Ambulance transport safety

CarolinaFireJournal - BRADLEY DEAN
01/11/2010 -

We are at the beginning of a safety revolution in EMS. For many years, safety issues have taken a backseat to the pressures of keeping the trucks rolling. Throughout the process we have learned about the dangers our paramedics and EMTs face in the line of duty, and it has become increasingly difficult to ignore the facts staring us in the face.


Simply put, it is dangerous working in EMS. EMS professionals have about twice the national average of fatal injury rates while on the job, with the two major causes being run down while working on the roadway and ambulance accidents. We have addressed the visibility while working on the roadway with legislation requiring high visibility safety vests, now it is time to address safety inside the ambulance.

It is estimated that there are about 6,500 ambulance accidents each year, with one EMS employee being killed about every two weeks. More of these occur in urban environments, but the likelihood of substantial injury and death is greater in rural incidents. Running with lights and sirens is associated with higher injury and death rates than non-lights and siren operations. The risk of a lawsuit against an EMS agency involved in a vehicle collision is estimated at anywhere from 10 to 35 times greater than the risk of a suit related to a clinical care issue. These frightening, and alarming high statistics reveal the need for some creative problem solving and better workplace controls. One of the first mitigations pioneered to address this problem were improving driver training. EVOC training programs are designed to improve driver awareness and emergency techniques in order to reduce accidents and injury.

In 2006, the ANSI/ASSE Z15.1 Safe Practices for Motor Vehicle Operation received final ANSI approval. This standard was intended to provide all fleet operators guidance about how to reduce commercial vehicle accidents. Unfortunately, the very design of the vehicles we use to transport patients dramatically increases our risks.

While the driver training programs worked to increase driver awareness it did little to reduce fatality rates. We need to drive at the core of the problem. The automotive industry is designing safer, and safer vehicles with an envelope of safety for the occupants. All motor vehicles must conform to certain safety standards that are designed and followed by all automotive manufacturers. These vehicles are developed by automotive engineers with human physiological knowledge and crash data to improve safety. Ambulances are designed by paramedics and built by metal fabricators and cabinetmakers with no engineering experience. This is done simply because there is no standard for ambulance safety. 

The National Institute for Occupational Safety and Health has released videos of ambulance crash tests, and the results were frightening and revealing. Features like the squad bench and CPR seat are obvious sources of preventable injury. The fundamental problem is that our work environment is mobile and subject to the unforgiving laws of physics and mass. When we get into an accident, the attendant in the back is at extreme risk of injury from impacting against the wall or bulkhead if they are not buckled in. These risks are made much worse by interior designs driven by ambulance purchasing committees and not by safety engineers. 

There have been many different approaches to reducing injuries from ambulance accidents. Several companies have pioneered advanced restraint systems for the attendant in the patient compartment. These new mobile restraint systems, which are designed to move with you while you work reduce movement and being thrown around, but are no better than a loose noose.

Another potential, yet still debated concept, is for EMS personnel to wear helmets to reduce head injuries. AllMed has introduced the third generation AVC helmet for EMS. The AVC helmet is the first designed EMS helmet to meet federal motor vehicle safety standards. Many helmets often considered by EMS providers can actually be dangerous while worn inside the vehicle. The AVC helmet is the only EMS helmet designed for use, both when working inside the ambulance, and while on the scene.

In February of 2008, the National Fire Protection Association issued a revision of NFPA 1901, effective for apparatus contracted on and after Jan. 1 of 2009. It states, “Fire helmets shall not be warn by persons riding in enclosed driving and crew areas. Fire helmets are not designed for crash protection and they will interfere with the protection provided by headrests. The use of seat belts is essential for protecting firefighters during driving.”

The problem is that firefighter-style helmets can cause more injuries than they prevent in a collision. The size and weight of these helmets, along with features like overhanging brims, oversized visors and hard mounted lights, all work to defeat vehicle safety measures like the headrest. For this reason, EMS providers should probably consider a different type of head protection than the ones that firefighters utilize.

EMS practitioners are not only healthcare providers but also transportation providers. The safety of practitioners depends on the vehicles we use and the conditions surrounding their usage. I believe that ambulance usage needs to be looked at constantly with important safety factors in mind. It seems that our profession has over 30 years of improvement and science impeded by tradition. I have been scrutinized for transporting patients routine when others thought that they should have been transported with lights and siren. I have also been scrutinized for responding routine, when the call was dispatched as an emergency. Provider discretion is an important factor for current road conditions, response modes and transport modes. According to a study authored in 1994 by Doug Kupas, MD, from the Department of Emergency Medicine at Geisinger Health System based in Danville, Penn., and the State of Pennsylvania EMS Medical Director, with multiple other studies since then, reveals that the use of lights and sirens adds virtually no benefit to patients. The use of lights and sirens, while adding no benefit, adds a substantial risk of injury and death to ambulance occupants and others on the road. Since there is no appreciable improvement in patient outcomes, why do we continue their use?

Another hot topic is why do we inherently find people “transporting the dead” ? Again, it seems that the traditional view is work it for the family. I have done multiple studies, that may be published at a later date, that shows that CPR cannot be effectively performed in the back of a moving ambulance. I am all for load and go with patients that have significant injuries or illness, unless they are in cardiac arrest. The emergency department has little to offer over ACLS performed in the field, and requiring personnel to transport these patients is unethical as related in the 2005 guidelines published by the American Heart Association.

In September of 2009 the National Association of Emergency Medical Technicians released a position statement on EMS Ambulance Safety. This positions statement supports the development of a culture of safety in all EMS systems in our nation. In order to improve ambulance safety it is important that the following occur:

  • Federal funding for ongoing research and testing of ambulance vehicle design including the overall structure and interior structures such as grab rails, compartments and equipment restraint systems.
  • Federal (or state) development of a reporting system or database to specifically identify and track ambulance crash related injury and death.
  • National Traffic Safety Bureau (NTSB) consistently investigates ground ambulance crashes involving all fatalities.
  • Department of Transportation (DOT) track ambulance crash data and make safety recommendations.
  • EMS systems to implement a safe ambulance operation management program that includes risk management.
  • EMS service selection and use of vehicles that meet or exceed government and industry safety standards. (A standard has to be developed first).
  • EMS system requirement of the use of functional occupant restraint systems and personal protective devices that meet or exceed government and industry standards.
  • EMS system requirement of the development, implementation and enforcement of safe driving policies and procedures that meet or exceed industry standards.
  • Employer required proficiency training, orientation and continuous quality assurance on vehicle driving and operation.
  • Employer monitoring of driving behaviors through the use of observation and onboard monitoring systems.
  • Employer implementation and documentation of vehicle maintenance programs that meet or exceed manufactures’ ’ and regulatory requirements.

Today, paramedic students are taught “Scene Safe, BSI” like it is a protective mantra. I am not convinced that repeating that over and over again makes us any safer. What truly makes us safer is having a realistic appreciation of the real risks of our work and placing logical workplace controls. The products and processes that will help make us safer are mostly new. It will take time for our industry and manufacturers to respond to our needs with solutions that will really work. While some of those potential solutions are just now being realized, we still have a lot of work yet to be done. For the very first time, we are learning the difference between what we think kills us and what really does kill us. The appreciation of safety in the back of an ambulance will lead to better engineering and boxes designed by something other than paramedics and cabinet makers.

Dean currently works as one of the Assistant Regional Emergency Response and Recovery Coordinator for the Triad Region of North Carolina through Wake Forest University Baptist Medical Center Trauma Department. He is a faculty member for the EMS Programs at Alamance Community College, a paramedic with Davidson County Emergency Services and a volunteer with Thomasville Rescue, and Holly Grove Fire Department.
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