By Greg Friese
The daredevils who rode in barrels over Niagara Falls in the early 20th century needed a compartment to protect them from blunt trauma and drowning. A stout barrel, made from wood, steel and rubber was subject to significant forces from tons of cascading water, a hard landing at the base of the falls and strong currents which could hold a barrel captive in downriver whirlpools for hours. Partial or catastrophic failure of the barrel quickly exposed its passenger to those forces.
“The Age of Daredevils” by Michael Clarkson tells the story of the everyday men and women — without specific knowledge of physics, structural engineering or pathophysiology — who built their own barrels and then attempted to float over Niagara Falls. As I read the book, I couldn’t help but think of the risks EMS providers take riding, far too often unsecured and in a compartment not much different than a wooden barrel held together with iron staves, in the back of an ambulance.
NHTSA examined 20 years of ambulance collision data and estimated there are 4,500 vehicle traffic crashes involving ambulances each year. On average, 34 percent of those crashes resulted in injuries and 33 people were killed. An ambulance, likely because of its size and speed at the time of the collision, is extremely dangerous for other vehicle occupants. More than 60 percent of the fatalities in collisions involving ambulances are drivers or passengers in other vehicles.
The ambulance, one of the few pieces of equipment used on every response, has evolved in the 50 years of modern EMS from a station wagon to the Type I, II and III designs we see today. Those early designs though, much like the Niagara Falls barrels, were modifications by tinkerers, entrepreneurs and entertainers. The evolution in ambulance design, which is just recently engaging the expertise of ergonomists and engineers, has not been fast enough to protect EMS providers, patients and bystanders.
‘What’ or ‘Who’ is to blame for ambulance collision death or injury
A parked ambulance isn’t dangerous. An ambulance in motion and sharing a roadway with other vehicles is at risk of causing injury. Until collision avoidance and self-driving technology is ubiquitous and reliable, the behaviors and decision-making capacity of drivers are critical to reducing ambulance-involved injuries and death.
When the concept of scene safety is more generally applied to incident or call safety, it can encompass the response and transport modes, as well as expanding beyond self and partner to include partner and public. The result of an emergency response should never be causing further emergencies.
Any safety innovation, whether it is a technology, a behavior practice, an equipment invention or adaptation, or engineering control needs to be evaluated based on the actual impact it will have. For example, replacing the patient care compartment’s squad bench with bucket seats is merely interesting if the EMS providers never use the seat belts and continue to walk about the compartment unsecured during transport. Safety innovation needs to happen in concert with other ergonomic changes to put patient assessment and care equipment close at hand and behavior modification to use a seat belt.
Start with free behavior changes
Before purchasing an ambulance that has structural strength to breach brick walls like an armored personal vehicle or to self-right itself after a lateral rollover, make the no-cost changes to driver behaviors. In the NHTSA data analysis, 84 percent of EMS providers were not restrained. Increasing seat belt use among EMS providers, perhaps more difficult than shepherding a new ambulance purchase through a city budgeting process, is a no cost but critical change to reduce injuries and fatalities from an ambulance collision.
Improving safety starts with setting minimum expectations for driver and occupant behavior. “When resources are limited, start by setting and enforcing policies,” said Ryan Pietzsch, director of education and training for VFIS. “Then apply additional resources towards training and then purchasing engineering controls.”
Another immediate behavioral change is reducing red lights and sirens scene responses and patient transports. Using lights and sirens invariably leads to increased speed, overtaking passenger vehicles on two-lane roads and driving through or barely pausing at intersections; all of the above increase the risk of collisions and rollovers.
“The hard evidence about whether RLS use helps patients is severely lacking,” wrote Doug Wolfberg, an attorney and longtime EMS provider. “No studies of which I am aware have ever directly linked the use of RLS to improved patient outcomes.”
Wolfberg makes six recommendations to reduce red lights and sirens use that can be implemented with any department’s existing ambulance fleet. He recommends:
1. Use of validated dispatch protocols and trained dispatchers. 2. Policies to make non-RLS use the rule and RLS use the infrequent exception. 3. Train personnel in emergency vehicle operation. 4. Make RLS part of clinical quality assurance programs. 5. Educate decision makers that emergency health care and RLS don’t go hand in hand. 6. Embrace vehicle-to-vehicle communication technologies which will allow emergency vehicles to warn, notify or direct other vehicles.
Commit to new designs before a disaster
Given that ambulances in the U.S. travel millions of miles every year, only 4,500 annual collisions is somewhat remarkable. But fleet miles without a collision are not a predictor of future success.
The EMS Safety Foundation wants to connect EMS leaders who are open to ambulance safety innovation with experts. “We want to get operational leaders on board with the science,” Nadine Levick, MD, MPH, said.
The foundation helps EMS leaders understand the application of ergonomics, industrial design and automotive engineering. The foundation’s patient care module demonstration is a full-scale model that allows EMS providers and leaders to experience a patient care compartment that only has curb or passenger side seating, the application of ergonomics to eliminate the need to stand and putting all equipment within reach.
Patient care compartments
Much of the innovation or safety improvements to ambulances have rightly focused on the patient care compartment. The NHTSA data highlights the increase in injury severity to EMS personnel and patients when restraints — seat belts and cot straps — are not used or improperly used.
1. Secure the patient to cot and the cot to ambulance
On many occasions, I have asked EMS providers if they know how to best use the shoulder straps and harness on the patient cot. The most common response is neither “yes” nor “no.”
Instead, I have most often heard, “I didn’t even know those were there.” A close second is, “We take those off and put them in the cabinet.”
In serious crashes, only a third of patients were secured to the cot with shoulder and lap restraints. Use the equipment as it is intended to reduce the risk of additional injury to the patient.
Once in the ambulance, the patient-loaded cot needs to be secured to the ambulance. In 2014, the Society of Automotive Engineers, a professional organization that primarily develops best practices for the automotive, aerospace and commercial vehicle industries, released recommendations regarding safety standards for ambulances. The four recommendations cover patient compartment restraint, litter integrity, equipment mounting systems and both front- and side-impact safety systems.
The standards set requirements for the forces a cot mounting system must be able to hold against and a maximum distance of forward movement after a front-end collision. Cot fasteners from Ferno and Stryker are designed to meet the new SAE crash safety recommendations.
2. Easy to don and easy to work in seat belts
For seat belt use to become a habit requires policy, provider buy-in, ease of use, functionality and culture change. First, 100 percent EMS provider seat belt use when the vehicle is in motion requires commitment to making the behavior change.
Second, for the EMS provider that has agreed to the behavior change, any types of seat belt, harnesses or restraints need to be as easy or easier to don as the seat belts in their private vehicles. The Horton Occupant Protection System has three parts — airbags, padding and occupant restraint devices. An easy-to-use, four-point single buckle restraint which is reminiscent of donning a personal flotation device is the most visible component of HOPS. The device allows the EMS provider some latitude to reach forward, turn side to side and lean over while remaining buckled into the system. The HOPS, as a standard feature, also includes supplemental restraint system airbags which automatically deploy in the event of a non-recoverable rollover from a side impact to the ambulance.
A variety of restraint systems are available for the EMS providers working in an ambulance. A three-point seat belt, which is a single strap with connection points at one shoulder and both hips, is familiar for EMS providers.
Third, and most importantly, the seat belt system needs to allow or enable the EMS provider to perform the functions of their job, which include, but are not limited to:
- Touching the patient to assess vital signs and manage injuries.
- Administering medications through different routes.
- Applying and removing patient monitoring equipment.
Fourth, a driver needs to be able to easily know if ambulance occupants are wearing a seat belt. A low-tech innovation is seat belts made from orange webbing. The contrast of orange on black, blue or white uniform shirts makes it an easy glance in the rearview mirror for the driver to know if occupants are wearing a seat belt. Crestline integrates a seat belt sensor to provide instant and ongoing monitoring of seat belt use.
The final step is to ensure the organizational culture, from the medical director and operations director to the field personnel, makes it acceptable and expected that the ambulance will come to a complete stop if an EMS provider needs to be unrestrained to perform an assessment or treatment.
3. Everything has a place and stays in place
The cabinets, drawers and shelves in the patient care compartment of most ambulances allow unlimited configuration. But to be flexible enough to accommodate every paramedic’s desired organizational scheme for airways, catheters and medications usually means the space is ergonomically ineffective for everyone.
It’s also a peculiar industry practice to spend $150,000 or more on an ambulance and then reuse cardboard boxes or plastic bins from a dollar store to organize the medical supplies. Some high-use items, like a blood pressure cuff or oral thermometer, never find a cabinet and are left loose on a counter or seat.
In a sudden ambulance deceleration, rollover or side impact the little stuff can and will go everywhere. It’s the unsecured large items that present the most danger and chance for causing injury. Cardiac monitors, first-in bags and oxygen bottles can become lethal blunt trauma projectiles if they are not secured with straps or behind cabinet doors designed and tested to withstand the forces generated in a collision or rollover.
The Ferno iN∫TRAXX Integrated Vehicle Component System secures medical equipment to tracks mounted to the ambulance wall interior with brackets, packs and pouches. Equipment stays in place should there be a sudden deceleration or rollover. EMS providers can also easily reposition supplies to accommodate their unique ergonomic reaching needs.
Ambulance vendors are increasingly testing their products by using or adapting crash testing guidelines for passenger vehicles to ambulances. Rollover testing, like the test conducted by Braun Industries, Inc., is done to assess the effectiveness for the patient care compartment to stay intact, absorb energy and stay connected to the chassis during a rollover. Demers Ambulances uses different types of load testing to apply forces to the ambulance walls and seats. Braun and Demers use the results of those tests to ensure ambulances meet applicable standards for crashworthiness and occupant protection, as well as to inform further safety innovations.
4. Impact absorption and occupant protection
Passenger cars, SUVs and light trucks are engineered to absorb the impact of different types of collisions. The occupant portion of the vehicle has additional protections to prevent intrusions into the occupant’s space.
In an ambulance’s patient care compartment, seat belt use is of minor utility if the occupants are not protected from the compartment collapsing, disintegrating, shearing, imploding or exploding. The walls of the ambulance, hopefully reinforced, need to protect the occupants from intrusion and prevent the occupants from ejection into the roadway.
The interior facing surface of the ambulance’s patient care compartment covers the underlying construction and can serve the additional purpose of storing equipment. Malley Industries creates plastic inserts for the ambulance interior which have rounded edges and are impact absorbing, should an EMS provider be unbelted and thrown into the ambulance’s interior wall. Multiple configurations of panels are available for the roadside and curbside of the ambulance, which is installed as a single piece of plastic.
Securing the patient care compartment to the chassis of the vehicle is critical for occupant protection. To best protect occupants during a rollover or side impact, the integrity of the compartment and its connection to the vehicle chassis should stay intact.
5. Collapsing the available space and lowering reaching distances
Reducing the volume of the patient care compartment can make it more likely that the patient, communications equipment and medical supplies are within reach of an EMS provider who is seated and using a seat belt. Smaller compartments available in Type II ambulances using a Ford Transit or Mercedes Sprinter lower reaching distance, reduce the need for standing or walking around the patient and likely increase the need for every piece of equipment to have its own place.
Getting the patient closer to the paramedic or EMT providing care by intentional mounting of the cot securing system and the attendant seats reduces reaching distance. A squad bench and its two or three seat belt positions rarely put the EMS provider in a position where they can easily reach the patient while staying belted. Some manufacturers, like Demers Ambulances, offer attendant chairs that travel forward and backward on a track and rotate for facing the patient, forward or backward.
Duplicate controls for communications, lighting and HVAC is another method to keep EMS providers belted during patient transport. Roadside and curbside controls put things paramedics are most likely to adjust during transport within easy reach.
For some types of transports, such as neonatal or critical care transport, larger patient care compartments in a Type III ambulance may make sense to accommodate three or more health care providers. Securing those additional providers, as well as their specialized equipment, is just as important.
6. Use vehicle technology and be open to smart tech
Collision avoidance technology that automatically decelerates vehicles, keeps vehicles from crossing the center line and notifies drivers of hazards or prevents oversteering rollovers is increasingly available for passenger vehicles. That technology might reduce the frequency of collisions between ambulances and passenger vehicles. Of course, the same technology built into ambulances could further reduce collisions.
Other existing technology for power management and idle reduction can make the ambulance safer for EMS providers, especially those who spend long hours posting in a parking lot or a street corner. The ability to use personal electronic devices, rest comfortably in a climate controlled driver cab or grab a cold bottle of water from an in-vehicle refrigerator without the constant noise, vibration, smell and combustion byproducts of an idling engine can likely play a role in helping drivers feel rested and may lower the impacts of fatigue during a long shift.
The Stealth Power system charges batteries, stored inside the ambulance, that when the ambulance is parked can provide power for heat or air conditioning, a mini-refrigerator for food and drinks and charge flashlights or laptop computers. Using power management technology reduces engine idle and saves on fuel and engine maintenance.
Power management technology is accompanying a significant change in reducing power consumption by use of LED lights in the ambulance interior. LED lights, because of their size and lower power use, can be placed throughout the ambulance, including inside cabinets, making it easier for EMS providers to find and access equipment quickly and have plentiful light for performing patient procedures. LED lights are bright without being hot.
Other available technology can be used to help drivers choose routes with the least traffic congestion or avoid a road that is blocked due to an accident. Waze, the popular consumer app for crowdsourced navigation assistance, is part of the Genesis PULSE decision-support software which integrates into CAD system.
The ability to monitor driver behavior data, either on an individual or aggregate level, can inform education and training efforts to reduce speed, increase braking distance and make acceleration more gradual. Driver and vehicle monitoring data is most effective when it is used for education and promoting safe driving practices, rather than as a punitive tool.
Finally, there are increasing anecdotal sightings of ambulances being emblazoned with the motto “In God We Trust.” Though this is not likely an intentional component of an EMS agency’s commitment to patient safety and ambulance design innovation, it is an interesting commentary on the persistent danger of death or significant injury from an ambulance collision. EMS leaders also need to put their trust in the importance of training drivers for emergency vehicle operations, increasing use of seat belts, making sure every patient is correctly secured to the cot and upgrading their ambulances with significant safety improvements before a collision occurs.
