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Human Emergency Life Programme

VAT Reg. No. 4530226622

GAUTENG

Emergency Tel: 084 124 (ER24 Emergency Medical Care)


E-mail: info@helpemt.co.za
Website: www.helpemt.co.za

Reg. No. CK 1996/019225/23

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Human Emergency Life Programme


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Human Emergency Life Programme

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16 Terrace Road, Eastleigh Ridge, Edenvale


PO Box 8808, Edenglen, 1613
Tel: +27 0(86) 101-HELP ( 4357)
Fax: +27 0(86) 514-9267
Cell:+27 0(82) 338-2847

AMBULANCE EMERGENCY ASSISTANT COURSE


OSCE SKILL SHEETS
There will be eight random OSCE skill stations in your final examinations. Those eight will come from the OSCE
skills contained in this booklet.
The pass mark for the practical component of the AEA course is 100%. This means that you are not able to be
assessed as NOT YET COMPETENT for any of the OSCE skills. Should you not attain 100% for your OSCE
skills, you will not gain entrance into your final patient simulation examination.
There are thirty-four OSCE skills in this booklet, and they are, in order:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
24)
25)
26)
27)
28)
29)
30)
31)
32)
33)
34)
35)
36)

Suctioning of the Mouth and Pharynx


Use of an Oxygen Cylinder
OP Tube and BVM Ventilation
Nebulisation
Use of ENTONOX
Vital Signs: Pulse, Respirations and BP
Determination of Blood Glucose Levels
Examination of an Unconscious Patient Medical
Examination of an Unconscious Patient Trauma
Application of a Field Dressing
Use of Pressure Points
Application of a Padded Board Splint Arm Fracture
Application of a Padded Board Splint Leg Fracture
Trauma Traction Splint
Log-roll of a Patient onto a Long Spine Board
Extrication of a Patient from a Vehicle
Normal Vaginal Delivery
Breech Delivery
Intravenous Therapy
Administration of 50% Dextrose
Use of an ECG Monitor
Use of a Pulse Oximeter
Defibrillation
Needle Cricothyrotomy
Upper Airway Obstruction with Equipment
Needle Thoracentesis
Pneumatic Anti-Shock Garment (MAST Suit)
One-Man Megacode
Adult 1-Rescuer CPR
Adult 2-Rescuer CPR
Adult FBAO in Responsive Patient (and Responsive Patient who becomes Unresponsive)
Child 1-Rescuer CPR
Integrated Child FBAO (Responsive and Unresponsive Patient; CPR and Rescue Breathing)
Infant 1-Rescuer CPR
Integrated Infant FBAO (Responsive and Unresponsive Patient; CPR and Rescue Breathing)
CPR and the Use of an AED

Human Emergency Life Programme (Gauteng) cc

Members:
D J Taylor (Btech EMC), M J Taylor (A11SA)

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
COURSE:

FULL TIME

_______

DATE: _____________________
PART TIME

_______

INTERMEDIATE LIFE SUPPORT SUCTIONING OF THE MOUTH AND PHARYNX

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

PREPARATION

Candidate ensures that the patient is in the lateral


position.
Candidate prepares all required equipment:
-

Suction Unit
Suction tubing
Suction catheter (yankauer)

Candidate turns suction unit on, blocks the flow to check


suction pressure, and turns the unit off.
Candidate connects suction catheter to suction tubing,
ensuring that it is kept clean.
SUCTIONING

Candidate turns the suction unit on.


Candidate inserts catheter correct distance into the
oropharynx (only as far as candidate can see).
Candidate blocks the suction catheter opening at the
coupling member.
Candidate ensures that airway is suctioned clear while
avoiding hypoxic delay.

*
*
*
*
*
*
*
*

*
*
*
*
*
*
*
*
*

ACTIVITY

SUCTIONING
CONT.

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate only suctions on the way out.


Candidate ensures that patient is placed back on oxygen
after the airway is clear.
Candidate flushes suction unit system after use.

*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

_________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT USE OF AN OXYGEN CYLINDER

ACTIVITY
PREPARATION OF
O2 CYLINDER

APPLICATION OF
THE REGULATOR

CONNECTION OF
DELIVERY
DEVICE

CRITICAL PERFORMANCE
Candidate opens the main valve slowly until an audible
rush of oxygen is heard.
Candidate closes the main valve rapidly
Candidate checks that the regulator is the correct one for
the cylinder and that the O-ring seal is present.
Candidate applies the regulator correctly.
Candidate opens the cylinder valve slowly, keeping
his/her face clear of the gauges.
Candidate listens for and notes any leaks.

Candidate opens the flow regulator

ADJUSTMENT
Candidate selects the correct flow rate for the chosen
delivery device
Candidate correctly applies the delivery device to the
patient, after explaining the procedure.
TERMINATION OF
O2 THERAPY

*
*
*
*
*

Candidate selects the correct oxygen delivery device.

Candidate connects oxygen tubing to the cylinder and to


the delivery device.
FLOW

DONE/
NOT
DONE

*
*
*
*

Candidate removes the delivery device from the patient.


Candidate turns off the flow meter
Candidate closes the main cylinder valve.
Candidate opens the flow meter to bleed the system of
trapped oxygen.

*
*
*

ACTIVITY

TERMINATION OF
O2 THERAPY
CONT

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate closes the flow meter

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT OP TUBE and BVM VENTILATION

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness.


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Ensures that adequate ventilation and
oxygenation are in progress.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

OP TUBE
INSERTION

VENTILATION

Candidate measures airway from the corner of the mouth


to the angle of the jaw.
Candidate opens the patients mouth.
Candidate depresses patients tongue with tongue
depressor.
Candidate inserts airway with tip facing downward, and
slides it over the tongue.
Candidate ensures that the patients tongue is not
displaced posteriorly into the oropharynx.
Candidate ensures that the flange of the OPT is against
the patients lips.
Candidate removes tongue depressor.
If a gag reflex is present, candidate does not re-insert OP
tube.
If patient rejects the OP tube, candidate does not re-insert
it.
Candidate correctly checks and assembles BVMR
Candidate correctly and snugly fits mask to patients
face.
Candidate ventilates patient until chest rises.

*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*

*
*

ACTIVITY

CRITICAL PERFORMANCE
Candidate attaches O2 tubing to O2 cylinder.
Candidate attaches O2 tubing to BVMR.
Candidate opens O2 cylinder and adjusts flow rate to 1215 litres/min.
Candidate resumes ventilations.

OXYGEN

DONE/
NOT
DONE
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT NEBULISATION

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Ensures adequate oxygenation.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.

BREATHING

CIRCULATION

COMPLETION OF
RESPIRATORY
ASSESSMENT

Candidate determines the need for B2 Stimulant


nebulisation and rules out contra-indications.

*
*
*
*
*

Candidate correctly checks and assembles all equipment


required for nebulisation:
PREPARATION

- Nebuliser
- Oxygen with tubing
- Syringe and needle
- B2 Stimulants
Candidate checks drug for:

*
*
*
*

- Correct drug
- Expiry date
- Cloudiness and leaks
- Dosage of drug.
Candidate calculates dose required.
Candidate injects required drug/s into nebuliser and
connects to oxygen source.

*
*
*
*
*
*

ACTIVITY

NEBULISATION

REASSESSMENT

CRITICAL PERFORMANCE
Candidate connects nebuliser to oxygen source.
Candidate selects an oxygen flow rate of 4-6 litres/min
and ensures that the nebuliser mask is misting
appropriately.
Candidate securely fits nebuliser mask to patients face.
Candidate instructs patient to take slow, deep breaths.
Candidate assesses the patient for effectiveness or sideeffects of nebulisation.
Candidate monitors the patients vital signs, including
noting the patients blood sugar level 5 minutes post
nebulisation.
Candidate records drug administration correctly.
Candidate repeats administration of B2 stimulant
nebulisation as required, and as per protocol.

DONE/
NOT
DONE
*
*
*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT USE OF ENTONOX

ACTIVITY
PREPARATION OF
ENTONOX
CYLINDER

APPLICATION OF
THE REGULATOR

EXPLANATION OF
PROCEDURE

TERMINATION OF
ENTONOX
THERAPY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate opens the main valve slowly until an audible


rush of ENTONOX is heard.

Candidate closes the main valve rapidly

Candidate checks that the regulator is the correct one for


the cylinder and that the O-ring seal is present.
Candidate applies the regulator correctly.
Candidate opens the cylinder valve slowly, keeping
his/her face clear of the gauges.
Candidate listens for and notes any leaks.
Candidate ensures that the patient understands how to
use the ENTONOX by demonstrating the procedure and
ensuring that the demand valve is functional
Candidate ensures that the face-mask fits the patient
snugly.
Candidate indicates that the ENTONOX will produce its
peak effect in 3 to 4 minutes

*
*
*

*
*
*

Candidate removes the delivery device from the patient.


*
Candidate turns off the flow meter
Candidate closes the main cylinder valve.
Candidate presses the orange purge button to bleed the
system of trapped ENTONOX.

*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT VITAL SIGNS: PULSE, RESPIRATIONS and BP

ACTIVITY

CRITICAL PERFORMANCE

PULSE

Candidate correctly locates a palpable pulse at the radial


artery.
Candidate palpates pulse with fingertips and not with the
thumb.
Using a watch with a second hand, or with a countdown
display, candidate times the pulse for 15 or 30 seconds.
Candidate reports the pulse rate, rhythm and strength.
Candidate is accurate in his/her assessment of the pulse
(examiner please to check)

MEASUREMENT

RESPIRATION
MEASUREMENT

Candidate observes the rise and fall of the patients chest


(may do so while holding the patients arm to their chest)
Using a watch with a second hand, or with a countdown
display, candidate times the respirations for 30 seconds.
Candidate reports the respiratory rate, rhythm and depth.
Candidate is accurate in his/her assessment of the
respirations (examiner please to check)

BLOOD PRESSURE Candidate explains the procedure to the patient


MEASUREMENT
Candidate snugly attaches the BP cuff in the correct
position
Candidate inflates the cuff to just above the point at
which the radial pulse disappears (systolic BP) or
approximately 160mmHg.
Candidate places the diaphragm of the stethoscope over
the brachial artery (medial aspect of the arm)
Candidate slowly deflates the cuff, observing the gauge
and listening for Korotkoff sounds.
Candidate is accurate in his/her assessment of the BP
(examiner please to chech within 10mmHg either side
of the actual measurement)

DONE/
NOT
DONE
*
*
*
*
*

*
*
*
*

*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT DETERMINATION OF BLOOD GLUCOSE LEVELS

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

EXAMINER STATES THAT THE PRIMARY AND


SECONDARY SURVEYS HAVE BEEN
PERFORMED
Candidate selects the correct equipment for the
procedure:

PREPARATION

PROCEDURE

EVALUATION

* Glucose test strips


* Blood Lancets
*Gauze swabs
* Watch with second hand/countdown display
* Gloves
* Alcohol swab (not essential)
Candidate checks the expiry date of the glucose test
strips.
Candidate selects a glucose test strip and closes the
container lid soon after removing the strip.
Candidate explains the procedure to the patient..
Candidate safely, and ensuring sterility, opens the blood
lancet.
Candidate milks the finger chosen for finger-prick.
Candidate pricks the finger at the tip and on the side of
the chosen finger squeezing the finger at the same
time.
Candidate obtains a suitably sized drop of blood.
Candidate places the drop of blood on the reagent strip of
the glucose test strip without touching the patients
finger excessively on the reagent strip.
Candidate waits 60 seconds
Candidate blots the blood carefully, yet firmly off the
test strip.
Candidate waits a further 60 seconds.

*
*
*
*
*

*
*
*

*
*

*
*
*

ACTIVITY

CRITICAL PERFORMANCE

EVALUATION
CONTINUED

Candidate compares the colour reagent strip to the colour


blocks on the test strip bottle.
Candidate obtains a reading in mg/% or mmol/L.
Candidate is accurate in his/her assessment of the HGT
(examiner please to check)

DONE/
NOT
DONE
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT EXAMINATION OF AN UNCONSCIOUS PATIENT


(Medical)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate determines that the patient is unresponsive.


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Checks patients mouth for foreign material
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

*
*
*
*
*
*
*
*

GENERAL
APPEARANCE

Candidate assesses patients skin colour, temperature and


condition.

HEAD-TO-TOE
SURVEY

Candidate assesses for facial symmetry.

Candidate checks patients pupils for size, equality and


reaction to light.
Candidate examines the patients neck for distended
neck veins.
Candidate examines for use of accessory muscles of
breathing.
Candidate observes patients respiratory excursion, and
auscultates for equal air entry and breath sounds.
Candidate examines patients chest for any implantable
devices.
Candidate examines patients chest for any unusual
markings or bruising including surgical scars.

*
*
*
*
*
*

ACTIVITY

HEAD-TO-TOE
SURVEY CONT.

CRITICAL PERFORMANCE
Candidate palpates the patients abdomen, and examines
for distension, tenderness, guarding and rigidity.
Candidate examines patients abdomen for any unusual
markings or bruising including surgical scars.
Candidate examines patient for signs of incontinence.
Candidate inspects the patients torso for signs of
oedema.
Candidate examines the patients limbs for signs of
oedema.
Candidate examines patients limbs for neurovascular
patency.
Candidate checks motor function in the patients limbs.
Candidate inspects patient for presence of medical
identification.
Candidate turns the patient and examines the patients
back for any unusual markings or bruising including
surgical scars.

DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT EXAMINATION OF AN UNCONSCIOUS PATIENT


(Trauma)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate determines that the patient is unresponsive.


*
Candidate ensures an open airway using the head-tilt
*
chin-lift or jaw thrust techniques.
Candidate:
- Checks patients mouth for foreign material
*
BREATHING
- Look, listen and feel for breathing
*
If breathing is absent or inadequate, candidate gives the patient 2 slow breaths (2 seconds
per breath), ensuring that there is adequate chest rise, and that he allows for exhalation
between breaths.
Candidate:
*
- Assesses patients pulse and perfusion.
CIRCULATION
*
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
*
Candidate attaches ECG monitor to patient.
*
AIRWAY

GENERAL
APPEARANCE
HEAD-TO-TOE
SURVEY

Candidate assesses patients skin colour, temperature and


condition.

Candidate notices obvious wounds and deformities.

Candidate examines patients scalp for injury and


bruising.
Candidate checks the patients nose and ears for injury
and discharge.
Candidate examines the patients eyes for signs of injury.
Candidate checks patients pupil size, equality and
reaction to light.
Candidate examines patients facial bones and jaw for
deformity and stability.
Candidate smells patients breathe for abnormal odours.
Candidate examines the patients neck for wounds and
deformity.

*
*
*
*
*
*
*

ACTIVITY

CRITICAL PERFORMANCE
Candidate checks for tracheal deviation and distended
neck veins.
Candidate correctly applies a cervical collar
Candidate examines patients chest for wounds and
stability.
Candidate observes patients respiratory excursion, and
auscultates for equal air entry and breath sounds.
Candidate examines patients chest for any implantable
devices.
Candidate examines patients chest for any unusual
markings or bruising including surgical scars.
Candidate palpates the patients abdomen, and examines
for wounds, distension, tenderness, guarding and
rigidity.
Candidate examines patients abdomen for any unusual
markings or bruising including surgical scars.
Candidate examines patients pelvis for wounds,
stability, signs of incontinence, and priapism (in males).
Candidate examines the patients limbs for wounds and
deformity.
Candidate examines patients limbs for neurovascular
patency.
Candidate checks motor function in the patients limbs.
Candidate inspects patient for presence of medical
identification.
Candidate logrolls the patient and examines his back for
wounds and deformity.
Candidate examines the patients back for any unusual
markings or bruising including surgical scars.

DONE/
NOT
DONE
*
*
*
*
*
*
*
*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:

______________________________________________________________________________
______________________________________________________________________________
__________
Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT APPLICATION OF A FIELD DRESSING

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

The Examiner states that the patient is conscious and has a wound Examiner to point out
the wound site
PATIENT
ASSESSMENT 1O
SURVEY

Candidate verbally indicates that a primary survey


should be done.
If profuse bleeding is present, Candidate is to state that
immediate direct pressure needs to be applied.
Candidate verbally indicates that a secondary survey
should be done.
Candidate checks pulse distal to the wound. IF the
wound is to a limb (preferred site)

WOUND CARE
OPENING OF
DRESSING

APPLICATION OF
THE DRESSING

Candidate checks the wound for presence of foreign


bodies.
Candidate opens the dressing packaging without causing
contamination and removes the dressing.
Candidate unrolls the short end of the bandage until the
dressing is free.
Candidate keeps the wound contact service of the
dressing folded-in on itself.
Candidate opens the wound contact surface of the
dressing and immediately applies it to the wound.
Candidate uses the bandage to secure the dressing in
place.
Candidate covers both open ends of the dressing.
Candidate ensures that the dressing is not so tight as to
restrict circulation.
Candidate checks pulses distal to the wound.
Candidate evaluates the injured part where possible.
Candidate assesses whether or not the bleeding is
controlled.

*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT USE OF PRESSURE POINTS

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient

BREATHING

CIRCULATION

PATIENT
ASSESSMENT

Candidate indicates that primary and secondary surveys


have been performed.

*
*
*
*
*

The Examiner is to state which pressure point is to be used by giving examples of bleeding
sites

TEMPORAL

FACIAL

Candidate correctly locates pulse point


Candidate uses the side of his/her thumb to compress the
artery
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)

Candidate correctly locates pulse point


Candidate uses the side of his/her thumb to compress the
artery
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)

*
*

*
*

ACTIVITY

BRACHIAL

FEMORAL

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate correctly locates pulse point


Candidate uses his/her fingertips to compress the artery
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)

*
*

Candidate correctly locates pulse point


Candidate sits at the patients side opposite to the side of
the injury
Candidate places his/her fist on the artery (on the injured
side) and uses his/her body weight to compress the artery
Candidate assesses whether or not indirect pressure is
successful (checks distal pulse or assesses for
slowing/stopping of bleeding)

*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT APPLICATION OF A PADDED BOARD SPLINT


(ARM FRACTURE)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.

BREATHING

CIRCULATION

PATIENT
ASSESSMENT

SPLINTING

Candidate indicates that primary and secondary surveys


have been performed.
Candidate exposes arm with suspected fracture without
unnecessary movement.
Candidate assesses:

*
*
*
*
*

*
*

- Radial pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate assesses wrists, elbow and shoulder for
associated injuries.

*
*
*
*
*

Candidate explains the procedure to the patient.


Candidate requests that partner applies steady
longitudinal traction and realign the limb as necessary.
Candidate evaluates for the presence of a radial pulse
following the application of longitudinal traction.
Candidate aligns a padded board splint under or
alongside the injured limb.

ACTIVITY

SPLINTING CONT.

CRITICAL PERFORMANCE
Candidate ensures that the padded splint extends from
the hand to the mid-humerus.
Candidate ensures that any natural hollows between the
splint and the patients limb are filled with gauze or
similar material.
Candidate secures the padded splint to the patients arm
with roller bandages, ensuring to cover the entire length
of the splint.
Candidate performs the splinting procedure with minimal
movement of the injured limb.
Candidate requests that partner releases longitudinal
traction if applied.
Candidate re-assesses:
- Radial pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate elevates the splinted arm.

DONE/
NOT
DONE
*

*
*

*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT APPLICATION OF A PADDED BOARD SPLINT


(LEG FRACTURE)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.

BREATHING

CIRCULATION

PATIENT
ASSESSMENT

SPLINTING

Candidate indicates that primary and secondary surveys


have been performed.
Candidate exposes leg with suspected fracture without
unnecessary movement.
Candidate assesses:

*
*
*
*
*

*
*

- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate assesses ankle, knee and hip for associated
injuries.

*
*
*
*
*

Candidate explains the procedure to the patient.


Candidate requests that partner applies steady
longitudinal traction and realign the limb as necessary.
Candidate evaluates for the presence of a pedal pulse
following the application of longitudinal traction.
Candidate aligns a padded board splint under or
alongside the injured limb.

ACTIVITY

SPLINTING CONT.

CRITICAL PERFORMANCE
Candidate ensures that the padded splint extends from
the foot to the mid-thigh.
Candidate ensures that any natural hollows between the
splint and the patients limb are filled with gauze or
similar material.
Candidate secures the padded splint to the patients leg
with roller bandages, ensuring to cover the entire length
of the splint.
Candidate performs the splinting procedure with minimal
movement of the injured limb.
Candidate requests that partner releases longitudinal
traction if applied.
Candidate re-assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate elevates the splinted leg.

DONE/
NOT
DONE
*

*
*

*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P.
CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT TRAUMA TRACTION SPLINT

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

PATIENT
ASSESSMENT

Candidate indicates that primary and secondary surveys


have been performed.
Candidate exposes leg with suspected fracture without
unnecessary movement.
Candidate removes the patients shoes and socks.
Candidate assesses:
-

SPLINTING

*
*
*
*
*
*
*
*
*
*

Pedal pulse
Movement in limb
Sensation in limb
Skin colour, temperature and condition in limb
Capillary refill

*
*
*
*
*

Candidate explains the procedure to the patient.


Candidate fastens ankle stirrup strap.
Candidate correctly measures traction splint against
patients uninjured leg.
Candidate requests partner to grasp the patients ankle
and apply gentle longitudinal traction.
Candidate slides traction splint into position.

*
*
*
*
*

ACTIVITY

SPLINTING CONT.

CRITICAL PERFORMANCE
Candidate ensures that the splint is seated correctly
against the ischial tuberosity, and ensures that the splint
is not pressing against the patients genitals.
Candidate secures the ischial strap of the splint.
Candidate attaches ankle strap to traction mechanism,
and starts pulling mechanical traction.
Candidate requests that partner releases his grip slowly
as the traction splint takes over traction.
Candidate re-assesses:
- Pedal pulse
- Movement in limb
- Sensation in limb
- Skin colour, temperature and condition in limb
- Capillary refill
Candidate adjusts traction as necessary.
Candidate secures traction splint to patients leg
ensuring not to strap over the fracture site.
Candidate elevates the foot of the splint.

DONE/
NOT
DONE
*
*
*
*

*
*
*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT LOGROLL OF A PATIENT ONTO A LONG SPINE


BOARD

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.

Candidate instructs the patient not to move.

BREATHING

CIRCULATION

C-SPINE
IMMOBILISATION

Candidate requests partner to place himself at the


patients head.
Candidate explains procedure to the patient.
Candidate requests that partner maintains support of the
patients head and neck in alignment with the patients
body.
Candidate correctly applies a cervical collar and
instructs partner to maintain manual stabilisation of the
patients head and neck.
Candidate prepares equipment:
PREPARATION
FOR LOGROLL

Spine Board
Base Plate
Head Blocks
Spider Harness/straps

Candidate positions him/herself at the patients side,


kneeling at the patients shoulders.
Candidate requests a third persons to kneel at the
patients buttocks on the same side

*
*
*
*
*

*
*

ACTIVITY

PREPARATION
FOR LOGROLL
CONT.

CRITICAL PERFORMANCE
Candidate ensures that he/she has a proper grasp by
placing one hand on the patients furthermost shoulder
and another hand at the patients hip.
Candidate ensures that third person places one hand at
the patients buttocks and the other hand at the patients
mid-thigh.
Candidate instructs the person maintaining manual
stabilisation of the patients head to be in control of the
logroll procedure.
On the count of the person at the patients head, the
patient is rolled onto his/her side as a unit whilst the
patients head and neck remains in alignment with the
rest of the patients body.
Candidate requests that spine board is pulled under and
aligned with the patient.
On the count of the person at the patients head, the
patient is lowered, as a unit, onto the spine board.

LOGROLL

SECURING THE
PATIENT TO THE
SPINE BOARD

DONE/
NOT
DONE

Candidate adequately secures the patient to the spine


board by placing straps over the patients chest, thighs
and knees (or by securing a full spider harness over the
patient).

*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________
Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT EXTRICATION OF A PATIENT FROM VEHICLE

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

C-SPINE
IMMOBILISATION

HEAD-TO-TOE
SURVEY

Candidate requests partner to place himself behind the


patient.
Candidate explains procedure to the patient.
Candidate requests that partner maintains support of the
patients head and neck in alignment with the patients
body.
Candidate correctly applies a cervical collar and
instructs partner to maintain manual stabilisation of the
patients head and neck.

*
*
*
*
*
*
*
*
*

Examiner states that there are no obvious injuries.


Candidate states that vital signs would also be checked.

PREPARATION
FOR EXTRICATION

Candidate correctly positions extrication device behind


patient.
Candidate correctly secures patient to extrication device.

*
*
*

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

PREPARATION
FOR

EXTRICATION
CONT.

Candidate places padding between the patients neck and


the extrication device as required.
Candidate secures the patients head to the extrication
device.
Candidate requests that partner release manual
stabilisation of the patients head and neck.

EXTRICATION

SECONDARY
SURVEY

Candidate supervises partner to assist him in positioning


the patient onto a long spine board.
Candidate, with assistance, places the spine board onto
the ground.
Candidate secures patient to spine board.
Candidate removes patient, on spine board, to a safe
place.
Candidate performs a full secondary survey on the
patient, and re-records a full set of vital signs.

*
*

*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT NORMAL VAGINAL DELIVERY

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

PREPARATION

Candidate positions mother with buttocks at the edge of


the bed with knees flexed.
Candidate prepares all required equipment:
-

DELIVERY

Cord clamps.
Scissors/blade
Pads
Warm blanket
Mucous extractor
Resuscitation equipment

Candidate places gentle pressure on the babys head to


prevent it from delivering too quickly.
Candidate protects the perineum from tearing.

*
*
*
*
*
*
*
*

*
*
*
*
*
*

*
*

ACTIVITY

DELIVERY CONT.

CRITICAL PERFORMANCE
Once the babys head is delivered, candidate removes
mucous and blood from the babys mouth and nose, and
suctions gently if necessary.
Candidate checks for the umbilical cord around the
babys neck:
a. If present, slip it over the babys head.
b. If it is too tight to slip over the babys head, it
must be double clamped and cut between the
clamps.
Candidate allows restitution to take place.
Candidate places palms on either cheek to apply gentle
downward traction to deliver the anterior shoulder.
Candidate applies gentle upward traction on the head to
deliver the posterior shoulders.
Candidate grasps the baby firmly as it delivers.
Candidate holds the infants head down to allow fluid to
drain from its airway.
Candidate places the infant in the lateral position and
clears the airway if necessary.
Candidate double clamps the umbilical cord and cuts the
cord between the clamps.
Candidate cleans and dries the infant.
Candidate takes the APGAR score one minute after birth
of the infant.
Candidate inspects the cord for bleeding.
Candidate wraps the infant in a warm blanket and gives
it to the mother.

DELIVER OF THE
PLACENTA

Candidate applies gentle pressure over, and massages the


uterus.
Candidate encourages the mother to push.
Candidate does not pull on the umbilical cord.
When the placenta delivers, candidate places it in a
plastic bag and takes it with to hospital.

DONE/
NOT
DONE
*

*
*
*
*
*
*
*
*
*
*
*
*
*

*
*
*
*

ACTIVITY

DELIVER OF THE
PLACENTA CONT.

CRITICAL PERFORMANCE
Candidate continues to massage the uterus.

DONE/
NOT
DONE
*

Candidate allows only 20 minutes for the delivery of the


placenta.
Candidate cleans the mother appropriately.
Candidate notes time of delivery of baby and placenta.
Candidate administers post natal care to the mother and
baby.

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT BREECH DELIVERY

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Assesses patients respiratory status
- Administers oxygen as necessary.
Candidate:
- Assesses patients pulse and perfusion.
- Arrests life-threatening haemorrhage.
Candidate establishes IV access.
Candidate attaches ECG monitor to patient.

BREATHING

CIRCULATION

PREPARATION

LOVESET
MANOEUVRE

Candidate positions mother with buttocks at the edge of


the bed with knees flexed.
Candidate prepares neonatal resuscitation equipment.
Candidate allows the foetus legs, buttocks and trunk to
deliver spontaneously (dont pull!).
Candidate supports babys weight on left forearm.
Candidate checks for the umbilical cord around the
babys neck.

*
*
*
*
*
*
*
*
*
*

Candidate grasps babys pelvis with both hands.

Candidate rotates baby 90o until anterior arm is freed.


If arm not free, locate arm and free it from under the
symphysis pubis, by gently pulling down across the face
and the chest.
Candidate gently rotates baby to the opposite side.
Candidate re-performs steps of Loveset manoeuvre to
free second arm.

*
*
*
*

ACTIVITY

MAURICEAUSMELLIE-VEIT
MANOEUVRE

CRITICAL PERFORMANCE

Candidate straddles baby on left forearm, with palm


facing upward.
Candidate inserts middle finger on babys occiput.
Candidate places index and ring finger on either side of
the babys neck.
Candidate lifts the babys body upwards.
Candidate flexes babys head by applying traction on jaw
and pressure on occiput.
Candidate slowly extracts babys head upward when
fully flexed.
Candidate checks for umbilical cord around babys neck
and removes if present.
Candidate administers post natal care to the mother and
baby.

DONE/
NOT
DONE
*
*
*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P.
CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT INTRAVENOUS THERAPY

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate assesses patients responsiveness


*
Candidate ensures an open, maintained and protected
*
airway.
Candidate:
*
- Assesses patients respiratory status
BREATHING
*
- Administers oxygen as necessary.
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
Candidate:
*
- Assesses patients pulse and perfusion.
CIRCULATION
*
- Arrests life-threatening haemorrhage.
AIRWAY

DETERMINE NEED Candidate obtains the patients vital signs and


FOR IV THERAPY determines the need for IV therapy.
PREPARATION

Candidate explains the procedure to the patient.


Candidate selects appropriate fluid.
Candidate checks vacolitre for cloudiness, leaks and
expiry date.
Candidate selects correct administration set and attaches
correctly to vacolitre.
Candidate fills the administration set chamber halfway
and flushes the tubing, ensuring the line is free of air.
Candidate closes the line clamp and recovers the tubing
tip.
Candidate selects correct cannula.
Candidate places BP cuff on patients arm and inflates to
just below the systolic BP.

*
*
*
*
*
*
*

ACTIVITY

VENIPUNCTURE

CRITICAL PERFORMANCE
Candidate selects suitable vein and cleans site with
alcohol swab.
Candidate stabilises vein with non-dominant hand.
Candidate inserts needle through the skin, bevel facing
upward, into a vein.
Candidate advances needle until backflow is seen.
Candidate slides the catheter over the needle into the
vein and withdraws the needle.
Candidate attaches IV administration set to catheter and
deflates the BP cuff.
Candidate opens the flow clamp wide open, and checks
the placement and checks the patients arm for swelling
indicating infiltration of the tissue.
Candidate adjusts the flow rate as desired.
Candidate secures cannula and tubing with appropriate
strapping.

DONE/
NOT
DONE

*
*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically unsatisfactory!


FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT ADMINISTRATION OF 50% DEXTROSE

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate assesses patients responsiveness


*
Candidate ensures an open, maintained and protected
*
airway.
Candidate:
*
- Assesses patients respiratory status
BREATHING
*
- Administers oxygen as necessary.
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
Candidate:
*
- Assesses patients pulse and perfusion.
CIRCULATION
*
- Arrests life-threatening haemorrhage.
AIRWAY

COMPLETION OF
SECONDARY
SURVEY

Candidate determines the need for 50% dextrose


administration and rules our contra-indications.

Candidate checks drug for:


PREPARATION

ADMINISTRATION

- Correct drug
- Expiry date
- Cloudiness and leaks
- Dosage of drug.
Candidate calculates dose required.
Candidate draws up correct dose into syringe and
eliminates excess air.

*
*
*
*
*

Candidate establishes IV access.


Candidate cleans the administration site with alcohol
swab.
Candidate ensures a free-flowing IV line.
Candidate slowly administers desired dose of 50%
dextrose.

*
*
*

ACTIVITY

REASSESSMENT

CRITICAL PERFORMANCE
Candidate assesses the patient for effectiveness or sideeffects of 50% dextrose administration.
Candidate monitors the patients vital signs, especially
noting the patients blood sugar level 5 minutes post
dextrose administration.
Candidate records drug administration correctly.
Candidate repeats administration of 50% dextrose as
required, and as per protocol.

DONE/
NOT
DONE
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT USE OF AN ECG MONITOR

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate assesses patients responsiveness


*
Candidate ensures an open, maintained and protected
*
airway.
Candidate:
*
- Assesses patients respiratory status
BREATHING
*
- Administers oxygen as necessary.
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
Candidate:
*
- Assesses patients pulse and perfusion.
CIRCULATION
*
- Arrests life-threatening haemorrhage.
AIRWAY

COMPLETION OF Candidate determines the need for ECG monitoring.


PRIMARY SURVEY

Candidate checks patient for:


-

Dry skin for application of ECG electrodes


Skin area free of excess hair for application of
ECG electrodes (shaves if necessary)

*
*

Candidate prepares the following equipment:


PREPARATION
-

Appropriate number of ECG electrodes (for


monitor)
ECG electrode wires CONNECTED to ECG
monitor
Pre-placement of ECG electrodes onto ECG
electrode wires.

*
*
*

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate places ECG electrodes as follows:


APPLICATION
(EUROPEAN ECG
MONITOR)

Red electrode to the right shoulder (infraclavicular)


Yellow electrode to the left shoulder (infraclavicular)
Green electrode to the left mid-axillary line at
base of costal margin.

If black electrode present:


-

*
*
*

Black electrode to the right mid-axillary line at


base of costal margin.

Candidate places ECG electrodes as follows:


APPLICATION
(AMERICAN ECG
MONITOR)

White electrode to the right shoulder (infraclavicular)


Black electrode to the left shoulder (infraclavicular)
Red electrode to the left mid-axillary line at base
of costal margin.

*
*
*

If green electrode present:


*
-

Green electrode to the right mid-axillary line at


base of costal margin.

Candidate ensures that the monitor is turned to lead II


for monitoring purposes.
INTERPRETATION

Candidate prints a six second (30 big block) strip of


lead II.
Candidate assesses the rhythm strip and accurately notes
the following features:
-

Rhythm (in terms of regularity)


Rate (as calculated from the strip and not
monitor)
ECG diagnosis (as per ILS rhythm strips)

*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT USE OF A PULSE OXIMETER

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate assesses patients responsiveness


*
Candidate ensures an open, maintained and protected
*
airway.
Candidate:
*
- Assesses patients respiratory status
BREATHING
*
- Administers oxygen as necessary.
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
Candidate:
*
- Assesses patients pulse and perfusion.
CIRCULATION
*
- Arrests life-threatening haemorrhage.
AIRWAY

COMPLETION OF Candidate determines the need for pulse oximetry.


PRIMARY SURVEY

Candidate checks patient for:

PREPARATION

APPLICATION

Signs and symptoms of profound shock


Pulse/ perfusion on the limb being used
Clean finger (for finger probe)
Presence of nail varnish (even clear coat)
Recent use of intravenous dyes (methylene blue,
etc)
Cold extremities
History of Sickle Cell Disease (underestimate
SaO2 by 8%)
Toxic Inhalations (carboxyhaemoglobinaemia &
methaemglobinaemia)

Candidate places finger probe snugly over the patients


finger.
Candidate ensures that there is not excessive ambient
light affecting the probe (may show poor signal)
Candidate ensures that patient is not excessively moving
his/her hand with probe attached to finger.

*
*
*
*
*
*
*
*

*
*
*

ACTIVITY

ASSESSMENT

CRITICAL PERFORMANCE
Candidate checks that pulse oximeter shows adequate
signal generation.
Candidate checks that an adequate waveform is seen on
pulse oximeter screen (if available).
Candidate notes pulse oximeter reading.
Candidate is aware of the difference between a false
positive and false negative pulse oximetry reading,
and the causes thereof.

DONE/
NOT
DONE
*

*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT DEFIBRILLATION

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate assesses patients responsiveness


*
Candidate opens patient airway (Head-Tilt/Chin Lift or
*
Jaw Thrust)
Candidate assesses patients breathing for maximum of
*
BREATHING
10 seconds.
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
Candidate assesses patients carotid pulse for a
*
CIRCULATION
maximum of 10 seconds.
If the arrest was not witnessed, candidate is to perform 2 minutes (5 cycles) of CPR prior to
defibrillation. If the collapse was witnessed, immediate defibrillation is to be done.
Set monitor to 360 Joules (monophasic) or to 150/200
*
PREPARATION
Joules (biphasic) (adult) or 2J/kg (child)
Ensure Sync button switched off
AIRWAY

Defibrillator gel to be placed on paddles.


*
Determine correct paddle position and press down with
*
at least 20kg force to reduce trans-thoracic impedance.
Check rhythm on monitor (Quick Look Paddles or lead
*
II)
If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, continue with
defibrillation.
Charge monitor to 360 Joules (monophasic) or to
*
150/200 Joules (biphasic) (adult) or 2J/kg (child)
Ensure that all persons are clear of the patient (Im
*
Clear, Youre Clear, Oxygen clear, Everybodys Clear).
Candidate depresses both discharge buttons at the same
*
1
time to deliver shock, and observes ECG rhythm.
After defibrillation, the candidate is to proceed with CPR starting with chest compressions.
Candidate performs 2 minutes (5 cycles) or CPR,
pushing hard and fast at a rate of at least 100
*
compressions a minute using the 30:2 compression-toventilation ratio.
DEFIBRILLATION

ACTIVITY
ALS ASSISTANCE

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate establishes ALS back-up.

Candidate assesses cardiac rhythm through paddles. If


the rhythm remains unchanged, candidate is to continue
with defibrillation.
Candidate is only to check the patients pulse if the rhythm displayed on paddle check is an
organised rhythm. If the presenting rhythm is not organised and not shockable, the
candidate is to continue with CPR.
Charge monitor to 360 Joules (monophasic) or to 150
*
Joules (biphasic) (adult) or 4J/kg (child)
Ensure that all persons are clear of the patient (Im
*
Clear, Youre Clear, Oxygen clear, Everybodys Clear).
Candidate depresses both discharge buttons at the same
*
2
time to deliver shock.
After defibrillation, the candidate is to proceed with CPR starting with chest compressions.
Candidate performs 2 minutes (5 cycles) or CPR,
pushing hard and fast at a rate of at least 100
*
compressions a minute using the 30:2 compression-toventilation ratio.
Candidate repeats cycles of defibrillation and CPR as
necessary and continues until ALS arrives, or until
return of spontaneous circulation.
DEFIBRILLATION
CONTINUED

* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name: __________________

Name: _________________

Qualific:

_____________________

Qualific:

____________________

Signature:

_____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT NEEDLE CRICOTHYROTOMY

ACTIVITY

SAFETY
AIRWAY

BREATHING
CIRCULATION
VENTILATION

CRITICAL PERFORMANCE
Candidate assesses the area with regards to scene
safety.

DONE/
NOT
DONE
*

Candidate assesses patients responsiveness


Candidate ensures an open, maintained and protected
airway.
Candidate:
- Look, listen and feel for breathing
Candidate:
- Assesses patients pulse and perfusion.

Candidate attempts to ventilate the patient.


Candidate repositions the patients airway and
reattempts ventilation.
All other methods (e.g. abdominal thrust) fail to remove
obstruction.

CRICOTHYROTOMY Candidate correctly assembles and checks equipment.


Candidate places the patient in a supine position.
Candidate cleans the anterior neck with alcohol swab.
Candidate correctly locates the cricothyroid membrane.
Candidate stabilises the thyroid cartilage.
Candidate punctures the skin midline directly above the
cricothyroid membrane with a 14G Jelco with a 20mL
syringe attached (saline in syringe for bubbling to
occur).
Candidate inserts needle into cricothyroid membrane
and directs needle 45o caudally, applying a negative
pressure to the syringe, and advancing until air is
aspirated.
Candidate withdraws the needle while simultaneously
advancing the 14G cannula into position.

*
*
*
*
*

*
*

*
*
*
*

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate attaches a 3-way tap to oxygen tubing, as well


as to the cannula:

VENTILATION

a. Open all taps in all directions on the 3-way tap.


b. Set oxygen flow rate at 1 lire per minute per year
of age (up to a maximum of 8 litres/minute).
c. Occlude the open 3-way tap hole for 1 second,
and release (open) it for 4 seconds.
d. Watch for chest rise.
Candidate secures the cannula and tap to the patients
neck.
Candidate ventilates the patient, auscultates the chest and
epigastrium for adequate ventilation.

*
*

IF A CRITICAL POINT IS OMITTED, THE FINAL RESULT IS AUTOMATICALLY NOT YET


COMPETENT!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT UPPER AIRWAY OBSTRUCTION (with equipment)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate assesses patients responsiveness.


Candidate opens the patients airway.
Candidate:
- Look, listen and feel for breathing
- Attempts finger sweep if obstruction visible.

*
*

Candidate attempts ventilation.


Candidate repositions the patients airway and reattempts ventilation.
If obstruction still visible and not removed by finger
sweep, candidate prepares equipment:

BREATHING

VENTILATION

REMOVAL OF
OBSTRUCTION

MANUAL
MANOEUVRES

Tongue depressor
Magills forceps

Candidate depresses patients tongue with tongue


depressor.
Under direct vision, candidate inserts Magills forceps
into patients airway and removes obstruction.
If obstruction can not be removed, attempt manual
manoeuvres.
For adults, children and infants, perform 2 minutes (5
cycles) of CPR using the appropriate compression-toventilation ratio
Candidate re-attempts removal of obstruction with
Magills forceps under direct visualisation.

*
*

*
*
*
*
*

*
*
*

If still unsuccessful after 2 attempts, candidate performs


needle cricothyroidotomy in the adult patient.
*
In the child or infant patient, candidate is to continue
with CPR and removal attempts.

ACTIVITY

CRITICAL PERFORMANCE
If effective, candidate assesses patients circulation.
Candidate resumes ventilations as necessary.

DONE/
NOT
DONE
*
*

* If a critical point is omitted, the final result is automatically not yet competent!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT NEEDLE THORACENTESIS

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

HELLO

Candidate assesses patients responsiveness

ABC

PATIENT
ASSESSMENT

BREATHING

Only if the candidate suspects the patient to be clinically


dead:
A- Open
B- Look, listen and feel
C- Pulse check

Candidate ensures an open, maintained and protected


airway.
Candidate:
a. Administers high flow O2 prn
b. Assesses respiratory status e.g. trachea, neck
veins, breath sounds
c. Diagnoses tension pneumothorax

*
*
*
*

ACTIVITY

DECOMPRESSION

CRITICAL PERFORMANCE
Candidate prepares equipment:
a. 14G IV cannula
b. Alcohol swab
c. Syringe with saline and air-space (for air
bubbling)
Candidate locates 2nd intercostals space, mid-clavicular
line on the side of the tension pneumothorax
Candidate cleans the intended area of centesis.
Candidate inserts the 14G IV cannula just over the 3rd
rib.
Candidate punctures the parietal pleura.
Candidate watches for air bubbles in saline.
Candidate removes syringe and listens for sudden
escape of air-relief from tension pneumothorax.
Using the Seldinger technique, candidate fully advances
the catheter to the hub and then removes the needle.
Candidate leaves the catheter in place as a marker.
Candidate reassesses the patients respiratory status.
Candidate assesses the patients circulation:
- assess pulse and perfusion
- treat accordingly

DONE/
NOT
DONE

*
*
*
*
*
*

IF A CRITICAL POINT IS OMITTED, THE FINAL RESULT IS AUTOMATICALLY NOT YET


COMPETENT!

FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
__________
Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT PASG

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate assesses patients responsiveness


*
Candidate ensures an open, maintained and protected
*
airway.
Candidate:
*
- Assesses patients respiratory status
BREATHING
*
- Administers oxygen as necessary.
If the patient is not breathing adequately, or is not breathing at all, the candidate is to give
2 slow breaths using an appropriate device (BVM).
Candidate:
*
- Assesses patients pulse and perfusion.
CIRCULATION
*
- Arrests life-threatening haemorrhage.
AIRWAY

Candidate obtains the patients vital signs and


DETERMINE NEED
determines the need for PASG (now or following IV
FOR PASG
fluids).
PREPARATION

Candidate establishes an IV line.


Candidate attaches the ECG monitor.
Candidate explains the procedure to patient (if patient
conscious)
Candidate prepares PASG on spineboard.
Candidate attaches the foot-pump and closes the
stopcock valves.
Candidate places patient onto PASG.
Candidate removes the patients shoes and socks.
Candidate removes all objects from the patients pockets

*
*

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate secures leg and abdominal sections to the


patient by means of Velcro fasteners.

USE OF PASG

If used for haemorrhage control, candidate inflates


required sections sequentially, starting with the legs (legs
only for ILS), to approximately 5mmHg above the
systolic BP, or otherwise inflate to 40mmHg.
Candidate closes stopcock valves after successful
inflation of each chosen section.
Once inflated, do not deflate pre-hospitally unless an
urgent need exists.
Candidate continually reassesses:
- respiration
- air entry
- pulse
- blood pressure
Candidate transports the patient to hospital.

*
*
*
*
*
*

* If a critical point is omitted, the final result is automatically not yet competent!
FINAL RESULT:

COMPETENT

______

NOT YET COMPETENT ______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT ONE MAN MEGACODE

ACTIVITY
SAFETY

CRITICAL PERFORMANCE
Candidate assesses the area with regards to scene safety.

DONE/
NOT
DONE
*

Candidate determines that the patient is unresponsive and


*
activates the emergency response system.
Candidate notes absent breathing or breathing which is not
*
normal (only gasping)
Candidate:
- Checks for carotid pulse, and
*
CIRCULATION
- Checks for other signs of circulation. (no longer than
*
10 seconds)
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate begins 30
chest compressions (rate of at least 100 compressions per
*
minute)
Candidate opens the patients airway using the head-tilt chin*
AIRWAY
lift manoeuvre (or jaw thrust if trauma)
Candidate delivers 2 breaths over 1 second each each with
*
BREATHING
enough volume to make the chest rise.
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations if defibrillator available, use as soon as possible.
*
DEFIBRILLATION Defibrillator gel to be placed on paddles.
Determine correct paddle position and press down with at
*
least 12kg force to reduce trans-thoracic impedance.
Check rhythm on monitor (Quick Look Paddles)
*
If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, continue with
defibrillation.
Charge monitor to 360 Joules (monophasic) or to 150 Joules
*
(biphasic) or 4 J/kg (paediatrics)
Ensure that all persons are clear of the patient (Im Clear,
*
Youre Clear, Oxygen Clear, Everybodys Clear).
RESPONSE

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

Candidate depresses both discharge buttons at the same time


*
to deliver shock.
After defibrillation, the candidate is to immediately resume chest compressions.
Candidate establishes ALS back-up while continuing with
*
ALS ASSISTANCE
CPR.
After 2 minutes (approximately 5 cycles) of 30:2
*
compression-to-ventilation CPR, the candidate re-evaluates
presenting rhythm. If the rhythm has not changed then the
CIRCULATION
candidate continues with defibrillation. Candidate is only to
check for a pulse is the rhythm has changed to one that looks
like an organised cardiac rhythm.
If there is a rhythm change to an organised cardiac rhythm, candidate is to check for a
pulse, and continue with the rhythm management as per protocol.
*
DEFIBRILLATION Charge monitor to 360 Joules (monophasic) or to 150 Joules
(biphasic) or 4 J/kg (paediatrics)
CONTINUED
Determine correct paddle position and press down with at least
*
12kg force to reduce trans-thoracic impedance.
Ensure that all persons are clear of the patient (Im Clear,
*
Youre Clear, Oxygen clear, Everybodys Clear).
Candidate depresses both discharge buttons at the same time
*
2
to deliver shock.
After defibrillation, the candidate is to immediately resume chest compressions.
After 2 minutes (approximately 5 cycles) of 30:2
*
compression-to-ventilation CPR, the candidate re-evaluates
presenting rhythm. If the rhythm has not changed then the
CIRCULATION
candidate continues with defibrillation. Candidate is only to
check for a pulse is the rhythm has changed to one that looks
like an organised cardiac rhythm.
Candidate is to place the ECG leads on patients chest
*
ECG MONITOR
Candidate switches ECG monitor from Paddles to Lead II
*
If there is a rhythm change to an organised cardiac rhythm, candidate is to check for a
pulse, and continue with the rhythm management as per protocol.
Charge monitor to 360 Joules (monophasic) or to 150 Joules
*
DEFIBRILLATION
(biphasic) or 4 J/kg (paediatrics)
Determine correct paddle position and press down with at least
*
12kg force to reduce trans-thoracic impedance.
Ensure that all persons are clear of the patient (Im Clear,
*
Youre Clear, Oxygen clear, Everybodys Clear).
Candidate depresses both discharge buttons at the same time
*
3
to deliver shock.
After defibrillation, the candidate is to immediately resume chest compressions.
1

ACTIVITY

DONE/
NOT
DONE

CRITICAL PERFORMANCE

After 2 minutes (approximately 5 cycles) of 30:2


*
compression-to-ventilation CPR, the candidate re-evaluates
presenting rhythm. If the rhythm has not changed then the
CIRCULATION
candidate continues with defibrillation. Candidate is only to
check for a pulse is the rhythm has changed to one that looks
like an organised cardiac rhythm.
If the initial presenting rhythm has not changed (i.e. remained in Ventricular Fibrillation
or Pulseless Ventricular Tachycardia) the candidate is to continue with defibrillation
according to protocol.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

BASIC LIFE SUPPORT ADULT 1-RESCUER CPR

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate determines that the patient is unresponsive


*
and activates the emergency response system.
Candidate notes absent breathing or breathing which is
*
not normal (only gasping)
Candidate:
- Checks for carotid pulse, and
*
CIRCULATION
- Checks for other signs of circulation. (no longer
*
than 10 seconds)
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate begins 30
chest compressions (rate of at least 100 compressions per
*
minute)
Candidate opens the patients airway using the head-tilt
*
AIRWAY
chin-lift manoeuvre (or jaw thrust if trauma)
Candidate delivers 2 breaths over 1 second each each
*
BREATHING
with enough volume to make the chest rise.
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
RESPONSE

PATIENT
REASSESSMENT

After 5 cycles of compressions and ventilations (30:2


ratio, about 2 minutes), candidate rechecks the patients
carotid pulse and signs of circulation.
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions.
If signs of circulation are present, but breathing is absent
or inadequate, candidate continues rescue breathing (1
breath every 5 to 6 seconds or about 10 to 12
breaths/minute).

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SUCCESSFUL CPR

If the patient is breathing, or resumes adequate breathing,


place in recovery position.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT ADULT 2-RESCUER CPR

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate determines that the patient is unresponsive


*
and activates the emergency response system.
Candidate notes absent breathing or breathing which is
*
not normal (only gasping)
Candidate 1:
- Checks for carotid pulse, and
*
CIRCULATION
- Checks for other signs of circulation (no more
*
than 10 seconds)
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate 2 begins
30 chest compressions (rate of at least 100 compressions
*
per minute).
Candidate 1 opens the patients airway using the head*
AIRWAY
tilt chin-lift manoeuvre (or jaw thrust if trauma)
Candidate 1 delivers 2 breaths over 1 second each each
*
BREATHING
with enough volume to make the chest rise.
Candidates continue with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
After 5 cycles of compressions and ventilations (30:2
ratio, about 2 minutes), candidate 1 delivers 2 rescue
PATIENT
*
REASSESSMENT breaths and rechecks the patients carotid pulse and signs
of circulation.
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
*
with chest compressions, until an AED or EMS team
arrives.
If signs of circulation are present, but breathing is absent
or inadequate, candidate continues rescue breathing (1
*
breath every 5 to 6 seconds or about 10 to 12
breaths/minute).
RESPONSE

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SUCCESSFUL CPR

If the patient is breathing, or resumes adequate breathing,


place in recovery position.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT ADULT FBAO IN RESPONSIVE PATIENT


(and RESPONSIVE PATIENT WHO BECOMES UNRESPONSIVE)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate determines that the patient is responsive and


indicating universal distress signal.

ABDOMINAL
THRUSTS

Candidate gives abdominal thrusts with proper hand


position (chest thrusts for patient who is obese or
pregnant), avoiding compressions over the lower
sternum (xiphoid).
Candidate repeats thrusts until the object is expelled
(obstruction relieved) or the patient becomes
unresponsive.

Adult FBAO Patient becomes unresponsive


PERFORMANCE

SUCCESSFUL

Candidate activates the emergency response system.


Candidate opens the patients airway with a tongue-jawlift; & performs a finger sweep if the foreign object is
visible.
Candidate opens the patients airway and attempts to
ventilate; if it is still obstructed (chest does not rise),
reopen the airway (reposition the head and chin) and try
to ventilate again.
If ventilation is unsuccessful, candidate starts CPR by
giving 30 chest compressions on the lower half of the
patients sternum in the midline between the nipples.
Continue with CPR until ALS arrives or patient begins
breathing normally.
If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.

*
*

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT CHILD 1-RESCUER CPR

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate determines that the patient is unresponsive


*
and activates the emergency response system.
Candidate notes absent breathing or breathing which is
*
not normal (only gasping)
Candidate:
- Checks for carotid pulse, and
*
CIRCULATION
- Checks for other signs of circulation. (no longer
*
than 10 seconds)
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 3 to 5 seconds, about 12 to 20 breaths/minute)
If no signs of circulation are present, or heart rate is less
than 60 bpm with signs of poor perfusion, candidate
begins 30 chest compressions (typically 1-hand
*
compression technique, rate of at least 100 compressions
per minute)
Candidate opens the patients airway using the head-tilt
*
AIRWAY
chin-lift manoeuvre (or jaw thrust if trauma)
Candidate delivers 2 breaths over 1 second each each
*
BREATHING
with enough volume to make the chest rise.
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
RESPONSE

PATIENT
REASSESSMENT

After about two minutes of rescue support, candidate


rechecks the patients carotid pulse and signs of
circulation.
If candidate is alone, candidate now activates the
emergency response system.
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions.

*
*
*

ACTIVITY

PATIENT
ASSESSMENT
CONT.

SUCCESSFUL CPR

CRITICAL PERFORMANCE

DONE/
NOT
DONE

If signs of circulation are present, but breathing is absent


or inadequate, candidate continues rescue breathing (1
breath every 3 to 5 seconds or about 12 to 20
breaths/minute).

If the patient is breathing, or resumes adequate breathing,


place in recovery position.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT INTEGRATED CHILD FBAO


(RESPONSIVE and UNRESPONSIVE PATIENT; CPR and RESCUE BREATHING)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

ABDOMINAL
THRUSTS

Candidate determines that the patient is responsive and


indicating universal distress signal.
Candidate asks Are you choking? (YES), if yes,
candidate asks Can you speak? (NO). If no, candidate
tells the child that he is going to help.
Candidate stands or kneels behind the child, with his
arms encircling the childs abdomen.
Candidate gives abdominal thrusts using the proper hand
position (avoid xiphoid) and supports the childs body.
Candidate repeats until the object is expelled or the
patient becomes unresponsive.

*
*

*
*

Child FBAO Patient becomes unresponsive


PERFORMANCE

If a second rescuer is available, candidate sends that


rescuer to activates the emergency response system.
Candidate opens the patients airway with a tongue-jawlift; and removes any foreign objects that can be seen (no
object seen = no finger sweeps).
Candidate opens the patients airway and attempts to
ventilate; if it is still obstructed (chest does not rise),
reopen the airway (reposition the head and chin) and try
to ventilate again.
If ventilation is unsuccessful, candidate starts CPR
beginning with chest compressions
Continue with CPR until ALS arrives or patient begins
breathing normally.

*
*

ACTIVITY

SUCCESSFUL

DONE/
NOT
DONE

CRITICAL PERFORMANCE
If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT INFANT 1-RESCUER CPR

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate determines that the patient is unresponsive


*
and activates the emergency response system.
Candidate notes absent breathing or breathing which is
*
not normal (only gasping)
Candidate:
- Checks for brachial pulse, and
*
CIRCULATION
- Checks for other signs of circulation. (no longer
*
than 10 seconds)
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 3 to 5 seconds, about 12 to 20 breaths/minute)
If no signs of circulation are present, or heart rate is less
than 60 bpm with signs of poor perfusion, candidate
begins 30 chest compressions (typically 2-finger
*
compression technique, rate of at least 100 compressions
per minute)
Candidate opens the patients airway using the head-tilt
*
AIRWAY
chin-lift manoeuvre (or jaw thrust if trauma)
Candidate delivers 2 breaths over 1 second each each
*
BREATHING
with enough volume to make the chest rise.
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
RESPONSE

PATIENT
REASSESSMENT

After about two minutes of rescue support, candidate


rechecks the patients carotid pulse and signs of
circulation.
If candidate is alone, candidate now activates the
emergency response system.
If no signs of circulation are present, candidate continues
30:2 cycles of compressions and ventilations, beginning
with chest compressions.

*
*
*

ACTIVITY

PATIENT
ASSESSMENT
CONT.

SUCCESSFUL CPR

CRITICAL PERFORMANCE

DONE/
NOT
DONE

If signs of circulation are present, but breathing is absent


or inadequate, candidate continues rescue breathing (1
breath every 3 to 5 seconds or about 12 to 20
breaths/minute).

If the patient is breathing normally, or resumes adequate


breathing, place in recovery position.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________

DATE: __________________

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT INTEGRATED INFANT FBAO


(RESPONSIVE and UNRESPONSIVE PATIENT; CPR and RESCUE BREATHING)

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

AIRWAY

Candidate determines that the patient is responsive.


Candidate confirms severe or complete airway
obstruction (signs of serious breathing difficulty,
ineffective cough, no strong cry).

BACK
BLOWS/CHEST
COMPRESSIONS

Candidate gives up to 5 forceful back blows with the


heel of the hand, and 5 forceful chest compressions using
the 2-finger compression technique (no abdominal
thrusts).
Candidate repeats until the object is expelled or the
patient becomes unresponsive.

Infant FBAO Patient becomes unresponsive


PERFORMANCE

If a second rescuer is available, candidate sends that


rescuer to activates the emergency response system.
Candidate opens the patients airway with a tongue-jawlift; and removes any foreign objects that can be seen (no
object seen = no finger sweeps).
Candidate opens the patients airway and attempts to
ventilate; if it is still obstructed (chest does not rise),
reopen the airway (reposition the head and chin) and try
to ventilate again.
If ventilation is unsuccessful, candidate starts CPR
beginning with chest compressions
Continue with CPR until ALS arrives or patient begins
breathing normally.

*
*

ACTIVITY

SUCCESSFUL

DONE/
NOT
DONE

CRITICAL PERFORMANCE
If the patient is breathing normally or resumes adequate
breathing, place the patient in the recovery position.

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

__________________

Qualific:

____________________

Qualific:

__________________

Signature:

____________________

Signature:

__________________

H.E.L.P. EMERGENCY MEDICAL TRAINING


CANDIDATE EXAM NUMBER: _____________________
_____________________

DATE:

COURSE:

PART TIME

FULL TIME

_______

_______

INTERMEDIATE LIFE SUPPORT CPR AND THE USE OF THE AED

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

SAFETY

Candidate assesses the area with regards to scene safety.

Candidate determines that the patient is unresponsive


and activates the emergency response system calling
*
for an AED
Candidate notes absent breathing or breathing which is
*
not normal (only gasping)
Candidate:
- Checks for carotid pulse, and
*
CIRCULATION
- Checks for other signs of circulation. (no longer
*
than 10 seconds)
If signs of circulation are present, but breathing is absent or inadequate, provide rescue
breathing (1 breath every 5 to 6 seconds, about 10 to 12 breaths/minute)
If no signs of circulation are present, candidate begins 30
chest compressions (rate of at least 100 compressions per
*
minute)
Candidate opens the patients airway using the head-tilt
*
AIRWAY
chin-lift manoeuvre (or jaw thrust if trauma)
Candidate delivers 2 breaths over 1 second each each
*
BREATHING
with enough volume to make the chest rise.
Candidate continues with 2 minutes (approximately 5 cycles) of 30 compressions and 2
ventilations.
RESPONSE

Candidate places the AED next to the patient as soon as


it is available and proceeds with AED use.
Candidate puts the AED on by pushing the POWER
*
ON button
Candidate attached the electrode pads in the proper
position (as pictured on each of the AED electrodes)
*
sternum and apex, with proper contact and no
overlapping of the electrodes.
Candidate clears the patient for analysis (automated)
*
The AED will analyse and will advise a shock and will charge the electrodes

AED USE

ACTIVITY

CRITICAL PERFORMANCE

DONE/
NOT
DONE

AED USE CONT.

Candidate clears the patient and presses the SHOCK


button.

The AED will only deliver one shock and will then instruct the candidate to continue with
CPR starting with chest compressions. The internal AED timer will now also commence
timing for 2 minutes.
Candidate continues with CPR until ALS arrives or until
the patient begins breathing normally
Pulse, breathing, coughing and movement are present

CPR

PATIENT CARE

Candidate continues to monitor breathing and signs of


circulation until ALS arrives.
If trauma is not suspected, candidate placed the patient in
the recovery position with the AED attached.

*
*

* If a critical point is omitted, the final result is automatically unsatisfactory!

FINAL RESULT:

SATISFACTORY

______

UNSATISFACTORY

______

COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________

Examiner One:

Examiner Two:

Name:

____________________

Name:

____________________

Qualific:

____________________

Qualific:

____________________

Signature:

____________________

Signature:

____________________