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HomeMy WebLinkAboutC09-203 Ambulance LicenseLICENSURE DATE: From:-7/l/2009— To: 6/30/2010 AMBULANCE SERVICE: _Western Eagle County Ambulance District ADDRESS: _ PO Box 1809 Eagle, CO 8163 PHONE: _970- 328 -1130 FAX: _970- 328 -11 MEDICAL ADVISOR: _ Benji Kitagawa, I (Name/Credentials) The inspection of the above named ambulance service was made on _6/18/2009 by _Staci Bruce, RN and Linda Maggiore, RN . This ambulance service has met licensing requirements for Eagle County as established in the resolution as approved by the Board of Commissioners May 2007. A INSPECTOR(s): (Signature) L Nrw ra (j,r,{ =z (Type Name & Credentials) ll aci Bruce, RN �,, (Signature) l .tiv -,�� O /� Arg :ze � (Type Name & Credentials) Linda Maggiore, RN COUNTY A PPP OV AT Tn T Q Q T TV T T!`AATCV- A CORD DATE (MM /DD/YYY) TM. CERTIFICATE OF LIABILITY INSURANCE 06/04/2009 PRODUCER Phone: (970) 686 -7120 Fax: (970) 686 -7131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EARL MCFARLAND INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 128 6TH STREET SUITE C HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WINDSOR CO 80550 AI T=R T14P rnvPRAr]F AFFr1Rn Fn RV TW= Dni IrICC Dol nw INSURED WESTERN EAGLE COUNTY AMBULANCE DISTRICT PO BOX 1809 EAGLE CO 81631 COVERAGES INSURERS AFFORDING COVERAGE INSURER A: American Alternative Insurance INSURER B: INSURER C: INSURER D: INSURER E: NAIC # THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD-L INSR TYPE of INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIOD POLICY EXPIRATION DATE MMIDD LIMITS GENERAL LIABILITY TR- 2061703 -1 01/01/09 01/01/10 EACH OCCURRENCE $ 1,000,1 X COMMERCIAL GENERAL LIABILITY X CLAIMS MADE FX] OCCUR DAMAGE TO RENTED PREMISES (Ea occurence) $ 1,000,1 MED. EXP (Any one person) $ 10,1 PERSONAL & ADV INJURY $ 1,000,1 A GENERAL AGGREGATE $ 3,000,( GEN'L AGGREGATE LIMIT APPLIES PER: POLICY P JECT RO LOC PRODUCTS- COMP /OP AGG. $ 3,000,1 AUTOMOBILE LIABILITY ANY AUTO CM- 1057201 -1 01/01/09 01/01/10 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,1 X ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ A BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY CU- 5055881 -1 01/01/09 01/01/10 EACH OCCURRENCE $ 5,000,1 X OCCUR FI CLAIMS MADE AGGREGATE $ 10,000,1 $ A $ DEDUCTIBLE RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC STATU- OTHER TORY LIMITS E.L. EACH ACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTIVE E.L. DISEASE -EA EMPLOYEE $ OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT $ OTHER: DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS The purpose is to show coverage for Western Eagle County Ambulance District for licensing. Professional Health Care Liability is included under the General Liability. CERTIFICATE HOLDER CANCELLATION EAGLE COUNTY HEALTH & HUMAN SERVICES P. O. BOX 660 EAGLE, CO 80631 Attention: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DR WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE' DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITt AGENTS OR REPRESENTATIVES. 4Atw"- Zn' r. 0 C. m u N N f0 coN O O N fD m eon •:Podsuejl jeBuol e s!;! j! ueAe jej!dSOH m81A )IleA011u9iledeql:podsuejl'lueiled ay} elepoww000eolelqeejeAeqlpue6uilejedosil!jI -p9j4ejsAIInjsiqeIt4jeo9qj j! eupielep ol 6ui:podsuejl ejojeq s6updS poomuelE) ui Iej!ds0H main A9118A 1081U00 '9108w ueeq set dale oeipjeo e 11 -Aiesseosu Alelnlosqe sselun sailpel eqj j!Ids LON OP APPS ewes Gqj wojj sjusiled eldilinw eie ejeqj 11 eqj supialap ol seililloel Isajeau eqj joeluoo ':podsuejl 6upinb -eieiesluailedleoil!joeldillnwiI -o!_4ei1jouoiloejipeqlloesneoeqjeq:pnIAlleoiqdei6oa6si1eqllel!dsoq eq; olwet4I 6uijq of jeNoinb eq Aew j! 'ejelsielui eqj uo euel punoqlsem jo Isee ue w04 pe:podsuejl Buieq si jueged eqj jI 'OLI uO I!x3 wnsdA!D eqj jo,1sem suoileool Ile of jesolo si IejIds0H m91A AGIleA 'Ise8 Pue OLI uO W 3 wnsdAE) 9LI1 w04 suOileO.01 Ile 01 M010 S' J9;u9:D IeOIP9Vi 491leA HeA 4oe 'uoilonilsuoo loi-4eil lieqjeem qjIm senssi ou eie ei9qj buiWnssV -Aj!j!o8j Isejeeu eqj of u9jej eq pinoqs sjuaged leoilpo Inq leoioqo jieqljo Al!l!oej eqj of poliodsuejl eq ueo sluailed Ie0'1P3-u0N 100010M 9u9OS 9LI1 01 bulm jolo-d e9s) aueos eqj wojl:podsuejl 6uim J010J e 81A A111pel ejeo IeAel jeqbiq e jo lsbuijdS poomugIE) ui Iej1ds0H me!A AelleA'I!P-A ul J91u90 1801P9114 AeIIBA IPA of lqbnojq aq ueo lel!dsoq e ol eueos e wojj:podsuejl buljlnbei sJualled A31.10d U01.18U181890 Acetaminophen (Tylenol Class/Action Antipyretic Indications 1. Pediatric Fever Dosage See Dosing Chart EMT-BASIC INTERMEDIATE PARAMEDIC Special Notes If giving Tylenol to a child, they are considered a patient. An appropriate history, physical, and paperwork must be completed. WEIGHT AGE DOSE 77777= IN TYLENOL 0-3 months 6-11 pounds .4 mL 4-11 months 12-17 pounds .8 mL 12-23 months 18-32 pounds 1.2 mL QTYLENOL 2-3 years 24-35 pounds 5 mL 4-5 years 36-47 pounds 7.5 mL 6-8 years 48-59 pounds 10 mL 9-10 years 60-71 pounds 12.5 mL 11 years 72-95 pounds 15 mL Drug Formulary — Acetaminophen 8/5/08—Page 147 Adenosine (A denocard ) Class /Action A nucleoside found in all cells of the body. It slows conduction time through the AV junction, can interrupt reentry pathways through the AV junction, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT) . Indications 1. Acute SVT 2. Wide Complex Tachycardia with a Pulse (refractory to amiodarone and magnesium) Contraindications 1. 2nd or 3rd Degree Heart Block 2. Sick Sinus Syndrome 3. History of MI, cerebral hemorrhage, asthma (relative) Side Effects 1. May produce new arrhythmias such as bradycardia, tachycardia, heart blocks, PVC 's, or asys- tole; usually transient, but be prepared to treat. 2. May produce dyspnea, flushing, CP or pressure, dizziness, HA, palpitations, and feelings of impending doom. Special Notes 1. Needs to be given with an antecubital IV site, use 20 cc saline flush in a separate syringe, clamp above IV port, print rhythm strip pre- treatment, elevate arm. 2. 10- second 1/2 life, the clinical effects occur rapidly and are very brief. 3. Larger doses may be required in patents taking theophylline or caffeine, smaller doses in pa- tients taking dipyridamole or carbamazepine. Drug Formulary— Adenosine Albuterol (Ventolin, Proventil y��,�fAetfepo Drug Form u lary—Albuterol Sulfate +"yam ` Amiodarone ( Cordarone ) Class /Action Arniodarone is a very complex drug with actions upon sodium, potassium, and calcium channels as well as alpha and beta - adrenergic blocking properties. Indications 1. VF/VT 2. Successfully defibrillated from VF/VT 3. Wide Complex Tachycardia with a Pulse - Contraindications 1. Ventricular escape beats or accelerated IVR 2.. Pulmonary congestion and cardiogenic shock (relative ) 3. WPW ( relative ) 4. Sympathomimetic toxidromes, i.e., cocaine or amphetamine overdose ( relative) Side Effects Hypotension, cardiogenic shock, pulmonary congestion. Special Notes • Amiodarone has potentially life- threatening side effects, and multiple complex -drug interactions. It should be used for only the above recurrent, or life- threatening arrhythmias only after other first =line treatments have failed. • Whea using Amiodarone after successfully defibrillating f1�, mix 6 G in 50 mL NS using a burette.. Iii e is determined as f ( Volume to be In i Rate of Tubing) /Time in Minutes to be Infused= Gtts/ Minute (5 0 x 60 gtt/mL) /15 to 30 minutes -- _1 tt/minute Drug Form ulary—Amiodarone ` Aspirin �r Atropine Sulfate Class /Action Anticholinergic that has the following effects: • Increases HR and AV conduction ( blocks vagal effects) • Reduces GI motility and tone, dilates pupils • Reduces action and tone of the urinary bladder ( may cause retention ) Indications 1. Pulseless Arrest_ ( pulseless. bradycardia, asystole 2. Hemodynamically Unstable Bradycardia 3. Organophosphate Poisoning Contraindications 1. Not effective in infranodal ( M obitz Type II) or new 3rd degree blocks,.maycause paradoxical slowing. 2. Hypothermic bradycardia 3. Shock Side Effects Palpitations, HA, blurred vision, tachycardia, dry mouth, drowsiness, and anxiety Special Notes 1. Atropine dilates pupils in a cardiac arrest situation 2. If administered too slowly or in too small a dose, paradoxical profound bradycardia may result 3. Bradycardia in the setting of an acute MI may be beneficial 4. Pediatric bradycardia is usually secondary to hypoxia. Correct the ventilation first. Epinephrine is almost always the 1st line drug for pediatric bradycardia. w5����cO6'ji Drug Formulary— Atropine Sulfate 1 Atrovent Benadryl Class /Action Antihistamine that blocks the release of histamine from cells during an allergic reation. It also has an anti- parkinsonian.effect which is used to treat acute dystonic reactions to antipsychotic drugs. ( H aldol ) These reactions include oculogyric crisis, torticollis, and facial grimacing. Indications 1. Allergic Reaction & Anaphyalaxis 2. Motion Sickness 3. Extrapyramidal Reactions 4. Given with Haldol Contraindications 1. Asthma, COPD, glaucoma, bladder obstruction ( relative — condition will be exacerbated ) 2. Nursing mothers (relative) Side Effects Dry mouth, dilated pupils, flushing, drowsiness Special Notes 1. IV route is preferred if established 2. May cause CNS stimulation in children 3. The direct effect.can be stimulant, or more commonly depressant depending on the individual variation. ,`�`�y'FASeECOO�t Drug Form ulary— Benadryl /; Calcium Chloride Class /Action Electrolyte that regulates cell permeability of sodium and potassium. It causes potassium to enter cells. Indications 1. Calcium Channel or Beta Blocker Overdose (for symptomatic bradycardia and /or hypoten- sion ) 2. Hyperkalemia or Hypocalcemia ( renal compromised patients or crush syndrome) Contraindications Hypercalcemia, digitalis toxicity, cardiac arrest Side Effects Cardiac dysrhythmias, HA, dizziness, hypotension, NN Special Notes 1. Avoid mixing with bicarbonate, precipitate will form 2. Use of calcium with digoxin can cause increased cardiac irritability _ FAS[fCpGy I [7 -- hni —r nit - i im (:hlnrirlP a � Dextrose Drug Formulary— Dextrose Dopamine Class /Action 1. Sympathomimetic that is. a chemical precursor to epinephrine, occurs naturally in humans. 2. Has the following. dose- related effects • 1 -2 mcg /Kg /min: dilates renal and mesenteric vessels, on effect on HR or BP • 2 -10 mcg /Kg /min: beta effects on heart, usually increases cardiac output, HR and BP • 10 -20 mcg /Kg /min: alpha peripheral effects cause peripheral vasoconstriction and in- 40 -40 mcg /Kg /min: a a effects reverse dilation of renal and mesenteric vessels with e lood flow Indications 1. Hypotension from causes other than hypovolemia such as cardiogenic, neurogenic, septic, or anaphylactic shock 2. Hemodynamically Unstable Bradycardia. Contraindications 1. Hypovolemic shock Side Effects Hypertensive crisis in susceptible individuals Special Notes 1. Dopamine may induce tachydysrhythmias. If the HR exceeds 140 BPM, the infusion should be stopped. 2. At low doses, decreased blood pressure may occur due to peripheral vasodilation. Increasing the infusion rate will correct this. 3. Should not be added to sodium bicarbonate or other alkaline solutions since dopamine will be inactivated at a higher pH 4. Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be sure to make ED staff aware if there has been any extravasation of dopamine- containing solutions so that proper care can be initiated. 5. Certain antidepressants potentiate the effects of dopamine. Notify base when calling in for or- ders if the patient is on an antidepressant. Dopamine Drip Rates (400 mcg in 250 mL NS Pt Wt Kg 40 45 50 55 60 65 70 75 80" 85 90 95 lob 105 110 115 120 Mcg /Kg /Min 2 3 3 4 4 5 5 5 6 6 6 7 7 8. 8 8 9 9 5 8 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 10 15 17 19 21 23 24 26 28 30 32 34 36 38 39 41 43 45 15 22 25 28 31 34 37 40 43 45 48 51 54 57 59 62 1.65 68 20 30 34 38 41 45 49 53 56 60 64 68 71 75 79 83 86 90 nri m Fnrmi Mani nnnnminp J )� Fentanyl ���`�HEA6tf ppGy� I nrim Fnrmiilarv— FPntanvl Class /Action Antihyopoglycemic agent that promotes the breakdown of liver glycogen to glucose thereby increas- ing the BGL. It also relaxes GI peristalsis and has the cardiac effects of increasing HR and contrac- tility, and promotes AV node conduction. Indications 1'. Hypoglycemia (BGL <60 mg /dL and unable to obtain IV access ) Side Effects Nausea, vomiting,_ headache Special Notes 1. When glucagon is given for hypoglycemia the patient should receive glucose as soon as possi- ble after the administration of glucagon. 2. If possible, obtain BGL before administration of glucagon. Drug Form ulary— Guucagon Oral Glucose Class /Action Carbohydrate that is rapidly absorbed into the oral mucosa, thus elevating the body 's glucose level. Indications 1. Hypoglycemia 2. Altered mentation and history of diabetes Contraindications Unable to swallow Special Notes 1. Squeeze a small portion of the tube (approximately 1/3 ) into the patient 's mouth between the cheek and gum. Or, utilizing a tongue depressor, deposit a small portion of the tube ( approximately 1/3 ) onto the tongue depressor and slide it into the patient 's mouth between the cheek and gum. Repeat the procedure until one full tube of glucose has been administered. Class /Action I Indications Haldol Antipsychotic medication that produces a dopaminergic blockade, mild alpha - adrenergic blockade, and causes peripheral vasodilation. 1. Chemical restraint of an agitated patient Contraindications 1. Excited delirium 2. Suspected acute myocardial infarction 3. Systolic BP <100 mmHg, or absence of radial pulse 4. Exhibiting signs of sedation, respiratory depression, CNS depression 5. Parkinson 's disease 6. Pregnant 7. Severe liver or cardiac disease 8. Under age 8 Precautions 1. Haloperidol lowers seizure threshold and should be administered with caution to anyone with a known seizure disorder. 2. Patients 65 and over will respond more readily to haloperidol and a reduced dose should be considered. Side Effects 1. Hypotension, tachycardia, prolongation of the QT interval. 2. Some patients may experience unpleasant sensations manifested as restlessness, hyperacitivy, or anxiety following haloperidol administration. 3. Extra - pyramidal reactions have been noted hours to days after treatment, usually presenting as spasm of the muscles of the tongue, face, neck, and back. This is treated with benedryl. 4. Rare instances of neuroleptic malignant syndrome (very high fever, muscular rigidity ) have been known to occur. Special Notes T. Paramedic must put patient on cardiac monitor and establish an IV as soon as possible. 2. Due to the vasodilatory effect, haloperidol can cause a transient hypotension that is usually self- limiting and can be treated with position and fluids. Should profound hypotension result, epi- nephrine should not be used since haloperidol may block its vasopressor activity and paradoxi- cally further lower the blood pressure. Haldol may also decrease the effectiveness of dopa- mine. 3. The action of haloperidol potentiates the effect of sedative /tranquilizer type medications and is relatively contraindicated in the presence of these types of medications. In this setting, be pre - pared for respiratory depression, apnea, muscular rigidity, and hypotension. Drug Formulary— Haldol (( 4 ,a Lidocaine Class /Action 1. Antiarrhythmic that suppresses ventricular ectopy, increases ventricular fibrillation threshold, and reduces velocity of electrical impulses through the conduction system. 2. Blunts spike in ICP with invasive procedure Indications 1. Adjunct to intubation in patients (especially pediatrics) with closed head injuries 2. Local anesthetic prior to fluid administration through an 10 cannulation ©c lnt Aa ' t b IT 0,10 .: � t"�' S ��J^ .+�'�• '� � 3.��2��- ,•Yttr a"'u�fGi OWN, .fi n . ` • '?6 4: y 3 � -ak . _. b FM ConteaIncications I\fR, ventricular es--ape rhythm, 2nd or Jld degree block, P"Ic s associated with bradycaroia Side Effects Anxiety, seizures, NN, drowsiness, widening of the QRS Special Notes Consider half dose for patients over 70 YO, history of CHF, or liver disease Drug Formulary- Lidocaine �� Class /Action Electrolyte that has the following effects: • Cardiac: stabilizes the potassium pump, correcting repolarizaiton. Shortens the QT interval in the presence of ventricular arrhythmias due to drug toxicity or electrolyte im- balance. • Respiratory: may act as a bronchodilator in acute bronchospasm • Obstetric: controls seizures by blocking neuromuscular transmission. Also lowers blood pressure and decreases cerebral vasospasm. Indications 1. Pulseless Arrest (due to hypomagnesemia or Torsades de Pointes ) 2. Wide Complex Tachycardia with a Pulse 3. Moderate to severe respiratory distress unresponsive to epinephrine and inhaled beta- agonists. 4. Pre - Eclampsia & Eclampsia ( >20 weeks gestation, BP >180 systolic, >.110 diastolic with ak tered mental status and /or seizure ) 'Contraindications 1. AV Block (relative ) 2. Decrease in respiratory or cardiac function ( relative) 3. Patients taking digitalis (relative) Side Effects Respiratory depression, ventilatory assistance may be required Special Notes • Pre - Eclampsia; >20 weeks gestation, BP >180 mmgHg systolic and /or >110 mmHg diastolic • Eclampsia: signs of pre- eclampsia with altered mental status or seizure • Drip rate is determined as follows: ( Volume to be Infused x Drip Rate of Tubing ) /Time in Minutes to be Infused = Gtts /Minute • �s�����COOyr Drug Formulary- Magnesium Sulfaten< Morphine Sulfate Class /Action Narcotic that has the following actions: • CNS depressant qualities that reduce sensitivity to pain • Hemodynamic property of vasodilation that decreases systemic resistance and preload. This contributes to decreased cardiac work, decreased cardiac oxygen consumption, and reduced pulmonary congestion. Indications 1. Chest pain or other signs /symptom indicative of acute coronary syndrome 2. Cardiogenic Pulmonary Edema 13. Pain Management Contraindications 1. Hypotension (relative ) 2. Respiratory distress, unless due to pulmonary edema 3. Major blood loss, the bodies compensatory mechanisms will be suppressed by the use of mor- phine and the hypotensive effect will become very prominent. Side Effects NN, hypotension, respiratory depression Special Notes 1. Pulse oximetry and ECG should be monitored IOU ca, __U^rnhino Qiiifnto i�S`/ J Vi.lyye Narcan Class/Action Narcotic antagonist that completely binds to narcotic sites but which exhibits almost no pharmacol- ogical effects of its own. Indications 1. Narcotic Overdose 2. Altered mental status of unknown origin 3. Seizure of unknown origin L) w- 2W EIN repeat 5__ M. T 5 _°.ds. X_ W-2- Special Notes 1. The duration of some narcotics is longer than narcan and the patient must be monitored closell Repeated doses of narcan may be required. Patients who have received this drug must be transported to the hospital because coma may occur when the narcan wears off. 2. With an ET tube in place and assisted ventilations narcotic OD patients may be safely manage without narcan. Think twice before totally reversing coma, airway may be lost, or worse the pa tient may become violent and refuse transport. Drug Form u lary—Narcan Neosynephrine Class /Action Sympathomimetic used for topical nasal administration. It primarily exhibits alpha - adrenergic stimu- lation. This stimulation can produce moderate to marked vasoconstriction and subsequent_ nasal decongestion. Indications 1. Nasallntubation Special Notes Avoid administration into the eyes as this will cause dilation _ ���1�`►FAn6CEC�CGy << Drug Form ulary—Neosynephrine p<1� Nitroglycerin. Y7) j Class /Action Nitrate. Cardiovascular effects include: • Reduced venous tone, causes blood - pooling in peripheral veins, decreasing venous return to the heart • Decreased peripheral resistance • Dilation of coronary arteries (if not already at maximum) and relief of coronary artery spasm Indications 1. Acute Coronary Syndrome 2. Cardiogenic Pulmonary Edema - Contraindications 1. Hypotension ( relative ) 2. Hypertensive Crisis ( relative, must call in for orders ) 3. Patients taking Viagra or some other erectile dysfunction medication with in the last 24 -36 hours Side Effects 1. Generalized vasodilation may cause profound hypotension and reflex tachycardia 2. Common side effects include throbbing headache, flushing, dizziness, and burning under the tongue. Less common is orthostatic hypotension. Special Notes 1. Nitroglycerin tables lose potency easily; they should be stored in dark glass container with tight lid and not exposed to heat 2. Must check BP prior to each dose 3. Therapeutic effects are enhanced, but adverse effects are increased when patient is sitting up- right. 4. Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in re- lieving chest pain caused by esophageal spasm. 5. Hypertensive crisis is a sudden and severe increase in blood pressure, up to 200/120 mmHg. If BP is lowered too quickly in the field, infarction of organs can occur. ��,NFA6(fgoG Drug Formulary— Nitroglycerin ��`�;�y;� Phen.ergen 1, G Y-V .Ilen ^�� Racemic Epinephrine Drug Form ulary—Racemic Epinephrine 3�� /I ✓a \yt� Sodium Bicarbonate Class /Action Sodium bicarbonate is an alkalotic solution which neutralizes acids found in the body. Acids are increased when body tissue become hypoxic due to cardiac or respiratory arrest. Indications 1, Tricyclic Antidepressant OD (widened QRS, hypotension, seizures ) Contraindications 1. Should not be given with catecholamines'or'calcium chloride Side Effects 1. Hyperosmolality of the blood can occur resulting in cerebral impairment. 2. Addition of too much may result in alkalosis, this is more difficult to correct than acidosis 3. Each ampule of sodium bicarbonate contains 44 -50 mEq of sodium This increases intravascu- lar volume which increases workload on the heart. Fs��COOyi Drua Formularv— Sodium Bicarbonate ::`a SoluMedrol Class /Action Synthetic steroid that suppresses acute and chronic inflammation. In addition, it potentiates vascu- lar smooth muscle relaxation by beta - adrenergic agonists and may alter airway hyperactivity. Indications 1. Pharmacological Treatment of Moderate to Severe Respiratory Distress Secondary to Anaphy- laxis and Bronchoconstriction Contraindications I Gastrointestinal bleeding, diabetes mellitus, or severe infection (all relative ) Side Effects GI bleeding, headache, hypertension, sodium and water retention, hypokalemia, alkalosis Special Notes 1. Be aware that the effect of SoluMedrol is generally delayed for several hours. Although it is worthwhile to administer it early in treatment of a patient with severe respiratory distress or ana- phylaxis you may not see any effects from the drug for several hours. 2. SoluMedrol is not a first -line drug. Be sure to attend to the patient 's primary treatment priori- ties first. Once primary treatment priorities have been addressed, SoluMedrol can be adminis- tered during transport. Drug Formulary— SoluMedrol / %yj� Valium Class /Action Diazepam acts as a tranquilizer, anticonvulsant, and skeletal muscle relaxant through effects on the central nervous system. Indications 1. Status Seizure (in the field this will be any seizure which has lasted longer than five minutes, or two consecutive seizures without regaining consciousness, if the patient is seizing upon arri- val to scene status seizure can be assumed ) 2. Valium for tremors associated with alcohol withdrawal and delirium tremens (mental confusion, constant tremors, fever, dehydration, tachycardia, and /or hallucinations ) per protocol. 3. Severe Musculoskeletal Back Spasms 4. Sedation & Chemical Restraint Contraindications 1. Under the influence of alcohol ( relative ) 2. Shock 3. Respiratory depression Side Effects 1. Common side effects include drowsiness, dizziness, fatigue, and ataxia. Paradoxical excite- ment or stimulation can occur. Special Notes 1. Patients on valium should be placed on pulse oximetry and oxygen 2. Should not be mixed with other agents or diluted with intravenous solutions. 3. Rectal administration in children should be through a TB /1 cc syringe with the needle removed. Lubrication may be required before insertion of the syringe. The syringe barrel should be com- pletely inserted prior to administration. ESti���c�G�i I nrua Formularv— Valium Versed Class /Action Benzodiazepine and anticonvulsant that has properties of CNS depressant, sedative /hypnotic, slee induction, anxiolysis (reduce anxiety ), and amnesitc. Indications 1. Sedation for Altered Mental Status 2. Sedation Prior to Card!oversion and Transcutaneous Pacing 3. Status Seizure (in the field this will be any seizure which has lasted longer than five minutes, or two consecutive seizures without regaining consciousness, if the patient is seizing upon arri- val to scene status seizure can be assumed ) 1��Tj(C ' �J tfi)Iax1� e.._ Contraind!cations 1. Glaucoma, depressed vital signs, concomitant use of barbiturates, alcohol, narcotics, or other CNS depressants ( relative) 2. Shock, coma Side Effects Respiratory depression, hiccup, cough, oversedation, pain at the injection site, nausea and vomit- ing, and headache Special Notes 1. Can cause sianificant respiratory depression, apnea; and hypotension especial!;: +n�hen used in combination with other sedatives such as alcohol or narcotics. Continuous pulse oximetry and cardiac monitoring are mandatory. Emergency resuscitative equipment must be immediately available. 2. Consider lower doses for elderly patients; significant respiratory depression, apnea, and hy- potension are more frequently encountered. Drug Formulary— Versed `WKEOQ /� t! -11- e, Zofran Class /Action Serotonin is released from cells in the small intestine. The released serotonin may stimulate the vagal afferent nerves through the 5 -HT3 receptors, thus stimulating the vomiting reflex. Zofran is a 5 -HT3 antagonist and blocks this effect of serotonin. Indications 1. Prolonged nausea and vomiting I Contraindications 1. Children under the age of 3 years 2. Liver impairment ff az' y'2 Drug Formulary- Zofran t �� Lasix Class /Action Loop diuretic that inhibits the reabsorption of NaCl and promotes rapid diuresis. This reduces ve- nous return to the right atria, and helps remove excess fluid in conditions of fluid overload. Indications 1. Cardogenic Pulmonary Edema Contraindications 1. Patients with allergies to sulfonamides may be sensitive to lasix 2. BP <100 mmHg systolic (relative) 3. Pregnancy Side Effects 1. Rapid administration can cause auditory changes including tinnitus and hearing loss. 2. HA, dizziness, hypovolemia, potassium depletion, N/V, diarrhea Special Notes 1. Drug may be deactivated by exposure to light. 2. Lasix is not considered a first -line drug. Be sure to attend to the patient 's primary treatment priorities (i.e, airway, ventilation, arrhythmia ) first. Do not delay transport to administer lasix. �yt�g.X ��CpGyl Drug Formulary—Lasix� EMERGENCY MEDICAL SERVICES APPLICATION AMBULANCE SERVICE LICENSE Date of Application: Name of Ambulance Services: arent company j-1) ( owner or P Doing Business As: `S ( VC Address: i U v Name And Address Of Each Stockholder Or Partner ownin 0% 6r More Of The Outstanding Stock Of The Company Or Having More Than A 10 % Ownership Interest (if applicable): �S�i cf Name, Address And Phone Number f Manager r Indivi Responsible fo The peration Of e Services: S er g i e ` i e 00-/- � hat Area Of Your County Will Be' S rved By This Company? Please Attach A Map Indicating List All Location (Central Station And Sub Stations) where ambulances How Many Ambulances Do You Operate? r If This Is An Initial Application (not a renewal application) Attach 0 �� a A SEPARATE Permit Request For Each Ambulance. ATTACH A CERTIFICATE OF INSURANCE TO THIS APPLICATION. I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO . WILLFUL MISREPRESENTATION OR FALSIFICATION. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. / Signature of Applicant Date SUBSC A AFFIRMED BEFORE ME THIS DAY ,� _6b, IN THE COUNTY OF , STATE O OLORADO. MylCommission expires: L0-1 (For Office Use Only) Date Received: / / / Documents Checked: Fee Paid or Excused: Remarks: Receipt #: Approval Recommended (Y/N): Date Referred to B.O.C.C. / Licensing Agent r k, r � a A SEPARATE Permit Request For Each Ambulance. ATTACH A CERTIFICATE OF INSURANCE TO THIS APPLICATION. I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO . WILLFUL MISREPRESENTATION OR FALSIFICATION. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. / Signature of Applicant Date SUBSC A AFFIRMED BEFORE ME THIS DAY ,� _6b, IN THE COUNTY OF , STATE O OLORADO. MylCommission expires: L0-1 (For Office Use Only) Date Received: / / / Documents Checked: Fee Paid or Excused: Remarks: Receipt #: Approval Recommended (Y/N): Date Referred to B.O.C.C. / Licensing Agent i t. COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT DATE: NAME OF VEHICLE OWNER _ NAME OF AMBULANCE SER t o ' fAEWAWi4VJ-Lf STATE: ZIP: • -.� TELEPHONE NUMBER: -32-O ` 113,0 DESCRIPTION OF AMBULANCE: O /' O 4 WHEEL DRIVE(Y/N): YEAR:ja MAKE: MODEI;(type): MANUFACTURERS IDENTIFICATION NUMBER (V.I.N.): /� 5 P 7 "O A 770 � s COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): REGISTERED WITH THE STATE OF COLORADO AS,AN EMERGENCY VEHICLE? (y/n):_ DATE AMBULANCE PLACED IN SERVICE:/ �/ U NORMAL LOCATION OF AMBULANCE ca4 rf 4C- INSURANCE COVERAGE ON THIS VEHICLE: / A. COMPANY: v B. AGENT: / V C. BODILY INJURY:$,d, go 0 / $ 00f D: PROPERTY DAMAGE:$ / wo D6C� / I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMINATION THAT A PERMIT HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR PERMIT REVOCATION. SIGNATURE OF APPLICANT :f2ttl]4-54�'. DATE: LL/ SUBSCRIBED AN AFFIRMED BEPORE E THIS, DAY OF i IN THE COUNTY OF STATE OF COLORADO . SIGNATURE OF NOTA /LMy Commission Expires:/ ,�L/ (FOR OFFICE USE ONLY Date Received: Documentation Verified: Inspection Satisfactory. (y /n): - Date: Hold For: Recommend Approval of Permit (y /n): Comments: SIGNATURE CERTIFICATE O/F MOTOR VEHICLE CONDITION ' 81 DATE:/ '�&1 The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future status of the ambulance due to conditions beyond my control. VEHICLE IDENTIFICATI NUMBER (V.I.N.): �� E-7 7 VEHICLE OWNER: EVALUATION ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering X Alignment X Suspension X Brakes Hand Brake ✓Vd AIt& Lights x Electrical System Glass K Exhaust System K Fuel System Body & Sheet Metal MECHANIC: (sIGNA ) AGENCY Oc✓ n� �jal J Fleet i `�" , ADDRESS S-00 Sr,-4 `�fiC7u /c� rc� Al o,) r cry Eagle County Ambulance Inspection List Public Health Division 4107'` Eagle County AMBULANCE INSPECTION LIST District: Ambulance: 9 0 ( Datedligigi_Time: BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT a. Portable suction unit /adult & pediatric and a house (fixed system) or back -up suction unit _V,"'b. Bulb syringe ✓c. Portable oxygen each with a variable flow regulator v 02 bottles house 02 ti'd. Transparent, non -re breather fixed oxygen (vehicle) V 02 mask, cannula for adult ,.� 02 mask, pediatric e. Hand operated, self inflating bag -valve masks resuscitators with 02 reservoirs and standard 15mm/21 mm fittings in the following sizes: 500 cc bag with newborn and infant 1000 cc bag with adult mask Transparent masks for infants, neonate patients, children and adults f. Nasopharyngeal airways in adult sizes 24 fr.. through 32.fr g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT ✓ a. Blood pressure cuffs to include large adult, regular adult, child, and infant b. Stethoscope c. Penlight III. SPLINTING EQUIPMENT a. Lower extremity traction splint b. Upper and lower extremity splints c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis _ d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis e. Pediatric spine board or adult spine board that can be adapted to pediatric use f. Adult & pediatric head immobilization equipment g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol IV. DRESSING MATERIALS a. Bandages, various types & sizes ✓ b. Dressings, various sizes ✓ c. Sterile burn sheets d. Adhesive tape Eagle County Ambulance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES a. Sterile OB kit to include towels, % 4x4 dressing, umbilical tape or cord clamps scissors bulb syringe _sterile gloves Ls thermal absorbent blanket 'b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT .� a. Heavy bandage scissors /shears b. Two working flashlights c. Thermal absorbent blankets /blanket and appropriate heat source VII. COMMUNICATIONS EQUIPMENT a. All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. b. Two -way communications that will enable the ambulance personnel to communicate Dispatch _Medical control facility or a physicians '✓ eceiving facilities Mutual aid agencies VIII. EXTRICATION EQUIPMENT with: a. s. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly.Sized To Fit All Personnel) a. Non - sterile disposable gloves, to include a minimum 1 box of latex free gloves. b-. protective eye wear c. Non - sterile surgical masks d. Safety protection gear for extrication Vie. Sharps containers for appropriate disposal and storage of medical waste and biohazards. /f. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT a: A set of 3 warning reflectors b. One ten pound (10 lb.) or two five pound (5 lb.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and vehicle exterior. c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. d. Properly secured patient transport system (i.e., wheeled stretcher), e. Triage tags Eagle County Ambulance Inspection List P,;blic Health Division 4%u1 AnVANCED LIFE SUPPORT — INTERMEDIATE II. , VENTILATION EQUIPMENT a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5 -5.5, and cuffed size ranging from 6.0 -8.0 per medical director protocol. b. Laryngoscope blades, straight & curved, sizes 0 -4 c. Adult and pediatric magill forceps d. End tidal CO2 detector or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT a. Portable, battery operated cardiac monitor - defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities V-/ b. Pulse oximeter with adult and pediatric probes. u,- c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT _a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol _ b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS 1. DISPLAYS /IDENTIFICATION a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE ✓ a. At the time of application for permit, the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifying the ambulance is in safe operating condition. b. Tires are safe and approved snow tires or chains are available when weather conditions demand. Eagle County Ambulance Inspection List Public Health Division 4/07 4 rl COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT DATE: / l / jT NAME OF VEHICLE OWNER: NAME OF AMBULANCE SERVICE: ADDRESS: CITY: STATE: ZIP:I TELEPHONE NUMBER: ?79 2 0 DESCRIPTION OF AMBULANCE:. YEAR.Q MAKE: / OCd MODEL(type): E / S0 4 WHEEL DRIVE(Y/N):,ff MANUFACTURERS IDENTIFICATION NUMBER (V.I.N.): 1 F 0 X jff Y,5 F6 3 6 COLORADO STATE LICENSE N�1JMBER (REGISTRATION NO.): 7 � REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y /n): DESCRIBE COLOR S Tj4EASIGN AG�NC IyfE, �,ONOGAND Q HE DIX7, I HrNNG `_ ._e j/�_ / DATE AMBULANCE PLACED IN SERVICE: 02 / OZ / n NORMAL LOCATION OF AMBULANCE: 079S INSURANCE, COVERAGE ON THIS VEHICLE: A. COMPANY: !� B. AGENT: Ea-rl &C F-�4, / C. BODILY INJURY:$ 1�120 0. DOcE) /s J,060 Q� D: PROPERTY DAMAGE:$ low Q 0( /s 066 I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMINATION THAT A PERMIT HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR PERMIT REVOCATION. SIGNATURE OF APPLICANT DATE: —L/ � g / � 1/ SUBSCRIBED AN AFFIRMED BEFO THIS DAY OF 200 ?IN THE COUNTY OF STATE OF COLORADO . SIGNATURE OF NOTARY: My Commission Expires:/ 2:0 / / _ -- _. _ • tr f t (FOR OFFICE USE ONLY Date Received: Documentation Verified: Inspection Satisfactory (y /n): Date: Hold For: Recommend Approval of Permit (y /n): Comments: SIGNATURE CERTIFICATE OF MOTOR VEHICLE CONDITION DATE:/ -1/ —Oi . The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future status of the ambulance due to conditions beyond my control. VEHICLE ID VEHICLE OWNER :ON NUMBER (V.I.N.: J" y EVALUATION CH9CK LIST Cil MECHANIC: 4L (SIGNATURE) AGENCY J , ADDRESS CA0 Eagle County Ambulance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES a. Sterile 'OB kit to include L- towels, -4x4 dressing, L✓ umbilical tape or cord clamps C,- scissors L.- bulb syringe Usterile gloves - thermal absorbent blanket b. Neo natal stocking cap Vi. MISCELLANEOUS EQUIPMENT a. Heavy bandage scissors /shears b. Two working flashlights c. Thermal absorbent blankets /blanket and appropriate heat source VII. COMMUNICATIONS EQUIPMENT - All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. LI Two -way communications that will enable the ambulance personnel to communicate with: ___(__„Qispatch _Medical control facility or a physicians _ Receiving facilities _ Mljjtual aid agencies Vill. EXTRICATION EQUIPMENT a. Appropriate for the level of extrication service the agency provides. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) _tea. Non - sterile disposable gloves, to include a minimum 1 box of latex free gloves. b protective eye wear . Non - sterile surgical masks Ali d. Safety protection gear for extrication i-�e. Sharps containers for appropriate disposal and storage of medical waste and . biohazards. f,—•f. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT C--I a. A set of 3 warning reflectors T�b. One ten pound (10 lb.) or two five pound (5 lb.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and vehicle exterior. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. r d. Properly secured patient transport system (i.e., wheeled stretcher) Vie. Triage tags ■ r. Eagle County Ambulance Inspection List Public Health Division 4/01 ADVANCED LIFE SUPPORT - INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT- SECTION I - XII (Check) II. VENTILATION EQUIPMENT a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 4 2.5 -5.5, and cuffed size ranging from 6.0 -8.0 per medical director protocol. b. Laryngoscope blades, straight & curved, sizes 0 -4 —L--'-c. Adult and pediatric magill forceps -1--d. End tidal CO2 detector or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT 'Z- a. Portable, battery operated cardiac monitor- defibrillator with strip chart recorder v and adult and pediatric EKG electrodes and defibrillation capabilities _ b. Pulse oximeter with adult and pediatric probes. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol . Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS L- a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) --(--.-b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYS /IDENTIFICATION a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. i b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE ri a. At the time of application for permit, the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifying the ambulance is in safe operating condition. b. Tires are safe and approved snow tires or chains are available when weather conditions demand. Eagle County Ambulance Inspection List Public Health Division 4/07 0 e c COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT DATE: j l --l-- l S�1 NAME OF VEHICLE NAME OF ADDRESS: TELEPHONE DESCRIPTION OF AMBULANCE: T � YEAR: �2 W MAKE: MODEL(type): v 4 WHEEL DRIVE(Y/N): MANUFACTURERS IDENTIFICATION NUMBER (V.I.N.): / FqD X E q-!]� F73 PA 09Z COLORADO STATE LICENSE NUMBER (REGISTRATION NO.): REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y /n):- DESCRIBE COLORS EME, INSI( IA, NAME, MONOG M AND OTIJER D S INGUISHING CHARA T RISTIC: �C- ('a DATE AMBULANCE PLACED IN SERVICE:/ -C)b 0a NORMAL LOCATION OF AMBULANCE: INSURANCE COVERAGE O[7FZIS IS VEHICLE: A. COMPANY: B. AGENT: % / % 1,—jt4 C. BODILY INJURY:$, D. PROPERTY DAMAGE:$ /� /J I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMINATION THAT A PERMIT HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS FOR PERMIT REVOCATION. SIGNATURE OF APPLICANT DATE: tw i SUBSCRIBED AN AFFIRMED 4BE-F?"E THIS DAY OF .SIN THE COLTN I Y OF STATE OF COLORADO . SIGNATURE OF NOTA My Commission Expires:/ / 5 (FOR OFFICE USE ONLY) Date Received: Documentation Verified: Inspection Satisfactory (y /n): Date: / / Hold For: Recommend Approval of Permit (y /n): Comments: SIGNATURI: CERTIFICATE OF MOTOR VEHICLE CONDITION DATE: / �c ? /�/ / The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future status of the ambulance due to conditions beyond my control. VEHICLE IDENTIFIC N NUMB (V.I.N.): T F-73 V&au 1 VEHICLE OWNER: "/ 10 G EVALUATION CHECK .TCT MECHANIC: U ( GNATURE) AGENCY ADDRESS 5 -56 I Eagle County Ambulance Inspection List public. lLbalth Division 4/07 Eagle County AMBULANCE INSPECTION LIST � ► Ambulance: Date District: �lt� • 1 t °q Time:_ BASIC LIFE SUPPORT I. V NTILATION EQUIPMENT a. Portable e suction unit /adult &pediatric and a house (fixed system) or back -up suction unit ,,/ b. Bulb syringe =c. Portable oxygen each with a variable flow regulator 02 bottles ✓ house 02 en (vehicle) _Vd..Transparent, non- v/ re breather fixed oxygen 02 mask, cannula for adult 02 mask, pediatric e. Hand operated, self inflating bag -valve masks resuscitators with 02 reservoirs and standard V 15mm/21 mm fittings in the following sizes: ✓ Soo cc bag with newborn and infant ✓ 7 n ✓ 1 000 cc bag with adult mask for infants, neonate patients, children and adults �/ Transparent masks �,. f. Nasopharyngeal airways in adul &si edia fr. 4c sizes to include: infant, child, small adult, adult, and g. Oropharyngeal airways in adult p large adult II. PATIENT ASSESSMENT EQUIPMENT V a. Blood pressure cuffs to include large adult, regular adult, child; and infant _ b. Stethoscope _ c. Penlight III. SPLINTING EQUIPMENT a. Lower extremity traction splint b. Upper and lower extremity splints c. Long board, scoop, vacuum mattress h or the equivalent immobilize immobilize the patient from to pelvis d. Short board K.E.D. or equivalent, with ability head to pelvis _Z_ e. Pediatric spine board or adult spine board that can be adapted to pediatric use f. Adult & pediatric head immobilization equipment g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol IV. DRESSING MATERIALS _ a. Bandages, various types & sizes ,r b. Dressings, various sizes v" _ c. Sterile burn sheets d. Adhesive tape Eagle County Ambulance Inspection List. . . Public Health Division 4/07 ` Ill. INSURANCE: ✓ No. ambulance shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: ,"Public Liability and Bodily Injury:+ Each Person .$1,000,000 Each Accident (Aggregate) $2,000,000 Property Damage: Each Accident $1,000,000 *- Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 . Eagle County Ambulance Inspection List `Public Health Division ,:,.4107 Eagle County AMBULANCE INSPECTION GENERAL INFORMATION District: WE--(,A0 Date: i V. MUTUAL AID AGREEMENT --/A written, contractual agreement between two licensees to supplement services in each other's response districts. VI. DESTINATION GUIDELINES ✓The Medical Director of the ambulance service shall establish destination guidelines that conform to state and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name Address Date of Birth Training Level 4 /07 /07:JAH Eagle County Ambulance Inspection List " Public Health Division 4/07 Y • ou COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT DATE:/ —o a � r, n NAME OF VEHICLE OWNER: NAME OF AMBULANCE SERVI Vp' cnLj fj�V ADDRESS: CITY: STATE ZIP: / TELEPHONE NUMBER: - -32�9 - / 1 30 DESCRIPTION OF AMBULANCE: / YEAR43 MAKE: %C MODEL(type): 4 WHEEL DRIVE(YN: �! r MANUFACTURERS IDENTIFICATION NUMBER (V.I.N *_1f VXE qS F'-1 3 COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y /n): DESCRIBE COLOR SCUE SI CHARACTERISTIC: U, x DATE AMBULANCE PLACED IN SERVICE: J-5/ j�f-3 NORMAL LOCATION OF AMBULANCE: � �© G1 INSURANCE COVERAGE ON THIS VEHICLE: 9= A. COMPANY: B. AGENT: �Y C. BODILY rNJURY:$ 1 6 D DD / $��_�D D. PROPERTY DAMAGE:$ /xv D / $ h� . ODD{ I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMINATION THAT A PERMIT HAS BEEN ISSUED BASED ON FALSE F TION TUTES GROUNDS FOR PERMIT REVOCATION. SIGNATURE OF APPLICANT Zvi 2 SUBSCRIBED AN AFFIRMED BEFORE THIS DAY OF T . IN THE COUNTY OF STATE OF COLORADO. SIGNATURE OF NOTAR �. Commission Expires: / a Date Received:-----j / Documentation Verified: Inspection Satisfactory (y /n): Date: / / Hold For: Recommend Approval of permit (y /n): Comments: SIGNATURE Eagle County Ambulance Inspection List ,. . Public Health Division 4/07 , rt 11 A TERM SHEET 1) Requested hearing date: (First choice) 6/30/09 Ambulance Licenses must be approved on or before June 30, 2009 2) For County Manager signature: No 3) Requesting department: Public Health 4) Title: Ambulance Service Licenses 5) Check one: Consent: X On the Record: 6) Staff submitting: Anne Robinson, Acting Public Health Director 7) Purpose: Eagle County Public Health is the local entity designated by the BOCC to inspect individual ambulances and license the ambulance services on an annual basis and according to state regulations. The licensing district within the county is Western Eagle County Ambulance District (a.k.a. WECAD). S) Schedule: Per state regulations, the license is good for one year: July 1, 2009 -June 30, 2010. 9) Financial considerations and New World Line Item: None 10) Budget Considerations: None 11) Other: RECEIVED JUN 2 4 2009 ?JV ED tQ T��O M EAGLE COUNTY ATTORNEY BY: �, C� �J� . °", Cou nty Attorney's Office Eagle County Commissioners' Office Please return executed contract and copies to Danielle Pieters in HHS. 970- 328 -8835.