Chapter 37 Transport Operation

Chapter 37 Transport Operation A) Emergency Vehicle Design a) An ambulance is a vehicle that is used for treating and transporting patients who need emergency medical care to a hospital i) First use occurred in the 1800s ii) They were called hearse-ambulances b) Today they are designed based on the NFPA 1917 Standard for Automotive Ambulances c) One of the most significant developments was to enlarge the patient compartment d) Another was the use of first-responder vehicles i) These respond initially to the scene with personnel and equipment to treat the sick and injured until an ambulance can arrive e) Ambulances have the following features: i) A driver’s compartment ii) A patient compartment that can accommodate 2 EMTs & usually 2 supine patients iii) Equipment and supplies to provide emergency medical care at the scene iv) Two-way radio communication so ambulance personnel can speak with the dispatcher, hospital, public safety authorities, and online medical control v) Design and construction that ensure maximum safety and comfort f) Star of Life – this six-pointed emblem identifies vehicles as ambulances B) Phases of an Ambulance Call a) The Preparation Phase i) Making sure equipment and supplies are in their proper places and ready for use ii) Store supplies in ambulance according to how urgently and how often they are used iii) Items like airway management, artificial ventilation, and oxygen delivery should be placed at the head of the primary stretcher iv) The most common cause of AED malfunction is a dead battery v) Make sure there are two portable artificial ventilation devices that operate independently of an oxygen supply carried on the ambulance vi) A CPR board provides a firm surface under the patient’s torso so you can give effective chest compressions vii) First ever prehospital use of a defibrillator was by a St. Vincent’s Hospital ambulance in NYC under direction of Dr. William Grace in early 1970s viii) Jump kit: a portable, durable, and waterproof kit that contains anything you might need in the first 5 minutes with the patient (except AED) ix) Must carry at least one obstetrics kit (childbirth) x) Medications, safety and operations equipment, personal safety equipment xi) Every ambulance must be staffed with at least one EMT in the patient compartment whenever a patient is being transported xii) Ambulance daily inspections: • Fuel, oil, transmission, and engine cooling system and fluid levels • Batteries • Brake fluid • Engine belts • Wheels and tires • Interior and exterior lights • Windshield wipers and fluid • Horn and siren • Air conditioners and heaters • Ventilating system • Doors • Communication systems; vehicle and portable • Windows and mirrors xiii) Review safety precautions b) The Dispatch Phase i) Should be staffed with trained personnel who are familiar with agencies they are dispatching to and working 24 hours ii) Dispatcher should gather the minimum information: • The nature of the call • The name, present location, and call back phone number • Location of the patient(s) • The number of the patients and some idea of the severity of their conditions • Any other special problems or pertinent information about hazards or weather iii) The dispatcher follows a set of guidelines to determine information given and guides the caller through basic care such as bleeding control c) En Route to the Scene i) In many ways, this is the most dangerous for responders ii) Crashes cause many injuries to EMS personnel iii) Inform dispatch your unit is responding & confirm the nature and location of the call iv) The team should prepare to assess and care for the patient v) Assign specific initial duties and scene management tasks to each team member vi) Arriving at the scene safely and safely transporting the patient are two of the most challenging aspects of being an EMT d) Arrival at the Scene i) Perform a scene size-up • Look for safety hazards to yourself, partner, bystanders, and patients • Evaluate the need for additional units • Determine the MOI (mechanism of injury) in trauma patients or nature of the illness on medical calls • Evaluate the need to immobilize the spine • Follow standard precautions ii) Report to dispatch the nature of the incident if part of local protocol iii) If first to arrive to a mass casualty incident, give dispatch a brief report iv) Park in front of or behind the scene on the same side • Usually EMS will be 100 feet beyond the scene while firefighters and law enforcement will be before it • However, the first vehicle to arrive on scene should park before it • Best to park uphill and/or upwind v) Care for patients first, but as soon as possible place appropriate warning devices vi) The main objectives in directing traffic are warn other drivers, prevent more crashes, & keep vehicles moving in orderly manner so care of injured people isn’t interrupted e) The Transfer Phase i) Many patients say the most terrifying part is the ambulance ride to the hospital ii) In most cases, excessive speed is unnecessary and may prevent the provider in the back from performing appropriate care iii) Common sense and defensive driving techniques iv) In most cases, you will provide lifesaving care right where you find the patient before moving them to the ambulance • Then you may begin less critical measures like bandaging and splinting • After you must package the patient for transport by securing them to a device like backboard or scoop stretcher • Then move to the ambulance and lift the patient into the patient compartment v) Secure the patient with at least three straps across the body vi) Use deceleration or stopping straps over the shoulders to prevent the patient from continuing forward in case of sudden stops f) The Transport Phase i) Inform dispatch when you are ready to leave with the patient • Report the number of patients you have, the name of the receiving hospital, and sometimes the beginning mileage of the ambulance ii) Continue to monitor patient en route • Every 15 minutes for a stable patient and every 5 minutes for an unstable patient iii) May also be a good time to begin patient report iv) Do not abandon the patient emotionally g) The Delivery Phase i) Inform dispatch as soon as you arrive to the hospital and sometimes ending mileage ii) Follow these steps to transfer patient to receiving hospital: • Report your arrival to the triage nurse • Physically transfer patient from the stretcher to the bed directed for your patient • Present a complete verbal report at the bedside to the nurse or physician taking over the patient’s care • Complete a detailed report, obtain required signatures, and leave a copy with appropriate staff member (a) Electronic reports are often used (b) Your service should have a method for printing or sending reports iii) The PCR should include a summary of history of the patient’s current illness/injury with pertinent positives and negatives, MOI, and findings on your arrival • Also list vital signs and briefly mention relevant past medical history, in addition to medications and allergies • Include treatment and its effect during prehospital setting h) En Route to the Station i) When you leave, inform dispatch whether you are in service or where you are going ii) When back at the station: • Clean & disinfect ambulance and any equipment used if you didn’t at the hospital • Restock any supplies you did not get at the hospital i) The Postrun Phase i) Complete and file any additional reports and inform dispatch of the unit status, location, and availability ii) Use a written checklist to document needed repairs or replacement of equipment iii) Know different terms: • 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 • High-level disinfection – the killing of pathogenic agents by the use of potent means of disinfection • Sterilization – a process, such as use of heat, which removes all microbial contamination iv) Do all of the following after every call: • Immediately strip used linens from the stretcher after use and place them in a plastic bag in the ED • Discard all disposable equipment used for care in appropriate receptacles • Wash contaminated areas with soap and water (this must be done first for disinfection to be effective) • Disinfect all non-disposable equipment used in the care of the patient • Clean the stretcher with an EPA-registered germicidal/virucidal solution or bleach and water at 1:100 dilution • Clean up any spillage or other contamination • Create a schedule for routine full cleaning for the vehicle • Have a written policy for cleaning each piece of equipment C) Defensive Ambulance Driving Techniques a) Not everyone who drives a vehicle is qualified to drive an emergency vehicle b) Due diligence and caution are important characteristics c) Many crashes occur because of a physical impairment of the driver d) Working long shifts or multiple consecutive shifts also puts drivers at risk for delayed reaction time or falling asleep e) Notify your employer if you feel unable to safely drive an emergency vehicle f) Emotional fitness i) Emotions often change when someone gets behind a steering wheel ii) Emotional maturity & stability are closely related to the ability to operate under stress g) The first rule to remember is that speed does not save lives, good care does h) The second is that the driver and all passengers must wear seat belts i) Brake pressures vary between different vehicles j) Siren risk-benefit analysis i) Activating sirens depends on local protocols, patient condition, and the anticipated clinical outcome of the patient ii) Studies show that while time is saved, it is often minimal iii) Always assume other motorists or pedestrians don’t hear sirens until proven k) Avoid using an ambulance’s PA system l) Cushion of safety – maintaining this while driving includes keeping a safe distance between your vehicle and the one in front of you, checking for tailgaters behind your ambulance, and keeping aware of vehicles potentially hiding in your mirrors’ blind spots i) Drive about 4 or 5 seconds behind the vehicle traveling at an average speed ii) If being tailgated, do not speed up to try to lose them iii) Slamming on brakes to scare them also does not typically work iv) The best method is to slow down, this will cause them to speed past you v) You can also have your dispatcher contact local police to let them know someone is driving recklessly behind you vi) Never get out of the ambulance to confront a driver m) Three blind spots to be aware of: i) The rearview mirror – obstructing the view ahead of you and preventing vision of pedestrians or other vehicles • Lean forward to eliminate this blind spot ii) The rear of the vehicle – this cannot be seen fully through the mirror • They cannot see the vehicles behind them. Because of this, many crashes occur when the ambulance is backing up • Highly recommended to have a spotter iii) The side of the vehicle – cannot be seen through side view mirrors at certain angles • To eliminate this, many systems place small round mirrors on the side mirrors to assist with visualizing the blind spot • If not available, lean forward or backward • Very important when switching lanes or making turns n) Driving fast is not necessary. Although many states allow EMS systems to drive above posted speed limits, they offer little protection if involved in a crash o) Road position means the position of the vehicle on the roadway relative to the inside or outside edge of the paved surface i) To corner efficiently, you must know vehicle’s current position and its projected path ii) Fastest path to a curve: enter high, apex low in the lane, and exit high iii) Safest path to a curve: enter high and exit low p) Hydroplaning i) On a wet road, speeds at 30 mph cause the tires to be lifted off the road as water piles up underneath and the vehicle will feel like it is floating ii) Causes driver to lose control q) Driving through moving water should be avoided at all times D) Laws and Regulations (Ambulance Drivers) a) Privileges do not lessen liability in a crash b) If using warning sirens, you may be able to do the following: i) Park or stand in an otherwise illegal location ii) Proceed through a red traffic light or stop sign, but never without stopping first iii) Drive faster than the posted speed limit iv) Drive against flow of traffic on a one-way street or make a turn normally illegal v) Travel left of center to make an otherwise illegal pass c) An emergency vehicle is NEVER allowed to pass a school bus that has stopped to load or unload children and is displaying flashing red lights or extended stop arm d) Three principles govern the use of warning lights and sirens: i) The unit, to the best of your knowledge, must be on a true emergency call ii) Audible and visual warnings devices must be used simultaneously iii) The unit must be operated with due regard for safety of all others, on and off roadway e) Intersection crashes are the most common and usually most serious type of crash that ambulances are involved in i) Be cautious of those who “time the traffic lights” ii) Another common hazard is when one emergency vehicle follows another ER vehicle f) When driving on highway, don’t put emergency lights on until reaching the far left lane g) In many states, it’s unlawful for emergency vehicle to exceed speed limit in school zones E) Air Medical Operations a) Air ambulances are used to evacuate medical and trauma patients b) Two basic types of units: i) Fixed-wing • Used for inter-hospital patient transfers for distances greater than 100-150 miles ii) Rotary-wing (helicopters) • Have become an important tool in providing emergency care F) Helicopter Medical Evacuation Operations a) Medivac – a medical evacuation is generally performed exclusively by helicopters b) Guidelines when considering whether to initiate a medivac operation: i) Calling for a Medivac • Why call for a medivac? (a) Transport time to hospital by ground is too long considering condition (b) Interferences that prohibit the use of ground ambulances (c) Patient requires advanced care you are unable to provide (d) Multiple patients that overwhelm the resources Who receives a medivac? (a) Time-dependent illnesses or injuries (b) Stroke, heart attack, or serious spinal cord injury (c) Remote areas (scuba diving accidents, near drownings, skiing or wilderness) (d) Amputations (e) Burns, hyperbaric chamber center, venomous bites • Whom do you call? (a) Dispatcher must be notified first (b) In some regions, EMS is able to keep an open line with flight crew c) Establishing a Landing Zone i) This is the responsibility of the ground EMS crew ii) Flying up and down is the most dangerous mode of operation iii) Consider when selecting and establishing a landing zone: • Ensure the area is a hard or grassy level surface that measures 100 feet x 100 feet (a) No less than 60 feet x 60 feet • Ensure the area is clear of any loose debris that could become airborne and strike the helicopter or the patient and crew (a) Branches, trash bins, flares, caution tape, medical equipment • Examine the immediate area for any overhead or tall hazards • To mark the landing site, use weighted cones or position emergency vehicles at the corners of the landing zone with the headlights facing inward to form an x (a) Essential during night landings (b) Never use caution tape or ask people to mark the site (c) Do not use flares because they can become airborne or start a fire/explosion • Move all nonessential people & vehicles to a safe distance outside landing zone • If the wind is strong, radio to the flight crew the direction of the wind • G) Landing Zone Safety and Patient Transfer a) Most important rule is to keep a safe distance whenever it is on the ground and “hot” i) Hot means when the helicopter blades are spinning b) If asked to enter the landing zone, stay away from the tail rotor c) Always approach the helicopter from the front