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Behind the Wheel

     Les R. Becker, PhD, NREMT-P, is a retired career paramedic from the Prince George's County (MD) Fire/EMS Department and a former associate research scientist with the Pacific Institute for Research & Evaluation. He coordinates medical simulation activities for the Maryland Fire Rescue Institute (MFRI), holds several adjunct faculty appointments in area community colleges, and has lectured and written on various aspects of safety in the emergency environment. He also serves as adjunct faculty for Medical Education Technology, Inc., a designer and manufacturer of full-body human patient simulators.

     Previously, Becker has added his expertise to the Ambulance Safety Subcommittee of the Federal Interagency Committee on Emergency Medical Services (FICEMS) and to the Injury Control and Emergency Health Services Section of the American Public Health Association (APHA).

     For this month's column, I had the opportunity to speak with Les, who has studied various topics such as the impacts of alcohol and fatigue on paramedic ALS skills and the risks of being a patient passenger in an ambulance accident, about the realities of driving safety in EMS and what the present and future hold in this regard.

     There is a lot of talk lately regarding safety in EMS. Have we seen any resultant action, or does it seem to be all talk at this time?

     I think we are seeing two things emerging in this regard. First is the discussion moving from behind closed doors—from the old and new FICEMS and other higher level committees—into the open via popular EMS publications and list serves. We are also seeing a lot of posturing, as though the issue of ambulance safety is a new issue, but it's not. Ambulance ground transport-related morbidity and mortality has been studied by EMS and traffic safety researchers for quite a while. It's only in the past 7–10 years where the issues have received any serious study and other attention. Although this "new" attention is positive, it certainly has taken some time, and we have to now play, on some level, a game of catch-up with other industries and best practices.

     What is your philosophy regarding the training of emergency drivers in EMS? Are classes like EVOC and CEVO enough?

     My overall philosophy in regard to training emergency drivers with classes such as the ones you mention is that they are just one piece of the safety puzzle. We have to retrain everyone who may provide care on a ground transport ambulance. The reality is that for the vast majority of patients, care can be provided from "behind" a seat belt. It is easy to blame the vehicle operators for the crashes; after all, they were driving. But, providers working in the patient compartment must step up and take responsibility by buckling up. The transport medicine arena is actually ahead in this regard; even critical care providers can provide most of their care while restrained. As far as the 9-1-1 community is concerned, we have to retrain providers to take advantage of natural pauses on the scene and during the loading sequence to provide urgent care. I'm not advocating the concept of "stay 'n' play"—far from it. What I am advocating is increased provider efficiency on scene, with an eye toward minimizing scene times and treating our patients. It's important to note that this approach will not be appropriate for every patient, but the next critical step in increasing the safety of EMS providers in the back of a moving transport vehicle is to shift the norm from hardly wearing seat belts to only riding unrestrained when life-saving care is truly prevented by their use. Those times have been and will continue to be relatively rare. This step will be a large one and will require retraining of the EMS cadre, as well as a cultural change. This change will need to come from industry leaders, as we have to continue looking at what is getting our providers hurt, or worse, killed, and act in a way to mitigate these failure points.

     What do you think of the idea of having the National Transportation Safety Board (NTSB) investigate ambulance accidents involving serious injury and/or a fatality?

     I think this will be useful, at least in the short term. A series of NTSB investigations of significant ambulance crashes (that is, those involving a serious injury and/or a fatality), based on their expertise in crash investigation and years of reconstruction techniques, will likely validate what we know already, but it is also important because it will provide a credible basis for recommendations for improvement.

     Additionally, as long as those in EMS work with the NTSB to establish the investigatory process and continue to work with them, they will bring an added expertise to our field and, hopefully, we will learn significant lessons and make things safer for providers.

Raphael M. Barishansky, MPH, EMT-B, is executive director of the Hudson Valley Regional EMS Council in Newburgh, NY, and a member of EMS Magazine's editorial advisory board. He can be reached at

Les Becker is a speaker at EMS at Firehouse Expo, July 22–27, in Baltimore, MD. For more information, visit

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