Emergency Care and Transportation of the Sick and Injured - Transport Operations

Emergency Care and Transportation of the Sick and Injured

Introduction

  • Modern ambulances are equipped with standard medical supplies and often state-of-the-art technology for data transmission to the emergency department.
  • Rapid response expectations increase the EMT's risk.

Emergency Vehicle Design

  • Ambulances are used for treating and transporting patients needing emergency medical care to a hospital.
  • Designs are based on NFPA 1917 standards and industry suggestions.
  • Components of a modern ambulance include:
    • Driver's compartment
    • Patient compartment (large enough for two EMTs and two supine patients)
    • Equipment and supplies
    • Two-way radio communication
    • Design focused on safety, efficiency, and comfort
  • Ambulance licensing and certification are managed at the state level.
  • The Star of Life emblem is displayed on the sides, rear, and roof.
  • Types of Ambulances:
    • Type I: Conventional, truck cab-chassis with a modular ambulance body that can be transferred to a newer chassis.
    • Type II: Standard van ambulance with a forward-control integral cab body.
    • Type III: Specialty van ambulance with a cab mounted on a cut-away van chassis.

Phases of an Ambulance Call

  • Preparation for the call
  • Dispatch
  • En route
  • Arrival at scene
  • Transfer of the patient to the ambulance
  • En route to the receiving facility (transport)
  • At the receiving facility (delivery)
  • En route to the station
  • Postrun

Preparation Phase

  • Ensure equipment and supplies are in proper places and ready for use.
  • Introduce new equipment only after proper training and medical director consultation.
  • Equipment should be durable and standardized.
  • Store equipment based on urgency and frequency of use.
    • Life-threatening condition items at the head of the primary stretcher.
    • Cardiac care, bleeding control, and blood pressure items at the side of the stretcher.
  • Use transparent or labeled cabinets and drawers for easy identification.
  • Medical equipment includes:
    • Basic supplies
    • Airway and ventilation equipment
    • CPR equipment (including a CPR board)
    • Basic wound care supplies
    • Splinting supplies
    • Childbirth supplies
    • Automated external defibrillator
    • Patient transfer equipment (wheeled ambulance stretcher locked in place)
    • Medications
    • Jump kit (portable kit with essential items for the first 5 minutes with a patient)
  • Safety and operations equipment:
    • Personal safety equipment
    • Equipment for work areas (weatherproof compartment for safeguarding and traffic control)
    • Preplanning and navigation equipment
    • Extrication equipment
  • Personnel requirements:
    • At least one EMT in the patient compartment during transport.
    • Two EMTs are strongly recommended.
    • Some services may have a non-EMT driver and a single EMT in the patient compartment.
  • Daily inspections:
    • Ambulance inspection includes cleanliness, quantity, and function of medical equipment and supplies.
  • Review safety precautions:
    • Traffic safety rules and regulations
    • Ensure safety devices are functional
    • Secure oxygen tanks and all equipment in the cab, rear, and compartments.

Dispatch Phase

  • Dispatch must be easily accessible and available 24/7.
  • It can be operated by local EMS or a shared service, serving one jurisdiction or a regional center.
  • Dispatcher responsibilities:
    • Gather and record call information:
      • Nature of the call
      • Name, current location, and callback number
      • Patient location
      • Number of patients and condition severity
      • Other pertinent details

En Route to the Scene

  • This is often the most dangerous phase for EMTs.
  • Crashes can cause serious injuries.
  • Safety measures:
    • Fasten seat belts and shoulder harnesses before moving the ambulance.
    • Review dispatch information.
    • Prepare for patient assessment and care.

Arrival at the Scene

  • Scene size-up:
    • Report findings to the dispatcher.
    • Look for safety hazards.
    • Evaluate the need for additional units.
    • Determine the mechanism of injury or nature of illness.
    • Assess the need for spinal immobilization.
    • Follow standard precautions.
  • Mass-casualty incidents:
    • Estimate and communicate the number of patients to the incident commander.
    • Request additional units through dispatch.
    • Establish the incident command system.
  • Safe parking:
    • Allow efficient traffic flow and control around the scene.
    • Park 100 feet before or past the crash scene, not alongside. Park on the same side of the road to allow an unobstructed departure path per Figure 38-2.
    • Park uphill/upwind of hazardous materials.
    • Leave warning lights or devices on.
    • Maintain a safe distance between the vehicle and operations.
    • Avoid fires, explosive hazards, downed wires, and unstable structures.
    • Set the parking brake.
    • Facilitate emergency care and rapid transport.
    • If blocking traffic is necessary, work quickly and safely.
  • Traffic control:
    • Prioritize care and scene safety.
    • Ensure orderly traffic flow, warn drivers, and prevent further crashes.
    • Place warning devices on both sides of the crash site.

Transfer Phase

  • Patient packaging for transport involves:
    • Securing the patient to a backboard, scoop stretcher, or wheeled ambulance stretcher.
    • Lifting the patient into the compartment.
    • Securing the patient with straps.

Transport Phase

  • When ready to transport, inform dispatch of:
    • Number of patients
    • Receiving hospital name
    • Beginning mileage of the ambulance
  • Patient care during transport:
    • Monitor the patient’s condition.
    • Recheck stable patients every 15 minutes and unstable patients every 5 minutes.
    • Contact the receiving hospital.
    • Provide emotional support to the patient.
    • Be aware of the patient’s needs.

Delivery Phase

  • Notify dispatch upon arrival at the hospital.
  • Report arrival to the triage nurse or receiving personnel.
  • Physically transfer the patient.
  • Present a complete verbal report.
  • Complete a detailed patient care report.
  • Restock items, if possible.

En Route to the Station

  • Inform dispatch about being in service and your destination.
  • At the station:
    • Clean and disinfect the ambulance and equipment.
    • Restock supplies.

Postrun Phase

  • Complete and file additional written reports.
  • Inform dispatch of status, location, and availability.
  • Perform routine inspections.
  • Refuel the vehicle.
  • Key terms:
    • Cleaning
    • Disinfection
    • High-level disinfection
    • Sterilization
  • Post-call procedures:
    • Strip linens and place them in a plastic bag or receptacle.
    • Discard medical waste.
    • Wash contaminated areas with soap and water.
    • Disinfect all nondisposable patient care equipment.
    • Clean the stretcher with germicidal/virucidal solution or a 1:100 bleach dilution.
    • Clean any spillage with the same solutions.

Defensive Ambulance Driving Techniques

  • Crashes can delay patient care and endanger EMTs, motorists, and pedestrians.
  • Driver characteristics:
    • Some states require an emergency vehicle operations course.
    • Other characteristics: physical fitness, alertness, emotional maturity, stability, and regard for safety and property.
  • Safe driving practices:
    • Speed does not save lives; good care does.
    • Wear seat belts and shoulder restraints.
    • Familiarize yourself with the vehicle's handling.
    • Stay in the extreme left-hand lane on multilane highways.
  • Siren risk-benefit analysis depends on local protocols, patient condition, and anticipated clinical outcome.
  • Driver anticipation: Assume other motorists have not heard or seen the ambulance.
  • Cushion of safety:
    • Maintain a safe following distance.
    • Avoid being tailgated.
    • Ensure blind spots do not obstruct visibility.
    • Never confront other drivers.
    • Be aware of blind spots and scan mirrors frequently.
  • Excessive speed:
    • It is unnecessary, dangerous, and it reduces patient survival chances.
    • It makes patient care difficult and hinders driver reaction time, and it increases stopping distance.
  • Siren syndrome:
    • It causes drivers to speed up due to anxiety.
  • Vehicle size and distance judgment:
    • Crashes often occur when backing up; use a spotter.
    • Size and weight influence braking and stopping distances.
  • Road positioning and cornering: Enter high in the lane and exit low to maintain proper lane position.
  • Weather and road conditions:
    • Ambulances require longer braking and stopping distances.
    • Uneven weight distribution increases rollover risk.
    • Be alert for hydroplaning, water, decreased visibility, ice, and slippery surfaces.
    • Hydroplaning can occur at speeds of 30 mph or greater.

Laws and Regulations

  • Emergency vehicle operation with lights and siren may allow:
    • Parking in illegal locations
    • Proceeding through red lights or stop signs
    • Exceeding speed limits
    • Driving against traffic flow
    • Traveling left of center for illegal passing
  • Restrictions:
    • Never pass a stopped school bus loading or unloading children.
  • Warning lights and siren use require:
    • A true emergency call
    • Simultaneous use of audible and visual warning devices
    • Operation with regard for others' safety
  • Right-of-way privileges:
    • Emergency vehicles can disregard traffic laws when responding to emergencies.
    • Do not endanger people or property.
    • Know local right-of-way privileges.
  • Use of escorts: Use only in unfamiliar territory.
  • Intersection hazards:
    • Intersections are the most common and serious crash locations.
    • Stop briefly and check for hazards if unable to wait for traffic lights.
  • Highways:
    • Turn off emergency lights and siren until in the far left lane.
  • Unpaved roads:
    • Drive at a lower speed with a firm grip on the steering wheel.
  • School zones:
    • Do not exceed the speed limit.

Distractions

  • Focus on driving and anticipating hazards.
  • Minimize distractions from:
    • Mobile dispatch terminals and GPS
    • Mounted mobile radio
    • Stereo
    • Cell phone
    • Eating/drinking

Driving Alone

  • Focus on the safest route while mentally preparing for the call.
  • Such situations require complete attention.

Fatigue

  • Recognize fatigue and alert your partner or supervisor.
  • Be placed out of service until fatigue passes.

Air Medical Operations

  • Air ambulances are used for medical and trauma patient evacuation.
    • Fixed-wing units (for distances greater than 200-250 miles)
    • Rotary-wing units (helicopters) for shorter distances
  • Specially trained crews accompany flights; EMTs provide ground support.
  • Medical evacuation (medevac) is performed by helicopters.
  • Capabilities, protocols, and procedures vary.
  • Why call for a medevac?
    • Ground transport is too long.
    • Road, traffic, or environmental conditions hinder ground transport.
    • The patient requires advanced care.
    • Multiple patients overwhelm resources reachable by ground.
  • Who receives a medevac?
    • Patients with time-dependent injuries or illnesses.
    • Stroke, heart attack, or spinal cord injury patients.
    • SCUBA diving, near-drowning, or wilderness accident victims.
    • Trauma patients.
    • Candidates for limb replantation, burn center, hyperbaric chamber, or venomous bite center.
  • Whom to call:
    • Notify the dispatcher first.
    • EMS may communicate with the flight crew after initiating the request in some regions.
  • Establish a landing zone:
    • Hard or grassy level surface between 60 ft×60 ft60 \, ft \times 60 \, ft and 100 ft×100 ft100 \, ft \times 100 \, ft (recommended)
    • Clear of loose debris; clear of overhead or tall hazards.
    • Mark the site using cones or vehicles, not caution tape or people; do not use flares.
    • Move nonessential personnel and vehicles.
    • Communicate wind direction to the flight crew.
  • Landing zone safety and patient transfer:
    • Maintain a safe distance when the aircraft is on the ground and "hot."
    • Avoid the tail rotor; always approach from the front.
    • The main rotor blade may dip as low as 4 feet off the ground.
    • Familiarize yourself with hand signals.
    • Do not approach the helicopter unless instructed and accompanied by the flight crew.
    • Secure equipment and the patient to the stretcher.
    • Smoking, open lights or flames, and flares are prohibited within 50 feet.
    • Wear eye protection.

Special Considerations

  • Night landings:
    • Do not shine lights in the air.
    • Direct low-intensity headlights or lanterns toward the ground.
    • Illuminate overhead hazards.
  • Landing on uneven ground:
    • The main rotor blade will be closer to the ground on the uphill side; approach from the downhill side only.
  • Medevacs at hazmat incidents:
    • Notify the flight crew.
    • Consult about approach and distance.
    • The landing zone should be uphill and upwind.
    • Decontaminate patients before loading.

Medevac Issues

  • Assess weather, environment, and terrain severity.
  • Helicopters are often limited to flying below 10,000 feet above sea level.
  • Medevac helicopters fly between 130 and 150 mph.
  • Assess the number and size of patients that can be safely transported due to cabin space.
  • Medevac flights are typically expensive compared to ambulance transports.

Review Questions and Answers

  • All of the following are examples of standard patient transfer equipment, EXCEPT:
    • Stokes baskets. (Correct)
    • Long backboards.
    • Wheeled stair chairs.
    • Wheeled ambulance stretchers.
  • The primary purpose of a “jump kit” is to:
    • Ensure that you have immediate access to the AED.
    • Have available all of the equipment that you will use in the entire call.
    • Have easy access to manage patients with severe uncontrolled bleeding.
    • Have available all of the equipment that will be used in the first 5 minutes. (Correct)
  • You have been dispatched to a call for an unresponsive patient. What is the MOST important information that you should obtain from the dispatcher initially?
    • The callback number of the caller
    • The severity of the patient’s problem
    • Whether the patient is breathing
    • The exact physical location of the patient (Correct)
  • While en route to a call for a major motor vehicle collision, the MOST important safety precaution(s) that you and your partner can take is/are:
    • Adhering to standard precautions.
    • Ensuring that the fire department arrives before you.
    • Using lights and siren and being aware of other drivers.
    • Wearing seat belts and shoulder harnesses at all times. (Correct)
  • Which of the following is NOT a guideline for safe ambulance driving?
    • Always use your siren if you have the emergency lights on.
    • Always exercise due regard for person and property.
    • Use one-way streets whenever possible. (Correct)
    • Go with the flow of the traffic.
  • At what speed will the ambulance begin to hydroplane when there is water present on the roadway?
    • 25 mph
    • 30 mph (Correct)
    • 40 mph
    • 50 mph
  • The most common and often most serious ambulance crashes occur at/on:
    • Stop lights.
    • Intersections. (Correct)
    • Highways.
    • Stop signs.
  • The recommended dimensions for a helicopter landing zone are:
    • 50 × 50 feet.
    • 75 × 75 feet.
    • 100 × 100 feet. (Correct)
    • 150 × 150 feet.
  • Which of the following statements about helicopters is true?
    • It is possible that the main rotor blade will dip to within 4 feet of the ground. (Correct)
    • A helicopter is considered “hot” when it is on the ground and the rotors are still.
    • If the helicopter must land on a grade, you should approach it from the uphill side.
    • If you must go from one side of the helicopter to the other, the best way is to duck under the body.
  • Upon arrival at a scene where hazardous materials are involved, you should park the ambulance:
    • Upwind from the scene. (Correct)
    • With the warning lights off.
    • Downhill from the scene.
    • At least 50 feet from the scene.