Medical Rescue Certification Inspection Form (New Mexico Dept. Of Health, Emergency Medical Systems Bureau) Page 3
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4New Mexico Dept. of Health
Emergency Medical Systems Bureau
Medical Rescue Certification Inspection Form
Name of Service: ____________
Location of Service:__________
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
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