Multi-County Ambulance Inspection Basic Life Support Checklist
Company Name: ______Date: ______Sticker Number: ______Old Sticker Number: ______Based in the following counties:
Adams Arapahoe Broomfield Douglas Elbert Jefferson
Unit No.: ______VIN: ______Lic #: ______Exp. Date: ______Ambulance Make: ______Manufacturer: ______Year: ______Odometer: ______Insurance Company: ______Policy No.: ______Exp. Date: ______
__Basic Life Support __Basic Life Support with Advanced Life Support Capabilities __Advanced Life Support (BLS) (BLS/ALS) (ALS) __ Reserve Vehicle (Will be fully stocked according to this Inspection list before going into service.)
Basic Life Support Check List Emergency Systems: __ AED-Automatic External Defibrillator Serial No ______Ambulance Service Medical Treatment __Adult Pads __Pediatric Pads Protocols (Current) __Computerized __Printed Passed Self-Test Date: ______Time:______Running Lights __ Emergency Lights __Siren __Opticom Dressings and Bandages: __Wipers __ ABD Pads __ Communications appropriate for jurisdiction served. __ Bandages, roller type, self-adhesive __cell phone __ Portable Radio __ Multi Trauma Dressing (10 x 36) __ Dispatched by: ______Sterile Burn Sheets __ A set of 3 warning reflectors or devices. __ Occlusive Dressing ______Triangular bandages (2) __ Spare Tire __Fleet __ Road side service __ Trauma Tourniquet __ Fire Ext. (ABC 5-10 lbs) - vehicle exterior __ Sterile 4 x 4’s Due Date: ______Adhesive Tape ___2” ___1” __ Oxygen (house supply) __ Adhesive Bandages __ Two (2) Flash lights or lanterns __ Hemastatic Gauze* __ Crew Reflective Vests Ventilation and Airway Equipment: Splints and Immobilization Equipment: __ Suction Units: ___House___ Portable __ Spine board (long) with straps __ Rigid Suction Tips Covered __ Spine board (short) with straps _____ KED __ Soft Catheter Fr. 6, 8, 10, 12, 14, other______Patient extrication device __ Pediatric board __ Bulb suction __ Mushroom Suction __ Scoop stretcher with straps __ Two (2) Portable Oxygen with regulators __ Cervical collars – rigid – adults and peds. __ Nasopharyngeal Airway: Adult: 24,26,28,30,32 __ Head immobilization devices adult and peds. __ Oropharyngeal Airway: Infant, Child, Small Adult, Adult, Type:______Large Adult __ Assorted splints and arm boards, adult & peds. __ Nasal Cannula: ___Adult ___ Pediatric __ Traction splint (lower extremity) with anklet __ NRB with Transparent Oxygen Masks: __ Child safety seat (per state guidelines) __ Adult___ Child __ Adjustable gurney (4-6 wheels) with holder __ Bag Valve Mask O2 Resuscitators __ Blankets (4) 500cc___ 750cc ___ 1000cc___ __ Pelvic Splint ___ Commercial ___ Other with transparent masks, oxygen reservoir, __ Stair Chair* and standard fittings 15mm – 21 mm ___ *Supraglottic Airway__ IGELS __Kings Diagnostic Equipment: ___ Atomizer __ Blood Pressure Cuffs __Large adult__ Reg. Adult__ Child__ Infant __ Stethoscope NOTES: __ Diagnostic Pen Light (pupil gauge) __ Thermometer - adult and pediatric. __ Pulse Oximeter __ Electronic Glucose measuring device
*Optional 2 Updated: 2/15/2019 Multi-County Ambulance Inspection Basic Life Support Checklist
Intravenous and Irrigation Equipment: BSI Continued:_ __ Sterile Irrigation __ N95 masks which can be universal of size __ IV solution volume expander, __1000mL__ 500mL __ Sharps containers for the appropriate disposal __ Heated storage: __Yes ___ No * and storage of medical waste and biohazards __ IV Arm boards, __Adult __Pediatric __ Sharps container in Jump Kit __ Constricting bands __ Alcohol Wipes __ Other: ______Safety Equipment: __ IV administration sets: __Micro__ Macro __ Fire Ext. (ABC 5-10 lbs) - vehicle interior Blood pumps __ Other: ______Due Date: ______IV venipuncture needles: sizes: ______thru______No smoking sign (patient compartment) (If required by Medical Director or company.) __ Shears, heavy duty (Trauma) __ *Blood specimen equipment __ Ring cutter * __ Safety seat belts, including squad bench Obstetrical Equipment: __ Restraining devices for all equip. in Pt. Comp. __ Sterile OB kit to include towels, 4x4’s, ABD pads, umbilical tape or cord clamps, scissors Additional Equipment and Supplies: or scalpel, bulb syringe, sterile gloves, drapes, __ Appropriate cleaning supplies including: blanket, or thermal absorbent blanket, stocking disinfectant cleaner. ______cap, heat source: ______Meconium/mucous trap/mushroom suction __ Trash Bags (biohazard). Disposed at: ______Body Substance Isolation (BSI): __ Vehicle cleanliness: __Cab __ Patient Compartment __ Protective eyewear __ Storage Cupboards __ Sterile Gloves __ Triage tags __ Non-sterile Latex Free Gloves __ Extrication Equipment * __Yes__ No __ *Masks, non-sterile surgical
NOTES: Other comments: ______
Medical Director: ______Medical Facility: ______
Approved Basic Life Support (BLS) Not Approved. - Re-inspection required.
Inspection Expires: Date of Re-inspection:
Please print Ambulance Service Representative’s Name:
Ambulance Service Representative Signature Date
Mona Fellers, Multi-County Ambulance Inspector Date
*Optional 2 Updated: 2/15/2019 Multi-County Ambulance Inspection Advanced Life Support Checklist
Company Name: ______Date: ______Sticker Number: ______Unit Number ______Medical Director: ______Medical Facility: ______
Advanced Life Support Checklist:
Ventilation Equipment: __ Chest Decompression: Commercial__ Self Kit__ Patient Assessment Equipment: Angiocath: 10g ___ Other: ______Monitor/Defibrillator Operational Check: __ Cricothyrotomy Tray: Commercial__or Self-Kit__ Make and Model: ______Including betadine______Monitor Serial No. ______Laryngoscope and Blades, straight and/or curved Patient Cables: sizes: Straight: 0, 1, 2, 3, 4, Curved: 0, 1, 2, 3, 4 __ Lead 1 (white/black) __*Video Scope __ Lead 2 (white/red) __ Endotracheal Tubes (1 each uncuffed & 2 each cuffed) __ Lead 3 (black/red) Uncuffed: __ 2.5 __ 3 __ 3.5 __ 4 __ 4.5 __ 5 __ 5.5 __ 12 –AED, PACE, CV, Defib. Cuffed: __6 __6.5__ 7__ 7.5__ 8__ 8.5__ *9 Pulse OX, BP, ET-CO2 * __ Stylets __Adult __Pedi ___PP __ *Bougie __ Adult Paddles or Combi-Pads __ End Tidal CO2, capnography or alternative device, FDA __ Pediatric Paddles or Combi-Pads approved to determine endotracheal tube placement __ Presentation __ CAP __Colormetric __ Recorder and Paper __ Endotracheal Tube Holder Date of last service: ______*BAM __ Passed Self-Test __ Curved Forceps __ Adult __ Pediatric __ Nebulizer __ Adult ___ Pediatric __Mask Adapt Miscellaneous Equipment: __ Nasogastric Tube * __ Size 16 __ Size 18 __ Pediatric “length-based” device for sizing drug __ CPAP dosage calculation and sizing equipment Type:______date:______IV Fluids and Equipment: __ Soluset ______D5W or NaCL, __*10 mL Flush __ 50mL or __100mL NOTES: __ NaCL or LR, __500mL or 1,000 ml bags __ *D5W 250 ml bags __IO ______Betadine
Medications: __ Denver Protocols Medication List (attached).
*Optional
Re-inspection Approved ALS Not Approved. required.
Approved BLS with ALS capabilities
Inspection Expires: Date of Re-inspection:
Please print Ambulance Service Representative’s Name:
Ambulance Service Representative’s Signature Date
Mona Fellers, Multi-County Ambulance Inspector Date
3 Multi-County Ambulance Inspection Advanced Life Support Checklist
Denver Metro Paramedic Protocols, Section VI DRUG PROTOCOLS
Company Name: ______Date: ______Sticker Number: ______Unit Number ______
Medical Director: ______Medical Facility: ______
TABLE OF CONTENTS
Drug Available on the Ambulance __Acetametaphine NOTES: __ Adenosine (Adenocard) __ Albuterol Sulfate __ Amiodarone __ Aspirin (ASA) __ Atropine Sulfate __ Calcium __ Dextrose 50% ____ D25% ____ D10% __ Diphenhydramine (Benadryl) __ Dopamine (Intropin) __ Epinephrine __ 1:1 AMP __ 1:1 MDV __ 1:10 M __ Furosemide (Lasix) __ Glucagon __ Haloperidol (Haldol) __ Ibuprofen __ Ipratropium Bromide (Atrovent) __ IV Solutions __ Lidocaine: __Vicous/Jelly __ 2% __ Magnesium Sulfate __ Mark I Nerve Agent Antidote Kit __ Methylprednisolone (Solu-Medrol) __ Metoclopramide (Reglan) __ Naloxone Hydrochloride (Narcan) __ Nitroglycerine: __ Tabs ___ Patch ___ Spray __ Odansetron: __Tabs ___IV __ Oral Glucose __ Oxygen __ Phenylephrine (Intranasal) __ Promethazine __ Racemic Epinephrine (Vaponephrine) __ Sodium Bicarbonate: __ 8.4 ____ 4.2 __ Topical Ophthalmic Anesthetics __ CI = crew issued __Ativan __ Fentanyl Citrate __ Diazepam (Valium) __ Dilaudid __Ketamine __ Midazolam (Versed) __ Morphine Sulfate
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