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The Hazards of Providing Care in Ambulances


Review of:Slattery DE, Silver A: "The hazards of providing care in emergency vehicles: An opportunity for reform." Prehospital Emergency Care. 13(3):388-397, 2009.

The Science

This review of the literature is a presentation of the current issues related to ground ambulance transportation safety. After examining all the relevant studies, they categorized the factors contributing to EMS vehicular related injuries and deaths.

Increased Risk of Ambulance-Related Minor Traffic Collisions:This included "Code 3" driving, or driving with lights and sirens on. It also included assuming other drivers see and/or hear the ambulance coming, which they say creates a false sense of security, and risky driving. They also cite a lack of situational awareness by crews and lack of awareness of ambulances by the general public

Poor Ambulance Safety Designs:In this section, the authors list the environment in the back of the ambulance, such as unsecured equipment and potential projectiles, sharp corners and side-facing seats. They also mention a lack of standards for crashworthiness and inadequate testing, and poor vehicle visibility due to pain color.

Delivery of Critical Patient Care:The authors listed such procedures as delivering chest compressions and managing airways as critical patient care that contributed to increased provider injuries. This is due to standing and a lack of use of restraints, head protection and poor balance due to hands being occupied.

The authors performed an exhaustive and unbiased review of the literature and presented numerous facts about EMS provider vehicular-related injuries, of which the following are just a few examples:

  • Of all EMS fatalities, 74% are transportation related.
  • Between 1988 and 1997, there were reports of more than 350 fatalities and nearly 23,000 injuries to people involved in ground ambulance accidents.
  • In total, 60% of ambulance crashes and 58% of crash fatalities occur during runs using lights and sirens (22.2 injuries per 100,000 runs for "Code 3" travel vs. 1.46 injuries per 100,000 runs for non "Code 3" travel).
  • The rear compartments of ambulances are particularly hazardous because of their "non-crashworthy structure," hostile interior surfaces, large compartment size, projectiles, hazardous head-strike zones and poor design. (Between 1988 and 1997, 72% of the ambulance occupants killed in ambulance crashes were occupants of the rear compartment, although only 40% of the total ambulance occupants were contained within the rear compartment during these crashes).
  • EMS providers don't wear seat belts in the back.

Based on the current literature, the authors suggested several strategies. These included the following:

  1. Improve ambulance design and safety standards;
  2. Improve driver behavior;
  3. Decrease use of lights and sirens; and
  4. Increase use of seat belts and hands-free driving.

The Street

I'll keep my comments brief, because I believe these two authors have presented all the points that need to be made. They have presented them in a succinct, professional and intelligent manner while recognizing that there are both economic and political reasons for the failure to implement their suggested strategies.

We are rightfully outraged after hearing stories of the cockpit voice recording of a crashed flight that the flight crew wasn't paying attention moments before impact and then later that neither had sufficient experience in this type of aircraft. But we quickly search for reasons to blame the guy who failed to yield the right-of-way to an ambulance that is T-boned in an intersection racing lights-and-sirens to the scene of a broken ankle while the crew was simultaneously talking on the radio, watching for traffic, and looking up the address on the mobile terminal.

Take the situation when an elderly EMT is standing in the back of an ambulance performing CPR while standing upright resting her head against the side cabinet while transporting a cardiac arrest victim. The ambulance takes a sharp turn, and the EMT feels a pain in her neck, which is later determined to be cervical facet fracture. She is left with numbness in her legs and the end of a 30-year volunteer EMT career. We just shrug and chalk it up to bad luck.

Another example is when a crew is wearing their seat belts during a transport without lights and sirens, and the ambulance is rear-ended by a semi-truck. The defibrillator, which is not secured to the bench, becomes airborne and strikes the medic in the head, killing him instantly. If it weren't for the defibrillator, he would've survived.

I don't know about you, but I'm tired of hearing these stories. It's not about blame, bad luck, policy, politics or money. It's about lives. It's time to get outraged. It's time for a change.

>> Also check out "Rig Safety 9-1-1." and read "Danger in Back" for an interview with Dr. Slattery.


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