1. SCENE SIZE-UP AND GENERAL IMPRESSION Presence Regional EMS March 2014 CE

2. OBJECTIVES  Discuss the concept of heightened awareness when approaching the scene of any emergency.  Discuss possible environmental, chemical and biological hazards that may be present at an emergency scene and ways to recognize these hazards.  Outline methods that EMS providers can employ to protect themselves from scene hazards.

3. OBJECTIVES  Using a variety of scenarios, develop entry and exit plans from emergency scenes.  Identify special precautions to take in light of concealed carry weapon laws.  Describe observations used to determine the degree of severity of a patient’s condition while developing a general impression.

4. INTRODUCTION FOR SCENE SIZE-UP  Scene size up is based on judgment and instinct  Scene size up is not a step by step process but a series of timely decisions.  Although you must consider all the elements of scene size up important, circumstances will determine the priority you give to each one.

5.  Emergency scenes are dynamic and can change suddenly  A call for an injury to a child can erupt into a violent domestic dispute if one parent blames the other.  A hazardous material spill can ignite.  An improperly stabilized car can shift.  A large number of inebriated people can be extremely unpredictable and dangerous.

6. WHEN DOES SCENE SIZE-UP BEGIN?  Scene size up begins when you are dispatched to the call  Shots fired at a neighborhood bar.  Patient with chest pain at a residence  School bus collided with a truck  Semi truck leaking “green liquid”  Imagining these situations in route can help formulate plans for scene size up and collection of resources

7. COMPONENTS OF SCENE SIZE-UP  Standard Precautions (personal protective equipment - “I have my gloves on”)  Scene safety  Determination of available or needed resources  Location and number of patients  Mechanism of injury/nature of illness

8. STANDARD PRECAUTIONS  The best defense against blood-borne, body-fluid-borne, and air-borne agents is to use appropriate personal protection equipment.

9. REMEMBER  If it is wet and its not yours…don’t touch it.

10.  With a suspected tuberculosis patient, you may place a surgical-type mask on the patient while you wear a HEPA or N-95 respirator.

11.  Careful, methodical hand washing helps reduce exposure to contagious disease.

12.  Place all contaminated items in the appropriate biohazard bag.

14. IS THE SCENE SAFE?  Your personal safety and that of your team is the top priority at any emergency scene.  Look for potential hazards during scene size up.  If your scene is unsafe either make it safe or wait until someone else does.

16. WHAT COULD BE A HAZARD AT A SCENE?  EnvironmentalSuch as??  Hazardous materialsSuch as??  ViolenceSuch as??  STOP. List at least 3 examples of each type of Hazard. If you are doing this lesson as self study, write down your ideas to submit later.

17. SCENE HAZARDS  Environmental  Weather  Terrain  Water  Electricity  Confined Space

18.  Hazardous Materials  Chemical  Biological  Nuclear  Exposives

19.  Violence  Weapons  Drugs  Pets  Gangs  Domestic Disputes

20. FOR EACH OF THE FOLLOWING SLIDES:  What hazards do you see in these scenes?  What can you do to protect yourself from these hazards?  What additional resources might be needed in each scene?  How can you safely enter and exit each scene?

21.  If you are doing this program as self study, write down the answers for these questions to submit later

23. WHAT ELSE DID YOU THINK OF?  Hazards  Dog under the tree  Uneven sidewalk  Large bushes near door  Additional resources  Have someone restrain dog  Additional lift help to get patient in and out of front door down steps

24. Source: © Keith D. Cullom

25. WHAT ELSE DID YOU THINK OF?  Hazards  Active fire  Unstable vehicle  Highway traffic  Additional resources  Wait till fire deems it safe to approach or have them bring patient to you  Police to control traffic

26. .. Source: Courtesy of James Tourtellote/U.S. Customs and Border Protection

27. WHAT ELSE DID YOU THINK OF?  Hazards  Rough terrain  Down hill slope  Additional resources  Will need multiple people to carry litter  Consider calling for a helicopter

29. WHAT ELSE DID YOU THINK OF?  Hazards  Snow and ice on sidewalks  Cold temperatures  Additional resources  Have someone shovel sidewalk or put down salt  Need additional lift help to get the patient out of the house

31. WHAT ELSE DID YOU THINK OF?  Hazards  Rough terrain  Large drop off  Additional resources  Need someone experienced in vertical rescue  Need special equipment for vertical rescue  Consider calling a helicopter for transport

33. WHAT ELSE DID YOU THINK OF?  Hazards  Angry patient with potential for violence  Potential weapon in patient’s hands  Possible small space with limited exits  Additional resources  Contact law enforcement  Have multiple providers if needed to subdue patient

35. WHAT ELSE DID YOU THINK OF?  Hazards  Already a crime scene  On lookers not secured a safe distance from EMS  Poor lighting  Additional resources  Police to control scene and keep bystanders back  Use scene command to control EMS poviders

37. WHAT ELSE DID YOU THINK OF?  Hazards  Loose rug by door  Additional resources  Remove rug so no one slips

39. WHAT ELSE DID YOU THINK OF?  Hazards  Possible leaking material from tank  Traffic  Additional resources  Call in Hazmat Team to deal with truck  Police to control traffic

40. EVEN THE MOST PEACEFUL-LOOKING SCENE CAN POSE POTENTIAL DANGERS.

42. EMS AND THE CONCEALED CARRY ACT

43. ILLINOIS FIREARM CONCEALED CARRY ACT  Effective January 1, 2014 Illinois citizens can obtain a permit to legally carry a concealed firearm.  EMS providers are likely to encounter an increasing number of such concealed firearms.  The potential for inadvertent harm to EMS responders is a concern.

44. PREFERRED PRACTICE  EMS providers should make all attempts to avoid transporting firearms of any kind.  Law enforcement should be involved as needed.  Region 6 will be requiring that an appropriate container be available in all transport vehicles to secure a firearm if necessary.  All firearm guidelines also apply to anyone requesting to accompany the patient to the hospital.  If it is necessary to transport a firearm in the ambulance, EMS providers should notify the receiving facility in the radio report.

45. PATIENT CARE WITH CONCEALED CARRY  During initial assessment ask the patient if they are carrying concealed firearms.  If the patient’s condition requires immediate transport, EMS providers must not delay transport unless there is an imminent threat to safety.  If the patient is stable and law enforcement is en-route, transport may be delayed in order to relinquish the firearm to police.

46.  If the patient is conscious ask the patient to secure the firearm at the residence/personal vehicle. If the patient refuses, delay transport until law enforcement arrives to intervene.  If the patient has an altered level of consciousness, EMS providers should not attempt to have the patient hand over the firearm on their own but leave this to law enforcement to manage.  If the patient is unresponsive and requires immediate care, and law enforcement is not available, EMS providers will need to carefully separate the firearm from the patient prior to transport.  EMS providers should not attempt to disarm a patient that they feel would potentially use the firearm against them.

47. FORMING A GENERAL IMPRESSION  First intuitive evaluation of your patient  Also known as your “view form the door”  Helps determine the patient’s general clinical status  Stable vs. unstable  “sick” vs “not sick”  Transport priority

48.  General impression is based on information gathered from:  The environment  The mechanism of injury or nature of illness  The patient’s posture and overall look  The chief complaint  Your instincts

49. GENERAL IMPRESSION  Based on your own instincts and what you can see of the environment determine a General Impression for the patients on the next set of slides.  Sick vs Not Sick  Problem vs No Problem

50.  If you are doing this program as self study, write down the answers for these slides to submit later

51. 1.

52. 2.

53. 3.

54. 4.

55. 5.

56. 6.

57. 7.

58. 8.

59. 9.

60. 10.

61. ANSWERS  1. Unconscious = sick  2. Tripod position + increased work of breathing = sick  3. Raccoon eyes, possible spinal fluid from nose, swelling and blood in airway = sick  4. Child has tracheostomy and is on ventilator, lots of other equipment = potential for problem but child looks ok  5. Pale, possible altered level of consciousness + elderly = sick

62.  6. Color good, no apparent problems = not sick  7. Active bleeding, pale + altered level of consciousness = sick  8. Child alert but exposed to hazardous material = problem  9. Elderly, appears anxious and clutching chest = sick  10. Child in tripod position + drooling + anxious = sick

63.  If doing this CE individually, please e-mail your answers to:  Shelley.Peelman@presencehealth.org Shelley.Peelman@presencehealth.org  Use “March 2014 CE” in subject box.  IDPH site code: 06-7100-E-1214  You will receive an e-mail confirmation. Print this confirmation for your records and document in your PREMSS CE record book.