Information
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Vehicle
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Conducted on
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Mileage
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Crew
- Bazzoni, Micheal
- Berni, Daniel
- Bryant, Judy
- Campbell, Larry
- Fischer, Dan
- Fischer, Tom
- Franke, Rex
- House, Tim
- Kelly, Sean
- Krazl, Patrick
- Light, Ryan
- Lofquist, Jeff
- Mathes, Matt
- Palmer, Jeremy
- Sanders, Scott
- Stratman, Dee
- Sullivan, Don
- Whelan, Tim
- Williams, Chaun
- Sumpter, Robert
- Hayes, Craig
- Knapp, Steve
- Sommer, Jim
- Wiley, JT
- Janes, Justin
- Davila, Dan
- Goss, Nancy
- Lawson, Robert
- Burns, Tyler
Truck Maintenance
Fuel above 3/4 Engine oil Power steering fluid Brake fluid Engine coolant Washer fluid Transmission fluid (check with engine running) Tire pressure 75 PSI(front) 85 PSI(rear)
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Full / Low
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Action taken:
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Air tanks purged (15th of the month only)
Operational check: Vehicle started Driving lights Emergency lights Siren, Queue Airhorn
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Deficiencies noted?
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Action taken:
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Any new vehicle damage?
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Description
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Attach picture
Cab
Map Books: Kirkwood Valley Park Creve Coeur Des Peres Meramec Campus Webster Groves West County Mall Wunnenberg's Knox Box Book St Louis area Hospitals
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Action taken:
Equipment: Laptop computer Walkie talkies (2) Cell Phone w/ Charger GPS w/ Charger Headsets (2) Knox Box Keys Street Vests (3) Gloves S/M/L/XL (1 box each) Binoculars CO monitor Mini Rad Fire Extinguisher
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Action taken:
Laptop Restarted?
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Action taken:
Fuel Card and Ground Service Ambulance License
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Action taken:
Exterior Compartments
Passenger side Compartment 1
Portable suction: Yankauer tip Suction tubing Suction canister
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Action taken:
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Operated to verify battery?
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Action taken:
Pediatric bag: OB kit Macro drip set Micro drip set IV start kit IV catheter 18/20/22/24 (2 each) Infant BVM Electrodes (3 pkgs) Stethoscope BP cuff infant Meconium aspirator (2) Broselow Tape Field guide Newborn cap Pen light Stuffed Animal
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Action taken:
Meds (Ped Bag) - Expiration dates to be checked daily. Epi 1:10000 (4mg) Atropine (1mg) D25 (5g) Ped bicarbonate (10mEq) Normal Saline (500 mL)
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Actions Taken:
Monitor: BP cuffs S/M/L/XL ECG and 12 lead wires Pulse oximetry sensors Adult/Ped/Infant Electrodes (4 pkgs) FAST patches Adult/Ped (1 each) ET CO2 Adult Sensors Nasal Cannula/ET Tube (1 each) ET CO2 Ped Sensors Nasal Cannula/ET Tube (1 each) Electric shaver w/ heads Disposable shaver w/ heads Temperature probes skin/internal (1 each) Extra monitor paper Monitor manual
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Action taken:
Batteries checked? 12 lead faxed AND received?
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Action taken:
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Photo of Operational Check. (This is done at the beginning of each shift)
Oxygen bag: Adult Nasal Cannula (2), NRB (2), Nebulizer (1) Ped Nasal Cannula (2), NRB (2), Nebulizer (1) Nebulizer with mouth piece (1) O2 key Extra O2 Washer Vent circuit
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Action taken:
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Oxygen >1000 PSI
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Action taken:
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Ventilator tested
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Action taken:
Blue bag: BP cuffs Adult/Thigh (1 each) Stethoscope CPAP circuit w/ T-connector (1) Syringes 1mL/3mL/5mL/10mL (3 each) Glucometer w/lancets and strips Adult BVM Mercy Stroke Phone King airway size 3/4/5 (1 each) Pen Light 2X2's Tourniquet (3) Trauma Shears Sharps container IV Caths 14/16/18/20/22/24 (2 each) IV start kits (3) IV drip set macro/micro (1 each) Convenience bags (2) 4x4 gauze Tape 1" Band aids Alcohol preps Saline locks IV extension loops Venigards Field guide EZ-IO bag: Drill Needles Blue/Pink/Yellow (2 each) Pressure infuser Saline flush (2)
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Action taken:
Meds (Blue Bag) - Expiration dates to be checked daily. Adenocard (30 mg) Albuterol (5 mg) Atropine (2 mg) Baby ASA (3 packs) Benadryl (100 mg) Calcium Chloride (1 g) Cordarone (300 mg) D50 (50g) Epi 1:1000 (1 mg) Epi 1:10000 (6 mg) Glucagon (1 set) Lasix (80 mg) Lidocaine (200 mg) Lidocaine EZ-IO bag (100 mg) Mag Sulfate (5 g) Narcan (4 mg) Nitro spray (1 bottle) Oral glucose (2 tubes in front pocket) Sodium bicarbonate (100 mEq) Solu-Medrol (250 mg) Vasopressin (80 units) Zofran (8 mg) Fluids: Normal Saline (500 mL in front pocket)
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Actions Taken:
Intubation Roll: Macintosh blade 1/2/3/4 (1 each) Miller blade 0/1/2/3/4 (1 each) Laryngoscope blade (1 each) CHECK LIGHT ET tubes 2.5-8 (1 each) C batteries (2) Syringe 10mL (1) Stylet M/L (1 each) Bougie Introducer (2) Tape 1" (1) Magill forceps S/L (1 each) ETCO2 ET tube (1) Nasal airway all sizes (1 each) KY jelly (3 pkgs) Oral Airway; Ped/Adult/Large adult (2 each) ET holder Adult/Ped (1 each) Bite stick
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Action taken:
Nitronox: Face mask Bottle of Nitrous Oxide Tested with needle in green when hooked to oxygen?
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Action taken:
Passenger side compartment 2: PFD (2 each) Water rescue rope Bolt cutters Cooler
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Action taken:
Passenger side compartment 3: Backboard (2) Scoop Stretcher Traction splint KED Stair chair Broom Bender EZ Lift (Blue Lift Assist Device)
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Action taken:
C-Collar bag (2): Adult adjustable C-Collar (2 each) Ped adjustable C-Collar (2 each) Spider straps (1) 3" tape (1) Sta-Blocks (2 each)
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Action taken:
Driver side compartment 1: SMART triage tags (3 bags) Ped Immobilization Board Ped Traction Splint Main Oxygen cylinder LBS Kit (Extension Straps, Large Moving Pad, Back Wedges, LBS Board) B.E.A.R. Wrap
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Action taken:
Evac-U-Splint bag: Small, Med, Large splints (1 each) Vacuum pump
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Action taken:
Driver side Compartment 2: Traffic cones (2) MacTac Bag
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Action taken:
Trauma Bag: Equipment; Stethoscope BP cuff Large/Thigh (1 each) Trauma Shears Ring Cutter Pen Light Supplies; Multi-Trauma dressing (2) Burn Sheets (2) Cook Kit (1) Pertrach (1) Combine pads (6) Yellow blanket (1) Hot/Cold packs (2 each) Sterile Water (2) Gauze wrap 6"/3" (4 each) Triangle bandages (2) SAM Splint (1) Tape 1"/3" (1 each) IV Caths 14/16/18/20 (2 each) Alcohol preps (1 box) 4x4 Gauze Band aids IV start kits
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Action taken:
Fluids (trauma bag) 1000 mL Normal Saline (2)
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Actions Taken:
Driver side Compartment 3: SCBA (2) Flashlights (2) Flathead Axe Haligan Tool Thermal Imaging Camera
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Action taken:
Interior compartments
Narcotic lock up: Narcotics and Narcotic check sheets Bristol jet plunger
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Actions taken:
Refrigerated Meds: - Expiration dates to be checked daily. Albuterol (6)
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Actions taken:
Controlled Substances - Expiration dates to be checked daily.
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Schedule 2 & 3:
Morphine
Fentanyl
Ketamine -
Tag 1:602230
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Tag 2:602241
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Schedule 4:
Valium
Versed
Etomidate-tracked substance -
Tag 1:253997
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Tag 2:253946
Passenger Compartment 1 (Below Narcotics lock-up): Intubation roll (see intubation roll checklist) ET tubes (2.5-8.0) (2 each) ET tube holder Adult/Ped (2 each) ET tube stylet M/L (3 each) Bougie Introducer (2) PerTrach kit (1) Oral airway each size (2 each) Nasal Airway each size (2 each) Soft suction catheter 10f/14f/18f (3 each) Lubricating jelly Bulb syringe (2 each) C-Collar Adjustable; Adult/Ped (1 each) Cryogenic Collar (2) Cryogenic Spare Cooling Packs (2)
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Actions taken:
Intubation Roll: Macintosh blades 1/2/3/4 (1 each) Miller blades 0/1/2/3/4 (1 each) Laryngoscope handle (1) CHECK LIGHT ET tubes 2.5-8 (1 each) C batteries (2) Syringe 10mL (1) Stylet M/L (1 each) Bougie introducer (2) Tape 1" (1) Magill forceps S/L (1 each) ETCO2 ET tube (1) Nasal Airway; all sizes (1 each) KY jelly (3 packets) ET holder; Adult/Ped (1 each) Oral airway; Ped/Adult/Large (2 each) Bite stick (1)
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Actions taken:
On Bench Seat: Multi BP cuff system Stethoscope
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Actions taken:
Under Bench Seat: Sheets Blankets Pillow cases Mega Mover Sharps container Spare O2 bottle Spare Nitrous Oxide bottle Cavi-Cide
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Actions taken:
Glove Compartment: M/L/XL (1 box each)
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Actions taken:
Rear Compartment Below Gloves: Triangular Bandages (4) 3" Kling (6) 6" Kling (6) 2X2 gauze (1 box) Petrolatum Gauze (2) 5X9 Combine pads (10) 4X4 Gauze (1 box)
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Actions taken:
Driver Side Compartment 1: BVM Adult/Ped (2 each) Adult Nasal Cannula (10) Adult NRB (5) Adult Nebulizer Mask/Flex tube (3 each) Ped Nasal Cannula/NRB (3 each) Ped BVM (2) Neonate Face Mask (2) "T" Adapter for CPAP (2) Suction Tubing/Yankauer tips (3 each) Auto circuit (2) Mini/Macro drip set (4 each) Blood tubing (2)
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Actions taken:
Fluids: N/S 1000 mL (2) N/S 500 mL (4)
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Actions taken:
Driver Side Compartment 2 and 3 (Right of Action Area): Suction Canisters w/ lids (3 each) King LTD size 3/4/5 (2 each) Spare CPAP kit (1)
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Actions taken:
Drawer 1 Meds (below action area) - Expiration dates to be checked daily. Atropine (2mg) Epi 1:10,000 (5 mg) Lidocaine (200 mg) Sodium Bicarbonate (50 mEq) Ped Sodium Bicarbonate (10 mEq) D 50 (50 g) D 25 (5 g) Activated charcoal (1 dose) Calcium Chloride (2 g)
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Actions taken:
Compartment 4 (above CPR seat): OB kits (2) Baby Knitted Caps (4) Sterile water (6) Under CPR seat: Pillows
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Actions taken:
Compartment 5: ET CO2; Adult - Nasal Cannula/ET tube (3 each) ET CO2; Ped - Nasal Cannula/ET tube (3 each) Electrodes EKG Shaver Heads (3) FAST patches; Adult/Ped (2 each) Temperature Probe; Skin/Rectal (1 each) Monitor paper rolls (2) Manual BP cuffs; Adult/Child/Obese (1 each) IV Caths; 14/16/18/20/22/24 (5 each) IV start kits (10) MicroClave Saline Locks (6) IV Extension Loops (6) Saline Flushes (6) Alcohol Preps (1 box) Printer Paper roll (2) Veni-guards (5) SSM Blood Draw Stroke Kits (2)
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Actions taken:
Drawer 2 supplies: Syringe w/ or w/o needle; 1mL/3mL/5mL/10mL (5 each) Syringe 60 mL (2) Needles; 18/22/23/27ga (5 each) Scalpel (2) Bite sticks (3) Razor (2) Glucometer Strips (1 box)
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Actions taken:
Drawer 2 Meds - Expiration dates to be checked daily. Oral glucose (2 tubes) Adenocard (30 mg) Amiodarone (450 mg) Aspirin (3 pkgs) Benadryl (100 mg) Epi 1:1,000 (2 mg) Glucagon (1 set) Lasix (120 mg) Magnesium Sulfate (5g) Narcan (4 mg) Solu-Medrol (250 mg) Nitro-Spray (1 bottle) Albuterol (5 mg) Vasopressin (80 units) Zofran (8 mg)
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Actions taken:
Drawer 3: Band-aids/Butterfly strips (1 box each) Tape 1"/2"/3" (2 rolls each) Long/short arm boards (4 each) Hand gel (1 bottle) Neosporin Iodine Wipes
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Actions taken:
Compartment 6: Yellow blankets (5) N95 Adult - Respirator masks (1 box) N95 Ped - Respirator masks (1 box) H1N1 kit (1) Burn sheets (3) Multi-Trauma dressings (5) Emesis buckets/bins (2 each) Convenience bags (5) Towels/washcloths Aluminum foil/cling wrap (1 roll each) Trash/Bio hazard bags (5 each) Stuffed animals (2)
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Actions taken:
Compartment 7: SAM Splints (3) Hot/cold packs (5 each) Gloves S/M/L/XL (1 box each) EZ-IO kit: Drill (1) Needles Pink/Blue/Yellow (2 each) Pressure Infuser (1) Saline flush (1) Masimo RAD 57 Quick Reference Guide Marking Pen Adult Sensor Light Shield
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Actions taken:
EZ-IO kit Meds - Expiration dates to be checked daily. Lidocaine (100 mg)
Front compartment: Soft restraints (2 sets) Animal oxygen masks Safety Vest (1) Pipeline Emergency Quick Reference Guide
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Actions taken:
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Actions taken:
Stretcher: Sheet Pillow Blanket Soft stretcher
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Actions taken:
House Stock/Drug Supply
Meds - Expiration dates to be checked daily. Adenocard (60 mg) Albuterol (1 box) Activated charcoal (50 g) Amiodarone (600 mg) Atropine (2 mg) Aspirin (10 packs) Benadryl (100 mg) Calcium Chloride (2 g) D50 (50 g) Epi 1:10,000 (5 mg) Epi 1:1,000 (1 mg) Glucagon (1 set) Lasix (80 mg) Lidocaine (400 mg) Magnesium Sulfate (10 g) Narcan (4 mg) Oral Glucose (2 tubes) Pediatric bicarbonate (10 mEq) D25 (5 g) Sodium bicarbonate (100 mEq) Solu-Medrol (250 mg) Vasopressin (40 units) Zofran (8 mg)
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Action taken:
Fluids: Normal Saline (500 mL bag) (1 box) Normal Saline (1000 mL bag) (1 box)
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Action taken:
Signature # 1
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Firefighter / Paramedic
Signature # 2
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Firefighter / Paramedic
