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FTP
MILFORD AMBULANCE SERVICE
Current Member Training Programs
Field Training Program ENHANCED
MILFORD AMBULANCE SERVICE
Field Training Programs
 Town of Milford Ambulance Service
Prepared by: Christopher Rousseau NREMT-I
Vicki Blanchard NREMT-P
1 Union Square Milford, NH 03055
Phone 603.673.1087 • Fax 603.673.2273
Table of Contents
Phase I Assmt Based Mngmt
Lesson 1 Introduction
Lesson 2 Approaching the scene
Lesson 3 Assessment
Lesson 4 Determining status
Lesson 5 Detailed exam
Phase II Documentation
Lesson 1 Review of State PCR
Lesson 2 Documentation tips
Lesson 3 Refusal of care
Lesson 4 Issues of consent
Lesson 5 Scenario based training
Phase III ACLS for EMT-Basics
Lesson 1 The life support team
Lesson 2 Airway eval and control
Lesson 3 Angina to AMI
Lesson 4 Rhythms of the heart
Lesson 5 Electrical interventions
Lesson 6 Cardiac pharmacology
Lesson 7 Challenging situations
Lesson 8 Legal considerations
Lesson 9 Provider care
Lesson 10 Putting it together
Phase IV Advanced CEVO
Lesson 1 Risks and ABS breaking
Lesson 2 Steering and tailgating
Lesson 3 Lane changes/fleet safety
Lesson 4 Driver impairment
Appendix
Performance skill sheets
Index
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1
Phase
LESSON ONE – Introduction and
Successful completion
This manual and training program has been divided into 4 phases, which consist of several
lessons to be completed within each phase. Current MAS members should follow the
format of this manual and complete the phases in the order in which they are presented.
This program is intended to provide enhanced training to current members to increase their
knowledge and confidence within the EMS setting.
T
he following program, known as the Field Training Program, here on in referred to as the FTP, is
designed to facilitate the training of current Milford Ambulance members in specially selected topics of
interest, importance, and those that are of concern from a liability standpoint. The FTP will help
increase the overall knowledge and confidence of the current member and make them an even more
valued member of the MAS team.
The enhanced FTP is a chance for MAS members to refine their current skills and knowledge and to obtain
advanced training that can begin to prepare them to handle incidents and calls for service in which they are the
primary care giver and the highest trained person on scene. In the absence of a paramedic, the MAS attendant
needs to be ready to handle not only the patient, but the overall scene as well.
This is a four-phase program designed to be run and maintained by Field Training Officers (FTO), who in turn
will be overseen by the Field Training Officer-In-Charge (FTO-C). Participants will be evaluated and required
to demonstrate skills for these FTOs. The program will be delivered in 4 classes that will range from 2 to 4
hours in length.
At the conclusion of this program, the FTO-In-charge will evaluate the performance of the attendant. If it is
deemed that they have successfully completed the program, they will be considered to have graduated from the
enhanced program.
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Requirements for successful completion:
1. Complete all practical skill sheets
2. Attend all training sessions in full
3. Successful completion of enhanced CEVO practical
4. FTO satisfaction
5. Final approval from Director and FTO-C
Materials provided to the trainee:
1. FTP enhanced manual
2. FTP situations manual (enhanced)
3. ACLS for BLS providers manual
I C O N
K E Y
 Valuable information

Video
 On-line situations
 On-line quiz(s)
throughout this manual, you will find the above icons. Each one depicts a special
feature of this manual that you, as the trainee, will find extremely helpful in successfully completing this training
program. Each one is specially designed enhancement to provide useful information to a wide range of
learning styles.
How to use the icons
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LESSON TWO – Approaching the
Scene
MAS members need to realize what their responsibilities are when responding to and approaching a scene. The
scene may be more than just an EMS scene; it may also be a crime scene. Below you will find a list of
responsibilities that all attendants should take into consideration when responding to and approaching a scene.
Responsibilities:
1. Personal safety
2. Crew safety
3. Patient safety
4. Bystander safety
Major safety concerns can be broken down into the following categories. Each one of these categories will be
spoken of in more detail.
1. Personal protective equipment
2. Hazardous substances
3. Violence
4. Environment
BODY SUBSTANCE ISOLATION – all attendants are familiar with what constitutes proper BSI. This
term refers to much more than just the wearing of gloves. Attendants should not only ensure that they are
wearing BSI, but that everyone one their crew is wearing them as well. BSI kits are available in the ambulance
as well as a solution of bleach and water in the BSI cabinet next to the turn out gear. Bleach free cleaning
solutions are made available to disinfect the ambulances with at the beginning of each shift. This takes into
consideration that straight bleach may ruin uniforms where as this cleaning solution does not.
TURN OUT GEAR – is another type of BSI. It has a fluid resistant barrier and has a heat resistant material
through out. This gear can resist punctures and tears where sharp objects are exposed. The helmets provide
head protection from falling objects as well as either a face shield or safety goggles. Too often, attendants have
entered into a motor vehicle at an accident scene without this gear on. It is up to the attendant to ensure that all
members of your team are dressed properly and safely. The gear also has a pair of protective pants, which are
also heat and flame resistant.
HAZARDOUS MATERIALS – specially trained personal and units should handle these types of incidents.
The fire department is much more suited and trained for this type of an incident. The role of EMS is to stay a
proper distance away from the scene and up wind, if possible, to ensure that they do not become part of the
scene. There are binoculars available in both ambulances to allow the attendants to view the scene from a safe
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distance and attempt to determine the substance that is being carried on the vehicle. That information should
be relayed to the dispatch center.
VIOLENCE – the police department prior to the arrival of MAS should handle these situations. Many times
MACC BASE relays information ahead of time to the responding unit that a scene is potentially hazardous and
that the ambulance crew should stage prior to the arrival of the police. EMS should never enter a scene that
may be violent. Sometimes the ambulance arrives to find violence at a scene when it was not originally
expected. Should this occur, have your crew and yourself back out and await the arrival of the police.
Observations of a potentially hazardous scene are made as you approach the residence. Note what you see and
try to avoid standing directly in front of windows and doors.
Observe the following:
1. Obvious violence
2. Crime scene
3. Alcohol or drug use
4. Weapons
5. Distraught family members and friends
6. Gathering bystanders
7. Perpetrators present
8. Pets
9. Gut instinct, something is just not right
All Attendants should be familiar with and utilize the three R’s of reacting. They are:
1. RETREAT
2. RADIO
3. REEVALUATE
RETREAT – flee the area and get rid of cumbersome equipment. You should never have anything around
your neck to begin with when responding to potentially violent scenes.
RADIO – call for police assistance and worn other responding units before they arrive of what you have
found. Make sure to speak clearly and calmly into the radio. You may only have one chance to call and you
need MACC BASE to hear and understand what you are saying.
REEVALUATE – from a safe distance and with cover, reevaluate the scene and attempt to determine the
specific threat, number of individuals that are involved and if there are any weapons involved. If so, what kind
of weapons and where did you last see them.
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Being aware of extreme environments is also important. Not only is the patient in jeopardy, but also so are you,
the attendant, and your crew. Considerations should be made to protect you and your crew if long exposures
to these conditions are expected.

EXTREAM COLD

EXTEAM HEAT

WATER HAZARDS

HEAVY TRAFFIC
Types of protection to keep in mind:
Rescuers should wear appropriate protective gear. In the case of motor vehicle accidents, all rescuers on the
scene should be in the turn out gear that is provided by the service.
Rotating of crews is another way to prevent exposure injury to rescuers. In the case of structure fires where a
long duration of on scene time is required by the ambulance, different crews could be sent to the scene
periodically to insure that all members have ample time to re-warm or cool down as needed.
The ambulance is also watching over the fire department members in the case of structure fires or other
hazards that require the fire department to respond. Vital signs and general appearance should be assessed and
re-assessed on fire fighters periodically. Fireman should be sent to the ambulance by fire command in rotating
shifts to be checked. If vitals are out of normal ranges for the type of work that is being done, the firefighter
should be retired from activity for an appropriate amount of time to recuperate.
Only specially trained rescuers should perform water rescues. If not careful, the rescuer may become a victim.
It is necessary to be familiar with drowning victims and the way that they act and respond to the drowning
situation.
There are a set of orange road cones in the medic cruiser that can be utilized for traffic accidents and other large
scenes that it is necessary to re-direct the pattern of traffic from rescuers operating in the scene. Ask law
enforcement to shut down roadways that are posing a hazard to rescuers. If resistance is met, speak with fire
command. Highly visible clothing is a must on motor vehicle accident scenes. When all else fails, use the
ambulance to provide protection between you and on-coming traffic. It is always better to use a fire truck or
police vehicle for these purposes if possible.
PROTOCOL ALERT

In addition to important information being displayed in these boxes
throughout the manual, you will also find protocols that are of importance
and in direct relation to the topic at hand to immediately follow.
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LESSON THREE – Assessing the
patient and the scene
You cannot treat or report a problem that is not found or identified.
You must gather, evaluate and synthesize information.
Differential Diagnosis
Narrowing Process
Field
Diagnosis
Differential Diagnosis:
Form a mental list of possible causes of the patient’s complaint. Consider as many causes as possible.
Think broadly. Avoid tunnel vision.
Narrowing Process:
Use information gathered during the assessment to eliminate some possible causes, support others based
on patterns of s/s and hx. Begin narrowing toward a field diagnosis.
Field Diagnosis:
Form a field diagnosis of the most probable cause or causes of the patient’s complaint, based on
information gathered.
MAS attendants are entrusted with a great deal of independent judgment and responsibility. (ET, ECG
IV therapy, drug admin., etc.) The ED must rely on your experience and expertise as you describe the
patient’s condition and your conclusions.
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The decisions you make are only as good as the information you gather.
You must remain non-judgmental.
The History:
Very often doctors will base 80% of their diagnosis upon history for medical conditions; in contrast, with
trauma the physical exam takes precedence over the history.
Do not allow your knowledge of a disease or your suspicion cut your hx taking short.
The Physical Exam:
Never forget or minimize your physical exam.
Some situations may change your approach and you may have to move the patient to the back of the
ambulance.
Trauma => unresponsive trauma or medical pts. or significant MOI = HEAD to TOE.
Medical or minor trauma => focused exam to associated systems of the chief complaint.
As an enhanced trained attendant one of the 1st new things you will find is that everyone on scene
will look to you for the answers. (Unless of course you are partnered up with a paramedic.)
Pattern Recognition:
Information compared with knowledge base and experience.
Pain location and its source do not always correlate, especially with visceral pain. Throat in ear, Kidney
problem can be groin pain. Neck & shoulder pain could be diaphragm, generalized shoulder pain is often
gall bladder attack, and mid to lower back could be associated with an intestinal disorder.
Assessment/Field Diagnosis:
Formulate a plan of action based on diagnosis.
BLS/ALS Protocols:
To be used, but do not replace attendant’s judgment.
Don’t give a med. just because protocol says to if the pt. is allergic to it.
Don’t give epinephrine to a relatively distressed allergic reaction to a 79 y/o with extensive cardiac
background.
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LESSON FOUR – Factors Affecting
Assessment and Decision Making
Personal Attitude:
Be nonjudgmental. Avoid “short circuiting” accurate data collection and pattern recognition by jumping
to conclusions.
(Old s/s vs. actual medical problems)
Uncooperative Patient:
Alcohol, drugs are not the only things to cause a person to be belligerent. Medical conditions: hypoxia,
hypovolemia, hypoglycemia, and head injuries.
Frequent flyers you’ve transported in the past for alcoholic behavior (is a disease too) maybe be
having a real medical emergency.
Treat all how you would want your family treated.
Patient Compliance:
Cultural and ethnic barriers, prior negative experiences.
Find interpreters, speak through friends, relatives, and find some one to sign if deaf,
If you live in a community with large # of a certain ethnic group, find out their customs. Such as some
customs find it rude to look one in the eye.
Distracting Injuries:
Another factor that can affect your assessment & decisions is distracting injuries.
Cover it. Have your partner take care of it, do not let it distract you from your ABC’s and evaluation of
the over all MOI, nature of illness, etc.
(Open femur with moderate bleeding is not as life threatening as the possible C-spine injury or a patients
SOB due to possible pnuemo.
Environmental & Personnel Considerations:
Scene chaos, violent or dangerous situations, high noise levels, crowds of bystanders or even responders.
In such situations some responders will need to be moved to a staging area or assigned to crowd control
As a rule one attendant performs general assessment. A single attendant can gather info and provide
treatment sequentially. With 2 attendants one can assess while the other provides simultaneous
treatment. With multiple responders, however, assessment and hx. taking may turn into a
COMMITTEE, leading to disorganized management.
Assessment/Management Choreography:
While too many people or multi-tiered responders, may make it hard to acquire a pt. hx and exam, it
becomes even more difficult if the responders are all at the same professional level and have no clear
direction.
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It is important to have pre-designated roles, which can be rotated so no one is left out. It is very import
that a plan be in place to avoid “freelancing”.
A universally understood plan for a 2-attendant crew involves the role of the
team leader and pt. care provider.
The Team Leader: (Usually accompanies the pt. through to definitive care)
Establishes and maintains dialogue with the patient.
Obtains history
Performs physical exam
Presents the pt.
Handles documentation
Acts as EMS commander
Must maintain overall patient perspective and provide leadership to the team by designating tasks and
coordinating transportation.
The Patient Care Provider
Provides scene cover (watch the leader’s back)
Gathers scene info (talk to relatives, bystanders)
Obtains Vital Signs
Performs interventions
Acts as triage group leader
The Right Equipment:
If you do not have the right equipment readily available, you have compromised patient care.
For all patient’s you must bring the following to his or her side whether you think you need it or not:
BSI
Airway: NP/OP, suction, suction catheters, ETT Kits.
Breathing: Pocket mask, BVM, 02 adjuncts, masks, oxygen, Occlusive dressings, Large bore IV
for decompressions
Circulation: Dressings, bandages, tape, sphyg/steth,
Disability: collar, flashlights
Dysrhythmia: Monitor/defib.
Expose: scissors blankets.
General Approach to the Patient:
Besides the right equipment, you need to have the essential demeanor to calm or reassure the patient.
“Bedside manner”. Patient = because they are not medically trained they probably will not be able to rate
your medical performance. They certainly can rate your people skills and service. Watch your body
language and what you say to others/your partner.
Once again preplan your general approach. 1 team member should engage in an active, concerned
dialogue with the patient. Taking notes avoids asking repeated questions. (MPD and MAS – ditto info,
listen, record)
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Scene Size Up:
BSI:
Scene Safety:
Hazards to yourself, pt, bystanders, others. Important at both medical & trauma scenes.
Locate all Pts:
Maybe someone has wandered from MVA or other people in a home with CO.
MOI or Nature of Illness:
Determine this as well as possible at this stage. Remain open for additional information. (Still at the
differential diagnosis stage)
Initial Assessment:
General Impression
AVPU- Mental status
ABC’s
Priority – Stay & Play or Load & Go.
Resuscitative Approach: (CPR, ACLS, other actions, oxygen, control bleeding, c-spine)
Take the resuscitative approach whenever you suspect life-threatening problems:
Cardiac/respiratory arrest
Respiratory distress
Unstable dysrhythmias
Status epilepticus
Coma or AMS
Shock, hypotension
Major trauma
Possible C-spine injury
Additional treatment after resuscitation and the rapid trauma assessment can be done enroute.
Contemplative Approach: Immediate intervention not necessary. You can stay & play.
Immediate evaluation: High priority pt., unstable pt.

PROTOCOL ALERT
On the upcoming page you will find the SNHMC protocol for dealing with
behavioral emergencies. These are a general guideline that should be
followed in any situation that involves a patient in an altered mental state
that presents a potential for harm to the attendant.
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LESSON FIVE – Focused History and
Physical Exam
Based on initial c/c and your assessment, pt. should belong to 1 of 4 of the following categories:
1 Trauma pt. With significant MOI or AMS.
2 Trauma pt. With isolated injury
3 Medical pt responsive
4 Medical pt unresponsive
(Head to Toe exam)
(Exam focused to c/c)
(Exam focused to c/c)
(Head to Toe exam)
For medical = gather history 1st then physical exam. (Unless pt. is unable to provide history and there are
no bystanders)
For trauma = do your physical assessment then gather history.
Of course some elements of the hx and physical exam are done simultaneously.
Ongoing Assessment and the Detailed Physical Exam:
Unstable = reassess q 5”
Stable = reassess q 15”.
Ongoing assessment includes:
Mental status
ABC’s
Transport priority
Vital signs
Focused assess of problem areas or condition
Effectiveness of interventions
Management plans
The Detailed Assessment:
Used generally only with your trauma pts. and only if time and pts. condition permits. Ongoing
assessment is considered more important then detailed physical exam.
Identifying Life Threatening Conditions:
From initial primary assessment to the delivery of your pt. to the ED, be constantly observing for life
threatening emergencies.
Work as a team with your partner.
Look for the relevant: Tingling in a possible spinal injury vs. hyperventilation. LRQ pain with hx of
appendicitis vs. LRQ pain with trauma & possible spinal injury.
10 on a 1-10 scale for a splinter under a nail vs. 4 on a 1-10 scale of substernal chest pain.
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If you have an educated suspicion of what you are looking for, you will be able to ask more productive
questions. Less likely to find something if you do not suspect it. So, throughout your assessment keep
the MOI or nature of the Illness in mind. Listen carefully. With time you will develop multitasking skills.
for now ask questions, listen and let your partner do necessary tasks so you can listen.
Presenting the Pt:
Radio, telephone, PCR, fact to face. All patients are required to be presented. This is often the weakest
link in attendant’s care.
Establishing Trust and Credibility:
Effective presentation and communication skills help you establish credibility, trust and confidence with
the pt. family members, MD’s, RN’s, hospital staff.
Presenting your assessment findings and treatment in clear concise organized manner give the impression
of a job well done. (Opposite = poor job done)
Others are not interested in rambling, disjointed presentations.
Use SOAP, CHART.
No doctor is going to give you orders for guesswork.
Developing Effective Presentation Skills
Oral reports should be less then 1 minute.
Avoid medical jargon
Follow an organized format (SOAP, CHART)
Include pertinent findings and pertinent negatives.
Conclude with actions, results and requests.
Maybe start with preprinted form until you become more practiced.
Ideal information to present:
Pt’s age, sex, level of distress
C/C
Present History/injury (details with pertinent negatives)
PMHx: allergies, meds, pertinent medical hx.
Physical Signs: VS, positive signs, negative signs
attendant impression
Plan: What’s been done, any changes? Orders? Requests?

PROTOCOL ALERT
On the next page you will find the general protocol review for patient care
guidelines that should be followed during any contact between an MAS
attendant and a patient.
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2
Phase
LESSON ONE – Documentation and
Review of the State PCR
Phase III deals with the ever-important topic of documentation. This is by far one of the weakest areas in
EMS across the State of New Hampshire, but one of the highest areas of liability for any service. Lawsuits
against EMS providers has sky rocketed from just a few hundred suits in the 1980’s to thousands in the
1990’s and 2000’s. Why this trend? Attorneys have discovered that EMS providers are easy targets and
do not have the legal training, backing, and support that other medical professions have. These providers are
also attached to municipalities with “deep pockets”. The EMS provider can present him or her self as the
“weak link” in a lawsuit.
Each licensed EMS unit in the State is required to complete a PCR for each call for service they do that has
patient contact.
Milford uses the State provided patient care report (PCR). Other services sometimes use their own PCR that
has been specially made for their unit.
This PCR is broken down into 4 copies. The first copy is the MAS copy. This is brought back to the bay to be
filed and used for billing purposes. The second copy goes to the hospital where the patient was delivered. This
will become a part of their permanent medical record. The third copy is sent to the State to have statistics
generated that can be sent back to the service for later use. It is also used by the Bureau to apply for grants and
assessing training needs for different locations of the State. The fourth copy is for the EMS coordinator. This
copy is usually left in a secured location for the coordinator to retrieve at a later date.
All PCR’s should be completed accurately. It is presumed that if it is not written down on the PCR, it did not
happen. This is the same wording that the Bureau uses on their guide to PCR documentation. The following is
a description of what should be recorded in each box or location of the form.
SERVICE – Place “Milford Ambulance or MAS here” Try to avoid using other abbreviations as they may
cause more confusion. The service number is 0075
DATE – is reserved for the current date of the call
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DISPATHCED TO – Place the address that you were sent to. This may not be the actual address of the
patient that you are treating.
PATIENT NAME – Place the last name first, then the first name and middle initial. The phone number
should follow to include the area code. These are important for billing purposes and follow up at later times by
the career staff.
PATIENT ADDRESS – Can be different from the “dispatched to” address
DOB – Date of birth. Always use six digits here i.e. 06/04/98
AGE – Place the patients age here. Next, check off whether the patient is male or female. If necessary, place
the approximate patient weight in the next section. This is important when administering certain medications
that are weight dependant.
PATIENT STATUS – Circle the correct patient status for your patient. If we transport, most likely the
patient will be a “status 3” at the very least.
TRAUMA SCORE – This number is derived from the reverse side of the form. Place the number in the box.
RELATIONSHIP – Place the next of kin or the person that the patient wants to use as a contact person in
the event that someone needs to be called. Include the type of relationship to the patient and the phone
number that they can be reached at.
CHIEF COMPLAINT – This is the reason that they called you today. Not what they have been
complaining about for the last 2 to 3 days. Question the patient and find out what is different about their ongoing illness TODAY that made him/her call you right now. Use quotes when ever possible.
MECHANISUM OF INJURY – Put down all of the events that took place prior to your arrival. This is
what they were doing when the illness or injury occurred. It is important to be accurate and complete.
Normally a one-sentence explanation is not enough.
PATIENT MEDICAL HISTORY – This box must be completed on all patients. Fill in the information
accurately. If a patient has no medical history or no allergies it is not sufficient to merle put “NONE”. This
does not indicate that you asked the patient. It only means that YOU DETERMINED there was none. The
correct response to an answer in the negative would be “PT. DENIES” or “PT. STATES NONE”
EMS RESPONSE TIMES – Place the times of the call that you received from MACC BASE in this
location. All times are recorded in military (24-hour) times. All boxes should be completed.
VITAL SIGNS – It is important to take more that one set of vital signs whenever possible. You will notice
that there are 4 separate lines for vital signs. If you do not use all of the spaces provided, put a line through
unused areas with your initials. This will prevent others from filling in information after the fact, and it shows
that you did not forget to complete a portion of the form.
NARRATIVE – Perhaps one of the most diverse sections of the PCR, this area is designed to have the
attendant fill in the condition of the patient, treatments that were completed, and responses to those treatments.
Attendants can use the SOAP, CHART, or chronological method for documenting such information.
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One of those diagnostic techniques is the SOAP method of note taking. On the PCR, some attendants
write down (on separate lines) the letters S, O, A, and P, standing for Subjective, Objective, Analysis, and Plan,
respectively. Therefore, if an attendant was faced with a pt. complaining of abdominal pain, he might
write
S: Patient reports stomach pain; ate hot chicken wings last night; extra work lately.
O: Palpation reveals tenderness in upper right quadrant.
A: Suspect acute gastritis.
P: O2 applied 15 LPM via NRB, Vitals assessed, IV est. 18g, NACL 0.9 KVO, monitor applied.
The subjective is what the patient tells the attendant, the objective is what the attendant sees, the analysis
is what he deduces from his additional questions and reasoning, and the plan is what he will do to try to
treat the problem, plus the next step. Attendants are used to not being able to get a black-and-white
answer; however, if they have a plan, they are going in the right direction.
CHART method
C: Chief complaint (in pt’s words)
H: History of present illness or injury
A: Assessment (primary and secondary assessments)
R: Rx (treatment) what was done for the pt. and how they responded
T: Transport
How was the pt. during transport, and transported to where
FIRST RESPONSE – Use this area to record when someone else, like the fire department, has responded to
the call ad arrived before the ambulance. This indicates that care was provided to the patient before the
ambulance arrived and allows you to explain who treated the patient and what they did. It also details the time
that they arrived.
AMBULANCE RESPONSE – Check off the type of response to the scene and from the scene.
DESCRIPTION OF CALL – Check off the boxes that apply to your call. Describe the type of call (try to
avoid using the “other” box all of the time. Most of the time your call will fit into one of the categories all ready
listed.) Check off the mechanism of injury and what kind of scene you were at. If any of these do not apply,
cross them out and initial it.
CARE GIVEN PATIENT – Check off all boxes that apply to the care that you gave. ALWAYS check off
“OTHER CARE” and put TLC. Even if nothing else was done, you did do this. It can speak volumes if you
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are brought into court and nothing else was checked off. Just by being there for the patient and comforting
them, answering their questions and mentally reassuring them, you are indeed providing “TLC” for them.
MILEAGE – MAS does not use this section. Leave it blank
PATIENT SIGNS AND SYMPTOMS – Check all that apply. If none apply, put a line through it and
initial.
SIGNS AND SYMPTOMS - Check all that apply. If none apply, put a line through it and initial.
GLASGOW COMA SCALE – This should be completed on ALL CALLS. Even if the patient has no signs
of altered mental status, it is a good idea to get the practice of completing this section. That way you will not
forget it when the “BIG, BAD, and THE UGLY” comes in.
REVISED TRAUMA SCORE – Complete this each time as well and place the results on the front of the
form in the space provided.
HOSPITAL DATA LINKAGE – This is where you put the name of the receiving hospital. Do not fill in
the patient disposition portion of this form. That is intended to be used by the hospital and not by EMS
personal.
BILLING INFORMATION – This section is used by EMS services if they do billing. In Milford, we have
our own forms to complete for billing. Place a line though this area and initial.

PROTOCOL ALERT
On the next page you will find the SNHMC protocol for the completion
of MAS PCR’s. It is important to understand that they are only listing the
bare minimum that must be completed on the document. MAS require
much more of all attendants as is stated earlier in this manual. You will
also find the protocol for handling reports or suspicions of child or elder
abuse.
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LESSON TWO – Documentation Tips
A person under the influence. Facts that can be documented:
Glassy eyes, dilated pupils, blood-shot eyes, slurred speech, unsteady gate, nystagmus (if you know what it
is and how to correctly assess.), presence of alcoholic containers at the scene, the presence of an
“alcoholic-like” substance on their breath.
Example:
UOA found 42 y/o male sitting at the kitchen table, slumped over with his chin on his chest with
snoring resp. and eyes closed. On the table were 6 empty 12 oz. cans of Budweiser beer as well as 2 cans
partially full. Pt. Responsive to verbal stimuli; when spoken to he opened his eyes and raised his head,
ending the snoring respiration. Airway patent, resp. 16 non-labored, equal chest expansion, skin pink,
warm and dry with strong radial pulse.
2o = neg dcap-btls to head, neck, torso, back or extremities, pupils dilated with glassy, blood-shot eyes, no
fluids ears, nose, mouth, dried vomitous around his lips with a beer-like odor coming from his breath,
speech was slurred, no JVD, trachea midline, chest as above with clear lung sounds, denies chest pain,
denies SOB, abdomen soft non-tender, denies nausea, pelvis stable, positive CMS’s X4, no pedal edema.
When the patient stood, he was unsteady on his feet, causing him to sway and stumble. With our
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assistance, he was transferred to the cot. (As you can see, I have documented fact, which certainly would
lead one to believe the patient was intoxicated, yet I never diagnosed him as such.)
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LESSON Three – Refusal of care
When documenting your patient refusal it is important to remember that you have a greater
understanding and knowledge of the kinematics of trauma and medical emergencies then the average
civilian. It is our responsibility to inform such patients of any and all possible conditions that could arise
from their particular situation. Not only do we need to inform these patients, additionally we need to
document this information and advice. Furthermore the patient’s ability to recite said information in
their own words and comprehension of said implications of said refusal must be acknowledged. Below
are some situations and suggestions for documentation.
Examples for patient refusals:
Minor MVA with no chief complaints: Explain to the patient that you are trained in pre-hospital
emergency care and through your training you know that there is potential for unforeseen internal
injuries, that could lead to life long disability and or death. Then you can give an example such as a spinal
fracture, which could lead to paralysis or internal bleeding which could lead to bleeding to death or to
internal infections. Further explain that you are not a physician and do not have x-ray eyes and therefore
would advise they seek further evaluation by a physician. Additional tips to convincing a patient to go to
the hospital is to recommend being checked out by the doctor and getting the necessary x-rays, so that
later tonight or tomorrow morning when they awaken sore or stiff, they can be reassured that they did
not have any fracture and in fact are suffering from only muscular pain. Additionally, the ED would be
able to prescribe or recommend pain relief should it be needed later.
Fallen and can’t get up (Lift Assist):
Thoroughly assess the patient for any possible injuries sustained from the fall. Solicit any and all
information as to why or how the patient ended up where they were. Even if it truly were only a lift
assist, state to the patient that the ambulance was available to transport them to the hospital for a
physician’s evaluation. Also tell them that it is MAS policy to explain to patient’s who are seen by our
Service and refuse transport that it is our obligation to explain to them that we are not physicians and
therefore not qualified to eliminate possibilities for life threatening injuries unforeseen by us.
Syncope:
Again after your thorough assessment, explain to the patient that it is just not normal for people to go
around fainting. Explain that it could be a sign of a life threatening condition including “heart
problems”, “nerve or neurological problems”; “fluid problems” or “other problems” Strongly advise
these patients to go to the hospital. Strongly explain that if indeed it were a “heart or neurological
problem” they could have another episode that could cause death. Use the would “death. Be very
adamant about it. If they refuse, then document that you explained it could be a sign of a life threatening
condition that could lead to death.
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Minor injuries.
Scratched finger: When you have a call to the scene of what appears to be a truly minor injury, that in
all probability does not need more then a bandage, we still must explain and document that we explained
to the patient that his/her wound is to be kept clean and dry. In addition we must explain and document
that we advised the patient to watch for signs of infection, which would include swelling, pain, oozing
and/or redness, and to seek out further medical treatment, for if they did not, the infection could
potentially spread causing greater infection within the body to the extent that death could occur.
Remember to not only explain this but to then document what exactly it was that you told the patient.
Twisted ankle, joint or long bone injury:
Thorough assessment. An explanation to them would include that you do not have x-ray vision and if
indeed there were a fracture, ligament and/or tendon damage to the joint it could lead to life long
disability if not correctly assessed, diagnosed and treated.
If they still do not wish to be transported, explain in your documentation “it was explained to the patient
that there could be unforeseen internal injuries that could cause life long disability and or death, including
…(whatever it is that you told them)… We advised that we were available to transport the patient to the
hospital for further evaluation and yet the patient still refused. I read and explained the patient refusal
form to the patient and the witness, they understood it’s intent and they signed.
The Witness: Whenever possible have a spouse, parent or family member be the witness. Explain
everything to both the patient and the witness when appropriate. Be sure the witness also understands
the possible consequences as well as the patient.
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LESSON Four – Issues of consent
Emergency Medical Services (EMS) providers are often presented with patients who are considered by
law to be minors. The issue of providing care and/or the patient’s right to refuse care becomes a complex
circumstance for EMS providers and must be addressed. In the pre-hospital situation the issue at hand is
not usually providing care but rather the failure to treat.
Legal Background
A minor, in New Hampshire, is defined as a person who is under eighteen (18) years of age (except in
cases of criminal acts).
A person who is eighteen or older may give effective consent for health care.
Exceptions to minors and consent
Enabling certain persons to consent for certain medical, health and hospital services.
1. Any person who is eighteen years of age or older, or is the parent of a
child or has married, may give effective consent for medical, health
and hospital services for himself or herself, and the consent of no other
person shall be necessary.
2. Any person who has been married or who has borne a child may give
effective consent for medical, health and hospital services for his
or her child.
3. Any person who is pregnant may give effective consent for medical,
health and hospital services relating to prenatal care.
4. Medical, health and hospital services may be rendered to
persons of any age without the consent of a parent or legal guardian
when, in the physician’s or EMS judgment an emergency exists and the person is in immediate need of medical attention and
an attempt to secure consent would result in delay of treatment which would increase the risk to the person’s life or health.
5. Anyone who acts in good faith based on the representation by a person
that he is eligible to consent pursuant to the laws of the state shall be
deemed to have received effective consent.
So long as the individual is a minor, the presumption is that he or she is not
emancipated and the burden of proof rests on the individual asserting it.
Additionally, peace and police officers have the right to ‘direct the
removal of any person to a hospital who is conducting himself in such a manner, which he/she is likely to
result in serious harm to himself or others’.
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Other governmental agencies, such as law enforcement, mental health or corrections, may have legal
definitions for individuals under eighteen that describe specific rights or responsibilities. Unfortunately,
these do not impact health care decisions including the ability to consent or refuse care in the prehospital setting.
Refusal of Medical Assistance
An individual who is legally a minor cannot give effective legal/informed consent to treatment and
therefore, conversely, cannot legally refuse treatment.
Documentation
Complete an assessment of the patient. Fully document all circumstances including subjective and
objective findings, attempts to contact parents, note any objections or refusals by the patient and all other
pertinent situational facts. Include witness statements. Always consider contacting medical control for
assistance.
Collaboration with other Agencies
EMS agencies are advised to work with hospital administrators, local law enforcement agencies, school
administrators and community youth group leaders to develop policies and procedures to best serve the
medical needs of minors in time of an emergency.
There are alternatives to EMS and hospitals for custody and supervision of minors. An uninjured child
may be supervised by law enforcement personnel or a school or activity (soccer, etc.) supervisor until a
parent is contacted. In some situations, a responsible adult (grandparent, aunt, brother, etc.) with the child
can assist in the decisions making.
EMS agencies should work with local youth activities to ensure they have made plans to contact parents,
have provided consent to treatment forms or have other permissions in place for the children in their
supervision.
EMS agencies also need to work and plan with all police agencies for those situations involving minors,
particularly those who are not injured and do not require hospitalization. Local and state police have
broad powers, which can be used to protect minors and facilitate custody.
However, all else failing, the EMS provider may remain responsible for providing care and/or
transportation of a minor to a hospital.
EMS Agency Protocols
Agency policies and regional BLS and ALS protocol sets can contain guidance for treating minors in the
pre-hospital setting. Contacting medical control is always an acceptable option for EMS providers faced
with uncertain situations. Medical control may be able to influence the situation, even if it can’t change
the consent options.
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Recommendations
EMS providers may find themselves responsible for minors, in situations they have been called to when
there is no parent or guardian present or reachable. Although it is easy to determine a legal definition of a
minor, the responsibility to treat or release is a much more complex legal, ethical, social and public
relations problem.
The nature of children and their special needs coupled with their inability to legally give informed
consent, present special and unique matters for EMS personnel to consider and evaluate. Careful
assessment, decision-making and documentation are key as is discussion and planning with other
agencies.
Act in the best interest of the patient – EMS providers must strike a balance between abandoning the patient
and forcing care. There may be instances in which a minor appears mature enough to make an
independent judgment, however legally; the minor is unable to make a decision. Always contact medical
control for assistance if there is any question!
Common sense, prior agreements, sufficient documentation, and acting in the best interest of the patient
must prevail.

PROTOCOL ALERT
On the next page, attendants will find the SNHMC protocol for patients
who refuse care from MAS attendants. When ever in doubt, always make
sure to contact medical control via phone for further instructions and
assistance.
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LESSON Five – Scenario Based
Training
The following pictures are presented to you for documentation purposes. Look at each patient. You will be
asked to describe the condition of the patient based on what you see. You will be provided some basic patient
information such as vitals, chief complaint, and any pertinent additional information. The main focus will be
on your ability to document findings and your visual findings. This exercise may be done in the classroom or at
home. All scenarios will be reviewed in class with the FTO.
On the four sample PCR’s that are provided, document your findings on the upcoming patients. Complete as
much of the PCR as possible. If you have questions, ask the FTO for additional patient history or information.
Use the current date and leave the EMS response times blank for this exercise.
If needed, refer to the hospital protocol, provided earlier in this manual, for assistance when documenting.
Ensure that you have completed all of the basic information that the hospital requires.
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3
Phase
LESSON ONE – ACLS for EMTBASICS
For this section of the Field Training Program – Enhanced, the manual will refer to the ACLS for BLS
providers’ manual produced by BRADY books. All aspects of the following lessons will be covered. Each
trainee shall be provided a copy of this manual and they are encouraged to keep it study from it often. As an
“enhanced” attendant, the service will look to you more and expect that you will have a higher degree of
knowledge and confidence.
TOPICS TO BE COVERED:
Lesson one – EMT-B and the life support team
Lesson two – Airway evaluation and control
Lesson three – From angina to AMI
Lesson four – Rhythms of the heart
Lesson five – Electrical interventions in cardiac care
Lesson six – Fundamentals of cardiac pharmacology
Lesson seven – Challenging resuscitations in cardiac care
Lesson eight – Legal considerations
Lesson nine – Provider care (taking care of you)
Lesson ten – pulling it all together
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4
Phase
LESSON ONE – Advanced CEVO,
Risks and ABS braking
This phase will allow the attendant ample time to review over the basic concepts of emergency vehicle operations
and MAS policies that pertain to the use of the ambulances utilized by the service. Enhanced driving
techniques will be discussed as will sufficient time allowed for practice driving on a cones course. It is understood
that during cones course practical driving and testing, all attendants shall exercise due regard and follow all
FTO and instructor rules to ensure that attendants will be as safe as possible. Any “fooling around” or
“playing” behind the wheel will result in immediate dismissal from the enhanced driving program. The
information contained within this phase is derived from STEVENS ADVANCED DRIVER
TRAINING car control program. The Stevens Advanced Driver Training Organization teaches this
program. These are excerpts from the program and not intended to be the full certifying program. The
information has been formatted to be conducive to MAS service policies and regulations.
Research shows that trained drivers have half as many accidents as non-trained drivers. The crashes that these
trained drivers are involved in also cost about one fifth as much per crash as accidents involving untrained
drivers. Trained drivers are more cautious.
Trained drivers use restraint systems to enhance their ability to control the vehicle and not for safety reasons.
Each driver will bring to the class “habits” both good and bad. For this reason, one-on-one training is
necessary.
All attendants have a comfort level when we drive. By staying within excepted limits when driving, a signal is
sent to other drivers on the road that indicate you are a “good” driver and others on the road can trust you.
Sudden lane changes, squealing of tires, speeding, etc, are driving behaviors that indicate to others that you
potentially are an “unsafe” driver. These are the same behaviors you should look for when operating the
ambulance.
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Studies have also shown that a driver and/or their passengers are “uncomfortable” when their vehicle exceeds
6 G’s of force. That means when the force is greater or equal to 6/10th of the persons body weight it is
recognized that the speed is too great and the operator should slow down.
Modern ambulances are capable of more speed then 6 g’s however. Most typical ambulances can generate a
force of 8 G’s of lateral force in a turn. All though this number seems small, it does generate a 25 percent
increase in handling potential for the operator.
SEATBELTS – Not only is this a mandatory Town policy, seatbelts also save lives. As shown in research and
publications, seatbelts equate to less injury to the occupant and driver when they are worn. Seatbelts play more
of a role then just safety however. They play a vital role in helping the operator of the ambulance maintain
control over the vehicle when evasive moves and actions are needed. If a typical ambulance is capable of
producing more than 6 G’s, this means that there is over 100lbs of pressure in most adults (depending on how
much the typical person weighs) that will be pushing them away from the steering wheel should they have to
make an immediate turn of the wheel. If the driver has to hold on “for dear life” to the wheel just to stay
seated, they loose that amount of maneuverability and ability to simply control the vehicle.
If the passenger is unbelted and begins flying around the interior of the vehicle, the operator now has to deal
with missing an object in the road and the unbelted passenger who is crashing against him/her. Lastly, if the
driver is halfway across the interior of the vehicle because he/she was thrown there from the G force, he/she
will not be in the proper place to take advantage of the airbag deployment. As EMS providers, we are aware of
what patients look like when the airbag is not in a proper place or not available at all.
SAFETY SYSTEMS – There are two types of safety systems built into the average vehicle. They are as
follows:
PASSIVE – Passive systems require nothing on the part of the operator of the ambulance. They include
airbags, safety glass, rollover re-enforcement, side-impact doors, auto fuel shut off valves, etc.
ACTIVE – Active systems require ambulance operator input in order to implement them. They include seat
belts, steering, headlights, defrosters, windshield wipers, etc. Almost all of these safety systems require one
constant thing in order to be the most effective. A restrained operator at the wheel.
AIRBAGS – Having an airbag in your steering wheel is the equivalent to having a loaded firearm right in front
of your face. If the device deploys in an accident the operator may end up with small or slight abrasions from
the friction. You may not even know that it deployed in a high-speed crash or accident until the event is over.
Ambulance operators should always keep their hands at the 9 and 3 o’clock positions on the steering wheel.
This will allow for the maximum width and area allowable for the airbag to deploy and allow the driver to
maintain control over the vehicle. Arms should be at a 45 degree angle when the driver’s hands are on the
wheel
For passenger side airbags, ensure that there is nothing mounted in front of them and the area is kept clear of
debris. When the airbag deploys, anything in front of it will become a projectile and can cause further damage
and injury to occupants.
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ABS BRAKING – Both of our ambulances are equipped with ABS (anti-locking Braking System) brakes.
These differ from common braking systems in that they automatically prevent the tires from locking up on the
pavement. Once a tire locks up and begins to slip or skid on the roadway surface, the operator has lost friction,
traction, and ultimately control of the vehicle. Without control of the vehicle, the operator can no longer steer
the ambulance and thus is at the mercy of the ambulance until it stops or until the tires begin to roll on the
surface again.
ABS brakes will automatically pulsate when the brakes are applied and the tires begin to slide on the pavement.
The operator will feel and hear the pulsating sound on the brake pedal. As the operator, you should depress
the pedal completely to the end and hold it there until you have brought the vehicle back under control.
With ABS brakes, the operator can maintain steering and control of the vehicle as he/she brings it to a stop.
DO NOT PUMP ABS brakes. This method is taught for standard braking systems where the operator must
make the brakes “pulsate” by pumping them allowing them to go on and off. If this method is done with ABS
brakes, it can trick the sensor for the ABS and shut it off completely, rendering the ambulance without any
brakes at all. Again, the key to ABS braking is to push the pedal down hard and stay “hard” on the pedal even
after the ABS comes on until the vehicle is brought under control of brought to a stop.
Adjust the seat and fasten the seatbelt properly.
a -Should ride over shoulder.
b -Should not be twisted.
c -Once seat is adjusted, you should be sitting all the way back in the seat.
d -Lap belt should be low across your pelvis.
e -Hands should rest comfortably on wheel.
f -Middle of headrest should be even with your ears.
g -Seatback should be angled so your back rests comfortably against it.
h -Feet should be able to fully depress pedals.
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LESSON TWO – Steering and
tailgating
Ambulance operators who have all ready learned how to maneuver a vehicle with standard brakes often have a
problem with ABS vehicles. Many accidents have occurred with less than 30% of the total vehicle’s breaking
and steering capacity being used for avoidance. Steering safely is a two-step process. The operator has to learn
the material, such as what is being presented here, and then they have to use that material and practice it
regularly. The operator must stay alert every second that he/she is driving the ambulance.
EFFECTS OF SPEED – Any small change in speed has a greater change on an ambulances handling than
the average operator realizes. This can be seen easily during a routine slalom course.
TIMING – Everyone has experienced the loss of control of a vehicle as it skids on snow or ice. It seems to
just get worse the more we try to correct the skid. The problem is timing. A small correction at just the right
time can bring a vehicle back under control, whereas that same correction just a few feet later can be disastrous.
TECHNIQUE – The correct technique is very important. If the ambulance operator is all ready in the right
position in the seat, has their hands in the proper position, and is programmed to be looking in the proper
directions, it can decrease the response time and maximize the braking and steering capability of the vehicle
during emergency times where immediate actions must be taken.
TAILGATING – Tailgating accounts for 40% of all ambulance and emergency vehicle crashes. Many drivers
follow other vehicles too closely and thus do not leave the appropriate amount of space and following distance.
The rule of thumb is to leave a 4 second following distance under speeds of 45 to 50 mph and at least 5
seconds when the speed exceeds 50 mph.
When you increase the following distance from the vehicle in front of you, you are more relaxed and less
fatigued. You increase your field of vision and most likely, you are going the same speed, as you would be if
you were tailgating. This of course equates to fewer crashes with the ambulance. The distance that you have
the most control over is the distance directly in front of you. If the vehicle behind you closes the gap, increase
your following distance.
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LESSON THREE – Lane changes /
Fleet safety
INTERSECTION CRASHES ARE PERSONAL INJURY CRASHES – Approximately 20% of all
ambulance fleet crashes occur at intersections. There is a high probability of side impact. Vehicles are much
more likely to disseminate the energy from frontal, head on, collisions because there is more space between the
impact zone and the driver and occupants as opposed to side impact where the occupants are right up against
the doors and the impact zone.
MAKING AN EMERGENCY LANE CHANGE WITHOUT BRAKES – This is rarely called for or the
best response. It is however, sometimes, the only option. In order for a maneuver like this to work, you need
to be doing half of the technique before you have to execute the move. For instance:

If both hands are not on the wheel in the correct positions, you are more likely to give a big yank with
one hand and throw the vehicle out of control. The hope of swerving back is all but lost at this point.

If your seat belt is not on, you will be thrown from your properly seated position on the first move.
This will make it nearly impossible for you to regain your position to execute the second “recovery”
move of the vehicle.

If you are not attentive and looking ahead, you will not see where you want the vehicle to end up after
you have swerved to miss the object.
Unless you are being followed extremely close or are operating an ABS vehicle on a slippery, wet road, there are
very few instances that you would want to execute a maneuver like this without some type of moderate braking.
In the case of the ambulances with the ABS, heavy braking will actually improve the steering of the vehicle
because it puts more weight on the front tires. If you have to make an evasive maneuver without brakes here’s
how:

With your hands at the 3 and 9 o’clock positions, turn the wheel quickly and smoothly about a third of
a turn. Turning the wheel more than this will not make the vehicle turn more, but may throw it into an
uncontrolled side skid.

Start the second turn the instant the front of the ambulance has cleared the object you are avoiding

The third turn will correct the skid, and also has to be started very early. This is done even before the
momentum of the second turn has finished. The wheel has to be turn smoothly and not quite as
quickly as the first two turns.
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EMERGENCY LANE CHANGE WITH BRAKES IS ALMOST ALWAYS THE BEST
RESPONSE – Using the brakes while steering is by far the best response in an emergency. Here’s how it
works:

FIRST BRAKES, THEN STEERING – By braking first, the ambulance weight will be transferred
to the front steering tires quickly and evenly.

USE HALF AS MUCH STEERING – When you use the brakes, turn the wheel half as much as
you would when not using the brakes. The more weight on the steering tiers, means they steer more
effectively and thus less input is needed from the driver.

WITH THE ABS BRAKES, SLAM THEM ON – Operators should concentrate on the steering
aspect and slam the brakes on and hold them there. With the ABS system, the brakes will automatically
be “pumped” thus keeping control of the vehicle, allowing you to be able to steer more effectively.
FLEET SAFETY ISSUES
PARKING LOTS AND BACKING – These are amongst the most expensive accidents. Half the amount
spent on repairs for ambulance crashes is within parking areas and backing. Almost all of these accidents
involve the operator hitting something that was not seen. See the following suggestions to help avoid backing
accidents:

Approach the driver’s door from the rear. This way you can look behind the ambulance, and not just
in the side view mirror before backing.

Don’t back up unless you have to. In parking lots, find a place that you can pull straight into and that
you will be able to pull out of straight without backing.

Back up as short a distance as possible. Its better to travel a short distance than a long distance that you
cannot see.

Do not ever back up FAST. The ambulance steering is designed to operate fully in a forward direction.
In reverse the vehicle wheel wants to snap back to the lock position, which in turn, can throw the
vehicle out of control.

Adjust your mirrors. You should only have to move you’re head slightly to see the rear quarter panel of
the ambulance. Do not adjust the mirrors so that you can see directly down the side of the ambulance.
It increases the blind spots to your sides.

Get out and look behind you if you are not sure or you are not backing with a spotter. It is a good idea
to clear the space behind you and then back immediately before the conditions behind you change.
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SMITH CUMMINGS METHOD – Mercedes-Benz conducted a study that showed that 90% of all
accidents would not have occurred if the operator had only one more second to react. The trick is to
finding that one more second. The following method can be used to maximize the amount of time an
operator has to react to an emergency situation behind the wheel.

AIM HIGH – Look as far in front of you as possible when driving. At night look past your headlights
into the dark. On curves look at the farthest point of the roadway you can see. When poor weather
forces you to look closer to your vehicle, slow down.

GET THE BIG PICTURE – Use your central vision to observe the entire traffic scene. This can
consist of three parts:
o Do not follow to closely behind the other vehicle. Make sure to keep sufficient following
distance behind the vehicle in front of you. If that driver slams on the brakes you will use up
approximately half of the distance in reaction time.
o Don’t fix sharp central vision on another vehicle. Only look at the other vehicles quickly
and their front tires. See which way they have turned them. This will tell you what direction
their vehicle is committed to traveling in for the next few moments. Then glance around at
other vehicles. Avoid checking out vehicles in great detail. It takes too much of your time that
could be spent on viewing the locations and actions of other vehicles and drivers.
o Keep scanning ahead, the sides, and behind the ambulance. Operators must be aware of
the traffic conditions a block ahead of time in town and a half-mile ahead on the highway. See
what issues are facing other drivers on the road. This will help you determine what actions
they must do to avoid an accident

KEEP YOUR EYES MOVING – When you develop the “BIG PICTURE” habit you avoid having
a fixed gaze on any one object and thus are more aware of the traffic situations around you.

LEAVE YOURSELF AN OUT – By leaving enough following distance behind the vehicle you are
following you can always have an “out”. This will allow you an area to stop, swerve, etc in should it be
needed. This can be done in any of the following ways:

Leave a space cushion. This space should be kept all around your vehicle. This is
commonly referred to as the cushion of safety. Always try to avoid from being boxed
in.

Adjust your speed to visibility. It only takes one car that has increased their following
distance to stop the chain reaction of a multi-car pileup. The worse the visibility gets,
the more of a space you should leave for following distance.

Play it safe in doubtful situations. In situations where there is a line of parked cars on
the side of the road, drive slower. Always assume that there will be objects, children,
or car doors that may come into your path while you are passing them. Always assume
that the vehicle pulling in front of you or beside you in the next lane does not see you.
Be ready to make an emergency move to stay clear. Drive as if you were the BEST
driver on the road and everyone else was the WORST driver there was.
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
Make sure that the other drivers see you. Do not count on traffic laws to protect you.
Just because it’s a law doesn’t mean that they will follow it. Use your headlights all the
time and keep them on low beam during rainy days or fog.
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LESSON FOUR – Driver Impairment
Driver impairment is a pervasive problem that has many causes. Below are lists of possible causes that all
ambulance operators should be inherently aware of any time they are driving in a vehicle.
ALCOHOL – It is a known fact that the more a driver consumes for alcohol the worse and slower their
reaction time and overall driving skills become. It is surprising, however, to see how LITTLE alcohol is needed
to affect judgment and impair driving skill. Since judgment is the first thing that is affected by the drinking
driver, there is NO SAFE limit to drink and still operate a motor vehicle.
FATIGUE – This is a hidden highway killer. Some examples include:
 40% of adults are shortchanged on sleep
 15 to 20% of all highway deaths are attributable to drowsiness
 Contrary to popular belief, research shows that drivers cannot tell when they are about to fall asleep
 Among drivers who crashed after falling asleep, one-third had consumed alcohol, and one half had
been working either the night shift or overtime.
CELL PHONES – Cell phones take the driver’s attention off the roadway. It is not the act of driving with
only one hand that is the problem. It is the fact that the driver is dividing their attention between two different
things. Without having 100% of the driver’s mental involvement on the road and their driving they are liable to
be weaving, not following road signs and directions, drive at inappropriate speeds, etc.
ROAD RAGE – Aggression is a factor in one-third of all accidents and two thirds of the resulting deaths
according to the National Highway Safety Administration. Most road rage incidents involve both drivers who
need very little provocation to threaten the safety of others. Here are some tips to avoid dangerous encounters
with a driver who may be filled with road rage:
Do not provoke an aggressive response with your driving. These are the four most common “triggers”
for aggressive acts: tailgating, changing lanes without signaling, driving in the left lane, passing on the
right.
Do not escalate the level of violence. By returning a sign or gesture, you could easily fuel a road rage
encounter. Do not make eye contact or glare at the other driver. If it takes two people to be involved,
don’t make your self on of them.
Do not teach other drivers lessons. By your teaching poor driving habits and habits that are considered
to be illegal or dangerous, you are only contributing to the overall problem. This can be said of giving
driving lessons or having others watch you as you drive.
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FIELD TRAINING PROGRAM - ENHANCED
Try not to make assumptions about the other cars driving on the road around you. A vehicle that is driving
slowly in the lane next to you in poor weather is most likely intimidated by the prevailing conditions and is not
attempting to make you angry.
37
FIELD TRAINING PROGRAM - ENHANCED
Driving Skills
The following driving skills and practice session are to be completed with the FTO-C. This portion MUST be
supervised thoroughly and all attempts are to be made to ensure that the hands-on skills portion is conducted as
safe as possible for all participants.
 Driver brings a fast moving ambulance to a complete stop around a designated curve that is marked
out with road cones to either the left or the right
 Driver brings a fast moving ambulance to a controlled stop after traversing through a designated cones
course (slalom style course)
 Driver negotiates around an object that suddenly appears in front of the ambulance that is traveling at a
controlled speed without the use of the vehicles brakes
 Driver negotiates around an object that suddenly appears in front of the ambulance that is traveling at a
controlled speed with the use of the vehicles brakes
CEVO REVIEW FROM BASIC MANUAL
As a trainee, it is important to remember to turn off the battery ON/OFF switch located under the driver’s
side seat, to the OFF position and take the key out of the ignition after the vehicle has been turned off, such as
upon arrival at the hospital. NEVER turn the ambulance off by turning the master ON/OFF switch to the
OFF position without first turning the ignition to the OFF position with the key. Additionally, inform your
fellow crewmembers that you have the keys after removing them from the ignition.
This will ensure that the ambulance cannot be taken or tampered with while the crew is inside tending to the
patient. When the ambulance is in the ambulance bay, it is to be turned to the OFF position and the keys left
in the ignition.
All trainees should understand that MAS utilizes wheel chalks on all calls when the ambulance is parked at a
scene and running. Once the driver has parked the vehicle, he/she should remove the wheel chalks from the
driver’s side back compartment and place them in front of and behind the rear wheel. The emergency brake
should not be set in wet conditions when the outside temperature is below freezing. This will avoid the
emergency brake from freezing in the “set” position, which in turn would prevent the release of the emergency
brake and subsequent movement of the ambulance.
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FIELD TRAINING PROGRAM - ENHANCED
All ambulance equipment modules requiring electrical power (emergency lights, siren, scanner, scene lights,
patient compartment lights, and environmental controls) are activated by the master switch located on the lefthand most side of the ambulance control panel in the cab. To operate any of the above-mentioned equipment,
the MASTER switch must be flipped up to the ON position.
Both ambulances are outfitted with separate environmental systems controls (heat and air conditioning) for
both the front (cab) and back (patient) compartments. In order for the patient compartment environmental
systems to function, both the master switch and the switch labeled “PT. heat/AC”, located on the master
panel in the cab, must be switched on. The Pt. heat/AC switch provides power to the patient compartment
environmental controls. Upon depressing the switch, the switch should illuminate indicating that the patient
compartment environmental systems have been activated. Controls for fan speed and temperature of the
patient compartment are located in the action area of the patient compartment.
The MASTER switch in the cab also controls patient compartment lighting. In order for the patient
compartment lights to function, both the master switch in the cab and the individual controls for the lights in
the patient compartment must be switched on.
Back-up alarm - This switch MUST always be in the ON position. The warning device only operates when
the transmission is in reverse and is designated to warn people that the ambulance is backing and that the driver
may not be aware of their presence.
Engine idler- Both ambulances are equipped with a high RPM engine idler. This device automatically
increases engine RPM while the ambulance is in PARK and a certain electrical voltage is reached. The system
is designed to protect the electrical charging system and avoid draining the batteries down to the point that the
ambulance will stop running.

ON-LINE SITUATIONS MANUAL
Trainees should go to the Milford web site and download the situations
manual. Answer the questions as best as possible and then review your
answers with an FTO. You should keep the manual for future reference.
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FIELD TRAINING PROGRAM - ENHANCED
APPENDIX
This section explains the ratings used to rank the trainee.
PASSING MARKS
1 - Mastery of objective: This indicates that the trainee has mastered the objective. The trainee completed the
objective without assistance from the FTO and exceeds the minimum requirements.
2 - Excellence in objective: This indicates that the trainee has demonstrated strong skills and or knowledge in
this objective. There is only slight room for improvement and the objective may or may not have been
completed with assistance from the FTO.
3 - Average ability in objective: This indicates that the trainee has demonstrated an average ability in
performing this objective. There is room for improvement. The trainee may or may not have needed the
assistance of the FTO in completing this objective.
FAILING MARK
4 - Unsatisfactory ability in objective: This indicates that the trainee has not completed the objective
correctly. He/she has not met the minimum standard and needed assistance with completion of the objective.
There is room for improvement and the trainee may improve with the assistance of the FTO.
5 - Poor ability in objective: This indicates that the trainee has not been able to perform the objective and has
demonstrated non-ability to the FTO. The trainee will need much remedial training and assistance from the
FTO to achieve a satisfactory skill performance.
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FIELD TRAINING PROGRAM - ENHANCED
PERFORMANCE SKILL SHEET CHECK OFF SHEET
Name of Trainee: ________________________________ Date: ___________________
SCENE SAFETY SCENERIO
#1
#2
#3
Final
Establishes initial scene safety
Verbalize wearing of BSI
As entering scene is watchful of changes in surroundings
Ensures that crew or team enters together
Ensures that no loose hair or jewelry is displayed
Calls for police assistance or stages prior to PD arrival as needed
Communicates with patient maintaining safe distance and stance
Recognizes unsafe conditions
Verbalizes looking for weapons, alcohol, distraught family members, pets, etc
Re-treats from immediate area
Uses radio for help (if not all ready on scene)
Communicates to Dispatch slowly and effectively the need for assistance
Re-evaluates the situation while waiting for assistance
Tries to determine the specific threat, number of persons involved, etc.
After scene has been secured, re-enters with caution
Re-establishes contact with patient
Medically evaluates patient
Determines need for transport
Team completes PCR for documentation
REFUSAL OF CARE SCENERIO
#1
#2
#3
Verbalizes scene safety and BSI
Makes contact with patient
Asses patient and makes determination on transport
After patient verbally refuses transport, attempts to explain medical situation to patient
After patient verbally refuses again, explains injuries and complications that may arise
Fully documents PCR on situation to include:
Conditions that were found with the patient
Treatment completed this fur
Refusal of care by patient
Explanation of condition and what may occur with lack of transport
Patients understanding of condition and possible outcomes
Verbally explains the refusal to patient
After signature of refusal form, explains that patient should seek med. Attn.
NOTE: All white boxes must be initialed and dated by an FTO before the skill is considered to be
“complete”. The “final” grade is determined when the trainee demonstrates and completes the last box (#3).
The FTO will place a number grade in the “final” box. Shaded boxes are considered optional and may be
used by the FTO for remedial training as needed.
41
Final
FIELD TRAINING PROGRAM - ENHANCED
CEVO – AVOIDANCE
NO BRAKES
BRAKE USE Final
Seatbelt utilized
Checks seat position and overall comfort in seat
Mirror adjustment to maximize views
Hands at three and nine o’clock positions on wheel
Accelerates down course after verification that area is clear and secure
When vehicle arrives at “braking” cones discontinues use of acceleration
As object enters in front of vehicle, driver swerves right or left with hands on wheel
Driver makes correction back to roadway without over steering
Maintains proper control over vehicle without letting go of steering wheel
Brings vehicle to a controlled stop
COMPLETION OF ACLS FOR EMT-BASICS SCENERIOS
TO BE DEVOLOPED
12 LEAD APPLICATION
#1
#2
#3
Needs to be developed
NOTE: All white boxes must be initialed and dated by an FTO before the skill is considered to be
“complete”. The “final” grade is determined when the trainee demonstrates and completes the last box (#3).
The FTO will place a number grade in the “final” box. Shaded boxes are considered optional and may be
used by the FTO for remedial training as needed.
42
Final
FIELD TRAINING PROGRAM - ENHANCED
Index
A
AMI, 15
J
K
L
ALS equipment, 15
Legal Considerations,
Approaching the
scene 5
Angina, 15
Airbags, 28
U
V
Violence, 6
15
ABS Brakes, 28
Lane Changes, 31
B
M
BSI, 5
Minor Injuries, 22
Backing, 32
Cardiac monitor, 10
N
O
P
CEVO, 27
Pattern Recognition.,
Cell phone, 35
9
D
PCR, 16
C
CHART, 14
Consent, 23
Parking lots, 32
Differential diagnosis,
8
Distracting Injuries,
10
Detailed exam, 13
Q
R
E
F
Rapid Assessment,
Field Diagnosis, 8
S
Fleet Safety, 31
10
Refusal of care, 21
Road Rage, 35
SOAP, 14
Syncope, 21
G
Scenarios, 26
Seat Belts, 28
Steering, 30
H
Smith Cummings
Hazardous Material, 5
T
I
Method, 33
Turnout Gear, 5
Introduction, 3
Team Leader, 11
Icons, 4
Tailgating, 30
Impairment, 35
43
W
X
44