EMT Operations: Driving, Scene Hazards, Lifting and Infection Control

In depth

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

Emergency vehicle law

State vehicle codes let an ambulance driver park where others may not, pass a red signal or stop sign, exceed the speed limit and disregard direction and turning rules, but never excuse the duty to drive with due regard for the safety of all persons, and are no defence to reckless conduct (Oregon ORS 820.300; Tennessee 55-8-108). Tennessee, like many states, grants the moving exemptions only while the vehicle uses audible and visual signals, and lets it pass a red signal only after slowing as needed for safety. With the siren off and only lights on, the ambulance is legally an ordinary vehicle on that stretch, so speeding there is a plain violation. Check your own state's code; wording differs.

• Other drivers are told to pull to the right edge and stop until the emergency vehicle has passed (California handbook) and to stay stopped until no other emergency vehicle is coming (Alberta). The ambulance therefore passes on the left, where the gap opens and where drivers look for it (classic teaching); the right shoulder is where yielding drivers are heading
• Following an emergency vehicle is unlawful within 300 ft in California and within 150 m in Alberta. A family car behind the ambulance has no exemption and meets the drivers who pull back out after it passes. Give the family the destination and tell them to drive normally; help find a ride if they are too upset to drive

Road handling

• Hydroplaning (California handbook): it happens on wet roads; do not use the brakes, because sudden braking can cost control, and slow down gradually. The handbook says to steer around standing water if possible; holding the wheel steady rather than steering hard, so the vehicle is pointed straight when grip returns, is classic teaching, not a handbook statement
• Wet roads: reduce speed by 5 to 10 mph; packed snow, by half; ice, to no more than 5 mph (California handbook). Steer around standing water when it is safe to do so
• Curves: slow as you approach sharp curves (California handbook). In a 1978 New Hampshire crash investigated by the NTSB, an ambulance at about 90 to 95 mph failed to negotiate a curve and rolled over; the probable cause was loss of control by an unskilled driver at high speed, and lack of high-speed training contributed. A tall, loaded box ambulance is braked on the straight so it enters the ramp at or below the advisory speed and holds a steady speed through it (classic teaching); lights and siren do not change the physics

Carbon monoxide and unit readiness

CDC notes that burning fuel in cars and trucks makes CO and that a small exhaust-system leak can let CO build up inside a vehicle. Symptoms (headache, dizziness, weakness, upset stomach, vomiting) are vague, and sleeping or intoxicated people can die before they notice. A compartment CO alarm with a symptomatic patient, after the detector passed its shift check, means a leak: airing the cabin out fixes the gas that is there, not the source. The unit goes out of service until the exhaust is inspected and repaired, and the patient and crew are evaluated.

Readiness after a call (classic teaching): separate what the next patient needs in the first minutes at the scene from what can be restocked later. Portable oxygen and portable suction go to the patient's side; the main oxygen tank and mounted suction help only after loading. Without them the crew cannot manage an unresponsive patient's airway at the scene, so the honest answer to dispatch is "unavailable until restocked". The 2020 joint position statement on essential BLS and ALS ambulance equipment says agencies carry equipment in quantities set by the medical director and the agency's approved protocols, and that some items may be optional locally.

Licensure, mutual aid and a parent's refusal

• The National Registry states that passing its exam does not grant the right to practice; a state-issued license is required. Many states use Registry certification for licensure or reciprocity. Working "under supervision" while a license is pending is still practicing without one
• Mutual aid agreements set the terms under which one party provides resources to another, because most jurisdictions cannot handle extreme events alone (USFA). NASEMSO asks crews to request additional resources when needed and to weigh the wait against rapid transport. With every unit committed and a neighboring ambulance closest, the supervisor asks dispatch for it at once.
• NASEMSO's refusal guideline applies when the patient, or the parent or legal guardian, refuses care or transport: the clinician assesses the decision-maker's capacity. A calm, sober parent who understands the risks may decline ambulance transport of a child with a non-emergent injury. Offer care such as a splint, advise calling back, and document the child's age, the guardian's name, contact and relationship, the risks explained and the plan. A 9-year-old cannot consent or refuse; implied consent covers a minor only in an emergency with no guardian available. Concern for abuse or neglect changes the plan (Behavioral Emergencies, Agitation and Abuse)

Technical-rescue scenes

• Carbon monoxide clusters: CDC tells clinicians to consider CO with multiple patients with similar complaints and no fever. Standard pulse oximetry cannot tell carboxyhemoglobin from oxyhemoglobin and often reads falsely reassuring (StatPearls abstract; CDC). An N95 or gown gives no protection from a gas. Stage outside, request fire with gas monitors and hazmat, have the building evacuated and treat people as they come out
• Trenches: OSHA requires a protective system (sloping, shoring or shielding) for excavations 5 ft or deeper, and shallower ones unless a competent person sees no sign of cave-in; materials and equipment stay at least 2 ft from the edge, and soil subject to vibration or previously disturbed is classed as less stable. After a collapse, have nearby machines shut off, keep people and vehicles back from the lip, and talk to the patient from a distance until technical rescue shores the trench. Do not dig with machinery or enter
• Grain bins: OSHA's grain-handling standard requires augers and other powered equipment to be deenergized and locked out before anyone enters, bans walking on grain to make it flow, requires a harness and lifeline that keep the entrant no deeper than the waist, a trained observer outside and rescue equipment. Flowing grain pulls a victim down (classic teaching), so the first act is stopping and locking out the auger; an untrained relative on a rope becomes a second victim
• Escalators and machinery: emergency stop buttons sit at or near the top and bottom landings, cut power to the driving machine and cannot restart it (California Title 8 section 3090); fire services tell the public to press the stop and call 911. Stop the machine first, then stop the pulling, support the limb as found and call fire and the mechanic. Never reverse the drive (classic teaching)
• Weapons: NASEMSO notes that police should have checked for weapons but the crew may need to re-check, and that weapons threaten the crew. A knife found on an intoxicated patient goes out of reach at once, police take custody under agency policy, it is handled as little as possible and never cleaned or returned, and the find is documented (classic teaching for custody). Crime-scene evidence rules: EMS Operations

Rail cars, oxidizers and vehicle access

• Trains: the railroad gives the crew a printed consist listing the position in the train and the contents of each hazardous material car by reporting mark and number, with shipping-paper and emergency response information, always immediately available to the crew (49 CFR 174.26). Tank cars carry the ID number on each side and each end; the shipping name is marked on each side only for listed materials (172.330). Read the reporting mark from a safe distance upwind, get the consist from the crew, and pass the product and ID number to command.
• Oxidizers: the OXIDIZER placard is yellow with a black symbol and division number 5.1 (172.550; the regulation text gives the colors, and the flame-over-circle symbol is classic teaching from the placard image). A Division 5.1 material may, generally by yielding oxygen, cause or enhance the burning of other materials (173.127), so a nearby fire can grow fast. Stay upwind, report the placard to command, and prepare for burns and smoke inhalation
• Vehicle access (classic teaching, "try before you pry"): with the scene safe and the car upright, in park and switched off, try every door, including the rear doors, before breaking glass. If all are locked or jammed, break the window farthest from the patient. Fire Engineering stresses protecting the patient during any maneuver with a board, blanket or cover, and notes that tempered glass shatters. Prying damaged doors and removing the roof belong to rescue crews (extrication duties: EMS Operations)

Cleaning, disinfection and airing out

• Spaulding classification (CDC): critical items enter sterile tissue; semicritical items, which include respiratory therapy and anesthesia equipment and laryngoscope blades, touch mucous membranes and minimally need high-level disinfection with chemical disinfectants after cleaning; noncritical items touch intact skin and take low-level disinfection. A surface wipe, rinse or alcohol is not enough for a blade; bag it for the agency's reprocessing per the maker's instructions.
• Bleach: CDC lists release of toxic chlorine gas when hypochlorite is mixed with ammonia or acid (such as household cleaners) among its drawbacks. In a closed compartment that gas reaches the crew quickly. Clean heavy soil first and use bleach at the right dilution with nothing added
• Norovirus: it can persist on surfaces for days or weeks and resists many common disinfectants (CDC). Clean, then disinfect with an EPA-registered product whose label claims norovirus (EPA List G), at the label dilution and contact time, meaning the time the surface stays wet. A tuberculocidal, HIV or MRSA claim on the label is not a norovirus claim. Wash hands with soap and water after care during outbreaks
• Tuberculosis transport (CDC 2005): the patient wears a surgical mask if possible; the ventilation runs nonrecirculating with maximum outdoor air and the rear exhaust fan on, so air flows from the cab over the patient and out the back; a HEPA recirculating unit, if fitted, adds air changes. For rooms, CDC asks for enough time to remove 99% of airborne contaminants before reuse. Applied to the compartment (judgment): keep the N95 on, doors open and exhaust running for the agency's clearing time, then do routine surface cleaning. Surface wipes do nothing about airborne droplet nuclei, and recirculating keeps them in

Safe patient handling and moves that protect the patient

• NIOSH names patient handling (manual lifting, moving and repositioning) as the single greatest risk factor for work-related musculoskeletal disorders in healthcare workers, and says assistive lifting devices let workers do these tasks without risking injury when they are easy to reach and workers are trained. More hands and good body mechanics lower each share but keep the manual lift; a facility ceiling lift with a trained operator is the better choice
• Wheeled loads (CCOHS): push rather than pull wherever possible, stand behind the load, keep fixed handles about 91 to 112 cm above the floor, and walk at a normal pace (3 to 4 km/h). One-handed pulling and pushing from the side twist the trunk
• Fragile skin (HIGN skin tear protocol): use a lift sheet so skin does not drag on the bed, choose transfers that limit friction and shear, pad rails and leg supports, support dangling limbs with pillows or blankets, and hold dressings with gauze wraps, stockinette or netting rather than adhesive tape. Lifting on a draw sheet beats sliding on it, and gripping the sheet beats gripping thin forearms
• Severe obesity (Porhomayon 2011): expiratory reserve volume falls most in the supine position, often so far that functional residual capacity nears residual volume, because the diaphragm is pushed into the chest; small airways then close during normal breaths, the bases stop ventilating and hypoxemia follows. A very obese patient who becomes drowsy and hypoventilates when laid flat is sat back up first, with BVM assistance as needed; NASEMSO advises elevating the head up to 30 degrees for BVM whenever possible. Move and transport upright, with lift assist or a bariatric stretcher (lift assist: EMS Operations)
• Varicose vein bleeding (Gentile 2021): an autopsy report describes a 91-year-old woman found dead at home, with antiplatelet tablets at the bedside, after a varicose vein breach of 0.5 x 0.3 cm; the authors give a time-lapse of death of 5 to 20 minutes (a general figure from the literature, not this case), and limb elevation with compression of the bleeding point are described as easy life-saving maneuvers. Once controlled with the leg raised, keep it raised: a stair chair or walking lets the foot hang and can restart the bleed (classic teaching). Carry the patient flat with the leg up, recheck the dressing and treat signs of blood loss

Acute stress in the crew

A crew member who freezes during a child's resuscitation is having an acute stress reaction, not a lapse of will. Care for the patient continues without a pause: hand his task to an available rescuer, and keep him with the team rather than alone in the cab. Stress First Aid, the VA National Center for PTSD framework for recovery from stress reactions, has a version for firefighters and EMS personnel. Its core actions are Check (watch for signs of distress), Coordinate (get help from a colleague or supervisor), Cover (make the person safe or feel safer), Calm (reduce distress), Connect (link to supportive people), Competence (help regain the ability to do the job and cope) and Confidence (restore trust in self, peers and leaders). After the call, the crew checks on him and offers peer support and follow-up.