Some Ambulance Basics Paul Bunge, MD, FACP October, 2014.
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Transcript of Some Ambulance Basics Paul Bunge, MD, FACP October, 2014.
Some Ambulance Basics
Paul Bunge, MD, FACPOctober, 2014
Overview
Ambulance Safety
Transport of suspected or probable Ebola Patients
Scene Safety
Trauma Tips
Ambulance Safety
Ensure Ambulance is Ready
Enough Gasoline
Familiar with area
Driver with experience
Lighting at night (can never have enough)
Ambulance Safety Driver: Only drive. No texting, phoning, eating
Look before exiting vehicle
Make sure equipment is not a danger to the driver and front seat passenger
No giving rides
Secure your gear
Wear your seatbelt
Be careful following another emergency vehicle, people may not recognize you as different
Keep the gear minimal and tied down
Ebola Transport
October, 2014Monrovia
Clinical Features of Ebola
Incubation period 2-21 days
Sudden onset: Fever, headache, chills, malaise, and myalgia GI symptoms common: vomiting, diarrhea,
abdominal pain Hemorrhagic symptoms: in ~45% of cases
Mild: petechiae, epistaxis, ecchymosis, bruising Severe: GI hemorrhage, shock, DIC
Less commonly seen: rash (trunk, shoulders), conjunctivitis, pharyngitis, cough, hiccups
Human-Human transmission Direct contact
Body fluids, blood, respiratory secretion, saliva Breast milk Semen -- up to 90 days following clinical resolution
Nosocomial transmission Reuse of needles and syringes Exposure to infectious tissue, excretions, waste
Funeral exposures Preparation of body for burial
Course of Disease & Virus shedding
Not transmissible prior to onset of symptoms All body fluids can carry virus
Virus quantity increases to death, usually 7-10 days post-onset
Convalescence/resolution of viremia Discharge
Contact
• Slept in the same house as Ebola patient
• Washed the clothes/bedding of someone who died
• Touched body or body fluids of Ebola patient
• Touched the body or body fluids of someone who died
• Took care of someone with suspect Ebola or very sick
• Took care of someone who died
Triaging a Patient with Suspect or Probable Ebola
ETU available?
Transfer to ETU Transfer to Ebola care center
(ECC)
“Dry” symptoms
1. “Wet” symptoms;
2. Confirmed
Yes No
• “Wet” symptoms: vomiting, diarrhea, bleeding, etc.• “Dry” symptoms: no vomiting, diarrhea, bleeding, etc.
If develop
Clinical Care: Fluids
• Dehydration threatens patient’s survival
• Use oral rehydration solution(ORS); Avoid intravenous fluids unless can be delivered safely
• Encourage normal eating
Deaths
Dead bodies are highly infectious
Call burial team right away to remove body
If burial team does not come soon: Always wear advanced PPE when handling body Cover body with sheet Move to separate area if can be done safely
Personal Protective Equipment (PPE)
Basic PPE: Staff in most patient care areas
Advanced PPE: Staff in Ebola care center and maternity ward
Never use your phone while wearing PPE
Additional items for high-risk areas
Everyone: Basic PPE• Closed toe shoes with
covers or boots• Face shield• Gown• Gloves (1 set)
High risk: Advanced PPE• Rain boots
o or closed toe shoes & covers
• 1st set of gloves• Gown• Head cover or hood• Mask• Shield • 2nd set of gloves
o outer set can be rubber• Apron
DOH Standard Operating Procedures
Dead bodies should be transported by the burial team.
The vehicle should have a separate space for the patient being transported and driver. This space should have a divider.
Staff who have direct physical contact with suspected or confirmed Ebola patients (EVD) (e.g. helping the patient to get into the ambulance; providing care to patients during the transport) patients should wear personal protective equipment (PPE).
If the patient is coughing, ask him/her to wear a mask.
When staff are assisting ambulatory patients who are not coughing, vomiting, or who have diarrhoea, PPE should include at least: gloves, face shield, and gown.
DOH Standard Operating Procedures
Properly dispose of PPE’s
PPE is not required for individuals driving or riding in the designated space with the driver, provided there is a barrier space between the patients and driver area and drivers or riders will not touch any patient or any person accompanying the patient.
DOH Standard Operating Procedures
Ambulances and other vehicles used for patient transport should be cleaned and decontaminated immediately after carrying any patient but especially a suspect, probable or confirmed Ebola patients. Otherwise the ambulance and other vehicles should be regularly (at least once a day) cleaned and decontaminated with standard detergents/disinfectants (e.g. a 0.5% chlorine solution). If the surfaces have been soiled with blood or bodily fluids, they should be cleaned twice and decontaminated immediately.
Ambulances and other vehicles used for patient transport should be always equipped with gloves and masks and full PPEs sets, alcohol-based hand sanitizer solutions, waste bags, body bags, a water tank, wipes, detergent and disinfectant.
Dr Bunge’s Opinions
Put on PPE AFTER you arrive. May need to put on in ambulance
Carry 2 liters of ORS already mixed in bottles
Carry artemether
Have 0.5% chlorine mixed
Questions?
Before we move to scene safety?
Scene Safety
To ensure safety and well-being of providers
Is it safe to approach the patient? Motor vehicle accident? Toxic substances? Crime, violence? Unstable surface? Water?
Protection of bystanders: no new patients
If unsafe, make it safe, otherwise no entry
Scene Assessment
How Many patients?
Triage: Suspect Ebola? – move immediately to Ebola
approach/transfer If Other, focus on immediate stabilization and
then transfer
Ebola Scene Assessment
How many patients?
Can the patient walk? Help in part?
Vomiting, diarrhea? (wet patients)
Are there angry people there?
Reassure that you will care for the patient
Be sensitive (patients are calling at night due to fear)
Correct: assisting and spraying
Correct
Incorrect
Questions?
Before we go to ABCDE
ABCDE
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure
(at the same time do not ignore major bleeding early)
Trauma Tips (NON-Ebola)
Airway – Obstructed?
Breathing – Breath sounds? Bilat
Circulation – peripheral pulse? Femoral? Carotid? (not BP). Look for bleeding
Disability – neuro, AVPU
Exposure – make naked, look for hidden trauma
Airway
Clear, not clear
Noisy, wheeze, stridor
Jaw Thrust
Head tilt if no neck injury
Breathing
Pneumothorax
Flail Chest
O2 if available and pt >24 or <8 RR
Circulation Hemorrhage
Hypovolemic Shock
Spinal Shock
Check pulse. <1 year: brachial
Assess: eyes, mucous membranes pale, flushed. Skin warm/hot/cool/clammy
Capillary refill in infant/child
Pressure to bleeding, tourniquet if avail and need
Disability
Levels of Mental Status (AVPU) A – Alert V – Responds to verbal P – Responds to Pain U - unresponsive
Trauma
Primary Survey
Resuscitation
Secondary Survey
Definitive Care
Trauma Resuscitation
Control Bleeding
2 IV - fliuds
Secondary Survey Can be done in part in ambulance
Head: palpate, inspect, look for crepitation
Neck – JVD, crepitation
Cervical spine immobilization
Chest – palpate, listen. Paradoxical motion
Abdomen – firm, soft, distended
Pelvis, palpate, gently compress
4 extremities: pulses, sens, motor, move
Roll patient (usually in hospital)
Baseline vital signs
SAMPLE history
Signs and symptoms
Allergies
Medications
Pertinent past history
Last oral intake
Events leading up to injury or illness
Focused Trauma Hx and PE Spinal Stabilization – fall from height, neck
pain, spinal trauma
Look for Examples/signs of injury: Deformities Contusions Abrasions Punctures/penetrations Burns Tenderness Lacerations Swelling
Fractures
Stabilize to prevent complication
Traction if need
Fractures are sharp edges
Unstable is more pain
Unstable is more bleeding
Unstable spine can mean paralysis
X-rays
Most Trauma patients will need urgent x-rays. Anticipate on arrival to hospital
You are the eyes/ears of the hospital providers. Must give report
Questions?