Simulating Emergency Vehicle Training

"I did it! It worked! I avoided him and the other car!" said the EMS recruit as he approached me. I recognized him and recalled that he had been through our EVOC training class recently. But I had no idea what he was talking about.

"I was on my way to the scene and this kid ran out between the cars chasing a ball. There was no way I was going to avoid him. I did that maneuver you taught us--to "jump" the vehicle around an object--which then put me head-on with a car in the other lane. I did it again in the opposite direction and was back in my own lane going the right direction! Nothing was touched. Nobody was hurt. It was great, I couldn't believe it worked."

It's not often that we get this kind of response, but when we do, it's a great reminder of the important work my staff and I perform every day. As a lieutenant paramedic with the Fire Department of New York (FDNY) EMS, my main focus is instruction and curriculum development for my staff and our Emergency Vehicle Operator's Course (EVOC).

Mandated by the state of New York and the Department of Health, our EVOC program is probably one of the nation's more comprehensive training programs. In existence since 1980, the program has trained some 15,000 student EMTs and paramedics, or approximately 700--1,000 students every year. Our week-long program is divided between 7½ classroom hours and six days in the field with the vehicles.

Custom Simulator Technology

Students spend about 15 minutes each day in our state-of-the-art simulator, developed by FAAC, Inc., of Ann Arbor, MI, makers of Driver Training System (DTS) simulators.

FAAC worked with FDNY in designing three simulators for the department to allow us to achieve as much realism as possible in emergency vehicle operation training. Two are in operation at the Fire Academy located on Randall's Island--one to simulate a Seagrave cab and the second with a networked tiller. The third is the Ford F350 cab design used by EMS, located at the EMS Academy on Fort Totten in Queens, NY. We have been using this FAAC simulator for approximately two years.

Simulation training does not replace actual vehicle training, but rather enhances it. Actual vehicle training develops a student's precision-driving skills, while simulation training develops decision-making skills.

To understand how the FAAC simulator works, imagine sitting inside an actual Ford F350 cab that's been cut and modified to accommodate the simulation screens. It's equipped with a dashboard, steering column, radios and a working mobile data terminal (MDT). It has full functioning lights and siren, horn, brakes, pedals, directional signals--everything you would expect to find in a Ford ambulance, minus the passenger seat. The driver's seat is built on a three-way hydraulic platform that replicates the driving experience. Hit a curb and you feel the vehicle bounce. Drive off-road and you feel the vibration. Step on the gas and the engine roars. Acceleration and inertia are also felt, as well as cornering and braking.

The simulator comes equipped with five visual displays that provide out-the-window views. Forward vision is provided by three rear-projection screen images that give the student a 180-degree field of view. Rear views are provided by two plasma screens (one mounted on each side), supplying visuals using actual side mirrors. This is a major departure from standard simulators, which use picture-in-picture overlays as the means to project the rear-view images. As in real life, all our FAAC simulators offer a depth of field, and actually create a blind spot in the side mirrors, since the student is only capturing about two-thirds of the plasma screens.

Though the student is sitting in the cab of an F350, the vehicle dynamics and visual appearance on the screen can mimic any of our department vehicles, allowing us to utilize the simulator in all aspects of vehicle operation training.

Custom Learning Environment

The student becomes acclimated to the simulator over the course of the program and is introduced to concepts in conflict resolution, intersection analysis and tactical placement at the scene of an assignment. A student will be "placed" on a street corner and will interact with the instructor who "dispatches" the assignment over the radio and MDT. The student must:

• Utilize the proper codes by radio and MDT;
• Find the location of the assignment on the map of the virtual world and plan the most appropriate route;
• Initiate the response in an appropriate manner (e.g., lights and sirens);
• Navigate through traffic and negotiate the intersections using approved methods;
• Perform a scene size-up and park the vehicle in a location that allows for proper access and egress from the scene, placing a safety barrier when needed;
• Transmit the proper radio and MDT signals upon arriving on the scene; and
• Accomplish all this in 3--4 minutes.

The instructor controls the session from the Instructor Operating Station. A simple click of a button can change the environment: Rain, snow, fog, daytime and nighttime operations are all possible. Changing the environment also changes the vehicle's dynamics--for example, causing it to slide on ice. He can view the entire scenario from any angle and driver perspective and further participate through a device called the "rabbit"--a video terminal with a driving console attached. Using the rabbit console, instructors have the ability to plant a car in the student's blind spot, enter into the exercise as a pedestrian or a vehicle, and simulate scenarios EMS personnel have actually encountered on the road.

The "Scenario Toolbox" allows an instructor to program scenarios involving any number of pedestrians, locations and objects: A bicycle interacting with traffic, a multiple vehicle collision involving a city bus, a fifth-floor building fire with people jumping out of windows. It's only limited by one's imagination. This graphics software provides the ability to "drag and drop" objects and create scenarios within a choice of five "worlds," such as an urban setting, rural farmland and suburban layouts that contain bridges, tunnels, pillars, highways and waterways. Using details collected from accident reports, we can recreate the scene of an actual collision and learn from it.

One significant feature of the simulator program is the playback option, a feature of the rabbit. After running through a scenario, the instructor can play back events as they unfolded in the simulation, showing the student where mistakes were made and how decisions could be handled differently.

All scenarios are followed by a critique of the exercise using this playback feature. The critique is a critical component of the training and, like any other training tool, the whole learning experience is lost if the instructor does not relay the proper information or attitude.

Statistics

On a national level, approximately 6,500 ambulance crashes occur every year, sending 10 people to the hospital every day and causing two fatalities a month. In 74% of all fatal collisions, the ambulance struck the other vehicle, with more than half of these occurring at an intersection.¹ Another study showed that the average EMT or paramedic will spend approximately 3% of their career in the back of an ambulance, yet 70% of all crew fatalities occur there. A contributing factor is the occurrence of unrestrained equipment and personnel becoming projectiles in the back of ambulances; new technologies and initiatives are being developed to reduce such occurrences. However, the ultimate responsibility falls on the emergency vehicle operator to ensure that he transports everyone to and from the scene safely.

Lessons Learned

Common denominators for the majority of collisions involving emergency vehicles are a lack of training and corrective action. A pervasive attitude within the nation's EMS community that allows emergency vehicle operators to drive with no additional training, and states that fail to regulate the licensing of these individuals perpetuate the problem. A minimum of three steps needs to be followed to ensure the safe and efficient operation of emergency vehicles within a service:

1. Training--Knowledge, skills, attitude.
2. Monitoring--Through direct supervision on every call and/or through commercial products that provide real-time data collection.
3. Corrective Action--Immediate and non-confrontational retraining, plus disciplinary action when other measures fail.

In NYC, FDNY EMS has reduced the overall number of collisions by approximately 12%, with a significant reduction of 38% in intersection collisions from the previous year. This reduction is attributed to the use of the simulator and its ability to help students identify common situations and learn to make the proper decisions before they occur.

We believe that students must understand the consequences of their decisions, especially if they were involved in a collision. They are each made to understand that their collision was not an individual event, but rather a global event that is now causing pain and wreaking havoc on families, on themselves and on the department. It's costing money and lives.

Some of our students walk away completely shaken up once they comprehend the consequences of their actions, but our job as instructors is to empower students, thus allowing them to make informed decisions under the most stressful conditions.

We base the FDNY EMS EVOC course on three premises:

Skills: Students must have a good skills base; they must demonstrate aptitude while driving a vehicle.

Knowledge: Students must have knowledge of vehicle dynamics, physical forces, department policies and municipal and state traffic laws.

Attitude: The final aspect is attitude. A student can demonstrate skill and knowledge, but without the proper attitude, a collision may be inevitable.

EVOC can educate students with their skills and knowledge base, but their attitude presents itself while working with the FAAC simulator.

Periodically, the FDNY EMS EVOC conducts an Accident Retraining Program, wherein employees who have been restricted from driving due to a variety of issues are re-evaluated and retrained. Our instructors evaluate employees' accident packages, including the details of their collisions, and through the FAAC simulator, each can reconstruct the scenario that led up to the point of impact.

In certain cases, when a behavior or medical condition presents itself as the cause of poor driving performance, we will employ our Counseling Services Unit to help identify issues and, if necessary, refer the individual to the Bureau of Health Services for medical evaluation.

In conclusion, simulation training has had a marked improvement on our performance and the students' understanding of the responsibility entrusted to them when behind the wheel of an emergency vehicle. But in the end--as with the student who approached me the other day--it's the look in their eyes and the sound of their voices that show the real value of our training and our work, for both the public and for each other.

Reference

1. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: An 11-year retrospective analysis. Prehosp Emerg Care 5:261--9, 2001.