EMT Ambulance Check- AC3 (International)

• Date/Time

  Date

• Your name.

• Previous shift EMT:

  Select ARMITAGE, K BAIER, D BRYANT, J COFFEE, J DEACON, K HYATT, S LUSHER, A MASTROGIUSEPPE, N MCKNIGHT, M MELZER, J MESSIER, J MILLER, C MILLER-EVANS, T PAPPAS, P SKIDMORE, J SMITH, B SUMNER, T WASHINGTON, F YANCHUNIS, A ADAMS, J FLORIO, J FLEET TARGAL, C GRECO, D

  • ARMITAGE, K
  • BAIER, D
  • BRYANT, J
  • COFFEE, J
  • DEACON, K
  • HYATT, S
  • LUSHER, A
  • MASTROGIUSEPPE, N
  • MCKNIGHT, M
  • MELZER, J
  • MESSIER, J
  • MILLER, C
  • MILLER-EVANS, T
  • PAPPAS, P
  • SKIDMORE, J
  • SMITH, B
  • SUMNER, T
  • WASHINGTON, F
  • YANCHUNIS, A
  • ADAMS, J
  • FLORIO, J
  • FLEET
  • TARGAL, C
  • GRECO, D

Exterior

• Take photo if needed.

  Media

• Lights operational?<br><br>Headlights<br>Turn signals<br>Marker (red /yellow)<br>Skirt (red / white) <br>Brake <br>Ground <br>Emergency <br>Flood / Scene

  Yes

  No

  N/A

• All doors operational?<br><br>Open/close?<br>Lock/unlock?

  Yes

  No

  N/A

• Lift operational and secure when locked?<br><br>No hydraulic fluid leaks?<br>

  Yes

  No

  N/A

• Tires in good condition? <br><br>Cat eyes in normal position<br>No nails/obvious damage<br>Tread wear (front > 1/8" ; rear > 1/16")<br>No bearing grease on rims or rim damage<br>

  Yes

  No

  N/A

• Is tire psi in safe operating range? (Tuesday)<br>**Fronts 95-100, Rears 90-95**<br><br>Document tire psi in notes.

  Safe

  At Risk

  N/A

• Exterior clean?

  Yes

  No

  N/A

Exterior storage compartments.

• Fire extinguisher present and up to date and secured safely? <br>Needle is in the green range?<br>Pin is zip tied?

  Yes

  No

  N/A

• Make sure card is signed once per month.

• Road triangles present?

  Yes

  No

  N/A

• Two Stryker/Ferno antlers and two lock bars present and in usable condition?

  Yes

  No

  N/A

• Shore lines plugged in and operational?

  Yes

  No

  N/A

• Inverter operational with no tripped breakers?

  Yes

  No

  N/A

• BLS bag present and in service?

  Yes

  No

  N/A

• NEO and PEDI immobilizers present and ready for service?

  Yes

  No

  N/A

• Long Spine board and applicable straps present and ready for service?

  Yes

  No

  N/A

• Onboard O2- no audible leaks and tank psi over 1000?

  Yes

  No

  N/A

• O2 psi reading

• Onboard Medical Air- no audible leaks and psi over 1000?

  Yes

  No

  N/A

• Medical Air psi reading

Generator

• Oil in range?

  Yes

  No

  N/A

• Coolant in range?

  Yes

  No

  N/A

• Belt free of cracks and frays?

  Yes

  No

  N/A

Engine compartment

• Oil in range?

  Yes

  No

  N/A

• Coolant in range?

  Yes

  No

  N/A

• Brake fluid in range?

  Yes

  No

  N/A

• Transmission fluid in range?

  Yes

  No

  N/A

• Power steering fluid in range? <br>

  Yes

  No

  N/A

• Windshield washer fluid full?

  Yes

  No

  N/A

• Belts free of cracks and frays?

  Yes

  No

  N/A

• Visible Engine Fluid Leaks?

  Select None Oil Coolant Transmission Fluid Power Steering Fluid Brake Fluid Unknown

  • None
  • Oil
  • Coolant
  • Transmission Fluid
  • Power Steering Fluid
  • Brake Fluid
  • Unknown

Interior: Cab

• Insurance present and current?

  Yes

  No

  N/A

• Issue date:

  Date

• Registration current and present?

  Yes

  No

  N/A

• Issue date:

  Date

• Two reflective vests present?

  Yes

  No

  N/A

• Fuel credit card present?

  Yes

  No

  N/A

• Direction book present?

  Yes

  No

  N/A

• Siren operational?

  Yes

  No

  N/A

• Climate control operational?

  Yes

  No

  N/A

• Fire extinguisher present and secured safely? <br>Needle is in the green range?<br>Pin is zip tied?

  Yes

  No

  N/A

• Make sure the card is signed once per month.

• Flashlight present and functioning?

  Yes

  No

  N/A

• Trash emptied and liner placed in can?

  Yes

  No

  N/A

• Cab clean: console wiped down, floors swept/mopped

  Yes

  No

  N/A

Dash

• Mileage:

• Next PM mileage:

• Fuel level:

  Select Full 7/8 3/4 5/8 1/2 3/8 1/4 Empty

  • Full
  • 7/8
  • 3/4
  • 5/8
  • 1/2
  • 3/8
  • 1/4
  • Empty

• Dashboard free from warning indicators?<br><br>Low air pressure<br>ABS<br>Amber Check Engine<br>Red engine <br>Flashing Regen Light

  Yes

  No

  N/A

• Oil pressure between 40 to 60 psi when running?

  Yes

  No

  N/A

• Voltage meters reads > 12.0 Volts?

  Yes

  No

  N/A

Interior: Patient Compartment

• Is patient compartment clean? (Wiped down, swept, mopped)

  Yes

  No

  N/A

• Take photo if needed.

  Media

• Trash emptied and liner in place?

  Yes

  No

  N/A

• Miscellaneous supplies present?

  Select EPCR cable Flashlight Suction canister w/ Ped Yankauer (under sat phone) 2 Suction Canister w/ Tubing Gloves ( S,M, L) (2each) O2 & Air Flowmeters TV/DVD Remotes

  • EPCR cable
  • Flashlight
  • Suction canister w/ Ped Yankauer (under sat phone)
  • 2 Suction Canister w/ Tubing
  • Gloves ( S,M, L)
  • (2each) O2 & Air Flowmeters
  • TV/DVD Remotes

• Sealed Cabinet # 1 All supplies present?<br><br>Diapers – Wipes – Ped/Neo electrodes – Thermometers – Pressure Infuser – 2x Transwarmer Mattresses – 4X4s – Spare BP Cuffs (Philips/Propaq)

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet # 2 All supplies present? <br><br>Two Liter bags: NS <br>Two Liter bags: ½ NS <br>Two 500cc bags: D5 0.9% NS <br>Two 500cc bags: D10W <br>Two Liter bags: D5 ¼ NS <br>Two Liter bags: D5 ¼ NS 20K <br>Two Liter bags: D5 ½ NS <br>Two Liter bags: D5 ½ NS 20K <br>

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet # 3 All supplies present? <br>​2 Turkel Chest Tube Trays – 1 Umbilical Catheter Kit – Transducer – 1 neo cooling pack – Infusion Sets - Gastroschesis bag

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet #4 All supplies present? <br><br>​Sterile Gowns – Non-sterile gowns – Surgical Masks – Box N95 Masks – 3 goggles – Surgical masks w/ eye shield

  Yes

  No

  N/A

• Sealed Cabinet # 5 All supplies present? <br><br>​Aspen collars (P1-5, Adult small, reg, tall) <br>Spare Suction Supplies (canisters and tubing) <br>Behavioral Restraint Bag<br>

  Yes

  No

  N/A

• Cabinet # 6 / Storage Area All supplies present? <br><br>​Nitric Bag (plugged in and charging) <br>Ambulance Code Bag

  Yes

  No

  N/A

• Black Ambulance Code Drug Bag sealed?

  Yes

  No

  N/A

• Next expiration date:

  Date

• Sealed Cabinet # 7 All supplies present? <br><br>22mm Vent Circuit, 15mm Vent Circuit, Neo Vent Circuit <br>Sterile Suction Cath (2x6fr, 2x8fr, 2x10fr, 2x14) <br>2 Nitric Kits<br>Nasal Cannulas: 2 NEO, 2 PEDI, 2 ADULT <br>Non-Rebreather Masks: adult and pedi <br>2 Ventimasks<br>BVMs (infant, ped, adult)<br>Neo-Tee (w/ infant and neo masks) <br>2 L D5 NS with 40 K<br>2 L NS with 40 K<br><br>

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet # 8 All supplies present? <br><br> Urinal – Bedpan – Emesis Basin – Sheets – Bath Blankets – Towels – Cleaning Spray/Wipes

  Yes

  No

  N/A

• Baby blanket warmer off?<br><br>Baby blankets present?

  Yes

  No

  N/A

• 3 O2 E-cylinders- Present and >1500 psi?

  Yes

  No

  N/A

• 1 O2 D-cylinder- present and >1500 psi?

  Yes

  No

  N/A

• 1 Medical Air E-cylinder- present and >1500 psi?

  Yes

  No

  N/A

• Drawer A All supplies present? <br><br>Assorted Large Syringes (20cc, 30cc, 60cc) <br>Med labels <br>Alcohol Preps <br>Rapid Fill Connector <br>Dispensing Pins <br>​Syringe Tubing (filtered and non-filtered) <br>EZ Lubricating Jelly<br>

  Yes

  No

  N/A

• Drawer B All supplies present? <br><br>Assorted Small Syringes (1cc, 3cc, 5cc, 10cc) <br>18g needles <br>Filter Needles<br>Blunt access <br>Twin Pack <br>Site-Scrub

  Yes

  No

  N/A

• Drawer C / Action Area All supplies present? <br><br>4x4s <br>Assorted Syringes <br>Assorted IV adapters<br>Flushes <br>18g needles <br>Med Labels <br>Alcohol Preps <br>Site-Scrub<br>Hand Sanitizer <br>24g IV Catheters <br>Tape

  Yes

  No

  N/A

• Drawer D All supplies present? <br><br>Emesis Bags – Hot/Cold Packs – ID/Allergy Bands – (2) NG/OG Syringes

  Yes

  No

  N/A

• Drawer E All supplies present? <br><br>Truck Check Sheets<br>Spare ACH Forms<br>Printer Paper (Philips/Propaq)<br>Ambulance Code Sheet Book<br>DVDs

  Yes

  No

  N/A

• Drawer F All supplies present? <br><br>​Bio Bags <br>Seals <br>Bolts

  Yes

  No

  N/A

• If there is an ISOLETTE on board, check that the following items are present.

  Select Not Applicable O2 and Air > 1000 2 Medfusion Syringe Pumps 1 IVAC 3-Channel Pump RN Equipment Bag RT Bag Neo Vent Circuit Neo-Tee Bag with flushes, heat packs, sweet-ease, Resp saline Bag with neo eye masks, neo wrap, hat Plugged in and pumps are charging

  • Not Applicable
  • O2 and Air > 1000
  • 2 Medfusion Syringe Pumps
  • 1 IVAC 3-Channel Pump
  • RN Equipment Bag
  • RT Bag
  • Neo Vent Circuit
  • Neo-Tee
  • Bag with flushes, heat packs, sweet-ease, Resp saline
  • Bag with neo eye masks, neo wrap, hat
  • Plugged in and pumps are charging

• If there is a stretcher onboard, please check that the following items are present.

  Select Not Applicable O2 > 1000 2 Medfusion Syringe Pumps 1 IVAC 3-Channel Pump RN Equipment Bag RT Bag LTV Ventilator Pedi-Mate Linens Clipboard Bag with flushes, heat packs, sweet-ease, Resp saline Plugged in and vent and pumps are charging

  • Not Applicable
  • O2 > 1000
  • 2 Medfusion Syringe Pumps
  • 1 IVAC 3-Channel Pump
  • RN Equipment Bag
  • RT Bag
  • LTV Ventilator
  • Pedi-Mate
  • Linens
  • Clipboard
  • Bag with flushes, heat packs, sweet-ease, Resp saline
  • Plugged in and vent and pumps are charging

• Phillips Defibrillator OPS check passed? (Monday) **Night shift do Op Check on 3rd Philips on shelf upstairs**

  Yes

  No

  N/A

• Philips supplies present and monitor plugged in?

  Select ECG Cable SpO2 Cable NIBP Cable IABP Cable Temp Cable w/ Probe EtCO2 Adapters (Neo and Ped) Defib Pads (2 infant & 2 child/adult) Paper

  • ECG Cable
  • SpO2 Cable
  • NIBP Cable
  • IABP Cable
  • Temp Cable w/ Probe
  • EtCO2 Adapters (Neo and Ped)
  • Defib Pads (2 infant & 2 child/adult)
  • Paper

• Ambulance safe to operate? If not, please explain why?

  Safe

  At Risk

  N/A

• If any critical failures are identified, ambulance should be downed until it can be evaluated. Notify Scott immediately and let team know.

• If ambulance was downed for mechanical failure, who was notified?

• If the ambulance has any new damage to the interior or exterior, take a photo and notify oncoming EMT and Scott Burford.

  Media

• I herby affirm that all information above is accurate to the best of my knowledge. EMT signature:

  Sign