EMS Operations

This section of our NREMT study guide provides a comprehensive overview of the essential knowledge required for the EMS Operations component of the NEMT exam.

It covers the structure of EMS systems, operational roles and responsibilities, incident management, scene safety, vehicle operations, medical legal concepts, and communication.

The EMS System

EMS System Models and History

There are two primary models of EMS care delivery:

• Anglo American Model: The model used in the United States, which focuses on bringing the patient to the hospital for definitive care.
• Franco German Model: A model common in Europe that focuses on bringing the hospital to the patient, often with a physician responding to the scene.

The origins of modern EMS can be traced to volunteer ambulances in World War I, field care in World War II, and the use of field medics and rapid helicopter evacuation in the Korean War. EMS as we know it today originated in 1966 with the publication of “Accidental Death and Disability: The Neglected Disease of Modern Society.” The Department of Transportation (DOT) is the governing body for EMS and published the first EMS training curriculum in the early 1970s.

Levels of EMS Training and Regulation

There are four nationally recognized training and licensure levels for EMS providers:

• EMR (Emergency Medical Responder): Provides basic immediate care until more advanced personnel arrive. Examples include law enforcement officers, firefighters, park rangers, and ski patrollers.
• EMT (Emergency Medical Technician): Provides basic life support (BLS), including airway management, CPR, bleeding control, and assisting with a limited set of medications.
• AEMT (Advanced Emergency Medical Technician): Provides all EMT skills plus some advanced life support (ALS) skills, such as IV therapy, administration of more medications, and use of advanced airway adjuncts.
• Paramedic: The highest level of prehospital provider with extensive training in ALS, including endotracheal intubation, emergency pharmacology, and cardiac monitoring.

EMS is regulated at multiple levels:

• Federal Level: The National EMS Scope of Practice Model provides guidelines for EMS skills.
• State Level: State laws regulate EMS provider operations and licensure.
• Local Level: The agency’s medical director decides the day to day limits of EMS personnel through protocols.

Medical Direction

The physician medical director authorizes EMTs to provide medical care in the field. This oversight is known as medical control.

• Online (Direct) Medical Control: Directions given over the phone or radio by a physician.
• Offline (Indirect) Medical Control: Care is provided based on written standing orders and protocols.
• Standing Orders: A type of offline medical control that is part of a protocol. An example is giving oxygen to a patient with chest pain. If an intervention requires contacting a physician for permission, it is not a standing order.

Quality Improvement

• Continuous Quality Improvement (CQI): A system of internal and external reviews and audits of all aspects of the EMS system. Periodic run review meetings are held to discuss patient care and identify areas for improvement.
• Quality Control: The responsibility of the medical director to ensure that the appropriate medical care standards are met on each call.

Workforce Safety and Wellness

Stress Management

• Cumulative Stress: Prolonged, excessive stress that can cause fatigue, appetite changes, GI issues, and sleep pattern issues.
• Delayed Stress (PTSD): Posttraumatic stress disorder that can occur after a critical incident.
• General Adaptation Syndrome: A three stage response the body goes through when exposed to stress: alarm, resistance, and exhaustion.

The Grieving Process

Patients, families, and providers may experience a grieving process with five common stages: denial, anger, bargaining, depression, and acceptance.

Infection Control

• Handwashing: The most important practice. Wash hands vigorously for at least 20 seconds.
• Personal Protective Equipment (PPE):
  • Gloves: Must be worn for any potential contact with body fluids. Should be removed by pinching the wrist and pulling the glove inside out.
  • Gown and Eye Protection: Required for situations with a high risk of splashing, such as childbirth, uncontrolled bleeding, vomiting, and suctioning.
  • HEPA (N95) Mask: Required for patients with suspected tuberculosis and when performing aerosol generating procedures such as suctioning, CPR, and endotracheal intubation. It is NOT required for bloodborne pathogens like HIV.

Hepatitis

Hepatitis is an inflammation of the liver.

• Hepatitis A, B, and C can all cause nausea, abdominal pain, and malaise. Jaundice and right upper quadrant pain can develop weeks after exposure.
• Hepatitis A is transmitted via the fecal oral route.
• Hepatitis B, C, and D can be transmitted through blood or sexual contact.
• Hepatitis B and C can lead to chronic infection, cirrhosis, and cancer. Vaccines are available for Hepatitis A and B.

Operations and Scene Management

Scene Size Up

The scene size up is the first component of patient assessment. Its steps are:

1. Take standard precautions (BSI/PPE).
2. Ensure scene safety.
3. Determine the Mechanism of Injury (MOI) or Nature of Illness (NOI).
4. Determine the number of patients.
5. Consider the need for additional or specialized resources.
   The general impression is the first part of the primary assessment, not the scene size up.

Ambulance and Equipment Operations

• Ambulance Types:
  • Type 1: A truck chassis with a modular ambulance body.
  • Type 2: A standard van configuration.
  • Type 3: A specialty van with a square patient compartment mounted on the chassis.
• Ambulance Cleaning: Use a bleach and water solution to clean the stretcher, rails, and mattress after each run and daily. Do not use alcohol or aerosol sprays on these surfaces.
• Oxygen Cylinders: Should be replaced when they reach a designated safe residual pressure, typically 200 or 500 psi.

Air Medical Operations (Helicopters)

• Landing Zone (LZ): Requires a flat area of at least 100 x 100 feet, clear of debris, litter, and overhead obstacles.
• Safety:
  • Approach the helicopter from the front in a crouched position, between the 10 and 2 o’clock positions, only after the pilot gives an OK signal.
  • Secure the perimeter of the LZ, positioning emergency vehicles at the corners with headlights facing inward.
  • Wear eye protection during approach and take off.
  • Ensure all patient equipment is secured.
  • Do not smoke or have open flames within 50 feet of the aircraft.

Patient Lifting and Moving

• Lifting Technique: Keep your back straight and locked. Spread your legs and bend at the knees, not the waist. Keep the patient’s weight close to your body. Lift with your palms facing upward and avoid twisting. Communicate with your partners.
• Emergency Move: Used when there is immediate risk of harm or you cannot access another critical patient. The patient is dragged along the long axis of the body without time for full immobilization. This can be done by pulling on clothing at the neck/shoulder (unbuttoning the top button), using a blanket, or grasping the wrists above the patient’s head.
• Patient Carrying Devices:
  • Long Backboard: Used for spinal motion restriction. Assess pulse, motor, and sensory function before and after securing the patient.
  • Scoop Stretcher: Fits around a patient in a supine position, useful in confined spaces.
  • Basket Stretcher (Stokes): Used for mountain, cliffside, or technical rescues and vertical lifts. Can break into two sections.
  • Flexible Stretcher: Used for moving patients through narrow openings or down deep staircases.
  • Vacuum Mattress: A device that molds around the patient as air is removed, providing excellent immobilization.
  • Bariatric Patients: Patients over 250 pounds require at least 4 providers. Request lifting assistance from dispatch.

Incident Management

Incident Command System (ICS) and NIMS

• ICS (Incident Command System): A standardized management tool used in mass casualty incidents (3+ patients) to ensure safety and efficient use of resources. It does not train or evaluate EMS systems.
• NIMS (National Incident Management System): A system created to standardize incident management for all hazards across all levels of government.
• ICS Command Section: Includes the Incident Commander (IC), Public Information Officer, Safety Officer, and Liaison Officer.
• ICS Functional Sections: Finance, Logistics, Operations, Planning.
• Medical Incident Command Roles: Triage, Treatment, Transportation, Staging, Rehabilitation, Extrication.

Mass Casualty Incidents (MCIs) and Triage

An MCI involves 3 or more patients or has the potential to produce multiple casualties, overwhelming initial resources.

• Initial Actions: Request additional resources, establish Incident Command, and begin primary triage.
• Triage Principle: Treatment does not begin until initial triage is complete.
• Triage Categories:
  • Red (Immediate): Life threatening problems with airway, breathing, circulation (shock), severe burns, open chest/abdominal wounds.
  • Yellow (Delayed): Serious injuries that are not immediately life threatening, like major bone injuries or burns without airway compromise.
  • Green (Minimal): Minor injuries like minor fractures or soft tissue injuries; the “walking wounded.”
  • Black (Expectant): Non survivable injuries, such as major open brain trauma, cardiac arrest, or respiratory arrest when resources are limited.
• Triage Systems:
  • START (Simple Triage and Rapid Transport): Used for adults. Assesses Respirations, Perfusion (pulse/capillary refill), and Mental Status (follows commands).
  • JumpSTART: Used for pediatric patients. An apneic child with a pulse receives 5 rescue breaths; if they start breathing, they are tagged Red. If not, they are tagged Black. A respiratory rate less than 15 or over 45 is tagged Red.
  • SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport): Allows for immediate lifesaving interventions like tourniquets or needle decompression during triage. Adds a Gray category for patients expected to die.
  • Hartford Consensus (THREAT): A protocol for mass shootings: Threat suppression, Hemorrhage control, Rapid Extrication, Assessment by medical, Transport.

Special Hazards and Operations

Hazardous Materials (HAZMAT)

• Safety: Always position yourself upwind and uphill.
• Hazard Zones:
  • Hot Zone: Contaminated area.
  • Warm Zone: Decontamination corridor.
  • Cold Zone: Safe area for command post and patient treatment.
• Identification:
  • DOT Placards: Diamond shaped symbols on transport vehicles.
  • NFPA 704 System: Used on fixed facilities. A diamond with four colored smaller diamonds: Red (flammability), Blue (health), Yellow (reactivity), White (special). Risk is rated 0 to 4.
  • Common Containers: Drums, cylinders, and carboys are used to transport hazardous materials.

Weapons of Mass Destruction (WMDs) and Blast Injuries

• Chemical Agents:
  • Nerve Agents: Cause SLUDGEM symptoms (Salivation, Lacrimation, Urination, Defecation, Gastric upset, Emesis, Miosis).
  • Vesicants: Blistering agents.
  • Pulmonary/Choking Agents: Cause lung injury and respiratory distress.
  • Cyanide Agents: Interfere with cellular oxygen use.
• Biologic Agents: Examples include viral hemorrhagic fevers like Ebola.
• Radiological Sources: Can emit alpha, beta, gamma (X rays), or neutron radiation. Delta is not a form of energy.
• Blast Injuries:
  • Primary: Injury from the blast wave itself (e.g., blast lung, ruptured eardrums).
  • Secondary: Injury from flying debris.
  • Tertiary: Injury from the body being thrown against an object.
  • Quaternary: Miscellaneous injuries (burns, crush injuries, toxic inhalation).
  • Quinary: Illness caused by toxic materials absorbed from the blast.

Other Operational Hazards

• Water Rescue: Follow the sequence: Reach, Throw, Row, then Go. Be aware of dangers like backwash, strainers, and boils.
• Motor Vehicle Collisions: Park 100 feet away in a “fend off” position. Be aware of significant MOIs like rollovers, ejections, or death of another occupant.

Medical, Legal, and Ethical Issues

Consent

• Expressed Consent: Permission given by a competent adult. Children cannot give expressed consent.
• Implied Consent: Assumed for unresponsive or incompetent patients who need emergency care.
• Involuntary Consent: Can be applied to mentally incompetent patients, often with legal or law enforcement involvement.

Legal Principles

• Duty to Act: Your responsibility to provide patient care.
• Negligence: Failure to provide the standard of care.
• Assault: Placing a person in fear of immediate bodily harm.
• Battery: Unlawfully touching a person without their consent.
• False Imprisonment: Unauthorized confinement of a person.
• Good Samaritan Law: Provides legal protection for those who provide emergency care in good faith.
• Physical Restraints: If used improperly, can cause asphyxia, aspiration, acidosis, and cardiac death.

Patient Confidentiality and Reporting

• HIPAA: Patient information may only be disclosed for treatment, payment (billing), or when legally required (e.g., suspected abuse, subpoena).
• Special Reporting Situations: You may be required to report cases of MCI, gunshot wounds, animal bites, infectious diseases, and physical or sexual abuse.

Advance Directives

• DNR (Do Not Resuscitate): To be valid, a DNR must have the patient or legal guardian’s signature, a physician’s signature, and an expiration date. You must still provide supportive treatment like oxygen and pain management.

Documentation and Communication

Patient Care Report (PCR)

The PCR is a legal document. An undocumented action cannot be proven to have occurred.

• Information Included: Patient info, chief complaint, LOC, vitals, findings, treatment provided, and all relevant times.
• Correcting Errors: Draw a single line through the mistake, write the correct information, and add your initials. It is not necessary to retrieve the original report or file a report with a supervisor for a simple correction.
• SOAP Method: Subjective, Objective, Assessment, Patient Care.

Communication

• Dispatch Information: Collects the nature of the call, location, callback number, patient’s age, chief complaint, and number of patients.
• Radio Report to Hospital: Be concise. Include your unit ID, ETA, patient age/gender, chief complaint, brief history, key findings, treatment provided, and the patient’s response. Do NOT include detailed medical history or your personal opinion of the incident.
• Language Barriers: Use family members, friends, or a smartphone to translate. It is inappropriate to refuse care or ask a patient to sign a document in a language they do not understand.

Anatomical and Assessment Terminology

• Objective (Sign): A finding that can be seen, heard, felt, or measured (e.g., rash, bleeding, fever).
• Subjective (Symptom): Something the patient tells you (e.g., “I feel dizzy”).
• Directional Terms:
  • Proximal: Closer to the origin or point of attachment.
  • Distal: Farther from the origin or point of attachment.
  • Superior: Nearer to the head.
  • Inferior: Nearer to the feet.
  • Lateral: Farther from the midline.
  • Medial: Closer to the midline.
• Patient Positions:
  • Prone: Lying face down.
  • Supine: Lying face up.
  • Fowler’s Position: Semi reclining with the head elevated (45 to 60 degrees).
  • High Fowler’s Position: Sitting upright at 90 degrees.