Chapter 37 (Transport Operations)

jump kit

- a bag or box containing equipment used by the emergency medical responder (EMR) when responding to a medical emergency; includes items such as resuscitation masks and airway adjuncts, gloves, blood pressure cuffs and bandages.

the modern ambulance is a vehicle for emergency medical care that has the following features:

- a driver's compartment - a patient compartment that can accommodate 2 EMTs and usually 2 supine patients positioned so at least one of the patients can receive CPR during transport - equipment and supplies to provide emergency medical care at the scene and during transport, to safeguard personnel and patients from hazardous conditions and to carry out light extrication procedures - two-way radio communication so ambulance personnel can speak with the dispatcher, the hospital, public safety authorities and online medical control - design and construction that ensure maximum safety and comfort

sterilization

- a process, such as the use of heat, which removes all microbial contamination

ambulance

- a vehicle that is used for treating and transporting patients who need emergency medical care to a hospital - ambulances today are based on NFPA 1917, Standard for Automotive Ambulances

medications and other supplies

- activated charcoal - drinkable water and cups - oral glucose - O2 - supplies for irrigating skin and eyes - duodote or other regional equipment depending on the area and local protocol - portable radio or cell phone

safe parking

- allow efficient traffic flow and control around an emergency scene - park 100 feet before or past the crash scene - do not park alongside a crash scene - park uphill/upwind of hazardous materials - leave warning lights or devices on - keep a safe distance between the emergency vehicle and operations - stay away from fires, explosive hazards, downed wires, and unstable structures - set the parking brake - facilitate emergency medical care and rapid transport from the scene - if it is necessary to block traffic, work quickly and safely

driver anticipation

- always assume that motorists around your vehicle have not heard your siren/public address system or seen you until proven otherwise by their actions - motorists may give you the right of way, but can also stop suddenly or cut left instead of right - PA systems can distract the motorists and the person who is driving the ambulance and put both at risk for an accident, so avoid using during an emergency call - always drive defensively; never rely on what a motorist might do unless you get a clear visual signal

weather and road conditions

- ambulances have a longer braking time and stopping distance. - the weight of the ambulance is unevenly distributed, which makes it more prone to roll over - if you drive at a speed that is appropriate for the weather and road conditions and maintain an adequate cushion of safety, you can minimize these situations

laws and regulations

- an emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children; wait for the bus driver to turn off the lights before proceeding - always travel at a speed that allows you to stop safely at all times - never assume that warning lights and siren will allow you to drive through a congested area without stopping or slowing down

establishing a landing zone

- area should be 100x100 feet & no less than 60x60. - the area should be hard, grassy, and clear of all debris. - the area must be surveyed for hazards - if the wind is strong, radio the wind speed to the crew. - clear of all overhead or tall hazards (telephone cables or antennas) - to make the landing sight, use weighted cones or position emergency vehicles at the corners of the landing zone with the headlights facing inward to form an x; never use caution tape or people to mark the landing site and do not use flares (can become airborne and cause explosions) - move all non-essential personnel and vehicles a safe distance outside the landing zone

hydroplaning

- at speeds of greater than 30 mph, tires may be lifted off the road as water piles up underneath and the vehicle may feel like it is floating - at higher speeds on wet roadways, the front wheels may actually be riding on a sheet of water - if hydroplaning occurs, gradually slow down without jamming on the brakes

postrun phase

- complete and file additional written reports - inform dispatch of status, location and availability - perform routine inspections and refuel the vehicle - use a written checklist to document needed repairs or replacement of equipment and supplies

type I ambulance

- conventional, truck-cab chassis with a modular ambulance body that can be transferred to a new chassis as needed

items carried in a jump kit

- disposable gloves - triangular bandages - trauma shears - adhesive tape - trauma dressings - self-adhering roller bandages - oropharyngeal airways - bag-mask device - BP cuff - stethoscope - penlight - sterile gauze dressings and abd pads - adhesive strips - oral glucose - activated charcoal

right-of-way privileges

- emergency vehicles have the right to disregard the rules of the road when responding to an emergency - do not endanger people or property under any circumstances - some will allow you to proceed through a red light or stop sign after you stop and make sure it is safe to go on or allow you to proceed through a controlled intersection with due regard

mass-casualty incidents

- estimate and communicate number of patients to the incident commander - request additional units through dispatch - the incident command system will be established

keep the following guidelines in mind:

- familiarize yourself with helicopter hand signals used within your jurisdiction - do not approach the helicopter unless instructed and accompanied by flight crew. - ensure that all equipment and the patient are secured to the stretcher - smoking, open lights or flames, and flares are prohibited within 50 feet - wear eye protection during approach and take off

air ambulances

- fixed-wing and rotary-wing (known as helicopters) aircrafts that have been modified for medical care; used to evacuate and transport patients with life-threatening injuries to treatment facilities - generally used when the patient needs to be transported over 100-150 miles - specifically trained crews accompany air ambulance flights while your role will be limited to providing ground transport for the patient and medical flight crew between the hospital and the airport - the crew may include flight paramedics, flight nurses, specialty providers such as respiratory therapists and/or physicians

distractions

- focus on driving and anticipating roadway hazards - minimize distractions from mobile dispatch terminals, GPS, mounted mobile radios, stereos, cell phones and drinking and eating - your partner should operate MDT, GPS device and portable radios and the siren

whom do you call for medivac?

- generally, the dispatcher should be notified first, after the medivac has been initiated, the ground crew may be able to access the flight crew on a specially designated radio frequency for one-to-one communications

ice and slippery surfaces

- goo all-weather tires and an appropriate speed will significantly reduce any traction problems - if you are in an area that is often snowy or icy conditions, consider using studded snow tires or tire chains - bridges and overpasses will lack the warming effect of the ground underneath so be especially careful

decreased visibility

- in areas where there is smog, fog, snow or heavy rain, slow down after warning vehicles behind you by turning your emergency lights on - at night, only use low light beams for maximum visibility without reflection

excessive speed

- in extreme life and death emergencies, speed is not indicated - you should never travel at a speed that is unsafe for the given road conditions - excessive speeds in addition to being unnecessary do not increase a patient's chance of survival - it makes it difficult for the EMT providing care because of the rough driving - excessive speed cuts down the driver's reaction time and increases the time and distance needed to stop the ambulance

airway and ventilation equipment

- infection control kits (goggles, masks, gowns - oropharyngeal & nasopharyngeal airways - advanced airway supplies - bag-mask devices - mounted & portable suction units - assorted oxygen delivery devices - oxygen supply kits - disposable humidifier - advanced airway equipment - pocket masks - portable oxygen supply - mounted oxygen supply - important to have two portable artificial ventilation devices that operate independently of any oxygen supply (one for use in the ambulance and one for use outside)

transport phase

- inform dispatch when you are ready to leave with the patient of the number of patients, name of the receiving hospital and beginning mileage of ambulance - continue to monitor the patient's condition en route (recheck the patient's vital signs and reassess the patient's clinical situation and record and address new problems and the patient's response to earlier treatment) - contact the receiving hospital and inform them f the patient(s) and the nature of the problem(s) - do not abandon the patient emotionally; be aware of the patient's level of need

delivery phase

- inform dispatch when you arrive at the hospital and end mileage 1) Report your arrival to the triage nurse or other arrival personnel. 2) Physically transfer the patient from the stretcher to the bed directed for your patient. 3) Present a complete verbal report at the bedside to the nurse or physician who is taking over the patient's care. 4) Complete a detailed report, obtain required signatures and leave a copy with an appropriate staff member. Electronic reports are commonly used. Your service should have a method for printing or sending electronic reports as well as obtaining electronic signatures. - the PCR should include a summary of the history of the patient's current illness or injury with pertinent positives and negatives, MOI, and findings on your arrival, list vital signs, relative past history and medications and allergies, and include any treatment performed en route and its effect - while at the hospital, restock items that were used on the call

en route to the station

- inform dispatch whether you are in service and where you are going - as soon as you are back at the station you should clean and disinfect the ambulance and equipment and restock supplies you did not get at the hospital

intersection hazards

- intersection crashes are the most common and most serious - always be alert and careful when approaching an intersection - if you cannot wait for traffic lights to change, come to a brief stop and look for pedestrians or other hazards - motorists who time the traffic lights present a serious hazard; the motorist at the red light is expecting it to turn green and to go through while you have the green light - another common intersection hazard is when the driver of one emergency vehicle follows another emergency vehicle through the intersection without carefully assessing the situation

landing zone safety and patient transfer

- keep a safe distance from the aircraft whenever it is on the ground and "hot." (helicopter blades are spinning) - rotor blades will usually remain running because the flight crew does not generally expect to remain on the ground for a long period of time - if you are asked to enter the landing zone, stay away from the tail rotor (tips of blade moves so rapidly that they appear invisible) - always approach the helicopter from the front (enter between the 10 and 2 o'clock positions) - never duck under the body, the tail boom, or the rear section of the helicopter (the pilot cannot see you) - rotor blade may dip as low as 4 feet off the ground; walk in a crouched position as you approach the aircraft - air turbulence created can blow off hats and loose equipment and can become a danger to the aircraft and personnel in the area

school zones

- lights and sirens tend to attract children to the roadway and create a potential hazard - it is unlawful to exceed the speed limit in school zones regardless of the condition of the patient

landing on uneven ground

- main rotor blade will be closer to the ground on the uphill side - approach from the downhill side only

cushion of safety

- maintain a safe following distance from the vehicles in front of you - must ensure the blind spots in your vehicle's rear view and side mirrors do not prevent you from seeing other vehicles or pedestrians on either side of the ambulance - keeping a safe distance between your vehicle and the one in front of you, checking for tailgaters behind your ambulance, and keeping aware of vehicles potentially hiding in your mirror's blind spots are considered maintaining a cushion of safety - drive 4 to 5 seconds behind a vehicle traveling at average speed - if you are being tailgated, never speed up to create more distance because the tailgater may speed up too decreasing your cushion of safety and reaction time and increasing your stopping distance - never get out of a vehicle to confront a driver because this will delay your response or transport of the patient and can lead to a dangerous situation

the preparation phase

- make sure equipment and supplies are in their proper places and ready for use - if items are missing or do not work, they are of no use to you or the patient - store new equipment only after proper instruction on its use and consulting with the medical director - equipment and supplies should be durable and standardized - store equipment and supplies according to how urgently and how often they are used - give priority to items that are needed to care for life-threatening conditions (airway management, artificial ventilation, oxygen delivery) - should be at the head of the primary stretcher - place items for cardiac care, external bleeding, and blood pressure at the side of the stretcher - cabinets and drawer fronts should be transparent or labeled

medivac

- medical evacuation of a patient by helicopter - in most rural and suburban EMS systems

en route to the scene

- most dangerous phase for EMTs - crashes cause many serious injuries - fasten seat belts and shoulder harnesses before moving the ambulance - review dispatch information - prepare to assess and care for the patient - assign specific initial duties and scene management tasks to each member and decide what equipment to take initially

dispatch phase

- nature of the call - caller's name, location and - call back number - exact location of patient - number of patients and - severity of condition - other pertinent information

transfer phase

- necessary to transport the patient safely and to the appropriate medical care facility in the shortest practical time - the patient must be packaged for transport - secure the patient to a backboard, scoop stretcher, or wheeled ambulance stretcher - lift the patient into the compartment - secure the patient with straps (secure with at least 3 straps and use deceleration or stopping straps over the shoulders to prevent the patient from continuing to move forward in case the ambulance slows or stops suddenly - especially important if the patient is lying flat or secured to a backboard)

medivacs at hazardous materials incidents

- notify the flight crew - consult about the best approach and distance from the scene. - landing zone should be uphill and upwind - decontaminate patients before loading them into the helicopter

unpaved roadways

- often have uneven surfaces as well as large potholes - must operate vehicle at a lower speed and maintain a firm grip on the steering wheel to maintain complete control of the ambulance at all times

traffic control

- only after all the patients have been treated and the emergency situation is under control should you be concerned with restoring the flow of traffic - traffic control is intended to ensure orderly traffic flow, warn other drivers, and prevent another crash - as soon as possible place appropriate warning devices, such as reflectors on both sides of the crash - main objectives in directing traffic are: warn the other drivers, prevent additional crashes and keep vehicles moving in an orderly manner so care of injured people is not interrupted

if you are on an emergency call and are using your warning lights and sire, you may be allowed to do the following:

- park of stand in an illegal location - proceed through a red light or a stop sign - drive faster than the speed limit - drive against the flow of traffic - travel left of center to make an illegal pass

who receives medivac?

- patients with time-dependent injuries or illnesses - patients suspected of having a stroke, heart attack or spinal cord injury - patients found in remote areas such as those that involve scuba diving accidents, near-drownings, or skiing and wilderness accidents - trauma patients, candidates for limb replantation, burn center, hyperbaric chamber, or venomous bite center

arrival at the scene

- perform a scene size-up and report your findings to dispatch - look for safety hazards to yourself, your partner, bystanders and your patients - evaluate the need for additional units or other assistance - determine the MOI in trauma patients of the NOI on medical calls - evaluate the need to immobilize the spine - follow standard precautions

basic supplies

- pillows and pillow cases - sterile sheets - blankets - towels - disposable emesis bags or basin - boxes of disposable tissue - bedpan (optional) - urinals - BP cuffs - stethoscope - disposable drinking cups - unbreakable container of water - wet wipes - chemical or hot packs - sterile irrigation fluid - restraining devices - plastic bags for waste or severed parts - hypoallergenic nitrile, vinyl or other disposable hypoallergenic gloves - sharps container - set of hearing protectors

night landings

- pilot will generally fly over the area twice with varying altitudes with the helicopter's lights on in order to identify any obstacles - do not shine spotlights, flashlights, or any other lights in the air to help the pilot (may temporarily blind the pilot) - direct low-intensity headlights or lanterns toward the ground to form the x - illuminate overhead hazards or obstructions, if possible

first-responder vehicles

- respond initially to the scene with personnel and equipment to treat the sick and injured until an ambulance can arrive

driver characteristics

- some states require an emergency vehicle operations course before you are allowed to drive the ambulance on emergency calls - due diligence and caution are important characteristics - many crashes occur as a result of a physical impairment of a driver (don't drive if taking cold remedies, analgesics, and tranquilizers, etc) - working long or consecutive shifts puts a driver at risk for delayed reaction time and/or falling asleep behind the wheel - emotional maturity and stability are closely related to the ability to operate under stress - must operate the vehicle with due regard for others and preservation of property

type III ambulance

- specialty van, forward-control integral cab-body ambulance

safe driving practices

- speed does not save lives; good care does - the driver and all passengers must wear seatbelts and shoulder restraints at all times - patients should also be properly restrained - restrain medical equipment so it does not go flying during a crash and put you and the patient at risk - learn how your vehicle accelerates, corners, sways and stops and see how the vehicle will respond to steering, braking and accelerating under various conditions - brakes on type I & III vehicles have a heavier feel than those on type II vehicles - when driving an ambulance on a multi-lane highway, you should usually stay in the extreme left-hand lane (fast lane)

type II ambulance

- standard van, forward-control integral cab-body ambulance

childbirth supplies

- surgical scissors - hemostats or cord clamps - umbilical tape or sterilized cord - bulb syringe - towels - gauze sponges - sterile gloves - sanitary napkins - plastic bag - baby stocking cap - baby blanket

siren syndrome

- the increased stress caused by the sound of the siren and the nature of the call can cause an increase in adrenaline flow which can result in both psychological and physiological response. - causes drivers to drive faster in the presence of sirens, due to increased anxiety

disinfection

- the killing of pathogenic agents by directly applying a chemical made for that purpose to a surface or equipment

high-level disinfection

- the killing of pathogenic agents by the use of potent means of disinfection

cleaning

- the process of removing dirt, dust, blood or other visible contaminants from a surface or equipment

blind spots on an ambulance

- the rearview mirror creates a blind spot by obstructing the view ahead and can be eliminated by leaning forward in your seat so the mirror does not obstruct the view - the rear of the vehicle cannot be seen fully through the mirror and is therefor a blind spot and many crashes occur when the driver is backing the ambulance up; spotters and rearview cameras prevent this - the side of the vehicle cannot be seen through the side mirrors at a certain angle; placing small rounded mirrors on the side mirrors assist in being able to see in this blind spot or if not available, lean forwards or backwards

use of warning lights and siren

- the unit must be on a true emergency call to the best of your knowledge - both audible and visual warning devices must be used simultaneously - the unit must be operated with regard for other's safety on and off the roadway

road positioning and cornering

- to keep the ambulance in the proper lane when turning, enter high in the lane, and exit low - this allows room for error if you enter the lane too fast

splinting supplies

- traction splints - arm and leg splints - triangular and roller bandages - short backboard - long backboard - head immobilization device - cervical collars - head immobilization devices

why call for a medivac?

- transport time by ground is too long considering the patient's condition - road, traffic, or environmental conditions prohibit the use of ground transport - the patient requires advanced care that you are unable to provide - multiple patients will overwhelm the resources at the hospital reachable by ground transport - may respond directly to the scene or transport from a hospital

basic wound care supplies

- trauma shears - sterile sheets and sterile burn sheets - adhesive tape - roller bandages - sterile dressings - gauze - abdominal pads - occlusive dressings - adhesive bandages - tourniquet

use of escorts

- use police escorts as a guide only when you are in unfamiliar territory - neither vehicle should use its warning lights or siren - follow at a safe distance if you are being guided

water on the roadway

- wet brakes will not slow the vehicle as efficiently as dry brakes and the vehicle may pull to one side or the other - of driving through standing water, slow the vehicle and turn on wipers and lightly tap the brakes after getting out of the water

patient transfer equipment

- wheeled ambulance stretcher - wheeled stair chair - scoop stretcher - portable/folding stretcher - flexible stretcher - transfer tarp or side board - basket stretcher

siren risk-benefit analysis

- will depend local protocols, patient condition and the anticipated clinical outcome of the patient - studies show that the sirens save time, but minimally - need to consider the patient's condition before activating the emergency lights (example: seizure can be caused again by the lights and sirens)

highways

- you should shut down emergency lights and sirens until you have reached the far left lane. - it minimizes the possibility that other drivers will get confused and not know what to do or where to go - when emergency devices are activated, always travel in the far left lane - when you exit the highway, you should follow the same procedures as when you entered the highway (move off to the ramp before putting the emergency lights and sirens on)

do the following after each call:

1) Immediately strip used linens from the stretcher after use, and place them in a plastic bag or in the designated receptacle in the ED. 2) Discard in an appropriate receptacle all disposable equipment used for care of the patient that meets your state's definition of medical waste. Most items will be considered general trash. Discard disposable equipment that is bloody or contaminated by body fluids in an OSHA-approved biohazard container. Discard noncontaminated disposable equipment used for the patient following OSHA and local guidelines. 3) Wash contaminated areas with soap and water. For disinfection to be effective, cleaning must be done first. 4) Disinfect all nondisposable equipment used in the care of the patient. For example, properly clean and disinfect stethoscopes, nondisposable blood pressure cuffs, pulse oximetry probes and other reusable equipment. 5) Clean the stretcher with and EPA-registered germicide/virucidal or bleach/water solution. 7) Create a schedule for routine full cleaning for the vehicle. 8) Have a written policy/procedure for cleaning each piece of equipment. Refer to the manufacturer's recommendations as a guide.

phases of an ambulance call

1) preparation for the call 2) dispatch 3) en route 4) arrival at scene 5) transfer of the patient to the ambulance 6) en route to the receiving facility (transport) 7) at the receiving facility (delivery) 8) en route to the station 9) postrun

daily ambulance inspection

fuel, oil, and transmission fluid engine cooling batteries brake fluid engine belts tire pressure lights wipers and fluid horn and siren air conditioner, heater and ventilation system doors and locks communication systems