Yolo County Emergency Medical Services Agency 630.9 37 N. Cottonwood Street, Woodland, CA 95695 Phone (530) 666-8645 www.yemsa.org ADVANCED LIFE SUPPORT (ALS) AMBULANCE INVENTORY INSPECTION FORM Provider: Unit ID #: Annual Unannounced Mileage: License Plate #: Vin #: Vehicle Make: Vehicle Year: Inspected by: Inspection Date: Pass Fail ** In addition to the Basic Life Support (BLS) Ambulance supply/equipment requirements, ALS units shall include, but are not limited to, the following: 00 Access Cannula 0 Adhesive tape ", ", or 3" rolls 0 Alcohol swabs 0 03 Ambulance Gurney capable of elevating the head & being adjustable, straps for securing patient to gurney, wheels, non-permeable covering material, and means of securing gurney in vehicle. 04 Ankle & wrist restraints (4 per set) set 05 Arm board(s) (adaptable for adult/child/infant) each 06 Arm splints soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable, vacuum or cardboard (able to accommodate each adult/pediatric/infants) 08 Automated External Defibrillator (AED) 0 Bag-Valve-Mask (BVM) - Self-inflating resuscitation device, with clear mask, capable of use with O (adult/pediatric/infant; mask sizes: each adult/child/infant/neonate) Bandages (Rolled) " or 3" 6 Band-Aids (assorted sizes) 3 Biohazard bags (Red) 5 4 Blankets (Clean) 5 Blood pressure cuff - Portable (sphygmomanometers) (adult/large arm/pediatric/infant) each 6 Burn sheets (sterile) commercially packaged or sterile burn sheet 7 Cellular telephone 8 Cervical collar (adjustable hard only): sizes to fit all patients over one () year of age (optional) Effective Date: January, 08 Page of 6 Revised Date: December, 07
630.9 Revised Date: December, 07 9 Cervical collars (hard) sizes to fit all patients over one () year of age each 0 Child safe restraints (pediatric/infant) each Coban Cold packs 8 3 CPAP - Continuous positive airway pressure equipment 4 CPAP Masks (S, M, L) 5 D.O.T. Emergency Response Guide 6 Defibrillator paddles/pads (adult/pediatric) each 7 Disinfectant solution and/or wipes (container or box) 8 Disposable trash container & bags 9 Dressing - multi-trauma (sterile) 3 EKG Electrodes/patches sets 3 EKG Electrodes Pediatric sets 33 EKG paper (rolls) rolls 34 Emergency Blanket thermal or equivalent (reflective foil) 35 Emesis basin or disposable emesis bags & covered waste container 36 Endotracheal tube introducer (ETTI) (e.g. Bougie; adult/pediatric) each 37 Endotracheal tubes (ETT):.5, 3.0, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0 each 38 End-tidal CO (EtCO ) detector (colorimetric) adult/pediatric each 39 EtCO Non-invasive adapter ETT 40 EtCO Non-invasive cannula 4 ETT nebulizer adapter 4 ETT securing device - adult/pediatric each 43 Extra charged batteries for monitor/defibrillator 44 Eye protection (face shield, goggles, splash resistance) 45 Fire extinguisher (Class ABC) 46 Flashlight (battery operated) 47 Footwear covers pair 48 Gauze pads 4 x 4" (sterile) 4 49 Gastric Tubes: 8 FR, FR, 4 FR, 6 FR, 8 FR each 50 Gloves Latex fee Assortment of sizes (S, M, L, XL) box each 5 Gloves work (multi-use) pairs 5 Glucometer (with lancets & test strips [0 ea.]) 53 Glucose paste or commercially bottled solution tubes 54 Hard Hat/work helmet (blue) Effective Date: January, 08 Page of 6
630.9 Revised Date: December, 07 55 HAZMAT Kit: 0 each - trash bags (Large) 6 each - chucks 4 each - disposable gowns, slippers, & surgical masks each - Vaseline (large container) kit each - dish soap (medium bottle) pairs - goggles (splash) 6 pairs - gloves (heavy duty) 56 Head immobilizer disposable firm body commercial device 59 Intraosseous (IO) needle (adult/pediatric/bariatric) each 6 IO insertion device (e.g. EZ-IO, Jamshidi ) each 6 IO needles (EZ-IO ) - Yellow 45 mm Adult Needle - Blue 5 mm Adult Needle each Pink 5 mm Pediatric Needle 63 IV catheters: 6 ga, 8 ga, 0 ga, ga, 4 ga 4 each 64 IV extension tubing 4 65 IV Fluid Warmer (9-- Providers ONLY) each 67 IV tubing: Mini drip (60 gtt), macro drip (0/5 gtt) (or equivalent [8]) 4 each mini/macro (8 each equivalent) 68 Jacket or vest full length with reflective stripes each 69 Kerlix Sterile Gauze Rolls 4 70 King LTS-D Airway Kit: Tube - Size 3, 4, 5, 60 ml syringe, Sterile lubricant each 7 Laryngoscope Batteries (extra) set 7 Laryngoscope blades: MacIntosh #, 3, 4 each 73 Laryngoscope blades: Miller # 0,,, 3, 4 each 74 Laryngoscope handle 75 Laryngoscope light bulb (extra) 76 Leg splints - with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable, vacuum or cardboard (able to accommodate adult/pediatric/infants) 77 Magill forceps (adult/pediatric) each 78 Map (current within two [] years) of entire county or ambulance zone maps) or GPS 79 Meconium aspirator 80 Medication Adenosine 6 mg 5 8 Medication Albuterol.5 mg/3 ml unit dose ampule 4 8 Medication Albuterol Sulfate Inhalation Aerosol ered Dose Inhaler (MDI), (Ventolin, Proventil or equivalent) (Optional) 83 Medication Amiodarone 50 mg 8 84 Medication Aspirin 8 mg tablets (chewable) bottle 85 Medication Atropine mg (preloaded syringe) 6 86 Medication Calcium chloride gm 4 Effective Date: January, 08 Page 3 of 6
630.9 Revised Date: December, 07 87 Medication Dextrose 0% (D0) 50 ml 88 Medication Dextrose 5% (D5) (Preload of 50 ml) 89 Medication Dextrose 5% in Water (D5W) 50 ml or 00 ml each 9 Medication Diphenhydramine (DPH/Benadryl) 50 mg/ml 9 Medication Diphenhydramine (DPH/Benadryl) elixir 00 mg 93 Medication Dopamine 400 mg 94 Medication Epinephrine (Epi) :0,000 ( mg/0 ml) 8 95 Medication Epinephrine (Epi) :,000 ( mg/ ml) 5 mg 98 Medication Fentanyl (optional) 00 mcg 99 Medication Glucagon mg/ ml 00 Medication Ipratropium 500 mcg/.5 ml,000 mcg 0 Medication Lidocaine % (IO/pain control) 00 mg 0 Medication Midazolam (Versed) 5 mg/ml (ampule/vial) 0 mg 03 Medication Naloxone (Narcan) 4 mg 05 Medication Nitroglycern Paste % 5 packets 06 Medication Nitroglycerin 0.4 mg/tab (or multi-dose spray) bottle 07 Medication NS solution 50 ml each 08 Medication NS solution 500 ml or 000 ml bag (adult) 4 L 09 Medication Ondansetron (Zofran) 4 Medication Sodium bicarbonate 50 meq/50 ml 3 Medication-added labels 4 Mucosal Atomizer Device (MAD) 5 N-95 or equivalent mask (assortment of sizes) 5 each 6 Nasal Cannula (adult/pediatric) each 7 Nasopharyngeal airways: 6,8, 0,, 4, 6, 8, 30, 3, 34 each 8 Nebulizer (hand held for inhalation) 9 Nebulizer mask (adult/pediatric) each 0 Needles: 8 ga, 0 ga, ga, 4 ga, 5 ga each Oropharyngeal airways: 00, 0,,, 3, 4, 5, 6 each Oxygen (O ) mask Non-rebreather (adult/pediatric) each 3 Oxygen (O ) mask (pediatric/infant) each 4 Oxygen (O ) tank fixed in vehicle with regulator (Mtank or equivalent) 5 Pediatric length-based weight determination tape (e.g. Broselow or equivalent) 6 Pen light 7 Pharyngeal tonsil tip (rigid) for suctioning 8 Pillow Cases Clean 4 9 Pillows Effective Date: January, 08 Page 4 of 6
630.9 Revised Date: December, 07 30 Pleural Decompression/Needle Thoracostomy kit (or equivalent) including: 4 each - Alcohol swabs each - Angiocatheter ga x 3 and 4 ga x 3 4 each - Betadine swabs each - One-way valve sets each - Rubber connecting tube each - Sterile gauze pads each - Syringe 30 ml each - Tape (roll) each - Vaseline gauze 3 Portable monitor/defibrillator with required features: Strip chart recorder -Lead cables Synchronized cardioversion EtCO monitoring Pulse Oximetry monitoring Pacing Defibrillator capable of discharging below 5 joules (J) for pediatric use 3 Portable O tank with variable flow regulator (sufficient to provide patient with not less than 0 LPM for 0 minutes.) 33 Portable Suction with regulator or portable suction adult/pediatric (e.g. high/low) settings, mechanical/hand powered 34 Pressure bag for adult intraosseous (IO) infusion 35 Prophylactic medications: MARK- auto injector kit Optional 36 Pulse Oximeter Device each 37 Pulse Oximeter probes (adult/pediatric) each 38 QuikClot Dressing 4 each 39 Razor 40 Saline for irrigation (sterile),000 ml 4 Saline lock with extension tubing 4 Scoop stretcher with straps (or equivalent) 43 Secured drug box 44 Sharps Container (appropriately sized) 45 Sheets Clean 4 46 Spine board long with four (4) straps (or equivalent) 47 Spine board short: (pediatric capable) short with two () straps or equivalent (Kendrick Extrication Device [KED] or Pedi Board) 48 Spring loaded center punch or equivalent 49 Stair chair or carrying chair Effective Date: January, 08 Page 5 of 6
630.9 Revised Date: December, 07 50 Sterile Obstetrics Kit: each- umbilical cord tape or clamps pair - scissors or scalpel each - aspirating bulb syringe pair - gloves (medical) kit each - drapes, dressings & towels each - clean plastic bag each - Newborn Stocking Cap 5 Stethoscope adult/pediatric (or combination) 5 Stylet (adult/pediatric) each 53 Suction catheters: 6 FR, 8 FR, 0 FR, 6/8 FR each 54 Syringes: ml, 3 ml, 5 ml, 0 ml, 50 ml each 55 Thermometer 56 Tourniquet (Combat/Commercial) 57 Tourniquet (IV start) 58 Traction splints with lower extremity limb support slings, padded ankle hitch traction strap & heel rest or each equivalent (reel, sager or equivalent; adult/pediatric) 59 Transparent Tape (Venaguard/Tegaderm) or equivalent 6 60 Transpore Tape 6 Trauma shears 63 Triage Tags 50 64 Triangular bandages 40" 4 65 Tubing - Blood administration (optional) 67 Universal vial adapter/dispensing pin 68 Vaseline gauze 69 Water soluble lubricant individual packets 3 70 Waterless hand cleanser (dispensing unit or wipes) 7 Wide bore tubing for portable suction 7 Field Manual & Policies (current) online or hardcopies Inspection : PASS FAIL REMEDIATION REQUIRED Inspector s Signature Date Effective Date: January, 08 Page 6 of 6