Policy: Historically in EMS, safety has been an afterthought to function in our vehicles and equipment.
Strategy: New ways of doing things here at home, including borrowed advances from our friends elsewhere, can improve our safety.
Vision: Safety is a top priority in ambulance and equipment design, resulting in reduced injuries to providers and patients.
Patient care outside of hospitals is not a new concept, but the coordinated deployment of providers in specialized vehicles to provide dedicated high-quality prehospital care is relatively recent. Through necessity and with available technology, we’ve modified vehicles and equipment to suit the needs of our profession, but since its inception, EMS has been plagued with safety problems. And ultimately we’ve discovered that many of the events that have injured and killed our providers and patients have been predictable and preventable.
Services and vendors have worked to improve safety and should be applauded for it, but we still have a ways to go. In our search for solutions, we can look to our European counterparts for ideas. The nearly 30 countries that make up the European Union have to meet strict ambulance construction standards, which include safety and crash test standards.
With a solid foundation like this, it is in our best interests to examine European vehicles and equipment to find ideas we might adopt to improve safety in our systems. Germany, one of the largest countries in the E.U., has a superb EMS system and is a perfect example to study.
Possibly the largest trade show for rescue vehicles and equipment in the world, RETTmobil is held each year in Fulda, Germany. RETTmobil 2013 was spread over 750,000 square feet and boasted more than 400 exhibitors and 20,000 visitors from around the world. As it has for the last five years, the EMS Safety Foundation sent a delegation to examine the hundreds of vehicles and other products on display; this year EMS World joined them.
The premise behind the EMS vehicles and equipment in Germany is data-driven design. Rarely is anything modified; rather it’s purpose-built specifically for EMS. Much thought goes into safety, ergonomics and use of space in each design.
The most obvious quality observed in European EMS is color. There is almost no red or blue to be found. Bold, fluorescent shades of yellow, orange and green color nearly every vehicle. Borders, edges and even entire surfaces are highlighted in retroreflective accenting colors, in striking patterns such as checkerboards and chevrons. Uniforms are the same bright colors, usually with a reflective stripe down the leg and/or arm.
American services can borrow these ideas to improve the visibility of their vehicles and crews. Incorporate the same noticeable fluorescent colors into vehicles and uniforms. Ensure all vehicle stripes, logos and other markings are retroreflective. Break up horizontal stripes with angles, curves and large logos. Add retroreflective chevrons to 50% of the rear surface of vehicles, including the insides of rear doors (this is already required by NFPA 1917). Provide yellow retroreflective vests (which are already required by the U.S. DOT when operating on federal highways).
Another obvious quality is the size of the European vehicles. They are small because they carry only the minimum necessary equipment and waste no space. These smaller vehicles are safer, lighter, less expensive and more fuel-efficient. Most ambulances use the Mercedes-Benz Sprinter chassis. The exteriors of these vehicles are not modified, other than sleek, molded lighting fixed to the outside. The Sprinter has a tall roof that allows providers to stand without the need for roof modification; it also comes standard with an electronic stability program that prevents rollover.
Slightly smaller Volkswagen and Renault chassis were also seen on the exhibit floor. Smaller still were several minivans equipped for nonemergency transports and wheelchairs. Perhaps most shocking were tiny first response cars, including a Mini Cooper jam-packed with equipment, including a spare stretcher. Again it made use of every inch, with no space wasted.
Surprisingly, there were a few Type III-style vehicles with box modifications. These larger ambulances, usually mobile intensive care units (and even a stroke unit with a CT scanner), are similar in comparison to U.S. ambulances, but strict safety standards give them superior structure and dictate much different interior surfaces.
The interiors of the ambulances are minimal, with little visible equipment. Walls are plastic with flush cabinets and few if any protrusions. Grab bars, lights and IV hangers are recessed into the roof. There are no sharp edges and no exposed metal; even cabinet and drawer handles are plastic and recessed. One even had thick padding on all vertical surfaces at the bulkhead. Any equipment mounted to the walls, such as heart monitors or suction units, is secured with specially designed and crash-tested brackets. This mounted equipment is usually portable/removable, and often enclosed in its own soft, padded case.
The attendant seat is always a molded bucket seat, facing forward, mounted very close to the stretcher. Forward-facing seats provide superior crash protection, and their proximity to the stretcher allows for patient care while seated and restrained. This configuration is present even in the larger box-type ambulances. Side-facing and bench seats are nowhere to be seen.
To improve access to the patient, stretchers load onto a platform. This platform elevates the patient to just above the attendant’s waist. With a foot lever, the platform unlocks and slides forward to provide better access to the patient’s feet, or rearward for better access to their head. Some platforms even have hydraulic suspensions to improve ride comfort.
In some ambulances attendant seats are moveable and can be locked into various forward- or rear-facing positions. Several manufacturers offer attendant seats on wheels. These seats lock in securely during transit, but can be removed on scene and used like stair chairs. Tracks at the rear deck allow the seated patient to be rolled into the ambulance, where they can then be easily transferred to the stretcher next to them. Alternatively, the patient can remain in the secured seat for transport.
German EMS providers do the majority of patient care on scene. This allows them to remain seated and restrained during transport, and reduces the equipment needed in the patient compartment. Essential equipment is located behind secure cabinets, drawers or panels within an arm’s reach of the attendant’s seat, eliminating the need to stand and move around during transport.
There are multiple best practices U.S. systems can draw from all this to reduce the potential for injuries:
• Eliminate the side-facing bench seat. Use bucket seats that face forward or rearward during transport. Rotating seats provide some adjustments to improve access to patients, but if they’re not mounted close to the stretcher, attendants will opt to ride side-facing and unrestrained, defeating their purpose. Fixed seats eliminate this problem.
• Improve seat belt compliance by positioning the most frequently used equipment within arm’s reach of the seated attendant. Promote and monitor seat belt compliance regularly. Mandate use of the stretcher shoulder harness for all patients.
• Eliminate excess and rarely used items and ensure all equipment and supplies in the patient compartment are properly secured. Store large or heavy equipment such as stair chairs in exterior compartments. Secure equipment such as cardiac monitors and suction units with heavy-duty brackets or straps that will not break or separate from the wall during an impact.
• Pad sharp edges and corners throughout the patient compartment. Reduce head-strike hazards around the attendant, such as protruding cabinets, shelves and walls. Reduce protruding equipment such as lights, grab bars, metal IV hangers and mounting brackets. Highlight necessary protrusions with fluorescent yellow paint.
• Use smaller, unmodified vehicles. Large spaces allow for the lethal movement of their contents in a crash. The Sprinter chassis is available in the U.S. Marketed by Dodge, it is smaller, safer, less expensive to purchase and maintain, and more fuel-efficient.
Beyond the Rig
Although several types of stretchers were on display, most common was a unique independent-leg H-frame stretcher. Compared to the X-frame most U.S. services now use, these stretchers appear both retro and futuristically complex. They can be loaded and unloaded by one person with little if any vertical lifting.
Easy-loading stretchers are only the first of many products used in Europe to prevent back injuries. In fact, it seems our colleagues there lift almost nothing. Medical bags look more like brightly colored luggage. They are plastic or vinyl-coated, with two small wheels and an extending handle for pulling. Most also have handles and straps for carrying by hand or on the back when terrain won’t allow rolling. In addition, all stair chairs glide easily down, and most are powered for an equally easy glide up stairs. One manufacturer offers a small motor and handle that locks onto the removable wheeled attendant seats, allowing them to function as powered stair chairs.
With ambulances and everything else used in EMS, safety is ultimately the buyer’s responsibility. Be savvy. Before purchasing, investigate. Do not rely solely on the marketing of manufacturers. Find out if equipment has been tested and how. Use the Internet to locate independent testing or reviews of the product. Consult with safety experts for additional advice and recommendations.
The same science, research and data we apply to our medicine needs to be applied to our vehicles and equipment. Much of this data already exists, in the U.S. and abroad. We should expand our horizons and seek help from our European counterparts who have many well-designed solutions to the problems we still face. Together we can change our culture, saving lives and money in the process.
David J. Turner, IC, NREMT-P, has more than 20 years of experience in EMS as a provider, fire/EMS lieutenant, field supervisor, educator and author. He is currently a paramedic and educator in Albuquerque, NM.
Sidebar: Operational Steps to Safety
To improve safety in American EMS, it needs to become a top priority. Providers must be aware of the risks around them and how they can be minimized. Managers must decide that safety improvements are an integral part of operations and a necessary piece of a budget. Safer vehicles and equipment are not always more expensive; there are many cost-effective options. In fact, policy changes cost nothing. Also, remember that money spent on proper safety improvements will never be wasted. Reducing crashes and injuries will save money while improving your service.
Here are three steps we can take now to ensure a safer future for EMS:
• Improve safety oversight. This includes developing data-driven safety standards that dictate vehicle construction and safety features and mandate crash testing; a central database for crash and injury data collection; and an independent agency to investigate major ambulance crashes.
• Institute a formal culture of safety. Designate or hire a safety manager to oversee all aspects of safety: Review and create policies, investigate events, collect crash and injury data, collaborate on vehicle and equipment purchases, educate employees and management on safety concerns and new equipment, oversee a safety committee, and implement changes that will improve safety and reduce costs.
• Hire and cultivate skilled drivers. Investigate the driving records of prospective employees and deny employment to those with excessive moving violations. Provide a comprehensive driver training program. Make vehicle operations an integral part of new employee orientation and training, providing additional field instruction, observation and evaluation.
Sidebar: EMS Head Protection
EMS helmets are relatively common in Europe. These aren’t bicycle or construction helmets painted in the local EMS spectrum, but helmets specifically designed and tested for EMS use. They are not used in all services, but many have discovered their ability to prevent injuries.
Sidebar: New and Exciting at This Year’s Show
This year’s RETTmobil offered several innovative products not seen in previous years:
• An electric one-seat first response vehicle;
• A Segway event vehicle;
• Seamless, molded plastic interiors;
• Overhead helmet storage with easy one-click drop deployment;
• Extensive cockpit-like “action areas” on the attendant’s right;
• Apps for iPads and smart phones now allow Web-based control of patient compartment lighting, climate controls, communications and patient data.