Alexander ch05 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 5
Ambulance Operations
and Responding to
EMS Calls

• The Advanced EMT applies knowledge of
operational roles and responsibilities to ensure
patient, public, and personal safety.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Give examples of the Advanced EMT’s responsibilities
during each of the major phases of an ambulance call.
3. Describe the recommendations of the National
Association of EMTs with respect to EMS provider
security and safety.
4. Describe the legal responsibilities and privileges afforded
to Advanced EMTs operating ambulances, and the
precautions that must be observed while using those
privileges.
Objectives (1 of 6)

5. Give examples of habits and behaviors that improve
driving safety.
6. Discuss factors that can affect your ability to maintain
control of an ambulance.
7. Explain precautions that should be taken when operating
an ambulance at night or in inclement weather.
8. Describe the appropriate use of emergency warning
devices, such as lights and sirens.
9. Describe the safety precautions to be taken when
working at scenes on and near roadways.
Objectives (2 of 6)

10.Explain precautions to avoid exposing yourself and
others to increased levels of carbon monoxide from
vehicle exhaust.
11.Compare the relative risk of ground ambulance operation
to other potential risks faced by EMS providers.
12.Relate features of ambulance design to both hazards and
safety in ambulance crashes.
13.Given a high-risk ambulance operation situation, such as
negotiating intersections or highway driving, describe
actions to reduce the risk as much as possible.
Objectives (3 of 6)

14.Explain the impact of speed on both emergency
response time and safety.
15.Describe the ways of minimizing distractions while
driving.
16.Explain the impact of fatigue and shift work on the safety
of ambulance operations.
17.Discuss situations in which air medical transportation
should be considered, disadvantages of air medical
transport, and guidelines for setting up a landing zone
and interacting with the air medical crew.
Objectives (4 of 6)

18.Apply principles of proper body mechanics to lifting and
moving patients and equipment.
19.Describe the importance of teamwork and
communications in lifting and moving patients.
20.Differentiate among situations that call for emergency,
urgent, and nonurgent moves.
21.Demonstrate the steps required to package a patient
properly for transport by ground or by air.
Objectives (5 of 6)

22.Describe the proper use of, advantages, disadvantages,
and techniques for using a variety of methods and
equipment for lifting and moving patients.
23.Determine the proper position for patients whose
conditions require specific positioning considerations.
Objectives (6 of 6)

• AEMTs must understand how to anticipate and
respond to challenges
– Ambulance operations
– Special equipment needed
– Lifting and moving
– Scene size-up
Introduction

• EMS providers have duties and responsibilities
from before a call is received to putting the
ambulance back in service after a call.
Phases of EMS Calls (1 of 8)

• Six phases
– Preparation
– Receiving and responding
– On-scene care and preparation for transport
– Transporting patient
– Transferring patient care
– Terminating call

Figure 5-1
A modern ambulance has many of the capabilities of a hospital emergency department.
(© Edward T. Dickinson, MD)

• Preparation
– Vehicle in good mechanical condition
– Equipment and supplies stocked
– Clean and safe for patient care
– AEMTs must be prepared for their work.

• Receiving and responding
– Be ready for calls at all times.
– Operate the vehicle safely.
– Determine the best route.
– Best location to park at scene
– Scene size-up

• On-scene care and preparation for transport
– Scene size-up continues throughout patient contact.
– Primary asasessment
– Secondary assessment
– Perform needed care.
– Prepare patient for transport.
– Communication and teamwork are required.

• Transporting the patient
– Determine transport destination.
– Select best route.
– Reassess and continue patient care en route.
– Communicate with receiving facility.
– Document care.

• Transferring patient care
– Transfer care only to someone of equal or higher level
of medical training.
– Transfer report.
– Leave copy of PCR.

• Terminating the call
– Clean and disinfect equipment.
– Replace supplies used.
– Complete paperwork.
– Inform dispatch you are back in service.

Prehospital Environment
and Types of Calls (1 of 10)
• Nonemergency calls typically involve interfacility
transfers
– Calls can be scheduled or urgent in nature.
– Reassess and monitor patients as needed.
– Complete PCR.

• Emergency calls require
– Emergency driving techniques
– Rapid patient assessment
– Quick decision making
– Advanced treatment
– Safe, prompt transport

• Emergency calls
– Received through 911
– Response time at minimum with safe vehicle operation
– Uncontrolled and emotional nature of emergencies can
increase risks to safety of EMS providers.
– Assess scene for other dangers.

• Medical calls
– Acute or chronic illnesses
– Affects all ages
– Determine nature of illness.
– Thorough medical history and assessment
– Provide safe transport.
– Reassess and continue care during transport.
– Notify receiving hospital.

• Trauma calls
– Determine mechanism of injury (MOI) and perform
thorough assessment.
– Be on-scene for 10 minutes or less.
 Consider air medical transport if necessary
– Provide immediate interventions to ensure
 Open airway and ventilation
 That life-threatening bleeds are controlled bleeding
 That you package the patient for transport

• Responding to a residence
– EMS can see patient’s environment.
– Treat patients, property, and belongings with care and
respect.
– If you gain access to patient’s home by breaking locked
door or window, do so in presence of police and with
little damage.
– Leave patient’s home safe and secure.

• Responding to roadway scenes
– Highest potential for provider and patient injuries and
fatalities
– Extreme caution must be observed at all times.
– Position vehicle so providers do not cross traffic to get
patients.
– Wear reflective clothing.
– Be aware of moving traffic and other roadway hazards.

Figure 5-3
Special training is required for rescue situations.

• Rescue situations
– Determine if additional resources are required.
– Rescues require specialized training and equipment.
– Safety of providers and patient must always be
considered.

• Hazardous materials situations
– Involve possible exposure to toxic chemicals or
substances
– Care to patients who have been exposed to hazardous
materials after trained personnel have properly
decontaminated them
– Never hesitate to contact hazmat teams.

Figure 5-4
A multiple-casualty incident exists when the number of patients exceeds the resources
available to care for them.
(© Rob Crandall/Image Works)

• Multiple-casualty incidents
– Involves multiple patients
– Overwhelming to available resources
– Use incident command system (ICS)
– Conduct MCI drills and training sessions
– Triage used to categorize patients

Ambulance Design (1 of 3)
• Not built by automotive industry, and do not
handle like automobiles.
• Begin as heavy-duty truck chassis (Type I
ambulance) or van chassis (Type II and III
ambulances) and then extensively modified.

Figure 5-6
A type II ambulance.

• Four standard types of ambulances
– Type I: built on pickup truck chassis
– Type II: built on van chassis
– Type III: built on van chassis, but has had extensive
modification
– Medium-duty: built on large truck chassis

• Ambulance design dictated by federal
specifications
– General Services Administration (GSA) specifications,
KKK-A-1822-E
– Not construction or safety standards

Vehicle Readiness (1 of 3)
• Crew responsibility
– Ambulance is in safe working order
– Stocked with supplies and equipment
– Vehicle inspection checklist

• Exterior vehicle and mechanical readiness
– Engine
– Brakes
– Lights
– Tires
– Windshield wipers
– Emergency warning devices
– Radios

• Patient care equipment and supplies
– Medical equipment standards agencies
 American College of Surgeons (ACS) Committee on Trauma
(COT)
 National Institute for Occupational Safety and Health
(NIOSH) and Occupational Safety and Health Administration
(OSHA)
 National Fire Protection Association (NFPA)
 Commission on Accreditation of Ambulance Services (CAAS)

Emergency Vehicle Operations (1 of 19)
• Most ambulance accidents are predictable and
preventable
– Primary cause of line-of-duty deaths in EMS is vehicle
crashes.
– Most injuries occur in patient compartment caused by
improperly restrained occupants and equipment.
– Cause of most crashes is human error.

• Defensive driving
– What is the definition of defensive driving?
– A defensive driver must always be three things. What
are they?

• Defensive driving (continued)
– Cushion of safety is area of clear space.
– Do not follow other vehicles too closely.
– Scan side mirrors.
– Be alert for tailgaters.

• Speed
– Primary factor in loss of control of vehicles.
– Cap speed 10 mph over limit; never exceed 75 mph
• Due regard
– Drive with due regard for safety of others.

• Emergency driving
– Scan 12–15 seconds ahead.
– Avoid other vehicles’ blind spots.
– Avoid sudden stops and lane changes.
– Smooth ride for patient and crew.
 Take turns slowly and cautiously.
 Avoid sudden movements

• Safe backing up
– Avoid backing up when possible
– Observe your surroundings.
– Open windows.
– Use a spotter.
– Use hand signals.
– Scan mirrors constantly.

• Night driving
– Reduces visual acuity
– Adjust speed and following distance accordingly.
– Never activate high beams when other vehicles are
approaching

• Highway driving
– Involves high speed and high risk
– Crashes less common but frequently result in fatalities
– Monitor speed
– Drive with due regard
– Increase following distance
– Scan far ahead

• Emergency response and use of warning devices
– Primary reasons for increased risk
 Civilian driver confusion
 Ambulance operator adrenaline and emotion

Emergency Vehicle Operations (10 of
19)
(continued)
– Most state laws allow emergency vehicles with both
lights and sirens to
 Exceed posted speed limit
 Disregard traffic control device
 Drive against flow of traffic
– However, you must still drive with due regard

19)
(continued)
– Downgrade emergency driving when
 Traffic has nowhere to go
 Approaching blocked intersection at red light
 Entering and exiting freeway
 Approaching school zones and school buses

Figure 5-10
Clear each lane of traffic as you proceed through an intersection.

19)
• Always pass on left.
• Smooth emergency driving imperative to reduce
provider and patient injury.
• Intersections most dangerous place for
emergency vehicles.
– Always come to complete stop at a red light or stop
sign.

19)
• Multiple emergency vehicles traveling together
should be avoided.
– May not realize there is more than one emergency
vehicle and pull back into your lane
• When you must travel with other emergency
vehicles.
– Follow far enough behind

19)
• Parking on the scene
– Vehicles positioned to permit best access to patients
– Backing up should be avoided
– On highways, if possible, position ambulance so there
is obstacle between traffic and ambulance
– Use retro-reflective materials

Figure 5-11
Proper parking positions at roadway scenes.

19)
• Occupant safety and vehicle security
– Most injuries occur in patient compartment
– Proper restraint of occupants and equipment
– Everything in back of ambulance must be properly
secured
– Patient and providers must be restrained

19)
• Seating positions
– Safest seating position in back is stretcher
– Most dangerous position is on side facing bench seat
– Child must never be transported in caregiver’s lap and
must always be properly restrained
– When possible, use child’s own car seat

19)
• Carbon monoxide in ambulances
– Ensure vehicle receives preventive maintenance
– Ensure vehicle exhaust exits beyond side of vehicle,
not under it
– Keep ambulance windows shut
– Ensure doors and windows close tightly

19)
• Carbon monoxide in ambulances (continued)
– Cover any opening to outside (vents)
– Keep heater or air conditioner on
– Do not use fuel-powered supplemental equipment
inside ambulance

19)
• Operational security
– National Association of Emergency Medical
Technicians (NAEMT) established recommended
guidelines for improved safety and security of EMS
vehicles.

Figure 5-13
Assess the safety of the scene.
(© Daniel Limmer)

Scene Size-Up (1 of 5)
• What is scene size-up?
• Operational purposes
– Determine general nature of situation
– Determine safety of a situation
– Determine number of patients
– Determine if additional resources are required

• Nature of the situation
– Determine general nature of illness (NOI) or
mechanism of injury (MOI)
 Decide how to approach scene
 Determine needed resources
 Identify hazards
 Assess and manage patient

• Scene safety
– Assess potential dangers
– Have personal protective equipment (PPE) ready
– Do not approach an unsafe scene
– Request resources needed to make scene safe

• Number of patients
– Determine if only one patient, or if there are multiple
patients
– Look around, ask patient, or ask witnesses or
bystanders
– Request additional transporting units if needed

• Additional resources
– More ambulances or air medical transportation
– Advanced life support
– Police
– Fire department/heavy rescue
– Utility companies
– Animal control
– Hazmat

Lifting and Moving Patients (1 of 6)
• Use proper lifting and moving techniques.
• Before lifting, know your personal limit.
– Do not be afraid to request additional help.
– Communicate throughout lift when lifting with an
assistant.

• Proper lifting techniques include:
– Planting your feet shoulder distance apart
– Positioning hands with palms forward
– Lifting with your legs not your back
– Never leaning or twisting as you lift

Figure 5-14
(a)
(b)
(A) Using a power grip and (B) a power lift.

• Equipment and techniques used to lift and move
patients
– Know your equipment.
– Use power grip and power lift or squat lift.
– Use proper techniques to place patient on stretcher,
depending on circumstances.
– Position patient according to condition and comfort.

Figure 5-19
A portable stretcher.

Figure 5-20
A scoop stretcher.

• Equipment
– Wheeled stretchers
– Portable stretchers
– Scoop stretchers
– Long backboards
– Stair chairs
– Bariatric patient devices
– Neonatal isolettes

• Emergency moves used when patient is in
immediate danger if he remains where he is
– Armpit-forearm drag
– Shirt drag
– Blanket drag

Think About It
• What circumstances or conditions might indicate
immediate danger?
• What moves might be used to remove a patient
from immediate danger?

Figure 5-24
Armpit-forearm drag.

Figure 5-26
Blanket drag.

Figure 5-27
Extremity lift.

• Techniques used in non-emergency moves
– Log roll
– Direct ground lift
– Direct carry
– Extremity lift
– Draw sheet
– Rapid extrication

Scan 5-1 (1 of 4)
Using a Draw-Sheet
1. Log-roll the patient. Lay a sheet or blanket along the back of the patient’s body. Bunch
up the edge of the sheet closest to the patient and tuck it underneath the length of his body.

Scan 5-1 (2 of 4)
Using a Draw-Sheet
2. Lower the patient and then log roll him to the opposite side. Straighten the edge of the
blanket that was tucked beneath the patient.

Scan 5-1 (3 of 4)
Using a Draw-Sheet
3. Lower the patient onto his back and position the stretcher next to the bed. Roll the edges
of the sheets up next to the patient. Grasp the edges of the sheet to support the patient’s
head, torso, and legs.

Scan 5-1 (4 of 4)
Using a Draw-Sheet
4. One EMS provider gives the command to move. The patient is lifted from the bed to the
stretcher.

Air Medical Transport (1 of 4)
• Fixed-wing aircraft
– used for long-distance critical care transports between
hospitals.
• Helicopters (rotary-wing aircraft)
– used for emergency transport of critically ill or injured
patients.

• Air medical transport providers are capable of
advanced level of care have additional education
in critical care. For example:
– Rapid sequence intubation
– Ventilators
– IV pumps

• Limitations of air medical transport
– Weather
– Altitude
– Aircraft cabin size
– Weight limit
– Terrain

Figure 5-30
Helicopter landing zone.

• Requesting air medical transport
– When absolutely necessary
 patient condition, transport time, destination.
– Takes time to prepare
 lift off, landing, safety precautions.
– Helicopters require landing zone preparation and
special safety precautions for approaching aircraft and
loading patient.

Chapter Summary (1 of 5)
• EMS providers work in unique patient care
environment.
• Risks and considerations different from those of
any other type of health care provider.

• Operational aspects include
– Vehicle operations
– Driving safety
– Scene size-up
– Lifting and moving patients
– Interacting with air medical services

• EMS providers responsible for vehicle being
– Fully stocked
– Clean
– Safe
– Mechanically capable of responding to scene

• AEMT must
– Be able to do scene size-up
– Determine
 nature of problem
 safety of situation
 number of patients
 need for additional resources
 patient’s general condition

• AEMT must (continued)
– Know how and when to move patients
– How to safely operate all equipment available on an
ambulance.
– Know how to transport patients and when air medical
transport is indicated and feasible

Alexander ch05 lecture

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