Introduction

Purpose

The West Chester University Emergency Medical Service [WCU EMS] Training Manual is designed to acquaint new members and re-acquaint old members with the policies, operating procedures, and functions of the organization. It should not necessarily be used as a "source of rules and regulations" when there are official questions in relation to the organization. However, it may be used as a source of guidance. Further, the manual is not intended to replace medical training courses or the WCU EMS training lectures, but rather function as a supplement.

Completion

After completion of the classroom and practical portions of the training program, the preceptee must schedule an interview to assess their knowledge concerning policies, bylaws, and patient assessment with the Training Officer and Director. If the interview is satisfactory, the preceptee may be considered for primary EMTship.

Note: At any time, should situations warrant, the Training Officer or Director may revoke certification in any one or more areas. At that time, the member must once again complete those areas in order to regain proficiency.

Superseding Documents

We have attempted to make the Training Manual as accurate as possible. However, the official policies of WCU EMS are specified in the Bylaws, Operating Policies, and Treatment Protocols. In the event of a conflict, those documents, Pennsylvania Act 45 (also known as the Emergency Services Act), and Pennsylvania Department of Health Rules and Regulations supersede the Training Manual.

Background Information

WCU EMS is officially known as West Chester University Emergency Medical Service and provides medical coverage and training for the West Chester University campus. Funded by West Chester University Health Center, WCU EMS receives authority to act on campus through the West Chester Department of Security, Emergency Medical Service Institute, and Commonwealth of Pennsylvania Act 45 (Emergency Services Act).

History & Background

Organizational History

Creed

Organization

Primary Role

The primary role of WCU EMS is response to campus medical emergencies. WCU EMS is dispatched by Campus Police to campus medical emergencies via two-way radio 24 hours a day, 7 days a week, when school is in session and during breaks as personnel allow. We provide a vital and life-saving service to the campus community.

Secondary Role

The secondary role of WCU EMS is the provision of training in EMS and related fields to the campus community, and education in injury and illness prevention. To this end, we provide our members and the campus community with classes in Cardiopulmonary Resuscitation [CPR]. Furthermore, WCU EMS helps make others on campus aware of classes that are available at the Good Fellowship Training Institute [GFACTI], the Chester County Department of Emergency Services [DES], and other locations in the West Chester area. Classes are available in areas such as Cardiopulmonary Resuscitation [CPR], First Responder [FR], Emergency Medical Technician-Basic [EMT-B], Emergency Medical Technician-Paramedic [EMT-P], rescue, hazardous materials [HazMat], and other specialized certifications.

Members are encouraged both to receive a certification that accurately reflects their ability, and to maintain and improve skills through volunteer or paid work either locally or at home. Members certified in Pennsylvania are eligible to act up to the Pennsylvania EMT-Basic standard of care. Members not certified in any capacity, or certified in another state or area, must either attend classes for certification or apply for reciprocity to be eligible to run calls with WCU EMS.

EMS Office

The EMS office is located on the ground floor of Tyson Hall, room 020. That room is the central equipment storage place and may contain notices of meetings, upcoming classes, or other events of interest. The rear half of the office contains two bunk beds. All primary EMTs are encouraged to obtain a key to the office by submitting a request to the Equipment Officer. Precepting members can borrow an office key from the WCUPD dispatcher when they need access to the office; to borrow a key, you may need to show your WCU EMS ID or WCU student ID.

The office phone may be used for personal (local and on-campus) calls; however, long distance and local long distance calls cannot be made from it without the use of a phone card. Please don't tie up the office phone for hours at a time with personal calls. Since we get business calls at the office, don't be a clown when answering the phone. Answer the phone "EMS" or "STATION 58," and state your name. If someone calls to request medical advice, they should be referred to Health Services; we do not give out medical advice over the phone. Should someone call the office with an emergency, have them contact WCUPD.

Crew Quarters

The EMS crew quarters are located in Tyson Hall, room 020. The crew quarters are intended for use by on-duty crew, to facilitate response to calls at night. The crew quarters have access to a bathroom with shower, a kitchen, two bunk beds, a TV and VCR. While all members are welcome to drop by the crew quarters at any time, it should be stressed that the quarters exist for the primary use of the on-duty crew, and any members or visitors which disrupt crew operations may be asked to leave.

Organization of Offices

WCU EMS is administered by the Director/Advisor.

The Director's main responsibilities include representing the organization to outside interests and managing all administrative concerns. The Director is also ultimately responsible for all aspects of the organization, including operations, and reports to the Assistant Dean of Students (Health Center Director).

Operations Chain of Command

The Director is ultimately responsible for all operational concerns. The Supervisor represents the Director on incident scenes, and controls response efforts of EMS for the campus. The three supervisors report to the Director. Each Supervisor has shared duties and specific duties assigned to each one. The primary EMTs are responsible for their on-duty crew, along with patient care. Secondary EMTs work under the Primaries for guidance and evaluation for obtaining Primary status. Attendants assist the rest of the crew as needed.

Performance Testing

In order to best determine the competency of each precepting member, the organization has established an evaluation system that assesses the performance of normal EMS duties, in addition to didactic knowledge and scenario-based skill evaluation. There are three areas of skills testing: didactic knowledge, scenario-based skills testing, and evaluation on actual calls. This evaluation system is described in the Primary EMT Standard, which enumerates the requirements for becoming a primary EMT. Note that simply completing the requirements in the Primary EMT Standard does not automatically make you a primary EMT; those are simply the minimum requirements.

Didactic Knowledge

There are numerous pieces of "book knowledge" that you will need to be familiar with in order to be an effective member of WCU EMS. This knowledge is tested through the verbal quiz section of the Primary EMT Standard and through the membership interview. Most of the didactic questions are answered in this training manual; if you have questions about any piece of information, feel free to ask any primary EMT, the Training Officer, or the Operations Manager.

Scenario-Based Skills Testing

You are expected to complete several training scenarios as part of the performance testing. The aim of these scenarios is to test skills that would otherwise not be exercised frequently on actual calls, to familiarize you with calls that they may not encounter on a regular basis, and to enable you to make mistakes without endangering yourself, your crew, or your patient.

Most scenarios can be completed successfully by one person working alone, but you may be given crew members depending on the scenario and the availability of other people at the time you run the scenario. (Note that additional crew members can be both a help and a hindrance. If you don't have crew members, you don't have to worry about giving them instructions...) Crew members for a scenario will usually function at the level of a (relatively new) precepting member, meaning that you can give them specific instructions and they will usually carry them out appropriately, but they cannot assess the patient or make treatment decisions. If you would like a "ghost person" to hold C-spine, you must first apply the cervical collar, at which point the ghost person can take over. (Ghost medics are only available at the discretion of the evaluator, of course.)

A scenario begins with the evaluator giving you the dispatch information. You can ask the evaluator any questions that you have (what does the scene look like, is Campus Police on the scene/on the way, etc.), and then enter the scene and begin treating the patient(s). Since one of the goals of scenario testing is to exercise your skills, you should treat the scenario as an actual call, and physically perform any skills or actions that you would on a real call. For example, if you want to know the patient's blood pressure, you should actually take the blood pressure (or have a crew member take it); if you would bandage the patient's injury on the actual call, you should also bandage the simulated patient during the scenario. During the scenario you should interact primarily with the patient, with the evaluator only stepping in to change vital signs as necessary and tell you what you "see."

Scenarios are evaluated according to objective and subjective criteria. You need to score at least an 85% in order to pass the scenario. Once the scenario is over, the evaluator will give you feedback about your performance and tell you whether or not you passed the scenario. Remember to keep all aspects of the call in mind when you run a scenario; the scenario may test skills other than patient assessment and treatment (such as scene safety/management, patient interaction, and so forth). If you disagree with the grading of a scenario that you ran, contact the Training Officer or the Operations Manager.

Call Evaluations

In addition to scenarios, you will also be evaluated on every call for which you direct care or in which you have a major role. Some members have argued that this puts an unfair amount of pressure on you, the precepting member, especially considering that some portions of the call evaluation are cumulative and negative scores count against you. However, it's important to remember that regardless of whether you are being evaluated by another WCU EMS member, you are always being evaluated by someone whose opinion matters even more than theirs: the patient. For this reason, we feel it is important that every member constantly be mindful of their performance on calls, and evaluations on every call help reinforce that for precepting members.

The call evaluation should be filled out by the crew chief on the scene. The evaluation form is fairly self-explanatory; if you have questions about it, contact the Training Officer. If you have any problems with a call evaluation, they can be referred to the Training Officer, the Operations Manager, and finally the Quality Assurance Board.

Local Procedures

Duty Shifts

Precepting members are eligible to be on duty and complete shifts with WCU EMS after completion of the requirements set out in the Precept Member Policy, which includes an orientation session and satisfactory interview. Precept members must sign up for shifts using the appropriate procedures, as set out by the Director and Scheduling Officer.

During the school year, shifts run with 2 6 hour shifts: from 7pm to 11pm and 11pm to 7am the following day. There are six slots for members to be on call during each shift. These slots are:

The Supervisor, primary EMTs, and precept members on duty should be available to respond to all calls during the shift. (For members who live off-campus, this includes sleeping on campus in the crew quarters or the office.)

Hospital/Treatment Options

If the patient requires further evaluation or treatment at a hospital or other treatment facility, they have a number of choices. WCU has a Student Health Center which can treat many simpler problems. The nearby hospitals include Chester County Hospital, Brandywine Hospital, and Paoli Hospital. If the patient has a preferred hospital, that preference should be taken into account; remember that the patient's decision is final, and we can only provide advice. Also keep in mind that many patients have health insurance that may restrict or specify their hospital choice. However, many of our patients are not familiar with the local hospitals and will ask you for a recommendation. Which hospital to recommend usually depends on the nature of the incident and the patient's affiliation with the university (if any).

Student Health Center/Health Service

Located on the second floor of Wayne Hall, Health Services will treat any WCU student (undergraduate or graduate), but will not treat staff members or faculty. They are open Monday to Friday 8am to 8pm, and Saturday 9am-5pm while classes are in session. During the summer, they operate on restricted hours: Monday to Friday 8am-5pm. Health Services can generally handle the following types of injuries:

Suturing simple lacerations on extremities (i.e., lacerations that do not require deep cleaning or debridement, and not on the face, head, torso, or back)

Evaluation of simple musculoskeletal injuries

OB/GYN patients who need a pelvic exam

Evaluation of sexual assault victims that do not want to go to a hospital

Keep in mind when you send a patient to Health Services that if they require services that Health Services can't provide (i.e., X-rays, complex suturing, etc.) that they will have to go down to a hospital anyway, so sending them to Health Services may delay their treatment. Also keep in mind that Health Services does not have the facilities to manage a serious emergency (uncontrolled hemorrhage, respiratory compromise, etc.), so serious patients should always be sent directly to the ED. The best analogy to use is that Health Services provides care similar to that in a family practitioner's office or urgent-care clinic. Since Health Services will likely be much less expensive than an ED visit, the patient should be given this option if their injury is eligible for treatment there and Health Services is open. Some patients who can go to Health Services will still choose to go to the ED, and that is a valid option; just because the patient is eligible to go to Health Services does not mean that it is their only choice.

Chester County Hospital

Located in West Chester on Marshall St, CCH is geared mainly towards primary care. Minor trauma and medical patients may have a shorter wait here. Shadyside is reputed for its cardiac department and cancer patient care. CCH is also the "comp hospital" for WCU employees, so WCU staff and faculty who are injured while on the job should go here in order to be eligible for worker's compensation. On-line medical command for WCU EMS EMTs is supplied by CCH ED Staff.

Brandywine Hospital

Located near Coatesville, Brandywine is a Level I trauma center, and usually all major trauma and medical patients are sent here. BWH has a large Emergency Department and can accommodate large numbers of patients. Unfortunately, patients with minor or moderate ailments may be triaged to a low priority, resulting in a long wait if the ED is busy with more serious patients. Presby is reputed for the SkyCare air ambulance service.

Paoli Memorial Hospital

Located in Paoli on route 30, PMH is primarily known for their psychiatric emergency department; however, they do have a conventional ED that treats medical emergencies.

Other hospitals that patients may mention, but will probably not be transported to from WCU, include: Chester-Crozier, Children’s Hospital of Philadelphia, and Presbyterian Hospital. You do not have to know where all of these hospitals are, but it is good to be familiar with their names.

Medical/Legal Concerns

Negligence

Most of the lawsuits filed against EMS agencies are for negligence, which alleges that the EMS provider did something they shouldn't have to cause the patient harm, or harmed the patient by failing to do something that they should have. While WCU EMS is covered by university insurance policies, it is important to be aware of what constitutes negligence, so you can avoid being negligent. There are four components of negligence, all of which must be fulfilled in order to be found negligent. They are duty to act, breach of the duty, injury to the plaintiff, and proximate cause.

Duty to act means that there must have been some obligation for you to provide care to the patient. As an ordinary citizen, you do not have a duty to act; for example, if you see a person lying unconscious on the ground, you are free to ignore them and continue on your way. However, if you are on shift with WCU EMS, you do have a duty to act, because by being on shift you have agreed to respond to medical emergencies and render appropriate care. Your duty to act is set by and limited by your state certification; you are obligated to render care as an "ordinary and reasonable" person at your certification level would. This means that you are not expected to provide interventions that are beyond your scope of care, but that at the same time you are expected to provide all interventions that an average person with your training would be able to.

Breach of the duty means that you need to have somehow failed to act in accordance with your duty. This might mean that you did not respond to the call quickly enough (where "quickly enough" is defined by how an average reasonable person would have responded), did not bring in the appropriate equipment, or did not provide the appropriate care. Breach of duty is an important component of negligence, because it means that if you do everything you are supposed to do and something bad still happens to the patient, you cannot be found negligent.

It is important to realize that if you begin to render care to someone, even if you did not have a pre-existing duty to act, you establish such a duty when you offer aid. This means that if you are the ordinary citizen who notices someone unconscious on the sidewalk, and you go over to them and shake them to see if they are okay, you have now established a duty to act and need to help them to the best of your abilities. Once you have started helping someone, you should not stop unless you finish helping them, someone with appropriate training takes over for you, they tell you to stop, or you become physically unable to continue.

Injury means what it seems to mean: the patient needs to sustain some injury or harm in order for you to be negligent. If nothing bad happens to the patient, even if you made a mistake, you cannot be found negligent.

Finally, proximate cause means that your actions must have been a reasonably direct cause of the injury or harm. For example, if you did not ventilate a patient who was in respiratory arrest and they died, your actions are likely the direct cause for their death. As a counterexample, say you are the only medic on duty and you are called to the scene of a cardiac arrest, which you take 10 minutes to get to because you decided to finish eating lunch before you went to the call. When you finally arrive, you determine that the patient has been dead for at least two hours, and do not resuscitate them. While you had a duty to act (respond to the scene in a timely manner) and you breached that duty (finished lunch before going to the call), and there was an injury (the patient died), your acts were not the proximate cause of the patient's death, because the patient likely would have died regardless of how quickly you responded.

Consent

In order to treat a patient, it is necessary to have their permission. Just because someone is sick or injured, does not mean that they have to accept help. Competent adults are allowed to refuse medical care, even if refusing such care is ultimately to their detriment. (Refusing care when such a refusal is medically inadvisable is called refusing "against medical advice," or AMA.)

The most common type of consent is "expressed consent." This is when a competent adult gives you permission to treat them. Note that a patient does not necessarily have to consent to all procedures that you wish to do; i.e., they might consent to verbal questioning, but not to any part of the physical exam. Typically, you obtain expressed consent by introducing yourself as a member of EMS and informing the patient of what you're doing as you do it.

Not all adult patients are capable of giving expressed consent, however. If a patient is unconscious or has an altered mental state, they may not be capable of making decisions regarding their medical care. In these cases, state law provides "implied consent;" the state assumes that any person who is unable to give consent, or rationally consider the issues involved in giving consent, would want medical care if they were able to give consent. This is an easy decision to make for a patient that is unconscious or physically incapable of refusing care, but what about a patient that is high on drugs or intoxicated? You must make a decision about whether they are capable of rationally considering the issues involved in refusing medical care, and document the reasons for the decision you make. Often this is not an easy decision to make, and if you are unsure, don't hesitate to consult with other medics on the call or call the supervisor.

Minors (persons under the age of 18, with a few exceptions) are not legally able to give consent, refuse care, or make other decisions about medical procedures. If the child's parents, legal guardian, or other adult relative of the child can reasonably be contacted, then they are responsible for making consent decisions on behalf of the minor. If no such person is available to give consent, then the child should be treated under the principle of implied consent; it is assumed that the parent or guardian would consent to treatment if they were present to do so. If necessary, a police officer can take a child into protective custody and act as their guardian.

Note that some persons under the age of 18 are considered emancipated minors. In Pennsylvania, a minor is considered emancipated if they are married, pregnant, or have obtained an appropriate court order. Emancipated minors are considered adults in the eyes of the law, and are capable of making all legal decisions on their own, including consenting to or refusing medical care.

There are some situations where a patient may be involuntarily subject to medical evaluation and treatment for psychiatric reasons. These situations are usually referred to as "involuntary commitment;" in Pennsylvania the term "302" is sometimes used, after the number of the state law that regulates the commitment circumstances and length. In Pennsylvania, a patient can only be involuntarily committed if they pose an immediate danger to their life or welfare, to the life or welfare of others, or are not capable of caring for themselves over the course of the next 30 days. Generally speaking, intoxicated patients cannot be involuntarily committed. The most common reason for committing a patient is if they have threatened suicidal gestures or have attempted suicide. At WCU, EMS does not handle psychiatric commitment; this is done by WCUPD. If you suspect that a patient may require involuntary commitment, notify the on-duty EMS supervisor and WCUPD. Obviously, this is a sensitive issue as far as patient confidentiality is concerned, and should not be broadcast over the radio if possible.

Because competent adults are permitted to refuse care, either for themselves or on behalf of their children, it is necessary to document the circumstances of the refusal. Due to the legal climate in the United States, it is very possible to be found negligent for not treating or transporting the patient even if the patient refused treatment or transport at the time. If the patient (or the patient's estate) later sues WCU EMS for negligence, it will be necessary to establish that the person refusing care was competent to refuse, and that WCU EMS was not obligated to treat the patient under implied consent. It will also be necessary to establish that the patient was aware of the extent of their injury or illness, and the implications of refusing care.

For these reasons, WCU EMS has developed a standard refusal form, which should be signed by the patient or the patient's guardian if they refuse medical care, or they refuse transport to the hospital by ambulance. (Because WCUPD transports the patient as a courtesy, independent of WCU EMS, even if the patient is transported by WCUPD they should sign a refusal form.) The refusal form has boxes for the date and time of the refusal, WCU EMS call number, the name of the patient, whether they are refusing treatment, transport, or both, and places for the patient and a witness to sign. The patient or patient's guardian should sign the refusal form, and you should have a WCUPD officer or other non-EMS person on the call witness the refusal, if possible. If the patient or guardian is not able to sign the refusal form, you must have a witness sign the refusal. You should note in your trip sheet if a refusal form was signed, who signed it and witnessed it, and whether the refusal was AMA.

Another option when dealing with patients that desire to refuse care or transport AMA is to contact medical command. If you contact medical command, they may be able to make a better decision as to whether the person needs to be seen at the hospital, and sometimes knowing that a doctor wants them to go will make the patient change their mind. If you call GFAC, then legally we have transferred care to a provider with a higher certification, and the patient's further care or refusal of care is GFAC’s responsibility.

Confidentiality

Since WCU EMS members respond to calls in an area where they also live and work, and may know the patient or the patient's friends, this is an especially important topic. All information regarding calls is private. Access to information about calls is restricted to the patient and health care providers who need to know in order to help the patient. It is important to note that the information is only to be released to individuals who need to know to help the patient. This means you may not discuss it with the media, Health Services, WCUPD, students, staff, or faculty, unless it will benefit the patient.

It is our job to provide emergency care to our patients, but it is also our job to protect their privacy. This is the same rule that applies throughout healthcare. If you are in a situation where someone requests information about a call or copies of call documentation, you should direct that person to the supervisor on duty. In some cases, patient information may be discussed for educational or quality assurance purposes; however the patient's identity must usually be concealed in order to maintain confidentiality.

Crime Scene Preservation

If you respond to the scene of a crime, such as an assault or a shooting, there are several considerations to keep in mind. Obviously, the first is scene safety: if someone was stabbed or shot, they were probably stabbed or shot by another person, who might still be nearby. To avoid being injured yourself, before entering the scene you should wait for a notification from WCUPD that the scene has been secured, and that the actor is in custody or is no longer on the scene. If you discover after you have arrived on the scene that a crime was committed, notify WCUPD and ensure that they are enroute. If the actor is still on the scene or the assault is still in progress, take appropriate actions to ensure your safety and the safety of your crew, including leaving the scene without providing care if necessary. If you do this, notify other medics who are enroute that the scene is dangerous, so that they don't inadvertently enter the scene until it has been secured.

Once you are on-scene, you should be careful not to disturb evidence. At a crime scene, everything at the scene is evidence, including the position of everything in the room, the position of the patient, and any blood spattered on the walls or on the floor. Avoid walking through blood or tracking blood around in the room. If you need to move anything, note its original location and inform the police. If the patient was shot or stabbed, avoid cutting through knife or bullet holes in their clothing, since the position and size of such holes provides important evidence.

If you notice things on the scene that may be important to the investigation (such as pill bottles, weapons, etc.) or move the patient prior to police arrival, you should write an incident report to document this. This information may be important to the investigation, and you should not rely on your memory to remember it for a trial that may come months or years later.

Patient Assessment

The patient assessment is the most important part of patient care, since the assessment is what drives the care that the patient receives. Without a proper assessment, it is impossible to correctly treat the patient.

Dispatch

The assessment begins before you even enter the scene. Information that you get from the dispatch can help you begin to form a picture of the patient. While you should be flexible, and not tunnel in on assumptions you make before reaching the scene, if the scene you find is significantly different from the dispatch information this is cause for suspicion.

In addition to obvious information, such as the age and sex of the patient and the chief complaint, you can often gain information from the dispatch location. If you're dispatched for an injury at the gym or an athletic field, it is probably not serious if the patient is conscious. On the other hand, a call for "person down" in the middle of Church St. is likely quite serious. Location can also provide clues to possible hazards: for example, if you are dispatched to a lab, you may need to be cautious of hazardous materials in the area.

While you are enroute to the scene, you should consider what the patient's condition is likely to be, and think about what information you will need to gather quickly when you arrive. You should also think about what questions you will ask the patient. Finally, while this is usually something that the crew chief does, you should consider what equipment and/or extra help (ALS, rescue, etc.) you will need on the call, and whether that equipment or help will be available or is enroute. If it is likely that equipment stored in the office will be needed, you need to consider who is responding from what locations, and who will be best able to stop and pick up the equipment. If you will need equipment from the WCUPD car, make sure that a car is enroute and that the officer is aware that you will need the equipment. If from the dispatch information you think it is likely that the patient will need an ambulance, one should be requested before EMS arrives on the scene.

Scene Survey

Once you arrive on the scene, you should assess the scene before you assess the patient. The primary concern is, of course, is the scene safe? However, scene safety goes beyond obvious concerns, such as a violent person on the scene or an unstable structure. You must learn to look at everything in a scene and continually assess whether new threats have appeared. Consider a patient who has attempted suicide by cutting their wrists: what did they use to cut their wrists? If it was a knife, where is the knife now? If the patient still has the knife, what prevents them from trying to cut you when you get closer to examine them? Regardless of the condition of the patient, you should never enter a hazardous scene without appropriate protection. If you're injured by the hazard, there is now a second patient and one fewer medic to treat the patients. If necessary, other agencies (fire department, rescue, power company, gas company, etc.) should be contacted to manage scene hazards.

After determining the scene is safe, you need to determine how many patients are present, and how severe their injuries are. Usually, this is easy, since you will have only one patient. However, don't assume that all your patients are visible or capable of telling you that they are there. Frequently, the patient screaming the loudest is the patient you have to worry about least, and the silent patient is the one who is most in need of your care. At vehicle accidents, remember to look around the vehicles, under the vehicles, and by the side of the road for patients that were thrown from their vehicle. If there are patients who can talk, ask them which car they were in, whether they were the driver or a passenger, and how many people were in the car, to make sure you don't miss any patients. Once you have determined how many patients there are and how severely they are injured, you can determine whether or not you need assistance. Generally speaking, an ambulance can transport one seriously injured patient, two patients with moderate injuries, and up to four "walking wounded" patients. Of course, "assistance" is more than transport: if you have patients that are trapped or pinned, or there are downed power lines that prevent you from reaching the patient, you will need assistance to even reach and/or extricate the patient. If you will need extra help it's better to call for it before you start treating the patient, to avoid becoming so focused on patient care that you forget to call for help.

After assessing the scene for safety, hazards, and number of patients, you can begin to assess it for clues to the patient's condition, or "mechanism of injury." This can be anything around that gives you information about the patient or their condition. If the patient is intoxicated, you may need to look around for bottles of alcohol; if they have overdosed, then you may need to look for empty pill bottles, a suicide note, etc. If the patient fell, how high did they fall from? Did they fall onto a relatively soft surface, such as grass, or a hard surface, such as cement? If you are called to the scene of a motor vehicle accident, the positions and number of cars, damage to the cars, and road conditions (straight road? curve? slippery from rain or snow?) are all important to note. Finally, it is important to note any details of the scene that conflict with the patient's history (i.e., patient claims they had "two beers" but there is an empty six-pack in the trash).

Finally, before beginning to treat the patient, you should take appropriate measures to protect yourself from contact with the patient's body fluids. In most cases, this will mean putting on a pair of gloves. However, if splashing or spurting body fluids may be present, a gown, safety glasses, and a mask may be needed.

Primary Assessment

The first stage of your hands-on assessment is to look for (and remedy immediately, if possible) life threats. The primary assessment starts with the "ABC" assessment taught in CPR class, and expands on it. Upon entering the scene and locating the patient, you should assess their level of consciousness, airway, breathing, circulation, neurological deficit or disability, and examine them for life-threatening injuries.

Level of consciousness: At this stage in the primary survey, you should only be concerned whether or not the patient is conscious; that is, whether they are alert or responsive to verbal or physical stimulus. If they are responsive, you should obtain informed consent before treating or assessing them further.

Airway and breathing: Since these are related, it makes sense to discuss them together. If the patient does not have an open airway, they will not be able to breathe, and thus you cannot ensure that the patient's airway is open if they are not moving air. In a normal adult, respirations occur approximately 12 to 24 times a minute, do not make excessive noise, and are not labored. If the patient deviates significantly from this, you should note it and, if necessary, take action to remedy it. To assess the airway, first inspect the area around and inside the nose and mouth for secretions, blood, vomitus, or foreign bodies that might obstruct the airway or be aspirated into the lungs, as well as signs of trauma that might cause an airway obstruction. If the patient is unresponsive, attempt to insert an oral airway to determine if they have a gag reflex (and are thus able to protect their airway). If they are breathing, determine if the patient's nostrils are flared (indicating labored breathing), and whether the patient's lips are cyanotic or ashen (indicating hypoxia). Assess the patient's neck, chest, and abdomen for adequate chest rise and fall, symmetric and smooth chest wall movement, accessory muscle use in the neck, retractions above the clavicles or between the ribs, and excessive movement of the abdomen. Next, listen to the patient's respirations. They should be normal and equal on both sides. If they are abnormal, or diminished or absent on one or both sides, that should be noted and remedied if necessary.

Circulation: The assessment of circulation should go beyond the mere presence or absence of a pulse. To fully assess circulation, you should palpate the patient's carotid and radial pulses simultaneously. While palpating them, note whether they are present and their rate, quality, character, and evenness. A normal adult has a strong, regular pulse of between 50 and 120 beats per minute, with equal central and distal pulses. Any deviations from this (irregular pulse, weak distal pulse, etc.) should be noted. You should also assess the color and temperature of the patient's skin; mottled, cyanotic, pale, or ashen skin are all signs of poor circulation, as is cool skin. If the patient is a young child (under six years of age), it may be helpful to assess their capillary refill; normal capillary refill occurs within two seconds.

Deficit/Disability (Neurologic): The primary method of determining the patient's neurologic function at this stage of the assessment is their level of consciousness. Level of consciousness is frequently measured using one of two scales: the AVPU scale and the Glasgow Coma Scale [GCS]. AVPU is very simple to use; you simply note whether the patient is "alert," responsive to "verbal" or "painful" stimulus, or "unresponsive." If the patient is responsive, you should note whether they are oriented to person, place, time, and events. GCS is somewhat more complicated, but includes more information about the patient's mental status. To calculate GCS, you sum the patient's score in three categories: eye opening, verbal response, and motor response (see table 1). The lowest possible GCS is 3 and the highest possible GCS is 15. GCS should be documented on the dot side of the trip sheet and in the narrative, and if it is anything other than 15, you should list the individual scores.

TABLE 1. Glasgow Coma Scale Eye Opening

EYE MOVEMENT	VERBAL RESPONSE	MOTOR RESPONSE
4 – Sponateous	5 – Oriented	6 – Obeys commands
3 – To Voice	4 – Confused	5 – Localizes pain
2 – To Pain	3 – Inappropriate	4 – Withdraws from pain
1 – None	2 – Garbled	3 – Flexion posturing
	1 – None	2 – Extension posturing
		1 – None

Expose/Examine: This step is usually only necessary for unconscious patients, or for patients with potentially serious injuries. You should expose the patient's head, neck, chest, and abdomen and examine them for evidence of gross trauma or life-threatening injuries. Such injuries would include a flail chest, sucking chest wounds, uncontrolled bleeding, or severe burns. Remember after exposing the patient to be aware of their surroundings. A patient can become hypothermic very quickly even in "comfortable" conditions after you cut off all their clothes. Always cover up your patient after you have finished examining them. This also protects their privacy; you probably don't want to lie in the middle of the street in your underwear, and neither does your patient.

Trauma Assessment

Once you have completed your primary assessment and identified and treated any immediately life-threatening injuries, you must perform a more detailed assessment to find any other injuries the patient might have. This assessment is typically called the "rapid trauma exam" or "head-to-toe." Obviously, it is not necessary to perform a full head-to-toe exam on every patient you see; it should be reserved for patients with more serious injuries, or that you suspect may have injuries other than the obvious ones. For a conscious patient with a single isolated injury, you can skip to a "focused" assessment of only the injured portion of their body, after assessing them sufficiently to ensure that there are not likely to be other injuries. Note that you should not allow the performance of a full physical exam to delay treatment of the patient or transport of a critically ill patient, but since it is possible to complete a full head-to-toe exam in under two minutes, a basic exam should be performed early in the call if possible.

The four examination methods you will use in a physical exam are inspection, palpation, auscultation, and percussion. While it is not necessary to perform the assessment in the order listed here, it is a good idea to establish a particular order and stick with it, so as to avoid forgetting parts of the assessment. It is also a good idea to do the head, chest, and abdomen at the beginning, since those are frequently where more serious injuries will be found. While palpating the body, you should remember to use you whole hand, not just your fingertips. Check your gloves frequently for blood, since bleeding may not always be immediately visible. Generally, the things that you are looking for in a physical exam can be summarized with the acronym DCAP-BLS: deformity, contusions, abrasions, punctures/penetrating injuries, burns, lacerations, swelling.

To examine the head, palpate the entire skull with your fingers, taking care not to displace skull fractures or move the head excessively. The head should be smooth, without deformity such as depressions or swelling. Any asymmetry, discoloration, deformity, or pain on palpation should be noted. You should also check for "raccoon eyes" (discoloration or bruising around the eyes) and "Battle's sign" (discoloration posterior and inferior to the ears), which are late signs of a skull fracture.

Examine the ears for signs of injury or blood/fluid drainage. Clear fluid draining from the ears, eyes, nose, or mouth may be cerebrospinal fluid (CSF), which is a sign of skull fracture and/or brain swelling. If possible, ask the patient if they are hearing normally, and if they hear ringing, a high-pitched whine, or any other unusual sound.

Examine the eyes for pupil response and movement. The pupils should be equal in size, round, and react equally to light. If the pupils are unequal, abnormally constricted or dilated, or are unresponsive to light, that should be noted. To check movement, have the patient follow your finger or the tip of a pen horizontally, vertically, and in an "X." Eyes should track movement together without wandering, delays, or jerkiness. You should also check for discoloration (jaundice, bloodshot, etc.), as well as signs of an impaled object, foreign body, bleeding, or lacerations to the eye. If the patient has contact lenses, note this; if the patient usually wears contact lenses but they are not visible in one or both eyes, note that as well.

The face should be examined for injury and bleeding. The bones of the face should be palpated for stability. Any discoloration, asymmetry, deformity, or limited motion of the jaw should be noted.

The mouth and nose should be examined for any injury, drainage, or obstruction. Residue around the mouth and nose can often indicate inhalation of a toxic substance, such as smoke. Singed nose hairs or facial hair can be a sign of respiratory tract burns from inhalation of hot gases. If there are odors emanating from the mouth or nose, this should be noted, but remember that not all patients who smell of alcohol are intoxicated. If the patient is unresponsive, consider removing false teeth to prevent them from becoming dislodged and obstructing the airway, but also keep in mind that removing dentures may soften the facial structure and make a good BVM seal more difficult to obtain. Remember to insert an oral airway or bite block before inserting your fingers into an unresponsive patient's mouth.

The neck should be examined for injury, deformity, edema, and jugular vein distention. Examine the trachea to ensure it is midline and stable.

The chest should be examined for signs of obvious injury and deformity. The rib cage and sternum should be palpated for deformity or instability. When the patient breathes, you should check for equal expansion of the chest with no paradoxical motion. The shoulders and back should also be examined and palpated for deformity and injury. You should listen to the lungs at the apexes, midpoints, and bases on the anterior and posterior chest walls and note any abnormal sounds, such as rales, ronchi, and wheezing, as well as compare lung sounds bilaterally for strength and quality. The chest can be percussed to check for pneumothorax or hemothorax.

The abdomen should be palpated in each quadrant for rigidity, distention, pain, and masses, and evaluated for rebound tenderness. Any unusual motion or pulsation should be noted.

The pelvis should be assessed for stability by compressing it, first medially, then posteriorly. Any instability may be a sign of a pelvic fracture. In addition, note a priapism (inappropriate erection) in male patients, and any signs of injury or bleeding.

Finally, the extremities should be fully palpated, and any signs of injury should be noted. Distal pulses (radial pulse in arms, pedal pulse in legs) should be noted, and any absence noted. You should check for sensation by asking the patient if they can feel you when you touch their fingers and toes, and movement by asking the patient to wiggle their fingers and toes. Pedal push/pull and grip strength should be assessed.

Patient History

While a head-to-toe secondary survey is useful for identifying trauma, the patient history is more appropriate for a patient whose complaint is primarily medical in nature. Keep in mind, though, that many patients are not purely "medical" or "trauma" (consider the patient who had a seizure and then fell down a flight of stairs), and so a complete assessment may include both a physical exam and a patient history.

The goal of the patient history is to obtain as much information as possible about the patient's current complaint (i.e., the reason they called for EMS). While there are many questions that can be asked about each individual complaint, it is frequently helpful to use the acronym OPQRST to remember questions that should be asked for most complaints:

Onset: When did the problem start? What was the patient doing when it started?

Provocation: Does anything in particular make the problem worse, or make it better?

Quality: [This question is mostly relevant to pain.] What kind of pain is it (sharp, dull, throbbing, etc.)? Note that when asking this question, it is best to let the patient provide the words; prompting them with examples may lead them to describe the pain using your words.

Radiation: [This question is also mostly relevant to pain.] Does the pain radiate anywhere, or move around?

Severity: How bad is this particular problem, compared to other times they have had it? For pain, have the patient rate the pain on a 1-10 scale, where 10 is the worst pain they have ever felt.

Time: How long has the problem been going on? Has it been steady over that period of time, or has it gotten worse or better, or come and gone?

You may also want to ask about previous episodes of the complaint, and how this episode compares to them, as well as whether there are any associated symptoms with the primary complaint. If the patient has already seen a doctor about their condition, you should ask what the doctor told them about it, and if they were given any instructions on when to return to the doctor's office or seek emergency care. If the patient is pregnant, you should ask how many weeks she is into the pregnancy, how many previous pregnancies and live births she has had, and whether there is anything unusual about this pregnancy. If the patient is female, you may need to ask if she is sexually active, and when her last period was. Note that all female patients that have been sexually active since their last period could be pregnant, regardless of what birth control method they claim to use.

After determining the history of the patient's present illness, you should ask about past medical history. This includes any medical conditions that they have, such as asthma, epilepsy, diabetes, or a heart condition, as well as any recent hospitalizations or surgery. Also ask if they take any medications on a regular basis, and if they are allergic to any medications.

Vital Signs

After arriving on the scene and completing your assessment and/or history, you should take a "baseline" set of vital signs. This set of vitals serves to document the patient's condition when you first arrived, so that any subsequent change can be noted. Trends in vital signs are more important than the actual numbers; i.e., 140/90 and 90/60 are both "normal" blood pressures, but if your patient goes from the first to the second in five minutes, you've got problems. A complete set of vital signs includes:

pulse rate and quality (normal range: 50-120 beats/min)

respiration rate and quality (normal range: 12-24 breaths/min)

blood pressure (normal range: systolic 80-120, diastolic 60-90)

skin color and temperature (normally warm, pink and dry)

pupils (normally equal, round, and reactive)

Treating life-threatening problems is always more important than taking vitals. If you have sufficient crew members, one can be taking vitals while another is assessing and treating the patient. If you are by yourself or need help to treat the patient, vitals can be deferred until additional help arrives or the patient is stabilized.

Reassessment

Once you have assessed the patient once, it is not sufficient to stop and go no further. Periodically you should reassess the patient to determine if their condition has changed, so you can render appropriate care. Stable patients should be reassessed about once every 10-15 minutes. Unstable patients should be reassessed at least every five minutes, and preferably continuously.

When reassessing the patient, start with the primary assessment: evaluate level of consciousness, airway patency, breathing, circulation, neurological deficit, and expose and examine for life-threatening injuries. However, you don't necessarily need to repeat every part of your assessment; after all, the cut on their leg isn't likely to have gone away in the past five minutes, and it isn't likely that what they were doing when they started having chest pain will have changed, either. However, you should reassess any injuries to determine if they have changed (area of discoloration growing larger, laceration started bleeding again, etc.). For a medical patient, you should assess the current state of their complaint: whether it has gotten worse or better since you arrived, whether any other complaints have begun, etc. You should also take and record another set of vital signs.

It is also important to reassess the patient following any interventions or treatments you perform. For example, ask the patient if their shortness of breath improves after administering oxygen, or determine if bleeding is controlled after applying direct pressure. Distal pulse, movement, and sensation should be reassessed after splinting an extremity.

Medical Alert Tags

Some people wear a tag on a necklace or bracelet to warn rescuers of their medical conditions, in the event that they are unable to communicate with EMS personnel. If you find a patient unresponsive or with an altered level of consciousness, it is important to check for medical alert tags for clues as to the cause of their condition. Sometimes, the medical alert tag will have a phone number to call, or directions to check for a wallet card with additional information. Note, however, that there is no rule stating that just because someone has a medical alert tag for a particular condition, that his or her present illness is related to that condition. For example, a patient can have a seizure disorder and be hypoglycemic, and just because you find them unresponsive with a medical alert tag that indicates they have epilepsy, that doesn't mean that they're not having a hypoglycemic episode.

Documentation

A good assessment is no use if you don't document it. In addition to documenting any positive findings, it is also important to document all negative findings. This serves to demonstrate that the person doing the assessment was thorough, and that the assessment was complete. If you do not document negative findings, then there is no proof that they were in fact negative when you checked them, and if the patient later alleges that you overlooked a problem, you have nothing in the documentation to back you up.

It is also important to note all your findings on the on-scene form. While the on-scene form will obviously not be as complete as your trip sheet, it should contain all of the relevant positive findings and any particularly pertinent negative findings. This serves several purposes: it provides you with a guide when you write your trip sheet; it serves as a guide for your report CC Fire Dispatch if necessary; and it serves as an addendum to your verbal report after you hand the patient off to GFAC. The last point is important; frequently when you give your verbal report, the paramedic may not pay attention to all of it, because they are preoccupied with assessing the patient themselves. If you note all of your findings on the on-scene form, then the paramedic at least has a written record which he or she can refer to later while transporting the patient or writing their trip sheet.

Radio Communications

WCU EMS uses two-way radios for all sorts of different communications: coordinating crew coverage, coordinating the response to a call, summoning additional help, and contacting medical command, just to name the common ones. Because of this, it is important to be familiar with proper radio use.

One important principle to keep in mind is that the radio is not like a telephone: only one person can talk at a time. If you are transmitting, then you can't listen to anyone else talk on the channel. You also prevent everyone else from transmitting while you are talking. For these reasons, radio transmissions should be kept short, direct, and to the point. Think about what you plan to say before you key the mic, so your transmission isn't full of ums, ahs, and dead air. Be careful not to accidentally key the mic by pressing the radio against a chair, a doorframe, or any other object. It's also not obvious who you are and who you're talking to (not everyone can recognize your voice), so be sure to transmit your identification and the unit you are calling.

Radio communications afford much less privacy than a telephone does. Try not to transmit personal details about the patient's condition over the radio, including their name. Keep your transmissions professional; you never know who may be listening, either on a scanner or standing next to someone else with an EMS radio.

Use of the Radio

To turn the radio on, rotate the leftmost knob (volume knob) clockwise. You should hear a click, followed by a "beep" as the radio turns on. To select the channel, use the right knob; generally you will use channel 1. To transmit, hold the radio approximately 2-3 inches away from your mouth, hold down the push-to-talk button, and speak in a normal tone of voice. When you are done transmitting, release the push-to-talk button. If someone else is transmitting nearby, you may need to turn your radio volume down to avoid causing feedback.

Radio Care

· Do not hold or pick up a radio by its antenna. Doing can damage the antenna connector, which is expensive to replace.

· Do not to drop or throw the radio.

· Be careful when running with your radio, that you don't drop the radio or spare batteries you are carrying. If you are wearing a jacket and have these items in a pocket, make sure the pocket is zipped or otherwise closed; you don't want to lose your battery down a sewer drain.

· Try to keep the radio dry. Never immerse the radio in water.

· If you are using a shoulder mike, make sure you have the retaining clip attached. Turn the radio off while attaching or detaching the shoulder mike. If the contacts are loose, the radio will sometimes cause false transmissions, tying up the channel.

Channel 1 (WCU POLICE) is the channel you will usually use. It uses our repeater, and is the channel that WCUPD uses to dispatch calls.

Channel 2 (WCU POLICE) is a non-repeated channel. It is used as a talk around for the WCUPD. You won't be using the repeater, so the range of the radios will be more limited.

Channel 3 and 4 (EMS Talkaround) is a shared frequency with a PL. You won't be using the repeater, so the range of the radios will be more limited. If a dispatch comes in while you're on channel 3 or 4, you must switch back to channel 1 before responding; otherwise the other responding medics won't be able to hear you.

Channel 5 (EMS to 96 Link) is a channel that is used to bridge your portable with CC Fire Board dispatcher on 33.96. This channel is used to report status when EMS is dispatched by the county. This channel only works when the QRS Truck is running or the QRS Truck Link is turned on.

Channel 6 (Chester County Dispatch) is, as the name implies, our county 911 center dispatch frequency. It is a receive only channel that allows you to listen to other dispatches broadcasted by Chester County Fire Board.

Channel 15 (CCFB EMS Pager w/TONE) is a silent channel programmed to activate when CCFB activates tones for EMS. Once the channel is activated, it will stay open until switched to a different channel.

Channel 16 (WCU POLICE w/TONE) is a silent channel programmed to activate when WCUPD activates tones for EMS. Once the channel is activated, it will stay open until switched to a different channel.

Our radios are programmed with a "tone alert" feature on channels 15 and 16. WCUPD has a tone encoder unit attached to our dispatch radio and will press the PAGE button on the tone encoder before dispatching a call. This causes the dispatch radio to transmit a pair of alert tones, which signal radios that are in page-only mode to activate and also serves to alert other medics that a call is being dispatched. If you have a radio, when the tones are activated your radio will beep four times and the light on top will flash orange. To reset the radio, switch channels (i.e., switch to channel 1).

Radio Operating Procedure

When using the radio, you should ensure that the proper channel is selected and the radio is on. While transmitting, you should follow the standard operating procedure:

Listen to make sure the channel is clear before you get on the air.

Press the transmit key for at least one second before starting to talk. This ensures that the repeater and other radios on the channel have enough time to recognize the signal, and prevents the beginning part of your transmission from being cut off.

Give the name of the unit being called first, then your own identification. Always identify yourself by medic number when calling dispatch or another unit. (i.e., "QRS58")

Keep your mouth close to the microphone, but not too close. About 2 to 3 inches away is sufficient.

Speak clearly and distinctly, in a normal pitch. Do not shout.

Do not talk with your mouth full.

Keep your voice free of emotion. This does not mean monotone, just a normal conversational tone.

Keep your transmissions brief.

Use discretion; protect the privacy of the patient. In particular, do not transmit the patient's name over the air.

Be professional. Do not try to be a comedian. Do not use profane language.

Avoid words that are difficult to hear. The word "yes," for instance, is easily lost in transmission; use "affirmative" instead.

Use the international phonetic alphabet when necessary (see appendix B).

Use a standard format for patient reports.

If you receive an order, repeat it back to make sure that you have understood it correctly.

Do not use the channel 1 for non-emergent. This is to avoid unnecessarily disturbing classes, meetings, and/or sleeping medics. "Non-emergent" means any transmissions that are not directly related to a call or to EMS operations.

Do not use the radios for excessive personal communication. When possible, landline telephones, cellular telephones, and the EMS Talkaround channel (when absolutely necessary) should be used for personal communications. EMS radios are not a substitute for cellular phones.

Battery Charging & Care

The batteries our radios use are Nickel Cadmium (NiCd) rechargeable batteries. They are rated for 8 hours of use, but since our duty cycle is less intense than "normal" use, they should last about 24 hours. Older batteries may die sooner.

When your radio emits a double beep, it means the battery is getting low and needs to be recharged. The radio will repeat this beep every 20 minutes until it dies. (Kenwood radios do not give a low battery warning.) If you hear this double beep when you transmit, it means you need to change batteries. If you hear a series of short beeps when you press the push-to-talk button, you are NOT transmitting. Your battery is dead. Change it to transmit.

Be aware that your battery may die with no warning whatsoever. Be sure to check it every few hours. To test if your battery is still charged, put your radio on Channel 3 and try to transmit. (Don't use channel 1 or channel 2, since that will key up the repeater and disturb everyone else.) You can also press the "volume check" button (the top button on the side of the radio), but since transmitting takes more power than receiving, your radio may not sense the low battery until you try to transmit.

Radio Codes

This section describes radio codes currently in use by WCU EMS and/or WCUPD. Although you may not necessarily use all of these codes, you should be familiar with all of them, since other members or the dispatcher may use them.

Ten codes

10-1 - Transmit Emergencies only 10-37 - Intoxicated Operator/Person

10-2 - Priority Traffic only 10-40 - See Complainant at ____

10-3 - Proceed with Message 10-41 - Fire

10-4 - OK Message Received 10-41A - Ambulance

10-5 - Off Duty 10-42 - Another Person Present

10-6 - Busy - Stand By 10-42F - Female

10-7 - Out of Vehicle/On Portable at ____ 10-42P - Prisoner

10-8 - In Service/ On Duty 10-45PD - Accident - Property Damage

10-9 - Repeat Last Message 10-45PI - Accident - Personal Injury

10-10 - Money Escort/Protection 10-45F - Accident -Fatal

10-11 - Call Your Home 10-45HR - Accident - Hit & Run

10-12 - Return to your Home 10-45M - Accident other than Vehicular

10-13 - Meet at ______ 10-46 - Escort

10-14 - Report of Explosives/Bomb Threat 10-47 - Animal Complaint

10-15 - Assist Officer - Emergency Only 10-54 -Tow Truck

10-17 - Vehicle Stop 10-60 - Unnecessary use of Radio

10-19 - Return to Station 10-65 - Traffic Violation/Citation

10-20 - What is your Location 10-67 - Alarm at ________

10-21 - Call by Phone 10-67A - Alarm has been Reset

10-22 - Disregard Last Message 10-80 - Traffic Duty

10-25 - Food/Meal Break 10-82 - Disabled Vehicle

10-26 - Prepare to Copy 10-88 - Warrant, Package, Etc.

10-27 - Does Not Conform To Procedures 10-90 - On Location at Scene

10-28 - Request Registration/Vin Data 10-91 - Clear/ Assignment Complete

10-28S - Request Operator Check 10-92 - Situation Under Control

10-29 - Request NCIC / Warrants 10-93 - Unit #___ Turn Radio Off

10-29N- Negative NCIC 10-95 - Backup Unit___ at ___ REF.__

10-29P - Positive NCIC 10-97 - Transmission Loud and Clear

10-34 - Officer at Home on Call 10-98 - OK on Last Request

10-35 - Domestic/Fight in Progress 10-99 - Change your Location

10-36 - Furnish the Correct Time 10-100 - Disable Repeater

Contacting Medical Command

On-line medical command is available through Chester County Hospital. Generally, the standing orders in the treatment protocols should be sufficient for treating most patients. However, if you encounter a situation that isn't covered by the treatment protocols or would like to do something different than the treatments prescribed in them, you may need to contact a command physician. The best way to contact medical command is by phone; their phone number is (610) 431-5150 and should be reachable from any campus phone. If a phone is not available, you can contact them by radio on 33.96 (channel 5 on the WCU EMS radios). Note that due to the distance and geography involved, if you are inside a building, you will probably have to go outside to contact medical command by radio.

When contacting command, identify yourself and state that you are requesting medical command. Over the radio, call using the phrase "QRS58 to Chester County Hospital for medical command" and wait for an acknowledgment. Once the doctor is on the radio, identify yourself by certification and name and check your signal; i.e., "This is EMT Joe Schmo from WCU EMS, how's the signal?" If the doctor states that you have a good signal, you may proceed with your patient report. After you have given the report, state what treatments you'd like to administer and ask the doctor if they have any questions or further orders. If you receive an order, repeat it back to confirm. Once you are done, clear the channel by saying "WCU EMS clear."

Use of on-line medical command must be documented on the trip sheet, including the MD number of the physician you consulted, the orders you received, and the orders you carried out. If you attempt to contact command and are unsuccessful, that should be documented on the trip sheet and also in an incident report. If you are unable to complete some or all of the orders you received, you should document that in your trip sheet, along with the reason(s) why you were unable to complete the orders.

Contacting Chester County Fire Board

Generally speaking, the initial request for an ambulance should be done by phone (610)436-4700 or through WCUPD. However, in some circumstances it may be necessary to contact the Fire Board on the 33.96 frequency to request an ambulance. If you do that, you will need the following information: street address or intersection where the medics are needed, age and sex of the patient, chief complaint, and whether the patient is conscious and breathing. WCUPD can be contacted to obtain the street address for a campus building.

After the ambulance has been requested and the medics have been dispatched, the crew chief should contact the incoming medic unit and give them a brief report on the patient's condition. This report should include the patient's age, sex, and chief complaint, whether they are conscious and breathing, and information about what interventions have already been performed (i.e., splinting, backboarding, etc.). The report should not include details such as vital signs or medical history, since those will not change the response level or the equipment that the medics need. If the patient's condition changes significantly (i.e., they lose consciousness or stop breathing) or you need additional assistance, such as medical backup or rescue, you should update the medics and the Fire Board. The medics should also be advised of any hazards present on or near the scene.

Proper Medical Report Format

The standard accepted format for medical reports by WCU EMS is as follows:

· Age

· Sex

· Chief complaint

· History of present illness

· Past medical history

· Medications

· Allergies to medications

· Results of the physical examination

· Treatments rendered and patient disposition

· Chief complaint

· What the patient states as his reason for calling, or the patient's major injury.

History of Present Illness

The series of events that led the patient to call us. For a trauma call, it would be how the injury occurred. For a medical call, it would be how long the complaint had been present, the quality/severity of the pain, if the pain radiates, associated complaints, alleviating factors, and aggravating factors.

Past Medical History

The patient's history of diseases and injuries that may be pertinent to this call, and pre-existing medical conditions.

This format may be followed for filling out trip sheets, giving reports over the radio, or reporting to GFAC. When giving a verbal report to another health care provider (be it another WCU EMS member, a paramedic from Medic 91, or a member of the emergency room staff) it is important to keep the report concise and focused. You should mention all relevant details first, and you can leave information out (or abbreviate it) if it isn't relevant to the patient's current complaint. For example, if the patient's vitals are stable and normal, you don't have to rattle off the five sets that you took; you can just say "vitals are stable and within normal limits, last set was..." When giving a report, speak in a normal tone of voice at a normal rate; don't try to go too fast or cram too much information in.

Documentation

Unfortunately, we live in an age where lawsuits are everywhere. For that reason, and to help ensure high quality care, we must document everything that happens on a call. The adage to follow is, "If you don't write it down, it didn't happen." The following forms of documentation are used in WCU EMS:

· On-scene forms

· Refusal forms

· Call files

· Call logs

· Incident report forms

· Personnel files

· Pennsylvania trip sheets

On-scene form

The on-scene forms are three-part carbonless forms that may be used at the option of the crew on the scene to assist in performing the patient assessment. These forms are used to make notes and record pertinent information. If appropriate, the second (yellow) copy may be given to WCUPD and the third (pink) copy to GFAC. Since we operate under the delegated authority of WCUPD, and the WCUPD officer usually files a report on the incident, the officer may ask you for information about the call. However, for reasons of patient confidentiality, WCUPD may not receive a copy of the narrative from your trip sheet, and you should use your discretion in providing information gained from the patient to WCUPD. Items such as the patient's name, sex, address, date of birth, etc. can be provided, but sensitive medical information or information about illegal activities (drug use, underage drinking, etc.) that was provided to you in confidence should not be passed on to the officer. If in doubt, refer the officer to the supervisor on duty.

Refusal form

The refusal form must be signed by any patient not requesting transport by ambulance. This form must be turned in to the OM along with the Pennsylvania tripsheet for the call. If possible, you should have the WCUPD officer on the scene witness the refusal and sign the form in the appropriate place. If the patient is not capable of signing the refusal (because of injury to their writing hand/arm, etc.), then the refusal must be witnessed. (If the patient is not capable of signing the refusal because of an altered level of consciousness, you should reconsider whether or not they are mentally competent to refuse care.)

Call files & Call Log

The call files and logs are maintained by the OM. The call files are files of all of the tripsheets from a year.

Incident Report Form

When a member wishes to file a complaint, document a problem, or report exposure to body fluids, they should fill out an incident report form. Incident reports can also be used to document any unusual circumstances or events, good or bad. These forms should be turned in to a member of the EBoard, who will take appropriate actions.

Personnel Files

The personnel files are maintained by the OM. These files are kept on every member for an indefinite period of time after they leave the organization. They contain information on the member such as the member's level of activity, certifications held, and incident forms. These files can only be accessed by the OM, Student Director, Training Officer, WCUPD liaison, and the member to whom the file belongs.

State Tripsheets

The Pennsylvania tripsheet is the same tripsheet used by all other EMS agencies in Pennsylvania. A tripsheet consists of the printed report from EMMA and any refusal forms required.

The completed tripsheet must be turned in no later than 24 hours that the call occurred in. However, you are encouraged to write the tripsheet immediately after finishing the call. If the patient was taken to the hospital in an ambulance, it is strongly recommended that you write the trip sheet immediately after the call and FAX it to the hospital.

There is a box for completed tripsheets near the scanner in the office. After a tripsheet has been turned in, it is reviewed by the Director and Training Officer for QA purposes, and then filed. One copy is kept on file in the call files indefinitely. Tripsheets for calls that involve protocol use are also reviewed by the service medical director. Note that until you have been authorized to write tripsheets without supervision, you must have the primary from the call review your tripsheet for correctness and completeness before you turn it in.

EMMA

The narrative side has three main areas and is fairly straightforward to fill out. The first area is the patient information section. This section is located in the top third of the narrative side.

The middle of the narrative sheet is the narrative itself. It starts with places to fill in the patient's chief complaint, medications, allergies (to medications), and past medical history. Below this are lines for writing the actual narrative. The narrative is a full summary of the call, which must include all of the information about the patient presented in the proper medical report format. This means all of the information; even if there is information provided in the chief complaint, allergies, etc. boxes, or in the "aids given" section, it should still be documented in the narrative. The narrative may be written in one of two ways, either following the medical report format, or in the chronological order of events. Proper medical abbreviations may be used in filling this form out.

A general outline for the format of the narrative is presented below. Note that you might not use all components of the outline for each tripsheet, but you should attempt to be as detailed as possible.

Dispatch : anything that happened before you arrived on the scene.

Location dispatched to, chief complaint given in dispatch

If not dispatched normally, note this (i.e., self-dispatch, on standby, etc.)

Scene Survey : anything you saw or happened before you made patient contact.

Age, sex, level of consciousness

Patient appearance (rapid breathing, pale, etc. -- your initial impression)

Position of patient (prone, sitting in chair, etc.), and actual location where patient was found (if different from location dispatched)

Scene conditions (rainy street, noisy party, etc.)

If multiple patients, triage notes

Chief complaint (what the patient states as the problem or the reason for calling EMS)

History of Present Illness/Chief Complaint : this section includes most of the information that you obtained by questioning the patient.

How long has problem been occurring?

Sudden or gradual onset?

Oral intake? (what kind, how much, how long ago, etc., including alcohol consumption and drug use)

Unusual circumstances before problem? (i.e., overactivity, emotional state)

If trauma, circumstances surrounding the trauma:

fall: how high, what surface patient landed on, what they were doing before falling

assault: what kind of weapon, how many wounds, how big are wounds, sex of attacker(s)

MVA: how fast were cars moving? what kind of collision (rear-end, head-on, T-bone, etc.)? what kind of cars? car vs. ped? exterior damage to cars (none, minor, moderate, severe)? interior damage/intrusion? location of exterior & interior damage? location of patient in car (driver, rear seat passenger, etc.)? was patient wearing seatbelt? did patient have an airbag; did airbag deploy in crash? windshield starring? steering wheel deformity? was patient ejected from vehicle? did patient self-extricate? were any other passengers in the same vehicle DOA?

severity of pain currently (1=minor, 10=worst pain ever; document this scale on tripsheet)

for female patient (especially abdominal pain in female of reproductive age): last menses, quality of menses (light/heavy flow, etc.)

pregnant? if so, how far along (months or trimester)? how many previous pregnancies? how many previous live births? is patient receiving prenatal care? any known complications?

associated signs/symptoms of the illness or injury

body positions/actions that alleviate or aggravate pain

Physical Exam & Vitals : this section includes a full description of your physical exam. If you only performed a focused exam of the injured area, you should note that. Don't forget to note pertinent negatives, which add credence to your narrative and demonstrate thoroughness in the exam.

initial vitals: pulse, respirations, BP, pupils, and time initial vitals were taken

skin quality: warm, damp, cold, dry, red, pale, etc.

lung sounds: clear, equal, absent, decreased, wheezes, rales, ronchi, etc. (include locations of abnormal sounds; i.e., posterior bases bilaterally)

head and neck: level of consciousness (by GCS if possible), vision deficits (double vision, hallucinations, ocular motor function), bleeding, headache, nausea/vomiting, dizziness, depressions in skull, JVD, tracheal deviation

chest: chest pain, bilateral expansion, flail segments, paradoxical movement, retractions, accessory muscle use

abdomen: soft, non-tender, distended, pain in quadrant, rebound tenderness, rigidity

back: pain w/ location

pelvis: stable, pain on palpation, priapism, crepitus

extremities: bilateral grips, bilateral push/pull (equal, unequal, strong, weak), PMS (pulse, motor, sensation)

DCAP-BLS-TIC

Pertinent negatives :

loss of consciousness

chest pain

shortness of breath

dizziness

nausea

vomiting

bleeding, deformity, discoloration, etc.

Past Medical History : cardiac history, asthma, seizure disorder, diabetes, recent pregnancy, congestive heart failure [CHF], etc.

Medication and Allergies : List all medications and allergies to medications, even if they do not seem pertinent to the patient's condition. This includes birth control pills and over-the-counter medications (if the patient is currently taking them). Include dosages and dosing schedules for medications, if possible. If patient did not take medication as prescribed today, note this. Note recent changes in medications (dose or type).

Treatment (Rx) and Patient Responses/Changes

oxygen: note delivery device (NRB, cannula, etc.) and flow rate. Does oxygen help patient's condition?

immobilization (spinal, extremity, etc.): note device used (SAM splint, C-collar, etc.) and assessment of distal PMS before and after splinting

wound irrigation or cleaning

dressing/bandaging wounds

protocol(s) initiated

MD number of physician consulted, orders received, orders carried out

Disposition of Patient (Tx)

transported by WCUPD

transported by POV (own vehicle, friend, etc.)

no transport

refusal type (written, verbal), witnesses, what patient was refusing (ambulance transport, all transport, treatment, etc.)

hospital patient was taken to (regardless of who transported)

person taking care of patient, if released into the care of someone else

Miscellaneous notes :

Any treatments that are rendered after care is transferred to Pittsburgh EMS need not be documented on the tripsheet, since at that point the medics are responsible for patient care.

If the patient refused treatment or transport against medical advice [AMA], note this, and note that the patient was informed of the specific risks of refusing care or transport (infection of wounds, increase in pain, worsening of condition, death, etc.).

Sample Narrative

Here is a sample narrative from an alcohol intoxication call. Note that on this call there was no physical exam performed, but that several sentences are used to explain the patient's emotional state. At the end of the narrative, the friend's name is included (which has been changed to Jane Doe), and the specific instructions he was given are documented. While this is a good narrative, note the absense of pertinent negatives (LOC, head injury, signs of trauma) in the HxPI section.

Dispatched by WCUPD to above loc. for F passed out. AOS t/f 18-yo F CAOx4 pacing room in emotional distress (crying, demanding ID back from security guard). HxPI: Pt & bystanders state she began drinking @ 11pm @ frat parties doing jello shots, vodka shots, beer. Pt states 8 drinks since 11pm, friends std 13 drinks. Pt stopped drinking ~1am. PE: CAOx4 P 92 R 16 BP 110/P, skin WPD, PERRL. Pt able to recite alphabet, stand upright unsupported w/ feet together >30 secs. Pt vomited 2 times while EMS on scene. Pt states she had fight w/ parents over phone that PM, parents told her not to call for 6 months. Pt was very concerned parents not find out about her intox, std they would not pay her tuition & she would kill herself if they found out. WCU intox procedures explained by WCUPD Off. L. Underwood.

Meds: none Allg: none PMHx: none. LOI: noon

Rx: none Tx: Pt advised of right to tx by ambulance and refused, signed refusal form. Jane Doe (friend) agreed to stay w/ her & watch her. Friend instructed to keep pt on her side, check LOC & breathing regularly, call back if any change. Pt refused further care & exam, requested she be left w/ friends in room and requested that EMS leave. EMS clear WFI.

Here is a second sample narrative, this time from a "person hit by car" call. This is also a good narrative, but note that the physical exam is missing some pertinent negatives and is not given in anatomical order.

WCU EMS dispatched by self when bystander approached and std person hit by car outside Cyert Hall. AOS TF 20 yo F supine in westbound lane of Forbes Ave (cross Morewood) in front of PAT bus stop. GCS 15 CAOx4. Bystanders std pt was crossing Forbes Ave. northbound when vehicle going <25 MPH hit pt on R side (travelling westbound). Pt rolled onto hood and landed on R side on ground (note: Pt L shoe found approx 20 ft west of pt). PE revealed 1" abrasion (hair missing) on R side of head above R ear; approx 0.25 inch lac on top of ear; minor abrasions on R hand knuckle; L thumb abrasion (+) swelling (+) tenderness; R thigh lac 0.5 inch long; abrasion on R hip. (-) neck pain, deform. (+) head pain localized on R side. (-) CSF. PERRL. (-) any other DCAPBTLS. Hips stable, lungs clear/(=), strong/(=) grips, (=) push/pull, abd SNT, (-) paresthesia, (-) dizziness, skin w/d. Vitals: PR 96 S/R, RR 16, BP 116/P, LOC x4, (-) SOB, (-) naus, (-) vom. Unknown LOC. NKDA, Meds, PMHx. Rx: C-spine held by bystander, C-collar, long spineboard. Care transferred to Pgh Rescue 5201 and Medic 5108. Assisted 5201 w/ patient care after arrival on scene. Pt. transported 5108ÆUPMC-Presby Hosp. WCU EMS CWFI.

Equipment

As a WCU EMS member, you will use a variety of equipment, including identification, protection, and treatment equipment. This section will familiarize you with some of the equipment you will be expected to carry and use while performing your duties.

Forms of Identification

The primary form of identification is the WCU EMS ID. All primaries are issued an ID (either a photo ID or a temporary non-photo ID). Your photo ID includes your name, WCU ID number, state certification number, and level of certification. A temporary non-photo ID includes only your level of certification. You are required to carry your WCU EMS ID at all times while on shift, and should wear it in a prominent location when on a call. If you lose your ID or it is damaged, you should notify the supervisor on duty as soon as possible.

The secondary forms of identification are WCU EMS jackets, hats, T-shirts, formal uniforms, and patches. The WCU EMS T-shirts are dark blue, heather, or white, with the WCU EMS logo on the front left breast, and "EMS" in large print across the back. The WCU EMS formal uniform consists of a white uniform shirt with our service patch on the left shoulder and an appropriate certification patch on the right shoulder, worn with dark blue trousers, a black belt, and black shoes or boots. A nameplate may be worn immediately above the right shirt pocket. All of these forms of identification may be worn at the discretion of the Operations Manager.

You are not required to wear a uniform while on shift; however, you must wear some form of WCU EMS identification (at a minimum, your WCU EMS ID) while on all calls. If you want to wear a WCU EMS jacket while on shift, you can borrow one from the office. Uniforms (the formal uniform, a T-shirt, or a jacket) may be required for special events or standbys.

Medical Equipment

There are two equipment cabinets in the EMS office, which hold most of our spare equipment. The tan cabinet on the left is normally unlocked, and has small amounts of commonly-used supplies, which may be taken by any member on shift to restock their jump kit after a call. The dark green cabinet on the left is normally locked, and has the rest of the commonly-used supplies, as well as less-commonly used supplies and more expensive reusable equipment. If you need to restock equipment and can't find it in the tan cabinet, contact an officer, who can unlock the dark green cabinet.

The QRS vehicle has 2 equipment bags and 2 oxygen bags. The blue equipment bag contains all the necessary supplies needed to assist a patient on a call. The 2 oxygen bags contain a D sized cylinder with at least 2 nasal canulas and 2 non-rebreather masks.

Personal Protective Equipment

All members on duty have latex gloves available to you, which must be carried at all times while on shift. (Carrying these items while off-duty is optional, but is recommended.) All of the jump kits have Laerdal pocket masks and latex gloves. Other protective items will be also found in the jump bags. All these items serve to help protect you from bloodborne pathogens, but remember that they not protect you unless you use them.

An important, though often-overlooked piece of protective equipment is your clothing. Wearing the appropriate clothing is necessary for personal safety reasons, and also helps protect you against bloodborne pathogens. While on-duty, you should wear closed-toe shoes with flat soles and long pants if possible. Skirts and dresses should not be worn: long, flowing dresses can be contaminated by body fluids or cause injury if they are caught in machinery or vehicles, while short dresses and skirts may make it difficult to run to the call and otherwise limit movement. For similar reasons, high heels, dangling earrings, necklaces, bracelets, or other items of jewelry that might be caught in machinery or vehicle doors should not be worn. Members with long hair should tie it back while on a call. When responding to a vehicle accident at night, you should wear an EMS jacket or some other article of reflective clothing. By following these guidelines, you can help increase your safety and the safety of your crew and patient.

Airway Devices

As you learned in CPR class, without a patent airway, no other interventions matter, and an open airway must be assured before the primary assessment of the patient can continue. Therefore, one of the most important interventions that we can perform is management of the patient's airway. The first step of airway management is to determine whether the patient can maintain their own airway. Generally speaking, this can be assessed by watching and listening to the patient breathe. Any patient that is conscious and speaking to you has a patent airway, and likely does not require additional airway management. Any unconscious patient who has a gag reflex can likely protect their own airway. However, if you hear snoring respirations, it may be necessary to proactively manage the patient's airway. Obviously, any patient that is not spontaneously breathing is very likely to require proactive airway management.

Manual Airway Management

The simplest method of airway management is manually opening the airway using the head-tilt/chin-lift method, or the modified jaw thrust. The head-tilt/chin-lift is the method taught in CPR class, and is the preferred method for opening the airway for a non-trauma patient. For a trauma patient, spinal precautions must also be considered, and the head-tilt/chin-lift cannot be performed while maintaining neutral in-line alignment of the cervical spine. For this reason, the modified jaw thrust is the preferred method of opening the airway in trauma patients.

If the patient is bleeding in their airway, or has foreign bodies or vomitus obstructing their airway, it may be necessary to suction their airway or remove the foreign bodies in order to maintain an open airway. Any assessment of the patient's airway should include looking into their mouth to check for secretions and/or foreign bodies. Don't forget that in a trauma patient, avulsed or chipped teeth can become foreign bodies in the mouth and obstruct the airway.

Airway Adjuncts

For patients whose airway cannot be maintained through manual methods (head-tilt/chin-lift or modified jaw thrust), it may be necessary to use an adjunct. The two types of adjunct used by WCU EMS are the oropharyngeal airway (oral airway or OPA) and the nasopharyngeal airway (nasal airway or NPA).

An oral airway is a curved piece of hard plastic that is inserted into the mouth to prevent the tongue from obstructing the airway. Oral airways come in six sizes, and it is necessary to choose the correct size airway, since an incorrectly-sized airway will not work properly. To size an oral airway, measure the distance between the corner of the mouth and the angle of the jaw. To insert the airway, hold it by the flanged end and insert it into the patient's mouth sideways or upside-down (with the concave side towards the roof of the patient's mouth). When the airway is approximately halfway in, rotate the airway while continuing to insert it, so that when the airway is fully inserted it is in the correct position (concave side towards the patient's tongue). The airway can also be inserted straight in if a tongue depressor is used to hold the patient's tongue out of the way. The key is to avoid pushing the patient's tongue further into their airway while inserting the OPA. When inserting an oral airway into an infant or child, you should insert it sideways or straight in, never upside-down. This is to prevent injury to the child's relatively delicate soft palate and subsequent bleeding into their airway.

Oral airways should not be used in patients with a gag reflex. If the patient gags while you are inserting the airway, immediately remove it, and assess their airway to see if they have vomited. If necessary, suction the airway to remove secretions or vomitus. You should never place your fingers inside an unconscious patient's mouth, whether to assist with the placement of an airway or for any other reason, unless a bite block is in place. If the patient unexpectedly regains consciousness or seizes, they could bite off your fingers.

A nasal airway is a long, slightly curved flexible tube of rubber or plastic which is inserted into one of the patient's nostrils to help maintain their airway. A nasal airway does not provide the same level of protection for the patient's airway that an oral airway does, but nasal airways are much better tolerated by conscious patients. A nasal airway can be used in an unconscious patient who has a gag reflex, or even in a semiconscious or fully conscious patient. Like oral airways, nasal airways come in multiple sizes, and an incorrectly-sized airway will not work properly. To size the nasal airway, measure the length of the airway from the patient's nostril to the tip of their earlobe, and compare the outside diameter of the airway to the diameter of the patient's pinkie finger. To insert the airway, first lubricate it, and then attempt insertion into the patient's right nostril first, with the bevel towards the septum. If resistance is met, remove the airway, re-lubricate it, and attempt to insert it into the left nostril (again, with the bevel towards the septum).

Vaseline and similar petroleum-based lubricants should not be used to lubricate the nasal airway, since some nasal airways are made from latex, and petroleum products degrade latex. Nasal airways should not be used in patients with a suspected skull fracture, since the airway could be inadvertently pushed through the fracture into the brain. Avoid using excessive force while inserting the airway, to prevent trauma to the septum and nasal passages. After inserting the airway, you should suction it with a flexible (French) catheter to clear it of secretions.

Suction

Sometimes the patient's airway may become clogged with secretions, blood, or vomit. Frequently the most effective way to clear it is to use a suction device to remove the secretions; this is usually faster than manually clearing the airway, though you must also consider the amount of time needed to set up the suction device. WCU EMS has two battery-powered portable suction units, one of which is carried in the QRS truck.

When using a suction unit, there are two types of catheter that can be connected to the tubing: a hard plastic catheter, called a "tonsil-tip" or Yankeur tip; and a soft flexible catheter, sometimes called a "French" catheter. The hard suction tip is easier to control in a patient's mouth, and the soft catheter is better for suctioning inside a nasal airway. If the patient's airway is blocked by larger chunks of vomit, it may be necessary to suction using the tubing without a tip.

To suction the patient's airway, first connect the tubing to the suction unit and attach the appropriate catheter. Make sure the suction unit is working, by turning it on and testing the suction against your finger. Then, turn off the suction by removing your thumb from the hole in the suction tip or kinking the suction tubing, and insert the tip into the patient's mouth. Do not insert the tip further than the end of the oral airway; you can measure this distance the same way you size an oral airway, from the corner of the mouth to the angle of the jaw. Once you have inserted the tip all the way, start suctioning by placing your thumb over the hole in the base of the suction tip or unkinking the tubing, and suction as you remove the tip from the patient's mouth. Repeat as necessary to clear the mouth and airway of secretions.

While suctioning the airway, you should avoid suctioning continuously for longer than 15 seconds, to avoid depriving the patient of oxygen. If the suction line becomes clogged, it can frequently be cleared by suctioning some sterile water or saline through the catheter. Sterile water is found in the jumpkits.

Oxygen

Oxygen Tanks and Regulators

Oxygen is carried in portable aluminum or steel cylinders. Cylinders come in different sizes, and sizes are labeled by letters. The cylinders we carry are "D" size cylinders, and hold approximately 500 L of oxygen when full. The oxygen inside the cylinder is under pressure; when full, the pressure is approximately 2000 psi, and the pressure decreases as the oxygen is used. When the pressure in a tank drops below 500 psi, the tank is empty and should be replaced.

Since the pressure inside the tank varies, it is necessary to use a regulator to control the rate at which the oxygen that flows out of the tank. To attach the regulator, first remove the oxygen tank seal, and place the plastic washer over the nipple on the inside of the regulator. Before attaching the regulator, you should "crack" the tank to blow out any debris that might be in the outlet hole; do this by opening the tank for a fraction of a second. Then, ensure the tank is closed by turning the valve all the way to the right with a tank wrench. If you look at the valve assembly on top of the tank, you will notice one side with three holes arranged in a triangle: a large hole on top, and two smaller holes below it. This is the side that fits into the matching three nipples on the regulator. (Oxygen only comes out of the larger hole; the two smaller holes are solely to prevent someone from using a non-oxygen regulator with the tank.) Once you have placed the regulator onto the tank, tighten the retaining screw, and test the seal by turning the tank valve to the left. You should hear no evidence of air leaks, and the pressure gauge on the regulator should indicate the correct tank pressure. If you hear an air leak, shut off the tank and make sure the regulator is connected properly and the retaining screw is tight enough.

After attaching the regulator and turning on the tank, you are ready to attach a delivery system, such as an oxygen mask. There is a knob on the end of the regulator which allows you to select the appropriate flow rate; it is marked in units of liters per minute (LPM). When you are finished using the oxygen tank, close the tank, and bleed the excess oxygen out of the regulator.

Remember when dealing with oxygen tanks that the oxygen inside the tank is at very high pressure. If the valve on top of the tank is damaged or breaks off, the tank will become a rocket, and could seriously injure or kill someone. For this reason, always keep the tank lying on its side; never leave it standing upright on the floor, since it could fall over. Most of the oxygen bags we use have a zipper which allows the oxygen tank to be used without even removing it from the bag.

Oxygen Delivery Systems

There are several different ways to deliver oxygen to the patient. The system you select depends on a number of factors, including the oxygen concentration you wish to deliver to the patient, and whether the patient is breathing spontaneously. If the patient is breathing spontaneously, and the rate and depth of their respirations are adequate, you can use a nasal cannula or oxygen mask. If the patient is not breathing spontaneously, or they are not breathing deeply enough or often enough on their own, you must manually ventilate them or assist their ventilations.

Oxygen Masks

The most commonly-used delivery systems are oxygen masks and nasal cannulas. Oxygen masks come in three types: simple, partial rebreather, and nonrebreather. Generally speaking you will only use the nonrebreather type, though you may sometimes see or use the other two types. Masks and cannulas also come in pediatric and adult sizes; generally speaking pediatric sizes should be used for patients under 6 years of age, and adult sizes for all other patients. It is important to check the mask or cannula size before connecting it, since a pediatric-size device should not be used on an adult patient.

A nasal cannula is the simplest type of delivery system. It delivers the lowest concentration of oxygen of any of the delivery systems, since the patient is still breathing mostly outside air. To put the cannula on a patient, loop the tubing over their ears so that the prongs fit into their nose, and then move up the retaining ring so that the tubing is snug under their chin. If you look closely at the prongs, you will note that they are curved; the cannula should be applied so that the prongs curve towards the patient's face, since that aligns them with the natural curve of the nasal passages. For a nasal cannula, the oxygen flow rate can be set anywhere between 1/2 LPM and 4 LPM.

A nonrebreather [NRB] mask allows the delivery of the highest concentration of oxygen of any of the types of mask; it's possible to deliver almost 100% oxygen to the patient with an NRB. The NRB appears very similar to a partial-rebreather, but adds two sets of one-way valves. One valve is between the bag and the mask; it allows the patient to inhale air from the bag, but prevents exhaled air from flowing back into the bag. The other set of valves is on the vent holes on the sides of the mask, which prevent the flow of outside air into the mask when the patient inhales. Some newer NRBs eliminate one or both of the vent hole valves; this is a safety feature intended to prevent the patient from suffocating if the oxygen becomes disconnected, runs out, or stops flowing for any other reason. For a nonrebreather mask, the flow rate should be set high enough to prevent the bag from fully deflating when the patient inhales; usually this means at least 15 LPM.

When applying a mask to a patient, you should first connect the mask to the oxygen cylinder, and then place the mask on the patient's face and put the strap behind their head. The strap can be tightened by pulling on the ends of the strap. The metal nose clip can be pinched together to provide a snug fit across the bridge of the patient's nose. If you are using a mask with a reservoir bag (either a partial- or non-rebreather), before placing the mask on the patient, you should fill the bag by placing your thumb over the valve or hole between the mask and bag and waiting for oxygen to flow into the bag.

Occasionally, someone may refer to "low," "medium," or "high" flow oxygen. Low-flow oxygen is defined as less than 6 LPM, and is usually provided by a nasal cannula. Medium-flow oxygen is defined as 6-12 LPM, and can be provided by a simple mask or partial-rebreather. High-flow oxygen is 12-15 LPM, and is provided by a nonrebreather mask. If you are not sure how much oxygen a patient needs, it is always safer to give too much rather than too little, so you should use a nonrebreather mask at 15 LPM.

Ventilation Devices

"Ventilation" refers to any situation where you are manually forcing air into the patient's lungs, as opposed to the patient breathing on their own. Any patient that is not breathing sufficiently on their own will need to be manually ventilated. If the patient is still breathing spontaneously, but the rate or depth of their respirations are insufficient, you may need to assist their respirations by providing "extra" breaths between spontaneous breaths, or by forcing additional air into their lungs with each spontaneous breath. Any time you ventilate a patient that still has some spontaneous respirations, you should attempt to synchronize your ventilations with their breathing, so that you are not trying to force air into their lungs at the same time they are trying to exhale or vice versa. Obviously, any patient that is not breathing at all (apneic) will need to be ventilated as well.

While CPR class teaches the mouth-to-mouth and mouth-to-mask methods of ventilation, those are generally not the preferred methods of ventilating patients by EMS providers. Instead, you will usually use a bag-valve-mask (BVM). The BVM allows a higher concentration of oxygen to be provided to the patient than mouth-to-mask does, and is not as tiring for the person providing ventilations. However, using a BVM properly is a skill that takes some practice to acquire, so it is important to practice and be familiar with its use.

The BVM consists of, as the name implies, three main parts: a bag, a valve, and a mask. Most BVMs that we use also have an oxygen inlet and a reservoir bag, similar to the bag found in a nonrebreather mask. When connected to an oxygen supply, the BVM can supply almost 100% oxygen to the patient. To use the BVM, you hold the mask against the patient's face, and squeeze the bag to deliver a ventilation. A valve between the mask and bag allows oxygen to flow from the bag into the mask, but prevents exhaled air from flowing back into the bag. If you have the reservoir bag and oxygen tubing connected, the bag refills from the reservoir with oxygen. When using a BVM with oxygen, the flow rate should be set to 15-25 LPM.

While using the BVM, it is necessary to have a good seal between the mask and the patient's face. Otherwise, when you squeeze the bag, the oxygen will leak out around the edges of the mask and will not be forced into the patient's lungs. If you are using the BVM by yourself, the best way to hold the mask is called a "C-clamp": make a "C" shape with your thumb and forefinger, and place the "C" around the top of the mask. Then, use your remaining three fingers to clamp underneath the patient's jaw and hold the mask to their face, and use your other hand to squeeze the bag. Unfortunately, it is difficult for a single person to use a BVM effectively, since obtaining a good mask seal requires a fair amount of hand strength, and it is difficult to squeeze the bag enough with one hand to provide enough air per breath. If an additional person is available, you can have them hold the mask on the patient's face using both hands, while you squeeze the bag with both hands. This provides a better mask seal, and provides a higher volume of air per breath.

Some other points to keep in mind: Squeeze the bag slowly and evenly. Don't squeeze quickly; you won't be able to force that much air into the patient at once. Don't squeeze the bag too much: watch for the chest rise, and ventilate only enough to make the chest rise. Make sure you allow enough time between ventilations for exhalation. Ensure that the airway is open; if possible, insert an airway adjunct, such as an oral or nasal airway. Pay attention to "compliance," or how easy it is to squeeze the bag: if it was easy to squeeze the bag at the beginning, but now it is becoming difficult, there may be a problem, such as an obstructed airway or a pneumothorax. In addition, watch the patient to make sure that they do not begin to vomit or passively regurgitate. If they vomit, suction and clear the airway before continuing with ventilations, to avoid forcing vomitus or other secretions into the lungs.

Spinal Immobilization

The spine consists of 33 vertebrae: 7 cervical vertebrae in the neck, 12 thoracic vertebrae in the upper back, 5 lumbar vertebrae in the lower back, 5 sacral vertebrae, and 4 fused vertebrae that form the coccyx. They are linked together with cartilage and ligaments, with the spinal cord running through the center. Nervous system impulses for most body functions, including breathing and voluntary movements, are conducted from the brain through the nerves in the spinal cord out into the body. Since damage to the spinal cord can result in paralysis or death, it is important to recognize when the potential for spinal injuries exists and take appropriate precautions.

During your assessment, any paralysis, numbness, tingling, or "odd sensations" that the patient reports, as well as tenderness or pain in the neck or back, indicate a potential spinal injury. In addition, any significant trauma with force applied to the spine, such as diving into shallow water, falling down a flight of stairs or out of a bunk bed, or being involved in a motor vehicle collision may cause spinal injury. A significant fraction of patients who lose consciousness as a result of a blow to the head also have spinal injuries, so you may need to consider spinal injuries in patients with traumatic loss of consciousness.

Spinal injuries are relatively rare, but due to the fact that a patient with an unrecognized spinal injury can be killed or have their future quality of life changed dramatically due to our treatment, it is necessary to maintain a high index of suspicion. Spinal precautions are frequently taken based solely on the fact that the "mechanism of injury" suggests that a spinal injury may exist, regardless of whether or not the patient is symptomatic. In general, any trauma patient (especially any unconscious trauma patient) should be considered to have a spinal injury until proven otherwise.

The most important consideration to remember when dealing with a patient with a potential spinal injury is that they should not be moved without appropriate precautions, if at all possible. A patient with an unstable vertebral injury but no damage to the spinal cord has the potential to make a full recovery, but if the spinal cord is damaged, even a partial recovery is doubtful. However, the general rule of "life over limb" applies here: if the patient has immediately life-threatening conditions and it is necessary to move them to treat those conditions, then they should be moved, while maintaining stabilization of their spine as best as possible. It's better to have a quadriplegic patient that's alive than a dead patient with an intact spinal cord.

Manual Stabilization

As soon as the need for spinal precautions is recognized, manual cervical spine [C-spine] stabilization should be initiated. This consists of nothing more than having a crew member place one hand on either side of the patient's head and holding it gently, but firmly, to prevent movement. If the patient was found with their head at an angle, it should be gently moved into the neutral position, stopping if the patient feels pain or loses feeling in their extremities, or if any crepitation is heard or felt. The person holding C-spine should not apply any force or traction to the spine.

Once manual stabilization is initiated by a crew member, it should not be discontinued unless someone else takes over stabilization, the patient is fully immobilized on a long backboard, or additional assessment reveals that spinal precautions are not necessary. During any patient movement, the crew member who is stabilizing the patient's head should direct the movement, so they can move the patient's head with their body.

If it is necessary to move the patient for any reason (assessing the back, patient begins to vomit, etc.), the "log roll" technique should be used. This method best maintains the alignment of the spine. To perform a log roll properly, at least three people are required. The first person sits or kneels above the head, holding C-spine. The other two people position themselves on one side of the patient, with the one closer to the head holding the patient's shoulder and lower hip, and the one further from the head holding the upper hip and legs. On the count of the person holding the head, the two crew members holding the body roll the patient towards them. To roll the patient back, the person at the head again calls the count, and the two crew members holding the body roll the patient back.

Applying a Cervical Collar

After initiating manual stabilization, a hard plastic cervical collar [C-collar] should be applied. The C-collar serves to help stabilize the head and neck; however, it does not fully immobilize the head or neck, and as a consequence manual stabilization must be maintained even after the C-collar has been applied.

The first step in applying a C-collar is selecting the appropriate size. A poorly-fitted C-collar will not properly stabilize the neck, and may interfere with the patient's ability to breathe or open their mouth. This can have serious consequences, should the patient need to vomit. As a result, after applying the collar you should reassess the patient to ensure that their breathing is not hampered, and they can still open their mouth.

The collars we use are Laerdal "Stiffneck" brand, and come in four adult sizes (No-Neck, Short, Regular, and Tall) and two pediatric sizes (Baby No-Neck and Pediatric). To measure the appropriate C-collar size, place your hand alongside the patient's neck, and measure the (vertical) distance between the top of their shoulder and the tip of their jaw by estimating the number of fingerwidths. Then, find the C-collar with the same distance between the black peg and the jaw support.

After you have selected an appropriately-sized collar, assemble the collar by pushing the black peg through the hole. To place the collar on the patient, first pass the rear neck portion with the Velcro tab behind the patient's neck. Then, curve the front jaw portion of the collar around, placing it under the patient's jaw. Finally, attach the Velcro tab to the matching Velcro hook section of the collar, ensuring that it fits snugly.

It may be necessary to cut away clothing, jewelry, etc. from the patient's neck before applying the collar. If the patient has long hair, you may have to be careful not to catch it in the collar. Remember to perform your assessment of the patient's neck and head before applying the collar, since once you have applied the collar it is not possible to fully assess the head and neck.

If the patient is in a sitting position, rather than supine, the collar is measured and applied the same way. It is usually easiest to have the person holding C-spine stand or sit behind the patient while applying the C-collar from the front.

For a patient that is found face-down (prone), it is usually easiest to log-roll the patient over onto their back before applying the collar. However, if necessary it is possible to apply the collar while the patient is prone.

Backboarding

Once you have applied the C-collar, you can proceed to strap the patient onto a long backboard. To place the patient onto the backboard, they are log-rolled onto their side, the backboard is placed underneath them at an angle, and they are log-rolled back onto their back. While the patient is rolled onto their side, their back and buttocks should be assessed. To reposition the patient on the backboard, you should slide them up and down the board while moving diagonally to one side or to the other, never straight side-to-side. While performing the log roll and positioning the patient, the person at the head should direct all movements.

Once the patient is positioned appropriately on the backboard, the straps can be applied. The body should be strapped down with a minimum of three straps (one across the chest, one across the hips, and one across the legs). For added stability, a fourth strap can be used, with two straps criss-crossing the patient's chest from shoulders to hips, a strap across the hips, and a strap across the legs. To prevent the patient from sliding up and down on the board, their feet should be secured with a figure-8 or similar hitch in the leg strap. If backboard straps are not available, wide tape can be used instead of straps. The backboard straps should be fairly tight, since the object is to prevent patient movement during transport.

Once the body has been strapped in, the head can be secured. Usually you will use the foam head immobilizer for this, which consists of two foam pillows that go on either side of the head, and two straps which hold the head in place. However, if a head immobilizer device is not available, rolled towels or bulky dressings can be used to immobilize the head, and tape used instead of straps.

After the patient has been fully immobilized on the backboard, manual C-spine stabilization can be discontinued. Don't forget to reassess the patient for distal pulses, movement, and sensation in all four extremities, just as you would for any other splinting operation.

While it may seem like a lengthy operation at first, with practice a three-person crew can stabilize the patient's head, apply a C-collar, and backboard the patient in two or three minutes.

Notes

It's important to remember that when taking spinal precautions, the goal is to keep the patient's spine in neutral alignment and prevent movement. If the patient is combative or is thrashing uncontrollably, holding their head while they move the rest of their body or forcing them to fight against the backboard straps may do more harm than good. In cases such as these, consider whether spinal precautions are truly necessary, and whether or not it will be more effective to simply instruct the patient to lie still without immobilizing them.

If you are the first person to arrive on scene, you should not allow manual spinal immobilization from preventing you from performing your primary assessment. If necessary, a bystander or Campus Police officer can frequently be recruited to hold manual stabilization. Don't forget, as well, that just because you're holding C-spine, that doesn't mean that you can't also talk to the patient and obtain a history.

Do not strap the patient's head to the backboard before strapping their body down. It is necessary to strap in the torso first in order to avoid creating a "pivot point" at the neck. If you are unsure of why this is, consider what would happen if the patient's head was strapped to the backboard and the torso shifted, due to accidental motion or due to the application or tightening of the straps.

In addition to immobilizing the spine, a long backboard can also be used as a splint for a patient with a hip fracture. Particularly for elderly patients, it may be necessary to pad the backboard with towels, a pillow, or bulky dressings for patient comfort.

Bloodborne Pathogens

WCU EMS, like other emergency medical services, believes that while patient care is the primary goal, the safety of the crew comes first. While most people think of scene safety as the only safety precaution taken by the crew, this is not so. Proper protection of members from infectious diseases is also a concern. These days, you are likely at some point to come into contact with a patient who has Hepatitis or Human Immunodeficiency Virus [HIV]; however, these are not the only infections that you should be concerned about. While the potential for infection exists when you come into contact with a person with an infectious disease, there are measures you can take which significantly reduce your risk of becoming infected. In order to protect yourself from any sort of infection, you should take the following precautions:

Cover any open wounds that you might have with a bandage, especially if they are on your hands or arms.

Wear gloves at all times when there is a possibility of contact with body fluids. Avoid touching your eyes, mouth, or face while treating a patient.

If you know or suspect the patient has a respiratory infection, wear a mask or have the patient wear a mask.

Wear other appropriate protective gear (gowns, goggles, etc.) when there is the potential for splashing or spurting body fluids.

Wash your hands thoroughly with soap and water, or disinfect them with Cal-Stat or Purell, after every call.

Disinfect any contaminated equipment which is to be reused. If you are unsure about how to disinfect a piece of equipment, consult the supervisor on duty.

Always maintain a least one barrier between yourself and the patient.

If you come in contact with body fluids, you should file an incident report and contact the supervisor on duty as soon as possible. After a potential exposure, there are two routes that may be taken to determine the extent of the exposure. The first is to test the patient for pathogens; this may require the patient's consent, but is the easiest on the exposed individual and is the most reliable test. The second is to have yourself tested for pathogens as soon as possible after the exposure, again in three to six months, and again one year after the exposure. If the second or third test results differ from those of the first, an exposure has occurred. There are vaccinations available for Hepatitis-A [Hep-A] and Hepatitis-B [Hep-B]. We strongly recommend that you receive at least a Hep-B vaccination. Many health insurance plans cover immunizations, so check with your insurance carrier. If you would like further information on vaccinations, or information on specific bloodborne pathogens, contact the Operations Manager.

Remember that we also owe our patients a duty to protect them from the spread of infectious diseases, both those that our members may harbor and those that other patients may have. For this reason, it is important to disinfect reusable equipment before using it on another patient, and you should always change your gloves (and wash your hands, if possible) before you treat a second patient.

Make sure you are familiar with the operational policy regarding infectious diseases. Although it is unlikely that you will become infected through contact with a small number of disease particles, you should still do everything you can to ensure your safety and the safety of the rest of the crew.

Radio-Related Details

You don't have to know all of the material in this section, but we've included it because radios are one of the items that we get a lot of questions about. Feel free to read this section if you are curious or have more questions about the radios. If you have a question that isn't answered here, see the primary or the Equipment Officer or Operations Manager.

Frequently Asked Questions

Q: I put the battery in my fast charger, and the red light started blinking. What does this mean?

A: This means that for some reason, the charger cannot start charging at the fast rate, so it has switched to the slow rate. This usually happens if the battery is extremely cold or hot, hasn't been charged in a while, or the contacts are dirty. It may also mean that the battery is shorted internally and can no longer be used (usually this only happens to very old batteries). If the light doesn't switch to solid red after 10-15 minutes, take the battery out, check the contacts, and let it sit until it gets to room temperature (if it's hot or cold), and try again. If it still occurs, let it charge for eight hours instead of three, and notify the supervisor on duty.

Q: Sometimes the radio makes a really loud, continuous, Emergency Broadcast System-style beep. Why?

A: This is sort of a "final warning" when the battery is on its last gasp. The radio has enough power to start turning on, but not enough to get past the power-on beep, so it gets stuck there. Turn your radio off and change batteries immediately.

Q: Why do some batteries last 24 hours and some only 18 hours or less?

A: As the batteries get used and age, their capacity drops. This can be slowed somewhat by following the battery care guidelines and periodically reconditioning the batteries, but eventually the battery will no longer hold a charge and needs to be discarded. If you notice that your battery is lasting an extremely short time (12 hours or less), tell the Equipment Officer.

Q: Why does the light on the radio glow orange for a few seconds after I press the middle button on the side of the radio?

A: The middle button on the side of the radio turns "monitor mode" on and off. When the radio is in monitor mode (the orange light came on when you pressed the button), PL, DPL, and tone paging are all disabled. (See the "PL and Tone Paging" section below.) You will hear everything that is transmitted on the channel, including random interference. When the radio is not in monitor mode (the orange light didn't come on when you pressed the button), any PL, DPL, or tone paging settings that are in effect for the channel are used. Generally speaking, you should leave monitor mode off.

Q: What does the top button on the side do, really?

A: In addition to generating the "volume level check" tone, the top button on the side also functions as a "nuisance channel delete" button. While the radio is scanning, there may be a channel in the scan list that you don't want to listen to (usually because there is a lot of irrelevant traffic on it). To temporarily remove a channel from the scan list, press the top button after the transmission on that channel has stopped, but before the radio starts scanning again. (You will know if you pressed it at the right time if you don't get the volume-check tone, and the radio starts scanning again after a few seconds.) If you change the radio channel or turn the radio off and on again, the scan list will be reset.

The Repeater

The radios that WCU EMS members carry while on duty are handheld 5-watt VHF transceivers. These radios are designed for portability, and as such are reasonably light, compact, and durable. However, their range is limited, due to the relatively low transmitting power and the fact that the antenna is not very high off the ground (no higher than you can hold it). Using only the portable radios, WCU EMS members would not be able to hear dispatches from all areas of campus, and the crew chief might not be able to hear all of the responding medics, depending on their location and his. To solve this problem, WCU EMS uses a special radio called a repeater in addition to the portable handheld radios. A repeater does what its name sounds like: it listens for radio transmissions on one frequency, and repeats them on another. Since the repeater doesn't have to be portable, it can have a much higher antenna location and a much more powerful transmitter than a handheld radio. WCU EMS's repeater is on the roof of Wean Hall. Most of the time you can just use your radio without noticing or caring that you are going through a repeater. However, there are a few reasons why you should know that we use a repeater:

After you key the mic on your handheld radio (to start transmitting), it takes a fraction of a second for the repeater to engage. It's for this reason that you need to pause approximately 1 second after keying the mic before you begin speaking.

If the repeater ever malfunctions, you won't be able to hear dispatches, since they are not transmitted on the same frequency as your radio receives. Therefore, everyone would need to switch to our backup dispatch frequency.

After you (or someone else) finishes transmitting, the repeater will transmit an empty signal for a couple seconds. This transmission is called the "repeater tail," and you can listen for it after you transmit. If you don't hear it, chances are good that you didn't hit the repeater, and as a result no one else heard your transmission.

PL and Tone Paging

Radios don't usually have the speaker turned on all the time; if they did, you'd hear static anytime there wasn't someone transmitting. The simplest method that a radios can use to figure out whether or not to turn the speaker on is called "carrier squelch." With carrier squelch, the radio turns on the speaker when it hears a transmission on the frequency. Carrier squelch has a problem, though; it's vulnerable to interference. Computers, cellular phones, and other radios can sometimes cause interference that is strong enough for the radio to unsquelch. When that happens, you get an annoying burst of static or noise.

One method for dealing with this problem is called Private Line [PL] or Continuous Tone Coded Squelch System [CTCSS]. It was originally designed to let more than one organization share a radio frequency without each having to hear the others' transmissions, but it also works well to decrease interference. PL is pretty simple: whenever the radio transmits, it also sends out a continuous subtone at a frequency you can't hear (around 100 Hz). When the radio receives, it listens for the subtone, and only opens the squelch when it hears a transmission with the proper subtone. This solves both problems at once: multiple organizations can share a radio channel by choosing different PL frequencies (as long as they don't transmit at the same time, since only one transmitter can be active on the frequency at a time regardless of the PL tone it's using), and since interference usually doesn't have the right PL tone, your radio only unsquelches when there's an actual transmission.

Another type of squelch control is called "two-tone paging" or "Quick-Call II." Instead of a continuous tone, tone paging uses a sequence of audible tones at the beginning of the transmission to signal the radios to open squelch. The advantage of tone paging is that there are many more combinations of tones than there are single PL or DPL tones, so more organizations can use a frequency without overlapping. Services can have multiple "call groups," so for instance there might be one set of tones that signals unit 10, another set of tones that signals unit 20, and still another set of tones that signals all the units. Tone paging also allows combining sets of tones; multiple tone pairs can be transmitted sequentially to signal multiple groups of radios. Two-tone paging was originally designed for voice pagers, but has been extended to radios because of its convenience and flexibility. Using two-tone paging, radios can have a "do not disturb" mode where they only unsquelch for a dispatch (preceded by the appropriate tone pair, of course), and the radio can sound an alert tone when it receives the appropriate paging tones.

Channel Assignments

The channel assignments for the Mobile Radio and HT1000 Portable radios are listed below.

WCU Mobile Radio

Channel	Function
1	WCU Police 1
2	WCU Police 2
3	EMS 3
4	County Pager Frequency (No Transmit)

County Mobile Radio

Channel	Function
86	CC Fire 33.86
88	CC Fire 33.88
90	CC Fire 33.90 (Old Pager Frequency)
96	CC Fire 33.96 (WCU – Fire Main Channel)

HT1000 Portable Radios

Channel	Function	Channel	Function
1	WCU Police 1	6	CC Pagers (OPEN)
2	WCU Police 2	15	CC Pager (58 Tones)
3	EMS 3	16	EMS Pager w/Tones
4	EMS 4
5	EMS-CC 33.96 Link

International Phonetic Alphabet

To avoid confusion between similar-sounding letters (F/S, P/T, etc.), you should use phonetics when spelling words or giving isolated letters over the radio. See the following table for the commonly-accepted international phonetic alphabet. Learning this alphabet is not required, but spelling words over the radio using phonetics is a lot easier if you don't have to stop and think of a word that begins with the appropriate letter.

Phonetic Alphabet.

	Emergency Medical Services Tyson Hall Basement West Chester, Pennsylvania 19383	Emergency: (610)436-3311 Office: (610)436-3138 http://ems.wcupa.edu/