Ch 37: TRANSPORT OPERATIONS
You should place items needed to care for life-threatening conditions within easy reach, at the head of the primary stretcher. Place items for cardiac care, control of external bleeding, and monitoring blood pressure at the side of the stretcher.
A Type I ambulance is a conventional, truck cab-chassis with a modular ambulance body that can be transferred to a new chassis as needed. A Type II ambulance is a standard van, forward-control integral cab-body ambulance.
Operating in a Landing Zone Familiarize yourself with helicopter hand signals used within your jurisdiction. Do not approach the helicopter unless instructed and accompanied by flight crew. Ensure all patient care equipment is properly secured to the stretcher and that the patient is fastened as well. This includes oxygen tanks, cervical collars, and head stabilizers. Any loose articles or belongings such as hats, coats, or bags that belong to the patient or crew should not be brought into the landing zone and will likely need to be transported to the hospital by ground. Some helicopters may load patients from the side, whereas others have rear-loading doors. Regardless of where the patient is being loaded, approach the aircraft from the front unless otherwise instructed by the flight crew. Always take the same path when exiting away from the helicopter, moving the patient headfirst. Smoking, open flames, and flares are prohibited within 50 feet of the aircraft at all times. Wear eye protection during approach and takeoff.
Communication Issues To prevent any miscommunication, when the request is made for a medivac response, the request should include a ground contact radio channel (typically a preestablished mutual aid channel), as well as a call sign of the unit that the medivac should make contact with.
Distractions, Driving Alone, and Fatigue
Distractions As technology progresses, so will the distractions you will face while operating the ambulance. Distractions include: MDTs and GPS devices Mounted mobile radio Listening to the stereo Talking on your cell phone Eating/drinking While the ambulance is in motion, focus on driving and anticipate roadway hazards. Your partner should operate the MDT, GPS device, and portable radios or turn on the siren. Minimizing distractions allows for a safer response and minimizes the potential for mishaps. Driving alone Although driving alone is not a standard practice or even allowable in certain systems, there may be an occasion when you need to respond to a scene by yourself in the ambulance and meet your partner on the scene. When presented with this situation, you have additional duties and responsibilities, such as: Figuring out the safest route to the call Operating the radios and emergency warning devices Mentally preparing for the call Fatigue Fatigue has many causes, such as stress, working the night shift, and lack of quality sleep in accordance with your body's circadian rhythms. Operating a large vehicle, such as an ambulance, while fatigued creates a high risk. You must be able to recognize when you are fatigued. Do not be ashamed to admit it to yourself, your partner, or your supervisor. If you feel fatigued, you should be placed out of service for the remainder of the shift or until the fatigue has passed and you feel capable of safely operating the vehicle.
The Postrun Phase Cleaning is the process of removing dirt, dust, blood, or other visible contaminants from a surface or equipment. Disinfection is the killing of pathogenic agents by directly applying a chemical made for that purpose to a surface or equipment. High-level disinfection is the killing of pathogenic agents by the use of potent means of disinfection. Sterilization is a process, such as the use of heat, that removes all microbial contamination. A basic rule is to do the following after every call: Immediately strip used linens from the stretcher after use and place them in a plastic bag or in the designated receptacle in the ED. Discard in an appropriate receptacle all disposable equipment used for care of the patient that meets your state's definition of medical waste. Discard disposable equipment that is bloody or contaminated by body fluids in an OSHA-approved biohazard container. Discard noncontaminated disposable equipment used for care of the patient following OSHA and local guidelines. Wash contaminated areas with soap and water. For disinfection to be effective, cleaning must be done first. Disinfect all nondisposable equipment used in the care of the patient. Clean the stretcher with an EPA-registered germicidal/virucidal solution or bleach and water at 1:100 dilution. Clean up any spillage or other contamination that occurred in the ambulance with the same germicidal/virucidal or bleach/water solution. Create a schedule for routine full cleaning for the vehicle. Have a written policy/procedure for cleaning each piece of equipment. Refer to the manufacturer's recommendations as a guide.
Driver Characteristics Do not drive if you are taking medications that may cause drowsiness or slow your reaction time. These include: Cold remedies Analgesics Tranquilizers Never drive or provide medical care after drinking alcohol. While most employers have guidelines that require an employee to stop drinking at least 10 to 12 hours prior to the start of his or her shift, many factors affect the rate of alcohol metabolism, so it is possible to stop drinking for this period of time and still be impaired. Working long shifts or multiple consecutive shifts puts drivers at risk for delayed reaction time and/or falling asleep behind the wheel. While many services have regulations against working beyond a specific number of hours, most do not consider EMTs who may work for more than one service. Notify your employer if you have previously worked a shift and feel unable to safely operate an emergency vehicle. Emotional maturity and stability are closely related to the ability to operate under stress. In addition to knowing exactly what to do, you must be able to do it under difficult conditions. You must operate the vehicle with due regard for the safety of others and preservation of property. A greater responsibility is placed on the driver of an ambulance, and generally a lower burden of proof is needed to find that an EMT has caused a crash. As a rule, whenever lights and siren are used on an emergency call and there is a crash, the actions of the emergency vehicle operator fall under the most scrutiny.
The Delivery Phase Follow these steps to transfer the patient to the receiving hospital: Report your arrival to the triage nurse or other arrival personnel. Physically transfer the patient from the stretcher to the bed directed for your patient. Present a complete verbal report at the bedside to the nurse or physician who is taking over the patient's care. Complete a detailed report, obtain the required signatures, and leave a copy with an appropriate staff member. Electronic reports are commonly used. Your service should have a method for printing or sending electronic reports as well as obtaining electronic signatures. The patient care report (PCR) should include: A summary of the history of the patient's current illness or injury with pertinent positives and negatives, MOI, and findings on your arrival Vital signs Relevant past medical or surgical history Information regarding medication and allergies Any treatment and its effect during the prehospital setting
En Route to the Station As soon as you are back at the station, you should: Clean and disinfect the ambulance and any equipment that was used, if you did not do so before leaving the hospital. Restock any supplies you did not get at the hospital.
Personal protective equipment Along with your ANSI 2 reflective vest, you should always carry personal protective equipment (PPE) that allows you to work safely in a limited variety of hazardous or contaminated situations, including the edges of a structural fire or explosion, vehicle extrication, and in crowds. The equipment should protect you from exposure to blood and other potentially infectious body fluids. You will not be equipped to face all hazardous materials (HazMat) and other exposure situations that you may encounter; this is the job of specially trained HazMat technicians and response teams. Your equipment might include: Face shields Gowns, shoe covers, caps Turnout gear Helmets with face shields or safety goggles Safety shoes or boots
Equipment for work areas A weatherproof compartment that you can reach from outside the patient compartment should hold equipment for safeguarding patients and EMTs, controlling traffic and bystanders, and illuminating work areas. The following items are recommended: Warning devices that flash intermittently or have reflectors (do not use road flares, as these can pose an additional hazard, such as ignition of flammable liquids or gases) Two high-intensity halogen 20,000 candlepower flashlights of the recharging battery-powered, standup type Fire extinguisher, type ABC, dry chemical, 5-lb (2.3-kg) minimum Hard hats or helmets with face shields or safety goggles Portable floodlights
Preplanning and navigation equipment GPS devices and MDTs are standard equipment in modern ambulances. The addresses of area hospitals and nursing homes should be stored for easy access. Enter the location of the hospital into the GPS device before initiating transport to the hospital. If you are alone in the front of the vehicle, never turn your attention away from driving to use a device of any type. Make sure you also have detailed street and area maps in the driver's compartment of the ambulance. Familiarize yourself with the roads and traffic patterns in your town or city so you can plan alternative routes to frequent destinations. Pay particular attention to ways around frequently opened bridges, congested traffic, and blocked railroad crossings. Be familiar with special facilities and locations within your regional operating area, such as other medical facilities, airports, arenas and stadiums, detention facilities, and chemical or research facilities that might pose unusual problems (staging areas may be predefined for emergency operations).
Extrication equipment A weatherproof compartment outside the patient compartment should contain equipment that is needed for simple, light extrication, even if an extrication and rescue unit is readily available. The table lists the items that may be included in the compartment. If rescue and extrication services are not readily available, additional equipment may be needed.
Positioning and Cornering When cornering, the aim is to take the corner at the speed that will put you in the proper road position as you exit the curve. Although the fastest path through a curve is to enter high in the lane (positioned to the outside of the lane), apex low in the lane (to the inside of the lane), and exit high, these actions can result in misjudgment of speed and position, creating the danger of ending up in the opposing lane or off the road if you are traveling too fast. The safest path is to enter high in the lane (to the outside) and exit low (to the inside). This allows room for error if you enter the turn too fast.
Hydroplaning On a wet road surface, tires are designed to move the water out of the way and stay in direct contact with the road. At speeds of greater than 30 mph, tires may be lifted off the road as water "piles up" underneath; the vehicle may then feel as if it is floating. This problem is known as hydroplaning. At higher speeds on wet roadways, the front wheels may actually be riding on a sheet of water, robbing the driver of control of the vehicle. If hydroplaning occurs, gradually slow down without jamming on the brakes. Water on the roadway Wet brakes will not slow the vehicle as efficiently as dry brakes, and the vehicle may pull to one side or the other. If at all possible, avoid driving through large pools of standing water. If you must drive through standing water, slow down and turn on the windshield wipers. After driving out of the water, lightly tap the brakes several times until they are dry. If the vehicle is equipped with antilock brakes, apply a steady, light pressure to dry the brakes. Driving through moving water should be avoided at all times. Decreased visibility In areas where there is fog, smog, snow, or heavy rain, slow down after warning vehicles behind you by turning your emergency lights on. At night, use only low headlight beams for maximum visibility without reflection. Always use headlights during the day to increase your visibility to other drivers. Also, watch carefully for stopped or slow-moving vehicles. Ice and slippery surfaces A light mist on an oily, dusty road can be just as slippery as a patch of ice. Good all-weather tires and an appropriate speed will significantly reduce traction problems. If you are in an area that often has snowy or icy conditions, consider using studded snow tires or tire chains, if they are permitted by law. Be especially careful on bridges and overpasses when temperatures are close to freezing, as these road surfaces will freeze much faster than surrounding road surfaces.
Keeping a safe distance between your vehicle and the one in front of you, checking for tailgaters behind your ambulance, and being aware of objects in your mirror's blind spots are considered maintaining a cushion of safety.
In a mass-casualty incident, you need to evaluate and ask for additional resources.
Always maintain a safe following distance. Use the "4-second rule": stay at least 4 seconds behind another vehicle in the same lane.
It is best to park uphill and upwind of the scene if smoke or hazardous materials are present.
Establishing a Landing Zone Things to do and consider when selecting and establishing a landing zone include: Ensuring the area is a hard or grassy level surface that measures 100 feet × 100 feet (recommended) and no less than 60 feet x 60 feet. If the site is not level, notify the flight crew of the steepness and direction of the slope. Ensuring the area is clear of any loose debris that could become airborne and strike the helicopter or the patient and crew This includes branches, trash bins, flares, caution tape, and medical equipment and supplies. Examine the immediate area for any overhead or tall hazards such as power lines or telephone cables, antennas, and tall or leaning trees. If you see any of these hazards, immediately inform the flight crew because an alternative landing site may be required. The flight crew may request that the hazard be marked or illuminated by weighted cones or that an emergency vehicle with its lights turned on be positioned next to or under the potential hazard. To mark the landing site, use weighted cones or position emergency vehicles at the corners of the landing zone with the headlights facing inward to form an X. This procedure is essential during night landings as well. It is common for fire suppression personnel to help mark the landing site because they are often called to the scene to stand by. Never use caution tape or ask people to mark the site. Do not use flares because not only can they become airborne, but they also have the potential to start a fire or cause an explosion. Move all nonessential people and vehicles to a safe distance outside of the landing zone. If the wind is strong, radio to the flight crew the direction of the wind. They may request that you create some form of wind directional device to aid their approach.
Landing Zone Safety and Patient Transfer The most important rule is to keep a safe distance from the aircraft whenever it is on the ground and "hot" (when the helicopter blades are spinning). The rotor blades will usually remain running because the flight crew does not expect to remain on the ground for long. All EMTs should stay outside the landing zone perimeter unless directed to come to the aircraft by the pilot or a member of the flight crew. Usually, the flight crew will come to the EMTs carrying their own equipment and do not require any assistance inside the landing zone. If you are asked to enter the landing zone, stay away from the tail rotor; the tips of its blades move so rapidly that they appear invisible. With the possible exception of a rear-loading aircraft, always approach a helicopter from the front, even if it is not running, and approach only after the pilot signals it is clear to do so. If you imagine the front of the helicopter as the number 12 on a clock, then you should enter only the area between the 10 o'clock and 2 o'clock positions. If you must move from one side of the helicopter to another, go around the front. Never duck under the body, the tail boom, or the rear section of the helicopter because the pilot cannot see you in these areas. On many aircraft, the main rotor blade is flexible and may dip as low as 4 feet off the ground. When you approach the aircraft, walk in a crouched position. Wind gusts can alter the blade height without warning, so protect your equipment as you carry it under the blades. Air turbulence created by the rotor blades can blow off hats and loose equipment. These objects can become a danger to the aircraft and personnel in the area. When accompanying a flight crew member, follow directions exactly. Never open any aircraft door or move equipment unless instructed by a crew member. When told to approach the aircraft, use extreme caution and pay constant attention to hazards.
Special Considerations Special considerations you should be aware of in medivac situations include: Night landings Landing on uneven ground Medivacs at HazMat incidents
Night landings Nighttime operations are considerably more hazardous than daytime operations because of the darkness. The pilot will generally fly over the area at least twice at varying altitudes with the helicopter's lights on in order to identify potential obstacles and overhead wires, which can be hard to see. Do not shine spotlights, flashlights, or any other lights in the air to help the pilot; they may temporarily blind the pilot. Instead, direct low-intensity headlights or lanterns toward the ground at the landing site from opposite corners to form an X at the center of the landing zone. Turn off all headlights or lanterns that are facing in the direction of the aircraft once it has landed. After the helicopter has landed, do not aim lights near the aircraft. Always make certain the flight crew is aware of any overhead hazards or obstructions, and illuminate these if possible. Landing on uneven ground If the helicopter must land on a grade (uneven surface), extra caution is advised. The main rotor blade will be closer to the ground on the uphill side. In this situation, approach the aircraft only from the downhill side or as directed by the flight crew. Do not move the patient to the helicopter until the crew has signaled that they are ready to receive you. Medivacs at HazMat incidents Notify the flight crew immediately of the presence of HazMat at the scene. The aircraft generates tremendous wind and may easily spread any HazMat vapors present. Always consult the flight crew and incident commander about the best approach and distance from the scene for a medivac. The landing zone should be established upwind and uphill from the HazMat scene. Any patients who have been exposed to a HazMat must be properly decontaminated before you load them into the aircraft.
Arrival at the Scene Immediately size up the scene by using the following guidelines: Look for safety hazards to yourself, your partner, bystanders, and your patient(s). Evaluate the need for additional units or other assistance. Determine the mechanism of injury (MOI) in trauma patients or the nature of illness (NOI) on medical calls. Evaluate the need to immobilize the spine. Follow standard precautions. The type of care that you expect to give will dictate the personal protective equipment you should wear. If you are the first to arrive on the scene of a mass-casualty incident, inform dispatch that you've arrived and give a brief report of what you see. Also report any unexpected situations, such as the need for additional units, a heavy rescue unit, or a HazMat team. Do not enter the scene if there are any hazards. If there are hazards at the scene, move the patient somewhere safe before you begin care. The patient may have to be moved by others if you are not appropriately equipped. Quickly estimate the number of patients and communicate with the incident commander.
Safe Parking Pick a position that will allow for efficient traffic control and flow around a crash scene. Do not park alongside the scene, as you may block the movement of other emergency vehicles. Park in front of or behind the scene, depending on whether other responders have arrived. The first vehicle to arrive on scene should: Park about 100 feet before the scene on the same side of the road. Create a barrier between the scene and oncoming traffic. If other responders have not arrived on scene, the ambulance can be positioned to block the scene to prevent oncoming traffic from getting too close. It is best to park uphill and/or upwind of the scene if smoke or hazardous materials are present. Always leave on your warning lights or devices, and use extra caution if you must park on the backside of a hill or curve. Do the same when parking at night. Always provide a cushion of space between your vehicle and operations at the scene. Stay away from any fires, explosive hazards, downed wires, and structures that might collapse. Set the parking brake. If your vehicle is blocking part of the roadway, leave on the emergency warning lights. Turn off headlights to prevent impairing the vision of oncoming traffic. Within these safety guidelines, you should try to park your ambulance as close to the scene as possible to facilitate emergency medical care. If necessary, you can temporarily block traffic to unload equipment and to load patients quickly and safely. Try to do it quickly so traffic is not blocked any longer than necessary. Park in a location that does not hamper leaving the scene. Remember to lock all doors when leaving the ambulance and ensure the designated driver has the keys.
Safe Driving Practices Wear restraints en route to the scene and whenever you are not performing direct patient care. Patients should be properly restrained. Unrestrained or improperly restrained patients and medical equipment (especially portable oxygen tanks) may become airborne during a crash and place you and your patient at an additional risk. All equipment and cabinets must be secured, as well as the patient and any passengers accompanying the patient. Getting a feel for the proper brake pressure comes with experience and practice. Each vehicle has a different braking action. The brakes on types I and III vehicles have a heavier feel than the brakes on a type II vehicle. The braking system on a diesel-powered unit will be different from the braking system on an identically equipped gasoline-powered unit. Certain heavy vehicles use air brakes, which have yet another feel. When driving an ambulance on a multilane highway, you should usually stay in the extreme left-hand (fast) lane. This allows other motorists to move over to the right when they see or hear the ambulance approach.
Siren Risk-Benefit Analysis Factors to consider in your siren risk-benefit analysis include: Local protocols Some local protocols require that all responses to the scene use emergency lights and siren, whereas other systems incorporate response modes based on the information received from dispatch. Patient condition Patients who have experienced a seizure may have another seizure as a result of the rapid flash pattern of the emergency lighting. In cases such as this, it may be better to transport your patient without lights and siren activated to minimize external stimuli and to prevent making your patient's condition worse. Anticipated clinical outcome of the patient Regardless of your jurisdictional requirements, as the driver of the ambulance, you need to evaluate the risk versus benefit of your response mode.
Driver Anticipation Whenever a motorist yields the right-of-way, the emergency vehicle operator should attempt to establish eye contact with the other driver. When anticipating how motorists may respond to your lights and siren, always assume that they will react in a manner that may cause a crash. You can also look at the direction of the other vehicle's front tires to get an early indication of which way the vehicle will turn. It is often difficult for motorists to hear instructions called out over the ambulance's PA system, especially when their windows are rolled up. The PA system may make the situation worse because motorists may hesitate or make unexpected moves in the attempt to hear or follow instructions. When the driver of the ambulance is shouting to motorists and pedestrians over the PA system, he or she is distracted from the business of driving and forced to handle the microphone when both hands should be on the steering wheel. Avoid using the ambulance's PA system during emergency driving. Always drive defensively. Never rely on what another motorist will do unless you get a clear visual signal. Be prepared to take defensive action in the case of a misunderstanding, panic, or careless driving on the part of the other driver.
The Cushion of Safety There are three blind spots around the ambulance that you cannot see with side or rearview mirrors: The rearview mirror creates a blind spot, obstructing the view ahead and preventing the driver from seeing objects such as a pedestrian or vehicle. Many new ambulance drivers will not be used to the larger mirrors on ambulances. To eliminate this blind spot, lean forward in your seat so the mirror does not obstruct the view, especially when making turns at intersections. The rear of the vehicle cannot be seen fully through the mirror. Because of the configuration of today's ambulances and the relative height of the vehicle, the rearview mirror generally gives the driver only a view of the patient compartment and is not intended to be used for alerting the driver of a vehicle behind the ambulance. Because of this blind spot, many crashes occur when the ambulance driver is backing up. It is highly recommended, and required in many jurisdictions, that a spotter be used to help you back up the vehicle. Rear-facing cameras are also helpful and much more common; however, they do not replace the use of a spotter if one is available. The side of the vehicle often cannot be seen through the side view mirrors at a certain angle. Entire vehicles may not be seen in the mirror, even though they are right next to the ambulance. To eliminate this problem, many EMS systems place small rounded mirrors on the side mirrors to assist you in visualizing this blind spot. If these mirrors are not available, you need to lean forward or backward in the seat to help eliminate the blind spot, especially when shifting lanes or making turns. Scan your mirrors frequently for any new hazards to maintain your cushion of safety, but keep in mind that your mirrors can give you a misleading view and may block people or vehicles. Adjust your position in the driver's seat to avoid blind spots in your mirrors. Keeping a safe distance between your vehicle and the one in front of you, checking for tailgaters behind your ambulance, and keeping aware of vehicles potentially hiding in your mirror's blind spots are considered maintaining a cushion of safety. If you are being tailgated: Never speed up to create more distance. Slamming on your brakes to scare the other driver does not work either and may also cause a crash. The best method for distancing yourself from the vehicle is to slow down. Generally, tailgaters are impatient and will speed up past you. You can also have your dispatcher contact the local police to let them know that someone is driving recklessly behind you. Never, under any circumstance, get out of the ambulance to confront a driver. This will only delay your response or transport of the patient and can lead to a dangerous situation. It is also unprofessional for you to become involved in a verbal argument with any member of the public and may lead to disciplinary actions or termination, depending on your service's conduct regulations.
Traffic Control The purposes of traffic control are to ensure an orderly traffic flow and to prevent another crash. Passing motorists often slow down and stare, paying little attention to the roadway in front of them. Some curiosity seekers may park down the road and return on foot, creating additional hazards. As soon as possible, place appropriate warning devices, such as reflectors, on both sides of the crash. The main objectives in directing traffic are to: Warn other drivers Prevent additional crashes Keep vehicles moving in an orderly manner so care of injured people is not interrupted
The Transfer Phase In almost every case, you will provide lifesaving care right where you find the patient, before moving the patient to the ambulance. You may then begin less critical measures, such as bandaging and splinting. Package the patient for transport, securing him or her to a device such as a backboard, a scoop stretcher, or the wheeled ambulance stretcher. Move to the ambulance and properly lift the patient into the patient compartment. Be sure to secure the patient with at least three straps across the body. Use deceleration or stopping straps over the shoulders to prevent the patient from continuing to move forward in case the ambulance suddenly slows or stops. This is especially important if the patient is lying flat or secured to a backboard.
Portable suctioning units must be powerful enough to generate a vacuum of 300 mm Hg when the tube is clamped.
The most common cause of AED malfunction is a dead battery.
Why call for a medivac? The transport time to the hospital by ground ambulance is too long considering the patient's condition. Road, traffic, or environmental conditions limit or completely prohibit the use of a ground ambulance. The patient requires advanced care that you are unable to provide, such as administering pain medications or other specialized medications and inserting advanced airways. There are multiple patients who will overwhelm resources at the hospital reachable by ground transport. The helicopter may respond directly to the scene or it may be called to the hospital to transfer a patient to a facility with the capacity to provide definitive care for the patient's condition.
Whom do you call? Generally, your dispatcher must be notified first. In some regions, after the medivac has been initiated, the ground EMS crew may be able to access the flight crew on a specially designated radio frequency for one-on-one communications. It is important to keep this frequency clear of chatter and lengthy communications. You may be asked to give a brief presentation or update on the patient's condition. Speak clearly and concisely, avoiding information that is not pertinent. Medical evacuations should be used for patients with time-dependent injuries or illnesses. Patients suspected of having a stroke, heart attack, or serious spinal cord injury, such as injuries sustained in a motor vehicle crash or while diving into a swimming pool or horseback riding, often require medivac service. Serious conditions that may require the use of helicopter medivacs may be found in remote areas and involve scuba diving accidents, near drownings, or skiing and wilderness accidents. Other patients who may require medical evacuation are trauma patients; candidates for limb replantation (for amputations); and patients requiring air transport to a burn center, a hyperbaric chamber center, or a venomous bite center. Because specific criteria vary by service, familiarize yourself with the criteria in your system used to call for this lifesaving service.
The Star of Life indicates vehicles that meet federal specifications as licensed or certified ambulances.
You may be allowed to drive faster than the speed limit, but you will still be liable if an accident occurs.
Another development is the use of first-responder vehicles, which respond initially to the scene with personnel and equipment to treat the sick and injured until an ambulance can arrive.
first-responder vehicles Specialized vehicles used to transport EMS equipment and personnel to the scenes of medical emergencies.