Transport Operations Lecture

Emergency Vehicle Design AN ambulance is a vehicle that is used for treating and transporting patients who

need emergency medical care to a hospitalo First motor-powered ambulance was introduced in 1906o The hearse was the vehicle most often used as an ambulance for decades

No room for EMT to fit in back with patient Today’s ambulance

o Designed according to government regulationso Have enlarged patient compartments

First-responder vehicles have personnel and equipment to treat patients until an ambulance can arrive

Modern ambulance containso Driver’s compartmento Patient compartment big enough for 2 EMTs and two supine patientso Equipment and supplieso Two-way radio communicationo Design for maximum safety and comfort

Type Io Conventional, truck cab-chassis with a modular ambulance body

Type IIo Standard van, forward-control integral cab-body ambulance

Type IIIo Specialty van

Ambulance licensing or certification standards are established by state The Star of Life emblem is affixed to the sides, rear, and roof of the ambulance

Preparation Phase Ensure equipment and supplies are in their proper places and ready for use

o Only store new equipment after proper instruction on its use and consulting with the medical director

o Should be durable and standardized Store equipment and supplies according to how urgently and how often they are

usedo Items for life-threatening conditions at the head of the primary stretchero Items for cardiac are, external bleeding, and blood pressure at the side of the

stretcher Cabinets and drawer fronts should be transparent or labeled

o Should open easily and close securely Medical equipment

o Basic supplies are common supplies carried on ambulanceso Airway and ventilation equipmento CPR equipment

o Basic wound care supplieso Splinting supplieso Childbirth supplieso AEDo Patient transfer equipmento Medicationso The jump kit

Safety and operations equipmento Personal safety equipmento Equipment for work areaso Any major roadmust wear yellow vest if out of ambulanceo Preplanning and navigation equipmento Extrication equipmento Lightso Helmets

Personnelo At least one EMT in the patient compartment during transporto Two EMTs are strongly recommendedo Some services have a non-EMT driver and a single EMT in the patient

compartment Perform daily inspections

o Ambulance inspectiono Inspect cleanliness, quantity, and function of medical equipment and supplies

Review safety precautionso Traffic safety rules and regulationso Proper working order of safety deviceso Properly secure oxygen tankso Properly secure all equipment in cab, rear, and compartments

Dispatch Phase Dispatcher should gather and record

o Nature of the callo Name, present location, call-back numbero Location of patiento Number of patients and severity of their conditionso Other pertinent information

En Route to the Scene Most dangerous phase for EMTs Collisions cause many serious injuries

o Fasten seatbelts and shoulder harnesses before mobbing the ambulanceo Review dispatch informationo Prepare to assess and care for the patient

Arrival at the Scene Perform a scene size-up and report your findings to dispatch

o Safety hazardso Evaluate need for additional unitso Determine MOI/NOIo Evaluate need for spinal stabilizationo Follow standard precautions

Mass-casualty incident (MCI)o Estimate and communicate number of patients to the incident commandero Request additional units through dispatcho The incident command system will be establishedo More patients than resourceso Get on scenego to incident commander

Safe parkingo Allow efficient traffic flow and control around an emergencyo Park 100’ before or past the crash sceneo Do not park alongside a crash sceneo Police on scene go in fronto No policebehindo Park uphill and/or upwind of smoke or hazardouso Leave warning lights or devices ono Keep distance between the emergency vehicle and operationso Stay away from fires, explosive hazards, downed wires, and unstable

structureso Set the parking brakeo Facilitate emergency medical care and rapid transport from the sceneo If it is necessary to block traffic, wok quickly and safely

Traffic controlo Provide care and ensure scene safety first

Ensure orderly traffic flow

Transfer Phase Patient must be packaged for transport

o Secure patient to backboard, scoop stretcher, or wheeled ambulance stretcher

o Lift the patient into compartmento Secure the patient with at least 3 straps

Transport Phase Excessive speed is unnecessary an dangerous When you are ready to leave with the patient, inform dispatch of:

o Number of patients

o Name of receiving hospitalo Beginning mileage of ambulance

Monitor patient’s condition en routeo 15 minutes vs. 5 minutes

Contact receiving hospital Do not abandon the patient emotionally Inform them of whether you are basic or paramedic

Delivery Phase Notify dispatch of your arrival that hospital Report your arrival to the triage nurse Physically transfer the patient Present a complete verbal report

Complete a detailed written report Restock items, if needed

En Route to the Stain Inform dispatch whether you are in service and where you are going Back at the station

o Clean and disinfect the ambulance and equipmento Restock supplies

Postrun Phase Complete and file additional written reports Inform dispatch again of status, locaton, and availability Perform routine inspections Refuel the vehicle Cleaning: process of removing dirt, dust, blood, or other visible contaminants from a

surface of equipment Disinfection: the killing of pathogenic agents by directly applying a chemical made

for that purpose to a surface or equipment High-level disinfectant After each call

o Strip linens from the stretcher and place them in a plastic bag or designate receptacle

o Discard medical wasteo Wash contaminated areas with soap and watero Disinfect all nondisposable equipment used for patient careo Clean the stretch with germicidal/virucidal solution or 1:100 bleach dilution

(quarter cup of bleach: 1 gallon of water)o Clena spillage or other contamination with one of those same solutions

Defensive Ambulance Driving Techniques An ambulance involved in a crash delays patient care, at a minimum

Intersections are biggest cause of these accidents Drier characteristics

o Some states require an emergency vehicle operations courseo Physical fitness and alertness are necessaryo Emotional maturity and stabilityo Respect for other motorists

Safe driving practiceso Speed does not save lives; good care doeso Wear seatbelts and shoulder restraintso Become familiar with how the vehicle accelerates, corners, sways, and stopso Stay in the extreme left-hand lane on multilane highways

Siren risk-benefit analysiso The decision to activate the emergency lighting and sirens will depend on

Local protocols Patient condition Anticipated clinical outcome of the patient

Driver anticipationo Always assume that motorists around your vehicle have not ehad your

siren/public address sytem or seen youo You must always drive defensively

The cushion of safetyo Maintian safe following distanceo Try to avoid being tailgated from behindo Ensure that blind spots do not prvent you from seeing vehicles or

pedestrianso Never get out of the ambulance to confront a driver

Problem of excessive speedo Unncessary, dangerous, and does not increase patient’s chance of survivalo Makes it difficult to provide care in the patient compartmento Hinders driver’s reaction timeo Increass time and distance need to stop the ambulance

Recongition of siren syndromeo Sirn syndrome causes drivers to drive faster in the preence of sirens, due to

increased anxiety Vehicle size and distance judgment

o Crashes often occur when the vehicle is backing up, so use a spottero Size and weight influence braking and sotpping distances

Road positioning and corneringo TO keep ambulance in proper lane when turning, enter high in the lane, and

exit low Weather and road conditions

o MAublances have longer braking time/stopping distanceo Weight is unevenly distributedprone ot roll over

o Be alert for hydroplaning, water on roadway, decreased visibility, and ice and slippery surfaces

More slippery when little rain than a lot of raino Oil rises upcompletely washed away with a lot of rain

Laws and Regulations If you are on an emergency call and are using your warning lights and siren, you

may be allowed to do the followingo Park or stand in an illegal locationo Proceed through a red light or stop sign

Stop, look both ways and then proceed through stop sign or red lighto Driver faster than the speed limito Drive against the flow of traffico Travel left center to make an illegal pass

An emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children

o Until yellow flashing, you cannot pass Use of warning lights and siren

Unit must be true emergency call Both audible and visual warning devise must be used simultaneously

Use of escortso Only use as a guide when you are in unfamiliar territory

Intersection hazardso Intersection crashes are the most common and most seriouso If you cannot wait for traffic lights to change, still come to a momentary stop

Highwayso Shut down emergency lights and sirens until you have reached the far left

lane Unpaved road

o Lower speed

Distractions Minimize distractions from

o Mobile dispatch terminals and GPSo Mounted mobile radioo Stereoo Cell phoneo Eating/drinking

Focus on driving and anticipating roadway hazards

Fatigue Recognize when you are fatigued, and alert your partner or supervisor

Air Medical Operations

Air ambulances are used to evacuate medical and trauma patientso Fixed-wing unitso Rotary-wing units (helicopters)

Specially trained crews accompany air ambulance flightso EMTs provide ground support

Medical evacuation (medivac) is performed by helicopterso Capabilities, protocols, and procedures vary

Medivac may receive extra training Why call for medivac?

o Transport time by group is too longo Road, traffic, or environmental conditions prohibit the use of ground

transporto Patient requires advanced careo Multiple patients will overwhelm resources at the hospital reachable by

ground transport Who receives a medivac?

o Patients with time-dependent injureis or illnesseso Stroke, heart attack, or spinal cord injuryo Scuba diving accidents, near-drownings, or skiing and wilderness accidentso Trauma patientso Candidates for limb replantation, burn center, hyperbaric chamber, or bite

center Whom do you call?

o Generally, dispatcher should be notifiedo IN some regions, EMS may be able to communicate with the flight crew after

initiating the medivac request Establish a landing zone

o Hard or grassy level surface between 60’x60’ and 100’x100’ (recommended (in MA, 100’x100’ is mandatory)

o Cleared of loose debriso Alert the flight crew of overhead or tall hazards o Mark the landing site using cones or vehicleso Move nonessential persons and vehicleso Communicate the direction of strong wind to the flight crew

Landing zone safety and patient transfero Keep a safe distance from the aircraft whenever it is on the ground and “hot”o Stay away from the tail rotoro Never approach the helicopter from the rear

Keep guidelines in mind:o Become familiar with hand signalso Do not approach unless instructed and accompanied by crew

Vehicle Extrication and Special Rescue Lecture

Safety Extrication requires mental and physical preparation

o Consider the safety of yourself and teamo Safety begins with proper mind-set and personal protective gear

Incident Management Lecture

National incident Management System Provides consistent nationwide template Enables federal, state, and local governments to work together

o As well as private and nongovernmental organizations Organizational structure must be flexible enough to be rapidly adapted Provides standardization in

o Terminologyo Resource classificationo Personnel trainingo Certification

Major NIMS componentso ICSo Command and managemento Preparednesso Resource managemento Communications and information managemento Supporting technologieso Ongoing management and maintenance

Incident Command System Sometimes referred to as the incident management system The purpose of the ICS is to

o Ensure responder and public safetyo Achieve incident management goalso Ensure the efficient use of resources

Controls duplication of effort and freelancing Limits the span of control

o One supervisor fro three to seven workers Organizational divisions include sections, branches, divisions, and groups Operations, Planning, Logistics, Finance

o Each goes to branch and then to division or group EMSTriage, Treatment, and Transport Command

o Incident commander (IC) is in charge

o It is important that you know how the IC is, where the command post is located, and how to communicate with your supervisor

o An IC may turn over command to someone with more experience in a critical area

Financeo Documenting expenditures at an incident for reimbursement

Logisticso Equipment, facilities, food and water, fuel, lighting, and medical

equipment/supplies Operations

o Managing tactical operations usually handled by the ICo Supervise people working at the scene

Planningo Solves problems as they ariseo Develops an incident action plan

Command staffo Public information officer (PIO) provides the media with clear informationo The liaison officer relays information and concerns among command and the

staffo The safety officer monitors the scene for conditions or operations that may

present a hazard

Communications and Information Management Communication= weak point It is recommended that communications be integrated

o All agencies should be able to communicate quickly via radioso Communications allow for accountability and instant communication

Mobilization and Deployment Accountability means keeping your supervisor advised of your location, actions, and

completed tasks Once the incident ahs been stabilized, the IC will determine which resources are

needed and when to begin demobilization

EMS Response Within the Incident Command System Preparedness

o Decisions made and basic planning done before an incident occurso Involves decisions and planning about he most likely natural disasters for the

areao Your EMS agency should have written disaster plans that you are regularly

trained to carry out Scene size-up

o Make an initial assessment and some preliminary decisions What do I have?

What do I need to do? What resources do I need?

Establishing commando Command should be established by most senior official

Communicationso If possible, use face-to-face communications to limit radio traffico If you communicate via radio, do not use codes or signalso Equipment must be reliable, durable, and field-testedo Be sure there are backups in place

Medical Incident Command Also known as the medical (or EMS) branch of ICS

o Primary roles: triage, treatment, and transport of injured people Triage supervisor

o In charge of counting/prioritizing patientso Ensures that every patient receives initial assessment of his or her conditiono Do not begin treatment until all patients are triaged

Treatment supervisoro Locates and sets up the treatment area with a tier for each priority of patiento Ensures that secondary triage is performed and that adequate patient care is

giveno Assists with moving patients t the transportation area

Transportation supervisoro Coordinates transportation and distribution of patients to appropriate

receiving hospitalso Communicates with the area hospitalso Documents and tracks the number of vehicles transporting, patients

transported, and the facility destination Staging supervisor

o Should be assigned when scenes require response by numerous emergency vehicles or agencies

o The staging area should be established away from the sceneo Place ambulances in separate area and call them in when neededprevents

cluster Physicians on scene

o Make difficult triage decisionso Secondary triage decisions in the treatment sectoro Provide on-scene medical direction for EMTso Provide care in treatment sector as appropriate

Rehabilitation supervisoro Establishes an area that provides protection from the elements and situationo Monitors responders for signs of stresso Rehabilitation is where a responder’s needs for rest, fluids, food, and

protection from the elements are met

Extrication and special rescueo Determines type of equipment and resources needed for the situationo Usually function under the EMS branch of the ICS

Morgue supervisoro Works with area medical examiners, coroners, disaster mortuary assistance

teams, and law enforcement agencies to coordinate removal of bodies and body parts

o The morgue area should be out of view of the living patients and other responders

Mass-Casualty Incidents A mass-casualty incident (MCI) is:

o Any call involving three or more patientso Any situation that requires a mutual aid responseo Any incident that has the potential for one of these situationso Any event that overwhelms your resources

Bus or trains crashes and earthquakes are exampleso Other causes, smaller in scope, are more common

Triage “Triage” means “to sort” patients based on the severity of their injuries

o Assessment is brief and patient condition categories are basico Primary triage is done in the field30 seconds per patiento Secondary triage is done as patients are brought to the treatment area

Four common categories give the order of treatment and transporto Immediate (red)

Pregnant Paralysis Chest pain Extreme pain

o Delayed (yellow) Significant soft-tissue Severely broken bones

o Minor or minimal (green; hold) Walking wounded

Have the ability to walko Expectant (black; likely to die or dead)

Tagging patients early assists in tracking them and can help keep accurate record of their condition

o Tags should be weatherproof, easily read, and color-coded START Triage

o Simple Triage And Rapid Treatmento Call out to patients and direct them to an easily identifiable landmarko Injured persons are the walking wounded

o Asses the respiratory, hemodynamic, and neurologic status of the nonambulatory patients

JumpSTART triage for pediatric patientso Intended for use in children younger than 8 years or who appear to weigh

less than 100 lbo Begin by identifying the walking woundedo If a child has no pulse or does not begin to breathe after rescue breaths, label

him or her as expectant Triage special considerations

o Patients who are hysterical and disruptive to rescue efforts may need to be made an immediate priority

o A rescuer who becomes sick or injured during the rescue effort should be handed as an immediate priority

o Identify patients as contaminated or decontaminated in HazMat incidents Destination decisions

o All patients triaged as immediate or delayed should be transported by ground or air ambulance

o In large situations, a bus may transport the walking woundedo Immediate-priority patients should be transported two at a time until all are

goneo Then patients in the delayed category can be transported two or three at a

timeo Finally, the slightly injured are transportedo Expectant patients whoa re still alive would receive treatment and transport

lasto Dead victims are handled or transported according to the SOP for the area

Disaster Management A disaster is a widespread event

o Disrupts the functions and resources of the communityo Threatens lives and propertieso Many disasters may not involve personal injuries, but many disasters (floods,

fires, hurricanes) result in widespread injuries Your role is to respond when requested and report to the IC for assigned tasks

o A casualty collection area may be established in a disaster with an overhwlming number of casualties

Introduction to HazMat Arrivalfirst step back and assess situation According to HAZWOPER, first responders at the awareness level should have

sufficient training or experience in following areaso An understanding of what hazardous substances are and the risks associated

with themo An understanding of the potential outcomes of an incident

Department of Transportation Marking System Explosive (1) G (2) Flammable (3) S (4) Oxidizer (5) P (6) Radiactive (7) Corrosive Misc.

References MSDS

o Explain chemical Book on each ambulance

HazMat Scene Operations Hot Zone

o Hazardous materialo Only HazMat crew allowedo Area immediately surrounding the releaseo Most contaminated areao Everyone leaving hot zone must be decontaminated

Warm Zoneo Decontamination corridoro Where people are washed and cleaned

Cold Zoneo Incident Commandero Command Post

If you can walkgo to warm zone as directed Decontamination tent lays across warm/cold zones EMTs work solely in the cold zone

Level A, B, C, D for HazMat Suits EMT= Level D

Terrorism Response and Disaster Management

What is Terrorism? Only a small % of groups actually turn toward terrorism to achieve their goals Terrorist forces began since early civilizations

o Common in Middle East Terrorism does not truly attack a certain party, it is used to institute fear into people Violent religious groups/doomsday cults

o Map participate in apocalyptic violence Extremist political groups

o Include violent separatist groups and those who seek political, religious, economic, and social freedom

Technology terroristso Those who attack a population’s technological infrastructure

Single-issue groupso Include antiabortion groups, animal rights groups, anarchists, racists,

ecoterrorists

Weapons of Mass Destruction Also called weapons of mass casualty Any agent designed to bring about:

o Mass deatho Casualtieso Massive damage to property and infrastructure

B-NICE and CBRNE and mnemonics for the kinds of WMDs B-NICE

o Biologico Nuclearo Incendiaryo Chemicalo Explosive

Explosives have been the preferred WMD Chemical agents consist of

o Vesicants (blister agents)o Respiratory agents (choking agents)o Nerve agents (e.g. organophosphates; pesticides)o Metabolic agents (cyanides)

Biologic terrorism/warfareo Biologic agents are organisms that cause diseaseo The primary types are

Viruses Bacteria Toxins

Nuclear/radiologic terrorismo Only two publicly known incidents: Hiroshima and Nagasakio These materials are far easier for a determined terrorist to acquire and less

expertise to useo “Dirty bombs” can cause widespread panic

EMT Response to Terrorism Basic foundations of patient care remain the same

o However, treatment can and will vary Recognizing a terrorist event

o Most acts of terror are coverto You must know the current threat level issued by the Department of

Homeland Security (DHS) Severe High Elevated Guarded Low

Homeland security advisory system alerts responders to the potential for an attacko Specifics of current threat will not be given

On every call, you must make the following observations:o Type of locationo Type of callo Number of patientso Victims’ statementso Preincident indicators

Response Actions Responder safety

o The best form of protection is preventing yourself from coming in contact with the agent

o Contamination occurs when you have direct contact with the WMDo Cross-contamination occurs when you come in contact with a contaminated

person

Notification procedureso Notify dispatcher of

Nature of event Any additional resources that may be required Estimated number of patients The upwind or optimal route of approach

o Establish a staging areao Trained responders in PPE are the only persons equipped to handle the

WMD Establishing command Secondary device or event

o Additional explosives are se to explode after the initial bombo Intended primarily to injure responders and to secure media coverageo May include types of electronic equipment such as cell phones or pagers

Chemical Agents Liquids or gases that are dispersed to kill or injure

o Persistent (nonvolatile) agents can remain on a surface for long periodso Nonpersistent (volatile) agents evaporate rapidly

Route of exposure is a term used to describe how the agent most effectively enters the body

o Agents with a vapor hazard enter through the respiratory tract in the form of vapors

E.g. Anthrax (85% death rate through respiratory tract)o Agents with a contact hazard give off very little vapor or no vapors and enter

through the skin

Vesicants Primary route is the skin

o If vesicants are left on the skin long enough, they produce vapors that can enter the respiratory tract

Cause burnlike blisters to form on the victim’s skin and in the respiratory tract Usually cause most damage to damp or moist areas of the body Signs of vesicant exposure on the skin

o Skin irritation, burning, and reddeningo Immediate, intense skin paino Formation of large blisterso Gray discoloration of skino Swollen and closed or irritated eyes

Sulfur mustard (H)o Brownish, yellowish oily substanceo Generally considered very persistento Attacks vulnerable cells within bone marrow and depletes the body’s ability

to reproduce white blood cells

o Begins an irreversible process of damage to the cells Lewisite (L) and phosgene oxime (CX)

o Produce blister wounds very similar to those caused by mustard Vesicant agent treatment

o No antidotes for mustard or CX exposureo Ensure that patient has been decontaminated before the ABCs are initiatedo Transport as soon as possibleo Generally, burn centers are best equipped to handle the wounds and

infections

Pulmonary Agents Gases that cause immediate harm to persons exposed to them Primary route is through respiratory tract Symptoms:

o Dyspneao Tachypnea

Chlorine (CL)o Initially, produces upper airway irritation and a choking sensationo May later experience

Shortness of breath Chest tightness Hoarseness and stridor Gasping and coughing

Phosgeneo Product of combustiono Very potent agent with a delayed onset of symptoms

Treatmneto Remove patient from cotnamianted atmosphereo ABCs

Nerve Agents Among most deadly chemicals Can cause cardiac arrest G series Tabun, Sarin, Soman, V agent Nerve agents all produce similar symtpoms but have varying routes of entry SLUDGEM

o Salivation, sweatingo Lacrimationo Urinationo Defecation, Drooling, Diarrheao Gastric upseto Emesiso Muscle twitching/miosis (pinpoint pupils)

Treatmento Mark 1 Nerve Agent Antidote Kit (NAAK)

Ctonains atropine and 2-PAMo Multiple doeses may need to be administered

Metabolic Agents Hydrogen cyanide (AC) and cyanogen chloride (CK) High doeses

o Tachycardiao Tachypneao Seizureso Comao Apneao Cardiac arrest

Cyanide agent treatmento All clothes removed to prevent off-gassing in the ambulanceo ABCso No antidotetransport

Biologic Agents Can be almost completely undetectable Communicability: how easily the disease is able to spread Incubation: period of time between the person becoming exposed to the agent and

when symptoms begin Dissemination is the means by which a terrorist will spread the agent A disease vector is an animal hat spreads disease to another animal

Viruses Germs that require a living host to multiply and survive Replicates itself to spread through host after invading host Smallpox is highly contagious

o Examination gloveso HEPAo Eye protectiono Observe the size, shape, and location of the lesions

Ciral hemorrhagic fever (VHF)o Blood in body to seep out from tissues and blood vesselso Flulike symtpmsinternal/external hemorrhaging

Bacteria Need no host to multiply and live Most fought with antibiotics Most begin with flulike symptoms Inhalation and cutaneous anthrax

o Caused by deadly bacterium that lays dormant in a sporeo Routes: inhalation, cutaneous, and gastrointestinalo Pulmonary anthrax is most deadlyo Antibiotics can be used to treat anthrax successfully

Plagueo Natural vectors are rodents and fleaso Infects lympathic system and creates buboes

Neurotoxins Most deadly substances known to humans Botulinum toxin

o Most potent neurotoxino Produced by bacteriao Voluntary muscle control diminisheso Causes muscle paralysis, leading to respiratory arresto Affects nervous system

Ricino Causes pulmonary edema and respiratory and circulatory failure leading to

deatho Treat: cardiovascular support and respiratory support as needo Quite stable and extremely toxic

Other EMT Roles Syndromic surveillance

o Monitoring of patients presenting to EDs and alternative care facilitieso Patients with signs and symptoms that resemble influenza are importanto Quality assurance and dispatch need to be aware of an unusual number of

calls from patients with “unexplainable flu” Points of distribution (POD)

o Established in the time of need for the mass distribution of antibiotics, antidotes, vaccinations, and other medications

o Deliver “push packs” to anywhere in country within 23 hours

Radiologic/Nuclear Devices Alpha/beta/gamma

Incendiary and explosive devices Notify authorities and safely evacuate the area Always remember that there is a possibility of a secondary device Primary, secondary, and tertiary blast injuries

o (Primary: hollow organ injury)o Secondary: debriso Tertiary: thrown against something

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