QAB Jam Sessions

  1. What equipment is mandatory to be brought in with the transport team when at a receiving facility
    1. Monitor

    2. Response bag
  2. What equipment is mandatory to be brought in with the transport team when at a sending facility
    1. O2 bag

    2. CCT bag

    3. Response bag

    4. Pump

    5. Monitor
  3. According to REACH definitions, what age range are the following:




    Neo - birth to 28 days

    Infant - 29 days to first birthday

    Peds - 1 year to 15th birthday

    Adult - 15 years of age to death
  4. Per REACH protocol, name the drugs that may be given intranasally
    1. Narcan

    2. Fentanyl

    3. Ativan

    4. Versed

    5. Ketamine
  5. Name the two primary medications specific to the Acute Aortic Disease protocol that are utilized for control of heart rate and blood pressure
    1. Esmolol

    2. Nitroprusside
  6. Per REACH protocol, what is the DO NOT MISS associated with the Severe Anaphylaxis protocol
    Utilize Epinephrine IM (or IV, IO without a palpable pulse) and via continuous infusion for refractory hypotension
  7. According to REACH protocol, we must re-zero an art line every _____ feet of cabin altitude change
    every 2000 feet of cabin altitude change
  8. If a patient has an art line, per REACH protocol this is optional to transduce and monitor during transport


    MUST be transduced in transport- even if waveform is dampened
  9. State the 8 patient rights per REACH standards
    • Right -
    • - Patient/person
    • - Medication
    • - Dose
    • - Time
    • - Route
    • - Documentation
    • - Reason
    • - Response
  10. In order to continue IV medication being infused at sending facility, what must we obtain?
    1. a physician's order to continue the medication


    2. obtain a copy of the original physicians's order
  11. What must BOTH crew members do PRIOR to continuation of a medicated infusion?
    All sending hospital infusions and medications are to be double checked and verified by both crew members prior to continuation of medication

    Must complete the Medication Timeout prior to administration of the infusion
  12. When calculating medication doses and rates, per REACH protocol, to what decimal point do we round up to?
    Round Up to the nearest tenth decimal point
  13. It is the responsibility of the medical crew to obtain physician orders for procedures and or chemical administration when these are not established by REACH policy/protocol

    Name 2 methods to obtain and document a physician order
    1. When receiving a physician order, the order must be written on a hospital issued order form.  Have it signed by the physician who rendered the order.

    2. When not practical to have the ordering physician sign the sheet, note it as a verbal or phone order and include appropriate documentation in the ePCR
  14. Perform and record neurologic exams at least every 15 minutes.  The neuro exam should include at least:
    • a. Level of consciousness
    • b. Glascow Coma Scale
    • c. Speech clarity
    • d. Pupil equality, size and reactivity and gaze
    • e. Motor exam:
    •       1) Facial symmetry - unilateral drooping
    •       2) Extremity strength - paresis (weakness), plegia (absent)
  15. Pain: Evaluation, Documentation & Management 

    DO NOT MISS criteria
    • - All pain must be assessed and documented for all patients
    • - Document which pain scale is used for the non-verbal patient
  16. According to REACH protocol, IV access utilizing the External Jugular vein is not allowed.

    True or False?
  17. When transporting to a Neonatal ICU or a Pediatric ICU what must the Medical Crew do prior to departing the referring facility?
    the Medical Crew must contact the receiving physician and discuss plan of care prior to departing the referring facility.  When practical, contact the receiving physician within 10 minutes of making patient contact
  18. True or False

    You have been dispatched to an interfacility transfer, your patient has a life threatening injury, because this is life threatening it is OK to initiate transfer before the regional trauma center has accepted the patient. The sending physician reassures you the trauma center will receive the patient because they are great friends and they will always accept his patients.

    This is a violation of EMTALA
  19. Your adult patient (85kg) has an allergy to Zofran, she is nauseated.

    Per REACH protocol, what drug is your option? and what are the routes of administration and the dose per route?

    • 25 mg IV/IO
    • 50 mg deep IM
  20. There are many medical/surgical/traumatic conditions affected by changes in atmospheric pressure.

    Per REACH protocol, name the 5 conditions that would limit your altitude to 8000 MSL?
    • - Abscesses
    • - Dental work
    • - Diseases of the middle ear
    • - Emphysematous bullae
    • - Pneumothorax or recent chest tube removal
  21. Name the Parkland formula
    • 4ml/kg/%BSA (max 80%)
    • 1/2 total amount in 1st 8 hours
    • 1/4 total amount in 2nd 8 hours
    • 1/4 total amount in 3rd 8 hours
  22. Per REACH protocol, is it necessary to add maintenance IV fluids to the Parkland formula?
  23. Name the Rule of Nines for an adult patient
    • Head 9%
    • Chest 18%
    • Back 18%
    • Arms 9% each
    • Legs 18% each
    • Genital 1%
  24. Name the Rule of Nines for a pediatric patient
    • Head 18%
    • Chest 18%
    • Back 18%
    • Arms 9% each
    • Legs 14% each
  25. Name the DO NOT MISS criteria for the Bubble CPAP protocol
    • Must have spontaneous respiratory effort present
    • For neonates and infants weighing <10 kg
    • Crew must have stron sense that intubation will not be required
  26. Bubble CPAP, describe how to select the appropriate size of RAM cannula
    • Prongs to occlude no more than 60-80% of the nare opening
    • Expect a leak with the cannula - designed to work this way
    • DO NOT attempt to completely seal nares
  27. GCS - Describe the 4 points of the Eye opening response
    • 4 Spontaneous (already open)
    • 3 To Speech
    • 2 To pain
    • 1 None
  28. GSC - Describe the 5 points of the Verbal response
    • 5 Oriented
    • 4 Confused
    • 3 Inappropriate
    • 2 Incomprehensible sounds
    • 1 None
  29. GCS - Describe the 6 points of Best Motor Response
    • 6 Obeys command
    • 5 Localized
    • 4 Withdraws
    • 3 Flexor response (decorticate)
    • 2 Extensor response (decerebrate)
    • 1 None
  30. What are the documentation requirements of the Pressure Easy device?
    A. Document Pressure Easy device indicator in "safe zone" and provide rationale if outside "save zone"

    B. Document rationale if Pressure Easy device is NOT utilized in presence of cuffed ETT
  31. Hypoglycemic Emergencies

    What glucose concentration is used to treat all hypoglycemic patients
  32. Hypoglycemic Emergencies

    Name the Abnormal glucose levels for:
    - Adult
    - Pediatric
    - Neonate
    • Adult <70 mg/dl
    • Pediatric <60 mg/dl
    • Neonate <50 mg/dl
  33. How soon should you assess blood glucose while caring for a child less than 1 yr of age
    Within the first 30 minutes
  34. When transporting a patient with a neurological emergent condition, how often must you document the neuro checks
    every 15 minutes
  35. Intracranial Hemorrhage or Brain Circulation Vascular Occlusion - Per REACH protocol, what are the two acceptable medications to be considered for anti-hypertensive therapy?
    • Nicardipine
    • Labetelol
  36. Pulmonary Edema

    DO NOT MISS points
    • NTG is the first line treatment
    • Consider CPAP/BIPAP prior to advanced airway management
  37. What is the process for an "auto-launch" request?
    • The term "auto-launch" is subject to interpretation
    • 1. According to flightguard an auto-launch is any time a crew is launched without a receiving facility, in which case crew goes to bedside and assists with patient care until a receiving bed is found
    • 2. Auto-launch on scene call will come from an outside source, at which time crew chief will notify FG of destination/manifest/planned receiving if known.  PIC will always check weather, do Baldwin and report this information to FG as with other scheduled flights prior to liftoff
  38. Esmolol for Aortic Disease

    Initial dose?

    Increase how often?

    Dosing Regimen?
    Initiate IV infusion at 50 mcg/kg/min

    Increase rate of infusion q 5 min

    • 50 mcg/kg/min
    • 100 mcg/kg/min
    • 200 mcg/kg/min
    • 300 mcg/kg/min
  39. Esmolol for aortic Disease

    What is MAP goal?
    What is HR goal?
    • MAP goal 60-80 mmHg
    • HR goal 60-80
  40. Acute Aortic Disease

    • Obtain and document bilateral blood pressure
    • Treat the higher pressure
    • Titrate all medications to the MAP goal of 60-80 mmHg
  41. C-MAC Video Laryngoscope
    • Use on all first intubation attempts
    • Do not forget to push record
  42. What is the REACH mission statement
    To provide customer oriented high quality air medical transport services in a safe and efficient manner. In every situation to do what is right for the patient
  43. Describe the components of the Uniform Policy
    • REACH flight suit
    • REACH name tag
    • T-shirt, white or black, crew or turtle neck
    • Boots, black leather or fire resistance material with steel or carbon safety toe
    • Underclothing - natural fibers only
    • Optional - Jacket - black leather, cotton, or Nomex with natural fiber liner
    • Vest/radio pouch, black, fire resistant recommended
    • Hat - REACH issued hat, branding must match that of the employees flight suit
    • Under-helmet scull cap: natural fiber, solid color white or black
  44. Duty Day
    Red Hour
    • 1st hour of shift
    • On-coming Flight team will present in full uniform at the start of the Red Hour
    • Off going crew will transfer the assigned controlled substance supply to the on-coming medical crew
    • Hand off assigned radios and phones
    • Report any significant info from prior duty shift that may have an immediate impact on operation for the on-coming team
    • Oxygen status aircraft/portable
    • Know equipment or supply deficiencies
    • Any required follow up
    • Any know customer relations events scheduled
  45. Fatigue mitigation

    Required rest prior to shift
    Medical crew will have at least ten hours of rest before standing duty on an assigned shift
  46. Fatigue stand-down
    • 1. Team member who identifies that they are fatigued to the point of no longer being able to safelyperform their assigned duties will immediately self-report to the other team members.
    • 2. The PIC will make immediate contact with Flight Guard to advise the unit service status has changedsecondary to a fatigue stand-down.
    • 3. The fatigued Flight Team member(s) will immediately retreat to the private crew rest area for twohours. During this two hour period, the fatigued Flight Team member(s) will not be disturbed except inthe case of an emergency.
    • 4. Flight Guard will notify the AOC that the unit’s service status has changed to out of service secondaryto a fatigue stand-down. The unit may remain available for “team flights only” dependent on thenumber of Medical Crew members requiring the fatigue stand-down and the mission profile of theeffected base.
    • 5. Flight Guard will automatically return the unit to in-service status at the end of the two-hour period.
    • 6. A Flight Team member who requires more than two hours rest during a fatigue stand-down willcontact the AOC via Flight Guard.
    • 7. A Flight Team member who identifies that they will require a fatigue stand-down while away from thebase (e.g. after the completion of a transport but still at the receiving facility) will immediately contactthe AOC via Flight Guard to discuss their ability to safely return to the base. If the Flight Team is notable to safely return secondary to fatigue, the AOC will provide assistance and resources as needed.If the Flight Team is capable of safely returning, the two hour stand down period will not begin untilthe Flight Team has arrived at the base. The PIC will re-contact Flight Guard on arrival at the base totrigger the beginning of the stand-down period.
    • 8. A Flight Team member that requests a fatigue stand-down within the last two hours of their assignedduty shift will be required to rest at the base even if the two hour rest period crosses over their end ofshift time.
    • 9. A fatigue stand-down request made after being assigned to a transport request will require a postshiftdebrief with the AOC and/or the Flight Team’s Program Manager
  47. Non-Patient Based Flight Operations

    Search Request
    • 1. The Flight Team may be used to assist in the search of a potentially lost or injured individual onlyafter confirmation that all local or regional search-capable assets have been utilized.
    • 2. The Flight Team will not assist in the recovery of a deceased individual.
    • 3. The unit status will remain in-service during the search activity.
    • 4. Search activity lasting longer than 30 minutes of flight time will require the Flight Team to consult withthe AOC for continued operations.
  48. The Flight Team will target the following on-scene time requirements:
    Scene call: 10 minutes from landing to take off at scene landing zone

    • Inter-facility transport total bedside time:
    • i. General medical or traumatic injury: 20 minutes
    • ii. Aortic emergency: 15 minutes
    • iii. STEMI or stroke: 15 minutes
  49. 1.2.8 Availability, Post-Transport
    • An encumbered aircraft will be returned to in-service and available status immediately uponlanding at the receiving facility helipad.
    • If the aircraft is unable to land directly at the receivingfacility, the aircraft will be returned to available status when the PIC contacts Flight Guard andplaces the aircraft in-service.
  50. The Medical Crew member designated to sit on the left side of the aircraft will utilize helmet mountedNight Vision Goggles during all phases of night-time flight operations to include:
    • a. En-route to a scene or referring facility.
    • b. En-route from a scene or referring facility to a receiving facility (when authorized by thespecific airframe NVG STC).
    • c. En-route back to base from any location.
  51. The following manufacturerrecommended aircraft litter-base weight limits should be considered when deciding if a patient can besafely transported in a specific airframe:
    • a. Agusta 109: 350lb/159Kg
    • b. Agusta 109 Power: 375lb/170kg
    • c. Agusta 119: 375lb/170kg
    • d. Bell 407: 450lb/204Kg
    • e. Beechcraft 200 King Air: 450lb/204Kg
    • f. Eurocopter AS350: 400lb/181Kg
    • g. Eurocopter 135/G: 350lb/159Kg
    • h. Pilatus PC-12 (tail number N271SM): 375lb/170kg
    • i. Pilatus PC-12 (tail numbers N273SM and N275SM): 560lb/254kg
  52. There are many times during the course of a flight wherein the Flight Team should observe sterile cockpitcommunications. Sterile cockpit is defined as refraining from all unnecessary communication includingunnecessary radio traffic. Listed below are general rules when all crewmembers should observe sterilecockpit rules:
    • Fixed-Wing Applications
    • a. Take-off and landing phases of flight.
    • b. During IFR operations
    • .c. When operating within Class B, C or D airspace.
    • 2. Rotor-Wing Applications
    • a. Take-off and landing phases of flight.
    • b. During landing zone reconnaissance operations.
    • c. During IFR operations.
    • d. When operating within Class B, C or D airspace.
  53. Clinical Quality Improvement
    Peer Review
    • The Primary Contact is responsible for assuring the completion of the daily CQI process
    • 1. The Medical Crew will perform peer review CQI on any and all outstanding base specific Patient CareRecords.
    • 2. Verification of peer review CQI completion will require both of the on-duty Medical Crew member’snames and credentials entered in the CQI section.
  54. Scheduled Shift Call-Off (<24 hours’ notice):
    • A Medical Crew member calling off for a shift scheduled within the next 24 hours will make directcontact with the on-duty Primary Contact at the effected base and notify them of their inability to workas scheduled.
    • a. If within reason a reasonable hour to do so, the on-duty Flight Team will contact all availablelocal off-duty staff to communicate the immediate staffing need and attempt to find coverage.
    • b. If unsuccessful in finding coverage, the Primary Contact will notify the AOC via Flight Guard.
    • c. The AOC will use ePro to immediately page out the open shift to all available regional staff.
    • d. If the call-out takes place before 17:00 hours, the AOC will contact the effected ProgramManager to assist with a staffing plan.
    • e. If the call-out takes place after 17:00 hours, the AOC will review the Medical Crew on-callstatus for the effected shift and consider the overall regional staffing picture.
    • f. If unsuccessful in finding coverage, the AOC will activate, if available and qualified, the oncallMedical Crew member for that base/region.
    • g. On-call Medical Crew members may be requested to work at bases or regions other thanwhere they are assigned as a full time employee. As such, on-call Medical Crew membersare strongly encouraged to have their flight helmet and uniform with them when standing anon-call shift.
    • h. Medical Crew members scheduled to be on-duty the day of a call-off may be requested tomove to a base other than where they are assigned as a full time employee. The AOC willattempt to minimize such movement but all Medical Crew members should understand theoperational necessity surrounding service-wide staffing needs.
    • i. The AOC will update ePro as needed.
    • j. If unable to staff the unit, the AOC will email the effected Program Manager and Director ofProgram Operations of the changed status.
  55. Controlled Substance Inventory count,
    When to perform
    • Controlled medications will be inventoried by ALL medical crew members presentat the base at least once daily and anytime there is a change in personnel. This willoccur each time there is a change in medical crew regardless of the frequency perday.
    • At the beginning of each shift or change of personnel, all off‐going medical crewmembers and all on‐coming medical crew members are to verify the types andamounts of controlled substances in stock.
  56. Controlled Substance Inventory count
    What does it include
    • This daily inventory of all controlled substances shall includeverification of expiration dates on each container, both in thenarcotic pouch AND the narcotic safe.
    • Handling of packaging MUST be conducted during the daily inventoryof controlled substances to ensure ALL original packaging is intactand has not been tampered with.
  57. Controlled Substance Inventory Count
    What is documented
    All entries from the day prior shall also be audited to confirm ALLrequired data has been entered (date, CAD number, name,given/wasted amounts, both signatures present, etc). If ANYinformation is missing during the audit, the off‐going crew may notleave the base until the information has been completed.
  58. Controlled Substance Inventory count

    The total counts of the pouch and the stock inventory will then be entered on thecontrolled substance inventory log and will be signed immediately by off‐goingcrewmember who was controlling the pouch and the on‐coming crewmemberwho will be receiving the pouch.

    Key points
    • i. Signatures must be legible and include the signee’s type of licensure.
    • ii. Entries shall be made in blue or black ink only.
    • iii. Errors shall be corrected by drawing a single line through the incorrect wording. The writing underneath the line must be readable and the error must be initialed adjacent to the correction by the crew member.
    • iv. The use of correction fluid or erasure material is not permitted.
    • v. Controlled substance may never be brought onto foreign soil, doing so is against Federal law and is prohibited.
  59. Controlled Drug Waste Procedures

    Unused or broken vials
    • a. All wasting of unused controlled substances or broken vials must bewitnessed by two medical crew members and entered on the narcotic log.
    • b. Wasting of medications must be completed in accordance with theMedication Management policy.
    • i. To render injectable controlled drugs unusable the medicationshould be withdrawn from the vial and disposed of in the sharpscontainer by “squirting” the drug into the receptacle.
    • ii. Do not put medications into the water system or garbage.
  60. Controlled Drug Waste Procedures

    • All expired controlled substance wastes must be completed in the presence of the Program Manager or Regional Clinical Manager.
    • In the event expired controlled substances are discovered in the supply(pouch or safe), the PM must be notified and the expired substances secured in the safe in such a way as to prevent their use.
  61. Controlled Drug Waste Procedures

    Full vial wastes
    • In the event a full vial of medication is wasted, a Controlled Substance Waste form must be completed and scanned and emailed to the Clinical Compliance Coordinator within 24 hours of the waste. The original form will be sent via inter office mail to the Program Manager. This shall include full container waste of expired controlled substances
    • The Clinical Compliance Coordinator will forward the form to the Medical Director and Director of Clinical Services. 
    • Examples of full vial waste include:
    • i. Broken vial
    • ii. Open, unused vial
    • iii. Full dose of medication drawn up and not administered.
  62. Controlled Drug Waste Procedures

    Reporting of Discrepancies
    • a. Any incident involving an unresolved discrepancy in the narcotic count,including loss of controlled substances, controlled substances removed from custody of the on‐duty crew member or any errors/omissions in the narcotic log will be immediately reported to the Administrator on call(AOC). The AOC will ensure that the Director of Clinical Services and Chief Medical Officer are notified within 24 hours of the event.
    • b. A company incident report will be completed and submitted via the company reporting system and an internal investigation will be initiated.
    • c. Loss of controlled substances or unresolved discrepancies will be reported by the Director of Clinical Services or designee to all appropriate regulatory agencies.
    • d. All efforts to resolve discrepancies should be exhausted before the off going crew will be relieved from duty by the AOC or Program Manager
  63. Controlled Drug Waste Procedures

    Record Keeping
    • All controlled drug use must be documented on the REACH Patient Care Record.
    • Each base will maintain a separate controlled substance log.
    • The Program Manager (PM) or designee will monitor controlled substance policy compliance through log audits and will ensure that all completed controlled substance logs are scanned and emailed to the Clinical Compliance Coordinator on the first business day following the end of the month.ii. These logs will be audited monthly by the Clinical Compliance Coordinator and the Chief Medical Officer or designee.
    • The Clinical Compliance Coordinator will maintain electronic copies of all Controlled Substance Inventory logs for a minimum of three years.
  64. Controlled Drug Crew Responsibilities
    It is the responsibility of each REACH Medical Crew member acting in the capacity of providing ALS services for the company to have all solutions, medications, and other ALS adjuncts within their respective scope of practices at their availability. This includes medications controlled by the D.E.A. and Section 1100 of the California Health and Safety Code
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QAB Jam Sessions
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