Field Handbook

Ambulance Service
of New South Wales

Ready Always

Disclaimer: this is a fictitious document and bears no medical integrity.

 PREFACE

This document aims to provide a basic outline of possible medical proceedings and general
paramedic conduct. Paramedics can use the information found herein to help guide their
assessment and treatment of injuries and illness in the field. Recruits and Trainee
Paramedics may find this document particularly useful during their induction phase. This
document is to be treated as an extension to the NSW Ambulance Clinical Guidelines.

Paramedics are not required to know all of the content contained within this Field Handbook.
This document contains over 12,000 words across over 60 pages.

This Field Handbook has largely been created from scratch and original-wording has been
emphasised throughout its entirety by the author. Please contact the author of this
document for more detailed information regarding the topics found in this Field Handbook,
or to deliberate potential additions/amendments to this document.

Concocted and created by Jack (J-Dub).

NSW AMBULANCE 2
 ACRONYMS & ABBREVIATIONS

A&E – Accident and Emergency

AED – Automated External Defibrillation

AOL – Away On Leave
BGL – Blood Glucose Level
BP – Blood Pressure
BPM – Beats Per Minute
CPR – Cardiopulmonary Resuscitation
DNR – Do Not Resuscitate
ECG (EKG) – Electrocardiogram
ELS – Emergency Lights and Sirens
EMS – Emergency Medical Services
EPI – Epinephrine (Adrenaline)
ER – Emergency Room
GSW – Gunshot Wound
HR – Heart Rate
IIL – Injuries Incompatible with Life
IV - Intravenous
MVA – Motor Vehicle Accident
POL – Police
POLASST – Police Assistance
PPE – Personal Protective Equipment
RTC – Road Traffic Collision

NSW AMBULANCE 3
 CONDUCT

When both on and off duty, you are representing the EMS. Your behaviour, attitude and
interactions with citizens, fellow EMS and police officers is to be professional and
appropriate at all times. Rude, derogative, discriminative or any derivative type of these
behaviours is never acceptable.
To diffuse tension and ensure the best chance of a positive outcome, you should always
have an aura of calm and understanding. EMS are often the victim of verbal abuse but you
will find that by remaining calm and respectful that you will have the smoothest experience.
EMS should endeavour to spread themselves appropriately around the city to best cover all
areas. When arriving on scene, it is best to introduce yourself to the patient and ask for their
name if possible. This establishes a certain level or rapport with the patient and makes them
feel more comfortable and well-treated. Additionally, this offers an extra level of security in
the case that the patient needs to be reported to police.
You should always do your best to communicate what procedures and treatments you are
administering to the patient. Using their name and keeping them informed will reassure
them that they are in safe hands and being well looked after. Even if the patient is
unconscious or not in a lucid state, you should still orate the medical process and use their
name.
EMS are never permitted to engage in any illegal or corrupt activities. While not in
emergency response, you are expected to follow all road rules. You will be fined for road
rule violations by police. Emergency lights and sirens are not permitted for use outside of an
emergency.

UNREASONABLE REQUEST BY A SUPERIOR

Respect should be shown to both superiors and subordinates at all times. You must abide by
all appropriate and reasonable requests made by a superior. If you believe a superior has
made an inappropriate or unreasonable request (be it ethical or otherwise), respectfully tell
them you cannot proceed with their request and seek a higher administrative power as
required. If possible, document the incident and save any evidence. It is in your best interest
to remain respectful.

INSUBORDINATION
Failing to comply with a reasonable request ordered by a superior can result in disciplinary
action taken against you. Respect is to be maintained at all times and the chain of command
is to be utilised whenever appropriate.

NSW AMBULANCE 4
 EMS personnel are required to follow all server and city laws at all times, both on and off
duty. This incorporates any and all forms of exploitation, abuse, disrespect, minging and
trolling. You are not allowed to partake in any form of criminal activity what-so-ever and
disciplinary action will be taken against you if you are found in violation of these codes of
conduct.
EMS are expected to maintain a reasonably active presence in terms of on-duty shifts.
Where prolonged periods of leave are expected, EMS personnel are to inform cabinet of
their planned absence so they can be granted AOL status.
EMS are never permitted to give a member of the public medical equipment of any kind.
On-duty EMS are the only approved personnel to administer medical treatment and all
equipment must be handled and used by them only. Members of the public are not allowed
to operate any ambulance vehicle.
On-duty EMS may offer civilians a small lift where appropriate – notably if it is a patient who
requires assistance reaching a nearby road or venue so transport can then be arranged for
them. You are not a taxi service and any lifts should not be found to impede your
emergency duties.
Any and all placeables that you have set up must be removed by yourself immediately after
their intended use. Appropriate care should be taken with equipment and vehicles to not
impede an inappropriate amount of traffic when responding to an emergency call. This also
reduces the risk of injury to yourself and bystanders as civilian drivers can be highly
unpredictable when traffic congestion occurs. Whenever possible, patients should be
moved away from danger and traffic to be treated.
If a member of the public is found to be repeatedly abusing, misusing or wasting EMS’
time/resources/efforts you may request that all EMS personnel stop responding to that
patient’s emergency calls. This includes if the person is continually incapacitating
themselves with a general lack of preserving their own life to an inappropriate extent.
Headlights should be used at all times at night and during areas with poor visibility. When
visibility is poor, you should reduce your speed and drive according to the road conditions.
The ambulance van is the primary mode of medical response for EMS. An ambulance van
must always be on patrol before any other vehicle can be taken out (excluding ambulance
helicopter). When other ambulance vehicles are patrolling, EMS should be conscientious
that the ratio of van : sedan : motorcycle approximates 1 : 1 : 1 for the best patient
treatment.
Paramedics should always start their shift with 5 medical kits, 20 bandages, a flashlight, a
diving suit (optional but recommended), 3 water and 3 food minimum. When resources are
low it is your responsibility to restock when next possible. Extra medical equipment may be
stored in your ambulance vehicle but the vehicle must remain locked at all times to prevent
a member of the public retrieving the equipment. Failure to comply will result in disciplinary
action being taken against you.

NSW AMBULANCE 5
 RANK STRUCTURE / MEETINGS

RANK RANK
ABBREVIATION

Cabinet A

Superintendent
Clinical Training Officer
Clinical Support Officer
Intensive Care Paramedic
Extended Care Paramedic
Paramedic
EA
EMS meetings are usually held
TO fortnightly on Saturdays at
approximately 1930h AEST
(+11 GMT). These timings are
CS subject to change and you
should look for an
I announcement in the EMS
Discord channel by EMS
cabinet. The meetings are held
E in the EMS TeamSpeak
channel.
P

Trainee Paramedic TP

NSW AMBULANCE 6
 TRAINING AND QUALIFCATION

Certain equipment and roles within the EMS require extra training and qualification.
Oftentimes, there is a minimum rank before paramedics can enrol is these courses. EMS
cabinet/administration have the ultimate decision on how these courses are to be run,
when they will be run and how the qualification is to be assessed.
Qualifications can be removed if you are found to be operating outside of the expected
code of conduct for EMS.
On very rare occasions, a superior officer may grant special privileges to a subordinate for a
limited period of time so they can effectively continue their duties. It is important that when
the duty has been appropriately completed or the superior officer is no longer able to
communicate their content with the further use of these privileges, that the privileged
access is to be terminated.

These occasions should be seen as one-off events and are not an invitation to begin using
equipment that you are not approved or qualified to use.
Appropriate disciplinary action will be taken against individuals who do not obey by the code
of conduct for paramedics.

PEER LEARNING
To learn from and observe their fellow EMS, paramedics are allowed to partake in a ride-
along or act as part of a multi-vehicle response to an emergency when it is appropriate for
them to do so. This is permitted primarily for the interest of improving the EMS department
as a collective.
This means that adequate response coverage should be active and calls must be responded
to in an appropriate amount of time while peer learning is taking place. The paramedics
involved in the peer observation should both be content with the peer response taking
place and they should not feel enforced or assessed in their duties. This should also be
approved by any active superior officer on duty at the time.
Occasionally, superior officers may tag along to callouts with subordinate paramedics to
ensure that quality of treatment and EMS standards are being met.
If any problems or complaints arise during peer learning, they should be respectfully
communicated in a private avenue, away from open communication and act as a suggestion
only. If you still have strong objections to an individual’s treatment standards then you
should contact EMS or staff administration as appropriate. Do not publicise your thoughts
regarding a fellow EMS’ actions.

NSW AMBULANCE 7
 UNIFORM & EQUIPMENT

While on duty, you are required to wear the appropriate uniform for your designated rank
and role. Consider if you require additional PPE for your duties such as: gloves, long pants
and shirt, a high-visibility fluorescent vest or a helmet.
At no point should you don an item of clothing that is designated for a rank/role that is
higher or lower than yourself. Some uniform is permitted for use by a series of ranks/roles
and appropriate discretion is to be taken to ensure you are not wearing unapproved
clothing.

EQUIPMENT
‘Equipment’ refers to any physical item that may be required for use by EMS. It can include,
but is not limited to: vehicles, medical equipment (such as bandages and medical kits) and
carried utility such as flashlights and fire extinguishers.
Weaponry of any sort is not to be carried at any time while on duty. No exceptions.
Fire extinguishers, flashlights and petrol cans (for refuelling vehicles only) are permitted for
use when appropriate.

All equipment must be stowed and off your person when you are off duty. This includes
returning any emergency vehicle and storing/disposing of excess medical kits and bandages.

If you are found to be in possession of any piece of uniform or equipment - while on or off
duty - that is unapproved for your use, you will face disciplinary action.

It is your responsibility to remain well-equipped, restocked and refuelled so you can

continue to treat patients. If you are not busy with calls, take the opportunity to resupply
and prepare for your next call.

NSW AMBULANCE 8
 VEHICLES

The NSW Ambulance Service has a host of vehicles at its disposal. Discretion and common
sense must be used at all times when traversing various geographies and road surfaces.
Ambulance vehicles are extremely likely to be involved in RTCs due to their fast response,
the required nimble manoeuvres and the unpredictability of civilian road users. It is never
advised that the ambulance vehicles be driven at maximum speed, or at any speed too
significantly over the optimal speed limit for that area. Safety to occupants of the
ambulance vehicle and other road users is paramount.
Where the ambulance vehicle is unable to reach, you must proceed on foot or liaise with
police or other departments to either reach the scene, or extract the patient back to the
ambulance vehicle.
Emergencies must be responded to in emergency ambulance vehicles. Appropriate ELS
(priority 1, 2, 3) must be used for the response as required. Priority 3 (no lights or sirens)
requires full compliance with all road rules. Priority 2 (lights, intermittent sirens) grants
liberation from lesser traffic rules. Priority 1 (lights and sirens) grants liberation from higher
traffic rules.

AMBULANCE VAN
The ambulance van is our primary vehicle. Medically, it is the best-equipped vehicle in our
fleet and offers the ability to transport a patient to hospital. The ambulance van can
transport 2 paramedics and is able to be driven on closed road surfaces as well as some
light, open road surfaces that are relatively well maintained. The ambulance van is sluggish
and extra diligence must be taken when performing high-speed manoeuvres or when
driving in sub-optimal conditions. With a general maximum speed of ~160 km h -1, the
ambulance van often requires deceleration and generous braking distance to safely get to
its destination. The ambulance van is unable to traverse steep hills or trails.

AMBULANCE SEDAN

As part of the rapid response unit’s fleet of vehicles, the ambulance sedan can dispatch up
to 4 crew members to the scene faster than a standard ambulance. Often occupied by an
incident commander, the ambulance sedan has room to store a wide range of medical
equipment but is limited by patient transport capability. With no designated patient
treatment area, only the lesser-injured patients can be transported to hospital in an
ambulance sedan. With a general maximum speed of ~200 km h-1, the sedan’s increased
speed is best utilised in open and ideal conditions. It can traverse more rough and steep
terrain than the ambulance van, but less so than the ambulance motorcycle.

NSW AMBULANCE 9
 AMBULANCE MOTORCYCLE
The ambulance motorcycle is part of the rapid response unit’s fleet of vehicles. It allows a
single, qualified and approved paramedic to reach the scene quicker than a standard
ambulance van and can be the difference between life and death for the patient. The
improved mobility comes at a cost with the ambulance motorcycle being unable to
transport patients or carry a diverse set of medical equipment. Lane-splitting and lane-
filtering requires the utmost care by the driver and extra precaution should be taken due to
the greater-increased chance of personal injury. Long sleeves, gloves, pants, enclosed
footwear, a high-visibility fluorescent vest and an approved helmet must be worn at all
times by riders. Ambulance motorcycles can reach more difficult to reach places than the
ambulance van and sedan, it can traverse steep hills and trails. With a general maximum
speed of ~200 km h-1, the ambulance motorcycle should only utilise its high speed in open
and ideal road conditions.

AMBULANCE HELICOPTER
The ambulance helicopter gives EMS more capabilities than ever before. Piloted by a
qualified and approved paramedic, the ambulance helicopter can transport 4 paramedics to
the scene and reach areas that are inaccessible to ground-based ambulances. Well-
equipped, the ambulance helicopter can provide patient transport where ambulance van
transport would not be sufficient. With a general maximum speed of ~210 km h -1, the
ambulance helicopter must always be flown at appropriate altitudes, avoiding restricted
airspaces and flown as to minimise any sudden and dangerous manoeuvres. Landing zones
must be carefully chosen, away from roadworks and any objects that may pose a risk to the
rotors of the helicopter during landing or take-off. Approach speeds should be appropriate
as to delicately touchdown in a safe location. Pilot communication with other departments
and people on scene is crucial when the helicopter is required. Stunt-like behaviour is never
acceptable in the ambulance helicopter and safety is always the primary concern. The
ambulance helicopter is not to be flown in severe storms and is only to be operated when
required.

MISUSE OF AMBULANCE VEHICLES

Certain ambulance vehicles require certification and approval before their use. If you are
found to be misusing any ambulance vehicle, disciplinary action will be taken against you,
including removal of your vehicle privileges.

NSW AMBULANCE 10
 SOCIAL MEDIA

While on duty, the utmost professionalism is expected in all social media messaging. You
should always indicate clearly in your messages if you are writing on behalf of the EMS.

To help you on patrol, and to keep the city informed on the status of EMS, below are some
pre-written messages that you may use as a general guide or as an exact copy. Some
messages may need to be amended where necessary.

PATROLLING
> Los Santos
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling the ^6LOS SANTOS^0 area.
> Sandy Shores
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling the ^6SANDY SHORES^0 area.
> Paleto Bay
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling the ^6PALETO BAY^0 area.
> Los Santos & Sandy Shores
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling the ^6LOS SANTOS^0 & ^6SANDY SHORES^0 region.
> Los Santos & Paleto Bay
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling the ^6LOS SANTOS^0 & ^6PALETO BAY^0 regions.
> Sandy Shores & Paleto Bay
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling the ^6SANDY SHORES^0 & ^6PALETO BAY^0 region.
> All Regions
/twt ^3EMS^0 are ^2ACTIVE^0. Stay ^3HYDRATED^0 and wear a ^3HELMET^0. Currently
patrolling ^6ALL^0 regions.

NSW AMBULANCE 11
 RESEND PINGS
/twt ^3EMS^0 are working to ^2RESOLVE^0 all calls. Please ^6RESEND^0 your pings if you
still require assistance.

MULTIPLE CALLOUTS
/twt ^3EMS^0 are responding to ^6MULTIPLE^0 calls. Please ^2UPDATE^0 EMS if you no
longer require assistance. Number of active calls:^3 3

EMS ON DUTY
/twt ^3EMS^0 are working to ^2RESOLVE^0 all calls. We appreciate your patience in this
time. Number of EMS on duty:^3 1

EMS UNAVAILABLE

/twt ^3EMS^0 are currently ^6UNAVAILABLE^0. Please exercise ^3CAUTION^0 during this
time. EMS back in (minutes):^2 5

NSW AMBULANCE 12
 RADIO COMMUNICATION

While on duty, you are always required to be in the appropriate patrol room channel with
working communication equipment. You must use PTT transmission modes only and
observe correct radio procedures. You can only silence radio communications for a brief
period of time and when appropriate you should inform the network that you are doing so.
Given that the network we operate on is an open network that hosts both the police
department and EMS’ radio transmissions, strict discipline is required at all times. The
acronym SAD is particularly useful for ensuring good radio communication at all times.
S - Security
A - Accuracy
D - Discipline
Security means using the correct radio call-signs and response codes in conjunction with
limiting the amount of personal communication that is transmitted.
Accuracy refers to being succinct and specific about what you are trying to say. Say what
you need to say. Say it right. Say it swift.
Discipline means refraining from personal chatter at all times and not clogging the radio up
with unnecessary transmissions. It also means working with the other radio operators, not
against them.
Radio communication demands the highest level of formal communication, remember
everything you say is broadcast to the entire channel and is kept on record.

Disciplinary action will be taken against you for improper radio communication.

Whenever possible, you should communicate by radio when you:

o are responding to a call,
o have arrived on scene (to update dispatch with patient/scene details) and;
o when discharging/transporting a patient from the scene.

NSW AMBULANCE 13
 EMERGENCY CALLS

Whenever feasible and safe, efforts should be made to communicate with patients or
bystanders on scene that have requested the ambulance service. Particularly important is
knowing if the patient is breathing or if their airway is likely to become compromised.
Understanding the major injuries the patient is suffering from is also very important in
preparing the crew and prioritising an ambulance accordingly to the scene.
Consider also what vehicles and equipment may be required to treat/extract the patient
safely and effectively from the scene.
As a general guide, some pre-written response messages are given below. These can be
copied and pasted into the chat box for a quick response.

CALL RECEIVED. PARAMEDIC: Jack Hunter (1) Is the patient breathing? > > > > > > > (2) What
are the major injuries? > > > > > > > > AN AMBULANCE HAS BEEN ARRANGED FOR YOU.

NSW AMBULANCE SERVICE. --------------------- Is the patient breathing? --- What are the
injuries?

Professionalism and etiquette should be maintained at all times when communicating with
patients and the public while both on and off duty.

Sometimes the best thing a paramedic can do is to just be calm and provide an aura of
reassurance and faith for the patient and bystanders on scene.

NSW AMBULANCE 14
 RESPONSE CODES

To prevent ambiguity and miscommunication with police radio codes, EMS codes are always
introduced with the letter R (Romeo). You should get into the habit of using the phonetic
‘Romeo’ in your pro forma.

Romeo 0 – clear communications, urgent transmission

Romeo 1 – responding priority 1

Romeo 2 – responding priority 2
Romeo 3 – responding priority 3
Romeo 4 – arriving on scene
Romeo 5 - patient discharged at scene
Romeo 6 – returning to hospital with patient
Romeo 7 – returning to police department with patient
Romeo 8 – request additional: ambulance van
Romeo 9 – request additional: rapid response unit
Romeo 10 – request additional: ambulance helicopter

Romeo 11 – cardiac arrest

Romeo 12 – respiratory arrest / drowning / choking
Romeo 13 – gunshot wounds / stabbing
Romeo 14 – RTC / MVA
Romeo 15 – major burns
Romeo 16 – falls / broken limbs
Romeo 17 – suicide attempt
Romeo 18 – other injuries (describe)

NSW AMBULANCE 15
Romeo 21 – cannot find patient on scene
Romeo 22 – patient refusing treatment
Romeo 23 – patient sedated / restrained for treatment

Romeo 31 – patient discharged on scene

Romeo 32 – returning to hospital with patient
Romeo 33 – patient discharged from hospital
Romeo 34 – patient in police custody
Romeo 35 – travelling to police department with patient

Romeo 41 – returning to hospital to resupply

Romeo 42 – ambulance vehicle broken down
Romeo 43 – ambulance vehicle involved in RTC

Romeo 51 – expired life by injuries incompatible with life

Romeo 52 – expired life by exhaustion of resuscitation
Romeo 53 – expired life by active DNR order

Romeo 91 – police assistance required (non-emergency)

Romeo 92 – request fire brigade
Romeo 93 – request mobile mechanic / tow truck
Romeo 99 – EMS personnel injured
Romeo 100 – police assistance required (emergency)

NSW AMBULANCE 16
 RESPONSE PRIORITIES

Calls fall under 3 general response priority categories.

Priority 3 calls require no emergency lights or sirens response. These typically include
routine duties that have no immediate threat to life. These include incidents where the
patient is able to walk around and is not majorly distressed.

Priority 2 calls require lights with intermittent sirens. These typically include severe injuries
but no immediate threat to life. These include incidents where the patient is able to walk
around but in a distressed state.

Priority 1 calls require lights and sirens. These typically include immediate threats to life.
These include incidents where the patient is incapacitated or the state of the patient cannot
be confidently determined.

IMPORTANT NOTE
ELS response may be affected by other problems/complications. If an individual is
incapacitated or their current state is unknown, EMS are to respond priority 1.
If an individual is known to not be incapacitated, paramedic discretion may be used to
downgrade the response to priority 2 or 3.

NSW AMBULANCE 17
 STAGING

Staging is an important process in scene preparation and medical response. EMS should
always stage at a safe distance away from any potentially hostile scene until they are
confident it is safe to approach and treat the patient. EMS should liaise with POL to ensure
scene safety at all times and may request an escort during patient treatment. If at any point
you feel genuinely unsafe, you are permitted to secure your own safety regardless of the
severity of the patient you are dealing with.

EMS should not attempt to become conflictive or aggressive towards any bystander or
patient. You should not retaliate in any way that may aggravate the situation.
You must abide by all reasonable requests made my the police. If they tell you to move back
or to move to a specific location you must oblige.

The more dangerous the scene, the farther away the staging distance must be. For very
small threats, it is sometimes appropriate to remain only several metres away while the
situation is being diffused. For more severe threats such as an active shooter situation or
bank heist you are always to remain at least 1 full block’s distance away from the scene.
Always consider the potential that the threat may become mobile and you should have
adequate cover and concealment if the assailant/danger was to head in your direction.

Consider having the patient brought away from the hostile area to your location. If that is
not possible, you must be given police clearance before attempting to enter any scene that
has contained a recent threat.
If a more senior paramedic advises that you increase your staging distance or tells you to
relocate to a specific position, you must oblige as long as that new location is appropriately
safe.

NSW AMBULANCE 18
 HOSPITAL TREATMENT

Hospital treatment is ultimately at the discretion of the paramedic in charge of the patient.
When confident, paramedics should consider assuming the role of an attending doctor at
the hospital and give a rough treatment plan to the patient.
Paramedics however are not obliged to carry out such proceedings and may instead leave
the patient at A&E to been seen by a doctor in their own time. In this instance, the patient is
free to discharge themselves from hospital at their own liberty instead of having to be
cleared by the acting doctor on site.

It is to be noted that the best care can be given at the city’s hospital rather than the 2 other
regional hospitals. Oftentimes, critical patients will need to be transported to the city
hospital for treatment even if it is farther away due to the critical nature of their injuries.
Operating theatres and treatment rooms are available and open 24/7 at the city hospital.
All critical injuries should be endeavoured to be treated further at a hospital but
unfortunately this is not always viable. In these instances, paramedics should inform the
patient that they should make their way to an A&E in their own time within a 24 hour
period.

NSW AMBULANCE 19
 LIAISON WITH POLICE

EMS and POL require good interdepartmental relations in order to operate effectively and
safely. EMS should always be respectful to police officers and should treat higher ranks in
the police department in a similar manner as higher ranks in the EMS department.
If you disagree with a member of POL, be respectful and explain why you do not agree.
Actively work to avoid conflicts and if you cannot diffuse the situation, ask them to take it to
a helpdesk. Similarly, if you believe a member of POL is being untoward with you, follow the
same protocol as ‘Allegations Against EMS’ and remain respectful while you seek
administration help.

Remember, as far as medical proceedings go, EMS have a duty of care and give the final
word on patient treatment. EMS should always cooperate with POL when on scene to best
understand what has occurred and the treatment plan for any patients.
Although POL are usually higher priority patients on a scene, they still fall under the same
treatment process as any other patient. Oftentimes, POL will be wearing PPE which may
reduce the severity of their injuries but discretion needs to be taken as to the survivability of
all POL patients.

NB: being fair in treatment to all parties is an important part of the job.
You should not become biased in your treatment of certain individuals or groups. If
somebody disagrees with your course of treatment but you believe you are giving the
correct treatment then stick with your decision.

NSW AMBULANCE 20
 AMBULANCE INVOLVED IN RTC

NOT RESPONDING TO A CALL

If you are not responding to a call, you are subject to all normal road rules and regulations.
If you are involved in an RTC, whether you are at fault or not, you are required to pull over,
exchange details and if required – contact police. You are held accountable for the safe
handling of your vehicle at all times and due diligence should be taken always to prevent an
incident occurring.
If you are found to have taken necessary precaution to avoid an incident, or the other driver
is deemed at fault then you will not face any further action.

WHILE RESPONDING TO A CALL

If you are involved in an RTC while responding to a call you are still required to pull over and
exchange details with the other driver. If required, contact police to assist with the
situation. Every effort should be made to ensure another EMS vehicle takes over your call
response so you can deal with the RTC.
However, if you are responding to a high priority call and the RTC is extremely minor (i.e. a
minor scrape or glance), it is your discretion whether or not you choose to quickly speak to
the driver of the other vehicle before continuing your response (with the potential to return
afterwards to sort out any further details).
Ensure you give the driver your full name and call-sign so they can follow the situation up if
they so wish.

Remember, ambulance vehicles are much more likely to be involved in RTCs and it is
recommended that you always save dashcam and bodycam footage to protect yourself
when out on the road. Most often, the ambulance vehicle is not at fault but remember to
stay respectful and work with the other driver, not against them.

NSW AMBULANCE 21
 ALLEGATION AGAINST EMS

It is always recommended that EMS use recording devices and body cameras to document
their time on duty. This is the best precaution you can take to protect yourself and other
individuals when operating in the city.

However, this protection means nothing unless you are ensuring that you conduct yourself
in an appropriate manner at all times.

In the rare event that you are accused of malpractice, be sure to save any documentation
you have of the incident and deal with the situation appropriately. If you are truly innocent
then you have nothing to worry about, so remember to stay calm, don’t act out hastily or
make any rash decisions. Stay professional and respectful, direct the individual to an admin
or EMS administration/cabinet with their complaint and try not to discuss the issue further.

Remember: there are avenues in place for individuals to submit reports to EMS and POL
administration.

If appropriate, you may wish to clarify your decisions and reasoning behind them but if the
individual does not seem to care for your deliberations: cease communication and await
further investigation by staff.
Reassure yourself that EMS can only work with the information they are provided and that if
you did not do anything wrong, you have no reason to worry.

It is not worth getting angry or upset.

NSW AMBULANCE 22
 FIRST PROTOCOL

Before arriving on scene, you should use all current knowledge of the situation to prepare
yourself and your crew. If there is a potential for hostile presence at a scene, you should
always liaise with police and ensure scene safety before entering.
When possible, especially for long-distance callouts, you should endeavour to extract
information from the patient/bystanders about the patient’s status and scene safety.
Most importantly: is the patient breathing? What are the major injuries?
The acronym DRSABCD (‘doctor’s ABCD’) gives you a skeleton to work from when assessing
the critical nature of patients. At all times and in any situation you should follow this order
of protocol when dealing with a patient on-scene.
D – Danger
R – Response
S – Send for Help
A – Airway
B – Breathing
C - Cardiopulmonary Resuscitation (CPR)
D – Defibrillation

Danger includes identifying the potential threats for further injury to the patient, yourself or
bystanders. You should always look to remove potential danger or attempt to
isolate/mitigate it.
Response means checking for verbal or physical (deliberate or reflex) communication from
the patient.
Send for help (from a paramedic’s point of view) means calling for additional EMS
crew/utilities where required. Rapid response units may require an ambulance to transport
patients to hospital.
Airway requires checking for an obstruction and maintaining an active and functioning
airway. It also means taking precautions to prevent the airway from becoming
compromised.
Breathing means checking whether or not the patient is breathing sufficiently. If the
patient’s breathing is too infrequent or they are not breathing at all, proceed with the
successive stages; otherwise maintain their condition and treat for injuries.

NSW AMBULANCE 23
CPR entails the standard 30 compressions followed by 2 breaths (oxygenation) at a rate of
approximately 100-120 BPM. Compressions should be sufficiently deep (⅓ the way into the
chest cavity). Take note of the differences in CPR technique for infants (under 1 year),
children (1 to 8 years) and adults.
Defibrillation means using an available defibrillator to assist with CPR and, if the rhythm is
right, provide an electrical charge across the heart to return the electrical rhythm back to
normal. In the field this is usually done with an AED which will automatically check the
patient’s electrical activity to see if it is a shockable rhythm.
Generally, (AED will prompt also), a rhythm check will need to be conducted every 5 cycles
of CPR to see if the heart can be defibrillated.

NB: Defibrillation cannot restart a stopped heart. Arrhythmia in the heart’s beating is
caused by mistiming of the electrical signals by the SA node. Defibrillation shocks the heart
and stops it for a breath period, allowing the SA node to essentially recalibrate and
hopefully return a successful rhythm.
‘Flat-lining’ is not a shockable rhythm and CPR is the main course of treatment.

RECOVERY POSITION

Less-utilised by paramedics, and more-so aimed at citizen first aiders. To be used when the
patient is breathing but usually unconscious. Does not matter a great deal which way you
roll the patient.

1. Place the person’s arm that is furthest from you at a right angle to their body, so that
it is bent at the elbow with the hand pointing upwards.
2. Now place the back of their uppermost hand onto their opposite cheek.
3. Roll them to your front, supporting their shoulders and buttocks.
4. Move their rearmost leg up and in front of them for extra support (it will look like
they’re in a sleeping position).
5. Gently raise their chin to tilt their head back slightly, as this will open up their airway
and help them to breathe. Check that nothing is blocking their airway – if it is,
remove it either with their fingers or yours.

From here, maintain a clear airway and make sure they are breathing.

NSW AMBULANCE 24
NSW AMBULANCE 25
 CPR FOR INFANTS (UNDER 1 YEAR)

CPR FOR CHILDREN (1 to 8 YEARS)

NB: Children under 8 years of age may require only one hand for ⅓ chest compression
depth.

NSW AMBULANCE 26
 CHECKING VITALS

BLOOD PRESSURE
BP is expressed as a measurement with two numbers, with one number on top (systolic) and
one on the bottom (diastolic), like a fraction. For example, 120/80 mm Hg.
The top number refers to the amount of pressure in your arteries during the contraction of
your heart muscle. This is called systolic pressure. The bottom number refers to your blood
pressure when your heart muscle is between beats. This is called diastolic pressure.
Both numbers are important in determining the state of the patient’s heart.
Numbers greater than the ideal range indicate that your heart is working too hard to pump
blood to the rest of your body. Conversely, massive blood loss would correspond to a drop
in blood pressure.

For a normal reading, your blood pressure needs to show a top number (systolic pressure)
that’s between 90 and less than 120 and a bottom number (diastolic pressure) that’s
between 60 and less than 80.

You’ll generally be diagnosed with high blood pressure if your systolic blood pressure
reaches between 130 and 139 mm Hg, or if your diastolic blood pressure reaches between
80 and 89 mm Hg. This is considered stage 1 hypertension.

Stage 2 high blood pressure indicates an even more serious condition. If your blood pressure
reading shows a top number of 140 or more, or a bottom number of 90 or more, it’s
considered stage 2 hypertension.

NSW AMBULANCE 27
Patients should seek emergency treatment if they have blood pressure in abnormal ranges,
which may accompany symptoms such as:

o chest pain
o shortness of breath
o visual changes
o symptoms of stroke, such as paralysis or a loss of muscle control in the face or an
extremity
o blood in your urine
o dizziness
o headache

However, sometimes a high reading can occur temporarily and then the patient’s numbers
will return to normal.

HEART RATE

A normal resting heart rate for adults ranges from 60 to 100 beats per minute.

Generally, a lower heart rate at rest implies more efficient heart function and better
cardiovascular fitness. For example, a well-trained athlete might have a normal resting heart
rate closer to 40 beats per minute.

Keep in mind that many factors can influence heart rate, including:
o age
o fitness and activity levels
o being a smoker
o having cardiovascular disease, high cholesterol or diabetes
o air temperature
o body position (standing up or lying down, for example)
o emotions
o body size
o medications
Heart rate is generally raised during traumatic experiences due to the rush of adrenaline
coursing through the body. High heart rates can be dangerous as they impose stress on the
heart.

NSW AMBULANCE 28
 DIFFICULT PATIENT

Your safety, and bystander’s, is the most important part of any emergency response. If at
any time you feel like there is a threat to life or chance of injury – STOP.

Contact police who will ensure scene safety while you continue your duties.
Remember, no matter how life-threatening the patient’s condition, your safety comes first.
If you need to leave the scene to ensure your safety then do so immediately.
Wait until police have gained control of the situation and cleared you to re-enter before
returning to the scene.

REFUSAL OF TREATMENT
Patients reserve the right to refuse treatment by EMS.
No matter the condition of the conscious patient, if they are self-aware and acknowledge
the risks associate with refusing treatment: they can do so. Know that you gave them every
opportunity to be treated but they chose to decline that option.
However, if the patient goes unconscious and is unable to declare refusal of treatment you
must give medical treatment. Treat every unconscious patient as if they wish to be treated
by paramedics (excluding active DNR orders).
The exception from patients being able to refuse treatment occurs when a qualified
physician instructs you that the person requires forceful treatment against their own wishes
in the interest of that patient’s health. In these cases, security or police will restrain the
patient and administer a sedative if necessary so you can proceed with the medical
examination.

PATIENT IN POLICE CUSTODY

If a patient in police custody refuses treatment by EMS, you must oblige. However, this does
not mean that the suspect will avoid incarceration by police. It is your duty, if the wounds
are survivable, to work with the police to get the patient up and on their feet so they can be
detained.

NSW AMBULANCE 29
 LIFE EXPIRED

Appropriate efforts should be taken such that all resuscitation attempts continue until the
patient is delivered to a hospital and 2 attending doctors both can confirm the patient as
deceased.
However, sometimes resuscitation attempts may be ceased in the field and consequently the
patient will be classified as deceased.

There are 3 occasions this may occur.

1. The patient is in cardiac arrest and has an active ‘Do Not Resuscitate’ order.

2. The patient has injuries incompatible with life. Resuscitation attempts are deemed
futile and not performed.

3. Resuscitation attempts are fully exhausted. Crew on scene are unable to physically
continue resuscitation efforts on the patient.

Time of expired life should be taken and details of the scene and patient should be sent to
the Coroner’s office.

NSW AMBULANCE 30
 RTC / MVA

Road Traffic Collisions (RTCs) or Motor Vehicle Accidents (MVAs) can vary greatly in terms of
severity. Upon arrival at an RTC, communicate with bystanders to see if POL assistance is
required. If appropriate, the fire brigade may need to be arranged to help with the retrieval
of patients from vehicles and they should work with POL to make the roadway safe for EMS
to do their job.
If there are numerous patients or vehicles involved in an RTC it is always best protocol to
request police assistance as well as additional EMS to help with patient treatment.
Injuries that may be associated with RTCs are extreme traumas which may include massive
haemorrhaging, internal bleeding, severe lacerations, severe concussions and spinal injuries.
You should always minimise the movement of patients involved in an RTC until you are fully
confident they do not have a spinal condition. Pain down the sides of the neck usually is
associated with injured muscles in the neck whereas pain in the back of the neck or spine
usually indicates something more serious.

Remember to stay calm when dealing with patients and to constantly reassure them. Always
treat the most serious patients first and remember it is good practice to check in on everyone
involved, no matter if they think they are uninjured. The shock and adrenaline from the
incident may mean they are unaware of underlying injuries.

When multiple emergency workers are on the same scene, an incident commander should be
delegated to oversee the situation and all personnel involved.
If available, a prehospital ultrasound is a great tool in identifying potential internal bleeding
or spinal misalignments. Always check RTC patients for concussions (especially if they lost
consciousness) and monitor their health.

NSW AMBULANCE 31
 ANAPHYLAXIS

Anaphylaxis is a potentially life threatening, severe allergic reaction and should always be
treated as a medical emergency. Anaphylaxis occurs after exposure to an allergen (usually to
foods, insects or medicines), to which a person is allergic. Not all people with allergies are at
risk of anaphylaxis.

SYMPTOMS
o Difficult/noisy breathing
o Swelling of tongue
o Swelling/tightness in throat
o Difficulty talking and/or hoarse voice
o Wheeze or persistent cough
o Persistent dizziness and/or collapse
o Pale and floppy (in young children)
o Swelling to face, eyes, lips
o Hives or welts
o Abdominal pain / vomiting

TREATMENT

1. Lay the person flat

2. Give epinephrine (adrenaline) with an epipen (epinephrine autoinjector)
3. Monitor their condition
4. Establish and maintain an airway
5. Oxygenate
6. Take to hospital

NSW AMBULANCE 32
 ANIMAL ATTACK

If the threat is still active, liaise with police or another appropriate department to ensure
scene safety. You are not permitted under any circumstances to carry a weapon with you. If
the scene becomes hostile during treatment, leave the area and request appropriate
assistance.

Animal attacks can include bites, lacerations and other traumatic wounds. The standard
treatment for injuries remains the same with an emphasis on sterilising the affected area,
cleaning the wound and getting them to hospital so they can be given the correct
medication to prevent further illness.

Human bites also follow the same medical procedure as dangerous bacteria can cause
further health problems for the patient.

It is important you let the patient know the value of seeking further medical attention at a
hospital to ensure their immune system is not compromised later on.

NSW AMBULANCE 33
 BURN / SCALD

With all hot burns, cool the affected area, clean and then bandage the site of the burn. Burns
caused by wet heat such as steam are called scalds.

First degree burns, or superficial burns, are minor and do not require hospital treatment –
often red and unblistered. Run the affected area under cold water for ~15 minutes and
remove any jewellery. Cool to prevent further damage.
Second degree burns extend beyond the outer layer of the skin and often form blisters.
Antibiotic creams and pain relief may be required but can often be treated out of hospital. If
there are signs of infection or the burn occurs in a sensitive area, take them to hospital.
Third degree burns go the full thickness of the skin/tissue and destroy nerve endings which
means the patient won’t actually feel much pain. They often look black, brown or leathery.
Chemical burns should be washed with water and any affected clothing is to be removed.
PPE and safe protocol for chemical burns – remember waste water is also dangerous. Do not
clean chemical burns with an acid or base as the reaction can create even more heat. If they
are burned by something (like an alkali metal) which reacts and heats by water, then brush
off first and use high-pressure water to eject leftover material. You can test with litmus
paper to see if the site is neutral enough.
Electrical burns usually have a small entrance and exit arc burn but they will have internal
injuries so treat accordingly. If they are struck by lightning, they are more likely to die by
cardiac arrest than their burns so treat accordingly.

Hyperextension of limbs is recommended as there is a chance of constriction creating poor

blood flow to the limbs.
Give oxygen. Clean wounds. Give fluids intravenously. Burnt limbs should be splinted. Avoid
using creams as they inhibit assessment of the burn later.
Rinse burns under cold water for ~15 minutes but then only use gel pads (and no water) to
ensure you do not promote hypothermia. Drape a space blanket over the patient.

Give adequate morphine and ensure the airway is protected as most fire-related burns will
also suffer airway problems and spasms which can shut off their airway and breathing.
Ketamine is a popular replacement for morphine for its strong pain relief and minimalistic
compromise to the cardiopulmonary system.
Do not peel off things that become stuck to the skin, just cool them off. If needed, you can
insert IVs through burned areas.
When a significant percentage of the skin is destroyed, patients will struggle to retain their
own heat properly. Use dry dressings (not wet) to slow the onset of hypothermia.

NSW AMBULANCE 34
 CARDIAC ARREST

A cardiac arrest happens when someone’s heart stops pumping blood around their body.
They will lose responsiveness almost immediately and show no other signs of life, such as
breathing or movement.
Acting fast is the most important thing. If CPR and an AED can be administered within 5
minutes of the arrest, the patient’s chance of survival can be increased by as much as 70%.
The standard chance of survival for a cardiac arrest is as little as 10%.
Once the airway is secured, compressions and defibrillation is the main course of treatment
for a cardiac arrest and should not be stopped until arrival at a hospital. People should take
shifts in administering CPR as detailed under the First Protocol. With one person on
oxygenation and another on compressions, a third may wish to treat any other major
injuries such as major blood loss etc. Epinephrine (adrenaline) is often injected to help
encourage proper heart function.

NB: defibrillation can only work to restart a misfiring heart. If the patient’s ECG shows flat-
lining then the AED will not help and is not to be used (it will tell you this automatically). CPR
is still to be conducted.

If breathing is restored, cease CPR and monitor the patient. If they relapse into cardiac
arrest, repeat the resuscitation efforts.

In the most severe cases of a cardiac arrest, a field or emergency thoracotomy may be
performed by a confident and qualified paramedic. In a thoracotomy, a large incision is
made across both sides of the breast of the patient, down towards the shoulders in the 5th
intercostal space (between 2 ribs). Retractors are then used to create an opening between
the ribs and a Gigli saw is used to cut through the sternum. Once the chest cavity is open,
the pericardium (lining of the heart) is cut along the median of the body and the heart is
able to be examined and directly massaged (as replacement of compressions). A
thoracotomy also allows inspection and haemorrhage control of other vital organs and
treatment of internal bleeding.

NSW AMBULANCE 35
 CHEMICAL ATTACK

STOP. With a chemical attack, the main priority is to secure the scene before anybody is
allowed to enter. Strong liaison with the POL and the fire brigade is crucial in declaring the
scene safe or extracting the patients from the scene. Never attempt to approach a chemical
attack without all appropriate PPE and having been checked over by another emergency
worker. If a terrorist incident, stage far away from the scene until POL also confirm the
scene is no longer under further threat.

Whenever possible, have trained personnel bring the patients out of the chemical-affected
area and treat them while wearing full PPE.

Knowing what chemical was used is crucial to best treating the patient. Work with the
poisons and chemical centre to work out a treatment plan for patients exposed to a
chemical.

Rudimentary treatment consists of washing the patient down with copious amounts of
water and avoiding any chemical spill off. Airway compromise is the biggest threat in a
chemical attack so ensure you maintain the airway and monitor the patient’s status
throughout.

NSW AMBULANCE 36
 DENTAL

Dental and oral injuries are not uncommon and, although not usually too serious on their
own, can be associated with other more serious injuries. Oral injuries also create the risk of
the airway becoming compromised from bleeding and tongue/dental debris.

Always treat the airway danger first.

The main priority is to maintain an active airway. This means putting the patient in the
recovery position and applying firm pressure to any haemorrhaging areas.

TEETH
However, the correct first aid can potentially save someone’s tooth.
If there are no serious injuries then you can focus on saving the patient’s teeth. Removed
teeth should be handled by the crown rather than the root. Get the patient to suck the
tooth clean and try to replace the tooth in the patient’s gum to preserve the root. Put a foil
splint over the tooth and ask them to bite down gently on it. Then seek a dentist within 30-
60 minutes for a chance to save the tooth.
If the patient is unable to assist, place the tooth is a small amount of milk.

NSW AMBULANCE 37
 DROWNING

There are 2 major types of drowning. Dry drowning and wet drowning.
Dry drowning occurs when the airway spasms and contracts before water enters the lungs.
The patient then asphyxiates as air cannot enter the lungs to recycle the oxygen in the
blood.
Wet drowning occurs when water enters through the airway and into the lungs. With the
lungs filled with water, air cannot recycle the oxygen in the blood and the patient will die
from anoxia-related injuries (absence of oxygen).
Secondary drowning is a colloquial term to describe drowning symptoms that occur a period
of time after a person has been exposed to water. Even small amounts of water entering the
lungs can cause drowning and can be fatal.

SYMPTOMS
Symptoms of drowning may begin up to 24 hours after water exposure. They include:
o Constant coughing
o Chest pain
o Trouble breathing
o Decreased energy
o Extreme fatigue (feeling tired or sleeping more than normal)
o Change in behaviour, such as being fussy or irritable

The underlying cause of wet drowning is pulmonary edema. This is a medical condition in
which water irritates the lungs and makes it hard to breathe.

ALTERATION TO ABC
Since the majority of drowning victims will suffer from ventilation issues rather than cardio
problems, it is recommended that 5 rescue breaths are given before commencing the usual
30:2 CPR procedure.
Time is crucial to determining survivability in drowning. A patient may have less than ~5
minutes before brain damage occurs and less than ~10 minutes before they are no longer
able to be resuscitated.
Your safety is paramount. Do not enter the water without proper PPE and/or diving
equipment.
If breathing is restored – treat the patient for hypothermia.

NSW AMBULANCE 38
 EPILEPSY / SEIZURE

A seizure is a sudden surge of electrical activity in the brain and usually affects how a person
appears or acts for a short time. Epilepsy is a common condition of the brain in which a
person has a tendency to have recurrent unprovoked seizures.
Safety precautions should be sensible and relevant to the person, with a balance between
risk and restrictions.
Typical causes of a provoked seizure include: head trauma, poisoning, chemical imbalances,
drugs, infections of the brain, high fevers and flashing lights.
A tonic-clonic seizure is where the body stiffens and muscles often jerk.

TREATMENT
o Stay calm and remain with the person
o If they have food or fluid in their mouth, roll them onto their side immediately
o Keep them safe and protect them from injury
o Place something soft under their head and loosen any tight clothing
o Reassure the person until they recover
o Time the seizure, if you can
o Gently roll the person onto their side after the jerking stops
o Do not put anything into their mouth or restrain or move the person, unless they are
in danger

NSW AMBULANCE 39
 FALL

The 50/50 rule generalises that a fall from ~50 feet (4 storeys) gives a patient roughly ~50%
chance of surviving. Survival is only defined here by the continuing ability to ventilate and
having an active heart rhythm. However, the patient may become paralysed or enter a
vegetative state.

Falls often produce immense traumatic injuries with major blood loss, internal bleeding and
have the high possibility of injuries being incompatible with life.

An assessment of the most life-threatening injuries should take place and an appropriate
action plan created. Minimising movement can help prevent the chance of paralysis for the
patient.

NSW AMBULANCE 40
 FRACTURE / DISLOCATION

Dislocation occurs when your bone slips out of its receptive joint. A fracture (broken bone)
is when the continuity of your bone is broken.

SYMPTOMS
o severe pain
o immobility in area
o apparent deformation
o visible bone
o swelling / bruising
o audible noise / cracking / grinding
o numbness
o bleeding

TYPES OF FRACTURE
o stable fracture (line up and are only slightly out of place)
o open / compound fracture (bone pierced skin)
o closed / simple fracture (bone has not pierced skin)
o complicated fracture (damage to surrounding structures also)
There are many other fracture types but they are unable to be distinguished with pre-
hospital checks and are non-essential to first responder treatment.

TREATMENT
Dislocation: support and immobilise, apply cold compress, take to hospital. If manageable
and non-complex, straighten the limb to realign the bone into place (pop back into place)
and then splint for transport to hospital.
Fracture: haemorrhage control, immobilise and splint the limb/area, apply cold compress,
treat for shock, take to hospital.

NSW AMBULANCE 41
 FROSTBITE

Frostbite occurs when skin tissue freezes after exposure to cold weather.
The extremities, such as the hands and feet, are at greater risk because they are more
susceptible to heat loss as blood is constricted back towards the internal organs to retain
the body’s core temperature.

SYMPTOMS
o Cold, white and hard skin
o Pain
o Itching
o Loss of feeling in the affected area
o Mottled skin
o Swelling and blistering
o The skin becomes red and blotchy when warmed
o Tissue loss, depending on the severity of the frostbite

SEVERE CASES
If the fluid inside blisters is clear, then a full recovery is likely. However blood-filled blisters
signal damage to the deeper tissues.
Typically, the affected skin becomes hard and black. This is called dry gangrene. Wet
gangrene, where the skin looks soft and grey, can also occur.

TREATMENT
o Seek shelter and reduce further exposure to the cold and wind
o Remove any wet or restrictive clothing and replace with dry clothing wherever
possible
o Wrap the person in blankets and warm the person’s entire body
o Do not rub the affected area
o Do not expose the person to direct radiant heat such as a fire
o Do not attempt to thaw affected part if there is a chance of it being refrozen
o Do not break blisters

NSW AMBULANCE 42
 GANGRENE

Gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood
supply due to an underlying illness, injury, and/or infection. Fingers, toes, and limbs are
most often affected, but gangrene can also occur inside the body, damaging organs and
muscles.

There are 2 main types of gangrene: dry and wet.

Dry: usually affects hands and feet. Develops due to impaired blood flow to the area. The
tissue dries up and becomes brown, purple, blue or black in colour and falls off. Infection is
typically not present.
Wet: almost always involves infection. Usually a result of burn or trauma injuries. Blood
supply is cut off to an area causing rapid death and increased risk of infection. The tissue
swells and blisters and excretes pus (wet).
Important: wet gangrene can also occur inside the body, blocking blood flow to organs
(internal gangrene).

SYMPTOMS

DRY
o Dry and shrivelled skin that changes colour from blue to black and eventually sloughs
off
o Cold and numb skin
o Pain may or may not be present

WET
o Swelling and pain at the site of infection
o Change in skin colour from red to brown to black
o Blisters or sores that produce a bad-smelling discharge (pus)
o Fever and feeling unwell
o A crackling noise that comes from the affected area when pressed

NSW AMBULANCE 43
 TREATMENT
Treatment for gangrene involves removing the dead tissue, treating and preventing the
spread of infection, and treating the condition that caused gangrene to develop. The sooner
the patient receives treatment, the better their chance of recovery.

Patients should be sent to hospital.

Giving intravenous fluids, pain medication and monitoring their vital signs is important.
Severe cases of sepsis can lead to cardiac arrest.

NSW AMBULANCE 44
 GUNSHOT WOUND / STABBING

Always ensure scene safety through liaison with police. If there are GSWs and you are
unsure if the assailant is still in the area, contact police for security. Do not enter an active
shooter situation or attempt to enter any GSW scene until cleared by police.
GSW: Quite easy to identify. Often accompanied by massive haemorrhaging with serious
potential for damage to internal structures. Often circular entry wound, sometimes exit
wound (not always bigger than entry).
STABBING: Obvious laceration with potential for mass haemorrhaging (not always).

TREATMENT

If possible, elevate injured limb above heart and immobilise. Treat haemorrhage and
compress with sterile bandaging. Ensure semi-successful circulation in limb. Apply
tourniquet. If wound in chest, create airtight seal to prevent development of a collapsed
lung.
Transport to hospital as quickly as possible. Haemorrhage control is vital for survival success
as well as maintaining cardiopulmonary activity.

SURVIVABILITY
Survivability of GSWs and stabbings depend on a number of factors. When assessing the
chance of survival you must consider all of the following:
1. Where was the patient shot/stabbed?
2. How many times was the patient shot/stabbed?
3. What calibre/blade-length was the patient injured with?
These conditions apply to both POL and civilian personnel. You cannot be biased in your
treatment of patients and ultimate discretion is left to the attending paramedic. You should
utilise all information accessible as to whether or not a person’s wounds are survivable.
Making the decision regarding a patient’s survivability is not an easy task and is one that
comes with experience. You must ensure that you endeavour to find a balance between
realism and creating a positive experience for all individuals involved. As a general guide…
Survivable wounds: flesh-wounds/grazes to outer areas, lower-leg, foot, hand, buttocks.
Less-survivable wounds: outer thigh, shoulder.
Least-survivable wounds: inner (medial) thigh, neck, head, chest, back, abdomen/stomach.
Remember to take into account the weapon and the number of injuries sustained. Any
patient with multiple ‘high-risk of death’ injuries are not survivable.

NSW AMBULANCE 45
 HEAD TRAUMA

Trauma to the head can lead to a number of obvious and hidden injuries and complications.
Head trauma can result in haemorrhaging, concussion, brain damage, paralysis, spinal
complications, internal bleeding and more.

CONCUSSION
Check the patient’s mental awareness. Check their eyes for visual stimulation response. A
good response is symmetrical dilation of the left and right pupil when you shine your light
past them. Watch them for vomiting and their airway becoming compromised.
Keep the patient awake so you can continue to monitor their mental awareness. Ask them
questions to gage their level of understanding and if they are lucid. Be aware that symptoms
may develop over time and can sometimes take weeks to recover.
Questions can include:
o What is your name?
o Who am I?
o What day is it?
o Where are you?
o Do you remember what happened?
Memory loss, nonsensicality, and lack of awareness are common with severe concussions.
Treatment includes: mild painkillers, no food/drink until checked by doctors, anti-nausea,
take to hospital.

BLEEDING FROM EAR

Can indicate fractured skull or more serious injury.
Do not plug the ear. Allow fluid to drain down with ear-side faced down to the ground.
Transport to hospital and monitor vitals.

FOREIGN OBJECT IN EAR / EYE

Do not remove. Immobilise. Take to hospital.

NSW AMBULANCE 46
 HEAT STROKE / DEHYDRATION

Heat stroke is the more severe case of heat exhaustion. Heat stroke occurs when the body
cannot give off more energy than it is receiving from the environment causing the internal
body temperature to rise to dangerous levels. Heat stroke occurs at 40°C or higher.

SYMPTOMS
o Feeling hot
o Headache
o Feeling dizzy or light-headed
o Severe thirst
o Extreme tiredness and weakness
o Pale, cool or clammy skin, which may later become red or flushed
o Muscle cramps (often affecting the calves and toes)
o Nausea and vomiting

TREATMENT
o Go to a cooler area right away - somewhere indoors or in the shade, preferably with
circulating air (from a fan or breeze)
o Lie down and rest with your legs higher than your head
o Remove any excess clothing and loosen tight clothes
o Sponge or spray your body with cold water and fan your skin
o Slowly sip cool water or other fluids, or suck on ice chips
o Gently stretch any muscles that are cramping
o If required: give intravenous fluids

People with heat stroke must be taken to a hospital.

DEHYDRATION
Often much less severe than heat stroke. Treatment follows much of the same suit but
requires more intake of water to rehydrate the patient.

NSW AMBULANCE 47
 HYPOGLYCAEMIA / DIABETES

Diabetic individuals suffer from hypoglycaemia. Referring to low blood sugar,

hypoglycaemia is often caused by too much insulin, missing meals, not eating enough
carbohydrates and engaging in unplanned physical activity. Like many medical conditions,
the risk increases with alcohol consumption.
If you are unsure if the patient is suffering from hyperglycaemia or hypoglycaemia and do
not have a BGL device, treating as per hypo will not significantly impact the patient if they
are actually hyperglycaemic.

SYMPTOMS
o Shaking, trembling or weakness
o Sweating
o Paleness
o Hunger
o Light headedness
o Headache
o Lack of concentration/ behaviour change
o Confusion
o Slurred speech
o Not able to drink or swallow
o Seizures

TREATMENT

o If available, check BGL to see if hypoglycaemic and not hyperglycaemic

o Use your hypoglycaemia kit and give oral candies / sugars
o Give them carbohydrate rich foods such as: pasta, bread, milk, fruit
o Monitor the patient’s blood glucose levels to see if they rise
o If patient’s condition does not improve, take to hospital

NSW AMBULANCE 48
 HYPOTHERMIA

Hypothermia is a medical emergency that occurs when your body loses heat faster than it
can produce heat, causing a dangerously low body temperature. Normal body temperature
is around 37°C. Hypothermia occurs when your body temperature falls below 35°C. Severe
hypothermia is life-threatening without prompt medical attention.

SYMPTOMS
o Shivering
o Slurred speech or mumbling
o Slow, shallow breathing
o Weak pulse
o Clumsiness or lack of coordination
o Drowsiness or very low energy
o Confusion or memory loss
o Loss of consciousness
o Bright red, cold skin (in infants)

Individuals suffering from hypothermia are generally not aware of their condition as
symptoms can take a while to present themselves. Additionally, they may also become
confused and lethargic.
Hypothermia can be caused by any activity or exposure that would compromise their body’s
ability to stay warm enough to function properly. Being wet makes the patient extra prone
to developing hypothermia as heat is more rapidly lost to the environment.

TREATMENT
o Remove any wet clothing
o Move the patient into the warmth of an ambulance or some other area
o Dry the patient off if wet
o Use a space blanket to retain their body heat
o Monitor the patient’s airway and vitals
o
Be prepared to performing resuscitation.

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 INTOXICATION

ALCOHOL
Alcohol poisoning is what happens to someone when they’ve drunk a dangerous amount of
alcohol, normally in a short space of time.
Drinking too much alcohol stops the nervous system from working properly, particularly in
the brain. This can severely weaken the mental and physical body functions, like sight,
speech, coordination and memory.
Alcohol poisoning can also send a person into deep unresponsiveness and, at worst, can slow
or even shut down their breathing, causing death.

TREATMENT
o Reassure them and cover them with a coat or blanket to keep them warm
o Check them over for any injuries, especially head injuries, or any other medical
conditions
o If they are breathing normally but are not fully responsive, place them into the
recovery position
o Keep checking their breathing, level of response and pulse
o Don’t make them be sick as this could block their airway and stop them from
breathing

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 NEEDLESTICK

Syringes and needles have the potential of spreading bloodborne illness to a patient unlucky
enough to be pricked by a used, unsanitary needle.

Blood-borne diseases that could be transmitted by a needlestick injury include human

immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV). There is also the risk
of contracting tetanus.

TREATMENT

Thoroughly wash the wound with soap and water, and take the patient to the nearest
emergency department or hospital as soon as possible. Apply an antiseptic.
Reassure the patient that the risk of disease transmission is low, however they do need to
go to a hospital for blood checks and boosters.
If any contents are on the skin/body, wash copiously with water.

The patient will then have to wait for the results of the blood checks to see if they have
contracted any bloodborne illness from the needlestick injury.

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 OVERDOSE

Almost any drug taken in excess can cause a person to suffer the effects of an overdose.
Some prescribed medicines and recreational drugs taken in excess or without medical
supervision can prove fatal unless prompt care is available.
The effects of any drug will vary depending on the nature of the substance

SYMPTOMS
o Drowsiness, loss of coordination and collapse
o Confusion or hallucinations
o Altered breathing pattern or breathing difficulty
o Mood changes including excitability, aggression or depression
o Pale, cold and clammy skin
o Nausea or vomiting
o Seizures
o Abdominal pain
o Evidence of poisons, containers, smells, etc.
o Agitation
o Paranoia
o Loss of consciousness
o Slow or erratic pulse
o Bluish fingernails or lips
o Chest pain

TREATMENT

Give fluids. Monitor their heart rate and status. Ensure their airway remains active and they
are breathing properly.

Knowing what drug they overdosed on is extremely helpful. Certain drugs, like heroin, will
have opposing drugs that can be administered to reverse the effects of an overdose.
However, these drugs often wear off much quicker than the recreational drugs the patient
will have taken.

Drug overdose patients will often become aggressive and refuse EMS treatment. As long as
they are conscious and are able to make this decision, you must oblige with their wishes.

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 POISON

Liaison with the Poisons Information Centre is an important step in patient treatment.
Identifying the poison and how it was contracted is greatly beneficial in forming the
treatment plan.
Liaise with the fire brigade if the poison requires containment or is at risk of producing
further injury. Police may also be required to secure scene safety.
Poisons can enter the body in 4 ways:
1. Ingestion
2. Inhalation
3. Absorption
4. Injection

INGESTION
For corrosive or petroleum-based poisons: do not induce vomiting. Wash off substance with
water. Give a small drink of milk or water only if ingested within 10 minutes of the poison
being taken.
For medicinal or natural poisons: induce vomiting, retain a sample of vomit if possible for
analysis.
Unknown poison: do not induce vomiting.

INHALATION
Move patient to fresh air. Loosen tight clothing. If no improvement or dangerous symptoms,
take to hospital. Give oxygen.

ABSORPTION
Remove clothing and wash skin with water. If any symptoms develop, take to hospital.

INJECTION

Primarily animal bites. Treat according to the animal type. Immobilise the patient as much
as possible to prevent the poison from spreading. Compress the area with a bandage,
moving away from the heart. Take to hospital to administer medication or possibly an
antidote/antivenom.

NSW AMBULANCE 53
 RESPIRATORY ARREST

Maintaining an active airway is the most important priority. Without the ability to
oxygenate, the patient will soon suffer organ damage and die. There are many ways a
patient’s airway can become compromised.
Unlike cardiac arrest, respiratory arrest still has a functioning heartbeat and appropriate
rhythm. This means that treatment should be focused on getting oxygen to the lungs.
Intubation may be required, where a tube is inserted through the mouth and into the
person’s airway – bypassing fluid, injuries or complications with the upper respiratory tract.
Crushing traumas, drowning, choking and allergic reactions are just some of the possible
causes of respiratory arrest

Patients in respiratory arrest may enter cardiac arrest at any moment so be prepared for
CPR and have an AED already set up. The AED will tell you if compressions or shocks need to
be administered.

Advanced procedures such as a tracheostomy may be deemed appropriate to ensure air is

able to reach the lungs. In a tracheostomy, a small incision is made in the trachea (windpipe)
and a tube is inserted.

NSW AMBULANCE 54
 SEPSIS

Sepsis is a potentially life-threatening condition caused by the body's response to an

infection.

The body normally releases chemicals into the bloodstream to fight an infection. Sepsis
occurs when the body's response to these chemicals is out of balance, triggering changes
that can damage multiple organ systems.

SYMPTOMS
o Change in mental status
o A first (systolic) number in a blood pressure reading that's less than or equal to 100
millimetres of mercury (mm Hg)
o Respiratory rate higher than or equal to 22 breaths a minute

SEVERE SEPSIS SYMPTOMS

o Patches of discolored skin
o Decreased urination
o Changes in mental ability
o Low platelet (blood clotting cells) count
o Problems breathing
o Abnormal heart functions
o Chills due to fall in body temperature
o Unconsciousness
o Extreme weakness

Getting people with sepsis to a hospital quickly is vital.

TREATMENT
o Antibiotics via IV to fight infection
o Vasoactive medications to increase blood pressure
o Insulin to stabilize blood sugar
o Corticosteroids to reduce inflammation
o Painkillers

NSW AMBULANCE 55
 SEVERED LIMB

Amputation, whether accidental or deliberate (as part of medical treatment), requires

immediate control of haemorrhaging. If possible have the patient laying own and elevate
the affected area. Apply direct pressure to the site of bleeding. If blood soaks through the
layer, add more layers of gauze and bandage but do not remove previous layers.

If bleeding is severe and is not controlled by direct pressure, use a tourniquet. This involves
applying an extremely tight and constricting device around the circumference of the limb
near the severed site in hope to prevent blood loss.
Tourniquets can cause tissue damage at the site of where they are applied but can mean the
difference between life and death for the patient. Do not remove the tourniquet until the
patient arrives at hospital.

Remember to treat the patient for shock and administer pain relief as required. If possible,
bag the limb and place into a bucket of ice (not directly on ice). Adults roughly have about
5L of blood in their system so treating mass haemorrhaging and if required, giving blood is
essential to the survival of the patient.

NSW AMBULANCE 56
 SHOCK

Shock often accompanies a wide range of traumatic events. It can be caused by bleeding,
plasma loss, burns, vomiting, dehydration and other injuries. Oxygen supply to the tissues
becomes inadequate and the patient may have the following symptoms:
o Pain at the site of injury
o Weakness
o Fatigue
o Giddiness
o Loss of consciousness
o Nausea
o Vomiting
o Pale, cold and clammy skin
o Shallow, rapid breathing
o Yawning and sighing (air hunger)
o Rapid weak pulse

If conscious, place in recovery position. If drowsy, elevate legs and keep head level with the
heart. Loosen clothing and reassure the patient. If the patient complains of thirst, moisten
their lips but do not give anything by mouth. Take to hospital.

NSW AMBULANCE 57
 SPINAL

Whenever there is suspicion of potential spinal trauma, ensure the patient remains as still as
possible, and always err on the side of caution.

Spinal injuries can arise from innumerous traumas including: falls, physical conflicts and
RTCs.
If the patient is unconscious as the result of a head injury you should always treat for spinal
injury. Do not move them. Put their head in a block and when transferring to a stretcher use
the logroll technique to keep their body as straight as possible. Avoid twisting and bending
and do not use a cervical collar on the patient.

SYMPTOMS
o pain at or below the site
o tenderness over the site
o absent or altered sensation below the site (tingling)
o loss of movement below the site
o impaired movement below the site

Pre-hospital ultrasound may show misalignment of the spinal column which is confirmation
of spinal injury – this procedure is not necessary if the patient has to be moved for it to be
conducted.
Treat other injuries while maintain the steady state of the patient, keeping them as
immobilised as possible. Transfer to hospital.

NSW AMBULANCE 58
 SUICIDE / SOCIAL

It is important that EMS workers understand the important role they play in mental health
issues in the 21st century. A large portion of emergency calls are related to social and
suicidal problems which require an ambulance team’s response.

SUICIDE
Suicide attempts often include various forms of self-harm through, self-inflicted lacerations,
overdose, high falls and drowning. For many individuals, paramedics are the difference
between life and death.
Being respectful and considerate is the best thing you can do for the patient. Listen to them
and understand where they are coming from.
Do not judge them or fail to take them seriously. Stay calm and diffuse the situation. As
soon as possible, get the individual to remove themselves from harm and into your
ambulance vehicle so you can talk to them in privacy.
If there is a physical condition that requires treatment, continue as normal. If there is no
immediate threat to life, attempt to take the patient to a safe haven or sanctuary.
Otherwise take the patient to A&E to be seen by a psychiatrist, or to the police station
where a mental health counsellor will assess them.

SOCIAL
Social problems are related to individuals who make an emergency call for social rather than
physical reasons but are not necessarily suicidal. They may be lonely, disconnected or not
fully aware. It is important to explain to the individual that the ambulance service is not an
appropriate avenue for these types of calls but efforts should still be made with carers,
family or a social department to have the person seen to and their needs assessed.

NSW AMBULANCE 59
 CHANGELOG

✓ 09/01/2019
Document concocted and created.

✓ 10/01/2019
Over 12,000 words reached.
✓ 12/01/2019
Draft version of document presented to EMS administration/cabinet.

NSW AMBULANCE 60
 ACTION PLAN

o Fix put in vehicle

o Change small heal to ‘full’ – pointless to have it in increments
o Put in CPR action
o Give helmets to motorbike patrolman (in uniform options)
o Pictures/diagrams
o Change autopsy to operating theatre
o Heli spawn in other regions
o Circle door to go into regional hospitals to another room for treatment
o If injuries too severe – mimed so cannot break RP
o Initial phase training

*This is a separate document to EMS rules/guidelines. Meant to extend on some things, add some
RP element and first aid guidance. Generally just to help EMS out with their duties etc.

PRESENT A DRAFT AT THE FORTNIGHTLY MEETING

on 12/01/2019

NSW AMBULANCE 61