The Basic of ALS Assistance - Charlottesville

The Basic of
ALS Assistance
Charlottesville-Albemarle
Rescue Squad, Inc.
Introduction
• As a CARS member, you are an integral part of a team
•
•
whose goal is to take care of a sick patient. Regardless
of your training level, you will be called upon at times to
set up an IV line, an albuterol treatment, or to get drugs
from the box. Therefore, a basic understanding of the
box will help the team out tremendously.
The contents and organization of the box changed in
October, 2001 with implementation of new protocols.
The additional information included here is never to be
used independent of the direct supervision and request
of a certified ALS provider.
Disclaimers
• For the sake of clarity, gloves have not been
•
used in most of the photographs. It should be
noted that you should
ALWAYS WEAR GLOVES
when taking care of patients.
This presentation presents you with the basics
of the drug box to help you be even more
helpful on an ALS call. Never do anything from
this presentation without an AIC asking you to
do so.
Table of Contents
I.
II.
III.
IV.
Basic drug box anatomy
Setting up an IV line
Setting up a nebulizer treatment
Preparing medication
–
–
–
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–
V.
VI.
Medication vials
Bristojet injectors
Tubex injector
Glass ampules
Administer Nitroglycerin and Nitropaste.
Basic drug review
Written Test
Section I - Drug box anatomy
• There are four basic compartments to the
box: three drawers and the bottom of the
box.
• The next few pages contain basic outlines
of the drawers’ contents. Don’t try to
memorize them, but get the basic layout.
• Section V will outline these contents in
more detail, and will give you a chance to
test you memory.
Opening the box…
(Okay, you think, this is dumb. How hard can it be?
Actually, very if you don’t know a few things…)
• Start by breaking the pharmacy’s red seal
tag by tearing it off. ONLY do this if the
released ALS AIC asks you to do so.
• Then, unlatch the front and two side
latches.
• Open the front flap.
• The pull out the top drawer a few inches.
• Only then will you be able to open the large
top, and the box opens like a tackle box.
NOTE: The drug boxes are sealed in the
pharmacy following a thorough check by a
pharmacist. Check for the intact seal each
time you look for the presence of the box.
Step 2
Step 1
General Layout
• There are three drawers and a
•
•
•
•
bottom basin.
Top drawer: IV catheters, needles
and syringes, and gray top tube.
Middle drawer: Most medications.
Bottom drawer: ‘Code’ (cardiac
arrest) drugs.
Bottom basin: IV fluids, tubing,
albuterol, a few more drugs, arm
splints, sharps container and
pharmacy complaint form.
Top Drawer
IV Catheters
2 – 14 g (orange)
2 – 16 g (gray)
3 – 18 g (green)
3 – 20 g (pink)
2 – 22 g (yellow)
2 – 24 g (blue)
Injection materials
IV starting materials
2 pairs of gloves
2 tourniquets
3 – 2x2’s
3 – 4x4’s
2 – 1 cc syringes with needle, ‘Tb syringe’
2 – 3 cc syringes with needle
2 – 5 cc syringe without needle
2 – 10 cc syringe without needle
2 heparin locks
Assorted needles
Random IV Materials
16 – Alcohol preps
1 – Roll of Transpore tape (“IV tape”)
2 – 10 cc saline flush bottles
1 – Blood sugar tube (see later)
2 – Versed 5 mg/1 cc
4 – Epinephrine 1:1,000
1 mg/1 cc
1 - Narcan 4 mg/10 cc
1 – Dopamine HCl 200
mg/5 cc, to mix
4 – Magnesium Sulfate
1 mg/2 cc
2 – Nitropaste packets
and application paper
Aspirin 81 mg tablets
1 – Solu-medrol 125 mg
3 – Metoprolol 5 mg/5 cc
1 – Bottle of nitroglycerin
1 – Epinephrine 1:1,000
30 mg/30 cc
1 – Lidocaine 1 g/25 cc
1 – Glucagon 1 mg,
needs to be mixed
2 – Morphine Sulfate
10 mg/1cc
3 – Lasix 40 mg/4 cc
1 – Valium
10 mg/2 cc
2 - Benadryl 50 mg/1 cc
3 – Adeonsine 6 mg/2 cc
Middle Drawer
2 – 14 g 2¼” Catheters
For chest decompression
2 – Vasopressin
20 Units/1 cc
4 – Epinephrine 1:10,000 1 mg/10 cc
4 – Epinephrine 1:10,000 1 mg/10 cc
2 – Lidocaine HCl 100 mg/5 cc
2 – Lidocaine HCl 100 mg/5 cc
1 – Calcium Chloride 1 g/10 cc
4 – Atropine 1 mg/10 cc
Bottom Drawer
Bottom of Box
2 – Ar
m boa
rds
2 – T-port extension sets
1 – Sharps container
1 – Albuterol hand held nebulizer set-up
4 – Albuterol bullets
1 – Ipatropium bullet
2 – 30 cc syringes
2 – Macrodrip tubing sets
2 – Minidrip tubing sets
2 – 1,000 cc bags of Normal Saline
2 – 250 cc bags of D5W
rd bag
1 – Biohaza
list
ox contents
1 – Drug b
form
1 – Problem
2 – Dextrose 50% 25 g/50 cc
2 – Sodium Bicarbonate 50 mEq/50 cc
Section II - Intravenous Lines
• IV lines are started for many reasons,
including administering fluid to
hypovolemic patients and as a route to
give medications.
• The basic set-up involves:
– The fluid to be infused, connected to …
– Tubing, which is connected to an…
– Extension set...
– Which connects to the IV catheter in the vein.
Fluids
Normal Saline (NS) – 1,000 cc/bag
– ALWAYS used in trauma and cardiac arrest.
Often used for patients with chest pain and other
medical complaints.
– The fluid is a salt, which is infused into the
bloodstream, part of which stays in the
vasculature.
– Consider it the default fluid.
• Dextrose 5% - 250 cc/bag
0.9% Sodium Chloride
aka “Normal Saline”
– Used for mixing drips of medications.
– Does not stay in vasculature, so it cannot be
used to resuscitate a hypotensive patient.
• The bottom line: ASK the AIC which fluid
they want, but you will almost always use
saline.
5% Dextrose
in water
aka “D5W”
Tubing
• The tubing connects the fluid bag to the
•
•
extension set
Drip chamber determines maximum flow rate
Macrodrip, aka ‘big drip’ or ’10-drop’ tubing
– 10 drops make 1 cc (1 ml)
– Has a wide drip chamber which makes big
drops, allowing quick delivery of high volumes
• Microdrip, aka ‘little drip’ or ’60 drop’ tubing
– 60 drops make 1 cc (1 ml)
– Has a small, needle-like dripper which allows
counting of drops to titrate medication drips
• Again, ask the AIC which tubing they want.
Off-clamp
Tubing Anatomy
Drip chamber
From the fluid bag down to the extension set
• Drip chamber
– Holds a reservoir of fluid preventing infusion
of air bubbles
Flow
– Allows observation of flow rate
regulator
• Clamp
Drug port
– Allows immediate cessation of flow
– Always check here if there is NO flow when
you ‘open up the line.’
aka ‘opening up the line.’
• Towards the patient decreases rate.
– Comes packaged in the open position.
• Drug port
– Rubber-covered allows repeated needle
puncture for medication administration
Incr
eas
es
• Towards the fluid bag increases flow rate,
D ec
r
e
a
ses
flow
– Manipulates flow
flow
• Flow regulator
Extension set
• Should be placed on all IV’s
• Serves as a reversible, one-way
•
•
•
connector between tubing and the IV
catheter.
Allows the ER staff to draw blood and
inject medications without resticking
the patient.
Provides a very proximal medication
port for medications that have very
short half-lives, eg adenosine.
Some providers do not like to use it
because of the twisting port used to
attach to the catheter. However, it is
of tremendous benefit to the patient,
so use them ☺
g
bin
u
T
IV
Extension
Tubing
Disposable
caps
One-way
valve
To
Clamp
IV
ca
th
et
er
Choosing the IV catheter
• IV supplies are found in the top
•
•
drawer of the drug box.
The catheters come in different
diameters and lengths. The
packages are color coded by size as
shown in the middle. You can see
the catheters come as a big mess,
so knowing the colors saves lots of
time.
The size, or gauge (g), is written in
the upper left corner of the
package. This number represents
1/(diameter of catheter in inches),
so 14g is 1/14” in diameter, and is
the biggest catheter. Next to it is
marked the length of catheter.
14 g - Orange
16 g – Gray
18 g – Green
20 g – Pink
22 g – Blue
24 g - Yellow
Anatomy of IV catheters
• The plastic catheter is the connection
•
•
between the IV tubing and the
patient’s vein. Most of the new
catheters are clear; they are not
defective.
The contraption shown in to top figure
is how the catheter-over-needle is
packaged.
PROCEUDRE: The protective cap is
removed, and after cleansing the skin
with alcohol, the needle-catheter
combination is introduced through the
patient’s skin, into a superficial vein.
Blood flows back through the needle,
and into the flash chamber. The
catheter is threaded over the needle
and into the vein, and the needle
withdrawn into the casing as shown in
bottom figure. The needle is removed
and tubing attached.
Protective
cap
Needle
Flash
chamber
Intravenous
catheter
Withdrawn needle
“Setting up a line…”
• Hopefully, you now understand the
•
•
parts of a functional IV: a fluid bag,
tubing, extension set and a catheter.
“Setting up a line” is a common
request of newer members, so you
should know how to do this. This
involves preconnecting the fluid,
tubing and extension set and letting
the fluid run through the line, getting
rid of the air.
Start by opening the box and
removing a bag of fluid, tubing and an
extension set. Your defaults should
be normal saline and a macrodrip (10
drop) tubing, unless your AIC tells you
differently. However, ALWAYS ask
what the AIC wants set up.
Extension
set
Tubing set
Normal
Saline
Precut edge
The fluid bag
• Packaging for both D5W and
saline bags have only one right
way to be opened…and several wrong,
though creative ways.
• There is a precut edge in the
•
•
•
upper left corner. Pull the corner
as shown down the length of the
bag.
Remove the bag and pull off the
blue cover.
The medication port is just that,
and is not to be removed.
At this point, hang the bag on the
hooks in the truck (by the precut
hole in the bag) or have a
bystander hold it.
Medication/ fluid
withdrawal port
Preparing the tubing and extension set
Remove
cap
Extension set contents
• Open the tubing by pulling the package
•
•
apart at the sides. It tears easily at the
serrated edge. Also open the extension
set.
The extension set comes with
everything as shown. The blue cap
should be removed by twisting off, the
one way valve must then be tightened1,
or it will leak or fall off. Leave the distal
cap on until ready to connect to the
catheter to keep the tip clean.
Then attach the distal end of the tubing
to the one way valve of the extension
set as shown2. Secure the two by
twisting cap as shown3.
Tighten (1)
Ensure
clamp is
off
Leave
cap on
3
2
Connecting the tubing to fluid
• Remove the cap that covers the drip
•
chamber (not shown1). Then grip
the nipple tightly with one hand2 and
squeeze the drip chamber as shown
with the other hand3, and push up
into the bag with a twisting motion.
The beveled edge will pierce the
membrane and allow fluid to flow
into drip chamber.
Remember that once you do this,
removing the tubing from that port
will lead to a high volume leakage of
fluid onto the floor…this constitutes
poor form.
2. Grip tightly
1. Remove cap
3. Squeeze and twist up
Important
slide
The drip chamber…
• The drip chamber serves two main
purposes:
–
–
to prevent air from going into the line and
to monitor fluid flow rate.
• There is a line engraved into the drip
•
•
chamber which marks the proper fluid
level.
If you do not put enough fluid in the
chamber, e.g. if you forget to squeeze the
chamber as you puncture the bag, air can
get into the line and flows into the
patient’s venous system. This can be very
dangerous if lots of air gets infused. To
correct, simply squeeze the chamber and
flow out the bubbles.
Too much fluid disallows you from
visualizing the drip rate, which is rather
annoying. To correct this, tip the bag
upside down allowing air to come to the
top of bag, then squeeze the chamber,
allowing bubbles to backflow into the
chamber.
Correct
Too much air!
Too much fluid
Fill the tubing…
• Having filled the drip chamber with the appropriate
•
•
•
•
•
•
level of fluid, allow the tubing to fill with fluid.
This happens by gravity, so the bag must be above
the end of the tubing, ideally hanging from the
ceiling.
Watch the tubing fill and ensure there are no air
bubbles throughout the length of the tubing (2-3
small ones are acceptable). Continue flowing saline
onto the floor until all bubbles are gone.
Shut off flow using the regulator as shown. Rolling
towards the bag increases flow, away from bag
shuts it off.
If there is NO flow, check for a clamped clamp.
Many good IV’s have been unnecessarily pulled
because of clamps!
The regulator holder is a little appreciated feature.
It can be clamped around the tubing just below the
drip chamber to allow easy visibility and access…you
get bonus points if you do this!
Leave the end of the tubing in an easy to reach
place, like hung up by the bag or behind the pillow,
NOT on the floor.
Clamp
Regulator
Regulator
holder
Opening the catheter package
Other preparation
• You have now completed the official
business of ‘setting up a line.’ To put
the catheter in and ‘start the line,’ you
should be on top of a few things:
– Get a tourniquet, gloves, alcohol preps,
2x2’s and 4x4’s ready (top drawer).
– Cut five pieces of transpore tape, each
about as long as your middle finger.
Cut one more piece down the middle as
shown.
– Open an alcohol prep as shown by
tearing down the middle, not where it
says ‘open here.’ This makes the
alcohol prep stick out and easy to grab.
– Four by fours and 2x2’s can also be
open by tearing down the middle.
Transpore tape
4x4
Tourniquet
2x2
IV catheter
Alcohol preps
The way to open an alcohol prep and tear tape.
Once the catheter is in…
• Usually you will just need to remove
•
•
•
the cap off the end of extension set
and hand the end of the tubing to
the AIC.
If they ask for extra assistance, this
is what to do. Hold the end of the
extension set as shown and insert it
into the hub of the catheter. Then
twist the lock onto the hub by
turning clockwise.
NOTE: sometimes the lock sticks,
making it hard to lock onto the hub.
Always loosen it by twisting it
around before attempting to attach
to the catheter.
Open the line using the regulator.
Twist to
loosen
Twist clockwise
Taping
• The catheter and tubing must now be held
•
Sticky down
in place until secured. This is done using
the tape you cut. Remember it is
everyone’s job to protect the IV, so watch
your step, and help the person taping.
Your end result should look like this.
– The first piece of tape is cut in half
lengthwise and turned upside down, and
forms a U around the catheter. Not all
providers use this technique.
– The remainder go across the catheter and
2x2.
– ALWAYS fold the tubing over on itself and
tape as shown to leave slack in the line.
– Do your best to leave the ports accessible.
• Remember that the bag of fluid must be
kept above the level of the heart at all
times. If you must lower the bag, eg
putting it on the patient’s lap to unload the
ambulance, make sure the regulator is to
off, or blood will backflow into the tubing.
Sticky up
Towards catheter
Sticky down
Arm board
Adjusting flow & Troubleshooting
• There are two basic rates that
IV fluids are run in the
prehospital setting:
– Slow: known as ‘KVO’ for
‘keep vein open’ or ‘TKO’ for
to keep open. This is about
one drop every two seconds.
Adjust the regulator as you
watch the drip chamber.
– Fast: known as ‘wide open.’
Open the regulator all the way
and allow the IV to flow at its
maximal rate.
• Always watch the IV site for
signs of infiltration, such as
pain, redness and swelling.
Top ten reasons your IV is
not running
1. It is not in the vein. Instead, it is in
the interstitial space. This is known as
infiltration.
2. The tourniquet is still on. This is very
common!
3. The blood pressure cuff is still on the
same arm and pumped up.
4. The bag is below the level of the
heart.
5. The tubing is clamped.
6. The extension set is clamped.
7. The regulator is set to off.
8. You are standing on the tubing.
9. The cot is on the tubing.
10. The drip chamber is overfilled, so
drips are not visible.
Sharps
• A ‘sharp’ is any sharp object (IV needle, IM
•
•
•
•
•
•
needle, glass ampule) that may be contaminated
by blood or body fluids.
Extreme caution must be exercised by all
members involved in patient care when a sharp is
present on a scene, as an inadvertent stick may
lead to transmission of infectious diseases, such
as hepatitis.
Place the retracted IV needle into a sharps
container.
Press down on the container as shown until it
snaps closed.
Do NOT close the container by squeezing it
between your two hands, as sometimes a sharp is
able to puncture the bottom of the container and
can pierce your hand.
There are also sharps containers on all
ambulances that are easier to use (look for the
big red box).
In contrast to this picture, always wear gloves.
Review
• The steps in setting up a line include
– Open the packaging for the fluid bag, tubing and
extension set
– Attach the tubing to the extension set
– Attach the tubing to the fluid, checking for proper
filling of drip chamber and absence of bubbles
– Turn off the flow using the regulator
– Cut tape, select catheters, open alcohol preps, etc.
• Nice work! Just a few more words about some
new additions to the drug box…
Heparin locks
• These little contraptions are also known as
•
•
•
‘hep locks,’ since they are sometimes
flushed with heparin to prevent clotting of
blood in the catheter.
They are used simply as an end-cap for
the catheter. They obviate the need to
run IV fluids to ‘keep the vein open.’
They can be punctured repeatedly as
necessary to inject medications.
To attach a hep lock:
– Open the package shown and remove the
blue protector.
– Fill the port with saline to remove the air.
– Connect the hep lock with the hub of the
catheter and secure with tape.
– Flush with saline to remove stagnant blood
in the catheter.
Alligator Clips
• Alligator clips are used to attach
•
•
•
accessories that usually attach
directly into the IV catheter into a
hep lock. It contains two plastic
clips which hug the hep lock and a
soft needle which punctures the
hep lock membrane.
Begin by attaching the IV line as
shown above1.
Then squeeze the clips2 and push
the needle through the membrane3.
Secure with tape and allow the IV
fluid to run in.
2
1
3
Section III - Nebulizers
• Nebulizers are small containers into which we
•
•
put drugs to be delivered to the lungs, like
albuterol and atrovent.
When oxygen flows through the nebulizer, it
aerosolizes the drug into small particles about 2
microns in diameter, small enough to travel all
the way into the patient’s lower airways.
The nebulizer is connected to oxygen on one
end. The other end may be connected to a
piece-pipe and held by the patient, or rigged up
to an NRB, allowing hands free drug delivery.
Set up
1.
2.
Open the packet, found in the bottom
compartment of the drug box, in a
sealed bag. Attached or included in it
are four albuterol bullets and one
atrovent bullet. There are no saline
bullets in the drug box.
The plastic nebulizer has two parts
which screw together. They usually
come put together, but always need to
be tightened.
NOTE – not all nebulizers in the drug box
will look like this one, but the
components are the same. Spare
nebulizers are kept with the NRB masks
on all the ambulances.
Albuterol nebulizer
setup
Albuterol
Atrovent
Saline
bullet
More nebulizer setup…
3.
4.
5.
6.
Connect one end of the oxygen tubing to the bottom
of the nebulizer and the other end to an O2 source,
set from 4-10 LPM; the old school states 4-6 LPM,
but the aerosol is more effective when set at 8-10
LPM.
The drugs for the nebulizer include albuterol ‘bullets’
(four/box) and atrovent (one/box), used for the
treatment of asthma. When you open the packet,
put the extra treatments in a pocket or somewhere
you will not lose them.
Ask the provider which drug/s they will want to give.
For some patients we will start with both an
albuterol and atrovent, for others we start with just
albuterol.
Open the bullet by twisting off the small plastic cap
(insert). Turn it upside down and place the open
end into the round opening of the nebulizer. It is
okay if the oxygen is flowing when you do this.
REMEMBER that once you do this to always keep the
nebulizer upright, or you will lose all the drug into
the patient’s lap, which is much less effective ☺
Assembling delivery devices
Hand-held nebulizer
The standard method of delivering nebulized
drugs is by hand held nebulizer (HHN). The
nebulizer is attached to a T-connector,
which has a piecepipe which the patient
holds in his mouth. The serrated tube
shown serves as a reservoir for nebulized
particles to buildup between breaths.
•
The T-connector2 has two ends, with either
a bigger or smaller diameter opening, as
denoted by the circles.
–
–
–
•
The mouthpiece3 fits inside the large
diameter end of the T-connector.
The piecepipe1 fits outside the small diameter
end of the T-connector.
Connect the T-connector to the round top of
the neb.
The patient holds the entire contraption in
his/her hand. It is good for claustrophobic
patients who need to feel in control.
1
2
3
Assembling delivery devices
Non-rebreather mask
Another option is to connect the
nebulizer to the mask portion
of the NRB.
•
Simply remove the reservoir
bag and tubing from a NRB
by pulling them apart. This
leaves the mask and strap
with a hole which fits the top
of the nebulizer perfectly.
•
This is the method of choice
for patients who are very
dyspneic, in whom you are
doing lots of treatment and
need the patient’s arms, or in
small children.
Section IV – Miscellaneous skills
• Injectable medications
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–
–
–
–
Assembling a syringe
Medication vials
Bristo-jet injectors
Tubex injectors
Glass ampules
–
–
–
Administering Nitroglycerin
Applying Nitropaste
Obtaining a blood sample
• Other skills
Syringes
• All syringes are found in the top
drawer, except the large 30-cc
syringe in the bottom of the box.
– The 1 cc and 3 cc syringes come with
a needle already attached.
– The 5, 10 and 30 cc syringes need to
have a needle attached to them.
– The lower picture is one of the new
protective needles, which are being
phased-in. The orange cover is
simply snapped over the needle
following use. They are still disposed
of in sharps containers.
Assembling a syringe
• Start by choosing the appropriate sized syringe.
•
•
•
2. Twist off
ch
1. Pin
•
You can figure this out by what volume of
medication you will be giving and choosing the
smallest one that will fit that volume. So don’t
chose a 3 cc syringe to give 40 mg of lasix,
since that is 4 cc, and you would have to draw
up medication twice…this is again, suboptimal.
Open the package by tearing it over the end of
the syringe as shown.
Then pinch the protective cap while you twist
the syringe off of it and pull it out of the
package. This is a time-saving maneuver.
Remove a needle (NOT an IV catheter) from
the top drawer and open it as you did the
syringe.
Then twist the syringe and needle together.
Medication vials
• The majority of the injectable medications in
•
•
•
•
•
the box come packaged as vials.
To prepare this for injection, it must be
drawn up into a syringe.
Begin by snapping off the protective cap as
shown. The rubber cap this uncovers is
sterile and should be maintained as such.
Invert the vial, puncture the rubber cap with
a syringe, inject in air approximately the
volume of medication you wish to withdraw,
and then withdraw the medication by pulling
back on the syringe. Then remove the
syringe.
Hold the syringe with the needle up and
expel any air you may have drawn up.
NOTE – all vials and needles are considered
sharps and should be disposed of the sharps
container. Never throw them in the trash.
Bristo-jet injectors
• Bristo-jets are premade syringes filled with medication,
made ready to inject with minimal preparation, often for
cardiac arrest situations. We have the following drugs
as bristo-jets:
–
–
–
–
–
–
Atropine – speeds up the heart.
Epinephrine 1:10,000 – constricts peripheral vessels.
Lidocaine – stops abnormal rhythms.
Dextrose 50% - ‘D50’ – simple sugar for diabetics.
Sodium bicarbonate – a ‘base’ to treat metabolic acidosis.
Calcium chloride – an ion to treat certain drug overdoses.
• You may find these set-ups in a prepackaged box (D50,
bicarbonate, lidocaine) or free-standing in the drawer
(epinephrine, atropine).
Setting up the bristo-jet
1. If the drug comes in a box, open it. Your life
2.
3.
4.
will be much easier if you follow the ‘open
here’ label on the box.
Pick up the glass ampule with the drug in it in
one hand, and a bristo-jet injector in the other.
Point the yellow caps to the ceiling, and pop
them off together using your thumbs. (This is
a key maneuver if you want to look cool as an
EMT).
Screw the two ends together. Beware that the
injector has two needles in it, one hidden by
the yellow plastic cover; the other punctures
the blue cap to the ampule.
An ALS provider will remove the yellow needle
cap, insert the needle into a drug port on the
IV, and inject the drug.
Twist
clockwise
Injector
Tubex injectors
•
•
•
•
Another way of packaging the drug is with a
syringe with a needle that does not have a
handle to push the drug with.
You may see epinephrine and benadryl pakaged
this way.
The ‘syringe holder’ contains two parts which
twist over one another. The ‘injector’ slides
through this contraption.
To prepare a medication for injection:
1. Hold the syringe holder as shown and place a
tubex syringe into the hole as shown.
2. Twist the two parts of the syringe holder around
each other in a clockwise fashion.
3. Then push the injector into the back of the syringe
and twist it clockwise.
Syringe
holder
Step 1
Step 2
Step 3
Glass ampules
• Some drugs, such as epinephrine, come
•
•
•
packaged as glass ampules, as shown.
To retrieve the medication from the
bottle, you must first swirl the bottle to
move the fluid stuck in the cap into the
ampule.
Then break the top off as shown. Always
wear gloves and protect yourself using a
2x2. Break the cap away from your body.
The ampule can then be turned upside
down (the fluid is kept in by hydrostatic
pressure). Insert a syringe and withdraw
the medication by pulling on the syringe.
Do NOT inject air into the ampule, or the
medication will go all over the floor.
Administering Nitroglycerin
• Nitroglycerin is a common medication that
•
•
•
•
is used to treat chest pain of suspected
myocardial origin.
There is a full bottle of it in the second
drawer of the box; you should be familiar
with it.
If asked to administer a tablet, open the
vial carefully, remove a tablet, and recover
the vial. Place it in a location where you
will not lose it, like back where you got it.
Ask the patient to lift their tongue and
place the tablet under the tongue as
shown. They are not to be chewed. They
can close their mouth after the medication
has been placed.
Effects include headache, hypotension,
tachycardia. Always make SURE the
patient has not had Viagra in the past 24
hours, which is an absolute contraindication
to giving them nitroglycerin.
Applying Nitropaste
• Nitropaste is an alternate form of nitroglycerin
•
•
•
•
•
•
that is applied to the skin and very quickly
absorbed. It is dosed in inches.
To prepare it, WEAR GLOVES. Then open the
package by twisting about the precut area
(insert).
Apply the paste to the paper as shown. A
package is a premeasured dose of 1”, so
squeeze out the whole package if asked to
give 1”, two packets for 2”.
Apply the paste and paper to the patient’s
skin. The preferred locations are the lateral
aspect of the arm (less headache, no
interference with the 12-lead) and the left
upper chest.
Always tape the paper as shown.
Change your gloves following this procedure.
To remove the paste, don gloves and use a
4x4 to wipe the paste from the patient’s skin.
Obtaining a blood sample
• This procedure is used to obtain a
•
•
•
grey topped tube filled with patient
blood prior to the administration of
sugar (D50) for the determination of
blood glucose prior to treatment.
Always attempt to obtain a sample
prior to giving ‘D50.’
The vacutainer comes in a sealed
package as shown (top drawer).
Prepare as shown.
The IV tubing is then attached to the
catheter as usual and D50
administered.
IV catheter
Section V - Basic Drug Review
In this section, we will review where in the box each of these medicines are
(organized by chief complaint) and some pearls to know for each.
• Asthma
–
–
–
Albuterol - Proventil
Ipatropium bromide - Atrovent
Methylprednisolone - Solu-Medrol
–
–
–
–
–
Aspirin - ASA
Nitroglycerin tab - NTG
Nitroglycerin paste - NTP
Morphine sulfate – MSO4
Metoprolol
–
–
Epinephrine - Epi
Diphenhidramine - Benadryl
–
–
–
–
–
Vasopressin - Pitressin
Epinephrine
Atropine
Lidocaine
Magnesium sulfate
• Anginal Chest Pain
• Allergic Reaction
• Cardiac Arrest
• Sick Hearts
–
–
–
–
Adenosine - Adenocard
Atropine HCl
Dopamine HCl
Lasix - Furosemide
–
–
Dextrose 50% - D50
Glucagon
–
–
Diazepam - Valium
Midazolam - Versed
–
–
–
Calcium Chloride
Naloxone – Narcan
Sodium bicarbonate
• Diabetic Emergenies
• Seizures
• Other
Asthma and COPD
Caused by inflammation and spasm/constriction of bronchioles.
• You are treating a 26 year old man with a
history of asthma for an acute asthma
exacerbation. Where would you find the
following and how would you set it up:
– Albuterol sulfate nebulizer
– Atrovent nebulizer
– Solu-Medrol injection
• THINK before you click to the next slide.
Asthma/COPD Drugs
Albuterol Sulfate
Dose: 2.5 mg in 3 cc bullet
Action: Dilates bronchioles when inhaled.
Prep: Squirt into assembled nebulizer
as previously described.
Cautions: Can cause tachycardia and
palpitations.
Ipatropium bromide (Atrovent)
Bottom of Box
Dose: 2.5 mg in 3 cc bullet
Action: Dilates bronchioles by
blocking parasympathetics.
Prep: As above. Always with
albuterol.
Cautions: As above.
Methylprednisolone (Solu-Medrol)
Middle Drawer
Dose: 125 mg IV (ped 1-2 mg/kg)
Action: Decreases inflammation in
the bronchioles, takes several
hours for effect.
Prep: Remove from box, then press
top down as shown. This pushes
stopper through and mixes the
drug. Draw up with 10 cc syringe.
Anginal Chest Pain
Caused by excessive work-load of the heart muscle relative to oxygen delivery.
In MI, this is due to a clot forming in a coronary artery.
• You are treating an 85 year old man with chest
pain. The medic then asks you to get him the
following:
– Aspirin – 4 tablets chewed
– Nitroglycerin – 1 tablet sublingually
– Nitropaste – 2” applied to the shoulder
– Morphine - 2 mg for IV use
– Metoprolol – 5 mg for IV use
Where would you find these medications and what are
the basic reasons we give them?
Chest Pain Drugs
Baby Aspirin
Dose: 4 tablets, chewed
Action: binds platelets and
decreases clotting in a
potential heart attack.
Sublingual Nitroglycerin
Dose: 1 tablet under the
tongue, repeated
Action: Dilates veins and
arterioles to decrease
work on the myocardium.
Cautions: headache,
hypotension, tachycardia.
NitroPaste
Middle Drawer
Metoprolol Tartate
Dose: 5 mg IV, repeated twice more
Action: Blocks epinephrine at the Breceptor, and slows down the heart.
Prep: Draw up in a 5 cc syringe.
Cautions: Do NOT use in asthmatic
patients.
Dose: 1-2” transdermal.
One packet equals 1”.
Apply to the deltoid area
and tape the sides.
Action: same as above.
Morphine Sulfate
Dose: 2 mg IV
Action: Binds to opioid receptors
and decreases pain.
Prep: Draw up with a 1 cc
syringe. Some medics dilute
1:10 in a 10 cc syringe.
Allergic reaction
Caused by release of histamine and other factors from mast cells,
which causes flushing and inflammation. A mast cell-aggravating stimulus (bee
stings, food) is necessary.
• You are called to treat a 3 year old who has
eaten peanuts and developed hives and
respiratory distress. You want to treat him with:
– Epinephrine SQ (subcutaneously)
– Benadryl IM (intramuscular) or IV
Where do you find these life-saving drugs?
– Do you remember how to get them ready?
Allergic reaction drugs
Epinephrine HCl
Dose: 0.3 mg SQ (peds 0.01 mg/kg)
Action: Binds to mast cells and inhibits the release of
histamine. Also bronchodilates.
Prep: Break open ampule and draw up in a 1 cc syringe.
NOTE: These also come packaged as tubex syringes, so
be prepared to set up whatever is in the box.
Cautions: Causes tachycardia, anxiety and hypertension.
Diphenhydramine (Benadryl)
Middle Drawer
Dose: 25-50 mg (peds 1 mg/kg)
Action: Inhibits the action of released histamine on
tissues, such as skin and vessels. Treats hives well.
Prep: Draw up into 1 cc syringe.
NOTE: These also come packaged as ampules or
tubex syringes.
Cautions: Can be sedating.
Cardiac arrest
Different from a ‘heart attack,’ this is the absence of any
spontaneous heart beat or respirations. The truest of emergencies.
• Cardiac arrest occurs following any number of insults,
but it results in loss of peripheral vessel tone and
abnormal heart rhythms. It is treated with vasopressors
(vessel squeezers) and antiarrhythmics (stopping
abnormal rhythms)
– Vasopressors
• Vasopressin
• Epinephrine
– Antiarrhythmics
• Atropine
• Lidocaine
• Magnesium Sulfate
• Would you know where to look for each of these drugs?
How do they come packaged? Could you get them
ready?
Cardiac Arrest-Vasopressors
Vasopressin (Pitressin)
Dose: 40 Units in 2 cc IV or ET
Action: Increases vascular tone and perfusion
of vital organs by shunting blood centrally.
Takes the place of epinephrine as a
vasopressor in certain rhythms.
Prep: Draw up both vials into a 3 cc syringe.
Third drawer
Epinephrine HCl
Dose: 1 mg every 3-5 minutes
(Peds 0.01 mg/kg)
Action: Increases vascular tone. Can
have detrimental effects on brain
perfusion if high dosed.
Prep: For regular strength epinephrine
(1:10,000), prepare bristojet as
shown to the left.
For the high dose (1:1,000), draw up
1 cc per dose. Vial shown on right.
Second drawer
Cardiac Arrest - Antiarrhythmics
Atropine Sulfate
Dose: 1 mg IV (peds 0.02 mg/kg)
Action: Blocks a parasympathetic receptor in the heart.
This speeds up the heart rate. It is given for a slow
heart rate or for asystole (no heart activity).
Prep: Prepare bristojet as described before.
Lidocaine Hydrochloride
Bottom Drawer
Dose: 1-1.5 mg/kg IV
Action: Blocks sodium channels in the heart muscle and
in nerves, which can get rid of abnormal heart rhythms
which are conducted by heart muscle (ventricular
tachycardia and fibrillation).
Prep: Prepare bristojet as described before. It can also
be administered as a drip. To do this, mix the entire
bottle in a 250 cc bag with microdrip tubing.
Cautions: Can cause hypotension and lethargy.
Magnesium Sulfate
Middle Drawer
Dose: 2 g IV
Action: Competes with calcium for calcium channels
which is another way to get rid of abnormal heart
rhythms. Especially good for a special form of
ventricular tachycardia called torsades de pointes.
Prep: Draw up both vials in a 5 cc syringe.
Cautions: Can cause hypotension and lethargy.
Sick Hearts
This is a hodgepodge of different medications used to treat
patients with various problems with their heart.
• Case 1 –
– You are treating a 25 year old man with a heart rate of 260 c/o
palpitations. Your team decides to treat him with adenosine…
• Where do you find this medicine?
• What size syringe will you use to draw up this medicine?
• What else will you need to prepare when giving this medicine?
• Case 2 –
– You are treating a 76 year old woman with congestive heart
failure. In addition to nitroglycerin and morphine as described
before, you might treat her with lasix or dopamine.
• Where do you find these medicines?
• What is special about dopamine that you should know?
Sick Hearts - Case 1
Adenosine (Adenocard)
Middle Drawer
Dose: 6 mg, repeated with 12 mg fast
IV
Action: Adenosine is a natural hormone
released by the body during periods
of cardiac stress. It binds to the adenosine receptor and
slows down the heart. It is used for patients with
supraventricular tachycardia to slow down the heart.
Prep: The AIC will need lots of help, since these patients are
fairly sick. The drug has a half life of 6 seconds once it
enters the vein, so you have to follow the bolus with
about 30 cc of normal saline (drawn up from the bag
into a 30 cc syringe) and pushed into a port in the
tubing.
-Draw up one vial of medicine in a 3 cc syringe.
-Draw up 30 cc of fluid in a 30 cc syringe with a needle)
-When the AIC pushes the medicine, push the ‘record’
button on the monitor so the cardiologists can see the
rhythm change.
Cautions: The drug causes asystole for usually about 5-10
seconds. This is very scary to the patient, and more so
to the person who pushed the medicine. Be ready!
Sick Hearts – Case 2
Furosemide (Lasix)
Dose: 40-120 mg (peds 1 mg/kg) IV/IM
Action: Causes increased urine production by
decreasing resorption in the loop of Henle. Also
briefly dilates vessels.
Prep: Draw up one or two vials in a 10 cc syringe.
There are 10 mg in each cc you draw up.
Cautions: Can cause hypotension and must be
administered slowly over a few minutes. Can cause
ringing in ears.
Dopamine (Intropin)
Dose: 2-20 µg/kg/min, given as a drip
Middle Drawer
Action: Depends on dose: 2-5 µg/kg/min leads to
dilation of renal arteries; 5-10 µg/kg/min leads to
increased rate and force of contraction of the heart;
10-20 µg/kg/min leads to the above and peripheral
vasoconstriction. Used anytime there is severe
hypotension refractory to fluids and rate control.
Prep: Draw up 200 mg of dopamine (1 vial) into a 5
cc syringe and inject it into a 250 cc D5W bag
connected to a minidrip tubing. This will be attached
to an injection port in a macrodrip tubing and
administered as a drip.
Diabetic Emergencies
Altered mental status or unresponsiveness can be caused by either
high or low blood sugar.
• You are treating a 48 year old diabetic woman
who took her usual dose of insulin today but
forgot to eat breakfast. She was found
unresponsive by her husband in the house.
Since she is unable to eat, you decide to treat
her with either IV D50% or glucagon.
– Dextrose 50% • What two things do you need to set up before you get the
D50 ready?
Where is the D50% and how do you set it up?
•
– Glucagon
• Where is the glucagon located?
• How do you prepare it? How is it administered?
Diabetic Emergencies – Dextrose 50%
Dextrose 50% (‘D-50’)
Dose: 25 g (Peds 0.5 mg/kg)
Action: Dextrose is an isomer of glucose. When given into
a vein, it raises blood sugar quickly.
Bottom of Box
Prep: Administration of intravenous sugar consists of
three steps:
• Set up a macrodrip IV with saline as the fluid.
• Set up the vacutainer as described before (shown at
bottom) to draw a blood sample before administration of
the drug. This allows documentation of hypoglycemia.
• Set up the D50 syringe. They come packaged in one of
two ways.
• Preassembled syringe (top picture). Just remove
the grey cover and attach a 19 g needle. It is now
injectable into an IV port.
Top Drawer
• Bristo-jet (middle picture). Set up as described
before.
• When given to a child, dextrose must be diluted in
a 4:1 dilution in 30 cc syringe.
Caution: Always watch the IV for good flow and the site
for signs of infiltration, since infiltrated D50 causes death
of surrounding tissues.
Diabetic Emergencies - Glucagon
Glucagon
Dose: 1 mg (peds 1 mg) intramuscular
Action: Enters the bloodstream after being
absorbed from the muscle. It then enters muscle
and liver where it breaks down glycogen into
sugar. It usually takes about 5-10 minutes before
a patient’s mental status will begin to improve if
this is the problem.
Middle Drawer
Prep: Open the plastic bag and inject the syringe
of fluid into the vial with the glucagon powder.
Mix up the combination by shaking the vial. Then
draw up the homogenous mixture with the
syringe. It can be injected IM or IV.
Cautions: None.
Seizures
Caused by uncontrolled discharges of neurons in the brain.
• You are treating a 26 year old alcoholic man
having a tonic-clonic seizure which has been
persisting for the past 6 minutes. After treating
with D50, you can treat the seizure with one of
two drugs:
– Diazepam (Valium) IV or PR (per rectum)
– Midazolam (Versed) IV or IM
• Where do you find these drugs and how do you
•
prepare them?
What is their mechanism?
Seizures
Diazepam (Valium)
Dose: 2 mg IV, 5 mg PR (peds 0.1 mg/kg)
Action: Goes into the CNS and hyperpolarizes the
neurons by opening a chloride channel. This stops
seizure activity, which is caused by neuronal
depolarization.
Prep: Draw up the entire vial into a 3 cc syringe.
It can then be injected IV or PR.
Caution: Causes sedation following cessation of
seizure activity. Basically, the patient will appear
drunk, since alcohol has much the same effect as
this class of drug.
Middle Drawer
Midazolam (Versed)
Dose: 2 mg IV/IM (peds 0.1 mg/kg)
Action: Same as above. Versed has a quicker onset
and is therefore a nice drug to sedate a patient for
cardioversion. It can also be given IM to a seizing
patient.
Prep: Draw up contents of one vial into a 3 cc
syringe.
Cautions: As above.
Miscellaneous Drugs
• You are treating a 17 year old boy who is unconscious.
•
•
You suspect a narcotic overdose because of his small
pupils. You decide to treat him with naloxone.
You are treating a 24 year old woman for a tricyclic
antidepressant overdose who is in an abnormal heart
rhythm due to the drug. The AIC treats her with sodium
bicarbonate.
Then, the father of the above two patients got
depressed and overdosed on his blood pressure
medicine called verapamil, a calcium channel blocker.
You decide to treat him with calcium chloride.
– Where are these drugs found and how are they prepared?
Miscellaneous Drugs
Naloxone (Narcan)
Dose: 0.8 mg (peds 0.8 mg) IV, IM or ET
Action: Blocks opioid receptors and thus the effect of opiates on the
CNS. Reverses narcotic coma.
Middle Drawer
Prep: Draw up 2 cc in a 3 cc syringe. Give slowly, titrated to
respirations. Note – sometimes packaged in a vial.
Sodium Bicarbonate
Dose: 50 mEq (peds 1 mEq/kg) IV
Base of Box
Action: When given IV, it raises the pH of the blood (makes it less
acidic). We do this because the heart and brain are significantly
impaired in severe acidosis. You will see this given in TCA overdose,
cardiac arrest or at an MVA with a trapped extremity (compartment’s
syndrome).
Prep: assemble bristo-jet injector.
Calcium Chloride
Dose: 1 gram IV
Action: Raises serum calcium. This helps to overcome calcium
channel blockade (CCB) and also causes vasoconstriction. You will
see it given in CCB overdose.
Bottom Drawer
Prep: Prepare the syringe by adding a needle to it, as we did before.
Section VI - Written Test
1. To which of the following
2.
syringes do you need to
add a needle to before
using?
Which of the following
syringes would you use to
draw up the following
medications?
A. 10 cc B. 5 cc C. 3 cc D. 1 cc
i.
Lasix
ii.
Benadryl
iii. Valium
iv. Morpine Sulfate
v. Metoprolol tartate
vi. Midazolam
vii. Adenosine
viii. Solu-Medrol
3. In which drawer will you find the
following drugs?
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
Epinephrine 1:1,000
Atropine
Adenosine
Aspirin
Nitro-Paste
Syringes
Albuterol nebulizer
Epinephrine 1:10,000
Naloxone
Valium
Dextrose
Glucagon
Benadryl
A. Top Drawer
B. Middle Drawer
C. Bottom Drawer
D. Bottom of Box
An AIC asks you to set up an IV line.
4. What are the different parts of an IV line?
5. Where in the box are they kept?
6. What are your default selections for each part of the line?
7. What are the steps of setting up the IV line?
An AIC asks you to set up a nebulizer treatment.
8. Where is the nebulizer located?
9. Where can you find a spare nebulizer set-up?
10. To what do you set the oxygen flow for a nebulizer treatment?
11. The patient is a young child who is moving around too much
12.
13.
to hold the nebulizer. What is the best way to deliver his
medication to him?
What two medications are usually delivered by nebulizer?
Where are they found?
14. You are asked to give nitroglycerin to a patient.
i.
ii.
Where will you give this?
What should you, as part of the medical team, be watching out for in your
patient?
15. You are then asked to administer aspirin to a patient.
i.
ii.
How do you do this?
How many tablets will you give them?
i.
ii.
iii.
How do you do this?
Where should you place it?
What additional step is necessary to ensure it will not move?
16. You are then asked to prepare 1” of nitropaste.
17. You are treating a hypoglycemic patient. What three things will you
18.
19.
20.
need to prepare for the AIC to give D50?
The above stated AIC was unable to attain the IV line and asks you to
prepare glucagon. What steps are there in preparing glucagon?
You are treating a patient with tachycardia. The AIC mentions
adenosine. What three things will you need to have ready for him?
What color is an 18 g IV catheter package? A 20 g? Which is bigger?
Answer Key
1.
2.
You will need to add a needle to the 5, 10 and 30 cc syringes.
The 1 and 3 cc syringes come attached to a needle.
The following syringes should be used:
i.
ii.
iii.
iv.
Lasix – 10 cc syringe
Benadryl – 1 cc syringe
Valium – 3 cc syringe
Morpine Sulfate – 1 cc syringe, though some providers will want a 10
cc syringe to dilute it 1:10.
v.
Metoprolol tartate – 5 cc syringe
vi. Midazolam – 3 cc syringe
vii. Adenosine – 3 cc syringe
viii. Solu-Medrol – 10 cc syringe
These sizes are shown just to emphasize that the syringe should be big
enough to hold the entire dose, but not so big as to be
inaccurate in delivering a small volume of concentrated medicine.
You will have a better feel for these as time goes on.
3. In which drawer will you find the following drugs?
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
Epinephrine 1:1,000 – There are TWO places you will find this
concentration (1 mg/cc) of epi. The high dose vial for cardiac
arrest is in the middle drawer (B), as are the small vials used
for treatment of allergic reactions.
Atropine – Bottom drawer (C).
Adenosine – Middle drawer (B).
Aspirin – Middle drawer (B).
Nitro-Paste – Middle drawer (B).
Syringes – Top drawer (A).
Albuterol nebulizer – Bottom of box (D).
Epinephrine 1:10,000 – Bottom drawer (C).
Naloxone – Middle drawer (B).
Valium – Middle drawer (B).
Dextrose – Bottom of Box (D).
Glucagon – Middle drawer (B).
Benadryl – Middle drawer (B).
4. The components of an IV line
–
–
–
–
–
IV fluid
IV tubing
Extension Set
IV catheter
Extras shown below (top
drawer).
5. The remainder of these
6.
components can be found in
the bottom of the drug box.
The default fluid is normal
saline. The default tubing
should be macrodrip tubing
(10 drips/cc). An extension
set should always be used.
7. Setting up the IV line
• Begin by opening the IV fluid bag, the IV tubing bag and the extension
set.
• Remove the caps and connect the extension set to the IV tubing.
• Squeeze the chamber and insert the tubing into the fluid bag, ensuring
there are no bubbles in the line.
• When the catheter is inserted into the vein, assist the AIC with connecting
the extension set to the catheter and securing it.
8.
9.
10.
11.
12.
13.
14.
The nebulizer set-up is found in the bottom of the box in a sealed
plastic bag. Either inside the bag or taped to the outside you will find
the albuterol and atrovent treatments.
If you have to treat two patients with nebulizers, you can find a
second one in compartment of the ambulance which carries the
NRB’s and NC’s.
Optimal drug delivery occurs at 8-10 LPM of flow. Most providers still
set the regulator to 4-6 LPM, which is consistent with traditional
teaching.
If treating an agitated, active or young patient, the nebulized oxygen
and medications are best delivered by attaching the nebulizer to a
NRB mask.
Albuterol and atrovent are the most common medications to be
delivered by nebulizer.
As noted above, the bullets can be found in or taped to the bag
which carries the nebulizer.
Nitroglycerin tablets are carried in the middle drawer of the box and
are administered under the lifted tongue. The patient then closes the
mouth, and will often feel a burning under the tongue or a headache.
As part of the team, you will always need to watch out for
hypotension caused by the medication. Frequent BP checks are
necessary and should be done without prompting.
14. You are treating a hypoglycemic patient. What three things will
15.
16.
15.
16.
17.
you need to prepare for the AIC to give D50?
The above stated AIC was unable to attain the IV line and asks
you to prepare glucagon. What steps are there in preparing
glucagon?
You are treating a patient with tachycardia. The AIC mentions
adenosine. What three things will you need to have ready for
him?
If asked to give aspirin, give the patient FOUR tablets in his
mouth to chew. They taste a bit sour.
The nitropaste is found in premade packets in the middle drawer.
You should apply one packet per inch you are asked to prepare
to the white paper supplied with the nitropaste. The paper
should then be placed on the shoulder to minimize headache and
interference with EKG monitoring. The nitropaste should always
be taped on both sides.
Glucagon is found in the middle drawer. To mix it, inject the
syringe of fluid into the powdered vial, mix it around, and then
withdraw the mixture back into the syringe.
18. If you are treating a patient with D50:
1.
2.
3.
You should first begin by setting up a default IV line.
Then you should prepare the vacutainer (top drawer) to
withdraw a blood sample prior to giving the drug.
Then prepare the D50 syringe (bottom of box) by either
assembling the bristojet or attaching a needle.
19. If you are treating a patient with adenosine:
1.
2.
3.
4.
You should first set up an IV with default fluids and tubing.
Then draw up one vial of adenosine in a 3 cc syringe.
Then you should draw up 30 cc of saline from the fluid bag
through the drug port into a 30 cc syringe from the bottom
drawer.
You get many extra points if you remember to press the
‘record’ button on the monitor when the medicine is pushed to
obtain an EKG strip of the change in rhythm.
20. An 18 g catheter package is green, and is bigger than
a 20 g catheter, which is packaged in a pink package.
Closing notes
Thank you for taking the time to go through this
presentation. I am well aware that there is a ton of
information here, and it is only intended as an
introduction. Please do not be discouraged. You will get
all of this stuff down with practice, which you should do
anytime you get the chance. Also, be active in asking
the questions you have to the members of your
crew…they are there to help you.
– Thanks also to all the supermodels who let me take pictures of
their hands and faces ☺
– Thanks to Dayton Haugh for being our great leader and for his
help with this.
– Please email me (john k) with questions: [email protected]
• “Wherever you are, be all there.” -Jim Elliot