There are nine phases of an ambulance call. There is the preparation phase, dispatch, en route, arrival at scene, transfer of the patient to the ambulance, en route to the receiving facility, at the receiving facility (delivery), en route to the station, and the post run.
In the preparation phase you make sure all equipment is functional and the appropriate supplies are in their proper place. Consider grouping equipment required for critical interventions in a similar location; storage cabinets and kits should open easily but not fly open when the ambulance is in motion. As an EMT, you have access to a large variety of medical equipment and supplies, far more than can be described here. Some examples of supplies are pillows, blankets, blood glucose monitor, stethoscope, wet wipes, cold/hot packs, sterile irrigation fluid, gloves, sharps container. Airway and ventilation equipment and infection control kits (goggles, mask, waterproof gowns), oropharyngeal airway and nasopharyngeal airways, CPAP, bag-mask, laryngeal mask airway, oxygen, portable suction unit, pulse oximeter. Basic wound care supplies; trauma shears, sterile sheet, sterile burn sheet, adhesive tape in several widths, self-adhering soft roller bandages (4 in, 2 in), sterile dressing, gauze, abdominal or laparotomy pads, occlusive nonadherent dressing, occlusive dressing or chest seals, assortment of adhesive bandages, wound packing, and tourniquets. Splint supplies: adult/child traction splint, variety of arm and leg splints, variety of triangular bandages and roller bandages, short and long backboard, cervical collars, head immobilization devices. Childbirth supplies which include an emergency obstetric kit. An AED. Patient transfer equipment; wheeled ambulance stretcher, wheeled stair chair, scoop stretcher, binder lift, portable/folding stretcher, flexible stretcher, transfer tarp or slide board, basket stretcher. Medications and other supplies: activated charcoal, drinking water, oral glucose, oxygen, supplies for irrigating the skin and eye, aspirin and epinephrine, naloxone, bronchodilator, portable radio or cell phone. Personnel: at least one EMT in the patient compartment whenever a patient is being transported.
You should do daily inspections which include inspecting fuel level, oil level, transmission fluid level, engine cooling system and fluid levels, batteries, brake fluid, engine belts, wheels and tires, including the spare, all interior and exterior lights, windshield wipers and fluid, horn, siren, air conditioning and heater, ventilating system, doors, communication system, all windows and mirrors. Check all medical equipment and supplies daily, including all oxygen supplies, jump kit, splints, dressings and bandages, backboards and other immobilization equipment, emergency obstetrics kit. Check all battery-operated equipment, AED, and rotate the batteries according to an established schedule and ensure that any charging cables are connected. Check seatbelts and make sure all equipment is secured. Never attempt to secure a tank to the stretcher or bench unless specifically designed.
There is then the dispatch phase where you should get the nature of the call, the name, current location and callback telephone number of the caller, the location of the patient or patients, the number of patients and some idea of the severity of their conditions, and any other special problems or pertinent information about hazards or weather conditions. Many areas implement emergency medical dispatching, which provides the caller with prearrival instructions for patient care before the ambulance arrives. The emergency medical dispatcher follows a set of guidelines to determine the type of information given and then guides the caller through basic care such as bleeding control or initiating CPR.
En route to the scene is the most dangerous for responders; always wear seatbelts. Review route and alternate routes and notify dispatch that your unit is responding and note the nature and location of the call. If the scene is not safe you may need to stage the ambulance and consider staging out of sight. If there is only one road into or out of the neighborhood to which you are responding, do not stage on that road; if the person who assaulted the patient is fleeing the scene you don’t want to provide this person with the opportunity to delay or harm emergency responders. You should prepare to respond and assign duties and the equipment you will take with you. Review the medical condition if that is known. The person who is not operating the ambulance should be responsible for using the GPS or a map book to help determine an alternate route.
Arrival at the scene: scene size-up. Do you see any hazards? Is the scene safe? This should start from inside the ambulance. Figure out whether you need a heavy rescue unit or a hazmat team. Look for safety hazards to yourself, your partner, bystanders, and your patient or patients; evaluate the need for additional units or other assistance; determine the MOI in trauma patients or the nature of the illness on medical calls; evaluate the need to immobilize the spine; follow standard precautions. Mass-casualty incidents are under an incident commander. When parking always use your parking brake and leave yourself an exit; park upwind and leave warning lights engaged. If you are the first vehicle you should park about 100 ft in a fend-off position. In a fend-off position, the ambulance is parked at a diagonal angle with the front wheels turned away from the scene. Stay away from any fires, explosive hazards, downed wires, and structures that might collapse. Traffic control: ensure an orderly traffic flow.
During the transfer phase be sure to secure the patient with all manufacturer-approved straps. Use deceleration or stopping straps over the shoulder and secure with three other straps 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 supine.
During the transfer phase you should continue to monitor the patient’s condition en route, checking them every 15 mins for a stable patient and every 5 mins for an unstable patient. Continually reassess the patient’s clinical situation, address new problems and the patient’s response to earlier treatment. Contact medical control about the patient and the nature of the problem. You may be able to begin documenting your patient care report while en route. Do not abandon the patient emotionally. The use of lights and sirens is debatable; rarely does such a response prove lifesaving or even close.
The delivery phase: report your arrival time 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. Include all pertinent information regarding your assessment and treatment. Answer any questions from the receiving staff. Complete a detailed written 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. At the hospital you may be able to restock any items that were used during the call.
En route to the station, clean and disinfect the ambulance and any equipment that was used. Restock any supplies you did not get at the hospital.
Postrun phase is the appropriate time to debrief following the call. Strengths and opportunities for improvement regarding clinical knowledge, assessment and skill proficiency. Cleaning is the process of removing dirt, dust, blood or other visible contaminants from a surface or equipment. Disinfection is the killing of pathogenic agents by directly applying chemicals made for that purpose to a surface or equipment. High-level disinfection is the killing of pathogenic agents by using potent means of disinfection and thorough application processes. Sterilization is a process, such as the use of heat, which removes all microbial contamination. Follow these steps: strip linens and discard all disposable equipment and equipment that is blood-contaminated to an OSHA-approved biohazard container. Wash contaminated areas with soap and water. Disinfect and clean the stretcher with an EPA-approved disinfectant or bleach and water at a 1:100 dilution. Clean up any spillage or other contamination with the same germicidal/virucidal or bleach/water solution.
There are three types of ambulance designs: type I through type III. Conventional, truck cab-chassis with a modular ambulance body that can be transferred to a newer chassis as needed. Type II: standard van, forward-control integral cab-body ambulance. Type III: specialty van cab with a modular ambulance body that is mounted on a cut-away van chassis. The six-pointed Star of Life emblem identifies vehicles as ambulances. It is often affixed to the sides, rear, and roof of the ambulance. Local or state regulatory authorities determine what emblems may be displayed on the side of a prehospital care ambulance and illustrate some of the required features of a licensed or certified ambulance.
Guidelines for safe ambulance driving include selecting the shortest and least congested route to the scene at the time of dispatch. Avoid routes with heavy traffic congestion; know alternate routes to each hospital during rush hours. Avoid one-way streets; they may become clogged. Do not go against the flow of traffic on a one-way street unless absolutely necessary. Watch carefully for bystanders as you approach the scene. Curious bystanders may be focused on the scene and not aware of approaching vehicles. Park the ambulance in a safe place once you arrive at the scene. If you park facing into traffic, turn off your headlights so they do not blind oncoming motorists unless they are needed to illuminate the scene. If the vehicle is blocking part of the road, keep your warning lights on to alert oncoming motorists. Drive within the speed limit while transporting patients, except in rare extreme emergencies. Go with the flow of traffic. Always drive defensively. Always maintain a safe following distance. Use the 4-second rule: stay at least 4 seconds behind another vehicle in the same lane. Maintain an open space or cushion in the lane next to you as an escape route in case the vehicle in front of you stops suddenly. Use your siren if you turn on the emergency lights. Always assume other drivers will not hear the siren or see your emergency lights. Always exercise due regard for persons and property. Hydroplaning can occur at speeds in excess of 30 mph; avoid driving through moving water. Never pass a stopped school bus that has its lights flashing. On highways you should turn off lights until you are in the far left lanes to minimize confusion. Maintain a safe distance between your vehicle and any vehicles around you, check for tailgaters behind the ambulance, and remain aware of vehicles potentially hiding in the mirrors’ blind spots. It is highly recommended to have a spotter when backing up the vehicle. When driving an ambulance, focus on safely maneuvering through a corner as opposed to taking the fastest route. This problem is known as hydroplaning and occurs when speeds are greater than 30 mph.
There are three basic principles that govern the use of warning lights and sirens on an ambulance. The unit, to the best of your knowledge, must be responding to a true emergency call as defined by local protocol. 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. EMS systems try to reduce use of lights and sirens because it puts EMTs, partners, patients, and the general public at risk. Some ambulances are equipped with a specialized siren (the Rumbler) that emits low-frequency sound waves that produce vibration and may penetrate vehicles better than traditional sirens, allowing motorists to feel the siren. Be mindful not to increase the speed of the ambulance just because the siren is in use. Operation of an emergency vehicle must still continue in a safe fashion so as not to endanger people or property under any circumstances. Using a police escort is extremely dangerous because motorists might assume there is only one emergency vehicle and may not see the ambulance.
Intersection hazards are the most common, so change the siren tone before you reach the intersection. If the call is urgent 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. On highways, turn off your emergency devices to minimize the possibility that other drivers will get confused until you reach the far left lane. When you exit the highway you should turn off your lights and emergency devices and move onto the off-ramp, and then turn on the emergency lights and siren if necessary. In school zones it is important to remember that the lights and siren tend to attract children to the roadway and create a potential hazard. It is unlawful for an emergency vehicle to exceed the speed limit in school zones, regardless of the condition of the patient.
Your partner should operate the MDT, GPS device, and portable radios or turn on the siren. This minimizes distractions and allows for a safer response and minimizes the potential for mishaps. Driving alone requires your complete focus. Operating an emergency vehicle while feeling the effects of fatigue creates a dangerous risk to yourself and others. You must be able to recognize when you are fatigued. Do not be ashamed to admit it to yourself, your partner, or your supervisor, and you will 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.
Sometimes you may need to call for a medivac or a helicopter or air ambulance. When doing this you need to establish a landing zone. Ensure the area is a hard or grassy surface that measures 100 x 100 ft (30 x 30 m) and no less than 60 x 60 ft (18 m x 18 m). The slope should not exceed 5 to 7 degrees. Ensure the area is clear of any loose debris that could become airborne. Look for overhead or tall hazards such as power lines, antennas, and communication hazards. Mark the landing site using weighted cones or position emergency vehicles at the corners of the landing zone with the headlights facing inward to form an X. Never use caution tape, people, or flares. Move all nonessential people and vehicles to a safe distance outside of the landing zone. Both the approach and departure will be performed into the wind. If the wind is strong, communicate the direction of the wind to the flight crew.
Stay away from the helicopter and go only where the pilot or flight crew member directs you. The most important rule is to keep a safe distance whenever on the ground and the helicopter is hot, which means the blades are moving. Usually the flight crew will come to the EMTs; they will carry 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 rear of the helicopter where the tail rotor is located. Always approach a helicopter from the front, even if it is not running, and only after being signaled. Then you should enter only the area between the 10 o’clock and 2 o’clock position.
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 rear section. When you approach the aircraft, walk in a crouched position. Wind gusts can alter the blade height without warning, so protect yourself and your equipment as you carry it under the blades. Most helicopter services are limited to flying at 10,000 feet above sea level. This could create a problem if your patient is located at 13,500 feet above sea level. Helicopters typically fly between 130 and 150 mph.
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