BSI and Personal Protective Equipment
Body substance isolation (BSI) and appropriate personal protective equipment (PPE) are the absolute first priority before any scene approach or patient contact. At minimum, wear gloves for every patient contact. Additional PPE is selected based on the anticipated exposure. Use eye protection (safety glasses or goggles) and a mask when there is potential for splash or spray of body fluids, such as arterial bleeding, suctioning, airway management, or childbirth. Wear a gown when significant blood or fluid contamination is expected. Use N95 or higher respiratory protection for patients with suspected airborne infectious diseases such as tuberculosis, measles, or novel respiratory pathogens. HEPA masks or powered air-purifying respirators (PAPRs) provide higher levels of respiratory protection. Ensure proper fit and donning technique for all PPE before patient contact. Remove and dispose of PPE properly to prevent cross-contamination.
Scene Safety Assessment
Evaluate the scene for potential hazards before approaching. Never enter an unsafe scene. Common hazards to assess include traffic (position apparatus to protect the scene, wear high-visibility vests), fire or explosion risk, downed power lines or electrical hazards, hazardous materials (look for placards, labels, spills, vapors, and unusual odors; maintain safe distance and call HazMat if indicated), structural instability in buildings or vehicles, environmental conditions (extreme heat or cold, water, ice, steep terrain), and violence or crime scenes (wait for law enforcement to secure the scene). If the scene becomes unsafe at any time during the call, withdraw to a safe distance immediately. Continually reassess scene safety throughout the call, as conditions may change dynamically.
Mechanism of Injury and Nature of Illness
Determine the mechanism of injury (MOI) for trauma patients or the nature of illness (NOI) for medical patients. For trauma, assess the forces involved and anticipate potential injuries. High-energy mechanisms that suggest serious injury include vehicle crashes at speeds over 20 mph with significant vehicle deformation, falls greater than 20 feet for adults or greater than 10 feet (or 2 to 3 times the child's height) for children, pedestrian struck by vehicle, motorcycle crashes, penetrating trauma to the head/neck/torso, ejection from a vehicle, death of another occupant in the same vehicle, and rollover crashes. For medical patients, determine the chief complaint, onset, and circumstances. Look for environmental clues such as medication bottles, medical devices (home oxygen, glucose monitors), medical alert jewelry, and drug paraphernalia. The MOI or NOI guides your index of suspicion for specific injuries or conditions and influences triage, treatment, and transport decisions.
Number of Patients
Quickly determine the total number of patients at the scene. For single-patient incidents, standard assessment and treatment protocols apply. When multiple patients are identified, activate mass casualty incident (MCI) protocols when the number of patients exceeds the resources available. Begin triage using a standardized system such as START (Simple Triage and Rapid Treatment) for adults or JumpSTART for pediatric patients. Assign triage categories: immediate (red, life-threatening but survivable with treatment), delayed (yellow, serious but can wait), minor (green, walking wounded), and expectant/deceased (black, not expected to survive or already dead). The first arriving unit's primary role shifts from patient care to scene command, triage, and resource coordination until additional resources arrive. Communicate the patient count and triage results to dispatch and the incoming units promptly.
Additional Resources
Based on your scene assessment, determine what additional resources may be needed and request them early. Waiting until the need is critical delays care and worsens outcomes. Additional resources to consider include additional ambulances for multiple patients, advanced life support (ALS) intercept if the initial response is BLS, aeromedical transport (helicopter) for critical patients in rural areas or when transport time exceeds 20 to 30 minutes, fire department for vehicle extrication, fire suppression, or structural collapse, law enforcement for scene security, traffic control, or violent scenes, utility companies for downed power lines or gas leaks, hazardous materials teams for chemical spills or exposure, technical rescue teams for confined spaces, high-angle rescue, or water rescue, and specialized resources such as pediatric teams or burn centers as needed. Request early and communicate clearly, providing the dispatcher with your location, situation summary, and specific needs.
Standard Precautions Summary
Standard precautions extend beyond PPE and include proper hand hygiene before and after every patient contact (alcohol-based hand sanitizer or soap and water), proper sharps disposal in puncture-resistant containers, cleaning and disinfection of equipment and the ambulance patient compartment after each transport, proper handling and bagging of contaminated linens and waste, and appropriate use of barrier devices for CPR. Consider vaccination status for hepatitis B, influenza, tetanus, and other relevant immunizations. Maintain current knowledge of exposure control plans and post-exposure procedures. Report any exposure incident to your supervisor immediately and follow your agency's exposure protocol for documentation and follow-up, including baseline blood draws and prophylactic treatment if indicated.