Chapter 38: Transport Operations

Ambulance

A vehicle used to treat and transport patients who are in need of medical care.

• Designs based on NFPA 1917, Standard for Automotive Ambulances

Star of Life

An emblem that identifies vehicles as ambulances.

Phases of an Ambulance Call

1. Preparation for the call

2. Dispatch

3. En route

4. Arrival at scene

5. Transfer of the patient to the ambulance

6. En route to the receiving facility (transport)

7. At the receiving facility (delivery)

8. En route to the station

9. Postrun

The Preparation Phase

Make sure all the equipment is functional and the appropriate supplies are in their proper place in the vehicle.

Preparation Phase | How should you store equipment and supplies?

• Store equipment based on how urgent and how often they are used

• Containers should be placed in transparent cabinets

• Hard equipment and bags should be mounted on brackets or strapped

Preparation Phase | Airway and Ventilation Equipment

• Oropharyngeal airways for adults, children, and infants

• Nasopharyngeal airways for adults and children

• CPAP equipment

• Equipment for advanced airway procedures

• Two portable artificial ventilation devices

• Portable and mounted suctioning units

• Two oxygen supply units (one portable and one mounted in the ambulance)

  • 425-L portable and delivers oxygen at 1–15 L/min

  • 3,000-L mounted and delivers oxygen at 1–15 L/min

Preparation Phase | CPR Equipment

• CPR board in a few ambulances

• Use a towel to raise a patient’s shoulders 3–4 inches

Preparation Phase | Basic Wound Care Supplies

Basic supplies for dressing open wounds

Preparation Phase | Splinting Supplies

• Splints

• Backboards

• Cervical collars

Preparation Phase | Childbirth Supplies

At least one sterile emergency obstetric kit should be carried.

Preparation Phase | Automated External Defibrillator

Should always be carried on the ambulance.

Preparation Phase | Patient Transfer Equipment

• Primary wheeled ambulance stretcher

• Wheeled stair chair

• Long backboard

• Short backboard

• Other stretchers from Chapter 8, Lifting and Moving

Preparation Phase | Medications

Carry valid and appropriate medications.

Preparation Phase | The Jump Kit

A portable, durable, waterproof jump kit that can be carried to the patient—a 5-minute kit.

• Disposable gloves

• Basic wound care supplies

• Bag masks

• Naloxone

Preparation Phase | Personal Safety Equipment

Equipment that will allow you to work safely in a limited variety of hazardous or contaminated situations.

• Face shields

• N95 masks

• Gowns, shoe covers, caps

• Turnout gear

• Helmets with face shields or safety goggles

• Safety shoes or boots

• Tactical vest

Preparation Phase | Equipment for Work Areas

Equipment for safeguarding EMTs, controlling traffic, and illuminating work areas.

• Warning devices

• Halogen, 20,000-candle power flashlights

• Fire extinguisher

• Hard hats

• Portable floodlights

Preparation Phase | Preplanning and Navigation Equipment

GPS devices and MDTs.

Preparation Equipment | Extrication Equipment

A waterproof compartment outside the patient compartment is needed for simple, light extrication.

Preparation Phase | Personal

There should be at least one EMT in the patient compartment.

Preparation Phase | Daily Inspections

Should include the following:

• 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

• All windows and mirrors. Check for cleanliness and position.

Check all medical equipment and supplies and always check the defibrillator at the beginning of each day.

Preparation Phase | Safety Precautions

• Includes standard traffic safety rules and regulations

• Check seatbelts

• Check if everything is secured appropriately

The Dispatch Phase

• Must be easy to access and in service 24 hours a day

• The nature of the call

• The name, current location, and callback telephone number

• The location of the patient/patients

• The number of patients and their conditions

• The hazards/weather conditions

En Route to the Scene

• Fasten seat belts

• Review the most appropriate route and alternatives

• Inform dispatch and confirm nature of call

• Ask for additional information

• In the event of violent crimes or the scene isn’t safe, stage the ambulance away from the scene

Arrival at the Scene

• Perform a scene size-up and evaluate the safety and stability of the scene

• Look for safety hazards

• Evaluate the need for additional units

• Determine MOI in trauma patients

• Evaluate the need to immobilize the spine

• Follow standard precautions

Arrival at the Scene | Safe Parking

Pick a position that will allow for safe operations on the scene, efficient traffic control, and a clear path for departing the scene.

• Arriving after responder vehicles, park 100 feet beyond the scene in the fend-off position

• Arriving first, park 100 feet before the scene

• Stay away from hazards

• If blocking roadway, turn on emergency lights

• Turn off lights during night scenes

• Try to get as close to the scene

• Lock the ambulance

Arrival at the Scene | Traffic Control

After all patients are treated, you must restore the flow of traffic. Place warning devices on both sides of the crash.

The Transfer Phase

Inform dispatch when you are ready to leave with the patient

• Number of patients

• The receiving hospital

• Beginning mileage (in some jurisdictions)

• Check vitals every 15 minutes for stable patients and every 5 minutes for unstable patients

• Do not abandon the patient emotionally

• Specific situations require lights and sirens

• Use common sense and defensive driving techniques

The Delivery Phase

Inform dispatch as soon as you arrive at the hospital and report ending mileage (in some jurisdictions)

1. Report arrival to the triage nurse.

2. Transfer the patient from the stretcher to the bed.

3. Provide verbal report to nurse or physician regarding assessment and treatment.

4. Complete a detailed written report, obtain signatures, and leave a copy with appropriate staff member

• Restock any supplies after

En Route to the Station

Inform dispatch when you are in service and your intended destination

• Clean and disinfect the ambulance

• Restock any supplies you did not get at the hospital

The Postrun Phase

Complete and file additional reports and inform dispatch of status, location, and availability. Debrief the following call.

1. Strip used linens and place them in a plastic bag or designated receptacle

2. Discard disposable equipment in the appropriate receptacle.

   • Bloody/bodily fluids into an OSHA-approved biohazard container

3. Wash the contaminated area with soap and water.

4. Disinfect all nondisposable equipment

5. Clean stretcher with EPA-registered germicidal/virucidal solution or 1:100 bleach solution.

6. Clean up any spillage with the same solutions.

Cleaning

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

Disinfection

The killing of pathogenic agents by directly applying a chemical made for that purpose to a surface or equipment.

High-level disinfection

The killing of pathogenic agents by using potent means of disinfection and use of thorough application processes.

Sterilization

A process, such as the use of heat, which removes all microbial contamination.

Defensive Ambulance Driving Techniques | Driver Characteristics

• Don’t drive if on medications that cause drowsiness and slows reaction time

• Don’t drive after drinking alcohol (10–12 hours before)

• Don’t drive if you feel tired after working long shifts

• Emotional fitness—remain calm and have a clear train of thought

• Drive with a proper attitude

Defensive Ambulance Driving Techniques | Safe Driving Practices

• Speed does not save lives; good care does

• All passengers must wear seatbelts

• Have a feel for braking

• Stay on the far left lane on the highway

Defensive Ambulance Driving Techniques | Siren Risk-Benefit Analysis

• Depends on several factors such as the patient’s condition, local protocols, and anticipated clinical outcome

Defensive Ambulance Driving Techniques | Drive Anticipation

• Never assume other drivers will see you or respond predictably

• Operate the ambulance to allow space

Defensive Ambulance Driving Techniques | The Cushion of Safety

• Safe distance between you and other vehicles: 4–5 seconds

• Slow down if you have tailgaters

• Never get out of the ambulance to confront the driver

• Three blind spots:

  • Rearview mirror creates a blind spot → lean forward to eliminate

  • The rear of the vehicle → requires the use of a spotter

  • The side of the vehicle → convex side mirrors or lean forward or backward

Defensive Ambulance Driving Techniques | The Problem of Excessive Speed

• Never travel at speeds unsafe for the given road conditions

• Doesn’t increase the patient’s chance of survival

• Decrease driver’s reaction time and increases time needed to stop the ambulance

Defensive Ambulance Driving Techniques | Recognition of Siren Syndrome

• Experience a rush of adrenaline; respiratory and heart rate increase, and palms become sweaty

• May increase the anxiety of other drivers to drive faster

Defensive Ambulance Driving Techniques | Vehicle Size and Judgement

• Greatly influences braking and acceleration

• Use a spotter when backing up

Defensive Ambulance Driving Techniques | Road Positioning and Cornering

Take a corner at a speed that will put you in the proper road position as you exit—enter high and exit low.

Defensive Ambulance Driving Techniques | Weather and Road Conditions

• Hydroplaning

  • Occurs when speeds exceed 30 mph, causing the vehicle to slide → slow down without jamming breaks

• Water on the Roadway

  • Wet brakes

  • Avoid standing water

  • Slow down and apply windshield wipers

  • Driving should moving waters should always be avoided

• Decreased Visibility

  • Slow down and use low headlight beams

  • Always use headlights during the day

• Ice and Slippery Surfaces

  • Use studded tires or snow chains

  • Be careful on bridges

  • Practice control maneuvers

Defensive Ambulance Driving Techniques | Laws and Regulations

• A driver is presumed to be guilty if they get in a crash with the sirens and lights on

• Allowed to do the following:

  • Park or stand in an illegal location

  • Proceed through a stoplight or a stop sign, but never without stopping first

  • Drive above the speed limit

  • Drive against the flow of traffic in a one-way or make an illegal turn

  • Travel left of center to make an illegal pass

• Never allowed to approach a school bus that has stopped to load or unload children

  • Turn off sirens and weight

Defensive Ambulance Driving Techniques | Use of Warning Lights and Siren

1. The unit must be responding to a true emergency protocol.

2. Audible and visual warning devices must be used simultaneously.

3. The unit must be operated with due regard for the safety of all others, on and off the roadway.

• Should be on only if the highest-trained provider believes there is a true benefit

• If you turn on the siren, let the patient know to reduce anxiety

Defensive Ambulance Driving Techniques | Right-of-Way Privileges

• Privileges vary by state

  • Some may allow you to proceed after stopping, while others may allow you to proceed with due regard

Defensive Ambulance Driving Techniques | Use of Escorts

• Extremely dangerous practice

• Only use when you are in an unfamiliar area

• Use different tones for warning lights and sirens

Defensive Ambulance Driving Techniques | Intersection Hazards

• Be alert and scan for hazards

• Still come to a brief stop before driving

• Motorists who time the light

• Multiple emergency vehicles responding to the same situation

Defensive Ambulance Driving Techniques | Highways

Turn off emergency lights until you reach the far left lane. Repeat for exiting the highway.

Defensive Ambulance Driving Techniques | Unpaved Roadways

• Uneven surfaces and potholes

• Drive slowly and grip the steering wheel tightly

Defensive Ambulance Driving Techniques | School Zones

• Emergency lights and sirens will attract children

• Don’t exceed speed limit regardless of the patient’s condition

Defensive Ambulance Driving Techniques | Distractions

• GPS and MDTs, radio, stereo, cell phone, eating, or drinking

• The partner should operate the GPS, MDTs, and radio

Defensive Ambulance Driving Techniques | Driving Alone

Figure out safest route, operate radios and emergency warning devices, and mentally preparing for the call

Defensive Ambulance Driving Techniques | Fatigue

• Caused by stress, working night shifts, and lack of sleep

Air Ambulances

Used to evacuate medical and trauma patients

• Landing at or near scenes and transporting patients to hospitals, trauma centers, stroke centers, or cardiac centers

• Fixed-wing aircraft (200–250 miles)

• Rotary-wing aircraft (short distances)

  • Capable of providing a high level of care

Medevac

An evacuation performed exclusively by helicopters.

Why call for a medevac?

• Call for a medevac when the transport time for a ground ambulance is too long

• The patient requires treatment that is not local, or road conditions prohibit ambulance usage

• Patient requires advanced care, multiple patients, or helicopter responds directly to scene or transfer patients to hospital

Who receives a medevac?

• Patients with time-dependent injuries/illnesses. Patients with stroke, heart attack, or serious traumatic injuries

• Serious conditions in remote areas and involve scuba diving accidents, near drownings, or skiing and wilderness accidents

• High-risk obstetric patients, candidates for limb replantation, or patients seeking transport to the burn center, hyperbaric chamber center, or a venomous bite center

Whom do you call for a medevac?

• The dispatcher must be notified first

• Ground EMS crew may be able to access the flight crew on a specifically designated radio frequency

Establishing a Landing Zone

• Don’t need an airport to land

• The area is a hard, grassy level surface that is 100×100 ft. Slope should not exceed 5–7°

• The area is clear of any loose debris that could become airborne

• Examine the area for overhead or tall hazards such as power lines, telephone cables, antennas, and tall or leaning trees

• To mark the landing site, use cones to position vehicles in a way that’ll form an X with their headlights

• Move nonessential people a safe distance from the landing zone

• Approach and departure into the wind

Landing Zone Safety and Patient Transfer

• When entering the landing zone, avoid going to the rear of the helicopter

• Enter the landing zone between the 10 and 2 o’clock positions

• Walk in a crouched position because the tail rotor height varies in wind gusts

• Familiarize yourself with hand signals

• Do not approach the helicopter unless instructed

• Ensure all equipment is fastened

• Smoking, open flames, and flares are prohibited within 50 feet

• Wear eye protection during approach and takeoff

Communication Issues with Medevac

• Interacts with many agencies and services on several radio frequencies

• Include ground contact radio station and call sign of unit which medevac should make contact with

Special Considerations with Medevac

• Night Landings

  • Do not shine spotlights, flashlights, or ant lights → use lanterns or low-intensity headlights

• Landing on Uneven Ground

  • Approach the helicopter from the downhill side

• Medevacs at Hazmat Incidents

  • Land uphill and upwind from the hazmat

  • Exposed patients must be decontaminated

Medevac Issues

• Unable to operate in severe weather conditions and in mountainous or desert terrain

• As elevation increases, air thins—maximum height is 10,000 feet

• Small cabin means a limited amount of patients

• Extremely expensive