New Mexico Dept. of Health
Name of Service: ____________
Location of Service:__________
Emergency Medical Systems Bureau
Medical Rescue Certification Inspection Form
Unit #: _________________
MEDICAL RESCUE - MINIMUM REQUIRED EQUIPMENT Inspector: Date:
All items shall be in quantities suitable for a Multiple Incident Response
ITEM DESCRIPTION
COMMENTS
Forward Compartment
Vehicle Registration Y / N / NA
U. S. DOT, Emergency Response Guidebook Y / N / N
A
*EDITION:
Maps or Navigational equipment Y / N / NA
Service specific protocols and resource guides Y / N / NA
Patient Care Reports or Reporting System Y / N / NA
Hand Sanitizer Y / N / NA
Flashlight Y / N / NA
*Battery Powered, Hand Crank, Mounted Batt. Chrg. Sys.
Fire Extinguisher
Y / N / NA
*10 pound, ABC type or functional equivalent, charged
Spotlight or auxillary lighting system Y / N / NA
Roadway Warning Devices Y / N / NA
*Safety Flares, Emergency Lights, Safety Cones
Vehicle Jack Y / N / NA
Spare tire Y / N / NA
Tire wrench Y / N / NA
COMMUNICATIONS EQUIPMENT
Radio Communications (Portable or Affixed):
Equipment sufficient to Establish
and Maintain direct or repeated
communications with:
Area Dispatch Y / N / NA
Secondary Providers Y / N / NA
N.M. EMSCOM Radio System Y / N / NA
Capable of Cellular and/or Text/Data Transmissions (optional) Y / N / NA
Spare batteries / charger system Y / N / NA
Personal Protective Equipment (PPE)
EMS turnout gear Y / N / NA
Helmets with Face Shield Y / N / NA
Gloves Y / N / NA
*Work gloves or Leather gloves
Eye Protection Y / N / NA *Glasses or Goggles
Hearing Protection
Safety Vest / Jacket (ANSI 2008 Compliant) Y / N / NA
*Break-away, reflective, High visibility Coloration
Exam Gloves Y / N / NA *assorted sizes
Disposable Splash Protection Y / N / NA *(Gowns, Scrubs, Eye Shieding, etc.)
Tyvex coveralls (optional) Y / N / NA
N-95 mask (or > particulate mask )
Y / N / NA
DIAGNOSTIC EQUIPMENT
Aneroid Sphygmomanometer, BP Cuffs
Y / N / NA
*with infant, pediatric, adult, and obese sizes
Stethoscope Y / N / NA *more than 1
Glucose Monitoring Instrument Y / N / NA *Portable
Pulse Oximeter Y / N / NA *Portable
End-tidal CO2 monitoring device Y / N / NA *Disposable, Colormetric
Penlights Y / N / NA
Shears Y / N / NA
*Trauma or Equivalent
PATIENT COMPARTMENT
Multi-Level Stretcher
Y / N / NA
*may be power assisted, 2 person
Revision 5/7/2010 1/4
New Mexico Dept. of Health
Name of Service: ____________
Location of Service:__________
Emergency Medical Systems Bureau
Medical Rescue Certification Inspection Form
Unit #: _________________
MEDICAL RESCUE - MINIMUM REQUIRED EQUIPMENT
Inspector: Date:
All items shall be in quantities suitable for a Multiple Incident Response
ITEM DESCRIPTION
COMMENTS
Shoulder / Chest and Lower Extremity straps
Y / N / NA
*capable of securing adult and pediatric patients
Pillow Y / N / NA *disposable, pillow with vinyl cover. Rolled Blanket
Blankets Y / N / NA
Stretcher Pad (Bed) Covers Y / N / NA
*(e.g. sheets)
Pt. Restraints Y / N / NA *2 ankle and 2 wrist, leather or nylon
Sharps Container Y / N / N
A
Emesis Basins Y / N / NA *Emesis Bags or equivalent
Body Bags
CARDIAC EQUIPMENT
Semi-Auto External Defibrillator Y / N / NA
Defibrillator pads (extra) Y / N / NA
Defibrillator batteries (extra) Y / N / NA
PHARMACOLOGICAL EQUIPMENT for First Response through ALS
Appropriate medications with the contents established and approved by the Y / N / NA
*The list of contents and earliest expiration dates
Service Medical Director, within N.M. Scope of Practice shall be affixed to the outside of the kit. Drug kits
must be maintained in a temperate, controlled
environment and must not be left unsecured.
Mark I Plus Kit Y / N / NA
PEDIATRICS
Pediatric Restraint System or Car Seat Y / N / NA
*may be Fold down Jumpseat w/ Child Restraint System
Obstetrical Kit: (Sterile Package)
Y / N / NA
*Receiving blanket, sterile bulb aspirator, wrapped
sanitary napkin, sterile scissors or scalpel blade, 4-inch
gauze pads, one pair of sterile gloves, 2 cord clamps
and plastic bag for placenta. All items are to be in a
container with identifying label showing contents.
Foil Blanket Y / N / NA
Pediatric drug dosage tape or chart Y / N / NA
BANDAGES / DRESSINGS
Triangular Bandages Y / N / NA
Universal Dressings Y / N / NA
* approximately 10 inches by 30 inches
Gauze Pads Y / N / NA *4 inches by 4 inches
Bandages - soft roller Y / N / NA * self-adhering
Bandages - elastic (bandaids) Y / N / NA *of assorted sizes
Occlusive dressings Y / N / NA *sterile, individually wrapped
Adhesive tape Y / N / NA *Various Sizes - 1", 2", Duct Tape ('Medical' - White)
Cold Packs Y / N / NA
Heat Packs Y / N / NA
Burn Sheets Y / N / NA
RESPIRATORY EQUIPMENT Y / N / NA
Mounted electric or manifold operation suction aspirator (meets GSA std.) Y / N / NA
Portable suction aspirator
Y / N / NA
*as approved by the Agency/Department
Sterile Suction Catheters and tubing (rigid and soft, if applicable) Y / N / NA *assorted sizes
Revision 5/7/2010 2/4
New Mexico Dept. of Health
Name of Service: ____________
Location of Service:__________
Emergency Medical Systems Bureau
Medical Rescue Certification Inspection Form
Unit #: _________________
MEDICAL RESCUE - MINIMUM REQUIRED EQUIPMENT
Inspector: Date:
All items shall be in quantities suitable for a Multiple Incident Response
ITEM DESCRIPTION
COMMENTS
Bag-Valve-Mask Resuscitator
Y / N / NA
*disposable, with transparent adult mask.
The BVM must operate in cold weather, must
be capable of use with an oxygen supply and be
capable of delivering approximately 100% oxygen.
Pediatric Bag-Valve-Mask Resuscitator Y / N / NA *disposable, with transparent child and infant mask,
must operate in cold weather, must be capable of
use with an oxygen supply, must be capable of delivering
100% oxygen
Adult Oxygen Masks with Reservoir (non-rebreather or partial non-rebreather) Y / N / NA
Adult Oxygen Masks (Simple) Y / N / NA
Pediatric Oxygen Masks with Reservoir (non-rebreather or partial non-rebreather) Y / N / NA
Pediatric Oxygen Masks (Simple) Y / N / NA
Nasal Cannulas Y / N / NA
Oxygen Supply Tubing Y / N / NA
Oropharyngeal Airways Y / N / NA
*with adult, child and infant sizes
Nasopharyngeal Airways Y / N / NA *with adult, child and infant sizes
Laryngeal, Supraglottic, Multi-Lumen or Laryngeal Airway Devices Y / N / NA *(device not intended to be placed into the trachea)
Oxygen: fixed system Y / N / NA *min. 2 wall-mounted oxygen outlets and 1 flowmeter.
System shall include a yoke-type pressure reducer
gauge and an approved cylinder retaining device that
meets DOT standards. The system shall be capable
of delivering an oxygen flow of at least 15 liters per
minute. If oxygen source is of a size less than “M”
cylinder, an additional full spare cylinder for the
fixed system shall be carried in the ambulance
Oxygen: portable (2) cylinders Y / N / NA *unit consisting of at least a “D” cylinder or equivalent,
yoke, pressure gauge, flowmeter and cylinder wrench
The unit shall be capable of delivering an oxygen flow
of at least 15 liters per minute. Cylinder holders with a
quick-release fitting shall be furnished to allow the use
of the portable unit outside the vehicle.
INTRAVENOUS THERAPY
IV Solution (Normal Saline) Y / N / NA
*1000 ml
IV Catheters Y / N / NA * various sizes
IO Needles Y / N / NA
Tubing /Infusion kits Y / N / NA
Pediatric fluid volume control device (ie: Burretrol or Volutrol) Y / N / NA
Arm Boards (For pediatric) Y / N / NA
IMMOBILIZATION DEVICES
Extremity Immobilization Devices Y / N / NA
*2 full arms and 2 full legs, or equivalent
Short Spinal Extrication Device**
Y / N / NA
*(KED or equivalent), Infant or Pediatric Immobilization**
Pediatric Immobilization Device** Y / N / NA *as approved by the department
Spine Boards Y / N / NA *long, at least 16"wide by 72" in length w/ 3 straps (min.)
Lateral Cervical Immobilization Devices Y / N / NA *commercial devices, foam blocks, blanket rolls
Cervical Immobilization Collars Y / N / NA *hard type, minimum 2 adult, 2 medium, 2 child
Revision 5/7/2010 3/4
New Mexico Dept. of Health
Name of Service: ____________
Location of Service:__________
Emergency Medical Systems Bureau
Medical Rescue Certification Inspection Form
Unit #: _________________
MEDICAL RESCUE - MINIMUM REQUIRED EQUIPMENT
Inspector: Date:
All items shall be in quantities suitable for a Multiple Incident Response
ITEM DESCRIPTION
COMMENTS
Traction Splint Y / N / NA *lower extremity, adjustable
**Equipment to be identified for the safe transport of Infant / Pediatric patients, as approved by the EMS Service Medical
Director with guidelines and Operating Procedures provided by the Agency / Department**
RESCUE / EXTRICATION EQUIPMENT
Tarp or Blankets
Y / N / NA
Seatbelt Cutter or Trauma Shears
Y / N / NA
Spring Loaded Center Punch / Window Punch Y / N / NA
Rescue Ax or Halligan Tool
Y / N / NA
Flathead Screwdriver
Y / N / NA
*minimum 6 inches
3 Pound Hammer Y / N / NA
Hacksaw with extra Bimetal-type Blades
Y / N / NA
Duct Tape Y / N / NA
One Ton "Come-A-Long "
Y / N / NA
Rescue-Rated Chains or Straps (2 at minimum) Y / N / NA
Hydraulic Spreader / Cutter / Ram (Combi-tool) Y / N / NA
Air Chisel-Air Cylinder, Regulator, Air Hose (optional) Y / N / NA
Air Bags-Air Cylinder, Regulator, Air Hose (optional) Y / N / NA
Winch with recovery straps and Blocking equip
Y / N / NA
Stabilization Equip - Cribbing, Blocks, Struts
Y / N / NA
Revision 5/7/2010 4/4
