Chapter 36: EMS Operations

The following activities may be required to prepare the patient for transport once he is in the ambulance:

1. CONTINUE YOUR ASSESSMENT. Make sure that a conscious patient is breathing without difficulty once you have positioned him on the stretcher. If the patient is unconscious with an airway in place, make sure he has an adequate air exchange once you have moved him into position for transport. 2. SECURE THE STRETCHER IN PLACE IN THE AMBULANCE. 3. POSITION AND SECURE THE PATIENT. During transfer to the ambulance, the patient must be firmly secured to a stretcher. This does not mean that he must be transported in that position. Positioning in the ambulance should be dictated by the nature of his illness or injury. - If he was not transferred to the ambulance in that position, shift an unconscious patient who has no potential spine injury or one with an altered mental status into the recovery position (on his side). This will promote maintenance of an open airway and the drainage of fluids. - Remember that the head and foot ends of the ambulance stretcher can be raised. A patient with breathing difficulty and no possibility of spinal injury may be more comfortable being transported in a sitting position. - A patient with a potential spinal injury must remain immobilized on the long spine board, with the patient and board together being secured to the stretcher. If resuscitation is required, he must remain supine with constant monitoring of the airway and suctioning equipment ready. If resuscitation is not required, the unresponsive patient and spine board can be rotated as a unit and the board propped on the stretcher so the patient is on his side for drainage of fluids and vomitus from the mouth. 4. ADJUST THE SECURITY STRAPS. Security straps applied when a patient is being prepared for transfer to the ambulance may tighten unnecessarily by the time he is loaded into the patient compartment. Adjust the straps so they still hold the patient safely in place but are not so tight that they interfere with circulation or respiration or cause pain. 5. PREPARE FOR RESPIRATORY OR CARDIAC COMPLICATIONS. If the patient is likely to develop cardiac arrest, position a short spine board or CPR board underneath the mattress prior to starting on the trip. Then if he does go into arrest, time will not be wasted locating and positioning the board. Riding on a hard board may not be comfortable, but temporary discomfort is better than permanent injury or even death from delayed resuscitation. 6. LOOSEN CONSTRICTING CLOTHING. Clothing may interfere with circulation and breathing. Loosen ties and belts, and open any clothing around the neck. Straighten clothing that is bunched under safety straps. Before you do anything to rearrange the patient's clothing, however, explain what you are going to do and why. 7. LOAD A RELATIVE OR FRIEND WHO MUST ACCOMPANY THE PATIENT. Consider the following guidelines if your service does not prohibit the transportation of a relative or friend with a patient: First, encourage the person to seek alternative transportation if available. If there is just no other way the relative or friend can get to the hospital, allow him to ride in the operator's compartment—not in the patient's compartment, where he may interfere with patient care. Make certain the person buckles his seat belt. If an uninjured child must come along, bring the family's child car seat and use it. 8. LOAD PERSONAL EFFECTS. If a purse, briefcase, overnight bag, or other personal item is to accompany the patient, make sure it is properly secured in the ambulance. 9. TALK TO YOUR PATIENT. Maintaining a conversation with the patient helps allay his fears and concerns, builds patient rapport, and simply helps pass the time. 10. AVOID LETTING PATIENTS SIT ON THE BENCH OR AIRWAY SEAT. Unless it's a multiple-casualty incident or there is some other extenuating circumstance, patients belong on the stretcher.

In Quarters: Once in quarters, you are ready to complete the cleaning and disinfecting chores. Consult for the levels of reprocessing to be used for equipment.

1. PLACE BADLY CONTAMINATED LINENS IN A BIOHAZARD CONTAINER AND NONCONTAMINATED LINENS IN A REGULAR HAMPER. 2. AS NECESSARY, CLEAN ANY EQUIPMENT THAT TOUCHED THE PATIENT. 3. CLEAN AND DISINFECT USED NONDISPOSABLE RESPIRATORY-ASSIST AND INHALATION THERAPY EQUIPMENT. - Disassemble the equipment so all surfaces are exposed. - Fill a large plastic container with the cleaning solution outlined in your service's infection control plan. - Clean the inner and outer surfaces with a suitable brush. - Rinse the items with tap water. - Soak the items in an EPA-approved germicidal solution. - After the prescribed soaking period, hang the equipment in a well-ventilated, clean area, and allow it to dry for twelve to twenty-four hours. 4. CLEAN AND SANITIZE THE PATIENT COMPARTMENT. Use an EPA-approved germicide to clean any fixed equipment or surfaces contacted by the patient's body fluids. 5. PREPARE YOURSELF FOR SERVICE. - Wash thoroughly, paying attention to the areas under your fingernails. - Change soiled clothes. It is a good policy to bring a spare uniform to work, and each EMS agency should have a washer and dryer. It is against OSHA regulations for blood- or body fluid-soiled clothes to be taken home to be washed. 6. REPLACE EXPENDABLE ITEMS. Exchange them with items from the unit's storeroom. 7. REPLACE OR REFILL OXYGEN CYLINDERS. Do this in accordance with your service's procedures. 8. REPLACE PATIENT-CARE EQUIPMENT. CARRY OUT POSTOPERATION VEHICLE MAINTENANCE PROCEDURES AS REQUIRED. If you find something wrong with the vehicle, correct the problem or make someone in authority aware of it. 9. CLEAN THE VEHICLE. A clean exterior lends a professional appearance to an ambulance. Check for broken lights, glass and body damage, door operation, and other parts that may need repair or replacement. 10. COMPLETE YOUR PAPERWORK. Complete any unfinished report forms as soon as possible, and report the unit ready for service.

You should make every effort to quickly prepare the vehicle for the next patient:

1. QUICKLY CLEAN THE PATIENT COMPARTMENT WHILE TAKING APPROPRIATE STANDARD PRECAUTIONS. - - Follow biohazard disposal procedures according to your agency's OSHA exposure control plan. Examples of biohazards are contaminated dressings and used suction catheters. - Clean up blood, vomitus, and other body fluids that may have soiled the floor. Place disposable towels used to clean up blood or body fluids directly in a red bag. - Remove and dispose of trash such as bandage wrappings, open but unused dressings, and similar items. - Sweep away caked dirt that may have been tracked into the patient compartment. When the weather is inclement, sponge up water and mud from the floor. - Bag dirty linens or blankets to be appropriately laundered. - Use a deodorizer to neutralize odors of vomit, urine, and feces. Various sprays and concentrates are available for this purpose. 2. PREPARE RESPIRATORY EQUIPMENT FOR SERVICE. - Clean and properly disinfect nondisposable, used bag-valve-mask units and other reusable parts of respiratory-assist and inhalation-therapy devices - Disinfect the suction unit. - Place used disposable items in a plastic bag and seal it. 3. REPLACE EXPENDABLE ITEMS. - If you have a supply replacement agreement with the hospital, replace expendable items from hospital storerooms on a one-for-one basis—such as sterile dressings, bandaging materials, towels, disposable oxygen masks, disposable gloves, sterile water, and oral airways. - If your agency has its own stock replacement policy, make sure to keep track of what has been used and what is needed upon return to the station. 4. EXCHANGE EQUIPMENT ACCORDING TO YOUR LOCAL POLICY. - Exchange items such as splints and spine boards. Several benefits are associated with an equipment exchange program: There is no need to subject patients to injury-aggravating movements just to recover equipment, crews are not delayed at the hospital, and ambulances can return to quarters fully equipped for the next response. - When equipment is available for exchange, quickly inspect it for completeness and operability. - If you do find that a piece of equipment is broken or incomplete, notify someone in authority so the device can be repaired or replaced. 5. MAKE UP THE AMBULANCE COT. The following procedure is one of many that can be used to make up a wheeled ambulance stretcher: - Raise the stretcher to the high-level position if possible; this makes the procedure easier. The stretcher should be flat with the side rails lowered and straps unfastened. - Remove unsoiled blankets and pillows, and place them on a clean surface. - Remove all soiled linen and place it in the designated receptacle. - Clean the mattress surface with an appropriate EPA-approved, low-level disinfectant unless there is visible blood, which should be cleaned up using a 1:100 bleach/water solution. - Turn the mattress over; rotation adds to the life of the mattress. - Center the bottom sheet on the mattress and fully open it. If a full-sized bedsheet is used, first fold it lengthwise. - Tuck the sheet under each end of the mattress; form square corners and tuck under each side. - Place a disposable pad, if one is used, on the center of the mattress. - Fully open the blanket. If a second blanket is used, open it fully and match it to the first blanket. This task should be done with an EMT at each end of the stretcher. - Open a top sheet in the same way, placing it on top of the blanket. Fold the blanket(s) and top sheet together lengthwise to match the width of the stretcher; fold one side first then the other. - Tuck the foot of the folded blanket(s) and sheet under the foot of the mattress. - Tuck the head of the folded blanket(s) and sheet under the head of the mattress. Place the slip-covered pillow lengthwise at the head of the mattress, and secure it with a strap. - Buckle the safety straps, and tuck in excess straps. - Raise the side rails and foot rest.

When answering a call for help, the EMD must obtain as much information as possible about the situation that may help the responding crew. The questions the EMD should ask are:

1. WHAT IS THE EXACT LOCATION OF THE PATIENT? The EMD must ask for the house or building number and the apartment number if any. It is important to ask for the street name with the direction designator (e.g., North, East), the nearest cross street, the name of the development or subdivision, and the exact location of the emergency. 2. WHAT IS YOUR CALL-BACK NUMBER? (Enhanced 911 will show the number.) "Stay on the line. Do not hang up until I [the EMD] tell you to." In life-threatening situations, the EMD will offer instructions to the caller, after the units have been dispatched, that the caller or others on the scene should follow until the units arrive. It is also important for the caller to stay on the line in case a question arises about the location that was given. 3. WHAT'S THE PROBLEM? This will provide the chief complaint. It will help the EMD decide which line of questioning to follow and the priority of the response to send. 4. HOW OLD IS THE PATIENT? Most ambulances are set up to respond to the scene with a pediatric kit if the patient is a child rather than an adult. If prearrival CPR instructions are given, it will be necessary to distinguish among an infant, a child, and an adult. 5. WHAT'S THE PATIENT'S SEX? Ask this if it is not obvious from the information given. 6. IS THE PATIENT CONSCIOUS? An unconscious patient is a higher response priority. 7. IS THE PATIENT BREATHING? If the patient is conscious and breathing, the EMD will often ask many additional questions relative to the chief complaint to determine the appropriate level of response; for example, Emergency Medical Responders, EMTs, or ambulances may respond "cold" (at normal speed—sometimes called Priority 3) or "hot" (an emergency, lights-and-siren mode—sometimes called Priority 1). If the patient is not breathing or the caller is not sure, the

Safety at Highway Incidents: Backing Up

As an operator of an emergency vehicle, you should avoid backing up, if possible, especially during emergencies. There are large blind spots in your mirrors and a danger of striking a pedestrian, an object, or another vehicle. If you must back up, position someone at the rear of the ambulance as a spotter to guide the backing process

Safety at Highway Incidents: Avoid Crossovers Unless a Turn Can Be Completed without Obstructing Traffic

Crossovers on limited-access highways involve high risk. Avoid using this maneuver if possible. It may be safer to go to the next off-ramp and change directions.

Ambulance Collisions

If you ever become involved in an ambulance collision, the laws will be interpreted by the court based on two key issues: (1) Did you use due regard for the safety of others? and (2) Was it, to the best of your knowledge, a true emergency? The requirement of due regard actually sets a higher standard for drivers of emergency vehicles than for other drivers. This is why an investigation by the district attorney or grand jury, as well as your ambulance service, is not uncommon following a collision.

The modern ambulance

The modern ambulance has come a long way from its primitive beginnings. Far more than just a means of transport, today's ambulance is a well-equipped and efficiently organized mobile prehospital emergency department and communications unit.

Before placing patient on carrying device:

You must complete all necessary care for wounds and other injuries, stabilize impaled objects, and check all dressings and splints before the patient is placed on the patient-carrying device. The properly packaged patient is covered and secured to the patient-carrying device.

Response Safety Summary - The following list summarizes important points about how to make a safe response:

- Minimize lights-and-siren "hot" responses. Remember: Driving with lights and siren involves high risk. - Wear your seat belts. - Know where you are going before you respond. Use the GPS and check the maps. - Be familiar with your response area. - Come to a complete stop at intersections. - Don't be a distracted driver. Have the crew leader operate the radio, siren, GPS, computer, and other devices. - Don't eat or drink when responding under emergency conditions. Pay complete attention to the task at hand. - Don't listen to music, text, talk on mobile phones, or indulge in any other distracting activities. Pay 100 percent attention to safe driving.

Most statutes allow emergency vehicle operators to:

- Park the vehicle anywhere if it does not damage personal property or endanger lives. - Proceed past red stop signals, flashing red stop signals, and stop signs. Some states require that emergency vehicle operators come to a full stop then proceed with caution. Other states require only that an operator slow down and proceed with caution. - Exceed the posted speed limit as long as life and property are not endangered. Some states will place limitations in miles per hour over the posted limit (e.g., ten to fifteen miles an hour over the posted speed limit). - Pass other vehicles in no-passing zones after properly signaling, ensuring the way is clear, and taking precautions to avoid endangering life and property. This does not include passing a school bus with its red lights blinking. Wait for the bus driver to clear the children and turn off the red lights of the bus. With proper caution and signals, disregard regulations that govern the direction of travel and turning in specific directions.

Although the siren is the most commonly used audible warning device, it is also the most misused. Consider the effects that sirens have on other motorists, patients in ambulances, and ambulance operators themselves:

- The continuous sound of a siren may cause a sick or injured person to suffer increased fear and anxiety, and his condition may worsen as stress builds up. - Ambulance operators themselves are affected by the continuous sound of a siren. Tests have shown that inexperienced ambulance operators tend to increase their driving speeds from 10 to 15 miles per hour while continually sounding the siren. In some cases operators using a siren were unable to negotiate curves that they could pass through easily when not sounding the siren. Sirens also affect hearing, especially if used for long periods with the siren speaker over the cab.

Many states have laws that regulate the use of audible warning signals. In areas where there are no statutes, ambulance organizations usually create their own policies. If your organization does not, you may find the following suggestions helpful:

- Use the siren sparingly and only when you must. Some states require use of the siren at all times when the ambulance is responding in the emergency mode. Others require it only when the operator is exercising any of the exemptions discussed earlier. - Never assume that all motorists will hear your signal. Buildings, trees, and dense shrubbery may block siren sounds. Soundproofing keeps outside noises from entering vehicles, and in-vehicle sound systems also decrease the likelihood that an outside sound will be heard. - Always assume that some motorists will hear your siren but ignore it. - Be prepared for the erratic maneuvers of other drivers. Some drivers panic when they hear a siren. - Do not pull up close to a vehicle then sound your siren. This may cause the driver to jam on his brakes, and you may be unable to stop in time. Use the horn when you are close to a vehicle ahead. - Never use the siren indiscriminately, and never use it to scare someone or get someone's attention.

The following list contains some points typically included in laws regulating ambulance operation:

1. An ambulance operator must have a valid driver's license and may be required to complete a training program and/or an additional endorsement to their driver's license. 2. Privileges granted under the law to the operators of ambulances apply when the vehicle is responding to an emergency or is involved in the emergency transport of a sick or injured person. When the ambulance is not on an emergency call, the laws that apply to the operation of non-emergency vehicles also apply to the ambulance. The source of many citizen complaints is the unsafe operation of ambulances during non-emergency operations. 3. Even though certain privileges are granted during an emergency, the exemptions granted do not provide immunity to the operator in cases of reckless driving or disregard for the safety of others. 4. Privileges granted during emergency situations apply only if the operator uses warning devices in the manner prescribed by law. Typically this means operation of the warning/emergency lighting systems as well as the siren.

To be a safe ambulance operator, you must:

1. Be physically fit. You should not have any impairment that prevents you from operating the ambulance or any medical condition that might disable you while driving. 2. Be mentally fit with your emotions under control. The judgment of someone operating an ambulance should not be compromised by the excitement of lights and sirens. 3. Be able to perform under stress. 4. Have a positive attitude about your ability as a driver but not be an overly confident risk-taker. 5. Be tolerant of other drivers. Always keep in mind that people react differently when they see an emergency vehicle. Accept and tolerate the bad habits of other drivers without flying into a rage.

The next steps require you to start the engine. Pull the ambulance from quarters if engine exhaust fumes will be a problem. Set the parking brake, put the transmission in park, and have your partner chock the wheels before undertaking the following steps:

1. Check the dash-mounted indicators to see if any light remains on to indicate a possible problem with oil pressure, engine temperature, or the vehicle's electrical system. 2. Check dash-mounted gauges for proper operation. 3. Depress the brake pedal. Note whether pedal travel seems correct or excessive. Check air pressure as needed. 4. Test the parking brake. Move the transmission level to a drive position. Replace the level to the park position as soon as you are sure that the parking brake is holding. 5. Turn the steering wheel from side to side. 6. Check the operation of the windshield wipers and washers. The glass should be wiped clean each time the blades move. 7. Turn on the vehicle's warning lights. Have your partner walk around the ambulance and check each flashing and revolving light for operation. Turn off the warning lights. 8. Turn on the other vehicle lights. Have your partner walk around the ambulance again, this time checking the headlights (high and low beams), turn signals, four-way flashers, brake lights, side and rear scene illumination lights, and box marker lights. 9. Check the operation of the heating and air-conditioning equipment in both the driver's compartment and the patient compartment. This is also a good time to check the on-board suction if the engine is running. 10. Operate the communications equipment. Test portable as well as fixed radios and any radio-telephone communications. 11. If your unit is equipped with a back-up camera, make sure that the camera is not damaged, is clean from debris, and the image on the driver's screen is clear. While you are backing up, have your partner note whether the backup alarm is operating (if the vehicle is so equipped).

The steps of transferring the patient to the emergency department staff:

1. IN A ROUTINE ADMISSIONS SITUATION OR WHEN AN ILLNESS OR INJURY IS NOT LIFE THREATENING, CHECK FIRST TO SEE WHAT IS TO BE DONE WITH THE PATIENT. If emergency department activity is particularly hectic, it might be better to leave your patient in the relative security and comfort of the ambulance while your operator determines where he is to be taken. Make sure an EMT remains with the patient at all times. Under no circumstances should you simply wheel a nonemergency patient into a hospital, place him in a bed, and leave him! Unless you transfer care of your patient directly to a member of the hospital staff, you may be open to a charge of abandonment. Staff members may be treating other seriously ill and injured persons, so suppress any urge to demand attention for your patient. Simply continue emergency care measures until someone can assume responsibility for the patient. When properly directed, transfer the patient to a hospital stretcher. 2. ASSIST EMERGENCY DEPARTMENT STAFF AS REQUIRED, AND PROVIDE A VERBAL REPORT. Stress any changes in the patient's condition that you have observed. 3. AS SOON AS YOU ARE FREE FROM PATIENT-CARE ACTIVITIES, PREPARE THE PREHOSPITAL CARE REPORT. Remember, the job is not over until the paperwork is complete. Find a quiet spot and complete your prehospital care report (PCR). 4. TRANSFER THE PATIENT'S PERSONAL EFFECTS. If a patient's valuables or other personal effects were entrusted to your care, transfer them to a responsible emergency department staff member. Some services have policies that involve obtaining a written receipt from emergency department personnel as protection from a charge of theft. Make sure to document any transfer of patient belongings. 5. OBTAIN YOUR RELEASE FROM THE HOSPITAL. This task is not as formal as it sounds. Simply ask the emergency department nurse or physician if your services are still needed. In rural areas where not all hospital services are available, it may be necessary to transfer a seriously ill or injured person to another medical facility. If you leave and have to be recalled, the patient will lose valuable time.

The following inspection steps can be taken while the ambulance is in quarters:

1. Inspect the body of the vehicle. Report any damage that may be evident. Indicate past damage that has not been repaired. 2. Inspect the wheels and tires. Check for damage or worn wheel rims and tire sidewalls. Check the tread depth. Use a pressure gauge to ensure that all tires are properly inflated. Do not forget to inspect the inside rear tires and their air pressure as well. 3. Inspect the windows and mirrors. Look for broken glass and loose or missing parts. See that mirrors are clean and properly adjusted for maximum visibility. 4. Check the operation of every door and all latches and locks. 5. Check the level of the fluids: oil, coolant, windshield wiper, brake, and transmission fluids. 6. Check the battery. Inspect the battery cable connections for tightness and signs of corrosion. 7. Inspect the interior surfaces and upholstery for damage and cleanliness. Wipe down the steering wheel with disinfectant. 8. Check the windows for operation. See that the interior surface of each window is clean. 9. Test the horn, siren, and emergency lights 10. Adjust the driver's seat and ensure the seat belts are operational. 11. Check the fuel level. Refuel after each call whenever practical. Note: Allow the engine to cool before removing any pressure caps.

Having at least one EMT in the patient compartment is minimum staffing for an ambulance, although having two is preferred. Seldom will you be able to merely ride along with your patient. You may have to undertake a number of activities en route:

1. NOTIFY THE HOSPITAL. Most EMS services radio the hospital with a patient report. 2. CONTINUE TO PROVIDE EMERGENCY CARE AS REQUIRED. If life support efforts were initiated prior to loading the patient into the ambulance, they must be continued during transportation to the hospital. Maintain an open airway, resuscitate, administer to the patient's needs, provide emotional support, and do whatever else is required, including updating your findings from the primary patient assessment. 3. USE SAFE PRACTICES DURING TRANSPORT. In most cases the patient packaging and preparation will be completed prior to loading. En route to the hospital, vitals may need to be repeated, the patient has to be tended to, and the hospital must be called on the radio. Remain seat-belted as much as possible. If a crash occurs, being belted improves your chances of survival and helps reduce injuries. Stow any unnecessary equipment because equipment can become projectiles in a crash. Probably the most important safety consideration is this: Is it really necessary to transport this patient with lights and siren on? When you are running "hot," the chances of a crash significantly increase. In most EMS systems, true emergencies needing a "hot" ride to the hospital constitute less than 5 percent of all transports. Don't use lights and siren for the drive to the hospital unless it is a life-threatening situation! 4. COMPILE ADDITIONAL PATIENT INFORMATION. If the patient is conscious and emergency care efforts will not be compromised, record the patient information. Compiling information during the trip to the hospital serves two purposes. First it allows you to complete your report. Second supplying information temporarily takes your patient's mind off his problems. Remember, however, that this is not an interrogation session. Ask your questions in an informal manner. 5. CONTINUE ASSESSMENT AND MONITOR VITAL SIGNS. Keep in mind that vital sign changes indicate a change in a patient's condition. For example, an unexplained increase in pulse rate may signify deepening shock. Record vital signs and be prepared to report changes to an emergency department staff member as soon as you reach the medical facility. Reassess vital signs every 5 minutes for an unstable patient, and every 15 minutes for a stable patient. 6. NOTIFY THE RECEIVING FACILITY. Transmit patient assessment and management information, and provide your estimated time of arrival.

When to Call for Air Rescue: Air rescue may be required for any of the following reasons:

1. OPERATIONAL REASONS. Operational reasons for air rescue include: (1) to speed transport to a distant trauma center or another special facility (2) when extrication of a high-priority patient is prolonged and air rescue can speed transport (3) when a patient must be rescued from a remote location that can be reached by helicopter only. Follow your local protocols. 2. CLINICAL REASONS. Medical reasons for air rescue primarily affect patients who are high priority for rapid transport, for example, a patient: - in shock - with a Glasgow Coma Scale total of less than 10 - with a head injury with altered mental status - with chest trauma and respiratory distress - with penetrating injuries to the body cavity - with an amputation proximal to the hand or foot - with extensive burns - with a serious mechanism of injury - who is post-cardiac arrest with a pulse NOTE: Cardiac patients requiring catheterization or surgery, stroke patients, and those patients requiring hyperbaric oxygen treatment (e.g., after carbon monoxide poisoning) are examples of medical patients who may also be flown by air. Cardiac-arrest patients are usually not transported by air rescue unless they are hypothermic. Follow your local protocols.

En Route to Quarters

1. RADIO THE EMD. Let him know that you are returning to quarters and that you are available (or not available) for service. Be sure that you notify the EMD if you stop and leave the ambulance unattended for any reason during the return to quarters. 2. AIR THE AMBULANCE IF NECESSARY. If the patient just delivered to the hospital has an airborne communicable disease or if it was not possible to neutralize disagreeable odors while at the hospital, make the return trip with the windows of the patient compartment partially open, weather permitting. 3. REFUEL THE AMBULANCE. Local policy usually dictates the frequency with which an ambulance is refueled. Some services require the operator to refuel after each call regardless of the distance traveled. In other services the policy is to refuel when the gauge reaches a certain level.

Transfer to the ambulance is accomplished in four steps, regardless of the complexity of the operation:

1. Select the proper patient-carrying device. 2. Package the patient for transfer. 3. Move the patient to the ambulance. 4. Load the patient into the ambulance.

Describe the landing zone to the air rescue service:

1. TERRAIN. "The landing zone is located on top of a hill." "The landing zone is located in a valley." 2. MAJOR LANDMARKS. "There is a river [major highway, factory, water tower] to the north [or other direction] of the landing zone." 3. ESTIMATED DISTANCE TO NEAREST TOWN. "The landing zone is approximately twelve miles west of Centerville." 4. OTHER PERTINENT INFORMATION. "There are wires on the east side of the landing zone." "There is a deep ditch to the west." "Winds are out of the north-northeast at about 10 miles per hour."

Shut off the engine and complete your inspection by checking the patient compartment and all exterior cabinets:

1. Using your checklist, conduct a detailed inspection and inventory of the equipment and supplies. 2. Check treatment supplies, interior equipment and exterior equipment. Items should not only be identified; they should also be checked for completeness, condition, and operation. Check the pressure of oxygen cylinders. Inflate air splints and examine them for leaks. Test oxygen and ventilation equipment for proper operation. Examine rescue tools for rust and dirt. Operate battery-powered devices to ensure that the batteries have a proper charge. Some equipment, such as the AED, may require additional testing. See that an item-by-item inspection of everything carried on the ambulance is done, with findings recorded on the inspection report. 3. When you are finished, complete the inspection report. Correct any deficiencies. Replace missing items. Make your supervisor aware of any deficiencies that cannot be immediately corrected. 4. Finally, clean the unit for infection control and appearance. Use only approved cleaning and disinfecting materials. Maintaining the ambulance's appearance enhances your organization's image in the public's eye while also inspiring confidence in your role. People who take pride in their work show it by taking pride in the appearance of their ambulance. If a call comes in while you are performing your vehicle check, take the call and finish the check when you return to service. The exception would be if any essential equipment is missing. In that case take your ambulance out of service until the critical items have been replaced, allowing for another, properly equipped ambulance to be dispatched.

How to Set up a Landing Zone

A helicopter requires a landing zone, or LZ, approximately 100 by 100 feet (approximately 30 large steps on each side) on ground that has a slope of less than 8 degrees. The landing zone and approach/departure path should be clear of wires, towers, vehicles, people, and loose objects. The landing zone should be marked with one flare in an upwind position. During night operations, never shine a light into the pilot's eyes during landing or takeoff or while the aircraft is running on the ground.

Straps on Patient-Carrying Devices

A patient-carrying device should have a minimum of three straps for securely holding the patient. The first should be at the chest level, the second at hip or waist level, and the third on the lower extremities. Sometimes there is a fourth strap if two are crossed at the chest. Newer stretchers have straps that act as a harness and restrain the upper body. If your stretcher has this type of harness, make sure to use it each time. All patients, including those receiving CPR, must be secured to the patient-carrying device before transfer to the ambulance.

Role of the Emergency Medical Dispatch

An EMD is trained to perform the following tasks: - Ask questions of the caller and assign a priority to the call - Provide prearrival medical instructions to callers and information to crews - Dispatch and coordinate EMS resources - Coordinate with other public safety agencies

Terminating the call

An ambulance run is not really over until the personnel and equipment that comprise the prehospital emergency care delivery system are ready for the next response. The functions of EMTs in this final phase of activity include more than just changing the stretcher linen and cleaning the ambulance. A number of tasks must be accomplished at the hospital, during the return to quarters, and after arrival at the station.

Ambulance Supplies and Equipment

An ambulance without proper equipment may have its agency cited and fined a considerable amount of money by a state EMS regulatory agency. In addition, the EMS personnel responsible may find themselves cited and fined. EMS services are regulated in most states, and each state has a list of equipment required to be carried by EMS response units. Please refer to your state or regional office for your specific regulations and an equipment list.

Ensuring Ambulance Readiness for Service

As a professional rescuer, you are expected by the public and your organization to be ready when an emergency occurs. Therefore, you must be sure that you, your vehicle, and your equipment are ready to respond. Most services require that an inspection of the vehicle and equipment be conducted at the start of every shift to ensure "ready-ness." Inspection of the vehicle and equipment are typically tracked by a checklist. The checklist and inspection process are an important part of recordkeeping for many different EMS services and may be a critical component of an investigation process if needed. Do a brief shift report with the off-going crew if possible. Learn whether they experienced any problems with either the ambulance or its equipment during their shift. If there was a problem described by the off-going crew, make sure to communicate that with a shift supervisor and thoroughly document the stated problem. There are usually two components to the inspection: a vehicle component and an equipment component. In most cases the EMT assigned to be the driver completes the vehicle component check, and the EMT crew leader completes the medical equipment check.

How to Call for Air Rescue?

As an EMT, you may radio dispatch for advice if you think such a service is needed. When calling an air rescue service, give your name and call-back number, your agency name, the nature of the situation, the exact location including crossroads and major landmarks, and the exact location of a safe landing zone. If you have the ability to provide GPS coordinates, use them. Follow your local protocols.

Safety at Highway Incidents: Unit Placement is Important

Avoid driving over debris and skid marks because the police consider these to be crime scene evidence. If extrication is necessary, leave room for placing rescue vehicles that will be needed to do the extrication. Create a "safe area" downstream; place ambulances downstream past the incident. Prevent anyone from blocking the egress of ambulances, and try to keep all ambulances heading in the same direction.

Cover the patient

Covering a patient helps to maintain body temperature, prevents exposure to the elements, and helps ensure privacy (Figure 36-5). A single blanket, or perhaps just a sheet, may be all that is required in warm weather. A sheet and blankets should be used in cold weather. When practical, cuff the blankets under the patient's chin, with the top sheet outside. Do not leave sheets and blankets hanging loose. Tuck them under the mattress at the foot and sides of the stretcher. In wet weather, place a plastic cover over the blankets during transfer. Remove it once you are in the ambulance to prevent overheating. In cold or wet weather, cover the patient's head, leaving the face exposed.

How to Approach a Helicopter

Do not approach a helicopter unless escorted by the flight personnel. Never approach the aircraft without permission or from the rear. Allow the helicopter crew to direct the loading of the patient. Stay clear of the tail rotor at all times. Keep all traffic and vehicles 100 feet or more distant from the helicopter. Do not smoke within 200 feet of the aircraft. Be aware of the danger areas around helicopters, as shown in Never walk around the tail rotor area. The area around the tail rotor is extremely dangerous. A spinning rotor cannot be seen. A sudden gust of wind can cause the main rotor of a helicopter to dip to a point as close as 4 feet from the ground. Approach the aircraft from the downhill when a helicopter is parked on a hillside.

Speed and Safety

Drive with these facts in mind: - Excessive speed increases the probability of a collision. - Speed increases stopping distance, reducing the chance of avoiding a hazardous situation. Remember that the laws in most states excuse you from obeying certain traffic laws only in a true emergency and only with due regard for the safety of others. Except in these circumstances, obey speed limits, stoplights and signs, yield signs, and other laws and posted limits. Approach intersections with caution, avoid sudden turns, and always properly signal lane changes and turns. Be sure that the ambulance driver and all passengers wear seat belts whenever the ambulance is in motion.

Understanding the law

Emergency vehicle operators are generally granted certain exemptions with regard to speed, parking, passage through traffic signals, and direction of travel. However, the laws also state that if an emergency vehicle operator does not drive with due regard for the safety of others, he must be prepared to pay the consequences, such as tickets, lawsuits, or even time in jail.

Four types of ambulances

Four types of ambulances: Type I, Type II, Type III, and medium duty. The U.S. Department of Transportation has issued specifications for Type I, Type II, and Type III ambulances. Because of the extra equipment now placed on ambulances for specialty rescue, advanced life support, and hazardous materials operations, their gross vehicle weight has been easily exceeded in some communities. This has necessitated the introduction of a medium-duty truck chassis built for rugged durability and large storage and work areas

Safety at Highway Incidents: Wear Your PPE

If there is no extrication in progress, wear an ANSI Class 2 safety vest and a helmet. If extrication is indicated, then you should wear turnouts. The basic idea is this: EMS workers should match the level of protection being worn by other responders, such as fire department personnel.

Safety at Highway Incidents: Keep Unnecessary Units and People off the Highway

If you are not the primary or first-arriving unit, stay off the highway. Park or stage your unit near the on-ramp until the first unit has sized up the incident and determined the resources needed. You don't want to expose people to any more risk than necessary when working on the highway. The more vehicles and people gathered, the greater the risk.

Factors that affect response:

In addition, an ambulance response can be affected by several factors: 1. DAY OF THE WEEK. Weekdays usually have the heaviest traffic because people are commuting to and from work. In resort areas weekend traffic may be heavier. 2. TIME OF DAY. In major employment centers, traffic over major roads tends to be heavy in all directions during commuter hours. 3. WEATHER. Adverse weather conditions reduce driving speeds and, thus, increase response times. A heavy snowfall can temporarily prevent any response at all. Be careful to lengthen your following distance whenever there is decreased road grip due to inclement weather. 4. ROAD MAINTENANCE AND CONSTRUCTION. Traffic can be seriously impeded by road construction and maintenance activities. Be aware of area road construction, and plan responses as needed. 5. RAILROADS. There are still more than a quarter-million grade crossings in the United States with traffic often blocked by long, slow freight trains. Some communities may use a secondary response system on the other side of train tracks that splits the town in half. 6. BRIDGES AND TUNNELS. Traffic over bridges and through tunnels slows during rush hours. Collisions—including ambulance collisions—tend to occur when drivers forget that bridges freeze before roadways. 7. SCHOOLS AND SCHOOL BUSES. The reduced speed limits in force during school hours slow the flow of vehicles. An emergency vehicle should never pass a stopped school bus with its red lights flashing. Wait for the school bus driver to signal you to proceed by turning off the lights. In addition, emergency vehicles attract children, who often venture out into the street to see them. The operator of every emergency vehicle should slow down when approaching a school or playground. Obey the directions given by school crossing guards.

Getting There: Navigating to the Scene

Many EMS services have global positioning satellite (GPS) navigation installed in their emergency vehicles. This is an excellent tool for navigation to emergency scenes and hospitals. Often a GPS suggests a route that may not be possible because of recent road construction or other changes in the area. GPS devices can also be a significant distraction! Be careful about attempting to operate the GPS while driving. Obtain detailed maps of your service area. Hang one map in quarters, and place another in the ambulance. Even if you have GPS navigation, check the maps before you leave for a call.

Safety at Highway Incidents

Operation at highway incidents exposes EMTs to significant danger. EMTs, firefighters, and police officers are injured and killed every year while operating at the scenes of highway incidents.

Safety at Highway Incidents: Place Cones/Flares and Reduce Emergency Lighting

Place cones/flares upstream to warn and direct traffic around the incident. Remember that response lights can blind approaching drivers and increase scene risks. Consider reducing emergency lighting to prevent blinding motorists.

Using the Warning Devices

Safe emergency vehicle operation can be achieved only when proper use of warning devices is coupled with sound emergency and defensive driving practices. Studies show that other drivers do not see or hear an ambulance until it is within one hundred feet, so never let the lights and siren give you a false sense of security.

Packaging

The term packaging refers to the sequence of operations required to ready the patient to be moved and to combine the patient and the patient-carrying device into a unit ready for transfer. A sick or injured patient must be packaged so his condition is not aggravated.

Commonly used device

The wheeled ambulance stretcher is the most commonly used device for transferring the patient to the ambulance.

Safety at Highway Incidents: If Yours Is the First Unit on Scene

The first unit on scene blocks the incident by parking the apparatus "upstream" from the incident. The apparatus is placed to block the crash from traffic by using the vehicle as a barrier. The best vehicle for this is a fire truck because of its size and weight. Ideally ambulances should be parked "downstream" in a safe loading area

The horn

The horn is standard equipment on all ambulances. Experienced operators find that the judicious use of the horn often clears traffic as quickly as the siren. The guidelines for using a siren apply to the horn as well.

Escorted or Multiple Vehicle Responses

When the police provide an escort for an ambulance, there are additional hazards. Too often, the inexperienced ambulance operator follows the escort vehicle too closely and is unable to stop when the lead vehicle makes an emergency stop. Because of the dangers involved with escorts, most EMS systems recommend no escorts unless the operator is not familiar with the location of the patient (or hospital) and must be given assistance from the police.

Protecting the EMT

When traveling in an ambulance, you should remain seated, wearing a seat belt or harness when possible. Although it isn't always possible to remain seated, avoid unnecessary movement during emergency response and transport. Unsecured equipment turns into projectiles upon collision, threatening both the patient and EMT. Always ensure that all equipment in the patient compartment (e.g., oxygen cylinders, kits) has been secured.

Visual Warning Devices

Whenever the ambulance is on the road, night or day, the headlights should be on. This increases the vehicle's visibility to other drivers. There are several types of lights on ambulances, including rotating lights, flashing lights, strobe lights, and the newer LED (light-emitting diode) lights. When the ambulance is in the emergency response mode, either en route to the scene or to the hospital with a high-priority patient, all the emergency lights should be used. The vehicle should be easily seen from 360 degrees. Do not be surprised if other drivers do not pull over when you are on an emergency run if they constantly see your ambulance with emergency lights on. Save the use of lights and siren for life- or limb-threatening emergencies.

At the hospital

While still at the hospital, the ambulance crew should begin making the ambulance ready to respond to another call. Time, equipment, and space limitations sometimes preclude vigorous cleaning of the ambulance while it is parked at the hospital