EMT Ambulance Check- AC4 and AC2 (Freightliner)

• Date/Time

  Date

• Vehicle: select one.

  AC 4

  AC 2

• 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 CRAMER, A 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
  • CRAMER, A
  • FLEET
  • TARGAL, C
  • GRECO, D

Exterior

• 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?

  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

  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

• Shorelines plugged in and operational?

  Yes

  No

  N/A

• Exterior clean?

  Yes

  No

  N/A

Exterior storage compartments.

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

• Inverter operational with no tripped breakers?

  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 psi >1000?

  Yes

  No

  N/A

• O2 psi reading

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

  Yes

  No

  N/A

• Medical Air psi reading

• BLS bag present and in service?

  Yes

  No

  N/A

• NEO and PEDI immobilizers present and ready for service?

  Yes

  No

  N/A

Generator

• Oil in range?

  Yes

  No

  N/A

• Coolant in range?

  Yes

  No

  N/A

Engine compartment

• Oil in range?

  Yes

  No

  N/A

• Coolant 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 sufficient?

  Yes

  No

  N/A

• Belts present and free of cracks and frays?

  Yes

  No

  N/A

• Visible engine fluid leaks?

  Select None Oil Coolant Transmission Fluid Power Steering Fluid

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

• Free from audible air leaks from engine compartments?

  Yes

  No

  N/A

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>Is needle in green range?<br>Is pin zip tied?

  Yes

  No

  N/A

• Make sure card is signed once per month.

• Flashlight present and functioning?

  Yes

  No

  N/A

• Trash emptied and liner in place?

  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 1/8 Empty

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

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

  Yes

  No

  N/A

• Oil pressure between 40 to 60 psi when running?

  Yes

  No

  N/A

• Primary and secondary air tank gauges fill and read between 100-125 while engine running?

  Yes

  No

  N/A

• Emergency braking system functioning? (Monday)<br><br>**The alarm should come on when one gauge reaches 65-75 psi and the parking brake should pop out when both gauges are at 25 psi.

  Safe

  At Risk

  N/A

• Voltage > 12.0 Volts?

  Yes

  No

  N/A

Interior: Patient Compartment

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

  Yes

  No

  N/A

• Photo documentation

  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) (2 each) 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)
  • (2 each) O2 & Air Flowmeters
  • TV/ DVD Remotes

• Cabinet # 1 Sealed? All supplies present?<br><br>​4X4s <br>Pressure infuser <br>ECG Electrodes (neo/ped) <br>Thermometers <br>Spare BP cuffs (Propaq/Philips) <br>

  Yes

  No

  N/A

• Next expiration date.

  Date

• Cabinet # 2 Sealed? 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

• Cabinet # 3 Sealed? All supplies present? <br>​A) Umbilical Catheter Kit - 1 Gastroschesis bag <br>B) Heat / Cold packs - Neo Cooling pack <br>C) IV Infusion Sets - Transducer <br>D) Four Sterile Gowns <br>E) Two Pack Non-sterile gowns <br>F) Two Transwarmer mattresses <br>G) Spare Stethoscopes <br>H) Two Liter bags: D5 NS 40K <br>I) Two Liter bags: NS 40K <br>J) Surgical Masks - N95 respirators - Eye shields <br>

  Yes

  No

  N/A

• Next expiration date.

  Date

• Cabinet #4 Sealed? All supplies present? <br><br>​Two Turkel Chest Tube Trays <br>Urinal<br>Bedpan<br>

  Yes

  No

  N/A

• Next expiration date.

  Date

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

  Yes

  No

  N/A

• Black Ambulance Code 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>Nasal Cannulas: 2 NEO, 2 PEDI, 2 ADULT <br>Non-Rebreather Masks: 1 adult and 1 pedi <br>2 Venturi Masks<br>BVMs (infant, ped, adult)<br>Neo-Tee (w/ infant and neo masks) <br>Two Nitric kits (NEO and Ped)<br>

  Yes

  No

  N/A

• Cabinet # 8 All supplies present? <br><br>Sheets <br>Baby Blankets (in warmer - warmer OFF) <br>Big Blankets <br>Towels <br>Gowns <br>Oxivir and Bleach Wipes<br>Cleaning spray/wipes <br>Bleach Wipes<br>

  Yes

  No

  N/A

• One O2 E-Cylinder (> 1500psi)

  Yes

  No

  N/A

• Two O2 D-Cylinders- (>1500 psi)

  Yes

  No

  N/A

• One Air E-cylinder - (>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>Site-Scrub

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Drawer D All supplies present? <br><br>​Bio hazard trash<br>Sharps (change out if > 3/4 full)

  Yes

  No

  N/A

• Drawer E All supplies present? <br><br>2 Pedi and 2 adult yankaurs <br>NG/OG Syringes <br>SpO2 probes

  Yes

  No

  N/A

• Drawer F All supplies present? <br><br>​Truck Checks - paper format <br>Spare ACH Forms <br>Spare monitor paper (Philips/Propaq) <br>Ambulance Code Sheet Book <br>Jump Drive Movies on Lock Ring

  Yes

  No

  N/A

• Drawer G All supplies present? <br><br>Diapers & Wipes <br>Bio Bags <br>Bolts <br>Seals<br>Patient ID/Allergy bands <br>ratchet straps

  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 neo eye masks, neo wrap, hat Bag with hot packs, flushes, sweet-ease, resp saline

  • 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 neo eye masks, neo wrap, hat
  • Bag with hot packs, flushes, sweet-ease, resp saline

• If there is a STRETCHER on board, please check that the following items are present.

  Select Not Applicable O2 >1000 psi 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 psi
  • 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? (On Monday). **Night shift do Op Check on 3rd Philips on shelf upstairs**

  Yes

  No

  N/A

• Philips Supplies All Present and Monitor Plugged In?

  Select ECG Cable SpO2 Cable NIBP Cable IABP Cable Temp Cable w/ Temp 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/ Temp 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 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