NREMT Study Guide: EMS Operations

This section of our NREMT Study Guide provides a comprehensive overview of EMS operations, which accounts for 10%–14% of the overall exam. This guide covers the nine phases of an ambulance call, safe driving practices, air medical operations, and establishing a landing zone.

After you have completed reviewing the study guide, you will find five practice questions to test your understanding and retention of the material.

Phases of an Ambulance Call

As an EMT, you must know the nine distinct phases of an ambulance call. These nine phases address the vehicle and your and your partners’ roles when responding to a call. The nine phases are as follows:

  1. Preparation for the call
  2. Dispatch
  3. En route
  4. Arrival at scene
  5. Transfer of the patient to the ambulance
  6. En route to the hospital (transport)
  7. At the hospital (delivery)
  8. En route to the station
  9. Post-run

Preparation for the Call

This phase is where you ensure all equipment and supplies are stocked and ready for use. Your equipment and supplies should be easily accessible and within reach. All storage cabinets should be stocked with the cabinet doors closed. Check the portable and fixed oxygen tanks to ensure the tanks are full or at an acceptable level. Inspect all batteries in your radios, flashlights, AED, and any other monitoring equipment you carry. You will also stock your personal protective equipment (PPE), including disposable gloves, gowns, masks, face shields, and eye protection.


You will be dispatched to the call during this phase. At the dispatch center, an emergency dispatcher will receive the 911 call and ask the following questions:

  • The nature of the call
  • The location of the call
  • The name of the caller and patient
  • The location of the patient
  • The number of patients
  • Any other pertinent information about hazards or the safety of the scene

En Route

This “response” phase is the most dangerous of all phases for EMS professionals. Many serious injuries and even death occur each year between emergency and other vehicles. You must always wear your seatbelt, let the dispatcher know you are responding, and use lights and sirens when appropriate. Intersections are the most dangerous location for crashes, so be sure to slow down or stop and “clear” the intersection before proceeding.

When responding to the call, review and update your partner with dispatch information, assign duties to each team member, and decide what equipment to initially take to the scene. Arriving at the scene safely and transporting the patient safely to the hospital are two of the most challenging aspects you will face as an EMT.

Arrival at Scene

As you approach the scene, you will notify dispatch of your arrival and perform a scene size-up, looking for life hazards, such as downed power lines or a hazardous material spill. You will determine if the scene is safe to enter, the number of patients, and if additional resources are needed. If additional resources are needed, request them at this time.

Transfer of the Patient to the Ambulance

During this phase, you will transfer your patient(s) into the ambulance after they have been packaged for transport. This phase has been reported by patients as being the most frightening part of becoming sick or injured – the ambulance ride to the hospital.

When transferring the patient to the ambulance, you want to ensure they are safely strapped to a backboard or gurney and that the gurney is secured once in the ambulance. If lights and sirens are needed, explain to the patient (if they are conscious) why they are being used while remaining calm and professional. The sirens can increase a patient’s fear and make them anxious, so it is your job to assure them they are in good hands.

En Route to the Hospital (Transport)

During this phase, you will advise dispatch that you are leaving the scene and transporting the patient to the hospital. In your report, you will inform dispatch of the number of patients you are transporting, your destination, and in some jurisdictions, the beginning mileage on the ambulance. While transporting the patient, you will continue to reassess their vital signs, monitor their condition, and continue treatment en route to the hospital. You will inform the hospital that you are en route and provide information about the number of patients and their chief complaints. Some EMTs will start on their patient care report (PCR) depending on the patient’s condition.

At the Hospital (Delivery)

When you arrive at the hospital, you will inform dispatch and give the ending mileage if your agency requires it. Then follow these four steps to deliver and transfer your patient to the receiving hospital:

  1. Announce your arrival to the triage nurse
  2. Transfer the patient from your gurney to the hospital bed
  3. Give a verbal report to the nurse or physician who is taking over the care of the patient
  4. Complete a detailed patient care report (PCR), obtain required signatures, and leave a copy with the appropriate hospital personnel. If electronic reports are used by your agency, follow your local protocols

The PCR will include a summary of the patient’s illness or injury, mechanism of injury or nature of illness, pertinent positives and negatives, and findings upon your arrival. You will also include the patient’s baseline vital signs, medical history, medications, allergies, treatment given, response to the treatment, and reassessed vital signs.

Depending on your local protocols, you might restock the supplies you used on the patient while at the hospital. If your protocols do not allow restocking from the hospital, you will restock back at the station. The priority in this phase is to transfer your patient, and then restock afterward.

En Route to the Station

During this phase, you will notify dispatch when leaving the hospital, advise if you are in service or not, and inform them where you are going. You may not be in service if you need to restock your supplies, have an issue with the ambulance, need to refuel, or need to decontaminate your equipment. However, you still need to notify dispatch of your status. When you arrive at your station, the following must be done:

  • Clean, disinfect, and decontaminate the ambulance and equipment used if not performed at the hospital, following your agency’s protocols
  • Restock any supplies you used


This is the phase where you will notify dispatch of your arrival at your station or another location and advise them of your availability (in-service or out-of-service). You will complete any additional reports that need to be filed, such as an exposure report if you were exposed to an infectious disease or stuck with a needle. You and your partner will inspect the ambulance and refuel or top off any fluids if needed. If you or your partner need debriefing from the call, this is the phase where you will do so.

Safe Driving Practices

The first rule to safely driving an emergency vehicle is that “speed does not save lives; good care does.” The second rule is that the driver and all passengers must wear shoulder restraints and seat belts at all times. This rule also applies to the patient, who should be restrained in a “jump seat” or on the gurney. The exception is when you are providing direct patient care and cannot be restrained. All medical equipment and cabinets must be secured so objects do not become airborne if involved in a crash. This is especially important for portable oxygen tanks.

Take time to learn how the ambulance takes corners, accelerates, decelerates, sways, and stops. Ambulances are top-heavy and handle differently than normal vehicles. You want to learn the proper brake and gas pressure needed so the patient and your partner will not be jostled around in the patient compartment.

When driving on a freeway, you want to stay in the far left lane, called the fast lane or number one lane. Motorists are taught to move to the right when they see and hear lights and sirens, so staying to the left allows them to do so. However, always be on the defense when driving an ambulance, and never assume motorists will see you or pull to the right. Many motorists panic and stop in the middle of the lane, pull to the left, or even speed up and try to race you. Always anticipate the worst and hope for the best.

Air Medical Operations

There are two types of air ambulances: fixed-wing and rotary-wing (the latter also known as helicopters). Fixed-wing planes are used for long-distance, inter-facility patient transfers greater than 100-150 miles, while helicopters are used for shorter distances. Specially trained medical crews are on board both types of aircraft and will accompany the patient to the hospital.

Helicopters are used to perform medical evacuations known as medivacs. It is your responsibility as an EMT to understand your local protocols for requesting a medivac, which is typically requested directly through dispatch. Every agency has particular criteria for requesting a medivac, but they generally follow these guidelines:

  • The patient’s condition is so severe that ground transport will be too long
  • The patient has a time-dependent injury or illness, such as a stroke, heart attack, major trauma, severe burns, or spinal cord injury
  • The patient’s location is inaccessible by ground ambulance, such as a hiker injured or sick high up a mountain

Usually, an air ambulance will be requested through dispatch. The EMS crew then may have direct contact with the flight crew on a designated channel.

Establishing a Landing Zone

After a helicopter has been requested, a landing zone (LZ) will need to be established. If you are responsible for patient care, this task will be designated to another agency, such as the fire department. It is still important to understand how to set up a landing zone and familiarize yourself with helicopter hand signals in case you are responsible for this task.

You will choose the best location to ensure the flight crew can land and take off safely. The guidelines to consider selecting and establishing an LZ are as follows:

  • Choose a hard or grassy level surface that measures at least 60 feet x 60 feet. However, 100 feet x 100 feet is preferred. If you cannot find a level surface, notify the flight crew of the direction and steepness of the slope so they can make adjustments when landing.
  • Ensure the area does not have loose debris that can become airborne, such as loose branches, flares, medical equipment, trash cans, and caution tape.
  • Look for overhead hazards, such as trees, antennas, power lines, and telephone poles. If there are overhead hazards, immediately notify the flight crew. They may request the hazards be illuminated or marked by EMS vehicles or weighted cones.
  • To mark the LZ, use emergency vehicles at the corners of the site with headlights facing inward to form an X or use weighted cones. Do not use people, caution tape, or flares to mark the site. Also, ensure no one is smoking at the site. Flares and cigarettes are a fire hazard and can cause a fire or explosion when the helicopter is landing.
  • Move bystanders and vehicles to a safe distance outside the landing zone.

Once the helicopter has landed, stay away from the aircraft unless instructed to approach by the flight crew. Most flight crews will exit the aircraft and come to you and your patient. If you are asked to enter the landing zone, stay clear of the tail rotor, which can appear invisible as it moves so rapidly. Most flight crews will guide you on where to approach for your safety.

EMS Operations Review Test

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