Ambulance Technician Training Manual PDF

• Acknowledgements There are many people whom the NHSTD, now the Institute of Health and Care Development (lHCD)wish to thank for their help in reviewing and compiling the NHSTD Ambulance Technician Training Manual. Their contributions and the role they played are acknowledged, but a special than...

• Acknowledgements There are many people whom the NHSTD, now the Institute of Health and Care Development (lHCD)wish to thank for their help in reviewing and compiling the NHSTD Ambulance Technician Training Manual. Their contributions and the role they played are acknowledged, but a special thanks is reserved for David Williams (South Yorkshire Metropolitan Ambulance Service NHS Trust), whose work whilst on secondment to the NHSTD has been instrumental in the shaping of this document. His modesty, enthusiasm and dedication in managing the enormous task in hand is noted as is the very professional way he set about his work with the various interest groups and speCialists he encountered during the review. We are also grateful for the support he received from his Service and family during his time with the NHSTD. This revised training manual, which is endorsed by the Joint Royal Colleges and Ambulance Services Liaison Committee, will provide Ambulance Services with an excellent learning resource for the foreseeable future, and is a worthy successor to the original Basic Training Manual. Technician Manual Review Group The first part of the review process involved trainers from the Service, who gave mainly of their own time to meet and redraft the manual. Their contribution and the support of their employing Services is acknowledged, and their local clinicians who provided first stage clinical editing. Those trainers on the Group were: Russ Chandler Scottish Ambulance Service NHS Trust Richard Claridge Wiltshire Ambulance Service NHS Trust Rob Ellery Hampshire Ambulance Service NHS Trust Francis Gale West Midlands Ambulance Service NHS Trust Trevor Hands Hereford and Worcester Ambulance Service NHS Trust Graham Kemp Westcountry Ambulance Services NHS Trust • Bill O'Neil London Ambulance Service Steve Rendi South Yorkshire Metropolitan Ambulance Service NHS Trust Neil Spike East Anglian Ambulance Service NHS Trust Gwyn Thomas North Wales Ambulance Service NHS Trust Andy Westley Two Shires Ambulance Service NHS Trust Joint Royal Colleges and Ambulance Services Liaison CommiHee We would wish to thank Dr Alan Mackintosh, the Chairman of JCALC who helped coordinate comments of the colleagues from the various Royal Colleges. The contribution of the following members of JCALC in reviewing the manual is acknowledged, who gave freely of their time and advice. Dr P Aston Royal College of General Practitioners Dr P Baskett Royal College of Anaesthetists Dr D Chamberlain Royal College of Physicians Dr T Clarke Royal College of Anaesthetists Professor S Cobbe Royal College of Physicians Mr G Cochrane Royal College of Obstetrics and Gynaecology Dr M Colquhoun Royal College of General Practitioners Mr S Crocker Royal College of Obstetrics and Gynaecology Dr T Evans Royal College of PhYSicians Dr J Fisher Royal College of General Practitioners Boyd Murdoch Mersey Ambulance Service NHS Trust Page 1 Acknowledgements Dr A Mackintosh Royal College of Physicians Mr A Marsden Royal College of Surgeons Dr I McNeil Royal College of General Practitioners Mrs V Nix Royal College of Nursing Mr A Redmond Royal College of Surgeons Dr J Robson Royal College of Physicians/British Paediatric Association Dr I Stewart Royal College of Surgeons Dr C Turton Royal College of Physicians Dr M Ward Royal College of Anaesthetists Dr 0 Williams Royal College of Physicians Dr P Worlock Royal College of Obstetrics and Gynaecology Walkgrove were responsible for the design, layout and structural editing of the manual together with the revision of all the photographs and illustrations it contains. The Walkgrove Project Team were: Andrew Allport Project Manager Sarah Smith Project Support Andy Wiles Project Support Howard Walker Graphic Designer Andy Gallacher Photography Susan Broad head Admin Support A special thanks is reserved for Andrew Allport, whose attention to detail on the layout and format of the manual has helped make it a first class product. Acknowledgment is given to Questar Limited for the design and layout of the A4 document. Photographs We wish to acknowledge the companies which loaned equipment for the photograph shoot. These were: FW Equipment Co Ltd (Ferno) Laerdal Mr C James Chief Executive, Oxfordshire Ambulance Service NHS Trust Marquette Mr M Willis Chief Executive, Westcountry Ambulance Services NHS Trust S&W Vickers A special mention is reserved for Dr Judith Fisher, who not only contributed to the clinical review, but also acted as backstop, umpire and final arbiter on the comments received from her colleagues within JCALC. We thank Dr Fisher for this, and for her patience and endurance during this last stage. Walkgrove Limited As well as acknowledging the work of the technical contributors of the manual, we would also wish to acknowledge the work of the contractors involved Walkgrove Limited - who managed the project with David Williams. Page 2 Physio-Control Finally, a big thank you to the staff and cadets of the South Yorkshire Metropolitan Ambulance Service who helped with the organisation and appeared in many of the photographs. A Howson IHCD Ambulance Awards Programme Contents Section 1 • Introduction 1.1 This Manual 1.2 Glossary Section 2 . Organisation and Management tit Section 6 • Airway Management and Resuscitation 6.1 Airway Management 6.2 Adult Cardiopulmonary Resuscitation (CPR) 6.3 Child Cardiopulmonary Resuscitation (CPR) 6.4 CPR for Laryngectomy and Tracheostamy Patients 2.1 Code of Conduct 2.2 Communicating with Patients 6.5 CPR in Pregnancy 2.3 Operational Control 6.6 Airway Adjuncts and Resuscitation Equipment 2.4 Emergency and Urgent Patients 6.7 Oxygen Equipment 2.5 Special Journeys 6.8 Suction Equipment 6.9 Entonox Section 3 - Non-Emergency Patients Section 7 - Introduction to the Body 3.1 Non-Emergency Journeys 3.2 Outpatients 3.3 Geriatric Patients Section 8 - Respiratory System 3.4 Amputees and Artificial Limb Patients 8.1 Respitory System 3.5 Handicapped and Disabled Patients 8.2 Respitory Arrest 3.6 Physiotherapy Patients 8.3 Chest Disease 8.4 Chest Injuries 8.5 Drowning 7.1 Section 4 - Moving and Lifting Patients I Introduction to the body 4.1 General Principals 4.2 Carrying Chair 9.1 Circulatory System 4.3 Lifting Aids 9.2 Cardiac Conditions 4.4 Rescue Stretchers 9.3 Fainting 4.5 Multi-Posture Cot 9.4 Sickle Cell Anaemia 4.6 Blankets 9.5 Shock 4.7 Patient POSitioning 9.6 Anaphylaxis 4.8 Light Rescue 9.7 Automated External Defibrillation Section 9 - Circulatory System Section 5 • Examination and Assessment • 5.1 Examination and Assessment 5.2 Blood Pressure 5.3 Management of Trauma I Page 1 I Contents Section 10 • Nervous System 16.2 Child Abuse 10.1 Nervous System 16.3 Solvent Abuse 10.2 Unconscious Patients 10.3 Head Injuries Section 17 • Special Conditions 17.1 Mental Illness 10.4 Injuries to the Spine 10.5 Maxillo Facial Injuries 10.6 Cerebrovascular Accidents (Stroke) 17.2 Haemodialysis (Issued April 1999) 17.3 Disease Information (Issued April 1999) 10.7 Epilepsy 17.4 Protection from Infection & Universal Precautions (Issued April 1999) 10.8 Removal of Crash Helmets 17.5 Category III Infection Control Section 11 • Skeletal System Section 18 . Special Procedures 11.1 Skeletal System 18.1 Law and Ambulance Staff 11.2 Injuries to Bones, Joints, Tendons and Ligaments 18.2 Suspected Death and Management of Bodies 11.3 Injuries to the Pelvis 11.4 Immobilisation and Support Section 12 . Digestive System 12.1 Digestive System, Abdominal and Pelvic Organs 12.2 Acute Abdominal Problems (Issued April 1999) 18.3 Major Incidents 18.4 Hazardous Substances (Re-issued July 1997) 18.5 Civil Disturbances 18.6 Managing Violence Section 19 . Assisting the Paramedic 19.1 Assisting the Paramedic Section 13 . Soft Tissue Injuries 19.2 Airway Managementllntubation 13.1 Wounds and Bleeding 19.3 Intravenous Access/Fluid Administration 13.2 Burns and Scalds 19.4 Cardiac Monitoring/Defibrillation 13.3 Eye Injuries 19.5 Drug Administration 13.4 Ballistic Injuries Section 20 • Notes Section 14 • Medical Emergencies 14.1 Diabetes This section has been added for your convenience to store lecture and revision notes etc. 14.2 Poisoning 14.3 Extremes of Body Temperature Section 15 • Maternity 15.1 Maternity 15.2 Premature Babies and Incubators Section 16 • Infants and Children 16.1 Infants and Children • '1 SECTION INTRODUCTION Contents • 1.1 This Manual 1.2 Glossary Section 1.1 This Manual INTRODUCTION TO THE MANUAL This publication, the Ambulance Service Basic Training Manual, provides information on various aspects of operational ambulance techniques and associated underpinning knowledge which in turn form part of the proposed Ambulance Awards. It is not intended to be a full and comprehensive training document. It should be used as background and support material during theoretical and practical training programmes in conjunction with other publications and more importantly, tutor input. Much of the original text has been rewritten and added to. There are also many new and modified photographs and illustrations. Other changes have been made in order to make the training manual more user friendly. For example: • You will notice a new style which is easier on the eye • The contents are divided into nineteen logical subject sections • Each section is separated by a tabbed divider for easy reference • A section is provided for your notes • An identity panel is provided for personal details Core Syllabus This manual also complements the introduction of the 'Training and Common Core Syllabus' for Ambulance Personnel. The reverse of each section contents page cross references each subject area with the contents of the Core Syllabus where applicable. Also included at the end of each sub-section is a list of 'Key Learning Points' for that particular subject area. These paints are a direct lift from the existing syllabus, and do not necessarily reflect the contents of the sub-section. They form the basis of what under­ standing a student should have on completion of a programme which includes tutor input and practical training. HOW TO USE THIS MANUAL Sectkm Eye Injuries 13.3 Page Header Each of the nineteen main subject sections is divided into sub-sections. The sub-section reference and title is continued through each page of the sub-section. For example Section 13.3 Eye Injuries. This Section Covers This box identifies key sub-section headings. In all cases these headings will be found in the text in bold capital letters. Page Footer The page number refers to the sub-section. The example page illustrated relates to Section 13.3 - Eye Injuries. • OppOSite the page number will always be a reference to remind you of the the main section heading, in this particular case, Eye Injuries is a sub-section of Section 13, Soft Tissue Injuries. Pagel Section 1 •1 This Manual 13.3 SeclfOn Eye Injuries TNflIUCTtON'COYBRSt .. TyPf!$-1)I£yllftijuttes • Slyn. tlI'Ey'e lniurles Management Where specific step by step guidance is provided in the effective management of patients, this will be denoted by vertical lines in the margin. Remember Boxes Remember boxes are intended to pick out significant points in the text and normally relate to advice on treatment management or the handling of a given situation. Key Learning Points These learning points are a direct lift from the existing syllabus. They do not necessarily reflect the contents of the section. Introduction Section 1.2 Glossary tHI,iECTI'" 'COVERS: .i~~""d~rdterms .;I/Iedl<=al T4Jrms STANDARD TERMS • • Medical Prefixes and Sllffb," Abbreviations Artificial Limb and Appliance Centre (ALAC) See Disablement Services Centre Accident and Emergency Department Hospital department which receives all accident and emergency patients from a specified area Aspirator Suction apparatus Activation Time Attendant The difference in time between notification of an incident and the deployment of an ambulance A member of the ambulance crew who is responsible for the patient's well being Admission (adm) Autoclave A patient entering hospital for an intended stay of at least one night Apparatus (high pressure steam) used for sterilising. for example, clothing, bedding and instruments Ambulance Control Barium The permanent office which receives all demands for the Ambulance Service in a specified area, coordinates them and allocates them to stations or vehicles Substance fed to patients whose digestive tract it is proposed to X-ray. Barium shows up as a shadow on X-rays Base Station (or Fixed Station) Ambulance Liaison Officer (ALO) • • An Ambulance Service Officer with liaison responsibilities covering a major hospital or group of hospitals An ambulance officer responsible for providing radio communications and for the supervision of Ambulance Service activity and liaison at a hospital receiving casualties from a major accident Ambulance Loading Point (ALP) The place designated at the scene of a major accident where ambulances are loaded Ambulance Parking Point The place designated at the scene of a major accident where arriving ambulances park so that the attendant can report arrival, thus avoiding congestion at the entrance to the site or at the ambulance loading point Appointment (App) The time at which a patient is required to attend at a hospital or clinic • Introduction A fixed radio installation operated by Control Bed Bureau (BB) An office which keeps up to date information of the bed state of hospitals in the area, and allocates patients for admission British Red Cross Society Voluntary organisation whose aim is to give auxiliary or supplementary personal service to the sick and disabled in cooperation with statutory bodies and other voluntary organisations. The organisation maintains its own fleet of ambulances Call Sign A code name allocated to each transmitter/receiver for identification purposes Case Notes A medical file containing information and reports on a patient's condition and treatment Casualty Any victim, dead or alive, of an accident or attack of sudden illness Page 1 Section 1 .2 Glossary Casualty Clearing Station Coroner A post set up at a major accident by the Site Medical Officer in liaison with the Ambulance Service, to sort casualties and direct their evacuation An officer of the Crown whose main duty is to inquire into the circumstances of certain deaths occurring within the coroner's jurisdiction; these include cases where there is reasonable cause to suspect violent or unnatural death, as well as sudden deaths of which the cause is unknown Casualty Label A tie on label used as part of the triage at the scene of a major incident to record information which will assist a hospital in the treatment of a patient Catheter A tube designed to be passed into a body cavity Date Time Group A six figure reference number on a message, the first two figures giving the date and the last four the time of origin on a 24-hour clock basis Cervical Collar Day Hospital A dressing designed to support the neck when moving patients with neck injuries A hospital which receives patients in the morning, nurses, treats and cares for them during the day, and sends them home again in the afternoon Chief Ambulance Officer (CAO) Designated Hospital An officer responsible to a Health Authority for the management, organisation and planning of that Authority's Ambulance Service • A hospital nominated by the Regional Health Authority to receive a particular kind of case (eg burns, poisoning) Communication Aid • The first' listed' hospital to be alerted by the Ambulance Service to receive casualties in the event of a major incident A portable device which may provide a communication-handicapped person with a means of communication; for example, an enhanced or artificial voice, or script on a monitor screen Community Nurse A State Registered Nurse who has undertaken further training which enables the person to give skilled nursing care to people in their own homes; Community Nurses work with general practitioners and also carry out a wide variety of treatment in health centres and GPs' premises Compulsory Order An order made under the Mental Health Act 1983 requiring the admission of a patient suffering from mental illness to a hospital for observation and/or treatment Consultant A hospital doctor who has received specialised train­ ing in a particular branch of medicine and who has full clinical responsibility for patients Control Procedures Systematic and detailed procedures used in Ambulance Controls to handle ambulance calls Disablement Service Centre Centre provided by the Department of Health and Social Security, or in Wales the Welsh Office, for supplying and fitting artificial limbs and appliances (wheelchairs etc) and to provide training in their use District Community Physician A doctor employed by the DHA with coordinating and advisory responsibilities for health care in the district Duty Officer Officer in charge of a station, control or ambulance service during a specified period Emergency An incident which requires an immediate response from the Ambulance Service Emergency Reserve Channel (ERC) A radio channel used by Ambulance Services in major accidents and to provide a hospital to ambulance radio telephone link in emergencies Environmental Health Officer An officer of a local authority responsible for enforcing measures safeguarding the public health Section 1.2 Glossary Escort Hospital Car Service • A person, such as a relative or friend, accompanying the patient on an ambulance journey • Qualified nurse who travels with a patient on medical direction A voluntary service providing transport by car for patients needing hospital treatment and unable to travel by public transport or other means; its drivers receive a mileage allowance • As 'Police escort', a police vehicle provided for the purpose of facilitating the passage of an ambulance Junior hospital doctor concerned, under a consultant, with medical cases Family Health Services Associations (FHSA) Junior hospital doctor concerned, under a consultant, with surgical cases House Physician House Surgeon An independent NHS body with prescribed functions in relation to the administration of contracts for ser­ vices of family practitioners and other persons ser­ vices (eg chemist contractors) Incident An accident or any other unforeseen event requiring the presence of an ambulance Family Practitioner General practitioner First Aid Post (FAP) A place preferably under shelter, in which first aid is available Incontinence Pads Squares or rectangles of absorbent material with a waterproof backing placed under incontinent patients to reduce the soiling of bed linen; some patients can wear body pads under the clothing General Practitioner (GP) Initiating Authority A doctor in general practice who is responsible for patients' medical care outside hospital, often known as family doctor An Ambulance Service arranging an ambulance journey by rail or air that starts in its own area and ends in the area of another Authority Geriatrics In-Patient Medical care of the elderly A patient who has been admitted to hospital for at least one night Grid Reference (GR) Six-figure number allowing a point on a map to be identified by reference to a system of coordinates Joint Consultative Committee • A local committee consisting of representatives of employees and employers to discuss matters of common concern which are outside the scope of the national negotiating machinery • A local committee of Health, and Local Authorities' members established to assist their respective authorities to colaborate on matters of common interest Gynaecology The study of the diseases special to women, especially these involving the pelvic organs Health Centre A building providing accommodation and facilities for health services and general practitioners; it may also have accommodation for the general dental services and pharmaceutical services Health Visitor (HV) A State Registered Nurse with Health Visitor qualifications employed by a Health Authority to give advice to families, particularly mothers and children • Liaison The act of effecting cooperation and coordination between services Logbook (Control and Station) A book maintained to record significant events; an aid to the management of the Ambulance Service Page 3 Section 1 .2 Glossary Major Accident Obstetric Flying Squad A major accident for health services purposes is one which, because of the number and severity of live casualties it produces, requires special arrangements Maternity flying squad Medical Officer for Environmental Health (MOEH) A medical officer with statutory responsibilities for communicable disease control and environmental health within a local authority district; usually the District Community Physician, or a specialist in community medicine Occupational Therapy (OT) A regulated course of suitable activity to promote recovery after illness or injury Out-Patient (OP) A patient who attends hospital for a consultation or treatment but is not admitted Pacemaker An apparatus for controlling the rhythm of contrac­ tion of the heart Metropolitan Ambulance Officer (MAO) An officer responsible to a Regional Health Authority for the organisation and management of a Metropolitan Ambulance Service Paediatrics The study of children's diseases Phonetic Alphabet Midwife A State Certified Midwife trained to give care and advice to women during pregnancy, labour and the post-natal period, and the care for the newly born infant An alphabet in words used in verbal communications to avoid confusion of names and places Physician Qualified specialist in medicine (as distinct from surgery) Midwifery The theory and practice of assisting at births Physiotherapy Mobile Medical and Nursing Team Treatment by exercise, heat, electricity or massage to promote recovery A team sent to the scene of a major accident at the request of the Ambulance Service or Site Medical Officer Planned Case Mucus Extractor A routine case, the request for which is made at least the previous day, and for which the times given must be adhered to as closely as possible An instrument for withdrawing mucus from the air passages, usually in newborn babies Protective Clothing National Health Service (NHS) The comprehensive health service originally set up under the National Health Service Act 1946, with the object of improving the physical and mental health of the people, and the prevention, diagnosis and treatment of illness Special clothing issued to ambulance crews when dealing with patients who are dirty and infected or suffering from an infectious disease Psychiatric Patient A patient suffering from mental illness Psychiatry Non-Emergency A patient who does not need to be moved immediately Branch of medicine dealing with disorders of the mind and emotions Psychology Nursing Home An establishment for the accommodation of patients where nursing and in some cases operating facilities are provided The scientific study of the mind Psychotherapy Treatment of mental or emotional disturbance by means other than drugs or physical treatment Introduction Section 1 .2 Glossary Radioactive St John Ambulance (SJA) Releasing ionising radiation A voluntary organisation which offers training to statutory standards in first aid and allied subjects to industry and the general public; incorporates a uniformed voluntary service providing first aid, home nursing, help in hospitals, escorts for patients, and welfare work in general; maintains a fleet of ambulances Radiography Examination by means of X-rays Radiotherapy The treatment of disease by X-rays or radioactive substances Situation Report (SITREP) Reconnaissance A preliminary survey of the scene of an accident An account of an incident including details of the location, the number of casualties, other services in attendance, and any special hazards Recovery Room A room in which patients are kept during recovery from anaesthesia Social Worker An officer of a local authority who helps members of the community with social problems Register The Single Professional Register kept by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting Special Case A patient who must be moved by the Ambulance Service at the times stated by the clinician Registered General Nurse (RGN) Speech Therapy A nurse registered in Part 1 of the Register (see Register) The treatment of all communication problems involving the understanding and production of speech and language Registered Mental Nurse (RMN) A nurse registered in Part 3 of the Register (see Register) Standby • Duty undertaken from home • A person registered in Part 10 of the Register (see Register) A radio term advising an ambulance crew tha control is busy and they should wait to be called • Being in attendance in reserve at a particular location Registered Nurse for the Mentally Handicapped (RNMH) State Certified Midwife (SCM) Registered Midwife (RM) A nurse registered In Part 5 of the Register (see Register) Rendezvous A pre-arranged meeting place A person whose name is on the register maintained by the United Kingdom Central Council (see Midwife) Suction Apparatus Repeater Station Used to extract mucus and vomit from the mouth and air passages A station which automatically receives and retrans­ mits signals Surgical Case Response Times A patient who has undergone or is about to undergo a surgical operation The time lapse between notification of an emer­ gency and arrival at the scene Talk Through A facility enabling one vehicle to communicate with another via a base station Page 5 Section 1 .2 Glossary Teaching Hospital Anaemia Hospital which provides, for a university, facilities for undergraduate or postgraduate clinical teaching, and is designated as a teaching hospital by the Secretary of State for England and Wales A deficiency of haemoglobin in the blood Angina (Pectoris) Condition of gripping pain associated with disease of the arteries of the heart Transfer A patient being conveyed from one hospital to another Anoxia Absence of oxygen Urgent Case Antenatal A case when for medical reasons a definite time limit is imposed Before birth Antepartum Haemorrhage Vaccination Bleeding from the vagina in late pregnancy Immunisation by giving a vaccine Anterior Vaccine In front of, further forward Substance made of the killed or weakened germs of an infectious disease Antibody Substance produced in the body as a defence against the presence of a specific foreign substance MEDICAL TERMS Antitoxin Abscess Substance capable of neutralising a given toxin (see toxin) Localised formation of pus in a tissue, organ or confined space Abduction Movement away from the midline of the body Abortion Discharge of the foetus before it is capable of independent life Acidosis An acid imbalance in the body: • Respiratory Acidosis - excess of carbon dioxide • Metabolic Acidosis - excess of lactic acid Acute (of disease) Aphonia Loss of voice Asphyxia Suffocation caused not only by smothering, but by any condition that prevents oxygen being taken up by the blood Asthma Spasms of difficult breathing accompanied by a sense of suffocation or tightness of the chest Asystole Cessation of cardiac activity evidenced by a straight line ecg Severe, rapidly developing, or of sudden onset Ausculation Adduction Techniques of listening for and interpreting sounds that occur within the body with a stethoscope Movement towards the midline of the body Amnesia Loss of memory Amputee A patient who has suffered the loss of one or more limbs Autonomic Nervous System That part of the nervous system which regulates the functions of the internal organs independently of the will power Bacterium (PL Bacteria) Type of germ 1 .2 Section Glossary Benign Circumduction Not tending to grow worse or recur, non-malignant (see malignant) Circular movement of a limb Collapse Bradycardia Abnormally low rate of heart contractions and consequent slow pulse Severe sudden prostration; sagging of an organ or falling together of its walls Cones Fracture Breech Delivery A birth where the infant's buttocks appear first instead of the head Of the radius at the wrist, typically produces a dinner fork deformity Colic Bright's Disease Severe gripping abdominal pain A disease of the kidneys Colitis Bronchitis Inflammation of the colon Inflammation of the bronchial tubes Coma Callus Complete unconsciousness A new growth of bony tissue around a fracture Congenital Cancer Present from before birth A malignant growth (see malignant) Contagious Carcinoma Communicated by bodily contact Form of cancer Contrecoup Haemorrhage Cardiac Relating to the heart Bleeding which occurs within the skull on the opposite side of the skull to that receiving the blow Cardiovascular Coronary Thrombosis Relating to the heart and circulatory system Blockage of one of the arteries which supply the heart muscle with blood Central Nervous System The brain and spinal cord Cortex The outer layer of an organ Cerebral Relating to the brain Crackles Cerebrovascular Accident Coarse or fine sounds heard through a stethoscope which would signify alveolar malfunction Stroke Cranial Chemotherapy Relating to the skull The treatment of disease, usually cancer, by drugs Cyanosis Cholecystectomy • The removal of the gall bladder Dusky bluish tinge to the skin due to lack of oxygen in the blood Cholecystitis Cyst Inflammation of the gall bladder A hollow swelling containing fluid or soft material Chronic (of disease) Cystitis Lasting a long time Inflammation of the urinary bladder Introduction Page 7 Section 1 .2 Glossary Death Dyspnoea The state in which, in the opinion of a doctor, life is extinct Difficult or laboured breathing Debility Fits which may occur when patient is suffering from toxaemia of pregnancy (see Toxaemia) Eclampsia Weakness Defibrillation Eczema Correction of ventricular fibrillation by electric shock An irritating eruption of the skin Degenerative Electro-Cardiogram (ECG) Involving deterioration of a tissue or organ A tracing of the heart's action made by recording its electrical activity Dermatitis Inflammation of the skin Electro-Convulsive Treatment (ECT) Dermatology Treatment of mental disorders by passing electric shocks through the brain whilst the patient is anaesthetised The study of the skin and it's disease Diabetes Mellitus Electro-Encephalograph (EEG) Disease caused by insulin deficiency A machine recording the rhythmical changes of the electric potential of the brain caused by the discharges of energy by nerve cells Diarrhoea A persistent looseness of the bowels Embolism Diastole The resting period between heartbeats when blood flows into the heart Blockage of a blood vessel by a blood clot, an air bubble, fat or a foreign body originating from elsewhere in the body Diphtheria Emphysema An infectious disease caused by a bacillus attacking the mucuous membrane of the throat The abnormal presence of air in tissues or cavities in the body Discharge Encephalitis • An in-patient who is being sent home Inflammation of the brain • Substance leaving the body, eg pus Disinfection Destruction of germs Disinfestation Endemic Occurring repeatedly in a particular locality Endocarditis Inflammation of the lining of the heart Cleaning from lice, fleas, or other parasites Endocrine Dropsy Secreting within. Applied to those glands whose secretions (hormones) flow directly into the blood Excess fluid in the tissues, especially the legs Dysentery Inflammation of the large intestine resulting in frequent bloodstained motions Dysphagia Interference with the act of swallowing Enteritis Inflammation of the bowels Entonox An analgesic mixture of nitrous oxide and oxygen to give relief to patients in severe pain Introduction Section 1.2 Glossary Epidemic Fomites An infectious disease which attacks a large number of people in a locality at the same time Articles (eg clothing, bedding, books etc) which have been used by a patient suffering from a contagious disease and are capable of transmitting it Epilepsy Convulsive fits caused by a disorder of the brain Gangrene Death of tissue due to failure of its blood supply Epistaxis Nose bleed Gas Gangrene Eversion Gangrene associated with infection by an aerobic gas producing germ Turning outwards Gastric Excreta Relating to the stomach The natural discharges from the body: faeces, urine and sweat Gastro-Enteritis Inflammation of the stomach and intestines Exhalation The act of breathing out Glandular Fever Extension An infectious disease characterised by fever and the enlargement and tenderness of the lymphatic glands A pull applied to a fractured, dislocated or contracted limb to keep it straight Glaucoma Disease of the eye External Outer Glyceril Trinitrate Exudate A substance given to increase the coronary blood flow by causing coronary artery vasodilation Accumulation of fluid in body tissue or cavities Haematemesis Faeces Vomiting blood from the stomach The discharge from the bowels Haematology Fever The study of blood and diseases of the blood A rise in body temperature Haematoma Fibrillation A swelling filled with blood; a bruise Uncoordinated contraction of muscle fibres in the heart Haematuria Blood in the urine Fistula Abnormal passage from one internal cavity to another or to the surface Haemodialysis Blood filtering by use of kidney machine Flowmeter Haemophilia Gauge attached to the outlet of a gas cylinder to indicate the rate of flow of the gas in litres per minute An inherited disease in which the blood lacks the power to clot Foetus Coughing up of blood An unborn child, after the end of the third month of pregnancy Haemorrhage Haemoptysis • Bleeding 'ntfcxfi.Jcmol"l Page 9 Section 1 .2 Glossary Haemothorax Immunisation Bleeding into the chest cavity Introduction of a substance into the body in order to produce immunity Hemiplegia Paralysis of one side of the body Immunity Hepatic The ability of the body to resist infection by a specific disease Relating to the liver Impetigo Hepatitis Acute contagious spotty inflammation of the skin Inflammation of the liver Incontinent Hereditary Transmitted from one's forebears Unable to control the passage of faeces or urine or both Hernia Infarct Rupture An area of dead tissue in an organ, caused by obstruction of an artery Herpes Zoster Shingles Infectious Disease Hodgkin's Disease A disease which can be passed from person to person, directly or indirectly Malignant disease of lymphoid tissue Inferior Hydrocephalus Lower Enlargement of the ventricles of the brain Infusion Hygiene The science of the preservation of health The introduction of fluid (eg blood, saline solution, dextrose) into the body intravenously Hyperemesis Ingestion Excessive vomiting The process of taking food into the body through the mouth Hyperglycaemia Excessive sugar in the blood - a feature of diabetes mellitus Inhalation The act of breathing in Hyperpyrexia Inoculation Excessively high body temperature (over 40°C) Immunisation Hypoglycaemia Insulin Low blood sugar Endocrine secretion of the pancreas which regulates sugar metabolism Hypothermia Excessively low body temperature (below 35°C) Intubation Hysterectomy The introduction of a tube through the larynx into the trachea to maintain a clear, protected airway Surgical removal of the womb Ischaemia Illness Any condition, mental or physical, requiring treat­ ment or nursing Deficiency of blood in a part of the body Isolation Separation from other people of a person suffering from an infectious disease Page 10 Introduction • Section 1 .2 Glossary Jaundice Mucus Extractor • Yellow discoloration of the skin • Disease causing this discoloration An instrument for withdrawing mucus from the air passages, usually in newborn babies Laryngectomee A person who has had total or partial surgical removal of the larynx Larynx Voice box Lateral Relating to the side; away from the midline Lesion An injury, wound or structural change in an organ Leukaemia A disease of the blood characterised by an increase of white cells Lumbago Pain in the small of the back Lumbar Pertaining to the loins Malignant Recurrent or incurable and tending to become increasingly severe Medial Near the midline Median On the midline Meninges The three membranes covering the brain and spinal cord Meningitis Inflammation of the meninges Metabolism The process of transforming foodstuffs and oxygen into body tissue, energy and waste products Miscarriage Multiple Sclerosis Disseminated sclerosis Narcosis A state of unconsciousness produced by a narcotic drug Neoplasm An abnormal formation of new tissue Nephritis Inflammation of the kidney Nephroma Kidney tumour Neurology The study of diseases of the nervous system Neurosurgery Surgery of the nervous system Nitrous Oxide (N20) Laughing gas; analgesic compound of Entonox Oesophagus The gullet Ophthalmic Relating to the eye Orthopaedic Relating to the prevention and treatment of bone ill­ nesses Osteology The study of bones Osteomyelitis Inflammation of bone and marrow Paraplegia Paralysis of the lower limbs Paratyphoid Abortion; the expulsion of the foetus before the 28th week of pregnancy An infectious disease resembling typhoid fever Monoplegia Causing disease Pathogenic Paralysis of one limb Page 11 Section 1 .2 Glossary Pathology Quadriplegia • the study of diseases Paralysis of all four limbs • the examination of tissues and body products for evidence of disease Quinsy Peripheral On the outside or outer edges Peritonitis Inflammation of the lining of the abdominal cavity Phlebitis Inflammation of a vein which tends to the formation of a blood clot Placenta Afterbirth Pleurisy Inflammation of the covering of the lungs Pneumonia Inflammation of the lungs Poliomyelitis Infectious disease affecting central nervous system, sometimes producing paralysis Post-Natal After the birth Post-Partum After childbirth Posterior Behind Prone Lying with the face downward Psychosomatic Pertaining to the interaction of mind and body Pulmonary Relating to the lungs Pyelitis Inflammation of the cavity of the kidney Pyrexia Body temperature higher than normal An abscess on the tonsil Rales Abnormal breath sounds that usually signal the presence of fluid in the lower airways Recumbent Lying down Renal Relating to the kidney Respiratory System The organs of breathing Retention (of Urine) Inability to pass urine Rhonchi Rattling respiratory sounds usually caused by s ecretions in the bronchial tubes Ringworm Contagious skin disease characterised by circular pink patches Rubella German Measles Rupture Escape of all or part of an internal organ through or between the structures which contain i~ (eg protrusion of the bowels through a small gap In the abdominal wall) Scabies A contagious itching skin disease caused by a mite Scarletina Scarlet fever Sedation Reduction of anxiety by the use of drugs Semi-Recumbent In half sitting position Sepsis Describes the condition of infection of the body by pus-forming bacteria Introduction Section 1 .2 Glossary Shingles Trauma Disease in which small, painful blisters are distributed on the skin along the area of disturbance of a nerve due to infection by Herpes Zoster virus A wound or injury Triage Sorting of casualties according to priority Sinus A cavity connecting with the outside of the body Tuberculosis Infectious disease produced by the tubercle bacillus Spondylitis Inflammation of the spine Tumour Swelling Spondylosis Condition in which spinal bones lock Uraemia Sputum Abnormal accumulation in the blood of urea which is normally excreted in the urine Phlegm Urea Stoma An artificially created opening, such as that made by tracheostomy The nitrogenous waste product of protein metabolism Uterus Systole The womb The contraction of the heart, associated with ejection of blood Ventricular Fibrillation Tachycardia An uncoordinated tremor of the ventricules resulting in ineffective contractions and cardiac arrest Abnormally rapid heart action resulting in rapid pulse Virus Tachypnoea A germ smaller than a bacterium Rapid respirations Viscera Tetraplegia The internal organs Paralysis of all four limbs Wheeze Therapy Healing or treatment High pitched whistling sound characterising obstruction or spasm of the lower airways Thrombosis The formation of a thrombus Thrombus A stationary blood clot Toxaemia Poisoning of the blood by the absorption of toxins Toxic Poisonous Toxoid A toxin that has been deprived of some of its harmful properties, but which remains capable of producing immunity Introduction Page 13 Section 1 .2 ' MEDICAL PREFIXES AND SUFFIXES Many of the words used in medical practice are made up of words, or parts of words, derived from Greek or Latin. The commonest of these are listed here. The translations offered are approximate, as some of these elements cover a wide range of meanings. a- Glossary ecto­ -lysis outer breakdown -ectomy macro- cutting out large endo­ mega- inner large entero­ melaen­ bowels black epi­ meso­ upon middle erythro­ micro- red small lacking ab­ from ad- eu­ mono- good; easily functioning one gastro­ -morph stomach form to, towards -aemia blood ante- haemo­ myo­ blood muscle against/before bi­ hydro- myco­ water fungus two -cele hyper- necro­ above or high death hypo- nephro­ below or low kidney swelling cerebro­ brain chole­ inter­ neuro­ between nerve bile derma­ intra­ -ology within study of -itis -oma inflammation tumour Iact- -opia milk sight skin ditwo diaacross -dura­ leuco­ ortho­ white upright, straight loco­ -osis place disease, abnormal state hard dys­ badly functioning P~ge 14 Introduction Section 1 .2 Glossary e osteo­ -therm BBA bone heat Born before arrival pan- -tomy BID whole cutting Brought in dead para- -tox­ BP beside poison Blood pressure -path- tri­ BRCS suffering, sick three British Red Cross Society per- ultra- CAO through beyond Chief Ambulance Officer peri­ CCU around Coronary Care Unit -phobia fear pneum­ ADO Assistant Divisional Officer polymany postafter pseudofalse pyo­ pus AED Automated External Defibrillator A&E Accident and Emergency ALAC Artificial Limb and Appliance Centre ALO retro­ behind -scope view, viewer spondyl­ spine -stasis stoppage -stomy making an opening syn­ e Adm Admission air e ABBREVIATIONS together Introduction Ambulance Liaison Officer ALP Ambulance Loading Point App Appointment ASA Ambulance Service Association (Formerly Association of Chief Ambulance Officers) BB Bed Bureau BAB Back at base CHCs Community Health Councils Dept Department DGH District General Hospital DGM District General Manager DHAs District Health Authorities DoH Department of Health DO Divisional Officer DOA Dead on arrival DoH Department of Health DP Dual purpose DSC Disablement Services Centre D&V Diarrhoea and vomiting Page 15 Section 1 .2 Glossary ECG 100M OT Electro-cardiogram Insulin dependent diabetes mellitus Occupational Therapy ECT PAM's Electro-convulsive therapy IHSM Professions Allied to Medicine ECV Institute of Health Service Management Path Lab Emergency control vehicle Pathology Laboratory ITU EEG Intensive therapy unit Electro-encephalograph PBI Premature Baby Incubator JCC ENT Joint Consultative Committee Ear, nose and throat PBU Premature Baby Unit JNC ERC Joint Negotiating Committee Emergency Reserve Channel PT Physiotherapy LA ETA Leading Ambulanceperson Estimated time of arrival PUO Pyrexia of unknown origin Mat FAP Maternity RGM Regional General Manager First Aid Post MAO FHSA's Family Health Services Authorities Metropolitan Ambulance Officer RGN Registered General Nurse MO Medical Officer FM RHA Regional Health Authority Frequency modulation MOEH Medical Officer for Environmental Health RM GP General Practitioner, ie family doctor NHS RMN National Health Service Registered Mental Nurse Registered Midwife GPFH's GP fund holders NHSE RNMH GR Registered Nurse for the Mentally Handicapped Grid Reference NHS Executive (Formerly NHS Management Executive) HCS NIOOM Hospital car service Non-insulin dependent diabetes mellitus HQ Headquarters Health Visitor Intensive care unit RTA Road Traffic Accident RTB Return to base OP Outpatient ICU Radiotherapy OiC Officer in Charge HV RT RV Rendezvous OPO Outpatient Department SCM State Certified Midwife .. Page 16 Introduction Section Glossary 1 .. 2 SCV Sitting case vehicle SEN State Enrolled Nurse SITREP Situation report SJA St John Ambulance SO Staff Officer/Station Officer e ST Speech Therapy Supt Superintendent TOO Time of despatch TOR Time of receipt UHF Ultra High Frequency UGM Unit General Manager VHF Very High Frequency Wd Ward WEF With effect from WHO World Health Organisation Xrds Crossroads , , IntrQdl,:l~ion, " Page 17 ORGANISATION AND MANAGEMENT Contents • 2.1 Code of Conduct 2.2 Communicating with Patients 2.3 Operational Control and Use 2.4 Emergency and Urgent Journeys 2.5 Special Journeys SECTION :! ORGANISATION AND Section ~ MANAGEMENT Core Syllabus Reference Section Reference TItle 2.1 Code of Conduct GP1-4 2.2 Communicating with Patients A1-1 2.3 Operational Control and Use A1-2 2.4 2.5 Emergency ~nd Urgent Journeys Special Journeys A1-3 2. 1 Section Code of Conduct THIS SECTION COVERS: • Purpose of the Code Conduct • Integrity and Reliability PURPOSE OF THE CODE OF CONDUCT Personal Standards • Conduct and Behaviour Towards Patients and Others PERSONAL STANDARDS Personal standards to which you should pay particular attention are: The efficiency and reputation of any Service, no matter how well organised and equipped it may be, depends upon the conduct and efficiency of its staff. You have a responsibility to perform your duties within the limits of the laid down Service procedures and the training that you have received. Actions outside these limits could have legal implications for: • personal hygiene and cleanliness • personal appearance • effectiveness and efficiency • fitness and health • the patient Personal Hygiene and Cleanliness • yourself and your employability • your employer Most people have very little knowledge of the Ambulance Service. To the public, the ambulance service is the personal attention which the crews give to their patients. To deserve the trust of patients, the respect of other Emergency Services, the Health Service in general and the public, it is necessary to have a Code of Conduct which imposes high standards of behaviour and self discipline. In other words, how staff conduct themselves when going about their daily duties. INTEGRITY AND RELIABILITY A person of integrity is one who has high moral and personal standards. In the ambulance service, integrity and reliability means that you are dependable and can be trusted to work efficiently without constant supervision and: • • Someone who has low personal standards is unhygienic and antisocial. Such a person coming into close contact with others, especially patients, can make them extremely uncomfortable. Be aware of unpleasant body odours which can be worsened during hot weather or during strenuous effort. You have to deal with patients suffering from: • injuries, including open wounds • illness, including infectious diseases Cleanliness and high standards of personal hygiene are of paramount importance in minimising the risk of cross infection. You mix with other health workers and enter patients' homes and so you should never need reminding about the need for personal cleanliness. Personal Appearance The public image of the ambulance service stems directly from the appearance and conduct of individual members of staff so you should always be smartly dressed. Hair should be kept under control and never let loose. Excessive jewellery should be avoided. Keep your uniform clean, tidy and in good repair. Never wear anything which does not conform to the pattern or style of the uniform issued to you. • have high personal standards • can conduct yourself appropriately to patients and others • have a sense of responsibility • are honest • have self discipline REMEMBER: • are loyal Clean smart ambulance stan give patients confidence. Organisation and Management Page 1 2. 1 Section Effectiveness and Efficiency Working through an action process may complete a task and thereby meet the objectives, but the process, although effective, may not necessarily have been very efficient. Therefore, it is important to follow processes and procedures that are equally efficient as they are effective, thus leading to a high quality outcome. Effectiveness and efficiency can be increased by training and improving your skills and underpinning knowledge. Fitness and Health Effectiveness and efficiency can be affected by fitness and health. Therefore, you should: Code of Conduct Be aware of the Patient's Charter. This sets out the rights of patients using the National Health Service and the standards of health care which they can expect to receive. It also explains how to make a complaint if not satisfied. As well as the national Patient's Charter, there are local charters and standards agreed by Health Authorities and NHS Trusts. Conduct Towards Others You will come in contact with others who care equally for patients, for example, relatives or other agencies. You should: • be aware of the needs of patients' relatives, friends or others who may be concerned with the patient • sleep regularly and take regular meals • cooperate with other Services • take care when you are lifting to avoid back injuries • not be drawn into arguments and always refer problems to a senior officer later • use the Occupational Health facilities available to you • • exercise regularly and keep fit do nothing to destroy the confidence of patients, relatives and bystanders; disagreements between members of an ambulance crew should never be aired in public Smoking can damage your health. Other people close to a smoker can suffer the effects of passive smoking and unpleasant odours. Be conscious of your diet and avoid being over weight. CONDUCT AND BEHAVIOUR TOWARDS PATIENTS AND OTHERS REMEMBER: You are a public servant. Your manners and actions uphold the good name of the ambulance service. Sense of Responsibility You have a duty of care to your patients: Conduct Towards Patients • Anxiety and stress can make some patients seem unreasonable. Try to recognise and relieve this by being tactful, reassuring, understanding and sympathetic. Never be bad tempered, impatient or officious. You should: When you are an attendant, always travel in the back of the ambulance with your patients. You are jOintly responsible for their care and welfare and you should be with them throughout the journey. • Your ambulance vehicle is a treatment area so high standards of hygiene and cleanliness apply • Even though there are occasions when you have to drive quickly, you must keep the safety of the vehicle and the occupants uppermost in your mind • always be respectful and avoid over familiarity • unless you know their names, always address patients as sir or madam • never discuss patients' conditions or treatment with others unless they are authorised to know • maintain the ethics of patient confidentiality • always show respect for customs, values and beliefs which may be different to your own Page 2 • You often have access to confidential information about patients. Never divulge information to unauthorised people. Do not give information or give statements about Service matters to local or national news media. Organisation and Management • 2.1 Section Code of Conduct • You must comply with all Service policies, procedures and protocols • Smoking in ambulances is prohibited. This also applies to patients. Smoking is not permitted in most Health Service premises. Always comply with no-smoking pOlicies and instructions. • Never consume alcohol before coming on duty or whilst on duty. Maintain the reputation and professional image of the Service by not entering a public house in uniform when off duty. REMEMBER: Alcohol can take a long time to wear off. Your driving licence is your livelihood. Honesty Do remember that you are in a position of trust. • Ambulance staff have to enter private homes, therefore honesty is paramount • Acceptance of gifts may be regulated by a Service policy • If you are involved in any form of inquiry or complaint, make sure you truthfully give all the facts Self Discipline and Loyalty The very nature of ambulance work and methods of operation means that ambulance services require a high degree of self discipline and loyalty. Ambulance services rely on a high degree of self discipline in their staff. If this fails, the disciplinary procedure may be involved. Be aware of your own Service's disciplinary procedure. Complaints Complaints should always be thoroughly investigated in line with Health Service procedures and should never be treated lightly. Complaints can often be a learning exercise highlighting areas of weakness and, as such, service improvements can often come from complaints. REMEMBER: • You represent the ambulance service • Your conduct forms the impression patients and the general public have of the ambulance service KEY LEARNING POINTS: • Purpose of the Code of Conduct • Integrity and reliability as applied to the Ambulance Service • The importance of maintaining high personal standards • Conduct and behaviour towards patients • Conduct towards others • • Need for self discipline • Importance of Patient confidentiality • Purpose of the Patient's Charter • Effects of stress and anxiety in patients and others • Need to represent the Service in a professional and competent manner • Relationships with other Emergency Services and other Health Service staff • Importance of fitness and health • Need to portray a profeSSional image Organisation and Management Page 3 THIS SECTION COVERS: • Communication • Dealing With Patients Having Little or no English COMMUNICATION DEALING WITH PATIENTS HAVING LITTLE OR NO ENGLISH Communicating is about transferring messages from one person to another. Effective communication is very important and could save lives. Various factors can hinder communication including anxiety, pain, stress, language and cultural barriers. These suggestions may help you communicate better with these patients: • People with little or no English will experience additional stress with resulting reduced capacity to communicate. This diagram illustrates the cycle. Allow more time than you normally would do for patients who speak English • Use non-verbal techniques to reassure the patient; for example, smiling, touching where appropriate, using gestures of encouragement and a sympathetic manner • Do not shout • Try to communicate some information about what is going on; do not maintain total silence as this may appear as if you are ignoring the patient • Try to pronounce the patient's name correctly • Try to find out if the patient has any particular worries or concerns (where appropriate) • Be aware that although a person may not speak English, they could easily understand the meaning of inappropriate non-verbal behaviour, a patronising attitude or an insulting tone of voice isolation confusion leeling of helplessness fear anxiety frustration lack of language ~ loss of concentration language ability falls below usual level You have a duty and responsibility to make every effort to communicate with all patients. Your attitude can affect their ability to understand and make themselves understood. The diagram below shows the ways your responses can affect the patient's condition. REMEMBER: Shouting and/or speaking slowly will not improve a person's understanding of English. Simplifying Your English The following suggestions may help you to simplify your approach and increase the patient's understanding: positive • Speak clearly and slowly tries to reduce stress patience avoids judgement • Use short simple sentences • Repeat sentences when you have not been understood; rephrasing could confuse the patient further • Do not speak pidgin English; it is not easier to understand and is condescending reduced anxIety increased confIdence improved communication Page 1 Organisation and Management 2 .2 Section Communicating with Patients • Give instructions in a logical sequence Using Someone to Interpret • Use mime or pictures (where possible) to get pOints across • Check back that what you have said is understood before moving on to the next point English speaking relatives or friends may be able to help you to communicate with a patient. Wherever possible an interpreter should be allowed to accompany the patient. KEY LURN.ING POINTS: • Cycle which occurs as a result of communication difficulties which increases stress • Additional ethnic factors which affect communication and may increase stress • • Means of using verbal and non-verbal language to reassure and reduce stress • Methods of simplifying language to aid comprehension Organisation and Management Page 2 THIS SECTION COVERS: • Emergency and Urgent Ambulance Service • Non~Emergency Patient Transport Service • Emergency Calls (AS1) • Patient's Charter • Urgent Calls (AS2) • Function of Ambulance Control • Standards of Performance EMERGENCY AND URGENT AMBULANCE SERVICE Scope of the Emergency Ambulance Service An emergency ambulance service should be provided to respond to: Emergency calls can occur at any time and for any reason, for example: • road traffic accident (RTA) • sudden illness • maternity • accident or illness at home; during leisure or sporting activities; at work; in a public place • emergency cases • urgent doctors' admissions Information Required • urgent inter-hospital transfers and high dependency transfers When taking an emergency call Ambulance Control requires the following information: • major incidents • the name and telephone number of the caller (in case Ambulance Control have to contact the caller) • the location of incident • the nature of the emergency • the number of casualties • any hazards, eg fire, chemicals • any persons trapped • directions if the location is difficult to find EMERGENCY CALLS (AS1) Definition Any case arising from a '999' call, irrespective of source, or is classified by a doctor as requiring an immediate response by the ambulance service. In the absence of information to the contrary,