Driver Training: In Search of That Still-Missing Link

Everybody makes mistakes. But when you’re behind the wheel of an ambulance, mistakes can have terrible consequences. It looks bad when you cause an accident, really bad when you hurt someone and really, really bad when you kill someone. So EMS agencies train their drivers. But how they do so…well, let’s just say it’s as fragmented as the rest of EMS.

Depending on your agency and your state, the training you receive can range from minutes to days. NHTSA, the lead federal agency that oversees EMS, offers a core national curriculum for ambulance driv­ers—the Emergency Vehicle Operators Course, or EVOC—but does not mandate that states follow it. States have their own laws; so do some cities.

There are some popular programs out there. The National Safety Council’s Coaching the Emergency Vehicle Operator (CEVO) course is in broad use; Pennsylvania-based EMS education, consulting and insurance provider VFIS offers a program as well. Both of these build on EVOC—which is essentially a competency course, rather than a full-fledged driver-safety program—with education and training beyond basic driving skills.

It’s a rare EMS agency these days that offers its drivers no training at all. Yet accidents still happen. An unscientific national log of ambulance crash accounts compiled at www.emsnetwork.com listed 23 in April alone. While data from ambulance crashes have never been thoroughly tracked on a national level, it has been calculated that EMS providers have a line-of-duty death rate that’s more than twice the national average. There’s no question that vehicle crashes account for a good number of those deaths. So what’s wrong with the training EMS drivers are getting? What’s it missing? What more can we be doing to keep people alive?

Driving From the Top Down

One theory: There’s a lack of true, genuine integration of safety concepts at the top.

“I think we’re doing a lot better with driver training—perhaps the best we ever have as an industry,” says Rick Patrick, VFIS’s director of EMS programs and services, and a member of EMS Magazine’s editorial advisory board. “The educational institutions are doing a better job; the emergency service organizations are doing a better job. But it does not appear that the overall leadership culture within a lot of emergency-service organizations puts safety as the No. 1 priority.”

To put a rough point on this notion: Leaders—who aren’t always bosses, by the way—may give a token nod to the importance of driv­er safety, but they don’t always walk the walk, so to speak.

“We’re saying it’s important, but when push comes to shove, it’s still not necessarily at the forefront of everything we do,” says Patrick. “There still seems to be a mentality in some places of ‘Here’s what the curriculum says, guys and girls. Now I’m going to tell you the way it is in the real world.’ For a lot of people, other things—running the calls, reimbursement—supercede safety. And nothing—absolutely nothing—can supercede safety.”

In this regard, making safety job No. 1 involves much more than running prospective drivers through a few cones. It entails providing good, quality vehicles, supported by good, quality maintenance, with good, quality operators that are well-trained and adhere to good, quality policies on the road and at scenes. Providers are supported when they practice safety and held accountable when they don’t. Drivers aren’t allowed to pick up bad habits from other drivers.

This approach, incidentally, extends backward, too, to the very hiring of EMS providers. Someone who’s a poor driver as a civilian isn’t likely to magically become better as an EMT.

“Someone’s overall driving habits definitely reflect how they’re going to drive an emergency vehicle,” says Patrick. “One of the scariest drivers we have in emergency services is the person who thinks they can drive their personal vehicle one way and an emergency vehicle another. They have years of driving experience before they got behind the wheel of an emergency vehicle, and you think you’re going to change that without having the culture at the top basically breathing safety? That’s not going to happen.”

Red Asphalt Redux

Another missing component is an overall understanding of the vehicle: how it works, and the forces that govern it.

“We have people driving ambulances and fire trucks who don’t even know how to check their oil or put wiper fluid in,” notes Patrick. “That’s basic stuff that I would argue is part of driver responsibility. That stuff should also be taught.”

“What people really need is education, rather than training,” says Thom Dick, a paramedic in the Denver (CO) area, and a member of EMS Magazine’s editorial advisory board. “They need to understand that ambulance. If you think about it, the ambulance can either earn them a living, or it can kill them any day. They deserve to understand properties of coolant, the properties of brake fluid, how the brakes work, how the tires work and stuff like that.”

Understanding that ambulance brings us to the larger issue of physics. Big, top-heavy vehicles, moving fast, turn over easily and need longer distances to stop.

“Most ambulance accidents—and I’ve never met anybody who disagrees with this—happen because people are driving too fast,” says Dick. “They rarely happen due to something completely unpredictable. That tells me the drivers don’t understand the consequences of speed.”

Anecdotally, there is some indication that gory displays of such consequences, presented the right way, may be a good deterrent. Who among us doesn’t remember the harrowing Red Asphalt films from high-school driver’s ed? They aimed to scare young driv­ers straight by showing, in gruesome detail, the carnage of real-life accidents.

Top ambulance-safety expert Nadine Levick, MD, has spent years stumping for improved safety in the vehicles, and her presentations frequently involve graphic images from actual ambulance crashes. From what she hears from her audiences, she says, they get the point across.

“I use real data, then some visually explanatory information showing what happens in a crash,” Levick says. “People say they just never forget seeing and hearing these things. They tell me, ‘You’ve changed the way I think.’ And I think that is an element of driver training—trying to get under someone’s skin and change the way they think.”

Spurred by the positive comments, Levick is now examining attendees’ awareness and attitudes of safety and risk in an attempt to determine just how much difference such an approach can make.

I Spy

Part of driver training involves identifying and remediating bad behaviors, which brings up the issue of driver-monitoring systems.

Among the best-known is DriveCam, which has a video component that captures and saves incidents in which certain driving parameters (speed, acceleration, braking forces) are exceeded. The visual record allows the counseling of employees who err; many fleets, both EMS and other, have realized reductions in crashes and body damage after utilizing it.

Intec Video Systems’ CarVision systems for emergency vehicles offer high resolution images and a wide field-of-view to eliminate the blind spot behind the vehicle to facilitate backing and help reduce accidents.

The more traditional “black box” offered by Road Safety sounds an alarm when it detects unsafe operation, and records the incident data for later review. One service in Florida that implemented it—Pinellas County’s Sunstar EMS—saw a head-turning 90% reduction in crash rates.

Levick is collaborating with Metropolitan EMS in Little Rock, AR, to track improvements following its installation of Road Safety units in more than two dozen ambulances. The results to date are extremely promising: A thousand-fold increase in safety proxies with no in-services or retraining required, and no change in response times.

“It’s impressive data,” says Levick. “I think the concept of a system that gives a driv­er real-time feedback, at the same time as he knows the box is watching, has clearly been demonstrated to be highly effective. I mean, to get a 90% reduction in crash rates? These devices pay for themselves.”

Metropolitan also witnessed dramatic reductions in seat belt violations (from 13,552 in the first month with the system to a current average of 10 a month) and the penalty points it assessed to drivers for unsafe behaviors. In their first two months with the system, its driv­ers averaged 56 points for every mile driven. Four months later, they drove nearly 16 miles between points.

“If I owned any sort of fleet of vehicles, I’d like to know that my drivers had the best behavior-modification and training equipment on board,” says Levick. “It’s going to save me money and lives and increase productivity and effectiveness. Every crash takes vehicles and people out of action, and that decreases the efficiency of a system. How can you justify not having it?”

Beyond Booby Traps

However promising that all may be, technology alone isn’t the answer. It’s just one possible component of what has to be an overriding, all-pervasive commitment to safety.

“My impression is that some people are concentrating more on outfitting ambulances with booby traps that spy on their people than on really teaching their people how to drive,” says Dick. “If they spent their money instead on teaching people basic auto mechanics and how the ambulance behaves when you slam on the brakes, stuff like that, I think it’d be money much better spent.”

So what else is missing, and what else should drivers learn? Some thoughts:

The law—Your state likely allows you more latitude behind the wheel than other drivers. Be clear on exactly what you can and can’t do.

“Most emergency providers, in my experience teaching driving courses, are in the ballpark when we talk about the law in their states, but very few are on the playing field when it gets right down to exactly what the law says,” says Patrick. “There’s so much ‘Well, I think that’s what it says,’ but then you read the motor vehicle code, and there are caveats here and there, and differences that are more than semantics. They need to understand that, because they’re operating these vehicles with more responsibility and accountability than somebody in their own personal car.”

Interaction—You can’t control other drivers, but you can master your own awareness. Beware the tunnel vision of an emergency response. Give other drivers time and space to react. Be patient with them.

“People see these red lights in their back window, and they panic,” says Dick. “They’d love to get out of your way if they knew how to do it, but they don’t know what to do. You can’t lose your temper—that’s when you make bad, bad mistakes.”

Peer pressure—It’s probably unavoidable. Make it work for you, not against you.

“All too often, people want to fit in,” says Patrick. “They see how their colleagues do it, and whether they know better or not, they tend to adopt their habits. If people model the right way to do things, hopefully, others will follow that lead.”

Enforcement—There’s no point in having rules you don’t enforce. Compliance shouldn’t be voluntary—your rules exist for a reason.

“You know that rule about stopping at opposing intersections? That’s a good freakin’ rule,” says Dick. “A lot of people don’t enforce it, but I’ve had my life saved by that rule at least a dozen times.”

Respect—That vehicle is a valuable partner and resource—treat ’er right.

“I’ve driven ambulances for more than 20 years and never got a scratch on one,” says Dick. “It wasn’t because I was ponderously slow; it was because I respected the equipment. And, to be honest, I was also lucky. But most of all because I respected the equipment.”

Conclusion

There are a lot more factors to the issue of driver training, and more factors still that play into the overall ambulance crash problem. Until a sufficiently large body of data concerning such crashes is developed, EMS will likely continue to struggle to get its arms fully around the issue.

“When you look at an ambulance crash, it’s rarely just one thing, or one mistake,” says Levick. “An ambulance is simply more complicated, going down the road, than a passenger vehicle. There’s so much happening—care being provided, dispatch, timing, all sorts of things. You’re always going to have human error; you just need to perform what interventions you can to reduce it.”