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In a July JEMS.com article, "Danger in the Back of the Ambulance," Las Vegas Fire and Rescue Medical Director David Slattery, MD, notes that many factors and practices increase the risk of injury and death to providers and patients. These include routine critical-care patient procedures, such as compressions and ventilation, performed by unrestrained crew members en route to the hospital. The facts he and other researchers present should make EMS managers pay close attention to the issues of safety and proper clinical performance and consider implementing mechanical CPR devices. On-scene compressions should be consistently delivered and monitored, preferably by direct-feedback technology. And compressions delivered in a moving ambulance should be mechanized.
Unrestrained personnel and equipment are thrown around the patient compartment during evasive maneuvers and collisions, injuring and killing crews and patients. And although some experts believe we shouldn’t be performing CPR in a moving ambulance, the fact remains that we are. In particular, we’re going to continue to resuscitate some patients in transit to the hospital as we move toward hypothermic resuscitation.
In "The Hazards of Providing Care in Emergency Vehicles: An Opportunity for Reform," published in the January issue of Prehospital Emergency Care, Dr. Slattery points out that the risk of occupational death to EMS providers is two-and-a-half times higher than that of other American workers and that 74% of EMS deaths are connected to transportation incidents.
The study reviewed the efficacy of mechanical chest-compression devices in ambulances. The authors videotaped providers attempting to perform CPR while positioned in the back of the ambulance as the vehicle was driven "Code 3" at just 15–20 miles per hour on a closed course. They also filmed providers who were properly restrained and using a mechanical chest-compression device. The difference in injury risk was dramatic. In the first test, the providers swayed as the ambulance turned and changed speed. They couldn’t maintain consistent compressions and were occasionally forced to interrupt compressions while avoiding a fall.
Significant evidence shows manual CPR isn’t effective in a moving ambulance. The study "Comparing CPR During Ambulance Transport: Manual vs. Mechanical Methods," published in September 1991 JEMS, illustrated that automated devices for compressions and ventilation delivered more consistent results. In the study, three CPR instructors competed against a mechanical compression device on 144 ambulance "runs." The device provided adequate compressions during 97% of the test cases. In contrast, manual compressions were adequate only 37% of the time. Manual compressions varied at a rate of 41% effectiveness under highway conditions and just 33% effectiveness under stop-and-start conditions. Manual compressions in a modular patient compartment proved to be successful just 19% of the time.
It’s time for EMS agencies to pay attention to the data on CPR and the efficacy of mechanical CPR. It’s our responsibility to avoid placing our crews in harm’s way with manual compressions in a moving ambulance, which risks lives and opens up agencies to liability. More importantly, it’s the right thing to do to deliver the proper level of care to our patients.
