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:
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 Headsets (2) Knox Box Keys Street Vests (2) 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: SCBA Flathead Axe Haligan Tool
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Action taken:
Passenger side Compartment 2:
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 are 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:
Daily Operational check performed.
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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:
Spare O2 bottles (2)
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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 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 are 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 3: SMART Triage packs (3) Traffic cones (2)
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Action taken:
Passenger Side Compartment 4: Backboards (2) C-Collar bags (2) KED Ped Traction Splint Traction splint Papoose Broom
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Action taken:
Main O2 Reading: Enter the reading in the field below.
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: SCBA TNT Tool
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Action taken:
Driver side compartment 2: DRAWER
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Action taken:
Driver side Compartment 3: Scoop Stretcher Ferno LBS Kit Stair Chair BEAR unit
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Action taken:
Driver side Compartment 4: Clip board Binder Easy Lift
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Action taken:
Evac-U-Splint bag: Small, Med, Large splints (1 each) Vacuum pump
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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 5: PFD (2) Water Rescue Rope 75' Wheel Chock Bolt Cutters Cooler
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Action taken:
Interior compartments
Narcotic lock up: Narcotics and Narcotic check sheets Bristol jet plunger Spare Nitrous bottle Laptop cord Trash bags
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Actions taken:
Controlled Substances: - Expiration dates are to be checked daily
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Schedule 2 & 3:
Morphine
Fentanyl
Ketamine -
Tag 1:
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Tag 2:
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Schedule 4:
Valium
Versed
Etomidate-tracked substance -
Tag 1:
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Tag 2:
Passenger Compartment 1: 8x10 Combine dressing (10) Triangular bandages (4) 2x2 (1 box) 4x4 (1 box) Petrolatum Gauze (2)
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Actions taken:
Passenger Compartment 2: 3" Kling (6) 6" Kling (6) Multi-Trauma dressing (5) Burn sheets (3)
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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 Cavi-Cide
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Actions taken:
Driver Side Top Compartment Top Shelf: Soft suction catheters 10/14/18 Fr (2 each) Suction canister w/lids (3) Suction Tubing/Yankauer tips (3 each) Mini/Macro drip set (4 each) Blood tubing (2) Cryogenic collar with cool pack (2) Spare cool packs (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 Top Compartment Bottom shelf: Ped NC/NRB/Neb (3 each) Pet O2 mask Adult NC (10) Adult NRB (5) Adult Neb (3) Neb Flextube/mouthpiece (3) Adult BVM (2) Ped BVM (2) C-PAP T-Adapter C-PAP Circuit (2) Neonatal mask (2)
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Actions taken:
Driver Side Below Action Area Compartment 1: IV Caths 14/16/18/20/22/24 ga (5 each) Lancets Alcohol preps Iodine preps Glucometer Glucometer strips (1 box) Ear thermometer w/ covers IV start kits (8) Code Stroke kits (2) Saline locks/ extension loops (6 each) Saline flushes (6) Vena guards Finger Pulse oximeter Pen light Field guide
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Actions taken:
Driver Side Below Action Area Compartment 2: H1N1 Kit Auto Circuits (2) Isolation kits (2)
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Actions taken:
Driver Side Compartment 3: Intubation roll (see below) E T tubes size 2.5-8 (1 each) PerTrach kit (2) Adult/Ped ET tube holder (2 each) Oral airway (2 each size) Nasal airway (2 each size) Bite sticks (3) C-Collar (1 each) Cook Pneumo kit King LTSD 3/4/5 (1 each) Stylet large/small (2 each) Bougie Introducer
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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:
Compartment 4 (above CPR seat): OB kits (2) Yellow Blankets (5) Sterile water (6) Meconium Aspirator Bulb Syringe (2) Under CPR seat: Pillows Sheets
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Actions taken:
Compartment 5 (Below Action Area 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) Nasal Atomizer (4)
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Actions taken:
Compartment 5 (Below Action Area 2) : Meds - Expiration dates are 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:
Compartment 6 (Below action area 2) : Meds - Expiration dates are 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:
Above Action Area 2 Top shelf: Gloves S/M/L/XL (1 box each)
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Actions taken:
Above Action Area 2 Bottom shelf: Fast Patches Adult/Ped (1 each) Cling wrap Aluminum foil Temp probes Skin/Rectal (1 each) Capnography NC Adult/Ped (3 each) Capnography ET Tube (3) Monitor paper rolls (2) Electrodes (1 box) Razor
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Actions taken:
Above Fridge Top shelf: Hot/Cold packs (5 each) Stuffed animals Emesis Buckets/Basins Convenience bags (4)
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Actions taken:
Above Fridge Bottom shelf: Bio-Hazard bags Large and Small N95 Respirator masks (1 box) Towels/Wash cloths
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Actions taken:
Next to Fridge Top shelf: Long/Short arm boards (4 each) Tape 1"/2"/3" Band aids/Butterfly strips Lubricating Jelly
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Actions taken:
Next to Fridge Bottom shelf: SAM Splints (3) Soft Restraints BP cuffs Adult/Child/Obese (1 each) EZ IO Kit: Drill Needles Pink/Blue/Yellow (2 each) Pressure Infuser Bag Quick reference card
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Actions taken:
EZ IO Meds: - Expiration dates are to be checked daily. Lidocaine 100mg prefill (1) Saline Flush (1)
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Actions taken:
Refrigerated Meds: - Expiration dates are to be checked daily. Albuterol (6)
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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 are to be checked daily. Adenocard (60 mg) Albuterol (1 box) 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) (8 Bags) Normal Saline (1000 mL bag) (8Bags)
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Action taken:
Signature # 1
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Firefighter / Paramedic
Signature # 2
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Firefighter / Paramedic
