eyelids with gauze or cotton balls, and rinse debris from the outer eye.<br />
8. Separate the eyelids using the thumb and forefinger, and hold the lids open.<br />
CAUTION: Do not put pressure on the eyeball.<br />
9. Irrigate the eye.<br />
a. Hold the irrigating tip 1 to 1 1/2 inches away from the casualty's eye.<br />
b. Direct the irrigating solution gently from the inner canthus to the outer canthus.<br />
c. Use only enough pressure to maintain a steady flow of solution and to dislodge the<br />
secretions or foreign bodies.<br />
d. Instruct the casualty to look up to expose the conjunctival sac and lower surface of the<br />
eye.<br />
e. Instruct the casualty to look down to expose the upper surface of the eye.<br />
10. Dry the area around the eye by gently patting with gauze sponges.<br />
CAUTION: Do not touch the eye.<br />
11. Remove the gloves, and perform a patient care handwash.<br />
12. Record the treatment given on the appropriate form.<br />
3-174
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the casualty and explained the procedure. —— ——<br />
2. Verified the type, strength, and expiration date of the medication, as<br />
appropriate.<br />
—— ——<br />
3. Asked the casualty to remove contact lenses or glasses, if necessary. —— ——<br />
4. Positioned the casualty. —— ——<br />
5. Positioned the equipment. —— ——<br />
6. Put on gloves. —— ——<br />
7. Cleaned the eyelids with gauze or cotton balls, and rinsed debris from the<br />
outer eye.<br />
8. Separated the eyelids using the thumb and forefinger, and held the lids<br />
open.<br />
—— ——<br />
—— ——<br />
9. Irrigated the eye. —— ——<br />
10. Dried the area around the eye by gently patting with gauze sponges. —— ——<br />
11. Removed the gloves and performed a patient care handwash. —— ——<br />
12. Recorded the treatment given on the appropriate form. —— ——<br />
13. Did not injure or contaminate the eye. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-175
STP 8-91W15-SM-TG<br />
TREAT FOREIGN BODIES OF THE EYE<br />
081-833-0056<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: cotton-tipped swabs, clean cloth, sterile irrigation solution (normal saline, water, or<br />
other prescribed solution), bandages, and a paper cup or cardboard cone.<br />
Standards: Treated foreign bodies of the eye, minimizing the effects of the injury, without<br />
causing additional injury to the eye.<br />
Performance Steps<br />
WARNING: Wear gloves for self-protection against transmission of contaminants whenever<br />
handling body fluids.<br />
1. Locate the foreign bodies.<br />
a. Method one.<br />
(1) Pull the lower lid down.<br />
(2) Tell the casualty to look up and to both sides and check for foreign bodies.<br />
(3) Pull the upper lid up.<br />
(4) Tell the casualty to look down and to both sides and check for foreign bodies.<br />
b. Method two.<br />
(1) Tell the casualty to look down.<br />
(2) Grasp the casualty's upper eyelashes and gently pull the eyelid away from the<br />
eyeball.<br />
(3) Place a cotton-tipped swab horizontally along the outer surface of the upper lid<br />
and fold the lid back over the swab.<br />
(4) Look for the foreign bodies or damage to the eyeball.<br />
CAUTION: If the foreign bodies cannot be located, bandage both eyes and seek further<br />
medical aid immediately.<br />
2. Remove the foreign bodies.<br />
CAUTION: Do not put pressure on the eyeball.<br />
a. Small foreign body on an anterior surface.<br />
(1) Hold the casualty's eye open.<br />
(2) Irrigate the eye.<br />
b. Foreign body stuck to the cornea or lying under the upper or lower eyelid.<br />
(1) For a foreign body under the lower eyelid, pull the lower lid down.<br />
(2) For a foreign body under the upper eyelid, pull the upper lid up.<br />
(3) Remove the foreign body with a moistened, sterile cotton-tipped swab.<br />
CAUTION: Bandage both eyes if foreign bodies are not easily removed by these methods or if<br />
there is pain or loss of vision in the eye. Seek further medical aid immediately.<br />
NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the<br />
casualty's safety.<br />
c. Foreign body stuck or impaled in the eye.<br />
CAUTION: Do not attempt to remove a foreign body stuck to or sticking into the eyeball. A<br />
physician must remove such objects.<br />
(1) Apply dry sterile dressings to build around and support the object.<br />
NOTE: This will help prevent further contamination and minimize movement of the object.<br />
(2) Cover the injured eye with a paper cup or cardboard cone.<br />
(3) Cover the uninjured eye with a dry dressing or eye patch.<br />
3-176
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the<br />
casualty's safety.<br />
(4) Reassure the casualty by explaining why both eyes are being covered.<br />
NOTE: The eyes move together. If the casualty uses (moves) the uninjured eye, the injured<br />
eye will move as well. Covering both eyes will keep them still and will prevent undue movement<br />
on the injured side.<br />
(5) Seek further medical aid immediately.<br />
3. Obtain details about the injury.<br />
a. Source and type of the foreign bodies.<br />
b. Whether the foreign bodies were wind-blown or high velocity.<br />
c. Time of onset and length of discomfort.<br />
d. Any previous injuries to the eye.<br />
4. Record the procedure on the appropriate form.<br />
5. Evacuate the casualty, as required.<br />
6. Do not cause additional injury to the eye.<br />
a. Do not probe for foreign bodies.<br />
b. Do not put pressure on the eyeball.<br />
c. Do not remove an impaled object.<br />
Performance Measures GO NO<br />
GO<br />
1. Located the foreign bodies. —— ——<br />
2. Removed the foreign bodies. —— ——<br />
3. Obtained details about the injury. —— ——<br />
4. Recorded the procedure on the appropriate form. —— ——<br />
5. Evacuated the casualty, as required. —— ——<br />
6. Did not cause additional injury to the eye. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-177
STP 8-91W15-SM-TG<br />
TREAT LACERATIONS, CONTUSIONS, <strong>AND</strong> EXTRUSIONS OF THE EYE<br />
081-833-0057<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: eye pads, field dressings, padding materials, scissors, and sterile water or sterile<br />
normal saline.<br />
Standards: Treated an eye injury, minimizing the effects of the injury, without causing additional<br />
injury to the eye.<br />
Performance Steps<br />
1. Position the casualty and remove his or her headgear, if necessary.<br />
a. Conscious--seated.<br />
b. Unconscious--lying on his or her back with the head slightly elevated.<br />
2. Examine the eyes for the following:<br />
a. Objects protruding from the globe.<br />
b. Swelling of or lacerations on the globe.<br />
c. Bloodshot appearance of the sclera.<br />
d. Bleeding.<br />
(1) Surrounding the eye.<br />
(2) Inside the eyeball.<br />
(3) Coming from the eyeball.<br />
e. Contact lenses. Ask the casualty if he or she is wearing contact lenses but do not<br />
force the eyelids open. Record that they are being worn, if appropriate..<br />
f. Extrusion (the eye is protruding from the socket).<br />
3. Categorize the injury.<br />
a. Injury to the tissue surrounding the eye (lacerations and contusions).<br />
b. Injury to the eyeball.<br />
c. Extrusion or avulsion.<br />
d. Protruding (impaled) objects.<br />
4. Treat the injury.<br />
NOTE: Torn eyelids should be handled carefully. Wrap any detached fragments in a separate<br />
moist dressing and evacuate with the casualty.<br />
a. Lacerations and contusions of tissue surrounding the eye.<br />
(1) Close the lid of the affected eye.<br />
(2) Cover the injury with an eye pad or a small sterile dressing.<br />
CAUTION: Do not put pressure on the eyeball.<br />
(3) Cover torn eyelids with a loose dressing.<br />
(4) Place a field dressing over the eye pad or dressing of the affected eye.<br />
b. Injury to the eyeball.<br />
(1) Cover the injured eyelid with a sterile dressing soaked in saline to keep the wound<br />
from drying.<br />
(2) Place a field dressing over the eye pad.<br />
(3) Cover the uninjured eye to prevent sympathetic eye movement.<br />
NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the<br />
casualty's safety.<br />
(4) Tell the casualty not to squeeze the eyelids together.<br />
c. Extrusion or avulsion.<br />
3-178
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Do not attempt to reposition the eyeball or replace it in the socket.<br />
(1) Position the casualty face up.<br />
(2) Cut a hole in several layers of dressing material, and then moisten it. Use sterile<br />
liquid, if available.<br />
(3) Place the dressing so the injured globe protrudes through the hole, but does not<br />
touch the dressing. The dressing should be built up higher than the globe.<br />
NOTE: If available, place a paper cup or cone-shaped piece of cardboard over the eye. Do not<br />
apply pressure to the injury site. Apply roller gauze to hold the cup in place.<br />
(4) Cover the uninjured eye to prevent sympathetic eye movement.<br />
NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the<br />
casualty's safety.<br />
d. Protruding object. (See task 081-833-0056.)<br />
CAUTION: Do not attempt to remove the protruding object.<br />
(1) Immobilize the object.<br />
(2) Dress the injured eye.<br />
(3) Cover the uninjured eye to prevent sympathetic movement.<br />
NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the<br />
casualty's safety.<br />
5. Record the procedure on the appropriate form.<br />
6. Evacuate the casualty.<br />
a. Transport the casualty on his or her back, with the head elevated and immobilized.<br />
b. Evacuate eyeglasses with the casualty, even if they are broken.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. Use a moulage kit<br />
or similar material to simulate the injury, or describe the type of injury to the soldier.<br />
Brief soldier: Tell the soldier to treat the eye injury.<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the casualty. —— ——<br />
2. Examined the eyes. —— ——<br />
3. Categorized the injury. —— ——<br />
4. Treated the injury. —— ——<br />
5. Recorded the procedure on the appropriate form. —— ——<br />
6. Evacuated the casualty. —— ——<br />
7. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
3-179
STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-180
STP 8-91W15-SM-TG<br />
TREAT BURNS OF THE EYE<br />
081-833-0058<br />
Conditions: All other more serious injuries have been treated. You have performed a patient<br />
care handwash. Necessary materials and equipment: irrigation equipment, irrigation solution,<br />
and field dressings.<br />
Standards: Treated burns of the eyes and stabilized the casualty without causing further injury<br />
to the casualty.<br />
Performance Steps<br />
1. Reassure the casualty and check for signs and symptoms to determine the type of burns.<br />
a. Chemical--such as acid, alkali, or petroleum.<br />
CAUTION: The chemical may stick to the eye.<br />
(1) Pain and redness.<br />
(2) Watering or tearing.<br />
(3) Possible erosion of the corneal surface.<br />
b. Radiant burns.<br />
(1) Electric burns--electric welding processor.<br />
(a) Gritty feeling.<br />
(b) Severe pain.<br />
(c) Inability to tolerate light.<br />
(d) Redness, swelling.<br />
(e) Watering or tearing.<br />
(f) Immediate decrease in vision.<br />
NOTE: Electrical burns often do not appear until several hours after exposure.<br />
(2) Laser burns--bright, visible light and invisible light such as ultraviolet or infrared.<br />
(a) Immediate decrease in vision.<br />
(b) No pain.<br />
c. Thermal burns.<br />
(1) Charred or swollen eyelids.<br />
(2) Singed eyelashes.<br />
(3) Pain or irritation.<br />
2. Treat the burn.<br />
a. Chemical burn.<br />
(1) Gently hold the casualty's eye(s) open.<br />
(2) Tilt the casualty's head toward the affected side if only one eye is involved.<br />
(3) Irrigate the eye(s) for 20 minutes with copious amounts of water. If the patient's<br />
complaint is renewed after 20 minutes, irrigate an additional 5 minutes.<br />
NOTE: Irrigate the eye(s) with sterile water or sterile normal saline, if available. If not available,<br />
use any potable water.<br />
CAUTION: Do not attempt to neutralize the chemical.<br />
(4) Cover the injured eye with a clean, sterile dressing.<br />
b. Radiant energy burn (electric/laser).<br />
(1) No specific treatment is recommended.<br />
(2) Bandage the eyes with sterile, moist pads.<br />
NOTE: In a combat environment, the eyes may have to remain uncovered so the casualty can<br />
see to get away from danger.<br />
(3) Avoid further light exposure.<br />
3-181
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) Evacuate the casualty for further examination.<br />
c. Thermal burn.<br />
(1) Do not bandage the eyes.<br />
NOTE: Burned eyelids swell to protect the underlying eyes. If the patient can be evacuated<br />
immediately, the eyes may be loosely covered with sterile dressings moistened with sterile<br />
saline.<br />
(2) Protect the casualty from exposure to light.<br />
WARNING: Casualties with severe burns to the eyes may have additional respiratory burns<br />
due to spontaneous inhalation.<br />
3. Record the treatment given on the appropriate forms.<br />
4. Evacuate the casualty.<br />
Performance Measures GO NO<br />
GO<br />
1. Reassured the casualty and checked for signs and symptoms to<br />
determine the type of burns.<br />
—— ——<br />
2. Treated the burn. —— ——<br />
3. Recorded the treatment given on the appropriate forms. —— ——<br />
4. Evacuated the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-182
STP 8-91W15-SM-TG<br />
Subject Area 8: Skeletal Dysfunction<br />
APPLY A PNEUMATIC SPLINT TO A CASUALTY WITH A SUSPECTED FRACTURE OF AN<br />
EXTREMITY<br />
081-831-0044<br />
Conditions: You are evaluating a casualty who has a suspected fractured extremity.<br />
Necessary equipment: pneumatic splint.<br />
Standards: Immobilized an extremity without causing unnecessary injury or impairing<br />
circulation.<br />
Performance Steps<br />
1. Check the equipment both visually and manually for the following:<br />
a. Holes.<br />
b. Function of the air valve.<br />
c. Function of the zipper.<br />
2. Open the splint completely and place it next to the injured extremity.<br />
3. Lift and support the injured extremity.<br />
4. Place the splint under the injured extremity and position the splint around the injured area.<br />
5. Inflate the splint.<br />
a. Draw the zipper completely closed.<br />
b. Inflate the splint by mouth until a slight indentation can be made with a thumb or finger.<br />
CAUTION: Do not use an air pump.<br />
6. Monitor the splint.<br />
a. Partially deflate the splint every 20 to 30 minutes to reestablish peripheral circulation.<br />
b. In an aircraft limit the inflation pressure to that which is adequate for fracture support<br />
only.<br />
CAUTION: Do not overinflate. Temperature and air pressure may cause too much pressure to<br />
be exerted, thereby cutting off circulation to the extremity.<br />
7. Check for peripheral circulation.<br />
a. Check the color and temperature of the limb distal to the splint.<br />
b. Question the casualty about numbness and tingling sensations.<br />
c. If the circulation is impaired, partially deflate the splint.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation have another soldier act as the casualty and specify the<br />
location of the fracture.<br />
Brief soldier: Tell the soldier to apply the pneumatic splint to the specified fractured extremity.<br />
To test step 6, have the soldier tell you what he or she would do to monitor the splint under<br />
normal conditions and in an aircraft.<br />
3-183
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the equipment both visually and manually. —— ——<br />
2. Opened the splint completely and placed it next to the injured extremity. —— ——<br />
3. Lifted and supported the injured extremity. —— ——<br />
4. Placed the splint under the injured extremity and positioned the splint<br />
around the injured area.<br />
—— ——<br />
5. Inflated the splint. —— ——<br />
6. Monitored the splint. —— ——<br />
7. Checked for peripheral circulation. —— ——<br />
8. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-184
STP 8-91W15-SM-TG<br />
APPLY A ROLLER B<strong>AND</strong>AGE<br />
081-833-0060<br />
Conditions: Necessary materials and equipment: roller bandages, tape, and scissors.<br />
Standards: Selected and applied the appropriate bandage and wrap without causing further<br />
injury to the casualty.<br />
Performance Steps<br />
1. Select the appropriate bandage material for the injury.<br />
NOTE: The width of the bandage to use is determined by the size of the part to be covered. As<br />
a general rule, the larger the part or area, the wider the bandage.<br />
a. Use gauze or a flex roller for bleeding injuries of the forearm, upper arm, thigh, and<br />
lower leg.<br />
b. Use a flexible roller bandage (Kling or Kerlix) for bleeding injuries of the hand, wrist,<br />
elbow, shoulder, groin, knee, ankle, and foot.<br />
c. Use an elastic roller bandage for amputations, arterial bleeding, sprains, and torn<br />
muscles.<br />
(1) Hand - 2 inch bandage.<br />
(2) Lower arm, lower leg, and foot - 3 inch bandage.<br />
(3) Thigh and chest - 4 to 6 inch bandage.<br />
NOTE: Elastic roller bandages may be used wherever pressure support or restriction of<br />
movement is needed. They should not be used to secure dressings.<br />
2. Prepare the patient for bandaging.<br />
a. Position the body part to be bandaged in a normal resting position (position of<br />
function).<br />
NOTE: Bending a bandaged joint changes the pressure of the bandage in places of stress<br />
(elbow, knee, ankle).<br />
b. Ensure that the body part that is to be bandaged is clean and dry.<br />
c. Place pads over bony places or between the skin surfaces to be bandaged (such as<br />
fingers and armpits).<br />
3. Apply the anchor wrap.<br />
CAUTION: Do not wrap too tightly. The roller bandage may act as a tourniquet on an injured<br />
limb, causing further damage.<br />
a. Lay the bandage end at an angle across the area to be bandaged. (See Figure 3-<br />
18A.)<br />
b. Bring the bandage under the area, back to the starting point, and make a second turn.<br />
(See Figure 3-18B.)<br />
c. Fold the uncovered triangle of the bandage end back over the second turn. (See<br />
Figure 3-18C.)<br />
d. Cover the triangle with a third turn, completing the anchor. (See Figure 3-18D.)<br />
3-185
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-18<br />
4. Apply the bandage wrap to the injury.<br />
a. Use a circular wrap to end other bandage patterns, such as a pressure bandage, or to<br />
cover small dressings. (See Figure 3-19.)<br />
Figure 3-19<br />
b. Use a spiral wrap for a large cylindrical area such as a forearm, upper arm, calf, or<br />
thigh. The spiral wrap is used to cover an area larger than a circular wrap can cover.<br />
(See Figure 3-20.)<br />
Figure 3-20<br />
3-186
STP 8-91W15-SM-TG<br />
Performance Steps<br />
c. Use a spiral reverse wrap to cover small to large conical areas, for example, from<br />
ankle to knee. (See Figure 3-21.)<br />
Figure 3-21<br />
d. Use a figure eight wrap to support or limit joint movement at the hand, elbow, knee,<br />
ankle, or foot. (See Figure 3-22.)<br />
Figure 3-22<br />
e. Use a spica wrap (same as the figure eight wrap) to cover a much larger area such as<br />
the hip or shoulder.<br />
f. Use a recurrent wrap for anchoring a dressing on fingers, the head, or on a stump.<br />
(See Figure 3-23.)<br />
3-187
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-23<br />
NOTE: Bandage width depends on the site: 1 inch wide for fingers and 3, 4, or 6 inches wide<br />
for the stump or head.<br />
5. Check the circulation after application of the bandage.<br />
a. Check the pulse distal to the injury.<br />
b. Blanch the fingernail or toenail, if applicable.<br />
c. Inspect the skin below the bandaging for discoloration.<br />
d. Ask the patient if any numbness, coldness, or tingling sensations are felt in the<br />
bandaged part.<br />
e. Remove and reapply the bandage, if necessary.<br />
6. Check for irritation.<br />
a. Ask the casualty if the bandage rubs.<br />
b. Check for bandage wrinkles near the skin surface.<br />
c. Check for red skin or sores when the bandage is removed.<br />
d. Remove and reapply the bandage, if necessary.<br />
7. Elevate the injured extremities to reduce swelling (edema) and control bleeding, if<br />
appropriate.<br />
8. Record the treatment given on the appropriate form.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected the appropriate bandage material. —— ——<br />
2. Prepared the patient for bandaging. —— ——<br />
3. Applied the anchor wrap. —— ——<br />
4. Applied the bandage wrap. —— ——<br />
5. Checked circulation. —— ——<br />
6. Checked for irritation. —— ——<br />
7. Elevated the injured extremity, if appropriate. —— ——<br />
8. Recorded the treatment given. —— ——<br />
3-188
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
9. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-189
STP 8-91W15-SM-TG<br />
IMMOBILIZE A SUSPECTED FRACTURE OF THE ARM OR DISLOCATED SHOULDER<br />
081-833-0062<br />
Conditions: Necessary materials and equipment: wire ladder splint, cravat bandages,<br />
basswood splint, and materials for improvising a splint.<br />
Standards: Completed all the steps necessary to immobilize a suspected fracture of the arm or<br />
dislocated shoulder without causing additional injury.<br />
Performance Steps<br />
1. Check the casualty's radial pulse. If no pulse is felt, bandage and/or splint the extremity<br />
and arrange for immediate evacuation.<br />
2. Positioned the injury.<br />
a. Position a fractured arm by having the casualty support it with the uninjured arm and<br />
hand in the least painful position, if possible.<br />
CAUTION: Do not try to reduce or set the fracture. Splint it where it lies unless a severe<br />
deformity makes it necessary to reposition the limb to keep it within the confines of the litter<br />
and/or evacuation vehicle.<br />
b. Position the arm for shoulder dislocations.<br />
CAUTION: Do not use force when moving the limb.<br />
(1) Posterior. Position the forearm across the midsection of the casualty's body with<br />
the hand or wrist slightly higher than the elbow.<br />
(2) Anterior. Maintain the arm in a fixed, locked position away from the body.<br />
(3) Turn the palm of the hand in towards the body, if possible.<br />
3. Immobilize the injury.<br />
a. Use an arm sling to immobilize a dislocated shoulder.<br />
b. Use a basswood or an improvised splint for a fractured forearm.<br />
(1) Pad the splint.<br />
(2) Place the padded splint under the casualty's forearm so that it extends from the<br />
elbow to beyond the fingertips.<br />
(3) Place a rolled cravat or similar material in the palm of the cupped hand.<br />
(4) Apply the cravats in the following order and recheck the radial pulse after each<br />
cravat is applied.<br />
(a) Above the fracture site near the elbow.<br />
(b) Below the fracture site near the wrist.<br />
(c) Over the hand and tied in an "X" around the splint.<br />
(5) Apply an arm sling and swathe.<br />
NOTE: Ensure that the fingernails are left exposed so that a blanch test may be performed.<br />
c. Use a wire ladder splint for a fractured humerus, and for multiple fractures of an arm or<br />
a forearm when the elbow is bent.<br />
(1) Prepare the splint using the uninjured arm for measurements.<br />
(a) Bend the prong ends of the splint away from the smooth side, about 1 1/2<br />
inches down on the outside of the splint.<br />
(b) With the smooth side against the elbow, place one end of the splint even with<br />
the top of the uninjured shoulder.<br />
(c) Select a point slightly below the elbow.<br />
(d) Remove the splint from the arm and bend the splint at the measured point to<br />
form an "L".<br />
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Performance Steps<br />
(e) Pad the splint.<br />
NOTE: If padding is unavailable, apply the splint anyway.<br />
(2) Position the splint on the outside of the injured arm, extending from the shoulder<br />
to beyond the fingertips.<br />
NOTES: 1. Extend the "L" angle of the splint beyond but do not touch the elbow of the injured<br />
arm. Extend the leg of the angle touching the forearm beyond the ends of the fingers. If the<br />
splint is too short, extend it with a basswood splint. 2. If possible, have the casualty support the<br />
splint.<br />
(3) Place a rolled cravat or similar material in the palm of the cupped hand.<br />
(4) Check the radial pulse. Make a note on the Field Medical Card if the pulse is<br />
absent or if the pulse was lost after treatment.<br />
(5) Apply the cravats in the following order and recheck the radial pulse after each<br />
cravat is applied.<br />
(a) On the humerus above any fracture site.<br />
(b) On the humerus below any fracture site.<br />
(c) On the forearm above any fracture of the forearm.<br />
(d) On the forearm below any fracture site.<br />
(e) Around the hand and splint.<br />
(6) Tie each cravat on the outside edge of the splint.<br />
NOTE: If the pulse is weaker or absent after tying the cravat, loosen and retie the cravat.<br />
(7) Apply an arm sling and swathe.<br />
d. Use a wire ladder splint for a fractured or dislocated humerus, elbow, or forearm when<br />
the elbow is straight.<br />
(1) Prepare the splint as in step 3c(1) but bend it only enough to fit the injured arm.<br />
(2) Position the splint on the outside of the arm against the back of the hand.<br />
(3) Apply the cravats in the following order and recheck the radial pulse after each<br />
cravat is applied.<br />
(a) Above the injury.<br />
(b) Below the injury.<br />
(c) High on the humerus, above the first cravat.<br />
(d) Around the hand and wrist.<br />
(4) Tie each cravat on the outside of the splint.<br />
NOTE: If the pulse is weaker or absent after tying the cravat, loosen and retie the cravat.<br />
(5) Apply swathes.<br />
(a) Place the arm toward the midline in front of the body. Bind the forearm to the<br />
pelvic area with a cravat. Tie the knot on the uninjured side.<br />
(b) Apply an additional cravat above the elbow. Secure it on the uninjured side<br />
at breast pocket level.<br />
4. Record the treatment given on the Field Medical Card (FMC).<br />
5. Evacuate the casualty.<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the injury. —— ——<br />
2. Checked the radial pulse. —— ——<br />
3. Immobilized the injury. —— ——<br />
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Performance Measures GO NO<br />
GO<br />
4. Recorded the treatment on the FMC. —— ——<br />
5. Evacuated the casualty. —— ——<br />
6. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-192
STP 8-91W15-SM-TG<br />
IMMOBILIZE A SUSPECTED DISLOCATED OR FRACTURED HIP<br />
081-833-0064<br />
Conditions: You have a casualty with a suspected dislocated or fractured hip. Three other<br />
soldiers are available to assist you. Necessary materials and equipment: litter, splints, cravats<br />
or commercial straps, padding material, spine board or other rigid object, a traction splint, and<br />
pneumatic anti-shock garment (PASG).<br />
Standards: Immobilized a suspected dislocated or fractured hip without impairing circulation or<br />
causing further injury to the casualty.<br />
Performance Steps<br />
1. Check for the signs and symptoms of a hip injury.<br />
CAUTION: Both a dislocated and a fractured hip are accompanied by considerable pain. The<br />
casualty will resist any movement because of pain. It is essential that medical personnel take<br />
all possible precautions, using the best available materials at hand while preparing the casualty<br />
to be immediately evacuated.<br />
a. Anterior dislocation (abduction).<br />
NOTE: Anterior dislocation is very rare and is caused by the legs suddenly being forced widely<br />
apart.<br />
(1) Hip pain.<br />
(2) Severe deformity of the affected leg.<br />
(a) The knee is turned outward.<br />
(b) The affected leg is shortened.<br />
(c) The hip is drawn away from the midline of the body.<br />
(d) The leg has rotated away from the midline of the body.<br />
(3) Impaired circulation in the affected extremity.<br />
(a) Loss of pulse distal to the injury.<br />
(b) Coolness and/or cyanosis.<br />
(c) Swelling due to internal blood loss.<br />
(d) Hypovolemic shock.<br />
WARNING: Significant blood loss may occur before swelling is evident. Take the casualty's<br />
vital signs as soon as possible and monitor them during stabilization and transport.<br />
(4) Impaired sensation in the affected extremity.<br />
(a) Tingling or other abnormal sensations (paresthesia).<br />
(b) Loss of sensation.<br />
b. Posterior dislocation (abduction).<br />
NOTE: Posterior dislocation is the most common type of hip dislocation.<br />
(1) Hip pain.<br />
(2) Severe deformity of the affected leg.<br />
(a) The hip joint is flexed with the knee drawn up.<br />
(b) The hip is drawn toward the midline of the body.<br />
(c) The leg has rotated toward the midline of the body.<br />
(3) Impaired circulation in the affected extremity.<br />
(a) Loss of pulse distal to the injury.<br />
(b) Coolness and/or cyanosis.<br />
(c) Swelling due to internal blood loss.<br />
(4) Impaired sensation in the affected extremity.<br />
(a) Paresthesia.<br />
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Performance Steps<br />
(b) Loss of sensation.<br />
NOTE: Weakness of muscles that raise the foot may occur. This condition, known as "foot<br />
drop," may be a sign of damage to the sciatic nerve.<br />
c. Fracture.<br />
NOTE: Some of the most common fractures are those that occur at the upper end of the femur.<br />
These have been called "hip fractures" even though the hip joint is rarely involved.<br />
(1) Hip pain.<br />
(2) The casualty is unable to walk on or move the affected leg.<br />
(3) Deformity.<br />
(a) The affected leg has rotated toward the midline of the body.<br />
(b) The affected leg will usually be shorter than the uninjured one.<br />
NOTE: Fractures of the femur are often open. Whether closed or open, they are always<br />
associated with a loss of large amounts of blood.<br />
(4) Impaired circulation in the affected extremity.<br />
(a) Loss of pulse in the femoral or popliteal arteries distal to the injury.<br />
(b) Coolness and/or cyanosis.<br />
(c) Swelling due to internal blood loss.<br />
(5) Impaired sensation in the affected extremity.<br />
(a) Paresthesia.<br />
(b) Loss of sensation.<br />
2. Check for circulation in the affected leg by checking the femoral and popliteal pulses and<br />
observing for swelling or cyanosis.<br />
3. Check for impaired sensation by asking the casualty if he or she has tingling,<br />
abnormal sensations, or loss of sensation in the affected limb.<br />
4. Immobilize the injury.<br />
CAUTION: Do not log roll a casualty with a hip injury onto the injured side. If available, place<br />
the casualty on a spine board using a scoop litter.<br />
a. Hip dislocations.<br />
(1) Place the casualty on a firm surface, such as a spine board. See task 081-833-<br />
0092<br />
(2) Support the leg in its abnormal position using pillows, blankets, or similar material.<br />
(3) Secure the support material with cravats.<br />
b. Hip fracture.<br />
(1) Place the casualty on a firm surface,.<br />
(2) Place support material under the buttocks to reduce abdominal pain only if there<br />
are no other major fractures in the lower extremities.<br />
(3) Place bulky support material between the casualty's legs and strap them together.<br />
(4) Bring the casualty's knees up.<br />
(5) Place bulky support material underneath the knees.<br />
5. Check for complications.<br />
a. Impaired circulation in the affected limb.<br />
b. Neurological deficit.<br />
c. Hypovolemic shock.<br />
6. Record the treatment given.<br />
WARNING: Spontaneous reduction of dislocation may occur during any movement. This may<br />
be accompanied by additional damage to nerves and blood vessels. The receiving facility must<br />
be informed if this occurs.<br />
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Performance Steps<br />
7. Evacuate the casualty.<br />
a. Position the casualty and spine board on a litter.<br />
b. Position the casualty resting slightly on the uninjured side.<br />
c. Support the injured side with padding material.<br />
d. Secure the casualty and spine board to the litter.<br />
WARNING: Avoid any bumping or jerking during transport. Excessive movement of a fracture<br />
or dislocation can increase blood loss and pain. Hip and leg injuries allow for a greater area of<br />
pooling of blood that is not evident early on, and may result in the casualty going in to<br />
hypovolemic shock.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked for the signs and symptoms of a hip injury. —— ——<br />
2. Checked for circulation in the affected leg. —— ——<br />
3. Checked for impaired sensation. —— ——<br />
4. Immobilized the injury. —— ——<br />
5. Checked for complications. —— ——<br />
6. Recorded the treatment given. —— ——<br />
7. Evacuated the casualty. —— ——<br />
8. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-195
STP 8-91W15-SM-TG<br />
TRANSPORT A CASUALTY WITH A SUSPECTED SPINAL INJURY<br />
081-833-0092<br />
Conditions: All other more serious injuries or conditions have been treated. Three or four<br />
soldiers are available for assistance. Necessary materials and equipment: straps, cravats,<br />
towels, long and short spine boards, safety pins, and materials to improvise a cervical collar and<br />
head supports.<br />
Standards: Completed all the steps necessary to immobilize and transport a casualty with a<br />
suspected spine injury without causing additional injury to the casualty.<br />
Performance Steps<br />
1. Check for the signs and symptoms of a spinal injury.<br />
WARNING: If you suspect that the casualty has a spinal injury, treat him or her as though he or<br />
she does have a spinal injury.<br />
a. Spinal deformity. Its presence indicates a severe spinal injury, but its absence does<br />
not rule one out.<br />
b. Tenderness and/or pain in the spinal region.<br />
(1) Detect it by palpation or ask the casualty.<br />
(2) The presence of any pain is sufficient cause to suspect the presence of a spinal<br />
injury.<br />
c. Lacerations and/or contusions in the spinal region indicate severe trauma and usually<br />
accompany a spinal injury.<br />
NOTE: The absence of lacerations and/or contusions does not rule out a spinal injury.<br />
d. Weakness, loss of sensation, and/or paralysis.<br />
(1) A neck level (cervical) spine injury may cause numbness or paralysis in all four<br />
extremities.<br />
(2) A waist level spinal injury may cause numbness or paralysis below the waist.<br />
(3) Ask the casualty to try to move the fingers and toes to check for paralysis.<br />
e. Palpate the spine for pain.<br />
(1) Carefully insert the hand under the neck and feel along the cervical spine as far<br />
as can be done without disturbing the casualty's spine.<br />
(2) Carefully insert the hand into the cavity formed by the small of the back and feel<br />
along the thoracic spine and down the lumbar spine as far as possible without<br />
disturbing the spine.<br />
(3) If the casualty says that an area of the spine is tender, consider that he or she has<br />
a spinal injury.<br />
2. Secure the casualty to a short spine board (if using Kendrick Extrication Device (KED) go to<br />
step 3).<br />
NOTE: Apply a short spine board when extricating a casualty from a vehicle or location that will<br />
not accommodate the use of a long spine board. If available use a KED which is a commercial<br />
spine board.<br />
a. Direct an assistant to immobilize the casualty's head and neck using manual<br />
stabilization.<br />
(1) Place the hands on both sides of the casualty's skull, with the palms over the<br />
ears.<br />
(2) Support the jaw (mandible) with the fingers.<br />
(3) Maintain manual stabilization until directed to release the stabilization.<br />
b. Apply a cervical collar, if available, or improvise one.<br />
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Performance Steps<br />
c. Push the board as far into the area behind the casualty as possible.<br />
d. Tilt the upper end of the board toward the head.<br />
e. Direct the assistant to position the back of the casualty's head against the board,<br />
maintaining manual stabilization, by moving the head and neck as one unit.<br />
NOTE: If the cervical collar or improvised collar does not fit flush with the spine board, place a<br />
roll in the hollow space between the neck and board. The roll should only be large enough to fill<br />
the gap, not to exert pressure on the neck.<br />
f. Secure the casualty's head and head supports to the board with straps or cravats.<br />
WARNING: Ensure that the cravats or head straps are firmly in place before the assistant<br />
releases stabilization.<br />
(1) Apply head supports.<br />
(2) Use two rolled towels, blankets, sandbags, or similar material.<br />
(3) Place one close to each side of the head.<br />
(4) Using a cravat-like material across the forehead, make the supports and head one<br />
unit by tying to the board.<br />
g. Secure the casualty to the short spine board.<br />
(1) Place the buckle of the first strap in the casualty's lap.<br />
(2) Pass the other end of the strap through the lower hole in the board, up the back of<br />
the board, through the top hole, under the armpit, over the shoulder, and across<br />
the back of the board at the neck.<br />
(3) Buckle the second strap to the first strap and place the buckle on the side of the<br />
board at the neck.<br />
(4) Pass the other end over the shoulder, under the armpit, through the top hole in<br />
the board, down the back of the board, through the lower hole, and across the lap.<br />
Secure it by buckling it to the first strap.<br />
h. Tie the casualty's hands together and place them in his or her lap.<br />
NOTE: When positioning a casualty who is secured to a short spine board, on a long spine<br />
board, line up the hand grip holes of the short spine board with the holes of the long spine<br />
board, if possible, and secure the two boards together.<br />
3. Secure the casualty to a KED.<br />
a. Direct an assistant to immobilize the casualty's head and neck using manual<br />
stabilization.<br />
(1) Place the hands on both sides of the casualty's skull, with the palms over the<br />
ears.<br />
(2) Support the jaw (mandible) with the fingers.<br />
(3) Maintain manual stabilization until directed to release the stabilization.<br />
b. Position the immobilization device behind the patient.<br />
c. Secure the device to the patient's torso.<br />
(1) Immobilize the torso, from the top to the bottom strap.<br />
(2) Apply the pelvic straps, ensuring to pad the groin area.<br />
d. Secure the patient's head to the device.<br />
(1) Pad behind the patient's head as necessary.<br />
(2) Place one cravat across the chin angle towards the ear, ensuring the cravat does<br />
not interfere with the airway. Tie cravats to the side of the device.<br />
(3) Place a cravat across the forehead angle towards the base of the head, and tie it<br />
to the side of device.<br />
e. Evaluate and adjust the straps. They must be tight enough so the device does not<br />
move excessively up, down, left, or right, but not so tight as to restrict the patient's<br />
breathing.<br />
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Performance Steps<br />
NOTE: The pelvic straps must be released after being placed on a long spine board.<br />
4. Place the casualty on a long spine board.<br />
NOTE: If a spine board is not available, utilize a standard litter or improvised litter made from a<br />
board or door. A hard surface is preferable to one that gives with the casualty's weight.<br />
a. The log roll technique.<br />
(1) Place the spine board next to, and parallel with, the casualty.<br />
(2) Immobilize the casualty's head and neck using manual stabilization.<br />
(a) Place your hands on both sides of the casualty's skull, with the palms over<br />
the ears.<br />
(b) Support the jaw (mandible) with the fingers.<br />
(c) Maintain manual stabilization until the casualty has been placed on the spine<br />
board.<br />
(3) Apply a cervical collar, if available, or improvise one. (See steps 2b(1) through<br />
2b(5).)<br />
(4) Brief each of the three assistants on their duties and instruct them to kneel on the<br />
same side of the casualty, with the spine board on the opposite side of the<br />
casualty.<br />
(a) First assistant. Place the near hand on the shoulder and the far hand on the<br />
waist.<br />
(b) Second assistant. Place the near hand on the hip and the far hand on the<br />
thigh.<br />
(c) Third assistant. Place the near hand on the knee and the far hand on the<br />
ankle.<br />
(5) On your command, and in unison, the assistants roll the casualty slightly toward<br />
them. Turn the casualty's head slightly, keeping it in a straight line with the spine.<br />
(6) Instruct the assistants to reach across the casualty with one hand, grasp the spine<br />
board at its closest edge, and slide it against the casualty. Instruct the number<br />
two assistant to reach across the board to the far edge and hold it in place to<br />
prevent board movement.<br />
(7) Instruct the assistants to slowly roll the casualty back onto the board. Keep the<br />
head and spine in a straight line.<br />
(8) Place the casualty's wrists together at the waist and tie them together loosely.<br />
NOTE: If the cervical collar or improvised collar does not fit flush with the spine board, place a<br />
roll in the hollow space between the neck and board. The roll should only be large enough to fill<br />
the gap, not to exert pressure on the neck.<br />
b. The straddle-slide technique.<br />
NOTE: Use this method when limited space makes it impossible to use the log roll technique.<br />
(1) Stand at the head of the casualty with your feet wide apart.<br />
(2) Apply stabilization to the casualty's head and apply a cervical collar. (See steps<br />
3a(2) through 3a(3).)<br />
(3) Instruct the first assistant to stand behind you (facing your back), to line up the<br />
spine board, and to gently push the spine board under the casualty at your<br />
command.<br />
(4) Instruct the second assistant to straddle the casualty while facing you and gently<br />
elevate the shoulders so that the spine board can be slid under them.<br />
(5) Instruct the third assistant (facing you) to carefully elevate the hips while the spine<br />
board is being slid under the casualty.<br />
(6) Instruct the fourth assistant (facing you) to carefully elevate the legs and ankles<br />
while the board is being slid into place under the casualty.<br />
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Performance Steps<br />
WARNING: Complete all movements simultaneously, keeping the head and spine in a straight<br />
line. NOTE: If the cervical collar or improvised collar does not fit flush with the spine board,<br />
place a roll in the hollow space between the neck and board. The roll should only be large<br />
enough to fill the gap, not to exert pressure on the neck.<br />
5. Secure the casualty to the long spine board.<br />
a. Secure the casualty's head and head supports to the board with straps or cravats.<br />
WARNING: Do not release manual stabilization until the cravats or head straps are firmly in<br />
place.<br />
(1) Apply head supports.<br />
(2) Use two rolled towels, blankets, sandbags, or similar material.<br />
(3) Place one close to each side of the head.<br />
(4) Using a cravat-like material across the forehead, make the supports and head one<br />
unit by tying to the board. (See Figure 3-24.)<br />
Figure 3-24<br />
b. Secure the casualty with straps across the chest, hips, thighs, and lower legs.<br />
NOTE: Include the arms if the straps are long enough. If the spine board is not provided with<br />
straps and fasteners, use cravats or other long strips of cloth.<br />
WARNING: Securely immobilize the casualty's head and neck. Fill socks with sand and place<br />
them on both sides of the head and neck to keep it from moving.<br />
6. Record the treatment on the Field Medical Card.<br />
7. Evacuate the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. You will need<br />
three or four soldiers to act as the assistants. The soldier being tested is to act as the team<br />
leader and direct the actions of the assistants. The casualty may be placed in a vehicle or other<br />
scenario, depending on available resources and the technique you are testing. Tell the casualty<br />
not to assist the soldiers in any way.<br />
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STP 8-91W15-SM-TG<br />
Brief soldier: To test step 1, tell the soldier to state the signs and symptoms of a spinal injury.<br />
Tell the soldier that the casualty has a suspected spinal injury. Then tell the soldier to position<br />
the casualty on a spine board and to direct the actions of the assistants.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked for signs and symptoms of a spinal injury. —— ——<br />
2. Secured the casualty on a short spine board or KED, if appropriate. —— ——<br />
3. Placed the casualty on the long spine board. —— ——<br />
4. Secured the casualty on the long spine board. —— ——<br />
5. Recorded the treatment on the Field Medical Card. —— ——<br />
6. Evacuated the casualty. —— ——<br />
7. Did not cause further injury to the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-200
STP 8-91W15-SM-TG<br />
APPLY A TRACTION SPLINT<br />
081-833-0141<br />
Conditions: You and an assistant have encountered a casualty. You have done your initial<br />
assessment and you suspect a femur fracture. Necessary materials and equipment: traction<br />
splint, long spine board, securing devices, and padding material.<br />
Standards: Applied the splint without restricting circulation. Immobilized the fracture and<br />
maintained traction throughout the procedure, minimizing the effect of the injury.<br />
Performance Steps<br />
1. Take body substance isolation precautions.<br />
2. Direct the assistant to manually stabilize the injured leg. (See Figure 3-25.)<br />
Figure 3-25<br />
3. Assess motor, sensory, and distal circulation of the injured leg. (See Figure 3-26.)<br />
Figure 3-26<br />
4. Adjust the splint to the proper length.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
a. Loosen the sleeve locking device.<br />
b. Place the splint next to the uninjured leg so that the ischial pad of the splint is next to<br />
the patient's iliac crest.<br />
c. Extend the splint until the bend in the splint is level with the casualty's heel. (See<br />
Figure 3-27.)<br />
Figure 3-27<br />
NOTE: The distal end of the splint should be 8 to 12 inches beyond the foot.<br />
d. Lock the sleeve.<br />
5. Position the splint.<br />
a. Open and position all straps.<br />
(1) One strap above the fracture site.<br />
(2) One strap above the knee but below the fracture site.<br />
(3) One strap below the knee.<br />
(4) One strap at mid-calf.<br />
b. Unfasten the ischial strap.<br />
c. Pull the release ring on the ratchet and release the traction strap.<br />
d. Move the splint between the assistant's legs so that it is aligned with the casualty's<br />
injured leg.<br />
6. Apply the ankle hitch.<br />
a. Direct the assistant to maintain manual stabilization.<br />
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Performance Steps<br />
b. Thread the ankle hitch under the casualty's ankle at the void created by the heel. (See<br />
Figure 3-28.)<br />
Figure 3-28<br />
c. Place the lower edge of the ankle hitch even with the bottom of the heel.<br />
d. Crisscross the side straps high on the instep. (See Figure 3-29.)<br />
Figure 3-29<br />
e. Bring the crisscrossed straps down to meet the center strap and hold them in place.<br />
7. Apply manual traction.<br />
a. Move your hands under the fracture site (one hand above the site and one hand below<br />
the site) in order to support the fracture as traction is pulled and the leg is lifted.<br />
b. Direct the assistant to indicate when he is ready to lift (i.e., on your count of three, we<br />
will lift the leg). (See Figure 3-30.)<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-30<br />
c. Apply gentle traction and lift the casualty's leg enough to fit the splint into place. (See<br />
Figure 3-31.)<br />
Figure 3-31<br />
CAUTION: Apply only enough traction to align the limb to fit into the splint. Do not attempt to<br />
align the fracture fragments anatomically. Once manual traction has been applied, it must<br />
remain constant until the traction splint has been put in place and is providing traction.<br />
d. Move one hand from the fracture site and pull the splint from between the assistant's<br />
legs.<br />
e. Slide the splint under the leg until the ischial ring is at the buttock.<br />
NOTE: Make sure the splint is aligned with the leg.<br />
f. When the splint is in place, position the hand back under the fracture site for<br />
stabilization only.<br />
g. On the assistant's signal, lower the leg into the cradle of the splint while maintaining<br />
manual traction.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
h. Extend and position the heel stand after the splint is in position under the leg.<br />
8. Apply the ischial strap. (See Figure 3-32.)<br />
Figure 3-32<br />
9. Apply mechanical traction. (See Figure 3-33.)<br />
Figure 3-33<br />
a. Insert the rings from the ankle hitch into the "S" hook from the splint.<br />
b. Direct the assistant to alert you when mechanical traction is equal to his or her manual<br />
traction.<br />
c. Twist the ratchet until the assistant alerts you that mechanical traction is equal to<br />
manual traction.<br />
3-205
STP 8-91W15-SM-TG<br />
Performance Steps<br />
10. Position and secure the leg support straps. (See Figure 3-34.)<br />
Figure 3-34<br />
a. Direct the assistant to maintain manual stabilization until the straps are secure.<br />
b. Secure the support straps.<br />
11. Reevaluate the ischial strap and ankle hitch.<br />
12. Assess the distal pulse, motor function, and sensation of the injured leg.<br />
13. Secure the torso to the long board to immobilize the hip.<br />
14. Secure the splint to the long board to prevent movement of the splint.<br />
Performance Measures GO NO<br />
GO<br />
1. Took body substance isolation precautions. —— ——<br />
2. Directed the assistant to manually stabilize the injured leg. —— ——<br />
3. Assessed distal circulation, motor function, and sensation of the injured<br />
leg.<br />
—— ——<br />
4. Adjusted the splint to the proper length. —— ——<br />
5. Positioned the splint. —— ——<br />
6. Applied the ankle hitch. —— ——<br />
7. Applied manual traction. —— ——<br />
8. Applied the ischial strap. —— ——<br />
9. Applied mechanical traction. —— ——<br />
10. Secured the leg straps. —— ——<br />
3-206
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
11. Reevaluated the ankle hitch and ischial strap. —— ——<br />
12. Assessed distal circulation, motor function, and sensation of the injured<br />
leg.<br />
—— ——<br />
13. Secured the torso to the long board to immobilize the hip. —— ——<br />
14. Secured the splint to the long board to prevent movement of the splint. —— ——<br />
Evaluation Guidance: The soldier will be retrained if a NO-GO is received in any of the<br />
following areas: failure to maintain traction after it has been assumed, failure to reassess the<br />
distal pulse, motor function, and sensation before and after splinting, failure to secure the ischial<br />
strap before taking traction, failure to apply mechanical traction before securing the leg straps,<br />
or if final immobilization fails to support the femur or prevent rotation of the injured leg.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-207
STP 8-91W15-SM-TG<br />
PROVIDE BASIC EMERGENCY TREATMENT FOR A PAINFUL, SWOLLEN, DEFORMED<br />
EXTREMITY<br />
081-833-0154<br />
Conditions: You have encountered a patient who presents with a musculoskeletal injury. You<br />
have already taken body substance isolation precautions and done your initial assessment.<br />
Necessary materials and equipment: cravats, splinting materials, oxygen, nonrebreather mask,<br />
and IV materials.<br />
Standards: Provided treatment without causing further injury to the patient. Immobilized the<br />
extremity, minimizing the effect to the patient.<br />
Performance Steps<br />
1. Identify the signs and symptoms of a musculoskeletal injury.<br />
a. Pain and tenderness, especially when the injured part is touched or moved.<br />
b. Deformity or angulation.<br />
NOTE: When in doubt, look at the uninjured side and compare it to the injured one.<br />
c. Crepitus.<br />
d. Swelling.<br />
e. Bruising.<br />
f. Exposed bone ends.<br />
g. Joints locked into position.<br />
h. Impaired circulation, motor function, and sensation.<br />
2. Splint the extremity (see tasks 081-833-0141, 081-831-0044, 081-833-0061, 081-833-0062,<br />
and 081-833-0064).<br />
NOTES: 1. In order for any splint to be effective, it must immobilize the adjacent joints and<br />
bone ends. 2. If the patient is unstable, immobilize on a long spine board and transport<br />
immediately.<br />
a. Manually stabilize the injury site. This can be done by you, your assistant, or the<br />
patient.<br />
NOTE: Maintain manual stabilization or traction during positioning and until the splinting<br />
process is complete.<br />
b. Assess pulse, motor function, and sensation.<br />
(1) Check for a pulse.<br />
(2) Ask if the patient can feel your touch distal to the injury.<br />
(3) Ask the patient to wiggle the fingers or toes, grasp your fingers, or push the feet<br />
against your hands.<br />
c. Attempt to realign once, if necessary.<br />
NOTE: Attempt to realign only if there is impaired circulation or the extremity is so deformed<br />
that splinting would not be effective.<br />
(1) Gently grasp the distal extremity while your assistant places one hand above and<br />
one hand below the injury site.<br />
(2) Gently pull manual traction in the direction of the long axis of the bone.<br />
(3) If resistance is felt or it appears that the bone ends will come through the skin,<br />
stop and splint the extremity in the position found.<br />
(4) If no resistance is felt, maintain gentle traction until the extremity is properly<br />
splinted.<br />
d. Measure or adjust the splint.<br />
e. Apply and secure the splint to immobilize adjacent bones.<br />
3-208
STP 8-91W15-SM-TG<br />
Performance Steps<br />
f. Reassess pulse, motor function, and sensation distal to the injury.<br />
3. Treat for shock (see task 081-833-0047).<br />
4. Consider administration of pain medication.<br />
5. Transport to the nearest medical treatment facility.<br />
6. Document all care given (see tasks 081-833-0145 and 081-831-0033).<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have one soldier be the patient with a musculoskeletal<br />
injury. Brief the patient on the location and complaints of a musculoskeletal injury. Use<br />
moulage if available.<br />
Brief soldier: Ask the soldier for signs and symptoms of a musculoskeletal injury and have him<br />
perform the appropriate treatment.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the signs and symptoms of a musculoskeletal injury. —— ——<br />
2. Splinted the extremity. —— ——<br />
3. Treated for shock. —— ——<br />
4. Considered administration of pain medication. —— ——<br />
5. Transported to the nearest medical treatment facility. —— ——<br />
6. Documented all care given. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-209
STP 8-91W15-SM-TG<br />
Subject Area 9: Environmental Injuries<br />
TREAT A CASUALTY FOR A HEAT INJURY<br />
081-831-0038<br />
Conditions: A casualty is suffering from a heat injury. No other more serious injuries or<br />
conditions are present. Necessary materials and equipment: water, salt, a thermometer, a<br />
stethoscope, and a sphygmomanometer.<br />
Standards: Provided the correct treatment based upon the signs and symptoms of the injury.<br />
Performance Steps<br />
1. Identify the type of heat injury based upon the following characteristic signs and symptoms:<br />
a. Heat cramps--muscle cramps of the arms, legs, and/or abdomen.<br />
b. Heat exhaustion.<br />
(1) Often--<br />
(a) Profuse sweating and pale (or gray), moist, cool skin.<br />
(b) Headache.<br />
(c) Weakness or faintness.<br />
(d) Dizziness.<br />
(e) Loss of appetite or nausea.<br />
(2) Sometimes--<br />
(a) Heat cramps.<br />
(b) Nausea (with or without vomiting).<br />
(c) Urge to defecate.<br />
(d) Chills.<br />
(e) Rapid breathing.<br />
(f) Tingling sensation of the hands and feet.<br />
(g) Confusion.<br />
c. Heat stroke.<br />
(1) Rapid onset with the core body temperature rising to above 106° F within 10 to 15<br />
minutes.<br />
(2) Hot, dry skin.<br />
(3) Headache.<br />
(4) Dizziness.<br />
(5) Nausea (stomach pains).<br />
(6) Confusion.<br />
(7) Weakness.<br />
(8) Loss of consciousness.<br />
(9) Possible seizures.<br />
(10) Pulse and respirations are weak and rapid.<br />
2. Provide the proper first aid for the heat injury.<br />
a. Heat cramps.<br />
(1) Move the casualty to a cool shaded area, if possible.<br />
(2) Loosen the casualty's clothing unless he or she is in a chemical environment.<br />
(3) Give the casualty at least one canteen of salt solution. Dissolve 1/4 teaspoon<br />
(one MRE packet) of salt in one canteen of water. If salt is unavailable, give plain<br />
water.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) Evacuate the casualty if the cramps are not relieved after treatment.<br />
b. Heat exhaustion.<br />
(1) Conscious casualty.<br />
(a) Move the casualty to a shaded area, if possible.<br />
(b) Loosen and/or remove the casualty's clothing and boots unless he or she is<br />
in a chemical environment.<br />
(c) Pour water on the casualty and fan him or her, if possible.<br />
(d) Slowly give the casualty one canteen of salt solution. (See step 2a(3).)<br />
(e) Elevate the casualty's legs.<br />
(2) An unconscious casualty or one who is nauseated, unable to retain fluids, or<br />
whose symptoms have not improved after 20 minutes.<br />
(a) Cool the casualty as in step 2b(1).<br />
(b) Evacuate the casualty to an MTF for IV therapy or if qualified, initiate an IV<br />
infusion of Ringer's lactate or sodium chloride.<br />
c. Heat stroke.<br />
CAUTION: Heat stroke is a medical emergency. If the casualty is not cooled rapidly, the body<br />
cells, especially the brain cells, are literally cooked; irreversible damage is done to the central<br />
nervous system. The casualty must be evacuated to the nearest medical treatment facility<br />
immediately.<br />
(1) Conscious casualty.<br />
(a) Remove the casualty's outer garments and/or protective clothing, if possible.<br />
(b) Keep the casualty out of the direct sun, if possible.<br />
(c) Immerse the casualty in cold water, if available, and massage him or her.<br />
WARNING: Cooling with cold water immersion may produce shivering, increasing the core<br />
temperature.<br />
(d) Lay the casualty down and elevate his or her legs.<br />
(e) Have the casualty slowly drink at least one canteen of salt solution. (See<br />
step 2a(3).)<br />
(f) Evacuate the casualty to an MTF for IV therapy or, if qualified, initiate an IV<br />
infusion of Ringer's lactate or sodium chloride to maintain a systolic blood<br />
pressure of at least 90 mm Hg.<br />
(2) Unconscious casualty or one who is vomiting or unable to retain oral fluids.<br />
(a) Cool the casualty as in step 2c(1) but give nothing by mouth.<br />
(b) Initiate an IV, if qualified.<br />
(c) Evacuate the casualty.<br />
3. Record the treatment given. (See task 081-831-0033.)<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, describe to the soldier the signs and symptoms of heat<br />
cramps, heat exhaustion, or heat stroke and ask the soldier what type of heat injury is indicated.<br />
Brief soldier: Ask the soldier what should be done to treat the heat injury.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the type of heat injury. —— ——<br />
2. Provided the proper first aid for the heat injury. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
3. Recorded the treatment given. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-212
STP 8-91W15-SM-TG<br />
TREAT A CASUALTY FOR A COLD INJURY<br />
081-831-0039<br />
Conditions: No other more serious injuries or conditions are present. Necessary materials and<br />
equipment: dry clothing or similar material, sterile dressings, and a thermometer.<br />
Standards: Provided correct treatment based upon the signs and symptoms of the injury.<br />
Performance Steps<br />
1. Recognize the signs and symptoms of cold injuries.<br />
a. Chilblain is caused by repeated prolonged exposure of bare skin to low temperatures<br />
from 60° F down to 32° F.<br />
(1) Acutely red, swollen, hot, tender, and/or itching skin.<br />
(2) Surface lesions with shedding of dead tissue, or bleeding lesions.<br />
b. Frostbite is caused by exposure of the skin to cold temperatures that are usually below<br />
32° F depending on the windchill factor, length of exposure, and adequacy of<br />
protection.<br />
NOTE: The onset is signaled by a sudden blanching of the skin of the nose, ears, cheeks,<br />
fingers, or toes followed by a momentary tingling sensation. Frostbite is indicated when the<br />
face, hands, or feet stop hurting.<br />
(1) Superficial (first and second degree).<br />
(a) Redness of the skin in light-skinned individuals and grayish coloring of the<br />
skin in dark-skinned individuals, followed by a flaky sloughing of the skin.<br />
(b) Blister formation 24 to 36 hours after exposure followed by sheet-like<br />
sloughing of the superficial skin (second degree).<br />
(2) Deep.<br />
(a) Loss of feeling.<br />
(b) Pale, yellow, waxy look if the affected area is unthawed.<br />
(c) Solid feel of the frozen tissue.<br />
(d) Blister formation 12 to 36 hours after exposure unless rewarming is rapid.<br />
(e) Appearance of red-violet discoloration 1 to 5 days after the injury.<br />
NOTE: Gangrene and residual nerve damage will result without proper treatment.<br />
c. Generalized hypothermia is caused by prolonged exposure to low temperatures,<br />
especially with wind and wet conditions, and it may be caused by immersion in cold<br />
water.<br />
CAUTION: With generalized hypothermia, the entire body has cooled with the core<br />
temperature below 95° F. This is a medical emergency.<br />
(1) Moderate hypothermia.<br />
NOTE: This condition should be suspected in any chronically ill person who is found in an<br />
environment of less than 50° F.<br />
(a) Conscious, but usually apathetic or lethargic.<br />
(b) Shivering, with pale, cold skin, slurred speech, poor muscle coordination,<br />
faint pulse..<br />
(2) Severe hypothermia.<br />
(a) Unconscious or stuporous.<br />
(b) Ice cold skin.<br />
(c) Inaudible heart beat or irregular heart rhythm.<br />
(d) Unobtainable blood pressure.<br />
(e) Unreactive pupils.<br />
3-213
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(f) Very slow respirations.<br />
d. Immersion syndrome (immersion foot, trench foot and hand) is caused by fairly long<br />
(hours to days) exposure of the feet or hands to wet conditions at temperatures from<br />
about 50° F down to 32° F.<br />
(1) First phase (anesthetic).<br />
(a) There is no pain sensation, but the affected area feels cold.<br />
(b) The pulse is weak at the affected area.<br />
(2) Second phase (reactive hyperemic)--limbs feel hot and/or burning and have<br />
shooting pains.<br />
(3) Third phase (vasospastic).<br />
(a) Affected area is pale.<br />
(b) Cyanosis.<br />
(c) Pulse strength decreases.<br />
(4) Check for blisters, swelling, redness, heat, hemorrhage, or gangrene.<br />
e. Snow blindness.<br />
(1) Scratchy feeling in the eyes as if from sand or dirt.<br />
(2) Watery eyes.<br />
(3) Pain, possibly as late as 3 to 5 hours later.<br />
(4) Reluctant or unable to open eyes.<br />
2. Treat the cold injury.<br />
a. Chilblain.<br />
(1) Apply local rewarming within minutes.<br />
(2) Protect lesions (if present) with dry sterile dressings.<br />
CAUTION: Do not treat with ointments.<br />
b. Frostbite.<br />
(1) Apply local rewarming using body heat.<br />
CAUTION: Avoid thawing the affected area if it is possible that the injury may refreeze before<br />
reaching the treatment center.<br />
(2) Loosen or remove constricting clothing and remove jewelry.<br />
(3) Increase insulation and exercise the entire body as well as the affected body<br />
part(s).<br />
CAUTION: Do not massage the skin or rub anything on the frozen parts.<br />
(4) Move the casualty to a sheltered area, if possible.<br />
(5) Protect the affected area from further cold or trauma.<br />
(6) Evacuate the casualty.<br />
NOTE: For frostbite of a lower extremity, evacuate the casualty by litter, if possible.<br />
CAUTION: Do not allow the casualty to use tobacco or alcohol.<br />
c. Generalized Hypothermia.<br />
(1) Moderate.<br />
(a) Remove the casualty from the cold environment.<br />
(b) Replace wet clothing with dry clothing.<br />
(c) Cover the casualty with insulating material or blankets.<br />
(d) If available, apply heating pads to the casualty's armpits, groin, and<br />
abdomen.<br />
NOTE: If far from a medical treatment facility and the situation and facilities permit, immerse the<br />
casualty in a tub of 105° F water.<br />
(e) If available, slowly give sugar and sweet warm fluids.<br />
CAUTION: Do not give the casualty alcohol.<br />
(f) Wrap the casualty from head to toe.<br />
3-214
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(g) Evacuate the casualty lying down.<br />
(2) Severe.<br />
CAUTION: Handle the casualty very gently.<br />
(a) Cut away wet clothing and replace it with dry clothing.<br />
(b) Maintain the airway. (See task 081-831-0018.)<br />
1) Administer oxygen if trained personnel and equipment are available.<br />
2) Assist with ventilation if the casualty's respiration rate is less than five per<br />
minute.<br />
NOTE: Do not use artificial airways or suctioning devices.<br />
CAUTION: Do not hyperventilate the casualty. Keep the rate of artificial ventilation at<br />
approximately 8 to 10 per minute.<br />
(c) Monitor the patient's pulse. (See task 081-831-0011.) If none is detected,<br />
apply AED, if available. (See task 081-833-3027.) Begin CPR. (See tasks<br />
081-831-0046 and 081-831-0048.)<br />
(d) Evacuate the casualty positioned on his or her back with the head in a 10<br />
degree head-down tilt.<br />
NOTE: The treatment of moderate hypothermia is aimed at preventing further heat loss and<br />
rewarming the casualty as rapidly as possible. Rewarming a casualty with severe hypothermia<br />
is critical to saving his or her life, but the kind of care rewarming requires is nearly impossible to<br />
carry out in the field. Evacuate the casualty promptly to a medical treatment facility. Use<br />
stabilizing measures en route.<br />
d. Immersion syndrome.<br />
(1) Dry the affected part immediately and gradually rewarm it in warm air.<br />
CAUTION: Never massage the skin. After rewarming the affected part, it may become swollen,<br />
red, and hot. Blisters usually form due to circulation return.<br />
(2) Protect the affected part from trauma and secondary infection.<br />
(3) Elevate the affected part.<br />
(4) Evacuate the casualty as soon as possible.<br />
e. Snow blindness. Cover the eyes with a dark cloth and evacuate the casualty to a<br />
medical treatment facility.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation have another soldier act as the casualty. Select one of the<br />
types of cold injuries on which to evaluate the soldier. Coach the simulated casualty on how to<br />
answer questions about symptoms. Physical signs and symptoms that the casualty cannot<br />
readily simulate, for example blisters, must be described to the soldier.<br />
Brief soldier: Tell the soldier to determine what cold injury the casualty has. After the cold injury<br />
has been identified, ask the soldier to describe the proper treatment.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the type of cold injury. —— ——<br />
2. Provided proper first aid treatment for the injury. —— ——<br />
NOTE: Although not evaluated, the soldier would record the treatment given<br />
on the appropriate form and evacuate the casualty as necessary.<br />
3-215
STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-216
STP 8-91W15-SM-TG<br />
INITIATE TREATMENT FOR ANAPHYLACTIC SHOCK<br />
081-833-0031<br />
Conditions: Necessary materials and equipment: needle, syringe, epinephrine (1:1000<br />
solution), stethoscope, sphygmomanometer, bag-valve-mask system, and oxygen equipment.<br />
Standards: Initiated treatment for anaphylactic shock, stabilized the casualty, and minimized<br />
the effects of anaphylaxis without causing further injury to the casualty.<br />
Performance Steps<br />
NOTE: Anaphylactic reactions occur within minutes or even seconds after contact with the<br />
substance to which the casualty is allergic. Reactions occur in the skin, respiratory system, and<br />
circulatory system.<br />
1. Check the casualty for signs and symptoms of anaphylactic shock.<br />
a. Skin.<br />
(1) Flushed or ashen.<br />
(2) Burning or itching.<br />
(3) Edema (swelling), especially in the face, tongue, or airway.<br />
(4) Urticaria (hives) spreading over the body.<br />
(5) Marked swelling of the lips and cyanosis about the lips.<br />
b. Respiratory.<br />
(1) Tightness or pain in the chest.<br />
(2) Sneezing and coughing.<br />
(3) Wheezing, stridor, or difficulty in breathing (dyspnea).<br />
(4) Sputum (may be blood tinged).<br />
(5) Respiratory failure.<br />
c. Circulatory.<br />
(1) Weak, rapid pulse.<br />
(2) Falling blood pressure.<br />
(3) Hypotension.<br />
(4) Dizziness or fainting.<br />
(5) Coma.<br />
2. Transport the casualty to the aid station.<br />
WARNING: Do not attempt to transport the casualty to an aid station unless the station can be<br />
reached within 4 minutes. Otherwise, start supportive treatment immediately and transport the<br />
casualty as soon as possible.<br />
3. Open the airway, if necessary.<br />
NOTE: In cases of airway obstruction from severe glottic edema, a cricothyroidotomy may be<br />
necessary. (See task 081-833-3006.)<br />
4. Administer high concentration oxygen. (See task 081-833-0158.)<br />
5. Administer epinephrine.<br />
a. Administer 0.5 ml of epinephrine, 1:1000 solution, subcutaneously (SQ) or<br />
intramuscularly (IM).<br />
NOTE: Annotate the time of injection on the Field Medical Card (FMC).<br />
b. Additional epinephrine may be required as anaphylaxis progresses. Additional<br />
incremental doses may be administered every 5 to 15 minutes IAW local SOP.<br />
3-217
STP 8-91W15-SM-TG<br />
Performance Steps<br />
6. Initiate an IV. (See task 081-833-0033.)<br />
NOTE: If the anaphylaxis is due to an insect bite or sting on an extremity, a constricting band<br />
should be applied 2 to 3 inches above and below the site. The band should be loose enough to<br />
allow arterial flow but tight enough to restrict venous circulation. A distal pulse must be<br />
palpable.<br />
7. Provide supportive measures for the treatment of shock, respiratory failure, circulatory<br />
collapse, or cardiac arrest.<br />
a. Infuse additional IV fluid if blood pressure continues to drop.<br />
b. Position the patient in the supine position with legs elevated if injuries permit.<br />
c. Apply pneumatic anti-shock garment, if necessary. (See task 081-833-3011.)<br />
d. Perform rescue breathing , if necessary. (See task 081-831-0048.)<br />
e. Administer external chest compressions, if necessary. (See task 081-831-0046.)<br />
8. Check the casualty's vital signs every 3 to 5 minutes until the casualty is stable.<br />
9. Record the procedure on the appropriate form.<br />
10. Evacuate the casualty, providing supportive measures en route.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the casualty for signs and symptoms of anaphylactic shock. —— ——<br />
2. Transported the casualty to the aid station, if feasible. —— ——<br />
3. Opened the airway, if necessary. —— ——<br />
4. Administered oxygen. —— ——<br />
5. Administered epinephrine. —— ——<br />
6. Initiated an IV. —— ——<br />
7. Provided supportive measures for the treatment of shock, respiratory<br />
failure, circulatory collapse, or cardiac arrest.<br />
8. Checked the casualty's vital signs every 3 to 5 minutes until the casualty<br />
was stable.<br />
—— ——<br />
—— ——<br />
9. Recorded the procedure on the appropriate form. —— ——<br />
10. Evacuated the casualty and provided supportive measures en route. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
3-218
STP 8-91W15-SM-TG<br />
TREAT A CASUALTY FOR INSECT BITES OR STINGS<br />
081-833-0072<br />
Conditions: Necessary materials and equipment: constricting bands, antiseptic cleanser,<br />
tourniquet, tweezers, pin or needle, calamine lotion, sphygmomanometer, stethoscope,<br />
thermometer, and ice packs.<br />
Standards: Treated the casualty, minimizing the effect of insect bites or stings, without causing<br />
further injury.<br />
Performance Steps<br />
1. Remove the casualty's clothing, shoes, or jewelry to expose the sting or bite area.<br />
NOTE: Remove rings, watches, and other constricting items that are in the area of the bite or<br />
sting to prevent circulatory impairment in the event swelling of an extremity occurs.<br />
2. Ask the casualty to identify, if possible, what bit or stung him or her.<br />
3. Check the casualty for the signs and symptoms of insect bites and stings.<br />
a. Black widow spider.<br />
NOTE: There are five species of widow spiders. Most are a glossy black with a red or orange<br />
hourglass shape on the underside of the abdomen. The brown widow may be either gray or<br />
light brown with a red or orange hourglass marking. The red widow has brilliant red spots or a<br />
yellow marking on its back.<br />
(1) An immediate pin-prick sensation from the bite.<br />
(2) A dull, numbing pain at the bite site.<br />
(3) Two red puncture marks.<br />
(4) Severely painful muscular or abdominal spasms.<br />
(a) Begin in 10 to 40 minutes.<br />
(b) Peak in 1 to 3 hours.<br />
(c) Persist for 12 to 48 hours.<br />
(5) Rigid, board-like abdomen.<br />
(6) Tightness in the chest and painful breathing.<br />
(7) Dizziness.<br />
(8) Nausea.<br />
(9) Vomiting.<br />
(10) Sweating.<br />
(11) Skin rash.<br />
b. Brown recluse spider.<br />
NOTE: The brown recluse spider is medium sized, yellowish to medium dark brown, and<br />
covered with fine short hairs. It has a distinct groove between its chest and abdominal body<br />
parts, and a violin shaped mark on its back.<br />
(1) Mild to severe pain within hours.<br />
(2) The area becomes red, swollen, and tender.<br />
(3) The area develops a pale, mottled, cyanotic center.<br />
(4) A small blister may form.<br />
(5) A large scab of dead skin, fat, and debris forms (over several days).<br />
c. Scorpion.<br />
NOTE: There are two general types of scorpions. The Arizona (black) scorpion is the only<br />
deadly type in the United States.<br />
(1) Harmless species.<br />
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Performance Steps<br />
(a) Severe pain and burning sensation at the sting site.<br />
(b) Local swelling and discoloration.<br />
(c) The symptoms last for 24 to 72 hours.<br />
(2) Deadly species.<br />
(a) "Pins and needles" sensation at the sting site.<br />
(b) No swelling at the sting site.<br />
(c) Excessive salivation.<br />
(d) Severe muscle contractions.<br />
(e) Hypertension.<br />
(f) Convulsions.<br />
(g) Circulatory collapse.<br />
(h) Cardiac failure.<br />
d. Bee, wasp, hornet, and yellow jacket.<br />
NOTE: A wasp or yellow jacket (slender body with elongated abdomen) retains its stinger and<br />
can sting repeatedly. A honey bee (rounded abdomen) usually leaves its stinger in the casualty.<br />
(1) Mild reaction.<br />
(a) Pain at the sting site.<br />
(b) A wheal, redness, and swelling.<br />
(c) Itching.<br />
(d) Anxiety.<br />
(2) Severe reaction.<br />
(a) Generalized itching and burning.<br />
(b) Urticaria (hives).<br />
(c) Chest tightness and cough.<br />
(d) Swelling around the lips and tongue.<br />
(e) Bronchospasm and wheezing.<br />
(f) Dyspnea.<br />
(g) Abdominal cramps.<br />
(h) Anxiety.<br />
(i) Respiratory failure.<br />
(j) Anaphylactic shock.<br />
e. Fire ant.<br />
NOTE: Fire ants inject a very irritating toxin into the skin. They bite repeatedly and in a very<br />
short period of time.<br />
(1) Burning sensation.<br />
(2) Wheal within minutes.<br />
(3) Clear, fluid-filled bubble or blister within minutes.<br />
(4) Cloudy, fluid-filled bubble within 2 to 4 hours.<br />
(5) Bubble on red base within 8 to 10 hours.<br />
(6) Ulceration (with scarring after healing).<br />
(7) Anaphylactic shock.<br />
f. Tick.<br />
NOTE: Hard ticks can transmit Rocky Mountain Spotted Fever and Lyme's disease, and may<br />
even cause anemia if the infestation is severe enough.<br />
(1) Itching and redness at the site.<br />
(2) Headache.<br />
(3) Moderate to high fever, which may last 2 to 3 weeks.<br />
(4) Pain in the joints or legs.<br />
(5) Swollen lymph nodes in the bitten area.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(6) Paralysis and other central nervous system disorders are possible after several<br />
days.<br />
NOTE: Generally, a tick must remain attached to the body for 4 to 6 hours in order to transmit<br />
infections. Early detection and proper removal may prevent transmission.<br />
g. Unknown, nonspecific insects.<br />
(1) Pain and swelling at the site.<br />
(2) Breathing difficulty.<br />
(3) Shock.<br />
4. Treat the bite or sting.<br />
a. Black widow spider, brown recluse spider and scorpion.<br />
(1) Keep the casualty quiet and calm.<br />
(2) Remove jewelry.<br />
(3) Apply constricting band(s).<br />
(a) Place 2 inches above and below the site. Bands should be 3/4 to 1.5 inches<br />
wide.<br />
(b) Use a single band above the ankle or wrist if the site is on a foot or hand.<br />
(c) Tighten the bands enough to stop superficial venous circulation but not<br />
enough to interfere with the distal pulse.<br />
(d) Advance the bands, as necessary, to remain at the edge(s) of the swelling.<br />
(4) Cleanse the bite site using antiseptic.<br />
(5) Apply ice or an ice pack to the site.<br />
(6) Treat the casualty for anaphylactic shock, if necessary.<br />
b. Bee, wasp, hornet, and yellow jacket.<br />
(1) Scrape the stinger from the site, if still in place.<br />
CAUTION: Do not squeeze the stinger or attempt to pull it out. More venom will be injected<br />
into the casualty.<br />
(2) Cleanse the site with soap and water.<br />
(3) Apply ice or an ice pack to the site.<br />
(4) Treat the casualty for anaphylactic shock, if necessary.<br />
c. Fire ant.<br />
(1) Cleanse the bite site using antiseptic.<br />
(2) Apply ice, an ice pack, or a cold compress to the site.<br />
(3) Treat the casualty for anaphylactic shock, if necessary.<br />
d. Tick.<br />
(1) Remove all parts of the tick. Leave nothing embedded in the skin.<br />
NOTE: Debride the area if the tick's head remains in the skin.<br />
(a) Using tweezers, grasp the tick as close to the skin as possible. Using steady<br />
pressure, pull the tick straight out.<br />
(b) If tweezers are not available, use an absorbent material (gauze, toweling) to<br />
protect your skin. Grasp the tick as close to the skin as possible and pull<br />
straight out using steady pressure.<br />
(2) If the tick breaks, thoroughly clean your hands with antiseptic.<br />
(3) Cleanse the bite site using antiseptic.<br />
NOTE: Ticks harbor pathogenic bacteria in their bodies. Adequate removal and cleansing is<br />
essential to prevent infection.<br />
e. Unknown, nonspecific insect.<br />
(1) Cleanse the site using antiseptic.<br />
(2) Apply ice, an ice pack, or a cold compress to the site.<br />
(3) Monitor the vital signs.<br />
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Performance Steps<br />
(4) Treat the casualty for anaphylactic shock, if necessary.<br />
5. Record the treatment on the appropriate form.<br />
6. Evacuate the casualty, if necessary.<br />
NOTE: It is necessary to evacuate any casualty who shows signs of respiratory distress, shock,<br />
anaphylaxis, or who does not respond to initial treatment.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. Indicate the area<br />
of the bite or sting. To test step 3, coach the casualty on how to answer the soldier's questions<br />
regarding signs and symptoms such as pain. Tell the soldier what signs and symptoms, such<br />
as respiratory distress or shock, the casualty is exhibiting.<br />
Brief soldier: Tell the soldier to treat the casualty for an insect bite or sting.<br />
Performance Measures GO NO<br />
GO<br />
1. Exposed the bite or sting site. —— ——<br />
2. Asked the casualty what bit or stung him or her. —— ——<br />
3. Checked for the signs and symptoms of the insect bite or sting. —— ——<br />
4. Treated the bite or sting. —— ——<br />
5. Recorded the treatment on the appropriate form. —— ——<br />
6. Evacuated the casualty, if necessary. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
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STP 8-91W15-SM-TG<br />
TREAT A CASUALTY FOR SNAKEBITE<br />
081-833-0073<br />
Conditions: Necessary materials and equipment: two constricting bands, antiseptic cleaning<br />
solution, iodine, water, soap, and ice packs.<br />
Standards: Determined the type of snakebite and provided treatment, minimizing the effects of<br />
the snakebite, without causing further injury to the casualty.<br />
Performance Steps<br />
1. Expose the injury site.<br />
2. Determine the type of snakebite.<br />
CAUTION: If the bite cannot be positively identified as nonpoisonous, the bite should be<br />
treated as a poisonous bite.<br />
a. Nonpoisonous.<br />
(1) Four to six rows of teeth.<br />
(2) No fangs.<br />
b. Poisonous.<br />
(1) Two rows of teeth.<br />
(2) Two fangs which create puncture wounds.<br />
NOTES: 1. Coral snakes are neurotoxic and leave only one or more tiny scratch marks in the<br />
area of the bite. 2. If the snake can be killed without risk of another bite, it should be brought to<br />
the MTF for identification.<br />
3. Check the casualty for signs and symptoms of a poisonous bite.<br />
NOTE: The casualty may exhibit any or all of the symptoms. Symptoms may develop in 1 to 8<br />
hours.<br />
a. Pain and progressive swelling at the bite site.<br />
b. Drowsiness.<br />
c. General skin discoloration.<br />
d. Blurred vision.<br />
e. Difficulty hearing.<br />
f. Fever, chills, or sweating.<br />
g. Nausea and vomiting.<br />
h. Shock.<br />
i. Difficulty breathing.<br />
j. Paralysis.<br />
k. Seizures.<br />
l. Coma.<br />
CAUTION: Antivenom is indicated in patients who, within 30 to 60 minutes following the bite,<br />
show progressive swelling involving the injured area, complain of paresthesia of the mouth,<br />
scalp, fingertips, or toes, or who have any signs or symptoms of poisoning.<br />
4. Initiate treatment.<br />
CAUTION: Do not give the casualty any sedatives, alcohol, food, or tobacco.<br />
a. Nonpoisonous bite.<br />
(1) Clean and disinfect the wound.<br />
(a) Use soap and water or antiseptic solution.<br />
(b) Apply iodine (betadine) if the casualty is not allergic to it.<br />
(2) If the casualty has a current tetanus toxoid series, return the casualty to duty.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(3) If the casualty does not have a current tetanus toxoid series or does not know,<br />
refer the casualty to a medical treatment facility for an immunization.<br />
b. Poisonous bites.<br />
(1) Immobilize the casualty.<br />
(a) Have the casualty lie down, if possible.<br />
(b) Tell the casualty not to move.<br />
(c) Keep the casualty calm and reassured.<br />
NOTE: Keeping the casualty calm and still will delay venom absorption.<br />
(d) If the bite is on an extremity, do not elevate the limb but rest it in a position of<br />
function at heart level.<br />
(e) Explain to the casualty what will be done.<br />
NOTE: Remove jewelry.<br />
(2) Apply constricting band(s).<br />
NOTE: A constricting band should be 3/4 to 1.5 inches wide.<br />
(a) Place constricting bands 2 inches above and below the fang marks.<br />
NOTE: Use a single band above the wrist or ankle if the site is on a hand or foot.<br />
(b) Tighten the bands enough to stop superficial venous circulation, but not<br />
enough to interfere with the distal pulse.<br />
NOTE: Use constricting bands to slow the spread of the venom by restricting lymphatic and<br />
venous flow. Do not restrict arterial blood flow. Verify this by palpating for a distal pulse.<br />
(c) Advance the bands, if necessary, to remain at the edges of the swelling.<br />
(3) Clean the wound with soap and water or antiseptic solution.<br />
(4) Apply cold treatment.<br />
(a) Use an ice bag or chemical ice pack only.<br />
(b) Place the ice bag over the bite area.<br />
(c) Monitor the casualty to prevent cold injury.<br />
CAUTIONS: 1. Do not use dry ice, ethyl chloride, or wet ice brine. 2. Do not place ice in direct<br />
contact with the skin. 3. Do not leave the ice pack in place for more than a few hours. 4. Do<br />
not pack the affected extremity in ice.<br />
(5) Monitor the casualty for development of breathing problems.<br />
(6) Check the distal pulse.<br />
WARNING: Antivenom, if available, may be administered only by specifically authorized<br />
personnel. Sensitivity testing should be conducted prior to administration. Use of antivenom<br />
may cause anaphylactic shock.<br />
5. Record the procedure on the appropriate form.<br />
6. Evacuate the casualty, if necessary.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. Simulate a<br />
snakebite on the casualty's arm or leg or describe its appearance to the soldier. Coach the<br />
casualty on how to answer the soldier's questions regarding signs and symptoms such as pain.<br />
To test step 2, ask the soldier what type of bite the casualty has. To test step 3, have the<br />
soldier tell you the symptoms of a poisonous snakebite. You may vary the testing by telling the<br />
soldier that the casualty cannot be evacuated for more than 1 hour, or that the casualty is<br />
having difficulty breathing.<br />
Brief soldier: Tell the soldier to treat a casualty for a snakebite.<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Exposed the injury site. —— ——<br />
2. Determined the type of snakebite. —— ——<br />
3. Checked the casualty for signs and symptoms of a poisonous bite. —— ——<br />
4. Initiated treatment. —— ——<br />
5. Recorded the procedure on the appropriate form. —— ——<br />
6. Evacuated the casualty, if necessary. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
EMERGENCY CARE<br />
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STP 8-91W15-SM-TG<br />
Subject Area 10: Chemical Agent Injuries<br />
TREAT A NERVE AGENT CASUALTY IN THE FIELD<br />
081-833-0083<br />
Conditions: You are in a chemical environment and have a casualty who is lying on the ground<br />
wearing protective outergarments, overboots, and mask carrier. You are wearing MOPP level 4<br />
gear. Necessary materials and equipment: aid bag, impermeable litter cover, litter, and<br />
blanket.<br />
Standards: Completed all the steps necessary to treat a nerve agent casualty in the field<br />
without causing further injury to the casualty. Did not kneel when providing treatment.<br />
Performance Steps<br />
1. Assess the casualty for the signs and symptoms of nerve agent poisoning.<br />
NOTE: If the casualty has been exposed to vapor or aerosol, the pupils will become pinpointed<br />
immediately. However, if the nerve agent is absorbed through the skin only or by ingesting<br />
contaminated food or water, the pinpointing of the pupils will be delayed or absent.<br />
a. Vapor exposure.<br />
NOTE: Effects from vapor exposure will occur within seconds to minutes after being exposed<br />
and will not normally worsen after being removed from the exposure for 15 to 20 minutes.<br />
(1) Mild.<br />
NOTE: Exposure to small amounts of vapor for a brief period usually causes effects in the<br />
eyes, nose, and lungs.<br />
(a) Unexplained runny nose.<br />
(b) Unexplained sudden headache.<br />
(c) Sudden drooling.<br />
(d) Difficulty in seeing (dimness of vision and miosis).<br />
(e) Tightness in the chest or difficulty in breathing.<br />
(f) Stomach cramps.<br />
(g) Nausea with or without vomiting.<br />
(h) Tachycardia or bradycardia.<br />
(2) Moderate.<br />
(a) All or most of the mild symptoms.<br />
(b) Fatigue.<br />
(c) Weakness.<br />
(d) Muscular twitching.<br />
(3) Severe.<br />
NOTE: Effects may occur after one breath but normally take place within several seconds of a<br />
large vapor exposure.<br />
(a) All or most of the mild and moderate symptoms.<br />
(b) Strange or confused behavior.<br />
(c) Wheezing, dyspnea, and coughing.<br />
(d) Severely pinpointed pupils.<br />
(e) Red eyes with tearing.<br />
(f) Vomiting.<br />
(g) Severe muscular twitching and general weakness.<br />
(h) Involuntary urination and defecation.<br />
(i) Convulsions.<br />
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Performance Steps<br />
(j) Unconsciousness.<br />
(k) Respiratory failure.<br />
(l) Bradycardia.<br />
(m) Paralysis.<br />
b. Skin (percutaneous) exposure.<br />
NOTES: 1. It is difficult to separate this type of exposure into categories due to the continued<br />
absorption of nerve agent into skin layers. Due to continued absorption, the effects from the<br />
nerve agent may be progressive in nature. They may occur from minutes up to 18 hours after<br />
exposure and continue even after the skin has been decontaminated. 2. The greater the<br />
amount exposure to nerve agent, the shorter the onset time of symptoms with increased<br />
severity.<br />
(1) Mild exposure.<br />
(a) Localized sweating at the exposure site.<br />
(b) Muscular twitching at the exposure site.<br />
(c) Stomach cramps and nausea.<br />
(2) Moderate exposure.<br />
(a) Fatigue.<br />
(b) Weakness.<br />
(c) Muscular twitching.<br />
(3) Severe exposure.<br />
(a) Sudden loss of consciousness.<br />
(b) Vomiting.<br />
(c) Convulsions.<br />
(d) Severe muscular twitching and general weakness.<br />
(e) Difficulty breathing or cessation of respirations.<br />
NOTE: Death would be the result of complete respiratory system failure.<br />
2. Mask the casualty.<br />
a. Instruct the casualty to mask self if he or she is able.<br />
b. Position the casualty face up and mask the casualty. Do not fasten the hood at this<br />
time.<br />
3. Check the casualty's pocket flaps and the area around the casualty for expended<br />
autoinjectors.<br />
4. Administer the antidote.<br />
a. Mild symptoms. Instruct the casualty to administer one Mark I Nerve Agent Antidote<br />
Kit. (See STP 21-1-SMCT, task 081-831-1044.)<br />
b. Severe symptoms. Administer three Mark I Nerve Agent Antidote Kits and one<br />
Convulsant Antidote for Nerve Agent (CANA) autoinjector to the casualty.<br />
(See STP 21-1-SMCT, task 081-831-1044.)<br />
NOTE: Removal of any liquid nerve agent on the skin, on clothing, or in the eyes should be<br />
accomplished as soon as possible after administration of the antidote. Decontamination should<br />
be performed by the casualty, if able, or by a buddy.<br />
5. Check the casualty for signs of effectiveness of treatment.<br />
a. Atropinization.<br />
(1) Heart rate above 90 beats per minute (carotid pulse).<br />
(2) Reduced bronchial secretions.<br />
(3) Reduced salivation.<br />
b. Cessation of convulsions.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
6. Administer additional atropine or CANA, if needed.<br />
a. Administer additional atropine at approximately 15 minute intervals until atropinization<br />
is achieved.<br />
b. Administer additional atropine at intervals of 30 minutes to 4 hours to maintain<br />
atropinization or until the casualty is evacuated to an MTF.<br />
c. Administer a second and, if needed, a third CANA at 5 to 10 minute intervals to<br />
casualties suffering convulsions.<br />
CAUTION: Do not give more than two additional CANA injections for a total of three.<br />
NOTE: Additional atropine and the two additional CANA injections can be administered by a<br />
Combat Lifesaver, the combat medic, or other medical personnel.<br />
7. Provide assisted ventilation for severely poisoned casualties, if equipment is available.<br />
NOTE: Far forward in the field, a cricothyroidotomy is the most practical means of providing an<br />
airway for assisted ventilation using a hand-powered ventilator equipped with an NBC filter.<br />
When the casualty reaches an MTF where oxygen and a positive pressure ventilator are<br />
available, these should be employed continuously until adequate spontaneous respiration is<br />
resumed.<br />
8. Record the number of injections given and all other treatment given on the FMC.<br />
9. Evacuate the casualty.<br />
Performance Measures GO NO<br />
GO<br />
1. Assessed the casualty for the signs and symptoms of nerve agent<br />
poisoning.<br />
—— ——<br />
2. Masked the casualty. —— ——<br />
3. Checked the casualty's pocket flaps and the area around the casualty for<br />
expended autoinjectors.<br />
—— ——<br />
4. Administered the antidote. —— ——<br />
5. Checked the casualty for signs of effectiveness of treatment. —— ——<br />
6. Administered additional atropine or CANA, if needed. —— ——<br />
7. Provided assisted ventilation for severely poisoned casualties, if<br />
equipment was available.<br />
8. Recorded the number of injections given and all other treatment given on<br />
the FMC.<br />
—— ——<br />
—— ——<br />
9. Evacuated the casualty. —— ——<br />
10. Did not kneel while treating the casualty. —— ——<br />
11. Did not cause further injury to the casualty. —— ——<br />
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STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
STP 21-1-SMCT<br />
3-229
STP 8-91W15-SM-TG<br />
TREAT A BLOOD AGENT (HYDROGEN CYANIDE) CASUALTY IN THE FIELD<br />
081-833-0084<br />
Conditions: You are in a chemical environment and have a casualty who is lying on the ground<br />
wearing protective overgarments, overboots, and mask carrier. You are wearing MOPP level 4<br />
gear.<br />
Standards: Completed all the steps necessary to treat a blood agent casualty in the field.<br />
Performance Steps<br />
CAUTION: Blood agent (hydrogen cyanide) causes symptoms ranging from convulsions to<br />
coma. After inhaling a high concentration of blood agent, a person may become unconscious<br />
and die within minutes. Blood agents in high concentration act quickly and death may result in<br />
15 seconds. These agents release an odor of bitter almonds or peach kernels. Anyone<br />
smelling the odors should mask immediately.<br />
1. Check for signs and symptoms of blood agent poisoning.<br />
a. Vertigo.<br />
b. Nausea.<br />
c. Increased respirations.<br />
d. Headache.<br />
e. Pink color of the skin.<br />
f. Violent convulsions.<br />
g. Coma.<br />
h. Respiratory arrest.<br />
i. Cardiac arrest.<br />
2. Mask the casualty immediately.<br />
3. Administer positive pressure ventilation, if available.<br />
CAUTION: No device currently exists that can provide medical assistance in a contaminated<br />
environment.<br />
4. Record the treatment given on the Field Medical Card.<br />
5. Evacuate the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty and exhibit<br />
symptoms, such as hyperventilation. Tell the soldier that the casualty is exhibiting symptoms<br />
such as slow pulse rate. You may decide whether the casualty is already masked or not.<br />
Brief soldier: Tell the soldier to state the signs and symptoms of blood agent poisoning, and<br />
then treat the casualty.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked for the signs and symptoms of blood agent poisoning. —— ——<br />
2. Masked the casualty immediately. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
3. Administered positive pressure ventilation, if available. —— ——<br />
4. Recorded the treatment given on the Field Medical Card. —— ——<br />
5. Evacuated the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References: None<br />
3-231
STP 8-91W15-SM-TG<br />
TREAT A CHOKING AGENT CASUALTY IN THE FIELD<br />
081-833-0085<br />
Conditions: You are in a chemical environment and have a casualty who is lying on the ground<br />
wearing protective overgarments, overboots, and mask carrier. You are wearing MOPP level 4<br />
gear.<br />
Standards: Completed all the steps necessary to treat a choking agent casualty in the field,<br />
without causing further injury to the casualty.<br />
Performance Steps<br />
NOTE: The treatment available for the choking agent casualty in the field is limited. It is<br />
essential that the casualty be masked and evacuated to increase the possibility of survival.<br />
1. Check for the signs and symptoms of choking agent poisoning.<br />
a. Immediate signs and symptoms.<br />
NOTE: Although heavy concentrations of poison bring on these symptoms very quickly, small<br />
doses may take up to 2 to 6 hours before there is any sign of poisoning.<br />
(1) Watery eyes.<br />
(2) Coughing.<br />
(3) Choking.<br />
(4) Tightness in the chest.<br />
(5) Nausea.<br />
(6) Vomiting.<br />
(7) Headache.<br />
(8) Transient blindness.<br />
(9) Increased salivation.<br />
(10) Tingling burning sensation on the skin.<br />
b. Delayed signs and symptoms.<br />
(1) Rapid shallow breathing.<br />
(2) Cyanosis.<br />
(3) Apprehension.<br />
(4) Severe coughing, producing frothy fluid.<br />
(5) Weak and rapid pulse.<br />
(6) Chest wall retractions.<br />
(7) Pulmonary edema.<br />
c. Asymptomatic. The casualty has been exposed, but shows no signs or symptoms.<br />
2. Mask the casualty, but do not fasten the hood.<br />
3. Position the casualty.<br />
a. Supine.<br />
b. In a semisitting position if dyspnea or orthopnea make the supine position impractical.<br />
4. Treat the casualty.<br />
a. Asymptomatic.<br />
(1) Restrict the casualty's activities to light duties to avoid stress to the respiratory<br />
system.<br />
(2) Monitor the casualty for the onset of symptoms.<br />
b. Symptomatic.<br />
(1) Keep the casualty at rest in a sitting position.<br />
(2) Provide intermittent positive pressure ventilation, if equipment is available.<br />
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Performance Steps<br />
(3) Keep the casualty warm.<br />
5. Record the treatment given on the Field Medical Card.<br />
6. Evacuate the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty and exhibit signs<br />
such as choking or coughing (coach the casualty on how to answer the soldier's questions on<br />
symptoms such as headache). Tell the medic the casualty is exhibiting symptoms such as<br />
cyanosis. You may decide whether the casualty is already masked or not.<br />
Brief soldier: Tell the soldier to state the signs and symptoms of a choking agent casualty, and<br />
then treat the casualty.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked for signs and symptoms of choking agent poisoning. —— ——<br />
2. Masked the casualty but did not fasten the hood. —— ——<br />
3. Positioned the casualty. —— ——<br />
4. Treated the casualty. —— ——<br />
5. Recorded the treatment given on the Field Medical Card. —— ——<br />
6. Evacuated the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References: None<br />
3-233
STP 8-91W15-SM-TG<br />
TREAT A BLISTER AGENT CASUALTY (MUSTARD, LEWISITE, PHOSGENE OXIME) IN<br />
THE FIELD<br />
081-833-0086<br />
Conditions: You are in a chemical environment and are treating a casualty who is lying on the<br />
ground wearing MOPP level 4 gear. You are wearing MOPP level 4 gear. Necessary materials<br />
and equipment: casualty's canteen and a personal decontamination kit.<br />
Standards: Completed all the steps necessary to treat a blister agent casualty in the field,<br />
without causing further injury to the casualty. Did not kneel when providing treatment.<br />
Performance Steps<br />
1. Check for the signs and symptoms of blister agent poisoning.<br />
NOTE: Moist areas of the body are highly susceptible to blister agents. Therefore, during hot<br />
weather, blister agents can cause a greater number of casualties.<br />
a. Skin.<br />
(1) Itching.<br />
(2) Redness.<br />
(3) Blisters.<br />
(4) Pain.<br />
(a) Intense and immediate if contaminated by lewisite (L) (arsenical) or phosgene<br />
oxime.<br />
(b) Delayed from 1 hour to days if contaminated by mustard (HD).<br />
b. Eyes (L--immediate, HD--1 hour).<br />
(1) Extremely sensitive to light.<br />
(2) Gritty feeling.<br />
(3) Painful.<br />
(4) Watery.<br />
(5) Involuntary spasms of the eyelids.<br />
(6) Swelling and blistering of eyelids.<br />
(7) Corneal lesion.<br />
(8) Permanent blindness (direct contact).<br />
(9) Redness.<br />
c. Respiratory tract (L--immediate, HD--4 to 6 hours).<br />
(1) Coughing.<br />
(2) Sore throat.<br />
(3) Frothy sputum.<br />
(4) Phlegm.<br />
(5) Nasal secretions.<br />
(6) Adema.<br />
d. Systemic disorders.<br />
(1) Malaise.<br />
(2) Headache.<br />
(3) Nausea and vomiting.<br />
(4) Severe skin burns.<br />
(5) Drop or increase in white blood cells (fever, infection).<br />
(6) Bloody diarrhea.<br />
(7) Liver necrosis (L).<br />
CAUTION: Seek overhead protection, or heavy forage if available.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
2. Tell the casualty to take a deep breath, hold it, and close the eyes.<br />
CAUTION: While the eyes are being irrigated, the breath should be held and the mouth kept<br />
closed to prevent contamination and absorption through mucous membranes.<br />
3. Lift the casualty's mask.<br />
4. Irrigate the casualty's eyes.<br />
a. Use water from the casualty's canteen.<br />
NOTE: If the casualty's water has been contaminated, use sterile water or sterile normal saline<br />
from the aid bag.<br />
b. Tilt the casualty's head to one side.<br />
c. Tell the casualty to open the eyes as much as possible.<br />
d. Pour water slowly into one eye.<br />
e. To avoid spreading contamination, let the water run off the side of the face.<br />
f. Repeat steps 4a through 4e for the other eye.<br />
NOTE: It may be necessary for the casualty to remask and take additional breaths if unable to<br />
hold the breath until both eyes are irrigated.<br />
5. Use the casualty's personal decontamination kit on both the face and the portion of the<br />
mask in contact with the face. (See STP 21-1-SMCT, task 031-503-1013.)<br />
6. Replace the casualty's mask.<br />
7. Tell the casualty to clear and check the mask.<br />
8. Tell the casualty to breathe normally.<br />
NOTE: Further decontamination procedures will be performed by the casualty (self-aid) or<br />
buddy aid.<br />
9. Record the treatment given on the Field Medical Card.<br />
10. Evacuate the casualty, if necessary.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty and exhibit signs<br />
such as coughing. Coach the casualty on how to answer the soldier's questions on symptoms<br />
such as headache. Tell the soldier that the casualty is exhibiting signs such as blisters.<br />
Training decontamination kits must be used.<br />
Brief soldier: Tell the soldier to state the signs and symptoms of blister agent poisoning, and<br />
then treat the casualty. For step 4, have the soldier tell you what should be done.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked for signs and symptoms of blister agent poisoning. —— ——<br />
2. Told the casualty to take a deep breath, hold it, and close the eyes. —— ——<br />
3. Lifted the casualty's mask. —— ——<br />
4. Irrigated the casualty's eyes. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Used the casualty's personal decontamination kit on both the face and the<br />
portion of the mask in contact with the face.<br />
—— ——<br />
6. Replaced the casualty's mask. —— ——<br />
7. Told the casualty to clear and check the mask. —— ——<br />
8. Told the casualty to breathe normally. —— ——<br />
9. Repeated steps 1-8 until decontamination was complete. —— ——<br />
10. Recorded the treatment given on the Field Medical Card. —— ——<br />
11. Evacuated the casualty, if necessary. —— ——<br />
12. Did not kneel at any time. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
STP 21-1-SMCT<br />
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STP 8-91W15-SM-TG<br />
DECONTAMINATE A CASUALTY<br />
081-833-0095<br />
Conditions: You are supervising the contaminated side of an established chemical<br />
decontamination station. Medical personnel and nonmedical augmentees are in MOPP level 4.<br />
Chemically contaminated casualties have been triaged by the senior medic and have been<br />
routed to your area for decontamination. Necessary materials and equipment: M258A1 or<br />
M291 decontamination kit, 5% chlorine solution, 0.5% chlorine solution, butyl rubber aprons,<br />
butyl rubber gloves, stainless steel buckets, cellulose sponges, water source, plastic bags,<br />
litters, litter stands, bandage scissors, M8 chemical detection paper, chemical agent monitor<br />
(CAM), contaminated disposal containers, bandages, gauze, and tourniquets.<br />
Standards: Removed the casualty's clothing without further contaminating the casualty or<br />
contaminating decontamination team personnel. Removed dressings, replaced tourniquets, and<br />
decontaminated splints. Effectively decontaminated and transferred the casualty across the<br />
shuffle pit without contaminating the clean side of the hot line.<br />
Performance Steps<br />
NOTES: 1. The supported unit must provide a minimum of 8 nonmedical personnel to<br />
augment the decontamination station as the decontamination team. Although casualty<br />
decontamination is routinely performed by these nonmedical personnel, the supervision of and<br />
final determination as to the completeness of the decontamination rests with medical personnel.<br />
2. Steps 1 through 17 will be performed by personnel in the clothing removal area. At the<br />
clothing removal area two to four persons will be working together as a team, one or two on<br />
either side of the casualty.<br />
1. Decontaminate the casualty's hood.<br />
a. Cover the mask air inlets with your hand. Instruct the casualty to do this if he or she is<br />
able.<br />
b. Wipe off the front, sides, and top of the hood with a cellulose sponge soaked with 5%<br />
calcium hypochlorite solution or use the M258A1 or M291 skin decontaminating kit.<br />
NOTE: The medical equipment set (MES) for chemical agent patient decontamination contains<br />
powdered calcium hypochlorite (high test hypochlorite or HTH). It is mixed with water to make<br />
the 5% and 0.5% decontaminating solutions. Liquid chlorine bleach (household bleach), a 5%<br />
solution of sodium hypochlorite, may also be used.<br />
c. Uncover the mask air inlets.<br />
2. Cut off the casualty's hood.<br />
a. Dip scissors in the 5% solution.<br />
CAUTION: Dip and scrub the scissors in the 5% solution after each separate cutting procedure<br />
and rinse your gloves in the same solution in order to reduce the spread of contamination.<br />
b. Cut the neck cord.<br />
c. Cut away the drawstring below the voicemitter.<br />
d. Release or cut the hood shoulder straps.<br />
e. Unzip the hood zipper.<br />
f. Begin cutting at the zipper, below the voicemitter.<br />
g. Proceed cutting upward, close to the filter inlet covers and eye lens outserts.<br />
h. Cut upward to the top of the eye lens outserts.<br />
i. Cut across the forehead to the outer edge of the next eye outsert.<br />
j. Cut downward toward the patient's shoulder, staying close to the eye lens outserts and<br />
filter inlet covers.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
k. Cut across the lower part of the voicemitter to the zipper.<br />
l. Dip the scissors and rinse your gloves in the 5% solution.<br />
m. Cut from the center of the forehead, over the top of the head.<br />
n. Fold the left and right sides of the hood to the sides of the casualty's head, laying the<br />
sides of the hood on the litter.<br />
3. Decontaminate the casualty's mask and exposed skin.<br />
a. Use the M258A1 or M291 skin decontamination kit or 0.5% solution.<br />
b. Cover the mask air inlets as in step 1a.<br />
CAUTION: Use only the 0.5% solution to decontaminate the skin and the parts of the mask that<br />
touch the face. The 5% solution is corrosive and may burn the skin.<br />
c. Decontaminate the exterior of the mask.<br />
d. Wipe down all the exposed skin areas, to include the neck and behind the ears.<br />
e. Uncover the mask air inlets.<br />
4. Remove the casualty's Field Medical Card (FMC).<br />
a. Cut the FMC tie-wire, allowing the FMC to fall into a plastic bag. If possible, do not<br />
allow any of the tie-wire to remain attached to the card. This will prevent the wire from<br />
poking a hole in the bag.<br />
b. Seal the plastic bag and rinse the plastic bag with the 0.5% solution.<br />
c. Place the plastic bag under the protective mask head straps.<br />
5. Remove gross contamination on the overgarment by wiping all visible contamination spots<br />
with a sponge soaked in 5% solution.<br />
6. Remove the casualty's protective overgarment jacket.<br />
CAUTION: Dip and scrub the scissors in the 5% solution before doing each cutting procedure<br />
to avoid contaminating the inner garment or the casualty's skin.<br />
a. Cut the sleeves from the cuff up to the shoulder of the jacket, and then through the<br />
collar. Keep the cuts close to the inside of the arms so that most of the sleeve material<br />
can be folded outward.<br />
CAUTION: Medical items are not removed at the clothing removal area. Cut around medical<br />
items such as dressings, splints, and tourniquets.<br />
b. Unzip the jacket (or cut alongside the jacket's zipper).<br />
c. Roll the chest sections to the respective sides, with the inner black liner outward.<br />
Carefully tuck the cut jacket between the arm and the chest.<br />
d. Roll the cut sleeves away from the arms, exposing the black liner.<br />
7. Remove the casualty's protective overgarment trousers.<br />
CAUTION: Dip and scrub the scissors in the 5% solution before doing each cutting procedure<br />
to avoid contaminating the inner garment or the casualty.<br />
a. Cut the trouser legs from the ankle to the waist. Keep the cuts near the insides of the<br />
legs, along the inseam, to the crotch.<br />
(1) Cut up the right leg and across the crotch of the trousers.<br />
(2) Cut up the left leg, cross over the crotch cut, and continue to cut up through the<br />
waistband.<br />
NOTE: Avoid cutting through the pockets.<br />
b. Fold the cut trouser halves onto the litter with the contaminated sides away from the<br />
casualty. Make sure the outer side of the protective overgarment does not touch the<br />
skin or undergarments of the casualty.<br />
c. Roll the inner leg portion under and between the legs.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
8. Remove the casualty's butyl rubber gloves.<br />
a. Decontaminate your butyl rubber gloves in the 5% solution.<br />
b. Lift the casualty's arm up and out of the cutaway sleeve unless contraindicated by the<br />
casualty's condition.<br />
c. Pull the butyl rubber gloves off by rolling the cuff over the fingers, turning the glove<br />
inside out. Do not remove the white glove liners at this time.<br />
d. Lower the casualty's arms and fold them across the chest.<br />
CAUTION: Do not allow the arms to come into contact with the exterior of the protective<br />
overgarments.<br />
e. Place the gloves in a contaminated disposal container.<br />
f. Decontaminate your butyl rubber gloves in the 5% solution.<br />
9. Remove the casualty's protective overboots.<br />
a. Stand at the foot of the litter facing the casualty.<br />
b. Cut the protective overboot laces.<br />
c. Grasp the heel of the protective overboot with one hand and the toe of the protective<br />
overboot with the other hand.<br />
d. Pull the heel downward, and then toward you until the overboot is removed.<br />
NOTE: While you and another team member hold the casualty's raised feet, have a third<br />
member wipe down the end of the litter with the 5% solution before lowering the feet to the litter.<br />
e. Place the overboots in a contaminated disposal container.<br />
10. Remove and secure the casualty's personal effects.<br />
a. Remove the casualty's personal articles from the overgarment and BDU pockets.<br />
b. Place the articles in plastic bags.<br />
c. Label the bags with the casualty's name and SSN. (Print the information on a piece of<br />
paper and place the paper in the plastic bag.)<br />
d. Seal the plastic bags.<br />
e. If the articles are not contaminated, return them to the casualty. If the articles may be<br />
contaminated, place the bags in the contaminated holding area until they can be<br />
decontaminated. The articles will then be returned to the casualty.<br />
11. Remove the combat boots following the same procedures as for removing the protective<br />
overboots.<br />
NOTE: Remove the boots without touching the patient's inner clothing or exposed skin.<br />
12. Cut off the casualty's battle dress uniform (BDU).<br />
CAUTION: Decontaminate your butyl rubber gloves in the 5% solution before you touch the<br />
casualty's garments or exposed skin.<br />
a. Cut off the BDU shirt.<br />
(1) Uncross the patient's arms.<br />
(2) Cut the BDU shirt using the same procedure as for the protective overgarment<br />
jacket.<br />
(3) Recross the casualty's arms over the chest.<br />
b. Unbuckle or cut the belt material.<br />
c. Cut off the BDU trousers following the same procedure as for the protective<br />
overgarment trousers.<br />
13. Cut off the casualty's undergarments.<br />
CAUTION: Decontaminate your butyl rubber gloves in 5% solution before you touch the<br />
casualty's garments or exposed skin.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
a. Cut off the underpants.<br />
b. Cut off the T-shirt.<br />
c. Cut off the brassiere, if necessary.<br />
(1) Lift the casualty's arm off the chest.<br />
(2) Cut between the cups.<br />
(3) Cut both shoulder straps where they attach to the cup.<br />
(4) Lay the cups away from the casualty onto the litter.<br />
(5) Lay shoulder straps up and over the shoulders onto the litter.<br />
NOTE: At this point, the white glove inner liners for a female may be removed while the<br />
casualty's arms are lifted off her chest.<br />
14. Remove the casualty's glove inner liners.<br />
a. Remove the glove liners using the same procedure as for removing butyl rubber<br />
gloves.<br />
b. Cross the casualty's arms over the chest.<br />
15. Remove the casualty's socks.<br />
a. Decontaminate your butyl rubber gloves in 5% solution.<br />
b. Position yourself at the foot of the litter.<br />
c. Remove each sock by rolling it down over the foot, turning it inside out or by cutting the<br />
sock off.<br />
d. Place the socks into a contaminated disposal container.<br />
16. Decontaminate the casualty's ID tags.<br />
a. Decontaminate your butyl rubber gloves in the 5% solution.<br />
b. Wipe the ID tags with the 0.5% solution.<br />
17. Move the casualty to the skin decontamination area.<br />
CAUTION: Observe proper body mechanics to avoid injury to your back. Use your legs instead<br />
of your back to lift the casualty.<br />
a. Decontaminate your butyl rubber aprons and gloves in the 5% solution.<br />
b. Lift the casualty out of the cutaway garments, using a three person arms carry.<br />
(1) Lifter #1 slides his or her arms (palms turned upward) under the casualty's<br />
head/neck and shoulders.<br />
(2) Lifter #2 slides his or her arms (palms turned upward) under the casualty's back<br />
and buttocks.<br />
(3) Lifter #3 slides his or her arms (palms turned upward) under the casualty's thighs<br />
and calves.<br />
(4) On the command of Lifter, bearer #1, lift the casualty. (PREPARE TO LIFT:<br />
LIFT.)<br />
c. Once the casualty has been lifted off the litter, all three lifters stand upright and turn<br />
the casualty in against their chests.<br />
NOTE: At this point, the casualty has nothing on his or her body except the protective mask<br />
and medical items (dressings, splints, tourniquets).<br />
d. While the casualty is being held, another team member quickly removes the<br />
contaminated litter and replaces it with a clean litter. A decontaminatable mesh litter<br />
should be positioned, if available.<br />
e. Lower the casualty onto the clean litter, in a supine position, on the command of lifter<br />
#1.<br />
f. Carry the litter to the skin decontamination area, and then return to the clothing<br />
removal area.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
g. Dispose of all contaminated material at the clothing removal area.<br />
(1) The casualty's contaminated clothing is placed in a bag and put in a contaminated<br />
disposal container.<br />
(2) The dirty litter is rinsed with the 5% decontamination solution and placed in a dirty<br />
litter storage area.<br />
CAUTION: Before obtaining another casualty, the clothing removal team should rinse their<br />
gloves and aprons in the 5% decontaminating solution and drink enough water to compensate<br />
for the heat and workload.<br />
NOTE: Steps 18 through 23 are performed by personnel in the skin decontamination area. At<br />
the skin decontamination area, two to four persons will be working together as a team, one or<br />
two on either side of the casualty.<br />
18. Perform spot skin decontamination.<br />
a. Spot decontaminate potential areas of chemical contamination with the M258A1 or<br />
M291 Skin Decontaminating Kit or the 0.5% solution.<br />
b. Pay particular attention to areas where gaps exist in the MOPP gear, such as the<br />
neck, lower part of the face, waistline, wrists, and ankles.<br />
19. Remove field dressings and bandages.<br />
NOTE: This step must be performed by medical personnel.<br />
a. Carefully cut off dressings and bandages.<br />
b. Cut off any remaining clothing that was covered by the dressings and bandages.<br />
c. Decontaminate the exposed areas of skin with the 0.5% solution.<br />
d. Irrigate the wound with the 0.5% solution if the wound is suspected to be<br />
contaminated.<br />
NOTE: Bandages are not replaced unless there is a critical medical need (for example, to<br />
control bleeding). Bandages are replaced when the casualty is in the clean (uncontaminated)<br />
treatment area.<br />
e. Place removed dressings and clothing in a contaminated disposal container.<br />
20. Replace any tourniquets.<br />
NOTE: Medical personnel must perform this step.<br />
a. Decontaminate an area above the existing tourniquet.<br />
b. Place a new tourniquet 1/2 to 1 inch above the old tourniquet.<br />
c. Remove the old tourniquet.<br />
d. Remove any remaining clothing or dressings covered by the old tourniquet.<br />
e. Decontaminate the newly exposed areas.<br />
f. Place the removed tourniquet, dressings, and clothing in a contaminated disposal<br />
container.<br />
21. Decontaminate any splints.<br />
NOTE: Splints are only removed by a physician.<br />
a. Stabilize the splinted extremity.<br />
b. Decontaminate the splint and the extremity by liberally flushing them with the 0.5%<br />
solution.<br />
CAUTION: Do not remove any part of a traction splint from a femoral fracture.<br />
22. Check the casualty for contamination.<br />
a. Use M8 chemical agent detector paper or the chemical agent monitor (CAM).<br />
b. Decontaminate any areas of detected contamination, as necessary.<br />
3-241
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Under no circumstances should a casualty who has not been entirely<br />
decontaminated be moved across the hot line. If a wound or splinted area cannot be entirely<br />
decontaminated, inform the senior medic. Do not move the casualty across the hot line. He<br />
must be treated on the contaminated side of the casualty decontamination station.<br />
23. Transfer the casualty to the shuffle pit.<br />
a. Personnel decontaminate themselves by rinsing their butyl rubber gloves and apron<br />
with the 5% solution.<br />
b. Carry the patient to the shuffle pit on the skin decontamination litter.<br />
c. Place the litter on the litter stand located in the shuffle pit.<br />
d. Lift the casualty from the decontamination litter using the same technique described in<br />
step 17.<br />
e. Remove the decontamination litter from the stand and a medic from the clean side will<br />
replace it with a clean litter.<br />
f. Lower the casualty onto the clean litter and move back from the hot line.<br />
NOTE: Do not step across the hot line. Personnel from the clean side of the hot line will take<br />
the casualty to the clean treatment station.<br />
Performance Measures GO NO<br />
GO<br />
1. Decontaminated the casualty's hood. —— ——<br />
2. Cut off the casualty's hood. —— ——<br />
3. Decontaminated the casualty's mask and exposed skin. —— ——<br />
4. Removed the casualty's Field Medical Card (FMC). —— ——<br />
5. Removed gross contamination. —— ——<br />
6. Removed the casualty's protective overgarment jacket. —— ——<br />
7. Removed the casualty's protective overgarment trousers. —— ——<br />
8. Removed the casualty's butyl rubber gloves. —— ——<br />
9. Removed the casualty's protective overboots. —— ——<br />
10. Removed and secured the casualty's personal effects. —— ——<br />
11. Removed the casualty's combat boots. —— ——<br />
12. Removed the casualty's battle dress uniform (BDU). —— ——<br />
13. Cut off the casualty's undergarments. —— ——<br />
14. Removed the casualty's glove inner liners. —— ——<br />
15. Removed the casualty's socks. —— ——<br />
16. Decontaminated the casualty's ID tags. —— ——<br />
17. Moved the casualty to the skin decontamination area. —— ——<br />
18. Performed spot skin decontamination. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
19. Removed field dressings and bandages. —— ——<br />
20. Replaced any tourniquets. —— ——<br />
21. Decontaminated any splints. —— ——<br />
22. Checked the casualty for contamination. —— ——<br />
23. Transferred the casualty to the shuffle pit. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any steps, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
STP 21-1-SMCT<br />
3-243
STP 8-91W15-SM-TG<br />
Subject Area 11: Shock<br />
INITIATE TREATMENT FOR HYPOVOLEMIC SHOCK<br />
081-833-0047<br />
Conditions: You are in the field and are assessing a casualty who is suffering from a severe<br />
loss of body fluids. All other more serious injuries have been treated. Necessary materials and<br />
equipment: intravenous (IV) infusion set, IV fluids, splints, stethoscope, sphygmomanometer,<br />
and a blanket or poncho.<br />
Standards: Initiated treatment for hypovolemic shock, stabilized the casualty, minimized the<br />
effect of shock, and prepared for immediate evacuation without further injury to the casualty.<br />
Performance Steps<br />
NOTE: Hypovolemic shock results when there is a decrease in the volume of circulating fluids<br />
(blood and plasma) in the body. If dehydration (loss of body water) is present at the time of<br />
injury, shock will develop more rapidly.<br />
1. Maintain the airway.<br />
NOTE: Administer oxygen, if available. (See task 081-833-0019).<br />
2. Reassure the casualty to reduce anxiety.<br />
NOTE: Anxiety increases the heart rate, which worsens the casualty's condition.<br />
3. Initiate two large bore (16 gauge) IVs. (See task 081-833-0033).<br />
NOTE: To replace fluid loss accompanying injury, Ringer's lactate is the fluid of choice. Normal<br />
saline is the second choice.<br />
4. Maintain the IV flow.<br />
a. Continue the flow wide open until the systolic blood pressure stabilizes at greater than<br />
90 mm Hg.<br />
(1) The usual amount is 1 to 2 liters of fluid or 300 ml for each 100 ml of blood loss.<br />
(2) A palpable radial pulse usually indicates that the casualty has a systolic blood<br />
pressure of about 80 mm Hg.<br />
b. Once the blood pressure has stabilized, decrease the IV flow rate to maintain the<br />
systolic blood pressure above 90 mm Hg.<br />
5. Elevate the casualty's legs.<br />
a. Elevate the casualty's legs above chest level, without lowering the head below chest<br />
level.<br />
NOTE: Splint leg or ankle fractures before elevating the legs, if necessary.<br />
b. If the casualty is on a litter, elevate the foot of the litter.<br />
6. Maintain normal body temperature.<br />
a. Watch for signs of sweating or chilling.<br />
b. Cover the casualty in cold weather.<br />
c. Do not cover the casualty in hot weather unless signs of chilling are noted.<br />
7. Monitor the casualty.<br />
NOTE: Give nothing by mouth. Moisten the casualty's lips with a wet cloth.<br />
a. Check vital signs every 5 minutes until they return to normal, and then check every 15<br />
minutes.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Check the casualty's level of consciousness.<br />
c. Check capillary refill.<br />
NOTE: If the blood pressure is unstable or drops, the pneumatic anti-shock garment should be<br />
applied by qualified personnel.<br />
8. Record the procedure on the Field Medical Card.<br />
9. Evacuate the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, have another soldier act as the casualty. For step 3, have<br />
the soldier state what actions are taken when an IV infusion is initiated.<br />
Brief soldier: Tell the soldier to initiate treatment for hypovolemic shock.<br />
Performance Measures GO NO<br />
GO<br />
1. Maintained the airway. —— ——<br />
2. Reassured the casualty to reduce anxiety. —— ——<br />
3. Initiated two large bore IVs. —— ——<br />
4. Maintained the IV flow. —— ——<br />
5. Elevated the casualty's legs. —— ——<br />
6. Maintained normal body temperature. —— ——<br />
7. Monitored the casualty. —— ——<br />
8. Recorded the procedure on the Field Medical Card. —— ——<br />
9. Evacuated the casualty. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-245
STP 8-91W15-SM-TG<br />
APPLY PNEUMATIC ANTI-SHOCK GARMENT<br />
081-833-3011<br />
Conditions: A soldier has signs or symptoms of shock. Life saving measures have been<br />
completed, but the casualty has not responded to treatment for shock. Another soldier is<br />
available to assist. Necessary materials and equipment: pneumatic anti-shock garment,<br />
backboard, watch, stethoscope, and sphygmomanometer.<br />
Standards: Applied the pneumatic anti-shock garment without causing further injury to the<br />
casualty. Completed all steps in order.<br />
Performance Steps<br />
WARNINGS: 1. Do not use the pneumatic anti-shock garment for psychogenic, anaphylactic,<br />
or septic shock. Do not apply the pneumatic anti-shock garment if the casualty's injury will be<br />
further aggravated by the pneumatic anti-shock garment, for example if the casualty has a<br />
protruding, impaled object such as a stick or a knife in the leg or abdomen, or an open fracture<br />
of a lower extremity. 2. If the pneumatic anti-shock garment is applied incorrectly, death could<br />
result. 3. The pneumatic anti-shock garment should not be used without direction of a<br />
physician if: a. Trauma involves significant head injury, b. Bleeding into the chest or chest<br />
wound is present, c. The casualty is in heart failure with pulmonary edema, d. Trauma is<br />
above the level of the pneumatic anti-shock garment application, e. Pregnancy exists or is<br />
suspected, f. Aortic aneurysm is suspected. 4. If the casualty has an injury to which you must<br />
have access, do not apply the pneumatic anti-shock garment to the injury. 5. If the femur of<br />
either leg is fractured, a traction splint should be applied before the pneumatic anti-shock<br />
garment is applied.<br />
1. Open the pneumatic anti-shock garment kit and remove the trousers and accessories.<br />
NOTE: There are several different models of pneumatic anti-shock garments. The models may<br />
have one, two, or three chambers. Follow the manufacturer's instructions on the pneumatic<br />
anti-shock garment container.<br />
2. Unfold the pneumatic anti-shock garment and unfasten the Velcro closures.<br />
NOTE: The use of a back board under the pneumatic anti-shock garment will help in positioning<br />
the trousers. The backboard will have the effect of splinting the whole body.<br />
3. Lay the trousers flat.<br />
a. Unfold the trousers so the left leg of the pneumatic anti-shock garment overlaps the<br />
right leg.<br />
b. Ensure that the outside Velcro fasteners face the ground and that the valves are on<br />
the outside adjacent to the ground.<br />
c. If there is sufficient space below the casualty's feet, lay the trousers out with the leg<br />
sections in the same direction as the casualty's legs.<br />
d. If there is insufficient space below the casualty's feet, lay the trousers beside the<br />
casualty with the leg sections in the same direction as the casualty's legs. Position the<br />
top of the trousers just below the casualty's lowest rib.<br />
CAUTION: To prevent squeezing the chest of an extremely short casualty, slide the trousers<br />
past the lowest rib and do not use the abdominal section.<br />
NOTE: If there are sharp objects in the casualty's pants, remove them before applying the<br />
pneumatic anti-shock garment.<br />
4. Place the casualty on the trousers in the supine position.<br />
3-246
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: Restrictive or bulky clothing could prevent pneumatic anti-shock garment application<br />
from stabilizing the casualty. Cut away any clothing which will interfere with the trousers.<br />
WARNING: If a back injury is suspected, log-roll the casualty onto the pneumatic anti-shock<br />
garment.<br />
a. Lift the casualty's legs high enough to slide the trousers underneath.<br />
b. Slide the trousers under the casualty's legs and up to the buttocks area.<br />
c. Lift the casualty's buttocks high enough to slide the trousers under the buttocks.<br />
d. Slide the pneumatic anti-shock garment up toward the casualty's waist. Position the<br />
garment so the top of the trousers is just below the casualty's lowest rib.<br />
WARNING: Do not lift the casualty any higher than is absolutely necessary. If the casualty has<br />
a pelvic injury or a traction splint, serious injury or extreme discomfort can result when the<br />
pneumatic anti-shock garment is applied to the casualty. With this type of injury the medic<br />
should position the casualty and direct the assistant to slide the trousers into position.<br />
5. Wrap the casualty's legs.<br />
NOTE: Either of the casualty's legs may be wrapped first; however, normally the left leg is<br />
wrapped first.<br />
a. Wrap the pneumatic anti-shock garment around the casualty's leg.<br />
b. Smooth the leg of the pneumatic anti-shock garment around the casualty's leg.<br />
c. Align the Velcro strips.<br />
d. Press the Velcro strips firmly together to secure the seam of the trouser leg.<br />
e. Repeat steps 5a through 5d for the other leg.<br />
6. Apply the abdominal section of the pneumatic anti-shock garment.<br />
a. Wrap the abdominal section of the pneumatic anti-shock garment.<br />
b. Align the Velcro strips.<br />
c. Press the Velcro strips firmly together to secure the pneumatic anti-shock garment.<br />
7. Attach the foot pump hoses.<br />
a. Connect each short tube on the pump to a leg tube on the trousers using a twisting<br />
motion.<br />
b. Connect the long tube on the foot pump to the abdominal section using a twisting<br />
motion.<br />
8. Inflate the leg sections of the trousers.<br />
CAUTION: Do not inflate the pneumatic anti-shock garment if the casualty's systolic blood<br />
pressure is higher than 90 mm Hg.<br />
a. Open the stopcock valve on each leg section by turning the valve knob to the "OPEN"<br />
position.<br />
NOTE: Ensure that the stopcock valve to the abdominal section is closed.<br />
b. Check the casualty's vital signs and foot (pedal) pulses while inflating the leg section.<br />
c. Close the stopcock valve to the leg section(s).<br />
d. Continue inflation until the air release valves open, or until the Velcro starts to crackle<br />
or stretch apart.<br />
9. Inflate the abdominal section, if necessary.<br />
NOTE: If inflation of the leg sections alone was not adequate to stabilize the casualty, the<br />
abdominal section should be inflated.<br />
a. Open the stopcock valve to the abdominal section.<br />
b. Inflate the abdominal section following the same procedure used for the leg sections.<br />
c. Recheck the vital signs.<br />
d. Close the stopcock valve to the abdominal section<br />
3-247
STP 8-91W15-SM-TG<br />
Performance Steps<br />
10. Initiate an IV using Ringer's lactate, if not already done.<br />
11. Monitor the casualty's blood pressure to ensure it remains stable.<br />
12. Monitor the pneumatic anti-shock garment pressure.<br />
a. If the pneumatic anti-shock garment looks and feels soft, reinflate it until the Velcro<br />
strips start to stretch apart.<br />
b. Stop inflating the pneumatic anti-shock garment if a loud, constant sound is heard<br />
coming from the air release valve.<br />
NOTE: A loud, constant sound coming from the air release valve indicates the pneumatic antishock<br />
garment is overinflated.<br />
CAUTIONS: 1. Do not remove the pneumatic anti-shock garment until ordered to do so by a<br />
physician. 2. If the casualty must be evacuated by air, it should be done at a low altitude and at<br />
low pneumatic anti-shock garment pressure.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, a mannequin will be used. Under no circumstances will<br />
another soldier act as a simulated casualty. Select a scenario that will allow you to evaluate the<br />
soldier.<br />
Brief soldier: Tell the soldier to apply the pneumatic anti-shock garment. Ask the soldier to<br />
describe and explain his actions.<br />
Performance Measures GO NO<br />
GO<br />
1. Opened the pneumatic anti-shock garment kit and removed the trousers<br />
and accessories.<br />
—— ——<br />
2. Opened the folded trousers and unfastened the Velcro closures. —— ——<br />
3. Laid the trousers flat. —— ——<br />
4. Placed the casualty in the supine position on the trousers. —— ——<br />
5. Wrapped the casualty's legs. —— ——<br />
6. Applied the abdominal section of the pneumatic anti-shock garment. —— ——<br />
7. Attached the foot pump hoses. —— ——<br />
8. Inflated the leg sections. —— ——<br />
9. Inflated the abdominal section, if necessary. —— ——<br />
10. Monitored the casualty's blood pressure. —— ——<br />
11. Initiated an IV, if not already done. —— ——<br />
12. Monitored the pneumatic anti-shock garment pressure. —— ——<br />
13. Did all steps in order. —— ——<br />
14. Did not cause unnecessary injury to the casualty. —— ——<br />
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STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-249
STP 8-91W15-SM-TG<br />
Subject Area 12: Urinary Catheterization<br />
INSERT A URINARY CATHETER<br />
081-833-3017<br />
Conditions: You have verified a doctor's order to insert a urinary catheter. The patient has<br />
been draped and all equipment has been prepared. You are wearing sterile gloves. Necessary<br />
materials and equipment: a container for contaminated waste.<br />
Standards: Inserted a urinary catheter without violating aseptic technique or causing further<br />
injury to the patient.<br />
Performance Steps<br />
1. Clean the urinary meatus with the prepared cotton balls or swabs.<br />
NOTE: Cotton balls should be held with forceps.<br />
a. Females.<br />
(1) Gently spread the labia open with the nondominant hand.<br />
NOTE: This hand is now considered contaminated.<br />
(a) Place the thumb and forefinger between the labia minora.<br />
(b) Separate the labia and pull up slightly.<br />
(2) With the dominant hand, clean the labia with cotton balls or swabs, moving from<br />
the clitoris toward the anus.<br />
(3) Use a cotton ball or swab to clean down the center, directly over the urinary<br />
meatus.<br />
(4) Keep the labia spread throughout the remainder of the procedure.<br />
b. Males.<br />
(1) Support the penis with the nondominant hand.<br />
NOTE: This hand is now considered contaminated.<br />
(2) With the dominant hand, clean the penis with a cotton ball or swab, moving in a<br />
circular motion from the urinary meatus toward the base of the penis.<br />
(3) Repeat the procedure, using a second and third cotton ball or swab.<br />
2. Lubricate the catheter.<br />
a. Pick up the catheter with the dominant hand about 4 inches from the tip.<br />
b. Keep the distal end of the catheter coiled in the palm of the hand.<br />
c. Apply lubricant to the catheter tip.<br />
3. Instruct the patient to relax and breathe through the mouth.<br />
4. Insert the catheter.<br />
a. Female.<br />
(1) Gently insert the catheter into the urethra about 2 to 3 inches until resistance is<br />
met.<br />
(2) Continue to advance the catheter until urine begins to flow (about 2 to 3 inches<br />
further).<br />
(3) Release the labia and hold the catheter securely with the nondominant hand.<br />
(4) Place the distal end of the catheter in the collection basin.<br />
NOTE: If the vagina is inadvertently catheterized, do not remove the catheter. Assemble new<br />
equipment and repeat the procedure. Leaving the first catheter in place temporarily will prevent<br />
catheterizing the vagina a second time.<br />
3-250
STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Male.<br />
(1) Draw the penis upward and forward to a 60 to 90 degree angle to the legs.<br />
(2) Gently insert the catheter into the urethra, advancing it about 7 to 8 inches or until<br />
resistance is felt.<br />
(3) Continue to advance the catheter until urine begins to flow (about 2 to 3 inches<br />
further).<br />
(4) Lower the penis and hold the catheter securely with the nondominant hand,<br />
resting the hand on the patient's pubis for support.<br />
(5) Place the distal end of the catheter in the collection basin.<br />
NOTE: With some commercially prepared catheterization kits, the catheter is preconnected to<br />
the drainage tubing of the collecting bag.<br />
5. Obtain a urine specimen, if ordered.<br />
a. Place the sterile specimen container from the kit into the collection basin.<br />
b. Pinch the catheter with the nondominant hand to stop urine flow.<br />
c. With the dominant hand, pick up the distal end of the catheter and hold it over the<br />
specimen container.<br />
d. Release the pinch and allow sufficient urine to drain into the specimen container<br />
(about 30 cc).<br />
e. Repinch the catheter, place the distal end into the collection basin, and release the<br />
pinch, allowing the urine to flow.<br />
f. Place the lid on the specimen container and set it aside.<br />
NOTE: If using a commercial kit with the catheter and drainage set preconnected, do not<br />
disconnect the catheter to obtain a specimen. Obtain the specimen from the drainage bag at<br />
the end of the procedure. The first specimen taken from a new sterile drainage set is<br />
considered sterile.<br />
6. Inflate the balloon if an indwelling catheter has been inserted.<br />
a. Inflate the balloon with the water in the prefilled syringe.<br />
NOTE: If the balloon is difficult to inflate, advance the catheter another 1/2 to 1 inch to ensure<br />
that the catheter tip is fully within the bladder.<br />
b. Tug gently on the catheter to ensure that the balloon is fully inflated and seated in the<br />
bladder.<br />
c. Remove the syringe from the catheter using a twisting motion.<br />
7. Attach the distal end of the catheter to the drainage tubing of the collection set, if not<br />
preconnected by the manufacturer.<br />
8. Remove the drapes and gloves.<br />
9. Tape the catheter in place.<br />
a. Female--to the inner thigh.<br />
b. Male--to the abdomen or inner thigh.<br />
NOTE: The penis may be positioned up or down (facing the patient's head or feet), depending<br />
upon the patient's diagnosis, the physician's order, and/or the patient's comfort preference.<br />
10. Secure the drainage bag to the side of the bed on the bottom of the bed frame.<br />
CAUTION: Do not secure the drainage bag to the bed siderails or loop the drainage tubing over<br />
or through the siderails.<br />
11. Reposition the patient.<br />
12. Dispose of the used equipment and clean the area.<br />
3-251
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: Destroy the syringe and dispose of it IAW local SOP for infectious waste.<br />
13. Report and record the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Cleaned the urinary meatus with the prepared cotton balls or swabs. —— ——<br />
2. Lubricated the catheter. —— ——<br />
3. Instructed the patient to relax and breathe through the mouth. —— ——<br />
4. Inserted the catheter. —— ——<br />
5. Obtained a urine specimen, if ordered. —— ——<br />
6. Inflated the balloon if an indwelling catheter has been inserted. —— ——<br />
7. Attached the distal end of the catheter to the drainage tubing of the<br />
collection set, if not preconnected by the manufacturer.<br />
—— ——<br />
8. Removed the drapes and gloves. —— ——<br />
9. Taped the catheter in place. —— ——<br />
10. Secured the drainage bag to the side of the bed on the bottom of the bed<br />
frame.<br />
—— ——<br />
11. Repositioned the patient. —— ——<br />
12. Disposed of the used equipment and cleaned the area. —— ——<br />
13. Reported and recorded the procedure. —— ——<br />
14. Did not violate aseptic technique. —— ——<br />
15. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-252
STP 8-91W15-SM-TG<br />
MAINTAIN AN INDWELLING URINARY CATHETER<br />
081-835-3010<br />
Conditions: You have a patient with a urinary catheter in place. You have performed a patient<br />
care handwash and have explained the procedure to the patient. Necessary materials and<br />
equipment: a basin of water, soap, a hand towel, a wash cloth, antibacterial ointment,<br />
protective pads, 4 X 4 gauze, clamps, a drainage set, gloves, sterile needle and syringe, sterile<br />
specimen container, thermometer, DD Form 792, and the patient's clinical record.<br />
Standards: Performed catheter care and maintained the indwelling catheter without<br />
contaminating the equipment or causing further injury to the patient.<br />
Performance Steps<br />
1. Provide privacy for the patient.<br />
2. Perform a patient care handwash (see task 081-831-0007).<br />
3. Place the patient in a comfortable position for catheter care.<br />
a. If the patient is awake and alert, place him or her in the semi-Fowler's position.<br />
b. If the patient is unconscious, place him or her in the supine position.<br />
NOTE: Catheter care should be performed as a part of the normal morning and evening patient<br />
care, and as necessary.<br />
4. Inspect the catheter, drainage tubing, all connections, and the drainage bag for cracks,<br />
leaks, kinks, or obstruction of drainage.<br />
CAUTION: Wears gloves for self-protection against the transmission of contaminants whenever<br />
handing body fluids.<br />
5. Observe the urinary meatus and the surrounding area for erythema, and leakage of urine.<br />
6. Clean the urinary meatus and the surrounding area with a cleaning solution (IAW local<br />
SOP), rinse thoroughly, and blot dry.<br />
NOTE: Apply antibacterial ointment to the urinary meatus only if ordered by the physician or<br />
IAW local SOP.<br />
7. Ensure that the catheter is secured to the patient without causing pressure within the<br />
bladder.<br />
a. Tape the catheter to the skin of the inner thigh for a female patient.<br />
b. Tape the catheter to the skin of the lower abdomen or inner thigh for a male patient.<br />
NOTE: The penis may be positioned up or down (facing the patient's head or feet), depending<br />
upon the patient's diagnosis, the physician's order, and/or the patient's comfort preference.<br />
8. Maintain patency of the drainage tubing.<br />
a. Keep the tubing free from kinks and twists.<br />
b. Keep the tubing free of pressure caused by bed rails, mattress, or the patient's body.<br />
c. Keep the tubing above the level of the drainage bag to ensure free gravity drainage.<br />
9. Maintain the correct position of the drainage bag at all times.<br />
a. Hang the drainage bag from the bed frame, not the bed rails.<br />
b. Do not allow the drainage bag to rest on the floor.<br />
CAUTION: The drainage bag must be kept below the level of the patient's bladder to prevent<br />
urinary reflux. If the bag must be raised to bladder level for any reason, it must be clamped first.<br />
3-253
STP 8-91W15-SM-TG<br />
Performance Steps<br />
10. Assess the patient for indications of urinary tract infections: chills, fever, back or flank pain,<br />
hematuria, and cloudy or foul smelling urine.<br />
NOTE: If a urinary tract infection is suspected, collect a urine specimen for culture.<br />
11. Collect a sterile urine specimen without contaminating or disconnecting the closed system.<br />
a. Clamp off the drainage tubing just below the aspiration port.<br />
b. Wait until a sufficient quantity of urine has pooled above the aspiration port (about 15<br />
minutes).<br />
NOTE: Post a sign at the patient's bed indicating the urinary drainage system is temporarily<br />
clamped off.<br />
c. Swab the aspiration port with alcohol.<br />
d. Withdraw the desired amount of urine using a sterile needle and syringe.<br />
e. Remove the clamp from the drainage tubing.<br />
f. Transfer the urine in the syringe to a sterile specimen container.<br />
12. Irrigate the catheter with the prescribed sterile solution IAW the physician's orders.<br />
13. Empty the drainage bag.<br />
a. Empty the drainage bag without disconnecting or contaminating the closed system.<br />
b. Measure and discard, or save, the urine as indicated by the physician's orders.<br />
NOTE: The drainage bag must be emptied before it overfills to prevent reflux of urine into the<br />
drainage tubing.<br />
14. Replace the urinary bag and tubing IAW local SOP.<br />
15. Perform a patient care handwash (see task 081-831-0007).<br />
16. Maintain an accurate I & O record (see task 081-833-0006).<br />
17. Document the procedure and all significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
Performance Measures GO NO<br />
GO<br />
1. Provided privacy for the patient. —— ——<br />
2. Performed a patient care handwash. —— ——<br />
3. Placed the patient in a comfortable position for catheter care. —— ——<br />
4. Inspected the catheter, drainage tubing, all connections, and the drainage<br />
bag for cracks, leaks, kinks, or obstruction of drainage.<br />
5. Observed the urinary meatus and the surrounding area for erythema, and<br />
leakage of urine.<br />
6. Cleaned the urinary meatus and the surrounding area IAW local SOP,<br />
rinsed thoroughly, and blotted dry.<br />
7. Ensured that the catheter was secured to the patient without causing<br />
pressure within the bladder.<br />
—— ——<br />
—— ——<br />
—— ——<br />
—— ——<br />
8. Maintained patency of the drainage tubing. —— ——<br />
3-254
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
9. Maintained the correct position of the drainage bag at all times. —— ——<br />
10. Assessed the patient for indications of urinary tract infections: chills, fever,<br />
back or flank pain, hematuria, and cloudy or foul smelling urine.<br />
11. Collected a sterile urine specimen without contaminating or disconnecting<br />
the closed system.<br />
12. Irrigated the catheter with the prescribed sterile solution IAW the<br />
physician's orders.<br />
—— ——<br />
—— ——<br />
—— ——<br />
13. Emptied the drainage bag. —— ——<br />
14. Replaced the urinary bag and tubing IAW local SOP. —— ——<br />
15. Replaced the urinary catheter IAW local SOP. —— ——<br />
16. Performed a patient care handwash. —— ——<br />
17. Maintained an accurate I & O record. —— ——<br />
18. Documented the procedure and all significant nursing observations on the<br />
appropriate forms IAW local SOP.<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-255
STP 8-91W15-SM-TG<br />
Subject Area 13: Gastric Intubation<br />
INSERT A NASOGASTRIC TUBE<br />
081-833-3022<br />
Conditions: You have a doctor's order to insert a nasogastric tube. Necessary materials and<br />
equipment: handwashing facilities, water soluble lubricant, stethoscope, 10 cc syringe,<br />
nasogastric tube, container for contaminated waste, a 50 cc syringe, stethoscope, adhesive<br />
tape, gloves, a cup containing water, and a straw.<br />
Standards: Inserted a nasogastric tube without causing further injury to the patient.<br />
Performance Steps<br />
1. Assemble equipment.<br />
2. Explain the procedure to the patient.<br />
a. Tell the patient that a tube will be inserted along the nasal passage.<br />
b. Explain that the procedure may cause him or her to gag and bring tears to his or her<br />
eyes.<br />
c. Explain that mouth breathing, panting, and swallowing will make it easier to insert the<br />
tube.<br />
d. Ask about any history of nasal injury or septal deviation.<br />
3. Wash hands and take body substance isolation procedures.<br />
4. Position the patient.<br />
a. If the patient is responsive, awake, and alert, place him or her in the Fowler's position<br />
(elevate the bed to approximately a 30 to 45 degree angle).<br />
b. If the patient is unconscious, place him or her on the left side with the uppermost arm<br />
flexed across the abdomen or supported on the body and hip.<br />
5. Measure the tube for insertion.<br />
a. Use the tip to measure from the tip of the nose to the tip of the earlobe.<br />
b. Measure from the tip of the earlobe to the xiphoid process.<br />
c. Mark the total length with a piece of tape or an indelible marker.<br />
6. Cut a piece of tape about 4 inches long and split one half of it into two pieces so that it<br />
forms a Y.<br />
7. Curve the end of the tube (about 4 to 6 inches) tightly around your fingers, hold for a few<br />
seconds, and then release.<br />
NOTE: This reduces the stiffness of the tube.<br />
8. Lubricate about 4 inches of the end of the tube with a water soluble lubricant.<br />
9. Perform a patient care handwash and put on gloves.<br />
WARNING: Wear gloves for self-protection against transmission of contaminants whenever<br />
handling body fluids.<br />
10. Insert the lubricated tip of the tube into the selected nostril.<br />
11. Advance the tube into the nostril.<br />
3-256
STP 8-91W15-SM-TG<br />
Performance Steps<br />
a. Gently rotate the tube at the point where the nostril drops into the pharynx, if<br />
necessary.<br />
b. Instruct the patient to swallow to aid advancement of the tube.<br />
NOTE: The patient may take sips of water through a straw, if permitted.<br />
c. Advance the tube 3 to 5 inches with each swallow.<br />
CAUTIONS: 1. Do not force advancement of the tube. 2. Remove the tube completely and<br />
relubricate it if the patient chokes, coughs, or if resistance is felt. Allow the patient to rest for 2<br />
to 3 minutes and repeat the procedure. If a second attempt at insertion fails, notify the doctor<br />
immediately.<br />
12. Continue advancing the tube until the tape marker touches the nostril.<br />
13. Check the placement of the tube.<br />
a. Aspiration.<br />
(1) Attach a syringe to the end of the tube. (If a bulb syringe is used, the bulb must<br />
be depressed prior to attaching it to the tube.)<br />
(2) Aspirate the stomach contents.<br />
NOTE: The presence of stomach contents in the tube or syringe indicates correct placement.<br />
(3) Remove the syringe.<br />
b. Auscultation.<br />
(1) Position the diaphragm of the stethoscope over the patient's stomach (about 2<br />
inches below the sternum).<br />
(2) Inject 10 cc of air into the tube.<br />
(3) Listen for the sound of the air entering the stomach (gurgling or whooshing sound)<br />
which indicates correct tube placement. Proceed to step 14 if placement is<br />
correct.<br />
(4) Check for tube placement in the trachea if air is not heard entering the stomach.<br />
(a) Reinject 10 cc of air into the tube.<br />
(b) Auscultate over the lung field.<br />
(c) Remove the tube if air injection is heard over the lungs.<br />
(5) Repeat steps 10 through 13b(3) to insert the tube.<br />
14. Secure the tube to the patient's nose with the tape and wrap the two ends of tape around<br />
the tube.<br />
15. Connect the tube to the suction apparatus, if ordered.<br />
16. Remove gloves and wash hands.<br />
17. Report and record the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Assembled equipment. —— ——<br />
2. Explained the procedure to the patient. —— ——<br />
3. Washed hands and took body substance isolation precautions. —— ——<br />
4. Positioned the patient. —— ——<br />
5. Measured the tube for insertion. —— ——<br />
3-257
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
6. Cut a piece of tape about 4 inches long and split one half of it into two<br />
pieces so that if formed a Y.<br />
7. Curved the end of the tube (about 4 to 6 inches) tightly around the fingers,<br />
held it for a few seconds, and then released it.<br />
—— ——<br />
—— ——<br />
8. Introduced the lubricated tip of the tube into the selected nostril. —— ——<br />
9. Advanced the tube into the nostril. —— ——<br />
10. Continued advancing the tube until the tape marker touched the nostril. —— ——<br />
11. Checked the placement of the tube. —— ——<br />
12. Secured the tube to the patient's nose with the tape and wrapped the two<br />
ends of tape around tube.<br />
—— ——<br />
13. Connected the tube to the suction apparatus, if ordered. —— ——<br />
14. Removed gloves and washed hands. —— ——<br />
15. Reported and recorded the procedure. —— ——<br />
16. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-258
STP 8-91W15-SM-TG<br />
PERFORM A GASTRIC LAVAGE<br />
081-835-3005<br />
Conditions: You nave verified a physician's orders requiring a gastric lavage. A patient care<br />
handwash been performed. Necessary materials and equipment: Ewald tube, nasogastric<br />
tubes, water-soluble lubricant, 50 cc catheter-tip syringes, basins, protective pads, towels,<br />
sphygmomanometer, stethoscope, thermometer, graduated containers, ice, prescribed lavage<br />
solution, gloves, and the patient's clinical record.<br />
Standards: Performed the gastric lavage in accordance with the physician's orders and without<br />
causing further injury to the patient.<br />
Performance Steps<br />
1. Assemble the necessary equipment and set it up at the patient's bedside.<br />
a. Ensure that there is enough irrigating solution on hand.<br />
NOTE: In most cases, the physician's order will be to lavage "until clear". Lavage will continue<br />
until the stomach contents return clear (nothing is returned but the irrigating solution itself). This<br />
requires preparation of at least 6 liters of the prescribed irrigating solution (usually normal<br />
saline).<br />
b. Ensure that ice or chilled solution is available when the physician orders "ice lavage".<br />
NOTE: When lavage is done to control gastric bleeding, the order is usually for "ice lavage".<br />
Chilling the irrigating solution promotes vasoconstriction, thereby helping to control bleeding.<br />
2. Explain the procedure to the patient.<br />
3. Establish baseline vital signs.<br />
4. Position the patient.<br />
a. A patient who is alert should be placed in the Fowler's or semi-Fowler's position.<br />
b. A patient who is not alert, or too weak to sit, should be positioned on the left side, with<br />
the head of the bed elevated 15 degrees.<br />
NOTE: This left lateral recumbent position will allow the tip of the tube to lie in the greater<br />
curvature of the stomach.<br />
5. Insert the appropriate tube if one is not already in place.<br />
a. For a stomach wash, the physician will specify insertion of large lumen nasogastric<br />
tube or the Ewald stomach tube.<br />
NOTE: The Ewald stomach tube is normally inserted through the mouth rather than the nose,<br />
because it is a large bore tube.<br />
b. For control of gastric bleeding, the physician will specify insertion of a large lumen<br />
nasogastric tube.<br />
c. In the event of severe bleeding, as in the case of esophageal varices, the physician<br />
will specify insertion of a nasogastric tube that has gastric and esophageal balloons<br />
(Blakemore tube, for example).<br />
NOTE: In any situation, a large lumen tube is indicated. Particles of food, mucous, or blood<br />
may occlude the lumen of a small tube.<br />
CAUTION: Gloves should be worn for self-protection against transmission of contaminants<br />
whenever handling body fluids.<br />
3-259
STP 8-91W15-SM-TG<br />
Performance Steps<br />
6. Aspirate all stomach contents.<br />
a. Using a 50 cc syringe, aspirate stomach contents and place the aspirate in a<br />
measured container.<br />
b. Repeat until all stomach contents have been aspirated.<br />
c. Record the total amount as output on the I & O worksheet.<br />
d. Save the aspirate for disposition as directed by the physician.<br />
7. Instill the irrigating solution, using the method specified by the physician's orders or local<br />
SOP.<br />
a. Syringe method. Using a 50 cc catheter-tip syringe, instill 100 cc of the solution.<br />
(Instillation and withdrawal are repeated 100 cc at a time, until clear or IAW physician's<br />
orders).<br />
b. Funnel method. Using a funnel (or syringe barrel), instill up to 500 cc of the solution by<br />
pouring it slowly into the funnel.<br />
CAUTION: When using the funnel method, it is imperative that the patient be carefully<br />
assessed for abdominal distention. The size and tolerance of the patient will determine how<br />
much fluid can be instilled at one time.<br />
8. Withdraw the irrigating solution.<br />
a. Syringe method.<br />
(1) Using a 50 cc catheter-tip syringe, withdraw all the irrigating solution and stomach<br />
contents.<br />
(2) Place the aspirate into a measured container.<br />
(3) Note the amount and character of the aspirate.<br />
NOTE: If syringe aspiration is difficult, or no aspirate can be obtained, the gastric tube may be<br />
resting against the gastric mucosa. Reposition the patient and aspirate again. If aspiration is<br />
still difficult, reposition the tube by advancing or withdrawing it slightly.<br />
b. Funnel method.<br />
(1) Lower the funnel end of the tube below the level of the patient's stomach to<br />
facilitate gravity drainage.<br />
NOTE: If the solution does not begin to drain by gravity, aspirate with a syringe (creating a<br />
siphon effect) to start the backflow of solution. If gravity drainage cannot be established,<br />
withdraw the solution by the syringe method.<br />
(2) Allow the irrigating solution and stomach contents to drain into a measured<br />
container.<br />
(3) Note the amount and character of the return solution.<br />
9. Continue the lavage by repeating steps 7 and 8 in accordance with the physician's orders.<br />
That is, continue until the stomach contents are clear, the prescribed amount of solution<br />
has been administered, or as otherwise directed.<br />
10. Clamp the tubing.<br />
a. Clamp and secure the tube if it is to remain in place.<br />
b. Clamp and withdraw the tube if it is to be removed.<br />
11. Remove all used equipment from the bedside.<br />
12. Measure the lavage return.<br />
a. Measure and record the total lavage return.<br />
b. Estimate the amount of stomach contents by subtracting the known amount of<br />
irrigating solution used from the measured amount of total lavage return.<br />
3-260
STP 8-91W15-SM-TG<br />
Performance Steps<br />
c. Record the amount of stomach contents as output on the I & O worksheet.<br />
13. Dispose of the initial stomach aspirate and all lavage solution returned as directed by the<br />
physician's orders or local SOP. That is, hold it for examination by the physician, send fluid<br />
samples to the laboratory, or discard it into the appropriate receptacle.<br />
14. Document the procedure and significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
a. Note the type and amount of lavage solution used.<br />
b. Note the color, odor, character, and amount of initial stomach contents aspirated.<br />
c. Note the color, odor, character, and amount of lavage return.<br />
d. Describe the patient's tolerance of the procedure.<br />
e. Note the disposition of any specimens.<br />
Performance Measures GO NO<br />
GO<br />
1. Assembled the equipment. —— ——<br />
2. Explained the procedure to the patient. —— ——<br />
3. Established baseline vital signs. —— ——<br />
4. Positioned the patient. —— ——<br />
5. Inserted the tube, if necessary. —— ——<br />
6. Aspirated the initial stomach contents. —— ——<br />
7. Instilled the irrigating solution. —— ——<br />
8. Withdrew the irrigating solution. —— ——<br />
9. Continued the lavage as directed by the physician's orders. —— ——<br />
10. Clamped the tubing. —— ——<br />
11. Removed the equipment. —— ——<br />
12. Measured the lavage return. —— ——<br />
13. Disposed of the initial aspirate and lavage return as directed by the<br />
physician's orders.<br />
—— ——<br />
14. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-261
STP 8-91W15-SM-TG<br />
Subject Area 14: Triage and Evacuation<br />
<strong>GUIDE</strong> A HELICOPTER TO A L<strong>AND</strong>ING POINT<br />
071-334-4001<br />
Conditions: Given a prepared landing site for a UH-1 or UH-60 helicopter (the location of which<br />
is known to the pilot), individual TOE equipment, night vision goggles, FM radio (SINCGAR),<br />
and the appropriate arm-and-hand signals to guide the helicopter to the landing site and land<br />
the helicopter on the landing site.<br />
Standards: Guided the helicopter to a safe landing by MEDEVAC request, identifying the<br />
landing site to the pilot and controlling the landing using the correct arm-and-hand signals.<br />
Performance Steps<br />
CAUTION: During training, dispose of all batteries IAW unit SOP.<br />
1. As the aircraft approaches, provide the pilot with tactical and security information. Tell him<br />
of conditions that may affect his landing such as terrain, weather, landing site markings,<br />
and possible obstacles.<br />
a. Confirm information or answer any questions the pilot may have pertaining to the<br />
landing site.<br />
b. Maintain communications with the pilot during the entire operation.<br />
2. Identify the landing site and guide the pilot in.<br />
a. Once the pilot is within your area, he establishes radio contact with the unit for positive<br />
identification.<br />
b. The pilot will be oriented to the landing site by using the clock method (12 o'clock is<br />
always the direction of flight). Tell the pilot the time position of your location. (For<br />
example: "The LZ is now at 3 o'clock to your position.")<br />
c. Mark or identify the landing site:<br />
(1) Day. The only signals required are colored smoke and a signalman. VS-17<br />
marker panels may be used to mark the landing site, but are NOT used any closer<br />
than 50 feet to the touchdown point. In addition to identifying the landing site, the<br />
colored smoke shows the pilot the wind direction and speed.<br />
(2) Night. The landing site and touchdown point are marked by an inverted "Y"<br />
composed of four lights (Figure 3-35).<br />
3-262
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-35<br />
3. Use arm-and-hand signals. (See Figures 3-36 through 3-43.)<br />
a. The signalman's position when directing a helicopter is to the right front of the aircraft<br />
where he can be seen best by the pilot. The signalman's position for utility helicopters<br />
is 30 meters to the right front of the aircraft during day or night operations.<br />
b. Signals at night are given using lighted batons or flashlights. In the illustrations, one of<br />
the men is using a lighted wand. This is a flashlight with a plastic wand attached to the<br />
end. The flashlight is used when visibility is decreased.<br />
c. The speed of the arm movement indicates the desired speed of aircraft compliance<br />
with the signal.<br />
3-263
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-36<br />
Figure 3-37<br />
3-264
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-38<br />
Figure 3-39<br />
3-265
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-40<br />
Figure 3-41<br />
3-266
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-42<br />
Figure 3-43<br />
NOTE: The "hover" signal should be used to change from one arm-and-hand signal to another.<br />
For example, assume that the signalman wants to land an approaching helicopter and has given<br />
the helicopter the "move ahead" signal. The helicopter is now positioned directly over the<br />
desired landing area. Before giving the helicopter the signal to move downward, the signalman<br />
should execute the "hover" signal. This gives the pilot time to change from the "move ahead" to<br />
the "move downward" signal.<br />
3-267
STP 8-91W15-SM-TG<br />
Evaluation Preparation:<br />
Setup: At the test site, provide all equipment and information given in the task conditions<br />
statement. For test purposes, the tester may act as the pilot.<br />
Brief Soldier: Tell the soldier that he is to land the helicopter using arm-and-hand signals.<br />
Performance Measures GO NO<br />
GO<br />
1. Advised the pilot of changes to the information given. —— ——<br />
2. Identified the landing site to the pilot. —— ——<br />
3. Controlled the landing using arm-and-hand signals. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 21-60<br />
FM 57-38<br />
FM 7-8<br />
3-268
STP 8-91W15-SM-TG<br />
ESTABLISH A HELICOPTER L<strong>AND</strong>ING POINT<br />
071-334-4002<br />
Conditions: Given an area to be prepared for the landing site; smoke grenades; strobe lights,<br />
flashlights, or vehicle lights; marker panels; and equipment and personnel to clear the site when<br />
required.<br />
Standards: The site is large enough for a helicopter to land and take off. All obstacles that<br />
cannot be removed are marked or identified, and the touchdown point on the landing site is<br />
identified.<br />
Performance Steps<br />
CAUTIONS: 1. During training, dispose of all batteries IAW unit SOP. 2. Comply with unit SOP<br />
and or local regulations concerning the cutting of live vegetation, digging holes, and/or erosion<br />
prevention.<br />
1. Select the landing site. The factors which should be considered are:<br />
a. The size of the landing site.<br />
(1) A helicopter requires a relatively level landing area 30 meters in diameter. This<br />
does not mean that a loaded helicopter can land and take off from an area of that<br />
size. Most helicopters cannot go straight up or down when fully loaded.<br />
Therefore, a larger landing site and better approach and departure routes are<br />
required.<br />
(2) When obstacles are in the approach or departure routes, a 10 to 1 ratio must be<br />
used to lay out the landing site (Figure 3-44). For example, during the approach<br />
and departure, if the helicopter must fly over trees that are 15 meters high, the<br />
landing site must be at least 150 meters long (10 x 15 = 150 meters).<br />
Figure 3-44<br />
b. The ground slope of the landing site (Figure 3-45). When selecting the landing site,<br />
the ground slope must be no more than 15 degrees. Helicopters cannot safely land on<br />
a slope of more than 15 degrees.<br />
3-269
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(1) When the ground slope is under 7 degrees, the helicopter should land upslope.<br />
(See Figure 3-45A.)<br />
(2) When the ground slope is 7 to 15 degrees, the helicopter must land sideslope.<br />
(See Figure 3-45B.)<br />
Figure 3-45<br />
c. Surface conditions.<br />
(1) The ground must be firm enough that the helicopter does not bog down during<br />
loading or unloading. If firm ground cannot be found, the pilot must be told. He<br />
can hover at the landing site during the loading or unloading.<br />
(2) Rotor wash on dusty, sandy, or snow-covered surfaces may cause loss of visual<br />
contact with the ground. Therefore, these areas should be avoided.<br />
(3) Loose debris that can be kicked up by the rotor wash must be removed from the<br />
landing site. Loose debris can cause damage to the blades or engines.<br />
d. Obstacles.<br />
(1) Landing sites should be free of tall trees, telephone lines, power lines or poles,<br />
and similar obstructions on the approach or departure ends of the landing site.<br />
(2) Obstructions that cannot be removed (such as large rocks, stumps, or holes) must<br />
be marked clearly within the landing site.<br />
2. Establish security for the landing site. Landing sites should offer some security from enemy<br />
observation and direct fire. Good landing sites will allow the helicopter to land and depart<br />
without exposing it to unneeded risks. Security is normally established around the entire<br />
landing site.<br />
3. Mark the landing site and touchdown point.<br />
a. When and how the landing site should be marked is based on the mission, capabilities,<br />
and situation of the unit concerned. Normally, the only mark or signals required are<br />
smoke (colored) and a signalman. VS-17 marker panels may be used to mark the<br />
landing site, but MUST NOT be used any closer than 50 feet to the touchdown point.<br />
In addition to identifying the landing site, smoke gives the pilot information on the wind<br />
direction and speed.<br />
b. At night, the landing site and touchdown point are marked by an inverted "Y"<br />
composed of four lights (Figure 3-46). Strobe lights, flashlights, or vehicle lights may<br />
also be used to mark the landing site. The marking system used will be fully explained<br />
to the pilot when contact is made.<br />
3-270
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-46<br />
Evaluation Preparation:<br />
Setup: At the test site, provide all equipment, information, and personnel given in the task<br />
conditions statement.<br />
Brief soldier: Tell the soldier that he or she is to select and prepare a helicopter landing site.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected a site large enough to permit the helicopter to land and take off. —— ——<br />
2. Removed or marked all obstacles and debris. —— ——<br />
3. Marked or identified the landing site and the touchdown point. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 21-60<br />
FM 57-38<br />
FM 7-8<br />
3-271
STP 8-91W15-SM-TG<br />
TRIAGE CASUALTIES ON A CONVENTIONAL BATTLEFIELD<br />
081-833-0080<br />
Conditions: You are in the field and have several casualties with conventional injuries. You are<br />
not in an NBC environment.<br />
Standards: Completed all the steps necessary to establish priorities for the treatment and<br />
evacuation of casualties.<br />
Performance Steps<br />
1. Assess the situation.<br />
a. Sort the casualties and allocate treatment.<br />
(1) Assess and classify the casualties for the most efficient use of available medical<br />
personnel and supplies.<br />
(2) Give available treatment first to the casualties who have the best chance of<br />
survival.<br />
(3) A primary goal is to locate and return to duty troops with minor wounds. However,<br />
at no time should abandonment of a single casualty be considered.<br />
(4) Triage establishes the order of treatment, not whether treatment is given. It is<br />
usually the responsibility of the senior medical person.<br />
b. Determine the tactical and environment situation.<br />
(1) Whether casualties must be transported to a more secure area for treatment.<br />
(2) The number and location of the injured and severity of injuries.<br />
(3) Available assistance (self-aid, buddy-aid, and medical personnel).<br />
(4) Evacuation support capabilities and requirements.<br />
NOTE: Nuclear weapons exposure will not be used as a criteria for sorting. Field experience<br />
with these injuries does not exist.<br />
2. Assess the casualties and establish priorities for treatment.<br />
a. Immediate--casualties whose conditions demand immediate treatment to save life,<br />
limb, or eyesight. This category has the highest priority.<br />
(1) Airway obstruction.<br />
(2) Respiratory and cardiorespiratory distress from otherwise treatable injuries (for<br />
example, electrical shock, drowning, or chemical exposure).<br />
NOTE: A casualty with cardiorespiratory distress may not be classified "Immediate" on the<br />
battlefield. The casualty may be classified "Expectant", contingent upon such things as the<br />
situation, number of casualties, and support.<br />
(3) Massive external bleeding.<br />
(4) Shock.<br />
(5) Burns on the face, neck, hands, feet, or perineum and genitalia.<br />
NOTE: After all life or limb threatening conditions have been successfully treated, give no<br />
further treatment to the casualty until all other "Immediate" casualties have been treated.<br />
Salvage of life takes priority over salvage of limb.<br />
b. Delayed--casualties who have less risk of loss of life or limb if treatment is delayed.<br />
(1) Open wounds of the chest without respiratory distress.<br />
(2) Open or penetrating abdominal injuries without shock.<br />
(3) Severe eye injuries without hope of saving eyesight.<br />
(4) Other open wounds.<br />
(5) Fractures.<br />
3-272
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(6) Second and third degree burns (not involving the face, hands, feet, genitalia, and<br />
perineum) covering 20% or more of the total body surface area.<br />
c. Minimal--"Walking wounded", can be treated by self-aid or buddy-aid.<br />
(1) Minor lacerations and contusions.<br />
(2) Sprains and strains.<br />
(3) Minor combat stress problems.<br />
(4) First or second degree burns (not involving the face, hands, feet, genitalia, and<br />
perineum) covering under 20% of the total body surface area.<br />
d. Expectant--casualties who are so critically injured that only complicated and prolonged<br />
treatment can improve life expectancy. This category is to be used only if resources<br />
are limited. If in doubt as to the severity of the injury, place the casualty in one of the<br />
other categories.<br />
(1) Massive head injuries with signs of impending death.<br />
(2) Burns, mostly third degree, covering more than 85% of the total body surface<br />
area.<br />
NOTE: Provide ongoing supportive care if the time and condition permits; keep separate from<br />
other triage categorized casualties. (See Common Core task 101-515-0002.)<br />
3. Record all treatment given on the Field Medical Card.<br />
4. Establish MEDEVAC priorities by precedence category.<br />
a. Urgent. Evacuation is required as soon as possible, but within 2 hours, to save life,<br />
limb, or eyesight. Generally, casualties whose conditions cannot be controlled and<br />
have the greatest opportunity for survival are placed in this category.<br />
(1) Cardiorespiratory distress.<br />
(2) Shock not responding to IV therapy.<br />
(3) Prolonged unconsciousness.<br />
(4) Head injuries with signs of increasing intracranial pressure.<br />
(5) Burns covering 20% to 85% of the total body surface area.<br />
b. Urgent Surgical. Evacuation is required for casualties who must receive far forward<br />
surgical intervention to save life and stabilize for further evacuation.<br />
(1) Decreased circulation in the extremities.<br />
(2) Open chest and/or abdominal wounds with decreased blood pressure.<br />
(3) Penetrating wounds.<br />
(4) Uncontrollable bleeding or open fractures with severe bleeding.<br />
(5) Severe facial injuries.<br />
c. Priority. Evacuation is required within 4 hours or the casualty's condition could get<br />
worse and become an "urgent" or "urgent surgical" category condition. Generally, this<br />
category applies to any casualty whose condition is not stabilized or who is at risk of<br />
trauma-related complications.<br />
(1) Closed-chest injuries, such as rib fractures without a flail segment, or other<br />
injuries that interfere with respiration.<br />
(2) Brief periods of unconsciousness.<br />
(3) Soft tissue injuries and open or closed fractures.<br />
(4) Abdominal injuries with no decreased blood pressure.<br />
(5) Eye injuries that do not threaten eyesight.<br />
(6) Spinal injuries.<br />
(7) Burns on the hands, face, feet, genitalia, or perineum even if under 20% of the<br />
total body surface area.<br />
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Performance Steps<br />
d. Routine. Evacuation is required within 24 hours for further care. Immediate<br />
evacuation is not critical. Generally, casualties who can be controlled without<br />
jeopardizing their condition or who can be managed by the evacuating facility for up to<br />
24 hours.<br />
(1) Burns covering 20% to 80% of the total body surface area if the casualty is<br />
receiving and responding to IV therapy.<br />
(2) Simple fractures.<br />
(3) Open wounds including chest injuries without respiratory distress.<br />
(4) Psychiatric cases.<br />
(5) Terminal cases.<br />
e. Convenience. Evacuation by medical vehicle is a matter of convenience rather than<br />
necessity.<br />
(1) Minor open wounds.<br />
(2) Sprains and strains.<br />
(3) Minor burns under 20% of total body surface area.<br />
5. Prepare the evacuation request. (See STP 21-24-SMCT, task 081-831-0101.)<br />
a. Pickup location--provided by the unit leader.<br />
b. Radio frequency, call sign, and suffix--provided by the radio/telephone operator (RTO).<br />
c. Number of patients by precedence category.<br />
d. Special equipment required--none, hoist, extraction equipment, ventilator.<br />
e. Number of patients by type--litter, ambulatory.<br />
f. Security of the pickup site.<br />
g. Method of marking the pickup site--provided by the unit leader.<br />
h. Patients' nationality and status.<br />
i. NBC contamination, if any.<br />
NOTE: As a minimum, the first five items must be provided in the exact sequence listed.<br />
Performance Measures GO NO<br />
GO<br />
1. Assessed the situation. —— ——<br />
2. Assessed the casualties. —— ——<br />
3. Initiated treatment in the correct sequence. —— ——<br />
4. Recorded the treatment given. —— ——<br />
5. Assigned the MEDEVAC priorities. —— ——<br />
6. Prepared the evacuation request. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
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STP 8-91W15-SM-TG<br />
References<br />
Required<br />
None<br />
Related<br />
STP 21-24-SMCT<br />
COMMON CORE<br />
FM 8-10<br />
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STP 8-91W15-SM-TG<br />
TRIAGE CASUALTIES ON AN INTEGRATED BATTLEFIELD<br />
081-833-0082<br />
Conditions: You are in a chemical environment and have casualties with conventional injuries<br />
and/or signs and symptoms of chemical agent poisoning. Both you and the casualties are in<br />
MOPP level 4. Necessary materials and equipment: aid bag.<br />
Standards: Completed all the steps necessary to correctly establish priorities for the treatment<br />
and evacuation of casualties on an integrated battlefield.<br />
Performance Steps<br />
1. Assess the situation.<br />
a. Number and location of the injured.<br />
b. Severity of the injuries.<br />
c. Assistance available (self-aid or buddy-aid).<br />
d. Evacuation support capabilities.<br />
e. Type of chemical agents used, if known.<br />
2. Assess the individual casualties.<br />
a. Assess for conventional injuries.<br />
b. Assess for signs and symptoms of chemical agent poisoning.<br />
(1) Determine if the casualty responds to commands.<br />
(a) Check the casualty's response to simple directions, such as "Hold up your<br />
right arm."<br />
(b) Ask the casualty to describe any symptoms.<br />
(2) Check for symptoms of chemical agent poisoning. (See tasks 081-833-0083<br />
through 081-833-0086.)<br />
3. Establish priorities for treatment.<br />
a. Immediate.<br />
(1) No signs and symptoms of chemical agent poisoning.<br />
(2) Presence of life-threatening conventional injuries.<br />
b. Chemical immediate.<br />
(1) Presence of signs and symptoms of severe chemical agent poisoning.<br />
(2) No conventional injuries.<br />
c. Delayed.<br />
(1) Presence of mild signs and symptoms of chemical agent poisoning.<br />
(2) Presence of conventional injuries that are not life-threatening.<br />
d. Minimal.<br />
(1) No signs and symptoms of chemical agent poisoning.<br />
(2) Presence of minor conventional injuries.<br />
e. Expectant.<br />
(1) Presence of severe signs and symptoms of both chemical agent poisoning and<br />
life-threatening conventional injuries.<br />
(2) No conventional injuries and not breathing due to chemical agent poisoning.<br />
NOTE: Expectant casualties are so critically injured that only prolonged and complicated<br />
treatment may offer increased life expectancy.<br />
4. Initiate treatment in the following order.<br />
a. Chemical agent poisoning.<br />
b. Conventional injuries.<br />
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Performance Steps<br />
NOTES: 1. Employ casualties who have only minor injuries or minimal chemical agent<br />
exposure to provide buddy-aid for those with more severe injuries. 2. Sorting and treatment<br />
should be done almost simultaneously.<br />
5. Move the casualties to the collection point.<br />
6. Record all observations and treatment on the appropriate form.<br />
7. Establish evacuation priorities. (See task 081-833-0080.)<br />
Evaluation Preparation:<br />
Setup: You will need several soldiers in MOPP level 4 to act as the casualties. Use a moulage<br />
kit or similar materials to simulate conventional wounds. Coach the soldiers on signs and<br />
symptoms of nerve agent poisoning to exhibit.<br />
Brief soldier: Tell the soldier to triage casualties on an integrated battlefield.<br />
Performance Measures GO NO<br />
GO<br />
1. Assessed the situation. —— ——<br />
2. Assessed the individual casualties. —— ——<br />
3. Established priorities for treatment. —— ——<br />
4. Initiated treatment. —— ——<br />
5. Moved the casualties to the collection point. —— ——<br />
6. Recorded all observations and treatment on the appropriate form. —— ——<br />
7. Established evacuation priorities. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 8-10<br />
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STP 8-91W15-SM-TG<br />
LOAD CASUALTIES ONTO GROUND EVACUATION PLATFORMS<br />
081-833-0151<br />
Conditions: You have completed treating and triaging multiple patients. You are in charge of<br />
loading litter and ambulatory patients on a standard ground transport platform (M996, M997, or<br />
M113).<br />
Standards: Configured the vehicle properly and loaded and unloaded patients in the correct<br />
sequence for the transport platform.<br />
Performance Steps<br />
1. Determine ambulance load capacities.<br />
a. Truck, ambulance, 4X4, 2 litter, utility (M996).<br />
(1) 2 litter patients.<br />
(2) 6 ambulatory patients.<br />
(3) 1 litter and 3 ambulatory patients.<br />
b. Truck, ambulance, 4X4, 4 litter, utility (M997).<br />
(1) 4 litter patients.<br />
(2) 8 ambulatory patients.<br />
(3) 2 litter and 4 ambulatory patients.<br />
c. Carrier, personnel, full tracked, armored (M113, T113E2).<br />
(1) 4 litter patients.<br />
(2) 10 ambulatory patients.<br />
(3) 2 litter and 5 ambulatory patients.<br />
NOTE: Patients are normally loaded head first. They are less likely to experience motion<br />
sickness or nausea with the head in the direction of travel. When en route care is required for<br />
an injury on one side, it may be necessary to load feet first to access from the aisle. Patients<br />
with wounds of the chest or abdomen or those receiving IV fluids are loaded in lower berths to<br />
provide gravity flow. Patients wearing bulky splints should be placed on lower berths.<br />
2. Determine the loading sequence.<br />
a. M996.<br />
(1) Load patients in the right berth first and then the left.<br />
(2) Load the most seriously injured patient last.<br />
(3) Go to step 3.<br />
b. M997.<br />
(1) Load patients in the upper right, lower right, upper left, and then the lower left<br />
berths.<br />
(2) Load the most seriously injured patients last.<br />
CAUTION: To install the litter suspension kit in the M113 ambulance, the spall liner must be<br />
removed. Litter patients cannot be safely moved if the litter suspension kit is not installed.<br />
(3) Go to step 4.<br />
NOTE: Unload the M113 ambulance in reverse sequence.<br />
c. M113, T113E2.<br />
(1) Load patients in the upper right, lower right, upper left, and then the lower left<br />
berths.<br />
(2) Load the most seriously injured patients last.<br />
3. Load and unload the M996 for ambulatory or litter patients.<br />
a. Prepare the M996 for ambulatory patients (Figures 3-47 and 3-48).<br />
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Performance Steps<br />
Figure 3-47<br />
Figure 3-48<br />
(1) Ensure litters are in stowed position.<br />
(2) Pull out and up on seat latch handle (5) and remove latch (7) from catch (6).<br />
(3) Lift seat back (4) to open position and fold seat back support (2) into recesses<br />
between seat cushions (9).<br />
(4) Ensure that seat braces (8) are fully extended and locked in position.<br />
b. Prepare the M996 for litter patients (Figures 3-47 and 3-48).<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(1) Press lock buttons (12) on seat braces (8) and fold braces (8) toward seat back<br />
(4).<br />
(2) Fold seat back support (2) outward and fold seat back (4) into closed position.<br />
Ensure that guide pins (11) on seat back support engage holes (10) in seat base<br />
(3).<br />
(3) Install seat back (4) to seat base (3) with seat latch (7) and secure with latch<br />
handle (5). If necessary to ensure security of seat back (4), adjust seat latch (7)<br />
to proper length by turning clockwise or counterclockwise.<br />
c. Prepare the M996 to utilize the litter rail extension for loading and unloading of<br />
patients.<br />
(1) Assemble litter rail extension for M996 (Figures 3-49 and 3-50).<br />
Figure 3-49<br />
Figure 3-50<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(a) Turn latch (1) counterclockwise and open stowage compartment door (2).<br />
(b) Loosen and disconnect securing strap (3) and remove folded litter rail<br />
extension (4) from stowage compartment (5).<br />
(c) Pull left and right rails (6) apart and let legs (11) drop down. Ensure feet (12)<br />
are flat on ground.<br />
(d) Lock support braces (13) and adjust straps (14) as necessary.<br />
(2) Load litters on litter rack (Figure 3-50).<br />
(a) Secure both rails (6) of litter rail extension (4) into slots (10) on litter rack (9).<br />
(b) Place litter (7) on litter rail extension (4).<br />
WARNING: Ensure straps and equipment do not inhibit litter loading operations. Load litters<br />
carefully to prevent patient injury.<br />
(c) Slide litter (7) onto litter rack (9).<br />
(d) Secure litter (7) to litter rack (9) with front and rear litter handle straps (8).<br />
(3) Unload litters from the litter rack (Figure 3-50).<br />
(a) Release front and rear litter handle straps (8) securing litter (7) to litter rack<br />
(9).<br />
(b) Secure both rails (6) of litter rail extension (4) into slots (10) on lower litter<br />
rack (9).<br />
(c) Slide litter (7) from lower litter rack (9) onto litter rail extension (4). Lift up and<br />
remove litter (7) from litter rail extension (4).<br />
(4) Fold and stow litter rail extension for M996 (Figures 3-49 and 3-50).<br />
(a) Unlock support braces (13).<br />
(b) Fold left and right rails (6) together.<br />
(c) Fold left and right litter rail legs (11) and feet (12) against rails (6).<br />
(d) Place folded litter rail extension (4) into stowage compartment (5) and secure<br />
with strap (3).<br />
(e) Close door (2) and turn latch (1) clockwise to secure door (2).<br />
4. Load and unload the M997 for litter and ambulatory patients.<br />
a. Prepare the upper litter rack (Figure 3-51).<br />
(1) Unhook tension strap (23) from footman loop (30) on lower litter rack (9).<br />
(2) Pull out upper litter rack handle (17) and support weight of upper litter rack (21).<br />
WARNING: The rear end of the upper litter must be supported before releasing the suspension<br />
strap hook. Injury to personnel may result if rear end of upper litter is not supported.<br />
(3) Unhook rear suspension strap hook (27) from loop (22) on upper litter rack (21).<br />
Clip suspension strap hook (27) to eye (26).<br />
(4) Release litter support latch stop (25), push latch (24) in, and lower upper litter rack<br />
(21) onto lower litter rack (9).<br />
(5) Slide litter rack handle (17) into upper litter rack (21).<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-51<br />
b. Assemble the litter rail extension (Figures 3-50 and 3-52).<br />
Figure 3-52<br />
(1) Turn latch (1) counterclockwise and open stowage compartment door (2).<br />
(2) Loosen and disconnect securing strap (3) and remove folded litter rail extension<br />
(4) from stowage compartment (5).<br />
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Performance Steps<br />
(3) Lift tray (15) slightly and push in tray supports (16) to lower tray (15) for access to<br />
stowed litters.<br />
(4) Pull left and right rails (6) apart and let legs (11) drop down. Ensure feet (12) are<br />
flat on ground.<br />
(5) Lock support braces (13) and adjust straps (14) as necessary.<br />
c. Load litters on upper litter racks (Figures 3-51 and 3-53).<br />
Figure 3-53<br />
(1) Secure both rails of litter extension (4) into slots in upper litter rack (21).<br />
(2) Place litter (18) on litter rail extension (4).<br />
(3) Slide litter (18) up rails (4) until litter (18) is clear of litter rail extension (4).<br />
(4) Secure rear litter handles (19) to upper litter rack (21) with rear letter handle<br />
straps (20).<br />
(5) Remove litter rail extension (4) from upper litter rack (21).<br />
(6) Unhook suspension strap hook (27) from eye (26).<br />
(7) Pull out upper litter rack handle (17).<br />
(8) Raise upper litter rack (21), push into litter support latch (24), and secure with<br />
latch stop (25).<br />
(9) Secure front litter handles (29) to litter rack (21) with front litter handle straps (28).<br />
(10) Hook tension strap (23) to footman loop (30) on lower litter rack (9) and adjust<br />
strap.<br />
(11) Slide litter rack handle (17) into upper litter rack (21).<br />
d. Load litters on lower litter rack (Figure 3-50).<br />
(1) Secure both rails (6) of litter rail extension (4) into slots (10) on lower litter rack (9).<br />
(2) Place litter (7) on litter rail extension (4).<br />
(3) Slide litter (7) onto lower litter rack (9).<br />
(4) Secure litter (7) to lower litter rack (9) with front and rear litter handle straps (8).<br />
e. Unload litters from the lower litter rack (Figure 3-50).<br />
WARNING: When unloading more than two litter patients, lower litter rack patients must be<br />
unloaded first. Ensure that straps and equipment do not inhibit unloading operations. Unload<br />
litters carefully to prevent patient injury.<br />
(1) Release front and real litter handle straps (8) securing liter (7) to lower litter rack<br />
(9).<br />
(2) Secure both rails (6) of litter rail extension (4) into slots (10) on lower litter rack (9).<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
(3) Slide litter (7) from lower litter rack (9) onto litter rail extension (4). Lift up and<br />
remove litter (7) from litter rail extension (4).<br />
f. Unload litters from upper litter racks (Figures 3-51 and 3-53).<br />
(1) Release litter support latch stop (28) from litter handles (29).<br />
(2) Unhook tension strap (23) from footman loop (30) on lower litter rack (9).<br />
(3) Pull out upper litter rack handle (17) and support weight of upper litter rack (21).<br />
(4) Unhook rear suspension strap hook (27) from loop (22) on upper litter rack (21).<br />
Clip suspension strap hook (27) to eye (26).<br />
(5) Release litter support latch stop (25), push latch (24) in, and lower upper litter rack<br />
(21) onto lower litter rack (9).<br />
(6) Slide litter rack handle (17) into upper litter rack (21).<br />
(7) Secure rails of litter rail extension (4) into slots in upper litter rack (21).<br />
(8) Release rear litter handle straps (20) from litter handles (19).<br />
(9) Slide litter (18) down litter rail extension (4) until litter (18) is clear of upper litter<br />
rack (21).<br />
(10) Lift and remove litter (18) from litter rail extension (4).<br />
(11) Remove litter rail extension (4) from upper litter rack (21).<br />
g. Fold and stow litter rail extension (Figures 3-50 and 3-52).<br />
(1) Unlock support braces (13).<br />
(2) Fold left and right rails (6) together.<br />
(3) Fold left and right litter rail legs (11) and feet (12) against rail (6).<br />
(4) Lift tray (15) and push tray supports (16) in, and lower tray (15).<br />
(5) Slide litters into stowage compartments (5) on top of lift tray (15). Pull out<br />
supports (16) to place lift tray (15) in raised position.<br />
(6) Place folded litter rail extension (4) into stowage compartment (5) and secure with<br />
strap (3).<br />
(7) Close door (2) and turn latch (1) clockwise to secure door (2).<br />
h. Fold upper litter rack to the backrest position (Figure 3-51).<br />
(1) Unhook litter rack tension strap (23) from lower litter rack footman loop (30).<br />
(2) Unhook two upper litter rack suspension straps hooks (27) from loops (22) on<br />
upper litter rack (21) and reattach strap hooks (27) to eyes (26).<br />
(3) Release upper litter rack latch (31) and disengage rack striker (32) from latch (31).<br />
(4) Lower upper litter rack (21) onto the lower litter rack (9), forming a backrest.<br />
i. Cover backrest to upper litter rack (Figure 3-51).<br />
(1) Raise upper litter rack (21) and engage rack striker (32) into upper litter rack latch<br />
(31). Ensure striker (32) is locked in latch (21).<br />
(2) Unhook two upper litter rack suspension strap hooks (27) from eyes (26) and hook<br />
to loops (22) on upper litter rack (21).<br />
(3) Hook upper litter rack tension strap (23) to footman loop (30) on lower litter rack<br />
(9).<br />
(4) Adjust straps (23 and 27) for proper tension.<br />
Performance Measures GO NO<br />
GO<br />
1. Assessed the casualties to determine loading sequence. —— ——<br />
2. Prepared the ambulance to receive the casualties. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
3. Acted as the number one person and with assistance of the noncandidate<br />
soldiers:<br />
a. Loaded the casualties head first, in the proper sequence, and used<br />
the proper berths.<br />
b. Secured the casualties for transport.<br />
c. Unloaded the casualties in the proper sequence.<br />
—— ——<br />
4. Did not cause further injury to the casualties. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 8-10-6<br />
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STP 8-91W15-SM-TG<br />
LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD VEHICLES, 1 1/4 TON, 4X4, M998<br />
081-833-0171<br />
Conditions: You have completed treating and triaging multiple patients. You are in charge of<br />
loading litter or ambulatory patients onto a nonstandard transport vehicle (M998).<br />
Standards: Configured the vehicle properly and loaded and unloaded in the correct sequence.<br />
Performance Steps<br />
1. Determine vehicle load capacities.<br />
a. M998 (four-man configuration)--three litters.<br />
b. M998 (two-man configuration)--five litters.<br />
2. Direct nonmedical soldiers to load an M998 (four-man configuration). (See Figure 3-54.)<br />
Figure 3-54<br />
a. Remove the cargo cover and metal bows. Secure them in the vehicle and lower the<br />
tailgate.<br />
b. Place two litters side-by-side across the back of the truck with the litter handles resting<br />
on the sides of the truck.<br />
c. Secure the litters to the vehicle with any available material.<br />
d. Place one litter lengthwise, head first, in the bed of the truck. Secure it in place.<br />
e. Leave the tailgate open. It is supported by the two tailgate chain hooks.<br />
3. Direct nonmedical soldiers to load an M998 (two-man configuration). (See Figure 3-55.)<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-55<br />
a. Fold the fabric cover and metal bows forward and together as an assembly. Secure<br />
them in place. Lower the tailgate.<br />
b. Place three litters side-by-side across the sideboards. Secure them in place with any<br />
material available.<br />
c. Place two litters lengthwise, head first, in the bed of the truck. Secure them in place.<br />
d. Leave the tailgate open. It is supported by the two tailgate chain hooks.<br />
4. Direct nonmedical soldiers to unload the vehicle in reverse sequence.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined vehicle load capacity. —— ——<br />
2. Prepared the vehicle to receive patients. —— ——<br />
3. Directed nonmedical soldiers to-- —— ——<br />
a. Load the casualties in the proper sequence.<br />
b. Load casualties side-by-side across the back of the truck.<br />
c. Load casualties lengthwise on the floor, head first.<br />
d. Secure the casualties for transport.<br />
4. Did not cause further injury to the casualties. —— ——<br />
3-287
STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 8-10-6<br />
3-288
STP 8-91W15-SM-TG<br />
LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD VEHICLES, 2 1/2 TON, 6X6 OR 5 TON, 6X6,<br />
CARGO TRUCK<br />
081-833-0172<br />
Conditions: You have completed treating and triaging multiple patients. You are in charge of<br />
loading litter patients onto a nonstandard transport vehicle (2 1/2 ton or 5 ton cargo truck).<br />
Standards: Configured the vehicle properly and unloaded in the correct sequence.<br />
Performance Steps<br />
1. Determine vehicle load capacities.<br />
a. 12 litters.<br />
b. 16 ambulatory.<br />
2. Direct nonmedical soldiers to load the vehicle.<br />
a. Remove the canvas cover. (The cover can be rolled toward the front of the truck and<br />
secured.)<br />
b. Lower the seats.<br />
c. Place three litters crosswise on the seats as far forward as possible and three litters<br />
lengthwise in the bed of the truck as far forward as possible.<br />
d. Secure the litters individually to the seats.<br />
e. Place three additional litters crosswise on the seats and three additional litters<br />
lengthwise in the bed of the truck.<br />
f. Secure the litters individually to the seats.<br />
g. Raise and secure the tailgate as high as possible to help secure the litters in place.<br />
3. Direct nonmedical soldiers to unload the vehicle in reverse sequence.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined vehicle load capacity. —— ——<br />
2. Prepared the vehicle to receive patients. —— ——<br />
3. Directed the nonmedical soldiers to-- —— ——<br />
a. Load the casualties in the proper sequence crosswise on the seats as<br />
far forward as possible and three litters lengthwise in the bed of the<br />
truck as far forward as possible.<br />
NOTE: Patients may be loaded either head to head or head to toe.<br />
b. Secure the casualties for transport.<br />
c. Load three additional litters crosswise on the seats and three<br />
additional litters lengthwise in the bed of the truck.<br />
d. Secure the casualties for transport.<br />
e. Unload patients in the proper sequence.<br />
4. Did not cause further injury to the casualties. —— ——<br />
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STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 8-10-6<br />
3-290
STP 8-91W15-SM-TG<br />
LOAD CASUALTIES ONTO NONST<strong>AND</strong>ARD VEHICLES, 5 TON M-1085, M-1093, 2 1/2 TON<br />
M-1081<br />
081-833-0173<br />
Conditions: You have completed treating and triaging multiple patients. You are in charge of<br />
loading litter patients onto a nonstandard transport vehicle. (M-1085, M-1093, M-1081)<br />
Standards: Configured the vehicle properly and unloaded in the correct sequence.<br />
Performance Steps<br />
1. Determine vehicle load capacities.<br />
a. Long Wheelbase, 5-Ton, M-1085.<br />
(1) 12 litter.<br />
(2) 22 ambulatory.<br />
b. Light Vehicle Air Drop/Air Delivery, 5 Ton, M-1093.<br />
(1) 8 litters.<br />
(2) 14 ambulatory.<br />
c. Light Vehicle Air Drop/Air Delivery, 2 1/2 Ton, M-1081.<br />
(1) 7 litters.<br />
(2) 12 ambulatory.<br />
2. Direct nonmedical soldiers to load an M-1085. (See Figure 3-56.)<br />
Figure 3-56<br />
a. Lower the seats and secure the vertical support brackets in place.<br />
b. Place four litters (litter numbers 1 through 4) crosswise on the seats, forward, next to<br />
the cab. Secure the litters individually to the seats.<br />
c. Place two litters (litter numbers 5 and 6) lengthwise on the floor, forward toward the<br />
cab, feet first, ensuring that patients' heads are exposed from under the upper litters.<br />
Secure the litters together and to the vertical seat supports.<br />
d. Place litter number 7 crosswise on the seats near the rear of the vehicle. Slide the<br />
litter as far forward as possible. Do not secure the litter at this time.<br />
e. Follow the same procedures in step 2d above for litter numbers 8 and 9.<br />
f. Place litter number 10 crosswise on the furthest seat rearward. Secure the litter to the<br />
seat.<br />
g. Slide litters (litter numbers 7, 8, and 9) rearward next to litter number 10. Secure the<br />
litters to the seats individually.<br />
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Performance Steps<br />
h. Place two litters lengthwise on the floor, head first, ensuring that the patient's head is<br />
exposed to the center opening, between the upper litters. Secure the litters together<br />
and to the vertical seat supports.<br />
NOTE: The combat medic or combat lifesaver rides in the center of the vehicle to monitor the<br />
patients. If the vehicle is loaded with the maximum number of patients, the combat medic will<br />
not be able to attend to the patients.<br />
3. Direct nonmedical soldiers to load an M-1093. (See Figure 3-57.)<br />
Figure 3-57<br />
a. Lower the seats and secure the vertical support bracket into place.<br />
b. Place three litters (litter numbers 1 through 3) crosswise on the seats, forward, next to<br />
the cab. Secure the litters individually to the seats.<br />
c. Place two litters (litter numbers 4 and 5) lengthwise on the floor, forward toward the<br />
cab, feet first. Secure the litters together and to the vertical seat support.<br />
d. Place litter number 6 crosswise on the seats near the rear of the vehicle. Slide the<br />
litter as far forward as possible. Do not secure the litter at this time.<br />
e. Place litter number 7 crosswise on the seats near the rear of the vehicle and slide it<br />
forward as in step 3d above. Secure the litter to the seats.<br />
f. Place litter number 8 crosswise on the seats as far rearward as possible. Secure the<br />
litter to the seats.<br />
g. Glide litter numbers 6 and 7 rearward next to litter number 8. Secure the litters to the<br />
seats.<br />
h. Raise and secure the tailgate.<br />
NOTE: The combat medic or combat lifesaver rides in the center of the vehicle to monitor the<br />
patients.<br />
4. Direct nonmedical soldiers to load an M-1081. (See Figure 3-58.)<br />
a. Lower the seats and secure the vertical support bracket into place.<br />
b. Place three litters (litter numbers 1 through 3) crosswise on the seats, forward, next to<br />
the cab. Secure the litters individually to the seats.<br />
c. Place two litters (litter numbers 4 and 5) lengthwise on the floor, forward toward the<br />
cab, feet first. Secure the litters together and to the vertical seat support.<br />
d. Place litter number 6 crosswise on the seats near the rear of the vehicle. Slide the<br />
litter as far forward as possible. Do not secure the litter at this time.<br />
e. Place litter number 7 crosswise on the seats as far rearward as possible. Secure the<br />
litter to the seats.<br />
f. Slide litter number 6 rearward next to litter number 7. Secure the litter to the seats.<br />
g. Raise and secure the tailgate.<br />
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Performance Steps<br />
NOTE: The combat medic or combat lifesaver rides in the center of the vehicle to monitor the<br />
patients.<br />
Figure 3-58<br />
5. Direct nonmedical soldiers to unload vehicle in reverse sequence.<br />
Performance Measures GO NO<br />
GO<br />
1. Determined vehicle load capacity. —— ——<br />
2. Prepared the vehicle to receive patients. —— ——<br />
3. Directed nonmedical soldiers to-- —— ——<br />
a. Load the casualties in the proper sequence.<br />
b. Load casualties side-by side across the back of the truck.<br />
c. Load casualties lengthwise on the floor.<br />
d. Secure the casualties for transport.<br />
4. Did not cause further injury to the casualties. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
Related<br />
None FM 8-10-6<br />
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Subject Area 15: Medication Administration<br />
PREPARE AN INJECTION FOR ADMINISTRATION<br />
081-833-0088<br />
Conditions: You have performed a patient care handwash. Necessary materials and<br />
equipment: needles and syringes, medication, alcohol sponges, dry sterile gauze, and<br />
physician's orders.<br />
Standards: Selected, inspected, and assembled the appropriate needle and syringe. Drew the<br />
correct medication. Followed aseptic technique throughout the procedure.<br />
Performance Steps<br />
1. Select an appropriate needle.<br />
a. Select a needle with the proper length based upon the following factors:<br />
(1) The type of injection to be given (subcutaneous, intramuscular, or intradermal).<br />
(2) The size of the patient (thin, obese).<br />
(3) The injection site (1 inch for deltoid, 1 1/2 inches for gluteus maximus).<br />
b. Select a needle with the proper gauge based upon the thickness of the medication to<br />
be injected.<br />
NOTE: The gauge of the needle is indicated by the numbers 14 through 27. The higher the<br />
number, the smaller the diameter (bore) of the needle. A small bore needle is indicated for thin<br />
medications. A large bore needle is indicated for thick medications.<br />
2. Select an appropriate syringe.<br />
a. Check the drug manufacturer's specifications to determine whether a glass or plastic<br />
syringe should be used for the medication.<br />
NOTE: Some medications deteriorate in a plastic syringe. Drug manufacturer's specifications<br />
provide guidance.<br />
b. Ensure that the total capacity of the syringe, usually measured in cubic centimeters<br />
(cc), is appropriate for the amount of medication to be administered.<br />
c. Check the intervals of the calibration marks on the syringe.<br />
3. Inspect the needle and syringe packaging for defects such as open packages, holes, and<br />
water spotting. Discard the equipment if any defect is found.<br />
4. Unpack the syringe.<br />
a. If the syringe is in a flexible wrapper, peel the sides of the wrapper apart to expose the<br />
rear end of the syringe barrel.<br />
b. Grasp the syringe by the barrel with the free hand.<br />
CAUTION: The needle adapter and the shaft of the plunger are sterile. Contamination could<br />
cause infection in the patient. The outside of the syringe barrel does not have to be kept sterile.<br />
c. Pull the syringe from the packaging.<br />
d. If the syringe is packaged in a hard plastic tube container, press down and twist the<br />
cap until a distinct "pop" is heard. If the "pop" is not heard, the seal has been<br />
previously broken and the equipment must be discarded.<br />
5. Inspect the syringe.<br />
a. Grasp the flared end of the syringe and pull the plunger back and forth to test for<br />
smooth, easy movement.<br />
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Performance Steps<br />
b. Visually check the rubber stopper (inside the syringe) to ensure that it is attached<br />
securely to the top end of the plunger, forming a seal.<br />
c. If the plunger is stuck or does not move smoothly, discard the syringe.<br />
d. Push the plunger fully into the barrel until ready to fill the syringe with medication.<br />
6. Unpack the needle.<br />
CAUTION: All parts of the needle are sterile. Be careful not to touch the hub. This would<br />
contaminate the needle and possibly pass an infection to the patient. Only the outside of the<br />
needle cover may be touched.<br />
a. If the needle is packaged in a flexible wrapper, peel the sides of the wrapper apart to<br />
expose the needle hub.<br />
b. If the needle is packaged in a hard plastic tube, twist the cap of the tube until a "pop" is<br />
heard. Remove the cap to expose the needle hub. If a "pop" is not heard, the seal<br />
has been previously broken, and the equipment must be discarded.<br />
7. Join the needle and the syringe.<br />
a. Insert the needle adapter of the syringe into the hub of the needle.<br />
b. Tighten the needle by turning 1/4 of a turn to ensure that it is securely attached.<br />
8. Inspect the needle.<br />
a. Hold the needle and syringe upright and remove the protective cover from the needle<br />
by pulling it straight off.<br />
NOTE: A twisting motion may pull the needle off the hub.<br />
b. Visually inspect the needle for burrs, barbs, damage, and contamination. If the needle<br />
has any defects or damage, replace it with another sterile needle.<br />
c. Place the protective cover back on the needle.<br />
9. Place the assembled needle and syringe on the work surface.<br />
a. Leave the protective cover on the needle.<br />
b. Leave the plunger pushed fully into the barrel.<br />
c. Keep the assembled needle and syringe continually within range of vision.<br />
NOTE: When you assemble a needle and syringe, you are responsible for maintaining sterility<br />
and security of the equipment.<br />
10. Verify the drug label and check the container for defects.<br />
a. Compare the medication with the doctor's orders. The medication label must be<br />
verified three times.<br />
(1) When obtained from the place of storage.<br />
(2) When withdrawing the medication.<br />
(3) When returning the container to storage.<br />
b. Examine the container.<br />
(1) Examine the rubber stopper for defects, such as small cores or plugs torn from the<br />
stopper.<br />
(2) Hold the vial to the light to check for foreign particles and changes in color and<br />
consistency. If the solution is in a dark vial, withdraw some solution to perform the<br />
checks.<br />
(3) Check the date a multidose vial was opened and check the expiration date of the<br />
medication.<br />
(4) Determine whether the medication was stored properly, such as under<br />
refrigeration.<br />
NOTE: If there is any evidence of contamination, discard the container and obtain another.<br />
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Performance Steps<br />
11. Prepare and draw the medication.<br />
a. Draw medication from a stoppered vial which contains a prepared solution.<br />
(1) Remove the protective cap.<br />
(2) Clean the stopper and neck of the vial with an alcohol sponge.<br />
(3) Pick up the assembled needle and syringe and remove the protective needle<br />
cover.<br />
(4) Slowly draw the plunger to the prescribed cc mark of medication.<br />
(5) Pick up the vial and insert the needle into the rubber stopper, exerting slight<br />
downward and forward pressure. Ensure that the needle tip passes completely<br />
through the cap.<br />
NOTE: To avoid contamination, the hub of the needle should not touch the rubber cap.<br />
(6) Push the plunger fully into the barrel to inject the air.<br />
(7) With the vial inverted (and keeping the needle tip in the solution), pull the plunger<br />
back to the desired cc mark, withdrawing the medication.<br />
(8) Withdraw the needle from the container.<br />
(9) Verify the correct dosage against the doctor's orders by raising the syringe to eye<br />
level and ensuring that the forward edge of the plunger is exactly on the<br />
prescribed cc mark.<br />
b. Draw medication from a stoppered vial which contains a powdered medication which<br />
must be prepared.<br />
(1) Remove the protective caps from the vial containing the powdered medication and<br />
the vial containing the sterile diluent.<br />
(2) Clean the stoppers of both vials with alcohol sponges.<br />
(3) Withdraw the required diluent, using the same procedure as for a stoppered vial.<br />
(See steps 11a(3) through 11a(8).)<br />
(4) Hold the vial with the powdered medication horizontally, insert the needle through<br />
the stopper, and inject the diluent.<br />
NOTE: If the vial with powdered medication contains air, the diluent may be difficult to inject.<br />
Air may have to be withdrawn to allow the diluent to be injected.<br />
(5) Withdraw the needle.<br />
(6) Gently invert the vial several times until all the powder is dissolved. Visually<br />
inspect the solution to ensure that it is well-mixed.<br />
(7) Change the needle (or needle and syringe) and insert it into the vial of<br />
reconstituted solution.<br />
(8) Withdraw the prescribed amount of medication. (See step 11a(7).)<br />
(9) Withdraw the needle from the container.<br />
(10) Verify the correct dosage. (See step 11a(9).)<br />
c. Draw medication from an ampule.<br />
(1) Lightly tap the upright ampule to force any trapped medication from the ampule<br />
neck and top.<br />
(2) Clean the neck of the ampule with an alcohol sponge and wrap it with the same<br />
sponge.<br />
(3) Grasp the ampule with both hands and snap the neck by bending it away from the<br />
breakline, directing it away from yourself and others.<br />
(4) Inspect the ampule for minute glass particles. If any are found, discard the<br />
ampule.<br />
(5) Remove the protective cover from the assembled needle and syringe.<br />
(6) Insert the needle and withdraw the medication by holding the ampule vertically or<br />
by placing the ampule upright on a flat surface.<br />
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Performance Steps<br />
(7) Withdraw the prescribed medication, being careful not to touch the outside edge<br />
or bottom of the ampule with the needle.<br />
(8) Withdraw the needle and verify the correct dosage. (See step 11a(9).)<br />
12. Check the syringe for air bubbles.<br />
a. Hold the syringe with the needle pointing up.<br />
b. Pull back on the plunger slightly to clear all the medication from the needle shaft.<br />
c. Tap the barrel lightly to force bubbles to the top of the barrel.<br />
d. Pull the plunger back slightly and push it forward until the solution is in the needle hub,<br />
clearing it of bubbles.<br />
13. Reverify the correct dosage. (See step 11a(9).)<br />
14. Cover the needle with the protective needle cover.<br />
Evaluation Preparation:<br />
Setup: If the performance of this task must be simulated for training and evaluation, colored<br />
solutions may be used to simulate medications. Have several sizes of needles and syringes<br />
available. Tell the soldier what type of medication is being simulated and what the route of<br />
administration would be. Have him or her select the appropriate needle and syringe. To test<br />
step 2, tell the soldier of any manufacturer's specifications. Testing may be varied by using<br />
various medications to be administered by different routes. Needles and syringes may be<br />
reused.<br />
Brief soldier: Tell the soldier to assemble the proper needle and syringe and draw the<br />
medication.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected the appropriate needle. —— ——<br />
2. Selected the appropriate syringe. —— ——<br />
3. Inspected the packaging for defects. —— ——<br />
4. Unpacked the syringe. —— ——<br />
5. Inspected the syringe. —— ——<br />
6. Unpacked the needle. —— ——<br />
7. Joined the needle and syringe. —— ——<br />
8. Inspected the needle. —— ——<br />
9. Placed the assembled needle and syringe on the work surface. —— ——<br />
10. Verified the drug label and checked the container for defects. —— ——<br />
11. Prepared and drew the medication. —— ——<br />
12. Checked the syringe for air bubbles. —— ——<br />
13. Reverified the correct dosage. —— ——<br />
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Performance Measures GO NO<br />
GO<br />
14. Covered the needle with the protective needle cover. —— ——<br />
15. Did not violate aseptic technique. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-298
STP 8-91W15-SM-TG<br />
ADMINISTER AN INJECTION (INTRAMUSCULAR, SUBCUTANEOUS, INTRADERMAL)<br />
081-833-0089<br />
Conditions: You have performed a patient care handwash and have verified the physician's<br />
orders. Necessary materials and equipment: syringe(s) with the prepared medication(s),<br />
antiseptic pads, alcohol sponge swabs, sterile gauze, adhesive tape, and the patient's record.<br />
Standards: Administered the injection IAW the physician's orders without violating aseptic<br />
technique or causing injury to the patient.<br />
Performance Steps<br />
1. Verify the required injection(s) with the physician's orders.<br />
2. Identify the patient by asking the patient's name and checking the identification tag or band.<br />
Ask the patient if he or she has any allergies or has experienced a drug reaction.<br />
WARNINGS: 1. If there is a known allergy, do not administer the injection. Consult your<br />
supervisor. 2. Determine if a female patient is pregnant because of possible side effects of<br />
certain immunizing agents on the unborn child. If there is a question, do not administer the<br />
injection without written authorization.<br />
3. Verify that the appropriate needle, syringe, and medication are being used. (See task 081-<br />
833-0088.)<br />
NOTE: Strict aseptic technique must be employed whenever foreign bodies (the needle and<br />
medications) are introduced into body tissues.<br />
WARNING: Have an emergency tray available for the immediate treatment of serious<br />
reactions. Include a constricting band and a syringe containing a 1:1000 solution of<br />
epinephrine. Have a tracheotomy set available since the majority of fatalities reported involve<br />
asphyxiation due to laryngeal edema.<br />
4. Select and expose the injection site.<br />
a. Intramuscular injection.<br />
(1) The upper arm deltoid muscle--the outer 1/3 of the arm between the lower edge of<br />
the shoulder bone and the armpit. Approximately three fingerwidths below the<br />
shoulder bone is the safe area.<br />
(2) Buttocks--the upper-outer quadrant of either buttock.<br />
NOTE: To identify the injection site, draw an imaginary horizontal line across the buttocks from<br />
hip bone to hip bone. Then divide each buttock in half with an imaginary vertical line. (See<br />
Figure 3-59.)<br />
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Performance Steps<br />
Figure 3-59<br />
WARNING: Do not give the injection in an area outside the upper-outer quadrant. The needle<br />
may do irreparable damage to the sciatic nerve or pierce the gluteal artery and cause significant<br />
bleeding.<br />
(3) Outer thigh--the area between a hand's width above the knee and a hand's width<br />
below the groin.<br />
b. Subcutaneous injection.<br />
(1) Upper arm.<br />
(2) Anterior thigh.<br />
(3) Abdomen.<br />
c. Intradermal injection.<br />
(1) Inner forearm.<br />
(2) Back of the upper arm.<br />
(3) On the back below the shoulder blades.<br />
5. Position the patient.<br />
a. Intramuscular.<br />
(1) Upper arm--standing or sitting with the area completely exposed, muscles relaxed,<br />
and the arm at the side.<br />
(2) Buttocks--lying face down or leaning forward and supported by a stable object<br />
with the weight shifted to the leg that will not be injected. The area is completely<br />
exposed.<br />
NOTE: If the patient is lying in a prone position (face down), place the toes together with the<br />
heels apart. This will relax the muscles of the buttocks.<br />
(3) Outer thigh- -lying face up or seated with the area completely exposed.<br />
b. Subcutaneous.<br />
(1) Upper arm--see step 5a(1).<br />
(2) Outer thigh--lying face up or seated, with the area completely exposed.<br />
c. Intradermal.<br />
(1) Inner forearm--standing, sitting, or lying. Palm up, with the arm supported and<br />
relaxed.<br />
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Performance Steps<br />
(2) Upper arm--see step 5a(1).<br />
(3) Back--seated, leaning forward and supported on a stable object, or lying face<br />
down.<br />
6. Clean the injection site.<br />
a. Intramuscular and subcutaneous.<br />
(1) Open the antiseptic pad package.<br />
(2) Begin at the injection site and with a spiral motion, clean outward 3 inches.<br />
b. Intradermal.<br />
(1) Use ethyl alcohol or acetone germicide and a sterile sponge.<br />
(2) Begin at the injection site and with a spiral motion, clean outward 3 inches.<br />
NOTE: The antiseptic pad may be held between the last two fingers for use when the needle is<br />
removed.<br />
7. Pull the needle cover straight off without bending or touching the needle.<br />
8. Prepare the skin for the injection.<br />
a. Intramuscular and subcutaneous. Form a fold of skin at the injection site by pinching<br />
the skin gently between the thumb and the index finger of the nondominant hand. Do<br />
not touch the injection site.<br />
b. Intradermal. Using the thumb of the nondominant hand, apply downward pressure<br />
directly below and outside the prepared injection site. Hold the skin taut until the<br />
needle has been inserted.<br />
CAUTION: Do not retract or move the skin laterally.<br />
9. Insert the needle.<br />
a. Intramuscular. With the dominant hand, position the needle, bevel up, at a 90 degree<br />
angle to, and about 1/2 inch from, the skin surface. Plunge the needle firmly and<br />
quickly straight into the muscle.<br />
b. Subcutaneous. With the dominant hand, position the needle, bevel up, at a 45 degree<br />
angle to the skin surface. Plunge the needle firmly and quickly into the fatty tissue<br />
below the skin.<br />
c. Intradermal. With the dominant hand, position the needle, bevel up, at a 15 to 20<br />
degree angle to the skin surface. Insert it just under the skin until the bevel is covered.<br />
Do not move the skin.<br />
10. Release the hold on the skin.<br />
11. Administer the medication.<br />
a. Intramuscular and subcutaneous.<br />
(1) Aspirate by pulling back slightly on the plunger of the syringe.<br />
(a) If blood appears, stop the procedure. Go to step 3 and begin the procedure<br />
again. Use a new needle, syringe, and medication, and select a different<br />
injection site.<br />
(b) If no blood appears, continue the procedure.<br />
WARNING: Failure to aspirate could cause the medication to be injected into the blood stream.<br />
(2) Using a slow continuous movement, completely depress the plunger, injecting the<br />
medication.<br />
NOTE: Rapid pressure may cause a burning pain.<br />
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Performance Steps<br />
(3) Place an antiseptic pad (or sterile 2 x 2) lightly over the injection site and withdraw<br />
the needle at the same angle at which it was inserted. Gently massage the<br />
injection site with the pad, unless this is contraindicated for the medication that<br />
has been injected.<br />
(4) Put an adhesive bandage strip over the injection site if bleeding occurs.<br />
b. Intradermal.<br />
NOTE: Do not aspirate.<br />
(1) Push the plunger slowly forward until all medication has been injected and a<br />
wheal appears at the site of the injection.<br />
(a) If no wheal appears, go to step 3 and begin the procedure again. Use a new<br />
needle, syringe, and medication and select a different injection site.<br />
(b) If a wheal appears, continue the procedure.<br />
(2) Quickly withdraw the needle at the same angle at which it was inserted.<br />
(3) Without applying pressure, cover the injection site with dry sterile gauze.<br />
(4) Instruct the patient not to scratch, rub, or wash the injection site.<br />
(5) If appropriate, instruct the patient when and where to have the test read IAW local<br />
SOP.<br />
12. Check the site for bleeding.<br />
13. Observe the patient for anaphylactic shock symptoms IAW local SOP. (See task 081-833-<br />
0031.)<br />
14. Dispose of the needle and syringe IAW local SOP.<br />
15. Record the procedure on the appropriate form.<br />
Evaluation Preparation:<br />
Setup: If the performance of this task must be simulated for training and evaluation, have<br />
another soldier act as the patient. If so, ensure that the prepared syringes contain no more than<br />
0.2 cc of a safe, sterile, injectable solution. Tell the soldier which type of injection to give.<br />
Ensure that medical coverage is available in case of reaction.<br />
Brief soldier: Tell the soldier to administer the injection.<br />
WARNING: If the soldier violates aseptic technique or starts to do something which could injure<br />
the patient, stop the evaluation immediately.<br />
Performance Measures GO NO<br />
GO<br />
1. Verified the required injection(s) with the physician's orders. —— ——<br />
2. Identified the patient and asked the patient about allergies or drug<br />
reactions.<br />
—— ——<br />
3. Verified the appropriate needle, syringe, and medication. —— ——<br />
4. Selected and exposed the injection site. —— ——<br />
5. Positioned the patient. —— ——<br />
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Performance Measures GO NO<br />
GO<br />
6. Cleaned the injection site. —— ——<br />
7. Removed the needle cover. —— ——<br />
8. Prepared the skin for injection. —— ——<br />
9. Inserted the needle. —— ——<br />
10. Released the skin. —— ——<br />
11. Administered the medication. —— ——<br />
12. Checked the site for bleeding. —— ——<br />
13. Observed the patient for adverse reactions. —— ——<br />
14. Disposed of the needle and syringe. —— ——<br />
15. Recorded the procedure on the appropriate form. —— ——<br />
16. Did not violate aseptic technique. —— ——<br />
17. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
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STP 8-91W15-SM-TG<br />
ADMINISTER MORPHINE<br />
081-833-0174<br />
Conditions: You are supporting a combat or peacekeeping operation. You are caring for a<br />
conscious casualty who has sustained an injury and is suffering from severe pain. You have<br />
gained authorization from a licensed provider to administer morphine to the casualty<br />
(authorization may have already been delegated to you in certain combat operations) .<br />
Necessary materials and equipment: morphine cartridge, injector device (or autoinjector),<br />
alcohol wipes, a semi-permanent marking device.<br />
Standards: Correctly prepared and administered morphine without causing further injury to the<br />
casualty.<br />
Performance Steps<br />
1. Verify five rights of medication administration.<br />
a. Right patient - verify that the casualty does not have any contraindications that<br />
preclude use of morphine.<br />
b. Right medication - check to ensure the medication you are about to administer is<br />
correct.<br />
c. Right dosage.<br />
(1) Administer an initial dose of 5 to 10 mg intramuscularly.<br />
(2) Repeat the dose after a suitable interval of time has elapsed if the patient is still<br />
complaining of pain (intramuscular absorption rate for this drug is 10 to 30<br />
minutes, pain control peaks within 30 to 60 minutes).<br />
CAUTION: Dosage must not exceed 20 mg within a 4 hour period of time.<br />
d. Right time - check casualty's forehead and Field Medical Card to ensure that casualty<br />
has not received more than 20 mg of morphine within the last 4 hours.<br />
e. Right route - inject intramuscularly (subcutaneous injection is acceptable but this<br />
method takes longer for the effects of the medication to peak..<br />
2. Load the pre-filled cartridge into the injector device.<br />
a. Insert the cartridge into the body and guard assembly.<br />
b. Align the finger grip assembly notches and snap into place.<br />
3. Lock the cartridge into the injector device by turning the plunger rod until the plunger is<br />
securely in place).<br />
4. Place the casualty in a supine position.<br />
NOTE: Once morphine has been administered, the casualty is considered nonambulatory.<br />
5. Select the site for an intramuscular injection.<br />
a. Deltoid muscle.<br />
b. Buttocks.<br />
c. Outer thigh.<br />
6. Administer the injection (see task 081-833-0089).<br />
7. If using an autoinjector, complete the following steps.<br />
a. Remove the safety cap.<br />
b. Place purple end on outer thigh and press firmly to deliver the dosage.<br />
8. Monitor for adverse reaction.<br />
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Performance Steps<br />
NOTE: The most common adverse reaction is severe respiratory depression. The casualty<br />
may require assisted ventilations.<br />
9. Write the letter "M" and time of injection on the casualty's forehead.<br />
10. Document on DD Form 1380 (see task 081-831-0033).<br />
Performance Measures GO NO<br />
GO<br />
1. Verified five rights of medication administration. —— ——<br />
2. Loaded the pre-filled cartridge into the injector device (eliminate this step if<br />
using autoinjector).<br />
3. Locked the cartridge into the injector device turning the plunger rod until<br />
the plunger was securely in place (eliminate this step if using autoinjector).<br />
—— ——<br />
—— ——<br />
4. Positioned the casualty. —— ——<br />
5. Selected the site for an intramuscular injection. —— ——<br />
6. Administered the injection. —— ——<br />
7. Monitored for adverse reaction. —— ——<br />
8. Wrote the letter "M" and time of injection on the casualty's forehead. —— ——<br />
9. Documented the administration of morphine on DD Form 1380. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-305
STP 8-91W15-SM-TG<br />
ADMINISTER ORAL MEDICATIONS<br />
081-835-3001<br />
Conditions: A patient care handwash has been performed. Necessary materials and<br />
equipment: calibrated medicine cups, disposable medicine cups, tray, medications, DA Form<br />
3949, and the patient's clinical record.<br />
Standards: Prepared and administered medications IAW the physician's orders. Observed the<br />
"five rights" (the right drug, the right dose, the right patient, the right route, and the right time).<br />
Performance Steps<br />
1. Check the medication sheet (DA Form 4678) against the physician's orders.<br />
(Abbreviations commonly used in prescribing medications can be found in Appendix B.)<br />
a. Name of the medication.<br />
b. Amount (dose) of medication.<br />
c. Route of administration.<br />
d. Right patient.<br />
e. Time to be administered.<br />
2. Select the medication.<br />
a. Check the medication label three times to ensure that the correct medication is being<br />
prepared for administration.<br />
(1) First time--when removing the container from the storage shelf.<br />
(2) Second time--when preparing the medication dose.<br />
(3) Third time--when returning the container to the storage shelf.<br />
b. Check the expiration date of the medication.<br />
c. Handle only one medication at a time.<br />
NOTE: If unfamiliar with a medication, look it up to determine contraindications, precautions,<br />
and side effects before preparing it for administration.<br />
3. Calculate the amount of medication required to equal the prescribed dose.<br />
(See Appendix B.)<br />
4. Prepare the prescribed dose of medication.<br />
a. Tablets or capsules. Transfer the prescribed dose of tablets or capsules to the<br />
medicine cup.<br />
b. Liquids.<br />
(1) Pour the prescribed dose of liquid medication into the medicine cup.<br />
NOTE: When liquid is poured into a cylinder, it forms a meniscus. In determining the volume of<br />
liquid, a reading must be made at the bottom of the meniscus, with the level of the liquid at eye<br />
level.<br />
(2) Small amounts of liquid medication should be drawn up in a syringe.<br />
c. Powders.<br />
(1) Pour the correct dose of powdered or granulated medication into the medicine<br />
cup.<br />
(2) Pour the required amount of water or juice into a paper cup.<br />
NOTE: Reconstitute the medication at the patient's bedside.<br />
5. Place all the prepared medications on a tray or the medication cart.<br />
NOTE: When preparing medication for more than one patient, mark each container with the<br />
patient's identification.<br />
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Performance Steps<br />
6. Sign for controlled drugs on DA Form 3949, IAW local SOP.<br />
7. Correctly identify the patient.<br />
8. Locate the correct medication.<br />
9. Give the medication to the patient at the prescribed time.<br />
a. Tablets, capsules, or liquids. Observe the patient swallow the tablets, capsules, or<br />
liquids.<br />
b. Sublingual medications. Instruct the patient to allow sublingual medications to dissolve<br />
in the mouth.<br />
c. Powdered medication. Reconstitute powdered or granulated medications in the<br />
prepared juice or water and observe the patient drink the preparation.<br />
CAUTION: Do not leave any medications at the patient's bedside without a specific physician's<br />
order to do so.<br />
NOTE: If a patient refuses a medication, offer it again in 5 minutes. If refused a second time,<br />
record the omission on DA Form 4678 and document the reason for the omission in the nursing<br />
notes.<br />
10. Record the administration of all medications on the appropriate medical forms.<br />
NOTE: Administration of all scheduled and nonscheduled (PRN) medication must be<br />
documented.<br />
a. Initial the medication sheet (DA Form 4678).<br />
b. Annotate the nursing notes when administering controlled drugs, nonscheduled (PRN)<br />
medications, and other medications as required by local policy.<br />
(1) Name of the medication.<br />
(2) Time the medication was administered.<br />
(3) Reason for the medication.<br />
11. Record the omission of a medication on the appropriate medical forms whenever a<br />
scheduled medication is not administered.<br />
a. Annotate the medication sheet (DA Form 4678) by placing a circle in the initial block.<br />
b. Annotate the nursing notes.<br />
(1) Name of the medication.<br />
(2) Time it should have been administered.<br />
(3) Reason it was not administered.<br />
(4) Follow-up action taken.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the medication sheet (DA Form 4678) against the physician's<br />
orders.<br />
—— ——<br />
2. Selected the medication. —— ——<br />
3. Calculated the amount of medication required to equal the prescribed<br />
dose.<br />
—— ——<br />
4. Prepared the prescribed dose of medication. —— ——<br />
5. Placed all the prepared medications on a tray or the medication cart. —— ——<br />
3-307
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
6. Signed for controlled drugs on DA Form 3949, IAW local SOP. —— ——<br />
7. Correctly identified the patient. —— ——<br />
8. Located the correct medication. —— ——<br />
9. Gave the medication to the patient at the prescribed time. —— ——<br />
10. Recorded the administration of all medications on the appropriate medical<br />
forms.<br />
11. Recorded the omission of a medication on the appropriate medical forms<br />
whenever a scheduled medication is not administered.<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-308
STP 8-91W15-SM-TG<br />
ADMINISTER TOPICAL MEDICATIONS<br />
081-835-3020<br />
Conditions: A patient care handwash has been performed. Necessary materials and<br />
equipment: calibrated medicine cups, disposable medicine cups, tray, medications, medicated<br />
pads or patches, application papers, tape, DA Form 3949, and the patient's clinical record.<br />
Standards: Prepared and administered medications IAW the physician's orders. Observed the<br />
"five rights" (the right drug, the right dose, the right patient, the right route, and the right time).<br />
Performance Steps<br />
1. Check the medication sheet (DA Form 4678) against the physician's orders.<br />
(Abbreviations commonly used in prescribing medications can be found in Appendix B.)<br />
a. Name of the medication.<br />
b. Amount (dose) of medication.<br />
c. Route of administration.<br />
d. Time to be administered.<br />
2. Select the medication.<br />
a. Check the medication label three times to ensure that the correct medication is being<br />
prepared for administration.<br />
b. Check the expiration date of the medication.<br />
c. Handle only one medication at a time.<br />
NOTE: If unfamiliar with a medication, look it up to determine contraindications, precautions,<br />
and side effects.<br />
3. Prepare the prescribed dose of topical medication.<br />
NOTE: Perform pharmaceutical calculations as necessary to determine the amount of<br />
medication required to equal the prescribed dose. (See Appendix B.)<br />
a. Obtain single dose packets of topical medication.<br />
b. Obtain the required number of medicated patches or pads.<br />
c. Apply the prescribed size ribbon of ointment to an application paper.<br />
d. Obtain the jar or tube of medication identified for that individual patient's use.<br />
e. Aseptically transfer the required amount of topical medication from the bulk storage<br />
container to a sterile, disposable container.<br />
4. Place all the prepared medications on a tray or the medication cart.<br />
NOTE: When preparing medication for more than one patient, mark the prepared medications<br />
with the patient's identification.<br />
5. Sign for controlled drugs on DA Form 3949, as appropriate.<br />
6. Correctly identify the patient and explain procedure.<br />
7. Prepare the skin.<br />
a. Provide privacy or screen the patient, as necessary.<br />
b. Expose the prescribed area of the patient's skin.<br />
c. Clean the skin IAW the physician's orders, if required.<br />
8. Apply the medication to the patient.<br />
a. Locate the correct medication.<br />
b. Apply the medication to the prescribed area IAW the physician's orders or local SOP.<br />
3-309
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: Wear gloves when appropriate.<br />
(1) Secure patches, pads, and application papers with tape.<br />
(2) Cover topical applications with sterile dressings IAW the physician's orders, if<br />
required.<br />
CAUTION: Do not leave any medication at the patient's bedside without a specific physician's<br />
order to do so.<br />
NOTE: If a patient refuses the application of a medication, offer it again in five minutes. If<br />
refused a second time, record the omission on DA Form 4678 and document the reason for the<br />
omission in the nursing notes.<br />
9. Record the administration of all medications on the appropriate medical forms.<br />
NOTE: Administration of all scheduled and nonscheduled (PRN) medication must be<br />
documented.<br />
a. Initial the medication sheet (DA Form 4678).<br />
b. Make a nursing note entry describing the location of the application and the condition<br />
of the skin at the time of application.<br />
c. Annotate the nursing notes when administering controlled drugs, nonscheduled (PRN)<br />
medications, and other medications as required by local policy.<br />
(1) Name of the medication.<br />
(2) Time the medication was administered.<br />
(3) Reason for the medication.<br />
10. Record the omission of a medication on the appropriate medical forms whenever a<br />
scheduled medication is not administered.<br />
a. Annotate the medication sheet (DA Form 4678) by placing a circle in the initial block.<br />
b. Annotate the nursing notes.<br />
(1) Name of the medication.<br />
(2) Time it should have been administered.<br />
(3) Reason it was not administered.<br />
(4) Follow-up action taken.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the medication sheet (DA Form 4678) against the physician's<br />
orders.<br />
—— ——<br />
2. Selected the medication. —— ——<br />
3. Prepared the prescribed dose of topical medication. —— ——<br />
4. Placed all the prepared medications on a tray or the medication cart. —— ——<br />
5. Signed for controlled drugs on DA Form 3949, as appropriate. —— ——<br />
6. Correctly identified the patient. —— ——<br />
7. Prepared the skin. —— ——<br />
8. Applied the medication to the patient. —— ——<br />
9. Recorded the administration of all medications on the appropriate medical<br />
forms.<br />
—— ——<br />
3-310
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
10. Recorded the omission of a medication on the appropriate medical forms<br />
whenever a scheduled medication was not administered.<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-311
STP 8-91W15-SM-TG<br />
ADMINISTER RECTAL OR VAGINAL MEDICATIONS<br />
081-835-3021<br />
Conditions: A patient care handwash has been performed. Necessary materials and<br />
equipment: disposable medicine cups, tray, medications, applicators, nonsterile gloves, watersoluble<br />
jelly, DA Form 3949, and the patient's clinical record.<br />
Standards: Prepared and administered medications IAW the physician's orders. Observed the<br />
"five rights" (the right drug, the right dose, the right patient, the right route, and the right time).<br />
Performance Steps<br />
1. Check the medication sheet (DA Form 4678) against the physician's orders.<br />
(Abbreviations commonly used in prescribing medications can be found in Appendix B.)<br />
a. Name of the medication.<br />
b. Amount (dose) of medication.<br />
c. Route of administration.<br />
d. Time to be administered.<br />
2. Select the medication.<br />
a. Check the medication label three times to ensure that the correct medication is being<br />
prepared for administration.<br />
b. Check the expiration date of the medication.<br />
c. Handle only one medication at a time.<br />
NOTE: If unfamiliar with a medication, look it up to determine contraindications, precautions,<br />
and side effects.<br />
3. Prepare the prescribed dose of medication.<br />
NOTE: Perform pharmaceutical calculations as necessary to determine the amount of<br />
medication required to equal the prescribed dose. (See Appendix B.)<br />
a. Place the suppository medication in the medication cup.<br />
b. Draw the correct dose of cream or foam medication into the applicator device.<br />
c. Prepare the prescribed amount of medicated solution for a vaginal irrigation (douche)<br />
or an enema.<br />
d. Obtain the prescribed single use, disposable douche or enema.<br />
NOTE: Leave medication wrapped or covered until ready to administer.<br />
4. Place all the prepared medications on a tray or the medication cart.<br />
NOTE: When preparing medication for more than one patient, mark each cup or applicator with<br />
the patient's identification.<br />
5. Sign for controlled drugs on DA Form 3949, as appropriate.<br />
6. Correctly identify the patient.<br />
7. Provide for privacy.<br />
8. Position the patient, as appropriate.<br />
a. Supine, with the legs spread and bent at the knees, for vaginal administration.<br />
b. Lateral, with the upper leg bent at the knee to facilitate spread of the buttocks, for<br />
rectal administration.<br />
9. Put on exam gloves.<br />
3-312
STP 8-91W15-SM-TG<br />
Performance Steps<br />
10. Insert the medication.<br />
a. Suppositories.<br />
(1) Lubricate the suppository with water-soluble jelly.<br />
(2) Insert the suppository into the appropriate orifice and advance it with the index<br />
finger.<br />
NOTE: Rectal suppositories must be advanced past the sphincter muscles (about 2 inches).<br />
b. Cream or foam applications.<br />
(1) Lubricate the tip of the applicator device with water-soluble jelly.<br />
(2) Insert the applicator into the appropriate orifice.<br />
(3) Push the applicator plunger to instill the medication.<br />
(4) Withdraw the applicator.<br />
c. Vaginal irrigation (douche).<br />
NOTE: Place a catch basin or bedpan under the patient to collect return solution.<br />
(1) Lubricate the douche tip with water-soluble jelly.<br />
(2) Gently insert the douche tip into the vagina.<br />
(3) Release the clamp on the tubing and allow solution to flow slowly. (If using a<br />
disposable douche, gently squeeze the container to dispense the solution.)<br />
(4) Rotate the douche tip to direct fluid over all parts of the vagina.<br />
(5) Administer all the solution and gently withdraw the douche tip.<br />
(6) Remove the bedpan or catch basin and place a sanitary pad over the vulva.<br />
d. Enema.<br />
NOTE: Provide a bedpan if the patient is unable to ambulate to the latrine to expel the solution.<br />
(1) Lubricate the rectal tip with water-soluble jelly.<br />
(2) Insert the rectal tip into the rectum about 3 to 4 inches.<br />
(3) Release the clamp on the tubing and allow the solution to flow slowly. (If using a<br />
disposable enema, squeeze the container to dispense the solution.)<br />
(4) Slow the flow of solution if the patient complains of cramping.<br />
(5) Administer all the solution and withdraw the enema tip.<br />
(6) Tell the patient how long the solution must be retained.<br />
CAUTION: Do not leave any medication at the patient's bedside without a specific physician's<br />
order.<br />
NOTE: If a patient refuses the instillation of a medication, offer it again in five minutes. If<br />
refused a second time, record the omission on DA Form 4678 and document the reason for the<br />
omission in the nursing notes.<br />
11. Record the administration of all medications on the appropriate medical forms.<br />
NOTE: Document the administration of all scheduled and nonscheduled (PRN) medication.<br />
a. Initial the medication sheet (DA Form 4678).<br />
b. Annotate the nursing notes when administering controlled drugs, nonscheduled (PRN)<br />
medications, and other medications as required by local policy.<br />
(1) Name of the medication.<br />
(2) Time the medication was administered.<br />
(3) Reason for the medication.<br />
12. Record the omission of a medication on the appropriate medical forms whenever a<br />
scheduled medication is not administered.<br />
a. Annotate the medication sheet (DA Form 4678) by placing a circle in the initial block.<br />
b. Annotate the nursing notes.<br />
(1) Name of the medication.<br />
(2) Time it should have been administered.<br />
3-313
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(3) Reason it was not administered.<br />
(4) Follow-up action taken.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the medication sheet (DA Form 4678) against the physician's<br />
orders.<br />
—— ——<br />
2. Selected the medication. —— ——<br />
3. Prepared the prescribed dose of medication. —— ——<br />
4. Placed all the prepared medications on a tray or the medication cart. —— ——<br />
5. Signed for controlled drugs on DA Form 3949, as appropriate. —— ——<br />
6. Correctly identified the patient. —— ——<br />
7. Provided for privacy. —— ——<br />
8. Positioned the patient, as appropriate. —— ——<br />
9. Put on exam gloves. —— ——<br />
10. Inserted the medication. —— ——<br />
11. Recorded the administration of all medications on the appropriate medical<br />
forms.<br />
12. Recorded the omission of a medication on the appropriate medical forms<br />
whenever a scheduled medication is not administered.<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-314
STP 8-91W15-SM-TG<br />
ADMINISTER MEDICATED EYE DROPS OR OINTMENTS<br />
081-835-3022<br />
Conditions: A patient care handwash has been performed. Necessary materials and<br />
equipment: tissues, sterile gauze, sterile normal saline, dressing materials, the prescribed<br />
medications, and the patient's clinical record.<br />
Standards: Administered eye drops and ointments without contamination and without causing<br />
further injury to the patient. Observed the "five rights" of medication administration (the right<br />
drug, the right dose, the right patient, the right route, and the right time).<br />
Performance Steps<br />
1. Check the medication sheet (DA Form 4678) against the physician's orders.<br />
(Abbreviations commonly used in prescribing medications can be found in Appendix B.)<br />
a. Name of the medication.<br />
b. Amount (dose) of medication.<br />
c. Route of administration.<br />
d. Time to be administered.<br />
2. Select the medication.<br />
a. Check the medication label three times to ensure that the correct medication is being<br />
prepared for administration.<br />
b. Check the expiration date of the medication.<br />
NOTE: If unfamiliar with a medication, look it up to determine contraindications, precautions,<br />
and side effects.<br />
3. Take the medication and other supplies to the patient's bedside.<br />
4. Identify the patient and explain the procedure.<br />
5. Position the patient.<br />
a. Supine in bed.<br />
b. Sitting, with the head supported.<br />
NOTE: The head must be supported for stability if the patient is seated. Support may be<br />
provided by a head rest or a high-back chair.<br />
6. Remove eye dressings, if present.<br />
a. Gently pull the dressing away from the forehead, and then pull it down and away from<br />
the eye area.<br />
b. Discard the contaminated dressing.<br />
c. Perform a patient care handwash.<br />
7. Remove accumulation of secretions, if present.<br />
a. Apply sterile gauze moistened with sterile normal saline to the closed eyes to soften<br />
the secretions.<br />
b. Remove loosened secretions by blotting with additional moistened gauze.<br />
8. Prepare the medication.<br />
a. Ointment tube.<br />
(1) Remove the cap from the tube and place the cap on a piece of sterile gauze to<br />
prevent contamination.<br />
3-315
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(2) Squeeze a small amount of ointment onto a piece of sterile gauze to remove any<br />
crust that may have formed.<br />
(3) Discard this gauze.<br />
b. Eye dropper.<br />
(1) Draw the prescribed amount of the medication into the dropper.<br />
(2) Do not invert the dropper after withdrawing the solution.<br />
c. Squeeze vial.<br />
(1) Remove the cap and place it on a piece of sterile gauze.<br />
(2) Invert the vial.<br />
9. Administer the medication.<br />
a. Instruct the patient to tilt the head back and look upward with the eyes open.<br />
b. Steady the hand holding the medication container against the patient's forehead.<br />
c. Place a finger on the skin below the lower eyelid and apply gentle, downward pressure<br />
to create a small conjunctival pocket.<br />
d. Instill the correct number of drops or amount of ointment into the conjunctival pocket.<br />
e. Apply ointment in a thin ribbon from the inner aspect to the outer aspect of the<br />
conjunctival pocket.<br />
f. Do not instill medication directly onto the eyeball.<br />
10. Instruct the patient to close the eyes gently and "roll" them to distribute the medication.<br />
NOTE: Instruct the patient not to squeeze the eyes tightly shut.<br />
11. Remove any excess solution or ointment by blotting gently with a clean tissue or gauze<br />
square.<br />
12. Apply fresh dressings or patches, if required.<br />
NOTE: If a patient refuses a medication, offer it again in 5 minutes. If refused a second time,<br />
record the omission on DA Form 4678 and document the reason for the omission in the nursing<br />
notes.<br />
13. Remove all equipment from the bedside.<br />
CAUTION: Do not leave any medication at the patient's bedside without a specific physician's<br />
order.<br />
14. Record the administration of all medications on the appropriate medical forms.<br />
NOTE: Administration of all scheduled and nonscheduled (PRN) medication must be<br />
documented.<br />
a. Initial the medication sheet (DA Form 4678).<br />
b. Annotate the nursing notes when administering controlled drugs, nonscheduled (PRN)<br />
medications, and other medications as required by local policy.<br />
(1) Name of the medication.<br />
(2) Time the medication was administered.<br />
(3) Reason for the medication.<br />
15. Record the omission of a medication on the appropriate medical forms whenever a<br />
scheduled medication is not administered.<br />
a. Annotate the medication sheet (DA Form 4678) by placing a circle in the initial block.<br />
b. Annotate the nursing notes.<br />
(1) Name of the medication.<br />
(2) Time it should have been administered.<br />
(3) Reason it was not administered.<br />
3-316
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(4) Follow-up action taken.<br />
Performance Measures GO NO<br />
GO<br />
1. Checked the medication sheet (DA Form 4678) against the physician's<br />
orders.<br />
—— ——<br />
2. Selected the medication. —— ——<br />
3. Took the medication and other supplies to the patient's bedside. —— ——<br />
4. Identified the patient and explained the procedure. —— ——<br />
5. Positioned the patient. —— ——<br />
6. Removed eye dressings, if present. —— ——<br />
7. Removed accumulation of secretions, if present. —— ——<br />
8. Prepared the medications. —— ——<br />
9. Administered the medication. —— ——<br />
10. Instructed the patient to close the eyes gently and "roll" them to distribute<br />
the medication.<br />
11. Removed any excess solution or ointment by blotting gently with a clean<br />
tissue or gauze square.<br />
—— ——<br />
—— ——<br />
12. Applied fresh dressings or patches, if required. —— ——<br />
13. Removed all equipment from the bedside. —— ——<br />
14. Recorded the administration of all medications on the appropriate medical<br />
forms.<br />
15. Recorded the omission of a medication on the appropriate medical forms<br />
whenever a scheduled medication was not administered.<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-317
STP 8-91W15-SM-TG<br />
Subject Area 16: Force Protection/Risk Assessment<br />
DISINFECT WATER FOR DRINKING<br />
081-831-0037<br />
Conditions: You are a member of a field sanitation team. You have just filled a Lyster bag or<br />
Water Buffalo from a source that is not safe for drinking. Necessary materials and equipment:<br />
calcium hypochlorite, clean stirring implement, mess kit spoon, a canteen cup, and a field<br />
chlorination kit.<br />
Standards: Disinfected water to a chlorine residual of 5 parts per million (ppm) or as ordered by<br />
the command surgeon.<br />
Performance Steps<br />
1. Mix the stock disinfecting solution.<br />
a. Add the prescribed dosage of calcium hypochlorite to 1/2 canteen cup of water.<br />
(1) 3 ampules per 36 gallons of water.<br />
(2) 22 ampules or 3 plastic MRE spoonfuls (from a bulk container) in 400 gallons of<br />
water.<br />
b. Stir the stock solution.<br />
2. Add the stock solution to the water container.<br />
a. Pour the stock solution into the water container.<br />
b. Mix the solution vigorously with a clean implement.<br />
c. Cover the container.<br />
3. Flush the faucets.<br />
4. Test the chlorine residual after 10 minutes.<br />
a. Follow the manufacturer's instructions on the color comparator in the chlorination kit to<br />
test the chlorine residual.<br />
b. Retest the chlorine residual after 20 minutes.<br />
5. Retest the water two or three times daily.<br />
Evaluation Preparation:<br />
Setup: Test this task only when there is a need to disinfect water for drinking. Do not simulate<br />
this task for training or evaluation.<br />
Brief soldier: Tell the soldier to disinfect the water. After the soldier completes step 5, ask him<br />
or her how often the water should be retested.<br />
Performance Measures GO NO<br />
GO<br />
1. Mixed the stock disinfecting solution. —— ——<br />
2. Added the stock solution to the water container. —— ——<br />
3. Flushed the faucets. —— ——<br />
3-318
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
4. Tested the chlorine residual after 10 minutes. —— ——<br />
5. Retested the chlorine residual after 20 minutes. —— ——<br />
6. Retested the water two or three times daily. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References: None<br />
3-319
STP 8-91W15-SM-TG<br />
Skill Level 2<br />
Subject Area 17: Advanced Procedures (SL 2)<br />
PERFORM ENDOTRACHEAL SUCTIONING OF A PATIENT<br />
081-833-0170<br />
Conditions: You have done an assessment and determined your patient needs suctioning.<br />
You have already done a patient care handwash. Necessary materials and equipment: suction<br />
unit, suction catheter, sterile basin, sterile water, sterile gloves, or a disposable suction kit.<br />
Standards: Performed endotracheal suctioning without violating aseptic technique or causing<br />
injury to the patient<br />
Performance Steps<br />
1. Explain the procedure to the patient.<br />
2. Position the patient in the semi-Fowler's (semi-sitting) position.<br />
NOTE: In some cases, such as spinal injuries, the patient will have to remain in whatever<br />
position he or she is in at the time.<br />
3. Check the pressure on the suction apparatus.<br />
a. Turn the unit on, place a thumb over the end of the suction connecting tube, and<br />
observe the pressure gauge.<br />
b. Ensure that the pressure reading is within the limits specified by local SOP and the<br />
recommendations of the equipment manufacturer.<br />
c. Notify the supervisor if the pressure is not within the recommended limits.<br />
d. Turn the unit off after verifying the correct pressure.<br />
WARNING: If the suction pressure is too low, the secretions cannot be removed. If the<br />
pressure is too high, the mucous membranes may be forcefully pulled into the catheter opening.<br />
4. Prepare the sterile materials. (See task 081-833-0007.)<br />
a. Open the sterile solution basin package on the bedside stand or table to create a<br />
sterile field.<br />
b. Pour sterile saline solution into the basin.<br />
c. Open the suction catheter package to expose the suction port of the catheter.<br />
d. Open the sterile glove package.<br />
NOTE: Disposable suctioning kits contain the same items.<br />
5. Oxygenate the patient.<br />
a. Hyperventilate the patient for 1 to 2 minutes.<br />
b. Monitor the patient's pulse oximeter reading during the entire procedure. (See task<br />
081-833-0164).<br />
6. Put on sterile gloves. (See task 081-831-0008.)<br />
7. Remove the catheter from the package using the dominant hand, keeping the catheter<br />
coiled to prevent contamination.<br />
NOTE: This hand must remain sterile.<br />
8. Measure the length of the suction catheter so that it will be approximately at the carina.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Do not touch the patient while measuring the length of the catheter. This will violate<br />
aseptic technique.<br />
a. Tip of catheter to the ear.<br />
b. From the ear to the nipple line.<br />
9. Attach the tubing to the catheter with the nondominant hand.<br />
NOTE: This hand does not have to remain sterile. The glove is for your protection.<br />
10. Test the patency of the catheter.<br />
a. Turn the suction unit on with the nonsterile hand.<br />
b. Insert the catheter tip into the sterile saline solution using the sterile hand.<br />
c. Place the nonsterile thumb over the suction port to create suction. Observe the saline<br />
entering the drainage bottle.<br />
NOTE: If no saline enters the bottle, check the suction unit and/or replace the catheter and<br />
retest for patency.<br />
11. Suction the patient.<br />
a. Remove the oxygen delivery device with the nondominant hand.<br />
b. Lubricate the catheter tip by dipping it into the saline solution.<br />
c. Gently insert the catheter into the airway to the measured length without suctioning.<br />
d. Apply intermittent suction by placing and releasing the nondominant hand over the<br />
vent of the catheter while withdrawing the catheter in a twisting motion.<br />
CAUTION: Do not suction any longer than 15 seconds.<br />
e. Replace the oxygen delivery device and hyperventilate the patient.<br />
f. Repeat steps 10a through 10e until secretions are removed.<br />
12. Observe the patient for hypoxemia.<br />
WARNING: Discontinue suctioning immediately if severe changes in color or pulse rate occur.<br />
13. Disconnect the catheter and remove the gloves.<br />
a. Hold the catheter in one hand.<br />
b. Remove that glove by turning it inside out over the catheter to prevent the spread of<br />
contaminants.<br />
c. Remove the other glove.<br />
d. Discard them in contaminated trash.<br />
14. Make the patient comfortable.<br />
15. Discard, or clean and store, used items.<br />
16. Record the procedure on the appropriate form.<br />
a. Respirations (rate and breath sounds before and after suctioning).<br />
b. Type and amount of secretions.<br />
c. Patient's toleration of the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Explained the procedure to the patient. —— ——<br />
2. Positioned the patient. —— ——<br />
3. Checked the pressure on the suctioning apparatus. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
4. Prepared the sterile materials. —— ——<br />
5. Oxygenated the patient. —— ——<br />
6. Put on sterile gloves. —— ——<br />
7. Removed the catheter from the package using the dominant hand,<br />
keeping the catheter coiled to prevent contamination.<br />
8. Measured the length of the suction catheter so that it will be approximately<br />
at the carina.<br />
—— ——<br />
—— ——<br />
9. Attached the tubing to the catheter using the nondominant hand. —— ——<br />
10. Tested the patency of the catheter. —— ——<br />
11. Suctioned the patient. —— ——<br />
12. Observed the patient for hypoxemia. —— ——<br />
13. Disconnected the catheter and removed the gloves. —— ——<br />
14. Made the patient comfortable. —— ——<br />
15. Discarded, or cleaned and stored, used items. —— ——<br />
16. Recorded the procedure on the appropriate form. —— ——<br />
17. Did not violate aseptic technique. —— ——<br />
18. Did not cause further injury to the patient. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-322
STP 8-91W15-SM-TG<br />
PROVIDE TRACHEOSTOMY CARE<br />
081-835-3024<br />
Conditions: You have an adult patient requiring tracheostomy care. You have explained the<br />
procedure to the patient and a patient care handwash has been performed. An assistant may<br />
be available. Necessary materials and equipment: tracheostomy cleaning kit, sterile and<br />
nonsterile gloves, masks, protective eyewear, suctioning equipment, neck tapes, sterile gauze,<br />
sterile normal saline, sterile water, hydrogen peroxide, pulse oximetry monitor, oximetry sensor,<br />
alcohol wipes, and the patient's clinical record.<br />
Standards: Provided tracheostomy care without contamination and without causing further<br />
injury to the patient.<br />
Performance Steps<br />
1. Position the patient.<br />
a. Elevate the bed to a working height.<br />
b. Place the patient in the semi-Fowler's position.<br />
c. Monitor the patient's pulse oximeter reading throughout the procedure. (See task 081-<br />
833-0164.)<br />
2. Suction the patient's tracheostomy and oropharynx. (See tasks 081-833-0170 and 081-<br />
833-0021.)<br />
CAUTION: Suctioning should always be done immediately prior to tracheostomy care.<br />
3. Prepare the sterile materials for tracheostomy care.<br />
a. Open the tracheostomy cleaning kit or tray and use the inner wrapper to set up a<br />
sterile field.<br />
b. Open sterile dressings and other supplies and place them on the sterile field.<br />
c. Pour hydrogen peroxide into one basin and sterile saline into another.<br />
4. Put on a mask and protective eyewear.<br />
5. Remove the soiled tracheostomy dressing.<br />
a. Put on nonsterile gloves.<br />
b. Carefully remove the soiled dressing, observing it for type and amount of drainage, if<br />
any.<br />
c. Discard the contaminated dressing.<br />
d. Remove and discard the nonsterile gloves.<br />
e. Observe the condition of the tracheostomy site.<br />
6. Clean the tracheostomy site.<br />
a. Put on sterile gloves.<br />
b. Using sterile swabs that have been moistened with saline solution, carefully clean<br />
around the tracheostomy site.<br />
NOTE: If encrustations are present around the stoma site, it may be necessary to remove them<br />
with sterile swabs that have been moistened with hydrogen peroxide. Rinse the area with saline<br />
soaked swabs after the encrustations have been removed. Take care to let none of the solution<br />
enter the tracheostomy.<br />
c. Pat the area dry with sterile gauze.<br />
7. Remove the inner cannula.<br />
a. Put on fresh sterile gloves if the gloves were contaminated in the previous step.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Unlock the inner cannula.<br />
c. Gently and carefully pull out the inner cannula.<br />
NOTE: Not all tracheostomy tubes have an inner cannula.<br />
8. Clean the inner cannula.<br />
a. Immerse the inner cannula in hydrogen peroxide or appropriate solution IAW local<br />
SOP.<br />
b. Clean the inner cannula with the sterile brush from the tracheostomy cleaning kit.<br />
c. Ensure the removal of all secretions and encrustations from both the inside and<br />
outside of the inner cannula.<br />
d. Rinse the inner cannula thoroughly with sterile saline.<br />
NOTE: If an assistant is available, instruct him or her to suction the outer cannula to remove<br />
accumulated secretions.<br />
9. Reinsert the inner cannula.<br />
a. Insert the inner cannula into the outer cannula.<br />
b. Lock the inner cannula into place.<br />
10. Replace soiled neck tapes.<br />
a. Direct your assistant to hold the outer cannula securely in position while you change<br />
the tapes.<br />
NOTE: If an assistant is not available to hold the outer cannula, apply the new neck ties prior to<br />
cutting and removing the old neck ties. This will prevent accidental dislodgement of the<br />
tracheostomy tube.<br />
b. Remove and discard the neck tapes.<br />
c. Secure the new tapes to the flanges of the outer cannula and tie the knot at the side of<br />
the neck.<br />
NOTE: The neck tapes should not be tied so tightly that they cause discomfort to the patient.<br />
You should be able to slip one or two fingers under the neck tapes.<br />
11. Apply a sterile dressing.<br />
a. Apply the prepared sterile dressing from the kit or sterile gauze folded in a V-shape.<br />
b. Position the dressing under the flanges of the outer cannula.<br />
NOTE: The gauze dressing is placed under the tube to absorb secretions. This piece of gauze<br />
should be changed as often as necessary.<br />
12. Position the patient for comfort and safety.<br />
a. Lock the bed rails in the up position.<br />
b. Lower the bed to its lowest position.<br />
CAUTION: The call bell must be within reach at all times, as the patient cannot speak or call<br />
out for help.<br />
13. Discard disposable equipment.<br />
14. Document the care provided and significant observations on the appropriate forms IAW<br />
local SOP.<br />
a. Note the type and amount of drainage on the dressing, if any.<br />
b. Describe the appearance of the tracheostomy site.<br />
c. Note the type and amount of secretions suctioned.<br />
d. Describe the patient's tolerance of the procedure.<br />
3-324
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Positioned the patient. —— ——<br />
2. Suctioned the patient. —— ——<br />
3. Prepared the sterile equipment. —— ——<br />
4. Put on a mask and protective eyewear. —— ——<br />
5. Removed the soiled dressing. —— ——<br />
6. Cleaned the tracheostomy site. —— ——<br />
7. Removed the inner cannula. —— ——<br />
8. Cleaned the inner cannula. —— ——<br />
9. Reinserted the inner cannula. —— ——<br />
10. Replaced soiled neck tapes. —— ——<br />
11. Applied a sterile dressing. —— ——<br />
12. Positioned the patient for comfort and safety. —— ——<br />
13. Discarded disposable equipment. —— ——<br />
14. Documented the care provided. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-325
STP 8-91W15-SM-TG<br />
PROVIDE NURSING CARE FOR A PATIENT WITH A WATERSEAL DRAINAGE SYSTEM<br />
081-835-3031<br />
Conditions: You have a patient with a waterseal drainage system. A patient care handwash<br />
has been performed. Necessary materials and equipment: sterile petroleum gauze, rubber<br />
padded hemostats, safety pins, water-soluble lubricant, thermometer, stethoscope,<br />
sphygmomanometer, sterile dressing materials, tape, pillow, antiseptic wipes, and the patient's<br />
clinical record.<br />
Standards: Provided patient care without causing further injury to the patient. Provided<br />
emergency care when the waterseal drainage system was disrupted, minimizing the effects to<br />
the patient.<br />
Performance Steps<br />
1. Review the patient's clinical record to determine the reason for the patient's waterseal<br />
drainage system.<br />
a. Chest injury.<br />
b. Chest surgery.<br />
c. Spontaneous pneumothorax.<br />
2. Explain all safety checks and procedures to the patient.<br />
3. Assess the waterseal drainage system to ensure proper setup and functioning. (See<br />
Figure 3-60.)<br />
Figure 3-60<br />
NOTE: Chest drainage can be accomplished with one, two, or three bottle (or chamber)<br />
systems. All can be used with or without suction.<br />
a. Single bottle system.<br />
(1) The end of the patient's chest tube is attached to drainage (connecting) tubing.<br />
(2) The drainage tubing is attached to a long glass rod which protrudes through the<br />
cap of a sterile bottle.<br />
3-326
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(3) The long glass rod extends into the bottle and is submerged in sterile water to a<br />
depth of approximately 2.5 cm (1 inch).<br />
(a) Fluid fluctuation should be observable in the long glass rod as the patient<br />
breathes. It goes up when the patient inhales and down when the patient<br />
exhales. This indicates effective communication between the chest cavity<br />
and the waterseal system.<br />
(b) Bubbling at the submerged end of the long glass rod may or may not occur.<br />
Vigorous bubbling, when suction is not in use, indicates an air leak in the<br />
system or the lung.<br />
(4) A short glass rod protrudes from the bottle cap.<br />
(a) If controlled suction is not in use, this rod is left open to the atmosphere to<br />
allow the escape of air.<br />
(b) If controlled suction is being used, the connection to the suction apparatus is<br />
made at the short glass rod.<br />
NOTE: This bottle is called the waterseal bottle. The submerged rod acts as a seal to prevent<br />
draining air and blood from being drawn back into the pleural space.<br />
b. Two bottle system.<br />
(1) The end of the patient's tube is attached to drainage (connecting) tubing.<br />
(2) The drainage tubing is attached to a short glass rod which protrudes through the<br />
cap of a sterile bottle.<br />
NOTE: This bottle is called the drainage bottle. It collects fluid and shunts air to the waterseal<br />
bottle. The fluid level in the waterseal bottle does not change, as fluid is collected in the<br />
drainage bottle.<br />
(3) A second short glass rod protrudes through the bottle cap and is connected to the<br />
long glass rod of the waterseal bottle described above.<br />
(4) The short glass rod from the waterseal bottle is vented or attached to suction as<br />
described in step 3a(4).<br />
c. Three bottle system.<br />
(1) Bottles one and two are the same as in the two bottle system, except that the<br />
short glass rod from the waterseal bottle is attached to a short glass rod<br />
protruding from the cap of a third sterile bottle.<br />
NOTE: This third bottle is called the manometer bottle, as it provides suction control.<br />
(2) A second short glass rod protrudes the cap and acts as a vent or is attached to<br />
suction.<br />
(3) A long glass rod protrudes through the cap and is submerged in sterile water to a<br />
prescribed depth.<br />
NOTE: When suction is applied at the vent tube, air is drawn into the manometer bottle through<br />
the long glass rod, assisting the controlled suction.<br />
d. Commercial systems. When using one of the commercially available disposable chest<br />
drainage systems, refer to the manufacturer's instructions to ensure correct setup.<br />
e. Suction.<br />
(1) Suction attachments must be made at the appropriate connection points, as<br />
described above.<br />
(2) Suction must be controlled. The physician will order the amount of suction to be<br />
applied, and whether it is to be continuous or intermittent suction.<br />
4. Observe safety precautions.<br />
a. The bottles must be below the level of the chest.<br />
b. The bottles must be secured in a holding device.<br />
c. Emergency equipment must be immediately available at the bedside.<br />
3-327
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(1) Bottle of sterile water.<br />
(2) Rubber padded hemostats.<br />
(3) Sterile petroleum gauze.<br />
(4) Flutter (Heimlich) valve.<br />
NOTE: An emergency flutter valve may be devised from a penrose drain or the finger of a<br />
sterile glove. (See Figure 3-61.)<br />
Figure 3-61<br />
5. Observe the dressing at the chest tube insertion site.<br />
a. Note air leakage and drainage.<br />
b. Reinforce or change the dressing IAW the physician's orders. Note the condition of<br />
the insertion site and surrounding skin when the dressing is removed.<br />
6. Observe the drainage tubing.<br />
a. Tubing should not be kinked or compressed by the bed or the patient's body.<br />
b. Tubing should not loop below the level of the top of the bottle(s).<br />
c. Tubing should be loosely fastened to the bed sheet, not the side rail.<br />
d. Drainage tubing connections should be taped for added security.<br />
7. Milk the drainage tubing if IAW the physician's orders.<br />
a. Lubricate the drainage tubing with water-soluble lubricant for about 12 inches.<br />
b. Pinch the tubing above the lubricated area with one hand.<br />
c. With the other hand, compress the tubing and slide your fingers down the lubricated<br />
area toward the bottle.<br />
d. Release both hands.<br />
NOTE: Mechanical devices, such as the Lundy roller, may be available for milking the tubing.<br />
8. Observe the chest drainage.<br />
a. Note the color and consistency.<br />
b. Note the amount of drainage and measure the drainage at the prescribed time<br />
intervals. (See Figure 3-62.)<br />
3-328
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-62<br />
(1) Mark the level of the drainage on the tape affixed to the bottle collecting the<br />
drainage.<br />
(2) Write the date and time and your initials at the drainage level mark.<br />
(3) Do not empty the collecting bottle unless directed to do so by the physician.<br />
CAUTION: Notify the charge nurse or physician if chest drainage exceeds 100 cc/hr or<br />
changes in the drainage color indicate an active bleeding problem.<br />
9. Assess the patient for signs and symptoms of distress.<br />
a. Monitor vital signs at least every 4 hours or more frequently IAW local SOP.<br />
b. Observe the patient's color for evidence of cyanosis from hypoxemia.<br />
c. Observe the patient's respiratory effort.<br />
d. Question the patient about pain or chest pressure.<br />
10. Auscultate the patient's lungs.<br />
a. Auscultate the lungs at least every 4 hours or more frequently if warranted by the<br />
patient's condition or IAW local SOP.<br />
b. Auscultate both anteriorly and posteriorly, covering all lobes. Listen to at least one<br />
cycle of inspiration and expiration over each area (lung field). (See Figure 3-63.)<br />
3-329
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-63<br />
c. Note absence of breath sounds and abnormal sounds.<br />
11. Assist the patient with coughing and deep breathing exercises every 2 hours.<br />
a. Assist the patient to a semi-Fowler's or Fowler's position to facilitate effective<br />
coughing.<br />
b. Instruct the patient to splint the affected side with a pillow to reduce the discomfort of<br />
coughing.<br />
NOTE: Coughing and deep breathing remove secretions from the tracheobronchial tree, with<br />
resultant of the lungs and prevention of atelectasis.<br />
12. Change the patient's position at least every 2 hours.<br />
a. Maintain proper body alignment.<br />
b. Ensure the patient is as comfortable as possible.<br />
c. Ensure that the chest tube and drainage tubing are not kinked or compressed.<br />
NOTE: Changing the patient's position promotes drainage, facilitates air exchange, and<br />
prevents complications.<br />
13. Assist the patient with range-of-motion (ROM) exercises.<br />
a. Encourage the patient to perform active ROM of the arm and shoulder on the affected<br />
side in order to maintain joint mobility.<br />
b. Put the arm and shoulder of the affected side through passive ROM if the patient is<br />
unable to perform active ROM.<br />
c. If the patient is confined to bed, encourage active ROM of all joints.<br />
14. Ambulate and/or transport the patient as required.<br />
3-330
STP 8-91W15-SM-TG<br />
Performance Steps<br />
a. Attach rubber padded hemostats to the patient's hospital clothing and place a package<br />
of sterile petroleum gauze in the patient's pocket for immediate access in an<br />
emergency.<br />
b. Disconnect suction from the system and leave the vent tube open to the atmosphere.<br />
c. Bottles must be kept below the level of the patient's chest.<br />
d. Bottles must be kept upright at all times.<br />
e. Nursing personnel must accompany the patient and assist personnel from other<br />
departments when transporting the patient.<br />
15. Perform emergency intervention as required.<br />
a. Chest tube is pulled out of the chest.<br />
(1) Cover the insertion site with a sterile petroleum gauze square.<br />
CAUTION: The chest tube insertion site must be covered immediately. Use your hand if no<br />
other material is available.<br />
(2) Notify the charge nurse and physician immediately.<br />
(3) Monitor the patient for signs of respiratory distress.<br />
b. Chest tube is disconnected from the system.<br />
(1) Immediately clamp the chest tube with the rubber padded hemostats.<br />
(2) Apply a flutter valve to the end of the chest tube and release the clamp.<br />
(3) Notify the charge nurse and physician immediately.<br />
(4) Observe the patient for signs of respiratory distress.<br />
c. Waterseal unit becomes broken.<br />
(1) Clamp the chest tube with the rubber padded hemostats and disconnect the<br />
drainage tubing from the broken system.<br />
(2) Immerse the end of the drainage tubing in a container of sterile water and release<br />
the chest tube clamp. Ensure that the container of sterile water remains below the<br />
level of the chest.<br />
(3) Notify the charge nurse and physician immediately.<br />
(4) Monitor the patient for signs of respiratory distress.<br />
d. Waterseal unit is tipped over.<br />
(1) Return the waterseal unit to an upright position.<br />
(2) Instruct the patient to deep breathe and cough in order to force air out of the<br />
pleural space.<br />
(3) Notify the charge nurse and physician immediately.<br />
(4) Monitor the patient for signs of respiratory distress.<br />
16. Document all procedures and significant nursing observations in the patient's clinical<br />
record.<br />
a. Presence or absence of fluctuation in the long glass rod of the waterseal bottle.<br />
b. Presence or absence of air leaks or bubbling in the waterseal system.<br />
c. Condition of the chest tube insertion site and dressing.<br />
d. Time and results of chest tube milking.<br />
e. Amount, color, and consistency of the chest drainage.<br />
f. Specific observations about the patient to include the vital signs, breath sounds, and<br />
skin color.<br />
g. Results of coughing and deep breathing.<br />
h. Activity and position changes, to include ROM.<br />
3-331
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
1. Reviewed the patient's clinical record. —— ——<br />
2. Explained all safety checks and procedures. —— ——<br />
3. Assessed setup and functioning of the system. —— ——<br />
4. Observed safety precautions. —— ——<br />
5. Observed the dressing at the chest tube insertion site. —— ——<br />
6. Observed the drainage tubing. —— ——<br />
7. Milked the drainage tubing. —— ——<br />
8. Observed the drainage. —— ——<br />
9. Assessed the patient for signs and symptoms of distress. —— ——<br />
10. Auscultated the lungs. —— ——<br />
11. Instructed the patient to cough and deep breathe. —— ——<br />
12. Repositioned the patient. —— ——<br />
13. Assisted the patient with ROM. —— ——<br />
14. Ambulated and/or transported the patient. —— ——<br />
15. Performed emergency interventions. —— ——<br />
16. Documented the procedure on the appropriate forms IAW local SOP. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-332
STP 8-91W15-SM-TG<br />
Skill Level 3<br />
Subject Area 18: Advanced Procedures (SL 3)<br />
INTUBATE A PATIENT<br />
081-830-3016<br />
Conditions: You have an unconscious, nonbreathing casualty with no gag reflex. A qualified<br />
assistant is performing CPR. Suction equipment is available and ready for use. A laryngoscope<br />
and endotracheal (ET) tube have been prepared. You are not in an NBC environment.<br />
Necessary materials and equipment: bag-valve-mask (BVM) resuscitator or oxygen with<br />
demand valve, gloves, oral bite block or J tube, suction equipment, adhesive tape, benzoin,<br />
stethoscope, pressure manometer, and a 10 cc syringe.<br />
Standards: Completed all the steps necessary to establish an endotracheal tube airway in<br />
sequence and without causing further injury to the patient.<br />
Performance Steps<br />
CAUTION: Wear gloves to protect yourself against the transmission of contaminants whenever<br />
handling body fluids.<br />
1. Put on gloves.<br />
2. Oxygenate the patient with the bag-valve-mask for 1 minute.<br />
CAUTION: Do not deprive the patient of oxygen for longer than 20 seconds at any time during<br />
the procedure.<br />
3. Position the patient's head by hyperextending the neck.<br />
4. Open the patient's mouth and hold it open.<br />
5. Insert the laryngoscope blade. (See Figure 3-64.)<br />
Figure 3-64<br />
a. Stand or kneel at the top of the patient's head.<br />
b. Hold the laryngoscope with your left hand.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
c. Open and lock the blade at a 90 degree angle to turn the light on.<br />
d. Place the blade into the right side of the patient's mouth.<br />
e. Move the laryngoscope to the center of the patient's mouth by moving the patient's<br />
tongue to the left side of his or her mouth with the laryngoscope blade.<br />
f. Advance the blade a short distance to observe the epiglottis. (See Figure 3-65.)<br />
Figure 3-65<br />
6. Retract the epiglottis and inspect the vocal cords. (See Figure 3-66.)<br />
Figure 3-66<br />
a. When using a curved laryngoscope blade (McIntosh), apply anterior pressure to the<br />
vallecula with the tip of the laryngoscope blade to fold back the epiglottis and expose<br />
the vocal cords. (See Figure 3-67.)<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-67<br />
b. When using a straight laryngoscope blade (Miller), hook the blade tip under the<br />
epiglottis and pull up to fold back the epiglottis and expose the vocal cords. (See<br />
Figure 3-68.)<br />
Figure 3-68<br />
WARNING: Exert upward traction on the handle to expose the glottic opening. Never use the<br />
handle with a prying motion. Do not use the patient's teeth as a fulcrum.<br />
7. Insert the ET tube into the trachea.<br />
a. Grasp the ET tube with your right hand.<br />
b. Insert the ET tube and carefully guide the tip of the tube between the vocal cords until<br />
the cuff is just below the level of the vocal cords. (See Figure 3-69.)<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-69<br />
8. Remove the laryngoscope.<br />
9. Remove the stylet from the ET tube.<br />
a. Hold the ET tube securely with your right hand.<br />
b. Pull the stylet straight out with your left hand.<br />
10. Inject the required amount of air to inflate the cuff (5 to 10 cc) by pressing the plunger of the<br />
syringe. (See Figure 3-70.)<br />
Figure 3-70<br />
11. Check placement of the ET tube.<br />
a. Place the resuscitative equipment over the end of the ET tube and blow air into the<br />
tube to inflate the lungs.<br />
b. Instruct an assistant to auscultate the patient's lung fields and epigastric area while<br />
you manually ventilate the patient through the ET tube.<br />
(1) If the patient's chest rises and bilateral breath sounds are heard without any<br />
abnormal sounds heard over the epigastric area, proceed to step 12.<br />
(2) If sound is heard over only one lung field, then you must partially deflate the cuff,<br />
withdraw the tube a little, reinflate the cuff, and listen again.<br />
NOTE: A misplaced ET tube is most likely to be in the right main stem bronchus.<br />
3-336
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(3) If a rushing sound is heard over the epigastric area, withdraw the tube completely,<br />
reoxygenate the patient, and wait at least three minutes before repeating the<br />
procedure.<br />
12. Check cuff pressure.<br />
a. Use a pressure manometer.<br />
(1) Connect a pressure manometer to the pilot balloon to ensure the cuff pressure is<br />
less than 25 cm H 2 O. Either inflate or deflate the pilot balloon to achieve the<br />
desired pressure.<br />
(2) Remove the pressure manometer from the pilot balloon.<br />
b. Use the minimal leak technique.<br />
NOTE: Benzoin may be applied to the skin to prevent the tape from coming off.<br />
(1) Suction the patient thoroughly first.<br />
(2) Attach and partially deflate the cuff using a 10 cc syringe.<br />
(3) During the positive pressure ventilation, add air until only a slight leak is heard<br />
around the cuff during peak inspiration.<br />
NOTE: Due to possible prolonged intubation, it is recommended that you use a tube with a<br />
high-volume/low pressure cuff to prevent possible necrosis at the cuff site. Using cuff pressures<br />
above 30 cm H 2 O may produce a decrease in capillary mucosal blood flow resulting in ischemia.<br />
(4) Hold the cuff valve in one hand and simultaneously twist and pull the syringe with<br />
your other hand to remove the syringe.<br />
13. Reoxygenate the patient.<br />
14. Wedge a bite block or J tube between the back teeth to prevent biting of the ET tube which<br />
may cause partial or complete obstruction of the tube. (See Figure 3-71.)<br />
Figure 3-71<br />
15. Secure the ET tube.<br />
a. Wrap the middle of a long piece of tape around the ET tube.<br />
b. Attach each end of the tape to the patient's face.<br />
NOTE: Benzoin may be applied to the skin to prevent the tape from coming off.<br />
16. Ventilate the patient once every 5 seconds.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
17. Monitor the patient and ensure correct tube placement is maintained by auscultating the<br />
lungs and epigastric area.<br />
NOTE: The tip of the tube should be 2 to 3 centimeters above the carina. Proper tube<br />
placement is confirmed by taking an x-ray of the patient's chest.<br />
18. Record the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Put on sterile gloves. —— ——<br />
2. Oxygenated the patient. —— ——<br />
3. Positioned the patient's head. —— ——<br />
4. Opened the patient's mouth. —— ——<br />
5. Inserted the laryngoscope blade. —— ——<br />
6. Retracted the epiglottis and inspected the vocal cords. —— ——<br />
7. Inserted the ET tube into the trachea. —— ——<br />
8. Removed the laryngoscope. —— ——<br />
9. Removed the stylet from the ET tube. —— ——<br />
10. Inflated the cuff. —— ——<br />
11. Checked the placement of the ET tube. —— ——<br />
12. Checked the cuff pressure. —— ——<br />
13. Reoxygenated the casualty. —— ——<br />
14. Wedged a bite block or a J tube between the back teeth. —— ——<br />
15. Secured the ET tube. —— ——<br />
16. Ventilated the patient once every 5 seconds. —— ——<br />
17. Monitored the casualty. —— ——<br />
18. Recorded the procedure. —— ——<br />
19. Completed all necessary steps in order. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References: None<br />
3-338
STP 8-91W15-SM-TG<br />
SET UP A CASUALTY DECONTAMINATION STATION<br />
081-833-0093<br />
Conditions: You are assigned to a division level medical facility (battle aid station (BAS) or<br />
division clearing station (DCS)). Chemical agents are being used against the units supported by<br />
your medical treatment facility. The commander has ordered that a decontamination station and<br />
protective shelter be established. Your current location is in a noncontaminated area, upwind<br />
from the chemical hazard. Necessary materials and equipment: medical equipment sets (MES)<br />
for patient decontamination and patient treatment, protective shelter, tentage, plastic sheeting,<br />
supertropical bleach (STB), shovels, chemical agent alarms, chemical agent monitors, engineer<br />
tape or wire, field radio or telephone, windsock, camouflage netting, water source, plastic bags,<br />
litters, litter stands, and contaminated disposal containers.<br />
Standards: Set up a fully operational decontamination station in a noncontaminated area<br />
upwind from the chemical hazard. Established the decontamination area on the downwind side<br />
of the protective shelter or other clean treatment area and clearly marked a hot line.<br />
Constructed a shuffle pit as the only point of access to the clean areas. Installed chemical<br />
agent alarms.<br />
Performance Steps<br />
1. Select sites for the location of the operation.<br />
a. Primary and alternate sites must be selected in advance of operations.<br />
NOTE: Alternate sites must be selected in conjunction with selection of the primary site. If the<br />
prevailing winds change direction, use of the primary site may no longer be possible.<br />
b. Site selection factors.<br />
(1) The direction of the prevailing winds.<br />
(2) The downwind chemical hazard.<br />
(3) The availability of protective shelters or buildings to house clean treatment<br />
facilities.<br />
(4) The terrain.<br />
(5) Availability of cover and concealment.<br />
NOTE: The protective shelter may possesses visual, audible, and infrared signatures.<br />
Therefore, concealment may be compromised.<br />
(6) The general tactical situation.<br />
(7) The availability of evacuation routes (contaminated and clean).<br />
(8) The location of the supported unit's vehicle decontamination point, personnel<br />
decontamination point, and MOPP exchange point.<br />
NOTE: It is sometimes best to collate with these unit decontamination sites. The arrangement<br />
of the operational areas must be kept flexible and adaptable to both the medical and tactical<br />
situations.<br />
2. Set up the decontamination area. (See Figure 3-72.)<br />
3-339
STP 8-91W15-SM-TG<br />
Performance Steps<br />
Figure 3-72<br />
a. Triage area.<br />
b. Emergency treatment area.<br />
NOTE: Sometimes, triage and emergency treatment are conducted in the same area.<br />
c. Clothing removal area.<br />
d. Skin decontamination area.<br />
e. Overhead cover.<br />
(1) Erect an overhead cover, at least 20 x 50 feet, to cover the decontamination area<br />
and the clean waiting and treatment area. If the protective shelter is used, the<br />
overhead cover should overlap the air lock entrance.<br />
(2) If plastic sheeting is not available, alternate materials such as trailer covers,<br />
ponchos, or tarpaulins may be used.<br />
3. Set up the clean side of the decontamination station on the upwind side of the<br />
contaminated areas.<br />
NOTE: Erect a windsock for easy determination of wind direction.<br />
a. Clean waiting area.<br />
b. Clean treatment area.<br />
4. Set up the shuffle pit as the only point of access between the decontamination area and the<br />
clean waiting and treatment area.<br />
a. Turn over the soil in an area that is 1 to 2 inches deep, and of sufficient length and<br />
width to accommodate a litter stand.<br />
NOTE: The shuffle pit should be wide enough that the litter bearers are not able to straddle the<br />
pit.<br />
b. Mix super tropical bleach (STB) with the soil in a ratio of two parts STB to three parts<br />
soil.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
5. Set up the protective shelter on the upwind side of the clean waiting and treatment area.<br />
a. Set up the protective shelter with the air lock adjoining the clean side of the<br />
decontamination station.<br />
b. When a protective shelter is not available for use, set up a protected medical treatment<br />
facility 30 to 50 meters upwind from the shuffle pit.<br />
6. Set up the evacuation holding area.<br />
a. Set up an overhead cover of plastic sheeting at least 20 x 25 feet.<br />
b. Make sure the cover overlaps part of the clean treatment area and part of the<br />
protective shelter.<br />
c. When the protective shelter is used, set up the cover on the side opposite the<br />
generator.<br />
7. Mark the hot line.<br />
a. Use wire, engineer's tape, or other similar material to mark the entire perimeter of the<br />
hot line.<br />
b. Ensure that the hot line is clearly marked.<br />
8. Establish ambulance points on both the "clean" and "dirty" evacuation routes.<br />
a. Establish a "dirty" ambulance point downwind from the triage area in the<br />
decontamination station.<br />
b. Establish a "clean" ambulance point upwind from the evacuation holding area on the<br />
clean side of the decontamination station.<br />
9. Set up a contaminated (dirty) dump.<br />
a. Establish the contaminated dump 75 to 100 meters downwind from the<br />
decontamination station.<br />
b. Clearly mark the dump with NATO chemical warning markers.<br />
10. Place chemical agent alarms upwind from the clean treatment area.<br />
11. Camouflage areas IAW tactical directives.<br />
Performance Measures GO NO<br />
GO<br />
1. Selected primary and alternate sites. —— ——<br />
2. Set up the decontamination area. —— ——<br />
3. Set up the clean treatment/waiting area. —— ——<br />
4. Set up the shuffle pit. —— ——<br />
5. Set up the protective shelter. —— ——<br />
6. Set up the evacuation holding area. —— ——<br />
7. Marked the hot line. —— ——<br />
8. Established ambulance points. —— ——<br />
9. Set up a contaminated (dirty) dump. —— ——<br />
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STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
10. Placed chemical agent alarms. —— ——<br />
11. Camouflaged areas. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References: None<br />
3-342
STP 8-91W15-SM-TG<br />
INSERT A CHEST TUBE<br />
081-833-0168<br />
Conditions: You have a casualty suffering from a hemothorax or pneumothorax who requires<br />
the insertion of a chest tube. Necessary materials and equipment: chest tube (16-36 French),<br />
gloves, one-way valve, scalpel handle and blades (#10 and #15), Kelly forceps, large hemostat,<br />
betadine solution, suture material (size 0 nylon), lidocaine 1% with epinephrine for injection, and<br />
needle and syringe.<br />
Standards: Inserted a chest tube and corrected the hemothorax or pneumothorax without<br />
causing further injury to the casualty.<br />
Performance Steps<br />
1. Assess the casualty.<br />
a. If necessary, open the airway (see task 081-831-0018).<br />
b. Ensure adequate respiration and assist as necessary.<br />
c. Provide supplemental oxygen, if available.<br />
d. Connect the casualty to a pulse oximeter, if available.<br />
e. Initiate an IV (see task 081-833-0033).<br />
2. Prepare the casualty.<br />
a. Place the casualty in the supine position.<br />
b. Raise the arm on the affected side above the casualty's head.<br />
c. Select the insertion site at the anterior axillary line over the 4th or 5th intercostal<br />
space.<br />
d. Clean the site with betadine solution.<br />
e. Put on sterile gloves.<br />
f. Drape the area.<br />
g. Liberally infiltrate the area with the 1% lidocaine solution.<br />
3. Insert the tube.<br />
a. Make a 2 to 3 cm transverse incision over the selected site and extend it down to the<br />
intercostal muscles.<br />
NOTE: The skin incision should be 1 to 2 cm below the interspace through which the tube will<br />
be placed.<br />
b. Insert the Kelly forceps through the intercostal muscles in the next intercostal space.<br />
c. Puncture the parietal pleura with the tip of the forceps and slightly enlarge the hole by<br />
opening the clamp 1.5 to 2 cm.<br />
CAUTION: Avoid puncturing the lung. Always use the superior margin of the rib to avoid the<br />
intercostal nerves and vessels.<br />
d. Immediately insert a gloved finger in the incision to clear any adhesions, clots, etc.<br />
e. Grasp the tip of the chest tube with Kelly forceps. Insert the tip of the tube in the<br />
incision as you withdraw your finger.<br />
f. Advance the tube until the last side hole is 2.5 to 5 cm inside the chest wall.<br />
g. Connect the end of the tube to a one-way drainage valve (e.g., Heimlich valve).<br />
h. Secure the tube using the suture materials.<br />
i. Apply an occlusive dressing to the site.<br />
j. Radiograph the chest to confirm placement, if available.<br />
4. Reassess the casualty.<br />
a. Check for bilateral breath sounds.<br />
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STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Monitor and record vital signs every 15 minutes.<br />
5. Document the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Assessed the casualty. —— ——<br />
2. Prepared the casualty. —— ——<br />
3. Inserted the tube. —— ——<br />
4. Reassessed the casualty. —— ——<br />
5. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-344
STP 8-91W15-SM-TG<br />
PERFORM A SURGICAL CRICOTHYROIDOTOMY<br />
081-833-3005<br />
Conditions: You are in a field environment. A casualty has an upper airway obstruction. The<br />
casualty's airway cannot be opened using manual methods or an endotracheal (ET) tube. A<br />
cricothyroidotomy needle is not available or performing a needle cricothyroidotomy is not<br />
effective. Necessary materials and equipment: cutting instrument (scalpel, knife blade, or tin<br />
can edge), suctioning apparatus, povidone-iodine, hemostats, needle holders, cannula<br />
(noncollapsible tube to maintain airway), knife handle, blanket, gloves, and tape.<br />
Standards: Established an emergency airway without causing unnecessary injury to the<br />
casualty. Completed steps 3 through 10 in order.<br />
Performance Steps<br />
CAUTION: Consider only casualties with a total upper airway obstruction or casualties with<br />
inhalation burns for a surgical cricothyroidotomy.<br />
1. Hyperextend the casualty's neck.<br />
WARNING: Do not hyperextend the casualty's neck if a cervical injury is suspected.<br />
a. Place the casualty in the supine position.<br />
b. Place a blanket or poncho rolled up under the casualty's neck or between the shoulder<br />
blades so the airway is straight.<br />
2. Put on gloves, if available.<br />
3. Locate the cricothyroid membrane.<br />
a. Place a finger of the nondominant hand on the thyroid cartilage (Adam's apple) and<br />
slide the finger down to the cricoid cartilage.<br />
b. Palpate for the "V" notch of the thyroid cartilage.<br />
c. Slide the index finger down into the depression between the thyroid and cricoid<br />
cartilage.<br />
d. Prep the skin over the membrane with povidone-iodine.<br />
e. Raise the skin to form a tent-like appearance over the cricothyroid space, using the<br />
index finger and thumb.<br />
4. With a cutting instrument in the dominant hand, make a 1 1/2 inch horizontal incision<br />
through the raised skin to the cricothyroid space.<br />
CAUTION: Do not cut the cricothyroid membrane with this incision.<br />
5. Relocate the cricothyroid space by touch and sight.<br />
6. Stabilize the larynx with one hand and make a 1/2 inch horizontal incision through the<br />
elastic tissue of the cricothyroid membrane.<br />
7. Insert a dilator (hemostat or needle holder) through the opening.<br />
8. Separate the blades of the dilator to make a larger opening.<br />
NOTE: A rush of air may be felt through the opening.<br />
9. Insert the end of a cannula (or improvised substitute) between the blades of the dilator.<br />
The cannula should be in the trachea and directed toward the lungs.<br />
10. Secure the cannula in place to reduce movement in the opening and to prevent inhalation<br />
of the cannula.<br />
3-345
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: Reflex coughing may be stimulated by the insertion of the cannula. This may aid in<br />
clearing the airway but necessitates proper securing of the cannula.<br />
11. Suction the casualty's airway, as necessary.<br />
a. Insert the suction catheter 4 to 5 inches into the cannula.<br />
b. Apply suction only while withdrawing the catheter.<br />
c. Administer 1 cc of saline solution into the airway to loosen secretions and help<br />
facilitate suctioning.<br />
NOTE: Allow the casualty to take several breaths between suctionings.<br />
12. Administer oxygen, as necessary.<br />
NOTE: Mouth-to-cannula resuscitation may be performed if needed.<br />
13. Apply a sterile dressing under the casualty's cannula by making a V-shaped fold in a 4 X 4<br />
gauze pad and placing it under the edge of the cannula to prevent irritation to the casualty.<br />
Evaluation Preparation:<br />
Setup: For training and evaluation, use a mannequin or have another soldier act as the<br />
casualty. Under no circumstances will the skin be incised. Have the soldier demonstrate and<br />
explain what he or she would do.<br />
Brief soldier: Tell the soldier to perform a surgical cricothyroidotomy.<br />
Performance Measures GO NO<br />
GO<br />
1. Hyperextended the casualty's neck. —— ——<br />
2. Put on gloves, if available. —— ——<br />
3. Located the cricothyroid membrane. —— ——<br />
4. With a cutting instrument in the dominant hand, made a 1 1/2 inch<br />
horizontal incision through the raised skin to the cricothyroid space.<br />
—— ——<br />
5. Relocated the cricothyroid space by touch and sight. —— ——<br />
6. Stabilized the larynx with one hand and made a 1/2 inch horizontal incision<br />
through the elastic tissue of the cricothyroid membrane.<br />
—— ——<br />
7. Inserted a dilator (hemostat or needle holder) through the opening. —— ——<br />
8. Separated the blades of the dilator to make a larger opening. —— ——<br />
9. Inserted the end of a cannula (or improvised substitute) between the<br />
blades of the dilator.<br />
—— ——<br />
10. Secured the cannula in place. —— ——<br />
11. Completed steps 3 through 10 in order —— ——<br />
12. Suctioned the casualty's airway, as necessary. —— ——<br />
13. Administered oxygen, as necessary. —— ——<br />
3-346
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
14. Applied a sterile dressing under the casualty's cannula. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
3-347
STP 8-91W15-SM-TG<br />
PERFORM A NEUROLOGICAL EXAMINATION ON A PATIENT WITH SUSPECTED<br />
CENTRAL NERVOUS SYSTEM (CNS) INJURIES<br />
081-833-3014<br />
Conditions: You have a conscious casualty with a head injury but without neck injuries. The<br />
vital signs have been taken. Necessary materials and equipment: a flashlight or penlight, a pin<br />
or sharp object, and a rubber hammer.<br />
Standards: Performed a neurological examination on a casualty with a suspected CNS injury<br />
without causing further injury to the casualty.<br />
Performance Steps<br />
1. Look for the cause(s) of the injury.<br />
a. Observe the casualty's position.<br />
b. Observe the environmental conditions.<br />
NOTE: If the casualty is unconscious, ask bystanders for information.<br />
2. Evaluate the casualty's mental status.<br />
a. Determine the level of consciousness.<br />
(1) Alert--awake and responsive (verbal and motor). The casualty responds<br />
immediately, fully, and appropriately to commands.<br />
(2) Lethargic--sleepy or drowsy. The casualty can be aroused and responds<br />
appropriately, but will fall asleep again as soon as he or she is left alone.<br />
(3) Comatose--partial to complete unconsciousness. Use the Glasgow Coma Scale<br />
to determine the level of coma. (See task 081-835-3030.)<br />
b. Ask the casualty to perform calculations (basic math) to assess cognition. For<br />
example, have the casualty count backward from 100 by three or sevens.<br />
c. Observe the casualty's verbal and nonverbal behavioral responses to evaluate affect<br />
(mood). For example:<br />
(1) Does the casualty laugh inappropriately?<br />
(2) Does the casualty display excessive or inappropriate anger, fear, anxiety, or<br />
confusion?<br />
(3) Does the casualty respond to stimuli in a normal manner?<br />
d. Question the casualty to evaluate long and short term memory.<br />
(1) Discuss the casualty's past to evaluate remote recall (long term memory). Verify<br />
the casualty's response with information on what company or unit he or she is<br />
assigned to and the company's mission or with the unit's members.<br />
(2) Discuss current events to evaluate recent recall (short term memory). For<br />
example, ask the casualty what he or she was doing just before being injured, or<br />
what his or her unit was doing the previous day.<br />
e. Question the casualty to evaluate his or her orientation to person, place, and time.<br />
(1) Ask the casualty to spell his or her name, name family or unit members, and recite<br />
his or her home or unit address. (This determines whether the patient knows who<br />
he or she is and who others are.)<br />
(2) Ask the casualty to identify his or her location, naming the city, state, or country.<br />
(This determines whether the casualty knows where he or she is.)<br />
(3) Ask the casualty to identify the day of the week, month, and year.<br />
3. Evaluate the casualty's cerebellar functions.<br />
a. Test coordination and balance.<br />
3-348
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(1) Ask the casualty to extend both arms, close the eyes, and alternately touch the<br />
index finger to the nose.<br />
(2) Ask the casualty to slap the palms of the hands on his or her legs, and then the<br />
backs of the hands on the legs, alternating in a rapid motion.<br />
(3) Ask the casualty to stand relaxed with the eyes open. Watch for movement.<br />
(4) Perform the "Romberg test".<br />
(a) Have the casualty stand up and relax. Instruct the casualty to close his or her<br />
eyes.<br />
(b) If the casualty cannot maintain balance when the eyes are closed, the test is<br />
positive.<br />
NOTE: The medic should stand close to the casualty to support the casualty if he or she starts<br />
to fall.<br />
b. Check the casualty for normal gait and heel-toe-heel walking.<br />
(1) Ask the casualty to walk a straight line both forward and backward.<br />
(2) Observe the casualty for coordination, balance, and posture. Note inability to<br />
walk heel-toe-heel with one foot in front of the other.<br />
4. Evaluate the casualty's motor function.<br />
a. Check for mild weakness.<br />
(1) Have the casualty stand with the arms outstretched, palms upward, and eyes<br />
closed for 20 to 30 seconds.<br />
(2) Observe the casualty's arms for the "pronator sign" (the arm starts dropping and<br />
the hand turns over slightly).<br />
b. Test muscle tone.<br />
(1) Ask the casualty to relax.<br />
(2) If the casualty is ambulatory, have him or her sit on the edge of the examining<br />
table. Watch the freedom of movement of the legs. This indicates tone.<br />
(3) If the casualty is in bed, lift the casualty's arm, drop it, and observe the arm as it<br />
falls. Look for atrophy--loss of muscle tone or strength.<br />
c. Test muscle strength.<br />
(1) Ask the casualty to walk on his or her heels.<br />
(2) Ask the casualty to walk on his or her toes.<br />
(3) Extend your hands to the casualty, and ask the casualty to firmly grip and<br />
squeeze your hands. Note strength and equality of grip.<br />
(4) Ask the casualty to alternately flex and extend the feet while providing resistance<br />
with your hands. Look for atrophy.<br />
5. Evaluate the casualty's cranial nerve function.<br />
a. Test pupillary reflexes.<br />
(1) Dim the lighting and shine a light into one of the casualty's eyes.<br />
(2) Observe the pupillary response.<br />
(3) Repeat the procedure on the other eye.<br />
(4) If the pupils are unreactive or unequal, they are abnormal.<br />
(5) If the pupils are equal and reactive, record PERRLA (pupils equal, round, and<br />
reactive to light and accommodation).<br />
b. Test facial nerves.<br />
(1) Ask the casualty to smile and raise his or her eyebrows.<br />
(2) Look for weakness or drooping on either side of the face when smiling.<br />
(3) Look to see if there is even movement of both eyebrows.<br />
6. Evaluate the casualty's sensory functions.<br />
3-349
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: When doing this test, ask the casualty not to watch what you are doing.<br />
a. Allow the casualty to assume a comfortable position with the eyes closed.<br />
b. Test perception of pain by using a safety pin. Lightly touch the skin with the sharp and<br />
dull areas of the pin.<br />
(1) Ask the casualty to identify the sensation felt (sharp or dull).<br />
(2) Ask the casualty to identify where the sensations were felt.<br />
c. Test perception of touch by using a cotton ball to lightly brush the skin, asking the<br />
casualty to tell you when and where he or she felt the sensation.<br />
7. Check for the presence of a Babinski reflex.<br />
a. Grasp the ankle with your left hand.<br />
b. With a blunt point and moderate pressure, stroke the sole near its lateral border, from<br />
the heel toward the ball of the foot. The course of the stroke should curve to the<br />
middle to follow the bases of the toes.<br />
c. Normal reflex--toes curl. (Recorded as the absence of a Babinski reflex.)<br />
d. Abnormal reflex. (Recorded as the presence of a Babinski reflex.)<br />
(1) Dorsiflexion of the great toe.<br />
(2) Fanning of all the toes.<br />
(3) Dorsiflexion of the ankle.<br />
(4) Flexion of the knee and hip.<br />
8. Evaluate the casualty's deep tendon reflexes (DTRs).<br />
a. Biceps.<br />
(1) Position the elbow at about a 90 degree angle of flexion with the arm slightly<br />
pronated.<br />
(2) Grasp the elbow with your left hand so the fingers are behind it and your abducted<br />
thumb presses the biceps brachia tendon.<br />
(3) Strike your thumb a series of blows with the rubber hammer, varying your thumb<br />
pressure with each blow until the most satisfactory response is obtained.<br />
(4) A normal response will be elbow flexion.<br />
b. Triceps.<br />
(1) Grasp the casualty's wrist with your left hand and pull the arm across the chest so<br />
the elbow is flexed about 90 degrees and the forearm is partially pronated.<br />
(2) Tap the triceps brachia tendon directly above the olecranon process.<br />
(3) A normal response is elbow extension.<br />
c. Knee.<br />
(1) Legs dangling.<br />
(a) Have the casualty sit on a table, high bed, or litter to permit free swinging of<br />
the legs.<br />
(b) Tap the patellar tendon directly.<br />
NOTE: The tendon is distal to the patella.<br />
(c) A normal response is extension of the knee.<br />
(2) Lying supine.<br />
(a) With your hand under the popliteal fossa, lift the knee from the table.<br />
(b) Tap the patellar tendon directly.<br />
(c) A normal response is extension.<br />
d. Ankle.<br />
(1) Legs dangling.<br />
(a) With your left hand, grasp the foot and pull it in dorsiflexion. Find the degree<br />
of stretching of the Achilles tendon that produces the optimal response.<br />
3-350
STP 8-91W15-SM-TG<br />
Performance Steps<br />
(b) Tap the Achilles tendon directly.<br />
(c) A normal response is contraction of the gastrocnemius and plantar flexion of<br />
the foot.<br />
(2) Lying supine.<br />
(a) Partially flex the hip and knee. Rotate the knee outward as far as comfort<br />
permits.<br />
(b) With your left hand, grasp the foot and pull it in dorsiflexion.<br />
(c) Tap the Achilles tendon directly.<br />
(d) A normal response is plantar flexion.<br />
Performance Measures GO NO<br />
GO<br />
1. Looked for the cause(s) of the injury. —— ——<br />
2. Evaluated the casualty's mental status. —— ——<br />
3. Evaluated the casualty's cerebellar functions. —— ——<br />
4. Evaluated the casualty's motor function. —— ——<br />
5. Evaluated the casualty's cranial nerve functions. —— ——<br />
6. Evaluated the casualty's sensory functions. —— ——<br />
7. Checked for the presence of a Babinski reflex. —— ——<br />
8. Evaluated the casualty's deep tendon reflexes. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BTLS FOR PARAMEDICS<br />
EMERGENCY CARE<br />
3-351
STP 8-91W15-SM-TG<br />
ADMINISTER BLOOD<br />
081-835-3000<br />
Conditions: You have verified a physician's orders requiring the administration of blood. You<br />
have identified the patient and explained the procedure. A patient care handwash has been<br />
performed. Necessary materials and equipment: blood pack with SF 518, thermometer, blood<br />
pressure cuff, stethoscope, blood transfusion recipient set ("Y" type), IV stand, tourniquet,<br />
needle and syringe, IV catheter, tape, alcohol and betadine prep pads, gloves, a container of<br />
0.9% normal saline for injection, and the patient's clinical record.<br />
Standards: Administered the blood IAW the physician's orders and without causing injury to the<br />
patient.<br />
Performance Steps<br />
1. Verify and inspect the blood pack received from the laboratory.<br />
a. Note the time the blood pack was received and record the time on the SF 518.<br />
NOTE: Infusion of a blood pack should be initiated within 30 minutes of being issued.<br />
b. Two people must verify and match the information on the blood pack label with the<br />
data on the requisition form (SF 518).<br />
NOTE: One of the verifiers must be a Registered Nurse when directed by local policy.<br />
c. Inspect the blood for abnormalities such as gas bubbles or black or gray colored<br />
sediment (indicative of bacterial growth).<br />
NOTE: Return the blood pack to the blood bank if any abnormality is present or suspected.<br />
d. Match the blood pack with the patient's identification.<br />
(1) The same two people must compare the information on the blood unit with the<br />
data on the patient's wristband. Ensure the patient's name, blood type, and<br />
hospital number positively match the data on the blood pack.<br />
(2) Sign the SF 518 IAW local policy when all the data has been confirmed as a<br />
positive match.<br />
2. Establish baseline data.<br />
a. Reconfirm data from the patient's history regarding allergies or previous reactions to<br />
blood or blood products.<br />
b. Measure and evaluate the vital signs.<br />
c. Record the vital signs on the SF 518 and in the nursing notes.<br />
3. Prepare the blood and the blood recipient set.<br />
NOTE: Use only tubing that is designed for the administration of blood products. It is equipped<br />
with a filter designed for the fine filtration required for blood products.<br />
a. Close all three clamps on the "Y" tubing.<br />
b. Aseptically insert one of the tubing spikes into the container of normal saline. Invert<br />
and hang this container about 3 feet above the level of the patient.<br />
c. Open the clamp on the normal saline line and prime the upper line and the blood filter.<br />
d. Open the clamp on the empty line on which you will eventually hang the blood.<br />
Normal saline will flow up the empty line to prime that portion of the tubing.<br />
NOTE: Use only 0.9% normal saline for injection with blood. Other solutions are not<br />
compatible.<br />
e. Once the blood line is primed with saline, close the clamp on the blood line.<br />
f. Leave the clamp on the normal saline line open.<br />
g. Open the main roller clamp to prime the lower infusion tubing.<br />
3-352
STP 8-91W15-SM-TG<br />
Performance Steps<br />
h. Close the main roller clamp.<br />
i. Aseptically expose the blood port on the blood pack.<br />
j. Aseptically insert the remaining spike into the blood port and hang the blood at the<br />
same level as the normal saline container.<br />
NOTE: If "Y" type recipient tubing is not available, use regular infusion tubing for the normal<br />
saline and the available blood recipient tubing for the blood pack. Prime each set. Attach a<br />
sterile, large bore (16 or 18 gauge) needle to the end of the blood tubing and "piggyback" the<br />
blood into the normal saline line below the level of the roller clamp. Hang the blood pack at<br />
least 6 inches higher than the normal saline.<br />
4. Perform the venipuncture (see task 081-833-0033).<br />
NOTE: Insert a large gauge IV catheter (14, 16, or 18) for administering blood to an adult<br />
patient. This will enhance the flow of blood and prevent hemolysis of the cells.<br />
5. Begin the infusion of blood.<br />
a. Attach the primed infusion set to the catheter, tape it securely, and open the main<br />
roller clamp.<br />
NOTE: If a preexisting catheter is being used, run in 50 cc of normal saline to flush out any<br />
incompatible solution. If a new catheter was inserted, this step is not required.<br />
b. Close the roller clamp to the normal saline and open the roller clamp to the blood.<br />
c. Adjust the flow rate with the main roller clamp.<br />
(1) Set the flow rate to deliver approximately 10 to 25 cc of blood over the first 15<br />
minutes.<br />
NOTE: When delivering blood by piggyback, begin the infusion by opening the roller clamp on<br />
the normal saline line and setting it to a TKO rate. Adjust the roller clamp on the blood line to<br />
deliver 10 to 25 cc of blood over the first 15 minutes.<br />
(2) Monitor the vital signs closely for the first 15 minutes and observe for indications<br />
of an adverse reaction to the blood (see Figure 3-73).<br />
3-353
STP 8-91W15-SM-TG<br />
Performance Steps<br />
PATIENT'S SYMPTOMS REACTION TIME TYPE OF REACTION<br />
* Nausea<br />
* Severe chills<br />
* Rapid elevation of<br />
temperature<br />
* Pain in the lumbar region<br />
* Flushed appearance<br />
* Tachycardia<br />
* Hypotension<br />
* After only 25 cc of blood<br />
have been transfused<br />
HEMOLYTIC<br />
* Extremely serious<br />
* Can be fatal<br />
* Transfusion of incompatible<br />
RBCs<br />
* RBC destruction<br />
* Mild to severe chills<br />
* Normal to elevated<br />
temperature<br />
* Headache<br />
* Flushed appearance<br />
* Anxiety<br />
* Hypotension<br />
* During the transfusion<br />
or<br />
30 to 60 minutes after the<br />
transfusion is completed.<br />
PYROGENIC<br />
* Serious<br />
* Contaminants may have<br />
been introduced into the<br />
blood or the IV equipment<br />
* Flushed appearance<br />
* Edema of the face and lips<br />
* Dyspnea (from laryngeal<br />
edema)<br />
* Wheezing<br />
* Anxiety<br />
* Itching<br />
* Hives<br />
* Anaphylaxis<br />
* During the transfusion<br />
or<br />
1 to 2 hours after the<br />
transfusion in completed<br />
ALLERGIC<br />
* Serious<br />
* Allergic response<br />
(hypersensitivity) by the<br />
recipient to substances in<br />
the donor blood.<br />
Figure 3-73<br />
CAUTION: Any time an adverse reaction is suspected, immediately stop the blood and infuse<br />
normal saline. Notify the charge nurse and physician immediately.<br />
(3) Set the main roller clamp to deliver the prescribed flow rate if, after the first 15<br />
minutes, no adverse reaction is suspected and the vital signs are stable.<br />
NOTE: Use the correct formula to calculate flow rate.<br />
6. Monitor and evaluate the patient throughout the procedure.<br />
a. Monitor vital signs every hour or more frequently IAW local SOP.<br />
b. Compare the vital signs with previous and baseline vital signs.<br />
c. Observe for changes that indicate an adverse reaction to the blood.<br />
3-354
STP 8-91W15-SM-TG<br />
Performance Steps<br />
d. Stop the blood, infuse normal saline, and notify the charge nurse and physician if a<br />
reaction is suspected.<br />
CAUTION: When a transfusion reaction occurs or is suspected, the unused blood and recipient<br />
tubing must be sent to the laboratory along with a 10 ml specimen of the patient's venous blood<br />
and a post transfusion urine specimen.<br />
7. Discontinue the infusion of blood.<br />
a. When the blood pack has emptied, close the clamp to the blood and open the clamp to<br />
the normal saline.<br />
b. Flush the tubing and filter with approximately 50 cc of normal saline to deliver the<br />
residual blood.<br />
c. After the residual blood has been delivered, run the normal saline at a TKO rate or<br />
hang another solution, if one has been prescribed.<br />
d. Take and record the vital signs at the completion of the transfusion and 1 hour after<br />
completion.<br />
NOTE: As a rule, a unit of blood should be infused within 2 to 4 hours unless contraindicated by<br />
risk of circulatory overload. If the prescribed flow rate will deliver the blood within a shorter or<br />
longer period of time, verify the order with the charge nurse or prescribing physician.<br />
8. Dispose of the used blood pack IAW local SOP.<br />
a. Return it to the laboratory blood bank with a copy of SF 518.<br />
b. Discard it in a container for contaminated waste.<br />
9. Document the procedure and significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
a. Complete the SF 518.<br />
(1) Return one copy to the laboratory blood bank.<br />
(2) Place one copy in the patient's chart.<br />
b. Record the procedure and the patient's response in a nursing note entry.<br />
Performance Measures GO NO<br />
GO<br />
1. Verified and inspected the blood pack. —— ——<br />
2. Established baseline data. —— ——<br />
3. Prepared the blood and transfusion recipient sets. —— ——<br />
4. Performed the venipuncture. —— ——<br />
5. Began the infusion of blood. —— ——<br />
6. Monitored and evaluated the patient. —— ——<br />
7. Discontinued the infusion of blood. —— ——<br />
8. Disposed of the used blood pack IAW local SOP. —— ——<br />
9. Documented the procedure on the appropriate forms IAW local SOP. —— ——<br />
3-355
STP 8-91W15-SM-TG<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-356
STP 8-91W15-SM-TG<br />
ADMINISTER MEDICATIONS BY IV PIGGYBACK<br />
081-835-3002<br />
Conditions: You have a physician's orders requiring the administration of a medication by the<br />
IV piggyback route. You must prepare the piggyback unit. A patient care handwash has been<br />
performed. Necessary materials and equipment: medication, diluent, needle, syringe, alcohol<br />
(or other antiseptic) prep pads, label, container of IV solution, IV administration tubing, tape, and<br />
the patient's clinical record.<br />
Standards: Prepared the IV piggyback unit without contamination and administered it to the<br />
patient without complications.<br />
Performance Steps<br />
1. Identify the patient, explain the procedure, and ask about allergies.<br />
2. Check the medication sheet (DA Form 4678) against the physician's orders.<br />
a. Name of the medication.<br />
b. Amount (dose) of medication.<br />
c. Route of administration.<br />
d. Time to be administered.<br />
3. Select the medication.<br />
a. Check the medication label three times to ensure that the correct medication is being<br />
prepared for administration.<br />
b. Check the expiration date of the medication.<br />
c. Handle only one medication at a time.<br />
NOTE: If unfamiliar with a medication, look it up to determine contraindications, precautions,<br />
and side effects.<br />
4. Prepare the medication.<br />
a. Calculate the amount of medication required to equal the prescribed dose.<br />
NOTE: If the medication is in powdered form, prepare it for use by adding the diluent specified<br />
on the drug information instructions.<br />
b. Draw the prescribed amount of the prepared medication into a syringe.<br />
c. Check the medication and calculations again to ensure that the correct medication and<br />
correct dose have been prepared.<br />
5. Prepare the piggyback unit.<br />
NOTE: Refer to the drug manufacturer's instructions to determine the type and amount of<br />
solution to be used as the piggyback unit.<br />
a. Use an alcohol prep pad to swab the injection port on the container of IV solution to be<br />
used as the piggyback unit.<br />
b. Inject the prepared medication into the container of IV solution.<br />
c. Mix the solution and medication into the container of IV solution.<br />
d. Label the piggyback unit with the name of the medication, the amount added, the time<br />
added, the date added, and the initials of the person who prepared the piggyback unit.<br />
e. Dispose of the needle and syringe IAW local SOP.<br />
6. Prime the piggyback infusion tubing.<br />
a. Close the clamp on the piggyback tubing.<br />
3-357
STP 8-91W15-SM-TG<br />
Performance Steps<br />
b. Aseptically insert the spike on the piggyback tubing into the solution port on the<br />
piggyback unit.<br />
c. Squeeze the drip chamber to fill it half full.<br />
d. Open the clamp on the piggyback tubing, allowing the solution to prime the tubing.<br />
e. Close the clamp on the piggyback tubing when the solution reaches the end of the<br />
tubing.<br />
NOTE: Attach a sterile needle to the end of the piggyback tubing if one is not provided by the<br />
manufacturer.<br />
CAUTION: Take care not to waste any medicated IV solution while priming the tubing.<br />
7. Connect the piggyback unit to the primary tubing.<br />
a. Swab the injection port on the primary tubing with an alcohol prep pad.<br />
b. Insert the needle into the injection port of the primary tubing.<br />
c. Secure the connection with tape.<br />
NOTE: Attach the piggyback tubing to the primary tubing below the level of the roller clamp.<br />
This will allow the piggyback unit to flow at its set rate without adjusting the flow rate of the<br />
primary solution.<br />
8. Hang the piggyback unit on the IV pole, ensuring that the piggyback unit is at least 6 inches<br />
higher than the primary container.<br />
9. Ensure patency of the primary IV.<br />
10. Begin the secondary (piggyback) infusion.<br />
a. Calculate the flow rate in accordance with the physician's orders.<br />
NOTE: If the physician does not specify a flow rate, set the flow rate IAW the drug<br />
manufacturer's instructions.<br />
b. Adjust the roller clamp on the piggyback tubing to regulate the flow rate of the<br />
piggyback solution.<br />
CAUTION: Do not adjust the flow rate of the primary container.<br />
NOTE: When fluid from the secondary line enters the primary tubing, the primary infusion is<br />
automatically interrupted. When all the solution in the piggyback unit has been delivered, the<br />
primary infusion will resume flow at the set rate.<br />
11. Label the piggyback infusion tubing with the time and date the medication was initiated.<br />
12. Observe the patient for signs of infusion complications or reaction to the medicine. (See<br />
task 081-833-0034.)<br />
13. Document the procedure and significant nursing observations on the appropriate forms<br />
IAW local SOP.<br />
Performance Measures GO NO<br />
GO<br />
1. Identified the patient, explained the procedure, and asked about allergies. —— ——<br />
2. Checked the medication sheet (DA Form 4678) against the physician's<br />
orders.<br />
—— ——<br />
3. Selected the medication. —— ——<br />
4. Prepared the medication. —— ——<br />
3-358
STP 8-91W15-SM-TG<br />
Performance Measures GO NO<br />
GO<br />
5. Prepared the piggyback unit. —— ——<br />
6. Primed the piggyback infusion tubing. —— ——<br />
7. Connected the piggyback unit to the primary tubing. —— ——<br />
8. Hung the piggyback unit on the IV pole, ensuring that the piggyback unit is<br />
at least 6 inches higher than the primary container.<br />
—— ——<br />
9. Ensured patency of the primary IV. —— ——<br />
10. Began the secondary (piggyback) infusion. —— ——<br />
11. Labeled the piggyback infusion tubing with the time and date the<br />
medication was initiated.<br />
12. Observed the patient for signs of infusion complications or reaction to the<br />
medicine.<br />
13. Documented the procedure and significant nursing observations on the<br />
appropriate forms IAW local SOP.<br />
—— ——<br />
—— ——<br />
—— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-359
STP 8-91W15-SM-TG<br />
SUTURE A MINOR LACERATION<br />
081-833-3208<br />
Conditions: You have a casualty with a minor laceration requiring closure. The laceration does<br />
not involve the face, hands, feet, or genitalia. You are not in an NBC environment. Necessary<br />
materials and equipment: sterile suture set, appropriate type and size of suture, staples, skin<br />
adhesive, steri strips, lidocaine 1% with and without epinephrine, saline irrigation solution,<br />
antiseptic solution, sterile gloves, antibiotic ointment, and sterile dressing.<br />
Standards: Properly cleaned, anesthetized, and closed the laceration without causing further<br />
harm.<br />
Performance Steps<br />
1. Prepare the site.<br />
a. Expose the area to be sutured.<br />
b. Gently scrub the site with an antiseptic solution using circular motions for a minimum<br />
of 5 minutes.<br />
NOTE: Use ample pressure to remove dirt and microorganisms.<br />
c. Irrigate the wound with a copious amount of normal saline at a low pressure.<br />
d. Dry the site using sterile gauze pads.<br />
2. Anesthetize the area.<br />
a. Cryoanesthesia.<br />
(1) Apply a moistened ice cube to the skin for about 5 minutes.<br />
(2) Spray the area with commercial refrigerants, as directed.<br />
b. Topical applications.<br />
(1) Apply the agent directly to the mucus membrane, serous surface, or onto the<br />
open wound.<br />
(2) Slightly saturate a gauze with the appropriate agent and place it on the wound for<br />
5 to 10 minutes.<br />
(3) Check the area for tissue blanching which indicates adequate anesthesia.<br />
NOTE: Often topical application is suboptimal for suture placement.<br />
c. Simple infiltration.<br />
(1) Ensure the casualty does not have an allergy to the agent.<br />
(2) Using a needle and syringe, draw up an adequate amount of 1% lidocaine.<br />
NOTE: Lidocaine with epinephrine is never used on the tip of the nose, ears, fingers, toes, or<br />
genitalia due to vasoconstriction.<br />
(3) Enter directly into the dermis through the laceration.<br />
(4) Aspirate prior to injecting the solution to ensure the needle is not in a vessel. (If<br />
blood returns into the syringe, withdraw, change the needle, and try a new site.<br />
(5) Slowly inject solution beneath the skin surface, raising a wheal in the area to be<br />
anesthetized.<br />
(6) Repeat steps 2c(3) through 2c(5) depending on the size of the laceration.<br />
3. Select the method of closure.<br />
a. Skin adhesive.<br />
(1) Hold the wound edges together and slightly everted with tissue forceps.<br />
(2) Apply adhesive with the applicator tip by lightly wiping along the long axis of the<br />
wound.<br />
3-360
STP 8-91W15-SM-TG<br />
Performance Steps<br />
NOTE: Three to four thin layers should be applied successively. Avoid droplets or a single<br />
thick layer.<br />
(3) Hold the wound edges together for approximately 1 minute.<br />
(4) Instruct the casualty not to apply ointment or dressing to the wound.<br />
b. Steri strips.<br />
(1) Apply benzoin to a 2 to 3 cm area beyond the wound edges. Do not allow<br />
benzoin to enter the wound.<br />
(2) Using forceps, attach the strip to the skin on one side and then pull it across the<br />
wound to close the wound edges.<br />
(3) Start in the center and progress toward each end. Leave some space between<br />
individual strips.<br />
(4) Instruct the casualty not to get the area wet.<br />
c. Staples.<br />
(1) Hold the wound edges together with tissue forceps.<br />
(2) Place the stapling device gently against the skin surface.<br />
(3) Slowly squeeze the trigger.<br />
(4) Evenly place only the necessary amount of staples to close the wound.<br />
NOTE: There is little to no benefit to locally infiltrating an area for 1 to 2 staple placement. The<br />
anesthetic is more discomforting than the procedure.<br />
d. Suture.<br />
(1) Select the proper size and type of material.<br />
(2) Check for adequate anesthesia by grasping the wound edges with tissue forceps.<br />
Note if the casualty can feel pain.<br />
(3) Grasp the needle with the needle holder about 1/2 to 1/3 the distance from where<br />
the suture is attached.<br />
(4) Hold the needle holder in the palm, using the index finger for fine control.<br />
(5) Enter the skin at approximately a 90 degree angle on the far side of the wound<br />
and exit on the near side.<br />
NOTE: You should enter and exit the skin about 2 mm from the edge. Entry and exit points<br />
should be directly across from each other.<br />
(6) Pull the suture through the wound until approximately a 2 cm tail remains on the<br />
far side of wound.<br />
(7) Hold the end of the suture attached to the needle in the nondominant hand.<br />
(8) Hold the needle holder in the dominant hand.<br />
(9) Loop the suture twice around the needle holder.<br />
(10) Grasp the free end of the suture with the blades of the needle holder.<br />
(11) Cross the hands so that the hand holding the swagged end is on the far side and<br />
the hand holding the needle holder and free end are on the near side of the<br />
wound.<br />
(12) Pull upward on the suture ends when clinching the first throw.<br />
(13) Adjust the tension of the first throw so that the wound edges come together snugly<br />
but not tightly.<br />
(14) For the second throw of the knot, the needle end is on the far side of the wound<br />
and the free end on the near side.<br />
(15) Hold the needle end of the suture in the nondominant hand and lay the needle<br />
holder on top.<br />
(16) Loop the suture only once around the needle holder.<br />
(17) Grasp the free ends with the blades of the holder.<br />
(18) Cross the hands so that the sutures smoothly intertwine.<br />
(19) Cinch down the throw.<br />
3-361
STP 8-91W15-SM-TG<br />
Performance Steps<br />
CAUTION: Take care not to cinch down too tightly on the second throw because the tightness<br />
will be transmitted to the wound.<br />
(20) Pull the knot to the side so that it will not directly overlie the laceration.<br />
(21) The pattern of looping the suture around the holder on alternate sides of the<br />
wound is repeated until the desired number of throws are completed.<br />
(22) Cut the ends of the suture material to approximately 3 to 5 cm length..<br />
4. Apply antibiotic ointment to the site.<br />
5. Apply a sterile dressing to the site.<br />
6. Document the procedure.<br />
Performance Measures GO NO<br />
GO<br />
1. Prepared the skin. —— ——<br />
2. Anesthetized the area. —— ——<br />
3. Selected the method of closure. —— ——<br />
4. Applied antibiotic ointment. —— ——<br />
5. Sutured the laceration. —— ——<br />
6. Applied a sterile dressing. —— ——<br />
7. Documented the procedure. —— ——<br />
Evaluation Guidance: Score each soldier according to the performance measures in the<br />
evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all<br />
performance measures to be scored GO. If the soldier fails any step, show what was done<br />
wrong and how to do it correctly.<br />
References<br />
Required<br />
None<br />
Related<br />
BASIC NURSING<br />
3-362
STP 8-91W15-SM-TG<br />
APPENDIX A<br />
FIELD EXPEDIENT SQUAD BOOK<br />
A-1
STP 8-91W15-SM-TG<br />
A-2
STP 8-91W15-SM-TG<br />
A-3
STP 8-91W15-SM-TG<br />
A-4
STP 8-91W15-SM-TG<br />
A-5
STP 8-91W15-SM-TG<br />
A-6
STP 8-91W15-SM-TG<br />
A-7
STP 8-91W15-SM-TG<br />
A-8
STP 8-91W15-SM-TG<br />
A-9
STP 8-91W15-SM-TG<br />
A-10
STP 8-91W15-SM-TG<br />
APPENDIX B<br />
Calculate Intravenous Drip Rates<br />
DRUG DOSAGE CALCULATIONS<br />
1. To calculate the drip rate per minute (flow rate) of intravenous (IV) fluids, first obtain the<br />
following information:<br />
a. Delivery rate (drops per cc) of the IV tubing set being used. This is also referred to as<br />
the "tubing factor." (The IV tubing package will state the rate of delivery for that particular IV<br />
set; for example, 10 drops per cc for standard drip tubing or 60 drops per cc for mini drip<br />
tubing.)<br />
b. Volume of fluid (in cc) to be infused. (This can be expressed in an hourly amount or in<br />
a total volume; for example, "100 cc/hour" or "2 liters over 6 hours.")<br />
c. Amount of time (in minutes) the fluid is to be infused. (This can be expressed in an<br />
hourly rate or total time; for example, "150 cc per hour" or "infuse 1 liter over 4 hours.")<br />
2. Calculate the flow rate in drops per minute using the following formula:<br />
1. To convert grams (Gm) to milligrams (mg), multiply Gm by 1000 and move the decimal<br />
point three places to the right; for example, 0.075 Gm = 75 mg and 0.25 Gm = 250 mg.<br />
2. To convert milligrams to grams, divide milligrams by 1000 and move the decimal point<br />
three places to the left; for example, 1000 mg = 1 Gm and 500 mg = .5 Gm.<br />
B-1
STP 8-91W15-SM-TG<br />
Calculation of Doses from Drugs in Solution<br />
1. Some drugs are dispensed as solutions. The strength of the solution is written on the label<br />
of the drug container; for example, "10 mg per ml." The problem is to determine what quantity<br />
of solution will contain the required dose of the drug. The method of solving the problem is by<br />
ratio and proportion. The formula is as follows:<br />
Required : Unknown :: ratio of strength<br />
amount of drug amount of solution of solution on hand<br />
is to as is to ________<br />
2. EXAMPLE: The physician has ordered Benadryl Elixir, 25 mg p.o. The Benadryl Elixir on<br />
hand contains 10 mg per ml. How many ml (cc) of the Elixir must be administered to achieve<br />
the required dose?<br />
a. Write out the formula.<br />
25 mg : x ml :: 10 mg : 1 ml<br />
b. Multiply the inner values.<br />
x times 10 (10x)<br />
c. Multiply the outer values.<br />
25 times 1 (25)<br />
d. The multiplied inner values equal the multiplied outer values, so:<br />
10x = 25<br />
e. Divide 25 by 10 to find x.<br />
x = 25 or 2.5<br />
10<br />
f. 2.5 ml of Benadryl Elixir must be administered to achieve the required dose of 25 mg.<br />
Convert from Apothecary to Metric<br />
1. To convert grains to milligrams, multiply grains by 60 to obtain milligrams; for example, 1/4<br />
grain = 15 milligrams.<br />
2. To convert milligrams to grains, divide milligrams by 60 to obtain grains; for example, 30<br />
mg = 1/2 grain.<br />
B-2
STP 8-91W15-SM-TG<br />
Metric<br />
Liquid Measure<br />
Approximate<br />
Apothecary<br />
Equivalents<br />
1,000 ml 1 quart<br />
750 ml 1 1/2 pints<br />
500 ml 1 pint<br />
250 ml 8 fluid ounces<br />
200 ml 7 fluid ounces<br />
100 ml 3 1/2 fluid ounces<br />
50 ml 1 3/4 fluid ounces<br />
30 ml 1 fluid ounce<br />
15 ml 4 fluid drams<br />
10 ml 2 1/2 fluid drams<br />
8 ml 2 fluid drams<br />
5 ml 1 1/4 fluid drams<br />
4 ml 1 fluid dram<br />
Metric<br />
Weight<br />
Approximate<br />
Apothecary<br />
Equivalents<br />
30 Gm 1 ounce<br />
15 Gm 4 drams<br />
10 Gm 2 1/2 drams<br />
7.5 Gm 2 drams<br />
6 Gm 90 grains<br />
5 Gm 75 grains<br />
4 Gm 60 grains/1 dram<br />
3 Gm 45 grains<br />
2 Gm 30 grains/1/2 dram<br />
1.5 Gm 22 grains<br />
1 Gm 15 grains<br />
0.75 Gm 12 grains<br />
0.6 Gm 10 grains<br />
0.5 Gm 7 1/2 grains<br />
0.4 Gm 6 grains<br />
0.3 Gm 5 grains<br />
0.25 Gm 4 grains<br />
0.2 Gm 3 grains<br />
0.15 Gm 2 1/2 grains<br />
0.12 Gm 2 grains<br />
0.1 Gm 1 1/2 grains<br />
75 mg 1 1/4 grains<br />
60 mg 1 grain<br />
50 mg 3/4 grain<br />
40 mg 2/3 grain<br />
Metric<br />
Liquid Measure<br />
Approximate<br />
Apothecary<br />
Equivalents<br />
3 ml 45 minims<br />
2 ml 30 minims<br />
1 ml 15 minims<br />
0.75 ml 12 minims<br />
0.6 ml 10 minims<br />
0.5 ml 8 minims<br />
0.3 ml 5 minims<br />
0.25 ml 4 minims<br />
0.2 ml 3 minims<br />
0.l ml 1 1/2 minims<br />
0.06 ml 1 minim<br />
0.05 ml 3/4 minim<br />
0.03 ml 1/2 minim<br />
Metric<br />
Weight<br />
Approximate<br />
Apothecary<br />
Equivalents<br />
30 mg 1/2 grain<br />
25 mg 3/8 grain<br />
20 mg 1/3 grain<br />
15 mg 1/4 grain<br />
12 mg 1/5 grain<br />
10 mg 1/6 grain<br />
8 mg 1/8 grain<br />
6 mg 1/10 grain<br />
5 mg 1/12 grain<br />
4 mg 1/15 grain<br />
3 mg 1/20 grain<br />
2 mg 1/30 grain<br />
1.5 mg 1/40 grain<br />
1.2 mg 1/50 grain<br />
1 mg 1/60 grain<br />
0.8 mg 1/80 grain<br />
0.6 mg 1/100 grain<br />
0.5 mg 1/120 grain<br />
0.4 mg 1/150 grain<br />
0.3 mg 1/200 grain<br />
0.25 mg 1/250 grain<br />
0.2 mg 1/300 grain<br />
0.15 mg 1/400 grain<br />
0.12 mg 1/500 grain<br />
0.1 mg 1/600 grain<br />
B-3
STP 8-91W15-SM-TG<br />
ABBREVIATIONS<br />
ac<br />
ad lib<br />
bid<br />
c<br />
cc<br />
caps<br />
Gm<br />
gr<br />
gtt<br />
h<br />
hs<br />
kg<br />
l<br />
mg<br />
ml<br />
od<br />
os<br />
ou<br />
pc<br />
po<br />
prn<br />
qd<br />
qid<br />
qod<br />
qs<br />
q2h<br />
q4h<br />
q6h<br />
q8h<br />
s<br />
stat<br />
sq or sc<br />
ss<br />
tab<br />
tsp<br />
tbsp<br />
tid<br />
before meals<br />
as much as desired<br />
twice a day<br />
with<br />
cubic centimeter<br />
capsule<br />
gram<br />
grain<br />
drop<br />
hour<br />
bedtime (hour of sleep)<br />
kilogram<br />
liter<br />
milligram<br />
milliliter<br />
right eye (oculo dextro)<br />
left eye (oculo sinistro)<br />
both eyes (oculus uterque)<br />
after meals<br />
by mouth<br />
when needed/as necessary<br />
every day (daily)<br />
four times daily<br />
every other day<br />
in sufficient quantity<br />
every 2 hours<br />
every 4 hours<br />
every 6 hours<br />
every 8 hours<br />
without<br />
at once/immediately<br />
subcutaneously<br />
one half<br />
tablet<br />
teaspoon<br />
tablespoon<br />
three times daily<br />
B-4
STP 8-91W15-SM-TG<br />
GLOSSARY<br />
ACCP<br />
AED<br />
The Army Correspondence Course Program<br />
automatic external defibrillator<br />
Army Training and Evaluation Program (ARTEP).<br />
The Army's collective training program that establishes unit training objectives critical to unit<br />
survival and performance in combat. They combine the training and the evaluation process into<br />
one integrated function. The ARTEP is a training program and not a test. The sole purpose of<br />
external evaluation under this program is to diagnose unit requirements for future training.<br />
AVPU<br />
BAS<br />
alertness, responsiveness to vocal stimuli, responsiveness to<br />
painful stimuli unresponsiveness<br />
battalion aid station<br />
Battle focus<br />
A process to guide the planning, execution, and assessment of the organization's training<br />
program to ensure they train as they are going to fight.<br />
BDU<br />
BSA<br />
BVM<br />
CAM<br />
CANA<br />
cc<br />
cc/hr<br />
cm<br />
cm H 2 O<br />
CMS<br />
CNS<br />
battle dress uniform<br />
body surface area<br />
bag-valve-mask<br />
chemical agent monitor<br />
convulsant antidote for nerve agents<br />
cubic centimeter<br />
cubic centimeters of fluid per hour<br />
centimeter<br />
centimeter of water<br />
Centralized Materiel Service/Section (depends on use)<br />
central nervous system<br />
Collective training<br />
Training, either in institutions or units, that prepares cohesive teams and units to accomplish<br />
their missions on the battlefield and in operations other than war.<br />
Common task<br />
A critical task that is performed by every soldier in a specific skill level regardless of MOS.<br />
Glossary-1
STP 8-91W15-SM-TG<br />
COPD<br />
CPR<br />
chronic obstructive pulmonary disease<br />
cardiopulmonary resuscitation<br />
Critical task<br />
A collective or individual task determined to be essential to wartime mission, duty<br />
accomplishment, or survivability. Critical individual tasks are trained in the training base and/or<br />
unit, and they are reinforced in the unit.<br />
Cross training<br />
The systematic training of soldiers on tasks related to another duty position.<br />
CSF<br />
DCS<br />
DTR<br />
EKG<br />
ET<br />
F<br />
FMC<br />
FROPVD<br />
gtts<br />
HTH<br />
I & O<br />
IAW<br />
ID<br />
IM<br />
cerebrospinal fluid<br />
division clearing station<br />
deep tendon reflex<br />
electrocardiogram/electrocardiograph<br />
endotracheal/endotracheal tube/evebt template (depends on<br />
use)<br />
Fahrenheit<br />
field medical card<br />
flow-restricted oxygen-powered ventilation device<br />
drops<br />
high test hypochlorite<br />
intake and output<br />
in accordance with<br />
identification; infantry division<br />
intramuscular<br />
Individual training<br />
Training which prepares the soldier to perform specified duties or tasks related to assigned duty<br />
position or subsequent duty positions and skill level.<br />
Integration training<br />
The completion of initial entry training in skill level 1 tasks for an individual newly arrived in a<br />
unit, but limited specifically to tasks associated with the mission, organization, and equipment of<br />
the unit to which the individual is assigned. It may be conducted by the unit using training<br />
materials supplied by the school, by troop schools, or by inservice or contract mobile training<br />
teams. In all cases, this training is supported by the school proponent.<br />
Glossary-2
STP 8-91W15-SM-TG<br />
IV<br />
JVD<br />
KED<br />
kg<br />
KVO<br />
LPM<br />
LZ<br />
MD<br />
MDI<br />
MEDEVAC<br />
MES<br />
METL<br />
intravenous<br />
jugular vein distention<br />
Kendrick Extrication Device<br />
kilogram(s)<br />
keep the vein open<br />
liters per minute<br />
landing zone<br />
medical doctor<br />
metered dose inhaler<br />
medical evacuation<br />
medical equipment set(s)<br />
mission essential task list<br />
Mission essential task list<br />
A compilation of collective mission essential tasks which must be successfully performed if an<br />
organization is to accomplish its wartime mission(s).<br />
ml<br />
mm Hg<br />
mm/sec<br />
MOPP<br />
MOS<br />
MOSC<br />
MRE<br />
MTF<br />
MVA<br />
NATO<br />
NBC<br />
NCO<br />
milliliter<br />
millimeters of mercury<br />
millimeters per second<br />
mission-oriented protective posture<br />
military occupational specialty<br />
military occupational specialty code<br />
meal, ready to eat<br />
medical treatment facility<br />
motor vehicle accident<br />
North Atlantic Treaty Organization<br />
nuclear, biological, and chemical<br />
noncommissioned officer<br />
Glossary-3
STP 8-91W15-SM-TG<br />
NPO<br />
PA<br />
PASG<br />
PEA<br />
ppm<br />
prn<br />
psi<br />
PVC<br />
ROM<br />
RTO<br />
nothing by mouth<br />
physician assistant<br />
pneumatic anti-shock garments<br />
pulseless electrical activity<br />
parts per million<br />
as necessary<br />
pounds per square inch<br />
premature ventricular contraction<br />
range of motion<br />
radio/telephone operator<br />
Self-Development<br />
Self-development is a planned, progressive, and sequential program followed by leaders to<br />
enhance and sustain their military competencies. Self-development consists of individual study,<br />
research, professional reading, practice, and self-assessment.<br />
SL<br />
SM<br />
SMCT<br />
SOP<br />
SQ<br />
SSN<br />
STAT<br />
STB<br />
skill level<br />
soldier's manual<br />
soldier's manual of common tasks<br />
standing operating procedures<br />
subcutaneous<br />
social security number<br />
immediately<br />
supertropical bleach<br />
Sustainment training.<br />
The provision of training to maintain the minimum acceptable level of proficiency required to<br />
accomplish a critical task.<br />
TG<br />
TKO<br />
trainer's guide<br />
to keep open<br />
Glossary-4
STP 8-91W15-SM-TG<br />
Train-up<br />
The process of increasing the skills and knowledge of an individual to a higher skill level in the<br />
appropriate MOS. It may involve certification.<br />
Unit training<br />
Training (individual, collective, and joint or combined) conducted in a unit.<br />
WP<br />
white phosphorus<br />
Glossary-5
STP 8-91W15-SM-TG<br />
REFERENCES<br />
New reference material is being published all the time. Present references, as listed below may<br />
become obsolete. To keep up-to-date, see DA Pam 25-30. Many of these publications and<br />
forms are available in electronic format from the sites listed below:<br />
U.S. Army Publishing Agency<br />
Administrative Departmental Publications and Forms<br />
(ARs, Cirs, Pams, OFs, SFs, DD & DA Forms)<br />
General Dennis J. Reimer Training and Doctrine Digital Library (RDL)<br />
Army Doctrinal and Training Publications<br />
(FMs, PBs, TCs, STPs)<br />
Required Publications<br />
Required publications are sources that are listed in task conditions statements and are required<br />
for the soldier to perform the task.<br />
Department of Army Forms<br />
DA FORM 3949<br />
Controlled Substances Record<br />
DA FORM 4678<br />
Therapeutic Documentation Care Plan (Medication)<br />
Other Product Types<br />
DD FORM 1380<br />
DD FORM 792<br />
OF 520<br />
SF 511<br />
SF 518<br />
US Field Medical Card<br />
Twenty-Four Hour Patient Intake and Output Worksheet<br />
Medical Record--Electrocardiographic Record<br />
Medical Record - Vital Signs Record<br />
Medical Record--Blood or Blood Component Transfusion<br />
Related Publications<br />
Related publications are sources of additional information. They are not required in order to<br />
perform the tasks in this manual.<br />
Army Regulations<br />
AR 40-66<br />
Medical Record Administration and Healthcare Documentation<br />
3 May 1999<br />
Department of Army Forms<br />
DA FORM 2028<br />
Recommended Changes to Publications and Blank Forms<br />
DA FORM 5164-R Hands-On Evaluation<br />
DA FORM 5165-R Field Expedient Squad Book<br />
Department of Army Pamphlets<br />
DA PAM 350-59 Army Correspondence Course Program Catalog 1 October 2000<br />
References-1
STP 8-91W15-SM-TG<br />
Field Manuals<br />
FM 21-60 Visual Signals 30 September 1987<br />
FM 25-100 Training the Force 15 November 1988<br />
FM 25-101 Battle Focused Training 30 September 1990<br />
FM 57-38 Pathfinder Operations 9 April 1993<br />
FM 7-8 Infantry Rifle Platoon and Squad 22 April 1992<br />
FM 8-10 Health Service Support in a Theater of Operations 1 March 1991<br />
FM 8-10-6<br />
Medical Evacuation in a Theater of Operations: Tactics,<br />
Techniques, and Procedures 14 April 2000<br />
Other Product Types<br />
BASIC NURSING Rosdahl, Textbook of Basic Nursing, 6th Edition, Lippincott 1<br />
August 1997<br />
BTLS FOR PARAMEDICS Campbell, Basic Trauma Life Support for Paramedics and Other<br />
Advanced Providers, 4th Edition, Prentice Hall. 1 August 1999<br />
EMERGENCY CARE O'Keefe (Editor), Brady Emergency Care, 8th Edition, Prentice<br />
Hall 1 July 1997<br />
Soldier Training Publications<br />
COMMON CORE Common Core Tasks - General Dennis J. Reimer Training and<br />
Doctrine Digital Library (http://155.217.58.58/atdls.htm)<br />
STP 21-1-SMCT Soldier's Manual of Common Tasks (Skill Level 1) 1 October 2001<br />
STP 21-24-SMCT Soldier's Manual of Common Tasks (Skill Levels 2-4) 1 October<br />
2001<br />
Training Circulars<br />
TC 8-800<br />
Semi-Annual Combat Medic Skills Validation Test (SACMS-VT)<br />
(to be published)<br />
References-2
STP 8-91W15-SM-TG<br />
10 October 2001<br />
By Order of the Secretary of the Army:<br />
ERIC K. SHINSEKI<br />
General, United States Army<br />
Chief of Staff<br />
Official:<br />
JOEL B. HUDSON<br />
Administrative Assistant to the<br />
Secretary of the Army<br />
0130601<br />
DISTRIBUTION:<br />
Active Army, Army National Guard, and US Army Reserve: Not to be distributed. To be<br />
published by electronic means only.