Continuing Education and Instant Certificates Online

In this EMS Operations course you will earn 1 CE hour. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

• List the phases of an out-of-hospital call.
• List various methods of gaining access to the patient.
• Distinguish between simple and complex access.
• Describe what you do if there is reason to believe that there is a hazard at the scene.
• State your role until appropriately trained personnel arrive at the scene of a hazardous materials situation.
• Describe the criteria for a multiple-casualty situation.
• Summarize the components of basic triage.

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

Phases of a Response

This lesson is designed to provide you with a brief overview of some of the operational aspects of out-of-hospital care. Be familiar with the medical and non-medical equipment for use in patient care and the phases of a response and your role in each. Although the First Responder is not usually responsible for rescue and extrication, a fundamental understanding of the process is required. Phases of an out-of-hospital call are 1) preparation, 2) dispatch, 3) travel enroute to the scene, 4) arrival at the scene, 5) transfer patient to ambulance, and 5) postrun.

Preparation for the Call

• Recommended Equipment
  • Medical
    • Basic supplies
    • Airways
    • Suction equipment
    • Artificial ventilation devices
    • Basic wound care supplies
  • Nonmedical
    • Personal safety equipment per local, state, and federal standards
    • Planned routes or comprehensive street maps
    • Personnel available for response
• Regular Equipment
  • Checked and maintained
  • Restocked and repaired
• Utilization of safety precautions and seat belts

Dispatch

• Central access
• 24-hour availability
• Trained personnel
  

Dispatch information

• Nature of call
• Name, location, and callback number of caller
• Location of patient
• Number of patients and severity
• Other special problems

Definitions

• Triage - people are categorized according to the seriousness of the injury.
• BSI - body substance isolation. Use gloves and protective clothing protect yourself.
• Scene size-up - Practice BSI, scene safety, and identify the mechanism of injury/nature of illness.
• Altered mental status - anyone with an altered neurologic exam ranging from completely unconscious, to someone who responds to painful stimuli only, or a verbal response which is confused, or an abnormal motor response.
• Regional Patient Care Procedures - a blueprint which identifies response to patients.

Steps in Disaster Triage Assessment:

Step 1 - Ventilation

• None: tag dead, black.
• More than 30/minute: red, immediate.
• Less than 30/minute: further evaluation: Go to Step 2.

Step 2 - Perfusion

• Capillary blanch test: lips or nail beds should regain color within 2 seconds. Go to Step 3. If not, tag immediate, red.
• Radial pulse; useful with reduced lighting.
  • Not palpable if BP below 80 systolic. Tag immediate, red.
  • If palpable, go to Step 3.
  • Control bleeding; bystander directs pressure.

Step 3 - Mental Status

• Altered mental status: tag immediate, red.
• Mental status normal: tag delayed, green.

Triage victims are separatedinto the appropriate category based on the three assessment steps.

1. Start where you stand.
2. Then identify walking wounded.
3. Send them to the designated area (away from immediate danger).

Basic triage involves sorting multiple casualties into priorities for emergency medical care or transportation to definitive care. Priorities are given in three levels in a mass casualty incident (MCI). Triage categories:

Highest Priority

• Airway and breathing difficulties.
• Uncontrolled or severe bleeding.
• Decreased mental status.

Second priority

• Burns without airway problems.
• Major or multiple painful, swollen, deformed extremities.
• Back injuries.

Lowest priority

• Minor painful, swollen, deformed extremities..
• Minor soft tissue injuries.
• Death.

The purpose of triage is:

• To ensure that major trauma patients are transported to the most appropriate facility.
• To ensure that the “right patient is transported to the right facility in the right amount of time.”
• To help an EMTB decide whether or not the patient they are treating is in fact a major trauma patient.
• To determine If a person is a major trauma patient. Take them to the highest level trauma facility within 30 minutes transport time, by either ground or air.
• To practice the “30-minute transport time” that begins the moment the patient is ready for either ground or air transport.

Trauma Triage Tool Components

Step 1 or Step 2 patients require prehospital personnel to notify medical control.

• Step 1 patients are determined by assessment of vital signs & level of consciousness. If a patient meets any of the criteria found in Step 1 then they are a major trauma patient and require transportation to the highest level trauma center within 30 minutes transport time via ground or air.
• Step 2 patients are determined by assessment of the anatomy of the patient’s injury. If patient meets any of the criteria found in Step 2, then they are a major trauma patient and require transportation to the highest level trauma center within 30 minutes transport time via ground or air.
• Step 3 patients are assessed using biomechanics of Injury and other risk factors. They require contact of medical control to determine patient destination.

Arrival at Scene

1. Notify dispatch.
2. Begin scene size-up.
   • Practice Body Substance Isolation (BSI). Before touching a patient, use gloves, gowns, and eyewear when appropriate.
   • Assess the scene for hazards using these scene safety questions:
     • Is the emergency vehicle parked in a safe location?
     • Is it safe to approach the patient?
     • Does the patient require immediate movement because of hazards?
   • Identify the mechanism of injury/nature of illness of a medical or a trauma emergency.
     • In a Mass Casualty Incident (MCI), identify the number of patients and obtain additional help.
     • Begin triage.
     • Stabilize the spine if necessary.
3. Follow procedures for First Responder arrival to a mass casualty incident (MCI). The most knowledgeable EMS provider arriving on the scene first becomes the triage officer, until relieved by a responder with a higher level of training.
   • Confirm the incident and establish a command post.
   • Request additional help.
   • Perform initial assessment on all patients first.
   • Start triage tag for each patient.
   • Assign available personnel and equipment to priority one patients.
   • Remain at the scene to assign and coordinate personnel, supplies, and vehicles.

If an incident command has been established, report to the command post, identify the Incident Commander, identify yourself and your level of training, and follow directions.

START Triage Plan

The START plan is a simple step-by-step triage and treatment method to be used by the first rescuers responding to a mass casualty incident. It allows these rescuers to identify victims at greatest risk for early death and to provide basic stabilization maneuvers. START was specifically designed for rescuers with basic emergency medical technician skills such as firefighters and ambulance personnel.

Goals of an effective triage plan are that it is simple and requires no special skills. It is rapid with no specific diagnoses needed. START provides stabilization of a chaotic situation and is easy to learn and to teach.

Triage Tags

Actions at the Scene

Be organized, rapid, and efficient. When transferring the patient to the ambulance:

• Assist the ambulance crew in preparing the patient for transport.
• Assist the ambulance crew with lifting and moving using the guidelines of the lifting/moving module.

Post-Run

• Prepare for the next call.
  • Clean and disinfect equipment.
  • Restock the disposable supplies.
  • Refuel unit.
• File reports.
• Notify dispatch.

Air-Medical Consideration

• Utilization
• Patient preparation
• Landing zones
• Safety

Getting to the Patient

• Simple access does not require equipment.
  a) Try opening each door.
  b) Roll down windows.
  c) Have patient unlock doors.
• Complex access requires use of tools, special equipment. These are separate programs that should be taken (Trench Rescue, High Angle Rescue, Vehicle Rescue).

Removing the Patient

• Work under the direction of the EMS providers.
• Maintain spine stabilization.
• Complete initial assessment.
• Provide critical interventions.

Hazardous Materials

Encountering hazardous materials is a common problem. However, the actual extent is unknown. Safety is your primary concern for the:

• First Responder and crew.
• Patient.
• Public.

When you approach the scene, try to identify hazardous materials, occupancy, containers (size/shape), placards, shiping papers, and use your senses of sight, hearing, (and precautionary smell) as first indicators.

General Procedures

• Park upwind/uphill from the incident, at a safe distance.
• Keep unnecessary people away from area.
• Isolate the area.
  • Keep people out.
  • Do not enter unless properly trained and fully protected.
  • Avoid contact with material.
  • Remove patients to a safe zone, if there is no risk to you as a First Responder.
• Do not enter a HAZMAT area unless you are trained as a HAZMAT Technician.
• Identify any environmental hazards.
• Check with local resources, such as
  • A hazardous materials response team.
  • Hazardous Materials, The Emergency Response Handbook, published by the United States Department of Transportation.
  • Review Occupational Safety and Health Administration (OSHA) and National Fire Protection Association (NFPA) HAZMAT requirements for EMS providers including First Responders.

These procedures are a blueprint which identifies response to patients. This process assures that the correct agency provides the appropriate personnel to the right patient and transports that patient to the appropriate facility in an acceptable amount of time.

Role of the First Responder

1. Administer necessary care to the patient before extrication and assure that the patient is removed in a way to minimize further injury.
2. Patient care precedes extrication unless delayed movement would endanger life of the patient or rescuer.
3. Work with others.
   a) In some instances, First Responders are also the rescue providers.
   b) A chain of command should be established to ensure patient care priorities.
4. Practice personal safety as the #1 priority for all First Responders. Use protective clothing that is appropriate for the situation.
5. After safety of the First Responder, the next priority is safety of the patient.
   a) Inform patients of the unique aspects of extrication.
   b) Protect patients from broken glass, sharp metal and other hazards, including the environment.

Triage

The purpose of the triage procedure is to ensure that major trauma patients are transported to the most appropriate hospital facility. Prehospital providers make quick identification of a major trauma victims. To determine whether an injury is major trauma, the prehospital provider conducts the patient assessment process. :Triage: means that people are categorized according to the seriousness of the injury. Any certified EMS and Trauma person can identify a major trauma patient and activate the trauma system. This may include requesting more advanced prehospital services or aero-medical evacuation. Steps are cited below.

1. Assess the vital signs and level of consciousness. The words "Altered mental status" mean anyone with an altered neurologic exam ranging from completely unconscious, to someone who responds to painful stimuli only, or a verbal response which is confused, or an abnormal motor response. If the airway is in jeopardy and the on-scene person cannot effectively manage the airway, the patient should be taken to the nearest medical facility or consider meeting up with an ALS unit. These factors are true regardless of the assessment of other vital signs and level of consciousness.
2. Assess the anatomy of injury. The specific injuries noted require activation of the trauma system. Even in the assessment of normal vital signs or normal levels of consciousness, the presence of any of the specific anatomical injuries does require activation of the trauma system.
3. Assess the biomechanics of the injury and address other risk factors. The conditions identified are reasons for the provider to contact and consult with Medical Control regarding the need to activate the system. They do not automatically require system activation by the prehospital provider. Other risk factors, coupled with a "gut feeling" of severe injury, means that Medical Control should be consulted and consideration given to transporting the patient to the nearest trauma facility. Please note that certain burn patients (in addition to those listed in Step 2) should be considered for immediate transport or referral to a burn center/unit.
4. Follow local patient care procedures. They are intended to further define how the system is to operate. They identify the level of medical care personnel who participate in the system, their roles in the system, and participation of hospital facilities in the system. They also address the issue of inter-hospital transfer, by transfer agreements for identification, and transfer of critical care patients.

In summary, these procedures work "hand-in-glove" to effectively address EMS and trauma patient care needs. By functioning in this manner, they may effectively reduce morbidity and mortality.