11 EMS Operations and Special Situations

Coordinate through incident command

The Incident Command System (ICS) is the on-scene management structure within the National Incident Management System. It gives multiple agencies a shared framework for command, communication, and resource coordination, and expands or contracts to match incident complexity.

The Incident Commander establishes objectives, assigns resources, and maintains overall responsibility for incident safety and operations. When multiple agencies or jurisdictions share authority, Unified Command agrees on common objectives while each agency retains its own responsibilities.

Depending on the incident, the organization may include these functions:

• Operations: Directs tactical work, including medical operations.

• Planning: Tracks the situation and resources and supports incident action planning.

• Logistics: Obtains facilities, supplies, and other support.

• Finance/Administration: Tracks costs, time, and claims.

• Command staff: Supports command through functions such as safety, public information, and liaison.

Use common terminology, follow the chain of command, and report to one assigned supervisor. If command is established before you arrive, announce yourself and request an assignment rather than self-deploying. For example, at a multi-vehicle collision, the first arriving unit may establish command, identify hazards, and request resources. Later-arriving EMS units receive assignments, such as triage or transport, from the designated supervisor.

Triage when resources are limited

Triage allocates limited resources to achieve the greatest overall benefit. Unlike routine patient assessment, it is rapid, focuses on immediate threats and available resources, and must be repeated as conditions change.

SALT means Sort, Assess, Lifesaving interventions, Treatment/transport. First, sort patients globally: assess those who are still or have an obvious life threat, then those who can wave or make purposeful movement. Direct walking patients to a designated area for later assessment.

During individual assessment, address permitted immediate lifesaving interventions, then evaluate breathing, perfusion, mental status, and injury severity. Examples of interventions include controlling major hemorrhage, opening the airway, chest decompression when indicated and within scope, or administering an available antidote.

SALT categories are Immediate (red), Delayed (yellow), Minimal (green), Expectant (gray), and Dead (black). Expectant is not the same as dead: it indicates that a patient is unlikely to survive given current injuries and available resources, and comfort-focused care may be appropriate. Follow local triage-tagging and secondary-triage procedures, and reassess when resources or patient status change.

Recognize and manage hazardous-materials risks

At the awareness level, the priority is to recognize a possible hazardous-materials incident, protect yourself and others, and notify appropriate resources. Do not enter a contaminated area or perform technical rescue without the required training, protective equipment, and assignment.

From a safe location, look for clues such as placards, container labels, shipping papers, unusual odors or clouds, multiple patients with similar symptoms, and reports of a release. Do not approach a suspicious container to read it, and do not rely on odor to judge safety. Move away from the hazard, consider wind and terrain, and report the location, observed indicators, patient count, and access concerns. Establish or follow incident command and keep unauthorized people out of the hazard area. Stay upwind or uphill where appropriate, ensure the air is safe to breathe, isolate the area, and establish control zones.

Use the Emergency Response Guidebook (ERG) for initial guidance at transportation-related hazardous-materials incidents. Use material identification information and the current guide's isolation and protective-action recommendations. Distances vary by material and circumstances, so a single rule-of-thumb distance is not a substitute for the guide. Request fire or hazardous-materials specialists and follow their direction.

Chemically exposed patients may contaminate rescuers, vehicles, and hospitals. Avoid unprotected contact and coordinate decontamination before routine transport when indicated.

Protect people during ambulance operations

Safe operations begin before the ambulance moves. Use appropriate personal protective equipment, maintain situational awareness, park to protect the scene without creating new hazards, and secure equipment and compartments.

Keep seat belts fastened whenever feasible. Secure the stretcher to its mount and restrain the patient according to equipment instructions and agency policy. Restrain crew members as well as patients: an unrestrained clinician can become a projectile during a crash.

Emergency lights and sirens do not remove the duty to drive with due regard. Reduce speed as conditions require, anticipate intersections, and proceed only when it is safe and permitted by law and policy. The driver should not be pressured into unsafe maneuvers.

If the ambulance is involved in a collision or becomes unsafe, stop in a safe location, notify dispatch, and arrange appropriate care and transport for the patient.

Communicate clearly and hand off care

Operational communication should be brief, accurate, and closed-loop. Identify yourself and your location, state the situation and immediate risks, make a specific request, and confirm that the message was received and understood. Use plain language and standard terminology, especially when agencies may use different local codes.

A useful hospital radio report includes unit identification, estimated arrival, patient age and chief concern, relevant findings and vital signs, important history, care provided and the patient's response, and any special resource request.

At bedside, give a structured handoff such as SBAR: Situation, Background, Assessment, Recommendation. Then transfer care explicitly and document the receiving clinician or team. Protect patient privacy. HIPAA permits providers to share information needed for treatment with other providers, but patient information should not be disclosed casually or to unauthorized listeners.

Plan and manage interfacility transport

Interfacility transport moves a patient between care facilities for a defined clinical purpose, such as access to a needed specialty or level of care. Before departure, clarify the reason for transfer, destination and acceptance, the sending clinician's orders, the patient's condition and foreseeable risks, and the required crew, equipment, and monitoring.

Match transport capability to the patient's needs. Escalate concerns if the patient may deteriorate beyond the crew's capacity or if essential equipment or information is missing.

During transport, continue appropriate monitoring and treatment. Reassess after interventions and whenever the patient's condition changes, and communicate significant changes to medical control or the receiving facility as directed by protocol. Provide a complete handoff and ensure relevant records accompany the patient.

For transfers governed by EMTALA, the sending hospital has responsibilities that include minimizing transfer risks, arranging qualified personnel and medically appropriate transport, obtaining agreement from the receiving facility, and sending pertinent records. EMS should follow applicable orders, laws, and agency policy and promptly raise safety concerns.

Maintain safety as conditions change

Across incident response, patient transport, and handoff, safe operations depend on working within the incident structure and assigned role, matching actions to available resources and patient needs, and communicating when conditions change. Reassess, report risks, and request the resources needed to keep care safe.

• closed-loop communication