Some Ambulance Basics

Paul Bunge, MD, FACPOctober, 2014

Overview

Ambulance Safety

Transport of suspected or probable Ebola Patients

Scene Safety

Trauma Tips

Ambulance Safety

Ensure Ambulance is Ready

Enough Gasoline

Familiar with area

Driver with experience

Lighting at night (can never have enough)

Ambulance Safety Driver: Only drive. No texting, phoning, eating

Look before exiting vehicle

Make sure equipment is not a danger to the driver and front seat passenger

No giving rides

Secure your gear

Wear your seatbelt

Be careful following another emergency vehicle, people may not recognize you as different

Keep the gear minimal and tied down

Ebola Transport

October, 2014Monrovia

Clinical Features of Ebola

Incubation period 2-21 days

Sudden onset: Fever, headache, chills, malaise, and myalgia GI symptoms common: vomiting, diarrhea,

abdominal pain Hemorrhagic symptoms: in ~45% of cases

Mild: petechiae, epistaxis, ecchymosis, bruising Severe: GI hemorrhage, shock, DIC

Less commonly seen: rash (trunk, shoulders), conjunctivitis, pharyngitis, cough, hiccups

Human-Human transmission Direct contact

Body fluids, blood, respiratory secretion, saliva Breast milk Semen -- up to 90 days following clinical resolution

Nosocomial transmission Reuse of needles and syringes Exposure to infectious tissue, excretions, waste

Funeral exposures Preparation of body for burial

Course of Disease & Virus shedding

Not transmissible prior to onset of symptoms All body fluids can carry virus

Virus quantity increases to death, usually 7-10 days post-onset

Convalescence/resolution of viremia Discharge

Contact

• Slept in the same house as Ebola patient

• Washed the clothes/bedding of someone who died

• Touched body or body fluids of Ebola patient

• Touched the body or body fluids of someone who died

• Took care of someone with suspect Ebola or very sick

• Took care of someone who died

Triaging a Patient with Suspect or Probable Ebola

ETU available?

Transfer to ETU Transfer to Ebola care center

(ECC)

“Dry” symptoms

1. “Wet” symptoms;

2. Confirmed

Yes No

• “Wet” symptoms: vomiting, diarrhea, bleeding, etc.• “Dry” symptoms: no vomiting, diarrhea, bleeding, etc.

If develop

Clinical Care: Fluids

• Dehydration threatens patient’s survival

• Use oral rehydration solution(ORS); Avoid intravenous fluids unless can be delivered safely

• Encourage normal eating

Deaths

Dead bodies are highly infectious

Call burial team right away to remove body

If burial team does not come soon: Always wear advanced PPE when handling body Cover body with sheet Move to separate area if can be done safely

Personal Protective Equipment (PPE)

Basic PPE: Staff in most patient care areas

Advanced PPE: Staff in Ebola care center and maternity ward

Never use your phone while wearing PPE

Additional items for high-risk areas

Everyone: Basic PPE• Closed toe shoes with

covers or boots• Face shield• Gown• Gloves (1 set)

High risk: Advanced PPE• Rain boots

o or closed toe shoes & covers

• 1st set of gloves• Gown• Head cover or hood• Mask• Shield • 2nd set of gloves

o outer set can be rubber• Apron

DOH Standard Operating Procedures

Dead bodies should be transported by the burial team.

The vehicle should have a separate space for the patient being transported and driver. This space should have a divider.

Staff who have direct physical contact with suspected or confirmed Ebola patients (EVD) (e.g. helping the patient to get into the ambulance; providing care to patients during the transport) patients should wear personal protective equipment (PPE).

If the patient is coughing, ask him/her to wear a mask.

When staff are assisting ambulatory patients who are not coughing, vomiting, or who have diarrhoea, PPE should include at least: gloves, face shield, and gown.

DOH Standard Operating Procedures

Properly dispose of PPE’s

PPE is not required for individuals driving or riding in the designated space with the driver, provided there is a barrier space between the patients and driver area and drivers or riders will not touch any patient or any person accompanying the patient.

DOH Standard Operating Procedures

Ambulances and other vehicles used for patient transport should be cleaned and decontaminated immediately after carrying any patient but especially a suspect, probable or confirmed Ebola patients. Otherwise the ambulance and other vehicles should be regularly (at least once a day) cleaned and decontaminated with standard detergents/disinfectants (e.g. a 0.5% chlorine solution). If the surfaces have been soiled with blood or bodily fluids, they should be cleaned twice and decontaminated immediately.

Ambulances and other vehicles used for patient transport should be always equipped with gloves and masks and full PPEs sets, alcohol-based hand sanitizer solutions, waste bags, body bags, a water tank, wipes, detergent and disinfectant.

Dr Bunge’s Opinions

Put on PPE AFTER you arrive. May need to put on in ambulance

Carry 2 liters of ORS already mixed in bottles

Carry artemether

Have 0.5% chlorine mixed

Questions?

Before we move to scene safety?

Scene Safety

To ensure safety and well-being of providers

Is it safe to approach the patient? Motor vehicle accident? Toxic substances? Crime, violence? Unstable surface? Water?

Protection of bystanders: no new patients

If unsafe, make it safe, otherwise no entry

Scene Assessment

How Many patients?

Triage: Suspect Ebola? – move immediately to Ebola

approach/transfer If Other, focus on immediate stabilization and

then transfer

Ebola Scene Assessment

How many patients?

Can the patient walk? Help in part?

Vomiting, diarrhea? (wet patients)

Are there angry people there?

Reassure that you will care for the patient

Be sensitive (patients are calling at night due to fear)

Correct: assisting and spraying

Correct

Incorrect

Questions?

Before we go to ABCDE

ABCDE

A – Airway

B – Breathing

C – Circulation

D – Disability

E – Exposure

(at the same time do not ignore major bleeding early)

Trauma Tips (NON-Ebola)

Airway – Obstructed?

Breathing – Breath sounds? Bilat

Circulation – peripheral pulse? Femoral? Carotid? (not BP). Look for bleeding

Disability – neuro, AVPU

Exposure – make naked, look for hidden trauma

Airway

Clear, not clear

Noisy, wheeze, stridor

Jaw Thrust

Head tilt if no neck injury

Breathing

Pneumothorax

Flail Chest

O2 if available and pt >24 or <8 RR

Circulation Hemorrhage

Hypovolemic Shock

Spinal Shock

Check pulse. <1 year: brachial

Assess: eyes, mucous membranes pale, flushed. Skin warm/hot/cool/clammy

Capillary refill in infant/child

Pressure to bleeding, tourniquet if avail and need

Disability

Levels of Mental Status (AVPU) A – Alert V – Responds to verbal P – Responds to Pain U - unresponsive

Trauma

Primary Survey

Resuscitation

Secondary Survey

Definitive Care

Trauma Resuscitation

Control Bleeding

2 IV - fliuds

Secondary Survey Can be done in part in ambulance

Head: palpate, inspect, look for crepitation

Neck – JVD, crepitation

Cervical spine immobilization

Chest – palpate, listen. Paradoxical motion

Abdomen – firm, soft, distended

Pelvis, palpate, gently compress

4 extremities: pulses, sens, motor, move

Roll patient (usually in hospital)

Baseline vital signs

SAMPLE history

Signs and symptoms

Allergies

Medications

Pertinent past history

Last oral intake

Events leading up to injury or illness

Focused Trauma Hx and PE Spinal Stabilization – fall from height, neck

pain, spinal trauma

Look for Examples/signs of injury: Deformities Contusions Abrasions Punctures/penetrations Burns Tenderness Lacerations Swelling

Fractures

Stabilize to prevent complication

Traction if need

Fractures are sharp edges

Unstable is more pain

Unstable is more bleeding

Unstable spine can mean paralysis

X-rays

Most Trauma patients will need urgent x-rays. Anticipate on arrival to hospital

You are the eyes/ears of the hospital providers. Must give report

Questions?