Advanced EMT: A Clinical Reasoning

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Detailed Contents
Letter to Students xx Health Care and Public Health 26
Prefacexxi The Health Care System 26
Acknowledgmentsxxxi The Public Health System 27
About the Authors xxxiii Getting to the Future 27
A Guide to Key Features xxxv

3 Workforce Wellness and

Section 1 Preparing for Personal Safety 31
Advanced Emergency Medical Introduction33
Technician Practice 1 Health of the Nation 33
Wellness and Emergency Medical Services 35
1 Introduction to Advanced Wellness and Maslow’s Hierarchy of Needs 35
Emergency Medical Technician Stress35
Practice2 Physical Wellness 40
Infectious Disease Prevention 43
Introduction3
Sleep49
EMS and EMS Providers 4
Nutrition50
The Contemporary EMS Profession 4
Physical Fitness 52
EMS Provider Levels 6
Other Physical Health Considerations 53
Advanced EMT Roles and Responsibilities 8
Other Aspects of Wellness 53
Emergency Vehicle Readiness and Operations 8
Safety9
Scene Leadership, Management, 4 Ethical and Medical/Legal
and Teamwork 10 Considerations in Advanced
Patient Assessment and Management 10 EMT Practice 57
Maintaining Certification or Licensure 11 Introduction59
Interprofessional Teamwork 11
Ethics60
Advanced EMT Professional Characteristics 11
Branches of Government and General Areas of Law 60
Authorization to Practice 61
2 Emergency Medical Services, Scope of Practice 61
Health Care, and Public Medical Direction 62
Health Systems 15 Consent and Refusal of Emergency Medical Care 62
Introduction17 Decision-Making Capacity 62
Evolution of the EMS System 17 Informed Consent 63
Transportation of the Sick and Injured 18 Refusal of Consent 63
Emergency Prehospital Care 18 Implied Consent 63
Military Influence 18 Minor’s Consent 63
Key Events in EMS 19 Legal Issues Related to Consent 65
Key Documents in EMS 20 Resuscitation Decisions and Recognizing Death 66
Key People in EMS 20 Advance Directives 66
Components of an EMS System 21 Present Directives 67
Legislation and Regulation 21 Presumptive Signs of Death 67
EMS Provider Education 23 Withholding or Terminating Resuscitation 67
National EMS Certification 23 Matters of Civil Law 67
EMS System Configuration and Workforce 23 Establishing the Elements of Negligence 69
Communication and System Access 25 Other Civil Claims 70
Medical Direction 25 High-Risk Situations 70
Evaluation26 Criminal Law Issues 70

vii
viii Detailed Contents

Legal Protections 71 Lifting and Moving Patients 94

Crime Scenes 72 Back Safety 94
Other Legal Situations 72 Equipment and Techniques Used to Lift and
Move Patients 94
5 Ambulance Operations and Air Medical Transport 100
Responding to EMS Calls 76 Advantages and Capabilities of Air Medical
Transport100
Introduction78 Limitations of Air Medical Transport 100
Phases of EMS Calls 78 Requesting Air Medical Transport 100
Preparation79 Setting Up a Landing Zone 101
Receiving and Responding 79 Air and Ground Crew Safety 101
On-Scene Care and Preparation for Transport 79
Transporting the Patient
Transferring Patient Care
79
80
6 Communication and
Terminating the Call 80
Teamwork106
Prehospital Environment and Types of Calls 80 Introduction108
Nonemergency Calls 80 Communication108
Emergency Calls 81 Sender Characteristics 108
Medical Calls 81 Receiver Characteristics 109
Trauma Calls 81 Message Characteristics 110
Responding to a Residence 81 Communication Channels, Interference, and
Responding to Roadway Scenes 82 Feedback110
Rescue Situations 82 Team Dynamics and Communication 110
Hazardous Materials Situations 82 EMS System Communication 111
Multiple-Casualty Incidents 82 Oversight, Maintenance, and Coordination 111
Ambulance Design 83 Radio Frequencies and Traffic 111
Vehicle Readiness 84 Communicating and Documenting Times 111
Exterior Vehicle and Mechanical Readiness 84 Communication Equipment 112
Patient Care Equipment and Supplies 84 Guidelines for Radio Communication 113
Emergency Vehicle Operations 84 Therapeutic Communication and Interviewing
Defensive Driving 85 Patients114
Speed86 Intercultural and Language Considerations 114
Due Regard 86 Trust and Rapport 115
Emergency Driving 86 Control the Environment 116
Safe Backing 87 Nonverbal Communication 116
Night Driving 87 Verbal Communication 117
Highway Driving 87 Pitfalls in Communication 118
Emergency Response and Use of Special Patient Communication Situations 118
Warning Devices 87 Documentation119
Always Pass on the Left 88 Standardized Data Collection 119
Emergency Patient Transportation 89 Sections of the Patient Care Report 121
Intersections89 Legal Considerations in Documentation 121
Following Other Emergency Vehicles 89 Special Documentation Circumstances 123
Parking on a Scene 89

Section 2 Human Development,

Occupant Safety and Vehicle Security 91
Carbon Monoxide in Ambulances 92
Operational Security 92
Health, and Disease 129
Scene Size-Up
Nature of the Situation
93
93
7 Medical Terminology 130
Scene Safety 93 Introduction131
Number of Patients 93 Medical Terminology Basics 131
Additional Resources 94 Anatomical Terms 134
Patient Assessment Aspects of Scene Size-Up 94 Terms by Body System 138
 Detailed Contents ix

8 Human Body Systems 144 Death in the Field

Hospice and Palliative Care
220
221
Introduction146
General Concepts in Anatomy and Physiology 147 10 Pathophysiology: Selected
Chemical Basis of Life 147 Impairments of Homeostasis 224
Cellular Basis of Life 153
Introduction226
The Cell Membrane 153
Mechanisms of Disease and Injury 227
The Organelles 155
Tissues156 Compensation and Adaptation 228
Anatomical Terminology and Topographic Hypoxic Cellular Injury 228
Anatomy156 Aerobic Metabolism 229
Body Cavities 157 Anaerobic Metabolism 230
Organs and Body Systems 157 Causes of Hypoxia 231
Support, Movement, and Protection 158 Cellular Glucose Use 238
Skeletal System 158 Acid–Base and Electrolyte Disturbances 239
Muscular System 164 Shock240
Integumentary System 165 Hypovolemic Shock 241
Respiration and Circulation 165 Cardiogenic Shock 243
Respiratory System 165 Distributive Shock 244
Cardiovascular System 171 Obstructive Shock 246
Control, Communication, and Integration 184 Pathophysiology of Shock 249
The Nervous System 184 Heat and Cold Emergencies 249
Endocrine System 191
Nutrition and Excretion 193
Gastrointestinal System 193 Section 3 Pharmacology 255
Urinary System 195
Reproduction197 11 Principles of Pharmacology 256
Reproductive System 197 Introduction258
Medication Sources 258
9 Life Span Development and Medication Reference Material 258
Cultural Considerations 204 Medication Profile 259
Introduction205 Medication Oversight and Regulation 259
Legislation260
Psychosocial Development 206
Medication Safety and Regulation 261
Piaget’s Theory of Cognitive Development 206
Special Considerations 261
Erikson’s Theory of Psychosocial Development 207
Kohlberg’s Theory of Moral Development 207 Medication Names 262
Physical Development 207 Medication Forms 263
Neonates and Infants 209 Solid Medications 263
Toddlers and Preschoolers 211 Liquid Medications 263
School-Age Children 212 Semisolid Medications 263
Adolescents213 Gases263
Young Adulthood 214 Classifications of Medications 263
Middle Adulthood 214 Medications That Affect the Nervous System 264
Late Adulthood 214 Medication Packaging 267
Cultural Differences 216 Pharmacokinetics268
Health Disparities 216 Absorption268
Health Care Beliefs and Social Interactions 216 Distribution269
Grief, Dying, and Death 218 Biotransformation269
Elisabeth Kübler-Ross’s Stages of Dying 218 Elimination269
Children and Grief 219 Pharmacodynamics269
Cross-Cultural Perspectives on Death Receptor Sites 270
and Dying 219 Affinity270
x Detailed Contents

Mechanism of Action 270 50 Percent Dextrose 318

Dose–Response Relationship 270 Epinephrine 1:1,000 318
Factors Influencing Medication Effects 271 Glucagon319
Medication Storage 272 Glucose319
Naloxone319

12 Medication Administration 275

Nitroglycerin—Sublingual Tablets and Spray
Nitrous Oxide
320
320
Introduction277 Oxygen321
Principles of Safe Medication Administration 277 Activated Charcoal 321
Six Rights of Medication Administration 277 Acetaminophen321
Additional Medication Safety Considerations 278 Ibuprofen322
Routes of Drug Administration 278 Nerve Agent Antidote Kits 322
Drug Orders 281
Interpreting Drug Orders 282
Section 4 Assessment and Initial
Drug Dosage Calculation 282
Management325
Review of the Metric System 282
Translating the Order to Units to Administer 283 14 General Approach to Patient
Techniques of Medication Administration 287 Assessment and Clinical
Aseptic Technique 288 Reasoning326
EMS Provider Safety 289
Introduction327
Oral Medication Administration 289
Purpose and Goals of Patient Assessment 328
Sublingual Medication Administration 289
Nebulized Medication Administration 290 General Approach to Patient Assessment 329
Medication Administration by Metered-Dose Inhaler 290 Components of the Patient Assessment Process 329
Nitrous Oxide Administration 290 Scene Size-Up 329
Equipment Used for Injections 292 Primary Assessment 331
Drawing Medication from Ampules and Vials 292 Secondary Assessment 335
Subcutaneous Injection 293 Reassessment337
Intramuscular Injection 294 Clinical Reasoning and Problem Solving 337
Auto-Injectors294 Readiness for Problem Solving 337
Intravenous Injection 294 The Hypothetico–Deductive Approach to
Problem Solving 338
Establishing a Peripheral Intravenous Line 300
Pattern Recognition 338
Equipment for Establishing IV Access 301
Heuristics: Rules of Thumb 339
Selecting a Suitable Vein 301
Pitfalls in Clinical Reasoning 339
Performing the Venipuncture 302
Unsuccessful IV Attempts and Discontinuing
IV Therapy 305 15 Scene Size-Up and Primary
Changing an IV Bag 305 Assessment343
Complications of IV Therapy 305 Introduction345
Pediatric Intraosseous Access 306 Scene Size-Up 345
Primary Assessment 348
13 Medications 313 Assessing the General Appearance 349
Introduction314 Assessing Level of Responsiveness 350
Medications in Patient Care 314 Assessing the Airway 353
Assessing Breathing 355
IV Solutions 315
Assessing Circulation 356
IV Fluids 316
Patient Care Decisions 357
Normal Saline (0.9 Percent Sodium Chloride
Solution) for Intravenous Infusion 316 Primary Assessments Compared 359
5 Percent Dextrose in Water for Intravenous Infusion 316 Reassessment and Documentation 362
Lactated Ringer’s Solution 316
Medications317 16 Airway Management, Ventilation,
Albuterol Sulfate 317 and Oxygenation 366
Aspirin317 Introduction368
 Detailed Contents xi

Anatomy and Physiology Review 369 Health Care Provider CPR 433
Physiology of Air Movement 369 Scene Size-Up and Primary Assessment 433
Upper Airway 370 Chest Compressions 435
Lower Airway 372 Airway and Ventilations 436
Gas Exchange 373 Integrating Advanced Airway Devices 436
Ventilation373 Defibrillation437
Pathophysiology of the Airway, Ventilation, and Intravenous Access and Medications 441
Oxygenation373 Resuscitation Outcomes and Postresuscitation
Upper Airway Problems 373 Care441
Lower Airway Problems 374 CPR in Infants and Children 441
Ventilation Problems 375 Secondary Assessment and History Taking
in Resuscitation 442
Assessment of the Airway, Ventilation, and
Oxygenation375 Ethical and Legal Considerations 443
Scene Size-Up 375 Return of Spontaneous Circulation 443
Primary Assessment 376 Management of Body Temperature 444
Secondary Assessment and Reassessment 381
Airway Management 385 18 Vital Signs and Monitoring
Positioning and Manual Maneuvers 386 Devices447
Removing Foreign Bodies and Fluids from Introduction450
the Airway 387
Prioritizing Information Collection 450
Airway Adjuncts 393
Vital Signs 450
Ventilation398
Assessing the Pulse 450
Positive Pressure Ventilation 399
Assessing Blood Pressure 454
Bag-Valve-Mask Ventilations 399
Orthostatic Vital Signs 458
Manually Triggered Ventilation Device and
Assessing Respirations 459
the Automatic Transport Ventilator 402
Assessing Body Temperature 461
Continuous Positive Airway Pressure 403
Assessing the Skin 462
Oxygenation403
Oxygen as a Medication 404 Assessing the Pupils 463
Oxygen Equipment 404 Monitoring Devices 464
Oxygen Safety 407 Pulse Oximetry 465
Oxygen Delivery Devices 407 End-Tidal Carbon Dioxide Monitoring 465
Blood Glucose Level 466

17 Resuscitation: Managing Shock

Cardiac Monitoring 469

and Cardiac Arrest 413

19 History Taking, Secondary
Introduction415 Assessment, and Reassessment 475
Pathophysiology of Shock 415
Introduction477
Hypoperfusion415
General Approaches to the Secondary Assessment
Mechanisms of Shock 415
and History Taking 478
Assessing for Shock 423
Medical Patients 478
Scene Size-Up 423
Trauma Patients 480
Primary Assessment 424
Field Impression 482
Secondary Assessment 424
Reassessment482
Clinical Reasoning 424
Documentation483
Reassessment425
Taking a Medical History 483
Managing Bleeding and Shock 425
The SAMPLE History 483
Bleeding Control 425
Working from the Presenting Problem or
Intravenous Access and Fluid Administration 429 Chief Complaint 487
Fluid Resuscitation in Nonhemorrhagic Shock 430
Overview of the Physical Examination 488
Pneumatic Anti-Shock Garments 431
Anatomical Approach to Secondary
Cardiac Arrest 431 Assessment490
The Chain of Survival 432 Body Systems Approach to Secondary
Cardiopulmonary Resuscitation 433 Assessment499
xii Detailed Contents

Section 5 Medical Emergencies 505 Clinical Reasoning and Decision Making 573
Reassessment573
20 Respiratory Disorders 506 Specific Neurologic Disorders 573
Altered Mental Status 573
Introduction508
Syncope574
Anatomy and Physiology Review 508
Stroke575
The Need for Oxygen 508
Seizures578
Structure and Function of the Lungs 510
Headache581
Ventilation510
Dementia and Delirium 582
General Assessment and Management 512
Vertigo583
Scene Size-Up 514
Nontraumatic Back and Neck Pain 583
Primary Assessment 515
Central Nervous System Infections 583
Secondary Assessment 515
Other Neurologic Disorders 584
Clinical-Reasoning Process 515
Treatment515 23 Endocrine Disorders 590
Reassessment515
Introduction592
Specific Respiratory Disorders 516
Anatomy and Physiology Review 592
Chronic Obstructive Pulmonary
Disease516 The Pancreas and Blood Glucose Level 594
Asthma519 The Thyroid Gland and Metabolism 596
Pulmonary Embolism 521 The Adrenal Glands 596
Pulmonary Edema 522 Assessment596
Spontaneous Pneumothorax 523 Scene Size-Up 596
Hyperventilation Syndrome 524 Primary Assessment 597
Infectious Respiratory Diseases 525 Secondary Assessment 597
Lung Cancer 528 Reassessment598
Cystic Fibrosis 528 Common Endocrine Disorders 598
Diabetes and Diabetic Emergencies 598
21 Cardiovascular Disorders 531 Thyroid Disorders 602
Adrenal Disorders 603
Introduction533
Anatomy and Physiology Review
Coronary Circulation
533
534
24 Abdominal Pain and
Gastrointestinal Disorders 607
The Vascular System and Blood 535
Perfusion, Cardiac Output, Introduction608
and Blood Pressure 536 Anatomy and Physiology Review 609
Cardiac Electrophysiology 538 Stomach and Intestines 610
General Assessment of Cardiovascular Accessory Organs of Digestion 611
Complaints541 Assessment and Management 612
Specific Cardiovascular Conditions 544 Scene Size-Up 612
Acute Coronary Syndrome 544 Primary Assessment 613
Signs and Symptoms 546 Secondary Assessment 613
Heart Failure 552 Clinical-Reasoning Process 614
Cardiogenic Shock 557 Treatment614
Hypertension557 Reassessment614
Aortic Aneurysm and Dissection 558 General Abdominal Complaints 614
Heart Rate Disturbances 560 Abdominal Pain 614
Nausea and Vomiting 616
22 Neurologic Disorders 564 Specific Abdominal Problems 616
Introduction566 Disorders of the Esophagus 616
Anatomy and Physiology Review 566 Disorders of the Stomach and Intestines 617
Assessment568 Pancreatitis621
Scene Size-Up 568 Liver Disease 621
Primary Assessment 568 Cholecystitis622
Secondary Assessment 569 Other Causes of Abdominal Pain 623
 Detailed Contents xiii

25 Renal, Genitourinary, and Immunocompromise671

Autoimmune Diseases 671
Gynecologic Disorders 626
Introduction628 28 Infectious Illnesses 675
Anatomy and Physiology Review 628
Introduction676
The Urinary System 628
Anatomy and Physiology Review 677
Kidneys628
Male Reproductive System 630 Infection and Disease Transmission 677
Female Reproductive System 631 Pathogens678
Infection Control 678
Urinary System Disorders 632
Assessment and Management 632 General Assessment and Management 679
Renal Disorders 634 Scene Size-Up 679
Urinary Tract Disorders 639 Primary Assessment 680
Secondary Assessment 680
Reproductive System Emergencies 641
Clinical-Reasoning Process 680
Male Genitalia 641
Treatment680
Gynecologic Disorders 643
Reassessment681
Sexually Transmitted Infections 646
Infectious Illnesses 681
Bloodborne Infections 681
26 Hematologic Disorders 650 Respiratory Infections 682
Introduction651 Infections of Regional Concern 684
Anatomy and Physiology Review 651 Childhood Illnesses 685
Plasma651 Meningitis and Encephalitis 686
Red Blood Cells 652 Other Vectorborne Illnesses 687
White Blood Cells 652 Gastrointestinal Infections and Botulism 687
Platelets653 Mononucleosis and Herpes 687
Hemostasis653 External Parasites and Skin Infections 688
Blood Groups 653 Sexually Transmitted Infections 690
Assessment and Management 656
Scene Size-Up 656 29 Nontraumatic Musculoskeletal
Primary Assessment 656 and Soft-Tissue Disorders 694
Secondary Assessment 656 Introduction695
Clinical-Reasoning Process 656 Anatomy and Physiology Review 696
Treatment657 The Skin 696
Reassessment657 Skeletal Muscle 696
Hematologic Conditions 657 Skeletal System 697
Blood Transfusion Reactions 657 General Assessment and Management 698
Red Blood Cell Disorders 657
Soft-Tissue and Musculoskeletal Disorders 698
White Blood Cell Disorders 658
Skin and Soft-Tissue Disorders 698
Clotting Disorders 659
Joint Disorders 699
Bone Disorders 700
27 Immunologic Disorders 663 Muscular Disorders 701
Neck and Back Disorders 702
Introduction664
Anatomy and Physiology Review 665
Assessment and Management 665
30 Disorders of the Eye, Ear, Nose,
Scene Size-Up 666 Throat, and Oral Cavity 705
Primary Assessment 666 Introduction706
Secondary Assessment 667 Anatomy and Physiology Review 706
Clinical-Reasoning Process 668 The Eyes 706
Treatment668 The Ears 708
Reassessment668 The Nose 709
Immunologic Disorders 668 The Oral Cavity 709
Allergies and Anaphylaxis 668 The Throat 709
xiv Detailed Contents

Assessment and Management 710

Section 6 Trauma 755
Specific Disorders 711
Disorders of the Eye 711 33 Trauma Systems and Incident
Disorders of the Ear 712 Command756
Disorders of the Nose 713
Introduction758
Disorders of the Oral Cavity and Throat 713
Injury Prevention 758
31 Mental Illness and Behavioral Trauma Systems 759
Emergencies716 Managing Multiple-Casualty Incidents 760
Communications760
Introduction718
National Incident Management System 761
An Overview 718
Incident Command System 761
Assessment and Management 718
On the Scene 763
Scene Size-Up and Primary Assessment 719
Triage763
History and Secondary Assessment 720
Treatment767
Clinical Reasoning 721
Transport768
Treatment and Reassessment 721
Common Disorders 721
Anxiety Disorders 721 34 Mechanisms of Injury, Trauma
Cognitive Disorders 722 Assessment, and Trauma
Eating Disorders 722 Triage Criteria 772
Factitious Disorders and Somatoform Disorders 722 Introduction773
Impulse Control Disorders 723 Kinematics of Trauma 775
Mood Disorders 723 Kinetics775
Personality Disorders 723 Classifying Trauma 776
Schizophrenia724 Assessment of the Trauma Patient 778
Substance Abuse, Addiction, and Withdrawal 724 Scene Size-Up 778
Alcohol724 Primary Assessment 786
Suicide725 Secondary Assessment 788
Violent Patients 726 Reassessment792

32 Toxicologic Emergencies 729

35 Soft-Tissue Injuries
Introduction730
and Burns 796
Toxicology731
Introduction798
Poison Control Centers 732
Anatomy and Physiology Review 799
Assessment and Management 733
Scene Size-Up 733 Soft-Tissue Injuries 799
Primary Assessment 733 General Guidelines for Emergency Care 799
History and Secondary Assessment 735 Closed Soft-Tissue Injuries 800
Clinical Reasoning 735 Open Soft-Tissue Injuries 801
Treatment735 Bleeding805
Reassessment737 Burns808
Specific Toxicologic Emergencies 737 Effects of Burns on the Body 809
Carbon Monoxide 737 Sources of Burns 810
Cyanide738 Classification of Burn Severity 810
Caustic Substances 738 Burn Injury Assessment 813
Hydrocarbons739 Emergency Management of Burn Injuries 813
Organophosphates739 Specific Burn Injuries 816
Ethanol and Toxic Alcohols 740
Food and Plant Toxins 741 36 Musculoskeletal Injuries 822
Venom742 Introduction824
Over-the-Counter Medications 745 Anatomy and Physiology Review 824
Prescription Medications 746 Skeletal Muscles 824
Street Drugs 748 Ligaments and Tendons 824
 Detailed Contents xv

Cartilage824 General Categories 866

Bones824 Open Chest Injury 866
Joints826 Closed Chest Injury 867
Emergency Care of Musculoskeletal Injuries 826 Specific Thoracic Injuries 867
Focused Assessment of Musculoskeletal Injuries 827 Rib Fracture 867
Splinting and Care of Musculoskeletal Injuries 828 Flail Chest 868
Fractures832 Pneumothorax869
Types of Fractures 833 Hemothorax871
Complications of Fractures 833 Traumatic Asphyxia 871
Managing Long-Bone Fractures 834 Blunt Cardiac Injury 872
Critical Fractures 836 Myocardial Contusion 872
Joint Injuries 837 Commotio Cordis 872
Muscle Injuries 841 Pericardial Tamponade 872

37 Head, Brain, Face, and Neck 39 Abdominal Trauma 876

Trauma844 Introduction877
Introduction846 Anatomy and Physiology Review 877
Anatomy and Physiology Review 846 General Assessment and Management 879
The Skull 846 Scene Size-Up 879
The Brain 846 Primary Assessment 880
The Neck 847 Secondary Assessment 880
The Face 847 Management of Abdominal Trauma 880
The Eye 847 Reassessment881
General Assessment and Management 848 Specific Abdominal Injuries 881
Injuries to the Head 849 Penetrating Trauma 881
Scalp Injuries 849 Blunt Trauma 882
Skull Injuries 850
Traumatic Brain Injuries 851 40 Spine Injuries 886
Cerebral Edema and Increased Intracranial
Introduction888
Pressure851
Assessment and Management of Traumatic Anatomy and Physiology Review 888
Brain Injury 852 The Spinal Column 889
Specific Brain Injuries 852 The Spinal Cord 890
Injuries to the Face 855 Mechanisms of Spine Injury 890
Eye Injuries 856 Spinal-Column Injury Versus Spinal-Cord
Ear Injuries 857 Injury892
Avulsed Teeth 857 Complete and Incomplete Spinal-Cord Injury 892
Injuries to the Neck 858 Spinal Shock 893
Injuries to the Cervical Spine 858 Assessment and Management 893
Injuries to Blood Vessels 858 Scene Size-Up 893
Injuries to the Airway 858 Primary Assessment 894
Secondary Assessment 894
38 Thoracic Trauma 861 Reassessment896
Spinal Motion Restriction 896
Introduction862
Spinal Trauma Management 900
Anatomy and Physiology Review 862
Current Trends 900
The Lungs and Ventilation 863
Spinal Motion Restriction for Supine and
The Heart 863
Prone Patients 901
General Assessment and Management 864
Spinal Motion Restriction for Seated Patient 902
Scene Size-Up 864
Spinal Motion Restriction and Rapid
Primary Assessment 865 Extrication902
Secondary Assessment 865 Special Considerations 903
Communication and Documentation 866 Spinal Motion Restriction for Infants and
Reassessment866 Children903
xvi Detailed Contents

41 Environmental Emergencies 906 Preparing for Delivery

Assisting Delivery
952
954
Introduction908 Complications956
Heat- and Cold-Related Emergencies 908 Neonate Assessment and Management 959
Anatomy and Physiology 908 Neonatal Resuscitation 960
Risk Factors 909 APGAR Score 960
General Assessment 910 Vital Signs 961
Specific Heat-Related Emergencies 911 Considerations in Neonatal
Specific Cold-Related Emergencies 913 Resuscitation961
Drowning916 Complications and Defects 962
Pathophysiology of Drowning 916
Assessment and Management 917 44 Pediatric Emergencies 968
Diving Emergencies 917
Introduction970
Effects of Pressure 918
Pediatric Development 970
Assessment and Management 918
Infants970
Specific Diving Injuries 919
Toddlers and Preschool Children 971
High-Altitude Illness 920
School-Age Children 971
Acute Mountain Sickness 921
Adolescents971
High-Altitude Pulmonary Edema 921
Assessment and Management 972
High-Altitude Cerebral Edema 921
Scene Size-Up 972
Lightning Injuries 921
Primary Assessment 973

42 Multisystem Trauma and Trauma Secondary Assessment

Clinical-Reasoning Process
975
977
Resuscitation924 Treatment977
Introduction925 Reassessment978
Assessment and Management 926 Pediatric Medical Emergencies 978
Scene Size-Up 926 Respiratory Emergencies 978
Primary Assessment 926 Cardiovascular Disorders 980
Transport Decision 927 Sudden Infant Death Syndrome 980
Secondary Assessment 928 Infectious Diseases 981
Multisystem Trauma Patient Packaging 928 Neurologic Disorders 982
Reassessment930 Diabetes982
Principles of Trauma Resuscitation 930 Gastrointestinal Disorders 983
Eye, Ear, Nose, and Throat Disorders 983
Behavioral Emergencies 983
Section 7 Special Patient Toxicologic Emergencies 984
Populations935 Shock and Trauma in Pediatric Patients 984
Mechanisms of Injury 984
43 Obstetrics and Care of the Assessment and Management 985
Newborn936 Considerations in Spinal Motion
Introduction938 Restriction986
Burns986
Anatomy and Physiology 938
Drowning986
Female Reproductive System 938
Child Abuse and Neglect 987
Pregnancy938
The Fetus 944
The Neonate 945
45 Geriatrics 992
The Pregnant Patient 946 Introduction993
Assessment and Management 946 Anatomy and Physiology 994
Obstetrical Complications and Emergencies 948 Psychosocial Aspects of Aging 997
Labor and Delivery 951 Assessment and Management 997
Signs and Symptoms 951 Scene Size-Up 997
Transport Decision 952 Primary Assessment 998
 Detailed Contents xvii

Secondary Assessment 999

Section 8 Rescue and Special
Clinical-Reasoning Process 1001
Operations1027
Treatment1002
Reassessment1002 47 Rescue Operations and Vehicle
Additional Considerations 1002
Extrication1028
Common Medical Disorders 1002
Introduction1029
Respiratory Disorders 1002
Cardiovascular Disorders 1003 Personal and Patient Safety 1029
Neurologic Disorders 1004 Personal Protective Equipment 1029
Renal and Genitourinary Disorders 1004 Patient Safety 1030
Gastrointestinal Disorders 1004 Phases of Rescue Operations 1031
Endocrine Disorders 1005 Phase One: Arrival and Size-Up 1031
Infectious Disease 1005 Phase Two: Hazard Control 1031
Musculoskeletal Disorders 1005 Phase Three: Patient Access 1031
Hematologic Disorders 1006 Phase Four: Medical Treatment 1031
Behavioral Emergencies 1006 Phase Five: Disentanglement 1032
Toxicologic Emergencies 1006 Phase Six: Patient Packaging 1032
Trauma in the Geriatric Population 1006 Phase Seven: Removal/Transport 1032
Mechanisms of Injury 1006 Types of Rescue Operations 1032
Shock1007 Hazardous Atmosphere 1033
Fractures1007 Disentanglement and Extrication 1033
Burns1007 Vehicle Extrication 1033
Environmental Emergencies 1007 Scene Size-Up 1033
Hazards1034
46 Patients with Special Vehicle Stabilization 1036
Impact Damage and Extrication 1036
Challenges1011
Interior of the Vehicle 1036
Introduction1012 Gaining Access 1037
Sensory and Speech Impairments 1013 Extrication Tools 1037
Hearing Impaired 1013
Vision Impaired 1013
48 Hazardous Materials 1041
Speech Impairment 1013
Introduction1042
Cognitive Impairment 1014
Developmental Impairments 1014 Initial Recognition and Response 1043
Brain-Injured Patients 1014 Recognize the Hazardous Material 1043
Avoid the Hazardous Material 1048
Paralyzed Patients 1014
Isolate the Hazardous Material 1049
Bariatric Patients 1015
Notify Responders About the Hazardous Material 1049
Homeless and Impoverished Patients 1015
Hazardous Materials Operations 1050
Abused Patients 1016
Training Levels 1050
Child Abuse 1017
Incident Command 1050
Elder Abuse 1018
Personal Protective Equipment 1050
Technology-Dependent Patients 1018
Decontamination1051
Medical Oxygen 1018
Rehabilitation1051
Apnea Monitors 1019
Medical Aspects of Hazardous Materials 1051
Tracheostomy Tubes 1019
Special Considerations in Radiation Incidents 1052
CPAP and BiPAP 1020
Radiation Injury 1052
Mechanical Ventilators 1020
Treatment for Radiation 1053
Vascular Access Devices 1021
Dialysis Shunts
Gastrointestinal and Genitourinary
1022
49 Response to Terrorism and
Devices1022 Disasters1055
Ventriculostomy Shunts 1023 Introduction1056
Hospice Care 1024 General Considerations 1057
xviii Detailed Contents

Natural Disasters 1058 Indications1089

Terrorism and Weapons of Mass Destruction 1058 Contraindications1089
Terrorist Groups 1059 Complications1089
Weapons of Mass Destruction 1059 Procedure for Tibial Intraosseous Access 1090
Scene Size-Up 1062
Patient Care 1063 Appendix 4:  Additional Emergency
Medications1094
Introduction1094
Appendices Activated Charcoal, U.S.P. 1094
Appendix 1: Endotracheal Intubation 1066 Adenosine1095
Introduction1066 Amiodarone1095
Equipment1067 Atropine Sulfate 1096
Laryngoscope1067 Calcium Chloride 1096
Endotracheal Tube 1068 Diazepam1096
Stylet1068 Diltiazem1097
10-mL Syringe 1069 Diphenhydramine1097
Magill Forceps 1069 Dopamine1097
Suction Unit 1069 Epinephrine, 1:10,000 1097
Securing Device 1069 Fentanyl Citrate 1098
Tube Placement Confirmation Devices 1069 Furosemide1098
Anatomy1069 Ipratropium Bromide 1098
Indications1070 Ketamine1099
Complications1070 Ketorolac Tromethamine 1099
Hypoxia1070 Levalbuterol1099
Equipment Malfunction 1070 Lidocaine Hydrochloride 1099
Damage to Teeth and Soft Tissues 1070 Lorazepam1100
Esophageal Intubation 1071 Magnesium Sulfate 1100
Endobronchial Intubation 1071 Midazolam Hydrochloride 1100
Endotracheal Intubation Procedures 1071 Morphine Sulfate 1101
Endotracheal Intubation of a Patient with Ondansetron1101
No Suspected Spine Injury 1071 Sodium Bicarbonate 1101
Endotracheal Intubation of a Patient with Thiamine1101
Suspected Spine Injury 1074 Tranexamic Acid 1102

Appendix 2:  Advanced ECG

Recognition1075
Answers1103
Introduction1075
Glossary1123
Standard ECG Monitoring 1075
Index1151
ECG Monitors 1076
ECG Waveforms and Tracings 1076
Pulseless Electrical Activity 1087

Appendix 3:  Adult Intraosseous

Infusion1088
Introduction1088
Purpose of Intraosseous Access 1088
Photo Scans
3-1 Proper Lifting Technique  41 17-1 Initial Cardiac Arrest Management for
3-2 Proper Technique for Removing Gloves  46 Adult Patients  439
5-1 Using a Draw-Sheet  99 18-1 Taking a Blood Pressure by Auscultation  457
12-1 Administering Medication by Small-Volume 18-2 Checking the Blood Glucose Level  468
Nebulizer  291 19-1 Secondary Assessment: Rapid Physical
12-2 Drawing Medication from an Ampule  293 Exam for Medical or Trauma Patients  492
12-3 Subcutaneous Injection  295 19-2 Secondary Assessment: Head-to-Toe Exam  493
12-4 Intramuscular Injection  297 32-1 Activated Charcoal  736
12-5 Intravenous Injection  299 34-1 Head-to-Toe Assessment  790
12-6 Obtaining IV Access  303 36-1 Properly Applied Sling and Swathe  830
12-7 Pediatric Intraosseous Access Using the 36-2 Splinting a Long Bone  835
EZ IO Device  307 36-3 Applying a Unipolar Traction Splint  838
14-1 General Approach to Patient Assessment  331 36-4 Applying a Bipolar Traction Splint  839
15-1 The Primary Assessment Process— 36-5 Splinting a Joint  840
Responsive Patient  360 39-1 Emergency Management of
15-2 Primary Assessment—Unresponsive Patient Abdominal Evisceration  883
with a Pulse  361 40-1 Assessing Neurologic, Motor,
16-1 Assessing and Managing the Airway— and Sensory Function  895
Unresponsive Patient  377 40-2 Sizing a Cervical Collar  897
16-2 Assessing Breathing—Unresponsive Patient  378 40-3 Applying a Cervical Collar to a Seated Patient  898
16-3 Assessing Airway and Breathing— 43-1 Assisting with Childbirth  955
Responsive Patient  379 A1-1 Endotracheal Intubation in a
16-4 Oral Suctioning  391 Patient with No Spine Injury  1072
16-5 Tracheal Suctioning of an Intubated Patient  392 A1-2 Endotracheal Intubation in a
16-6 Inserting an Oropharyngeal Airway  395 Patient with Suspected Spine Injury  1073
16-7 Inserting a Nasopharyngeal Airway  396 A3-1 Intraosseous Access Using the EZ-IO Device  1090
16-8 Administering Oxygen  405

xix
Letter to Students
Welcome, students!

You are beginning an exciting learning experience, and this textbook will help you. We have designed
it to help you learn facts, principles, and concepts in EMS. But we have gone beyond simply presenting
facts, principles, and concepts. This textbook contains features that will help you learn critical thinking
and problem solving, which are essential skills in the health care professions. The process of using criti-
cal thinking to solve patient care problems is called clinical reasoning. The clinical-reasoning process is
a cornerstone of safe, excellent patient care, and we have made it a foundation of this textbook.

We, as authors, educators, and clinicians, are excited about the unique focus of our textbook on
clinical reasoning. Each chapter begins with a case study that includes problem-solving questions. Each
case study frames the material in the chapter in a way that establishes its importance. Beginning each
chapter with a specific problem in mind helps you read the chapter for deeper understanding of how
the material can be applied in your real-life Advanced EMT practice. After the chapter material is pre-
sented, the case study wrap-up with an accompanying clinical-reasoning process helps you understand
how the Advanced EMTs in the case study determined and solved the problems. This approach provides
you with a model for transferring what you have learned from the classroom to the work environment.

Congratulations on your decision to further your professional development in EMS by becoming

an Advanced EMT. We are glad to have you among our peers in the profession. We welcome your ques-
tions and correspondence. Please do not hesitate to contact us at the e-mail addresses provided. If you
have the opportunity to attend professional conferences, we hope we will have the chance to meet you
in person!

Melissa Alexander, EdD, MS, Paramedic

melalexander1@gmail.com

Richard Belle, BS, NRP

rbelle2024@yahoo.com

Steven Weiss, MD, MS, FACEP, FACP

sweiss@salud.unm.edu

xx
Preface
New to This Edition
A
dvanced EMT: A Clinical-Reasoning Approach, 2nd
Edition, was developed to assist you in success­
fully completing the Advanced EMT course and
­ultimately obtaining licensure. The National EMS Education
Standards serve as the foundation of the text, and special
care was taken to ensure that the most up-to-date evidence-
based patient care has been included. Specifically, content
that has been added or updated for Advanced EMT: A Clinical-
Reasoning Approach, 2nd Edition, includes the following.
What’s New in Section 1: Preparing
for Advanced Emergency Medical
Technician Practice
New to Chapter 1 is an expanded section on professionalism
and social media use, and added emphasis on self-directed
learning as a professional characteristic. Chapters 1 and 2
also include new content on mobile integrated health care
(MIH) and community paramedicine (CP). Chapter 3 has
expanded the information on National Health Goals, and
the section on EMS provider mental health now includes
shift-work disorder. Chapter 4 now includes an updated
concept of decision-making capacity, and physician’s or-
ders for life-sustaining treatment (POLST). Chapter 5 now
offers updated information on the anticipated replacement
of the DOT’s specifications for ambulance design.
What’s New in Section 2: Human
­Development, Health, and Disease
In Chapter 8, the In the Field features have been expanded
and updated to highlight the importance of understanding
anatomy and physiology.
What’s New in Section 3:
­Pharmacology
Chapters 11 and 12 now include discussion of obesity and
weight-based medication calculations. Chapter 12 also has
new information on medications administered via auto-
injector.
What’s New in Section 4: Assessment
and Initial Management
Chapter 14 expands the first edition’s discussion of diagno-
sis and differential diagnosis in EMS, and it offers updated
field triage guidelines. New to Chapter 15 is information
on situational awareness. Both Chapters 15 and 16 include
an updated description of the approach to patients with
suspected cervical-spine injury. Chapter 17 now offers in-
formation on tranexamic acid in hemorrhagic shock and on
systemic inflammatory response (SIRS) and the potential
role of prehospital serum lactate measurement. It also has
expanded information on topical hemostatics, common
prescription anticoagulants, teamwork in resuscitation,
and end-of-life care terminology related to physician’s or-
ders for life-sustaining treatment (POLST). Chapter 18 clar-
ifies the uses and limitations of estimating blood pressure
by palpation and pulse oximetry waveform methods, and
offers additional information on temporal artery-scanning
thermometers. Chapter 19 now includes anatomic and
systems-based frameworks in the discussion of the clinical-
reasoning approach. Where appropriate, the chapters in
this section reflect the newest American Heart Associa-
tion’s 2015 guidelines.
What’s New in Section 5: Medical
Emergencies
Chapter 20 now includes guidelines for administering
oxygen to patients with advanced COPD, and new infor-
mation on MERS and the importance of obtaining a travel
history. Additional emphasis has been added to reflect the
importance of pneumococcal vaccine for susceptible popu-
lations, and the information on asthma and lung cancer has
been updated. Chapter 21 has been reorganized to enhance
clinical reasoning, focusing on pertinent positives and neg-
atives for specific cardiovascular emergencies. Chapter 22
now includes an updated list of medications prescribed for
neurological disorders. Chapter 23 now includes hyperos-
molar hyperglycemic state (HHS) in the discussion on dia-
betes. Chapter 24 has added information on chronic opioid-
induced constipation and on pediatric abdominal pain and
foreign body ingestion. Chapter 26 offers an updated list
of medications that affect blood clotting. Chapter 28 now
provides information on the special concerns related to
pregnant women and fetuses, updates the discussion of in-
fectious diseases of global concern, and lists resources for
infectious disease information. Chapter 31 adds new em-
phasis to addiction as a mental illness and now includes in-
formation on mental illness among EMS personnel. Chap-
ter 32 provides updated information on the public health
crisis related to increased abuse of opiates and opioids, on
the use of synthetic cannabinoids and vaping, and on de-
signer drugs.
xxi
xxii Preface
What’s New in Section 6: Trauma
Information on the American College of Surgeons Commit-
tee on Trauma Level V Trauma Center has been added to
Chapter 33, as has a discussion on the SALT triage system.
Chapter 34 now addresses quinary blast injuries. Chapter 40
has been updated to reflect new research on the use of spi-
nal motion restriction and current trends that deemphasize
the use of long backboards.
What’s New in Section 7: Special
Patient Populations
Chapter 43 has been updated with new information on the
use of suctioning in the neonate.
What’s New in Section 8: Rescue
and Special Operations
Chapter 47 now incorporates new information on s­afety
procedures when working with hybrid and electric
­vehicles.
What’s New in the Appendixes
Ketamine has been added to Appendix 4 as a sedative for
endotracheal intubation and in patients with excited de-
lirium, and tranexamic acid has been included for reducing
internal bleeding in trauma patients.
An Introduction to Your
Course of Study
No doubt you are beginning your Advanced EMT course
with both excitement and anxiety, as every student does.
Students are excited at the prospect of learning new infor-
mation and skills, meeting new people, having new experi-
ences, being intellectually challenged, and being prepared
for a new step in their careers. One of the main sources of
anxiety comes from wondering if you will be successful in
the course. Being successful means completing the class,
having met all of the standards of your program, and be-
ing prepared to pass the high-stakes examinations required
for licensure. Most of all, successful completion of your Ad-
vanced EMT course means having the knowledge, skills,
empathy, and confidence it takes to provide emergency care
to a wide variety of patients. Most students are willing to
put in the tremendous amount of work involved, but they
may not use their study time as efficiently and effectively as
possible. There are no short cuts: Learning takes time and
work. However, there are a number of ways to make sure
you are using your time and effort in the best ways possible.
Academic success relies on a number of factors
aside from desire and aptitude. In addition to commit-
ting to attending every scheduled class and putting in
your clinical experience time, you must be ready to com-
mit substantial time outside class to prepare. You must
have good time management and organizational skills.
You also must develop learning habits that give the best
­results for your time and effort. As a general rule for
learning required content, students must spend three
hours outside class for every hour in lecture. But often
students either wait until just before the first exam or,
worse, until finding out they did not do well on the exam
to ask their instructor, “What is the best way to study for
the test?”
The best way to study for any test is not to study for the
test but instead to study for understanding. Understanding
can only develop incrementally over time, not in the last
days and hours before a test. You must spend time every
day immersing yourself in the course content in order to
build understanding. This is where your excitement comes
in: It gives you the motivation and energy required to keep
going even when you might feel somewhat discouraged or
anxious. Beyond motivation, though, there are a number of
concrete actions and tools that will help you organize the
content for understanding.
Because time is at a premium for everyone, you should
use your study time to your best advantage. The follow-
ing sections offer you some basic information about how
learning occurs; to what degree learning styles play a role
in how you should approach studying; and some specific
skills, tips, and tools you can use to help yourself acquire
the knowledge and problem-solving skills needed to com-
plete your course successfully.
The Nature of Advanced EMT
­Learning
Whether or not you are taking your course for college cred-
it, the complexity of concepts in Advanced EMT courses
are college level. However, the information in most college
classes is memorized for a short period of time, regurgi-
tated on a test, and then largely forgotten. As an Advanced
EMT, you must maintain and build on the required knowl-
edge in a useful form throughout your career. This requires
a different approach than you might have used in other
learning situations.
Readiness for Learning
The nature, situation, and experience of each student
are different. Those differences have an impact on learn-
ing. Whether you are a working professional, a parent,
or a college student with other courses to take, you
and your fellow classmates have responsibilities out-
side ­Advanced EMT class. For some, the load is heavier
than for others. It is important that you assess the mean-
ing this class has for you, how it fits with your other

priorities, whether the ­current time is the right time for
you, and how you can allow sufficient time not only to
attend class but to commit the time needed outside class
in order to succeed. You must bring time and effort to the
learning situation. Your instructor cannot provide these
for you.
Learning Styles
Learning styles include visual, auditory, and kinesthetic
(hands-on). The most important thing to know about
them is that they are no more than preferences for the
way people take in and process information. In truth,
everyone can and does learn by all of those means. The
most effective way to learn something has more to do
with what is being learned than how people prefer to
learn it. Most complex concepts have components that
are better learned in one way than another. For example,
the concepts behind measuring blood pressure are best
learned through reading and lecture, often with accom-
panying figures and diagrams. However, the skill of taking
a blood pressure is best learned by demonstration and
hands-on practice.
Study Habits
There are many prescriptions for effective study habits.
Some of the key ideas behind them include being organ-
ized, planning study time, and having an environment
that is conducive to focusing and learning. An example
of being organized is making sure that everything you
need, such as a pen or pencil, paper, computer, textbook,
and perhaps a beverage or snack are readily at hand.
This prevents an interruption in your thinking process
to retrieve needed items. Commit to study time. Block
out specific time in your schedule to study (Figure 1). For
the period of time you are taking your Advanced EMT
course, consider your study time a necessary appoint-
ment with yourself. Depending on your work schedule
and lifestyle, the time that works best for you to study
may vary. Intervals between classes, or between work
and class, or even 20 minutes in the car spent waiting
to pick up your child from school can serve as planned
study time. Learning occurs best when you study
for short periods of time with a small break between
Sunday Monday Tuesday
• Review previous • Class, 6:00 pm • Review Ch. 4
class notes notes
• Prepare for class • Review & • Prepare for
(Ch. 4) summarize class class (Ch. 5)
notes
Figure 1 Plan your study time.
Preface xxiii
s­egments. For example, you might study for 20 to 50
minutes and take a five-minute break before resuming
study. Take some time to reflect on what study environ-
ment works for you. Some people prefer to study with a
partner or in a group, while others prefer to study alone.
Create a comfortable place as free from distractions as
possible. Many of the specifics of these factors depend
on individual preference.
The Nature of Learning
Not only must you learn for the short-term goals of test-
ing, but you also must be able to transfer knowledge and
skills to the job. This requires learning in three domains:
cognitive (facts, concepts, thinking, and problem solving),
psychomotor (hands-on skills), and affective (values and
professionalism). The main focus of this preface is the cog-
nitive domain.
Knowledge is arranged in hypothetical mental
structures called schemas. A schema is a collection of
related information that helps in making sense of what
we see, hear, read, and experience in other ways. When
you can relate new information to an existing schema,
learning is easier and more effective. A schema provides
a context and framework for interpreting and storing
information. Much of the rest of the information in this
preface takes advantage of how schemas work and the
ideas that learning occurs in small increments over time,
and with repetition.
Graphic Organizers
Graphic organizers are learning tools that help arrange
information in ways that make it easier for you to pro-
cess and learn. You are most likely familiar with graphic
organizers, even if you have not heard them called by
this name. Tables, flowcharts, and Venn diagrams are
common types of graphic organizers (Figures 2 and 3).
Graphic organizers are powerful learning tools because
they allow you to see how information is organized in
a way that goes beyond words. By using graphic organ-
izers, you can better understand overall relationships be-
tween concepts and ideas.
This textbook contains many graphic organizers to
help structure your learning process. However, creating
Wednesday Thursday Friday Saturday
• Class, 6:00 pm • Do homework • Study group,
for Ch. 4 & Ch. 5 7:00 pm
• Review &
summarize class
notes
xxiv Preface

Type 1 Diabetes Type 2 Diabetes

• Onset at young age
• Insulin-dependent
• Develops diabetic
ketoacidosis
• May develop
hypoglycema • Onset in middle age
• Prone to infection, • Non-insulin dependent
cardiovascular • Develops non-ketotic
disease, kidney hyperosmolar coma
disease

Figure 2 Venn diagrams are used to compare and contrast the features of two or three related items. The organization of overlapping circles
allows information to be organized according to what features are unique to each item and which features are shared. The example here shows a
Venn diagram for type I and type II diabetes.

Feature Cushing’s Syndrome Addison’s Disease

Cause Excess adrenal cortical Insufficient secretion of adrenal

hormones due to glucocorticoid
therapy (steroid medications) or
pituitary tumor resulting in
increased ACTH.
cortical hormones due to
destruction of adrenal cortex.
Adrenal insufficiency may
occur due to sudden
withdrawal of corticosteroid
therapy.

Associated conditions COPD, asthma, cancer, or Inability to respond to

inflammatory conditions stressors such as infection,
requiring steroid therapy. surgery, trauma, or illness.
Diabetes, infection. Increased
risk of cardiovascular disease
and stroke.

Signs and symptoms Weight gain in the trunk, often Hyperpigmentation of the skin
with thin extremities. “Moon face” and gums, fatigue, weakness,
appearance, accumulation of and weight loss.
fat in the upper back (“buffalo
hump”). Thin, easily bruised
skin. Delayed wound healing.
Development of facial hair in
women.

Emergencies Increased risk of MI, stroke, and Adrenal crisis (Addisonian crisis).
infection. May be present with hypo-
glycemia, hypotension, and
cardiac rhythm disturbances due
to electrolyte abnormalities.

Figure 3 Tables can be used to organize and summarize information for side-by-side comparison. This example compares the features of two
adrenal-gland disorders.

your own graphic organizers as part of your study process
adds even more to your learning power. For example, KWL
(know, want, learn) charts are effective because they help
identify what you do not yet know (Figure 4). This is criti-
cal because learning cannot take place until you recognize
the boundaries of your current knowledge. (A variation of
a KWL chart is shown in Figure 5.)
A variety of configurations can be used to create mind
maps or webs, cause–effect diagrams, processes, time lines,
and other ways of summarizing and representing informa-
tion (Figures 6, 7, and 8). If you prefer to use computer-
based tools rather than drawing those structures in your
notes, Microsoft Word has a number of graphic organizer
templates in its online resources.
 Preface xxv

KWL Chart: Advanced EMT Chapter 2 EMS Systems

What I Know About EMS What I Want to Know About What I Learned About EMS
Systems EMS Systems Systems

Figure 4 KWL Chart. KWL stands for know, want, learn. Information is organized by what you already know, what you want to know, and
what you then learned.

KWHL Chart: Advanced EMT Chapter 2 EMS Systems

2. What I Want to Know

1. What I Know About EMS Systems
About EMS Systems

• History of modern EMS began in 1966 with • What are the specific goals of the EMS
the White Paper Agenda for the Future?
• Much of what is known about prehospital
care is based on military experience
• The EMS Agenda for the Future outlines
goals for EMS system development

4. What I Learned
3. How I Learned About EMS Systems
About EMS Agenda Goals

• National Highway Transportation Safety • Integration of health services

Administration, The EMS Agenda for the • EMS research
Future at www.ems.gov • Legislation and regulation
• System finance
• Human resources
• Medical direction
• Education systems
• Public education
• Prevention
• Public access
• Communications systems
• Clinical care
• Information systems
• Evaluation

Figure 5 The KWHL chart is a variation of the KWL chart that includes a “how” section for listing references for information.

Note Taking
Taking notes on both your assigned reading and your
instructor’s lectures is a way of creating study materi-
als for later use. An effective method is Cornell note
taking, which is explained later in this section (Figure 9).
When taking notes in class, do not write word for
word what your instructor is saying or what he might
have on a slide. Writing word for word is rote, requires
little ­thinking, and interferes with listening for mean-
ing. ­Mentally summarizing what is said and writing in
your own words helps you develop understanding. Ap-
proaching note taking in this way helps you listen for
meaning as you translate your instructor’s words into
your own.
xxvi Preface

Vocabulary Sheet
Chapter 1

Vocabulary Term Defnition Relevance to Chapter

Advanced Emergency Medical
Technician (Advanced EMT)
A prehospital emergency care 1 of the 4 nationally recognized
provider who uses basic and levels of EMS providers.
limited advanced life support
skills to care for acutely ill
and injured patients.

Advanced life support (ALS) Complex patient care Advanced EMTs provide basic
assessments and and limited advanced life support.
interventions that require
in-depth training.

Figure 6 Vocabulary sheet.

Initial Primary Patient Secondary Treatment

Scene Size-Up Reassessment
Impression Assessment Priority Assessment

• Scene safety • Airway • History • Primary

• Situation • Breathing • Vital signs assessment
• Circulation • Physical exam • Aspects of
secondary
assessment
• Effects of
treatment

Figure 7 A variety of charts and graphs can illustrate the steps in a process, such as a skill, or the steps of a physiological or pathophysiological
process. The example here shows the main steps in patient assessment.

Pathophysiology of Asthma

Inflammation and constriction narrow the bronchioles. It requires more work to move air past
the obstruction, especially on exhalation. Oxygen and carbon dioxide exchange are impaired.

Inspection (See) Palpation (Feel) Auscultation (Hear) Smell

• Increased work of • Air movement at • Patient • None expected

breathing: use of mouth and nose complaints:
accessory muscles. may be decreased difficulty
breathing, chest
• Impaired gas • Pulse may be
tightness, history
exchange: signs of increased.
of asthma
hypoxia, such as
cyanosis and • Wheezing breath
increased sounds
respiratory rate
• Chest may be silent
• Decreased oxygen in severe attack
saturation.

Figure 8 A pathophysiology and presentation graphic such as this can be used to show the relationship between disease pathophysiology and
the signs and symptoms it causes in the patient.

Write date here.
Cue Column
This should be two
and one-half inches
in width. After class,
formulate questions
about the material in
the notes and write
key ideas (cue words)
here. Then cover the
note-taking column
with a piece of paper
and answer the questions
or discuss the
concepts indicated
by the cue words.
Figure 9 Cornell note taking is a system that allows for effective organization of information and recognition of key points.
An effective way of preparing for class is discussed in
the following section. As you listen to your instructor, write
only what you do not already have in your reading notes,
or anything that bears special emphasis. If you have not
prepared for class and are being exposed to the material
for the first time, you will not be able to determine what
to write and will likely attempt to write down everything.
Attempting to write down everything causes you to fall be-
hind the pace of the lecture and miss a great deal of infor-
mation. Don’t do it.
Instead, use the Cornell note-taking method. Cornell
note taking is a simple, effective and widely used note-taking
structure that you can use to take notes while reading
and during class. The steps are to divide, document, write,
review and clarify, summarize, and study. First, divide
your paper as shown in Figure 9. Write the course name
and the date at the top of the page. Write your notes in the
main section of the paper. Learn to use abbreviations and
symbols to help you write your notes more quickly and
concisely. (Once you have read Chapter 7, “Medical Termi-
nology,” you will have an ample supply of symbols and ab-
breviations at your disposal.) Review and clarify the notes
by pulling out main concepts and key ideas and writing
them in the cue column on the left side of the paper. Also
write any questions you have in that column. Summarize
your notes at the bottom of the page, and then study from
the page.
Preface xxvii
Advanced EMT Class
Note-Taking Column
This should be six inches
in width. Write your notes
in this column from reading
or lectures.
Summary
This should be two inches
in height. After class, use
this area to summarize the
notes on this page.
Three Time Frames for
Learning Activities
Learning for each concept in the course can be divided into
three time frames: preparation for class, time in class, and
review and reinforcement after class (Figure 10). None of
these three time periods can be sacrificed. The use of all
three underscores the importance of repetition in learning.
It is rarely possible, even with simpler concepts, to grasp a
concept fully on first exposure. Each time you are exposed
to the same concept, you will pick up additional under-
standing of it. Repetition allows you to correct misconcep-
tions, fill in gaps in knowledge, and develop deeper and
more sophisticated understanding of concepts.
The variety of different ways in which you are exposed
to a concept through repetition also enriches your under-
standing of it. Just reading about vital signs will not give
you a complete understanding. You will learn more by
also hearing your instructor talk about vital signs, working
on case studies in which patients’ vital signs have differ-
ent meanings, seeing your lab instructor demonstrate the
skills, practicing hands-on skills in lab, seeing other health
care providers perform the skill, and incorporating the
skills into practice scenarios and clinical experience. Being
exposed to the same concept in various settings helps you
transfer learning from one context to another (such as from
in the classroom to on the job).
xxviii Preface

Preparation
Preread, Read for Review, Summarize Test Knowledge, Fill-
Understanding in Knowledge Gaps

Class Time

Come Prepared Take Effective Notes Engage and Participate

Review and Reinforce

Review Notes, Do Homework Use Graphic Organizers Practice Test

Figure 10 Study process.

Prepare for Class
Preparation provides a framework for making sense of the
information that will be provided when you are in class
­(recall the concept of schema introduced earlier). Prepa-
ration allows you to be an active and therefore a more
­effective learner. It also allows you to participate fully, both
mentally and in interactions with your instructor and class-
mates. Coming to class prepared with questions, for exam-
ple, helps focus your attention during lecture so that you
can begin to fill in gaps in understanding. At a minimum,
preparation consists of completing assigned reading and
reviewing your notes. Effective reading of assigned material
requires prereading, reading for understanding, review,
summarization, testing to identify gaps in knowledge, and
filling gaps in knowledge. The design of this textbook helps
you in these activities.
Preread the Assigned Text Chapter  Begin pre-
reading the chapter by reading the chapter introduction
and summary. Next, review the objectives, key terms, and
subject headings. Each of these chapter features serves as a
preview of the content to come and helps you prepare
mentally to receive the information. The features are
turned into even more powerful learning tools when you
phrase each of them as a question to be answered. For
example, when you see a chapter learning objective that
says “After reading this chapter, you should be able to
identify signs and symptoms of stroke,” turn it into a ques-
tion to be answered in your reading, “What are the signs
and symptoms of stroke?” If one of the key terms in the
chapter is aphasia, ask yourself, “What is aphasia?” If a
subject heading is “Pathophysiology of Type I Diabetes,”
turn it into a question, “What is the pathophysiology of
type 1 diabetes?” Read each of the chapter review ques-
tions to get an idea of the answers you will look for in your
reading. Reading for answers is an effective way of reading
for meaning.
Read for Understanding  Begin a chapter by read-
ing the case study. The case studies and questions that
accompany them are specifically designed to prime your
thinking to read for understanding and problem solving.
Read for meaning by looking for material that answers
each of the questions posed by the objectives, key terms,
and subject headings. Take notes on your reading.
Review and Summarize  Review the assigned chap-
ter by reading again the introduction, the subject headings,
and summary. Then summarize the chapter in your own
words. It helps to do this in writing, but you can also do it
mentally or by talking with a classmate or mentor.
Test Your Knowledge and Identify Learn-
ing Gaps  Test your knowledge by changing each of
the objectives and subject headings into questions and
then answering them. Use the review questions at the
end of the chapter to test your knowledge further. Iden-
tify gaps in knowledge by noting anything that you were
not able to answer. Go back and read for the answer.
Before class, write any questions you have from your
reading in the Cues column of a fresh page of notes to be
used in class. Listen for the answers to those questions,
and ask for clarification if you do not hear the answers to
your questions.
Time in Class
Your time in class allows repetition and explanation of key
information and is an opportunity for your instructor to
elaborate on concepts and give examples. It is also an op-
portunity for critical thinking and asking questions. Creat-
ing and taking advantage of those opportunities is a joint

responsibility between you and your instructor. To do your
part, begin by attending class prepared and well rested. Be
ready to focus and engage fully with the instructor, con-
tent, and your classmates. An important step in doing this
is to avoid distractions. If your instructor does not have a
policy regarding phone calls, texting, and Internet use dur-
ing class, avoid those temptations voluntarily. The ability
to multitask effectively is a myth. When two tasks are un-
dertaken simultaneously, both tasks suffer.
Take the perspective of cooperation rather than com-
petition in learning with your classmates. Form working
relationships with them because it is important for your
learning and theirs. Also form a good working relationship
with your instructor. Mutual trust and respect are key com-
ponents in a successful learning experience. Keep an open
mind about the information you receive. Ideas that seem
to be in conflict often can be reconciled. At earlier levels of
learning, complex concepts can be presented very simply.
When presented at a more complex level, there can at first
seem to be a contradiction when, in reality, there is not. It
is helpful to ask your instructor how your previous under-
standing of the concept relates to the current explanation.
Review and Reinforcement
After class, while the lecture is still fresh, review or rewrite
your notes to fill in any gaps. Use graphic organizers to
summarize and clarify information. As you study your
notes on a daily basis, focus more and more on the main
ideas in the Cues column, moving back to the detailed
notes or the text when you are unable to fully explain the
main ideas to yourself or a study partner. Prior to quizzes
and tests, repeat your prereading of the chapter, answering
each of the questions developed from objectives, key terms,
and headings. For anything that you are not able to answer,
go back and reread that section of the chapter.
Testing and Practice Testing
An effective supplement to your study regimen is frequent
practice testing. A number of resources, including the end-
of-chapter reviews in this text, allow you to test yourself.
Practice testing provides you with feedback on your learn-
ing process and guides you to specific areas in which you
need more work. Practice testing also helps you prepare for
your in-class and licensing exams.
Keep in mind a few strategies when taking graded ex-
ams. Everyone experiences some level of anxiety regarding
exams. To a point, that anxiety provides motivation that
Preface xxix
improves performance. However, performance declines
when anxiety levels are high. At high levels of anxiety, you
may have difficulty reading and understanding test in-
structions and test items. You may experience the phenom-
enon of drawing a blank on a test item, only to remember
it as soon as you turn in your test. Some factors that lead
to test anxiety are under your immediate control. Under-
standing the material well enough to recall it when you are
under stress is a key way to decrease test anxiety. This kind
of understanding develops over time. Putting off reading
and studying until the night before the exam is a sure way
to increase your anxiety level.
To decrease anxiety during the test, focus on one item
at a time. Do not worry about how many questions you
have answered or how many questions you still need to
answer. Do not entertain thoughts about poor performance
on the exam and do not worry about how long it takes
other people to finish the exam. There is little correlation
between test performance and how long it takes to com-
plete the test. In general, do not change your answers on
multiple-choice items. If you are not sure of the answer,
stay with your first choice. Change your response only if
you mismarked the answer or you misread the question or
one or more of the responses to it.
If possible, first answer the questions you find easiest,
and then come back to the more difficult ones. This makes
the most efficient use of the limited time you have to take
a test. However, a drawback is the possibility of skipping a
question or mismarking the answer. Whether you answer
questions in order or not, take a few minutes at the end
of the exam to check your answers. Make sure you have
answered all the questions and that you have marked your
answer sheet correctly.
Test anxiety is reduced and mental performance is en-
hanced by taking good care of yourself. Get a full night’s
sleep prior to the exam. Eat nutritious foods and avoid
­excess sugar and caffeine.
In Summary
By taking this class, you have set a high but achievable goal
for yourself. Achieving any important goal requires plan-
ning, time, and work. Being successful in your Advanced
EMT class is no different. Study skills provide you with
tools that can make the most efficient use of the time you
are dedicating to this class. By using them, you will be able
to organize the considerable amount of information you
are about to receive in ways that make it easier to learn.
This page intentionally left blank
Acknowledgments
The hard work and expertise of many people go into trans-
forming an idea into a textbook. The professionalism, guid-
ance, expertise, and support of those individuals make the
work of the authors better, more meaningful, and more
personally rewarding. We thank the following people for
their long hours and dedication to making this the best text
possible.
We are grateful to the Brady editorial staff for their
trust in us and their leadership and guidance. Thank you to
Sladjana Repic, Monica Moosang, Julie Boddorf, and Lisa
Narine.
Thank you to Josephine Cepeda, our development
­editor. It has been a pleasure to work with Jo. Her tireless
work, attention to detail, and expertise have been invaluable.
We also acknowledge the extraordinary attention to
every nuance of scientific and medical accuracy provided
by our medical editor, Steven Weiss, MD. Dr. Weiss held
our work to the highest levels of scrutiny, providing his
incomparable medical expertise in the preparation of this
textbook. His time, effort, and dedication to EMS education
are greatly appreciated.
Thank you to Michal Heron for her intuitive under-
standing of communicating key ideas through art and her
hard work and excellent guidance in managing the photo-
graphs for this text.
Content Contributors
Becoming an Advanced EMT requires study in a number of
content areas ranging from airway to medical and trauma
emergencies and to pediatrics and rescue. To ensure that
each area is covered accurately and in the most up-to-date
manner, we enlisted the help of several expert contributors
in the development of the first edition of the text. We are
grateful for the time and energy that each put into his or
her contribution.
Dan Batsie, BA, NRP, Education Coordinator, North East
Maine EMS, Bangor, ME
John Grassham, BS (in EMS), EMS Educator, University
of New Mexico School of Medicine, Albuquerque, NM
Patrick Hardy, MSc, LLM, EMT, President, Hytropy,
LLC, Baton Rouge, LA
Dustin Hillerson, BS, MD, Internal Medicine Resident,
University of Michigan, Ann Arbor, MI
Sean M. Kivlehan, MD, MPH, NRP, Emergency Medi-
cine Resident, University of California–San ­Francisco,
San Francisco, CA
Lt. J. Harold “Jim” Logan, BS, EMT-P I/C, EMS Conse-
quence Management, The Fire Department of Memphis,
Memphis, TN
Christopher L. Mixon, AAS, NRP, Education Coor­
dinator, Acadian Ambulance/National EMS Academy,
Lafayette, LA
Greg Mullen, MS, NRP, EMS Program Manager, National
EMS Academy, Lafayette, LA
Charles “Harry” Murphy, Jr., NRP,
CCEMT-P, Education Coordinator, National EMS Acad-
emy, Lafayette, LA
Scott Oglesbee, BA, CCEMT-P, Research Coordinator,
Department of Emergency Medicine, University of New
Mexico, Albuquerque, NM
Phillip T. Sanderson, NRP, BS, MHA, Manager,
EMS Operations, Methodist Le Bonheur Healthcare
Systems-Methodist University Hospital, Memphis,
TN
David J. Turner, BS, NRP, Flight Paramedic, Albuquer-
que, NM
Steven Weiss, MS, MD, Professor of Emergency Medi-
cine, University of New Mexico, Albuquerque, NM
We wish to thank the following reviewers for pro-
viding invaluable feedback in preparation of the second
­edition of Advanced EMT: A Clinical-Reasoning Approach.
Amanda Broussard, AAS, BA, Education Manager, Loui-
siana Bureau of EMS, LA
Rebecca Carmody, EMT-P, AAS, Master EMS Instructor,
College of Southern Nevada, NV
Frank Killebrew, Level III EMS Instructor, Paramedicine
Technology Program Director, Ogeechee Technical Col-
lege, GA
Richard Main, MEd, NRP, Instructor, College of Southern
Nevada, NV
Scott Nelson, B.S, NRP, LP, Director, Emergency Medical
Science Program, Texas Southmost College, TX
Matthew Ozanich, MHHS, NRP, EMS Coordinator,
Trumbell Memorial Hospital, Warren, OH
James D. Turner, BA, MA, JD, EMT, Allan ­Hancock
­College, Santa Maria, CA
Walter Webel, BSHS, AS, NRP, Program Director,
­Savannah Technical College, Savannah, GA
Thomas Craig Williams, NRP, Instructor, South Plains
College, Levelland, TX
Donald Woodyard, AAS, BGS, MAML, NRP, Director,
Louisiana Department of Health and Hospitals, ­Bureau
of EMS, Baton Rouge, LA
xxxi
xxxii Acknowledgments

We wish to thank the following reviewers for providing M. Allen McCullough, PhD, Fire Chief/Director of
invaluable feedback and suggestions in preparation of the ­Public Safety, Department of Fire and Emergency
first edition of Advanced EMT: A Clinical-Reasoning A
­ pproach. ­Services, Fayetteville, GA
Deborah Poskus Medley, RN-BC, MSN, CCRN, Excela
Jeffrey L. Barnes, EMT-P, Instructor, Operation’s Man-
Health Westmoreland, Greensburg, PA
ager, Firefighter, Haz Mat Tech, Weatherly, PA
Elizabeth E. Morgan, EMT, Mt. Hood Community
Lauri Beechler, RN, MSN, CEN, EMT, Loyola ­University
­College, Gresham, OR
Medical Center, Maywood, IL
Tom Nevetral, BS, NRP, ALS Training Coordinator, Vir-
George Blankinship, EMT-FP, Flight Paramedic, Moraine
ginia Department of Health ­Office of Emergency Medi-
Park Technical College, Fond du Lac, WI
cal Services, Glen Allen, VA
David Bryant, BS, EMT-P, Associate Professor, Health
Steve Nguyen, MS, NRP, Tulsa Technology Center,
­Related Professions, Northeast State Community
Tulsa, OK
­College, Blountville, TN
Mark Podgwaite, NREMT-I, NECEMS I/C, Training
David Burdett, NRP, Training Officer/Clinical Coordi-
Coordinator, VT EMS District 6, Berlin, VT
nator, Hamilton County EMS and Chattanooga State
Warren J. Porter, MS, BA, LP, NRP, Director, ­Clinical and
­Community College, Chattanooga, TN
Education American Medical Response-South Region,
Rebecca Burke, BS, RN, NRP, Wallace Community
Arlington, TX
­College, Dothan, AL
Barry Reed, MPA, RN, EMTP, CCRN, CEN, CCEMTP,
Helen T. Compton, NRP, Mecklenburg County Rescue
EMS, Fire, AHA Programs Director, Northwest Florida
Squad, Clarksville, VA
State College, Niceville, FL
Steve Creech, BA, MMin (NC), EMT-P, National
Douglas P. Skinner, BS, NRP, NCEE, Training ­Officer,
­Director, Nazarene Disaster Response, Lenexa, KS
Loudoun County Fire Rescue, Leesburg, VA
Lyndal M. Curry, MA, NRP, University of South Ala-
Dale Trusty, EMT-P, Paramedic/Instructor, North
bama, Mobile, AL
­Georgia Technical College, Clarkesville, GA
Glenn Faught, AAS, BS, MS, Program Chair and
Rebecca Valentine, BS, CCEMT-P, I/C, EMS Instructor,
­Associate Professor, Emergency Medical Technology,
Natick, MA
SW Tennessee CC, Memphis, TN
Kelly Weller, MA, GN, LP, EMS-C, EMS Program
James W. Fogal, MA, NRP, EMS Instructor, ­Opelika, AL
­Coordinator, Lone Star College-Montgomery, Conroe,
David C. Harrington, AS, NRP, City of Oak Ridge Fire
TX
Department, Oak Ridge, TN
Randy Williams, NRP, Instructor of Paramedic
James F. Jones, NRP, Program Director, Southeastern
­Technology/EMS Programs Coordinator, Bainbridge
Technical College, Vidalia, GA
College, Bainbridge, GA
Kevin F. Jura, NRP, Lead ALS Instructor, DC Fire & EMS,
Washington, DC
Deb Kaye, EMT, BS Health Education, Physical
­Education, Director/Instructor Dakota County Technical
Photo Advisors
We wish to thank the following for their valuable assis-
College, EMT–Sunburg Ambulance, Lakes Area Rural
tance on the photo program: Michael J. Grant, President &
Responders, Rosemount, MN
CEO, Alan J. Skavroneck, VP & COO, and Debbie Har-
Robin Kinsella, NECEM I/C, Mad River Valley Ambu-
rington, BS, EMT, Director, Community Relations, Ambi-
lance Service, Waitsfield, VT
trans Medical Transport, Inc., Punta Gorda, FL. Thanks
Peggy Lahren, NRP, Regional EMS Coordinator, ­Arizona
also to medical advisors Skippi Farley, EMT-P, and Rodney
Bureau of EMS and Trauma System, Phoenix, AZ
VanOrsdol, FF/EMT-P, and for photography, Maria Lyle
Jim Massie, BS, NRP, Instructor, EMS Program, College
Photography, Sarasota, FL.
of Southern Idaho, Twin Falls, ID
About the Authors

Melissa Alexander, EdD, Richard Belle, BS, NRP

Paramedic
Melissa Alexander be-
came an EMT-A in 1982
and earned a Certificate
in Paramedicine from
Home Hospital School
of Paramedicine in La-
fayette, Indiana, in 1984.
She has a BA in Commu-
nity Health Education
from Purdue University,
an MS in Health Sciences
Education from Indiana
University, and an EdD
in Human Resources Development from The George Wash-
ington University. Dr. Alexander is the Senior Director of
Planning, Assessment, and Evaluation for Medical Student
Education for Indiana University School of Medicine. She
is actively involved in national-level innovations in medi-
cal education, including the American Medical Association
(AMA) Accelerating Change in Medical Education (ACE)
grant and the American Association of Medical Colleges
(AAMC) initiative for creating entrustment-based curricula
and assessments to ensure medical students’ readiness to
enter residency.
Dr. Alexander previously served as the Director of the
EMS Academy at the University of New Mexico, as an Assis-
tant Professor of Emergency Medicine at The George Wash-
ington University, as an Assistant Professor of Criminal Jus-
tice, Fire Science, and EMS at Lake Superior State University,
and as a paramedic at Wishard Ambulance Service in Indi-
anapolis. She has authored and contributed to several EMS
texts and educational products. Dr. Alexander’s research
interests include assessing and improving clinical-reasoning
skills, and creating valid assessments of learning. She has
three daughters, Lindsay (Chris) Giroux, Brittany Streuker,
and Eleanor Shook; and five grandsons, Asher, Ethan, Grant,
Rhys, and Jasper. She enjoys bicycling, spending time with
family, organic gardening, and hanging out with her dogs
Sabrina and Benito.
Richard Belle, a native
of New Orleans, Loui-
siana, began his EMS
career in 1996 after com-
pleting EMT-Basic and
Paramedic training at
Nicholls State University
in Thibodaux, Louisi-
ana. Richard has worked
throughout south Louisi-
ana as a field paramedic,
new employee precep-
tor, student preceptor,
and as a flight paramedic. He has been actively involved
in EMS education since 1999. Richard served as Educa-
tion Coordinator for Acadian Ambulance’s southeastern
district while he returned to Nicholls State University and
earned a bachelor of science degree. After four years of
teaching EMT Basic and Paramedic courses, he transferred
to Lafayette, Louisiana, to serve as Acadian Ambulance’s
Continuing Education Coordinator; he was responsible
for providing refresher training and continuing education
opportunities to medics across Louisiana, Texas, and Mis-
sissippi. Currently, Richard works in Lafayette, Louisiana,
as Continuing Education Manager for Acadian Ambulance
and the National EMS Academy. Richard lives in south
Louisiana with his wife Rhonda and their three children,
James, Victoria, and Allison.

xxxiii
xxxiv About the Authors

Medical Editor in New Mexico. Over 20 years working in EMS, he has been
a medical director of numerous EMS services and EMS
Steven Weiss, MD, MS, training programs. During his time in Tennessee, he was
the State EMS medical director.
FACEP, FACP Dr. Weiss has been involved in training residents, phy-
sicians, and EMTs in EMS concepts and practice. He has
Dr. Weiss was first
published over 30 articles related to EMS and presented
drawn to EMS as a
over 20 abstracts at national meetings. He spent four years
working EMT in the
as the medical director for the EMS Academy in Albuquer-
mountains of Colorado.
que, which trains all levels of EMS providers throughout
After completing medi-
the state. Most recently, he helped to start the Critical Care
cal school, he trained
Paramedic program with Albuquerque Ambulance and
and received board cer-
has acted as the program medical director for five years.
tifications in both Emer-
Presently, Dr. Weiss is a tenured professor of Emergency
gency and Internal Med-
Medicine at the University of New Mexico, where he works
icine at Charity Hospital
as a research director with the EMS fellows and with the
in New Orleans. He is a
ambulance services. He is on the editorial board of Prehos-
fellow of the American
pital and Emergency Care. He is married to Amy Ernst, a
College of Emergency
fellow emergency physician with an interest in injury pre-
Physicians and the American College of Physicians. In
vention and intimate partner violence. His only daughter
2016, he became boarded in EMS medicine. His career has
has worked as an Intermediate EMT and is interested in
spanned a great diversity of emergency medicine and EMS
pursuing a career in health sciences.
systems including Louisiana, Tennessee, California, and now
Another random document with
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN