Threat Reduction

This article is from the supplement Ambulance Safety Solutions sponsored by ZOLL Medical Corporation

Expert sources: David Slattery, MD, FACEP, FAAEM, Assistant Professor, University of Nevada School of Medicine & EMS Medical Director, Las Vegas Fire and Rescue; Tim Crowley, EMT-P, Battalion Chief (Ret.) Las Vegas Fire and Rescue

   It's no great leap of logic to fathom: To reduce a risk, you have to identify the risk. The only problem, in the risk-abundant world of ambulance operations, is where do you start?

   Ambulances are not built to a federal crash standard. Their patient compartments can have sharp edges, head-strike hazards and unsecured equipment flying about in a crash. Providers are often unrestrained to deliver care and can become projectiles themselves in accidents. Crash, injury and fatality rates are high, associated with numerous factors that include lights-and-siren driving, operator distraction and encounters with other vehicles, particularly at intersections. There are a lot of elements of danger.

   What can we do about them? Increasingly, there are answers. Consider the following strategies for some key danger areas:

    Code 3 driving--The seconds you might save using lights and siren with a patient on board are rarely worth the risk they increase to you and everyone else. Increasingly, EMS systems are limiting their Code 3 transports.

   "There are very few scenarios where driving Code 3, and making a difference of a couple of minutes, really makes a difference in a patient's outcome," says David Slattery, MD, FACEP, FAAEM, EMS medical director for Las Vegas Fire and Rescue and a frequent conference speaker on ambulance safety issues. "But it does put our crews at risk, and that's something we need to work on."

   Organizations such as the National Association of EMS Physicians (NAEMSP) and National Association of State EMS Officials (NASEMSO) have published position statements that say Code 3 driving should be used only in life-threatening situations where patient outcome could be affected by delay. Systems that have restricted Code 3 driving via dispatch protocols and transport criteria, notes Tim Crowley, a retired EMS battalion chief for Las Vegas Fire and Rescue, have observed minimal effect on patient outcome. The advantages to the patient, the ambulance crew and other motorists far outweigh any need for speed.

   Las Vegas leaders are attacking the problem with educational emphasis on the risks and general lack of benefit of running hot, and may ultimately develop a protocol for it. For now they present the facts and leave transport-mode decisions to their providers. But the issue has a lot of relevance for the department. In 2003, a city fire truck responding to a call rolled over, leaving a captain paralyzed. A judge ruled the driver was going too fast for conditions.

   That was during a response to a call, where providers may have less discretion about their travel mode. But as tragedies have elsewhere, this one helped focus greater scrutiny on patient-transport modes, too. In particular, in Las Vegas and lots of places, hot cardiac arrest transports are getting an increasingly skeptical eye.

   When talking on the subject, Slattery poses audiences the case of an 80-year-old with terminal cancer going into asystolic cardiac arrest. Medics can't get return of spontaneous circulation in the field, but are told by medical control to transport. Would they go Code 3, or not?

   "Its usually about 50-50," Slattery says. "A lot of people say yeah, you have to, even though you have someone who clearly fits all TOR guidelines. That patient's dead, and it's well-based in evidence. But there is still a group of providers who feel compelled to drive Code 3, because they think they're at medico-legal risk if they don't. And actually it's just the opposite."

    Restraints--A classroom survey at EMS EXPO in 2008 found 98% of respondents had, at some point, stood in the back of an ambulance traveling Code 3. But even at low speeds, the forces on unrestrained providers can be perilous.

   Another article in this supplement examines those forces. Slattery demonstrated them visually in a video that can be seen on EMSResponder.com. In that clip, a provider is standing, unrestrained, to deliver chest compressions while traveling 15-20 mph on a closed course. He is noticeably jostled around, even at low speeds.

   It's a nice visual argument for staying seated and restrained--and embracing technologies that permit that.

   "Automatic chest compression devices are a big benefit, and so are automatic ventilators," says Slattery. "Using those, our providers are able to be hands-free and provide a very dialed-in ventilation rate. Anything we can do to allow people to stay restrained and hands-free is good. Hands-free communications is another--there are headsets that allow us to communicate to the driver."

   Judicious design is part of the answer, too. Medical care supplies can be organized and positioned so they can be easily reached while restrained in a seat. Getting ride of side-facing seats can also improve survivability. LVFR is speccing out new rescues where it's working to eliminate bench seats and head-strike hazards, and position equipment so providers on either side of the patient, seated in captain's chairs, can reach supplies without getting up.

   Rounded corners, closed and latched storage bins and padded surfaces also reduce injuries. On the horizon, the National Fire Protection Association is drafting new standards for ambulance construction which should be published in the next few years.

   Driver distraction--Against the many distractions ambulance operators can face, particularly at our most dangerous moments, the best defense may be a concept drawn from the airline industry: the sterile cockpit. It's exactly what it sounds like: The environment up front is "sanitized" to let the driver focus fully on driving.

   "The most critical portions of an airline flight are from liftoff until the plane reaches that 10,000-foot ceiling, and then again when it descends from 10,000 feet until landing--that's when things can go catastrophically wrong," says Slattery. "During that time, there has to be absolute focus and no distractions in the cockpit. Before the FAA made this rule, flight attendants were allowed up there. There was all this extraneous conversation, and sometimes even a party kind of atmosphere. That sometimes related to very simple mistakes being made that led to serious consequences."

   By the same token, EMS' journeys to and from scenes are periods of time when things can also go dreadfully awry. It's no time for anything less than full attentiveness.

   "That's the most dangerous part of our mission, especially when driving Code 3," Slattery says. "At every intersection, we have to maintain this concept of a sterile cockpit. On the way to a call, the crew member who's not driving needs to have his eyes and ears looking out for vehicles and other obstacles. You're not texting, you're not talking on the cell phone, you're not doing anything else." In short, you're a copilot, with all the responsibility that entails.

   Use of onboard computer monitoring devices and cameras (i.e., "black boxes") has also been shown to improve driver behavior, notes Crowley. Vehicle speed, acceleration/deceleration forces, cornering velocity and G-forces, use of emergency lights and sirens, front seat belt use, turn signals, parking brake and back-up spotters can all be monitored, reviewed and used to initiate remedial driver's training. Using monitoring devices has decreased the incidence of preventable accidents by as much as 80%.

  Employ technologies to deliver better and safer patient care--Use of automated devices such as the AutoPulse and mechanical ventilators can increase provider seat belt use, reduce the number of providers needed in the patient compartment, and free them to perform other interventions.

What Else?

   Slattery and coauthor Annemarie Silver, PhD, looked at various elements that contribute to vehicle-related provider injuries for a 2009 article in the journal Prehospital Emergency Care (see sidebar below). There's more on some of those throughout this supplement.

   Above all lies the necessity of restraint. Collisions may never be wholly eradicated, but the harm they cause to EMS personnel can likely be reduced. It's a matter of driving that message home, and giving providers the resources to do things the right, safe way.

   "One of our most important challenges is changing the culture that it's okay to not wear your seat belt," says Slattery. "When you're in the back, you have to have your seat belt on. For a lot of EMS systems, the culture is just the opposite--they wear restraints while they're in front, but don't routinely wear them in back. Even if you just unbuckle for a second to get up and reach for a piece of tape or something, thats an extremely vulnerable period of time for a provider. We have to recognize that."

What Hurts Providers in Ambulances?

   In a paper published last year in Prehospital Emergency Care, Slattery and Annemarie Silver, PhD, broke down vehicle-related injuries to providers into three main contributing areas, each with multiple aspects:

Motor Vehicle Collisions

• Code 3 driving is an inherently risky business. It is multitasking taken to the extreme with flashing lights, siren noise, radio chatter, the adrenaline of the emergency at hand, a mind's focus split between driving in emergency mode while also contemplating the patient's condition and needs--all in a moving multiton vehicle.
• Code 3 responses also lead to risky driving behaviors such as driving too fast, driving against traffic and failure to thoroughly clear intersections before driving through them. Driver error is not only possible, given the conditions, but seems nearly inevitable.
• Ambulance drivers can be lulled into a false sense of security when the lights and siren scream for attention and clear passage from other drivers. Unfortunately, other drivers may not see or hear the ambulance, and when they do, their reactions are completely unpredictable.
• Ambulance crews can lose their situational awareness of what is happening in and around the ambulance through inattention, failure to maintain a "sterile cockpit" and driver fatigue.

Design Factors

• The design and engineering that goes into making the rear compartment of an ambulance steadily improves. However, there are fleets of older ambulances on the road, and safety engineering still has a long ways to go. Current dangers to providers in the patient compartment include sharp corners and edges, unsecured equipment, side-facing seats, and large compartment size which necessitates standing unrestrained to reach otherwise inaccessible equipment.
• Ambulances are exempted from federal motor vehicle safety standards. This means the ambulance body itself is built for structural integrity, but not to withstand the same dynamic forces of a moving collision the chassis is. Crashworthiness testing and engineering have been lacking, along with optimal patient and crew restraint systems.

Risks of Providing Care

• Critical patients who require the most intense clinical interventions are also the patients most likely to be transported Code 3 to the hospital. Chest compressions, airway management, critical procedures and patient control become risky and less effective in the back of a moving ambulance. Such procedures require standing, leaning and walking and preclude wearing any restraints.
• Providers are blind to directional changes, bumps, acceleration, deceleration and sudden stops. Hands are engaged with patient care and unavailable for self-preservation, and most providers wear no head protection.

--Ed Mund

The Scope of a Very Large Problem

   An ambulance hurtling down the road is one of the highest-risk workplaces in America. Compared to other emergency vehicles, ambulances are responsible for greater injury severity, more fatalities and a higher number of injured individuals per incident. But agency administrators and individual patient care providers can improve this picture.

   Nearly three-quarters (74%) of all on-the-job deaths among U.S. EMS workers can be attributed to transportation incidents. Between 1988 and 1997, ground EMS accidents resulted in 23,000 injuries and 350 fatalities. The cost of these crashes exceeds $500 million a year.

   Ambulance crashes are a prominent medico-legal risk for EMS agencies. EMS workers have more than twice the risk overall of occupational death as compared to other U.S. workers. When you look at just transportation-related fatalities, EMS employees are dying at a rate nearly five times higher than other U.S. workers. In addition to the EMS crew, you also have to factor in the dangers and liability to the public when a patient is also on board.

--Ed Mund