While there are engineering changes that can result in a safer work environment, the mitigation of the risk in ambulance crashes has to start with prevention.
Ambulance manufacturers have taken a variety of approaches to building a safer vehicle and these efforts are commendable, showing that the industry is looking in the right direction. But until there is a comprehensive change in both standards and practices in ambulances in the United States, much about this issue will remain unchanged. That being said, this issue is by no means dormant. Both the National Fire Protection Agency (NFPA) and the Commission on the Accreditation of Ambulance Services (CAAS) are developing new standards to replace those currently adopted by many states. Both of these bodies of work will identify responder and patient safety as a priority. There is however a number of things that can be done at the local level that can and will make a difference in mitigating the hazards of driving and riding in ambulances. And the return on this investment not only will serve to better protect the men and women operating and working in these vehicles, but also the patients that depend on EMS for safe transportation.
So how big of a problem is ambulance safety as a threat to EMS personnel and others on the highways? Per the National Highway Transportation Safety Administration (NHTSA) analysis of data gathered between 1992 and 2011, there were an average of 4500 ambulance crashes per year in the United States — one every two hours (NHTSA, 2012). That’s a rather significant statistic when you drill it down to that level. It’s also important to note that in 34 percent of these events the result included an injury or death (NHTSA, 2012). That equates to an injury or death from an ambulance crash every six hours — every day, every year, for 20 years. That statistic alone should be enough to inspire EMS personnel to confront this hazard in every way possible.
Addressing the issue of ambulance safety will require much research and engineering to truly create a safer work environment in regards to the design and safety features of the vehicle, but there are many solutions that can be implemented at the local level that can and will make a difference. EMS agencies should start with the simple changes that can and will reduce the threat of this hazard. First and foremost on this list is mandating the use of seat belts. In the cab of the ambulance, this should be mandatory, 100 percent of the time by everyone in every situation. There are no commercially produced ambulance chassis that do not have seat belts as a standard accessory — they just have to be utilized to be effective. And the personnel that rely upon them should check their operation on a regular basis. Seats without properly operating seat belts should never be occupied with the vehicle in motion. Seat belts in ambulances cannot be mentioned without wading into the age-old discussion of the use of restraints for personnel in the back of the truck.
Over the last 10 years, a variety of approaches to seat belts in the patient care area have been designed and incorporated into new ambulances. For the most part, the better secured those doing patient care are, the less able they perceive themselves to be able to provide patient care. One approach to this dilemma is to minimize activities while the vehicle is in motion by doing more on the scene. While this sounds good in theory, providing quality patient care will at times require a hands on approach that must be done while en route to the hospital. Practices should be scrutinized locally to minimize what is permissible to be done while the ambulance is moving, allowing such activity only when there is a clear benefit to patient outcome. And while we are speaking of the patient, they too should be properly secured at all times while inside the ambulance. Current models of the most popular patient cots are delivered with three sets of horizontal straps and a fourth set of straps that are specifically designed to harness the patient’s shoulders. These straps serve a vital function in restraining the patient from sliding forward horizontally during rapid deceleration events. These unanticipated events are also why transporting the backboarded patient on the bench seat should be avoided whenever possible. The proper use of the shoulder straps may require some re engineering of practices when there is a clinical need to access the patient’s chest and he or she require the proper adjustment based on patient size to function as intended. The shoulder straps should never be considered as optional equipment for any patient secured to the cot. Ambulatory patients that are anywhere in the ambulance other than on the cot should always be secured with lap and shoulder belts.
Patients are not the only things that should be properly secured in the ambulance. Look around the cab and the patient care area to see what could become an injury-causing projectile in the event of a collision or rollover. A ruggedized laptop weighs about eight pounds. Now hurl that laptop at 55 miles per hour (or whatever the speed of the ambulance is at the time of a rapid deceleration collision) and see what kind of damage results. Laptops, battery chargers, helmets, oxygen cylinders, etc. should be properly secured in such a manner that they will not be projectiles in the event of an incident. It may be convenient to type with the computer on your lap while riding to the hospital or other location, but that convenience could come at a significant cost — such as injury or death — in the event of a collision.
Larger pieces of equipment, such as defibrillators, should be secured as well, either in an accessible compartment or soundly strapped in a sturdy location. And this is not exclusive to medical equipment. Look at what items personnel are placing in the cab each shift to see if they present a hazard. Objects like large metal coffee cups, smart phones or tablets, and even small coolers all present a significant hazard when they are not properly secured. Agencies and personnel should take the initiative to look at how equipment is being stored in the cabs and modules of ambulances and implement procedures to identify the proper and safe location for storing items to eliminate them from being hazards.
While there are engineering changes that can result in a safer work environment, the mitigation of the risk in ambulance crashes has to start with prevention. The safest way to survive a collision is to have taken the appropriate steps to have never had the collision. And the most logical strategy is to look at how EMS personnel are trained to operate these vehicles and what measures are used to reinforce that training.
In the 2000 “EMS Education Agenda for the Future,” NHTSA published a document having the goal to “enhance consistency in education quality and ultimately lead to greater entry level graduate competency” (NHTSA, 2000). Upon reviewing this very well laid out document, crafted by leaders from all disciplines of EMS, there are no mentions of driving, crashes, seat belt, or collisions in a search of the text. Yet every year for the past 20, EMS has documented an ambulance collision that resulted in an injury of death every six hours. The focus on safety has to start at the highest of levels in the United States if we are to truly see a comprehensive change for the better. But that does not mean that EMS agencies should not step up and take ownership of the issue at the local level.
In North Carolina, a good place to start in the training realm would be with the Emergency Vehicle Driver certification provided by the Office of the State Fire Marshal. While a common delivery and certification in the fire service, the content of this program is equally as beneficial in EMS, teaching key aspects such as the impact of physical forces on response vehicles, the legal responsibilities of being the emergency vehicle operator, and the importance of being physically and mentally sound to be a driver. The program also includes a practical assessment using a competency course with the actual vehicles used at work. Instructors are available through the community college system. This training is good for initial instruction and should be reviewed periodically as a refresher program. Regardless of the curriculum adopted, EMS agencies must ensure that an employee is properly trained and has a documented competency of every type of vehicle that they are expected to operate during the course of work. Many agencies have fleets that consist of a variety of types of ambulances. Each of these vehicles has unique physical characteristics that require both training and experience behind the wheel to develop proficiency and safety for emergency operation. An ambulance is not an ambulance — and agencies must recognize that fact when they have diverse fleets and personnel are expected to operate them.
In support of good training should be sound departmental policies and procedures. These policies and procedures should reflect best practice in safe emergency vehicle operations. Samples of such policies are widely available from other departments on the Internet, and VFIS has available downloadable resources on their website to assist in the local development of these documents. Once developed and adopted, it is essential that all departmental personnel be trained in the expectations created by the new policies and procedures, including both compliance from field personnel and the responsibility of monitoring and accountability from supervisory personnel.
There are a number of technology solutions currently available for monitoring the behaviors of personnel driving ambulances, and when used as intended, they can provide instant feedback to the driver when they are close to or exceeded pre-established thresholds in regards to speed or braking. These systems also provide administrators with the necessary data to identify those on their staff with good and bad driving behaviors. These solutions have been proven many times to be a sound investment at the agencies where they have been implemented. The best feedback system is free. When you have a culture of safety in your organization and everyone grasps the notion that they are responsible for the safety of everyone else, a loud “slow down” or “stop” is the best driver feedback mechanism available.
Ensuring that everyone goes home is an issue not owned exclusively by any one group in the industry. Everyone in the industry owns it. And collectively, from the designers of the vehicles themselves to the local agencies that determine the way their ambulances are utilized, everyone must focus on making a change for the better. Your lives depend on it.
National Highway Transportation Safety Administration (2014) 2014 NHTSA Ground Ambulance Data. Retrieved 8 November 2014 from http://naemt.org/Files/HealthSafety /2014%20NHTSA%20Ground%20Amublance%20Crash%20Data.pdf
National Highway Transportation Safety Administration (2000) EMS Education Agenda for the Future: A Systems Approach. Retrieved 8 November 2014 from http://ems.gov/education/EducationAgenda.pdf
Jonathan Olson is the chief of operations for Wake County Emergency Medical Services and assistant fire chief with the Wendell Fire Department. He is a graduate of the NFA Executive Fire Officer program, has over 25 years of experience in EMS and fire operations, and is a co-author of “Management of Ambulance Services” by NEMSMA.