On May 15, 2001, a 26-year-old Kentucky-based EMT died when the ambulance she was working in was struck head-on by another motorist. The EMT was riding unrestrained in the patient compartment while attending an elderly patient during a nonemergency transport, when the ambulance was hit on its right-side front quarter by a pickup truck traveling in excess of 70 mph. The EMT struck the front bulkhead of the patient compartment and died en route to a local trauma center of blunt force trauma to the head and chest. The paramedic driver, who was also unrestrained, suffered multiple serious injuries, including a broken leg, but recovered after a stay in the hospital. During a subsequent investigation, it was determined that the ambulance service for which they worked required members of patients' families to use seat belts when riding as ambulance passengers, but seat belt use by employees was not addressed in the company policy, except when they were driving. They were then expected to comply with state motor-vehicle laws.
Unfortunately, this was not an isolated incident. Concern over the rising number of ambulance crash-related injuries prompted the National Institute for Occupational Safety and Health (NIOSH) to undertake ambulance safety research and vehicle occupant restraint testing to determine what needs to be done to prevent injuries in ambulance patient compartments.
"Other researchers have looked at this issue, but we looked at the National Highway Traffic Safety Administration's Fatality Analysis Reporting System, which is a census of all fatal traffic accidents in the United States, based primarily on police reports," says Paul H. Moore, a safety engineer with NIOSH's Fatality Assessment and Control Evaluation Team. "Between 1991 and 2000, these data identified 300 fatal crashes involving ambulances. In those 300 crashes, the number of EMS folks who experienced a fatal injury was 27. What also concerns us is, if you look at the ambulance patient compartment and consider the advances in vehicle safety over the last 10-15 years, not much has happened in the back of the ambulance. One of the reasons my colleagues and I here at NIOSH got involved in this effort was that we believe there should be technology available to make things better and to protect people."
Some EMS agencies are looking at injury prevention measures like five-point harnesses. In the meantime, says Moore, EMS providers need to wear the seat belts that are provided as often as possible.
"I know sometimes that might cause them difficulty in their work," he says, "but being unrestrained in a crash puts them at risk of serious injury from striking bulkheads and cabinets. We have tested what we're calling 'mobile restraints,' which allow the wearer the mobility to move off the seat and be on their feet, if need be. But we're not looking at this so much as a final solution to any of the problems that occur in the patient compartment, but as part of the potential solution that might include a redesigned compartment with movable seats to make it easier to care for patients while being restrained, improved padding, air bag technology and seat compartmentalization. At any rate, the restraints look promising as far as providing crash protection, and I think they can offer a significant improvement and are a good step forward."
Agencies that are considering purchasing new vehicles also need to look at things other than restraints, says Moore.
"They need to look at whether the mounting brackets for different pieces of equipment, like the defib unit and oxygen bottle, are crashworthy," he says. "Any kind of loose materials need to be secured in a cabinet or latched down so they don't become projectiles during a crash. Are the mounts for the gurney attached to the floor, and is it crashworthy? As far as transporting the patient, I know that a number of EMS folks don't use the shoulder restraints that are supplied with the cots. Our tests have shown that it's important to keep the patient restrained to the cot during a crash-not only for the patient's safety, but for the safety of anyone else in the compartment whom the patient might collide with."
As for the number of serious injuries that did not result in a fatality, there is currently no database at the federal level with that information, says Moore, which means there is still work to be done from a surveillance standpoint on that issue. In the meantime, he says, interest is growing in how to improve ambulance safety. Dialogue is ongoing between NIOSH and the Ambulance Manufacturers' Division of the National Truck Equipment Association, as well as with the General Services Administration (GSA), which is responsible for federal ambulance specifications.