A Cultural Approach to Ambulance Safety
The year was 1994. The setting was rural north Louisiana, on a deserted country road, at o-dark-thirty on a Saturday morning. And on this country road, two EMTs worked desperately in a futile attempt to resurrect a traumatic cardiac arrest patient who, in all likelihood, was never even viable anyway.
The EMT in the back — a newly minted medic — desperately did CPR, pushed drugs, and bagged the patient, all the while shouting to his partner in the front to drive faster. And for his part, the EMT driver dutifully tried to push his right foot ever deeper into the carburetor.
The EMTs were young, idealistic, and invincible, and they were driving a 1985 Ford Type II van ambulance that had suspect suspension and steering, and even more suspect tires. About the only thing in that old Ford ambulance that still had plenty of life was its big-block V8 engine, and believe me — we made good use of every single one of its 351 cubic inches.
And as we roared, siren screaming, toward the hospital with our dead — but not officially — patient, we passed a Louisiana State Trooper on his way to the scene we had just left. After the call, that same State Trooper chewed those EMTs a new anal orifice for driving, as he put it, "a gosh-darned antique ambulance on a gosh-darned potholed country highway at 130 gosh-darned miles an hour!"
I was the medic on that call, and my partner Mike was the driver. And in the interests of full disclosure, the words the State Trooper used were nowhere near as G-rated as "gosh darned," and his tirade fell on deaf ears. In fact, after he left we shared an unrepentant high five to celebrate a job well done.
It took fifteen years of experience and losing a few partners and friends in ambulance crashes to change my perspective. So it was with some interest that I read of the proposed NFPA ambulance standards in this article on Mutual Aid: A Fire Chief Blog.
The 1973 National EMS Systems Act, passed by Congress in 1974 and fully implemented in 1978, introduced new ambulance manufacturing requirements that we've all come to know as the Federal KKK 1822 Standards. Currently on their sixth revision, all ambulances manufactured in the United States are built to these standards.
Now, the NFPA proposes devising its own ambulance standards, to be implemented as early as 2013. They intend to build upon the original KKK 1822 specs, as well as those of NFPA 1901 and the standards of the Ambulance Manufacturers Division of the National Truck Equipment Association.
And I can't help but agree with the blog authors, who wonder if they are reinventing the wheel, and to what purpose? We already have standards in place. Can't we simply revise them again? Why promulgate another set of regulations, one that only promises to get more unwieldy and expensive in the future? It is the nature of regulations to become more complex with each revision, not less.
There is little argument that ambulances need to be built to more stringent safety standards, particularly in the areas of restraint systems and structural integrity and layout of the patient module. Largely due to the efforts of EMS safety advocates like Dr. Nadine Levick, industry leaders have begun to pay more than lip service to those concerns. And make no mistake, some of those safety advances, while more expensive, pay dividends in other ways. At my own employer, the use of power stretchers and slide boards has decreased lost time accidents and worker's compensation claims so much that the new stretchers — no small investment at roughly $10k each — practically paid for themselves.
But there comes a point when the cost of implementing these safety measures becomes prohibitive. The fire chiefs in the blog lamented that fact in a link to a previous post about the evolution of NFPA 1901, in which the cost of implementing the latest standards makes new fire apparatus unaffordable for many departments. Another figure also stood out in my mind:
"According to one ambulance manufacturer, current prices of ambulances are in the $225,000–$275,000 range."
I don't know about you, but if I were the operations director at a small department, in an era where reimbursement only figures to dwindle even more in the future, and I was expected to pay a quarter of a million dollars for one ambulance, that ambulance had better come staffed with sophisticated Johnny Gage and Roy DeSoto cyborgs as a standard feature.
If an agency opts to stretch the service life of a 10-year-old ambulance because all of the bells and whistles required on new ones are prohibitively expensive, have all those additional safety standards actually made those crews safer? Or has it done just the opposite?
It occurs to me that things like stricter ambulance manufacturing standards and power stretchers, while necessary, are the Band-Aid solution. It is easy for risk managers to look at the purchase of X number of power stretchers and new ambulances fitted with Y number of shiny new gadgets like vehicle data recorders and drive cams, and tell themselves that they've made a commitment to safety. Much harder, and more difficult to quantify, is the act of promoting a safety culture within an organization, and change the attitudes of its members.
Of what use is a vehicle data recorder if the drivers it tracks would rather blow through a red light than risk a hard braking maneuver? Of what use is a drive cam when we ignore the fact that the person in the driver's seat has been on duty for 24 straight hours? Of what use are sophisticated vehicle lighting systems when we refuse to admit — to ourselves or the public — that lights and siren response is not necessary for the vast majority of our patients?
As so often seems to be the case, the answer comes down to education. Making EMS providers safer cannot be done solely through requiring fancier equipment. It must be done by educating new providers in the importance of crew safety, and negating the influence of adrenaline and testosterone. And it may well take a complete personnel turnover at an agency before crew safety truly becomes part of the organizational culture.
As one of my personal heroes was known to say:
"Safety is something that happens between your ears, not something you hold in your hands."
- Colonel Jeff Cooper