Chapter 48: Operations

PART 1: Ambulance Operations

Ambulance Standards Essential equipment- equipment/supplies required on every ambulance. Minimum standards- lowest least allowable standards, set by government agencies. Gold standard- ultimate standard of excellence, set by local &/or regional EMS systems Ambulance Design DOT KKK 1822D specs- manufacturing and design specifications produced by the Federal General Services Administrative Automotive Commodity Center. o Type I- conventional truck cab-chassis w/modular body o Type II- standard van, forward control integral cab-body o Type III- specialty van, forward control integral cab-body Medical Equipment Standards Set up by: OSHA, NIOSH, NFPA, and Local medical direction boards. Additional Guidelines Commission on Accreditation of Ambulance Services (CAAS) provides a voluntary Gold Standard for EMS Checking Ambulances The shift checklist makes the work environment safer by assuring mechanical maintenance and the availability of personal protection equipment. Expiration dates on medications should be checked each shift, and the older, unexpired drugs marked appropriately so that they will be used first. It is your responsibility to report ambulance/equipment problems or failures to supervisors in accordance to SOPs. Ambulance Deployment & Staffing Deployment Factors o Location of facilities to house ambulances o Location of hospitals o Anticipated volume of calls o Local geographic and traffic considerations Deployment- strategy used by EMS agency to maneuver its ambulances and crews in an effort to reduce response times. Demographic- pertaining to population makeup or changes. Peak load- the highest volume of calls at a given time. Primary area of responsibility (PAR)- stationing of ambulances at specific high-volume locations. System status management (SSM)- a computerized personnel and ambulance deployment system. Traffic Congestion o Tiered response system- system that allows multiple vehicles to arrive at an EMS call at different times, often providing different levels of care of transport.

Operational Staffing o Reserve capacity- the ability of an EMS agency to respond to calls beyond those handled by the on-duty crews. Safe Ambulance Operations Educating Providers o Reportable collisions- collisions that involve over $1000 in damage or a personal injury. o Most safety-minded ambulance operators agree that the days of blowing through an intersection at high speeds w/lights blazing and siren blasting have come and gone. o A typical ambulance collision: a lateral collision that takes place on a dry road during daylight hours on a clear day in an intersection w/a traffic light. Reducing Ambulance Collisions o Routine use of driver qualification checklists and drivers license checks. o Preventative Maintenance o Hands on drivers training o Practice @ slow-speed course to assure operators can use mirrors, back up, & park ambulance sized vehicles o Training for emergency situations such as: loss of brakes, loss of power steering, a stuck accelerator, blown out tire, or vehicle break down. o Understanding rules, regulations, and laws that DMV has set for drivers of ambulances. SOPs o Use of a spotter- the person behind the left rear side of the ambulance who assists the operator in backing up the vehicle. The Due Regard Standard- legal terminology found in the motor vehicle laws of most states that sets up a higher standard for operators of emergency vehicles. o Ambulances are rarely or never exempt form prohibitions against passing over a railroad crossing w/the gates down or passing a school bus w/flashing lights. Lights and Siren: A False Sense of Security o As a general rule, do not rely solely on lights and siren to alert other motorists of your approach. o Studies have shown that most motorists do not see or hear your ambulance until it is within 50-100feet of their vehicles. o The role of lights and siren in the modern emergency response situation has diminished. Recent data has shown that lights and siren shave only a few seconds off response time but significantly increase the possibility of injury to the responding crew. Escorts/Multi-Vehicle Responses Parking and Loading the Ambulance The Deadly Intersection- 72% of ambulance collisions occur in intersections. Utilizing Air Medical Transport Aeromedical evacuations- transport by helicopter or fixed-wing aircraft.

Fixed-wing Aircraft- used for transport of patients >100miles. Rotorcraft- helicopter Advantages & Disadvantages of Air Transport o Advantages: rapid transport, access to remote areas, access to specialty unit centers, and access to special supplies. o Disadvantages: weather and environmental restrictions to flying, altitude limitations, and airspeed limitations. Activation- consider the need for medevac as early as possible. Indications for Use o Stable patients who are accessible to ground vehicles are best transported by ground vehicles. o Clinical Criteria Trauma score <12 Glasgow Coma Scale <10 Penetrating trauma to abdomen, pelvis, chest, neck, or head Spinal cord or spinal column injury or any injury producing paralysis or lateralizing signs Partial or total amputation of an extremity (excluding digits) Two or more long bone fractures or pelvis fracture Crush injury to abdomen, chest, or head Major burns or burns to face, hands, feet, or perineum; burns w/respiratory involvement; electrical or chemical burns Patients in serious traumatic event <12 or >55 yrs of age Patients with near-drowning injuries Adult patients with: Systolic b/p <90 mmHg Respiratory rate <10 or >35 per minute Heart rate <60 or >120 per minute Unresponsive to verbal stimuli o Mechanism of Injury Vehicle roll-over with unbelted passengers Vehicle striking pedestrian >20mph Falls >10feet Motorcycle victim ejected at >20mph Multiple victims o Difficult Access Wilderness rescue Ambulance egress or access impeded by road conditions, weather, or traffic o Time/Distance Factors Transport to trauma center >15minutes by ground Transport time to local hospital by ground ambulance greater than transport time to trauma center by helicopter Patient extrication time >20min

Utilization of local ground ambulance results in absence of ground ambulance coverage for local community. o It is important to weigh the risks versus benefits before using a helicopter for EMS patient transport. Patient Preparation & Transfer o Remember that air pressure is changed by altitude, which affects IV bags, air cuffs of tubes, and the use of a PASG. Scene Safety and the Landing Zone

PART 2: Medical Incident Command

Multiple Casualty Incident (MCI)- incident that generates large numbers of patients and that often makes traditional EMS response ineffective because of special circumstances surrounding the event; Mass Casualty Incident Incident Management System (IMS)- national system used for the management of multiple casualty incidents, involving assumption of responsibility for command and designation and coordination of such elements as triage, treatment, transport, & staging Scene-authority Law- state or local statute specifying who has ultimate authority at an MCI. Functional sections of the IMS system- C-FLOP Command Finance/Administration Logistics Operations Planning Command @ MCIs Command (IC)- the individual or group responsible for coordinating all activities and who makes final decisions on the emergency scene. The IC is the ultimate authority for decision-making @ a MCI. Span of control- # of people or tasks that a single individual can monitor. The range of that control may be from 3-7people averaging 5. Singular command- a single individual is responsible for coordinating an incident; usually one jurisdiction. Unified command- managers from different jurisdictions coordinate their activities and share responsibility for command. Command post (CP)- place where command officers from various agencies can meet w/each other and select a management staff. Establish command early on calls were >2 units respond Incident Priorities 1. Life safety 2. Incident stabilization Open incident- an incident that has the potential to generate additional patients. (Incident is out of control) Closed incident- an incident that is not likely to generate additional patients. (Incident is controlled) 3. Property Conservation

Communications are the cornerstone of the IMS. The primary role of an IC is the strategic deployment of all necessary resources at an incident. Transfer of Command- is only done face to face, w/ the current IC conducting a short but complete briefing on the incident status. Termination of Command- is done when IMS is no longer needed and there is only one unit left on scene. Demobilization- resources personnel, vehicles, and equipment- released for use outside the incident when they are no longer needed at he scene. Support of the IC Management Staff Functions- officers who perform supervisory roles in the IMS rather than actually performing a task. Command Staff o Safety Officer- monitors all on scene actions and ensures that they do not create any potentially harmful conditions. o Liaison Officer- coordinates all incident operations that involve outside agencies. o Public Information Officer (PIO)- collects data about the incident and releases it to the press. o Critical Incident Stress Management (CISM) Team- monitors the emotional status of all on-scene personnel and provides the necessary support. o Finance/Administration- responsible for maintaining records for personnel, time, and costs of resources/procurement, reports directly to the IC. o Logistics- supports incident operations, coordinating procurement and distribution of all medical resources. o Operations- carries out directions from command and does the actual work at an incident. o Planning- provides past, present, and future information about an incident. Divisions of Functions o Branches- functional levels within the IMS based upon primary roles and geographic locations. May be organized into Groups or Divisions Groups- groups are based upon function. Ex: Triage Divisions- are based upon geography. Ex: Responders working on the 3rd floor. Units- Groups & Divisions can be broken into taskspecific groups called units o Sector- interchangeable name for a branch, group, or division; does not, however, designate a functional or geographic area. Functional Groups within an EMS Branch o Triage- act of sorting patients based upon the severity of their injuries. Primary Triage- triage that takes place early in the incident, usually on 1st arrival. Ex: START triage

Secondary Triage- triage that takes place after patients are moved to a treatment area to determine any change in status. START (Simple Triage & Rapid Transport) Signs and Symptoms in START o Ability to Walk- Walking wounded? o Respiratory Effort- attempt to open airway 1x o Pulse/Perfusiono Neurological Status o Morgue- area where deceased victims of an incident are collected. o Treatment- were Secondary Triage & treatment takes place for patients. Treatment Units Red Treatment Unit- provides care for all critical patients Yellow Treatment Unit- provides care for all non-critical patients Green Treatment Unit- provides care for all walking wounded o On-Scene Physicians o Staging- location where ambulances, personnel, and equipment are kept in reserve for use at an incident. o Transport- group that coordinates w/staging and treatment to transport patients to area hospitals. o Extrication/Rescue- group or branch responsible for removing patients from entanglements and transferring them to the treatment area. o Rehabilitation- coordinates w/Logistics to establish an area to support on-scene Operational responders. Rapid Intervention Team (RIC-Team)- ambulance and crew dedicated to stand by in case a rescuer becomes ill or injured. o Communications- group is the cornerstone of the IMS. Disaster Management-management of incidents that generate large numbers of patients often overwhelming resources and damaging parts of the infrastructure. o 4 Stages of Disaster Management 1) Mitigation- involves the prevention or limiting of disasters in the first place. Ex: public safety, fire prevention 2) Planning- provides past, present, and future information about an incident. 3) Response- the response to the incident to control and/or correct/treat it. 4) Recovery- the incident has come to an end and everything is returning to normal.

PART 3: Rescue Awareness & Operations

Environments of Rescue/Operations Surface water- dams, flat water, moving water Hazardous Atmospheres- confined spaces, trenches, HazMat incidents Highway Operations- unstable vehicles, Hazardous cargo, volatile fuels Hazardous Terrains- high-angle cliffs, off-road wilderness areas Safety Procedures Rescue SOPs Crew Assignments Preplanning Rescue Operations Phases of a Rescue Operation o Phase 1: Arrival & Size Up o Phase 2: Hazard Control o Phase 3: Patient Access o Phase 4: Medical Treatment o Phase 5: Disentanglement o Phase 6: Patient Packaging o Phase 7: Removal/Transport Surface Water Rescues Heat Escape Lessening Position (HELP)- an in-water, head up tuck or fetal position designed to reduce heat loss by as much as 60% Water Rescue Model: Reach-Throw- Row-GO! Recirculating current- movement of currents over a uniform obstruction; Drowning Machine Strainer- a partial obstruction that filters, or strains, the water, such as downed trees or wire mesh, causing an unequal force on the two sides. Eddies- water that flows around especially large objects and, for a time, flows upstream around the downside of an obstruction; provides an opportunity to escape dangerous currents. Factors Affecting Survival o Age o Posture o Lung volume o Water temperature o Use of pfds o Mammalian diving reflex- when the face of a human, or any mammal, is plunged into water less than 68F, the parasympathetic nervous system is stimulated (Vagus nerve). In-Water Patient Immobilization o Phase 1: In-Water Spinal Immobilization o Phase 2: Rigid Cervical Collar Application o Phase 3: Back Boarding and Extrication from the Water Hazardous Atmosphere Rescues Confined-Space Hazards

o Risk factors O2-Deficient Atmospheres Toxic or Explosive Chemicals Engulfment Machinery Entrapment Electricity Structural Concerns Highway Operations & Vehicle Rescues Highway Hazards o Traffic Hazards- is the largest single hazard associated w/EMS highway operations. o Fire & fuel o Alternative Fuel Systems o Sharp Objects o Electric Power- stay the distance of the span of one power poll from down power lines o Energy-Absorbing Bumpers o Supplemental Restraint Systems (SRS)/Airbags o Hazardous Cargoes o Rolling Vehicles o Unstable vehicles Rescue Strategies o Initial scene size-up o Control hazards o Assess the degree of entrapment and fastest means of extrication o Establish circles of operation o Treatment, packaging, removal Hazardous Terrain Rescues 3 types of hazardous terrain o Steep slope or low angle terrain o Vertical or high-angle terrain o Flat terrain with obstacles Good BLS skills are mandatory in hazardous terrains, but limit ALS skills to those that are really needed. Do not complicate any already complicated operation.

PART 4: Hazardous Materials Incidents

Hazardous Materials (HazMat)- any substance that causes adverse health effects upon human exposure. Role of the Paramedic st EMS Hazmat 1 Responder Tasks 1. Size up incident

2. Assess toxicological risk 3. Activate the IMS 4. Establish command Hazmat Requirements/Standards OSHA publication CFR 1910.120- Hazardous Waste Operations and Emergency Response Standard (1989) EPA regulation 40 CFR 311 NFPA standard 473- Standard for competencies for EMS Personnel responding to Hazardous Materials Incidents. Levels of Hazmat training 1. Awareness Level 2. EMS Level 1- operations level 3. EMS Level 2- technician level Warning Placard- diamond shaped graphic placed on vehicles to indicate hazard classification. UN #- a 4-digit # specific to a given chemical NFPA 704- places placards on tanks & storage vessels at fixed facilities. (the #ed blue, red, yellow,& white diamond placard) Shipping papers/Bills of lading- documents routinely carried aboard vehicles transporting hazardous materials. Material Safety Data Sheets (MSDS)- easily accessible sheets of detailed information about chemicals found at fixed facilities. CAMEO (Computer-Aided Management of Emergency Operations)- website developed by the EPA and NOAA as a source of information, skills, and links related to hazardous substances. CHEMTREC (Chemical Transportation Emergency Center)- maintains a 24-hour toll-free hotline @ 800-424-9300. CHEMTEL, Inc. (Chemical Telephone, Incorporated)- maintains a 24-hour toll-free hotline @ 800-255-3024. Weapons of Mass Destruction (WMD)- variety of chemical, biological, nuclear, or other devices used by terrorists to strike at government or high profile targets, designed to create a maximum number of casualties. WMD Targets o Public buildings o Multinational HQs o Shopping centers o Workplaces o Sites of assembly Hazardous Materials Zones Hot Zone (Contaminated)- location at a hazmat incident where the actual hazardous material and highest levels of contamination exist. Warm Zone (Control)- location at a hazmat incident adjacent to the hot zone; area where decontamination corridor is established. Cold Zone (Safe)- location outside the warm zone; where incident operations take place.

Boiling point- temperature @ which a liquid becomes a gas. Flammable/explosive limits- range of vapor concentration in the air at which an ignition will initiate combustion. Flash point- lowest temperature at which a liquid will give off enough vapors to ignite. Ignition temperature- lowest temperature at which a liquid will give off enough vapors to support combustion; slightly higher than the flash point. Specific gravity- the weight of a volume of liquid compared with an equal volume of water. Chemicals w/a specific gravity >1 will sink in water. <1 will float in water. Vapor density- the weight of a vapor or gas compared w/the weight of an equal volume of air. Chemicals w/ a vapor density >1 will fall to the lowest point possible, <1 will rise. Vapor pressure- pressure of a vapor against the inside walls of a container. As temperatures increase, so do vapor pressures. Water solubility- ability of a chemical to dissolve into solution in water. Types of Radiation Alpha (weakest)- neutrons & protons released by the nucleus of a radioactive substance. Wont penetrate paper, clothing. Beta - electrons released w/great energy by a radioactive substance. Will penetrate few millimeters of skin. Gamma (strongest)- high-energy photons, such as x-rays. Types of Contamination Primary contamination- direct exposure of a person or item to a hazardous substance. Secondary contamination- transfer of a hazardous substance to a noncontaminated person or item via contact w/someone or something already contaminated by the substance. Routes of Hazmat Exposure Respiratory inhalation- most common Topical absorption Parenteral injection Gastrointestinal ingestion- least common Acute effects- signs and/or symptoms rapidly displayed upon exposure to a toxic substance. Delayed effects- signs, symptoms, and/or conditions developed hours, days, weeks, months, or even years after the exposure. Local effects- effects involving areas around the immediate site; should be evaluated based upon burn model. Systemic effects- effects that occur throughout the body after exposure to a toxic substance. Bio-transformation- chemical alteration of a substance within the body; in hazmat situation the body tries to create less toxic materials. Synergism- a standard pharmacological principle in which 2 drugs or other substances work together to produce an effect that neither of them can produce on its own. Methods of Decontamination Dilution- involves the application of large quantities of water. Absorption- entails the use of pads or towels to blot up the hazardous material.

 Neutralization- occurs when one substance reduces or eliminates the toxicity of another, such as adding an acid to a base. Isolation- is separating the patient or equipment from the hazardous substance. 4 Most Common Decontamination Solvents 1. Water 2. Tincture of green soap 3. Isopropyl alcohol 4. Vegetable oil 2 Step Decon- for patients who can not wait for a more comprehensive decon process. 1. Removal of clothing and personal effects 2. gross decon (2x) 8 Step Decon 1. rescuers enter the decon area 2. rescuers drop equipment in a tool-drop area and remove outer gloves 3. decon personnel shower and scrub all victims and rescuers, using gross decontamination. As surface decontamination is removed, the dilution is conducted into a contained area. Victims may be moved to Step 6-7. 4. rescuers remove and isolate their SCBA. 5. rescuers remove all protective clothing. 6. rescuers remove all personal clothing. 7. rescuers and victims receive a full-body washing, using soft scrub brushes or sponges, water, and mild soap or detergent. 8. patients receive rapid assessment and stabilization before being transported to hospitals for further care. Hazmat Protection Equipment Level A- Provides the highest level of respiratory and splash protection. Level B- offers full respiratory protection when there is a lower probability of dermal hazard. Level C- includes a non-permeable suit, boots, and gear for protecting eyes and hands. Instead of SCBA it uses an air-purifying respirator (APR). Level D- structural firefighting bunker gear.

PART 5: Crime Scene Awareness

Tactical Emergency Medical Services (TEMS) Potentially Dangerous Scenes Highway encounters Violent street incidents- most common location for violent crimes o Murders, assaults, robberies Hate crimes- crimes committed against a person wholly on the basis of the individuals actual or perceived race, color, national origin, ethnicity, gender, disability, or sexual orientation. o Dangerous crowds

o Street gangs Gang Characteristics Appearance Graffiti Tattoos Hand signals/language Drug-related crimes Clandestine drug labs o Methamphetamine- one of the most common substances manufactured @drug labs. Domestic violence Safety Tactics Retreat Cover & Concealment o Cover- hiding the body behind solid and impenetrable objects that PROTECT a person from bullets. o Concealment- hiding the body behind objects that shield a person from view but that offer little or NO PROTECTION against bullets or other ballistics. Distraction & Evasion Contact & Cover Warning signals & communication SWAT (Special Weapons & Tactics)- a trained police unit equipped to handle hostage holders & other difficult law enforcement situations. Body armor (bullet proof vest)- vest made of tightly woven, strong fibers that offer protection against handgun bullets, most knives, and blunt trauma. EMT-Tacticals (EMT-Ts)- EMS personnel trained to serve w/ a Technical Emergency Medical Service or a law enforcement agency. CONTOMS (Counter Narcotics Tactical Operations)- program that manages the training the certification of EMT-Ts & SWAT-Medics. Types of Evidence Prints- fingerprints, footprints, tire prints Blood & Blood splatter o Blood splatter evidence- the pattern that blood forms when it is splattered or dropped at the scene of a crime. Body fluids Particulate evidence- evidence such as hairs or fibers that can not be readily seen w/the human eyes; also known as microscopic or trace evidence. On-scene EMS observations