EMS Operations

1. EMS Operations Lesson 18

2. Introduction Understand your role, especially in complex operations Special responsibilities/operational factors Air transport Extricating patients from wreckage Hazardous material incidents Situations requiring special response teams Personal safety is first priority

3. Phases of a Response Preparation for the Call Dispatch En Route to Scene Arrival at Scene Transferring the Patient After the Run

4. Preparation for the Call Personal preparedness Response vehicle preparedness Equipment Preparation Oxygen cylinders Dressings, bandages, other equipment Follow agency guidelines/local protocol 

5. Medical Equipment and Supplies Personal protective equipment Basic supplies, including scissors, cold packs Basic wound care supplies Oral and nasal airways Suction equipment Oxygen equipment AED Splints Backboard Cervical collars Bag mask Obstetrical kit Blanket

6. Miscellaneous Equipment and Supplies Planned routes or comprehensive street maps Flashlight DOT Emergency Response Guidebook Extrication equipment Flares, cones, reflective triangles Fire extinguisher

7. Preplanning Response plan prepared in anticipation of an emergency Industrial plants Areas at high risk for an emergency Sports stadiums, theatres, public buildings

8. Dispatch EMS center staffed 24 hours/ day In some cases, you may contact dispatch center to request assistance May dispatch you via a variety of communication devices

9. Information from Dispatcher Write down this information so that it is accessible to you en route Nature of the call Name, location, and callback number of caller Location of patient(s) Number of patients Severity of the problem Other pertinent information, such as help being given to the patient

10. En Route to the Scene Gather necessary medical equipment - depart for scene Follow local laws/ guidelines for using emergency warning equipment In a private vehicle, obey all traffic laws/signs and drive safely Wear seat belts and shoulder harnesses Notify dispatch that you are en route Confirm essential information about emergency Check with dispatch if anything is not clear

11. Arrival at the Scene Park safely where your vehicle will not be in way of ambulances Keep emergency lights/ flashers on Notify dispatch when you arrive Update dispatcher with information differing from original information Size up scene before approaching patient

12. Considerations As You Approach Need for body substance isolation precautions Any need to move patient due to hazards at scene MOI or medical emergency Need for additional help Number of patients 

13. Transferring the Patient When EMS personnel arrive, provide patient assessment/treatment information Remain with patient and assist other EMS personnel as required If labor-intensive procedures are necessary, stay with patient Patient Packaging Following stabilization, patient is prepared for transport You may assist with this process

14. After the Run Complete any required documentation Clean and disinfect equipment Restock disposable supplies that were used Refuel your vehicle if needed Notify dispatch that you are ready for the next call

15. Helicopter Transport

16. Helicopter Transport and Evacuation Uses First Responder�s responsibilities may include: Determining that such transport is required and making the request Preparing patient for transport Setting up helicopter landing zone

17. Requesting Air Transport Follow local protocol for requesting a helicopter Consider these factors Will ground transport of a critical patient take too long? Will patient extrication be prolonged for an unstable patient? Is ground access to patient impossible or may be delayed?

18. Preparing the Patient for Helicopter Transport Secure anything that may be disturbed by high winds Protect the patient and yourself against debris/dirt blown Use eye protection and protect exposed skin Assist the helicopter crew to secure patient to stretcher Patient may be placed in ambulance in preparation for transport to helicopter

19. Setting Up the Landing Zone Should be set up by trained personnel following local protocols, state requirements, and other recommendations Landing zone should be flat area free of obstructions A safe distance from emergency scene At least 100 feet by 100 feet Select an area free of loose objects

20. Setting Up the Landing Zone continued Corners of landing zone marked with clearly visible objects At night, mark corners with strobe lights, chemical light sticks, or flares if no fire risk (but not railroad flares) Don�t point vehicle headlights toward the center of zone If police vehicles are present, they may be used to mark the corners with their emergency red lights Communicate with the pilot and describe landing zone and corner markings

21. Helicopter Safety Guidelines Keep other rescuers/ bystanders far away from landing zone Close doors and windows of nearby vehicles Do not let any bright lights shine upward or toward helicopter as it lands Never approach helicopter until pilot signals that it is safe Approach only from the front Stay low when approaching the helicopter, do not raise your arms over your head

22. Patient Extrication

23. Patient Extrication Patients frequently trapped inside wrecked vehicles, buildings, etc. Your responsibility may include assisting with extrication Special training required for all but simple forms of extrication

24. Patient Extrication from a Wrecked Vehicle Rescue more complicated if patient pinned by wreckage Your personal safety is highest priority, followed by patient�s safety Administer necessary care to patient before extrication Ensure patient is removed in a way to minimize further injury A chain of command should be established to ensure patient care priorities

25. Assess Extrication Scene First concern is always your/bystanders� safety Approach carefully. Retreat if scene unsafe Assess scene to determine What happened Number of patients Whether any hazards are present What specialized rescue personnel, equipment, and tools will be required

26. Extrication Decision After assessment, call dispatch for additional personnel Never attempt a rescue for which you are not trained Never attempt a rescue with improper/ inadequate safety/ rescue equipment Evaluate the scene to ensure your/bystanders� safety 

27. Extrication Decision continued Wear appropriate protective devices Don�t attempt to do anything you are not trained to do If you have not already done so, call for additional personnel Check scene for other patients Control scene while waiting for other rescuers

28. Stabilizing Vehicles

29. Stabilizing the Vehicle Before accessing patient, ensure vehicle is stable If safe, put upright vehicle�s automatic transmission in park If safe, set emergency brake; remove key from ignition If it may move in any way, try to stabilize wheels

30. Vehicle on its Side Head/neck injuries common when the vehicle has rolled onto its side Don�t attempt to return car to upright position before removing patients If possible, stabilize vehicle using ropes, tires, blocks, etc. Don�t climb on top to open a door/window; instead, break rear window

31. Vehicle That Has Flipped Upside-Down Don�t attempt to right vehicle, prevent bystanders from doing so If fuel is leaking, clear scene Don�t allow smoking anywhere near rescue operation Try to access patient after stabilizing vehicle 

32. Gaining Access

33. Tools for Gaining Access to Patient in Vehicle Protective clothing, leather gloves, protective goggles Pliers Pocket knife Jack Jack handle Rope Screwdriver Hammers Hacksaw Pry bar Spring-loaded center punch Slim Jim

34. Route of Entry Into Vehicle Try vehicle doors first. If one is locked, check others If all doors are locked, ask patient to unlock one If needed, use a special tool designed for unlocking vehicle doors If you cannot access patient through a door, try to enter through a window

35. Route of Entry Into Vehicle continued Ask patient to open window if possible. If not, window must be removed Breaking glass is dangerous for patient/rescuer

36. Breaking Safety Glass Use proper protective equipment If protective equipment is unavailable : Cover window with blanket, coat, or tarp Use pointed object to puncture glass Make entry in corner farthest from patient Tape window first Remove glass until opening is large enough Once inside, you may be able to unlock/ force open door

37. Breaking Safety Glass Removing Windshield Use screwdriver/pry bar to remove liner Pry window free - remove it

38. Other Ways to Access Patient If you cannot access a patient safely, wait for additional rescuers Cut doors open, remove parts of roof If patient pinned under vehicle, wait for rescue squad with special equipment If patient's life is in danger, attempt to lift car slightly with help of others If a patient in imminent danger is trapped by wheel or vehicle frame, try jacking car up, blocking it, and sliding patient out Never crawl under the vehicle yourself After Accessing the Vehicle Turn off the ignition to reduce the risk of fire

39. Providing Emergency Care After Accessing Patient Provide basic emergency care while patient is in vehicle Perform BLS skills required until additional EMS personnel arrive Unless explosion is possible, administer supplemental oxygen If scene is dangerous, consider an emergency move

40. Disentanglement of Patient Freeing patients generally not a First Responder responsibility Paramedics may give Advanced Life Support procedures while patient is trapped Remain at scene during disentanglement process to assist 

41. Removal of Patient Remove patient after being stabilized and packaged Spine immobilized and critical interventions given If patient has life-threatening trauma EMS may remove patient immediately for transport Removal not a First Responder responsibility, but you may assist

42. Hazardous Materials

43. Hazardous Materials Incidents Hazardous materials are common and pose a special hazard Hazardous materials include: Poisonous substances Explosives Flammable gases, liquids, and solids Chemicals and substances that react with other substances Radioactive materials

44. Assessing for Hazardous Materials Check for clues A spilled chemical or liquid Smoke or vapors The smell of fumes Hazardous materials are not limited to industrial sites or vehicles transporting substances Homes contain potentially hazardous materials Some hazardous materials are explosion hazards

45. Hazardous Materials Placards

46. Hazardous Materials Placards If You Do Not See a Placard But Suspect a Hazardous Material Try to obtain additional information before approaching scene Do not enter scene. Retreat and call for help Most fire departments have specially trained hazmat teams for managing hazardous materials incidents Hazardous materials spills under the jurisdiction of National Incident Management System (NIMS)

47. When Hazardous Material Is Present Primary responsibility is personal safety, maintaining safety for bystanders and the patient Manage scene and keep others from scene while awaiting the hazmat team Try to identify the substance involved, give this information to dispatch and arriving EMS personnel Remain upwind of the scene

48. Hazardous Materials Training Do not attempt to manage the hazardous substance Typical levels of training: Hazardous materials awareness training Hazardous materials operations training Hazardous materials technician Hazardous materials specialist Hazmat guidelines mandated by Occupational Safety and Health Administration (OSHA)

49. Managing the Scene Never enter a scene unless trained as hazardous materials technician and fully protected Park upwind or uphill at a safe distance Goal is to isolate area and keep unnecessary people away Avoid any contact with material Don�t provide ignition source

50. Managing the Scene Move at-risk patients to safe area only if no exposure risk to yourself Patient who has been exposed should be decontaminated Once a patient is removed, perform basic care

51. Identifying Hazardous Material If you are first on scene, try to identify the specific hazardous material Federal regulations require that hazardous materials are clearly labeled

52. Identifying Hazardous Material Drivers carrying hazardous materials must have shipping papers that identify substance All vehicles transporting hazardous materials must have placards identifying material/hazards

53. Placards The color and design indicate hazard Four-digit number on the placard identifies material Try to read placard from safe distance using binoculars Report this information to hazmat team and other personnel on site The Emergency Response Guidebook identifies hazardous materials codes

54. NFPA Warnings The National Fire Protection Association system used on storage and industrial buildings. These placards identify the specific hazard by color: Red - flammable Blue - health hazard Yellow - instability hazard such as explosive or unstable material White - other information The placards also rate hazard level , ranging from very low hazard (0) to a very high hazard (4).

55. Water Rescue

56. Water and Ice Rescue Emergency involving person in water/ ice is dangerous If you cannot safely approach, stay away and call for specialized help A crew with appropriate training/ equipment will be dispatched

57. Water Rescue Situations A non-swimmer may have gotten into deep water A swimmer may have sustained injury or sudden illness Any victim of hypothermia If someone in deep water cannot reach safety An unresponsive person as a result of drowning, injury, or illness usually needs immediate BLS after rescue Choice of Water Rescue Technique Depends On Type of situation Equipment /objects at hand Circumstances

58. Stay Out of the Water Resist temptation to jump immediately into water to save person Drowning person is panicked Lifeguards receive special training in how to break a victim�s hold It may be appropriate to swim to an unresponsive victim

59. Safe Water Rescue Techniques Reach-throw-go priority

60. �Reach� Rescue Let responsive person hold on to pole while you slowly pull him/her to edge Hook an unresponsive victim�s body and pull to safety Use anything available to reach to the victim If the victim is close enough, you may reach with your body

61. �Throw� Rescue Throw anything that floats to a responsive person Swimming pool/boating equipment may include a life ring, rescue tube, or life jacket Some boats carry a throw bag If no throwable rescue device is available, use anything that will float

62. �Go� Rescue Don�t enter water to go to victim except a small child or unresponsive victim Look for other ways to go to the victim Wear a personal flotation device, take something person can hold on to

63. Unresponsive Patients in Water An unresponsive patient should be assumed to have a potential spinal injury Stabilize head/neck Turn patient face up to allow breathing or rescue breathing If patient is breathing, do not attempt removal alone - wait for other EMS If alone, stabilize the patient�s head and back

64. Unresponsive Patients in Water With two responders, one holds patient at shoulder and hips while other supports head and neck in line If patient is not breathing and you are alone, float patient into shallow water for rescue breathing Check patient�s pulse Don�t remove patient with a pulse, continue rescue breathing until additional EMS personnel arrive If patient is pulseless, remove him or her from the water to give CPR Try to support the patient�s head /spine during removal

65. Turning A Patient in Water Using a Head Splint 1. Bring patient�s arms along both sides of his / her head Holding both of patient�s arms against sides of head, rotate the patient toward you Maintain the head stabilization while assessing breathing

66. Walking Assist With Sloping Bottom Once at depth where he/she can stand, help patient exit with a walking assist Support the patient as you walk patient out of the water

67. Beach Drag Remove unresponsive patient from shallow water on a gradual shoreline with beach drag Slowly back out of the water, dragging patient out 

68. Ice Rescue Ice rescues are dangerous Cold-water immersion is very serious Call immediately to summon appropriate emergency personnel Attempt ice rescue using same priorities as a water rescue: reach-throw-go

69. Ice Rescue: Reach-Throw-Go Use pole or tree limb to reach to person who has broken through ice Throw a rope or any buoyant object tied to a rope Only as an extreme last resort try to go to the person Lie down to distribute your weight over a larger surface area Push a branch or other object ahead of you to the victim Patient is likely to need treatment for hypothermia

70. Special Response Situations

71. Special Response Situations Many emergencies/rescues require teams with special training and equipment Call for assistance and to provide as much information as possible

72. Confined Space Emergencies Hazards may include: low oxygen levels toxic or explosive gasses risk of collapse hypothermia or heat stroke Rescue teams are organized by fire departments, industrial organizations, and other agencies Special equipment/ training are needed Report the situation, keep bystanders out of the area, and provide support to the rescue team After the removal of patients, assist other EMS personnel in providing care

73. Rural and Agricultural Settings Emergency response may differ from that in urban areas Longer response times Limited cellular telephone coverage Workers often alone and not immediately discovered First Responders/EMS personnel are frequently volunteers

74. Differences in Rural EMS and Healthcare Facilities May not have sophisticated equipment or advanced training Small rural hospitals may not have continuous emergency department coverage or lack resources Patients may let chronic medical problems become emergencies 

75. Agricultural Hazards and Injuries Deaths among farm workers are higher than almost all other occupations Equipment entanglement may involve lengthy extrication procedures Hazardous chemicals are common Temperature extremes frequently contribute stress in emergencies

76. First Responders in Rural and Agricultural Settings Be prepared for patient conditions that have deteriorated because of response time Get to know the area/types of hazards Get training for medical care needed during longer periods awaiting EMS resources Have right equipment/supplies Get advanced training in special skills such as hazardous materials incidents Recognize the need to keep your skills updated

77. Industrial Settings Particularly hazardous due to hazardous machinery /equipment Presence of hazardous materials Risks of fire/explosion Confined spaces An industrial response team is often present, with specialized training

78. First Responders in Industrial Settings Learn about special industrial response teams and how to contact them If site has emergency plan, ensure it is activated Your personal safety is your first priority Talk to on-site managers/staff to learn about specific hazards before entering scene Be aware of potential for multiple patients in an industrial incident, activate Incident Command System

79. Natural Disasters Natural disasters often cause widespread damage/ injury.

80. Natural Disasters First Responders reporting to Incident Command System may have many roles NIMS directs response involving state/local disaster agencies Report within command structure and focus on your specific task assignments

81. Terrorist Acts NIMS has planned response to wide range of possible attacks First Responders receive special training about their role in different types of attacks 

82. First Responder Awareness Maintain awareness of different types of terrorist attacks Be observant whenever responding to an unusual emergency scene Be watchful/suspect a terrorist incident when arriving at scene involving: A large number of patients Patients with unusual signs and symptoms possibly related to an exposure Any incident at a facility or public place that may be targeted by terrorists Other unusual incidents

83. Secondary Explosive Devices Be aware of possibility of secondary device Devices are timed to explode later to injure emergency personnel

84. First Responsibilities at the Emergency Scene Maintain personal safety Evaluate scene carefully before entering Report emergency as quickly/ fully as possible Protect bystanders and help maintain scene safety Follow your chain of command for large-scale incidents Assist other emergency personnel at the scene

85. Terrorist Acts Threat of terrorist acts omnipresent Possible attacks include Explosions in structures Nuclear explosions Crashes of airliners, trains, ships, other vehicles of mass conveyance Release of biological agents Release of chemical agents Release of radioactive material

86. Terrorist Acts continued Suspect a terrorist incident in emergency scenes involving: Large number of patients Patients with unusual signs and symptoms related to an exposure Any incident at a facility or public place that may be targeted by terrorists Other unusual incidents

87. First Responder Responsibilities Maintain personal safety Evaluate the scene carefully before entering Report the emergency quickly and fully Protect bystanders and help maintain scene safety Follow chain of command Assist other emergency personnel with triage, patient care