Appendix E
Psychomotor Skills Evaluations

The following skill evaluation instruments were developed by the National Registry of EMTs. They are in draft format and have not yet been approved for usage in Advanced Level National Registry examinations.

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

PATIENT ASSESSMENT-TRAUMA

NOTE: Areas denoted by A**@ may be integrated within sequence of Initial Assessment

Possible Points

Points Awarded

Takes or verbalizes body substance isolation precautions

1

 

SCENE SIZE-UP

Determines the scene/situation is safe

1

 

Determines the mechanism of injury/nature of illness

1

 

Determines the number of patients

1

 

Requests additional help if necessary

1

 

Considers stabilization of spine

1

 

INITIAL ASSESSMENT/RESUSCITATION

Verbalizes general impression of the patient

1

 

Determines responsiveness/level of consciousness

1

 

Determines chief complaint/apparent life-threats

1

 

Airway

-Opens and assesses airway (1 point) -Inserts adjunct as indicated (1 point)

2

 

Breathing
-Assess breathing (1 point)
-Assures adequate ventilation (1 point)
-Initiates appropriate oxygen therapy (1 point)
-Manages any injury which may compromise breathing/ventilation (1 point)

4

 

Circulation
-Checks pulse (1 point)
-Assess skin (either skin color, temperature or condition) (1 point)
-Assesses for and controls major bleeding if present (1 point)
-Initiates shock management (1 point)

4

 

Identifies priority patients/makes transport decision

1

 

FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID TRAUMA ASSESSMENT

Selects appropriate assessment

1

 

Obtains, or directs assistant to obtain, baseline vital signs

1

 

Obtains SAMPLE history

1

 

DETAILED PHYSICAL EXAMINATION

Head
-Inspects mouth**, nose**, and assesses facial area (1 point)
-Inspects and palpates scalp and ears (1 point)
-Assesses eyes for PEARRL **(1 point)

3

 

Neck**
-Checks position of trachea (1 point)
-Checks jugular veins (1 points)
-Palpates cervical spine (1 point)

3

 

Chest **
-Inspects chest (1 point)
-Palpates chest (1 point)
-Auscultates chest (1 point)

3

 

Abdomen/pelvis**
-Inspects and palpates abdomen (1 point)
-Assesses pelvis (1 point)
-Verbalizes assessment of genitalia/perineum as needed (1 point)

3

 

Lower extremities **
-Inspects, palpates, and assesses motor, sensory and circulatory functions (1 point/leg)

2

 

Upper extremities
-Inspects, palpates, and assesses motor, sensory, and circulatory functions (1 point/arm)

2

 

Posterior thorax, lumbar, and buttocks**
-Inspects and palpates posterior thorax (1 point)
-Inspects and palpates lumbar and buttocks area (1 point)

2

 

Manages secondary injuries and wounds appropriately (1 point/injury or wound)

1

 

Ongoing assessment (1 point)

1

 

TOTAL

43

 

CRITICAL CRITERIA
____ Failure to initiate or call for transport of the patient within 10 minute time limit
____ Failure to take or verbalize body substance isolation precautions
____ Failure to determine scene safety
____ Failure to assess for and provide spinal protection when indicated
____ Failure to voice and ultimately provide high concentration of oxygen
____ Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)
____ Failure to differentiate patient=s need for immediate transportation versus continued assessment and treatment at the scene
____ Does other detailed or focused history or physical examination before assessing and treating threats to airway, breathing and circulation
____ Orders a dangerous or inappropriate intervention

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

PATIENT ASSESSMENT-MEDICAL

Possible Points

Points Awarded
Takes or verbalizes body substance isolation precautions

1

SCENE SIZE-UP

Determines the scene/situation is safe

1

Determines the mechanism of injury/nature of illness

1

Determines the number of patients

1

Requests additional help if necessary

1

Considers stabilization of spine

1

INITIAL ASSESSMENT

Verbalizes general impression of the patient
Determines responsiveness/level of consciousness

1

Determines chief complaint/apparent life-threats

1

Assesses airway and breathing
-Assessment (1 point)
-Assures adequate ventilation of patient (1 point)
-Initiates appropriate oxygen therapy (1 point)

3

Assesses circulation
-Assesses/controls major bleeding (1 point)
-Assesses skin (either skin color, temperature or condition) (1 point)
-Assesses pulse (1 point)

3

Identifies priority patients/makes transport decision

1

FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT

History of present illness
-Onset (1 point) -Severity (1 point)
-Provocation (1 point) -Time (1 point)
-Quality (1 point) -Clarify questions (2 points)
-Radiation (1 point)

8

Past medical history
-Allergies (1 point) -Last oral intake (1 point)
-Medications (1 point) -Events leading to present illness (1 point)
-Past pertinent history (1 point)

5

Performs focused physical examination (assess affected body part/system or, if indicated, completes rapid assessment)
-Cardiovascular -Integumentary
-Pulmonary -GI/GU
-Neurological -Reproductive
-Musculoskeletal -Psychological/Social

5

Vital signs
-Pulse (1 point) -Respiratory rate & quality (1 point each)
-Blood pressure (1 point) -AVPU (1 point)

5

Diagnostics

2

States field impression of patient

1

Verbalizes treatment plan for patient and calls for appropriate intervention(s)

1

Transport decision re-evaluated

1

ON-GOING ASSESSMENT

Repeats initial assessment

1

Repeats vital signs

1

Evaluates response to treatments

1

Repeats focused assessment regarding patient complaint or injuries

1

TOTAL

48

CRITICAL CRITERIA
_____ Failure to take or verbalize body substance isolation precautions
_____ Failure to determine scene safety
_____ Failure to voice and ultimately provide appropriate oxygen therapy
_____ Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)
_____ Failure to differentiate patient’s need for immediate transportation versus continued assessment and treatment at the scene
_____ Does other detailed or focused history or physical examination before assessing and treating threats to airway, breathing and circulation
_____ Failure to determine the patient’s primary problem
_____ Orders a dangerous or inappropriate intervention


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

VENTILATORY MANAGEMENT (ET) 

NOTE: If candidate elects to ventilate initially with BVM attached to reservoir and oxygen, full credit must be awarded for attempts denoted "**" so long as first ventilation is delivered within initial 30 seconds.

Possible Points

Points Awarded
Takes or verbalizes body substance isolation precautions

1

Opens the airway manually

1

Elevates tongue, inserts simple adjunct (oropharyngeal or nasopharyngeal airway)

1

NOTE: Examiner now informs candidate no gag reflex is present and patient accepts adjunct
**Ventilates patient immediately with bag-valve-mask device unattached to oxygen

1

**Hyperventilates patient with room air

1

NOTE: Examiner now informs candidate that ventilation is being performed without difficulty and that pulse oximetry indicates the patient’s blood oxygen saturation is 85%
Attaches oxygen reservoir to bag-valve-mask device and connects to high flow oxygen regulator (12-15 L/minute)

1

Ventilates patient at a rate of 10-20/minute with volumes of at least 800 ml

1

NOTE: After 30 seconds, examiner auscultates and reports breath sounds are present, equal bilaterally and medical direction has ordered intubation. The examiner must now take over ventilation.
Directs assistant to hyperventilate patient

1

Identifies/selects proper equipment for intubation

1

Checks equipment for: - Cuff leaks (1 point)
-Laryngoscope operational with bulb tight (1 point)

2

NOTE: Examiner to remove OPA and moves out of the way when candidate is prepared to intubate
Positions head properly

1

Inserts blade while displacing tongue

1

Elevates mandible with laryngoscope

1

Introduces ET tube and advances to proper depth

1

Inflates cuff to proper pressure and disconnects syringe

1

Directs ventilation of patient

1

Confirms proper placement by auscultation bilaterally over each lung and over epigastrium

1

NOTE: Examiner to ask, "If you had proper placement what should you expect to hear?
Secures ET tube (may be verbalized)

1

NOTE: Examiner now asks candidate, "Please demonstrate one additional method of verifying proper tube placement in this patient."
Identifies/selects proper equipment

1

Verbalizes findings and interpretations (Compares indicator color to the colormetric scales and states reading to examiner)

1

NOTE: Examiner now states, "You see thick fluid in the tube and hear gurgling sounds with the patient’s exhalation."
Identifies/selects a flexible suction catheter

1

Pre-oxygenates patient

1

Marks maximum insertion length with thumb and forefinger

1

Inserts catheter into the ET tube leaving catheter port open

1

At proper insertion depth, covers catheter port and applies suction while withdrawing catheter

1

Ventilates/directs ventilation of patient as catheter is flushed with sterile water

1

TOTAL

27

CRITICAL CRITERIA
_____ Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for greater than 30 seconds at any time
_____ Failure to take or verbalize body substance isolation precautions
_____ Failure to voice and ultimately provide high oxygen concentrations (at least 85%)
_____ Failure to ventilate patient at a rate of at least 10/minute
_____ Failure to provide adequate volumes per breath (maximum 2 errors/minute permissible)
_____ Failure to pre-oxygenate patient prior to intubation and suctioning
_____ Failure to successfully intubate within 3 attempts
_____ Failure to disconnect syringe immediately after inflating cuff of ET tube
_____ Use of teeth as a fulcrum
_____ Failure to assure proper tube placement by auscultation bilaterally and over the epigastrium
_____ If used, stylette extends beyond end of the ET tube
_____ Inserts any adjunct in a manner dangerous to the patient
_____ Suctioning the patient for more than 15 seconds
_____ Does not suction the patient

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

CARDIAC ARREST SKILLS STATION
DYNAMIC CARDIOLOGY 

Possible Points

Points Awarded
Takes or verbalizes infection control precautions

1

Checks level of responsiveness

1

Checks ABC’s

1

Initiates CPR if appropriate (verbally)

1

Performs "Quick Look" with paddles

1

Correctly interprets initial rhythm

1

Appropriately manages initial rhythm

2

Notes change in rhythm

1

Checks patient condition to include pulse and, if appropriate, BP

1

Correctly interprets second rhythm

1

Appropriately manages second rhythm

2

Notes change in rhythm

1

Checks patient condition to include pulse and, if appropriate, BP

1

Correctly interprets third rhythm

1

Appropriately manages third rhythm

2

Notes change in rhythm

1

Checks patient condition to include pulse and, if appropriate, BP

1

Correctly interprets fourth rhythm

1

Appropriately manages fourth rhythm

2

Orders high percentages of supplemental oxygen at proper times

1

TOTAL

24

CRITICAL CRITERIA
____ Failure to deliver first shock in a timely manner due to operator delay in machine use or providing treatments other than CPR with simple adjuncts
____ Failure to deliver second or third shocks without delay other than the time required to reassess and recharge paddles
____ Failure to verify rhythm before delivering each shock
____ Failure to ensure the safety of self and others (verbalizes "All clear" and observes)
____ Inability to deliver DC shock (does not use machine properly)
____ Failure to demonstrate acceptable shock sequence
____ Failure to order initiation or resumption of CPR when appropriate
____ Failure to order correct management of airway (ET when appropriate)
____ Failure to order administration of appropriate oxygen at proper time
____ Failure to diagnose or treat 2 or more rhythms correctly
____ Orders administration of an inappropriate drug or lethal dosage
____ Failure to correctly diagnose or adequately treat v-fib, v-tach, or asystole


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

CARDIAC ARREST SKILLS STATION
STATIC CARDIOLOGY

NOTE: Only document incorrect responses in spaces provided

Possible Points

Points Awarded
STRIP #1
Diagnosis:

1

Treatment:

2

STRIP #2
Diagnosis:

1

Treatment:

2

STRIP #3
Diagnosis:

1

Treatment:

2

STRIP #4
Diagnosis:

1

Treatment:

2

TOTAL

12


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

INTRAVENOUS THERAPY

Possible Points

Points Awarded
Checks selected IV fluid for:
-Proper fluid (1 point)
-Clarity (1 point)

2

Selects appropriate catheter

1

Selects proper administration set

1

Connects IV tubing to the IV bag

1

Prepares administration set (fills drip chamber and flushes tubing)

1

Cuts or tears tape (at any time before venipuncture)

1

Takes/verbalizes infection control precautions (prior to venipuncture)

1

Applies tourniquet

1

Palpates suitable vein

1

Cleanses site appropriately

1

Performs venipuncture
-Inserts stylette (1 point)
-Notes or verbalizes flashback (1 point)
-Occludes vein proximal to catheter (1 point)
-Removes stylette (1 point)
-Connects IV tubing to catheter (1 point)

5

Releases tourniquet

1

Runs IV for a brief period to assure patient line

1

Secures catheter (tapes securely or verbalizes)

1

Adjusts flow rate as appropriate

1

Disposes/verbalizes disposal of needle in proper container

1

TOTAL

21

CRITICAL CRITERIA
_____ Exceeded the 6 minute time limit in establishing a patent and properly adjusted IV
_____ Failure to take or verbalize infection control precautions prior to performing venipuncture
_____ Contaminates equipment or site without appropriately correcting situation
_____ Any improper technique resulting in the potential for catheter shear or air embolism
_____ Failure to successfully establish IV within 3 attempts during 6 minute time limit
_____ Failure to dispose/verbalize disposal of needle in proper container


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

EXTERNAL JUGULAR VEIN CANNULATION 

Possible Points

Points Awarded

Checks selected IV fluid for:
-Proper fluid (1 point)
-Clarity (1 point)

2

Selects appropriate catheter

1

Selects appropriate administration set

1

Connects IV tubing to IV bag

1

Prepares administration set (fills drip chamber and flushed tubing)

1

Cuts or tears tape (prior to venipuncture)

1

Takes/verbalizes body substance isolation precautions prior to venipuncture

1

Distends jugular vein

1

Cleanses the puncture site

1

Performs venipuncture:
-Inserts stylette (1 point)
-Notes or verbalizes flashback (1 point)
-Occludes vein proximal to catheter (1 point)
-Removes stylette (1 point)

4

Connects IV tubing to catheter

1

Runs IV for brief period to assure patent line

1

Secures catheter (tapes securely or verbalizes)

1

Adjusts flow rate as appropriate

1

Disposes of needle in proper container

1

TOTAL

19

CRITICAL CRITERIA
____ Exceeded the 6 minute time limit in establishing a patent and properly adjusted IV
____ Failure to take or verbalize infection control precautions prior to performing venipuncture
____ Contaminates equipment or site without appropriately correcting the situation
____ Any improper technique resulting the potential for catheter shear or air embolism
____ Inserts catheter against flow of blood
____ Failure to successfully establish an IV within 3 attempts during the 6 minute time limit
____ Failure to dispose of needle in proper container


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

INTRAVENOUS BOLUS MEDICATIONS

NOTE: Check here (___) if candidate did not establish a patent IV and do not evaluate these skills.

Possible Points

Points Awarded
Asks patient for known allergies

1

Selects correct medication

1

Assures correct concentration of drug

1

Assembles prefilled syringe correctly and dispels air

1

Continues infection control precautions

1

Cleanses injection site (Y-port or hub)

1

Reaffirms medication

1

Stops IV flow (pinches tubing)

1

Administers correct dose at proper push rate

1

Flushes tubing (runs wide open for a brief period)

1

Adjusts drip rate to TKO (KVO)

1

Voices proper disposal of syringe and needle

1

Verbalizes need to observe patient for desired effect/adverse side effects

1

IV BOLUS SUB-TOTAL

13

CRITICAL CRITERIA
____ Failure to begin administration of medication within 3 minute time limit
____ Contaminates equipment or site without appropriately correcting situation
____ Failure to adequately dispel air resulting in potential for air embolism
____ Injects improper drug or dosage (wrong drug, incorrect amount, or pushes at inappropriate rate)
____ Failure to flush IV tubing after injecting medication
____ Recaps needle or failure to dispose/verbalize disposal of syringe and needle in proper container


INTRAVENOUS PIGGYBACK MEDICATIONS

Possible Points

Points Awarded
Has confirmed allergies by now (award point if previously confirmed)

1

Checks selected IV fluid for:
-Proper fluid (1 point)
-Clarity (1 point)

2

Checks selected medication for:
-Clarity (1 point)
-Concentration of medication (1 point)

2

Injects correct amount of medication into IV solution given scenario

1

Connects appropriate administration set to medication solution

1

Prepares administration set (fills drip chamber and flushes tubing)

1

Attaches appropriate needle to administration set

1

Continues infection control precautions

1

Cleanses port of primary line

1

Inserts needle into port without contamination

1

Adjusts flow rate of secondary line as required

1

Stops flow of primary line

1

Securely tapes needle

1

Verbalizes need to observe patient for desired effect/adverse side effects

1

Labels medication/fluid bag

1

IV PIGGYBACK SUB-TOTAL

17

CRITICAL CRITERIA
____ Failure to begin administration of medication within 5 minute time limit
____ Contaminates equipment or site without appropriate correcting situation
____ Administers improper drug or dosage (wrong drug, incorrect amount, or infuses at inappropriate rate)
____ Failure to flush IV tubing of secondary line resulting in potential for air embolism
____ Failure to shut-off flow primary line

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

INTRAMUSCULAR/SUBCUTANEOUS MEDICATION ADMINISTRATION

Possible Points

Points Awarded
Confirms the verbal order

1

Explains procedure to patient

1

Takes/verbalizes body substance isolation precautions prior to administration of medication

1

Checks for known allergies, contraindications, or incompatibilities

1

Checks medication for:
-Correctness (1 point)
-Clarity (1 point)
-Expiration date (1 point)
-Concentration (1 point)

4

Selects proper equipment

1

Draws up appropriate amount of medication

1

Identifies proper site for injection

1

Cleanses site appropriately

1

Introduces needle at appropriate angle with bevel up

1

Aspirates for blood return

1

Administers medication

1

Withdraws needle and dresses the injection site

1

Disposes of syringe and needle in proper container

1

Verbalizes need to observe patient for desired/adverse side effects

1

Voices proper documentation of medication administration

1

TOTAL

19

CRITICAL CRITERIA
____
Failure to administer medication within 3 minute time limit
____ Failure to take or verbalize body substance isolation precautions
____ Contaminates equipment or site without appropriately correcting the situation
____ Administers improper medication or dosage (wrong drug, incorrect amount, or pushes at an inappropriate rate)
____ Technique or equipment utilized would have resulted in medication being deposited into wrong tissue
____ Failure to dispose of needle and syringe in proper container

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

ENDOTRACHEAL MEDICATION ADMINISTRATION

Possible Points

Points Awarded
Confirms the verbal order

1

Takes/verbalizes body substance isolation precautions prior to administration of medication

1

Checks for known allergies, contraindications and incompatibilities

1

Checks medication for:
-Correctness (1 point)
-Clarity (1 point)
-Expiration date (1 point)
-Concentration (1 point)

4

Selects proper equipment to administer medication deeply into tracheobronchial tree

1

Prepares medication

1

Pre-oxygenates patient

1

Injects medication

1

Resumes ventilation of patient

1

Disposes of syringe and needle into proper container

1

Verbalizes need to observe patient for desired/adverse side effects

1

Voices proper documentation of medication administration

1

TOTAL

15

CRITICAL CRITERIA
____ Failure to administer medication within 3 minute time limit
____ Failure to take or verbalize body substance isolation precautions
____ Contaminates equipment or site without appropriately correcting the situation
____ Administers improper medication or dosage (wrong drug or incorrect amount )
____ Technique did not deliver medication in a manner to provide for deep tracheal absorption
____ Failure to appropriately adjust the concentration or increase the dose
____ Interruption of ventilations for greater than 30 seconds at any time
____ Failure to dispose of needle and syringe in proper container

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

AEROSOLIZED MEDICATION ADMINISTRATION

Possible Points

Points Awarded
Confirms the verbal order

1

Explains procedure to patient

1

Takes/verbalizes body substance isolation precautions prior to administration of medication

1

Checks for known allergies, contraindications and incompatibilities

1

Checks medication for:
-Correctness (1 point)
-Clarity (1 point)
-Expiration date (1 point)
-Concentration (1 point)

4

Selects proper equipment

1

Unscrews lid on nebulizer to expose medication cup

1

Adds appropriate amount of medication to cup and reattaches lid

1

Attaches mouthpiece and any extension tube to nebulizer

1

Attaches oxygen supply to nebulizer cup and adjusts oxygen flow to create a fine mist of medication

1

Coaches patient to breathe deeply through the mouth until all liquid is used

1

Verbalizes need to observe patient for desired/adverse side effects

1

Disposes of treatment delivery system into proper container

1

Voices proper documentation of medication administration

1

TOTAL

17

CRITICAL CRITERIA
____ Failure to begin administration of the medication within 3 minute time limit
____ Failure to take or verbalize body substance isolation precautions
____ Contaminates equipment without appropriately correcting the situation
____ Administers improper medication or dosage (wrong drug or incorrect amount)
____ Technique did not deliver medication in a manner to provide for adequate absorption
____ Failure to dispose of delivery system in proper container

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

PEDIATRIC (<2 yrs.) VENTILATORY MANAGEMENT (ET

NOTE: If candidate elects to ventilate initially with BVM attached to reservoir and oxygen, full credit must be awarded for steps denoted by "**" so long as first ventilation is delivered within initial 30 seconds.

Possible Points

Points Awarded

Takes or verbalizes body substances isolation precautions

1

Opens the airway manually

1

Elevates tongue, inserts simple adjunct (oropharyngeal or nasopharyngeal airway)

1

NOTE: Examiner now informs candidate no gag reflex is present and patient accept adjunct
**Ventilates patient immediately with bag-valve-mask device unattached to oxygen

1

**Hyperventilates patient with room air

1

NOTE: Examiner now informs candidate that ventilation is being performed without difficulty and that pulse oximetry indicates the patient’s blood oxygen saturation is 85%
Attaches oxygen reservoir to bag-valve-mask device and connects to high flow oxygen regulator (12-15 L/min)

1

Ventilates patient at a rate of 20/minute and assures adequate chest expansion

1

NOTE: After 30 seconds, examiner auscultates and reports breath sounds are present, equal bilaterally and medical direction has ordered intubation. The examiner must now take over ventilation.
Directs assistant to pre-oxygenate patient

1

Identifies/selects proper equipment for intubation

1

Checks laryngoscope to assure operational with bulb tight

1

NOTE: Examiner to remove OPA and moves out of the way when candidate is prepared to intubate
Places patient in neutral or sniffing position

1

Inserts blade while displacing tongue

1

Elevates mandible with laryngoscope

1

Introduces ET tube and advances to proper depth

1

Directs ventilation of patient

1

Confirms proper placement by auscultation bilaterally over each lung and over epigastrium

1

NOTE: Examiner to ask, "If you had proper placement, what should you expect to hear?"
Secures ET tube (may be verbalized)

1

TOTAL

17

CRITICAL CRITERIA
____ Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for greater than 30 seconds at any time
____ Failure to take or verbalize body substance isolation precautions
____ Failure to voice and ultimately provide high oxygen concentrations (at least 85%)
____ Failure to ventilate patient at a rate of at least 20/minute
____ Failure to provide adequate volumes per breath (maximum 2 errors/minute permissible)
____ Failure to pre-oxygenate patient prior to intubation
____ Failure to successfully intubate within 3 attempts
____ Use of gums as a fulcrum
____ Failure to assure proper tube placement by auscultation bilaterally and over the epigastrium
____ Inserts any adjunct in a manner dangerous to the patient
____ Attempts to use any equipment not appropriate for the pediatric patient

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

INTRAOSSEOUS INFUSION

Possible Points

Points Awarded
Checks selected IV fluid for:
-Proper fluid (1 point)
-Clarity (1 point)
-Expiration date (1 point)

3

Selects appropriate equipment to include:
-IO needle (1 point)
-Syringe (1 point)
-Saline (1 point)
-Extension (1 point)

4

Selects proper administration set

1

Connects administration set to bag

1

Prepares administration set (fills drip chamber and flushes tubing)

1

Prepares syringe and extension tubing

1

Cut or tears tape (at any time before IO puncture)

1

Takes or verbalizes body substance isolation precautions (prior to IO puncture)

1

Identifies proper anatomical site for IO puncture

1

Cleanses site appropriately

1

Performs IO puncture:
-Stabilizes tibia (1 point)
-Inserts needle at proper angle (1 point)
-Advances needle with twisting motion until "pop" is felt (1 point)
-Unscrews cap and removes stylette from needle (1 point)

4

Attaches syringe and extension set to IO needle

1

Slowly injects saline to assure proper placement of needle

1

Connects administration set and adjusts flow rate as appropriate

1

Secures needle with tape and supports with bulky dressing

1

Disposes of needle in proper container

1

TOTAL

24

CRITICAL CRITERIA
____ Failure to establish a patent and properly adjusted IO line within the 6 minute time limit
____ Failure to take or verbalize body substance isolation precautions prior to performing IO puncture
____ Contaminates equipment or site without appropriately correcting situation
____ Any improper technique resulting in the potential for air embolism
____ Failure to assure correct needle placement before attaching administration set
____ Failure to successfully establish IO infusion within 2 attempts during 6 minute time limit
____ Performing IO puncture in an unacceptable manner (improper puncture site, incorrect needle angle, etc.)
____ Failure to dispose of needle in proper container

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

NASOGASTRIC TUBE INSERTION

Possible Points

Points Awarded
Takes or verbalizes body substance isolation precautions

1

Explains procedure to patient

1

Measures and marks NG tube to proper length

1

Positions patient in upright or semi-sitting position

1

Lubricates distal 3-6" of tube

1

Slightly flexes patient’s head

1

Inserts tube into widest nostril and advances straight back until tube is visible in oropharynx

1

Instructs patient to repeatedly swallow or sip water while continuing to advance tube

1

Inserts tube until mark reaches outer edge or nostril

1

Injects 20-35 ml of air into tube while auscultating epigastrium to confirm proper placement

1

Secures tube

1

TOTAL

11

CRITICAL CRITERIA
____ Failure to take or verbalize body substance isolation precautions
____ Failure to explain procedure to patient before attempting to place tube
____ Failure to measure and mark NG tube to proper length prior to insertion
____ Failure to verify proper placement by auscultation over the epigastrium
____ Attempts to insert NG tube in a manner dangerous to patient

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

SPINAL IMMOBILIZATION
SEATED PATIENT

Points Possible

Points Awarded
Takes, or verbalizes, body substance isolation precautions

1

Directs assistant to place/maintain head in the neutral in-line position

1

Directs assistant to maintain manual immobilization of the head

1

Reassesses motor, sensory and circulatory function in each extremity

1

Applies appropriately sized extrication collar

1

Positions the immobilization device behind the patient

1

Secures the device to the patient’s torso

1

Evaluates torso fixation and adjusts as necessary

1

Evaluates and pads behind the patient’s head as necessary

1

Secures the patient’s head to the device

1

Verbalizes moving the patient to a long board

1

Reassesses motor, sensory and circulatory function in each extremity

1

TOTAL

12

CRITICAL CRITERIA
____ Did not immediately direct, or take, manual immobilization of the head
____ Released, or ordered release of, manual immobilization before it was maintained mechanically
____ Patient manipulated, or moved excessively, causing potential spinal compromise
____ Device moved excessively up, down, left or right on the patient’s torso
____ Head mobilization allows for excessive movement
____ Torso fixation inhibits chest rise, resulting in respiratory compromise
____ Upon completion of immobilization, head is not in the neutral position
____ Did not assess motor, sensory and circulatory function in each extremity after voicing immobilization to the long board
____ Immobilized head to the board before securing the torso

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

SPINAL IMMOBILIZATION
SUPINE PATIENT

Points Possible

Points Awarded
Takes, or verbalizes, body substance isolation precautions

1

Directs assistant to place/maintain head in the neutral in-line position

1

Directs assistant to maintain manual immobilization of the head

1

Reassesses motor, sensory and circulatory function in each extremity

1

Applies appropriately sized extrication collar

1

Positions the immobilization device appropriately

1

Directs movement of the patient onto the device without compromising the integrity of the spine

1

Applies padding to voids between the torso and the board as necessary

1

Immobilizes the patient’s torso to the device

1

Evaluates and pads behind the patient’s head as necessary

1

Immobilizes the patient’s head to the device

1

Secures the patient’s legs to the device

1

Secures the patient’s arms to the device

1

Reassesses motor, sensory and circulatory function in each extremity

1

TOTAL

14

CRITICAL CRITERIA
____ Did not immediately direct, or take, manual immobilization of the head
____ Released, or ordered release of, manual immobilization before it was maintained mechanically
____ Patient manipulated, or moved excessively, causing potential spinal compromise
____ Patient moves excessively up, down, left or right on the patient’s torso
____ Head immobilization allows for excessive movement
____ Upon completion of immobilization, head is not the neutral position
____ Did not assess motor, sensory and circulatory function in each extremity after immobilization to the device
____ Immobilized head to the board before securing the torso

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

BLEEDING CONTROL/SHOCK MANAGEMENT
 

Points Possible

Points Awarded
Takes, or verbalizes, body substance isolation precautions

1

Applies direct pressure to the wound

1

Elevates the extremity

1

NOTE: The examiner must now inform the candidate that the wound continues to bleed.
Applies an additional dressing to the wound

1

NOTE: The examiner must now inform the candidate that the wound still continues to bleed. The second dressing does not control the bleeding.
Locates and applies pressure to appropriate arterial pressure point

1

NOTE: The examiner must now inform the candidate that the bleeding is controlled.
Bandages the wound

1

NOTE: The examiner must now inform the candidate the patient is now showing signs and symptoms indicative of hypoperfusion.
Properly positions the patient

1

Applies high concentration oxygen

1

Initiates steps to prevent heat loss from the patient

1

Indicates the need for immediate transportation

1

TOTAL

10

CRITICAL CRITERIA
____ Did not take, or verbalize, body substance isolation precautions
____ Did not apply high concentration oxygen
____ Applied a tourniquet before attempting other methods of bleeding control
____ Did not control hemorrhage in a timely manner
____ Did not indicate a need for immediate transportation

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

MOUTH TO MASK WITH SUPPLEMENTAL OXYGEN

Points Possible

Points Awarded
Takes, or verbalizes, body substance isolation precautions

1

Connects one-way valve to mask

1

Opens patient’s airway or confirms patient’s airway is open (manually or with adjunct)

1

Establishes and maintains a proper mask to face seal

1

Ventilates the patient at the proper volume and rate (800-1200 ml per breath/10-20 breaths per minute)

1

Connects the mask to high concentration of oxygen

1

Adjusts flow rate to at least 15 liters per minute

1

Continues ventilation of the patient at the proper volume and rate (800-1200 ml per breath/10-20 breaths per minute)

1

NOTE: The examiner must witness ventilations for at least 30 seconds

TOTAL

8

CRITICAL CRITERIA
____ Did not take, or verbalize, body substance isolation precautions
____ Did not adjust liter flow to at least 15 liters per minute
____ Did not provide proper volume per breath (more than 2 ventilations per minute were below 800 ml)
____ Did not ventilate the patient at a rate a 10-20 breaths per minute
____ Did not allow for complete exhalation

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

VENTILATORY MANAGEMENT
DUAL LUMEN AIRWAY DEVICE (COMBITUBE OR PTL)

NOTE: If candidate elects to initially with BVM attached to reservoir and oxygen, full credit must be awarded for steps denoted by "**" as long as first ventilation is delivered within 30 seconds.

Possible Points

Points Awarded
Takes or verbalizes body substance isolation precautions

1

Opens the airway manually

1

Elevates tongue, inserts simple adjunct (either oropharyngeal or nasopharyngeal airway)

1

NOTE: Examiner now informs candidate no gag reflex is present and patient accepts adjunct
**Ventilates patient immediately with bag-valve-mask device unattached to oxygen

1

**Hyperventilates patient with room air

1

NOTE: Examiner now informs candidate that ventilation is being performed without difficulty
Attaches oxygen reservoir to bag-valve-mask device and connects to high flow oxygen regulator (12-15 liters/min)

1

Ventilates patient at a rate of 10-20/min and volumes of at least 800 ml

1

NOTE: After 30 seconds, examiner auscultates and reports breath sounds are present and equal bilaterally and medical control has ordered insertion of a dual lumen airway. The examiner must now take over ventilation.
Directs assistant to hyperventilate patient

1

Checks/prepares airway device

1

Lubricates distal tip of the device (may be verbalized)

1

NOTE: Examiner to remove OPA and move out of the way when candidate is prepared to insert device
Positions the head properly

1

Performs a tongue-jaw lift

1

9 USES COMBITUBE

9 USES PTL

Inserts device in mid-line and to depth so printed ring is at level of teeth Inserts device in mid-line until bite block flange is at level of teeth

1

Inflates pharyngeal cuff with proper volume and removes syringe Secures strap

1

Inflates distal cuff with proper volume and removes syringe Blows into tube #1 to adequately inflate both cuffs

1

Attaches/directs attachment of BVM to the first (esophageal placement) lumen and ventilates

1

Confirms placement and ventilation through correct lumen by observing chest rise, auscultation over the epigastrium, and bilaterally over each lung

1

NOTE: The examiner states, "You do not see rise and fall of the chest and you only hear sounds over the epigastrium."
Attaches/directs attachment of the BVM to the second (endotracheal placement) lumen and ventilates

1

Confirms placement and ventilation through correct lumen by observing chest rise, auscultation over the epigastrium and bilaterally over each lung

1

NOTE: The examiner confirms adequate chest rise, absent sounds over the epigastrium, and equal bilateral breath sounds.
Secures device or confirms that the device remains properly secured

1

TOTAL

20

CRITICAL CRITERIA
____ Failure to initiate ventilations within 30 seconds after taking body substance isolation precautions or interrupts ventilations for greater than 30                   seconds at any time
____ Failure to take or verbalize body substance isolation precautions
____ Failure to voice and ultimately provide high oxygen concentrations (at least 85%)
____ Failure to ventilate patient at rate of at least 10/minute
____ Failure to provide adequate volumes per breath (maximum 2 errors/minute permissible)
____ Failure hyperventilate patient prior to placement of the dual lumen airway device
____ Failure to insert the dual lumen airway device at a proper depth or at either proper place within 3 attempts
____ Failure to inflate both cuffs properly
____ Combitube-failure to remove syringe immediately after inflation of each cuff
        PTL-failure to secure the strap prior to cuff inflation
____ Failure to confirm that the proper lumen of the device is being ventilated by observing chest rise, auscultation over the epigastrium, and bilaterally                  over each lung
____ Inserts any adjunct in a manner dangerous to patient

 


National Registry of Emergency Medical Technicians
Advanced Level Practical Examination

VENTILATORY MANAGEMENT (EOA)

NOTE: If candidate elects to initially ventilate with BVM attached to reservoir and oxygen, full credit must be awarded for steps denoted by "**" so long as first ventilation is delivered within initial 30 seconds.

Possible Points

Points Awarded
Takes or verbalizes infection control precautions

1

Opens airway manually

1

Elevates tongue, inserts simple adjunct (either oropharyngeal or nasopharyngeal airway)

1

NOTE: Examiner now informs candidate no gag reflex is present and patient accepts adjunct
**Ventilates patient immediately with bag-valve-mask device unattached to oxygen

1

**Hyperventiliates patient with room air

1

NOTE: Examiner now informs candidate that ventilation is being performed without difficulty
Attaches oxygen reservoir to bag-valve-mask device and connects to high flow oxygen regulator (12-15 liters/min)

1

Ventilates patient at a rate of 10-20/min, and volumes of at least 800 ml

1

NOTE: After 30 seconds, examiner auscultates and reports breath sounds are present and equal bilaterally and medical control has ordered placement of an EOA. The examiner must now take over ventilation.
Directs assistant to hyperventilate patient

1

Identifies/selects proper equipment

1

Assembles airway

1

Tests cuff

1

Inflates mask

1

Lubricates tube (may be verbalized)

1

NOTE: Examiner to remove OPA and move out of way when candidate is prepared to insert EOA
Positions head properly with neck in neutral or slightly flexed position

1

Grasps tongue and mandible and elevates

1

Inserts tube in same direction as curvature of pharynx

1

Advances tube until mask sealed against face

1

Ventilates patient while maintaining tight mask seal

1

Directs confirmation of proper placement by auscultation bilaterally over epigastrium

1

Inflates cuff to proper pressure and disconnects syringe

1

Continues ventilation of patient

1

NOTE: Examiner to ask "if you had proper placement, what would you expect to hear?"

TOTAL

21

CRITICAL CRITERIA
____ Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for greater than 30 seconds at any time
____ Failure to take or verbalize infection control precautions
____ Failure to voice and ultimately provide high oxygen concentrations (at least 85%)
____ Failure to ventilate patient at a rate of at least 10/minute
____ Failure to provide adequate volumes per breath (maximum 2 errors/minute permissible)
____ Failure to hyperventilate patient prior to placement of the EOA
____ Failure to successfully place the EOA within 3 attempts
____ Failure to assure proper tube placement by auscultation bilaterally and over the epigastrium
____ Inserts any adjunct in a manner dangerous to patient