The headlines are tragic, the photos grisly: ambulances with their sides torn off or roofs crushed, leaving patients and crews badly injured—or worse, dead. Every year, at least 50 people, including 14 paramedics and EMTs, are killed in traffic collisions involving ambulances nationwide, making motor vehicle crashes the primary cause of on-the-job fatalities, according to the EMS Safety Foundation.
Overall occupational fatality rates are higher for firefighters and police, research shows, though the picture changes when traffic collisions are considered alone. According to a 2002 study, the death rate for EMS workers in vehicle crashes was 9.6 per 100,000, compared to 6.1 for police and 5.7 for firefighters. The study, published in the Annals of Emergency Medicine, used 1992–1997 data from the Census of Fatal Occupational Injuries, the National EMS Memorial Service and the National Highway Traffic Safety Administration.
Grim news reports and statistics such as these are driving growing concerns about just how dangerous it is to be bouncing around in the back of an ambulance and what can be done to minimize the risk. Some within EMS have begun calling for better driver training; vehicles that follow the more stringent European and Canadian automotive design and safety requirements; and cultural change within organizations to encourage and enforce safe driving, seatbelt use and other safety measures.
Experts also say there is a need for more complete collection of crash data to gauge the full extent of the problem. According to Jerry Overton, former head of the Richmond (Va.) Ambulance Authority and now CEO of Road Safety International Inc. in Thousands Oaks, Calif., there is no such national reporting system for doing so.
“In EMS, we have always placed the emphasis on patient care, which clearly is important,” he says. “When we talk about the welfare of the paramedic, we have tended to define it in terms of retention, not safety. But we know now that safety is an issue in three areas: driving, the patient compartment and the design of the ambulances themselves. It’s overdue that we place an emphasis on safety.”
Even the few statistics that do exist are likely underestimates, says Nadine Levick, M.D., an emergency physician and founder of the EMS Safety Foundation, a nonprofit organization that is working with government agencies to improve the crash reporting system, among other EMS safety initiatives. Police are required to report fatal crashes to their state department of transportation, which then reports the data to the U.S. DOT, which compiles the Fatal Analysis Reporting System. The problem is, not all states even have a line item for “EMS vehicle” or ambulance—instead, collisions might be listed as a “van” or “truck” crash, Levick says. “There are big holes in the data,” she adds.
Overton’s company, Road Safety International, makes a data recorder and monitoring device for ambulances to measure the speed of acceleration and G-forces on the vehicle, which can indicate if a responder is braking hard or taking corners too fast. If a driver exceeds pre-set safety parameters, the device sends out an audible warning, the goal being that the driver will slow down and prevent crashes before they happen. The devices, which are used in more then 200 EMS systems, cost about $2,300 per ambulance, plus a one-time charge to the agency of $3,000 for a base station and software.
Unlike commercial truck drivers, EMS personnel aren’t required to have special training to operate ambulances, although perhaps they should, Overton says. An internal study in Richmond using the Road Safety monitor found that responders were more likely to push the envelope on safe driving when headed to a shooting than to a heart attack patient over age 65, suggesting adrenaline kicks in on exciting, highly time-sensitive calls.
“We are putting young people behind the wheel of a 5-ton truck, giving them very little training and telling them to go lights and sirens to a shooting or cardiac arrest,” Overton says. “Their focus isn’t going to be on driving, but on patient care and what they are going to do at the scene.”
Are they doing it better elsewhere?
One of Road Safety’s clients and an organization taking the lead in pursuing safer alternatives in ambulance design is CareFlite, a nonprofit provider of air medical and ground ambulance transportation throughout the Dallas–Fort Worth area. After attending the Association of Air Medical Services’ Medical Transport Leadership Institute in Wheeling, W.Va., James Swartz, CareFlite’s CEO, realized that while much of the attention lately has gone toward improving safety in air medical [see BP Interview on page 10], less attention has been paid to ground safety. “You are more likely to get killed while driving as a paramedic or an EMT than if you are in the fire service or the police,” says Swartz, a former Army helicopter pilot. “The ground ambulance industry has seen approximately 10 times as many fatalities as the air medical industry over the past 30 years. That, to me, is scandalous.”
The main problem, according to Swartz: Ambulances (and, shockingly, school buses) are exempted from the Federal Motor Vehicle Safety Standards, which determine safety requirements for passenger cars and other vehicles. What this means for ambulances is that the cab and chassis, which are made by the original equipment manufacturer, are subject to federal safety rules. But aftermarket modifications to the patient compartment are not, Swartz says.
As a result, some dangerous practices have become commonplace, including side-facing seats, patient compartments that have not been adequately crash-tested, unsecured equipment that can become a projectile in crashes and a culture that permits crews to ride unrestrained. Even when crews do use seatbelts, the combination of side-facing seats and the shoulder harness can pose a threat. In a collision, says Swartz, “They can cut somebody’s head off.”
To learn more about safety in ambulances, Swartz and his team studied European, Australian and Canadian ambulance regulations. As part of that effort, in 2009, Swartz sent his ground director to RETTmobile, an EMS vehicle trade show in Germany.
In Europe, a popular choice for ambulances is the Mercedes-Benz Sprinter. (Until recently, Sprinter was sold under the Dodge badge in the United States.) In Sprinters, no seats face to the side during transport. A seat at the head of the patient is rear-facing; seats to the side of the patient pivot to face front during transport. All equipment is securely fastened or kept in secured compartments during travel, preventing objects from coming loose in a crash. Importantly, EMS personnel can reach nearly everything from a seated position, Swartz says.
CareFlite ordered 24 Sprinters, which are configured for ambulances by Crestline Coach in Canada. Four are in service and another 20 will be delivered later this year. “We took advantage of the crash-testing and their automotive design and engineering standards and copied them,” Swartz says. “Their ambulances are far superior.”
Made in the USA
Mark Van Arnam, CEO of American Emergency Vehicles Inc. in Jefferson, N.C., and a past president of the Ambulance Manufacturers Division of the National Truck Equipment Association, takes issue with depictions of American-made ambulances as unsafe, though he agrees the federal standards should be more stringent. He points out that ambulance manufacturers test patient compartments using the KKK standard, a federal purchasing specification that requires a load 2.5 times the weight of the vehicle be placed on top and on the side of the body to make sure the test weight does not bend the frame or distort any components. Some manufacturers, including his company, go further still: American Emergency Vehicles tests vehicles to five times their weight and also does crash tests, according to Van Arnam.
“The ambulance is a complicated creature, and our federal standards have been lacking,” he says. “They are due for an overhaul, and that process is going on now with the newly proposed NFPA [National Fire Protection Association] standard. Certainly things could be improved—there is no doubt about that. You have 28 different manufacturers building ambulances in a variety of ways. The fact that the standards allow so much variation is not good at face value.”
(In 2008, the NFPA decided for the first time to develop design standards for ambulances. The committee is expected to take several years to issue new standards, possibly in 2011 or 2012. Adoption of NFPA standards is voluntary.)
But there are several obstacles to transitioning to a different style of ambulance, including cost and tradition—a powerful force, Van Arnam says. Sprinters are narrower than the Ford and Chevy vans used in Type II ambulances, and much smaller still than the Type I and Type III or medium duty ambulances built on truck chassis favored by U.S. fire departments and many government EMS agencies.
“You are not going to change the protocols and practices of the EMS industry overnight,” Van Arnam says. “Fire departments want big vehicles that carry lots of people and equipment.”
Education, attitude shift integral
Swartz agrees that there is much work to be done in educating people and changing attitudes about driving and vehicle risks. At EMS conferences around the nation, he does a PowerPoint presentation with image after image of ambulances mangled in crashes. In one, the cab is crushed from a head-on collision, while the patient compartment looks unscathed. The driver of the vehicle survived—and the unbelted paramedic in the back was killed. “This is a horrifying, inexcusable, inappropriate situation,” Swartz says.
Among his own staff, Swartz and his team had to work to make cultural changes. He thought crews would like to drive the nimble Sprinter, only to find them grumbling about the change. “People get used to doing their job a certain way, and they don’t like change—any change,” he says, noting that educating employees about the dangers helps bring them on board.
Crews were taught that there are only two conditions during which responders can unlatch their seatbelts. One is while doing emergency CPR; the other is for 15 seconds if they can’t reach a piece of equipment, in which case they must notify the driver and anyone else in the vehicle before standing up.
If nothing else, EMS providers should consider the cost implications of not transitioning to safer vehicles and instituting safety standards for their crews. One study showed an ambulance provider is 27 times more likely to get sued for transportation issues than medical issues, according to Swartz.
“I’ve had manufacturers say to me, ‘What do you want?’ I say, ‘What do I look like? An automotive engineer?’ It’s not what I would like. It’s what’s safe that matters and that requires science-based decisions,” he says. “This is a complete national disgrace.”
