Ch46 Transport Operations.docx

Chapter 46 Transport Operations Unit Summary Upon completion of this chapter and related course assignments, students will be able to summarize the types of medical, safety, and operations equipment carried on ambulances. Completing regular vehicle inspections is very important. There are dangers to consider while operating an ambulance in emergency mode and safety guidelines that should be followed while driving the ambulance. The risk of operating the ambulance in emergency mode should be analyzed and additional risks during travel and transport need to be considered. Issues of safety also need to be considered for air medical transport, particularly when preparing a landing zone and approaching the aircraft.This chapter will help the student understand their operational roles and responsibilties to ensure the safety of themselves, their patients, and the public. National EMS Education Standard Competencies EMS Operations Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Principles of Safely Operating a Ground Ambulance • Risks and responsibilities of emergency response (pp 2173-2176) • Risks and responsibilities of transport (pp 2178-2179) Air Medical • Safe air medical operations (pp 2188-2192) • Criteria for utilizing air medical response (pp 2188-2189) • Medical risks/needs/advantages (pp 2186-2192) Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Infectious Diseases Awareness of • A patient who may have an infectious disease (p 2179) • How to decontaminate equipment after treating a patient (p 2179) Assessment and management of • A patient who may have an infectious disease (see chapter, Infectious Diseases) • How to decontaminate the ambulance and equipment after treating a patient (p 2179) • A patient who may be infected with a blood-borne pathogen (see chapter, Infectious Diseases) - Human immunodeficiency virus (HIV) (see chapter, Infectious Diseases) - Hepatitis B (see chapter, Infectious Diseases) • Antibiotic-resistant infections (see chapter, Infectious Diseases) • Current infectious diseases prevalent in the community (see chapter, Infectious Diseases) Knowledge Objectives Summarize the medical equipment, safety equipment, and operations equipment carried on an ambulance. (pp 2173-2174) Discuss the importance of performing regular vehicle inspections, and list the specific parts of an ambulance that should be inspected daily. (pp 2173-2176) Provide examples of some high-risk situations and hazards that may affect the safety of the ambulance and its passengers during both pretransport and transport. (pp 2178-2179) Discuss specific considerations that are required for ensuring scene safety, including personal safety, patient safety, and traffic control. (p 2178) Define the terms cleaning, disinfection, high-level disinfection, and sterilization, and explain how they differ. (p 2179) Identify the dangers to consider when operating an ambulance in the emergency mode. (pp 2179-2186) Discuss the guidelines for driving an ambulance safely and defensively, and identify key steps EMS personnel can take to improve safety while en route to the scene, the hospital, and the station. (pp 2180-2184) Describe the elements that dictate the use of lights and siren to the scene and to the hospital and the factors required to perform a risk-benefit analysis regarding their use. (pp 2181; 2185) Give examples of the specific, limited privileges that are provided to emergency vehicle drivers by most state laws and regulations. (pp 2185-2186) Explain why using police escorts and crossing intersections pose additional risks to EMS personnel during transport, and discuss special considerations related to each. (pp 2185-2186) Describe the capabilities, protocols, and methods for accessing air medical transport. (pp 2186-2192) List the safety concerns when operating a landing zone for helicopter transport. (pp 2189-2192) Describe key scene safety considerations when preparing for a helicopter medevac, including establishing a landing zone, securing loose objects, mitigating onsite hazards, and approaching the aircraft. (pp 2189-2192) Skills Objectives Demonstrate how to perform a daily inspection of an ambulance. (pp 2173-2176) Demonstrate how to clean and disinfect the ambulance and equipment during the postrun phase. (p 2179) Readings and Preparation • Review all instructional materials including Chapter 46 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials. • Consider reading these articles ahead of time and summarizing for students or using for further discussion of the issues surrounding transport operations. “Dispelling Myths on Ambulance Accidents” by R. Elling: http://www.emergencydispatch.org/articles/dispellingmyths1.htm “Analysis of Ambulance Crash Data” by C. Grant & B. Merrifield: http://www.nfpa.org/assets/files//Research%20Foundation/RFAmbulanceCrash.pdf “EMS Equipment and Transport Vehicle Cleaning and Disinfection: Challenges and Best Practices” by J. Fleming: http://www.emsworld.com/article/10320653/ems-equipment-and-transport-vehicle-cleaning-and-disinfection-challenges-best-practices “Are We Making Our Patients Sick?” by R. Merryfield: http://www.usfa.fema.gov/pdf/efop/efo44611.pdf Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation • To use case studies in the classroom, consider using Emergency Medical Services Vehicle Operator, available at www.jblearning.com, ISBN: 9780763781675. • Contact your local EMS agency to obtain forms or checklists used by EMS personnel to complete ambulance inspections. • Contact your local hospital’s infection control department to obtain their most current infection control guidelines regarding forms of personal protective equipment (PPE). • Consider researching current YouTube videos that highlight safe ambulance operations or completion of an EVOC training course, as well as current videos that reflect unsafe ambulance operations. These videso may be appropriate to use for exercises in the classroom. Enhancements • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities. • Contact your local air ambulance provider to request that they speak to the class on their policies and protocols for requesting their service and the level of acuity of patients that they typically transport. • Contact your local state highway patrol office to determine if there is an officer who can speak on the hazards associated with emergency vehicle operations. • Contact your local EMS agency director to determine if he/she can speak to the class about any experiences with ambulance crashes. Content connections: Remind students of the importance of maintaining strict infection control procedures when caring for patients with unknown, as well as known, infectious diseases. Review PPE guidelines as well as infectious control procedures in Chapter 36 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition. Cultural considerations: Students should be reminded that they will see patients from all parts of the world. Many of these patients have diseases or carry pathogens that are not typically seen in the United States. They should be aware of how to protect themselves from diseases based on route of transmission. Discuss various infectious diseases that are prevalent internationally and not commonly seen in the United States. Pediatric patients and elderly patients can often be frightened by the emergency operation of an ambulance. This may present challenges for adequately securing them for transport. Remind students to take this into consideration as they analyze the risks versus benefits of transporting in emergency mode. Review methods of safely transporting pediatric patients in an ambulance. Teaching Tips • Be cautious of assuming that all paramedic students have operated an ambulance in emergency mode. Some students may not have driven an ambulance but are enrolled in paramedic school. You should be familiar with your students’ work and driving histories. • Students may not be familiar with all the components of an ambulance inspection form or aware of how to inspect all types of ambulances. Try to incorporate pictures of the various ambulance types or have ambulances available to demonstrate the areas that should be inspected. • Not all students may be familiar with operation of warning devices in the ambulance. Provide pictures of common equipment or have an ambulance on hand to show students how these devices work. Unit Activities Writing activities: Assign students to research media coverage of an ambulance accident within the last ten years. Ask that students consider the information presented and identify how the accident may have been prevented. If there is insufficient information to determine how the accident occurred, students should also include what this missing information is. Student presentations: Assign students an infectious disease or pathogen to research and present their findings to the class. Students should identify the type of pathogen, causative agent, mode of transmission, prevention strategies, signs and symptoms of infection, treatment options, and susceptible populations. Group activities: Using groups of three to four students, have students identify traffic and road conditions that present increased safety risks for operation of an emergency vehicle. Have groups identify ways or methods to mitigate these risks and prevent crashes. Visual thinking: Using the YouTube videos or supplemental text scenarios from Emergency Medical Services Vehicle Operator, have students review safe and unsafe emergency vehicle operation scenes. Ask students to summarize actions that were properly executed and identify those that were not. If the clip involves a crash, have students identify factors that may have contributed to the crash and ways that it might have been prevented. Pre-Lecture You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Medic” scenario found throughout Chapter 46. • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. Today’s ambulances are equipped with state-of-the-art technology. 1. Defibrillators and monitors that can transmit information to the emergency department 2. Blood and oxygen testing equipment 3. Automatic ventilators 4. Automated cardiopulmonary resuscitation (CPR) machines 5. Global positioning systems (GPS) 6. Computer-aided dispatch consoles B. Driving an ambulance or service vehicle requires good technique and judgment. 1. Need to be aware of the safety of your crew and passengers 2. Responsible for the safe passage of other vehicles on the road II. Emergency Vehicle Design A. The US General Services Administration is responsible for determining ambulance standards. B. Design and manufacturing guidelines, outlined by the DOT KKK 1822, are reviewed and updated every 5 years. 1. The KKK Standards established three main ambulance designs: a. Type I: Conventional, truck-cab chassis with a modular ambulance body that can be transferred to a new chassis as needed. b. Type II: Standard van, forward-control integral cab-body ambulance. c. Type III: Specialty van, forward-control integral cab-body ambulance. 2. Improvements made to emergency vehicles over the years include: a. Enlargement of the patient compartment b. Safety nets on the squad bench c. Padded cabinet corners III. Ambulance Equipment A. Every inch of space on an ambulance is dedicated to storing and securing equipment. B. Many organizations have influenced the list of supplies and equipment that should be carried on ambulances. 1. The Occupational Safety and Health Administration (OSHA) makes recommendations regarding infection control practices. 2. The American College of Surgeons (ACS) developed the first standardized list of equipment in 1970. a. Continually updated as technologic advances are made in the field 3. The National Fire Protection Association (NFPA) develops ambulance safety standards. IV. Checking the Ambulance A. Prior to a call, crew members are responsible for ensuring the unit is capable of responding and that the proper equipment and supplies are available. 1. Each time supplies and equipment are used, they should be properly cleaned or replaced. 2. Medication expiration dates must be checked regularly. 3. Diagnostic equipment must be tested or calibrated regularly. B. The ambulance inspection should include: 1. Fuel levels 2. Oil levels 3. Transmission fluid levels 4. Engine cooling system and fluid levels 5. Batteries 6. Brake fluid 7. Engine belts 8. Wheels and tires a. Check inflation pressure and look for signs of unusual or uneven wear. 9. All interior and exterior lights 10. Windshield wipers and fluid 11. Horn 12. Siren 13. Air conditioners and heaters 14. Ventilating system 15. Doors a. Make sure they open, close, latch, and lock properly. 16. Communication systems, vehicle and portable 17. All windows and mirrors a. Check for cleanliness and position. 18. All compartments in the ambulance should be checked regularly. C. A daily check of the ambulance should ensure that it can: 1. Start 2. Steer 3. Stop 4. Stay running D. Warning signs of impending problems include: 1. Belt noise: Chirping or squealing sound a. Usually related to a load on one of the appliances operated by a drive belt b. Always significant as it will eventually put the unit out of commission 2. Brake fade: Sensation of losing power brakes a. Common causes include: i. Overheating of brake surfaces ii. Loss of vacuum iii. Loss of brake fluid iv. Wet or greasy brake drums v. Failed master cylinder b. Vehicle should be taken out of service immediately. c. You should not ever hear, smell, or feel brakes. 3. Brake pull: Feels like someone is trying to pull your steering wheel left or right whenever you depress the brake a. Causes may include: i. Brake fluid or grease on a brake pad ii. Serious mechanical malfunction b. Vehicle should be taken out of service immediately. 4. Drift: Vehicle wanders to left or right when you let go of steering wheel. a. Slight pull to the right is okay but vehicle should not consistently pull to the left 5. Steering pull: Persistent tug on the steering wheel as the unit drifts to one side or another a. Causes may include: i. Uneven tire pressure ii. Misaligned wheels iii. Mechanical problem b. Can cause loss of control during a sudden stop 6. Pulsating brake pedal: Up-and-down motion of brake pedal while decelerating a. Causes may include: i. Warped brake rotors or drums ii. Bent wheel b. Vehicle should be taken out of service immediately. 7. Steering play: Looseness or sloppiness while steering a. Causes may include: i. Wear ii. Underinflated tires b. Vehicle should be taken out of service immediately. 8. Tire squeal: Singing sound when you turn the vehicle at parking speeds a. Normal on smooth concrete; abnormal on asphalt b. Causes may include: i. Underinflated tires ii. Misaligned wheels c. Warrant’s a mechanic’s attention 9. Wheel bounce: Vibration felt in the steering wheel or driver’s seat a. Causes may include: i. Defective shock absorber ii. Bubble in tire iii. Unbalanced wheel 10. Wheel wobble: Found at low speeds with a bent wheel V. Ambulance Staffing and Development A. Ambulance staffing has been a major source of controversy over the past decade due to escalating costs of medical care, fuel, and ambulance operation. 1. In an effort to maximize productivity and minimize response times, high-performance EMS systems analyze: a. Response times i. A significant fraction (usually 90%) of all responses must be achieved in an established time. ii. Standards are based on recommendations by the Commission on the Accreditation of Ambulances (CAAS). b. Productivity i. Unit-hour utilization measures how many patient transports per hour each ambulance achieves. c. Unit costs i. Determined by the cost to respond to calls as well as number of hours units were active ii. Costs include paramedics’ salaries plus vehicle and equipment operational costs. d. Taxpayer subsidies i. Local government might help lower fees. ii. Some services offer annual subscription fees in exchange for free services. B. Ambulance and EMS systems 1. In the United States, most first-response EMS and ambulance service is delivered by the fire department whose personnel are cross-trained in EMS. a. In other areas, ambulance service is provided by private, for-profit agencies. b. Ambulance service may also be delivered by a public agency (not part of the fire department). i. Known as third service delivery model. c. Another model involves public-private partnerships. 2. Staffing of ambulances varies. C. System Status Management 1. SSM was developed by Jack Stout in 1983. 2. Goals are to maximize efficiency and reduce response time. 3. Data is compiled and used to determine ambulance service demands, taking into consideration: a. Peak loads: Increased demand during certain hours 4. Strategic deployment is used to minimize response times when demand is higher. a. Deployment to a posting (location) can take advantage of satellite vehicle location and GPS. 5. SSM helps organize peak demand staffing. a. Shift schedules provide a sufficient number of ambulances during peak load hours. 6. SSM can take a toll on personnel who have less downtime in between calls. D. Ambulance stationing 1. Goals are to maximize efficiency and minimize response times. 2. Factors include: a. Distance vs. call volume b. Special facilities that create increased ambulance demand i. Example: Long-term care facilities c. Need for maintenance of vehicles and equipment d. Storage e. Classrooms for training and meetings f. Sleeping quarters for personnel who spend the night VI. Mitigating Hazards Throughout the Call A. En route to the scene 1. The en route phase is potentially very dangerous due to crashes that happen. 2. As you prepare to respond to the scene: a. Fasten seatbelts and shoulder harnesses. b. Inform dispatch your unit is responding. c. Confirm nature and location of call. d. Ask for other available information. 3. While on route: a. Prepare to assess and care for the patient. b. Review dispatch information. c. Assign specific duties and scene management tasks. d. Decide which equipment to take. e. If appropriate, decide which stretcher to take. B. Arrival at the scene 1. Perform scene size-up and report to dispatch. 2. Do not enter the scene if there are any hazards to you. 3. If there are hazards, the patient should be moved before you begin care. 4. Use the following guidelines: a. Look for safety hazards. b. Evaluate the need for additional units or other assistance. c. Determine the mechanism of injury in trauma patients or the nature of the illness in medical patients. d. Evaluate the need to stabilize the spine. e. Follow standard precautions. The type of care you expect to give will determine which equipment to wear. 5. If you are the first EMS provider at a multiple-casualty incident, estimate the number of patients. a. Inform dispatch if additional units are needed. b. EMS personnel might be assigned roles such as triage, treating patients, and loading patients for transport to hospital. C. Traffic control 1. Purpose is to ensure orderly traffic flow and prevent another crash 2. Traffic control is difficult under ordinary circumstances. a. A disaster scene creates more problems. 3. As soon as you can, place reflectors and other warning devices on both sides of crash. D. Securing equipment 1. Make sure all equipment is secured before placing a vehicle in motion. a. Driving rapidly can cause items to shift. b. Some equipment can become lethal projectiles if not secured properly. E. Safe patient transfer 1. Excessive speed is unnecessary and dangerous. 2. Common sense and good driving techniques are required to get the patient safely to the hospital in the shortest time possible. a. Speed is no substitute for common sense and solid driving. b. No matter how careful the driver may be, patients can experience discomfort or danger. 3. Secure the patient with at least three straps across the body. a. Deceleration or stopping straps over the shoulders prevent forward movement if the ambulance suddenly slows or stops. F. Postrun activities: Restocking, cleaning, and disinfection 1. Clean and disinfect ambulance and equipment used. 2. Restock supplies you didn’t get at hospital. 3. Perform routine inspections. a. Use written checklist to document needed repairs and/or replacements of supplies or equipment. 4. Decontaminate the ambulance. a. Cleaning: Remove dirt, dust, blood, or other visible contaminants. b. Disinfection: Kill pathogenic agents by applying chemicals made for this purpose. c. High-level disinfection: Kill pathogenic agents by use of a potent disinfectant. d. Sterilization: Remove all microbial contamination with the use of heat or other appropriate process. 5. After each trip, you must do the following: a. Strip used linens and place in plastic bag or designated receptacle. b. Appropriately discard all disposable equipment that is considered medical waste. c. Wash all contaminated areas with soap and water, scrubbing blood, vomit, and other substances from floors, walls, and ceilings. i. Cleaning must be done prior to disinfection. d. Disinfect all nondisposable equipment. e. Clean the stretcher with an EPA-registered germicidal/virucidal solution or bleach and water at 1:100 dilution. f. Clean up any spillage with the same germicidal/virucidal or bleach/water solution. g. Clean outside of ambulance as needed. h. Replace or repair broken or damaged equipment immediately. i. Replace any equipment or supplies as needed. j. Refuel vehicle and check the oil. k. Create schedule for routine full cleaning for vehicle. l. Create written procedure for cleaning each piece of equipment, referring to the manufacturer’s guidelines for recommendations. VII. Defensive Ambulance Driving Techniques A. More than 6,000 ambulance crashes occur each year. 1. Learning how to properly operate your vehicle is just as important as knowing how to care for patients. 2. An ambulance involved in a crash: a. Delays patient care b. Could take the lives of EMS providers, other motorists, or pedestrians 3. Participation in a certified defensive driving course is strongly recommended. a. Every ambulance service must ensure their personnel are safe drivers before they begin employment and continue their training after they are hired. B. Driver characteristics 1. Not everyone who drives an automobile is qualified to drive an emergency vehicle. a. In some states you must pass an emergency vehicle operations course. 2. Important characteristics to possess include: a. Diligence and caution b. Positive attitude about your ability c. Tolerance of other drivers 3. Requirements include: a. Physical fitness i. Do not drive if you are taking medications that may cause drowsiness or slow reaction time. ii. Do not drive or provide care after drinking alcohol. iii. Do not drive if fatigued. b. Emotional fitness i. Emotional maturity and stability are directly related to your ability to operate under stress. c. Proper attitude d. Good judgment and knowledge C. Safe driving practices 1. Route planning and navigation a. Even if you use GPS, make sure you have easy access to detailed street and area maps. b. Become familiar with the roads and traffic patterns in your area so you can plan alternative routes. i. Avoid heavy traffic areas. ii. Know ways around: (a) Frequently opened bridges (b) Congested areas (c) Railroad crossings (d) School zones (e) Construction zones iii. Be familiar with special facilities and locations in your area: (a) Medical facilities (b) Airports (c) Arenas and stadiums (d) Chemical or research facilities 2. Fatigue a. Recognize when you are fatigued. b. Do not be ashamed to admit when you are fatigued. c. Place yourself out of service until fatigue has passed. 3. Distractions a. Personnel riding in the passenger side is responsible for talking on the radio and operating audible devices. b. Do not rely totally on a GPS to lead you to a call. c. While driving, never attempt to: i. Type on a computer while driving ii. Text iii. Operate personal data devices iv. Listen to music when listening to the service radio v. Eat or drink 4. Use of safety restraints a. All passengers, including EMS personnel (unless critical for patient care), should wear seatbelts. i. Parents should not be allowed to hold children. ii. Children should not be transported on the stretcher unless properly restrained. iii Adult seatbelts should not be used on children. 5. Speed a. Do not allow the type of call to affect how you respond while driving. b. Always drive with caution. 6. Siren risk-benefit analysis a. Lights and sirens should never be used to transport a nonemergency patient. i. Paramedic riding in rear of ambulance with patient should make decision. ii. Decision should not be guided by surrounding traffic. 7. Driver anticipation a. Recognize that all other drivers are unpredictable. i. Expect vehicles to pull to the left and right to allow your vehicle to pass. ii. Some drivers may not even realize you are behind them. iii. Some drivers may stop suddenly out of panic. b. Always maintain a safe travel distance behind vehicles. c. Do not respond aggressively if a driver doesn’t respect your vehicle. d. Do not accelerate through intersections, even if you have the right of way. e. Make eye contact with fellow drivers until it appears your intentions are clear. f. Use turn signals. g. Never force a vehicle into oncoming traffic in an effort to get around it. 8. The cushion of safety a. Maintaining a cushion of safety consists of: i. Maintaining a safe following distance from vehicles (a) Drive 4 or 5 seconds behind a vehicle driving at an average speed. ii. Avoiding being tailgated. (a) Constantly scan your rearview and side mirrors. (b) Never get out of your vehicle to confront a driver. iii. Make sure you’re aware of blind spots. (a) Mirror obstructs view ahead (1) To eliminate, lean forward so your view is not obstructed. (b) Rear of vehicle cannot be seen fully through mirror. (c) Side of vehicle cannot be seen through driver and passenger mirrors at a certain angle. (1) Small rounded mirrors placed on side mirrors may assist in seeing blind spots. (2) May need to lean forward or backward to eliminate blind spot 9. Vehicle size and distance judgment a. Vehicle length and width are critical when: i. Maneuvering ii. Driving iii. Parking iv. Braking and passing (a) Use someone outside of the vehicle as a guide when backing up. 10. Backing up the emergency vehicle a. Should be avoided whenever possible b. If backing up a vehicle is necessary, follow these rules: i. Use a spotter to guide you. ii. Agree with the spotter before you begin moving the vehicle. iii. Keep your spotter in view at all times; stop if you lose sight of the spotter. iv. Agree on hand signals before moving. v. Keep your window cracked open so you can hear people warning you of unseen dangers. vi. Do a walk-around before getting behind the wheel. vii. Use audible warning devices when the vehicle is in motion. viii. Do not rely totally on a backup camera if available. 11. Parking at an emergency scene a. Allow for efficient traffic control and flow. b. Do not block the movement of other emergency vehicles. i. Park about 100 ft past the scene on the same side of the road. c. Park uphill or upwind in case of smoke or hazardous materials. d. Keep warning lights on if you must park on back side of hill or curve or if parking at night. e. Stay away from structures that might collapse. f. Always use your parking brake. g. Leave emergency warning lights if blocking part of a roadway. i. Use only flashing yellow lights if possible. h. Try to park as close to the scene as possible. i. Park where your departure will not be hampered. j. Be aware of terrain. i. Heat underneath vehicle may start a grass fire in dry weather. ii. Weight of ambulance may cause vehicle to sink in mud in wet weather. k. Turn off headlights to avoid blinding oncoming traffic at night. l. Always wear visible protective clothing such as reflective vests. D. Emergency vehicle control 1. There are two ways to control a vehicle: Changing directions and changing speed. a. Both require continuous rolling contact between surface of tires and surface of road. i. Grip on road may vary depending on: (a) Condition of surface (b) Age of road (c) Weather (d) Tire’s tread design and wear b. Drivers must constantly evaluate the road surface, especially when cornering the vehicle. 2. Road positioning and cornering a. Road position: Position of the vehicle on the road relative to the inside or outside edge of a paved surface b. Take corners at the speed that will put you in the proper road position. i. Apex of turn through a curve: Point at which vehicle is closest to inside edge of curve (a) If reached early, vehicle will be forced outside of roadway. (b) If reached late, vehicle will stay on inside of roadway. E. Braking 1. Getting a feel for brake pressure comes with experience and practice. a. Types I and III vehicles have heavier feeling brakes than Type II vehicles. b. Diesel-powered units will brake differently than an identically equipped gasoline-powered unit 2. Get to know each vehicle you drive. F. Controlled braking 1. Used to control vehicle’s movement and direction 2. Braking while traveling in a straight line is most efficient. a. Braking while cornering could cause the vehicle to skin or spin. 3. Weather and road conditions a. Weight distribution of the vehicle should be taken into consideration during inclement weather. i. You will need more room to come to a complete stop. ii. Line of sight is limited. b. Hydroplaning: Tire is lifted off the road as water piles up under it. i. Occurs at speeds of greater than 30 mph on wet roads ii. Gradually slow down without slamming on the brakes if this occurs. c. Water on the roadway i. When possible, avoid driving through standing water. (a) Wet brakes slow the vehicle and pull to one side. ii. If you cannot avoid driving through standing water, lightly tap the brakes several times after driving out the water to dry them. iii. If anti-lock brakes, apply steady, light pressure to dry brakes. d. Decreased visibility i. During fog, smog, snow, or heavy rain, slow down and use low headlights. ii. Always use headlights during the day to increase visibility. e. Ice and slippery surfaces i. All-weather tires and appropriate speed will reduce traction problems. ii. Consider studded snow tires. iii. Be especially careful on bridges and overpasses when temperatures are close to freezing. (a) Freeze faster than surrounding road surfaces G. Laws and regulations 1. Vary from state to state and city to city 2. Emergency vehicle drivers have certain limited privileges. a. Privileges don’t lessen liability in a crash. i. Driver presumed guilty if crash occurs while vehicle is operating with warning lights and sirens. ii. Largest source of lawsuits against EMS personnel and services 3. The use of warning lights and sirens allows EMS driver to do the following: a. Park or stand in otherwise illegal location. b. Proceed through red light or stop sign after stopping. c. Drive faster than posted speed limit. d. Drive against the flow of traffic on a one-way street or make an illegal turn. e. Travel left of center to make an illegal pass. 4. Use of warning lights and sirens a. EMS drivers must adhere to the following: i. Unit must be on a true emergency call. ii. Both audible and visual warning devices must be used simultaneously. iii. Unit must be operated with due regard for the safety of others on and off the roadway. b. Siren is most overused piece of equipment on ambulance. i. Warn patient before use. ii. Do not increase speed just because siren is on. c. Do not assume lights and sirens will allow you to drive through congested areas without stopping or slowing down. d. High-beam flasher units are the most visible, effective warning devices. 5. Right-of-way privileges a. Varies from state to state and should be used only when absolutely necessary. i. Some states allow you to proceed through a red light or stop sign after stopping. ii. Some states allow you to proceed through controlled intersection “with due regard,” using flashing lights and siren. b. Know your local right-of-way privileges. 6. Use of escorts a. Following another emergency vehicle through traffic as an escort is generally not a good idea. i. Many drivers see only the first set of lights and assume the way is clear. ii. If doing so, leave enough space between vehicles so you have enough time to react if someone pulls in front of you unexpectedly. b. Instruct family members that they cannot drive closely behind you. i. If someone has not heeded the warning, consider turning off your lights and siren and slowing down to normal speed. 7. Intersection hazards a. Intersection crashes are the most common and most serious type of crash for an ambulance. b. Look for other motorists and pedestrians before proceeding into the intersection. c.. Common hazard include: i. Motorists who “time the traffic lights.” ii. One emergency vehicle following another emergency vehicle through an intersection (a) Yielding motorists are often not expecting more than one vehicle. 8. Unpaved roadways and rural settings a. Operate the vehicle at a lower speed. b. Maintain a firm grip on the steering wheel. c. Do not drive onto unpaved or grassy areas when the ground has been saturated with rain and there is a chance your vehicle will get stuck. d. Often other agencies, such as the Forestry Service, will help in remote locations. e. Be cautious of animals entering the roadway. 9. School buses a. Never pass a school bus that has stopped to load or unload children or that has its stop arm extended. b. Stop before reaching a bus with its lights flashing. i. Wait for the driver to ensure children’s safety, close the door, and turn off the lights before proceeding. 10. School zones a. Lights and sirens could attract children to the roadway, creating a dangerous situation. b. In many states it is illegal for an emergency vehicle to exceed the speed limit in school zones. 11. Funeral processions a. Most states offer no exemption when approaching a funeral procession. b. Out of respect, most drivers turn off audible devices. VIII. Air Medical Transports A. Air medical transport can speed up the transfer of patients from the trauma scene to definitive care. 1. Only appropriate in certain circumstances. 2. Factors to consider: a. Does the patient’s condition warrant the risk of using air transport? b. Will the use of air transport truly save time? B. Rotor-wing versus fixed-wing air ambulances 1. Rotor-wing aircraft (helicopters) are standard of care for transportation of critically injured. 2. Fixed-wing aircraft are used mainly for long-distance transportation. C. Advantages of using air ambulances 1. Reduces transport time if distance is extreme a. Decision should be made as early as possible i. Can always be returned if not needed b. Weigh all time factors: i. Machine must be started. ii. Personnel and gear must be loaded. iii. Great distances may need to be covered. iv. Aircraft must land at scene. v. Patient must be transferred to the air crew. vi. Patient must be packaged and loaded. 2. Provides less injury to patients with spinal injury over rough terrain a. Paramedic on scene is the best judge of needs. 3. Specialized skills or equipment is needed. 4. Can provide access to remote areas 5. Helicopter hospital helipads are available. 6. Availability of medical crew with advanced skills D. Disadvantages of using air ambulances 1. Cardiac arrest patients need to be transported by ground due to space limitations in the aircraft. 2. Weather/terrain can prevent use. 3. Altitude limitations 4. Airspeed limitations 5. Cost 6. Patient’s condition 7. Restrictions on number of caregivers 8. Potential for crash E. Helicopter medical evacuation operations 1. Medevac: Medical evacuation a. Become familiar with medevac: i. Capabilities ii. Protocols iii. Procedures 2. Calling for a medevac a. Why call for a medevac? i. Ground transportation will take too long, given the patient’s condition. ii. Road, traffic, or environmental conditions limit or prohibit the use of ground transportation. iii. Patient requires advanced care. iv. Multiple patients will overwhelm a hospital if reached by ground transport. b. Who receives a medevac? i. Patients with time-dependent injuries or illnesses, such as stroke, heart attack, or spinal cord injury ii. Patients with serious conditions, such as diving accident, near drownings, or skiing or wilderness accidents iii. Trauma patients and candidates for: (a) Limb replantation (b) Burn center (c) Hyperbaric chamber (d) Venomous bite center c. Who do you call? i. Notify dispatcher of request, including: (a) Chief complaint (b) Patient’s weight (1) Some helicopters have weight limits ii. After medevac has been initiated, ground crew may access flight crew on radio frequency (a) Present patient’s condition clearly and concisely. 3. Medevac issues a. Factors to consider before requesting medevac include: i. Weather (a) Generally unable to operate in severe weather (thunderstorms, blizzards, heavy rain) ii. Environment/terrain (a) Helicopter must be able to safely land. iii. Altitude (a) The higher the elevation, the thinner the air and the more difficult it is to breathe. (b) Most services are limited to 10,000 ft above sea levels. iv. Airspeed limitations (a) Typically fly between 130 and 150 mph v. Cabin size (a) Limits number of patients that can be safely transported (b) Limits size of patient that can be safely transported vi. Cost (a) Typically ranges from $8,000-$10,000 (1) Ambulance typically ranges from $400 to $1,000 F. Establishing a landing zone 1. Area should be a hard or a grassy level surface. a. Not less than 60 ft by 60 ft (100 ft x 100 ft is recommended) 2. Area should be cleared of loose debris, including: a. Branches b. Trash bins c. Flares d. Accident tape e. Medical supplies and equipment 3. Immediate area should be clear of overhead or tall hazards, such as telephone cables, antennas, and tall trees. a. Flight crew must be notified immediately if any hazards are seen. 4. Mark the landing zone using weighted cones or position emergency vehicles at the corners of the landing zone with headlights facing inward to form an X. a. Never use accident tape, people, or flares to mark the area. 5. Nonessential persons and vehicles should be moved to a safe place outside the landing zone. 6. Radio the flight crew the direction of the wind if it is strong. a. Be prepared to improvise a wind direction device if asked by the flight crew. i. A bed sheet works well; never use tape. G. Landing zone safety and patient transfer 1. Be familiar with capabilities, protocols, and methods for accessing helicopters in your area. 2. Be sure to do nothing near the helicopter and go only where the pilot and crew directs you. a. Keep the pilot in view at all times. b. Approach and depart the aircraft from the front. 3. Keep a safe distance from the aircraft whenever it’s on the ground and “hot” (tail rotor is spinning). a. If asked to enter the landing zone, stay away from the tail rotor. i. Tips of the blades move so rapidly they are invisible. 4. Never approach the helicopter from the rear or duck under the body, tail boom, or rear a. The proper approach is between nine-o’-clock and three-o’-clock. 5. Walk in a crouched position when approaching an aircraft. 6. Never carry anything above your head. 7. When you are operating at a landing zone: a. Pay attention to the flight crew. b. Become familiar with hand signals used in your jurisdiction. c. Do not approach helicopter unless instructed by the flight crew. d. Make sure all equipment and patients are properly secured. e. Always approach the aircraft from the front unless otherwise instructed by the flight crew. f. Smoking, open lights or flames, and flares are prohibited within 50 ft of the aircraft. H. Communicating with other agencies 1. When requesting a medevac response, always include: a. Ground contact radio channel b. Call sign of the unit that the medevac should make contact with I. Special considerations 1. Night landings a. Do not shine spotlights, flashlights, or other lights in the air to help the pilot. i. They can temporarily blind the pilot. b. Direct light toward the ground. c. Smoking, open lights or flames, and flares are prohibited within 50 ft of the aircraft. 2. Landing on uneven ground a. Approach the aircraft from downhill side only because the rotor blade will be closer to the ground on the uphill side. b. Do not move the patient to the helicopter until signaled. 3. Medevacs at hazardous materials incidents a. Flight crew should be notified immediately of hazardous materials. b. Because the aircraft generates tremendous wind, hazardous vapors will spread. c. Landing zone should be established upwind and uphill from the scene. d. Patients exposed to a hazardous material must be decontaminated before being loaded into the aircraft. IX. Summary A. Federal Regulation DOT KKK 1822 sets the standards for ambulance design and manufacturing specifications. B. Three body style types identified: Type I: Conventional, truck-cab chassis with a modular ambulance body that can be transferred to a new chassis as needed Type II: Standard van, forward-control integral cab-body ambulance Type III: Specialty van, forward-control integral cab-body ambulance C. Check the ambulance, including medical equipment and supplies, at the beginning of every shift to ensure all equipment is available and in good working order. D. Preventive maintenance is just as important as operating skills. Looking for problems before the unit is in motion may prevent breakdowns while you are en route to calls. E. After the call, be sure to clean, disinfect, and restock. Perform a routine inspection to ensure the ambulance is ready to respond to the next call. F. Learning how to properly operate your vehicle is just as important as learning how to care for patients when you arrive on the scene. The first rule of safe driving in an emergency vehicle is that speed does not save lives; good care does. G. Drivers must be qualified to drive the ambulance, must be physically and emotionally fit, and must have the proper attitude. The driver must know and follow safe driving practices, including wearing a seat belt, using an appropriate speed, using sirens appropriately, and maintaining a cushion of safety H. All drivers and passengers should use appropriate safety restraints while a vehicle is in motion. Pediatric patients should be secured in devices designed for them. I. Make sure all equipment is secure before leaving the scene. J. Lights and sirens should be used when you are responding to emergencies but used sparingly when transporting a patient to the hospital. K. Avoid backing up the vehicle if possible. If it is necessary, use a spotter to assist in the procedure. Make sure everyone is clear on where the unit is to be placed and that hand signals used are agreed upon. L. Use extreme caution when you are driving in heavy traffic areas or in rural areas where the roadways themselves may not be suitable for travel with a heavy ambulance. Watch out for other dangers such as animals running onto the roadway. M. Slow down in inclement weather, being aware that the ambulance requires greater travel time and distance to stop properly. N. Any specific exemption from traffic laws does not negate your responsibility to proceed with due regard to prevent ambulance crashes. O. Escorts should not be used due to the danger of motorists not seeing both the ambulance and the escort. P. Air ambulances are used to evacuate medical and trauma patients. Q. A medical evacuation is commonly known as a medevac and is generally performed exclusively by helicopters. R. You must follow certain safety rules when you are working around landing zones and helicopters. Be sure you are familiar with these rules before working any call involving air transport. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 46. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: B. Will the difference in time make a difference in patient outcome Rationale: Air medical transport—especially the use of helicopters—has done much to speed up the transfer of patients from the trauma scene to definitive care. This mode of transport presents certain risks, however, and it is only appropriate in certain circumstances. Several factors must be considered before calling for an air ambulance: Does the patient’s condition warrant the risk of using air medical transport? Will use of the air ambulance truly save the patient time in getting to definitive care once all other factors are considered? 2. Answer: A. Inclines or depressions make it harder to judge rotor blade distance from the ground. Rationale: Helicopters operate with two “rotor-wings.” Traditionally one is located on the top of the aircraft and the other is located on the tail. Rotor blades spin at a high velocity, causing lift and enabling the pilot to control the aircraft. Even on level ground, approaching a helicopter with the blades turning should be undertaken with an abundance of caution. Approaching a helicopter on uneven terrain makes it much harder to judge distance between the rotor and the ground. 3. Answer: C. 100 ft × 100 ft Rationale: The landing zone should be large enough to accommodate a rotor-winged aircraft of any size; standard dimensions are 100 ft × 100 ft. 4. Answer: D. Place one strobe light at each corner of the zone. Rationale: Mark the landing site with one visible light (preferably a strobe light) at each of the four corners. Helicopters take off and land best into any existing wind, so it may be helpful to mark the side of prevailing winds with an extra strobe light. During a night landing, do not shine flashlights or spotlights up at the aircraft while it is descending; they may blind the pilot. Likewise, turn off headlights. Consider placing emergency vehicles under any overhead wires to signify the hazard. 5. Answer: D. When the pilot signals you to approach Rationale: After the helicopter has landed, you should not approach the helicopter until signaled to do so by the pilot or a crewmember. If possible, all rotors should be stopped before you approach the aircraft. If the aircraft continues to operate in a “hot” mode (with rotor blades active), the tail rotor is the most dangerous part of the aircraft and should be avoided at all times. Additional Questions 6. Rationale: Do not allow loose objects or debris in the immediate vicinity that might be pulled up into the rotors and engine, including clothing worn by emergency workers, such as caps and scarves, and IV poles. Remove the sheet from the stretcher before putting the backboard on it so the sheet is not pulled up into the rotor blades when the patient-loaded backboard is removed. Never carry anything above your head and make sure someone is always in charge of each piece of equipment when around the aircraft. Stretchers can easily roll into the tail rotors if no one is physically holding onto the cot after the patient is loaded into the helicopter. Assignments A. Review all materials from this lesson, and be prepared for a lesson quiz to be administered (date to be determined by instructor). B. Read Chapter 47, Incident Management and Multiple-Casualty Incidents, for the next class session. Unit Assessment Keyed for Instructors 1. Identify and discuss potential warning signs of impending ambulance problems or failure. Answer: Because your ambulance is considered an essential piece of equipment for emergency responses, it is important to recognize when it may have a mechanical problem that can result in a critical failure during the response to or transport of a patient. Belt noises are always considered significant because belt breakages can prevent the ambulance from operating. You may hear a chirping or squealing sound that is typically related to a load on an appliance operated by a drive belt. Brake fade is a sensation that the ambulance has lost its power brakes. If this occurs, place the vehicle out of service immediately. It is commonly caused by overheating of brake surfaces, loss of brake fluid, wet or greasy brake drums, or a failed master cylinder. Although cold brakes may squeak in wet weather, brakes should not be felt, smelled, or heard. Brake pads that are wearing out typically make a noise, such as a rub or squeak, to indicate it is time to change them. Brake pull or the movement of the vehicle to the side when braking is a serious concern and the vehicle should be placed out of service immediately. Drift occurs when the vehicle wanders left or right when you are not holding the steering wheel. Minor rightward drift may occur but it should not consistently drift to the left. Steering pull is felt as the ambulance drifts. It is a persistent tug commonly caused by uneven tire pressures such as is seen with a flat tire. Because loss of control in a sudden stop is a possibility, this should always be checked. Steering play is also a serious concern, as it can mean you have underinflated tires and should not occur in a newer vehicle. Wheel bounce is often felt by the driver at speeds greater than 45 mph. The ambulance may have a defective shock absorber, a bubble in the tire, or an improperly balanced wheel. (pp 2175-2176) 2. Identify and discuss the four factors analyzed in an effective, cost-efficient ambulance service. Answer: The four factors include response times, productivity, unit costs, and tax payer subsidies. Response times are an important factor to consider when determining whether established thresholds are being met. Many services have developed fractile response time standards to meet accreditation standards or contractual agreements. Productivity, measured as unit hour utilization, assists in determining whether allocated resources are being used optimally. Decreased productivity can reflect excessive resources or inappropriate allocation during periods of high versus low demand. Unit costs reflect the overall expense to operate the ambulance, including personnel salaries and operational costs of the ambulance. Tax payer subsidies are sometimes offered to offset cost of providing ambulance service in a community and lower fees. They may also include annual subscriptions to eliminate fees at time of service. (pp 2176-2177) 3. Discuss what it means to operate under system status management. Answer: System status management has two main goals: maximizing efficiency and reducing response times. Under this system, historical data is analyzed to determine ambulance service demands with consideration given to fluctuations. Peak load times are identified for those periods when ambulance service requests are higher than normal. Strategic deployment is implemented so that the amount of resources allocated increases during these periods of peak loads and is reduced when periods reflect low demand. Increasing the number of allocated resources helps reduce response times by strategically scheduling more resources when volume is expected to be high and allowing more units to be posted at satellite locations in areas identified as those having higher demand. The disadvantage of this pre-planned identification of peak load hours is that less time is left for personnel to rest between responses. (p 2177) 4. Identify at least five ways to mitigate hazards throughout the phases of a call. Include the rationale for why these are appropriate. Answer: During the response phase of the call, both you and your partner should wear safety belts and take the opportunity to request additional information about the nature of the call so that you can plan what actions might be needed to safely access, treat, and transport the patient. You may also be able to obtain additional information about scene hazards that would necessitate the request of additional resources. During the scene size-up phase, you should critically assess the scene for potential hazards that were not previously known and request additional assistance as needed for these. You should not enter an unsafe scene until it has been secured. At crash scenes, traffic control is needed once your own safety has been secured. Traffic control should be conducted by law enforcement, but if they are not on the scene you may be needed to perform this task to prevent additional crashes or further injury to your patient(s) and risk of injury to yourself or partner. Securing all equipment prior to the vehicle moving is important to reduce the risk of injury should the equipment shift during travel. Patients should also be properly secured in the ambulance prior to transport. All safe transport recommendations by your agency, ambulance manufacturer, and stretcher manufacturer should be followed. (p 2178) 5. Compare and contrast what is meant by cleaning the ambulance versus disinfecting the ambulance. Answer: Cleaning an ambulance reflects the processes used to remove dirt, dust, blood, and other contaminants that are visible to the naked eye from the ambulance. Disinfecting also includes processes to remove contaminants but is typically reflective of those substances that are pathogenic in nature. Disinfection kills these agents by applying chemicals directly to surfaces that are made for that purpose. High-level disinfection requires a more potent disinfectant; and sterilization may be used when the equipment requires the removal of all microbial contamination. (p 2179) 6. Discuss how the following driving factors can impact crash prevention: route planning and navigation, distractions, speed, driver anticipation, and cushion of safety. Answer: Route planning should be used to identify the route that will allow you to respond safely to a scene. You should have detailed street maps in the cab of your ambulance and your partner should navigate while you operate the vehicle. You should not rely on GPS devices alone for route planning, as they may fail. Be familiar with your local response area, locations of railroad crossings, alternate routes for areas that experience heavy delays or school zones, high congestion areas such as stadiums and airports, staging areas for industrial sites where hazardous incidents may occur, and location of facilities with heavy traffic. Distractions are common causes of all types of crashes. When your partner is your passenger, they may serve as additional eyes and ears for oncoming traffic, pedestrians, or other hazards. They should also navigate for you so that you can remain focused on the road. You should allow your partner to communicate by radio and you should never text while driving. Do not attempt to operate GPS devices or the mobile data terminals while driving. Turn off all non-essential devices such as vehicle stereos during a response. Speed should be controlled and within local or state guidelines for safe operation of the emergency vehicle. Avoid letting emotions related to the response increase your speed. Speed is not more important than safety. Driver anticipation is important to prevent crashes. While your actions may be predictable, those of other drivers are not. Drivers of other vehicles may not leave the roadway, leave the roadway on the wrong side, stop suddenly, or cross/turn in front of your vehicle without warning. Stop at all intersections to attempt to make eye contact with other drivers to ensure they see you and to improve the chances that they will remain stopped as you pass through the intersection. Use all turn signals and alert drivers to your intentions while traveling. Maintain a cushion of safety as you travel. A safe distance of 4-5 seconds should be observed when following another vehicle to allow for sudden stops or turns by the vehicle. If a another vehicle is tailgating, do not speed up to attempt to remove them. Have your dispatcher contact local law enforcement instead. Leave space between the ambulance and the car ahead so that you may pull around them safely if an emergency response is needed. (pp 2180-2181) 7. Explain what is meant by operating the ambulance with ‘due regard.’ What is the impact of state or local statutes in regards to due regard? Answer: Due regard refers to operation of the emergency vehicle such as not to endanger other people or property. While all states offer some level of privilege to emergency vehicle operators when traveling in emergency mode, these are not to exempt you or your agency from liability if you cause a crash, injure others, or damage property while operating your ambulance. These are privileges that should be used sparingly and with due regard for the safety of others and property. Use of warning devices does not grant you right of way under any circumstance but serve as a request that others grant you right of way. It is the responsibility of the ambulance operator to ensure that it is safe to use these privileges. (p 2185) 8. Identify several advantages and disadvantages to using air ambulances for patient transport. Answer: Advantages of using air ambulance transport include the availability of specialized skills and equipment when needed to adequately treat the patient. Some air ambulances staff registered nurses that may perform additional procedures or carry medications and equipment that would be more effective in treating your patient. Transport times are typically shorter by air ambulance and an air ambulance is better able to access remote areas that may inhibit ground access. Disadvantages of air ambulance use include limitations related to weather or environment, altitude, airspeed, cabin size, and weight. Not all terrains will offer suitable landing zones for the air ambulance to land. Cost of air ambulance transport is typically much higher than that of a ground ambulance. There is also a limit to the number of providers that can care for a patient during transport. Not all patient conditions are suitable for air transport and there is always a risk of crashing. (pp 2187-2188) 9. Discuss considerations that should be made prior to establishing a landing zone for an air ambulance. Answer: The safest way for a helicopter air ambulance to land and take-off is to allow space for gradual descent and for gradual lift. Although they can typically move straight up and down, this is not the safest maneuvers for helicopters. Establishing the landing zone is the responsibility of the ground crew. The area should be hard, preferably with a level grassy surface. If there is an angle, this must be communicated to the pilot. All loose debris should be cleared to avoid it from becoming projectiles in the wash from the rotors. Overhead hazards should be avoided when possible. If there are some present, they should be noted to the pilot and potentially illuminated. Weighted cones or emergency vehicles may be placed at the corners of the landing zone to identify the appropriate area for the crew. Do not use flares. If there is a strong wind, be sure to communicate the direction to the crew and use a piece of cloth, sheet, or pillowcase on a tree or pole to provide the pilot with wind direction. (p 2189) 10. Discuss safety guidelines for approaching an air craft. Answer: When the rotors are turning, the air craft is considered to be “hot” and it should not be approached during this period. Ground crews should remain outside the landing zone unless directed to enter by flight crews. Typically the flight crew will come to the patient and assist with or handle loading during the period when the rotors are in operation. If you are asked to enter the landing zone, stay away from the tail rotor, as the tips of the blades in motion are invisible. Do not approach the aircraft from the rear, but always from the front. Proper approach is from nine o’clock to three o’clock to allow the pilot full visibility of your movement. Approach the air craft in a crouched position, as the main rotor can dip even when not in motion. Do not wear hats or loose clothing. Have someone monitor each piece of equipment and maintain tight control over the stretcher. Do not attempt to open aircraft doors or move equipment unless you are directed by a member of the flight crew. (p 2189) Unit Assessment 1. Identify and discuss potential warning signs of impending ambulance problems or failure. 2. Identify and discuss the four factors analyzed in an effective, cost-efficient ambulance service. 3. Discuss what it means to operate under system status management. 4. Identify at least five ways to mitigate hazards throughout the phases of a call. Include the rationale for why these are appropriate. 5. Compare and contrast what is meant by cleaning the ambulance versus disinfecting the ambulance. 6. Discuss how the following driving factors can impact crash prevention: route planning and navigation, distractions, speed, driver anticipation, and cushion of safety. 7. Explain what is meant by operating the ambulance with ‘due regard.’ What is the impact of state or local statutes in regards to due regard? 8. Identify several advantages and disadvantages to using air ambulances for patient transport. 9. Discuss considerations that should be made prior to establishing a landing zone for an air ambulance. 10. Discuss safety guidelines for approaching an air craft.