EMS Operations

In depth

The one-page summary above is what the PDF prints. These sections go further.

Size-up in detail

NASEMSO's universal care guideline opens every encounter the same way: look for hazards to the crew, patient and bystanders, move the patient out of the hazard before starting care, count patients, decide the mechanism or source of illness, call for resources (weighing the wait against rapid transport), and consider declaring a mass casualty incident. PPE is chosen for the hazards present, and high-visibility retroreflective apparel is worn at night and on or near roadways.

Planning starts at dispatch. Premise notes, the caller's description and the call type let the crew ask for a dog to be shut away, request a lift assist or bariatric stretcher, or stage for police before arriving. The size-up report then adjusts resources both ways: more units when the scene needs them, cancelled or downgraded units when it does not.

• Confined spaces (manure pits, silos, tanks, sewers) can hold hydrogen sulfide, methane, carbon dioxide or silo gas with little warning. Two collapses in one space means the atmosphere is the cause until proven otherwise. A 1989 MMWR report on manure-pit deaths cites unpublished NIOSH data that about 43% of confined-space deaths involved co-workers or other people trying to rescue the first victim, and says hydrogen sulfide at 300 ppm or more can cause sudden death.
• Electricity: NASEMSO says the source must be disabled before assessment. A downed line is treated as live; occupants are told to stay in the vehicle unless fire forces them out, and the crew waits for the utility.
• Gas odor: anything that sparks (light switches, doorbells, phones, radios) is avoided; everyone leaves and the gas company and fire department are called.
• Unstable vehicles: a car on its side or roof moves when someone climbs on it. Talk to the patient from outside until fire crews crib and stabilize it.
• Electric and hybrid vehicles (classic teaching): a silent car may still be on. Chock it, put it in park, turn it off and move the key away, and never cut or touch orange high-voltage cables.
• Floodwater: the National Weather Service says 6 inches of fast water can knock an adult down, 12 inches can carry away most cars and 2 feet carries away SUVs and trucks; more than half of flood drownings happen in vehicles. Take the detour and tell dispatch.
• Water rescue (classic teaching): reach, throw, row, and go into the water only with training, a flotation device and a team.
• Violence: stage until police secure the scene. If a hostile crowd builds, a patient whose bleeding is controlled is loaded and assessed in the moving ambulance.

Roadway scenes

Passing traffic is the main danger at a roadway crash. The first large apparatus parks at an angle upstream as a block, making a protected work area. The ambulance parks downstream of the wreck inside that area, so the blocking vehicle shields the rear loading doors (classic traffic incident management teaching).

• Turn off headlights that face oncoming traffic once parked; warning lights stay on
• Get out on the side away from moving traffic
• Stay inside the protected area; never stand behind the blocking vehicle as a lookout
• Do not ask the blocking apparatus to move to reopen a lane; do not drive against traffic unless police have closed the road
• Wear a high-visibility retroreflective vest whenever working near traffic, day or night

Hazmat awareness and the ERG

At the awareness level an EMT recognizes a hazardous materials incident, protects self and others, isolates the area, keeps people out and calls for trained help. CHEMM says to keep a safe distance upwind of the incident. Uphill and upstream add distance from liquids and heavier-than-air vapors (classic teaching).

The Emergency Response Guidebook (2024 edition) is a first-responder guide for the initial phase of a hazardous materials transportation incident. Yellow pages list materials by their four-digit UN/NA ID number and blue pages by name; both point to an orange guide, whose sections cover potential hazards, public safety and emergency response (including fire, spill and first aid). Entries highlighted in green are poisonous when inhaled; for one that is not on fire, the green pages (Table 1) give an initial isolation distance and a downwind protective action distance, which generally apply to the first 30 minutes. For a highlighted material that is on fire, the ERG says to take evacuation distances from the orange guide first and protect downwind according to Table 1. If nothing else applies, start with Guide 111 (for example for unidentified cargo; classic teaching).

• Placards (49 CFR 172.504): Table 1 materials (explosives 1.1-1.3, poison gas, dangerous when wet, poison inhalation hazard, some organic peroxides, Radioactive Yellow III) are placarded in any amount
• Most other classes need no placard on a highway vehicle carrying less than 1,001 lb (454 kg) in total, so a small spill from an unplacarded van can still be hazmat
• A single DANGEROUS placard may replace separate placards for non-bulk packages of two or more classes, unless 1,000 kg or more of one class was loaded at one place
• Shipping papers (classic teaching) give the ID number, shipping name, hazard class and an emergency phone number; on a highway vehicle they are in the cab within the driver's reach, often the door pocket or seat
• NFPA 704 (classic teaching) marks fixed facilities: blue health, red flammability, yellow instability, white special hazards such as water-reactive or oxidizer, each rated 0 to 4

Zones (hot, warm, cold), PPE levels A to D and decontamination are on the Mass Casualty Triage page; an EMT works in the cold zone and treats patients after decon.

Infection control by organism

Standard precautions apply to every patient: hand hygiene, PPE chosen for the expected exposure, respiratory hygiene, safe sharps and injection practice, and cleaning of equipment and surfaces. CDC's isolation guideline (Appendix A) then adds precautions by organism.

• Airborne: pulmonary TB; measles (until 4 days after rash onset); chickenpox and disseminated zoster (airborne plus contact). Localized zoster in an immunocompromised patient is airborne plus contact until dissemination is ruled out; localized zoster in a healthy patient with covered lesions needs only standard precautions
• Measles: every staff member wears an N95 regardless of immunity, and susceptible staff stay out when immune staff are available; the same staffing rule applies to chickenpox
• Droplet: influenza (facemask; patient masked for transport); meningococcal disease until 24 h after effective antibiotics begin. Close contacts of meningococcal disease are offered prophylaxis (CDC); report an unprotected airway exposure
• Aerosol-generating procedures in influenza (CDC): a fitted N95 or equivalent, eye protection, gown and gloves; CDC lists CPR, emergent intubation and open suctioning among unplanned procedures (CPAP is not on its list)
• Contact: C. difficile (hand sanitizer does not kill spores; use a sporicidal EPA List K product on surfaces and wash hands with soap and water), RSV in infants, MRSA in a wound that a dressing cannot contain
• Drug powder (NIOSH): nitrile gloves whenever illicit drugs may be present, respiratory protection when powder is visible or suspected, no tasks that make powder airborne, wash skin with soap and water and never use sanitizer or bleach

Measles exposures (CDC): staff without presumptive evidence of immunity are excluded from the 5th day after first exposure through the 21st day after the last, even if they receive post-exposure prophylaxis. Staff who had a first MMR dose before the exposure need no work restriction, get the second dose as soon as possible (at least 28 days after the first) and monitor for symptoms daily over the same window. Which records count as evidence of immunity is set by ACIP criteria; follow the agency's occupational health policy.

Respirators (29 CFR 1910.134): a medical evaluation comes before the fit test; fit testing is done before first use, with any new model or size, and at least yearly; a user seal check is done every time the respirator goes on, and facial hair may not cross the seal.

Bloodborne pathogens: the OSHA standard

An exposure incident is blood or other potentially infectious material reaching the eye, mouth, other mucous membrane, non-intact skin, or entering through the skin, during work. Mucous membranes are flushed with water immediately or as soon as feasible and hands washed after glove removal.

• The employer makes a confidential medical evaluation immediately available: route and circumstances documented, source identified and tested after consent, the worker's blood tested, PEP when medically indicated, counseling
• Hepatitis B vaccine offered within 10 working days of assignment, at no cost
• PPE provided at no cost; contaminated needles never bent, recapped or broken (a one-handed or mechanical method only where unavoidable)
• Sharps containers closable, puncture-resistant and leakproof, replaced before overfilling
• Surfaces decontaminated with an appropriate disinfectant after a procedure, after a spill and at the end of the shift
• The exposure control plan is reviewed at least yearly and training repeated at least yearly

Cleaning the ambulance: gross soil comes off first, because organic material shields organisms from disinfectant; then an EPA-registered hospital disinfectant is applied for its listed contact time (a sporicidal product after C. diff).

Lifting, moving and extrication

NIOSH lists lifting patients and equipment among the leading hazards of EMS work. Classic teaching: know the weight, call for more hands or a lift assist before the lift, use the power lift and power grip, keep the load close, avoid twisting, communicate on a count, and use equipment (powered stretchers, stair chairs, slide boards, scoop stretchers, basket stretchers for terrain, flexible stretchers for tight spaces, bariatric stretchers).

• Emergency move: immediate danger, or the patient must be moved to give lifesaving care; drag along the long axis of the body
• Urgent move: altered mental status, inadequate breathing or shock with no immediate danger
• Non-urgent move: stable patient, chosen for comfort and safety

Extrication: while rescuers cut, the EMT's job is the patient: protect them from glass and tools with a blanket or shield, keep airway, bleeding and stabilization going, and stay clear of the tools. Anyone entering a damaged vehicle wears rescue gloves over disposable gloves, eye protection, a helmet and protective clothing. Undeployed airbags stay live until the rescue team has disconnected the battery: stay out of their path and put nothing hard between an airbag and the patient (classic teaching).

Ambulance operations

NASEMSO's universal care guideline says routine use of lights and sirens is not warranted, and that even with them on, speed stays at a level safe for the vehicle and the road. A February 2022 joint statement from NAEMSP and 13 other organizations sets out principles for lights-and-siren operation and the duties of medical directors, agency managers, drivers, dispatch and governments. In a national EMS database analysis (Watanabe, 2019), crash-related delays were more likely with lights and sirens: adjusted odds about 1.5 times as high on response and about 2.9 times on transport. Reviews of time saved (cited by NAEMSP) found roughly 43 to 181 seconds in urban settings and up to about 6 minutes in rural ones, and one transport study found none of the patients received a time-critical intervention within the time saved.

• Due regard: laws exempt emergency vehicles from some rules but never from responsibility for everyone's safety; the ambulance never assumes the right of way
• Intersections: stop or nearly stop, make eye contact, and clear one lane at a time
• No police escorts: drivers yield to the first vehicle and pull out in front of the second
• Backing: a spotter at the rear driver's side, visible in the mirror, with agreed signals; stop if the spotter disappears
• The driver does not use a phone or the mobile data terminal while moving
• Everyone wears seat belts (NIOSH); the attendant stays belted rather than standing, and equipment is secured (classic teaching)
• Children (classic teaching, NHTSA 2012): an ill child who does not need continuous care rides in a size-appropriate restraint secured to the cot, never held in arms or on a lap; a well child goes in another vehicle
• Fatigue impairs driving; use the agency's fatigue policy rather than pushing through
• If the ambulance crashes: stop, check everyone, notify dispatch, request another unit and document
• Shift check: vehicle, oxygen, suction, AED status indicator and pads, and every device's battery; take failing equipment out of service

Air medical transport

NASEMSO suggests air transport for time-critical conditions when ground transport would exceed 30 minutes, and for higher-acuity trauma when it saves significant time, when the right destination cannot be reached by ground, or for patients meeting the high-acuity field triage criteria; it can also help stroke and STEMI patients in remote areas.

• Landing zone: at least 100 x 100 ft, square, round or rectangular; relatively flat (Beacon gives under 10 degrees slope; some programs want less); free of debris; corners marked
• Find wires, poles, trees, antennas and signs; tell the pilot about them with the wind, surface and slope
• Keep people and vehicles at least 200 ft from the touchdown area, and nobody within 100 ft of the helicopter during takeoff and landing except as the crew directs (Beacon)
• At night, mark the LZ with strobes, cones or headlights, but never shine a light at the aircraft (it ruins the pilot's night vision)
• Approach only when the pilot or crew signals, from the front, in the pilot's view; never toward the tail rotor, which is nearly invisible when turning (classic teaching)
• Hold nothing above head height and keep loose articles away from the blades (Beacon); carry long objects low and secure hats (classic teaching), and let anything that blows away go

Incident command and NIMS

FEMA describes ICS as one management structure combining facilities, equipment, people, procedures and communications, normally organized into Command, Operations, Planning, Logistics, Intelligence and Investigations, and Finance and Administration. The first arriving unit establishes command, sizes up the scene (including hazards and secondary devices), requests resources and starts triage.

• Transfer of command (classic ICS teaching): when a more senior officer takes over, the outgoing commander briefs the new one face to face (situation, objectives, organization, resources, communications), and the change and its time are announced to everyone on the incident. A more qualified person arriving does not automatically take command
• Unified command: when several agencies or jurisdictions share responsibility, their commanders run the incident together from one command post, each keeping its own authority
• Unity of command: each person reports to one supervisor; common terminology and plain language, no codes
• START, JumpSTART, SALT, the EMS branch roles, staging and span of control are on the Mass Casualty Triage page

Consent, refusal, end-of-life orders and legal duties

Refusal (NASEMSO; state law and local protocol vary, so follow yours): an alert, oriented adult who understands the illness and the risks of refusing, and whose judgment is not impaired by illness, injury, drugs or alcohol, usually has capacity. Someone who attempted suicide or voiced suicidal intent does not. If capacity is in doubt, contact medical direction. Explain the risks to the patient and everyone responsible, give the care the patient accepts, say they can call again, and never risk the crew to force care: request law enforcement. NASEMSO frames the task as a balance between abandoning the patient and forcing care.

Minors (NASEMSO): all states allow emergency treatment when a parent is not available to consent (the emergency exception, or implied consent). EMS may presume consent when the child has an emergent condition, no guardian can be reached, treatment cannot safely wait, and only emergency treatment is given; medical direction can be contacted when authority is in doubt. An emancipated minor can refuse care as an adult can.

DNR, POLST and advance directives (NASEMSO): a valid order meets the state's form rules, is intact, and shows the patient's name (and physician's if required). With a valid order and no pulse, no CPR or airway management is started, but comfort care, including pain relief, continues. With a pulse and breathing, the patient gets standard treatment under protocol; an order removes only the interventions it specifically prohibits (a do-not-intubate order removes intubation, so CPAP and other care continue), and medical direction is contacted if a prohibited intervention is being considered. If the document is in doubt, start resuscitation and contact medical direction. The patient's own physician, or a hospice nurse working under that physician's orders, present at the scene may decide whether to resuscitate.

• Obvious death (NASEMSO; not for lightning, drowning or hypothermia): decapitation; decomposition or putrefaction; transection of the torso; incineration; injuries incompatible with life such as massive crush injury, complete exsanguination or severe displacement of brain matter; blunt or penetrating trauma with apnea, pulselessness and no other signs of life; a nontraumatic arrest with dependent lividity or rigor mortis; or futile attempts as defined by agency policy. This is the NASEMSO model list; state and agency protocols differ
• Abandonment (classic teaching): stopping care, or handing a patient to a lower level of care while they still need yours
• Negligence needs all four: duty, breach, damages, proximate cause; no harm, no negligence claim
• Assault and battery, false imprisonment: treating or transporting a capable adult against their will
• Good Samaritan laws protect unpaid, good-faith care within training; they do not cover gross negligence and do not create a duty to stop off duty
• Scope of practice is what state law and the medical director allow; the standard of care is what a reasonable, prudent provider of the same level would do
• Organ-donor status and medical ID jewelry do not change care; pass them to the hospital

Documentation, privacy, radio and medical direction

The verbal report never replaces the written or electronic PCR (NASEMSO). HIPAA lets an EMS agency use and share protected health information for treatment, payment and operations (45 CFR 164.506). The minimum-necessary rule does not apply to disclosures to a provider for treatment (164.502(b)), so a full handoff, including sensitive history, is appropriate. Bystanders, media and curious coworkers get nothing identifiable; media questions go to the public information officer. Posting scene photos or details that could identify the patient risks a privacy violation.

• State laws can require abuse, neglect and certain wound reports; HIPAA permits those disclosures and disclosures in answer to a court order or warrant (164.512(c) and (f))
• Police requests outside those: only what law and agency policy permit; refer the rest to the privacy officer
• Family members: share what the patient agrees to or what care requires, as agency policy directs
• Online medical direction: repeat the order back word for word, and question any order that seems wrong before acting
• Offline medical direction: protocols, standing orders, training and quality review set by the medical director
• A bystander physician does not replace medical control; contact online medical direction
• Radio (classic teaching): plain language, brief, no patient names; a repeater boosts weak portable signals

Paramedic: EMTALA (42 CFR 489.24). A patient in a non-hospital-owned ambulance off hospital property has not yet come to that emergency department, so a hospital on diversion may redirect the crew; once the patient is on hospital property, including the ambulance bay, the hospital must give a medical screening exam. An appropriate transfer needs treatment within the sending hospital's capacity, a receiving facility that has accepted and has space and staff, the available records sent, and qualified personnel and equipment; an unstable patient may go when a physician certifies that the benefits outweigh the risks.

Exam pearls

• The answer to an unsafe scene is almost never "go in": stage, request the right team, talk from a distance
• Two patients down in an enclosed space: the atmosphere is the hazard
• A placard number highlighted in the ERG means an inhalation hazard
• Measles, TB and chickenpox: N95; flu: mask, but N95 for aerosol-generating care; C. diff: soap and water
• Needlestick: wash, report, evaluate, in that order and now
• Lights and siren are the exception; due regard is the rule
• A valid DNR stops CPR, not care; a patient with a pulse gets treated
• HIPAA never blocks the handoff to the receiving team