Date / Time

//Date

Time

Zoll Monitor

Zoll Daily / Shift Check Procedure (Check as you do each step): *

Ensure that the X Series unit is clean (with no fluid spills) and free of visible damage.
Inspect all cables, cords, and connectors for signs of damage or excessive wear (cuts in insulation, fraying, broken wires, dirty or bent connector pins). Replace if damaged.
Inspect the battery, ECG patient cable, multifunction cable (MFC), OneStep cable, pulse oximetry sensor, blood pressure cuff, and hose and temperature sensors for signs of damage or excessive wear. Replace if damaged.
Inspect the external AC adapter and its power cords for signs of damage. Replace if damaged.
Check supply inventory (below) and add supplies as needed.
Open the printer door on the left side unit and verify that an appropriate (> 1/2 roll) of paper is installed in the unit. Change if needed.
Verify that a charged battery is fully inserted into the battery compartment of the X Series unit.
Ensure that a fully charged spare battery pack is available.
Check the Ready For Use (RFU) indicator on the X Series front panel. Verify that the RFU symbol is displayed.

If the READY-FOR-USE (RFU) indicator is flashing or displaying the Do Not Use symbol, then either an equipment fault has been detected or the unit's battery is low or not properly installed. Install a fully charged battery in the unit and check the RFU indicator again. If the RFU indicator continues to flash or display the Do Not Use symbol, remove the unit from service and contact the appropriate technical personnel or the ZOLL Technical Service Department.

Zoll Supplies

ECG Patches

Left Side, Open Pouch (2 Packs)

ECG Patches (Packs) *

ECG Patch Expiration *//

Adult Defib / Pacing Pad

Right Side Pouch, Minimum 1

Adult Statpadz Qty *

Adult Statpadz Expire *//

Pediatric Defib / Pacing Pad

Right Side Pouch, Minimum 1

Ped StatPadz Qty *

Ped StatPadz Expire: *//

Curbside Drawer (Upper)

ECG Patches

Enter the number of unopened ECG patches and the nearest expiration date

ECG Patches (Packs) *

ECG Patch Expiration//

IV Catheters

For each size IV catheter size, enter quantity and expiration date.

14 G x 1-1/4" Qty *

14 G Catheter Expiration *//

There should be a minimum of two catheters of each size.

16 G x 1-1/4" Qty *

16 G Catheter Expiration *//

18 G x 1-1/4" Qty *

18 G Catheter Expiration *//

20 G x 1-1/4" Qty *

20 G Catheter Expiration *//

22 G x 1" Qty *

22 G Catheter Expiration *//

24 G x 1" Qty *

24 G Catheter Expiration *//

Supplies

Ensure the listed supplies are present in the correct quantities.

Supplies

Band Aids (5)
2 x 2's (10)
Tegaderm Film Dressings (5)

Supplies

Alcohol Preps (10)
1" Transport Tape (> 1/2 Roll)
Spare Tourniquets (1)

IV Start Kits

Minimum two start kits with blood draw tubes. Check expiration dates of all items in kit if needed. List nearest expiration date.

IV Start Kit Qty *

IV Start Kit Expiration *//

IV Fluids

500 ml 0.9% Normal Saline, minimum quantity 1 bag.

500 ml NS Qty *

NS Expiration *//

15 gtts / ml primary IV set, minimum quantity 1. May not have expiration date.

Primary IV Set Qty *

Primary IV Set Expiration//

Curbside Drawer (Lower)

Spare Glucometer

Minimum 1 spare drum for glucometer

Glucometer Drum Quantity *

Spare Drum Expiration *//

Spare Lancets (Yellow) *

Spare Lancets (Orange) *

End-Tidal CO2 Supplies

Minimum (2) nasal cannula type and (2) in-line adapaters.

ETCO2 Cannula Quantity *

ETCO2 Adapter Quantity *

Zoll StatPadz

Minimum (1) Adult and (1) Pediatric Set

Adult StatPadz Quantity *

Adult StatPadz Expiration *//

Pediatric StatPadz Quantity *

Ped StatPadz Expiration *//

Front Wall (Upper)

General Supplies

Disinfectant Wipes
Paper Towels (>1/2 Roll)
Nitrile Gloves (XL) (> 1/2 Box)

Glove Cabinet Above Side Door *

Nitrile Gloves (S) (> 1/2 Box)
Nitrile Gloves (M) (> 1/2 Box)
Nitrile Gloves (L) (> 1/2 Box)

Dell Laptop *

Damaged?
Charging?
Keyboard Cover?

Portable Suction

Portable Suction Unit *

Unit plugged in and charging?
New container?
Suction tubing & catheter?

Unplug portable suction and run for 15 seconds.

Working properly
Not working properly

EZ-IO Kit (Yellow Bag)

Supplies *

IO Driver
Alcohol Preps (5)
Instruction Card

10 ml Normal Saline Flush (Min 1)

NS Flush Qty

NS Flush Exp.//

Extension Sets (Min 1)

Extension Set Qty

Extension Set Exp.//

IO Needle plus Stabilizer (Min 1)
Pink 15 mm x 1.8 15 Gauge

Pink Set Qty

Pink Set Exp.//

IO Needle plus Stabilizer (Min 1)
Blue 25 mm x 1.8 15 Gauge

Blue Set Qty

Blue Set Exp.//

IO Needle plus Stabilizer (Min 1)
Yellow 45 mm x 1.8 15 Gauge

Yellow Set Qty

Yellow Set Exp.//

Front Wall (Lower)

Spare Oxygen

Minimum 2 Spare Cylinders

Spare O2 Qty

Spare O2 Expires://

Fire Extinguisher

Confirm the extinguisher is visible, unobstructed, and in its designated location.
Verify the locking pin is intact and the tamper seal is unbroken.
Examine the extinguisher for obvious physical damage, corrosion, leakage, or clogged nozzle.
Confirm the pressure gauge or indicator is in the operable range or position.
Lift the extinguisher to ensure it is still full. Invert/shake to ensure contents aren't caked.
Make sure the operating instructions on the nameplate are legible and facing outward.
Check the last professional service date on the tag.
Initial and date the back of the tag. Use MO/YR on date.

Miscellaneous

Safety Vests (2 Minimum)
Mass Casualty Triage Kits (2)
Triage Tags (1 Pack)

Drug Cabinet

Drug Box Number *

Drug Box Seal Number *

Drug Box Expiration *//

Drug Box Comments

Ancillary Drugs

Narcan (Naloxone) Nasal Spray, 4mg
Minimum 1 Box of 2 Doses

Narcan Quantity

Narcan Expiration//

EpiPen (Epinephrine) Adult, .3mg unit dose
YELLOW, Minimum One Dose

Adult (Yellow) EpiPen Qty

Adult (Yellow) EpiPen Exp.//

EpiPen (Epinephrine) Pediatric, .15mg unit dose
GREEN, Minimum One Dose

Peds (Green) EpiPen Qty

Peds (Green) EpiPen Exp.//

Cabinet 1 (Upper Shelf)

Loose Items

Resq-O2 Kids Bear
PetO2 Pet Oxygen Kit

Tray 1: Miscellaneous / Batteries

Tray 2: Airway Adjuncts

Front Section

Pocket Masks (2)

Middle Section

Nasopharyngeal Airways(NPA)

Nasopharyngeal Airway, 24 FR
Minimum (1) Required

NPA 24 Qty

NPA 24 FR Exp//

Nasopharyngeal Airway, 26 FR
Minimum (1) Required

NPA 26 Qty

NPA 26 FR Exp//

Nasopharyngeal Airway, 28 FR
Minimum (1) Required

NPA 28 Qty

NPA 28 FR Exp//

Nasopharyngeal Airway, 30 FR
Minimum (1) Required

NPA 30 Qty

NPA 30 FR Exp//

Lubricating Jelly
Water-soluble
Minimum (5) Packets

Lubricating Jelly Qty

Lubricating Jelly Exp//

Rear Section

Adult ETCO2 Detector
Minimum (2) Required

Adult ETCO2 Det. Qty

Adult ETCO2 Det. Exp.//

Pediatric ETCO2 Detector
Minimum (2) Required

Peds ETCO2 Det. Qty

Peds ETCO2 Det. Exp.//

Tray 3: ET Tube Holders

ET Tube Holders

Adult ET Tube Holder (Min. 1)
Pediatric ET Tube Holder (Min. 1)
2" Wide Hy-Tape (Pink Tape)

Cabinet 1 (Lower Shelf)

Loose Items

Single-Use BP Cuffs (2)
Penlight (1, Working)
Suction Tubing (1)

Tray 1: Suction Catheters

Yankauer Suction Catheters
(with or without control vent)
Minimum (2) Required

Yankauer Qty *

Suction Catheter (6 FR)
Minimum (2)

6 FR Suction Qty *

Suction Catheter (8 FR)
Minimum (2)

8 FR Suction Qty *

Suction Catheter (10 FR)
Minimum (2)

10 FR Suction Qty *

Suction Catheter (12 FR)
Minimum (2)

12 FR Suction Qty *

Suction Catheter (14 FR)
Minimum (2)

14 FR Suction Qty *

Suction Catheter (16 FR)
Minimum (2)

16 FR Suction Qty *

Suction Catheter (18 FR)
Minimum (2)

18 FR Suction Qty *

Lubricating Jelly
Water Soluble
Minimum 5 Packets

Lube Jelly Pack Qty *

Lube Jelly Expires//

Tray 2: Nebulizers & Humidifiers

Nebulizer Kit
Minimum (2)

Nebulizer Kit Qty *

Humidifier Kit
Minimum (2)

Humidifier Kit Qty (copy) *

Tray 3: Adult Cannulae

Adult Nasal Cannulae
Minimum (2)

Adult Nasal Cannula Qty *

Tray 4: Adult Non-Rebreathers

Adult Non-Rebreathing Face Masks
Minimum (2)

Adult NRB Qty *

Tray 5: Pediatric Oxygen

Pediatric Nasal Cannula
Minimum (2)

Peds Nasal Cannula Qty *

Pediatric Non-Rebreathing Face Masks
Minimum (2)

Peds NRB Qty *

Tray 6: Infant Oxygen

Infant Nasal Cannula
Minimum (2)

Infant Nasal Cannula Qty *

Infant High-Concentration Face Masks
Minimum (2)

Infant High-Conc Mask Qty *

Cabinet 2

Upper Shelf

Lower Shelf

HALO Chest Seals

HALO QTY

HALO EXP//

LSMFR Chest Decompression Kit (Ziploc Bag Back of Cabinet) Note 1st expiring item.

Decomp Kit QTY

Decomp Kit EXP//

Tray 2 *

Ammonia Inhalants (6)
Sting-Ease Swabs (6)
Z-Fold Gauze Dressings (2)

Tray 3 *

4x4's (48)
2x2's (24)
Band Aids (24)
Trauma Shears (1)

Tray 4 *

1" Tape (4)
2" or > Tape (4)

Tray 5 *

Toruniquets (2)
2" Elastic Bandage (2)
4" Elastic Bandage (2)

Cabinet 3

Protocol Manuals

New (2019) Protocols
Prev (2016-2019) Protocols

Adult Bag-Valve-Mask *

AIRWAY ROLL

Magill Forceps

Large
Small

Large Laryngoscope Handle

Batteries Checked
Ready for Use

Laryngoscope Blades *

	Ready for Use	Bulb Checked
Miller 0	Miller 0 Ready for Use	Miller 0 Bulb Checked
Miller 1	Miller 1 Ready for Use	Miller 1 Bulb Checked
Miller 2	Miller 2 Ready for Use	Miller 2 Bulb Checked
Miller 3	Miller 3 Ready for Use	Miller 3 Bulb Checked
Mac 3	Mac 3 Ready for Use	Mac 3 Bulb Checked
Mac 4	Mac 4 Ready for Use	Mac 4 Bulb Checked
Wisconsin 2	Wisconsin 2 Ready for Use	Wisconsin 2 Bulb Checked

ENDOTRACHEAL TUBES & SUPPLIES

1 Set 2.5mm - 10mm in Airway Roll 1 Set 2.5mm - 10mm in Cabinet

2.5 mm Uncuffed ET Tube

2.5 MM ETT QTY *

2.5 MM ETT EXP *//

3.0 mm Uncuffed ET Tube

3.0 MM ETT QTY *

3.0 MM ETT EXP *//

3.5 mm Uncuffed ET Tube

3.5 MM ETT QTY *

3.5 MM ETT EXP *//

4.0 mm ET Tube

4.0 MM ETT QTY *

4.0 MM ETT EXP *//

4.5 mm ET Tube

4.5 MM ETT QTY *

4.5 MM ETT EXP *//

5.0 mm ET Tube

5.0 MM ETT QTY *

5.0 MM ETT EXP *//

5.5 mm ET Tube

5.5 MM ETT QTY *

5.5 MM ETT EXP *//

6.0 mm ET Tube

6.0 MM ETT QTY *

6.0 MM ETT EXP *//

6.5 mm ET Tube

6.5 MM ETT QTY *

6.5 MM ETT EXP *//

7.0 mm ET Tube

7.0 MM ETT QTY *

7.0 MM ETT EXP *//

7.5 mm ET Tube

7.5 MM ETT QTY *

7.5 MM ETT EXP *//

8.0 mm ET Tube

8.0 MM ETT QTY *

8.0 MM ETT EXP *//

9.0 mm ET Tube

9.0 MM ETT QTY *

9.0 MM ETT EXP *//

10.0 mm ET Tube

10.0 MM ETT QTY *

10.0 MM ETT EXP *//

Adult Bougies, Minimum (2)

Adult Bougie QTY *

Adult Bougie EXP *//

Adult Stylettes, Minimum (2)

Adult Stylette QTY *

Adult Stylette EXP *//

Lubricating Jelly, Minimum (5) Packs

Lube Jelly QTY *

Lube Jelly EXP *//

Cabinet 4

Infant Bag-Valve Mask
Minimum (1)

Infant BVM Qty *

Child Bag-Valve Mask
Minimum (1)

Child BVM Qty *

Adult CPAP Kit
Minimum (1)

Adult CPAP Kit Qty

Adult CPAP Kit Expires//

Cabinet 5

Stethoscopes

Adult Stethoscope
Pediatric Stethoscope

Cabinet 6

Obstetrical Kits

Minimum (2), Sealed

Numbers

Instant Hot Packs

Minimum (3)

Hot Pack Quantity

Instant Cold Packs

Minimum (3)

Cold Pack Quantity

Trauma Dressings

10" x 30" or larger, Minimum (4)

Trauma Dressing Qty

WaterJel Burn Kit

Kit, Complete Minimum 1

Checkboxes

Normal Saline for Irrigation

500 ml or 1 L Sealed Containers Minimum 4 Liters Total

NS Qty *

NS Expires *//

Cabinet 7

LUCAS2 Chest Compression System

Please inspect/test the LUCAS2 as outlined:

Remove from carrying case
Device is clean and has no damage.
Check the bellows and suction cup.
Check patient straps and stabilizer strap.
Power the unit ON and check battery.
Verify the unit starts and runs without unusual sounds.
Check 30:2 mode to be sure it alerts and pauses for ventilation.
Check continuous mode - LED should blink every 12 strokes.
Return to carrying case.

Cabinet 8

Linen Cabinet

Sharps & Waste Drawers

Sharps and waste drawers are located under the streetside drawer stack and the curbside attendant seat.

Curbside Drawer

Sharps container is < 1/2 full
Waste basket has new red biohazard bag.
Check if trash / sharps changed out.

Streetside Drawer

Sharps container is < 1/2 full
Waste basket has new red biohazard bag.
Check if trash / sharps changed out.

Comments

Signature

Name

LSMFR Medic / Rescue 35 Checklist

Zoll Monitor

Zoll Supplies

ECG Patches

Adult Defib / Pacing Pad

Pediatric Defib / Pacing Pad

Curbside Drawer (Upper)

ECG Patches

IV Catheters

Supplies

IV Start Kits

IV Fluids

Curbside Drawer (Lower)

Spare Glucometer

End-Tidal CO2 Supplies

Zoll StatPadz

Front Wall (Upper)

Portable Suction

EZ-IO Kit (Yellow Bag)

Front Wall (Lower)

Spare Oxygen

Fire Extinguisher

Drug Cabinet

Ancillary Drugs

Cabinet 1 (Upper Shelf)

Loose Items

Tray 1: Miscellaneous / Batteries

Tray 2: Airway Adjuncts

Front Section

Middle Section

Nasopharyngeal Airways(NPA)

Rear Section

Tray 3: ET Tube Holders

Cabinet 1 (Lower Shelf)

Loose Items

Tray 1: Suction Catheters

Tray 2: Nebulizers & Humidifiers

Tray 3: Adult Cannulae

Tray 4: Adult Non-Rebreathers

Tray 5: Pediatric Oxygen

Tray 6: Infant Oxygen

Cabinet 2

Upper Shelf

Lower Shelf

Cabinet 3

AIRWAY ROLL

ENDOTRACHEAL TUBES & SUPPLIES

1 Set 2.5mm - 10mm in Airway Roll 1 Set 2.5mm - 10mm in Cabinet

Cabinet 4

Cabinet 5

Cabinet 6

Obstetrical Kits

Instant Hot Packs

Instant Cold Packs

Trauma Dressings

WaterJel Burn Kit

Normal Saline for Irrigation

Cabinet 7

LUCAS2 Chest Compression System

Cabinet 8

Linen Cabinet

Sharps & Waste Drawers