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EMS face peril from ambulance crashes
Lack of restraints, poor design cause injury
The ambulance was 20 minutes into a 60-minute drive, taking a patient with complications of influenza from a clinic to an urban hospital. No lights or sirens. This was a transport, not an emergency run. Suddenly, the driver of a Chevrolet Lumina crossed the center lane. The ambulance driver veered to the right, trying to avoid impact, but the Chevrolet hit the front left portion of the ambulance. The impact severed the ambulance wheel .The ambulance spun and fell off a steep embankment beside the road, landing on its side. The ambulance driver, who was not wearing a seat belt, was ejected and died of his injuries three days later. The patient, who was restrained with leg straps but not shoulder straps, was thrown from the cot, propelled against the paramedic, and tossed against the ambulance wall. She died at the scene from internal thoracic injuries. A cardiac monitor also came loose and struck the paramedic, who was sitting unrestrained on a jump seat. He landed against the passenger entry door. He had multiple injuries, including spinal fractures, but survived.
Emergency Medical Services (EMS) workers enter an ambulance prepared to take care of any emergency but their own. As this 2009 crash scenario shows, EMS workers are at risk from equipment that isn't properly secured, unsafe design features of ambulances, and their own failure to wear seat restraints. Patients who aren't properly secured also are at risk – and can endanger the paramedics caring for them.
"There's about one fatality involving an ambulance every week, and about 10 serious injuries every day," including injuries to other drivers and pedestrians, estimates Nadine Levick, MD, MPH, an emergency room physician at Brookdale Hospital in Brooklyn, NY, and chair of the National Academies Transportation Research Board (TRB) EMS Transport Safety Subcommittee. She notes that there is little detailed data on deaths and injuries in ambulance crashes and what causes them.
Yet there's growing evidence about how to reduce the hazards to EMS workers and their patients. The main message: Use the restraints that are available.
Even a sudden jolt in an ambulance that is racing down the road – a relatively common event – can result in minor injuries to EMS workers monitoring patients in the rear of the vehicle, says Jim Green, BSME, MBA, safety engineer in the Division of Safety Research at Protective Technology Branch of the National Institute for Occupational Safety and Health (NIOSH) in Morgantown, WV.
"You can go to any ambulance service in this country and talk to workers, and they will tell you either they have been injured or a partner or coworker has been injured in an ambulance event," he says.
Bench seats are inherently less safe than forward- or rear-facing seats in the back compartment of an ambulance, says Levick. But wherever the paramedics sit, they should wear the belt as much as possible, she says. If the paramedic must release the seat restraint to care for a patient, he or she should notify the driver, as EMS workers do in helicopter transports, she says.
In older ambulances, it actually wasn't possible to care for a patient and sit in a restraint at the same time. "If you scooted just two inches from the seat back, you would have to release the seat belt and you weren't protected anymore," says Green. "There are folks who are sitting at the edge of their seat all the time and working with patients."
NIOSH is now working with manufacturers of ambulances to create voluntary safety design standards, he says.
Whether in older or newer ambulances, EMS workers also need to be sure to secure equipment, such as monitors and defibrillators, so they don't become projectiles in a crash, says Green. The patient should be secured on the cot with shoulder straps not just the leg straps, says Levick.
Why speed kills
Do ambulances really need to fly down the road with sirens blaring? That may sound like an odd question, since emergency responders are judged by how quickly they respond and get the patient to a hospital. But going as fast as possible isn't necessarily safe for the patient or EMS worker, says Levick, who founded the EMS Safety Foundation and a resource-rich website, www.objectivesafety.net.
"The scoop-and-run philosophy began when we didn't have the lifesaving skills and paramedic training we have now. The only thing they could do is drive really fast to get to the hospital," she says.
Now patients are getting quality emergency care and monitoring, she says. Furthermore, "driving really fast to the hospital can have detrimental effects on your patient," she says. The jolts and bumps may be uncomfortable or even frightening, which can impact patients with cardiac conditions, she says.
A review of ambulance crashes found that intersections weren't the only dangerous moments in the race to the hospital. From 1991 to 2000, 27 EMS workers died in 25 fatal ambulance crashes. Almost three-quarters (72%) did not take place at an intersection and 60% occurred during daylight hours. "While it is intuitively acknowledged that traveling through intersections is inherently dangerous for an ambulance, it may be that the higher speeds traveled away from intersections are a significant crash factor as well," the authors stated.1
In more than half of the fatalities, the EMS workers were not wearing seat restraints, whether they were driving, riding in the passenger seat or attending to the patient in the rear compartment.2
Hospitals and other EMS employers should emphasize safety by setting policies that require safety belt use and provide performance incentives for compliance, says Levick. Employee health professionals can play a role in raising awareness among EMS workers about the risks of motor vehicle accidents and the benefits of seat restraints, she says.
New technology and design also can help save lives. Driver feedback devices can alert drivers to unsafe conditions, such as speeds that are too high, says Levick. After all, 97% of EMS transports are non-urgent and do not involve life-threatening situations, she says.
Meanwhile, work continues on improving the design of ambulances. Most ambulances are vehicles that are modified by manufacturers who create the rear transport "box." They are not required to meet federal motor vehicle safety standards that apply to passenger vehicles. "We're trying to bring that environment up to the same level of protection as you would have in your passenger vehicle," Green says.
Levick prefers focusing on a new, integrated ambulance design that is retrofitted into the Mercedes Sprinter van. The rear transport area is smaller, but that enables the paramedic to reach items and care for patients while remaining seated, Levick says.
Side benches are inherently unsafe, even with a harness, she says. Paramedics should ride in forward-facing or rear-facing seats.
"It saves you time, lives and money to have an evidence-based safety solution," she says.
1. Proudfoot, SL. Ambulance crashes: Fatality factors for EMS workers. EMS 2005;34:71-74.
2. Centers for Disease Control and Prevention. Ambulance crash-related injuries among emergency medical services workers-United States, 1991-2002. MMWR 2003;52:154-156.