1 Respirator, volume-cycled, on/off operation, 100% oxygen, 40–50 psi pressure (child/infant capabilities) Blood sample tubes, adult and pediatric Automatic blood pressure device Nasogastric tubes, pediatric feeding tube sizes 5F and 8F, sump tube sizes 8–16F Size curved laryngoscope blade Gum elastic bougies Needle cricothyrotomy capability and/or cricothyrotomy capability (surgical cricothyrotomy can be performed in older children in whom the cricothyroid membrane is easily palpable, usually by puberty ) Rescue airway devices for children Atomizers for administration of intranasal medications Optional medications A Optional medications for BLS emergency ambulances Albuterol Epipen Oral glucose Nitroglycerin (sublingual tablet or paste) Aspirin B Optional medications for ALS emergency ground ambulances Intubation adjuncts, including neuromuscular blockers Extrication equipment In many cases, optimal patient care mandates appropriate and safe extrication or rescue from the patient’s situation or environment It is critical that EMS personnel possess or have immediate access to the expertise, tools, and equipment necessary to safely remove patients from entrapment or hazardous environments It is beyond the scope of this document to describe the extent of these Local circumstances and regulations may affect both the expertise and tools that are maintained on an individual ground ambulance, and on any other rescue vehicle that may be needed to accompany an ambulance to an EMS scene The tools and equipment carried on an individual ground ambulance need to be thoughtfully determined by local features of the EMS system with explicit plans to deploy the needed resources when extrication or rescue is required From American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons Committee on Trauma, et al Equipment for ground ambulances Prehosp Emerg Care 2014;18(1):92–97 Reprinted by permission of Taylor & Francis Ltd, www.tandfonline.com TABLE 134.4 EXAMPLE OF STATE-APPROVED MEDICATIONS—REQUIRED AND OPTIONAL Medical Records An accurate medical assessment and record of any and all interventions in the field during an EMS encounter are vital for the receiving ED staff Any accompanying paperwork, such as a 12-lead ECG tracing, or paperwork given to the EMTs should be provided with documentation that is left at the hospital EMS run sheets become an important part of the patient’s permanent medical record and may play an important role in determining the patient’s hospital care Especially important aspects of documentation are serial vital signs, medical allergies, initial evaluation and responses to interventions, and any changes en route, as well as a record of the mechanism of injury and details that help put the incident in perspective It is essential to have times and dosages associated with any medications that were given EMS providers use paper or electronic charts to document EMS runs Paper “run sheets” have certain disadvantages, such as legibility challenges due to poor handwriting or carbon copies and potential misplacement in the transfer of the patient With the recent advancement in computers and tablets that are smaller and more durable, many EMS providers now use some type of electronic patient care record (ePCR) Some medical centers are able to receive ePCRs ahead of the ambulance’s arrival ED capability to electronically access or print ePCR records from EMS is an important part of the information transfer process ePCRs have the potential to improve the quality of EMS records and the timeliness of patient handoff information The use of standardized ePCRs also allows EMS operators to gather and analyze clinical data and to participate in clinical research NEMSIS has established a uniform data set used by most ePCR vendors Health Information Exchanges have been successfully implemented in several communities and states, allowing patients’ clinical outcomes to be distributed back to the EMS agencies Telemedicine in EMS The use of HIPAA compliant telemedicine from the scene of an accident, mass casualty scene, or other disaster could be of benefit in a variety of ways Scene telemedicine would have clear theoretical advantages when there are shortages of medical staff or in medical emergencies involving infectious, biologic, or chemical emergencies The utility of telemedicine during transport has not yet been defined In a simulation study by Charash et al., the use of telemedicine in a moving ambulance improved the care of simulated trauma patients including the time to identify abnormal physiologic variables and the recognition rates for key signs, processes, and critical interventions Further research will be needed to identify which technologies and for which types of patients telemedicine will offer the most benefit ISSUES IN EMS CARE Culture of Safety One of the most important aspects of the transit to the hospital is patient safety EMS system safety practices also affect EMS personnel and members of the community EMS personnel often work long hours under unpredictable circumstances and with limited supervision and resources This combination can lead to preventable adverse medical events for patients Pediatric emergencies are low-frequency, but at times high-stakes, events that are at high risk for adverse events and patient harm EMS personnel are exposed to risks such as infectious diseases, physical violence, occupational injury, and emotional stress, and the interaction of an ambulance and the general motoring public puts both EMS providers and members of the community at risk Following the 1999 Institute of Medicine (IOM) report To Err Is Human , inpatient and outpatient healthcare settings moved toward a culture of safety Bringing these concepts to EMS, ACEP led a project, in cooperation with NHTSA and the EMSC program, to develop a Strategy for a National EMS Culture of Safety , which was made public in 2013 EMS leaders envision changing the status quo via a cultural shift to one in which “safety considerations and risk awareness permeate the full spectrum of activities of EMS everywhere, every day—by design, attitude, and habit.” Medication errors gained immense attention after the 1999 IOM report, but little literature exists studying the prevalence and outcomes of medication errors in the prehospital pediatric population Both chart review and patient simulation studies have documented medication error rates from 35% to 73% for pediatric doses of epinephrine, atropine, diphenhydramine, and albuterol One theme noted in these studies is the failure to use, or incorrect usage of, length-based weight estimation tools A single data set does not exist to analyze the precise number of crashes involving emergency vehicles; however, insurance companies report that approximately 10,000 ambulance crashes result in injury or death each year The relative risk of injury and death is high when collisions involve ambulances An 11-year retrospective review found that 339 fatal ambulance crashes from 1987 to 1997 resulted in a total of 405 deaths and 838 injuries to EMS patients, EMS personnel, and nonoccupant victims There are few times when a higher-speed drive with lights and siren (L&S) will be of benefit to a sick or injured child EMS personnel injury rates are nearly 15 times higher when ambulances are operating with L&S, and time savings have not been shown to be meaningful Sixty percent of these accidents are the fault of the emergency vehicle driver Intersections are the most common site for accidents involving EMS vehicles operating L&S The NAEMSP recommends that EMS services develop a policy on L&S use that should be reviewed by the medical director, because accidents while running “hot” with L&S are a common cause of litigation Emergency vehicle accidents are an area of high, and frequently unnecessary, liability in EMS that is borne more out of a tradition of L&S use than a medical necessity for the patient Every ambulance should have the capacity to secure a child or infant safely Although specialized products exist to secure a child to an ambulance cot, the EMS provider must take great care to ensure that it is properly attached to the cot, and that the child’s head, torso, and pelvis are appropriately secured to prevent injury in an accident Many of these products may not have established crashworthiness, and the degree of protection they provide is unclear Additional research, including crash testing of ambulance and child restraint devices, is on the horizon In 2012, NHTSA published the Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances The recommendations outline ideal transport mechanisms for five situations, defined by the patient’s clinical status and the number of patients being treated (http://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf ) Ideally, children should be secured to ambulance cots either in a size-appropriate child restraint system or with three horizontal restraints across the torso and one vertical restraint across each shoulder The family’s own car seat secured properly in the ambulance may often be the best alternative, providing it is medically safe and appropriate for the patient’s condition This also encourages a safe discharge home from the hospital by already having the child’s safety seat available in the ED The report also notes that “A child passenger … must never be transported on an adult’s lap.” Additional means of making the ambulance interior safe for all occupants include: seat belt use for all occupants; securing movable equipment, such as monitors; and monitoring of driver practices, including through the use of technology MEDICAL–LEGAL ISSUES Prehospital care providers and their medical overseers are legally responsible for their actions or lack thereof Good Samaritan laws are variable by state and may not provide any coverage if a provider, from an EMT to a physician, is being paid to be present at the scene of the emergency It is vital to understand what type of professional liability coverage exists for both EMS providers as well as medical control clinicians Many medical directors will obtain a separate medical license and Drug Enforcement Agency registration number to help distinguish their activities performed as a medical director from that used for other clinical duties All prehospital providers and medical control personnel should provide care that mirrors the standards of practice that apply to their profession Standards of care and medical control are established to protect the EMS provider professionally as well as serve the patient Deviation from one’s level of training or from an established and reviewed protocol with or without the involvement of medical control can expose the EMT to unfortunate legal scrutiny in the event of a poor patient outcome When a situation is unclear, prehospital care providers should consult with the online medical control physician Proper documentation of EMS activities is the best defense against potential legal action Special attention should be given to accurately documenting the patient’s condition on arrival, including vital signs, position, and restraint during transport, medication and fluid administration, airway status, and other interventions Of special importance is the documentation of a properly placed, secured, and patent airway if intubation is performed by EMS Some departments use a separate intubation checklist with multiple redundant confirmations for this important but inherently risky procedure All EMS documentation should be completed legibly, with errors noted by a single line cross out, initial, and date The provider’s signature must be legible and include a printed name and credentials The EMS chart is a medical–legal document as well as a simple record of what transpired in the field It should reflect the medical decision-making thought process as well as document any online medical control orders that were acquired Many lawsuits that involve EMS result from the transport of patients to inappropriate facilities, deviation from standardized protocols, perceived or actual slow response time, or the failure to transport patients when indicated ... agencies Telemedicine in EMS The use of HIPAA compliant telemedicine from the scene of an accident, mass casualty scene, or other disaster could be of benefit in a variety of ways Scene telemedicine... or chemical emergencies The utility of telemedicine during transport has not yet been defined In a simulation study by Charash et al., the use of telemedicine in a moving ambulance improved the... medication errors in the prehospital pediatric population Both chart review and patient simulation studies have documented medication error rates from 35% to 73% for pediatric doses of epinephrine,