ALS/BLS Vehicle Inspection Form

Transcription

1 ALS/BLS Vehicle Inspection Form Name of Provider: Inspection Date: Location: Unit #: License/Permit Level: Ambulance: EMS Vehicle: VEHICLE INFORMATION: Year: Make: Type: License#: VIN #: General Condition and Cleanliness: Exterior/Exterior Compartments: Interior/Interior Compartments: Patient Compartment Doors (hinges, gaskets, latches, and pins): Other: Items in ( ) are for ALS First Response Vehicles * Recommended for ALS First Response Vehicles *** Recommended for BLS Ambulance # May be combined with cardiac monitoring equipment ALS/BLS VEHICLE REQUIREMENTS: KED or comparable device 1* 1* Scoop Stretcher 1* 0 Long Backboard 2 (1*) 1* Backboard Straps 2 (1*) set 1* set Pediatric Immobilization Device 1* 1* Burn Pack (clean sheets, towels, gown, sterile gloves) Foam or Cardboard head restraints 2 (1*) 1* Rigid Collars (Peds, no-neck, short, 1 ea 1 ea regular, tall) Hot Packs 4 0 Cold Packs 4 0 Traction Splints (adult & Peds) 1* ea 1* ea Rigid Extremity Splints (leg & arm, 1 ea 1 ea adult & Peds) Petroleum Gauze 6 2 (0 for BLS) 12 sterile bandage compress (or 4 2 equivalent)

2 ALS/BLS VEHICLE REQUIREMENTS: 3 x 3 or 4 x 4 sterile bandage 4 2 2, 3, 4, or 6 roller gauze 6 2 Bandage shears 10 x 30 trauma dressing 2 1 Rolls of tape (assorted sizes, one 4 rolls 1 roll must be hypo-allergenic) 4 x 4 s; non-sterile, bag Triangular bandage 2 1 Exam gloves (sm, med, lrg) 1 box ea 1 box ea Non-Latex exam gloves (sm, med, 2 pairs ea 1 pair ea lrg) OB Kit - Commercial/Pre-packaged, meeting Title 13, section 1103,2(a)(17) requirements Space Blanket, Silver Swaddle, Commercial aluminum type blanket for conserving newborn warmth Sterile scissors or scalpel (may be part of OB kit) OPA (Sizes 00 6) 2 (1) sets 1 set NPA (Peds adult) 2 (1) sets 1 set BVM (Adult, Peds, Neonate) 1 ea 1 ea Wall mounted O 2 flow meter ( (0) 2 (0) lpm) Disposable O2 humidifier 2 (0) 2 (0) Nasal Cannula (Adult) 6 (2) 2 (1) Nasal Cannula (Peds) 4 (2) 2 (1) NRB O 2 Mask (Adult & Peds) 4 (2) 2 (1) O 2 Supply > 10 lpm x 20 min 1 (0) 1 (0) Portable O 2 Supply w/bottle Spare Portable O 2 bottle 1 0 O 2 wrench Suction device (on board) 1 (0) 1 (0) Suction device (portable) Suction Tip (Tonsil Tip) Suction 2 (1) 1 catheters Suction Tubing 2 (1) 1 Blood Pressure Cuff (Adult) 2 (1) 1 Blood Pressure Cuff (Peds) Blood Pressure Cuff (xl) Linen (sheets, pillow, pillow cases, 2 (0) sets 0 towels) Blankets 2 1 Ankle and wrist restraints 1 (0) 1 (0) Emesis Basin 4 (2) 0 Bedpan 1 (0) 1 (0) Bite stick 2 0 Stethoscope 2 1 Saline for Irrigation (1 liter) 4 (2) 2 (1) Urinal 1 (0) 1 (0) Antibacterial disinfectant solution for cleanup Instant glucose 2 tubes 1 tube Adhesive Bandages (assorted sizes) 1 pkg 0 pkg Defibrillator pads 1 set (BLS only) 1 set (BLS only)

3 ALS/BLS VEHICLE REQUIREMENTS: AED 1 (BLS only) 1(BLS only) Radio (Dispatch) Radio (MedNet) Radio (Portable) 1 (ALS) 1*** 1 (ALS) (BLS) ALS VEHICLE REQUIREMENTS: Suction catheters size 6-14 French 1 ea 1 ea Perilaryngeal Airway Device 2 (1) 1 (King Airway or Combitube) ETCO 2 Detector 2 1 Wave Form Capnography Monitor with recording capability.# CPAP device capable of delivering adjustable CPAP pressures ranging from 5-10 cm H 2 O with FiO 2 concentrations equal to or greater than 30% oxygen and capable of fitting small, medium, and large adult sizes. Laryngoscope w/ 2 sets of batteries 2 1 Laryngoscope blades, 1 set of 5 1 set 1 set straight (4 0) Laryngoscope blades, 1 set of 5 1 set 1 set curved (4 0) Spare bulbs (1 lg, 1 sm) 1 ea 1 ea Endotracheal tubes, Adult (5.5 mm 1 set 1 set through 9.5mm) cuffed, in increments of 0.5 mm Endotracheal tubes, Peds (2.0 mm 1 set 1 set through 5.0 mm) uncuffed, in increments of 0.5 mm ET Stylets to fit all size tubes 1 set 1 set McGill Forceps (child & adult) 1 ea 1 ea Water soluble lubrication jelly Multiple 0 Nebulizer (hand held) 2 1 Nebulizer (mask) 2 1 Mucosal Atomizer 3 ml 4 2 Jet Insuflation Device capable of delivering 50 psi with on/off valve and luer lock tip IV Catheters (10 or 12 ga) 2 2 Pulse Oximeter Glucose Monitoring System Activated Charcoal 100 mg (50 gm) 50 gm Adenosine, 6mg/2ml 36 (18) mg 18 mg Albuterol, 3 ml of a 0.5% solution or 12 (6) vials of 6 (3) vials of 12 unit-dose vials unit dose unit dose Aspirin, 81 mg, chewable 16 (8) tablets 16 (8) tablets Atropine Sulfate, 1mg/10 ml concentration (1 mg preload) 4 (2) preloads 1mg/10ml 4(2)mg 4 (2) preloads 1mg/10ml 4(2)mg

4 ALS VEHICLE REQUIREMENTS: Atropine Sulfate, 20 ml of.4mg/1ml 1 vial 1 vial concentration Calcium Chloride 2 (1) gm 2 (1) gm Dextrose, 50% preload 25 gm/50ml 100 (50)gm 50gm 4 (2) preload 4 (2) preload Dextrose 25% 25 gm 25 gm 4 (2) preload 2 (1) preload Diphenhydramine (Benadryl), (50) mg 100(50) mg mg/1 ml or 25 mg/ml Dopamine, 400 mg /250 ml (pre mix) 1(0) 1(0) or equivalent Epinephrine, 1:10,000 ((1mg/10ml) 6 mg 3 mg Epinephrine, 1:1,000 (1mg/1ml) 3 mg 3 mg Furosemide (Lasix) 40mg/ml 160 mg (0) 80 mg (0) Glucagon, 1 mg/ml 2 mg(1) 1 mg(1) Lidocaine, 10mg/ml or 100 mg/10ml 300mg (3 300 mg (3 (preloads) preload) preloads) Naloxone, (Narcan) (2mg/5ml or 2 8 mg 4 mg mg/2ml) Nitroglycerine Spray, 0.4 mg/spray 1 bottle 1 bottle providing metered doses or tablets. 0.4 mg Nitroglycerine Paste 2% ointment 1 ointment 1 ointment with tape for application Odansetron(Zofran) 24 mg 12 mg Intraosseous Needles 15 ga & 18 2(1) ea 2(1) ea ga, IV Catheters size ga 5 ea 3 ea Huber Needle. 20 ga, Needles for injection, ga, and 5 (3) ea 3 (2) ea ga NaCl, 250 ml 2 (or add (or ml) ml) Catheter Tip Syringes 2 oz. Syringes 1, 3, 5, 60 ml 2 ea 1 ea Constricting bands 3 1 Sharps Container (as necessary) Alcohol Preps Multiple 0 12 Lead EKG Monitor with paper printout capable of transcutaneous pacing NaCL for dilution 20 ml 20 ml Sodium Bicarbonate, 50mEq/50 ml 200 meq (50) 100 meq (50) Midazolam (Versed) 20 mg (5 mg/ml) 40 (20) mg 20 mg **** Maximum 40 mg Morphine Sulfate, 10 mg/ml 60 mg (20) 30 mg (20) **** Maximum 60 mg) Arm boards (infant, child, adult) 1 ea 0 Non-Alcohol Sterile Preps Multiple 0 Medication Added Labels Multiple 0 NaCl, 500 ml 4 (2) 2 NaCl, 1000 ml 8 (2) 4 (2) IV extension tubing 4 (2) 2 (1)

5 ALS VEHICLE REQUIREMENTS: Variable Drip Administration Sets (or the following three set types): 8 (4) 4 (2) Macro-Drip (10-20 gtts/ml) Micro-Drip (60gtts/ml) Pediatric 100 ml Volume Control Chamber (Volutrol) 4 (2) 4 (2) 2 2 (1) 2 (1) 1 Defibrillator Pediatric paddles or pads Defibrillator pads Multiple Multiple 12 Lead Electrode pads Multiple Multiple 12 Lead Monitor Cables 2 sets 1 set Charged Batteries (back-up) 2 1 Sterile Gloves in various sizes 6 1 Broselow Tape, Latest Version MCI TRIAGE PACK REQUIREMENTS: (Required for ALS units) Set of 5 MCI vests (per MVEMS Policy ) Triage Tags Set of MCI forms and Duty Sheets 2 1 (per MVEMS Policy ) Complete set of OPA (size 0 to 6) Additional OPA (size 4, 5, 6) x 4 compress with ties 4 2 Tourniquets 4 2 Bandage scissors/shears Skin Markers 2 1 Grease Pencils 2 1 Additional pens and pencils 2 1 RECOMMENDED PPE: Hard Hat Work Helmet (Blue) Eye Protection Hearing Protection Body Garment (uniform) Footwear covers 1 pair per Person Scissors/Shears (carried on Person) Jacket EMS w/protective stripes Gloves Chemical Protective Nitrile 1 box Gloves Work 1 pair per Person Footwear (worn on Person) 1 pair per Person N-100 or N-95 mask 5 Escape Hood Flashlight or Headlamp Knife, folding (carried on Person) Stethoscope

6 RECOMMENDED PPE: Mark 1 Auto-Injector Kit Garment single use Personal Communication Device (radio) RECOMMENDED EXTENDED OPERATIONS EQUIPMENT Daypack GO pack for the 1 following equipment Quart of water 1 Water purification unit 1 Rain Gear 1 Emergency Garments 1 MRE s for 72 hours 1 Ear Protection 1 Mark 1 Antidote Kit 1 Field Operations Guide (FOG) 1 OPTIONAL ALS EQUIPMENT 2 (0) 0 Vacutainer type blood drawing device with needles Blood tubes: SST & EDTA 2 (0) 0 3-way stopcock with tubing 1 0 Cath-n-Sleeve Sterile Suction Cath 1 (0) 1 (0) Lidocaine drip, 2 gm/500 ml pre-mix 1 0 Lidocaine Jelly 1% 1 tube 1 tube Endotracheal Tube Introducer (ETTI) 2(1) 1 IO Drill Intraosseous Needles - If using EZ- IO 15 mm, 25 mm, and 45 mm 2(1) ea 2(1) ea OPTIONAL ALS & BLS EQUIPMENT Thermometers (non-mercury) 1 0 Cell Phone 1 0 Satellite Phone 1 0

7 s: Inspected By: Date Time Pass Fail Initial Failure - Pass Upon Immediate Resupply OUT OF SERVICE Provider Representative s Signature: Date: If Fail, note reason above. Failure shall be indicated if any minimum amounts required above were not immediately present at the time of the inspection. All supplies immediately added to ambulance to meet minimum requirements shall be noted in s section. I, acknowledge the deficiencies on this inspection form and recognize that the service has days to correct them. Upon correction of said deficiencies, I understand the provider must notify Mountain-Valley EMS Agency of the corrective action taken by completing the bottom of this form and returning a copy to Mountain-Valley EMS Agency, 1101 Standiford Ave, Suite D1, Modesto, CA Tel: (209) , Fax: (209) Provider Representative s Signature: Date: All deficiencies as noted within this inspection report have been corrected. I hereby verify by my signature that this vehicle/equipment now meets or exceeds Mountain-Valley EMS Agency requirements as set forth in the MVEMSA Policy Provider Representative s Signature: Date: