Seattle/King County EMT-B Class

Topics

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Ambulance Operations: Chapter 35

Gaining Access: Chapter 36

3 Special Operations: Chapter 37

1 Ambulance Operations

Ambulance OperationsEmphasis on rapid response places theEMT-B in great danger while driving to calls.

EMT-Bs should know:• How to equip and maintain an

ambulance• Techniques for the safe operation of an

ambulance• How to work safely with air ambulances

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Type I1

Type II1

Type III1

Phases of an Ambulance Call• Preparation• Dispatch• En route• Arrival at scene• Patient transfer

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• En route to receiving facility

• At the receiving facility

• En route to station• Post-run

Preparation Phase• Medical equipment and supplies check• Personal safety equipment• Equipment for work areas• Preplanning and navigation• Extrication equipment• Daily inspections

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Medical Equipment1

• Airway and ventilation devices

• Suction unit• Oxygen delivery• CPR equipment• Basic wound care• Splinting supplies

• Childbirth supplies• AED• Patient transfer

equipment• Medications• Jump kit

Personal Safety Equipment• Face shields• Gowns, shoe covers, caps• Turnout gear• Helmets with face shields or safety

goggles• Safety shoes or boots

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Equipment for Work Areas• Warning devices that flash

intermittently or have reflectors• Two high-intensity halogen flashlights• Fire extinguisher• Hard hats or helmets with face shields• Portable floodlights

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Other Preparations Preplanning and navigation

• Carry detailed maps and directions.• Be familiar with local area.

Extrication equipment• Equipment needed for simple, light

extrication

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Personnel • Every ambulance must be staffed with at

least one EMT-B in the patient compartment during patient transport.

• Two EMTs are strongly recommended.• Some services may operate with a non-

EMT driver.

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Inspections and Safety Precautions

• Being fully prepared means inspecting the ambulance and equipment daily.

• Check medical equipment and supplies at least daily.

• Review standard traffic safety rules and regulations.

• Make sure seat belts work and that oxygen tanks are secured.

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Dispatch PhaseThe dispatcher should gather minimum information such as:

• Nature of the call• Name, person, location, and call-back

number• Location of the patient(s)• Number of patients and idea of the

severity of their conditions• Special problems or other pertinent

information

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En Route to the Scene• Fasten your seat belt.

• Confirm response and location.

• Prepare for arrival.

• Decide what equipment to take initially.

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Arrival at the Scene• Scene safety

• Safe parking

• Traffic control

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• Look for safety hazards. • Evaluate need for additional units. • Determine MOI/NOI. • Evaluate spinal precautions. • Follow BSI precautions.

1 Scene Size-up

Safe Parking and Traffic Control • Park away from hazards and out of flow

of traffic. • Do not block other responding EMS

vehicles. • Place appropriate warning devices on

both sides of the accident.

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Transfer Phase• Provide lifesaving treatment.• Package patient for transport.• Be sure to secure the patient with at

least three straps across the body.

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Transport Phase• Inform dispatch when you are ready to

leave the scene.• Report the number of patients and the

name of receiving hospital. • Conduct ongoing assessments.• Contact medical control.

– Report number of patients– Nature of problems

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Delivery Phase• Report arrival to dispatch.

• Give report to staff.

• Physically transfer the patient.

• Complete written report.

• Leave a copy with an appropriate staff member.

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En Route to the Station• Inform dispatch

whether or not you are in service and where you are going.

• Clean and disinfect the ambulance and any equipment used.

• Restock supplies.

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Postrun Phase• Complete and file any additional

written reports.

• Inform dispatch of your status, location, and availability.

• Clean and restock the ambulance.

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Defensive Driving • 6,000 ambulances involved in crashes

every year • 300 fatalities between 1991 and 2001• Properly operating the ambulance is as

important as taking care of patients.

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Driver CharacteristicsPhysical fitness

• Effects of medication• Fatigue

Emotional fitness• Maturity and stability• Proper attitude

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As a public servant, your actions will be scrutinized.

Safe Driving Practices• Speed does not save lives; good care

does. • Seat belts must be worn. • Learn how your vehicle accelerates,

corners, sways, and stops.

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Driver Anticipation • Anticipate the actions of other

motorists and pedestrians. • Assume actions of other drivers will

cause a collision. • Use of PA system may add to

confusion.

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Cushion of Safety • Keep safe following distance. • Watch for tailgaters. • Be aware of blind spots. • Use a spotter when backing up.

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Excessive Speed• Speeding is unnecessary if patient is

properly assessed and stabilized. • Decreases reaction time• Increases stopping time and distance

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Vehicle Size and Cornering • Vehicle length and width are critical

factors in maneuvering. • Vehicle size and weight greatly

influence braking and stopping distances.

• Always be aware of your position on the roadway.

• Take corners at the speed that will put you in the proper road position as you exit the curve.

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Weather and Road Conditions Be alert to changing conditions. Decrease speed and increase distance in poor conditions, such as:

• Hydroplaning• Water on roadway• Decreased visibility• Ice and slippery surfaces

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Laws and Regulations • Vary from state to state• EMS drivers have certain limited

privileges. • These privileges do not lessen drivers’

liability.

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Warning Lights and Sirens• Must be responding to an emergency• Use both audible and visual devices. • Operate with due regard.

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Right-of-Way Privileges • You must not endanger people or

property under any circumstances. • Know your local right-of-way privileges. • Exercise them only when necessary for

the patient’s well-being.

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Escorts and Intersection Hazards Use of escorts

• A dangerous practice• Follow escorts at a safe distance.

Intersection hazards• Most common place for collisions• Even on urgent calls, come to a

momentary stop at the light.

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Air AmbulancesFixed wing

• Interhospital transfers

Rotary-wing

• Used for shorter distances

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Medivac OperationsBecome familiar with local capabilities. Calling for a medivac:

• Ground transport would take too long.• Spinal cord injuries, amputations,

burns, diving emergencies, venomous bites

Notify your dispatcher first.

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Establishing a Landing Zone• Area should be hard or grassy level

surface that measures 100' x 100'(recommended)

• Clear area of loose debris and survey for overhead or tall hazards.

• Mark landing site with weighted cones or headlights.

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Safety Precautions• Do nothing near the helicopter and only

go to where the crew or pilot directs you.

• Keep a safe distance away from the aircraft.

• Stay away from the tail rotor.• Never approach the helicopter from the

rear.

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Special ConsiderationsNighttime landings

• Considerably more dangerous than daytime operations

Landing on uneven ground• Main rotor blade will be closer to the

ground on uphill side. Hazardous materials incidents

• Land zone should be upwind and uphill.

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Landing on Uneven Ground1

2 Gaining Access

SafetyPreparation

• Mental• Physical

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Vehicle Safety Systems• Shock-absorbing bumpers• Airbags

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Fundamentals of ExtricationExtrication

• Removal from entrapment or a dangerous situation or position

Entrapment• To be caught within a closed area with

no way out

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10 Phases of Extrication1. Preparation2. En route to the scene3. Arrival and scene size-up4. Hazard control5. Support operations

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6. Gaining access7. Emergency care8. Disentanglement 9. Removal and transfer10. Termination

2 10 Phases of Extrication, cont'd

Preparation• Training• Equipment maintenance

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En Route to the Scene• Safe driving practices• Good steering techniques• Road positioning and cornering• Controlled acceleration• Controlled braking• Laws and regulations

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Arrival and Scene Size-up• Traffic hazards• Additional resources• Coordination within ICS• Rescue team responsibilities• EMS responsibilities

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Hazard ControlLaw enforcement

• Traffic control• Investigation• Scene control

Fire fighters• Extinguishment• Spill control

Rescue team• Extrication

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Hazards• Downed power lines• Sharp metal• Broken glass• Toxic substances• Hazardous substance ignition• Unstable vehicles

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Support Operations• Lighting• Tool and equipment

staging areas• Helicopter landing

zones

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Gaining Access• Is the patient in a vehicle or other

structure?• Is the vehicle or structure severely

damaged?• What hazards exist that pose risk to the

patient and rescuers?• What is the position of the vehicle?• What type of surface is it on?• Is it stable?

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Gaining Access, continuedSimple access

• Access without the use of tools or force

Complex access• Requires the use

of tools and force

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Emergency Care• Provide manual immobilization to protect the

cervical spine.• Open the airway.• Provide high-flow oxygen.• Assist or provide for adequate ventilation.• Control any significant external bleeding.• Treat all critical injuries.

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Disentanglement

Techniques include:• Brake and gas pedal displacement• Dash roll-up• Door removal• Roof opening and removal• Seat displacement• Steering column displacement• Steering wheel cutting

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Removal of the motor vehicle from around the patient.

Removal and Transfer• Determine urgency of move.• Plan moves and communicate with the team.• Once patient is freed, rapidly reassess and

recheck vital signs.• Make certain spine is immobilized.

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Removal and Transfer, cont'd• Move the patient in slow, controlled

steps.• Choose a path that requires the least

manipulation of the patient and equipment.

• Move the patient as a unit.• If the patient’s condition is critical,

perform remaining steps en route.

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Termination• Check tools and equipment.• Replace used supplies.• Clean unit and conform to bloodborne

pathogen standards.• Complete all necessary reports.

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Specialized Rescue Situations• Cave rescue• Confined space rescue• Cross-field and trail rescue• Dive rescue• Lost person search and rescue• Mine rescue• Mountain, rock, and ice-climbing rescue

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Specialized Rescue Situations• Ski slope and cross-country or trail snow

rescue (ski patrol)• Structural collapse rescue• Tactical emergency medical support (SWAT)• Technical rope rescue (low- and high-angle

rescue)• Trench rescue• Water and small craft rescue• White-water rescue

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Lost Person Search and Rescue• Primary role will be to take care of

patient when found.• Prepare equipment and stand by in area

designated by incident command.• Only incident command should deliver

information to the family unless someone else is designated to do so.

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Trench Rescue• Poor outcome for victims• Risk of secondary collapse• Proper safety reduces potential for injury.• Stage response vehicles.

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Tactical Emergency Medical Support

• EMT-Bs, paramedics, nurses, and physicians with specialized tactical and medical training

• Nonstandard medical procedures similar to battlefield medicine

• Examples of tactical situations– Hostage situations– Snipers– Barricaded suspects

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Response procedures• Shut off lights and siren when approaching

the scene• Report to the command post

Planning• Specific location of the incident• Rally point with tactical EMS providers• Helicopter landing zones• Hospital locations and route of travel

2 Tactical Emergency Medical Support

Structure Fires• Ask incident command where the

ambulance should be positioned.• Do not block arriving equipment or

become blocked.• Only leave the scene if transporting a

patient or cleared by incident command.

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3 Special Operations

Incident Command System • ICS is used to help control, direct, and

coordinate resources. • It ensures clear lines of responsibility and

authority.• Incident commander has overall

responsibility for the scene. • Safety officer is designated to circulate

among responders.

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Incident Command System3

Information Officer 3

All information to the public and news media originates at the

command post.

Safety Officer• Circulates through incident scene to

ensure safety of responders and victims. • Orders by the safety officer have full

authority of the incident commander.

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Sector Commanders Coordinate activities of specialty groups

• EMS• Rescue• Fire

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Sectors of Typical IC Structure • Operations • Planning • Logistics• Finance

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Incident Command• Command structure must be established

early and expanded as needed. • Incident command may vary in different

communities. • An EMT-B must not deviate from the

directions and orders given by command.

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Key Components of ICS at an MCI• Command center• Staging area• Extrication area • Decontamination area • Triage area• Treatment area• Supply area• Transportation area• Rehabilitation area

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NIMSNational Incident Management System

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Nationwide model to enable federal, state, and local governments and private-sector and non-governmental organizations to work together in an emergency.

• Applicable to all jurisdictions• Utilized by a variety of disciplines • Improves coordination and cooperation • Built on existing incident management

systems

3 NIMS, continued

Mass-Casualty Incidents • Incidents involving

three or more patients

• Places high demand on available resources

• May require mutual aid response

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Triage• Triage is the sorting of two or more

patients based on the severity of their conditions.

• Patients are ranked in the order of the severity of their conditions.

• Treatment priority is determined by rank.

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Triage is an essential component of operations at a mass-casualty incident.

3 Triage, continued

Triage Categories 3

Triage Priorities • Patients should be color coded early. • Patients tagged red should be assessed in

the treatment area. • Patients in dangerous areas should be

removed to a non-hazardous environment prior to triage.

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Triage Procedures• Rotate hospital

destinations. • Trauma center

should receive the most critical patients.

• Utilize a transport officer to evenly distribute patients.

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Disaster Management • The role of the EMT-B is to respond

when requested and report to incident command.

• A casualty collection area may be set up and staffed by nursing and medical staff with equipment.

• You may have to bring patients to this area.

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Introduction to HazMat• Any substance that is toxic, poisonous,

radioactive, flammable, or explosive and can cause injury or death with exposure

• Responders must have special training before becoming involved with hazardous materials.

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Hazardous Materials Situations• A train or truck with a leaking substance• A leak, fire, or other emergency at an

industrial plant, refinery, or other storage facility

• A gas pipe leak or rupture• Deterioration of underground fuel tanks• Buildup of methane in sewers• Car crash involving a ruptured gas tank

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Recognizing Hazardous Materials• Warning signs• Placards• Labels

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• Visible cloud or odd-looking smoke coming from an escaping substance

• A leak or spill from a tank, container, truck, or railroad car

• An unusually strong, noxious, acrid odor

3 Recognizing Hazardous Materials

HazMat PlacardsThe four-digit number on the warning placard identifies the hazardous material.

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First Arrival• Stop at safe distance.• Call for a HazMat team.• Stay out of danger zone.• Gather information. • Do not reenter the scene.• Do not leave until cleared by HazMat.

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Identifying Hazardous Materials• Safety perimeters• Uphill and upwind• Efforts to ensure safety and survival of

the masses.

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Approach a hazardous incident cautiously from upwind.

HazMat Scene Safety3

HazMat Scene Operations • HazMat will determine the specific

hazardous material involved.• Only those trained in HazMat and

wearing protective gear should enter the zone.

• As an EMT-B, your job is to remain in the designated treatment area.

• HazMat will bring patients to you.

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Decontamination Area• Designated area where contaminates

are removed.• Anyone who leaves the hazard zone

must pass through this area.• Wait for the patients to be brought to

you.

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Treating Patients at a HazMat Incident

• Only essential treatment will take place in the hazard zone and decontamination area.

• Injuries should be treated as any other patient.

• Treatment for exposure will be mainly supportive.

• Initiate transport.

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Special Care• Some patients may need to be treated

without full decontamination.• Protect yourself with proper gear.• Ensure the receiving hospital is aware

patient has not been fully decontaminated.

• Ambulance will need to be decontaminated after transport.

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Resources• Emergency Response

Guidebook• Chemical

Transportation Emergency Center (CHEMTREC)• 1-800-424-9300

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PPE Levels• Level A—Fully encapsulated, chemical-

resistant protective clothing • Level B—Non-encapsulated protective

clothing with respiratory protection• Level C —Non-permeable clothing, eye

protection, filtering face mask• Level D —Work uniform; minimal

protection

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Four Levels of Protection

Level A Level B Level C Level D

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• What questions do you have?

Questions

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