Emergency Care CHAPTER. Operations THIRTEENTH EDITION. Emergency Care, 13e Daniel Limmer Michael F. O'Keefe

Transcription

1 Emergency Care THIRTEENTH EDITION CHAPTER 36 Operations

2 Topics Preparing for the Ambulance Call Receiving and Responding to a Call Transferring the Patient to the Ambulance Transporting the Patient to the Hospital continued on next slide

3 Topics Transferring the Patient to the Emergency Department Staff Terminating the Call Air Rescue

4 Preparing for the Ambulance Call

5 Preparing for the Call Four types of ambulances: Type I.

6 Preparing for the Call Four types of ambulances: Type II.

7 Preparing for the Call Four types of ambulances: Type III.

8 Preparing for the Call Four types of ambulances: medium duty.

9 Ambulance Supplies and Equipment An ambulance without proper equipment may have its agency cited and fined a considerable amount of money by a state EMS regulatory agency. Learn where each item is, what it is for, and when it should be used.

10 Ambulance Supplies and Equipment 4. Check the interior surfaces and upholstery.

11 Ensuring Ambulance Readiness for Service Make sure vehicle and equipment are ready for use at beginning of every shift

12 Ensuring Readiness for Service 1. Check the ambulance body, wheels, tires, and windshield wipers.

13 Ambulance Inspection, Engine Off Inspect the body of the vehicle. Report any damage that may be evident. Indicate past damage that has not been repaired. Inspect the wheels and tires. Check for damage or worn wheel rims and tire sidewalls. Check the tread depth. Use a pressure gauge. continued on next slide

14 Ambulance Inspection, Engine Off Inspect the windows and mirrors. Look for broken glass and loose or missing parts. See that mirrors are clean and properly adjusted for maximum visibility. Check the operation of every door and all latches and locks. continued on next slide

15 Ambulance Inspection, Engine Off Check the level of all fluids. Check the battery. Inspect the battery cable connections for tightness and signs of corrosion. Inspect the interior surfaces and upholstery for damage and cleanliness. Wipe down the steering wheel with disinfectant. continued on next slide

16 Ambulance Inspection, Engine Off Check the windows for operation and cleanliness. Test the horn, siren, and emergency lights Adjust the driver s seat and ensure the seat belts are operational. Check the fuel level. Refuel after each call whenever practical.

17 Ambulance Inspection, Engine Off 3. Check under the hood.

18 Ambulance Inspection, Engine On Check the dash-mounted indicators to see if any light remains on to indicate a possible problem with oil pressure, engine temperature, or the vehicle s electrical system. Check dash-mounted gauges for proper operation. Depress the brake pedal. Note pedal travel. Check air pressure as needed. continued on next slide

19 Ambulance Inspection, Engine On Test the parking brake. Move the transmission level to a drive position. Replace the level to the park position as soon as you are sure that the parking brake is holding. Turn the steering wheel from side to side. continued on next slide

20 Ambulance Inspection, Engine On Check the operation of the windshield wipers and washers. The glass should be wiped clean each time the blades move. Turn on the vehicle s warning lights. Have your partner walk around the ambulance and check each flashing and revolving light for operation. Turn off the warning lights. continued on next slide

21 Ambulance Inspection, Engine On Turn on the other vehicle lights. Have your partner walk around the ambulance again, this time checking the headlights (high and low), turn signals, four-way flashers, brake lights, side and rear scene illumination lights, and box marker lights. continued on next slide

22 Ambulance Inspection, Engine On Check the operation of the heating and air-conditioning equipment in both the driver s compartment and the patient compartment. Check the onboard suction. Operate the communications equipment. Test portable and fixed radios and any radio-telephone communications. continued on next slide

23 Ambulance Inspection, Engine On If your unit is equipped with a back-up camera, make sure that the camera is not damaged and is clean.

24 Inspection of Patient Compartment Supplies and Equipment Using your checklist, conduct a detailed inspection and inventory of the equipment and supplies. Check all items for completeness, condition, and operation. continued on next slide

25 Inspection of Patient Compartment Supplies and Equipment Check treatment supplies, interior equipment and exterior equipment. Check the pressure of oxygen cylinders. Inflate air splints and examine them for leaks. Test oxygen and ventilation equipment for proper operation. Examine rescue tools for rust and dirt. Operate battery-powered devices to ensure that the batteries have a proper charge. continued on next slide

26 Inspection of Patient Compartment Supplies and Equipment Some equipment, such as the AED, may require additional testing. See that an item-by-item inspection of everything carried on the ambulance is done, with findings recorded on the inspection report. continued on next slide

27 Inspection of Patient Compartment Supplies and Equipment Complete the inspection report. Correct any deficiencies. Replace missing items. Make your supervisor aware of any deficiencies that cannot be immediately corrected. Finally, clean the unit for infection control and appearance. Use only approved cleaning and disinfecting materials.

28 Think About It As I walk around the vehicle (engine-on and engine-off check), what information do I get from what I hear, see, and smell?

29 Receiving and Responding to a Call

30 Role of the Emergency Medical Dispatcher Ask questions of caller and assign priority to call Provide prearrival medical instructions to callers and information to crews Dispatch and coordinate EMS resources Coordinate with other public safety agencies continued on next slide

31 Role of the Emergency Medical Questions Dispatcher What is the exact location of the patient? What is your call-back number? What s the problem? How old is the patient? What s the patient s sex? Is the patient conscious? Is the patient breathing?

32 Operating the Ambulance Being a safe ambulance operator Be physically and mentally fit. Be able to perform under stress. Have a positive attitude about your ability as a driver but not be an overly confident risk taker. Be tolerant of other drivers. Never drive while under the influence of any substance.

33 Operating the Ambulance Being a safe ambulance operator Never drive while taking prescription medications that can impair your ability to operate a motor vehicle. Never drive with a restricted license. Always wear your glasses or contact lenses if required for driving. Evaluate your ability to drive based on personal stress, illness, and fatigue. continued on next slide

34 Operating the Ambulance Understanding the law An ambulance operator must have a valid driver s license and may be required to complete a training program. Privileges granted under the law to the operators of ambulances apply when the vehicle is responding to an emergency. Not applicable if not on call continued on next slide

35 Operating the Ambulance Understanding the law Even though certain privileges are granted during an emergency, the exemptions granted do not provide immunity to the driver. Privileges granted during emergency situations apply only if the operator uses warning devices in the manner prescribed by law. continued on next slide

36 Operating the Ambulance Understanding the law Most statutes allow: Parking wherever necessary as long as life and property are not endangered Proceeding past stop signs/signals Exceeding the posted speed limit as long as life and property are not endangered Passing other vehicles in no-passing zones after properly signaling and taking precautions continued on next slide

37 Operating the Ambulance Understanding the law Most statutes allow: Disregard for regulations that govern direction of travel and turning in specific directions with proper caution and signals Laws interpreted by the court based on: Using due regard for safety of others Whether to the best of your knowledge, the situation was a true emergency continued on next slide

38 Operating the Ambulance Using the warning devices The siren Never use it indiscriminately. The horn Visual warning devices Day or night Vehicle should be easily seen from 360 degrees in emergency response mode. continued on next slide

39 Operating the Ambulance Speed and safety Excessive speed increases the probability of a collision. Speed increases stopping distance, reducing the chance of avoiding a hazardous situation. continued on next slide

40 Operating the Ambulance Escorted or multiple-vehicle responses Inexperienced ambulance operator often follows the escort vehicle too closely and is unable to stop when the lead vehicle makes an emergency stop. Recommendation of no escorts unless absolutely necessary Greater care must be used. continued on next slide

41 Operating the Ambulance Factors that affect response Day of the week Time of day Weather Road maintenance and construction Railroads Bridges and tunnels Schools and school buses continued on next slide

42 Operating the Ambulance Navigating to the scene Global positioning satellite (GPS) navigation often installed No substitute for an intimate knowledge of the response area. May become a distraction Obtain detailed maps of your service area. continued on next slide

43 Operating the Ambulance Response safety summary Minimize lights-and-siren hot responses. Driving with lights and siren involves high risk. Wear your seat belts. Know where you are going before you respond. Use the GPS and check the maps. Be familiar with your response area. continued on next slide

44 Operating the Ambulance Response safety summary Come to a complete stop at intersections. Don t be a distracted driver. Have the crew leader operate the radio, siren, GPS, computer, and other devices. Pay complete attention to safe driving. continued on next slide

45 Operating the Ambulance Safety at highway incidents Keep unnecessary units and people off the highway Avoid crossovers unless a turn can be completed without obstructing traffic If yours is the first unit on scene Park apparatus "upstream" from incident continued on next slide

46 Operating the Ambulance Safety at highway incidents Wear Your PPE Place cones/flares and reduce Emergency lighting Unit placement is important! Backing up Avoid backing up, if possible, especially during emergencies.

47 Transferring the Patient to the Ambulance

48 Transferring the Patient to the Ambulance 1. Select proper patient-carrying device 2. Package patient for transfer 3. Move patient to ambulance 4. Load patient into ambulance

49 Four Steps of Transferring This patient is packaged for cold, wet conditions.

50 Transferring the Patient to the Ambulance Packaging the patient Readying patient to be moved and combining patient and patient-carrying device as unit ready for transfer Sick or injured patient must be packaged so that condition is not aggravated. continued on next slide

51 Transferring the Patient to the Ambulance Packaging the patient Before placing patient on carrying device Complete necessary care for wounds, other injuries. Stabilize impaled objects. Check dressings and splints. Cover patient and secure to patientcarrying device. continued on next slide

52 Transferring the Patient to the Ambulance Protecting the patient Must be secured to patient-carrying device Minimum of three straps to secure Chest level Waist level Lower extremities Use shoulder harness if available. continued on next slide

53 Transferring the Patient to the Protecting the EMT Ambulance EMT at greater risk in patient compartment Make sure all equipment is secured. Remain seated. Wear seat belt and harness if possible. Avoid unnecessary movement during response and transport.

54 Transporting the Patient to the Hospital

55 Preparing the Patient for Transport Continue assessment. Secure stretcher in place in ambulance. Position and secure patient. Adjust security straps. Prepare for respiratory and cardiac complications. continued on next slide

56 Preparing the Patient for Transport Loosen constricting clothing. Load relative or friend who must accompany patient. Load personal effects. Talk to your patient. Avoid letting patients sit on bench or airway seat.

57 Caring for the Patient en Route Notify the hospital. Continue to provide emergency care as required. Use safe practices during transport. Compile additional patient information. Continue assessment and monitor vital signs. Notify the receiving facility.

58 Pediatric Note The entire scene may create a terrifying experience for a child. A toy such as a teddy bear can do much to calm a frightened child. The presence of a female EMT or police officer may be helpful. Small children do not, as a rule, carry identification.

59 Transferring the Patient to the Emergency Department Staff

60 Transferring the Patient to the Emergency Department Staff If routine admission situation or when an illness or injury is not life threatening injury, check first to see what is to be done with patient. Assist emergency department staff as required, and provide a verbal report. continued on next slide

61 Transferring the Patient to the Emergency Department Staff As soon as you are free from patientcare activities, prepare the prehospital care report. Transfer the patient's personal effects. Obtain your release from the hospital.

62 Terminating the Call

63 At the Hospital Quickly clean the patient compartment while taking appropriate Standard Precautions. Prepare respiratory equipment for service. Replace expendable items. Exchange equipment according to your local policy. Make up the ambulance cot.

64 Terminating the Call: At the Hospital 1. A low-level disinfectant approved by the U.S. Environmental Protection Agency (for example, a commercial product such as Lysol) will clean and kill germs on ambulance floors and walls.

65 En Route to Quarters Radio the EMD. Air the ambulance if necessary. Refuel the ambulance.

66 Terminating the Call: En Route to Quarters 6. Replace expendable items as required.

67 In Quarters Place badly contaminated linens in a biohazard container and noncontaminated linens in a regular hamper. As necessary, clean any equipment that touched the patient. Clean and disinfect used nondisposable respiratory-assist and inhalation therapy equipment. continued on next slide

68 In Quarters Clean and sanitize the patient compartment. Prepare yourself for service. Replace expendable items. Replace or refill oxygen cylinders. Replace patient-care equipment. continued on next slide

69 In Quarters Carry out postoperation vehicle maintenance procedures as required. Clean the vehicle. Complete your paperwork.

70 Air Rescue

71 When to Call for Air Rescue Operational reasons To speed transport to distant trauma center When extrication of high-priority patient is prolonged and air rescue can speed transport When patient must be rescued from remote location

72 When to Call for Air Rescue Patients are sometimes transported by air rescue helicopter.

73 When to Call for Air Rescue Clinical reasons Patient in shock Glasgow Coma Scale total less than 10 Head injury with altered mental status Chest trauma and respiratory distress Penetrating injuries to body cavity continued on next slide

74 When to Call for Air Rescue Clinical reasons Amputation proximal to hand or foot Extensive burns Serious mechanism of injury Patient is post cardiac arrest with a pulse.

75 How to Call for Air Rescue Name and call-back number Agency name Nature of situation Exact location Crossroads, major landmarks Exact location and description of landing zone If possible, GPS coordinates

76 How to Set up a Landing Zone Describe the landing zone to the air rescue service. Terrain Major landmarks Estimated distance to nearest town Other pertinent information Such as wires, ditches, or wind

77 Landing Zone Helicopter landing zone.

78 Landing Zone (A) The area around the tail rotor is extremely dangerous. A spinning rotor cannot be seen.

79 How to Approach a Helicopter Do not approach unless escorted by flight personnel. Allow the crew to direct loading of the patient. Stay clear of tail rotor at all times. Keep all traffic and vehicles at least 100 feet from the helicopter. Do not smoke near the aircraft. Be aware of danger areas.

80 Chapter Review

81 Chapter Review Inspect the vehicle to assure that it is complete and that critical items can be easily located. A "hot" response means using lights and siren. Hot responses involve high risk. A "cold" response means no lights or sirens. Cold responses decrease risk. continued on next slide

82 Chapter Review The laws in most states allow the driver of an emergency vehicle running "hot" to break some of the vehicle and traffic laws. However, it must be done with due regard for the safety of others. Pay attention to driving! Do not text, make phone calls, drink beverages, or be in any way distracted while driving. continued on next slide

83 Chapter Review Secure all gear. It can become a projectile in a crash! Do not let your patient become a projectile. Use the stretcher shoulder straps. continued on next slide

84 Chapter Review Wear your seat belt in front and back (whenever possible). Know the medical and operational reasons for helicopter transport and know how to set up a safe landing zone.

85 Remember Ambulances must be properly stocked and prepared. Pre-call inspections assure readiness and appropriate equipment. Emergency Medical Dispatchers enhance patient care by providing prearrival instructions and by obtaining information for responders. continued on next slide

86 Remember Each state has statutes regulating operation of emergency vehicles. EMTs must be familiar with local rules and regulations. EMTs should use good judgment and due regard for safety of others when operating an ambulance. continued on next slide

87 Remember The four steps involved in transferring the patient to the ambulance are selecting proper patient-carrying device, packaging patient for transfer, moving patient to ambulance, and loading patient into ambulance. continued on next slide

88 Remember Patients should be safely secured prior to the ambulance's moving. Assessment and care must continue during transport. The primary concern of transfer of care is continuation of patient care. Failure to do so properly can be considered abandonment. continued on next slide

89 Remember Cleaning the ambulance, replacing used supplies and equipment, and readying the ambulance stretcher are important elements the EMT must complete while terminating a call. However, EMTs should be prepared for unusual circumstances. continued on next slide

90 Remember Indications for utilizing air rescue may include both operational and medical reasons. EMTs should be familiar with local protocols for accessing and utilizing air rescue transport.

91 Questions to Consider Does the patient have a true emergency adversely affected by time? How can I park to best protect the scene and personnel? Does my personal protective equipment "match" what is being worn by others?

92 Critical Thinking What equipment should you include in a kit that you carry to the scene? How should the equipment be positioned so that you can reach urgently needed items quickly? What special items, if any, should be in the kit to meet local needs?

93 Emergency Care THIRTEENTH EDITION CHAPTER 37 Hazardous Materials, Multiple-Casualty Incidents, and Incident Management

94 Topics Hazardous Materials Multiple-Casualty Incidents

95 Hazardous Materials

96 Hazardous Materials "Any substance or material in a form which poses an unreasonable risk to health, safety, and property when transported in commerce." U.S. Department of Transportation (DOT)

97 Training Required by Law First Responder Awareness No minimum First Responder Operations 8 hours Hazardous Materials Technician 24 hours Hazardous Materials Specialist 24 additional hours

98 Responsibilities of the EMT Recognize a hazmat incident Incidents involving common carriers, trucking terminals, chemical plants or places where chemicals are used, delivery trucks, agriculture and garden centers, railway incidents, and laboratories. All patients leaving the site should be considered contaminated until proven otherwise. continued on next slide

99 Responsibilities of the EMT Control the scene Establish the danger zone. Hot zone Area of contamination or danger Warm zone Area immediately adjacent to hot zone continued on next slide

100 Responsibilities of the EMT Control the scene Establish the danger zone. Cold zone Area immediately adjacent to warm zone Where equipment and emergency rescuers are staged continued on next slide

101 Responsibilities of the EMT Control the scene Establish the safe zone. Identify the substance You must make an attempt to assess the material and severity.

102 Identify Hazardous Material Identify the substance Ways to obtain information safely Use binoculars to look for identifying signs, labels, or placards from a safe distance. Search for placards. Look for labels. Check invoices, bills of lading (trucks), and shipping manifests (trains). continued on next slide continued on next slide

103 Identify Hazardous Material Identify the substance Ways to obtain information safely Review safety data sheets (SDS). Interview workers or others leaving the hot zone. Get expert advice about next actions Emergency Response Guidebook Chemical Transportation Emergency Center (CHEMTREC) continued on next slide

104 Identify Hazardous Material Identify the substance Get expert advice about next actions CHEM-TEL, Inc. A current list of state and federal radiation authorities Regional poison control centers Be sure to leave thorough information about the scene, call-back, container, conditions, location, quantity, and injuries and exposures.

105 Identify Hazardous Material Have the latest edition of the Emergency Response Guidebook in your vehicle at all times.

106 Establish a Treatment Area Rehabilitation operations Located in the cold zone Protected from weather Large enough to accommodate multiple rescue crews Easily accessible to EMS units Free from exhaust fumes Allows for rapid reentry into the emergency operation continued on next slide

107 Establish a Treatment Area Care of injured and contaminated patients Decontaminate in warm zone Treat in cold zone Field-decontaminated patients are not completely "clean." Personal protective equipment or clothing (PPE/PPC) is needed to prevent secondary contamination of rescuers. continued on next slide

108 Establish a Treatment Area Care of injured and contaminated patients Protect vehicles from contamination. Consider used equipment as disposable. Structural firefighting clothing is not designed or recommended for use when working in hazardous material environments. continued on next slide

109 Establish a Treatment Area Care of injured and contaminated patients Four types of patients Uninjured and not contaminated Injured and not contaminated Uninjured and contaminated Injured and contaminated continued on next slide

110 Establish a Treatment Area Care of injured and contaminated patients Take precautions appropriate to the substance as listed in the Emergency Response Guidebook. Follow the first-aid measures listed in the Emergency Response Guidebook. Manage the patient's critical needs. Do not forget to manage the ABCs. continued on next slide

111 Establish a Treatment Area Care of injured and contaminated patients If treatment calls for irrigation with water, remember that water only dilutes most substances; it does not neutralize them. After treating the patient, decontaminate yourself. Your clothing may need disposal. continued on next slide

112 Establish a Treatment Area Phases of decontamination Gross decontamination Chemical or majority of contaminant Secondary decontamination Residual product contamination More thorough continued on next slide

113 Establish a Treatment Area Mechanisms for decontamination Emulsification Chemical reaction Disinfection Dilution Absorption or adsorption Removal Disposal continued on next slide

114 Establish a Treatment Area Decontamination procedures Objectives Determine the appropriate level of protective equipment based on materials and associated hazards Properly wear and operate in PPE Establish operating time log Set up, operate decontamination line Prioritize the decontamination of patients according to a triage system continued on next slide

115 Establish a Treatment Area Decontamination procedures Objectives Perform triage in PPE Be able to communicate while in PPE Basic list of equipment Buckets Brushes Decontamination solution Decontamination tubs continued on next slide

116 Establish a Treatment Area Decontamination procedures Basic list of equipment Dedicated water supply Tarps or plastic sheeting Containment vessel for water runoff Pump to transfer wastewater from decontamination tubs to a containment vessel continued on next slide

117 Establish a Treatment Area Decontamination procedures Basic list of equipment A-frame ladder Appropriate-level PPE for responders performing decontamination Decontamination for patients wearing PPE Rinse, starting at head and working down. continued on next slide

118 Establish a Treatment Area Decontamination procedures Decontamination for patients wearing PPE Scrub suit with brush, starting at head and working down. Rinse again, starting at head and working down. Assist responder in removing PPE. Contain runoff of hazardous wastewater. continued on next slide

119 Establish a Treatment Area Decontamination procedures Decontamination for patients not wearing PPE First consideration is for responder safety. Use public address system to direct ambulatory patient to decontamination line. Patients remove clothes and contact lenses. continued on next slide

120 Establish a Treatment Area Decontamination procedures Decontamination for patients not wearing PPE Double-bag clothing. Receive 2- to 5-minute water rinse, starting at the head. Provide patient cover for modesty.

121 Multiple-Casualty Incidents

122 Multiple-Casualty Incidents Multiple-casualty incidents may range from small to large. In this bus crash, all passengers were triaged and forty-four patients were transported to area hospitals. Mark C. Ide/CMSP

123 Multiple-Casualty-Incident Operations Know local disaster plan Written to address events conceivable for particular location Well publicized Realistic Rehearsed

124 Incident Command System National Incident Management System (NIMS) Command Operations Logistics Planning Finance Single incident or unified continued on next slide

125 Incident Command System Command functions Incident Command assumed by most senior member of first service on scene Options once reinforcements arrive Continue to be in Command Transfer Command to someone of higher rank Modes of action Scene size-up/triage Organization/delegation continued on next slide

126 Incident Command System Scene size-up Arrive at scene and establish Incident Command. Do a quick walk through the scene to assess number of patients, hazards, and degree of entrapment. Get as calm and composed as possible to radio in an initial scene report and call for additional resources. continued on next slide

127 Incident Command System Communications On arrival, give brief report and request necessary resources. Incident Commander only person to converse with communications center, disseminates information to others Have face-to-face conversations among command staff whenever possible. continued on next slide

128 Incident Command System Organization Early and aggressive organization vital Have a plan to deploy resources. Think about supply and staging areas. Think big. Order big. Prevent "freelancing." Have some personal tools, such as a "tactical worksheet." continued on next slide

129 Incident Command System EMS branch functions Mobile command center Extrication Staging area Triage area Treatment area Transportation area Rehabilitation area

130 Triage Goal Afford greatest number of people greatest chance of survival Most knowledgeable EMS provider becomes the triage supervisor. continued on next slide

131 Primary Triage Priority 1 Treatable life-threatening illnesses or injuries Priority 2 Serious but not life-threatening illnesses or injuries continued on next slide

132 Primary Triage Priority 3 "Walking wounded" Priority 4 (sometimes called Priority 0) Dead or fatally injured

133 START Triage: A National Standard for Rapid Primary Triage Simple triage and rapid treatment Foundation of system is speed, simplicity, consistency of application Simple commands to patients Patient evaluation based on RPM Respiration Pulse Mental status continued on next slide

134 START Triage: A National Standard for Rapid Primary Triage Able to walk? Yes Priority 3 No Check respirations continued on next slide

135 START Triage: A National Standard for Rapid Primary Triage Only three treatments provided during START triage Open an airway and insert an oropharyngeal airway. Apply pressure to bleeding. Elevate an extremity. continued on next slide

136 START Triage: A National Standard for Rapid Primary Triage Assess respiration (breathing status) first. Yes and >30/minute Priority 1 Yes and <30/minute Check pulse continued on next slide

137 START Triage: A National Standard for Rapid Primary Triage Assess respiration (breathing status) first. No Position airway; recheck respirations Not breathing and attempts to open airway do not start breathing Priority 0 continued on next slide

138 START Triage: A National Standard for Rapid Primary Triage Assess radial pulse second. Unresponsive, not breathing, no pulse Priority 0 Breathing, no apparent pulse Priority 1 Breathing, pulse, good skin signs, capillary refill Check mental status continued on next slide

139 START Triage: A National Standard for Rapid Primary Triage Assess level of consciousness (mental status) third. Alert Priority 2 Altered mental status Priority 1

140 START Triage: A National Standard for Rapid Primary Triage Now retriage the Priority 3 walking wounded patients. Respiration Pulse Mental status

141 Patient Identification Color code patients with a triage tag. Priority 1 Red Priority 2 Yellow Priority 3 Green Priority 4 Black

142 Secondary Triage and Treatment Secondary triage is performed at a patient collection point or triage area. Patients are separated into treatment groups based on their priority level. Each treatment area should have its own treatment supervisor. It may be necessary to recategorize a patient whose condition has deteriorated or improved.

143 Transportation and Staging Logistics Once assessed, triaged, and treated, patients are transported according to priority. Ambulances in staging area in designated area to await direction and patients continued on next slide

144 Transportation and Staging Staging supervisor Logistics Transportation supervisor Overwhelming a hospital's surge capacity could bring about poor outcomes.

145 Communicating with Hospitals Receiving facilities contacted early to determine capabilities and update on expected patient counts Transportation officer, not individual EMTs, should communicate. Generally too many patients to allow a good radio report Only basic information given

146 Psychological Aspects of MCIs Caring, honest demeanor can reassure patient. Do not attempt to psychoanalyze a person's distress. "Psychological first aid" may be necessary on the scene of MCI.

147 Think About It If you are the first rescue vehicle to reach the scene of an MCI, what should you do?

148 Chapter Review

149 Chapter Review Maintain a high index of suspicion and awareness. Many hazmat incidents start out as routine EMS calls. The biggest problem in most hazmat incidents in identifying the offending substance. Look for the shopping placard and the SDS. Use the Emergency Response Guide to help determine your initial actions. continued on next slide

150 Chapter Review Remember the hot zone warm zone cold zone. Once you realize it's a hazmat incident, get to the cold zone and call for help. Keep responders in rehab until they are rested, hydrated, and vitals return to normal. continued on next slide

151 Chapter Review Patients who have been "decontaminated" almost always still have some contamination. Patients being transported must be cared for by competent EMS responders with Operations-level training and equipment. continued on next slide

152 Chapter Review Use your MCI plan and procedure at small incidents, as this will make managing larger ones will be easier. NIMS and Incident Management are the national standard for incident management. continued on next slide

153 Chapter Review Learn and practice START triage essentials. Be alert for signs of stress after incidents, and seek help as necessary.

154 Remember A hazardous materials response requires specialized training and resources. Common responsibilities of initial responders must be identification of the incident, scene control, and activation of appropriate resources. continued on next slide

155 Remember Scene safety is highest priority; when possible, use scene clues, product information, and specific resources to identify hazardous materials. Decontamination prevents the spread of a hazardous material. EMTs are commonly involved in various levels of this process. continued on next slide

156 Remember Multiple-casualty incident overwhelms resources of responding units. When this occurs, organization is the most important priority. NIMS and its incident command system provide organization resources and structure to improve management of large-scale incidents. continued on next slide

157 Remember Triage allows EMTs to prioritize care and transport of patients when resources are limited.

158 Questions to Consider What is the hazardous substance? What risk does it pose? If a patient has some contamination, can we safely start decontamination? Should I start using triage tags?

159 Critical Thinking Your call is to a motor-vehicle collision with an unknown number of injuries. As your unit approaches the scene, you see that three cars and downed wires are involved. You get a whiff of gasoline as you pass by. continued on next slide

160 Critical Thinking The drivers are visible in each vehicle one appears to be conscious and the other two are bent forward or slumped back. There are passengers visible in two vehicles, one or more of whom may need extrication. How should you proceed?

161 Emergency Care THIRTEENTH EDITION CHAPTER 38 Highway Safety and Vehicle Extrication

162 Multimedia Directory Slide 50 Rapid Extrication Video

163 Topics Highway Emergency Operations Vehicle Extrication

164 Highway Emergency Operations

165 Highway Emergency Operations Oncoming traffic at highway incidents is one of the greatest hazards emergency responders face today. Responding agencies and personnel need to be cognizant of their responsibilities in these types of hazardous environment. continued on next slide

166 Highway Emergency Operations EMS response should be limited to only the manpower and vehicles needed to accomplish the mission. The first-arriving unit should institute "blocking" to protect the work area. Preferably fire apparatus If it is necessary to block lanes of traffic, clear them quickly as possible so flow of traffic can return to normal.

167 Highway Emergency Operations A vehicle collision where extrication of the patient is required is the most common type of rescue across the United States. Edward T. Dickinson, MD

168 Initial Response Limited access highways Only primary or first-due units should proceed directly to scene. On-scene units Park single file in same direction to minimize on-scene congestion. continued on next slide

169 Initial Response First-arriving units should: Establish Command and confirm exact location of incident with dispatch center. Use apparatus to institute "upstream blocking" to protect work area. Rescue trucks arriving to perform extrication should be positioned downstream of initial blocking vehicle.

170 Position Blocking Apparatus Create one and a half to two lanes of blockage. Position apparatus at angle with front wheels rotated away from incident.

171 Position Blocking Apparatus Positioning the other apparatus Leave space immediately next to crash for vehicle extrication units. Position ambulances, command vehicles, and other units downstream from crash. Allows safer patient loading and rapid departure from scene

172 Exiting the Vehicle Safety Responders should always exit into the safe zone, if possible, after checking to be sure traffic has stopped. Be alert for oncoming traffic.

173 Be Seen and Warn Oncoming Traffic Place flares or traffic cones to slow traffic and channel away from incident lane. Night operation Shut off vehicle's headlights and white response lights

174 Night Operations Shut off vehicle's headlights and white response lights. Best combination of lights to provide maximum visibility Red/amber warning lights on Headlights off Fog lights off Traffic directional boards operating

175 Think About It Is it safe to enter the highway scene? Which units are necessary?

176 Vehicle Extrication

177 Vehicle Extrication Phases Preparing for rescue Sizing up the situation Recognizing and managing hazards Stabilizing vehicle prior to entering Gaining access to patient continued on next slide

178 Vehicle Extrication Phases Providing primary patient assessment and rapid trauma assessment Disentangling patient Immobilizing and extricating patient from the vehicle Providing assessment, care, and transport to most appropriate hospital Terminating the rescue

179 Preparing for Rescue Combination of training, practice, and the right protective gear and tools Availability of training will depend on the kinds of rescues most likely to be required in your area.

180 Sizing Up the Situation Conduct a good size-up to evaluate hazards and address need for additional resources. How many patients are involved, their priority, and MOI? Are additional ambulances needed? What is extent of patient's entrapment?

181 Think About It What does scene size-up tell me about the need for extrication?

182 Recognizing and Managing Hazards Protective gear for EMS responders At a crash any personnel working in the "inner circle" should wear full protective gear to avoid being injured. If your service does not provide protective gear, then get your own. Use your protective gear! continued on next slide

183 Recognizing and Managing Hazards Protective gear for EMS responders Working in traffic Wear helmet. Wear safety vests to enhance visibility. Wear ANSI safety vests when working in highway operations per federal highway standards. continued on next slide

184 Recognizing and Managing Hazards Protective gear for EMS responders During extrication operations Increased risk of exposure to flame, glass, fluids, and sharp objectives Best practice to wear EMS or firefighter turnout clothing including helmet and eye protection Matching the level others are wearing Look at other workers in the industry. continued on next slide

185 Recognizing and Managing Hazards Protective gear for EMS responders Helmets Eye protection Hand protection Body protection

186 Protective Gear for EMS Responders Complex access involves the use of tools and equipment to reach and extricate the patient. Edward T. Dickinson, MD

187 Safeguarding Your Patient To protect your patient, you should have: Aluminized rescue blanket Lightweight vinyl-coated paper tarpaulin Wool blanket Short and long spine boards continued on next slide

188 Safeguarding Your Patient To protect your patient, you should have: Hard hats, safety goggles, industrial hearing protectors, disposable dust masks, and thermal masks Emotional support for the patient

189 Managing Traffic Use ambulance and its warning lights as first form of traffic control Position other warning devices as soon as possible Using flares for traffic control Look for and avoid spilled fuel, dry vegetation, other combustibles, especially at a road edge. Do not throw out of moving vehicles.

190 Supplemental Restraint Systems: Air Bags Air bags designed to inflate on impact, dissipate kinetic energy, minimize trauma to body Creates "smoke" in vehicle Cornstarch and talcum powder (and sometimes sodium hydroxide) Watch for an air bag that remains undeployed after a crash.

191 Energy-Absorbing Bumpers If the bumpers were involved in the collision, you may notice that the bumper's shock absorber system is compressed, or "loaded." Never stand in front of a loaded bumper. Diagonal or perpendicular instead Chain the shock absorber to prevent an uncontrolled release.

192 Spectators May interfere with rescue and emergency care efforts in addition to traffic. If policies permit, ask responsiblelooking bystanders to keep spectators away. Give barricade tape. Do not put in unsafe positions. You may be held liable in adverse event.

193 Electrical Hazards High voltage lines common Assume entire area around exposed wire dangerous. Conductors may have touched and energized. Ordinary protective clothing gives no protection against electrocution. continued on next slide

194 Electrical Hazards Broken utility pole with wires down Very dangerous Set up a large safety zone and discourage occupants of collision from leaving the wreckage. Determine the number of the nearest pole you can safely approach, and ask your dispatcher to advise the power company of the pole number and its location. continued on next slide

195 Electrical Hazards Broken utility pole with wires down Do not attempt to move downed wires. Stand in a safe place until power company disconnects the power or cuts the wire. Broken utility pole with wires intact Park the ambulance outside the danger zone. Notify your dispatcher of the situation. continued on next slide

196 Electrical Hazards Broken utility pole with wires intact Stay outside the danger zone until power company representatives can deenergize the conductors and stabilize the pole. Keep spectators and other emergency service personnel out of the danger zone. continued on next slide

197 Electrical Hazards Damaged pad-mounted transformer Request an immediate power company response. Do not touch either the transformer case or a vehicle touching it. Warn other emergency personnel. Stand in a safe place until the power company de-energizes it. Keep spectators out of the danger zone.

198 Vehicle Fires Small fires 15- or 20-pound class A:B:C dry chemical fire extinguisher extinguishes almost anything burning. Fire in the engine compartment Do not attempt extinguishment unless hood fully open.

199 Vehicle Fires Extinguishing a fire in the engine compartment when the hood is fully open.

200 Vehicle Fires Fire in the passenger compartment or trunk Apply extinguisher sparingly until occupants can be freed. If in trunk, apply same principles as engine compartment fire. Fire under the vehicle Sweep from under the passenger compartment continued on next slide

201 Vehicle Fires Truck fires A:B:C extinguisher Burning truck tires are especially dangerous. Never stand directly in front of one. Flames can spread to cargo or the tires can explode.

202 Disabling a Vehicle's Electrical System Remember that many cars have electrically powered door locks, window operators, and seat adjustment mechanisms. Disconnect the negative cable from the battery.

203 Stabilizing a Vehicle Vehicle on its wheels Turn off engine. Step-chock three sides.

204 Stabilizing a Vehicle Stabilizing a car on its wheels with cribbing while patient contact is initiated.

205 Stabilizing a Vehicle Vehicle on its side Stabilize with ropes, cribbing, or stabilizer bars. Vehicle on its roof Utilize 4 4 wood blocks to build crib box.

206 Stabilizing a Vehicle A vehicle on its side stabilized with struts. For maximum stability, it may be best to place cribbing on one side, struts on the other.

207 Gaining Access Simple access Check if door or window can be opened. "Try before you pry." Complex access Utilize tools and equipment. Break glass in side or rear window as far from passengers as possible.

208 Disentanglement: A Three-Part Action Plan Steps one and two: gain access by disposing of doors and the roof Makes vehicle interior accessible Creates large exit Provides fresh air and helps cool heated patient Quick access to critical patient can improve survivability and perhaps decrease morbidity continued on next slide

209 Disentanglement: A Three-Part Action Plan Step three: disentangle occupants by displacing the front end Easily accomplished with heavy duty jacks and hacksaws Do not cut steering column or airbag wiring; may cause unexpected firing.

210 Rapid Extrication Video Click on the screenshot to view a video on rapidly extricating patients from a vehicle. Back to Directory

211 Chapter Review

212 Chapter Review Remember, highway operations are high risk. Take these precautions: Wear high-visibility garments. Position the ambulance for blocking until fire apparatus arrives. Then positions ambulances "downstream" in the safe zone. continued on next slide

213 Chapter Review Remember, highway operations are high risk. Take these precautions: Reduce lighting that may blind passing drivers. Avoid crossing traffic lanes with patients. continued on next slide

214 Chapter Review Scene size-up is key. How many patients are there? What is the triage status? Are additional resources needed? Protect yourself. Look out for: Traffic Undeployed airbags Loaded bumpers Sharp metal continued on next slide

215 Chapter Review Match the level of PPE being worn by other public safety responders. Ensure scene safety: If wires are down, keep spectators back. Make sure the vehicle is stable. First try simple means to gain access. Protect your patient during the extrication process.

216 Remember Highway response is a significant safety hazard for EMTs. Specific safety planning and procedures must be utilized to keep responders safe. Responding units should evaluate need for further units, institute "blocking" to protect work area, and always exit apparatus into safe zone. continued on next slide

217 Remember Use protective equipment and warning devices. Vehicle extrication often requires specialized training and resources. Know local resources and procedure for activating those resources. continued on next slide

218 Remember Determine extrication resources needed and patient extrication priority through thorough scene size-up. Extrication can pose a variety of threats. Evaluate the scene carefully and employ safety procedures. continued on next slide

219 Remember Gaining access to patients frequently requires mechanical and technological assistance. Always start simply and escalate only when simple measures fail.

220 Questions to Consider What is the best access for my unit? Where should I park the apparatus? Does the vehicle need to be stabilized?

221 Critical Thinking The highway crash you are dispatched to is a seven-car pile-up. Your unit is first on the scene. What steps are required that are different from those for a crash involving one car striking a tree?

222 Emergency Care THIRTEENTH EDITION CHAPTER 39 EMS Response to Terrorism

223 Topics Defining Terrorism Terrorism and EMS Time/Distance/Shielding Responses to Terrorism Dissemination and Weaponization Characteristics of CBRNE Agents Strategy and Tactics Self-Protection at a Terrorist Incident

224 Defining Terrorism

225 Defining Terrorism The bombing of the Boston Marathon in 2013 was perpetrated by two young men who may have become radicalized partly via the Internet. AP Images/Charles Krupa

226 Defining Terrorism "The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segments thereof, in furtherance of political or social objectives" The U.S. Department of Justice, Federal Bureau of Investigation

227 Domestic Terrorism Groups or individuals whose terrorist activities are directed at a government or population, without foreign direction Environmental terrorists Antigovernment militias Racial-hate groups Groups with extreme political, religious, or other philosophies or beliefs

228 International Terrorism Groups or individuals whose terrorist activities are foreign based and/or directed by countries or groups outside the targeted country or whose activities cross national borders. Growing trend toward loosely organized, international networks of terrorists

229 Types of Terrorism Incidents Incidents of terrorism may involve CBRNE agents. Chemical Biological Radiological Nuclear Explosive Also called weapons of mass destruction (WMD)

230 Terrorism and EMS

231 Terrorism and EMS The Twin Towers of the World Trade Center in New York City were destroyed and thousands were killed on September 11, 2001, when terrorists flew hijacked jetliners into the famous skyscrapers. AP Images/Shawn Baldwin

232 Emergency Medical Responders as Targets Emergency Medical Responders are often principal targets of terrorist attacks. Safety of EMS provider is most important consideration when responding to potential terrorist incident.

233 Identify the Threat Posed by Event Incident that is a potential act of terrorism is also a crime scene. Recognizing OTTO signs may help protect against secondary attack. Occupancy or location Type of event Timing of event On-scene warning signs

234 Occupancy or Location Symbolic or historic targets Public buildings or assembly areas Controversial businesses Infrastructure systems

235 Type of Event Explosions and/or incendiaries Incidents involving firearms Nontrauma mass-casualty incidents

236 Timing of Event National holidays Anniversary dates of previous attacks April 19 Incidents occurring in major public areas at busy points of business day

237 On-Scene Warning Signs Unexplained patterns of illness or death Unexplained signs and symptoms or skin, eye, or airway irritation Containers that appear out of place

238 Recognize the Harms Posed TRACEM-P harms Thermal harm by the Threat Caused by either extreme heat or extreme cold Radiological harm From alpha particles, beta particles, or gamma rays, generally produced by nuclear events continued on next slide

239 Recognize Harms Posed by Threat TRACEM-P harms Asphyxiation Caused by lack of oxygen in atmosphere Chemical harm Caused by toxic or corrosive materials Etiological harm Caused by disease continued on next slide

240 Recognize Harms Posed by Threat TRACEM-P harms Mechanical harm Caused by physical trauma (gunshot, bomb fragments) Psychological harm Results from any violent event

241 Think About It How can I tell if I am responding to a terrorist incident?

242 Time/Distance/Shielding

243 Time/Distance/Shielding Time Minimize time in dangerous area or exposed to hazardous material, biological agent, or radiation. Execute rapid entries to perform reconnaissance or rescue. continued on next slide

244 Time/Distance/Shielding Distance Maximize distance from hazard area or projected hazard area. Follow recommended guidelines regarding hazardous materials in Emergency Response Guidebook. continued on next slide

245 Time/Distance/Shielding Shielding Use appropriate shielding for specific hazards. Can be vehicles, buildings, fireprotection clothing, hazmat suits, positive-pressure self-contained breathing apparatus, PPE Vaccinations against specific diseases

246 Responses to Terrorism

247 Responses to a Chemical Incident Includes many classes of hazardous materials Can be inhaled, ingested, absorbed, injected Can include industrial chemical or warfare-type agents

248 Types of Harm from Chemical Incidents Thermal harm Reactions create heat Asphyxiation harm Reactions deplete oxygen Chemical harm Systemic effects continued on next slide

249 Types of Harm from Chemical Mechanical harm Incidents Corrosive chemicals weaken structures Psychological harm Secondary and either at the scene or some time after the event

250 Self-Protection Measures at a Chemical Incident Respiratory protection Protective clothing Be aware of possible contamination from patients.

251 Responses to a Biological Incident Presents as focused emergency or public health emergency Focused emergency Potential or actual point of origin located Attempts made to prevent or minimize damage and spread Public health emergency Sudden demand upon public health infrastructure with no apparent explanation continued on next slide

252 Responses to a Biological Incident Causative agents Bacteria Viruses Toxins

253 Critical Information about Biological Incidents What is an exposure? Dose or the concentration of the agent multiplied by time Chemical doses Concentration continued on next slide

254 Critical Information about Biological Incidents Four major routes of entry Absorption Skin contact Ingestion By mouth Injection From needles or projectiles Inhalation By breathing continued on next slide

255 Critical Information about Biological Incidents What is contamination? Substance clings to surface areas of body or clothing. Things that can be contaminated Hard and soft surfaces Skin and hair Clothing continued on next slide

256 Critical Information about Biological Incidents Exposure versus contamination Exposure occurs when a substance is taken into the body through one of the routes of exposure. Permeation Spreading or movement of a substance through a surface or, on a molecular level, through intact materials. Remove clothing but preserve dignity.

257 Types of Harm from Biological Incidents Chemical harm Scene of clandestine laboratory Etiological harm Agents classified as poisons Mechanical harm Explosives used to disperse agents Psychological harm Even the thought can cause distress.

258 Self-Protection Measures at a Biological Incident PPE and respiratory protection Get as much information as possible. Prioritize protective measures. Self-protection Buddy system Availability of Rapid Intervention Teams Civilian protection

259 Responses to a Radiological/Nuclear Incident Small nuclear devices ("suitcase bombs") stockpiled in foreign nations Radiologic dispersion more practical and difficult to detect as radiation symptoms are delayed for hours or days Sickness treatable if detected early

260 Types of Harm from Radiological/Nuclear Incidents Thermal harm Nuclear explosion Radiological harm Radiological materials Ongoing hazard Chemical harm Radiological substances also chemical hazards continued on next slide

261 Types of Harm from Radiological/Nuclear Incidents Mechanical harm Explosion Psychological harm Immediate or delayed reaction

262 Self-Protection Measures at a Radiological/Nuclear Incident Time, distance, shielding Radiologic detecting equipment helps determine effectiveness of measures. Assume dissemination of radiological, biological, or chemical materials. Follow decontamination procedures.

263 Responses to an Explosive Incident Wide variety of devices from small pipe bombs to large vehicle bombs May involve attacks on a fixed target or group of people May be designed to disperse biological, chemical, or radiological materials

264 Types of Harm from Thermal harm Explosive Incidents Heat of detonation Asphyxiation harm Possibility of extremely dusty conditions Chemical harm Result of explosive reaction from chemicals present at detonation site continued on next slide

265 Types of Harm from Explosive Incidents Mechanical harm Typically seen at bombing incidents Psychological harm Stunned response can last seconds or minutes Delayed response in the form of posttraumatic stress

266 Self-Protection Measures at an Explosive Incident Responder needs both preblast and postblast protection. Preblast Operations occurring after written or verbal warning received but before explosion takes place Postblast Operations occurring after at least one detonation

267 Dissemination and Weaponization

268 Respiratory Route Most effective, most common means Vast and delicate surface area Various levels, sizes of passageways into lungs

269 Other Routes Ingestion route Dermal route Human-to-human contact

270 Weaponization Most effective when targeted through inhalation route Particles in 3 to 5 microns in diameter Such airborne dissemination can be created by applying energy to material. Heat, explosives, and sprayers can aerosolize materials.

271 Characteristics of CBRNE Agents

272 Chemical Agents Chemical agent considerations Physical Can be gaseous, liquid, or solid Vapor pressures and densities can vary across the spectrum. Volatility Low boiling point and high vapor pressure will evaporate more readily. Allows agent to have greater airborne release potential continued on next slide

273 Chemical Agents Chemical agent considerations Chemical Sufficiently stable to survive dissemination and transport to site of action Toxological Not all individuals of a species react in the same way. Route of entry can also influence.

274 Chemical Agents Some emergency and rescue services carry detectors to help identify the presence of various CBRNE agents. Examples include this chemical agent monitor.

275 Chemical Agents Classifications of chemical agents Choking agents Predominately respiratory Vesicating (blister) agents Cause chemical changes in cells of exposed tissue Cyanides Prevent use of oxygen within cells continued on next slide

276 Chemical Agents Classifications of chemical agents Nerve agents Inhibit enzyme critical to proper nerve transmission, causing out of control parasympathetic nervous system Signs and symptoms of exposure Salivation Lacrimation Urination Defecation continued on next slide

277 Chemical Agents Classifications of chemical agents Nerve agents Signs and symptoms of exposure GI Upset Emesis Miosis Riot control agents Irritating materials and lacrimators (tearflow increasers)

278 Biological Agents Microorganisms or toxins that can cause disease processes Bacteria Small, free-living microorganism Viruses Organisms that requires a host cell inside which to live and reproduce continued on next slide

279 Biological Agents Microorganisms or toxins that can cause disease processes Toxins Poisonous chemical compound that is produced by or derived from a living organism

280 Biological Agent Considerations Features of biological agents that influence their use as weapons Infectivity Virulence Toxicity Incubation period Transmissibility Lethality Stability

281 Bacteria Like human body cells, they have an internal cytoplasm surrounded by a rigid cell wall; unlike human body cells, they lack an organized nucleus and other intracellular structures. Anthrax Plague Q fever Tularemia

282 Toxins Chemical compounds produced by living organisms Not volatile and do not replicate Botulinum Ricin Staphylococcal Enterotoxin B (SEB) Trichothecene Mycotoxins (T2)

283 Viruses Simplest microorganisms Obligatory intracellular parasites Replicate only inside host cells Not easy to manufacture viruses in large quantities Smallpox Encephalitis The Viral Hemorrhagic Fevers (VHFs)

284 Radioactive/Nuclear Devices Potential scenarios Military nuclear devices Improvised nuclear devices Radiological dispersal device (RDD) or dirty bomb" Sabotage continued on next slide

285 Radioactive/Nuclear Devices Effects of radiation Bone marrow Gastrointestinal system Central nervous system

286 Effects of Radiation Some emergency and rescue services carry detectors to help identify the presence of various CBRNE agents. Examples include this radiation detector.

287 Incendiary Devices Use more plausible than the use of nuclear devices Not hard to obtain or initiate items Specialized teams generally available to deal with incendiary devices

288 Blast Injury Patterns Lung injury Bradycardia, apnea, and hypotension from blast wave Ear injury Rupture of tympanic membrane continued on next slide

289 Blast Injury Patterns Abdominal injury Rupture of gas-containing section of intestine Brain injury Concussion or mild traumatic brain injury (MTBI) from blast wave

290 Treatment for Blast Injuries No different from the treatment for patients of any other thermal or blast injury Follow local protocol.

291 Strategy and Tactics

292 Strategy and Tactics The DOT Emergency Response Guidebook provides information for the common terrorist weapons. Strategies Broad general plans designed to achieve desired outcomes Tactics Specific operational actions responders take to accomplish assigned tasks

293 Isolation Initial considerations Controlling scene, isolating hazards, and attempting to conduct controlled evacuation is resource-intensive and requires law enforcement personnel. Establishing perimeter control Law enforcement must establish and control perimeter throughout incident. continued on next slide

294 Isolation Perimeter control factors Amount and type of resources on hand Capability of available resources Ability of resources to self-protect Size, configuration of incident

295 Notification Generally required by established directives, procedures, and statutes Request for additional specialized agencies carried out by communications center based upon early reports of EMTs on scene

296 Identification Observe indicators of particular agent or presence of chemical containers or lab materials Consult current edition of Emergency Response Guidebook

297 Protection People, vehicles, equipment/supplies Make an initial scene size-up to determine security threats. Request protection (read security) via radio as soon as practical. Establish vehicle staging and triage/treatment areas in protected locations. continued on next slide

298 Protection Advise EMS Command about protection/security concerns. Immediately report suspicious people or activities.

299 Decontamination Gross decontamination by EMS personnel Removing surface contamination via mechanical means and initial rinsing Amount of surface contamination significantly reduced

300 Self-Protection at a Terrorist Incident

301 Protect Yourself First Scene size-up and situational awareness Patients displaying signs of hazardous substance exposure? Unconscious patients? Patients exhibiting SLUDGEM signs? Blistering, reddening of skin, discoloration or skin irritation? Patients having difficulty breathing? continued on next slide

302 Protect Yourself First Consider if there is evidence of the following: Medical mass casualties or fatalities with minimal or no trauma Responder casualties Dead animals and vegetation Unusual odors, color of smoke, vapor clouds

303 How to Protect Yourself Recognize a Possible Terrorist Event Occupancy or location Type of event Timing On-scene clues

304 How to Protect Yourself Don't rush in! Wait until appropriate authority says scene is safe. Follow Incident Command protocols. Wear appropriate PPE. Beware of possible secondary explosive devices or booby traps. Search all patients for explosives or weapons. continued on next slide

305 How to Protect Yourself Understand the TRACEM-P harms Time, distance, shielding At a chemical incident Chemical harm primary At a biological incident Etiological harm primary continued on next slide

306 How to Protect Yourself At a radiological/nuclear incident Radiological harm primary At an explosive incident Thermal and mechanical harms primary

307 Protect Yourself A specialized truck contains equipment for handling explosives.