ࡱ>  _ YbjbjPP ay:<\y:<\  < fv(<H===DjGTHp;tttttt$Dxz\+tJP DD"JPJP+t==" v$V$V$VJPR==p$VJPp$V$Vmn=P/46Pmp6v0fvm6V{BQV{,nn&V{$ojI>KN$VL MjIjIjI+t+tSJjIjIjIfvJPJPJPJPV{jIjIjIjIjIjIjIjIjI > N: John R. Kasich, Governor John Born, DirectorBureau of Motor VehiclesMelvin R. HouseEmergency Management AgencyExecutive DirectorEmergency Medical ServicesOffice of Criminal Justice ServicesEmergency Medical ServicesOhio Homeland Security1970 West Broad StreetOhio State Highway PatrolP.O. Box 182073Columbus, Ohio 43218-2073(614) 466-9447 ( (800) 233-0785 HYPERLINK "http://www.ems.ohio.gov" www.ems.ohio.gov Dear EMT Reciprocity Candidate: Thank you for your interest in providing emergency medical care in Ohio. Attached is the reciprocity application you requested. An applicant for an Ohio certificate to practice must have completed a U.S. D.O.T. National Standard Curriculum course of instruction, which is substantially similar to the curriculum requirements of Ohio. If there are any areas of deficiency identified in the curriculum or certification standards, you will be required to correct these deficiencies through an Ohio accredited training institution prior to receiving a certificate to practice. At the EMT-Basic level, most applicants will need to complete additional training in advanced airway insertion prior to receiving Ohio certification. (A complete listing of accredited facilities is available on our Web site at  HYPERLINK "https://ext.dps.state.oh.us/emstrainingfacility/" https://ext.dps.state.oh.us/emstrainingfacility/.) NOTE: Any candidate with areas of deficiencies will be notified by the Division of EMS. In the event that you require additional training, the division shall provide you with the appropriate documents that you will need to provide to the training facility personnel. Applicants who completed training in another state: Complete the reciprocity application and attach a copy of a current state certification and a valid National Registry card at the level for which certification is sought. The Verification Form is to be forwarded (by the candidate) to the state certifying agency of the state in which initial training was completed, as well as any other state in which you hold, or have ever held, certification. The verification form will be used to determine if additional course work is needed to meet Ohio curriculum requirements. Mail all documents (application, state card, and National Registry card) to the address listed on the letterhead. Applicants who are or were a member of the United States armed services and who received their EMT training while in the military: Complete the reciprocity application and attach a copy of a valid National Registry card at the level for which certification is sought. Proof of military membership (DD Form 214, current military ID badge, statement of service) or proof of armed services training is required at the time the application is submitted. If you are a Department of Defense (DOD) candidate, a valid letter from the Directorate of Personnel attesting that you have military affiliation must accompany the initial submission of the application. The Verification Form is to be forwarded for completion to the military site where training was conducted. A copy of the course outline, including topic areas and hours of instruction in each topic area, must be included with the form. The verification form, and course information, will be used to determine if additional course work is needed to meet Ohio curriculum requirements. Mail all documents (application, National Registry card, proof of military status, completed Verification Form, course outline, and a DMA Form) to the address listed on the letterhead. Please review the application carefully before submitting to ensure the application is complete and all the required documentation is attached. All documentation must be submitted before your application can be processed. You may not function as an EMT in Ohio until you have been issued an Ohio certificate to practice. *** NOTE: The information submitted to the Division of EMS will remain active for a period of six (6) months. Should your application process require additional time, you must contact the division and obtain a new candidate application form. If you have any questions regarding the application process, please contact the Ohio Division of EMS at the address and phone numbers listed on the letterhead. OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMS RECIPROCITY APPLICATION CHECK SHEETPlease refer to the initial application for clarification of needed information.Application Procedure:Documentation Needed:Before mailing, did you FORMCHECKBOX  Complete the application in its entirety (both front and back)? FORMCHECKBOX  Complete Part I of the Verification Form, then forward it to the state (or military installation) where you received your original training, as well as any other state(s) that you have held (or currently hold) certificates? FORMCHECKBOX  Copy your National Registry certification and attach it to the application? FORMCHECKBOX  Copy your current state(s) certification and attach it to the application? FORMCHECKBOX  If military personnel, copy your military DD214 or current Military ID Badge and attach it to the application? FORMCHECKBOX  Include a check or money order in the amount of $75.00 made payable to Ohio Treasurer of State.Upon evaluation of all documentation, EMT-Basics and Intermediates may need to achieve additional training to meet the requirements in the State of Ohio. Applicant submissions and the Verification Form(s) will be the determining factor in the necessity for additional training. If additional training is required, the Division of EMS will provide you with the appropriate forms that will be necessary for completion. OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMS RECIPROCITY APPLICATIONPlease Print Use InkSECTION 1 GENERAL INFORMATIONLAST  FORMTEXT      FIRST  FORMTEXT      MIDDLE  FORMTEXT      *SOCIAL SECURITY NUMBER  FORMTEXT      STREET OR PO BOX  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      COUNTY  FORMTEXT      DATE OF BIRTH  FORMTEXT      HOME TELEPHONE NUMBER  FORMTEXT      BUSINESS TELEPHONE NUMBER  FORMTEXT      LEVEL FOR WHICH YOU ARE APPLYING: FORMCHECKBOX  First Responder FORMCHECKBOX  EMT  Basic FORMCHECKBOX  EMT  Intermediate FORMCHECKBOX  EMT - Paramedic*Disclosure of social security number is mandatory pursuant to Ohio Revised Code (R.C.) 3123.50 in furtherance of licensing provisions and any other state or federal requirements.ARMED FORCES INFORMATION* Mark at least one response.Using the definition of armed forces provided, check all that apply and provide information requested."Armed forces" means the armed forces of the United States, including the army, navy, air force, marine corps, coast guard, or any reserve components of those forces; the national guard of any state; the commissioned corps of the United States public health service; the merchant marine service during wartime; such other service as may be designated by congress; or the Ohio organized militia when engaged in full-time national guard duty for a period of more than thirty days. (R.C. section 5903.01) FORMCHECKBOX  I am a veteran of the armed forces, discharged / released under honorable conditions. Year of discharge / release  FORMTEXT        FORMCHECKBOX  I am a current member of the armed forces. FORMCHECKBOX  I am a spouse of a current member of the armed forces or a veteran, discharged / released under honorable conditions. Year of veteran s discharge / release  FORMTEXT        FORMCHECKBOX  I am a surviving spouse of a service member or veteran, discharged / released under honorable conditions. Year of veteran s discharge / release  FORMTEXT        FORMCHECKBOX  None of the above.SECTION 2  EDUCATION AND TRAINING INFORMATIONOUT OF STATE EMS CERTIFICATE NUMBER  FORMTEXT      EXPIRATION DATE  FORMTEXT       LEVEL  FORMTEXT      NATIONAL REGISTRY OF EMTS CERTIFICATE NUMBER  FORMTEXT      EXPIRATION DATE  FORMTEXT      LEVEL  FORMTEXT      COPIES OF THE ABOVE CARD(S) MUST ACCOMPANY APPLICATIONSTATE IN WHICH YOU RECEIVED YOUR INITIAL TRAINING  FORMTEXT      DATE  FORMTEXT      STATE(S) IN WHICH YOU RENEWED YOUR CERTIFICATION  FORMTEXT      DATE(S)  FORMTEXT        FORMTEXT      OTHER STATE(S) IN WHICH YOU HAVE HELD CERTIFICATION:  FORMTEXT      DATE LAST HELD  FORMTEXT      NUMBER OF CONTINUING EDUCATION HOURS YOU HAVE ACCUMULATED SINCE YOUR LAST CERTIFICATION EXAM OR RENEWAL:  FORMTEXT      MILITARY PERSONNEL ONLYMILITARY BRANCH  FORMTEXT      EMS TRAINING OBTAINED AT  FORMTEXT      CONTACT PERSONNEL / DIVISION  FORMTEXT      PHONE NUMBER  FORMTEXT      Copies of the National Registry EMT card, and appropriate military documentation, must accompany application (e.g., DD214 or military ID badge) SECTION 2 (Continued) EDUCATION AND TRAINING INFORMATION Paramedic Applicants Please skip to Section 3 First Responders, EMT - Basics and EMT-Intermediates Please mark the skills that were included in your training:FIRST RESPONDEREMT - BASICEMT - INTERMEDIATE FORMCHECKBOX  Automated External Defibrillator FORMCHECKBOX  Automated External Defibrillator FORMCHECKBOX  Automated External Defibrillator FORMCHECKBOX  Epinephrine Auto-Injector FORMCHECKBOX  Epinephrine Auto-Injector FORMCHECKBOX  Manual Defibrillation  FORMCHECKBOX  Oxygen Administration FORMCHECKBOX  Dual Lumen Airway FORMCHECKBOX  Epinephrine Auto-Injector FORMCHECKBOX  Nasal Gastric Tube Insertion FORMCHECKBOX  Dual Lumen Airway FORMCHECKBOX  Adult Endotracheal Intubation FORMCHECKBOX  Nasal Gastric Tube Insertion FORMCHECKBOX  Pedi. Endotracheal Intubation FORMCHECKBOX  Adult Endotracheal Intubation FORMCHECKBOX  Pedi. Endotracheal Intubation FORMCHECKBOX  Epinephrine auto-injection (Epi-pen administration) FORMCHECKBOX  Epinephrine Subcutaneous Injection FORMCHECKBOX  Peripheral IVs FORMCHECKBOX  Intraosseous Infusion FORMCHECKBOX  Other Medication Admin / Route (List)  FORMTEXT       NOTE: If your training did not include the above skills, you will have to complete the training at an accredited training institution in Ohio PRIOR to receiving Ohio CertificationSECTION 3  CERTIFICATION HISTORYHave you ever: Had disciplinary action taken against your EMS personnel certification? Been suspended / revoked in any state? Been denied certification in any state? Previously received reciprocity in any state(s)  FORMCHECKBOX  Yes  FORMCHECKBOX  Yes  FORMCHECKBOX  Yes  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  No  FORMCHECKBOX  No  FORMCHECKBOX  No If yes, list which state(s): FORMTEXT       SECTION 4  FELONY / MISDEMEANOR INFORMATION (All applicants are required to complete this section)ALL APPLICANTS ARE SOLELY RESPONSIBLE FOR THEIR CERTIFICATE TO PRACTICE AND ALL ASSOCIATED REQUIREMENTS TO MAINTAIN A CURRENT CERTIFICATION.1.Do you, as the person accepting responsibility by signing this form, have charges pending or have a conviction for a felony or misdemeanor other than a minor traffic violation or a judicial finding of eligibility for treatment in lieu of conviction?  FORMCHECKBOX  Yes  FORMCHECKBOX  No2.Have you committed any act in another state that, if committed in Ohio would be applicable to caption (1.) listed above?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf you answered yes to either question above, then you must submit documentation and court records to explain the circumstances in your case. Documentation should include a certified judgment entry from the court where the conviction occurred and a copy of the law enforcement investigative report.SECTION 5 ATTESTED SIGNATURE AND DATEI attest that all information provided is true and accurate to the best of my knowledge. I understand that a false statement on this application may constitute falsification under Section 2921.13 of the R.C. and is a misdemeanor of the first degree. Any false statement may also be grounds for denial, suspension, revocation, or other disciplinary action taken against my certificate, as determined by the Ohio State Board of Emergency Medical, Fire, and Transportation Services (EMFTS). I further attest that I satisfy all the requirements for a certificate at the level sought in this application as set forth in Section 4765.30 of the R.C. and Chapter 4765-8 of the Ohio Administrative Code (O.A.C.). I am solely responsible for my certificate. I understand that I must maintain records relating to the requirements for continuing education. Such records are subject to audit by the Division of EMS as directed by the Ohio State Board of EMFTS. I hereby give permission to the Ohio Department of Public Safety, Division of EMS to verify any of the above information.SIGNATURE XDATE  FORMTEXT       OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES VERIFICATION OF EMT STATUSApplicants with out-of-state certification are to complete Part I and mail this form to the issuing state certification board. Part II is to be completed by the state certifying agency. This form must be forwarded to the state where initial training was completed, as well as any other state the applicant has held or currently holds EMT certification.PART I. - TO BE COMPLETED BY APPLICANTPLEASE INDICATE THE LEVEL OF CERTIFICATION FOR WHICH YOU ARE REQUESTING VERIFICATION: FORMCHECKBOX  First Responder FORMCHECKBOX  EMT Basic FORMCHECKBOX  EMT Intermediate FORMCHECKBOX  EMT - ParamedicAPPLICANTS FULL NAME FIRST  FORMTEXT      MIDDLE  FORMTEXT      LAST  FORMTEXT      CERTIFICATION / LICENSE NUMBER  FORMTEXT      STATE  FORMTEXT      EXPIRATION DATE  FORMTEXT      SOCIAL SECURITY NUMBER  FORMTEXT      *ARMED SERVICES APPLICANTS have form completed by training officer at site where training was completed. You MUST attach a copy of course outline with number of hours in each topic area. If training was completed at more than one site, forward a copy of this form to each site from which credit for training is sought.PART II. - TO BE COMPLETED BY THE STATE CERTIFYING AGENCYCERTIFICATION / LICENSE TYPENUMBEREXPIRATION DATEFirst Responder FORMTEXT       FORMTEXT      EMT  Basic FORMTEXT       FORMTEXT      EMT - Intermediate FORMCHECKBOX   85 FORMCHECKBOX   99 FORMTEXT       FORMTEXT      EMT - Paramedic FORMTEXT       FORMTEXT      CERTIFICATION / LICENSE STATUS FORMCHECKBOX  Current FORMCHECKBOX  Lapsed FORMCHECKBOX  InactiveTHE ABOVE CERTIFICATION / LICENSE WAS ISSUED BASED UPON: FORMCHECKBOX  Initial training completed within your state FORMCHECKBOX  Recertification through continuing education FORMCHECKBOX  Reciprocity from (state):  FORMTEXT       FORMCHECKBOX  Other (please explain):  FORMTEXT       DID THE TRAINING MEET USDOT CURRICULUM GUIDELINES? FORMCHECKBOX  Yes FORMCHECKBOX  NoTotal number of hours in training:  FORMTEXT       HAS THE APPLICANT INCURRED ANY DISCIPLINARY PROCEEDING IN YOUR STATE, OR ARE THERE DISCIPLINARY PROCEEDINGS PENDING? FORMCHECKBOX  Yes (if yes, please attach certified copies of any actions) FORMCHECKBOX  NoHAS THE APPLICANTS CERTIFICATION / LICENSE EVER BEEN LIMITED, DENIED, SURRENDERED, REPRIMANDED, SUSPENDED OR REVOKED? FORMCHECKBOX  Yes (if yes, please attach certified copies of any actions) FORMCHECKBOX  NoHAS THE APPLICANT EVER BEEN CONVICTED OF A FELONY? FORMCHECKBOX  Yes (if yes, please explain):  FORMTEXT        FORMCHECKBOX  No FORMCHECKBOX  Unknown DO YOU KNOW OF ANY REASON WHY CERTIFICATION IN OHIO SHOULD BE DENIED? FORMCHECKBOX  Yes (if yes, please explain):  FORMTEXT        FORMCHECKBOX  NoIF APPLYING FOR FIRST RESPONDER, DID THE APPLICANTS TRAINING INCLUDE THE FOLLOWING (check the appropriate box[es]): FORMCHECKBOX  Automated External Defibrillation (AED) FORMCHECKBOX  Oxygen Administration FORMCHECKBOX  Epinephrine Administration (Epi-pen)IF APPLYING FOR EMT-BASIC, DID THE APPLICANTS TRAINING INCLUDE THE FOLLOWING (check the appropriate box[es]): FORMCHECKBOX  Automated External Defibrillation (AED)  FORMCHECKBOX  Endotracheal Intubation Adult FORMCHECKBOX  Epinephrine Administration (Epi-pen)  FORMCHECKBOX  Endotracheal Intubation Pediatric  FORMCHECKBOX  Dual Lumen Airway  FORMCHECKBOX  Nasal Gastric Tube InsertionIF APPLYING FOR EMT-INTERMEDIATE, DID THE APPLICANTS TRAINING INCLUDE THE FOLLOWING (check the appropriate box[es]): FORMCHECKBOX  Automated External Defibrillation (AED)  FORMCHECKBOX  Manual Defibrillation  FORMCHECKBOX  Epinephrine Administration (Epi Pen)  FORMCHECKBOX  Epinephrine Administration (Subcutaneous) FORMCHECKBOX  Endotracheal Intubation - Adult  FORMCHECKBOX  Endotracheal Intubation Pediatric  FORMCHECKBOX  Dual Lumen Airway  FORMCHECKBOX  Nasal Gastric Tube Insertion FORMCHECKBOX  Peripheral IVs  FORMCHECKBOX  Intraosseous Infusion  FORMCHECKBOX  Medication administration other than 02 and epinephrineNAME (PRINT) OF STATE / MILITARY OFFICIAL COMPLETING THIS FORM  FORMTEXT      TITLE OF OFFICIAL  FORMTEXT      SIGNATURE OF ABOVE OFFICIAL XTELEPHONE NUMBER OF ABOVE OFFICIAL  FORMTEXT      PLEASE RETURN TO: Division of Emergency Medical Services 1970 West Broad Street P.O. Box 182073 Columbus, Ohio 43218-2073 Phone (800) 233-0785 Fax (614) 466-9461 OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES ADVANCED AIRWAY CURRICULUM REQUIREMENTSCANDIDATE NAME  FORMTEXT      SOCIAL SECURITY NUMBER*  FORMTEXT      *Disclosure of social security number is mandatory pursuant to Ohio Revised Code 3123.50 in furtherance of licensing provisions and any other state or federal requirements.COGNITIVE OBJECTIVES FORMCHECKBOX Given a list of statements, the student should identify the statement that best describes the purpose of using the double lumen airway. FORMCHECKBOX Given a list of situations describing airway maintenance problems or potential airway maintenance problems, the student should be able to identify situations in which the use of the double lumen airway is indicated and contraindicated. FORMCHECKBOX The student should be able to identify those situations in which the double lumen airway may be removed. FORMCHECKBOX The student should be able to identify the advantages of using the double lumen airway over other methods of airway control. FORMCHECKBOX The student should be able to match airway adjuncts with their advantages and disadvantages. FORMCHECKBOX Given a list of equipment and material, the student should be able to identify those items that must be available before esophageal obstruction is begun. FORMCHECKBOX Given a diagram of the double lumen airway, the student should be able to label and describe the function of all component parts. FORMCHECKBOX Given a list of equipment and materials, the student should be able to list the procedures for insertion of the double lumen airway, including all steps in proper sequence. FORMCHECKBOX Given a list of errors, the student should be able to identify common errors involved in the use of the double lumen airway. FORMCHECKBOX Discuss the methods of assuring and maintaining correct placement of the double lumen tube. FORMCHECKBOX Describe how the cervical spine is protected throughout these maneuvers. FORMCHECKBOX Discuss the techniques for evaluating the effectiveness of ventilation including: visualization, auscultation, oximetry. FORMCHECKBOX Describe the problems associated with ventilation. FORMCHECKBOX Identify and describe the airway anatomy in the infant, child, and the adult. FORMCHECKBOX Differentiate between the airway anatomy of the infant, child, and the adult. FORMCHECKBOX Explain the pathophysiology of airway compromise. FORMCHECKBOX Describe the proper use of airway adjuncts. FORMCHECKBOX Review the use of oxygen therapy in airway management. FORMCHECKBOX Describe the indications, contraindications, and technique for insertion of nasal gastric tubes. FORMCHECKBOX Describe how to perform the Sellick maneuver (cricoid pressure). FORMCHECKBOX Describe the indications for advanced airway management. FORMCHECKBOX List the equipment required for orotracheal intubation. FORMCHECKBOX Describe the proper use of the curved blade for orotracheal intubation. FORMCHECKBOX Describe the proper use of the straight blade for orotracheal intubation. FORMCHECKBOX State the reasons for and proper use of the stylet in orotracheal intubation. FORMCHECKBOX Describe the methods of choosing the appropriate size endotracheal tube in an adult patient. FORMCHECKBOX State the formula for sizing an infant or child endotracheal tube. FORMCHECKBOX List complications associated with advanced airway management. FORMCHECKBOX Define the various alternative methods for sizing the infant and child endotracheal tube. FORMCHECKBOX Describe the skill of orotracheal intubation in the adult patient. FORMCHECKBOX Describe the skill of orotracheal intubation in the infant and child patient. FORMCHECKBOX Describe the skill of confirming endotracheal tube placement in the adult, infant, and child patient. FORMCHECKBOX State the consequence of and the need to recognize unintentional esophageal intubation. FORMCHECKBOX Describe the skill of securing the endotracheal tube in the adult, infant and child patient. AFFECTIVE OBJECTIVES FORMCHECKBOX Recognize and respect the feelings of the patient and family during advanced airway procedures. FORMCHECKBOX Explain the value of performing advanced airway procedures. FORMCHECKBOX Explain the need for the EMT to perform advanced airway procedures. FORMCHECKBOX Explain the rationale for the use of a stylet. FORMCHECKBOX Explain the rationale for having a suction unit immediately available during intubation attempts. FORMCHECKBOX Explain the rationale for confirming breath sounds. FORMCHECKBOX Explain the rationale for securing the endotracheal tube.PSYCHOMOTOR OBJECTIVES FORMCHECKBOX Demonstrate how to perform the Sellick maneuver (cricoid pressure). FORMCHECKBOX Demonstrate the skill of orotracheal intubation in the adult patient. FORMCHECKBOX Demonstrate the skill of orotracheal intubation in the infant and child patient. FORMCHECKBOX Demonstrate the skill of confirming endotracheal tube placement in the adult patient. FORMCHECKBOX Demonstrate the skill of confirming endotracheal tube placement in the infant and child patient. FORMCHECKBOX Given an adult intubation manikin, a double lumen airway, and a ventilation device, the student should be able to demonstrate the techniques for the insertion of the airway. FORMCHECKBOX Demonstrate the skill of securing the endotracheal tube in the adult patient. FORMCHECKBOX Demonstrate the skill of securing the endotracheal tube in the infant and child patient.REQUIRED HOURS: 12With my signature, I attest the above named individual has received instruction and formal evaluation in the areas marked. The individual has successfully completed written and practical testing in these areas.DATE(S) OF COURSE  FORMTEXT        FORMTEXT      TOTAL NUMBER OF HOURS  FORMTEXT      LOCATION OF TRAINING  FORMTEXT      INSTRUCTOR(S)  FORMTEXT      ACCREDITED TRAINING SITE NUMBER  FORMTEXT      SIGNATURE OF PROGRAM COORDINATOR XPRINTED NAME OF PROGRAM COORDINATOR  FORMTEXT      TELEPHONE NUMBER  FORMTEXT      FAX NUMBER  FORMTEXT       OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMT - INTERMEDIATE RECIPROCITY CURRICULUM REQUIREMENTSCANDIDATE NAME  FORMTEXT      SOCIAL SECURITY NUMBER*  FORMTEXT      *Disclosure of social security number is mandatory pursuant to Ohio Revised Code 3123.50 in furtherance of licensing provisions and any other state or federal requirements.INTRAOSSEOUS INFUSION TRAINING COURSE BREAKOUT (3 HOURS)Pathophysiology, Anatomy, Process and ProceduresIntraosseous LaboratoryProgram Completion TestingSTUDENT PERFORMANCE OBJECTIVES FORMCHECKBOX Discuss the equipment needed for fluid resuscitation in the adult and pediatric patient FORMCHECKBOX Discuss the Body Substance Isolation procedures used in starting I/Os FORMCHECKBOX Explain the proper aseptic techniques in starting I/Os FORMCHECKBOX Explain the administration of a fluid bolus for pediatric patients FORMCHECKBOX Discuss the advantages and disadvantages of I/O cannulation for the infant, child and adult patient FORMCHECKBOX Anatomically locate I/O infusion sites on simulated adult, child and infant patient FORMCHECKBOX Identify and discuss the equipment needed for I/O cannulation FORMCHECKBOX Discuss the proper techniques for insertion of an I/O needle FORMCHECKBOX Demonstrate the Body Substance Isolation procedures used in starting I/Os FORMCHECKBOX Demonstrate proper assembly of I/O therapy equipment (e.g., fluid bag, administrative tubing, extension sets, three-way stop cocks, syringes, etc.) FORMCHECKBOX Demonstrate the administration of a fluid bolus for pediatric patients FORMCHECKBOX Demonstrate the proper techniques for insertion of an I/O needle FORMCHECKBOX Demonstrate the proper documentation of I/O insertion and fluid administration FORMCHECKBOX Achieve at least a 70% on a written examination covering I/O infusion FORMCHECKBOX Achieve a passing score on a practical skill test of the I/O process CARDIAC MONITORING AND MANUAL DEFIBRILLATION TRAINING COURSE BREAKOUT (20 HOURS)Assessment and Management of the Cardiac PatientAnatomy, Physiology, Pathophysiology and Electrophysiology of the HeartCardiac Monitoring - Electrocardiogram InterpretationCardiac Monitoring Electrocardiogram Interpretation LaboratoryManual DefibrillationManual Defibrillation LaboratoryProgram Completion TestingSTUDENT PERFORMANCE OBJECTIVES FORMCHECKBOX Name the common chief complaints of cardiac patients FORMCHECKBOX Describe why the following occur in patients with cardiac problems: chest pain or discomfort, shoulder, arm, neck, or jaw pain / discomfort, dyspnea, syncope, and palpitations / abnormal heart beat FORMCHECKBOX Describe those questions to be asked during history taking for each of the common cardiac chief complaints FORMCHECKBOX Describe the four most pertinent aspects of the past medical history in a patient with a suspected cardiac problem FORMCHECKBOX Describe those aspects of the physical examination that should be given special attention in the patient with suspected cardiac problems FORMCHECKBOX Describe the significance of the following physical exam findings in a cardiac patient: Altered level of consciousness, peripheral edema, cyanosis, poor capillary refill, and cool, clammy skin FORMCHECKBOX Describe the emergency medical care of the patient experiencing chest pain / discomfortSTUDENT PERFORMANCE OBJECTIVES (continued) FORMCHECKBOX Discuss the position of comfort for patients with various cardiac emergencies FORMCHECKBOX Establish the relationship between airway management and the patient with cardiovascular compromise FORMCHECKBOX Predict the relationship between the patient experiencing cardiovascular compromise and basic life support FORMCHECKBOX Recognize the need for medical direction of protocols to assist in the emergency medical care of the patient with chest pain FORMCHECKBOX List the indications for the use of nitroglycerin FORMCHECKBOX State the contraindications and side effects for the use of nitroglycerin FORMCHECKBOX Explain the rationale for administering nitroglycerin to a patient with chest pain or discomfort FORMCHECKBOX Demonstrate the assessment and emergency medical care of a patient experiencing chest pain / discomfort FORMCHECKBOX Perform the steps in facilitating the use of nitroglycerin for chest pain or discomfort FORMCHECKBOX Demonstrate the assessment and documentation of patient response to nitroglycerin FORMCHECKBOX Explain the proper application of the chest compression in the adult, child and infant patient of cardiac arrest FORMCHECKBOX Explain the proper ventilation to compression ratio for one and two person CPR in the adult, child and infant patient of cardiac arrest FORMCHECKBOX Discuss the use of mechanical cardiopulmonary resuscitation devices in the pre-hospital setting FORMCHECKBOX Explain the importance of pre-hospital ACLS intervention if it is available FORMCHECKBOX Define the role of EMT-Intermediate in the emergency cardiac care system FORMCHECKBOX Explain the importance of urgent transport to a facility with ACLS if it is not available in the pre-hospital setting FORMCHECKBOX Discuss the importance of post-resuscitation care FORMCHECKBOX List the components of post-resuscitation care FORMCHECKBOX Practice completing a pre-hospital care report for patients with cardiac emergencies FORMCHECKBOX Describe the size, shape, and location / orientation (in regard to other body structures) of the heart muscle FORMCHECKBOX Identify the location and describe the function of the following structures on a diagram of the normal heart: pericardium, myocardium, epicardium, right and left atria, interatrial septum, right and left ventricles, intraventricular septula, superior and inferior vena cava, aorta, pulmonary vessels, coronary arteries, tricuspid valve, mitral valve, aortic valve, pulmonic valve, papillary muscles, and chordae tendinae FORMCHECKBOX Describe the distribution of the coronary arteries and the parts of the heart supplied by each artery FORMCHECKBOX Differentiate the structural and functional aspects of arterial and venous blood vessels FORMCHECKBOX Define the following terms that refer to cardiac physiology: stroke volume, Starlings law, preload, afterload, cardiac output, blood pressure FORMCHECKBOX Describe the pathophysiology of cardiac arrest FORMCHECKBOX Discuss the differences in outcome for medical and trauma related cardiac arrest FORMCHECKBOX Explain the primary causes of cardiac arrest in the adult, child and infant patient FORMCHECKBOX Describe and discuss the primary interventions that the EMT can provide to the adult, child and infant patient in cardiac arrest FORMCHECKBOX Describe the electrical properties of the heart FORMCHECKBOX Describe the normal sequence of electrical conduction through the heart and state the purpose of this conduction system FORMCHECKBOX Describe the location and function of the following structures of the electrical conduction system: SA node, internodal and interatrial tracts, AV node, bundle of HIS, bundle branches, and Purkinje fibers FORMCHECKBOX Define cardiac depolarization and repolarization and describe the major electrolyte changes that occur in each process FORMCHECKBOX Describe an ECG FORMCHECKBOX Define the following terms as they relate to the electrical activity of the heart: Isoelectric line, QRS complex, P - wave and T - wave FORMCHECKBOX Define ECG artifact and name the causes FORMCHECKBOX State the steps in the analysis format of ECG rhythm strips FORMCHECKBOX Describe the two common methods for calculation of heart rate on an ECG rhythm strip and the indications for using each method FORMCHECKBOX Identify Normal Sinus Rhythm by analysis of: P-wave, P-R interval and QRS complex FORMCHECKBOX Be able to describe, discuss and identify the following cardiac dysrhythmias: ventricular tachycardia, ventricular fibrillation, asystole, pulseless electrical activity and artifact FORMCHECKBOX Name eight causes of dysrhythmia FORMCHECKBOX Identify on a cardiac monitor, normal sinus rhythm, bradaycardia, tachycardia, ventricular tachycardia, ventricular fibrillation, asystole, artifact, and pulseless electrical activity FORMCHECKBOX Demonstrate proper application of ECG electrodes and obtain a sample Lead II FORMCHECKBOX Demonstrate the proper use of the defibrillator electrodes to obtain a sample Lead II rhythm strip FORMCHECKBOX Demonstrate the proper use of the defibrillator pad electrodes to obtain a sample Lead II rhythm strip FORMCHECKBOX Demonstrate how to properly assess the cause of poor ECG tracing FORMCHECKBOX Discuss and identify when defibrillation is needed FORMCHECKBOX Discuss the proper assessment of a patient to assure defibrillation is needed for manual defibrillation FORMCHECKBOX Identify the components of a defibrillatorSTUDENT PERFORMANCE OBJECTIVES (continued) FORMCHECKBOX Identify and discuss the differences between manual, semi-automated and automatic defibrillators FORMCHECKBOX Discuss the care and maintenance of defibrillators in reference to: paddles, batteries and cables FORMCHECKBOX Discuss the use of remote defibrillation through adhesive pads FORMCHECKBOX Discuss the hazards associated with manual defibrillation FORMCHECKBOX Explain the impact of age and weight on defibrillation FORMCHECKBOX Discuss the fundamentals and rationale for early defibrillation FORMCHECKBOX Discuss the circumstances which may result in inappropriate shocks FORMCHECKBOX Explain the considerations for interruption of CPR, when using the manual defibrillator FORMCHECKBOX Discuss the importance of coordinating ACLS trained providers with personnel using manual defibrillators FORMCHECKBOX Explain the importance of frequent practice with the manual defibrillator FORMCHECKBOX Discuss the need to complete the manual defibrillator Operators Skill Shift Checklist FORMCHECKBOX Explain the role medical direction plays in the use of manual defibrillation FORMCHECKBOX State the reasons why a case review should be completed following the use of the manual defibrillator FORMCHECKBOX Discuss the components that should be included in a case review FORMCHECKBOX Discuss the goal of quality improvement in manual defibrillation FORMCHECKBOX Define the function of all controls on a manual defibrillator, and describe event documentation and battery defibrillator maintenance FORMCHECKBOX Discuss the reasons for obtaining initial training in manual defibrillation and the importance of continuing education FORMCHECKBOX Discuss the reason for maintenance of manual defibrillators FORMCHECKBOX Discuss the standard of care that should be used to provide care to a patient with persistent recurrent ventricular fibrillation and no available ACLS FORMCHECKBOX Demonstrate effective cardiopulmonary resuscitation for an adult, child and infant patient in accordance with the current American Medical Association guidelines FORMCHECKBOX Demonstrate the proper use of the monitor pad electrodes to obtain a sample Lead II rhythm strip FORMCHECKBOX Demonstrate the proper use of the defibrillator paddle electrodes to obtain a sample Lead II rhythm strip FORMCHECKBOX Demonstrate the proper use of the defibrillator / monitor pad electrodes to obtain a sample Lead II rhythm strip FORMCHECKBOX Demonstrate correct operation of a monitor / defibrillator to perform defibrillation on an adult, child and infant patient FORMCHECKBOX Demonstrate the application and operation of the manual defibrillator FORMCHECKBOX Demonstrate the maintenance of a manual defibrillator FORMCHECKBOX Demonstrate the assessment and documentation of patient response to the manual defibrillator FORMCHECKBOX Demonstrate the skills necessary to complete the manual defibrillator Operators Skill Shift Checklist FORMCHECKBOX Achieve at least a 70% on a written examination covering cardiac monitoring and manual defibrillation FORMCHECKBOX Achieve a passing score on the practical skill application of cardiac monitoring and the manual defibrillation processEPINEPHRINE TRAINING COURSE BREAKOUT (1 HOUR)Pathophysiology of Anaphylaxis Assessment and Care of the Patient with Allergic ReactionPharmacology of Epinephrine Subcutaneous Injection and Auto-InjectionSubcutaneous Injection laboratoryProgram Completion TestingSTUDENT PERFORMANCE OBJECTIVES FORMCHECKBOX Identify signs and symptoms of anaphylaxis FORMCHECKBOX Recognize causes of anaphylaxis FORMCHECKBOX Define terms associated with allergic reactions FORMCHECKBOX Recognize the patient experiencing an allergic reaction FORMCHECKBOX Assess the patient with possible anaphylaxis reaction through medical history and physical observation FORMCHECKBOX Identify the proper treatment of individuals suffering life-threatening allergic reactions FORMCHECKBOX Establish the relationship between the patient with an allergic reaction and airway management FORMCHECKBOX Describe the mechanisms of allergic response and the implications for airway management FORMCHECKBOX Identify the role of the EMT in administration of epinephrine to persons suffering life-threatening allergic reactions FORMCHECKBOX Identify pharmacological actions of epinephrine FORMCHECKBOX Calculate appropriate dosage of epinephrine for individuals of various age groups FORMCHECKBOX Explain how to prepare a subcutaneous injection of epinephrine using a syringe and glass ampule, syringe and multi-dose vial and a pre-filled syringe FORMCHECKBOX Explain the proper technique for subcutaneous injection of epinephrine FORMCHECKBOX Explain the rationale for administering epinephrine using an 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names, medication forms, dose, administration, action and contraindications for epinephrine FORMCHECKBOX Evaluate the need for medical direction in the emergency medical care of the patient with an allergic reaction FORMCHECKBOX Differentiate between the general category of those patients having an allergic reaction and those patients having an allergic reaction and requiring immediate medical care, including immediate use of epinephrine FORMCHECKBOX Demonstrate the Body Substance Isolation procedures used in subcutaneous and auti-injections FORMCHECKBOX Demonstrate the emergency medical care of the patient experiencing an allergic reaction FORMCHECKBOX Demonstrate how to prepare a subcutaneous injection of epinephrine using a syringe and glass ampule, syringe and multi-dose vial and a pre-filled syringe FORMCHECKBOX Demonstrate a subcutaneous injection of epinephrine using proper technique FORMCHECKBOX Demonstrate proper disposal of all items used (e.g., syringe, glass ampule, multi-dose vial and pre-filled syringe) FORMCHECKBOX Demonstrate the use of an epinephrine auto-injector FORMCHECKBOX Demonstrate proper disposal of an auto-injector FORMCHECKBOX Demonstrate the assessment and documentation of patient response to an epinephrine injection FORMCHECKBOX Demonstrate completing a pre-hospital care report for patients with allergic emergencies FORMCHECKBOX Achieve at least a 70% on a written examination covering anaphylaxis and epinephrine FORMCHECKBOX Achieve a passing score on a practical skill test of the subcutaneous injection and auto-injection processes With my signature, I attest that  FORMTEXT       has received instruction and formal evaluation in the areas marked. The individual has successfully completed written and practical testing in these areas  and I have provided them with a Certificate of Completion in each of these specified area(s): FORMCHECKBOX  I/O Infusion  FORMCHECKBOX  Cardiac Monitoring and Manual Defibrillation  FORMCHECKBOX  Epinephrine (Subcutaneous and Auto-Injector) DATE(S) OF COURSE  FORMTEXT        FORMTEXT        FORMTEXT      TOTAL NUMBER OF HOURS  FORMTEXT      LOCATION OF TRAINING  FORMTEXT      INSTRUCTOR(S)  FORMTEXT      ACCREDITED TRAINING SITE NUMBER  FORMTEXT      PRINTED NAME OF PROGRAM COORDINATOR  FORMTEXT      TELEPHONE NUMBER  FORMTEXT      FAX NUMBER  FORMTEXT      SIGNATURE OF PROGRAM COORDINATOR X OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES INTERMEDIATE TRANSITION COURSE VERIFICATION 40-HOUR INTERMEDIATE TRAINING COURSESTUDENT CERTIFICATION NUMBER  FORMTEXT      STUDENT NAME  FORMTEXT       STUDENT SOCIAL SECURITY NUMBER  FORMTEXT      Disclosure of social security number is mandatory pursuant to Ohio Revised Code 3123.50 in furtherance of licensing provision and any other state or federal requirements.INSTRUCTOR CERTIFICATION NUMBER  FORMTEXT      INSTRUCTOR NAME  FORMTEXT      CLASS START DATE  FORMTEXT      CLASS END DATE  FORMTEXT       I attest that I am the authorized Program Coordinator for the accredited school named below and that the above named student successfully completed the required Intermediate Transition Course in accordance with the Ohio Administrative Code (O.A.C.) and that the above named instructor was certified in accordance with the O.A.C. at the time of this class to teach all required materials. 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Box 182073 Columbus, Ohio 43218-2073      Ohio Department of Public Safety Page  PAGE 2 Mission Statement to save lives, reduce injuries and economic loss, to administer Ohios motor vehicle laws and to preserve the safety and well being of all citizens with the most cost-effective and service-oriented methods available. EMS 0065 7/15 [760-0984] Page  PAGE 2 of  NUMPAGES 14 John R. Kasich, Governor Thomas P. Charles, DirectorAdministrationRichard N. RuckerBureau of Motor VehiclesExecutive DirectorEmergency Management AgencyEmergency Medical ServicesEmergency Medical ServicesOffice of Criminal Justice Services1970 West Broad StreetOhio Homeland SecurityP.O. Box 182073Ohio Investigative UnitColumbus, Ohio 43218-2073Ohio State Highway Patrol(614) 466-9447 ( (800) 233-0785 HYPERLINK "http://www.ems.ohio.gov" www.ems.ohio.gov EMS 0065 1/11 Page  PAGE 3 of  NUMPAGES 14 Mission Statement to save lives, reduce injuries and economic loss, to administer Ohios motor vehicle laws and to preserve the safety and well being of all citizens with the most cost-effective and service-oriented methods available. EMS 0066 3/15 [760-0984] Page  PAGE 3 of  NUMPAGES 14 EMS 0067 9/15 [760-0984] Page  PAGE 5 of  NUMPAGES 14 EMS 0068 3/15 [760-0984] Page  PAGE 6 of  NUMPAGES 14 EMS 0069 3/15 [760-0984] Page  PAGE 9 of  NUMPAGES 14 Mission Statement to save lives, reduce injuries and economic loss, to administer Ohios motor vehicle laws and to preserve the safety and well being of all citizens with the most cost-effective and service-oriented methods available. 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