How We Built a Better Ambulance

It’s time to buy a new truck. The old bus has served its purpose and is now on its last legs. You have probably waited too long to make this purchase.

As the manager, you are now faced with a common dilemma: Should you purchase a conventional, standard, off-the-rack ambulance, or should you try to be innovative? There are demo models out there you could purchase for a reasonable price. However, lately you’ve had sleepless nights. These have come because you’re afraid you’ll have to write a letter to the parents of one of your staffers saying they’ve been injured—or worse—in the line of duty.

So, what to do about this situation? In an attempt to make your life easier and your staffers’ lives safer, you decide to build a new vehicle that will keep your staff and patients out of harm’s way. But how do you do this? Do you involve your staff? Do you involve experts? Do you do research? Do you look around you to see what others are doing?

The answer is, of course, all of the above.

The MIT Experience

Having hosted the NAEMT’s EMS Safety Program, our agency—Massachusetts Institute of Technology EMS—believed we could do better. One look at the videos used in that program will convince even the most skeptical that the back of the bus is a dangerous place to work.

This is how we decided to try to make a vehicle that would be safer for everyone involved in EMS transport, both patients and staff.

First we contacted Nadine Levick, MD, head of the EMS Safety Foundation and EMS’ well-known safety guru. We had a video conference with her in which she gave her input, with all appropriate best practices in place. In all honesty, she was not pleased with the result—her problem wasn’t with the concept itself, but she felt we had not gone far enough, that there was more that we could do.

We looked at other innovative designs and researched local providers. We contacted the Massachusetts Office of Emergency Medical Services, in particular their Division of Ambulance Regulation. This was pre-emptive. We had to know what our legal parameters were. It would be inappropriate to build a vehicle that could not be licensed. As it turned out, most all of our original ideas were OK. Some, like a driver’s side rear window, were not. But the state’s Bud McDonough was a font of information, directing us to others who had started down this road. He suggested we look at Brewster EMS, which had different seat designs, cabinet designs and structural innovations. (Thank you, Brewster EMS.)

We then opted to look at what aviation had done. Having been required by the FAA to build safety into their designs, we figured they should have innovations we could apply. We took a field trip to Boston MedFlight to look at their rotor-wing, fixed-wing and ground transport options. As it turned out, we could not apply a significant amount of what we learned from their systems, as the aircraft structures were so different. But we did gain a lot from their mandatory restraint protocols and culture of safety.

When all was said and done, we found we needed to look at designs that were compatible with current EMS practices, could be flexible, had room to accommodate more than two staffers, and fit the needs of staffers from outside the service (our local ALS service, Professional Ambulance, also had to be able to function in the ambulance). With these parameters in mind, we attempted to develop a vehicle design that would be appropriate for current operating procedures yet give us the safest product we could have.

The subsequent development process extended over months. We started with tape on the floor and cardboard boxes (yes, really). We took the floor plan of our current ambulance compartment in feet and inches and put it on the floor with tape. For MIT, this was decidedly low-tech.

We started the actual design process in cooperation with two ambulance builders, PL Custom and Braun. We took a number of their designs that seemed to be similar to our initial thoughts and started working with them to suit our remaining needs.

Compartment Changes

Since our major goal was safety, we looked seriously at our present construction and design and decided to first get rid of the squad bench. Using this standard ambulance fixture leads techs to be unrestrained during transport, or unable reach and work with the patient if they are restrained. As well, in a collision, lap belts provide poor restraint.

Additionally we realized that in a number of ambulance designs, overhead cabinets cause significant head-strike zones. But we still needed space. We’d seen a number of vehicles with drawers; these seemed to be an answer. As it turned out, the eight drawers we put in more than made up for the cabinets. The reason was simple: About half the space in a cabinet is waste—the top half stays empty, and you can’t access the back through the sliders. Full-exposure drawers allow better utilization of available space.

Although it’s not required by federal KKK specifications, we thought it would be good to be able to transport a second patient. We accomplished this by adding a forward bracket with the cabinets and a fold-down seat. A backboard can now drop into the space across the top of the cabinets. This seems more secure than previous designs, as the board has very little forward-and-back motion allowed in its space. Horizontal motion is limited by the three “over-the-top” straps that extend from the wall to the floor.

Of course, with the new specifications, the engineering was complex. The truck had to be pulled from sequence a few times to re-engineer portions to make the design work. In the end it came together. The step wells were added by Braun and turned out to be a good addition in terms of comfort and usefulness. They provide an excellent leverage point for working.

None of this does any good if the folks don’t use the features. Our protocols now require that everyone be restrained and remain that way while the vehicle is moving. This is a major part of this journey; we have to change the culture.

We also restricted the seat swivel (by SOPs) to 45 degrees; we don’t want lateral impacts if we can avoid them. If there is no patient aboard, staff in the rear seats must be facing forward.

We believe this is a safer design; yet we know it is not perfect and can be improved upon. We all need to look to how we do our jobs and how we can perform our tasks in a manner that is safer for both us and our patients. Keep the tape and cardboard boxes handy.

Mark Forgues, MEd, EMT-P, has more than 30 years of EMS experience in municipal, hospital-based, volunteer, private, fixed-wing, collegiate and fire-based EMS agencies. He is director of Medical Resources Group, LLC, an education and consulting firm; technical director of the Massachusetts Institute of Technology Emergency Medical Services; and a per diem paramedic with Wayland (MA) Fire Department Advanced Life Support. He is also a nationally and internationally known speaker. Contact him at mforgues@mit.edu.