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The dos and don’ts of transporting children in ambulances

10 recommendations to decrease likelihood of an ambulance crash

By Bob Waddell

On September 11, 2001, despite being emotionally devastated by the events occurring in Washington, DC, Pennsylvania, and New York City, I had the honor of being one of the first three EMS professionals ever asked to present at the Society of Automotive Engineers (SAE) annual meeting. The lectures focused on the lack of dynamic crash safety design and subsequent hazards of transporting children in ambulances.

To state the understated, the audience was mortified by the facts. No fewer than five different groups approached me and my co-presenter to offer their assistance in designing and building safe, ergonomic, and functional ambulances. That’s the good news. The bad news is that they needed one million dollars (US) to get started. The term “orphan profession” suddenly had a new haunting definition.

Zooming 100 months ahead, we find that approximately six million children — as defined by the US Department of Health and Human Services is a person between the ages of zero to 21 years of age — are transported by EMS providers each year. The risks associated with these transports are frequently forgotten in the mysterious rationalization of “ambulances must be safe a vehicle because they save lives, don’t they?”

Motorcycles are ‘statistically safer’
As one international expert has stated, “Statistically, based on the total number of miles driven, it is safer to transport an ill or injured child on the back of a motorcycle with no helmet than it is in an ambulance.” This may be an egregious manipulation of statistics, but is a tremendous illustration of just how inherently unsafe an ambulance is.

Despite significant strides over the past few decades, there continues to be little — if any — federally required dynamic crash safety standards. It appears that EMS has been relegated to the category of orphan industry and therefore appropriate safety standards are not going to be available anytime soon.

This is not to say that the vehicle class manufacturers or the ambulance customers are not concerned about the global transportation safety issue; rather, they simply don’t have many mandates requiring them to develop and design a functionally safe ambulance. Why? Mainly because most of the safety regulations are focused on passenger vehicles, which an ambulance is not. Need proof? When was the last time your wife or husband asked to borrow the ambulance to take a Cub Scout troop to its soccer match?

Ambulances are not passenger vehicles, and their safety design is not at that level of safety. This simple fact explicitly demonstrates why passenger vehicle safety concepts, practices, and techniques cannot generally be imposed on the ambulance. In recent years, numerous products have been introduced with the claim that they increase the safety of those inside our rolling domain.

Each year, a variety of products is introduced to enhance the safety of patients being transported by ambulance. Fortunately, some of these products do what they claim; unfortunately, many do not. Just because a salesperson states their product is the greatest “gadget” does not make it so. Extreme caution is recommended in review and consideration in the purchase of any product not proven by evidence-based evaluation.

Panel recommendations
In an effort to begin building a foundation of knowledge and start moving our industry towards safe transport practices, the Emergency Medical Services for Children (EMSC) program — in collaboration with the National Highway Traffic Safety Administration (NHTSA) — brought together a panel of experts from across the nation to answer the question, “How do we transport children safely in an ambulance?”

Dr. Nadine Levick, the lead EMS presenter at the SAE conference and Capt. Garry Criddle provided insight into the work already being done and helped indentify the various gaps in knowledge and practice. Knowing the scientific evidence was lacking, the expert panelist reviewed numerous documents and recommendations from around the world in an effort to formulate a best practices document.

The panel developed a listing of specific practices that significantly decrease the likelihood of an ambulance crash and practices that reduce the potential of injury to occupants. The top 10 recommendations are divided into the Do’s and the Don’ts. They are:


  • DO drive cautiously at safe speeds observing traffic laws.
  • DO tightly secure all monitoring devices and other equipment.
  • DO ensure available restraint systems are used by EMTs and other occupants, including the patient.
  • DO transport children who are not patients, properly restrained, in an alternate passenger vehicle, whenever possible.
  • DO encourage utilization of the DOT NHTSA Emergency Vehicle Operating Course (EVOC), National Standard Curriculum.


  • DO NOT drive at unsafe high speeds with rapid acceleration, decelerations, and turns.
  • DO NOT leave monitoring devices and other equipment unsecured in moving EMS vehicles.
  • DO NOT allow parents, caregivers, EMTs or other passengers to be unrestrained during transport.
  • DO NOT have the child/infant held in the parent, caregiver, or EMT’s arms or lap during transport.
  • DO NOT allow emergency vehicles to be operated by persons who have not completed the DOT EVOC or equivalent.

These have been revised and updated since first being introduced in 1999, but the foundation lessons remain the same. Further scientific studies by Dr. Ron Pirrillo et al found that unsafe drivers allowed to drive an ambulance remain unsafe drivers. Dr. Bob Swor has found that speed — either combined with or lacking emergency warning systems — increases the risk of disability and death in the EMS industry and has no positive impact on patient outcome.

Dr. Levick continues her work advocating for safer ambulances designed to match the workload requirements of the EMS provider with the objective of safe EMS transport. The ability to safely transport children in an ambulance starts with a few simple rules. With both hands on the wheel, you may the only force of nature smart enough to deny Death this child on this day.

Robert (Bob) K. Waddell II has been involved in EMS for over 30 years, working as a volunteer EMT in rural Wyoming, a paramedic in the Front Range of Colorado, state training coordinator for Colorado, and founder of an international health education corporation providing EMS education and consultation for nations across the world.

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