Chapter 37 Transport Operations

Extrication Equipment

12inch wrench, adjustable, open end 12inch screwdriver, standard square bar 8inch screwdriver, Phillips head #2 Hacksaw with 12nich carbide wire blades Vise-grip plier, 10 inch 5lb hammer with 15 inch handler Fire axe, 24 inch handle Wrecking bar with 24 inch handle 51 inch crowbar pinch point Bolt cutter with 1 inch to 1.25 inch jaw opening Folding shovel Tin snips, double action 8inch minimum Gauntlets, reinforced leather covering past, midforearm Rescue blanket Ropes 5400lb Mastic kife Spring lad center punch Roll of duct tape Pruning saw Heavy duty (2x4) and (4x4)

CPR board

A device that provides a firm surface under the patient's torso.

The modern ambulance has the following features:

A driver's compartment A patient compartment that can accommodate two EMTs and usually two supine patients (one on the stretcher, one on a bench or area designed with swivel seats to accommodate a backboard) positioned so at least one of the patients can receive CPR during transport Equipment and supplies to provide emergency medical care at the scene and during transport, to safeguard personnel and patients from hazardous conditions, and to carry out light extrication procedures Two-way radio communication so ambulance personnel can speak with the dispatcher, the hospital, public safety authorities, and online medical control Design and construction that ensure maximum safety and comfort

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.

You must carry at least one sterile emergency obstetric kit that includes the supplies listed in the table, including:

A pair of surgical scissors Hemostats or special cord clamps Umbilical tape or sterilized cord A small rubber bulb syringe Towels Gauze sponges Pairs of sterile gloves Plastic wrap Sanitary napkins A plastic bag A baby stocking cap A baby blanket

Basic supplies for dressing open wounds include:

A pair of trauma shears Sterile sheets Sterile burn sheets Adhesive tape in several widths Self-adhering, soft roller bandages Sterile dressings Gauze Abdominal or laparotomy pads Sterile universal trauma dressings Sterile, occlusive, nonadherent dressings (aluminum foil sterilized in original package) An assortment of adhesive bandages Tourniquets

spotter

A person who assists a driver in backing up an ambulance to help adjust for blind spots at the back of the vehicle

Each ambulance should carry the following patient transfer equipment:

A primary wheeled ambulance stretcher A wheeled stair chair for use in narrow spaces A long backboard A short backboard or short immobilization device

Other patient transfer devices that can be used include:

A scoop stretcher A portable/folding stretcher A flexible stretcher A basket stretcher

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.

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.

Medication and other supplies

Activate charcoal Drinkable water and cups Oral glucose Oxygen Supplies for irrigating the skin and eyes Aspirin and epinephrine DuoDote or other regional equipment Portable radio or cell phone

Splinting Supples

Adult and Child size traction splint A variety of arm and leg splints, such as inflatable, vacuum, cardboard, plastic, foam-covered wire-ladder or aluminum alloy, or padded board A variety of triangular bandages and roller bandages Short backboard/ short immobilization device Long backboard Cervical collars Head Immobilization devices

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.

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.

For every emergency request, the dispatcher should gather and record the following minimum information:

The nature of the call The name, present location, and call-back telephone number of the caller The location of the patient(s) The number of patients and some idea of the severity of their conditions Any other special problems or pertinent information about hazards or weather conditions

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

Examples of supplies for splinting fractures and dislocations that may be carried on ambulances include:

An adult-size and a child-size traction splint A variety of arm and leg splints, such as inflatable, vacuum, cardboard, plastic, foam wire-ladder, or padded board A variety of triangular bandages and roller bandages Both a short and a long backboard Head immobilization devices Cervical collars in an adjustable size or a variety of sizes

Phases of an Ambulance Call

An ambulance call has nine phases. These nine phases address the vehicle and its crew and their roles when responding to a medical emergency. The details of patient care are not included in these nine phases.

blind spots

Areas of the road that are blocked from your view by your vehicle or mirrors.

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.

The Dispatch Phase and En Route to the Scene

As you and your partner prepare to respond to the scene, make sure you fasten your seat belts and shoulder harnesses before you move the ambulance. Inform dispatch that your unit is responding and confirm the nature and location of the call. This is also an excellent time to ask for any other available information about the location. Review dispatch information about the nature of the call and the location of the patient. Assign specific initial duties and scene management tasks to each team member, and decide what type of equipment to take initially. Depending on your operating procedures, you may also decide which stretcher to take to the patient.

The ambulance should carry at least two oxygen supply units: one portable and one installed on board.

The portable unit should be located near a door or in the jump kit for easy use outside the ambulance. It should have a minimum capacity of 500 L of oxygen and be equipped with a yoke, pressure gauge, flowmeter, oxygen supply tubing, nonrebreathing mask, and nasal cannula. This unit must be able to deliver oxygen at a variable rate between 1 and 15 L/min. At least one extra portable 500-L cylinder should be kept on the ambulance. The mounted oxygen unit should have a capacity of 3,000 L of oxygen. It should also be equipped with visible flowmeters that are capable of delivering 1 to 15 L/min that are accessible when you are at the head of the stretcher.

An important part of the preparation phase of an ambulance call is making sure the appropriate medical equipment is available on the ambulance.

Basic Supplies Airway and Ventilation Equipment CPR Equipment Basic Wound Care Supplies Splinting Supplies Childbirth Supplies Automated External Defibrillator Patient Transfer Equipment Medications The Jump Kit

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.

Do not drive if you are taking medications that may cause drowsiness or slow your reaction time. These include:

Cold remedies Analgesics Tranquilizers

Type 1

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

Identify which of the following statements is/are true with regard to laws and regulations governing ambulances. When you are on an urgent call and cannot wait for traffic lights to change, you can proceed through as long as the ambulance's lights and sirens are activated. An emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children and is displaying its flashing red lights or extended "stop arm." When driving on a highway with your emergency devices activated, always travel in the far left-hand lane. The use of the siren is critical in ensuring the fastest possible travel time to the ED. Submit Clear

Correct. An emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children and is displaying its flashing red lights or extended "stop arm," and you should always travel in the far left-hand lane.

Removal of all microbial contamination is accomplished through ________. Cleaning Disinfection High-level disinfection Sterilization Submit

Correct. Sterilization uses a process such as heat to remove all microbial contamination.

Many are equipped with state-of-the-art technology, including:

Defibrillators and monitors that can transmit information directly to the emergency department (ED) Blood- and oxygen-testing equipment Automatic ventilators Automated CPR machines GPS devices Computer-aided dispatch consoles It is very important that the EMT in the passenger's seat operates the mobile data terminal (MDT) and GPS device and does the actual communicating via radio or cell phone, so the driver is freed up to focus solely on the road, particularly when responding on a call. Anything that takes the driver's attention away from the road for even a second greatly increases the risk of a crash.

Include basic items such as:

Disposable gloves Sharps Airway and ventilation equipment Basic wound care supplies Splinting supplies Childbirth supplies An automated external defibrillator (AED) Patient transfer equipment Medications Other regionally appropriate supplies

Other issues you should be aware of include:

Distractions Driving alone Fatigue

History of the Ambulance

During the late 1700s, horse-drawn ambulances were in use in major cities in the United States. American hospitals initiated their own professional ambulance services during the late 1860s. In the late 1800s, ambulance attendants traveled with limited medical supplies, including brandy, a few tourniquets, several assorted bandages and sponges, basic splinting material, and blankets. Today's ambulances are stocked with standard medical supplies.

Driver Characteristics (continued)

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.

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.

Excessive speed

Even in extreme life-and-death emergencies, excessive speed is not indicated. No matter what the situation, you should never travel at a speed that is unsafe for the given road conditions. Excessive speed: Does not increase a patient's chance of survival Results in crashes in which the EMT, the patient, and occupants of other vehicles are killed Makes it difficult for the EMT attending to the patient to be able to provide care Cuts down on the driver's reaction time and increases the time and distance needed to stop the ambulance While many state laws allow emergency vehicles to travel beyond the posted speed limits in emergencies, they offer little or no protection against prosecution should the driver become involved in a motor vehicle crash.

Personnel

Every ambulance must be staffed with at least one EMT in the patient compartment whenever a patient is being transported. Certain situations, such as performing CPR, may require more assistance. Some EMS systems may allow non-EMT drivers to operate the ambulance when warranted by patient condition with two EMTs in the patient compartment. In these instances, the driver is usually a firefighter or law enforcement official who is properly trained to operate the vehicle in emergency situations.

The safe operation of an ambulance involves consideration of:

Excessive speed Siren syndrome Vehicle size and distance judgment

Your equipment might include:

Face shields Gowns, shoe covers, caps Turnout gear Helmets with face shields or safety goggles Safety shoes or boots

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.

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.

There are two basic types of air ambulances:

Fixed-wing Generally are used for interhospital patient transfers over distances greater than 100 to 150 miles Your role in fixed-wing aircraft transfers probably will be limited to providing ground transport for the patient and medical flight crew between the hospital and the airport. Rotary-wing (helicopters) Used for shorter distances Most helicopters that are used for emergency medical operations fly well in excess of 100 mph in a straight line, without road or traffic hazards, straight to a hospital helipad. The crew may include flight paramedics, flight nurses, specialty providers such as respiratory therapists, and/or physicians.

air ambulances

Fixed-wing and rotary-wing (known as helicopters) aircrafts that have been modified for medical care; used to evacuate and transport patients with life-threatening injuries to treatment facilities.

Oxygen-powered devices are also available to provide ventilation to a patient, but may quickly deplete available oxygen sources.

Follow local guidelines to identify the specific ventilation equipment carried on the ambulance.

The ambulance inspection should include checking:

Fuel level Oil level Transmission fluid level Engine cooling system and fluid levels Batteries Brake fluid Engine belts Wheels and tires, including the spare, if there is one Check inflation pressure and look for signs of unusual or uneven wear. All interior and exterior lights Windshield wipers and fluid Horn Siren Air conditioners and heaters Ventilating system Doors Make sure they open, close, latch, and lock properly. Communication systems, vehicle and portable equipment All windows and mirrors Check for cleanliness and position.

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.

Potential road dangers include:

Hydroplaning Water on the roadway Decreased visibility Ice and slippery surfaces

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.

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.

An emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children and is displaying its flashing red lights or extended "stop arm."

If you approach a school bus that has its lights flashing, you should stop before reaching the bus and turn off your siren. Wait for the bus driver to make sure the children are safe, close the bus door, and turn off the flashing lights. Only then may you carefully proceed past the stopped school bus.

Preplanning and navigation equipment

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).

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.

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.

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.

The Transport Phase

Inform dispatch when you are ready to leave with the patient. Report the number of patients you have; the name of the receiving hospital; and, in some jurisdictions, the beginning mileage of the ambulance. Recheck the patient's vital signs en route. Checking them every 15 minutes for a stable patient and every 5 minutes for an unstable patient is a practice that many services use. Continually reassess the patient's clinical situation and record and address new problems and the patient's responses to earlier treatment. Contact the receiving hospital. Inform online medical control about the patient(s) and the nature of the problem(s). Do not abandon the patient emotionally. You are there to help the patient, so use this time to reassure him or her. Some patients, such as very young or older people, may benefit from added attention during transport. Be aware of your patient's level of need.

Intersection Hazards

Intersection crashes are the most common, and usually the most serious, type of crash that ambulances are involved in. Always be alert and careful when approaching an intersection. If you are on an urgent call and cannot wait for traffic lights to change, you should still come to a brief stop at the light; look around for other motorists and pedestrians before proceeding into the intersection. Motorists who "time the traffic lights" present a serious hazard. Another common intersection hazard occurs when the driver of one emergency vehicle follows another emergency vehicle through an intersection without assessing the situation. To signal motorists that a second unit is approaching, use a siren tone that is different from that of the first vehicle.

Check all medical equipment and supplies daily.

Is the equipment functioning properly? Are the supplies clean? Are there enough of them?

A CPR board provides a firm surface under the patient's torso so you can give effective chest compressions.

It also assists in establishing an appropriate degree of head tilt. Only a few ambulances across the country carry this item, so if yours does not have one, use a tightly rolled sheet or towel to raise the patient's shoulders 3 to 4 inches; this will also keep the patient's head in a position of maximum backward tilt and keep the shoulders and chest in a straight position. Caution: Do not use this roll to hyperextend the neck if you suspect a spinal injury.

Medications

It is important that the ambulance carry valid and appropriate medications. Keep the telephone number and radio frequency of online medical control or the local poison control center with you on the ambulance. The back of your clipboard is a good place to keep this information.

School Zones

Lights and sirens tend to attract children to the roadway and create a potential hazard. In many states, it is unlawful for an emergency vehicle to exceed the speed limit in school zones regardless of the condition of the patient.

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

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.

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

medivac

Medical evacuation of a patient by helicopter.

Who receives a medivac?

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.

Automated External Defibrillator

Modern-day EMS was ushered in by the first-ever prehospital use of the defibrillator by a St. Vincent's Hospital ambulance in New York City under the direction of Dr. William Grace in the early 1970s. Now a prehospital standard of care, semiautomated defibrillation equipment or manual monitor/defibrillators that have automated external defibrillation capability, as permitted by regulation and the local medical director, should always be carried on the ambulance.

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.

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.

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.

Items Carried in a Jump Kit

Nitrile, vinyl, or otherv disposable gloves Face shield or masks with gogles Triangular bandages Trauma shears Adhesive tape in various widths Universal trauma dressings Self-adhering soft roller bandages (4x5) and 2x5) Oropharyngeal airways in adults, child, infant sizes BM with masks for adult,children, and infants BP cuff Stethescope Penlight Sterile gauze (4x4) Sterile dressings (6x9) or (8x10) Adhesive tapes Oral glucose Activated charcoal Other medications allowed by local protocols

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.

hydroplaning

Occurs when the tires of a vehicle are lifted off the road surface as a result of water "piling up" underneath them, making the vehicle feel as though it is floating.

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.

Ambulance services that often transport patients on runs lasting longer than 1 hour should consider using a disposable, single-use humidifier for the mounted oxygen system.

On runs of less than 1 hour, humidification is not usually necessary. Humidification may increase a patient's risk of infection unless the equipment is disposable and

Airway management equipment that should be carried on ambulances includes:

Oropharyngeal airways for adults, children, and infants Nasopharyngeal airways for adults and children Equipment for advanced airway procedures if your service is authorized by state regulation and the medical director to perform them

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

Park or stand in an otherwise illegal location Proceed through a red traffic light or stop sign, but never without stopping first Drive faster than the posted speed limit Drive against the flow of traffic on a one-way street or make a turn that is normally illegal Travel left of center to make an otherwise illegal pass

To do the job effectively, your team will need the following equipment:

Personal protective equipment Equipment for work areas Preplanning and navigation equipment Extrication equipment

Additional considerations during the preparation phase include:

Personnel Daily inspections Safety precautions

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.

Basic Supplies

Pillows and pillowcases Sterile sheets \ Blankets Towels Disposable emesis bags Boxes of disposable tissue Bedpan Urinals BP cuffs Stethescope Disposable drinking cups Unbreakable container of wipes Wet wipes Chemical cold/hot packs Sterile irrigation fluid Plastic bags for waste Hypoallergenic nitrile, vinyl, or other dispoasable hypoallergenic gloves Sharps container Set of hearing protectors

Phases of an Ambulance Call

Preparation of a Call Dispatch Enroute Arrival at scene Transfer of the patient to the ambulance En route to the receiving facility At the recieving facility En route to the station Postrun

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

All battery-operated equipment, including the defibrillator, should be operated and checked each day.

Rotate the batteries according to an established schedule.

As part of the arrival phase, you must decide where to park the ambulance to ensure safety and efficient traffic control.

Safe Parking Traffic Control

The Cushion of Safety

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.

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.

Guidelines for Safe Ambulance Driving

Select the shortest and least congested route to the scene at the time of dispatch Avoid routes with heavy traffic congestion Avoid oneway streets Watch carefully for bystanders as you approach the scene Drive withing the speed limit while transporting patients Go with the flow of traffic Always drive defensively Always maintain a safe following distance (Use 4 second rule ) Maintain an open space or cushion in the lane next to you as an escape route in case the vehicle suddenly stops Use your siren if you turn on the meergency lights Always assume other drivers will not hear the siren or see your emergency lights Always excercise due regard for person or property

Auytomated externa defibrillator

Semiautomated defibrillation equipment

Siren syndrome

The siren may have a psychologic effect on EMS providers as well as other drivers. Recognizing that the siren may increase the anxiety of other drivers will help you become aware of your or other drivers' tendencies to drive faster in the presence of sirens. Although a siren signifies a request for drivers to yield the right-of-way, drivers do not always do so. The adrenaline rush you experience may cause you to have limited focus and also interfere with your ability to judge distance or the potential actions of others. One of the biggest mistakes an EMT can make is to assume motorists will hear the siren and take proper action.

Star of Life

The six-pointed star emblem that identifies vehicles that meet federal specifications as licensed or certified ambulances.

Type 3

Specialty van cab with a modular ambulance body that is mounted on a cut-away van chassis

Type 2

Standard van, forward-control integral cab-body ambulance

Right-of-Way Privileges

State motor vehicle statutes or codes often grant an emergency vehicle the right to disregard the rules of the road when responding to an emergency. In doing so, the operator of an emergency vehicle must not endanger people or property under any circumstances. Right-of-way privileges for ambulances vary by state. Some states allow you to proceed through a red light or stop sign after you stop and make sure it is safe to go on. Other states allow you to proceed through a controlled intersection "with due regard," using flashing lights and siren. This means you may proceed only if you consider the safety of all people who are using the highway. If you fail to use due regard, your service may be sued. If you are found to be at fault, you may personally have to pay punitive damages or face civil and criminal sanctions. Get to know your right-of-way privileges. Exercise them only when it is absolutely necessary for the patient's well-being. The use of lights and audible warning devices is a matter of state and local practice and protocol.

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.

The Preparation Phase

Store equipment and supplies in the ambulance according to how urgently and how often they are used. Give priority to items needed to care for life-threatening conditions, including equipment for airway management, artificial ventilation, and oxygen delivery. Place these items 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. Make sure batteries are fresh and equipment is functioning properly. The most common cause of automated external defibrillator (AED) malfunction is a dead battery.

You should be able to tilt the head of the stretcher upward to at least a 60-degree angle, semisitting position. Stretchers must be provided with fasteners to secure them firmly to the floor or side of the ambulance during transport.

Stretcher restraints should be capable of holding the stretcher in place in case the vehicle rolls over. Make certain that the wheeled stretcher is properly locked into position. Make sure there are at least three restraining devices for the patient, such as deceleration or stopping straps over the shoulders.

Childbirthing Supplies

Surgerical scissors Hemostats or special cord clamps Umbilical tape or sterilized cord Small rubber bulb syringe Towels Gauze sponges Sterile gloves Sanitary napkins Plastic bag Baby blanket Baby stocking cap

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.

The Jump Kit

The ambulance must be equipped with a portable, durable, and waterproof jump kit that you can carry to the patient. Think of the jump kit as the 5-minute kit, containing anything you might need in the first 5 minutes with the patient except for the semiautomated external defibrillator, possibly the oxygen cylinder, and portable suctioning unit. The jump kit must be easy to open and secure. The table lists the items that are typically contained in a jump kit.

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.

Carry two portable artificial ventilation devices that operate independently of an oxygen supply: one for use in the ambulance and one for use outside the ambulance or as a spare.

These devices include disposable pocket masks and bag-valve masks (BVMs). BVMs capable of oxygen enrichment and, when attached to an oxygen supply with the oxygen reservoir in place, able to supply almost 100% oxygen should also be carried on the ambulance. Masks for these devices come in a variety of sizes.

The ambulance should carry portable and mounted suctioning units.

These units must be powerful enough to generate a vacuum of 300 mm Hg when the tube is clamped. The suctioning force must be adjustable for use on infants and children. The units should include large-bore, nonkinking suction tubing with semirigid tips available. The installed unit should include a suction yoke, an unbreakable collection canister, suction catheters, water for rinsing the suction tips, and suction tubing, all easily accessible when you are sitting at the head of the stretcher. The tubing must reach the patient's airway, regardless of the patient's position. All components of the suctioning unit must be disposable or made of material that is easily cleaned and decontaminate.

Ambulances do not handle the same as motor vehicles.

They have a longer braking time and stopping distance. The weight of the ambulance is unevenly distributed, which makes it more prone to roll over.

Storage cabinets and kits should open easily.

They should also close securely so they do not fly open while the ambulance is in motion. The fronts of cabinets and drawers should be transparent so you can quickly identify the contents inside; if they are not, be sure to label each container.

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.

Use of Warning Lights and Siren

Three basic principles govern the use of warning lights and siren on an ambulance: The unit, to the best of your knowledge, must be on a true emergency call. Audible and visual warning devices must be used simultaneously. The unit must be operated with due regard for the safety of all others, on and off the roadway. In general, the siren does not help you as you drive, nor does it really help other motorists. If you do have to turn on the siren, tell the patient before you do. Be especially mindful not to increase the speed of the ambulance just because the siren is in use. Always travel at a speed that allows you to stop safely at all times, especially so you are prepared for drivers who do not give you the right-of-way. Never assume that warning lights and siren will allow you to drive through a congested area without stopping or slowing down. Slow down to ensure all drivers are stopping as you approach an intersection, and proceed with caution. Driving through a busy intersection against a directional signal without using the siren may be dangerous and may violate your state law. Some ambulance headlights are equipped with a high-beam flasher unit. These are very visible, effective warning devices for clearing traffic in front of the vehicle.

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.

Basic Wound Care Supplies

Trauma shears Sterile sheets Sterile burn shets Adhesive tape in several widths Self-adhering, soft riller bandages (4x5) (2x5) Sterile dressing (4x40) Sterile universal trauma dressing (10x36) folded into (9x10) Sterile, occlusive, nonadherent dressings Occlusing dressing or chest seals Assortment of adhesive bandages Tourniquets

There are three types of basic ambulance designs:

Type 1 Type 2 Type 3

Unpaved Roadways

Unpaved roadways often have uneven surfaces, as well as large potholes. While responding on this type of roadway, operate the vehicle at a lower speed and maintain a firm grip on the steering wheel to maintain complete control of the ambulance at all times.

Use of Escorts

Using a police escort is an extremely dangerous practice. Other motorists might assume the police vehicle is the only emergency vehicle and not see the ambulance. The only time an escort is justified is when you are in an unfamiliar area and truly need a guide more than an escort. In such cases, vehicles using warning lights or siren should use different tones to alert other motorists and be prepared to stop if needed. If you are being guided, follow at a safe distance. Assume nearby traffic will not be aware of your presence.

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

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.

Factors involved in making a medivac request include:

Weather Typically, helicopters are unable to operate in severe weather conditions such as thunderstorms, blizzards, and heavy rain. The environment/terrain In mountainous or desert terrain, there may be too many hazards in the immediate vicinity to safely land the helicopter in the desired location. Altitude As the elevation increases, the air thins, which makes it more difficult for pilots and patients to breathe. Because of this, helicopters have a maximum limit on flight elevations. Most helicopter services are limited to flying at 10,000 feet above sea level. Airspeed limitations It takes time for helicopters to arrive on the scene because of limitations in airspeed. Typically, medivac helicopters fly between 130 and 150 mph. Cabin size Because of the helicopter cabin's confined space, helicopters are limited in the number of patients that can be safely transported and by the size of the patient that they can safely transport. Although a helicopter may be able to safely lift off with a 500-lb (227-kg) patient, because of his or her size and girth, it may be impossible to safely fit and secure the patient into the cabin area. Cost Typical medivac flights are extremely expensive compared to ambulance transports; however, the level of care may be higher and the overall transport time may be much shorter in the helicopter. The decision to request a medivac should not be based on the perceived ability of the patient to pay the bill, but rather on the medical necessity.

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.

Patient Transfer Equipment

Wheeled ambulance stretcher Wheeled stair chair Other devices also carried on ambulanced include: Scoop stretcher Portable stretcher Flexible stretcher Transfer tarp Basket stretcher

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.

Highways

When responding to an emergency call and you must travel on the highway, turn off your emergency lights and siren until you have reached the far left lane. This minimizes the possibility that other drivers will get confused and not know what to do or where to go. When driving on a highway with your emergency devices activated, always travel in the far left-hand lane. This allows the ambulance to safely pass vehicles, while still leaving a safety corridor on the left side of the ambulance in case of emergency or unexpected obstacles. When you exit the highway, follow the same procedures as when you entered the highway: Turn off all emergency devices. Move onto the off-ramp. Turn on the emergency lights and siren if necessary.

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.

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.

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.

A medical evacuation is commonly known as a medivac and is generally performed exclusively by helicopters.

Why call for a medivac? Who receives a medivac? Whom do you call?

Review your knowledge of the material by answering the following questions. Select whether each statement listed is true or false. You should place items needed to care for life-threatening conditions at the side of the stretcher. TrueFalse A Type I ambulance is a standard van, forward-control integral cab-body ambulance. TrueFalse Portable suctioning units must be powerful enough to generate a vacuum of 300 mm Hg when the tube is clamped. TrueFalse The most common cause of AED malfunction is a dead battery. TrueFalse Submit

You should place items needed to care for life-threatening conditions at the side of the stretcher. TrueFalse Correct. 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 standard van, forward-control integral cab-body ambulance. TrueFalse Correct. 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. Portable suctioning units must be powerful enough to generate a vacuum of 300 mm Hg when the tube is clamped. TrueFalse Correct. 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. TrueFalse Correct. The most common cause of AED malfunction is a dead battery.

Airway and Ventilation Equipment

infection control kits OPA and NPA of various sizes Advanced airway supplies BVMs Mounted suction unit and a portable suction unit Assorted oxygen delivery devices Oxygen supply units Disposable humidifier

Sterilization

is a process, such as the use of heat, that removes all microbial contamination.

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.

Cleaning

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

Vehicle size and distance

judgment Vehicle length and width are critical factors when maneuvering, driving, and parking an emergency vehicle. They are especially important with types I and III vehicles, which are wider than they look from behind the steering wheel. To brake and pass effectively, you must know the width and length of your vehicle. Crashes often occur when the driver is backing up the vehicle, so always use someone outside the ambulance as a ground guide when you are backing up to avoid any incidents. Vehicle size and weight greatly influence braking and stopping distances. Good peripheral vision and depth perception will help you judge distances, but they are no substitute for intensive training, experience, and frequent evaluation of the vehicle.

first-responder vehicles,

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