Section 7

hazardous material

"any substance or material in a form which poses an unreasonable risk to health, safety, and property when transported in commerce. The American Society of Safety Engineers estimates that 800,000 hazmat shipments occur daily (2006). Hazardous materials are used for the manufacture of products and can be the waste products of manufacturing. Even though safety procedures have been established and are followed for the most part, accidents involving hazardous materials do occur. Hazardous material incidents are especially likely to take place at factories; along railroads; and on local, state, and federal highways.

disaster plan

A disaster plan is a predefined set of instructions that tells a community's various emergency responders what to do in specific emergencies (Figure 37-8). Although no disaster plan can address every problem that could arise, there are several features common to every good disaster plan. The disaster plan should be: WRITTEN TO ADDRESS THE EVENTS THAT ARE CONCEIVABLE FOR A PARTICULAR LOCATION (e.g., Kansas needs to plan for tornadoes, not hurricanes). WELL PUBLICIZED. Each emergency responder should be familiar with the plan and how it is to be put into operation. REALISTIC. The plan must be based on the actual availability of resources. REHEARSED. Experience has proven that the only way to get a plan to work correctly is to exercise it and, in so doing, work out the unforeseen "bugs."

MCI

A multiple-casualty incident (MCI)—or, in some areas, a multiple-casualty situation (MCS)—is an event that places a great demand on EMS equipment and personnel resources. The number of patients required before an MCI can be declared varies in practice. Some jurisdictions will declare an MCI for as few as three patients on the grounds that practice with smaller-scale incidents will help EMTs prepare for larger ones. Other jurisdictions reserve the MCI designation for five, seven, or more patients (Figure 37-7). The most common MCI is an automobile collision with three or more patients.

truck fires

An A:B:C extinguisher can also be used to combat truck fires. Be aware, however, that burning truck tires are especially dangerous. Flames can quickly spread to the vehicle's body and its cargo, or the tires can blow apart when heated by fire. Never stand directly in front of a truck wheel when there is a fire; instead, approach from a 45-degree angle.

Be Seen and Warn Oncoming Traffic

Before exiting the vehicle, all responders should be in full protective clothing or, at a minimum, ANSI Class 2 traffic safety vests and helmets

incident command system

By federal declaration, the National Incident Management System (NIMS) is the management system used by federal, state, and local governments to manage emergencies in the United States (Figure 37-9). A subset of the NIMS system is also known as the Incident Command System (ICS). Although not specifically a plan designed for MCI management, it provides a clear management framework for all types of large-scale incidents. In addition, it is mandated by law for the management of some types of incidents, such as those involving hazardous materials.

Classifications of Chemical Agents

CHOKING AGENTS. These predominately respiratory irritants can be found not only as weaponized materials but also as commonly encountered industrial chemicals. Many of these common industrial chemicals are classified as simple asphyxiants such as chlorine. VESICATING AGENTS (BLISTER AGENTS). These agents cause chemical changes in the cells of exposed tissues almost immediately on contact. However, in many cases, the effects are not felt or realized until hours after the exposure. CYANIDES. Formerly referred to as "blood agents," these actually have no impact on the blood. They work by preventing the use of oxygen within the body's cells and therefore are cellular asphyxiants. NERVE AGENTS. These agents inhibit an enzyme that is critical to proper nerve transmission, allowing the parasympathetic nervous system to run out of control. Many agencies carry nerve agent antidote kits for their emergency response personnel (Figure 39-7). Many of these nerve agents are stronger versions of common pesticides from the organophosphate family and are easily absorbed through the skin. Most have a smell of petroleum and have a milky off-white color. They produce the signs and symptoms that make up the mnemonic SLUDGEM (see Inside/Outside feature). RIOT CONTROL AGENTS. These agents include irritating materials and lacrimators (tear-flow increasers). The effects of these materials seldom last more than several minutes after exposure has ended, although pepper spray can trigger asthmatic reactions. Riot control agents such as mace, pepper spray, and CS gas have the ability to trigger respiratory distress in people with a history of asthma. These agents are effective crowd control/crowd dispersal countermeasures; however, the EMT must recognize the effectiveness of these agents and take appropriate precautions if working within the area of use.

patient carrying device

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. 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.

Preparing the Patient for Transport

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. SECURE THE STRETCHER IN PLACE IN THE AMBULANCE. Always ensure that the patient is safe during the trip to the hospital. Before closing the door, and certainly before signaling the ambulance operator to move, make sure that the cot is securely in place. Patient compartments are equipped with a locking device that prevents the wheeled stretcher from moving about while the ambulance is in motion. Failure to fully engage the locking device at both ends of the stretcher can have disastrous consequences once the ambulance is in motion. 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. 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. 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. 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. Remember that clothing bunched at the crotch may be painful. Before you do anything to rearrange the patient's clothing, however, explain what you are going to do and why. 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. 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. If you load personal effects at the scene of a collision, be sure to tell a police officer what you are taking. Follow policies and fill out forms, if any, required by your local system for safeguarding personal effects. TALK TO YOUR PATIENT. Apprehension often mounts in a sick or injured person after he is loaded in an ambulance. Not only is he held down by straps in a strange, confined space, but he may also be suddenly separated from family members and friends. Maintaining a conversation with the patient helps allay his fears and concerns, builds patient rapport, and simply helps pass the time. 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. Simply put, it's the safest place for them to be. If the patient suddenly becomes uncooperative and wants to jump out of a moving vehicle or assault the EMT, the stretcher and its restraints will slow him down. This restraint might even avert a tragedy.

How to approach a helicopter:

Do not approach a helicopter unless escorted by the flight personnel. 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 Scan 36-6. Never walk around the tail rotor area.

Emergency Medical Responders as Targets

Emergency Medical Responders are often the principal targets of a terrorist attack, as will be discussed in more detail later. Responders must stay alert and never assume the incident scene is safe until this is verified by appropriate agencies or authorities. Responders must weigh the threat or risk of their actions against the benefit of their actions. This is true at all emergency scenes, of course, but even more true at the scene of a terrorist attack.

Broken Utility Pole with Wires Intact

Even if wires are intact, a broken utility pole is still dangerous. Wires that are still holding up the pole can break at any time, dropping the pole and wires onto the scene. If you arrive to find such a situation: Park the ambulance outside the danger zone. Notify your dispatcher of the situation. Stay outside the danger zone until power company representatives can de-energize the conductors and stabilize the pole. Keep spectators and other emergency service personnel out of the danger zone.

timing of the event

For many years to come, April 19 will be a day around which government facilities operate at a heightened state of security awareness. It is the anniversary of both the fire at the Branch Davidian compound in Waco, Texas, and the bombing of the Alfred P. Murrah building in Oklahoma City and so has become a rallying point for antigovernment extremists. National holidays are also possible target dates. Foreign terror organizations also carry out attacks on certain anniversary dates. Aside from significant anniversaries and holidays, events that occur on specific days of the week and times of day are worth treating with suspicion. A fire in a subway tunnel at the height of rush hour, possibly aimed at harming a large number of people and alarming the public, may indicate terrorism

vehicle fires

For small fires, a 15- or 20-pound class A:B:C dry chemical fire extinguisher can extinguish virtually anything that may be burning in a vehicle, including upholstery, fuel, and electrical components. Only burning magnesium and other flammable metals cannot be extinguished by an A:B:C extinguisher. Before you try to put out a fire, always put on a full set of protective gear.

Fire in the Passenger Compartment or Trunk

If the fire is under the dash or in upholstery or other combustibles, carefully apply the agent directly to the burning material. Apply sparingly to avoid creating a cloud of powder that may be harmful to occupants. If there is fire in the trunk, as with fire under a closed hood, leave extinguishment to the fire department and continue working to get patients out of the vehicle. Please note that burning materials in a vehicle are among most dangerous, posing an immediate danger to life and health. The EMT must be mindful of this and take as many protective measures as he can to protect his own and the patients' well-being and safety.

types of terrorism incidents

In addition to armed attacks, incidents of terrorism may involve what are often called the CBRNE agents: Chemical Biological Radiological Nuclear Explosive The CBRNE agents are considered to be technological hazardous agents—a broad field, of which hazmats (the types of hazardous materials that were discussed in the chapter "Hazardous Materials, Multiple-Casualty Incidents, and Incident Management") are a subcategory. The CBRNE agents, often called weapons of mass destruction (WMD), are intended to cause widespread harm and/or fear among a population.

How to Call for Air Rescue

In some areas rescue may be called for by any law enforcement, fire, or EMS command officer at the scene of an incident. In addition, 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.

Regardless of whether the agent is a bacterium, a virus, or a toxin, there are certain features that influence their potential for use as weapons. They are:

Infectivity Virulence Toxicity Incubation period Transmissibility Lethality Stability

freelancing

It is important to prevent "freelancing." Freelancing is uncoordinated or undirected activity at the scene. Given the opportunity, most rescuers will arrive on the scene and begin setting their own priorities. Command can prevent this problem. When Command is established early, people and crews are assigned to tasks as they arrive. Freelancing can be found as the primary cause of many line-of-duty injuries (LODI) and line-of-duty deaths (LODD).

Remember the following points when you place flares:

Look for and avoid spilled fuel, dry vegetation, and other combustibles before you ignite and position flares, especially at a road edge. Do not throw flares out of moving vehicles. Position a few flares at the edge of the danger zone as soon as the ambulance is parked. They will supplement the ambulance warning lights. Take a handful of flares and walk (carefully) toward oncoming traffic. Position the flares every 10 feet, if possible, to channel vehicles into an unblocked lane. (Do not turn your back to traffic while placing flares.) If the collision has occurred on a two-lane road, position flares in both directions. Be careful when lighting the flare. The flare should be held away from your body and ignited in a motion away from your body. Never use a flare as a traffic wand; flares can spew molten phosphorous, which can cause third-degree burns to the skin.

Response Safety Summary

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.

Although recognizing suspicious incidents may be difficult, being alert to clues, surroundings, and events will greatly assist in identification. Clues such as the OTTO signs, discussed in the following list, will help with this process:

Occupancy or location Type of event Timing of the event On-scene warning signs

in quarters

PLACE BADLY CONTAMINATED LINENS IN A BIOHAZARD CONTAINER AND NONCONTAMINATED LINENS IN A REGULAR HAMPER. AS NECESSARY, CLEAN ANY EQUIPMENT THAT TOUCHED THE PATIENT. Brush stretcher covers and other rubber, vinyl, and canvas materials clean; then wash them with soap and water. 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. Inner surfaces can be cleaned with a small bottle brush, whereas outer surfaces can be cleaned with a hand or nail brush. Make sure all encrusted matter is removed. Rinse the items with tap water. Soak the items in an EPA-approved germicidal solution. An inhalation therapist at a local hospital can suggest a germicide suitable for respiratory equipment. Follow directions for dilution, safe handling, and soaking time. Gloves are recommended when using some germicides. 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. 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. PREPARE YOURSELF FOR SERVICE. Wash thoroughly, paying attention to the areas under your fingernails. Remember that contaminants can collect there and become a source of infection not only to you but also to the persons you touch. Change soiled clothes. Clean contaminated clothing as soon as possible, especially if you were exposed to someone with a communicable disease. 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. REPLACE EXPENDABLE ITEMS. Exchange them with items from the unit's storeroom. REPLACE OR REFILL OXYGEN CYLINDERS. Do this in accordance with your service's procedures. 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. 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. COMPLETE YOUR PAPERWORK. Complete any unfinished report forms as soon as possible, and report the unit ready for service.

There are ten phases of the extrication or rescue process that you, as an EMT, should understand and understand the safe manner of performing:

Preparing for rescue Sizing up the situation Recognizing and managing hazards Stabilizing the vehicle prior to entering Gaining access to the patient Providing primary patient assessment and a rapid trauma assessment Disentangling the patient Immobilizing and extricating the patient from the vehicle Providing assessment, care, and transport to the most appropriate hospital Terminating the rescue As an EMT, you are responsible for the medical component of the rescue process; others are responsible for the mechanical or physical components. As you carry out your responsibilities, attention to safety must be your highest priority—to help minimize the potential for injury to yourself and the other rescuers as well as any additional injury to your patient. Although you may never personally perform disentanglement, it is important for you to understand the rescue process so you can keep your patient informed and anticipate any dangerous steps in the extrication action plan.

At the Hospital terminating call

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. Wipe down any equipment that has been splashed. 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. 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 to keep them from becoming reservoirs of infectious agents that can easily contaminate the next patient. Disinfect the suction unit. Place used disposable items in a plastic bag and seal it. Replace the items with similar ones carried in the ambulance as spares. 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. Do not abuse this exchange program. Keep in mind that the constant abuse of a supply-replacement program usually leads to its discontinuation. At the very least, abuse places a strain on ambulance-hospital relations. 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. Parts are sometimes lost or broken when an immobilizing device is removed from a patient. 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. 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.

Types of Harm from Radiological/Nuclear Incidents

THERMAL HARM. This is the primary harm from a nuclear explosion. RADIOLOGICAL HARM. This is the primary danger from radiological materials. Because of the nature of the materials, this will represent an ongoing hazard, the scope of which will be determined only when the amount and identity of the substance involved is ascertained. Radiological exposure is generally more dangerous to children, pregnant women, and the elderly. The first signs and symptoms are often nausea, vomiting, and diarrhea. CHEMICAL HARM. This secondary harm is a concern because many radiological substances are also chemical hazards. This is an area often overlooked by responders who are concentrating on radiation effects. MECHANICAL HARM. This is a primary harm from a nuclear explosion. PSYCHOLOGICAL HARM. This is a secondary harm. As in all terrorist incidents, a sudden traumatic occurrence can cause immediate or delayed emotional or psychological reactions

stabilize vehicle on its wheels

The best method of stabilizing a vehicle on its wheels is using three step chocks, one on each side and a third under the front or back of the vehicle. Deflating the tires so the vehicle rests on the chocks is a common practice among many rescue services across the country. It is important to follow your local protocols in this regard. Then—in situations where significant "tool work" must be done to extricate, such as door or roof removal—all the tires should be deflated. This can be accomplished by simply pulling the valve stems from their casing with pliers. (Slashing the tires is an inappropriate technique for deflating tires.) A police officer should be told the tires have been deflated so investigators will not think that the tires are flat as a result of the collision. Record that intervention in your documentation. In fact, record as much as you can on the extrication process in your ambulance call report.

vehicle on its roof

This is usually accomplished by building a box crib with 4 × 4s under the vehicle. A vehicle on its roof is likely to be in one of four positions: Horizontal, with the roof crushed flat against the vehicle's body and both the trunk lid and hood contacting the ground Horizontal, resting entirely on the roof, with space between the hood and the ground and space between the trunk lid and the ground Front end down, with the front edge of the hood contacting the ground and the rear of the car supported by the C-posts (rear posts) Front end up, with the trunk lid contacting the ground and much of the weight of the vehicle supported by the A-posts (front posts)

Fire under the Vehicle

Using a portable unit to extinguish burning fuel under a vehicle may be an exercise in futility when the spill is large. However, when people are trapped in the vehicle, you may feel the urge to try. Attempt to sweep the flames from under the passenger compartment as you apply the agent. If you do extinguish the fire, be sure that sources of ignition are then kept away. The vehicle's own catalytic converter (usually found in the area under the front passenger's feet) can be an ignition source since its temperature can reach more than 1,200 degrees.

Damaged Pad-Mounted Transformer

When electrical cables run underground, the transformer may be mounted on a pad above ground (Figure 38-7). When an aboveground pad-mounted electrical transformer is struck and damaged, it poses a serious threat. In such a situation: Request an immediate power company response. Do not touch either the transformer case or a vehicle touching it, and warn other emergency service personnel not to touch it either. Stand in a safe place until the power company de-energizes the transformer. Keep spectators out of the danger zone.

Implement your agency's Incident Management System.

stablish Command and maintain that role until you are relieved by someone higher in the chain of command. Maintain the Incident Management System until you are relieved or until the incident is taken care of and you are released.

distance of farthest warning device

stopped distance for that speed + posted speed in ft

Night Operations

drivers of emergency apparatus parked at highway incidents should turn off vehicle headlights. In addition, they should shut off any white response lighting that could blind oncoming drivers. The best combination of lights to provide maximum visibility is: Red/amber warning lights—on Headlights—off Fog lights—off Traffic directional boards operating

If the steering wheel hub is large and rectangular, the car probably has an air bag or bags (the passenger-side bag being in the glove compartment area). If the bags have not deployed, they are not likely to deploy now unless extrication involves displacing the dash or steering wheel. If such displacement is to be done, air bag manufacturers recommend following these guidelines:

Disconnect the battery cables, starting with the negative terminal. Remember that the air bag may deploy as vehicles and their electrical systems are different and at times will vary with respect to eliminating electrical discharge to the system. Avoid placing your body or objects against an air bag module or in its path of deployment. (Even after disconnecting the battery cables, a slight electrical charge capable of deploying an air bag remains.) Do not displace or cut the steering column until the system has been fully deactivated. Do not cut or drill into an air bag module. Do not apply heat in the area of the steering wheel hub.

start triage Assess Respiration (Breathing Status) First

If the patient is not breathing and your attempts to open the airway do not start breathing, tag the patient as a Priority 0 (black tag) patient. If the patient starts breathing after the airway is opened, then tag as a Priority 1 (red tag). Is the patient breathing more than 30 times per minute? If so, tag the patient as a Priority 1 (red tag) patient. Is the patient breathing less than 30 times per minute? If so, go to the next step.

start triage Assess Radial Pulse Second

If the patient is unresponsive, not breathing, and has no pulse, tag the patient as a Priority 0 (black tag) patient. If the patient is breathing but has no pulse, tag as a Priority 1 (red tag) patient. If the patient is breathing and has a pulse, good skin signs, and capillary refill less than 2 seconds, go to the next step.

incident command

Initially Incident Command is assumed by the most senior member of the first service on the scene. Very often this will be an EMS unit. Depending on jurisdiction, laws, or protocols, Incident Command may be later transferred to another individual or may be continued by whoever established it. Two modes or phases of action must then be undertaken: scene size-up/triage and organization/delegation. First Command and the crew do an initial scene size-up, start the triage process, and call for backup. While waiting for help, initial triage is completed and Command gets ready for arriving resources, beginning to construct a plan of action. When reinforcements arrive, there are two options for the person who initially assumed Command: Continue to be in Command or transfer Command to someone of higher rank. In a unified system, Incident Command would be assumed cooperatively by the Command of each service. Command is positioned at a location close enough to allow observation of the scene but secure enough to permit management of incoming resources and communication with others. In a unified command system, EMS, Police, and Fire Command establish one field command post together and stay there. Some plans call for the field command vehicle or command post to be designated by placing two traffic cones on top of the vehicle being used. In a single incident command mode, one person acts as Command, and EMS would typically be a group under the Operations section.

EMS operations generally include the Mobile command center and what other six areas?

Mobile command center Extrication (in cases of entrapment) Staging area Triage area Treatment area Transportation area Rehabilitation area

SDS

Safety data sheets (SDS), formerly called material safety data sheets (MSDS), must be provided on hazardous materials by all manufacturers. These sheets must be maintained at the work site by the employer and available to all employees on the grounds that employees working with hazardous materials have a right to know about them. If you can safely obtain these sheets, they generally name the substance, its physical properties, fire and explosion hazard information, health hazard information, and emergency first-aid treatment.

Decontamination for Patients Wearing PPE

Take the following steps to decontaminate a patient who is wearing PPE: Rinse, starting at the head and working down. Scrub the suit with a brush, starting at the head and working down. Pay special attention to heavily contaminated areas (e.g., hands, feet, front of suit). Rinse again, starting at the head and working down. Assist the responder in removing PPE. Contain the runoff of hazardous wastewater.

hot zone cold zone warm zone

While help is on the way, establish control zones. Isolate the hot zone (the area of contamination or the area of danger). Establish a decontamination corridor (area where patients will be decontaminated) in the warm zone, an area immediately adjacent to the hot zone. Equipment and other emergency rescuers should be staged in the next adjacent area—the cold zone. Station yourself in the cold zone.

Responsibilities of the EMT at hazmat incident

Your responsibilities as an EMT at a hazardous material incident include recognizing that a hazmat incident exists, calling in appropriate resources, controlling the scene, and identifying the substance.

airbags

supplemental restraint systems (SRS). Air bags are designed to inflate on impact, dissipate kinetic energy, and minimize trauma to the body. During rescue, it is important to see if an air bag has deployed. One hazard to watch for is an air bag that remains undeployed after a crash. If an air bag deploys during the extrication process, it can seriously injure rescuers. To disable the air bags, the battery must be disconnected. Disconnecting the power will cause the system to power off in 2 to 3 minutes, depending on the type of system. However, check the Air Bag Deactivation Times chart (this can be found on the Internet at www.nhtsa.dot.gov) to find out how long it takes for the backup system to completely deactivate. Some vehicles may take up to 30 minutes to deactivate, but most vehicles take 1 minute or less. While this will significantly lower the chance of accidental deployment, it does not make it 100 percent safe. Keep in mind that turning off the ignition alone may not disable the system because most systems operate independently of the ignition.

command

which must be established at all incidents, is the person who assumes responsibility for incident management. This individual stays in the position of Command unless that function is transferred to another person or until the incident is brought to a conclusion. IMS systems recognize that the manageable span of control is six people. As the MCI escalates and becomes more complex, the number of people and span of control become too large for one person to effectively manage. At this point, Command designates people to handle the specific functions needed to manage the operation. The basic elements of the Incident Management System—with sections such as Operations being subordinate to Command—are: Operations Planning Logistics Finance Command assumes all incident management functions except those that Command may delegate to someone else. Unless an incident is very complex, the most common function designated is Operations.

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 (Figure 36-8). 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. Also consider that some aeromedical systems extend the size of their landing zone (e.g., 125 by 125 feet). Keep emergency red lights on. Describe the landing zone to the air rescue service: TERRAIN. "The landing zone is located on top of a hill." "The landing zone is located in a valley." MAJOR LANDMARKS. "There is a river [major highway, factory, water tower] to the north [or other direction] of the landing zone." ESTIMATED DISTANCE TO NEAREST TOWN. "The landing zone is approximately twelve miles west of Centerville." 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."

placards

A commonly used placarding system is the National Fire Protection Association (NFPA) 704 System. It uses numerical and color coding to show the type and degree of health hazard, fire hazard, reactivity, and specific hazard contained within a fixed facility Diamond-shaped placards used in the transportation of dangerous goods not only show the hazard class, such as "explosives," "flammable gas," "poison," or other; they also bear a division number that provides more specific information on the material, as shown in Table 37-2. In addition, a four-digit identification number may appear on the placard itself or on a panel near the placard. Older placards are usually orange and have an identification number preceded by the letters UN or UA. Your dispatcher may have access to the name of the material through this identification number.

The following items can be used to protect the patient from heat, cold, flying particles, and other hazards:

An aluminized rescue blanket offers protection from bad weather and, to a degree, from flying particles. A paper blanket does not afford this protection; it merely hides the patient's view of the debris that is about to strike him. A lightweight vinyl-coated paper tarpaulin can protect the patient from bad weather. A wool blanket should be used to protect the patient from cold. Cover the wool blanket with an aluminized blanket or a salvage cover whenever glass must be broken near a patient since glass particles are just about impossible to remove from wool blankets. Short and long spine boards can shield a patient from contact with tools and debris. Hard hats, safety goggles, industrial hearing protectors, disposable dust masks, and thermal masks (in cold weather—and unless the patient has airway or breathing problems or is on oxygen) will protect a patient's head, eyes, ears, and respiratory passages. Emotional support for the patient may not be a specific PPE-related component, but the EMT should recognize that verbal communication and compassion for the conscious patient who is entrapped will be of significant benefit.

laws regulating ambulance operation:

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. 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 nonemergency vehicles also apply to the ambulance. The source of many citizen complaints is the unsafe operation of ambulances during nonemergency operations. 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. 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. 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 direction of travel and turning in specific directions.

scene size up MCI

Arrive at the scene and establish Incident Command. Put on the proper identification. Do a quick walk through the scene (or if it is a hazmat scene, observe from a safe distance) and assess the number of patients, hazards, and degree of entrapment. Identify the number of patients, including the "walking wounded," apparent priority of care, need for extrication, number of ambulances needed, other factors affecting the scene and corresponding resources needed to address them, and areas where resources can be staged. Get as calm and composed as possible to radio in an initial scene report and call for additional resources. Once scene size-up has been done, you should make an initial scene report to the communications center

start triage Assess Level of Consciousness (Mental Status) Third

Assess Level of Consciousness (Mental Status) Third If alert, tag as a Priority 2 (yellow tag) patient. If there is any altered mental status, tag as a Priority 1 (red tag) patient. then: Now Retriage the Priority 3 "Walking Wounded" Patients Just because they could initially walk does not mean some of the Priority 3 patients do not have serious medical conditions and may deteriorate! Many could have an altered mental status, be bleeding, and have significant signs of shock, which could cause them to be recategorized as a higher-priority patient. Move methodically using the same START assessment of (1) respiration, (2) pulse, and (3) mental status.

Being a Safe Ambulance Operator

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. 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. Be able to perform under stress. Have a positive attitude about your ability as a driver but not be an overly confident risk taker. 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. Some additional safety tips include: Never drive while under the influence of alcohol, illicit or "recreational" drugs such as marijuana or cocaine, medicines such as antihistamines, "pep pills," or tranquilizers. Never drive while taking prescription medications that can impair your ability to operate a motor vehicle. These same medications also affect your ability to treat patients. Your agency should have a standard operating guideline or other counsel regarding what medications warrant this warning and how long after the last dose is deemed safe. Never drive with a restricted license. Always wear your glasses or contact lenses if required for driving. Evaluate your ability to drive based on personal stress, illness, fatigue, or sleepiness. Energy drinks should be used with caution. Drinking these beverages when you are tired or sleepy may make you feel more awake, but you will still have reduced reaction times and other negative consequences of prolonged fatigue.

Ex of hazardous materials

Benzene (benzol) Toxic vapors; can be absorbed through the skin; destroys bone marrow Benzoyl peroxide Fire and explosion Carbon tetrachloride Damages internal organs Cyclohexane Explosive; eye and throat irritant Diethyl ether Flammable and can be explosive; irritant to eyes and respiratory tract; can cause drowsiness or unconsciousness Ethyl acetate Irritates eyes and respiratory tract Ethylene chloride Damages eyes Ethylene dichloride Strong irritant Heptane Respiratory irritant Hydrochloric acid Respiratory irritant; exposure to high concentration of vapors can produce pulmonary edema; can damage skin and eyes Hydrogen cyanide Highly flammable; toxic through inhalation or absorption Methyl isobutyl ketone Irritates eyes and mucous membranes Nitric acid Produces a toxic gas (nitrogen dioxide); skin irritant; can cause self-ignition of cellulose products (e.g., sawdust) Organochloride (Chlordane, DDT, Dieldrin, Lindane, Methoxyclor) Irritates eyes and skin; fumes and smoke toxic Perchloroethylene Toxic if inhaled or swallowed Silicon tetrachloride Water-reactive to form toxic hydrogen chloride fumes Tetrahydrofuran (THF) Damages eyes and mucous membranes Toluol (toluene) Toxic vapors; can cause organ damage Vinyl chloride Flammable and explosive; listed as a carcinogen

response to biological incident

Biological incidents (Figure 39-6) will present as either a focused emergency or a public health emergency. A focused emergency is a situation in which a potential or actual point of origin or source of a disease is located (such as a single case or a small and localized number of cases of a disease) and attempts are made to prevent or minimize damage and spread. A public health emergency manifests itself as a sudden demand on the public health infrastructure with no apparent explanation for the occurrence. Causative agents may be bacteria, viruses, or toxins. These agents may cause harm by being inhaled or ingested into the body. BACTERIA. These single-celled organisms can grow in a variety of environments. Dangers to humans come from two directions: disease-causing bacteria growing in the human body and bacteria that grow outside of the body but produce toxins that may pose a danger. (Rickettsia are sometimes classified as a genus of bacteria, and sometimes as organisms that share characteristics of both bacteria and viruses. Like bacteria, they can be destroyed by antibiotics. Like viruses, they can live and multiply only inside cells. They cause diseases such as Q fever and typhus. In the remainder of this chapter, Rickettsia will be grouped with bacteria.) Anthrax, a bacterium, has been the weapon of choice in several American bioterrorist events. VIRUSES. These are the smallest known entities capable of reproduction. They grow only inside of living cells and cause those cells to produce additional viruses. Viruses cannot be treated with antibiotics. TOXINS. These are poisons produced by living organisms. The organisms may be bacteria, fungi, flowering plants, insects, fish, reptiles, or mammals. Often toxins are distilled from plant material. For example, the extremely potent toxin ricin is distilled from the castor bean plant. A tiny drop of ricin can be deadly. The FBI has disrupted terrorist attempts to use ricin, such as a 2009 event in Las Vegas, Nevada, in which a police officer was sickened by secondary contamination from ricin at a crime scene.

type of event

EXPLOSIONS AND/OR INCENDIARIES. These are among the favorite weapons of terrorists. Any bombing or suspicious fire may raise suspicions of terrorist involvement, especially when combined with a previously listed type of location or occupancy. INCIDENTS INVOLVING FIREARMS. These should always be treated as suspicious. If they occur in conjunction with other indicating factors, such as a sniper attack or taking of hostages in a mall, terrorism is a definite possibility. NONTRAUMA MASS-CASUALTY INCIDENTS. These incidents have occurred as the arsenal of terrorism increases in sophistication. When large numbers of victims are generated without obvious (physical) injury but with symptoms of illness, you may suspect terrorist involvement.

sources: for hazmat

EMERGENCY RESPONSE GUIDEBOOK (ERG2008) (Figure 37-5). This essential booklet, published by the U.S. Department of Transportation, Transport Canada, and the Secretariat of Communications and Transportation of Mexico, provides the names of chemicals and concise but thorough descriptions of the actions that should be taken in case of a hazmat emergency. Be sure to have the latest edition in your vehicle at all times. CHEMICAL TRANSPORTATION EMERGENCY CENTER (CHEMTREC). This group has been established in Washington, D.C., as a service of the Chemical Manufacturers Association. They can provide your dispatcher or you with information about the hazardous material through a twenty-four-hour toll-free telephone number for the United States and Canada, which is 800-424-9300. For calls originating elsewhere and for collect calls, the number is 703-527-3887. When you call, keep the line open so changes at the scene can be reported to CHEMTREC and the center can confirm that they have contacted the shipper or manufacturer. CHEMTREC will be able to direct you as to your initial course of action. CHEM-TEL, INC. This emergency response communication service can be reached twenty-four hours a day at 800-255-3924 in the United States and Canada. For calls originating elsewhere or collect calls, use 813-979-0626. A CURRENT LIST OF STATE AND FEDERAL RADIATION AUTHORITIES. These organizations provide information and technical assistance on handling incidents involving radioactive materials. The list is maintained by both CHEMTREC and CHEM-TEL, Inc. REGIONAL POISON CONTROL CENTERS. This source is often overlooked during a hazardous material situation. Using their reference and medical resources, they can provide essential guidance in the decontamination and treatment of patients affected by hazardous materials. When you call one of the previously named sources for advice, do the following: Give your name, call-back number, e-mail address, and FAX number. Explain the nature and location of the problem. Report the identification number(s) of the material(s) involved if there is a safe way for you to obtain this information. Give the name of the carrier, shipper, manufacturer, consignee, and point of origin. Describe the container type and size. Report if the container is on rail car, truck, open storage, or housed storage. Estimate the quantity of material transported and released. Report local conditions (e.g., the weather, terrain, and proximity to schools or hospitals). Report injuries and exposures. Report local emergency services that have been notified. Keep lines of communication open at all times.

The care of the injured and safety of the responders are both high priorities at a highway incident. Responding agencies and personnel need to be cognizant of their responsibilities in this hazardous environment. To achieve these goals, it is important that:

EMS response should be limited to only the manpower and vehicles needed to accomplish the mission and should not expose more people than necessary to the risks of highway operations. The first-arriving unit should institute "blocking" to protect the work area. Because of its size and weight, fire apparatus is preferred for this purpose. If it is necessary to block lanes of traffic, they should be cleared as quickly as possible so the flow of traffic can return to normal. However, if scene safety dictates blocking lanes of traffic, blocking should be maintained until response and extrication tasks are completed.

Disabling a Vehicle's Electrical System

If there is a reason to disrupt the electrical system, disconnect the negative cable from the battery. In this way you will not be likely to produce a spark that can drop onto spilled fuel or ignite battery gases. Such a spark can be created when the positive cable is pulled away from the battery terminal or when a tool touches a metal component while in contact with the positive terminal or cable.

Types of Harm from Explosive Incidents

Explosives are categorized as high-order explosives (HE) or low-order explosives (LE). HE explosives produce a defining supersonic overpressurization shock wave. Examples of HE explosives include TNT, C-4, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil (ANFO). LE explosives create a subsonic explosion and lack the overpressurization wave produced by HE explosives. Examples of LE explosives include pipe bombs, gunpowder, and most pure petroleum-based bombs such as Molotov cocktails or aircraft used as guided missiles. HE and LE explosives cause different injury patterns. Bombs and explosives have been and probably will continue to be the weapons used most frequently by terrorists along with assault weapons (e.g., AK-47s). Types of Harm from Explosive Incidents The following types of harm can result from explosive incidents: THERMAL HARM. This is a primary hazard to those exposed to the heat generated by the detonation. It is usually not an ongoing risk unless unexploded materials are present. ASPHYXIATION. This is a potential secondary harm because of the possibility of extremely dusty conditions that can aerosolize a variety of toxins, such as asbestos. CHEMICAL HAZARDS. These hazards are created as a result of the explosive reaction either from chemicals already present at the detonation site or if chemicals have been included in the device for dispersal. MECHANICAL HARM. This is another primary harm typically seen at bombing incidents. It can result from blast overpressure, shock waves, and fragmentation. (Review the information on types of blast injuries in the chapter "Soft-Tissue Trauma.") PSYCHOLOGICAL HARM. This often results, as happens in any violent incident. A stunned response could last seconds or minutes, causing individuals to "freeze" and be temporarily unable to think or act. Delayed reaction shows up later in the form of posttraumatic stress.

exposure to biological incident

Exposure equals the dose or the concentration of the agent multiplied by time (the duration of the exposure). CHEMICAL DOSES. These are generally measured in milligrams per kilogram of body weight. Biological doses are measured in fractions of micrograms per kilogram of body weight. CONCENTRATION. The concentration of an agent is measured in parts per million. Routes of entry are critical concepts that must be understood prior to studying individual WMD agents. Exposures occur through "routes" or pathways into the body. Biological agents can enter the body through four routes: Absorption (skin contact) Ingestion (mouth) Injection (needles or projectiles) Inhalation (breathing) Biological agents seldom enter the body through the skin. The exception is T2 mycotoxins, which can be absorbed through the skin. Items that affect skin absorption are: Injury to the skin Skin temperature/blood flow Higher concentration = greater exposure Area with more hair = more exposure Length of exposure Type of agent The following types of harm can result from biological incidents: CHEMICAL HARM. This could be a secondary hazard; for example, at the scene of a clandestine laboratory. ETIOLOGICAL HARM. This is the primary type of harm. These materials are classified as Class 6 Hazardous Materials (Poison) by the U.S. Department of Transportation. MECHANICAL HARM. This is a possible secondary hazard where explosives have been used to disperse the agent. PSYCHOLOGICAL HARM. This is a secondary harm. Just the thought of possible exposure to or contamination by a biological agent can cause stress, even if the person has not actually come in contact with the agent.

The following points are important when treating and transporting hazmat patients:

Field-decontaminated patients are not completely "clean." Chemicals that pose a risk of secondary contamination to rescuers sometimes settle in hard-to-clean areas of the body. These areas are typically the scalp/hair, groin, buttocks, armpits, and between fingers and toes. Personal protective equipment or clothing (PPE/PPC) is needed to prevent secondary contamination of rescuers. EMS personnel need to wear PPE such as Tyvek coveralls and booties to prevent contamination and exposure. They may also need to wear a double layer of gloves. Often nitrile or neoprene is best because these are more resistant to chemicals than standard latex or vinyl gloves. Consult with the decon officer to determine if your PPE is suitable or if they have more appropriate PPE. Protect vehicles from contamination. In the decon process, patients are washed and are usually dripping wet. Since they cannot be completely decontaminated in the field, some of their water runoff could contaminate an emergency vehicle. To prevent this, the water runoff must be contained by either placing the patient in a disposable decontamination pool or covering the inside of an ambulance with plastic. Follow your agencies' standard operating guidelines. Consider used equipment as disposable. When an item such as a spine board, splint, blood pressure cuff, or stethoscope is used, it may not be able to be decontaminated and may require disposal. Many EMS systems have plans/logistical considerations for this kind of situation. Structural firefighting clothing is not designed or recommended for use when working in hazardous material environments. If personnel in firefighting gear encounter a hazardous chemical environment, they should take precautions to minimize the chance of contamination. A team in bunker gear can stand back and apply a fog stream to contaminated persons.

Keep in mind the safety points in the following list. Many have to do with taking precautions around conductors. A conductor is a wire or any other object or material that will carry electricity.

High voltages are not as uncommon on roadside utility poles as people often think. In some areas, wood poles support conductors of as much as 500,000 volts. Assume that the entire area is extremely dangerous. Conductors may have touched and energized any part of the system, including electrical, telephone, cable TV, and other wires supported by the utility pole, guy wires, ground wires, the pole itself, the ground surrounding the pole, and nearby guard rails and fences. Assume that severed or displaced conductors may be touching and energizing every wire and conductor at the highest voltage present. Dead wires may be reenergized at any moment. Energized conductors may arc to the ground. Keep overzealous bystanders and untrained civilians away from these hazards. Ordinary protective clothing does not protect against electrocution.

how to determine triage

How triage is performed depends on the number of injuries, the immediate hazards to personnel and patients, and the location of backup resources. Local operating procedures will give you more guidance on the exact method of triage for a given situation. Basic principles of triage are presented here. The first triage cut can be done rapidly by using a bullhorn, PA system, or loud voice to direct all patients capable of walking (Priority 3) to move to a particular area. This has a two-fold purpose. It quickly identifies the individuals who have an airway and circulation, and it physically separates them from patients who will generally need more care. You must rapidly assess each remaining patient, stopping only to secure an airway or stop profuse bleeding. It is important that you not develop "tunnel vision"—spending time rendering additional care to any one patient and thus failing to identify and correct life-threatening conditions of the remaining patients. If Priority 3 patients are nearby and well enough to help, they may be employed to assist you by maintaining an airway or direct pressure on bleeding wounds of other patients. (In this situation you should provide the appropriate personal protective equipment.) Priority 3 patients who have been reluctant to leave ill or injured friends or relatives may be permitted to stay near them where they can be of possible help later, especially in situations of language differences. Once all patients have been assessed and treated for airway and breathing problems and severe bleeding, more thorough treatment can be initiated. You will need to render care to the patients who are most seriously injured or ill but who stand the best chance of survival with proper treatment. This requires treating all the Priority 1 patients first, Priority 2 patients next, and Priority 3 patients last. Priority 4 patients do not receive treatment unless no other patients are believed to be at risk of dying or suffering long-term disability if their conditions go unattended. Usually patients will be immobilized on backboards, if necessary, and carried by "runners" to the appropriate secondary sector (as described later). Extensive treatment does not occur at the incident site since it is in a hazard zone and could impede rescue and initial treatment of other patients.

Transferring the Patient to the Emergency Department Staff

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. Otherwise the patient may be subjected to distressing sights and sounds and perhaps be in the way. (If you do this, 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! This is an important point. 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. ASSIST EMERGENCY DEPARTMENT STAFF AS REQUIRED, AND PROVIDE A VERBAL REPORT. Stress any changes in the patient's condition that you have observed. 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). 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. 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.

Fire in the Engine Compartment

If the hood is fully open, stand close to an A-post (front roof-supporting post) of the vehicle and, if possible, with your back to the wind to guard against the agent blowing back into your face or entering the passenger compartment. (Dry chemical extinguishing agents irritate respiratory passages and may contaminate open wounds.) Then sweep the extinguisher across the base of the fire with short bursts. Use no more than necessary to extinguish the fire. You will need what is left if there is a subsequent flare-up. If the hood is open to the safety latch, do not raise the hood farther; leave it where it is. This will help to restrict airflow and deprive the fire of oxygen. Direct the agent through any opening to the engine compartment: between hood and fender, around the grill, under a wheel well, or through a broken headlamp assembly. Again, use no more agent than is needed. If the hood is closed tight, let the fire burn under the closed hood, leaving its extinguishment to the fire department, and continue to get the patients out of the vehicle. The firewall should protect the passenger area long enough to get the patients out of the vehicle, using emergency moves. It is important to note that if resources are immediately available, a rapid extrication modality should be employed on the patient(s).

transportation and staging logistics

It is advisable to have a staging area from which ambulances can be called to transport patients. The staging area will be the responsibility of the staging supervisor, who must keep track of the ambulance vehicles and personnel. In large-scale incidents, the staging supervisor may need to arrange for certain human needs, such as rest rooms, meals, and rotation of crews. No ambulance should proceed to a treatment area unless requested by the transportation supervisor and directed by the staging supervisor. The staging supervisor is responsible for communicating with each treatment area regarding the number and priority of the patients in that area. This information can then be used by the transportation supervisor to arrange for transport of patients from the scene to the hospital in the most efficient way. It is vital that no ambulance transport any patient without the approval of the transportation supervisor since the transportation supervisor is responsible for maintaining a list of patients and the hospitals to which they are transported. This information is relayed from the transportation supervisor to each receiving hospital. (In a large-scale incident, the transportation officer may actually have an aide who does nothing but speak to hospitals.) In this way the hospitals know what to expect and receive only the patients they are capable of handling. It is critical that the EMTs on the ambulance comply with the instructions of the transportation supervisor. Failure to do so may result in patients' being transported to the wrong facilities. During an MCI, it is very important that the transportation officer know local hospital capabilities. Taking too many patients to one hospital could overwhelm that hospital's capability to treat them. Overwhelming a hospital's surge capacity could bring about poor outcomes.

Role of medical dispatcher

Many cities and communication centers train and certify Emergency Medical Dispatchers (EMDs) based on the medical priority card system. This system originated in 1979 through the leadership of Jeffrey Clawson, MD. 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 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: 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. 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. 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. 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. WHAT'S THE PATIENT'S SEX? Ask this if it is not obvious from the information given. IS THE PATIENT CONSCIOUS? An unconscious patient is a higher response priority. 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 EMD will dispatch the maximum response and begin the appropriate prearrival instructions for a nonbreathing patient, which may also involve telephone CPR if the patient does not have a pulse.

energy absorbing bumpers

Most cars are equipped with 5-mile-per-hour bumpers designed to absorb low-speed front and rear-end collision forces. If the bumpers were involved in the collision, you may notice that the bumper's shock absorber system is compressed, or "loaded." Never stand in front of a loaded bumper. If it springs out and strikes your knees, it could cause serious injury. Some rescuers chain the shock absorber to prevent an uncontrolled release. A safe practice is to place yourself diagonally (at an oblique angle) or perpendicularly to the bumpers.

Caring for the Patient en Route

NOTIFY THE HOSPITAL. Most EMS services radio the hospital with a patient report. 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. 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! 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. 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. NOTIFY THE RECEIVING FACILITY. Transmit patient assessment and management information, and provide your estimated time of arrival.

when to call for air rescue

OPERATIONAL REASONS. Operational reasons for air rescue include: (1) to speed transport to a distant trauma center or other special facility, (2) when extrication of a high-priority patient is prolonged and air rescue can speed transport, or (3) when a patient must be rescued from a remote location that can be reached by helicopter only. Follow your local protocols. 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 Patients with certain medical conditions may also be flown by helicopter. 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. In many cases you will transport these patients to your local hospital for stabilization, and the helicopter will transfer the patient from one hospital to another. Cardiac-arrest patients are usually not transported by air rescue unless they are hypothermic. Follow your local protocols.

triage

Once organization has been established, the next task is to quickly assess all the patients and assign each a priority for receiving emergency care or transportation to definitive care. This process is called triage, which comes from a French word meaning "to sort." The most knowledgeable EMS provider becomes the triage supervisor. The triage supervisor calls for additional help (if needed), assigns available personnel and equipment to patients, and remains at the scene to assign and coordinate personnel, supplies, and vehicles.

A Start Summary

Order the walking wounded to some type of temporary collection point. They are considered Priority 3 (green) for now. Assess all others for RPM (respiration, pulse, and mental status) and tag as follows: Priority 1 (red) are patients who have: Altered mental status or . . . Absent radial pulse or . . . Respirations of greater than 30/minute Priority 2 (yellow) are patients who: Are alert and . . . Have radial pulses present and . . . Have respirations less than 30/minute Priority 0 (black) are patients who: Are not breathing (after an attempt to open the airway) or . . . Have no pulse and are not breathing Retriage all walking wounded.

If you discover that a utility pole is broken and wires are down:

Park the ambulance outside the danger zone. Before you leave the ambulance, be sure that no portion of the vehicle, including the radio antenna, is contacting any sagging conductors. Order spectators and nonessential emergency service personnel from the danger zone. Use perimeter tape to set up a large safety zone. Discourage occupants of the collision vehicle from leaving the wreckage; keep them calm and reassured. Prohibit traffic flow through the danger zone. Determine the number of the nearest pole you can safely approach, and ask your dispatcher to advise the power company of the pole number and its location. Advise dispatch to instruct the power company that this is an emergent situation that requires an appropriate response. Do not attempt to move downed wires. Metal implements will, of course, conduct electricity, but even implements that may not appear to be conductive, such as tools with wood handles or natural fiber ropes, may have a high moisture content that will conduct electricity and may electrocute a well-intentioned rescuer. Stand in a safe place until the power company cuts the wires or disconnects the power.

Protective Gear for EMS Responders

Protective gear is important. Get your own if your service does not provide it (most states require it on ambulances) and use it! Consider reviewing the following National Fire Protection Association standards when purchasing protective gear and uniforms: NFPA 1951 (USAR Protective Equipment), NFPA 1973 (Gloves for Structural Firefighting), and NFPA 1975 (Station/Work Uniforms). Today rescuers have a wide variety of compact, lightweight helmets with integral eye protection. Eye protection is as important as any other personal protective intervention that an EMT can use. There are now PPE garments designed for urban search and rescue (USAR) operations that are ideal for EMS. They are lightweight, breathable, and provide protection from flame, fluids, and common chemicals. This is in stark contrast to firefighter PPE, which is designed with greater insulation to provide protection from heat/flame. As a result, firefighter PPE is much heavier and more bulky. When extrication is in progress at a motor-vehicle collision, the rescuer has an increased exposure to flame, glass, fluids, and sharp objects. The best practice is to wear EMS or firefighter turnout clothing, including a helmet and eye protection One good piece of headgear that offers adequate protection is a rescue helmet that meets NFPA 1951 Standards for USAR PPE All helmets should be brightly colored with reflective stripes and lettering to make the wearer visible both day and night and should display the Star of Life on each side to identify the wearer as an EMS provider. Eye protection is vital. Hinged plastic helmet shields do not provide adequate protection; Eye protection is vital. Hinged plastic helmet shields do not provide adequate protection;

en route to quarters

RADIO THE EMD. Let him know that you are returning to quarters and that you are available (or not available) for service. Valuable time is lost if an EMD has to locate and alert a backup ambulance when he does not know that a ready-for-service unit is on the road. Be sure that you notify the EMD if you stop and leave the ambulance unattended for any reason during the return to quarters. 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. If the unit has sealed windows, use the air-conditioning or ventilating system (do not set on recirculate) to air the patient compartment out. 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. At any rate, the fuel should be at such a level that the ambulance can respond to an emergency and get to the hospital without fear of running out.

occupancy and location

SYMBOLIC AND HISTORICAL TARGETS. These include targets that represent some organization or event that is particularly offensive in the minds of an extremist individual or group. Examples may include: Government buildings (including the Washington Monument, the U.S. Capitol, and the like) The Statue of Liberty The Liberty Bell The Wall Street Financial District The World Trade Center (Figure 39-3), with its great height and location at the financial hub of New York City, became such a target twice, in 1993 and on September 11, 2001. PUBLIC BUILDINGS OR ASSEMBLY AREAS. These areas provide the opportunity for attention-getting mass casualties. Some of these public buildings are also symbolic targets, so the terrorist can cause massive casualties and link the owner/operator of the building or assembly area with danger in the minds of the public. These targets include shopping malls, convention centers, entertainment venues, sporting arenas, and tourist destinations. CONTROVERSIAL BUSINESSES. These businesses usually have a history of attracting the enmity of extremist groups. Family-planning clinics, nuclear facilities, animal-research facilities, car dealerships, large-scale commercial developments perceived to be adversely affecting the environment, and furriers all fall into this category. INFRASTRUCTURE SYSTEMS. These operations are necessary for the continued functioning of our society. Major cities are full of targets such as bridges, power plants, phone companies, water-treatment plants, mass transit, and hospitals. Attacks on any of these have the potential to disrupt entire regions and cost hundreds of millions of dollars to correct.

secondary triage

Secondary triage is generally performed at a patient collection point or triage area from which patients are assigned to a treatment group. Patients are physically separated into treatment groups based on their priority level as designated by a triage tag. Some systems call for vehicles to carry red, yellow, and green tarps, which are used to designate these areas. An area to which triaged patients are removed is referred to as a treatment area. Each treatment area should have its own treatment supervisor, an EMT responsible for overseeing the triage and treatment within that area. The treatment supervisor should retriage the patients in that area to determine the order in which they will receive treatment. Secondary triage is important to ensure that patients are treated and transported according to their priority. During secondary triage, it may be necessary to recategorize a patient whose condition has deteriorated or improved or who was incorrectly triaged. That patient should be designated to a higher- or lower-priority group than was medically warranted. This will necessitate moving the patient to the proper treatment area as resources permit. Some systems use a different disaster tag during secondary triage on which more detailed information about the patient can be recorded (review Figure 37-18). The treatment area EMTs will need supplies and equipment from the ambulances such as bandages, blood pressure cuffs, and oxygen.

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

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

simple and complex access

Simple Access First remember that, as an EMT, your responsibility is not to rescue the vehicle but to rescue the patient. You will usually assume that an occupant or occupants of the vehicle have sustained life-threatening injuries and that at least one EMT needs to gain quick access to the patient, even while rescuers are working to gain a more wide-open access, create exits, and disentangle occupants. After the vehicle is stable enough for you to approach it safely, check to see if a door can be opened or if an occupant of the vehicle can roll down a window or unlock a door. ("Try before you pry!") Such ordinary ways of getting into the vehicle are known as simple access. Many EMTs have been humbled by not being able to open a car door and beginning a mechanical extrication process then having another EMT or responder open the opposite door without a problem. Common sense can easily overcome an adrenalin rush. Complex Access If simple access fails, you may need to use tools or special equipment to break a window and gain access even while the rescue crew is dismantling the vehicle for extrication of the occupants (Figure 38-8). When tools or equipment are used for this purpose, the process is known as complex access. All automotive glass is one of two types: laminated or tempered. Windshields and some side and rear van and truck windows are laminated safety glass—two sheets of plate glass bonded to a sheet of tough plastic like a glass-and-plastic sandwich. Most passenger car side and rear windows are tempered glass. They are very resilient, but when they do break, rather than shattering into sharp fragments, they break into small, rounded pieces. You will usually try to gain access through a side or rear window as far as possible from the passengers. Use a spring-loaded center punch against a lower corner to break the glass (Figure 38-9). Punch out finger holds in the top of the window, and use your gloved fingers to pull fragments away from the window. A flathead ax is usually required to break through a windshield. This can also be done very quickly using a Glas-Master or similar saw (Figure 38-10). Although a windshield is usually not broken to gain access, the rescue squad may need to remove it if they plan to displace the dash or steering column or remove the roof. Before breaking the windshield, cover the passengers with aluminized rescue blankets or tarps if possible. Avoid the use of hospital-style blankets that will allow the tiny slivers of glass to pass through and come in contact with the patient. Making verbal contact with the patient(s) and providing emotional support is very important in this type of situation. Imagine having your vision restricted and being covered by a tarp while you are injured and trapped in a vehicle.

ground gradient

Sometimes, especially in wet weather, a phenomenon known as ground gradient may provide your first clue that a wire is down. Voltage is greatest at the point where a conductor touches the ground then diminishes with distance from the point of contact. That distance may be several inches or many feet. Being able to recognize and respond properly to energized ground can save your life. Stop your approach immediately if you feel a tingling sensation in your legs and lower torso. This sensation means that you are on energized ground. Current is entering one foot, passing through your lower body, and exiting through your other foot. If you continue, you risk being electrocuted! Move immediately opposite to your present direction, using exactly the instructions that follow. Turn 180 degrees and take one of two escape measures. Hop to a safe place on one foot. Alternatively, shuffle away from the danger area with both feet together, allowing no break in contact between your two feet or between your feet and the ground. Either technique helps prevent your body from completing a circuit with energized ground, which can cause electrocution. (A circuit is a circular path for electrical flow, such as up one leg, down the other, and through the ground. Hopping on one leg or keeping your feet together creates a straight path rather than a circular circuit, which may prevent electrocution.)

Protection of the EMR is based on avoiding or minimizing exposure through the principles of time, distance, and shielding.

TIME. Minimize your time at a dangerous scene, such as a crime scene or a hazmat scene. Spend the shortest amount of time possible in the dangerous area or exposed to a hazardous material, a biological agent, or radiation. An example of using time constraints would be executing rapid entries to perform reconnaissance or rescue. The less time you spend in the affected area, the less likely you are to become injured. Minimizing the time you spend in the affected area will also reduce your chances of contaminating a crime scene. DISTANCE. Maximize your distance from the hazard area or the projected hazard area. One example of using distance would be avoiding contact by following the recommended guidelines regarding hazardous materials in the current edition of the Emergency Response Guidebook. You can determine the safe distances from vehicles suspected of containing explosives from the recommendations in Vehicle Bomb Explosion Hazard and Evacuation Distance Tables obtainable from the Bureau of Alcohol, Tobacco, and Firearms (Figure 39-5). SHIELDING. Use appropriate shielding to address specific hazards. Shielding can consist of vehicles, buildings, fire-protection clothing, hazmat suits, positive pressure self-contained breathing apparatus, and personal protective equipment (PPE). Also consider the vaccinations recommended by your service to provide immunization against specific diseases. Always remember that a vehicle does not provide adequate protection from explosive devices.

If you are confronted with contaminated patients prior to the arrival of the hazmat team, do the following:

Take precautions appropriate to the substance as listed in the Emergency Response Guidebook. This usually means isolation from the substance. Be sure to use personal protective equipment similar to what you would use for splash protection from bloodborne pathogens. Follow the first-aid measures listed in the Emergency Response Guidebook. Manage the patient's critical needs. Do not forget to manage the ABCs. If treatment calls for irrigation with water, remember that water only dilutes most substances. It does not neutralize them. Cut the patient's clothing off and irrigate the patient's body with large amounts of water. Try to contain the runoff. If possible, use tepid or warm water to prevent hypothermia. Try to avoid flushing contaminants directly into open wounds. Pay particular attention to cleaning areas such as dense body hair, ear canals, navel, fingernails, crotch, armpits, and so on. Use disposable equipment whenever possible. Discard it later. After treating the patient, decontaminate yourself. Your clothing may need disposal.

multiple devices

Terrorists have a history of using multiple devices and/or booby traps to target emergency responders. In January 1997 a bomb went off outside an Atlanta family-planning clinic. One hour after the initial detonation, a second bomb went off close to the point where the Incident Command post had been established, which resulted in several injuries to responders and could have caused deaths. Imagine if the second bomb at the Boston Marathon in 2013 had detonated one to two minutes after the first one instead of seconds later. The results could have been much more catastrophic. A related term is secondary devices, referring to those intended to harm those who respond to the initial attack; however, emergency response planners prefer the term multiple devices because it is more likely to make first responders aware of and prepared for the possibility of more than one destructive event following the first one.

Positioning Blocking Apparatus

The apparatus that is used to block should be positioned to create one and a half to two lanes of blockage (Figure 38-2). This will usually create a large enough work zone. The driver of the apparatus must also consider preservation of the crash scene and must avoid running over road debris or crash evidence. Incapacitation of an ambulance could seal the fate of the victim of a critical multivehicle crash. Ideal blocking placement has the fire apparatus positioned at an angle, with its working side toward the work zone to protect the crew. The front wheels are rotated away from the incident. In the event that a motorist strikes the engine, the engine will be a barrier. If the engine is pushed by the striking vehicle on impact, the unit will move away from the work zone. Some incidents may require more than one piece of blocking apparatus. It is important to leave space in the area immediately next to the crash to position vehicle extrication units (Figure 38-3). Ambulances, command vehicles, and other units should be positioned downstream from the crash. Positioning units in this manner allows for safer patient loading and rapid departure from the scene.

where to park on highway collison

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 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. 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.

Disentanglement: A Three-Part Action Plan

The following is a description of a three-part procedure that can be accomplished by fire, rescue, and EMS personnel with the appropriate equipment. The procedure is not vehicle specific; that is, it can be used on virtually any car or truck. Furthermore, the procedure does not include a lot of techniques that require special equipment. Personnel can be trained in a short course. Most important to EMS personnel, there is no need to fill several compartments of the ambulance with rescue equipment. Steps One and Two: Gain Access by Disposing of Doors and the Roof For more than twenty-five years, emergency service personnel have been trained to carry out a progression of procedures to reach the occupants of a wrecked vehicle: first try the doors; if that fails, unlock and unlatch the doors by nondestructive or destructive means; when all else fails, gain access through window openings. However, this multipart procedure is time consuming and requires a number of tools. A quicker and far more efficient procedure is first to dispose of the doors then to dispose of the roof as soon as hazards have been controlled and the vehicle is stable. Disposing of the doors and roof has four benefits: It makes the interior of the vehicle accessible. EMS personnel can stand beside or climb into the vehicle and pursue emergency care efforts while rescuers carry out disentanglement procedures. It creates a large exit through which an occupant can be quickly removed when he has a life-threatening injury or when fire or another hazard is threatening the operation. It provides fresh air and helps cool off the patient when heat is a problem. Quick access to a critical patient can improve survivability and perhaps decrease morbidity. Scan 38-4 illustrates procedures for removing the doors and roof using hydraulic tools. If you don't have a hydraulic rescue tool, you can accomplish these procedures with ordinary hacksaws and a spray container of lubricant. Step Three: Disentangle Occupants by Displacing the Front End Most vehicle rescue training courses include procedures for displacing or removing seats, dash assemblies, steering wheels, steering columns, and pedals. A quicker and more efficient way to disentangle an injured driver and/or passenger from these mechanisms of entrapment is to displace the entire front end of the vehicle. Although the task sounds difficult, it is not. Scan 38-5 illustrates a procedure for displacing the front end of a passenger car with a hydraulic rescue tool. A dash displacement can also be accomplished with heavy-duty jacks and hacksaws.

SLUDGEM is a mnemonic used to remember the signs and symptoms of nerve agent poisoning

The letters stand for: SALIVATION— due to stimulation of the salivary glands LACRIMATION— due to stimulation of the lacrimal glands URINATION— due to relaxation of the internal sphincter muscle of the urethra DEFECATION— due to relaxation of the anal sphincter GI UPSET— changes to smooth muscle tone in the GI tract EMESIS— vomiting because of GI system effects MIOSIS— abnormal contraction of the pupils

START triage

The most commonly used method of prioritizing patients in the United States is the START method of triage (Figure 37-15). It was developed by the Newport Beach, California, Fire Department and Hoag Hospital in Newport Beach, California. START stands for Simple Triage and Rapid Treatment. The foundation of the system is the speed, simplicity, and consistency of its application. It relies on some simple commands and the following physiologic parameters that can be remembered by the mnemonic RPM: respiration, pulse, mental status START triage is intended to be completed in about 30 seconds per patient. Begin by asking all patients who can walk to get up and go to a collection point such as an ambulance or a building. Since those who can do this are ... Conscious Able to follow commands Able to walk . . . they obviously are perfusing their brain, are breathing, have a pulse, and have a nervous system that is currently working. All of these patients are considered to be Priority 3 (green tag) patients for right now. (They are often called the "walking wounded.") This also leaves people at the site who are unable to hear, walk, or follow commands and are the Priority 0, 1, or 2 patients. Among these patients, you must now focus your attention on those who are likely to be of higher priority. Start making your triage sweep methodically by avoiding patients who are obviously conscious. The only three treatments provided during START triage are to: Open an airway and insert an oropharyngeal airway Apply pressure to bleeding Elevate an extremity

Decontamination Procedures

The objectives of the responders assigned to decontamination are to: Determine the appropriate level of protective equipment based on materials and associated hazards Properly wear and operate in PPE Establish operating time log Set up and operate the decontamination line Prioritize the decontamination of patients according to a triage system Perform triage in PPE Be able to communicate while in PPE A basic list of equipment required for decontamination is: Buckets Brushes Decontamination solution Decontamination tubs Dedicated water supply Tarps or plastic sheeting Containment vessel for water runoff Pump to transfer wastewater from decontamination tubs to a containment vessel A-frame ladder (to reach the top of the responder's suit) Appropriate-level PPE for responders performing decontamination

Phases of Decontamination

The two major phases of decontamination are gross decontamination and secondary decontamination. (There is usually a third or tertiary decontamination phase, but it generally occurs at a medical facility and may involve such processes as sterilization or debridement.) Gross decontamination is the removal or chemical alteration of the majority of the contaminant. It must be assumed that some residual contaminant will always remain on the host after gross decontamination. This residual contamination can cause cross-contamination. Secondary decontamination is the alteration or removal of most of the residual product contamination. It provides a more thorough decontamination than the gross effort. However, some contaminant may still remain attached to the host.

mechanisms for decontamination

There are seven common mechanisms for performing decontamination. They are: EMULSIFICATION. This is the production of a suspension of ordinarily immiscible (unmixable)/insoluble materials using an emulsifying agent such as a surfactant, soap, or detergent. CHEMICAL REACTION. This is a process that neutralizes, degrades, or otherwise chemically alters the contaminant. Normally a chemical reaction does not ensure that all hazards have been eliminated, and reaction procedures can be both difficult and dangerous to perform. Chemical reaction is therefore not recommended for use on living tissue. DISINFECTION. This is a process that removes the biological (etiological) contamination hazards as the disinfectant destroys microorganisms and their toxins. DILUTION. This is a process that simply reduces the concentration of the contaminant. It is most commonly used for substances that are miscible (mixable)/soluble. Huge quantities of solvent may be required to dilute even small volumes of some solute contaminants. ABSORPTION AND ADSORPTION. This is the penetration of a liquid or gas into another substance. An example is water soaking into a sponge. REMOVAL. This is the physical process of removing contaminants by pressure or vacuum. Most efforts involve the use of water, though solids can be removed with brushes and wipes; even air can be used. DISPOSAL. This is the aseptic removal of a contaminated object from a host, after which the object is disposed of. (Aseptic means using sterile instruments and/or otherwise preventing the spread of the contaminant.)

types of harm

These types of harm—Thermal, Radiological, Asphyxiation, Chemical, Etiological, Mechanical, and Psychological—can be categorized using the acronym TRACEM-P. The TRACEM-P Harms THERMAL HARM. This refers to harm caused by either extreme heat, such as that generated by burning liquids or metals, or extreme cold from cryogenic materials, such as liquid oxygen. Radiant heat can melt protective clothing and other equipment if an individual is too near the heat source. RADIOLOGICAL HARM. This refers to danger from alpha particles, beta particles, or gamma rays, which are generally produced by sources such as nuclear fuels, by-products of nuclear power production, or nuclear bombs. Figure 39-4 shows the relative penetrating power of the three types of radiation. ASPHYXIATION. This is caused by a lack of oxygen in the atmosphere. One common cause of this is heavier-than-air gases such as argon, carbon dioxide, or chemical vapors in a confined space. Extremely dusty situations such as the site of the World Trade Center towers' collapse create additional problems. An oxygen level of 19.5 percent is required for normal breathing. CHEMICAL HARM. This harm is posed by toxic or corrosive materials. These can include acids such as sulfuric acid, caustics such as lye, and chemical toxins ranging from cyanides to nerve agents. ETIOLOGICAL HARM. Etiology concerns the causes of disease—whether it comes from disease-causing organisms such as bacteria and viruses or toxins derived from living organisms. MECHANICAL HARM. This is any sort of physical trauma such as gunshot wounds, slip-trip-and-fall injuries, and injury from bomb fragments or shrapnel. PSYCHOLOGICAL HARM. This can, of course, result from any violent or traumatic event. Terrorist events are designed to create fear, invoke panic, reduce faith in government, and (as the name indicates) cause terror. In fact, psychological harm is generally the purpose of a terrorist attack. Responders and patients will be subject to posttraumatic stress and survivor guilt. These effects may occur during or right after the event or may manifest themselves at a much later time.

primary triage

To properly triage a group of patients, you should quickly classify each patient into one of four groups: PRIORITY 1: TREATABLE LIFE-THREATENING ILLNESSES OR INJURIES. Patients with airway and breathing difficulties, uncontrolled or severe bleeding, decreased mental status, severe medical problems, shock (hypoperfusion), and/or severe burns. PRIORITY 2: SERIOUS BUT NOT LIFE-THREATENING ILLNESSES OR INJURIES. Patients who have burns without airway problems, major or multiple bone or joint injuries, and/or back injuries with or without spinal cord damage. PRIORITY 3: "WALKING WOUNDED." Patients with minor musculoskeletal injuries or minor soft-tissue injuries. PRIORITY 4 (SOMETIMES CALLED PRIORITY 0): DEAD OR FATALLY INJURED. Examples include patients with exposed brain matter, cardiac arrest (no pulse for more than 20 minutes except with cold-water drowning or severe hypothermia), decapitation, severed trunk, and incineration. Patients in arrest are considered Priority 4 (or 0) when resources are limited. The time that must be devoted to rescue breathing or CPR for one person is not justified when there are many patients needing attention. Once ample resources are available, patients in arrest become Priority 1.

Rehabilitation Operations

To safely enter the hot zone, the hazmat team members must wear chemical-protective clothing and breathing apparatus that both slows heat loss and prevents heat stress. Team members must be carefully monitored prior to, during, and after emergency operations. This is done to make sure that their condition does not deteriorate to a point where safety or the integrity of the operation is jeopardized. To address this need, you should establish an area of operations called rehabilitation (rehab). Although the rehab area supervisor may not be an EMS provider, all rehab operations must include EMTs or advanced-level EMTs. The characteristics of the rehab area must include the following: Located in the cold zone Protected from weather (shielded from rain or snow, a warm area in a cold environment, a cool area in a warm environment) Large enough to accommodate multiple rescue crews Easily accessible to EMS units Free from exhaust fumes Allows for rapid reentry into the emergency operation While suiting up in chemical-protective equipment, hazmat team members should have their baseline vital signs taken. When the hazmat team members show signs of fatigue or when they have had 45 minutes of work time, they are sent to rehab. As soon as possible after exit from the hot zone, reassess their vital signs including blood pressure, heart rate, and oral temperature. Vital sign parameters will vary based on local guidelines. Team members who display an elevated heart rate (usually greater than 110 beats per minute) or any elevation in body temperature will require ongoing medical reassessments in the rehab area until pulse and temperature return to baseline. Always follow your local protocols and consult medical direction. All preentry and exit vitals should be tracked on a flow sheet.

hazmat training levels

Two federal agencies—the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA)—have developed regulations to deal with the increasing frequency of hazmat emergencies. The regulations are described in the OSHA publication "29 CFR 1910.120—Hazard Communication Standard (2012) The regulations identify four levels of training: FIRST RESPONDER AWARENESS. Rescuers at this level are likely to witness or discover a hazardous substance release. They are trained only to recognize the problem and initiate a response from the proper organizations. There are no minimum training hours required. FIRST RESPONDER OPERATIONS. This level of training is for those who initially respond to releases or potential releases of hazardous materials to protect people, property, and the environment. They stay at a safe distance, keep the incident from spreading, and protect others from any exposures. A minimum of 8 hours of training is required. HAZARDOUS MATERIALS TECHNICIAN. This level is for rescuers who actually plug, patch, or stop the release of a hazardous material. A minimum of 24 hours of training is required. HAZARDOUS MATERIALS SPECIALIST. This level of rescuer is expected to have advanced knowledge and skills and to command and support activities at the incident site. A minimum of 24 hours of additional training is required. Most of the training levels outlined by OSHA have a fire-service focus.

single incident command

Two methods of Command defined under NIMS are single incident command and unified command. In single incident command, a single agency controls all resources and operations. In many communities, for example, EMS is managed by fire services. Accordingly, single incident command is often used at fire and rescue incidents with the Incident Commander provided by the fire service (Figure 37-10A). However, if police agencies have major involvement, if there is a separate EMS provider, or if other agencies are involved, unified command is more appropriate (Figure 37-10B). In unified command several agencies work independently but cooperatively rather than one agency exercising control over the others. In most communities unified command is the best way to manage resources. It recognizes that large-scale incidents tend to be complex and that the right agency must take the lead at the right time, with Command officers from all agencies cooperating.

on scene warning signs

When you arrive on the scene, you should always watch for signs that you are dealing with a suspicious incident. Unexplained patterns of illness or deaths can be attributed to chemical, radiological, or biological agents. Some of these substances have recognizable odors and/or tastes. Unexplained signs and symptoms of skin, eye, or airway irritation may be linked to chemical contamination, as may unexplained vapor clouds, mists, and plumes. Always remain on the lookout for chemical containers, spray devices, or lab equipment in unusual locations. Watch for items or containers that appear out of place at unusual incidents, which might contain a secondary device. Large fires, spot fires, and fires of unusual behavior may also arouse suspicion, as can anything that appears abnormal for a given incident scene. Early recognition of suspicious signs and early reporting of these observations by the first responding agencies can mean the difference between an ineffective and an effective mitigation of the event.

nader pin

Why does a car door not fly open in a crash? The answer is the Nader pin (named for Ralph Nader, the consumer advocate who lobbied for the device), a case-hardened pin in an automobile door. In a collision, the cams in the door locks grasp the pin to keep the door from flying open, preventing occupants from being thrown from the vehicle. All cars sold in the United States since 1966 have the Nader pin. The Nader pin is a safety device since being thrown from a vehicle (ejection) is far more dangerous than being kept inside during a crash. The main complicating factor now with ejections is not wearing a seatbelt. However, the Nader pin does make gaining access to vehicle occupants more difficult. Prior to the device, rescue personnel could open a door with a crowbar. Subsequently rescuers had to start using a hydraulic spreader to peel the cams off the pins. Ironically safety features designed to keep occupants inside wrecked vehicles were keeping rescuers out! Each new safety improvement to vehicles created a new challenge to rescue personnel.

Types of ambulances

type 1, 2, 3, and medium duty

Decontamination for Patients Not Wearing PPE

You should use a public address system to direct ambulatory patients to a decontamination line. This provides a rapid form of triage. Note that patients who may have been involved in an explosion incident may have loss of hearing; you may have to use hand signals or use large signs to communicate your commands. Patients should be instructed to begin decontamination by removing their clothing. Have people remove shoes, socks, jewelry, watches, and other items that trap materials against the skin. They should also remove contact lenses as soon as possible. Double-bag their clothing for disposal or decontamination later. Valuables and identification should be bagged and may (based on hazards) be carried by the patients. Next the patients should receive a 2- to 5-minute water rinse. Solid or particulate contaminants should be lightly brushed off (dry decontamination) as completely as possible prior to washing (wet decontamination). Viscous liquid contaminants (including vesicants, which are blistering agents) should be blotted off prior to washing. If the material is water reactive, it must be brushed off prior to the application of water. Rinsing is done as needed to flush remaining chemicals that may react with the moisture of the skin and eyes. You should also use an appropriate decontamination solution. Washing and rinsing should start at the head to reduce contamination on or near the nose, mouth, ears, and eyes. If the patient has removed his contact lenses, the eyes should be irrigated. Open wounds should be irrigated starting from the area nearest the body core and working outward. You may use plastic wrap to isolate the wound once it has been cleaned. Use a low-water-pressure system to avoid aggravating soft-tissue injuries and to avoid overspray and splashing. A low-pressure system will also help prevent the creation of an aerosol out of dry product. During decontamination, patients should be given some type of cover for modesty and protection from the elements. Protection from hypothermia should be a consideration. Although not strictly a form of self-protection, decon is vital to prevent, reduce, and remove contamination for both responders and patients.

international terrorism

involves groups or individuals whose terrorist activities are purely foreign based and/or directed by countries or groups outside the targeted country or whose activities cross national boundaries. As already noted with regard to domestic terrorism, a trend in international terrorism is the shift from well-organized, state-sponsored localized groups to loosely organized, international networks of terrorists.

domestic terrorism

roups or individuals whose terrorist activities are directed at their own government or population. It can occur with or without foreign direction. Domestic terrorism in the United States as well as in other countries is changing somewhat, with a trend away from structured organizations to a fragmented, leaderless phenomenon in which individuals or small groups act independently in planning and executing their attacks. However, it should be anticipated that this trend may move back toward better organized schemes in the future. Terrorism is a dynamic tactic that is used by many different groups with many different ideologies.

terrorism

the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segment thereof, in furtherance of political or social objectives." domestic and international