Document No.2161

DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

CHAPTER 61

Statutory Authority: S.C. Code Sections 44-61-150,

44-78-65, and Act 263 of 1996 (effective January 1, 1997).

R.61-7. Emergency Medical Services.

Synopsis:

The Department is substantially amending R.61-7. The regulation is being replaced in its entirety. Amendments include: licensing procedures; the process and standards for approving ambulance permits; standards for training and certification of ambulance attendants; personnel requirements for transporting patients; criteria for revocation or suspension of certificates of emergency medical technicians (EMT's); standards for air ambulances; and standards for the prehospital DNR (Do Not Resuscitate) Procedure. The revisions update the criteria in each section of the regulation as the result of considerable study by the State Emergency Medical Advisory Council and its subcommittees. Revisions also include changes necessary to implement Act 263, 1996 (House Bill 4365), codified at S.C. Code Section 44-61-65, and which took effect on January 1, 1997.

Provisions of the Act require that DHEC license first responder organizations who respond and provide advanced life support patient care at the scene with certified emergency medical technicians, but which do not seek license for transport. See Table of Changes below and Statement of Need and Reasonableness herein at the end of the text of the regulation.

Discussion of Revisions:

Table of Contents Addition of Sections 310 and 606 to incorporate new First Responder regulations.
Section II Revises the definitions of: Advanced Life Support; Advanced Life Support Service; Medical Control; Off-Line Medical Control Physician; On-Line Medical Control Physician; Enhanced Basic Life Support Service; and Intermediate Extended Life Support Service. Adds two new definitions: EMT First Responder Service; and Basic Life Support Service.

These revisions and additions to definitions provide consistence with the requirements of the law as revised and effective January 1, 1977.

Section 301.A.1 Revises the language to incorporate the licensure of first responder organizations.

Section 301.A.4 Revises the language to incorporate the licensure of first responder organizations. It also provides further definition of the requirements for notification of substantial changes in the organization of the licensee.

Sections 301.A.7, Revises the language to incorporate the licensure of first responder 8 and 9 organizations and corrects other language for grammar and accuracy.

Section 301.A.10 Addition to provide minimum limits for liability and malpractice coverage.

Section 301.B Revised for grammatical corrections.

Section 301.C Revision relaxes the period requirement for inspections of ambulances and enables random inspections dependent on past history of compliance.

Section 301.D Revises the language to incorporate the licensure of first responder F and G organizations and corrects other language.

Section 301.H&I Addition provides the Department with the opportunity to make exceptions for the benefit of the community.

Section 302-A.1 Revises the language to incorporate the licensure of first responder B, and C organizations and corrects other language.

Section 302.F Addition provides for medical control physician to withdraw medical control authority to EMS personnel.

Section 303 Revised to provide clearer requirements for response times of ambulance services and corrects other language.

Section 304 Revises to specify that the requirements of this section are for ambulance services only.

Section 305 Revised to specify that the requirements of this section are for ambulanceservices only, and corrects other language.

Section 306 Revised to specify that the requirements of this sections are for ambulance services only, and corrects other language.

Section 307 Revised to provide clarification of the use of special purpose ambulances.

Addition to clarify use of special purpose ambulances.

Section 308 Corrects grammar and language. Addition of descriptive title.

Section 309 Addition of descriptive title.

Section 310 New section added to provide description of requirements for licensure of First Responder providers as provided under the law as amended.

Section IV.A. Addition to further define the process for issuing a permit for an ambulance vehicle. Corrects grammar.

Section 501 Introductory paragraph is revised to correct language to allow update of federal KKK standards. Paragraph A remains the same.

Section 501-B; Replaced in entirety - Deletes the requirements which allow modification

B.1 and B.2 of vehicles to become ambulances and also causes the remaining paragraphs to be renumbered consecutively.

Section 501-C Renumbered section is revised to correct grammar and language.

Section 501.D.1 Renumbered section is revised for grammatical change

Section 501.E.1.a, Renumbered paragraphs are revised to exempt Special Purpose

E.2.c & d Ambulances from requirements for doors. Also corrects grammar and language.

Section 501.G.3 Renumbered paragraph removes combustible flares as acceptable. Also corrects spelling.

Section 501.H.1; Renumbered sections corrects spelling, grammar and language.

I.3;I.5.a; and J.c

Section 501.K Addition to renumbered section provides exception on requirement for spare tire within 20 mile radius of home county.

Section 501.L, Renumbered sections are revised to correct spelling and grammar.

and 501.M

Section 601 Revised in entirety. Provides an updated list of minimum equipment required on an ambulance, reflecting the changes in technology and in the "state of the art" for providing prehospital care, especially for pediatric patients.

Section 602 Revisions provide an updated list of equipment required on an ambulance for "advanced life support" services, reflecting the changes in technology and in the "state of the art" for providing prehospital care, especially for pediatric patients.

Section 603 Revised in entirety to update the list of rescue equipment required on an ambulance, to reflect the changes in technology in rescue equipment.

Section 604 Revised in entirety to correct spelling grammar and references.

Section 605 Corrects grammar and clarifies equipment.

Section 606 New section added to provide list of equipment required of Licensed First Responders as enabled under revision of the law.

Section VII Changes sanitation standards from "ambulance" to licensed providers to Title include Licensed First Responders.

Section 701.A Corrects spelling.

Section 702; Adds wording to make this section specific to ambulances, corrects 702.D; 702.G spelling and grammar.

Section 702.H Revised to meet new infection control standards.

Section 702.I Adds requirements for a "Sharps container" and container for disposal of medical waste.

Section 703.A&B Revises the language to incorporate the licensure of first responder organizations

Section 704.B&D Corrects spelling and grammar, and expands acceptable options for humidifiers.

Section 705.C Revised to correct to current infection control standards.

Section 706.A, Corrects spelling.

C & E

Section 707.B&C Corrects grammar and clarifies name of equipment.

Section 708.A&B Replaces sandbags with "state of the art" devices.

Section VIII Revises title by deleting wording that confines requirements to ambulance Title services.

Section 801.A Revised to correct terms described in this section.

Section 801.B Updates terminology and description of the Intermediate Training Program.

Section 801.C; Revised to update terminology. Section 4.b incorporated into section 4.a

802.D.1,2&3; to clarify the relationship between the requirements. Section 4.c is

801.D.4.b&c renamed as Section 4.b.

Section 802.A Revised to update terminology related to the levels of EMT's and revises and 802.A.1 grammar.

Section 802.A.2 Revised to allow the Department flexibility in requirements as they relate to the National Registry.

Section 802.B Revised to update terminology related to the levels of EMT's.

Section 802.C Revised to clarify terminology.

Section 802.D Revised to updates terminology and description of process for re-activating EMT certification.

Section 803; Revised to update terminology and changes the wording that simplifies 803.A the process and requirements for the EMT to become certified and adds and 803.Ba requirement to carry a pocket I.D. card

Section 804 Revised in entirety to update terminology and changes the wording that simplifies the process and requirements for the EMT to become certified. Section 804-B also requires that an EMT, on duty, carry a pocket card at all times to identify himself.

Section 805 Revised in entirety to update terminology and changes the wording that simplifies the process and requirements for the EMT to become recertified.

Section 806 Revised in entirety to update terminology consistent with amended legislation.

Section 807.A&C Revised to update terminology.

Section 808 Revised in entirety the requirements for instructors involved in EMT training at all levels.

Section IX.A Revised to update terminology.

Section X.A Revised language for clarity.

Section X.B Additions of five conditions under which an EMT may have his certificate revoked or suspended.

Section 1101 Adds title in text to be consistent with table of contents.

Title

Section 1101.E. Revised to provide clearer language.

1.d. and e.

Section 1101.G. Revised to provide clearer language and updated terminology.

1.2&3

Section 1102 Revised in entirety - Provides an updated list of minimum equipment required on an Air ambulance, reflecting the changes in technology and in the "state of the art" for providing prehospital care, especially for pediatric patients.

Section 1104 Revised in entirety - Provides an updated list of equipment required on an ambulance for "advanced life support" services for Air Ambulances, reflecting the changes in technology and in the "state of the art" for providing prehospital care, especially for pediatric patients.

Section 1105 Revised to update terminology.

Section 1206.F Revised to correct grammar.

Section 1207.C.4 Added to clarify for the EMT that he must have, in his possession, the original or a copy of the DNR order during transport of the patient.

Instructions: Replace R. 61-7, Emergency Medical Services, in its entirety.Text:

61-7. EMERGENCY MEDICAL SERVICES.

TABLE OF CONTENTS

SECTION I. SCOPE OF ACT 1118 of 1974 AS AMENDED.

SECTION II. DEFINITIONS.

SECTION III. LICENSING PROCEDURES.

Section 301. Application.

Section 302. Medical Control Physician.

Section 303. Licensing Basic Life Support.

Section 304. Licensing Enhanced Basic Life Support.

Section 305. Licensing Intermediate Life Support.

Section 306. Licensing Advanced Life Support.

Section 307. Licensing Special Purpose Ambulance Providers.

Section 308. Advanced Life Support Information.

Section 309. Advertising Level of Care.

Section 310. Criteria for License Category - EMT First Responder

SECTION IV. PERMITS, AMBULANCE: VEHICLE AND EQUIPMENT.

SECTION V. STANDARDS FOR AMBULANCE PERMITS.

Section 501. Ambulance Design and Equipment.

SECTION VI. EQUIPMENT.

Section 601. Minimum Ambulance Medical Equipment.

Section 602. Intermediate and Advanced Equipment.

Section 603. Minimum Ambulance Rescue Equipment.

Section 604. Convalescent Transport Units.

Section 605. Special Purpose Ambulance Equipment

Section 606. EMT First Responder Equipment

SECTION VII. SANITATION STANDARDS FOR LICENSED PROVIDERS

Section 701. Exterior Surfaces.

Section 702. Interior Surfaces - Ambulance.

Section 703. Linen.

Section 704. Oxygen Administration Apparatus.

Section 705. Resuscitation Equipment.

Section 706. Suction Unit.

Section 707. Splints.

Section 708. Cots, Stretchers, and Spine Boards.

Section 709. Bandages and Dressings.

Section 710. Obstetrical Kits.

Section 711. Oropharyngeal Appliances.

Section 712. Communicable Diseases.

Section 713. Miscellaneous Equipment.

Section 714. Equipment and Materials Storage Areas.

Section 715. Personnel.

SECTION VIII. TRAINING AND CERTIFICATION OF AMBULANCE ATTENDANTS.

Section 801. Emergency Medical Technician Training Programs.

Section 802. Certification.

Section 803. Application for Certification as an Emergency Medical Technician- Basic.

Section 804. Application for Certification as an Emergency Medical Technician-Intermediate or Paramedic.

Section 805. Recertification as an Emergency Medical Technician-Basic.

Section 806. Recertification as an Emergency Medical Technician-Intermediate or Paramedic.

Section 807. EMT Course Approval Regulations.

Section 808. EMT Instructor Training Programs and Certification.

SECTION IX. PERSONNEL REQUIREMENTS.

SECTION X. REVOCATION OR SUSPENSION OF CERTIFICATES OF EMTs.

SECTION XI. AIR AMBULANCES.

Section 1101. Licensing.

Section 1102. Basic Life Support Air Ambulance, Medical Equipment Requirements.

Section 1103. Interfacility and Special Purpose Air Ambulance.

Section 1104. Advanced Life Support Air Ambulance Medical Equipment Requirements.

Section 1105. Medication and Fluids for Advanced Life Support Ambulances.

Section 1106. Rescue Exception.

SECTION XII. DO NOT RESUSCITATE ORDER.

Section 1200. Purpose and Authority of Emergency Medical Services Do Not Resuscitate Order.

Section 1201. Definitions.

Section 1202. General Provisions.

Section 1203. Revocations of EMS DNR Order.

Section 1204. Patient's Assessment and Intervention.

Section 1205. Resuscitative Measures to be Withheld or Withdrawn.

Section 1206. Procedures to Provide Palliative Treatment.

Section 1207. DNR Information for the Patient, the Patient's Family, the Health Care Provider and EMS Personnel

SECTION I. SCOPE OF ACT 1118 OF 1974 AS AMENDED.

A. Establishment of EMS program.

B. General licensing, certification, inspection and training procedures.

C. Establishment of an Emergency Medical Service Council and duties of the Council.

D. Establishment of the Department of Health and Environmental Control authority for enforcement of these rules and regulations.

SECTION II. DEFINITIONS.

A. Definitions as stated in the Act.

B. EMT is defined as an Emergency Medical Technician.

C. Continuing education is defined as an educational program designed to update the knowledge and skills of its participants by attending conventions, seminars, workshops, educational classes, labs, symposiums, etc. Points toward recertification may be awarded for successful completion of approved activities.

D. Special purpose ambulance: means an ambulance equipped and designated to transport only patients in need of specialized types of care. Examples include neonatal ambulances, cardiac-care ambulance, etc.

E. Air ambulance: Any aircraft that is intended to be used for and is maintained or operated for transportation of persons who are sick, injured or otherwise incapacitated.

F. Rotocraft: A helicopter or other aircraft that uses a rotary blade to permit vertical and horizontal flight without the use of wings.

G. Fixed Wing: Any aircraft that uses fixed wings to permit it to take off and fly.

H. FAA: Federal Aviation Administration. The agency of the federal government that governs aircraft design, operations, and personnel requirements.

I. Flight Nurse: A licensed registered nurse who is trained in all aspects of emergency care except roadside pickups and who has been so designated by the Department.

J. Advanced Life Support: Treatment of life-threatening medical emergencies through the use of techniques such as endotracheal intubation, administration of drugs or intravenous fluids, cardiac monitoring, and electrical therapy by a qualified person pursuant to these regulations.

K. Advanced Life Support Service:

A service provider that in addition to basic life support minimum standard, provides at least 2 EMT's, one of which is an EMT-Intermediate or Paramedic and demonstrates the capability to provide IV therapy, advanced airway care, approved drug therapy, cardiac monitoring and electrical therapy on 80% of all emergency calls.

L. Medical Control: Medical Control is usually provided by a unit's physician who is responsible for the care of the patient by the provider's medical attendants. Actual medical control may be direct by two-way voice communications (on-line) or indirect by standing orders or protocols (off-line) control.

M. Off-Line Medical Control Physician: A provider's medical control physician who actually takes responsibility for treatment of patients in the prehospital setting, by standing orders or protocols.

N. On-Line Medical Control Physician: The physician who directly communicates with EMT's regarding appropriate patient care procedures en-route. An on-line medical control physician must be available for all EMT's performing procedures designated as such by DHEC.

O. Enhanced Basic Life Support Service: A service provider that meets all criteria for basic life support minimum standard and is able to provide two Basic EMT's to 80% of all calls.

P. Intermediate Extended Life Support Service:

A service provider that, in addition to basic life support minimum standard, provides at least 2 EMT's, one of which is an EMT-Intermediate or EMT-Paramedic and demonstrates the capability to provide IV therapy and advanced airway care on 80% of all emergency calls.

Q. EMT First Responder Service. A licensed agency providing medical care at the EMT-Basic level or above, as a nontransporting first responder.

R. Basic Life Support Service. A service provider that meets all criteria for basic life support minimum standard and is able to provide one EMT-Basic to 100% of all calls.

SECTION III. LICENSING PROCEDURES.

Section 301. Application.

A. Application for license shall be made to the Department by private firms, volunteer groups or non-federal governmental agencies. The application shall be made upon forms in accordance with procedures established by the Department and shall contain the following:

1. The name and address of the owner of the licensed provider or proposed licensed provider;

2. The name under which the applicant is doing business or proposes to do business;

3. A description of each ambulance, including the make, model, year of manufacture or other distinguishing characteristics to be used to designate applicant's vehicle.

4. The location and description of the place or places from which the licensed provider is intended to operate. The Department shall be notified within five (5) working days of any expansion of the service or if the headquarters or any substation locations are changed.

5. Personnel roster showing EMT's name, certification number and expiration date.

6. Type of license applied for.

7. Name, address, and phone number of medical control physician.

8. Name, fax, e-mail, and phone number of person in charge of day-to-day operations.

9. Number of units and level of service provided from each transporting station.

10. Insurance information, to include name of insurance company, agent and type of coverage. The minimum limits of coverage shall be $500,000 liability and $250,000 malpractice per occurrence.

11. Such other information as the Department shall deem reasonable and necessary to a fair determination of compliance with this regulation.

B. The Department shall issue a license valid for a period of two (2) years when it is determined that all the requirements of this regulation have been met.

C. Subsequent to issuance of any license, the Department shall cause to be inspected each licensed provider (ambulances, equipment, personnel, records, premises, and operational procedures) whenever that service is initially licensed. Thereafter, services will be inspected by the Department on a random basis with a percentage of permitted ambulances inspected. These random inspections will be conducted dependent upon past compliance history.

D. The Department is herein authorized, pursuant to Section 44-61-70 of the code, to suspend or revoke a license so issued at any time it determines that the holder no longer meets the requirements prescribed for operating as a licensed provider.

E. Renewal of any license issued under the provision of this Act shall require conformance with all the requirements of this Act as upon original licensing.

F. The Department shall be notified within five (5) working days when changes of ownership of a licensed provider are impending or occur so that a new license may be issued.

G. The issuance of a license shall not be construed so as to authorize any person, firm, corporation, or association to provide EMT first responder services or ambulance services or to operate any ambulance not in conformity with any ordinance or regulation enacted by any county, municipality or special purpose district or authority.

H. The South Carolina Department of Health and Environmental Control reserves the right to make exceptions to these standards where it is determined that the health and welfare of the community requires the services of the provider. When an "exception" applies to an existing provider, it will continue to meet the standards in effect at the time it was licensed.

I. Conditions which have not been covered in these regulations shall be handled in accordance with the standard practices as interpreted by the Department.

Section 302. Medical Control Physician.

Each licensed provider that provides patient care shall retain a medical control physician to maintain quality control of the care provided, whose functions include the following:

A. Quality assurance of patient care including development of protocols, standing orders, training, policies, and procedures; and approval of medications and techniques permitted for field use by direct observation, field instruction, in-service training or other means including, but not limited to:

1. Patient care report review

2. Review of field communications tapes

3. Post-run interviews and case conferences

4. Investigation of complaints or incident reports

B. The medical control physician shall serve as medical authority for the licensed provider, to perform in liaison with the medical community, medical facilities, and governmental entities.

C. The medical control physician may have disciplinary authority sufficient to oversee the quality of patient care for all EMT's and retain other responsibilities as may be negotiated by agreement with the service.

D. Providers will register their medical control physician with the Department and provide a copy of their current standing orders and authorized drug list signed and dated by medical control physician.

E. The Department must be notified of any change in medical control physician, drug list or standing orders within ten (10) days.

F. The medical control physician may withdraw at his/her discretion, the authorization for personnel to perform any or all patient care procedure(s).

Section 303. Criteria for License Category of Basic Life Support (Ambulance)

(Minimum Standard):

A. Must have ambulances that are permitted or can be permitted pursuant to these regulations.

B. Fifty percent (50%) of personnel assigned to ambulance duty must be currently certified EMT's with no less than five (5)

EMT's associated with the provider.

C. Must have staffing patterns, policy and procedure, and if necessary, mutual aid agreement to assure that an ambulance is en route with at least one EMT to all emergent calls within five (5) minutes or the next closest staffed ambulance must be dispatched, excluding prearranged transports. (Minimum crew shall be one driver and one EMT.) Volunteer Services (services not utilizing paid personnel) without on site personnel must have staffing patterns, policy and procedure, and if necessary, mutual aid agreement to assure that an ambulance is en route with at least one EMT to all emergent calls within ten (10) minutes or have the closest staffed ambulance dispatched. (Minimum crew shall be one driver and one EMT.)

D. The Department will, upon request, be furnished with staffing patterns, policy and procedure, and mutual aid agreements that assures compliance with the en route times noted in section 303-C.

E. Industries that provide ambulance service for their employees may exempt the minimum number of EMT's noted in Section 303-b, as long as they meet en route times and staffing requirements of the regulations.

F. The provider conducts a minimum of three (3) hours of provider based training in equipment use and patient care for each EMT associated with the service each quarter. A training record is kept on each EMT and will be available for inspection by the Department.

G. The provider maintains records that include, but are not limited to, approved ambulance run reports, employee/ member rosters, time sheets, call rosters, training records and dispatch logs that show at least time call received, type call and time unit is en route. Such records are to be available for inspection by the Department with copies furnished upon request.

Section 304. Criteria for License Category - Enhanced Basic Life Support: (Ambulance)

To be categorized as an enhanced basic life support provider, the provider must meet all criteria established for basic life support, minimum standard. Additionally, the provider must demonstrate the ability to have an ambulance en route with a minimum of two EMT's (any level) at least 80% of the time.

Section 305. Criteria for License Category - Intermediate/Extended Life Support: (Ambulance)

To be categorized as an intermediate/extended life support provider, the provider must meet all criteria established for basic life support, minimum standard. Additionally, the provider must demonstrate sufficient equipping and staffing capability to assure that life support consisting of at least IV therapy and advanced airway care are en route with two EMT's, one of which must be an Intermediate or Paramedic, at least 80% of the time on emergency calls.

Section 306. Criteria for License Category - Advanced Life Support: (Ambulance)

To be categorized as an advanced life support provider, the provider must meet all criteria established for basic life support, minimum standard. Additionally, the provider must demonstrate sufficient equipping and staffing capability to assure that life support consisting of IV therapy, advanced airway care, cardiac monitoring, electrical therapy and drug therapy, approved by the Department and the unit medical control physician, are en route with a minimum of two EMT's, one of which must be an EMT-Paramedic at least 80% of the time on emergency calls.

Section 307. Criteria for License Category - Special Purpose Ambulance Provider: (Ambulance) A. Have an approved vehicle that is in compliance with Section II (D) of these regulations and meets minimum equipment requirements, as noted in Section 605.

B. Have a medical control physician as delineated in Section 302 of these regulations. .

C. Provide the Department with copies of policy and procedure for the operation of the special purpose ambulance.

D. Provide a list of special purpose equipment that is carried on the special purpose ambulance and is approved by the medical control physician for review and approval by the Department.

E. Provide other license information delineated in Section 301 of these regulations.

F. Except during extenuating circumstances, special purpose ambulances shall be used for interfacility transports only.

Section 308. Advanced Life Support Information: Ambulance service providers professing to provide advanced life support level of care for a patient must at all times transport said patient in an ambulance which is fully equipped as an advanced life support unit, per the regulations, with an EMT-Paramedic, physician or RN, as delineated in the regulations, in attendance with the patient.

Section 309. Advertising Level of Care: Ambulance service providers may not advertise that they provide a level of life support above the category for which they are licensed.

Section 310. Criteria for License Category - EMT First Responder

A. Fifty percent (50%) of personnel assigned to First Responder duty must be currently certified EMT's with no less than five (5) EMT's associated with the provider.

B. Must have staffing patterns, policy and procedure, to assure that a First Responder unit is en route with at least one EMT to all emergent calls within five (5) minutes. Volunteer units (services not utilizing paid personnel) without on site personnel must have staffing patterns, policy and procedure to assure that a First Responder unit is en route with at least one EMT to all emergent calls within ten (10) minutes.

C. The Department will, upon request, be furnished with staffing patterns, policy and procedure to assure compliance with the en route times noted in Section 310-B.

D. The provider conducts a minimum of three (3) hours of provider based training in equipment use and patient care for each EMT associated with his service each quarter. A training record is kept on each EMT and will be available for inspection by the Department.

E. The provider maintains records that include, but are not limited to, approved patient care report forms, employee/member rosters, time sheets, call rosters, training records and dispatch logs that show at least time call received, type call and time unit is en route. Such records are to be available for inspection by the Department with copies furnished upon request.

SECTION IV. PERMITS, AMBULANCE: VEHICLE AND EQUIPMENT.

A. Before a permit may be issued for a vehicle to be operated as an ambulance, its registered owner must apply to the Department for an ambulance permit. Prior to issuing an original or renewal permit for an ambulance, the Department shall determine that the vehicle for which the permit is issued meets all requirements as to design, medical equipment, supplies and sanitation as set forth in the regulations of the Department. Prior to issuance of the original permit, if the ambulance does not meet all minimum requirements and loses points during the inspection, no permit will be issued.

B. Permits will be issued for specific ambulances and will be displayed on the lower left-hand corner of the windshield of the ambulance.

C. No official entry made upon a permit may be defaced, altered, removed or obliterated.

D. Permits may be issued or suspended by the Department.

E. Permits must be returned to the Department when the ambulance or chassis is sold or removed from ambulance service.

SECTION V. STANDARDS FOR AMBULANCE PERMIT.

Section 501. Ambulance Design and Equipment. The minimum criteria for design of emergency ambulances utilized in South Carolina is contained in the Federal Specification KKK-A-1822-A, 1974 and any subsequent changes or future additions which are incorporated by reference as a part of these regulations. For purposes of simplification, the following designs have been extracted from the above Federal Specification and are hereby established as criteria effective with the publication of these regulations. Any emergency ambulance purchased after publication of these requirements must meet the following minimum criteria.

A. Based Unit: Chassis should not be less than three quarter ton. In the case of modular or other type body units, the chassis shall be proportionate to the body unit, weight and size; power train shall be compatible and matched to meet the performance criteria listed at 3.4 and 3.6 of the above Federal Specifications; maximum effective sized tires; power steering; power brakes; heavy duty cooling system; heavy duty brakes; west coast mirrors; heavy duty front and rear shock absorbers; 70 amp battery; 100 amp alternator; front end stabilizer; driver and passenger seat belts; padded dash; collapsible steering wheel; door locks for all doors; inside mirror; inside control handles on rear and side doors. Four-wheel drive is recommended for operating in mountainous area during winter months where snow and ice is prevalent, in rough terrain and at the seashores where traction in sand is difficult.

B. Color: Color of the exterior surface of the vehicle shall be white in combination with an international orange stripe to be 6" in width and blue lettering.

C. Emblems and Markings: The "Star of Life" shall be on each side and the rear of the body. The same shall be on the front if the vehicle design permits. The word "AMBULANCE" shall be under or beside each star, in blue letters of not less than 6" in height. The word "AMBULANCE" in blue letters shall be in mirror image (reverse reading) on the front of the vehicle for mirror identification by drivers ahead, 4" in height with a star to the left and right of "AMBULANCE." The name of the licensee shall be on each side of the ambulance at least 3" high.

D. Interior Patient Compartment Dimensions:

1. Length: The compartment length shall provide a minimum of 25" clear space at the head and 15" at the foot of a 76" litter.

Minimum inside length will be 116".

2. Width: Minimum inside width is 69 inches.

3. Height: Inside height of patient compartment shall be a minimum dimension of 60" from floor to ceiling.

E. Access to Vehicle:

1. Driver Compartment.

a. Driver's seat will have an adjustment to accommodate the 5th percentile to 95th percentile adult male.*

*Note: This means that the driver's area will accommodate the male drivers who are 90% of the smallest and largest in stature, which includes weight and size.

b. There shall be a door on each side of the vehicle in the driver's compartment.

c. Separation from the patient area is essential to afford privacy for radio communication and to protect the driver from an unruly patient. Provision for both verbal and visual communication between driver and attendant will be provided by a sliding shatterproof glass partition at upper portion of partition. The bulkhead must be strong enough to support an attendant's seat in the patient area at the top of the patient's head and to withstand deceleration forces of the attendant in case of accident.

2. Patient Compartment:

a. There shall be a door on the right side of the patient compartment near the patient's head area of the compartment. The side door must permit a technician to position himself at the patient's head and quickly remove him from the side of the vehicle should the rear door become jammed.

b. Rear doors shall swing clear of the opening to permit full access to the patient's compartment.

c. All patient compartment doors shall incorporate a holding device to prevent the door closing unintentionally from wind or vibration. When doors are open the holding device shall not protrude into the access area. Special purpose ambulances are exempt as long as access/egress is not obstructed due to wheelchair ramps or other specialized equipment.

d. Spare tire storage shall be positioned such that the tire can be removed without disturbing the patient.

F. Interior Lighting:

1. Driver Compartment: Lighting must be available for both the driver and an attendant, if riding in the driving compartment, to read maps, records, etc. There must be shielding of the driver's area from the lights in the patient compartment.

2. Patient Compartment: Illumination must be adequate throughout the compartment and provide an intensity of 40-foot candles at the level of the patient for adequate observation of vital signs, such as skin color and pupillary reflex, and for care in transit. Lights should be controllable from the entrance door, the head of the patient, and the driver's compartment. Reduced lighting level may be provided by rheostat control of the compartment lighting or by a second system of low intensity lights.

G. Illumination Devices:

1. Illumination Devices: Flood and load lights - there shall be at least one flood light mounted not less than 75" above the ground and unobstructed by open doors located on each side of the vehicle. A minimum of one flood light, with a minimum of 150 lumens equivalent, shall be mounted above the rear doors of the vehicle.

2. Warning lights - at a minimum alternating flashing red lights must be on the corners of the ambulance so as to provide 360' conspicuity.

3. FlaResolution Number: Six red reflectorized or chemically induced illumination devices may be substituted for flares. Combustible type flares are not acceptable.

4. One set battery jumper cables, minimum 04 gauge copper, 600 amp rating.

H. Seats:

1. A seat for both driver and attendant will be provided in the driver's compartment with armrests on each side of driver's compartment.

2. Technician (Patient Compartment): two fixed seats, padded, 18" wide 18" high; to head of patient behind the driver, the other one may be square bench type located on curb (right) side of the vehicle. Space under the seats may be designed as storage compartments.

I. Safety Factors for Patient Compartment:

1. Litter Fasteners: Crash-stable fasteners must be provided to secure a primary and secondary litter.

2. Litter Restraint: If the litter is floor supported on its own support wheels, a means shall be provided to secure it in position under all conditions. These restraints shall permit quick attachment and detachment for quick transfer of patient.

3. Patient Restraint: A restraining device shall be provided to prevent longitudinal or transverse dislodgement of the patient during transit, or to restrain an unruly patient to prevent further injury or aggravation to the existing injury.

4. Safety Belts for Drivers and Attendants:

a. Quick-release safety belts will be provided for both driver and attendants, plus all seated patients (squad bench). These safety belts will be retractable and self-adjustable.

5. Mirrors:

a. There shall be two exterior rear view mirrors (West Coast type), one mounted on the left side of the vehicle and one mounted on the right side. Location of mounting must be such as to provide maximum rear vision from the driver's seated position.

b. There shall be an interior rear view mirror to provide the driver with a view of occurrences in the patient compartment.

6. Windshield Wipers and Washers:

a. Vehicle is to be equipped with two electrical windshield wipers and washers in addition to defrosting and defogging systems.

7. Sun Visors:

a. There shall be a sun visor for both driver and attendant.

J. Environmental Equipment:

1. Driver/Patient Compartment:

a. Heating: Shall be capable of heating the compartment to a temperature of 750F. within a reasonable period while driving in an ambient temperature of O0F. It must be designed to recirculate inside air, also be capable of introducing 20% of outside air with minimum effect on inside temperature. Fresh air intake shall be located in the most practical contaminant-free air space on the vehicle.

b. Heating Control: Heating shall be manually controlled. The heater blower motors must be at least a three (3) speed design.

Separate switches will be installed in patient compartment.

c. Air Conditioning: Air Conditioning shall have a capacity sufficient to lower the temperature in the driver's and patient's compartment to 75'F within a reasonable period and maintain that temperature while operating in an ambient temperature of 95'F. The unit must be designed to deliver 20% of fresh outside air of 95'F ambient temperature while holding the inside temperature specified. All parts, equipment, workmanship, etc., shall be in keeping with accepted air conditioning practices.

d. Air Conditioning Controls: The unit air delivery control may be manual or thermostatic. The reheat type system is not required in the driver's compartment unit. Switches or other controls must be within easy reach of the driver in his normal driving position. Air delivery fan motor shall be at least a three (3) speed design. Switches and other control components must exceed in capacity the amperage and resistance requirements of the motors.

e. Insulation: The entire body; side, ends, roof, floor, and patient compartment doors shall be insulated to minimize conduction of heat, cold, or external noise entering the vehicle interior. The insulation shall be vermin and mildew-proof, fireproof, non-hygroscopic, non-setting type. Plywood floor when undercoated will be considered sufficient insulation for the floor area.

K. Spare Tire: A spare wheel with appropriate size, inflated, mounted, tire shall be provided in addition to a jack and wheel lug wrench. An exception to the above is that no spare tire is required provided the ambulance remains within a twenty (20) mile radius of its home county. Any out-of-county transports beyond this twenty (20) mile radius will require a spare tire and all associated equipment.

L. Storage Cabinets: All cabinets must meet the criteria of 3.10.17 as to types of surfaces and 3.11.3 as to design and storage.

All cabinets must be screwed or bolted together and fully braced so as to reduce noise and hold up under continued use. All cabinets must be screwed or bolted to the floor or body so that they can be removed in the event that body work is needed on base vehicle. Cabinets must be of sufficient size and configuration to store all necessary equipment. All equipment must be accessible to attendant at all times, even when loaded.

M. Two-Way Radio Mobile: Two way radio mobile equipment shall be included which will provide a reliable system operating range of at least a 20 mile radius from the base station antenna. An RF power output of 30-50 watts will usually be required.

The mobile installation shall provide microphones for transmitting at both the driver's position and in the patient's compartment.

Selectable speaker outputs, singly and in combination, shall be provided at the driver's position, in the patient's compartment, and through the PA system. Radio frequencies shall be consistent with the State EMS Radio Communication Plan so as to meet the need of the routine ambulance service.

N. Siren-Public Address: Siren and public address systems shall be provided. If a combined electronic siren and public address system is provided, in siren operation, the power output shall be 100 watts. In voice operation the power output shall be 45 watts through two exterior mounted speakers. The public address amplifier shall be independent of the mobile radio unit.

O. InterCommittee Involved: An intercommunication facility shall be provided between the driver's position and the patient compartment. The speaker/microphone unit in the patient compartment shall stand by in the "talk" mode. Any necessary talk/listen switching shall be done by the driver. The intercom amplifier shall be independent of the mobile radio equipment.

P. Antenna: Rooftop mounted with coaxial cable installed to cab compartment of ambulance.

Q. Glass Windows: All windows, windshield and door glass must be shatterproof.

SECTION VI. EQUIPMENT.

Section 601. Minimum Ambulance Medical Equipment - Effective the date of these Rules and Regulations, all ambulances will be required to be equipped with, but not limited to the following:

A. Minimum of two litters.

1. One multilevel, elevating, wheeled cot with elevating back. Two patient restraining straps (chest and thigh) minimum, at least two inches wide shall be provided.

2. One secondary patient transport litter, with a minimum of two patient restraining straps. Minimum acceptable litter is vinyl covered, aluminum frame, folding stretcher.

B. Suction Devices.

1. An engine vacuum operated or electrically powered, complete suction aspiration system, shall be installed permanently on board to provide for the primary patient. It shall have wide bore tubing.

2. A portable suction device, battery or gas operated, with wide bore tubing and six ounce reservoir and a "Y" or "T" valve to control suction. The unit must provide continuous suction for 15 minutes.

3. There must be an assortment of suction catheters (minimum of 2 each) on board. Sizes 6 fr, 8 fr, 10 fr, 16 fr, 18 fr. A rigid suction catheter (e.g. Yankaur) will also be carried. Minimum 2 each.

C. Bag Mask Ventilation Units.

1. One adult, hand-operated. Valves must operate in all weather, and unit must be equipped to be capable of delivering 90-100% oxygen to the patient.

2. One pediatric, hand-operated. Valves must operate in all weather and unit must be equipped to be capable of delivering 90-100% oxygen to the patient. Must include safety pop off mechanism with override capability.

3. One infant, hand-operated. Valves must operate in all weather and unit must be equipped to be capable of delivering 90-100% oxygen to the patient. Must include safety pop-off mechanism with override capability.

4. The following sized masks will be carried aboard all permitted ambulances to be used in conjunction with the ventilation units above, 0,1,2,3,4,5. Masks must be clear. Either the disposable or non-disposable types are acceptable.

D. Nonmetallic Oropharyngeal Airways - Berman type, adult, child and infant sizes. All airways shall be clean and individually wrapped.

1. Large adult - 100 mm

2. Med. adult - 90 mm

3. Large child - 80 mm

4. Child - 60 mm

5. Infant - 43 mm

E. "S" tube type airways may not be substituted for Berman type airways.

F. Oxygen Equipment

1. Portable oxygen equipment: Minimum "D" size (360 Liter) cylinder, two required (one full spare cylinder). Liter flow gauges shall be non-gravity, dependent (Bourdon Gauge) type. Additionally, when the vehicle is in motion, all oxygen cylinders shall be readily accessible and securely stored.

2. Permanent On-Board Oxygen Equipment: The ambulance shall have a hospital type piped oxygen system, capable of storing and supplying a minimum of 2400 liters of humidified medical oxygen.

3. Single use, individually wrapped, non-rebreather masks and cannulas in adult and pediatric sizes shall be provided (3 each).

4. A no smoking sign will be prominently displayed in the patient compartment.

G. Bite sticks, either commercially made or three tongue blades taped together and padded. (Clean and individually wrapped).

H. Twelve sterile dressings (minimum size 5" x 9").

I. Thirty-six each sterile gauze pads 4"x 4".

J. Twelve each bandages, self adhering type, minimum three inches by five yards. Bandages must be individually wrapped or in clean containers.

K. Aluminum Foil, roll, 18" x 25", sterile and wrapped or a minimum of four commercial sterile occlusive dressings, four inches by four inches.

L. Adhesive Tape, hypoallergenic, one, two and three inches wide.

M. Burn sheets, two, sterile.

N. Splints:

1. Traction type, lower extremity, overall length of splint 43 inches, with limb support slings, padded ankle hitch, traction device and heel stand. Either the Bi-polar or Uni-polar type is acceptable.

2. Padded type, two or more, three feet long, of material comparable to four-ply wood for coadaptation splinting of the lower extremities.

3. Padded wooden type, two or more, 15 inches by three inches, for fractures of the upper extremity. (By local option, commercially available arm or leg splints may be substituted for items N-2,3 above).

O. Spinal immobilization devices:

1. Short spine board, at least 16 inches by 36 inches. Commercially vest type KED, XP1 or other equivalent is acceptable.

Addition: Child backboard or pedi-board or any type commercially available spinal immobilization device sized for the pediatric patient.

2. Long spine board, at least 16 inches by 72 inches constructed of three-quarter inch plyboard or equivalent material and having at least three quarter inch runners on each side for lifting. If not equipped with runners, board must be designed so handholds are accessible even with gloves on.

3. Cervical collars to accommodate the infant, child, medium adult and large adult sizes. Collars must be manufactured of semirigid or rigid material.

4. Three, two inches by nine foot patient restraint straps.

5. Head immobilization device, commercially available or towel/ blanket rolls.

P. Five each triangular bandages.

Q. Two blankets.

R. Bandage shears, large size.

S. Obstetrical kit, sterile. The kit shall contain gloves, scissors or surgical blades, umbilical cord clamps or tapes, dressings, towels, perinatal pad, bulb syringe and a receiving blanket for delivery of infant.

T. Poison kit, syrup of ipecac and activated charcoal.

U. Blood pressure manometer, cuff and stethoscope.

1. Blood pressure set, portable (non mercurial type).

2. Stethoscopes.

V. Emesis basin or commercially available emesis container.

W. Bedpan and urinal.

X. Two dependable flashlights or electric lanterns, minimum size, two-D-cell or six volt lanterns.

Y. Minimum of one fire extinguisher, C02 or dry chemical, five pound capacity.

Z. Working gloves, two pair with leather palms.

AA. Minimum of 1000 cc of sterile water or normal saline solution for irrigation.

BB. Personal protective equipment (gloves, masks, gowns and eyeshields).

CC. At the option of the medical control the following equipment may be added:

1. Laryngoscope handle with batteries.

2. Laryngoscope blades, adult, child and infant sizes. Infant sizes shall be 0,1,2 (straight). In addition, a #2 curved blade will be carried.

3. Six disposable endotracheal tubes, sizes to be from 2.5-9.0 with at least one of each size available. An intubation stylette sized for the neonate patient shall also be available (6 fr.).

Section 602. Intermediate and Advanced Equipment. Ambulances providing intermediate and advanced life support must, in addition to meeting all other requirements of section 601 must have the following equipment:

A. Butterfly or scalp vein needles between 19 and 25 gauge, a total of four.

B. Four each 14, 16, 18 and 22 gauge IV cannulae.

C. Two Macro drip sets.

D. Two Micro drip sets.

E. Three 21 or 23 and three 25 gauge needles, total six.

F. Three tourniquets.

G. Laryngoscope handle with batteries.

H. Laryngoscope blades, adult, child, and infant sizes. Infant sizes shall be 0,1,2 (straight). In addition, a #2 curved blade will be carried.

I. Six disposable endotracheal tubes sizes to be from 2.5-9.0 with at least one of each size available. An intubation stylette sized for the neonate patient shall also be available (6 fr.).

J. Equipment for drawing blood samples. (Medical Control Option)

K. Syringes, two each 1 ml, 3 ml, 10 ml, 20 ml, and one 50 ml.

L. Twelve (12) alcohol and iodine preps for preparing IV injection sites.

M. One (1) roll of tape, at least ¸ inch wide.

N. Five (5) band-aids.

O. A minimum of 4 liters of ringers lactate, normal saline or a combination thereof.

P. Antishock trousers MAST. (Medical Control option)

Q. Intraosseous needles in sizes 14, 18, ga. (1 each).

R. Ambulances providing advanced cardiac life support must be equipped with a battery powered (DC) portable monitor-defibrillator unit with EKG printout. The monitor-defibrillator equipment utilized by the service has the capability of producing hard copy of patient's EKG.

S. Such drugs as may be approved by the Board for possession and administration by EMT's trained and certified in their use and authorized by the medical control physician, as documented to the Department.

T. A minimum of 2 liters of D5W.

Section 603. Minimum Ambulance Rescue Equipment.

A. The following additional items will be carried by each ambulance:

1. Wrench. One 12-inch with adjustable open end.

2. Screwdriver, one 6-inch, with regular blade.

3. Screwdriver, one 6-inch, Phillips type.

4. Hacksaw, one, with six blades.

5. Pliers, one 10-inch vise grip.

6. Hammer, one four pound with 15 inch handle

7. One axe.

8. Wrecking Bar, one 24-inch (bar and two preceding items can either be separate or combined as a forcible entry tool).

9. Crowbar, one 51", with pinch point.

10. Tin Snip, double action, one, minimum eight inches.

11. Protective head gear and eye protection devices (minimum two each) must be carried on each ambulance. Standard fire face shield not acceptable.

B. The following additional items will be carried when an ambulance is not normally accompanied by a rescue vehicle on rescue calls.

1. Bolt cutter, one with one and one-half inch jaw opening.

2. Power jack and spreader tool, one portable.

3. Shovel, one with pointed blade.

4. Ropes, two each 50 feet in length. Diameter of at least three quarter inch, except for nylon which may be one-half inch.

5. Reflective vest, one for each crew member.

Section 604. Convalescent Transport Units.

A. Convalescent transport units must meet the requirements of Section 601, minimum ambulance medical equipment, minus items C-3, H, K, M, T, Z.

B. Convalescent transport units are exempted from Section 603, minimum ambulance rescue/extrication equipment.

C. Convalescent transport units are required to be equipped with a radio that meets the requirements of Section 501-N (minus the PA system) whenever transporting a patient outside of its home county.

D. Convalescent transport units may not have any emergency markings, but shall display the words "Convalescent Transport" and the name of the licensee in letters a minimum of 3" in height, on each side of the ambulance.

Section 605. Special Purpose Ambulance Equipment:

A. All special purpose ambulances will be equipped with at least the following items from Section 601 of these regulations: A-1, B, C(appropriate size), D, F, G, U, V, W, X, Y, in addition to special purpose equipment that is documented to the Department per Section 307. Item A-1 can be replaced by a specialized patient transfer device so long as there is a provision to safely secure the device in the special purpose ambulance.

B. Special purpose equipment as documented to the Department per Section 307 of these regulations must be on the special purpose ambulance when it is in use and is subject to inventory and inspection by the Department as provided for in Section 307 of these regulations.

Section 606. EMT First Responder Equipment.

A. The First Responder Agency's vehicle must be properly marked as to identify the vehicle as an emergency vehicle.

B. The First Responder Agency will provide a minimum of one EMT-Basic for each response.

C. All first responder vehicles will be equipped with at least the following items from section 601 of these regulations: B-2,B-3,C,D,F-1,F-3,F-4,G,H,I,J,K,L,M,N-2,N-3,O,P(3 each),Q,R,S,U,X(1 each),Y,Z,BB,CC.

D. The first responder agency must at all times be able to communicate with (a) on-line medical control, (b) dispatch center and (c) the local transporting service.

E. Equipment In Addition to 606-C To Be Carried By EMT-Intermediate First Responders.

1. Four each, 14, 16, 18 and 22 gauge IV cannulae.

2. Two Macro Drip sets.

3. Two Micro Drip sets.

4. One Sharps type container.

5. A minimum of 4 liters of Ringers Lactate, Normal Saline or a combination thereof..

6. 500cc of D5W.

7. Three Tourniquets.

8. Syringes, two each, 1ml, 3ml, 10ml and 20ml.

9. Twelve each, Alcohol and Betadine Preps for preparing IV injection sites.

10. Five Bandaids.

F. Equipment In Addition To 606-C & D To Be Carried By EMT-Paramedic First Responders.

1. A battery powered Monitor-Defibrillator capable of producing hard copy of the patient's EKG.

2. Such drugs as may be approved by the Board for possession and administration by EMT's trained and certified in their use and authorized by the medical control physician, as documented to the Department.

G. All medical and patient care equipment used by a licensed first responder organization shall meet the same standards for cleanliness and communicable diseases as is required of transporting EMS units.

SECTION VII. SANITATION STANDARDS FOR LICENSED PROVIDERS:

Section 701. Exterior Surfaces:

A. The exterior of the vehicle shall have a reasonably clean appearance.

B. All exterior lighting should be kept clear of foreign matter (insects, road grime, etc.) to assure adequate visibility.

Section 702. Interior Surfaces Patient Compartment-Ambulance.

A. Interior surface shall be of a nonporous material to allow ease of cleaning. Carpet-type materials shall not be used on any surface of the patient compartment.

B. Floors shall be free from sand, dirt and other residue that may have been tracked into the compartment.

C. Wall, cabinet, and bench surfaces shall be kept free of dust, sand, grease, or any other accumulated surface matter.

D. Interiors of cabinets and compartments shall be kept free from dust, moisture or other accumulated foreign matter.

E. Bloodstains, vomitus, feces, urine and other similar matter must be cleaned from the unit and all equipment after each call, using hypochlorite solution described in Section 702-H.

F. Window glass and cabinet doors shall be clean and free from foreign matter.

G. A receptacle shall be provided for the deposit of trash, litter, and all used items, etc.

H. An EPA recommended germicidal/viralcidal agent or a hypochlorite solution of 99 parts water and 1 part bleach must be used to clean patient contact areas not otherwise soiled, as noted in Part E above. For surfaces where such a EPA solution is not recommended, alcohol or hypochlorite solution can be used. I. A container specifically for the deposit of contaminated needles or syringes and a second container for contaminated or infectious waste shall be provided and will be easily accessible from the patient compartment.

Section 703. Linen.

A. Storage area for clean linens shall be provided in such configuration so that linens remain dry and clean. (Ambulance)

B. Freshly laundered or disposable linens (minimum of six sets) shall be used on cots and pillows, and shall be changed after each patient is transported. (Ambulance)

C. Soiled linen is to be transported in a closed plastic bag or container and removed from the ambulance as soon as possible.

D. Blankets and towels shall be clean and stored in such a manner to assure cleanliness.

1. Towels shall not be used more than once between laundering.

2. Blankets shall be laundered/cleaned as they become soiled. Blankets should preferably be of a hypoallergenic material designed for easy maintenance.

Section 704. Oxygen Administration Apparatus.

A. Oxygen administration devices such as masks, cannulas, and delivery tubing shall be disposable.

B. All masks and cannulas and tubing shall be individually wrapped and not opened until used on a patient.

C. Once used, the masks, cannulas and tubing is to be disposed of and not reused.

D. Oxygen humidifiers should be filled with distilled or sterile water upon use only. Reusable humidifiers must be cleaned after each use. The humidifier must be dated when initially hooked up. Disposable, single use humidifiers are acceptable in lieu of multiuse types.

Section 705. Resuscitation Equipment.

A. Bag mask assemblies and masks shall be stored in the original container, jump kit, or a closed compartment to promote sanitation of the unit.

B. The bag mask assembly shall be free from dust, moisture and other foreign matter.

C. Masks, valves, reservoirs and other items or attachments for bag mask assemblies shall be cleaned and sanitized after each use. A ten (10) minute sodium hypochlorite soak ninety-nine (99) parts water to one (1) part bleach, or other acceptable method shall be used.

Section 706. Suction Unit.

A. Suction hoses shall be clean and free from foreign matter. Preferably, disposable type hoses should be used.

B. Suction reservoir shall be clean and dry.

C. Suction units shall be clean and free from dust, dirt or other foreign matter.

D. Tonsil tips and suction catheters shall be of the disposable type, stored in sterile packaging until used. Tonsil tips and suction catheters shall not be reused.

E. Suction units with attachments shall be cleaned and sanitized after each use. (See Section 705-C).

Section 707. Splints.

A. Padded splints shall be neatly covered with a nonpermeable material and clean. When the outside cover of the splint becomes soiled, they should be thoroughly cleaned and replaced.

B. Pneumatic trousers, if used, shall be clean and free from dust, dirt or other foreign matter.

C. Commercial splints shall be free of dust, dirt or other foreign matter.

D. Traction splints with commercial supports shall be clean and free from accumulated material.

E. All splinting materials must be stored in such a manner as to promote/maintain cleanliness.

Section 708. Cots, Stretchers and Spine Boards.

A. Pillows, mattresses and head immobilization devices (HIDs) shall be covered with a nonpermeable material and in good repair.

B. Cots, pillows, stretchers, HIDs and spine boards shall be clean and free from foreign material.

C. Canvas or neoprene covers on portable type stretchers shall be in good repair.

D. All restraint straps/devices shall be kept clean and shall be washed immediately if soiled.

E. Wooden spine boards shall be sealed with an appropriate substance to facilitate cleaning.

F. All spine boards shall be free from rough edges/areas that may cause splinters.

Section 709. Bandages and Dressings.

A. Bandages need not be sterile, but they must be clean. They should be individually wrapped, or stored in a closed container or cabinet to insure cleanliness.

B. Dressings must be sterile, individually packaged and sealed, and stored in a closed container or compartment. If the seal is broken or wrap is torn, the dressing is to be discarded.

C. Dressings or burn sheets that are not commercially wrapped must be sterilized in an autoclave or gas sterilizer, with the date of sterilization shown on each item. Items with a sealed plastic dust cover may remain on the unit no longer than six months without being resterilized or rotated with other sterile equipment. Cloth covered items must be resterilized or rotated at least every thirty (30) days.

D. Triangular bandages must be washed after each use if not the disposable type.

E. All bandages or dressings that have been exposed to moisture or otherwise have become soiled must be replaced.

Section 710. Obstetrical Kits.

A. All OB kits must be sterile and wrapped with cellophane or plastic. If the wrapper is torn or the kit is opened but not used, the items in the kit that are not individually wrapped must be resterilized or discarded and replaced.

B. OB kits that are not commercially wrapped must be sterilized in an autoclave or gas sterilizer with a date of sterilization shown on the item. Items with a sealed plastic cover may remain on the unit no longer than six months without being resterilized or rotated at least every thirty (30) days.

Section 711. Oropharyngeal Appliances

A. Instruments inserted into a patient's mouth or nose shall be single service, individually wrapped and stored properly. Oropharyngeal airways designed for multi use shall be sterilized in an autoclave or gas sterilizer, Cidex or sodium hypochlorite soak (ninety-nine (99) parts water to one (1) part bleach) and individually wrapped.

Section 712. Communicable Diseases.

A. When an ambulance or transport vehicle has been utilized in the transport of a patient known to have a communicable disease, the vehicle must be taken out of service until cleaning and disinfecting is completed.

B. Linen must be removed from the cot and properly disposed of, or immediately placed in a plastic bag or container and sealed until properly cleaned.

C. Patient contact areas, equipment and any surface soiled during the call, must be cleaned in accordance with Section 702, Part H of these guidelines.

Section 713. Miscellaneous Equipment.

A. Miscellaneous equipment such as scissors, stethoscopes, BP cuffs and/or other items used for direct patient care should be cleansed as they become soiled. Items should be kept clean and free from foreign matter.

Section 714. Equipment and Materials Storage Areas.

A. Equipment not used in direct patient care shall be in storage spaces that prevent contamination/damage to direct patient care equipment or materials.

Section 715. Personnel.

A. All personnel functioning on the vehicle shall present themselves in a clean, neat appearance at all times.

B. Hands and forearms should be thoroughly washed with soap and tepid water after handling each patient, paying particular attention to cleanliness of the nail beds.

C. Uniforms/clothing should be neat, clean or changed if they become soiled or exposed to vomitus, blood or other foreign

matter.

SECTION VIII. TRAINING AND CERTIFICATION

Section 801. Emergency Medical Technician Training Programs.

A. Emergency Medical Technician-Basic Training Program - This program is established by the South Carolina Department of Health and Environmental Control and is conducted in local technical colleges, colleges and vocational schools. The curriculum for this training program is the Department of Transportation curriculum for EMT's or any other curriculum approved by the South Carolina Department of Health and Environmental Control.

B. Emergency Medical Technician-Intermediate Training Program - This program is established by the South Carolina Department of Health and Environmental Control to provide a level of care between the basic and Paramedic programs. The curriculum for this training program is the Department of Transportation curriculum for EMT-Intermediate or any other curriculum approved by the South Carolina Department of Health and Environmental Control.

C. The Emergency Medical Technician-Paramedic Training Program - To develop greater proficiency in skills, especially life-saving emergency care, through advanced study in the basic sciences and management of life-threatening problems, EMT-Paramedic training will be promoted. This program is established to further the paramedical education within South Carolina. This program, more lengthy in substance and training requirements, is designed to produce emergency medical personnel with a higher degree of capability. The curriculum for this program is the curriculum developed by the U.S. Department of Transportation and referred to as the National Standard EMT-Paramedic Training Course and any other EMT-Paramedic training program as developed or established and approved by the South Carolina Department of Health and Environmental Control.

D. Candidates may complete their required refresher training program by one of the following methods:

1. Complete a state developed and approved EMT-Basic, EMT-Intermediate, or EMT-Paramedic refresher course as appropriate to the individual certification level, including a state practical and written examination.

2. Complete refresher course requirements by attending state approved C.E. unit lectures and/or seminars that equate to the regular structured refresher courses, including a state practical and written examination.

3. Complete a state approved in-service training program that meets the requirements of DHEC, including a state practical and written examination. In-service training program requirements include, medical control physician participation and supervision of the service's program. Participation includes development of the service's in-service training program to meet DHEC requirements and the needs of the individual service.

4. EXCEPTIONS - Candidates may exempt the state written and/or practical examinations if they meet the following criteria:

a. Candidates that complete a state approve in-service program may, if otherwise qualified, exempt the practical examination if the medical control physician signs a statement indicating the individual is competent in all the skills published by DHEC for the level of EMT certification the candidate is pursuing. Candidates may also exempt the written examination if the medical control physician signs a statement indicating they are knowledgeable, proficient, and capable of performing all of the duties for the level of EMT certification they are pursuing.

b. Candidates that are nationally reregistered may exempt the state written and practical examinations provided they complete a state approved refresher course and obtain a medical control physician waiver.

E. Criteria for Special Purpose EMT. In order to be issued a valid special purpose EMT certificate, one must meet all of the following criteria:

1. The special purpose EMT must be a registered nurse.

2. The special purpose EMT must have completed an acceptable training program for delivery of the special area or possess experience in that special care area satisfactory to the Department.

3. The special purpose EMT must be employed by the medical service which utilizes the special purpose ambulance and recommended by the director of the medical service which utilizes a special purpose ambulance.

4. The medical service by which the special purpose EMT is employed must have operational procedures and medical protocols directing the daily operations of the special purpose EMT and special purpose ambulance. These medical protocols must be in written form, approved and signed by the director of the medical service in order for the special purpose EMT to administer medical treatment required by the protocols. These protocols must be reviewed and signed annually by the director of the medical service.

F. Pilot Programs. The Department is authorized to initiate pilot programs to provide training in new and innovative procedures that have potential for lifesaving care. The EMT's who participate in these programs are allowed to perform the pilot procedures, under medical control physician supervision, during the period of the pilot program. Research gained from the pilot projects will be used to revise and upgrade existing EMT programs.

Section 802. Certification.

A. Effective September 1, 1975, no persons shall act or serve in the capacity of attending a patient in an ambulance without first completing, minimally, an approved Emergency Medical Technician-Basic Training Program and holding a South Carolina certificate as an emergency medical technician-Basic. Emergency medical technician-Basic certificates are in force for three years and are subject to renewal before expiration date if the candidate continues to meet state qualification. Certified emergency medical technician-Basic may perform those functions taught in the approved EMT Basic curriculum. Emergency medical technician-Basic certificates may be issued to eligible personnel, 18 years of age or older, upon the satisfactory completion of any of the following requirements:

1. Any person completing the South Carolina Department of Health and Environmental Control approved "Emergency Medical Technician-Basic Course" (to include examination),

or . . .

2. Any person who has successfully passed the written and practical portions of the "National Registry of Emergency Medical Technician-Basic" examination and other requirements established by the Department, and is currently registered, (applies to initial State certification only) "These candidates are exempt from the state practical and written certification examinations,"

or . . .

3. Any person who receives comparable training within three years of their application. Comparable course credit may be determined by submitting copies of course certification and content to the South Carolina Department of Health and Environmental Control for review. Comparable course credit is normally allotted to selected individuals completing extensive emergency courses, such as emergency room nurses, RNs, and armed forced medical personnel. These personnel must satisfactorily pass the State approved practical and written emergency medical technician examinations.

4. Special Purpose EMT Qualifications. DHEC may issue a valid special purpose EMT certificate to those registered nurses who are both extensively trained in a particular special area of care and approved by the Department to attend patients needing that particular care while being transported in special purposes ambulances. These special purpose EMT's may be assisted by other health professionals who are determined qualified and approved by the Department to assist in attendance of the patient during transportation in a special purpose ambulance.

B. Emergency Medical Technician-Intermediate or Paramedic - No person shall act in the capacity of an emergency medical technician-Intermediate or Paramedic without satisfactorily completing an approved emergency medical technician Intermediate or Paramedic training course and holding a South Carolina certificate. EMT-Intermediate or Paramedic certificates are in force for three years and subject to renewal if the candidate continues to meet State qualifications.

Appropriate certificates will be issued to candidates who satisfactorily complete an EMT-Intermediate or Paramedic program approved by the Department.

C. Guidance for EMT's - All currently certified emergency medical technicians may only "engage in those practices for which they have been trained" in a state approved curriculum and for which the supervising physician will assume responsibility. In all cases, an EMT will perform procedures under the supervision of a physician licensed in the State of South Carolina. Means of supervision should be direct, by standing orders or by radio and telephone communications.

D. Emergency medical technician certificates that have expired may be reactivated by the candidate completing an appropriate EMT refresher course and submitting an application for certification prior to taking state examinations.

E. Emergency medical technicians must notify the EMS Division each time they have change of address and furthermore, provider associated EMT's will provide their correct address on the personnel roster required in Section 301-A-5 of these regulations each time their provider submits a license or relicensure application.

Section 803. Application for Certification as an Emergency Medical Technician-Basic.

A. Applications for certification as a emergency medical technician-Basic in South Carolina are to be submitted to the Division of Emergency Medical Services, South Carolina Department of Health and Environmental Control, indicating that the student has satisfactorily completed the required curriculum to include any required clinical experience. Reciprocity candidates must provide a copy of their out-of-state certificate that has at least six months remaining on it prior to its expiration date, and have met other requirements as established by the Department. After passing the state examinations, candidates will be issued certificates that expire three years from the issued date of their out-of-state certificate. National registry candidates requesting initial reciprocity may exempt the state practical and written examinations providing they have a certificate that has at least six months remaining on it prior to its expiration date and have met other requirements as established by the Department.

B. Upon receipt of the completed application, practical and written examinations will be given at such times as will be scheduled by the Department. An emergency medical technician-Basic certificate will be issued by the South Carolina Department of Health and Environmental Control upon satisfactory completion of the practical and written examinations, and will be effective for three years from the date of issue. A pocket ID card will be issued along with the Basic certificate and must be in the possession of the EMT-Basic at all times that patient care is rendered.

Section 804. Application for certification as an Emergency Medical Technician-Intermediate or Paramedic.

A. Applications for certification as an EMT-Intermediate or Paramedic in South Carolina are to be submitted to the Division of Emergency Medical Services, South Carolina Department of Health and Environmental Control, using forms provided by the Division of EMS as follows:

1. Candidates completing a South Carolina approved course must provide a certificate application card that indicates satisfactory completion of the course.

2. Candidates applying for certification by reciprocity must provide a certificate application card along with a copy of their out-of-state certificate that has at least six months remaining on it prior to its expiration date and have met other requirements as established by the Department. They must also provide statements from a South Carolina licensed provider and the unit medial control physician indicating sponsorship. After passing the state examinations, candidates will be issued certificates that expire three years from the out-of-state issue date. National Registry EMT-Paramedic candidates requesting reciprocity, may on their initial certification, exempt the state practical and written examinations.

B. Candidates that meet the requirements in "A." above will be permitted to take the state examinations. Candidates that pass the state examinations will then be issued an intermediate or advanced EMT certificate as appropriate by DHEC which will be effective for three years. Candidates from out-of-state will be provided certificates that expire three years from the issue date of the out-of-state certificate. A pocket ID card will be issued along with the EMT-Intermediate or Paramedic certificate and must be in the possession of the EMT-Intermediate or Paramedic at all times that patient care is rendered.

Section 805. Recertification as a Emergency Medical Technician-Basic.

A. Recertification as an emergency medical technician-Basic within a 12-month period prior to the expiration date of the EMT-Basic certificate, each emergency medical technician-Basic is required to submit an application for recertification, indicating completion of an approved EMT-Basic refresher course, CEUs or state approved in-service training program, to qualify for recertification. Upon receipt of this application, the Department will schedule and conduct the practical and written examination, as necessary. Upon satisfactory completion of the practical and written examinations, the Department of Health and Environmental Control will extend the individual's EMT-Basic certification for another three-year period of time.

Section 806. Recertification as an EMT-Intermediate or Paramedic. Each EMT-intermediate or paramedic must do the following prior to their certificate expiring in a three-year period:

A. Submit an application for recertification to DHEC requesting recertification. Application to include:

1. Signed statement from licensed provider's medical control physician indicating he will sponsor and supervise the candidate.

2. Signed statement from the licensed provider's director indicating the candidate is a functioning member of the service.

Provides documentation that he has the required continuing education points, refresher course completion certificate or in-service EMT training completion record as appropriate.

3. Pass the state practical and written examination. Candidates completing in-service training may with concurrence of the medical control physician, exempt the practical and/or written state examinations.

4. Upon successful completion of the above requirements, the Department will renew the applicant's EMT-intermediate or paramedic certificate, as appropriate, for another three-year period.

Section 807. Emergency Medical Technician Course Approval Regulations.

A. All EMT courses at all levels, conducted by EMS regional offices or local technical colleges or vocational centers must be taught by state certified EMT instructors for the level they are teaching.

B. All EMS training institutions must receive prior approval from South Carolina DHEC prior to starting any course.

C. All licensed providers who wish to conduct approved in-service training program must receive prior approval of DHEC and follow the established guidelines of the program.

Section 808. Emergency Medical Technician Instructor Training Programs and Certification.

A. The South Carolina Department of Health and Environmental Control is responsible for the review and approval of all EMT instructor courses. Instructors that meet the requirements and satisfactorily complete an approved instructor's course, will be certified by the Department. Certification will coincide with the EMT certification date.

B. Emergency Medical Technician - Basic Instructor Training Program and Authorization. Requirements for authorization as an initial EMT-Basic instructor are as follows:

1. Be 21 years of age with a high school diploma or GED.

2. Must be currently certified Paramedic with 1 year of experience as an EMT-Paramedic.

3. Have obtained the required score on the paramedic examination(s) as determined by the Department.

4. Complete a state approved EMS instructor course.

5. Be recommended by a teaching institution that sponsors EMT-Basic courses.

6. Provide the Department with an approved and current CPR instructor card.

7. Meet all other requirements as determined by the Department.

C. The South Carolina Department of Health and Environmental Control is responsible for certification of EMT-Intermediate and Paramedic Instructors who must meet the following qualifications:

1. Be a registered nurse with experience and knowledge in critical care areas; OR be a current EMT-Paramedic with 1 year experience, high school or GED, and be 21 years of age.

2. Have obtained the required score on the EMT-Paramedic examination(s) determined by the Department.

3. Meet all instructor requirements in areas such as Pediatrics, Trauma and Cardiology as determined by the Department.

4. Be recommended by teaching institution that sponsors EMT-Intermediate or Paramedic courses.

5. Provide the Department with a copy of an approved and current CPR instructor card.

6. Meet all other requirements as determined by the Department.

7. Complete a state approved EMS instructor course.

D. Instructor certificates may be renewed as follows:

1. Must provide a letter of endorsement from the teaching institution.

2. Be currently certified as an EMT-Paramedic.

3. Provide the Department with a copy of an approved and current CPR instructor card.

4. Have met all teaching requirements as determined by the Department.

5. Pass the paramedic examination(s) with the score determined by the Department; OR participate in 12 hours of Department approved continuing education in Instructor Methodology during the 3 year certification period.

6. Meet all other requirements as determined by the Department.

SECTION IX. PERSONNEL REQUIREMENTS

A. During the transportation of patients, there shall be an emergency medical technician-Basic, intermediate or paramedic in the patient compartment at all times. The crew member with the highest level of certification shall determine which crew member will attend the patient during transport. If advanced life support procedures are in use, the responsible EMT-intermediate or paramedic shall attend the patient in the patient compartment during transport.

B. Exception: Transferring or receiving medical facilities registered nurses are authorized as ground ambulance attendants when assisting emergency medical technicians in the performance of their duties when all of the following requirements are met:

1. The medical care of the patient is beyond the limit of certification of the EMT.

2. When the ambulance transport is between medical facilities or from medical facility to patient's home.

3. When the responsible physician, transferring or receiving, assumes responsibility of the patient and provides appropriate orders, written preferred, to the registered nurse for patient care.

4. The registered nurse is on duty with the appropriate medial facility during the ambulance transport.

SECTION X. REVOCATION OR SUSPENSION OF CERTIFICATES OF EMERGENCY MEDICAL TECHNICIANS

A. The Division of Emergency Medical Services of the South Carolina Department of Health and Environmental Control shall, upon receiving a complaint of misconduct as herein defined, initiate an investigation to determine whether or not suitable cause exists to take action against an emergency medical technician certificate.

1. The initial complaint shall be in the form of a brief statement, dated and signed by the person making the complaint, which shall identify the person who is the subject of the complaint and contain a summary as to the nature of the complaint.

2. Information received by the Department through inspection, complaint or otherwise authorized under S.C. Code, Section 44-61-10, Et. Seq., shall not be disclosed publicly except in a proceeding involving the question of licensing, certification or revocation of a license or certificate.

B. "Misconduct," which constitutes grounds for a revocation or suspension or other restriction of a certificate, shall be a satisfactory showing of any of the following:

1. That a false, fraudulent, or forged statement or document has been used, or any fraudulent, deceitful, or dishonest act has been practiced by the holder of a certificate in connection with any of the certification requirements or official documents required by the Division of Emergency Medical Services.

2. That, while holding a certificate, the holder is convicted of a felony or any other crime involving moral turpitude, drugs, or gross immorality.

3. That the holder of a certificate is addicted to alcohol or drugs to such a degree as to render him unfit to perform as an EMT.

4. That the holder of a certificate has sustained any physical or mental disability which renders further practice by him dangerous to the public.

5. That the holder of a certificate is guilty of obtaining fees or assisting obtaining such fees under dishonorable, false or fraudulent circumstances.

6. That the holder of a certificate is guilty of disregarding an appropriate order by a physician concerning emergency treatment and transportation.

7. That the holder of a certificate has, at the scene of an accident or illness, refused to administer emergency care on the grounds of age, sex, race, religion, creed or national origin of the patient.

8. That the holder of a certificate has, after initiating care of a patient at the scene of an accident or illness, discontinued such care or abandoned the patient without the patient's consent or without providing for the further administration of care by an equal or higher medical authority.

9. That a holder of a certificate has revealed confidences entrusted to him in the course of medical attendance, unless such revelation is required by law or is necessary in order to protect the welfare of the individual or the community.

10. That the holder of a certificate has, by action or omission and without mitigating circumstance, contributed to or furthered the injury or illness of a patient under his care.

11. That the holder of a certificate is guilty of the careless, or reckless, or irresponsible operation of an emergency vehicle.

12. That the holder of a certificate is guilty of a breach of any section of the Emergency Medical Services Act of South Carolina (Act 1118 of 1974) or any subsequent amendment of the Act or any of the Rules and Regulations published pursuant to the Act.

13. That the holder of a certificate has performed skills above the level for which he was certified or performed skills that he was not trained to do.

14. That the holder of a certificate did allow sub-standard care to be administered by another individual without documenting a supervisor being notified.

15. That the holder of a certificate has, by his actions, or inactions, created a substantial possibility that death or serious physical harm could result therefrom.

16. That the holder of a certificate has not taken or completed remedial training or other courses of action as directed by the division as a result of an investigation.

17. That the holder of a certificate is found to be guilty of the falsification of any documentation as required by the Department.

C. The suspension or revocation of the emergency medical technician certificate shall include all levels of certification.

SECTION XI. AIR AMBULANCES

Section 1101. Licensing: It shall be unlawful for any ambulance service provider, agent or broker to secure or arrange for air ambulance service originating in the State of South Carolina unless such ambulance service meets the provisions of South Carolina Emergency Medical Services Law and Regulations.

A. Air Ambulance Licensing and Insurance Requirements:

1. Air ambulance licensing procedures are contained in Section III of these regulations. Aircraft ambulance permit procedures are contained in Section IV of these regulations. A permit is required for each aircraft.

2. As part of the licensing procedure, every air ambulance operator shall carry an air ambulance insurance policy. This policy shall cover malpractice, bodily injury and property damage with solvent and responsible insurers licensed to do business in the State of South Carolina. This policy shall provide payment for any loss or damage resulting from any occurrence arising out of or caused by the medical treatment or operation or use of any of the operator's aircraft. Each aircraft shall be insured for the sum of at least $1,000,000 for injuries to or death of any one person arising out of any one incident and the sum of at least $3,000,000 for injuries to or death of more than one person in any one incident. In addition, the provider shall carry at least $300,000 malpractice insurance. Every insurance policy or contract for such insurance shall provide for the payment and satisfaction of any financial judgment entered against the operator and present insured, or any person flying the insured aircraft.

All such insurance shall provide for thirty-day cancellation notice to the Department.

B. Out-of-State Air Ambulances

1. Out-of-state air ambulances transporting patients from locations in South Carolina must be licensed in their home state, if applicable. The medical attendant must be a basic or advanced EMT or have flight nurse who is certified in the home-ported state.

2. Out-of-state air ambulances operating in a state where no license is available must obtain a license in South Carolina and meet all requirements in Section XI.

C. Air Ambulance Categories:

1. Interfacility Transport. Air ambulance services that transport patients receiving definitive care within the medical care system are those services which provide inter hospital, medical facility to hospital, hospital to other facility, or similar transports where the patients involved are transported from a definitive care medical setting. These transports may be accomplished by fixed-wing or rotary wing aircraft, and range from the transport of a critically ill patient requiring a sophisticated aircraft equipped with special care facilities, staff and supplies to the transport of a patient who has no special medical requirements. It is the responsibility of the medical director to insure that the level of patient care required in any given transport is adequate for that patient's medical needs.

2. Prehospital Transport. Air ambulance services that transport patients in the prehospital setting will be permitted as either an advanced or basic life support service and each prehospital service shall be required to meet the requirements and be licensed accordingly. Each such service shall contract with a medical control physician.

3. Special Purpose Ambulance. Air ambulances that meet the special purpose ambulance requirements.

D. Air Ambulance Aircraft Requirements. The aircraft operator shall, in all operations, comply with all federal aviation regulations which are adopted by reference, Part 135. The aircraft shall meet the following specifications:

1. Be configured in such a way that the medical attendants have adequate access for the provision of patient care within the cabin to give cardiopulmonary resuscitation and maintain patient's life support.

2. Allow loading of a supine patient by two attendants.

3. Have appropriate communication equipment to insure both internal crew and air to ground exchange of information between individuals and agencies appropriate to the mission, including at least medical control, air traffic control, and navigational aids.

4. Be equipped with radio headsets that insure internal crew communications and transmission to appropriate agencies.

5. Have adequate interior lighting, so that patient care can be given and patient status be monitored without interfering with the pilot's vision.

6. Have hooks and/or appropriate devices for hanging intravenous fluid bags.

7. Helicopters must have an external landing light.

8. Design must not compromise patient stability in either loading, unloading or in-flight operations.

E. Aircraft Flight Crew Manning Requirements. The aircraft operator shall, in all operations, comply with all federal aviation regulations which are adopted by reference, Part 135.

1. Rotor craft

a. The pilot must possess commercial rotor craft certification and a minimum of 500 rotor craft flight hours as pilot in command and 50 hours of pilot in command flight time in helicopters within the 12 months prior to application for permitted air ambulance certification. Of this time during which the pilot is in command (referred to as "pilot in command time"), 25 hours must be in the same make and model of aircraft to be used in the proposed air ambulance operation.

b. The pilot must have received factory training or equivalent and must have at least five hours in the specific type of aircraft, before flying as pilot in command on patient missions.

c. The pilot must have received factory training in flying over the types of terrain and under the conditions unique to the air

ambulance flight program.

d. The pilot must be readily available within a defined call-up time to insure an expeditious and timely response.

e. The helicopter mechanic is vital to mission readiness and, as such, should possess at least two years of experience and must be a certified air frame and power plant mechanic.

f. The mechanic must be properly trained and FAA certified to maintain the aircraft designed by the flight service for its

aeromedical program.

2. Fixed-Wing

a. The pilot must possess a commercial pilot airplane license with a multi-engine land rating and a minimum of 500 flight hours as pilot in command and 50 hours of pilot in command flight time in multi-engine airplanes within the 12 months prior to application for permitted air ambulance certification.

b. If flying IFR, the pilot must possess an aircraft instrument rating with a minimum 50 hours of instrument flying time, to include no more than 20 hours in a ground simulator acceptable to the FAA.

c. The pilot must have received factory training or equivalent and must have at least five hours in the specific type of aircraft, before flying as pilot in command on patient missions.

d. The pilot must be readily available within a defined call-up time to insure an expeditious and timely response.

e. The mechanic is vital to mission readiness and must be a certified air frame and power plant mechanic.

f. The mechanic must be properly trained and FAA certified to maintain the aircraft designated by the flight service for its

aeromedical program.

F. Off-Line Medical Control Physician (Medical Director). The off-line medical control physician of air ambulance services shall be responsible for:

1. Being knowledgeable of the capabilities and limitations of the aircraft used by his service.

2. Being knowledgeable of the medical staff's capability relative to the patient's needs.

3. Being knowledgeable of the routine and special medical equipment available to the service.

4. Ensuring that each patient is evaluated prior to a flight for the purpose of determining that appropriate aircraft, flight and medical crew and equipment are provided to meet the patient's needs.

5. Ensuring that all medical crew members are adequately trained to perform in-flight duties prior to functioning in an in-flight capacity.

6. All duties and responsibilities listed in these regulations.

G. Aircraft Medical Crew Requirements:

1. Each basic life support air ambulance must be staffed with at least one currently certified South Carolina EMT.

2. Each advanced life support air ambulance must be staffed with at least one currently certified EMT-Paramedic or flight nurse as may be required by the patient's condition.

3. Each special purpose air ambulance must be staffed with at least one special purpose EMT, EMT-Paramedic or RN with specialty training, as approved by the Department.

H. Orientation Program:

1. All medical flight crew members must complete flight orientation program approved by the Department and supervised by the service's medical control physician. The program shall be of sufficient duration and substance to cover all patient care procedures, including altitude physiology, and flight crew requirements.

Section 1102. Basic Life Support Air Ambulance Medical Equipment Requirements. Each prehospital basic life support air ambulance shall be equipped with the following basic life support equipment:

A. There shall be one vinyl covered folding litter or acceptable equivalent with at least two patient restraint straps and litter fasteners for each patient (spine board is not acceptable). Litter fasteners must be bolted directly on the air frame of the aircraft.

B. Suction Device:

1. A portable suction device, battery or gas operated, with wide bore tubing and six ounce reservoir and a "y" or "t" valve to control suction - The unit must provide continuous suction for 15 minutes.

2. There must be an assortment of suction catheters (minimum of two each) on board. Sizes 6 fr, 8 fr, 10 fr, and 14 fr. A rigid suction catheter (e.g. Yankaur) will also be carried. Minimum, 2 each.

C. Bag Valve Ventilation Units:

1. One adult, hand operated. Valves must operate in all weather, and unit must be equipped to be capable of delivering 90-100% oxygen to the patient.

2. One pediatric, hand operated. Valves must operate in all weather and unit must be equipped to be capable of delivering 90-100% oxygen to the patient. Must include safety pop-off mechanism with override capability.

3. One infant, hand operated. Valves must operate in all weather and unit must be equipped to be capable of delivering 90-100% oxygen to the patient. Must include safety pop-off mechanism with override capability.

4. The following sized masks will be carried aboard all permitted ambulances to be used in conjunction with the ventilation units above, 0,1,2,3,4,5. Masks must be clear. Either the disposable or non-disposable types are acceptable.

D. Nonmetallic oropharyngeal airways: Berman type, adult, child, and infant sizes. All airways shall be clean and individually wrapped.

1. Large adult - 100 mm

2. Medium adult - 90 mm

3. Large child - 80 mm

4. Child - 60 mm

5. Infant - 43 mm

E. "S" tube type airways may not be substituted for Berman type airways.

F. Fixed and portable oxygen equipment - The portable equipment should be: Minimum "D" size (360 liter) cylinder (one required), adequate tubing and semirigid valveless, transparent, single use, individually wrapped nonrebreather masks and nasal cannulas in adult and pediatric sizes, minimum of three each. In addition, a "No Smoking" sign with minimum one inch letter shall be displayed in the patient compartment. When the vehicle is in motion, all oxygen cylinders shall be affixed to a wall or floor with crash stable, quick release fittings. Liter flow gauge shall be non gravity dependent (Bourdon gauge) type.

G. Bite stick either commercially available or made of three tongue blades taped together and padded. (Clean and individually wrapped.)

H. Six sterile dressings (minimum size 5"x 9") compactly folded and packaged.

I. Thirty-six each sterile gauze pads 4"x 4".

J. Four each bandages, self adhering tape, minimum three inches by five yards. Bandages must be individually wrapped or in clean containers.

K. Aluminum foil, roll, 18"x 25", sterile and wrapped, or a minimum of four commercial sterile occlusive dressing, 4"x 4".

L. Adhesive tape, hypoallergenic, one, two, and three inches wide.

M. Burn sheets, two, sterile.

N. Splints:

1. Traction type, lower extremity splint. Uni-polar or bi-polar type is acceptable (Medical Control Option).

2. Padded, wooden type splints, two each, 15"x 3" and 36"x 3", or other approved commercially available splints for arm or leg fractures.

3. Pneumatic splints not acceptable.

O. Spine Boards:

1. Long, at least 16"x 72". Must be available on general purpose units. (The use of folding backboards is acceptable as a substitute for the long spine board.)

2. Cervical collars. Small, medium, and large. (Each cervical collar should be manufactured with rigid or semirigid material)

P. Triangular bandages, four each.

Q. Nine foot straps, three required.

R. Bandage shears, large size.

S. Obstetrical kit, sterile. The kit shall contain gloves, scissors or surgical blades, umbilical cord clamps or tapes, dressing, towels, perinatal pad, bulb syringe and a receiving blanket for delivery of infant. (Medical Control Option)

T. Poison kit, syrup of ipecac and activated charcoal.

U. Blood pressure manometer, cuff and stethoscope.

1. Blood pressure set, portable (non mercurial type).

2. Stethoscopes.

V. Emesis basin.

W. Bedpan and urinal. (Medical Control Option)

X. Two dependable flashlights or electric lanterns, minimum size, two "D" cell or six volt lanterns.

Y. Minimum of one fire extinguisher, Halon five pound capacity.

Z. Working gloves.

AA. Minimum of 1000 cc of sterile water or normal saline for irrigation.

Section 1103. Interfacility and Special Purpose Air Ambulances

All inter facility and special purpose air ambulances must be equipped with at least the following items from Section 1102:A, B,C, D, F, G, U, V, W, X, and Y.

Section 1104. Advanced Life Support Air Ambulance Medical Equipment Requirements

Air ambulances providing advanced life support in the prehospital, interfacility or special purpose category must have the following equipment and supplies on board in addition to Section 1102.

A. Battery powered (DC) portable monitor-defibrillator unit with EKG printout.

The monitor-defibrillator equipment utilized by the service has the capability of producing hard copy of patient's EKG.

B. Butterfly or scalp vein needles 26 gauge, total of two.

C. Two each 14, 16, 18, and 20 gauge IV cannula.

D. Two macro drip sets.

E. Two micro drip sets.

F. Three 21 or 23 and three 25 gauge needles, total six.

G. Three tourniquets.

H. Laryngoscope handle with batteries.

I. Laryngoscope blades, adult, child, and infant sizes. Sizes must include 0,1,2 straight and #2 curved.

J. Six disposable endotracheal tubes, assorted sizes (2.5-9.0). An intubation stylet sized for the pediatric patient will also be carried (6 fr.).

K. Suitable equipment and supplies for collection and temporary storage of two blood samples (Medical Control Option).

L. Syringes, two 1 ml, 3 ml, 10 ml, 20ml, and one 50 ml.

M. Backup power supply for all patient care devices carried.

N. Twelve (12) alcohol and iodine preps for preparing IV injection sites.

O. One (1) roll of tape.

P. Five (5) Band-Aids.

Q. Intraosseous needles in sizes 14, 18 ga. (1 each).

R. Four liters of lactated ringers or normal saline and two liters of D5W required.

Section 1105. Medication and Fluids for Advanced Life Support Ambulances

Such drugs and fluids approved by the Board for possession and administration by EMT's, and specified by the medical control physician, will be carried on the air ambulance. Drugs not included on the approved drug list for paramedics may be carried on board the air ambulance so long as there is a written protocol which is signed and dated by the medical control physician, for the use of the drug and delineates administration only by a registered nurse or physician.

Section 1106. Rescue Exception

A non permitted aircraft may be used for occasional non routine missions, such as the rescue and transportation of victim/patients, who may or may not be ill or injured, from structures, depressions, water, cliffs, swamps or isolated scenes, when in the opinion of the rescuers or EMS provider present at the scene, such is the preferred method of rescue and transportation incident thereto due to the nature of the entrapment, condition of the victim, existence of an immediate life-threatening condition, roughness of terrain, time element and other pertinent factors:

A. Provided that after the initial rescue, an EMT or higher level EMS technician accompanies the victim-patient en- route with the necessary and appropriate EMS supplies needed for the en-route care of the specific injuries or illness involved.

B. Provided the aircraft is of adequate size and configuration to effectively make the rescue and to accommodate the victim-patient, attendant(s) and equipment.

C. Provided reasonable space is available inside the aircraft for continued victim-patient comfort and care.

D. Provided a permitted aircraft is not available within a reasonable distance response time; and

E. Provided the victim-patient is transferred to a higher level of EMS ground transportation for stabilization and transport if such ground unit is available at a reasonably safe landing area.

SECTION XII. DO NOT RESUSCITATE ORDER.

Section 1200. Purpose and Authority of Emergency Medical Services Do Not Resuscitate Order

A. Title 44, Chapter 78 of the 1976 S.C. code as amended directs the South Carolina Department of Health & Environmental Control to promulgate regulations necessary to provide directions to emergency medical personnel in identifying and honoring the wishes of patients who have executed a Do Not Resuscitate Order for Emergency Services. The Do Not Resuscitate Order for Emergency Services is commonly referred to as the EMS DNR law.

B. The EMS DNR law is applicable only to resuscitative attempts by EMS providers in the pre-hospital setting such as the declarant's home, a long-term care facility, during transport to or from a health care facility and in other locations outside of acute care hospitals.

C. Specific statutory authority is found in Section 44-78-65.

Section 1201. Definitions

A. The definitions contained in S.C. Code Section 44-78-15 are hereby incorporated by reference.

B. Agent or Surrogate means a person appointed by the declarant under a Health Care Power of Attorney, executed or made in accordance with the provisions of Sec. 62-5-504 and/or Sec. 44-77-10.

C. Cardiac Arrest means the cessation of a functional heartbeat.

D. Cardiopulmonary Resuscitation or CPR means the use of artificial respirations to support restoration of functional breathing combined with closed chest massage to support restoration of a functional heart beat following cardiac arrest.

E. Department means the South Carolina Department of Health & Environmental Control.

F. Respiratory Arrest (Pulmonary Arrest) means cessation of functional breathing.

G. Do Not Resuscitate Order for Emergency Medical Services marker is a bracelet or necklace that is engraved with the patient's name, the health care provider's name and telephone number and the words "Do Not Resuscitate" or the letters DNR.

Section 1202. General Provisions

A. The EMS DNR Form. The document which is to be a "Do Not Resuscitate Order" for EMS purposes must be in substantially the following form:

NOTICE TO EMS PERSONNEL

This notice is to inform all emergency medical personnel who may be called to render assistance to_____________________________

(Name of patient)

that he/she has a terminal condition which has been diagnosed by me and has specifically requested that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardio-pulmonary arrest.

REVOCATION PROCEDURE

THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT TO EMS PERSONNEL, OR BY MUTILATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER.

Date:____________________________________

_________________________________________

Patient's Signature (or Surrogate or Agent)

_______________________________________

Physician's Signature

_________________________________________

Physician's Address

_________________________________________

Physician's Telephone Number

B. Distribution of the EMS DNR Form. The EMS DNR form, along with instructions for execution and a patient information sheet shall be distributed by the Department to health care providers. Informational pamphlets shall be prepared by the department and made available to other interested parties upon request.

C. Location of the Executed EMS DNR Form. The executed EMS DNR Form shall be placed in a location where the document is easily observed and recognized by EMS personnel. The form shall be displayed in such a manner that it will be visible and protected at all times.

D. EMS DNR Marker. The DNR marker shall be a bracelet or necklace as approved by the department. The marker may be worn upon the execution of the EMS DNR Document. Wearing of the marker shall not be mandatory but is encouraged. The marker will alert EMS personnel of the probable existence of the EMS DNR document. The marker shall be of metallic construction and shall be unique and easily recognizable. The marker shall contain the patient's name, the health care provider's name and telephone number and the words "Do Not Resuscitate" or the letters DNR.

Section 1203. Revocation of EMS DNR Order. The EMS DNR Order may be revoked at anytime by the oral expression of the patient to EMS personnel or by the mutilation, obliteration or destruction of the document in any manner. If the order is revoked, EMS personnel shall perform full resuscitation and treatment of the patient.

Section 1204. Patient's Assessment and Intervention. When EMS Personnel report to a scene, they shall do a patient assessment. If an EMS DNR bracelet or necklace is found during the assessment, EMS personnel shall make a reasonable effort to determine that a EMS DNR form exists and to assure that the EMS DNR form applies to the person on which the assessment is being made. If no DNR form is found, resuscitative measure will be initiated. If after starting resuscitative measures a EMS DNR form is later found, resuscitative measure must be stopped.

Section 1205. Resuscitative Measures to be Withheld or Withdrawn. In the event that the patient has a valid EMS DNR order, the following procedures shall be withheld or withdrawn.

A. CPR

B. Endotracheal intubation and other advanced airway management

C. Artificial ventilation

D. Defibrillation

E. Cardiac resuscitation medication

F. Cardiac diagnostic monitoring

Section 1206. Procedures to Provide Palliative Treatment.

The following treatment may be provided as appropriate to patients who have executed a valid EMS DNR order.

A. Suction

B. Oxygen

C. Pain medication

D. Non-cardiac resuscitation medication

E. Assistance in the maintenance of an open airway as long as such assistance does not include intubation or advanced airway management

F. Control of bleeding

G. Comfort care

H. Support to patient and family

Section 1207. DNR Information for the Patient, the Patient's Family, the Health Care Provided and EMS Personnel

A. Responsibilities of the patient or his/her Surrogate or agent.

The patient and his/her surrogate or agent:

1. Make all care givers aware of the location of the EMS DNR Form and ensure that the form is displayed in such a manner that it will be visible and available to EMS personnel.

2. Be aware of the consequences of refusing resuscitative measures.

3. Be aware that if the form is altered in any manner resuscitative measures will be initiated.

4. Understand that in all cases, supportive care will be provided to the patient.

B. Responsibilities of the Health Care Provider (Physician) The patient's physician:

1. Has determined that the patient has a terminal condition.

2. Has completed the patient's EMS DNR Form.

3. Has explained to the patient and family the consequences of withholding resuscitative care; the medical procedures that will be withheld and the palliative and supportive care that will be administrated to the patient.

C. Responsibilities of EMS Personnel

EMS personnel:

1. Will confirm the presence of the EMS DNR Form and the identity of the patient.

2. Upon finding an unaltered EMS DNR Form, will withhold or withdraw resuscitative measures such as CPR, endotracheal intubation or other advanced airway management, artificial ventilation, defibrillation, cardiac resuscitation medication and related procedures.

3. Will provide palliative and supportive treatment such as suctioning the airway, administration of oxygen, control of bleeding, provision of pain and non-cardiac medications, provide comfort care and provide emotional support for the patient and the patient's family.

4. Must have in his possession either the original or a copy of the DNR Order during transport of the patient.

Fiscal Impact Statement:

The Department estimates that the licensed providers will incur a fiscal impact of a range between $1,100 savings for advanced life support ambulances to an increase of $600 for basic life support ambulances. The new First Responder licensees will see a range of $0 change to a maximum of $2,500 per vehicle depending on the amount of required equipment they do not presently have for first responder use. Costs will be borne by the licensee. The costs to the Department are unknown because of the uncertainties in the volume of EMT First Responders seeking licensure.

Statement of Need and Reasonableness:

The statement of need and reasonableness was determined by staff analysis pursuant to S.C. Code Section 1-23-115(C)(1)-(3) and (9)-(11):

DESCRIPTION OF REGULATION: Amendment of Regulation 61-7, Emergency Medical Services. The proposed amendment to 61-7 adds section 310 which establishes the Criteria License Category of "EMT First Responders" and section 606 which outlines the equipment requirements for "EMT First Responders." It also updates language throughout as needed for the integration of this new licensed category. It further makes changes in standards for equipment and training that are consistent with national standards. See Preamble and Table of Changes above.

Purpose: The amendments to this regulation satisfy the legislative mandate and will enable licensed first responders to assist in improving the response time of trained EMT's to a medical or trauma emergency. It also updates criteria, standards, and terminology to those consistent with national standards and those of the leading EMS services in South Carolina. See Preamble above.

Legal Authority: S.C. Code Sections 44-61-150, 44-78-65, and Act 263 of 1996 (effective January 1, 1997).

Plan for Implementation: Staff will review applications and issue licenses for First Responder Organizations. They will also inspect the operations, equipment, and records of these organizations on the same schedule as is presently being applied to licensed ambulance services. Staff will also approve and training programs for certification and recertification of the additional EMT's resulting from additional licensees. Staff will test these EMT's and issue certification and recertification. Modifications of standards other than First Responders will require only changes in policy.

DETERMINATION OF NEED AND REASONABLENESS BASED ON ALL FACTORS HEREIN AND EXPECTED

BENEFITS: The proposed amendment provides guidance to the staff and the regulated community by establishing criteria for the License Category of "EMT First Responders" and the equipment requirements for "EMT First Responders." It also makes changes in standards for equipment (additions and deletions) and training that are consistent with national standards as found in the National EMS for Children guidelines, the American College of Surgeons -- Committee on Trauma Guidelines, the American College of Emergency Physicians Guidelines, etc. Without these changes the present EMS system (which began implementation in S.C. in 1974) will not be able to continue to provide the lifesaving care that is possible with the equipment and training that are not available. It also will enable the numerous Fire Departments, Industries, and others to become a part of a system that provides much more rapid response to medical emergencies and appropriate care until the Ambulances arrive.

See Preamble and Table of Changes above.

DETERMINATION OF COSTS AND BENEFITS: Inasmuch as the process for issuing licenses and certification of EMT-Basic and EMT-Intermediate involves no additional costs to the "First Responder Organizations" there should be no extra costs for these processes to these organizations. However, there are other costs involved in this voluntary licensure and certification.

Internal Costs: The additional costs to the Department will be those incurred in the process of inspecting and licensing these new organizations. Additional costs will also be incurred by the department in the process of approving and monitoring the additional training programs necessary to train the additional EMT's, and the additional time for the EMS compliance personnel to test these additional EMT's. The problem in specifying these additional costs are presented in the paragraph on "Uncertainties of Estimates."

External Costs: The costs borne by those outside the Department are those of two groups, those ambulance services who are presently licensed and must add certain equipment to meet the changes in standards and the added group of "First Responder Organizations" which can now be licensed under the law as amended. The net changes in costs to the present Ambulance services is expected to be an increase of approximately $600 per service for those 218 Basic ambulances, however, many of which already have a large portion of this equipment. This will be offset by a reduction of approximately $1,100 per ambulance for the 585 Advanced ambulances. The net costs for those fire and other organizations which desire to be licensed involve mainly additional equipment of $2,500 and additional costs of running their vehicles for this purpose. However, a number of these already run first response with some of the required equipment.

UNCERTAINTIES OF ESTIMATES: Additional costs to the department can only be quantified after it is determined how many organizations seek licensure as first responder organizations. Presently we have approximately 200 licensed ambulance services, to include government, private, rescue squads and others. The recent legislation is the response to fire departments being interested in providing medical care in the first minutes of a medical or trauma emergency. Costs to the department depend on the sincere interest of these departments, which number in excess of 600. Interest will primarily come from the larger departments, since there is the requirement of equipment and trained manpower. Presently there are 10 employees within the department which are responsible for working with the licensure, training and certification needs of the present licensees.

Uncertainties of total costs as they relate to the newly licensed agencies are affected by the uncertainty of the number who may want to be licensed.

EFFECT ON THE ENVIRONMENT AND PUBLIC HEALTH: The regulations as amended will have a positive effect on the public health of the citizens of the state in that with the licensure of "First Responder Organizations" the citizens of South Carolina will have more prompt medical attention to their emergency needs for medical and trauma emergencies. It will also mean that the EMT's will have appropriate equipment and training to be able to manage these emergencies, especially those of pediatric patients.

DETRIMENTAL EFFECT ON THE ENVIRONMENT AND PUBLIC HEALTH IF THE REVISIONS IN THE REGULATION ARE NOT IMPLEMENTED: The detrimental effect if these regulations are not implemented, in addition to inconsistency with the law as revised, will be that the response times to trauma and medical emergencies will not be improved, and the abilities for the EMT's to administer emergency medical care for all needs, especially pediatric, will not be improved.

However, the public health of the citizens would not be reduced over that which is present today.

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