Ambulance safety has special significance to the staff at the National Highway Traffic Safety Administration (NHTSA) and its Office of Emergency Medical Services. As current or former EMTs, paramedics, firefighters, emergency nurses and state EMS officials, many of us have spent time in ambulances and routinely respond to traffic crashes.
The people at NHTSA all work to advance emergency medical services by collecting and analyzing critical EMS data and by leading collaborative efforts among national, state and local organizations engaged in improving EMS nationwide. But we serve a broader mission as well: keeping people safe on our nation’s roadways.
The incredible story of an ambulance crash in Minnesota (see “A Profound Impact”) demonstrates the serious impact a single crash can have on an EMS agency. At the national level, significant efforts are underway to better understand the causes and effects of crashes to help identify ways of keeping both patients and practitioners as safe as possible.
How Many Fatal Ambulance Crashes Are There?
At NHTSA, we analyzed data from the past 20 years and found that each year, the nation averages 29 fatal crashes involving an ambulance, resulting in an average of 33 fatalities annually.1 While one-fourth of those fatalities are inside the ambulance at the time of the crash, in the majority of fatal crashes involving an ambulance, the driver or passenger of another vehicle is the one who is killed.
We see a different distribution of nonfatal injuries: We estimate that an average of 1,500 ambulance crashes per year result in injury, with 46% of injuries occurring among people inside the ambulance at the time of the collision.2
The number of ambulance crashes and fatalities may seem high, but the nation lost 32,719 people in roadway crashes during 2013; our job is to make sure those numbers decrease.3
Lesson From Crash Investigations
For more than a decade, NHTSA’s Special Crash Investigations teams have conducted investigations of serious ambulance crashes. Investigators collect information about pre-crash, crash and post-crash events. These events include pre-crash activities of the persons involved and the circumstances or contributing factors to the crash, including any environmental, roadway or equipment factors.
By using visual inspections of roadways and vehicles along with interviewing all involved, the investigations provide factual insight into the crash. This type of data is invaluable to determine the nature and causes of injuries sustained in the crash by all occupants. NHTSA has conducted more than 50 of these in-depth investigations.
While we continue to analyze the data, our most significant finding has been a tragically simple one: EMS personnel are not buckling up. Fully 4 in 5 EMS providers in the back of the ambulance were unbelted at the time of a serious crash. Of the 45 providers in the patient compartment at the time of the crash, only 7 (16%) were wearing a seat belt at the time of the crash, meaning 38 (84%) were unrestrained.4 In addition, 11 of the providers (22%) driving the ambulance were unbelted.
Data from every fatal crash involving an ambulance for the last 20 years shows a similar pattern of results—most ambulance occupants are not wearing seat belts during crashes.
We found that whether ambulance occupants wear seat belts or not significantly predicts the severity of occupant injuries and fatalities. And unbelted providers are doing more than just getting injured: They also risk injuring their patients. Occupant-to-occupant contact was identified as a source of the injuries sustained by patients, and in at least two cases, these injuries were fatal.4
When EMS arrives at a scene and patients are loaded into the ambulance, they and their families should feel safe knowing help has arrived. Because of this, the EMS profession has an incredible responsibility; keeping our patients safe during a call is paramount to good care and should be a priority for any EMS crew transporting a patient.
The good news is that EMS personnel are excellent about buckling up their patients: Investigations show that 96% of those patients were belted at the time of the crash.
The bad news is that 61% of them were restrained with only lateral belts, while only 33% were correctly restrained with lateral belts and shoulder straps to keep them secured to the cot. Of the serious crashes investigated, 44% of patients were ejected from their cots and patients not restrained by both shoulder and lateral restraints were at a significantly greater risk of being ejected from the cot and sustaining serious or fatal injuries.4
In other words, simply using those shoulder restraints can save our patients’ lives and prevent devastating injuries. Our analysis found that providers reported that a shoulder harness was not attached or available in 33% of serious crashes.5 However, in more than a third (38%) of the cases, providers reported that though the shoulder harness was attached to the cot, it was not used.5
Identifying Ambulance Crash Factors
Factors associated with ambulance crashes are not unlike those of the general driving population, although they are sometimes exacerbated or influenced by the nature of EMS work. NHTSA is addressing several of these to help keep responders safe.
Fatigue affects everyone—especially those who work long shifts or in the middle of the night. A number of recently published peer-reviewed research studies have demonstrated not only that about half of EMS providers report symptoms of severe fatigue, but also that drowsy or fatigued EMS providers are substantially more likely to be injured on the job,6,7 commit a medical error, or perform a safety-compromising behavior while driving.6 This year, NHTSA’s Office of Behavioral Safety Research will begin bringing together fatigue experts and EMS stakeholders to help improve fatigue-related guidelines, scheduling and reporting in EMS.
Equipment defects can occur in an ambulance like they can in any vehicle (such as in the suspension or braking system) or in special mission-critical components of an ambulance (like the HVAC system or a fastening device). The NHTSA Office of Defects Investigations collects complaints from drivers and fleet managers who think something just isn’t working the way it should and addresses them with the manufacturer. If you think a mission-critical component of your ambulance isn’t working properly, report it immediately to your fleet manager and to NHTSA at www.Safercar.gov. This will give NHTSA the data it needs to determine whether the defect is specific to your agency or something occurring nationally that requires further investigation—or potentially a recall.
Effective driver training remains a top priority for EMS agencies across the country. NHTSA’s Office of Behavioral Safety Research is currently conducting a nationwide review of emergency vehicle operator training practices. As part of this review, we are talking to state and local EMS stakeholders to determine what emergency vehicle driver training they require, what other prerequisites they have in place before drivers can get behind the wheel of an ambulance, and what steps they take after a crash to determine the cause and prevent future incidents from occurring.
Easy Steps to Prevent Injury to Yourself and Your Patient
There are several things you can do to prevent injuries and fatalities from ambulance crashes, from staying rested to using safe driving techniques. But the easiest steps are:
Sit down and buckle up. When you get injured in an ambulance crash, it can have devastating effects on you, your family, your colleagues and your patients. Sitting in a proper seat and wearing a seat belt can significantly decrease your chance of injury in a crash or even a sudden maneuver (such as hard braking), and can also decrease the severity of injury in such an event.
Secure all equipment safely. In a crash or during emergency maneuvering, unsecured items can become dangerous missiles and cause serious injury or death.
Ensure everyone—your patients and your colleagues—is properly restrained. Don’t be afraid to speak up. You just might save your partner’s life.
How Is National Crash Data Collected?
Since 1975, NHTSA has collected information on every fatal crash in the country through the Fatality Analysis Reporting System (FARS). Through NHTSA’s General Estimates System (GES) program, we conduct a nationally representative sample of police-reported crashes across the country and estimate the number of total crashes resulting in injuries, including those involving ambulances. We know whether the people killed or injured were drivers or passengers in the ambulances involved in crashes, but we are still working to collect consistent data on whether they were patients, providers or neither, such as patient family members.
Safety is a critical component of great patient care, and NHTSA works as a team to help put the right information in your hands to make the best decisions on scene. Ultimately, the responsibility rests on you as an EMS provider to keep yourself, your patients and your partners safe.
1. NHTSA. Fatality Analysis Reporting System (FARS) 1992–2010 Final and 2011 Annual Report File (ARF).
2. NHTSA. National Automotive Sampling System (NASS) General Estimates System (GES), 1992–2011.
3. Op. cit., NHTSA National Automotive Sampling System.
5. Higgins JS, Gormley M, Farnstrom E. The use and impact of safety restraints among EMS workers and patients in ground ambulance crashes. NAEMSP Annual Meeting Abstracts Pre Emerg Care, 2015; 19(1):140–177.
6. NHTSA Special Crash Investigations Ground Ambulance Crash Reports 2002–2012; NIOSH Fire Fighter Fatality Investigations and Prevention Program 2001—2010; Fatality Assessment and Control Evaluation 2001.
7. Patterson DP, et al. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Pre Emerg Care, 2011; 16(1): 86–97.
8. Pirrallo RG, et al. The prevalence of sleep problems in emergency medical technicians. Sleep and Breathing, 2012; 16(1):149–162. Special acknowledgement goes to the many NHTSA staff members who contributed to this article and ongoing ambulance safety research, especially Steve Higgins and Mirinda Gormley.
Noah Smith, MPH, EMT, is an EMS specialist with the National Highway Traffic Safety Administration’s Office of EMS in Washington, D.C., where he focuses on EMS performance improvement, innovative care models, reimbursement policy and EMS data utilization. He is an active volunteer EMS provider in Prince George’s County, MD.