Chapter 61: Emergency Vehicle Operations

Cleaning & Maintenance

- Beginning of shift Checks - Check vehicle - Perform maintenance - Tasks such as checking the oil, transmission fluid level, and tire pressure and radiator fluid levels can be performed quickly - Add fluid and air if necessary - Always ensure the ambulance has enough gasoline - Emergency lights check - Medical equipment Test every shift - Cardiac monitors, suction devices, and all other equipment must be charged - All battery operated equipment such as laryngoscopes, pulse oximeters, and glucometers must be checked - make sure there is adequate O2 in portable & main tanks - make sure the gurney is clean/working - if you notice any malfunction or failure of any mechanical or electrical component of the vehicle, take the vehicle out of service to have it repaired or replaced by a qualified technician - Cleaned at start of shift - Cleaned after every call - Medically clean - possibility of spreading infection because bacteria/viruses can linger - Not a sterile environment - Ensures minimal risk of contamination

Inventory

- Most places have minimum ambulance stock levels - Check at the beginning of each shift - All cabinets & Jump kit must be checked - Use service inventory sheets - Document compliance - Check stock in portable kits - Check drug box for stock - Check expiration dates (required to be done at least once a month) - Make sure drugs haven't been damaged - Schedule II drugs checked to ensure they are sealed and secure - They must be Signed for at shift change

Ambulances

- Three types - They are regulated by the Federal government - The guidelines are outlined in the Federal Specifications for Ambulances which is prepared by the NHTA - National Highway Transportation Agency - In addition State and local governments may have certain requirements - State and local government may have additional variations or requirements for the design of the ambulance - Whatever type of vehicle is selected, the ambulance must meet KKK-A-1822E guidelines to be allowed to display the Star of Life Ambulance selection factors: - Ambulance agency's call volume - Service area size - City versus rural driving - Number of EMS riding in back - Agency budget When the federal ambulance standards were rewritten in 2002 they were expanded to include "additional duty" classes, or type I-AD and type Ill-AD (General Services Administration, 2002). - These categories pertain to what were formally referred to as medium duty ambulances - They are mounted on large chassis such as a freightliner, which allows for a larger ambulance box, the ability to carry heavier equipment, and the ability to store more equipment on the ambulance, including rescue equipment

Stair chair

A collapsible, portable chair with handles on the front and back used to carry patients in sitting position down stairs.

Jump kit

A hard-sided or soft-sided bag used by paramedics to carry supplies and medications to the patient's side.

Rotor-wing aircraft

A helicopter.

Specialty center

A hospital that has met criteria to offer special care as a burn center, level I trauma center, stroke center, or pediatric center.

Type III ambulance

A van chassis with a modified modular back.

Bariatric ambulance

Ambulance designed to transport morbidly obese patients

Emergency Vehicle Stationing

Ambulance stationing is a dynamic process that should be regularly reevaluated - factors such as population, roads and access, and businesses must be evaluated Fixed positioning - Used by most fire-based and volunteer services or ambulance services that work 24 or 48 hour shifts - Respond from assigned station - must evaluate its service area to determine geographic centers - ex: if a system has one EMS vehicle, it looks at its response area and determines a central point from which the vehicle can respond. The vehicle is stationed at this point 24 hours a day - Larger systems will have multiple stations covered 24 h/d - This system has potential for a fair amount of downtime for slow periods System status management - More dynamic positioning - used by many larger cities with high call volumes and whose EMS system is primarily focused on medical response - the response area is evaluated geographically and based on the numbers of calls in each area - Calls are monitor/tracked on basis of location/time of the call - after info has been gathered, staffing is based on predicting calls - Vehicle staffing varies according to time of day and predicted ca ll volume for that time - Vehicles positioned to meet changing needs - This system continually evaluates vehicle efficiency with a formula to determine unit hour utilization (Uh U) - calculates how many calls a vehicle will run in an hour - Most systems strive for a UHU of .4-.5 (one call every 2 hours) - More cost effective than fixed positioning Several systems use fixed positioning systems and supplement their response area with extra ambulances during busy times no system can predict the exact location, time, and number of all calls, Nor can they predict multiple-casualty incidents - All systems must establish mutual aid and backup agreements with neighboring agencies and EMS systems Ambulance deployment factors - Location of facilities to house ambulance - Hospital locations - Anticipated call volume - Local geographic, traffic considerations

Fixed-winged aircraft

An airplane.

Landing zone

An area used to land a helicopter that is 100 x 100 feet and free of overhead wires.

Stopping time

An average type III ambulance weighs just over 10,000 lb. At a speed of 45 mph, at least 200 feet is required to stop a vehicle of this size. That is two thirds the length of a football field.

Medically clean

Disinfected.

System status management (SSM)

Dynamic process of staffing, stationing, and moving ambulances according to projected call volumes.

Fixed positioning

Establishing a single location in a central point to stat ion an emergency vehicle, such as a fire stat ion.

Air Medical Transport

Fixed-wing (Airplanes) & rotor-wing aircraft (helicopters): - Airplanes are used for long distance interfacility transports - Transport ranges for airplanes commonly are limited to a 500 mile radius - Helicopters usually is more commonly used from scene to facility - Most helicopters can provide service within a 130-mile radius from the base facility - Most medical aircraft have at least one registered nurse, however staffing varies - Factors for using helicopter: - Transport time - Specialty center (trauma I, burn, pediatric) - Helicopters may be beneficial to get them there - Landing spot-how close to scene can they land? - Time for landing, loading considered - how long is the flight - Some helicopters can provide a higher level of care - the flight teams in some states carry fibrinolytic drugs. - If a helicopter would be a benefit to the patient. then logistic concerns must be considered - An extra EMS or fire crew is usually required to be on the scene to land the helicopter - extra police may be required to control traffic Logistic concerns: - Landing zone - must be 100 feet × 100 feet - No power or phone lines - Flat area away from hills & free of debris - mountain areas and cities aren't often suited for it - Weather - Some general conditions that would preclude air medical transport of a patient would be low clouds causing decreased visibility, excessive precipitation such as rain or snow, and extreme wind. - Temperature - the cooler the air, the easier it is for a helicopter to lift. Aircraft approach: - EMS crew should have eye contact with the pilot - Depending on the aircraft and the situation, the pilot may stop the rotors before loading and unloading the patient - Other times the EMS crew may need to do a hot load, which means loading the patient with the rotors still turning. - Follow directions of crew/pilot - the pilot will signal when it is safe to approach - Always approach from front of helicopter keeping head low - If the terrain is on a hill approach from the downhill side - wind can cause rotors to dip and cause injruy - Hot load - No loose articles - Avoid tail rotor at rear

Sterile

Free of any living organism.

Liability

If a paramedic knows of a malfunction and does not address it, he or she may be held legally liable for any injuy incurred because of the malfunction

Paramedic Liability

Liable for decisions, actions taken while operating ambulance that result in harm to patient/society Negligence - Drug box missing medication Accidents - Failure to drive with due regard

Mobile Data Device

Many emergency vehicles are equipped with a mobile data device, also known as a mobile data terminal or mobile data computer In addition to providing responding crews with updated incident information for active calis, this device can provide map navigation and road condition information.

Unit hour utilization (UhU)

Mathematic calculation used to determine the effectiveness of an ambulance;one call per hour = 1 UhU.

District Familiarization

Must know response area (district): - Roads (dead ends, mile markers, exits) - Congestion areas and times - Construction - Weather impacts - Local businesses - Neighborhoods Road maintenance and construction can change a response area as well. The EMS crew should obtain regular updates regarding where road crews are working and how traffic will be diverted - if you come across road work, notify dispatch so they can tell everyone else Maps - Current - Familiar with how to use

Responsibilities

Paramedic responsibilities: Operating and maintaining vehicle Ensure all needed equipment is on vehicle and in good working order Operational status of vehicle evaluated Location of equipment and supplies Clean and safe Drive with safety Park with safety of all concerned

Due regard

Principle used when driving an emergency vehicle of ensuring that all other vehicles and citizens in the area sec and grant the emergency vehicle the right of way.

Type I ambulance

Regular truck cab and frame with a modular ambulance box mounted on the back.

Safe Vehicle Operations

Respond with due regard - Drive with due regard - Due regard is remembering that lights and sirens only request the right of way - driver of is responsible for ensuring that other drivers and pedestrians see and hear the lights and sirens and yield the right of way - If you hit someone you can be found liable even if your lights and sirens were running - Use lights and siren only when necessary Responding : - The tones go off; the lights come on in the station and the pager gives an address at which a patient is requesting emergency medical care - there should be no delays getting to the vehicle - back ambulance in so you can drive straight out when you get a call - They should know where they are headed before moving the vehicle - Should determine the mode of response - Notify dispatch as soon as you respond - Avoid common causes of ambulance collisions - Other drivers "timing" lights - Emergency vehicles following each other - Multiple emergency vehicles converging on same location - Motorists going around stopped traffic - Vision of pedestrians in crosswalk obstructed by other vehicles Tiered response system: - Multiple vehicles should communicate with each other as they approach the scene On scene: - Notify dispatch once on scene - Safe positioning & easy access to patient - EMS crew safety - Patient safety - Don't let the ambulance be blocked by structures or other vehicles - park to allow easy egress from scene - If ambulance is first on scene Park 50 feet behind collision - If a police or fire apparatus arrive on scene first, it should be parked behind the scene, and the ambulance should be parked 100 feet in front of the scene - If there is any evidence of fire, leaking liquids, or fumes the ambulance should be parked a minimum of 100 feet from the scene regardless of the presence of another apparatus. - If hazardous materials, park uphill and upwind at the distance recommended by DOT emergency handbook - Staging zone in criminal scenes - In the cases of crime scenes, hazardous materials, or multiple-causality incidents, a staging zone is usually identified & you should wait in the staging area until called to the scene - On the scene of traffic accidents, fire apparatuses are usually positioned to protect the scene - The apparatus should be visible to other drivers - Leave flashers on at scene - Leave emergency lights on while on the scene of an MVC - Easy egress from scene Lifting, moving, and loading: - Back injuries one of most common EMS injuries - Stay in shape - aerobic, strength, and flexibility training - Know limitations-call for help Know your equipment: - 1 ½ person stretchers common - a set of wheels is under the head of the stretcher. These wheels are rolled into the back of the ambulance. The foot end of the stretcher is then lifted and the wheels are released. A second paramedic lifts the wheels up, and the stretcher is rolled into the ambulance. - 1 person stretchers - the stretcher is simply pushed into the ambulance. As the wheels meet the ambulance, they fold under the stretcher. Because this can jolt the patient, use caution when pushing the gurney into the ambulance - Two-person dead-lift stretchers are rarely used any more because of the high incidence of back injury associated with their use. - Gurneys - Stair Chairs - Some have motors that raise and lower bed - Bariatric ambulances - ambulances designed for transporting morbidly obese patients. They have winches that can pull the gurney up a ramp for easy loading. - Winches that pull gurney up - Use good lifting posture - Keep back straight - Lift with legs - Do not bend over or twist - Do not lift until all are ready - Person at the head initiates lifting with a 3 count - When lifting patients on the stretcher, the persons lifting should not release the stretcher until they are positive the wheels have locked Transporting : - Once patient is loaded and ambulance is headed to hospital, notify dispatch -Smooth drive as possible using most direct route -Allows better patient care -Most direct route - Notify in advance if sharp turn ect. - Try to avoid sudden stops or turns -Wear safety restraints -General driving -Always drive with due regard -Take an emergency vehicle operating class - wear safety restraint - Several different versions of nets and harnesses are available but work with varying degrees of effectiveness - Use the seat belts on the bench and captain's chair whenever possible - The laws pertaining to ambulances generally do not provide exemption from laws that require the use of restraints - the patient should be secured to the stretcher using all straps, including shoulder straps if they are available - All loose equipment should be secured to avoid injury in the event of a sudden stop, turn, or collision - Once at the hospital, notify dispatch - Make every attempt to provide a good patient hand-off to receiving facility staff, clean and restock the ambulance, and get back in service as quickly as possible

Driving Rules

Responding rules: - The emergency vehicle can exceed the speed limit when responding to a call - The laws vary regarding the degree which they can exceed the speed limit - ambulances are generally allowed to pass through a stop sign or red traffic Signal after ensuring it is safe to do so, disregard restrictions on turning and direction of travel, and stop or park the ambulance in areas that would be prohibited for nonemergency vehicles - in most states ambulances are not permitted to pass a school bus that is displaying Its red flashing lights. In this situation the paramedic must stop, leave the emergency lights on, turn off the siren. and wait until the bus driver motions you to pass - Change the siren sound when approaching intersections. - Between intersections, use a long wail sound. - When approaching an intersection, change the sound to a shorter, faster yelp or, in some states, the Hi-Lo siren sound - Slow down when approaching intersection - When traveling though an intersection with a green light, the driver of the emergency vehicle should slow down and enter the intersection with one foot covering the brake in case a sudden stop is needed - At red lights and stop signs, stop the emergency vehicle to ensure that all other vehicles have yielded - Proceed only after all other vehicles have stopped - Intersections are the most dangerous situation & are where the majority of ambulance collisions occur - Pass on the left side toward the center of the road as much as possible - Passing on the right may catch drivers off guard because they are used to seeing emergency vehicles in the center of the road - driving a heavy vehicle and stopping distances are longer than for a regular vehicle - When approaching vehicles from behind, be prepared to stop, leaving the vehicle in front enough room to react and move out of the way - When following another vehicle, a good idea to use is the 4-second rule. Watch as the vehicle in front of you passes an object on the side of the road, such as a telephone pole. Then count None thousand one, one thousand two, one thousand three, one thousand four." As you finish counting, your front bumper should be passing the same object. If you reach that object sooner, you should slow down -When responding with a convoy of multiple emergency vehicles or with a police escort, extra caution is required at intersections. - Allow adequate distance between emergency vehicles to avoid intersection confusion - When multiple emergency vehicles are responding from different directions, such as in a tiered response system, the vehicles should communicate with each other as they get closer to the scene. - Multiple emergency vehicles from different directions can converge on an intersection at the same time, once again resulting in an emergency vehicle collision Many EMS services are using cameras mounted on the dashboard - Activated by a collision or abrupt maneuvering of the vehicle, the camera will record 10 seconds before and 10 seconds after the event. If the crew sees crash occur in front of them, a switch can activate the recorder to provide valuable information on what exactly happened

Emergency response

Sirens should be used only when responding to a medical emergency. The U.s. Department of Trallsportalion Emergency Vehicles Operators Guide defines a true emergency as a situation with a high probability of death or serious injury to an individual or sign ificant properly loss and in which act ion by an emergency vehicle operator may reduce the seriousness of the situation

Gurney

Stretcher or cot used to transport patients. Hot load Loading a patient into a helicopter while the rotors are spinning.

Route Planning

Take the most direct route Driver drives, passenger navigates If lost, can become negligent - If the crew becomes lost responding to a call, resulting in a delayed response, the crew could be found guilty of negligence and held liable for a negative patient outcome. - GPS can help - Does not account for: Traffic Weather Construction - Ultimately an appropriate, timely response is the responsibility of the EMS crew

Response area

The geographic area assigned to an emergency vehicle for responding to the sick and iniured.

Ambulance - Type I

Type I: - Regular truck cab and frame - w/ a Modular ambulance box mounted on back They commonly have a pass-through window from the cab to the ambulance box so that the driver can communicate with the medic in the back Advantages: - Box and truck chassis can be purchased/ replaced separately - Can replace worn or damaged components - Large work area Disadvantages: - Limited driver-to-attendant communication in the back - Limited driver view of activity in back

Ambulance - Type II

Type II: - Vans Vans are narrower and have less space to work in the back. Advantages: - Relatively inexpensive - Better gas mileage - More affordable to purchase and operate - Better driver-to-attendant communication - They have an open passageway from the driver's compartment to the patient compartment - Better driver view of activity in back Disadvantage: - Less work space in back - If more than one emt is working it gets overcrowded

Ambulance - Type III

Type III: - Combination of I and II - On a Van chassis with a modified modular back Advantages: - Large work area - Better driver-to-attendant communication - They have an open passageway from the driver's compartment to the patient compartment - Better driver view of activity in back Disadvantages: - Expensive - Heavier - Uses more fuel

Type II ambulance

Van-style ambulance.

Common Types of Ambulance Collisions

• Other drivers "timing" lights • Emergency vehicles following each other • Multiple emergency vehicles converging on same location • Motorists going around stopped traffic • Vision of pedestrians in crosswalk obstructed by other vehicles