Driver Training

     Across EMS and public safety, few will speak ill of driver training. It's accepted as a prerequisite for running a safe system, and a necessary prophylactic against consistently high crash and injury rates. Whenever something bad happens to an ambulance on the road, among the first questions you're likely to hear is, "What kind of training did they do?"

     Thing is, the notion that driver training yields a safety benefit isn't quite substantiated in the literature. A review of the science by researchers with Canada's Traffic Injury Research Foundation led them to conclude that "international literature provides little support for the hypothesis that formal driver instruction is an effective safety measure." A similar review at www.ambulancedriving.com agreed that "the assumptions upon which [the safety benefit] argument is based are not supported by the research." And a spokesperson for the Insurance Institute for Highway Safety flatly told the New York Times in 2000 that "There has never been a study in this country or any other country that shows there is a reduction in crashes as a result of taking driver training."

     And yet...it seems intuitively insane to put a newbie EMT behind the wheel of a rig and unleash them on the community without some specific training. So what's a boss to do? When it's up to you, how can you maximize your providers' chances of going and coming safely, ensure the safest possible environment for your patients, and do what you can to protect the citizens around you?

     If you're the sort to start with evidence, you might consider a real-time driver monitoring and auditory feedback system.

     "The bottom line is, the only independent data showing effectiveness and sustainability [in creating safer EMS driving behaviors] is the data on the real-time auditory feedback devices," says ambulance safety expert Nadine Levick, MD, who has authored two of the strongest of these studies (available at www.objectivesafety.com). "It is profoundly powerful data that shows up to a thousand-fold improvement in safety proxies. No other device has come close to that."

     Levick's studies tracked use of the Road Safety system by Little Rock's Metro EMS in 2003-04 and Pennsylvania's Cetronia Ambulance in 2004-06. Both systems saw big improvements in safe driving behaviors. Metro improved from a baseline of 0.018 miles between penalty counts (instances of drivers exceeding defined thresholds for things like braking, turning and acceleration forces, etc.) to a high of 15.8, and saw a 99.97% drop in seat-belt violations. Most important, their crashes were fewer and less severe. Cetronia saw speeding incidents drop from 14.94 penalties per mile driven to 0.00003, and seat-belt violations from 4.72 to 0.001. During the study period, it experienced no major crashes after full implementation.

     The key to these improvements, Levick suggests, is the real-time auditory feedback that alerts drivers when their operation crosses a line.

     "Human beings respond to auditory stimulus much more rapidly than to visual," she says. "That's why we have auditory alarms on our medical devices, and things like microwaves and pagers. There's a lot of literature documenting that."

     Yet simply sticking black boxes into your ambulances, then sitting back to tally up violations isn't enough. Services that utilize solutions like Road Safety and DriveCam (a popular video-based feedback system) aren't likely to derive full benefit from them without some additional elements. Management has to stay involved in defining desired driving behaviors, imparting and refreshing them for personnel, examining performance data and addressing those with persistent problems.

     "Training and management are important," says Kurt Krumperman, a longtime top executive at Rural/Metro who spoke on driver performance, training and supervision at the Transportation Research Board's 2008 Ambulance Transport Safety Summit. "Without the emphasis of management, things tend to degrade. With whatever device you put on board, if you don't accompany it with policy, procedure, training and the involvement of both management and employees, you're ultimately going to have issues."

     For driver training--a frankly nebulous term--that points to the crux of the question: What kind and how much is appropriate? How do we combine it with technological tools to maximize safety? If training's a necessity--and "You can't just get behind the wheel of any vehicle and drive it without being trained," says Levick--what should it look like?

     In EMS, current trends are toward low-risk, low-force driving. Programs have classroom time, of course, and typically a behind-the-wheel component. But sometimes, the latter amounts to little more than navigating through some cones. "A lot of people do parking lot exercises and stuff like that," notes veteran medic and author Thom Dick, who's researching programs toward developing one in Colorado, "but not much actual in-town driving."

     This may be a weakness of EMS driving instruction. High-force driving is typically when the bad stuff happens, but high-force training is pretty much unheard of, and many new hires don't even get medium-force practice time on actual city streets. From a performance perspective, that's important.

     "You need to know the limits of the vehicle," says EMS driving guru Dave Long, head of training for North Memorial Ambulance Service in Minneapolis. "The problem is that most programs don't teach you the limits of the vehicles. Most of us have not had a chance to drive large vehicles. So at North Memorial, we have our people drive around and experience different types of traffic scenarios--freeway, highway, city, neighborhoods. It's a minimum of 4-6 hours of forward driving time."

     That gives North Memorial's drivers a feeling for braking, cornering and performing other maneuvers under a variety of conditions. And, combined with the rest of the organization's program, it's contributed to a strong safety record, even without black boxes. "Our incident rate is so low, we can't justify them," says Long.

     No one has this all figured out, but as a potential model for combining the best of both worlds, consider Michigan's LifeCare Ambulance Service. Since 1988--the year after a spectacular accident that injured a child led the service to install black boxes--its drivers have traveled more than 7 million miles without an at-fault injury crash. In 2004, its driver safety program was adopted as a best practice model by the American Ambulance Association. In 2008, its total collision repair costs for a fleet of 25 vehicles was under $20,000.

     "The initial training when we hire somebody isn't something that's glossed over here," says LifeCare Operations Manager Craig Dieringer. "We provide a lot of information, and people can decide how they want to drive. Hopefully they'll use this information to make objective, informed decisions."

     LifeCare employees get eight hours of classroom instruction and at least an hour behind the wheel. The service utilizes a multimedia assortment of instructional aids to drive home the potential consequences of bad decisions, emphasizing the math and science of vehicle operations, and defines 12 clear standards to which its drivers must adhere.

     The multifaceted approach is part of an overall focus on safety that pervades the organization.

     "We impress upon people that this is for your safety, your partner's safety and the community's safety," says Operations Director Steve Frisbie. "They have to understand that we're not just protecting our truck and the company; we're protecting them. We're successful because they've bought into that. It has to be a culture of safety--you can't get safety in your driving if you're inept with safety everyplace else. Eventually the driving will catch up to you."

     A lack of supporting literature notwithstanding, most in EMS still believe in the value of training. "To the extent that programs do training, I think it creates awareness," notes Krumperman. "And the first thing that helps people alter their behavior is awareness."

     More every day, meanwhile, believe in driver monitoring and feedback systems. Dick, a veteran of more than three decades in EMS, was a skeptic who began rethinking things after researching a story on Louisiana's Acadian Ambulance Service, which uses Road Safety's program.

     "Some organizations use systems like that in lieu of a training program, basically as a 'gotcha!' kind of thing," Dick observes. "But it sounds like they really do provide a lot of training, and use it as a biofeedback mechanism. I think that could make it a viable option, if it doesn't cheat EMTs out of their training. People deserve to be taught how to be safe."

     That's the point of training. And, Levick notes, it's what makes driver monitoring and feedback systems training devices in their own right.

     "Training means learning something to improve performance," Levick notes. "I'd say real-time monitoring and auditory feedback devices are a state-of-the-art form of driver training, and are demonstrated unequivocally to produce better drivers. Isn't that what training is about?"

Training: What's Missing?

     Even with technological assistance in the safe-driving quest, most believe good training is invaluable. But what tends to get overlooked in such instruction? Here are five common omissions cited by Dave Long, driving chair for North Memorial Ambulance in Minneapolis.

     1. Braking systems

     "There's a lack of training in four-wheel antilock brakes," Long says. "The first thing you need to know how to do is stop the rig. We use a GM tape and materials from an antilock manufacturers alliance."

     EMS author/columnist Thom Dick takes the point farther: "There has to be an understanding of all the mechanics of the vehicle," he says. "Shimmy, wheel balance, brake pull--these are all things any UPS driver learns. An ambulance can earn you a living or kill you, and people deserve to understand how the thing works."

     For more on antilock braking systems, there's the ABS Education Alliance, www.abs-education.org.

     2. Speed control

     Most EMS newcomers have never driven anything as big as an ambulance. It doesn't exactly handle like dad's Celica. While much training today tends toward low-force driving, North Memorial puts its drivers out on actual Twin Cities streets, where they can do everything but operate with lights and sirens.

     Until the last two hours: Then comes the Code 3 training.

     "If a call comes in during that time that's near wherever they might be," Long says, "they'll actually jump the run. That way the instructor gets to observe the new driver with lights and siren on, which is going to increase their adrenaline." The instructor then gets to see how the newbie responds under such pressure.

     3. One-on-one time

     Most driver trainees have limited one-on-one time with their driving instructor. North Memorial gives new employees six hours of individual instruction on the streets. Its every-two-years refresher also includes an hour of street time...and a session with the refreshing driver strapped to the stretcher in the patient compartment, experiencing driving forces the way a patient would.

     4. Cornering

     "Most people don't know how to corner in an ambulance," Long says. "Corners should be taken wider, with a philosophy of 'slow in, fast out.' The problem is, we're driving hard in and hard out, and that's where we're rolling all these rigs."

     5. Intersection negotiation

     This old bugbear still bugs. Take it one lane at a time, people.

     "One reason why we're having so many crashes, I think, is because we're clearing the first half of the intersection, but not the back half," says Long. "We initially clear it, then traffic blows by and hits us in the middle or the back half. I don't think you necessarily have to stop at every intersection, if visibility's clear in every direction. But if there are obstructions or traffic, you're going to need to stop or snail-roll through one lane at a time."

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