BY BARRY S. DASKAL
The concept of riding positions and tool assignments is nothing new to the fire service. Departments across North America have established standardized firefighting crew responsibilities and tool assignments for bread-and-butter structural firefighting, vehicle extrication, collapse rescue, hazmat incidents, and so on. What about our other bread-and-butter responses, the work we do nearly 75 percent of the timeemergency medical care?
MY BASIC EMS RULES
After a number of years in the EMS field treating a good number of patients and teaching quite a few students, I hold a few truths about EMS to be self-evident. Trauma jobs are fairly easy when you get down to it: “See a boo-boo, fix a boo-boo.” When you’re talking advanced life support (ALS), unless you have a dire life-and-death circumstance or a long-distance transport, you’re basically just adding an IV to basic life support (BLS) modalities. The real difference between a good EMT/medic and a great EMT/medic is how you handle medical emergencies. One of my mentors imparted this gem, “If you ask the right questions and actually listen to what your patient has to say, 95 percent of the time, the patient will tell you exactly what is wrong with him.”
WHY WE NEED RIDING POSITIONS
We need riding positions for EMS runs for the same reasons we need them for fire calls. To properly prepare for and respond to our bread-and-butter calls, every team member must know what equipment to take and what his responsibilities are.
Riding positions are an accepted practice on fire apparatus across the nation in paid and volunteer departments. No particular system, terminology, or tool assignment is universal or better than the other. It is whatever works in each particular department. The important thing is to have a system in place.
The same principles apply to EMS runs. Some departments already have a great system that works; some may never have thought of this type of approach for medical calls. The suggested riding positions/equipment assignments discussed below are intended to generate discussion within those latter agencies so they will establish some type of system.
LEVEL OF CARE AND TRANSPORT OPTIONS
The level of care provided ranges far and wide and often illustrates the East Coast/West Coast differences we see in the fire service. The East Coast agencies generally staff BLS first responder or basic EMT level-trained firefighters and a municipal ambulance response. Most West Coast agencies staff ALS engine companies with BLS/ALS ambulance response through the same municipal agency or a contract service.
The standard staffing for municipal ambulances is usually two EMS providers. The equipment ambulance crews carry into a scene is essentially the same as that covered below, with a few differences.
Crew sizes onboard fire apparatus vary across the nation; local politics determines the appropriate crew size. We’ll cover the most common minimum response crews.
Single-provider first responder. This is a “fly car” or other single-firefighter response vehicle designated to arrive prior to the fire apparatus or transport vehicle.
Equipment. A decent sized oxygen (O2 ) bag capable of holding a D-size cylinder, a nonrebreather face mask, a bag valve mask, a set of oropharyngeal airways, a patient care report, a blood pressure cuff with stethoscope, and a manual suction device. An automatic external defibrillator (AED, or EKG monitor if ALS equipped) must also be brought in, regardless of call type. If dispatch information indicates a traumatic injury, add a small well-equipped trauma bag.
 (1) Typical fire department first-response EMS equipment. (Photos by Jessica M. Daskal.) |
The first responder establishes patient responsiveness, begins the initial assessment, establishes a rapport with the patient, makes a transport priority decision, and conducts the “SAMPLE/OPQRST” interview (Table 1). This responder should immediately initiate any required lifesaving interventions during the primary survey.
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Three-member fire apparatus response. Personnel include an apparatus officer and two firefighters.
Officer.The apparatus officer is responsible for the radio and the clipboard/patient care report. The officer immediately determines if the scene is safe, assesses the scene for clues to the mechanism of injury or nature of the illness, and begins family and bystander interviews. The officer also generally fills out the basic or “pedigree” information on the patient care report and records pertinent auxiliary information discovered (e.g., patient medications, allergies).
 (2) Riding positions preplan what equipment firefighters carry into EMS calls and each member’s duties on-scene. |
Firefighter 1. This member handles the BLS or ALS jump bag and the defibrillator/EKG monitor. He is the lead EMT/medic and is responsible for establishing responsiveness, beginning the initial assessment, establishing a rapport with the patient, making a transport priority decision, and conducting the SAMPLE/OPQRST interview (Table 1). This firefighter should immediately initiate any lifesaving interventions required during the primary survey.
 (3) Firefighter 1 (left) carries the jump bag and AED; firefighter 2 (right) brings oxygen with a suction device and a patient-movement device. |
Firefighter 2.This member is responsible for the oxygen bag, portable suction, and patient-movement device. He assists with critical lifesaving interventions, initiates O2 therapy, and gathers vital signs. On noncritical patients, this member can then plan for patient removal by evaluating the easiest path, moving furniture, and so forth.
EQUIPMENT
There are many types of bags, belts, pouches, boxes, vests, and slingsall with various types of bells and whistles. I prefer to carry the minimum but maximize the value of what I am carrying. Let’s look at the essentials.
O2 bag.This should be capable of holding a D-size cylinder. Many new bags are padded and have sufficient storage space to carry several facemasks and nasal cannulas of various sizes, a bag valve mask, suction, and a set of oropharyngeal airways, among other items. This type of bag, with the addition of a blood pressure cuff with stethoscope and a nebulizer with the drug of choice, according to local protocols, should get you through nearly every EMT-Basic level medical call you may confront. With the addition of a handful of drugs, this setup will also suffice for ALS calls.
Suction device. All CFR, EMT, and paramedic textbooks, as well as many regional protocols, consistently recommend that any first responder making patient contact carry some type of suction device, whether an electric suction unit or the old-fashioned “turkey baster” (which I carry in my personal vehicle trauma kit).
Trauma/jump bag. The contents of your trauma bag are generally dictated by state, regional, or agency protocols. Whatever type of trauma bag you use, the most important recommendation is that the bag should have a waterproof bottom. There are numerous styles of bags; the type used is based on individual preference. Overpacking is the most common problem, regardless of the type of bag used. In addition to adding weight, an overpacked bag can cause equipment to become worn or damaged. Equipment can fall out of the bag or even get lost inside the bag so that you can’t find it when you need it, or it is useless when you do find it.
BLS trauma bag. A good medium trauma bag will include some of the following: 4 × 4s, 5 × 9s, a large multitrauma dressing, a burn sheet, two rolls of tape, three to four rolls of gauze, six triangular bandages, an occlusive dressing, two cold packs, a tube of glucose, a manual suction device, and body substance isolation equipment. Again, consult your regional or agency protocols.
ALS trauma bag.An ALS bag need not carry anything particularly extravagant. In addition to the above, all that is really required is a larger size bag stocked with an intubation module, intravenous therapy equipment, and a medication module. Many regions dictate that all medications be stored in a locked container. A good solution to lugging around a large drug box with everything you have on the rig is to remove your first-line medications from the packaging; leave the plastic “shooters” in the trauma bag, and pack the medication vials in a small plastic food storage container. Keep this small-sized care package in a locked cabinet. Place the date of the first expiring medication on the lid of the container and then seal it. Separate containers can be made up for cardiac or other specific call types. On arrival at the scene, open the locked cabinet and place the container with the medications in your ALS bag.
An AED or EKG monitor, if ALS-equipped. Many people would question the wisdom of always bringing the AED into every call. Why would a “male down with a reported arm injury” require an AED? Well, if that’s all the dispatch information you have, are you positive that this is what is going on? What the caller may not have witnessed or realized was that the patient’s squatting and sitting on the floor was a reaction to a sharp substernal pain in the chest. The caller reported that he saw a man on the floor cradling himself in a way that looked to him as if the subject had injured his arm. The caller had no way of knowing that the man was not actually cradling his arm for an injury but was actually hugging himself trying to relieve his fear and the pain in his chest.
Pediatric bag. I recommend having a completely separate pediatric bag stocked according to your regional protocols. Keep the bag sealed with tape; mark on it the date the bag was last inspected. A separate independent pediatric medication module should also be labeled and kept in a locked cabinet.
Patient-movement device. Even as a first-line suppression unit, many fire apparatus carry a range of patient-movement devices from stair chairs to long boards to folding stretchers. A patient-movement device must be brought in on every call. If removal of the patient may be difficult or you are confronted with an unstable or a critical patient, time will be of the essence. Start getting your patient packaged and ready to move before the ambulance crew arrives. This will be advantageous to your patient.
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Just as covering all the basics as quickly as possible on the fire scene helps to facilitate mitigation of the fire, the faster EMS personnel execute the tasks of patient care on the emergency medical scene, the better the patient outcome will be.
BARRY S. DASKAL is a police officer/aircraft rescue firefighter with the Port Authority of New York and New Jersey Police Department at John F. Kennedy International Airport in New York City. He is also a certified EMT-critical care and clinical lab instructor at the Nassau County (NY) EMS Academy. He previously served as a police officer with the New York City Police Department and as a supervising fire alarm dispatcher with the Fire Department of New York. He has been a volunteer firefighter since 1990 and has served as a captain and a training officer.
