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DRIVE TO SURVIVE Part 2: AN EXCLUSIVE SUPPLEMENT Sponsored by: WHEELED COACH
Few areas of EMS are more important than vehicle safety. Many of you spend hours every day behind the wheel or in the back of a rig, treating and transporting, making your communities safer and better places to live. Your safety in that ambulance is a top concern for all of us. For vehicle designers and manufacturers, this means incorporating the latest and best features designed to protect their occupants. And for EMS providers, that means operating these vehicles with the proper training, equipment and attitude. In this special three-part supplement, we examine this equation in more depth. Last month, we looked at how agencies can create a "culture of vehicle safety." This month, we review what's new in terms of safety features in the back of the ambulance.
Ambulance safety has always been a hard area to get our hands around in a scientific way. Data are imprecise as to how many accidents occur, how many providers, patients and others are hurt and killed, and just how those deaths and injuries happen.
But that hasn't stopped efforts to make the ambulance environment safer. Even without optimal data, recent years have seen such commonsense improvements as securing equipment so it doesn't become airborne and placing netting to keep personnel from striking the bulkhead in frontal collisions (this, you'll remember, killed the young providers discussed in the first installment of this series).
Across the industry, efforts in this vein continue-perhaps more than ever.
"For a long while, it didn't seem like much happened (in regards to ambulance safety)," says Paul Moore, a safety engineer with the National Institute for Occupational Safety and Health's Division of Safety Research, who's been involved in both crash investigations and safety research for that federal agency. "But now I think we're on the verge of seeing some changes. There are indications that people are rethinking what happens in the back of an ambulance and what's needed to better support EMS providers."
"There have been huge strides forward," concurs top ambulance-crash researcher Nadine Levick, MD, whose new organization, Objective Safety, is dedicated to EMS vehicle safety awareness and improvement. "If you compare what's happened in the area of safety over the last, say, 3-4 years to what happened in the 15 years before that, it's huge."
This article will look at some of what's current and potentially coming in the area of ambulance safety.
Beyond The Belt
Some EMS providers have already worked to design enhanced-safety vehicles. The central aspect of their approach is facilitating patient access for providers who are seated and restrained. Some have experimented with arranging the interior so that necessities like drugs, oxygen, suction and radios can be within personnel's reach without standing. They have included harness restraints, rather than lap belts. Others have offered safeguards like collision-avoidance warning systems, external caution lights and "black box" computer systems to enforce safe-driving parameters.
These approaches are too new and limited to say if they've been successful, but there's no question that restraints are a major part of any safety equation. In a recent survey conducted by this magazine, roughly three-quarters of respondents said their current restraint systems were impractical or inhibited their doing their jobs.
This view isn't new, and neither are efforts to build a better belt. As far back as the early 1990s, firefighters in Phoenix developed a retractable harness that allowed movement, but would snap wearers back into place and hold them secure in an accident. But their idea has yet to be broadly embraced.
How much a restraint like this might add to ambulance safety is uncertain. There's a perception among EMS providers that they must be unrestrained to do much of what they need to do in the back-as much as 41% of the time, according to one study. But some feel providers may be overestimating their need to be unbelted. Dr. Les Becker of the Pacific Institute for Research and Evaluation, who has written on the subject, notes that patient airways can be managed by providers belted into properly positioned captain's chairs, and patients can be monitored if things like cardiac monitors and pulse oximeters are arranged correctly before transport begins. And as far back as 1991, a study in Prehospital Disaster Medicine suggested that providers need not be unrestrained in the back as much as they think they do.
"The majority of the care we need to provide in the back of an ambulance, I think we can do seated and restrained," says Rick Patrick, director of EMS programs for Pennsylvania-based emergency services insurer VFIS. "Providers think they have to be unrestrained to provide most of the care they do, but there's research that suggests essentially the opposite. But people are taught a certain way of doing business, so to speak, and that can be hard to change."
Restraints have also been a focus of NIOSH's work. But Moore emphasizes that even the best-designed harness or belt is only one piece of the overall safety puzzle.
"We've focused on the restraints as a way of providing crash protection to folks who need some mobility," he says. "But from the beginning, we realized there were a lot of issues involved and a lot of ways to look at it. Something like a retractable harness might be piece of a solution, but there's no one magic bullet."
Measurable Improvements
As far as magic bullets, driver monitoring systems may be the closest we've come. As systems like Road Safety, DriveCam and others come into ever-wider use, they are leading to measurable improvements in many departments.
In Little Rock, for instance, an 18-month trial saw drivers go from a baseline low of 0.018 miles between driving infractions to 15.8. At the same time, seat belt violations dropped from 13,500 to 4. The department realized a 20% savings in vehicle maintenance costs within six months.
"I don't think there's anybody who doesn't see these as a good thing," says Larry Wiersch, chair of the American Ambulance Association's Mobile Medical Transportation Safety (MMTS) working group and executive director of the Cetronia Ambulance Corps in Allentown, PA. "I know it's been effective for us. We basically collected data blindly at first, so people could get used to the system and not feel like they'd be blamed if something happened. Then we gradually turned on the tones and started evaluating how we were doing. And for the most part, our drivers have become pretty darned good at staying within the parameters we've set."
"You start a project having a ballpark idea of how good something is, but in this case it's really consistently performed way beyond our expectations," says Levick, who was involved in the Little Rock study. "I was very impressed with that, and we'll probably be doing more work to look at these technologies and how to get the best you can out of them. It looks very promising."
Marshmallows and Light Bulbs
There are other intriguing ideas being kicked around, but at this point they're either in the early stages of research or barely more than light bulbs above people's heads. Some possibilities include:
- Some sort of helmet or headgear with integrated communications, so the wearer doesn't have to unbuckle and stand to use the radio.
Levick is working with the International Safety Equipment Association to develop an EMS head-protection standard. - Air bag systems for the patient compartment.
"So, in a rollover situation," Patrick says, "it'd be like a giant marshmallow in the back." - Movable seats for easier patient care without being unrestrained.
"In a moving vehicle, your safety is dependent on the seat," notes Levick. "The seat is the safety device, and the seat belt is something to keep you in the safety device. So a harness or anything else that allows-or, even worse, encourages-you to be out of that seat may not be the best path to go down. It may be that having a seat that slides forward is a much safer solution than any sort of harness."
"Could we all have forward-facing seats in the back that could pivot?" wonders Connie Eastlee, RN, director of the Arkansas Children's Hospital's Angel One transport program. "One of the things we've entertained is how to situate the seats so they could be pivoted and face forward. Then when you have a patient, you could pivot them back around."
A different route to the same destination might be redesigning the patient compartment as some have already attempted, to make things more accessible to a restrained provider. The air-medical environment is a potential model.
"These are people who have a good understanding of optimizing access to the patient," says Levick. "There's an enormous amount to learn from the air-medical environment."
Conclusion
These notions only scratch the surface. Clearly, there's plenty of fertile ground left for investigating in the area of ambulance safety.
"A whole gamut of things are wide open to being looked at-air bags and helmets and sliding seats and relocating seats and relocating equipment so people don't have to move as much-by NIOSH or anybody else," says Moore. "The group of us here in the Division of Safety Research have been working on this issue for a while, and from time to time we've discussed just about all of them; we just haven't, as yet, found the time and resources to devote to them. But I get probably two or three requests a week from EMS services and fire departments that are buying new vehicles and want advice on what they might change and things they might do. So I think there's a great interest in looking at that patient compartment and trying to redefine that environment to make it safer and easier for folks to work."
In the meantime, we still need more and better data on exactly how providers in ambulances get injured and killed. And as efforts continue, we must, as always, keep in mind financial realities. Even commonsense interventions must be balanced with cost.
"There are some things we can do today-getting rid of sharp corners, recessing the grab bar on the ceiling-fairly simply," says Wiersch. "It doesn't take a lot to figure out that if you have something with a sharp edge sticking out during a crash, it could take your head off. Yes, changing it might add cost to the vehicle. But what's the cost of a human life?"
It's also worth remembering that all risk cannot be engineered away. The greatest variable of all-the human component-is also the least controllable. If you don't address the way your vehicles are operated, all those safety add-ons can be money down the drain in a crash.
"I don't ever want to downplay these risk-control things-they are extremely important," says Patrick. "But you have to address the human factors as well. Once you have an ambulance that has a black box, cameras everywhere, air bags, seat belts and all that, if you don't address the human element, crashes are still going to occur."
Next month: Driver training.
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