Selling Small: How an Oklahoma Service Moved to Type II Trucks

When the leaders of Oklahoma’s Oologah-Talala EMS (OTEMS) decided to order four transit-style Type II ambulances in a complete redesign of their previous box truck-style units, they knew getting employee buy-in might not be easy. After all, as one OTEMS paramedic put it, “We don’t like to change.” Said another: “I was definitely not on board in the beginning.” 

So Ryan Setzkorn, who was OTEMS’ assistant director of EMS at the time, knew he needed to involve his team at each step in the process. He gathered their design ideas and weighed each one, he brought employees to the Osage Ambulance facility in Missouri so they could give input, and he proved to them these smaller ambulances could keep them safe. EMS providers in the patient compartment would have all equipment at arm’s reach while staying belted during transport.

It was an emotional play for Setzkorn, who turned to the Internet to find distressing coverage of ambulance crashes throughout the world.

“I wanted them to get out of the mind-set of, This can’t happen to me,” says Setzkorn. “I replayed the news clip of our own 2010 OTEMS crash as well as other ambulance crash videos to show them that this can happen anytime.”

While Setzkorn wasn’t with OTEMS for the 2010 crash that retired two providers, he knew that had the paramedic in back been belted, things may have played out differently. The OTEMS ambulance was transporting a patient when EMT Austin Moore, who was driving, swerved to avoid hay bales in the road. This caused a rollover, and the ambulance pirouetted in an end-over-end crash so forceful it ripped the cot, with patient, from its antlers. The paramedic in the back, Todd Barron, said he tried to grab on to the bar on the ceiling during the crash but just couldn’t hang on. 

OTEMS Director Kelly Deal, who praises Setzkorn’s passion, said he didn’t need any convincing for this new venture. In more than 40 years as an EMS provider, Deal says he never stopped thinking, Here I am on my knees, unrestrained, providing patient care—will today be the day I’m going to crash and hit the bulkhead?

Seven years on from Barron’s and Moore’s crash, OTEMS has four new ambulances of the Type II standard, paid for with $800,000 of bond money from the local taxpayers. OTEMS was thrilled to learn that instead of buying just two new Type III ambulances from Osage, it could afford four new units for the same price.

Safety First 

You can’t accuse Setzkorn of not knowing the importance of safety: While working as a flight medic, he survived two helicopter crashes. After recovering from both with relatively minor physical injuries and being treated for PTSD, Setzkorn read the NTSB reports. He noticed the NTSB’s praise of the design of the interior of the helicopter’s patient compartment, specifically how all the equipment stayed in place, secured to the walls or floor. 

Here’s a massive crashed machine that has enough integrity inside to keep the equipment from flying around the compartment, Setzkorn thought. The design stayed with him because he knew the same principles should apply to an ambulance.

Then Setzkorn hit the jackpot when he saw a former peer, Chad Pore, then director of Kansas’ Butler County EMS, post on Facebook that Butler County EMS had designed and ordered its own Type II units. 

“The ideas were definitely stolen from Chad and Butler County EMS,” says Setzkorn. “I remember watching their Facebook videos and thinking, Chad, you just put into words a lot of what I have been thinking over the years.” 

Setzkorn’s proposal was a no-brainer for his boss. 

“For us it is employee safety first, patient safety second,” Deal says. “But we also do not want to hinder patient care in any way.” Deal knew his employees were the best resource and their involvement was crucial to the redesign process. 

Taking It to the Streets

Paramedic Amanda Hearn has been in EMS for 10 years, five with OTEMS. When she heard of the plan to go to smaller units, Hearn was skeptical.

“I’ve always been in the big box trucks, and I’m not going to lie, we didn’t wear our seat belts much,” she says. “At a prior service we worked out of a van-style ambulance, and I was not a fan. I felt like I couldn’t do patient care, and I had limited access to my equipment.”

Hearn’s opinions were echoed by OTEMS Supervisor Shelbie Wayman. 

“I remember the first day I heard about this, it was a hard ‘no’ from me—absolutely not interested in this design,” says Wayman.

But Deal and Setzkorn followed through with their promise to involve the staff in the redesign process. Wayman says this made her feel valued.

“Ryan constantly involved us: options, decisions, as many crew members as we could,” she says. “Even if our ideas were not taken to the final draft, they were still considered and modified and used.” 

Upon stepping foot in the unit, she found it far more spacious than she’d anticipated. “It was clear the ambulance was designed for the provider to work efficiently within the unit, rather than the provider being an afterthought,” she says.

Assessing, Treating on Scene

Changing the way providers interact with patients inside the unit also meant changes to the management of the entire call. Part of the culture change at OTEMS came in the form of re-examining patient needs in terms of the speed and cadence of the encounter. OTEMS providers began rethinking what assessments, treatments, and intervention could be done on scene—not because there wasn’t room in the new units but because it was ultimately safer for the provider and patient.

Hearn says she now finds herself completing much of her care on scene, especially if the patient is stable, which is most of her calls. “We’ve run emergent traumas, don’t get me wrong,” she says. “But I can now start an IV during transport while staying belted. We utilize our space and time more efficiently.”

A smaller patient compartment does require a bit more attention to the choreography of loading a patient, hooking up equipment, and making a plan for continued care. The moves are more efficient, to be sure.

Setzkorn says his experience in the small space in the backs of helicopters has been invaluable. “It helps to have a background in flight medicine,” he says.

Another change has come in debunking the pervasive myth that to provide effective care, providers must be able to stand up, move around, perform CPR en route, access equipment, etc. Even a news anchor reporting on the 2010 OTEMS crash perpetuated the idea, suggesting the reason Barron wasn’t belted was because “[The paramedic in the back] has to be free to move to treat the patient.”

Setzkorn was thankful for that news clip. 

“I focused on this the most, not only with our crews but when presenting to board,” he says. “We needed to correct that inaccuracy.”

Naysayers emerged within the OTEMS organization. When Deal began getting asked, “How are we going to transport multiple patients on backboards?” he decided to examine the data in order to prove necessity. 

“I wanted to see how often we did this in the past, and it turned out only about three times per year,” Deal says. “It was hard to justify designing an ambulance around such an infrequent event.”

The reliance-on-hard-data approach proved helpful when rebutting future devil’s advocates, as Setzkorn spent a good deal of time on Facebook carefully and thoughtfully answering critics of the smaller units (see sidebar). He even provided a video response to one critic who said the unit wasn’t big enough for tall paramedics. Setzkorn found the tallest paramedic he knows, who is 6’10”. That medic’s reaction to sitting in the attendant’s seat? “I feel good. I can do everything. I can reach everything.”

Most important, Deal and Setzkorn wanted to give providers a sense of responsibility for their own safety. They treated the crews as teams, expecting them to perform together safely and look out for each other. 

Setzkorn emphasized to the EMTs who often drive that level notwithstanding, they have full control of the ambulance. He told them they’d be in trouble if it was found their paramedic colleague wasn’t wearing a seat belt.

“I told them, ‘Before you put it in gear, ask your partner: Are you belted?’ Then listen to hear the click,” Setzkorn says.

An Intimate Experience

Six months on OTEMS providers have overwhelming praise for the Type II van-style. From running cardiac arrests to managing multisystem traumas, the providers haven’t been hindered, and they report feeling safer and more secure. Worries about these smaller units being able to perform in a rural setting with rough roads and long miles of highway have turned out to be unfounded. 

Aside from a few minor design flaws, such as the screws holding the lights on the ceiling snagging a ponytail or two and a hanging IV bag swinging too close to the patient, providers report the ride is smoother and patients even comment on its comfort and design.

Patients are pleasantly surprised at the spaciousness of the compartment, and while it was not a planned benefit, patients and providers alike are enjoying the intimacy of the experience. “We build a better rapport with the patient by sitting in the attendant’s seat within their view,” Setzkorn says. 

Hearn admits there’s a bit of an adjustment to sitting face-to-face with a patient the whole time. “In the past, during longer transports with stable patients, I might have gone to sit in the captain’s chair, since it had a lap and shoulder belt,” Hearn says. “Now I communicate better with my patients.”

Setzkorn told a recent story of a patient who saw the provider sit in front of him and said, “Oh, you’re going to stay here with me? You’re not going away? That’s so nice!” 

“I was blown away by that. That means the patient thought he was going to be alone,” Setzkorn says. “We in healthcare know the importance of being kind to your patients. It means you care about their needs, and it gives you a little forgiveness if you make a mistake.”

Wayman has noticed being in constant view of her patient makes her a more observant and astute provider. 

“I don’t rely so much on the monitor anymore; I’m talking to my patients more, observing changes in mental status, skin color, etc.,” Wayman says. “Most important, I’m building a better relationship and hearing some pretty amazing stories in the process.”

Another unanticipated result has come in recruiting. Deal says OTEMS is getting applicants who come to interview specifically because they heard about OTEMS’ commitment to safety.

“When I’m interviewing these candidates one on one, I go into great detail as to why we made these design changes, what our thought process was, and how we know this job is inherently dangerous,” says Deal. “I show them the new units, and they know we’re offering them something that few others can: a better guarantee of safety.”

‘The Responsibility Is Ours’

While Setzkorn is no longer with the company, he’s proud of what he helped establish and realizes, looking back, that all EMS leadership has a duty to make provider and patient safety priority number one. 

“The responsibility is ours,” Setzkorn says. “Being complacent and allowing an outdated and dangerous practice to remain the standard can send the message that it’s OK to be unbelted during transport. We shouldn’t be allowing this.”

Ultimately OTEMS leaders remain committed to this improved culture of safety, pride in strong leadership, and a sense of personal responsibility. Just take a look at their Facebook page, which reads, in part: 

When you stop making excuses as to why something can’t be done and start looking for better ways to do something, anything can be accomplished… We learned early in school that a good medic learns to adapt and overcome in different situations. That’s exactly what our medics are doing, adapting their approach to patient care to overcome the years of unsafe practices while providing excellent patient care… If employees are not promoting safety, then we have to look at the leadership to be sure the example and expectations are being set. A safer-designed ambulance will never cure apathy and an unsafe practice… This is the quintessential example of learning from our past and seeking out a path that will lead to a better future!  

Sidebar: Answering the Critics

When OTEMS posted photos of its newly designed ambulances on Facebook, the reactions were swift, and comments ranged from praise to criticism to even “this can’t work.” Leaders took time to answer many. Here are some excerpts:

Post: How well does this vehicle handle on the road? Does the engine lag under the heavy load?

Response: Vehicle handles very smoothly on our city streets and highways… The ride in the back is 100 times smoother for patient and provider. We are rural out here and have not encountered a road yet it has not handled well on—dirt, gravel, falling-apart asphalt.

Hope you never have to work a code in there.

If you have a LUCAS and a vent, what would be so difficult about it?

Can you simulate delivery of a newborn? Would you have to stand outside the ambulance with the doors open or load the patient backward?

You’d deliver just like any other ambulance. Sit on the back/foot end of the cot and catch. There is room for that, as we thought about that during the design phase.

So you can only take one patient. That’s cute for an IFT rig but not in our system!

We can still take multiple patients. We don’t spineboard anyone anymore, so we could take a second patient and place them in the airway seat if needed. If it were a serious mass-casualty situation, I could transport three easily enough and still be safely belted.

What about multisystem trauma, managing multiple fractures, checking distal pulses, etc.?

Every part of the body can be assessed from the forward-facing captain’s seat, including distal pulses. We recently had a crew stabilize a femur fracture in the back of the unit.

With the growing bariatric community, I don’t understand why any service would want a Type II. 

We have so far transported patients up to 400 lbs. with no problems. Neither the patient nor the medic have felt cramped. In the less than 1% chance we encounter a patient that is over our cot’s max weight limit, we will utilize other resources to transport that patient. However, we can’t design an ambulance for the 1% of the population we may never see.

Hilary Gates, MAEd, NRP, is the senior editorial and program director for EMS World.