hello and welcome to chapter 38 transport operations lead this chapter and the related coursework you will be able to describe and apply effective preparation for transport safe emergency vehicle operations appropriate transport decisions safe patient transfer techniques and a responsible approach to patient care during transport you will be able to identify the nine phases of a call and describe the emt's role in each phase you will be able to discuss the differences between ground and air transport and furthermore you'll be able to understand the steps necessary to properly clean disinfect the emergency vehicle and the equipment following the call so let's get started today's ambulances are stocked with standard medical supplies and many are equipped with state-of-the-art technology that can transmit data directly to the emergency department today's emphasis on rapid response places the emts in a greater danger while driving to calls so let's talk about an ambulance is a vehicle that is used for treating and transporting patients who need emergency care to the hospital today's ambulances are designed and based on nfpa 1917 it's the standard for automo automotive ambulances and on suggestions from the ambulance industry and from ems personnel components of a modern ambulance include a driver's compartment also has a patient's compartment big enough for two amts and at least one supine patient and additional patients may be seated on the bench seat or swivel seat with appropriate safety restraints it has equipment and supplies to provide emergency medical care at the scene and during transport to safeguard personnel and patients from hazardous conditions and to carry out light extrication procedures it has it also has a two-way radio for communication and it's designed and constructed that to ensure a maximum safety efficiency and comfort okay and this table shows the basic ambulance designs and so there's three types you have type one type two and type three okay each state establishes its own stem standards for ambulance licensing and certification many states use federal specifications so the star of life enables and identifies vehicles as ambulances and is often affixed to the sides rear and roof of the ambulance the figure shown the different types of ambulance okay so let's talk about the phases of an ambulance call okay so you have the ambulance and it has nine different phases an ambulance call has the first phase is the preparation second is dispatch third is in route fourth is arrival at the scene five is the transfer of the patient um six is in route to the receiving facility or we also call this transport and um then you arrive at the receiving facility you deliver the patient then enroute to the station and post run so let's talk about those different nine different phases of the ambulance call the first one we're going to talk about is the preparation phase and so this is when we make sure all the equipment and supplies are in their proper places and they're ready for use new equipment should be placed on the ambulance only after proper instruction on its use in consulting with the medical director equipment and supplies should be durable and standardized we are going to store the equipment and supplies in the ambulance according to how urgently and how often we use it so we're going to place items needed for life-threatening conditions within easy reach sometimes at the head of the stretcher and we're going to place items for cardiac arrest external bleeding and blood pressure monitoring at the sides of the stretcher so cabinets and drawers should be transparent they should have transparent fronts and be labeled um and should open easily and close securely okay and then medical equipment in the preparation preparation phase we're going to have basic supplies personal protective equipment and sharps containers airway and ventilation equipment basic wound supplies care supplies splinting child birth supplies aed patient transfer equipment medications communications and other appropriate supplies then we're going to have airway and ventilation and so we have to have the ops for adults children and infants nps for adults and children and cpap equipment we need to have equipment for advanced airway procedures we need to have a portable artificial vent and then um that needs to operate independently of an oxygen supply we want to have bag valves mask also non-rebreathers nebulizer masks portable and mounted suction units and at least two different types of oxygen supply units so portable and then one installed on board then for cpr equipment we need to have a cpr board mechanical device that could deliver chest compressions we could have that and then of course basic wound care supplies splinting and childbirth and an automatic aed patient transfer equipment and what would be a patient transfer equipment of course is that stretcher um maybe a stair chair a long backboard short backboards and immobilization devices then also medications we're also gonna have a jump kit and so what a jump kit is is it's a five minute kit it includes anything that we might need within the first five minutes with the patient so everything except for the aed of course okay and so including in the preparation phase is also the safety equipment we already talked about the the ppe and then maybe we want to have um equipment for work areas so maybe warning devices or flashers or some type of fire extinguisher maybe a dry chemical extinguisher hard hat or helmets with face shields portable flood lights and flashlights too and these could be in the um outside waterproof compartment then we want to have some type of gps so we need the navigational aids to help us get to the call mdt which are mobile data terminals and then we need to keep detailed street maps or areas in the driver's compartment just in case the electronic equipment goes goes down then extrication equipment so located in the another outside compartment usually outside of the patient compartment and it contains equipment that is needed for simple light extrication even if an extrication or rescue unit is readily available and then of course personnel we want to have our at least one emt in the compartment during transport the prep phase is going to have daily instructions or daily inspections and so these are items included in the ambulance inspection is usually fuel oil transmission levels engine cooling batteries brake fluid engine belts we want to make sure the wheels and the tires are inflated and all interior and exterior lights should work then windshield wiper fluid corn siren air conditioner ability of the doors to open and close communication systems must work it needs to be clean and positioned all the windows and mirrors and then we want to have inspect the cleanliness quality and function of all the medical equipment and then the safety equipment so this is the last uh last different area of the prep phase and we want to review standard traffic safety rules and rags make sure that the safety devices such as seat belts are working properly and then oxygen tanks must be secured while with a fixed clasp okay all equipment in the cab and rear and compartments must be secured appropriately so the next phase we're going to talk about dispatch so the second phase we have the prep phase then you have the dispatch phase and this is dispatch must be easily easy to access and in service 24 hours a day the dispatcher should gather the information so the nature of the call the caller's name present location and callback number the exact location and the number of patients and the severity of their conditions and other pertinent info and then we're going to have the end route the end route so in route to the scene in many ways the enroute to the scene phase is the most dangerous phase for the emt crashes cause many serious injuries so always fasten seat belts and shoulder harnesses before moving the ambulance review dispatcher information and prepare to assess and care for the patient assign specific duties and scene management tasks and decide which equipment should be taken then the next the next phase is going to be the arrival at the scene if you are the first to arrive on scene you will perform a scene size up and give a brief report of your findings to dispatch use the following guidelines so we're going to look for safety hazards for ourselves the our partner by standards and patient we're going to evaluate the need for additional units or other assistance we're going to determine the mechanism of injury and the nature of illness and we're going to evaluate the need for spinal precautions and we're going to follow standard precautions for mass casualty incidents we need to estimate and communicate the number of patients to the incident commander okay now we're at the scene so once we get to the scene we want to make sure that we're parking safely all right the very first thing is to park we're going to pick a position that will allow for efficient traffic flow and flow around the emergency scene we want to park 100 feet before or past the crash to create a barrier between the emt and traffic do not park alongside the scene you may block the movement of other emergency vehicles park uphill and upwind of the scene with smoke or hazardous materials we want to leave our learning warning lights on or devices and keep a safe distance between your vehicle and the operations at the scene so the figure on this slide shows a safe parking distance for the ambulance okay all right and so we're going to stay away from fires of course hazards down wires and unstable structures we definitely want to set the parking brake but we're going to park as close to the scene as possible to facilitate emergency medical care and rapid transport to the scene if it is necessary to block traffic to unload equipment or load the patient do so quickly and safely and then traffic control only when all the patients have been treated and the emergency situation is under control should you be concerned with restoring the flow of traffic traffic control is intended to ensure an orderly traffic flow warning the other drivers and prevent another crash crash so as soon as possible place warning devices such as reflectors on both sides of the crash then we have the transfer phase so the patient must be packed for transport and this includes securing the patient to the backboard or scoop stretcher or the wheeled ambulance stretcher we want to properly lift the patient into the patient compartment secure the patient with at least strap three straps to the body and use deceleration or stopping straps over the patient's shoulders especially if the patient is lying flat or secured to a backboard okay so after the transfer phase we have the transport phase and we're going to provide dispatch with the inf with the following information when we're ready to leave with the patient and so we're gonna tell dispatch the number of patients we have in the ambulance the name of where we're going and the beginning mileage of the ambulance and that's some in some jurisdictions because they charge by the mileage we're going to monitor the patient in route we're going to recheck stable patients every 15 minutes and recheck unstable every five contact the receiving facility and let them know we're coming and do not abandon the patient emotionally be aware of the patient's need level of need and use common sense and defensive driving techniques at all times then we have the delivery phase so we're going to inform dispatch as soon as we arrive at the hospital we're going to report our arrival to the triage nurse or any arriving personnel other arriving personnel at the hospital we're going to physically transfer the patient we're going to present a complete verbal report and we're going to complete a detailed patient report then we're going to restock items that we've used during the call and route to the station we're going to talk to dispatch let them know that we're coming in service and where we're going as soon as we're back at the station we're going to clean and disaffect the ambulance and equipment if not done already at the hospital and then we're going to restock supplies if not already done at the hospital and then the post run so the post run phase consists of completing and filing any additional reports and again informed dispatch of your status location and availability and this is the appropriate time to debrief following the call you could also perform routine ambulance inspections and refuel the vehicle and then so let's talk about some key terms and there's a difference between cleaning disinfecting high level disinfecting and sterilization okay so when you clean that's the process of just removing dust dirt blood or visible contaminants from the surface or equipment when you disinfect you're killing the pathogenic agents by directly applying a chemical made for the purpose for that purpose high level disinfection is killing the pathogenic agent by the use of potent means of disinfection and then sterilization this is a process such a uses heat that removes microbial contamination okay so after each call of that post run phase um you're going to strip in all the used linens from the stretcher and place them in plastic bags we're going to discard medical waste of course in appropriate receptacles and then we're going to wash contaminated areas with soap and water we're going to disinfect all non-disposable equipment used for the patient during the call we're going to clean the stretcher with an epa registered germicidal and vurocidal solution or bleach and water at a 1 to 100 dilution we're going to clean spillage or other contamination with the same solution or bleach water solution okay so let's talk about some defensive ambulance driving techniques so if their ambulance is invited involved in the crash that delays patient care at a minimum and at the worst it may take the lives of the emts or other motorists or pedestrians so you are strongly encouraged to participate in a certified defensive driving program before attempting to operate an emergency vehicle all right so you need to have certain driver characteristics to operate an emergency vehicle so you want physical fitness and alertness and that's very necessary to properly operate an emergency vehicle you should not be driving if you take medications that cause drowsiness or slow your reaction you shouldn't be driving if you're drinking alcohol you shouldn't be driving if you've been working long shifts or multiple consecutive shifts notify your employer if you have worked a shift previously and feel unable to safely operate an emergency vehicle emotional maturity and stability are necessary to operate under stress you cannot drive in a manner that pleases you simply because you have lights and sirens on you must operate the vehicle with due regard for safety and the safety of others and preservation of property so some safe driving practices so all drivers and passengers must wear their seatbelts and shoulder restraints at all times if you remove your seatbelt to provide care fasten it again as soon as possible unrestrained or improperly restrained patients and equipment may become airborne during a collision so become familiar with how your emergency vehicle accelerates corners sways and stops under various conditions in a multi-lane highway stay in the extreme left or fast lane allowing other motorists to move over to the right when they see you or hear you approach so the siren risk benefit analysis so the decision to activate the emergency lights and sirens will depend on several factors and this includes your local protocols patient conditions and the anticipated clinical outcome of the patient so consider the patient's condition before activating the lights because emergency lights and siren noise may increase the patient's anxiety level and then we're going to talk about driver anticipation we want to always assume that motorists around the vehicle have not heard the siren or public address system or or have seen you until proven otherwise by their actions so look at the direction of the other vehicle's front tires to get an early indication of which way they might turn always drive defensively we want to have a cushion of safety so what this means is we want to maintain a safe following distance from the vehicles in front of us and try to avoid being tailgated from behind we want to ensure that the blind spots in their vehicles mirrors do not prevent us from seeing other vehicles or pedestrians on either side of the ambulance to distance yourself from a tailgater slow down or contact police never get out of the ambulance or to confront the driver so there are three blind spots around the ambulance there's going to be a rear view mirror it creates a blind spot in front of the driver the rear of the vehicle cannot be seen fully through the mirror and then there's the sides of the vehicle okay so scan your mirrors frequently for any hazards and use a spotter and pre-determine hand signals when you're back in the ambulance excessive speed is unnecessary dangerous and does not increase the patient's chance of survival it makes it difficult for emts to provide care in the back it hinders the driver's reaction time and it increases the time and distance needed to stop the ambulance and then there's the siren syndrome so this causes the drivers maybe to drive faster in the pre in the presence of siren and that's due to increased anxiety so although a siren signifies a you know a request for the drivers to yield right away it does not mean the drivers are always going to do this all right so then there's vehicle size in in distance okay and so a vehicle's length and width are critical factors when maneuvering driving and parking preventable accidents often occurs when the vehicle is backing up so always use someone outside the ambulance as the ground guide when you're backing up to avoid any incidents vehicle size and weight greatly influence breaking and stopping distances so let's look at this road positioning and cornering road positioning means the position of the vehicle on the roadway on the inside and outside of the paved services okay so to keep the ambulance in the proper lane when turning the corner enter high in the lane to the outside and exit low to the inside weather and road conditions so ambulance have a longer breaking time and stopping distance the weight of the ambulance is unevenly distributed and it makes it for much more prone to roll over so be alert to changing weather and road conditions there's also hydroplaning so at speeds of greater than 30 miles per hour a tire may lift off the road as water piles up under it the vehicle may often feel like it's floating if hydroplaning occurs you should gradually slow down without jamming the brakes on and then there's water on the roadway so what brakes will not slow the vehicle as efficient as efficiently as drive breaks and the vehicle may pull to one side or the other so avoid driving through large puddles of standing water or through moving water then don't forget decrease visibility so in areas where there is a lot of fog or smoke or snow heavy rain just slow down to a soft safe operating speed you always use your headlights watch carefully for stopped or slow-moving vehicles and then icy or slippery surfaces so good all-weather tires and an appropriate speed will reduce traction problems significantly and consider using um snow tires or tire chains if they are permitted by law so that's good let's start talking about laws and regulations so although emergency vehicle drivers are exempt exempt from normal operating upper vehicle operations during a call certain laws and regulations must be filed followed so motor vehicle crashes account for a large number of lawsuits against eml per ems personnel and services if you're on an emergency call and you are using your warning lights and sirens you may be allowed to do the following you may be allowed to park or stand in an otherwise illegal location you may be able to proceed through a red light or a stop sign but never without stopping first you may be able to drive faster than the posted speed limit or drive against the flow of traffic on a one-way street or make a turn that isn't normally illegal and you may travel left of center to make an otherwise illegal pass an emergency vehicle is never allowed to pass a school bus though so if the if it is stopped or unloading children and it displays the flashing red lights you have to stop you need to use the use of warning lights and sirens is governed by three principles the unit must be a true on a true emergency call audible and visible warning devices must be used simultaneously unit must be operated with due regard for the safety of others right away privileges okay so state motor vehicle statutes or codes often grant an emergency vehicle the right to disregard the rules of the road when responding to an emergency so in doing so though the operator of the emergency vehicle must not endanger other people or property under any circumstances get to know your local right-of-way privileges and exercise them only when it's absolutely necessary for the patient's well-being you could also have the use of escorts and this uses police escorts to guide only when you're on unfamiliar territory so vehicles use warning lights or sirens should be in different tones or alerts um and if you are being guided follow at a safe distance then intersection hazards so intersection crashes are the most common and usually the most serious type of collision in which ambulances are involved always be alert and careful when approaching approaching intersections if you are on an urgent call and cannot wait for the light to change please come to a complete stop check all other motorists and pedestrians before proceeding and highways so shut down the emergency lights and sirens until you have reached the far left lane when you exit the highway follow the same procedure as when you've entered the highway and then on paid roads you have to take special care and operate the vehicle at a lower speed and maintain a firm grip on the handle on the steering wheel and then school zones so it's unlawful for an emergency vehicle to exceed the speed limit in school zones regardless of the condition of the patient and distractions so the ambulance is in motion focus the driving on driving and anticipating roadway hazards you want to mine minimize distractions from mobile dispatch terminals or mdt's minimize try and minimize the mounted radio or stereo cell phone or eating or drinking okay and so driving alone so when you're driving alone it's your responsibility to focus on figuring out the safest way of route while mentally preparing for the call such situations demand your complete attention and focus understand that there's going to be fatigue you need to recognize when you are fatigued and alert your partner or your supervisor if you are feeling fatigued you should place out a service for the remainder of the shift or until the fatigue has passed and you are capable of operating the vehicle safely let's talk about air medical operations next so air ambulances are used to evacuate medical and trauma patients there are two different kinds so fixed wings units are used for inner facility patient transfers or distances greater than 200 to 250 miles an hour then you have rotary wing units these are helicopters and they are efficient for shorter distances specially trained crews accompany air ambulance flights the emt duties are limited to providing ground support so helicopter medical evaluation of evacuation operations so medical evacuation or medvac is performed exclusively by helicopters the capabilities protocols and procedures vary between ems systems when you're calling for a medvac why call for a medvac maybe the transport time to the hospital by ground is too long road traffic or environmental conditions may prohibit the use of a ground ambulance the patient requires advanced care beyond the emt's capabilities and there might be multiple patients who will overwhelm the resources at the hospital reachable by the ground unit so who receives a med vac patients with time dependent injuries or illnesses patient susceptible suspected of a stroke heart attack or spinal injury patients who are found in remote areas trauma patients or candidates for limb replantation a burn center or hyperbaric chamber or maybe a venomous bite center so whom do you call generally the dispatcher should be notified first in some regions ems may be able to communicate with the flight crew after initiating the request we want to establish a landing zone so the safest most effectively effective way to to land and take off is similar to that of fixed wing aircraft landing to at a slight angle allows for safer operations establish a landing zone is the responsibility of the ground ems crew an appropriate site for the landing zone should be a hard or grassy level surface 100 by 100 feet and no less than 60 by 60. you want to clear all loose debris you want it to be cleared of overhead or tall hazards you're going to mark the landing site using weighted cones or emergency vehicle position at the corner of the landing zone with the headlights facing inward to form an x never use caution tape or ask people to mark the spot do not use flares move non-essential persons and vehicles to a safe distance outside the landing zone and communicate the direction of strong wind to the flight crew landing zone safety and patient transfer so stay away from the helicopter and go only when the pilot or crew directs you keep a safe distance from the aircraft whenever it is on the ground or hot and hot means that the helicopter copter blades are spinning still so stay outside the landing zone perimeter unless directed to come by the aircraft or crew member and if you're asked to enter the landing zone stay away from the tail rotor the tips of the blades move so rapidly that they are invisible always approach the helicopter from the front even if it's not running an approach only after the pilot or flight crew member signals it's clear for you to do so enter only in the area between 10 o'clock and 2 o'clock and never duck under the body the tail or the rear section of the helicopter when you approach the aircraft walk in a crutch position so the figure shows the danger zones surrounding a helicopter keep the following guidelines in mind when operating at a landing zone be familiar with your jurisdictions helicopter hand signals do not approach the helicopter unless instructed or accompanied by a flight crew make certain that all patient care equipment and the patient are properly secured some helicopters may load patients from the side whereas others may have rear loading doors smoking open flames and flames are permitted within 50 feet of the aircraft at all times and you want to wear protection eye protection so this figure shows the hand signals used around helicopters so special considerations when it comes to a helicopter so night landings do not shine spotlights flashlights or any lights up in the air to help the pilot they may be temporarily blinded so direct low visib low intensity headlights or lanterns towards the ground at the landing site and illuminate overhead hazards or obstructions if possible so landing on an even ground if the helicopter must land on uneven ground they need to use extra caution the main rotor blade will be closer to the ground on the uphill side okay so approach the aircraft from the downhill side only or directed by the flight crew and medvax at hazmat incident so immediately notify the flight crew of the presence of a hazardous material at the scene we want to consult the flight crew and instant commander about the best approach in the distance from the scene to for the med back the landing zone should be uphill upwind from the hazmat scene and properly decontaminate patients before you load them into the helicopter then there's some med vac issues so factors that influence the decision to request mad back should include access the severity of the weather okay the most helicopter services are limited to fly below 10 000 feet above sea levels level so med vac helicopters fly between 130 to 150 miles per hour because of the cabin's confined space as us assess the number and size of the patient who can safely transport in that helicopter med evac flights are extremely expensive compared to an ambulance transport all right so this concludes chapter 38 of the transport operations chapter next we're going to go through some of the review questions to see what we learned okay so which of the following are examples of standard patient transfer equipment all right so we have the stokes basket we know wheeled we have wheeled stair chair we have wheeled ambulance stretchers hmm long back boards i think it's a stokes basket so stokes baskets are called basket stretchers and that's usually a specialized piece of equipment okay the primary purpose of a jump kit is to and we know this is everything we need within the first five minutes so that's going to be d right so you are dispatched to a call for an unresponsive patient what is the most important information you should obtain from the dispatcher all right so initially we need to know the location of the patient right we need to know how where we're going so yep everything is important but first let's get us to the scene okay when in route took off for a motor vehicle crash the most important safety precaution that you and your partner should take are i think it's probably either seat belt or safety precautions seat belt most important safety precaution you could take which of the following is not a guideline for safe ambulance driving so we're going to use our sirens if you have the yep you want to exercise due regard you want to use one-way streets whenever possible i think that's probably the wrong one c okay at what speed will the ambulance begin the hydroplane if water's in the road we know that this is 30 miles an hour so 30 miles an hour greater we're gonna lose control of that the most common and often most serious ambulance crashes occur we know in the intersections in the intersections yep the recommended dimensions for the helicopter so we know it's a hundred hundred and minimal is sixty by sixty hundred by hundred which of the following statements about helicopters are true all right so the helicopter is considered hot when it's on the ground and the rotors are still going but it is possible that the main rotor blade will dip within four feet of the ground that is true okay upon arrival at the scene where hazmat is involved you should park oh well we know we want to park up wind and we want to be uphill so upwind a okay and that concludes chapter 38 transport operations lecture if you like this uh go ahead and check out some of the other lectures all right thank you