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Ambulance Safety Lessons from Europe


European ambulances have long been known for their sleek lines, bright colors and familiar "high/low" siren, qualities deemed odd by most American observers. Why are European ambulances so different? Have they just evolved differently, or are they superior? Can we, and should we, be learning lessons from our European counterparts? As the U.S. struggles with staggering numbers of ambulance crashes and the resulting injuries and fatalities, members of one organization traveled to Europe looking for answers.

On May 4, 2010, the EMS Safety Foundation embarked on an educational journey to Fulda, Germany. The organization, founded by ambulance safety pioneer Nadine Levick, MD, MPH, sent a delegation of EMS providers, safety and ergonomic experts, researchers and U.S. ambulance manufacturers to a European EMS and patient transport trade show.

Rettmobil has been billed as Europe's largest exhibition of rescue and mobility vehicles and equipment. The outdoor venue houses more than 750,000 square feet of exhibition space, with 350 exhibitors from 12 European countries. The three-day event recorded nearly 20,000 attendees from across the globe for the 2010 edition. (1)

Safety Standards
Unlike the U.S., Europe has ambulance safety standards. Called Europaische Norm (EN), or "European Standards," they're used by 29 European countries and include construction and crash test standards. (2) European ambulances, and all the equipment inside them, must be dynamically crash tested. Unlike the static (or stationary) testing done in the U.S., the dynamic test is an accurate predictor of real-world performance in a crash. All materials and equipment in European ambulances must withstand 20 G frontal impact tests and 10 G rear- and side-impact tests.

Vehicle Size
Despite the popular notion that bigger is better, this isn't the case when it comes to safety. Large ambulance boxes are heavier, contain more equipment and allow the lethal movement of their contents. Most European ambulances are small and compact, with little or no exterior modifications. Manufacturers have eliminated unnecessary equipment, moving some to exterior compartments and some to other specialized vehicles.

Vehicle Modifications
Whereas most U.S. ambulances have extensive body modifications, the exteriors of most European ambulances remain as produced by the automotive industry, maintaining their structural integrity. Box construction in the U.S. consists primarily of plywood and sheet metal; in Europe, it's steel, aluminum and carbon fiber, with plastic interior surfaces. Interior cabinets are commonly flush with walls, eliminating the head-strike zones common to overhead mounted cabinets.

Most European ambulance manufacturers use the Mercedes-Benz Sprinter chassis, which offers a model with a taller roof. If a manufacturer makes a body modification, crash test standards ensure that its structure is equally as strong as the factory's. The resulting ambulance, with minimal or no modification, is smaller, lighter and safer, as well as cheaper to produce. In addition, the Sprinter comes standard with numerous safety features, including rollover mitigation, enhanced under-steer control and acceleration skid control. (3) The Sprinter chassis, marketed by Dodge in the U.S., is currently offered by a few progressive American ambulance manufacturers.

Restraints & Seating
The leading cause of patient and provider injuries in the back of U.S. ambulances is improper restraint of occupants and equipment. (4) The evolution of large box modifications and poorly designed seating configurations has resulted in habitually unrestrained attendants. The side-facing seat (not allowed in any other motor vehicle) is likely the most common contributor to provider injuries. This isn't the case in Europe. Attendant seats are forward-facing, with a standard shoulder and lap belt, providing crash protection close to that of the front seat. To conserve aisle space, most seats swivel to the side and/or fold up against the wall. Remember, these folding seats and alternative seating configurations have met rigorous crash test standards.

Along with the safer, forward-facing seating arrangement, essential equipment is located within reach of the attendant, allowing care to be rendered during transport while safely seated and restrained. Equipment is stored in cabinets and drawers that latch closed, and ECG monitors are secured to the walls with mounts that have been crash tested to 20 Gs.

In combination with stretcher shoulder harnesses, these factors all but eliminate the projectiles responsible for countless injuries.

Stretchers in Europe are loaded and secured onto an adjustable platform. The platform allows the stretcher to move up and down, left and right, and forward and backward, to increase access to the patient. Many of these platforms have a pneumatic suspension system providing a smoother, more comfortable ride for the patient.

Several manufacturers offer seats that are secured into tracks, allowing movement and multiple seating configurations. Still others offer forward-facing attendant seats on wheels. These seats can be removed and used to load the patient (like stairchairs), and then lifted (or rolled on tracks) into the ambulance. Once the seat is locked into the floor, the patient can be transferred to the stretcher next to them or transported seated in the chair.

European stretchers are very different from the X-frame or H-frame designs used in the US. First, they must load onto the specialized platforms. Second, they have superior ergonomics, requiring little or no vertical lifting during loading. The European stretchers have independent front and rear legs. As these stretchers are pushed into the ambulance, the legs at the head-end fold up first. The weight is then supported by the floor of the ambulance and the second set of legs. By the time the foot-end legs reach the bumper, the weight is almost entirely supported by the floor of the ambulance. With one last push, the second set of legs folds up and the stretcher is locked into place. These stretchers are significantly easier to load, thereby reducing provider back strain and minimizing patient drops.

Europeans are known for being stylish, and their ambulances are no exception. They're colorful, not for looks, but for visibility and conspicuity. Research has proven that the most commonly used colors for U.S. fire and EMS, red and blue, are two of the least visible colors to the human eye.(5) European ambulances don't have this problem; they're bold in sharp, eye-catching colors, such as as orange and yellow. They're also traced in highly visible retro-reflective material, making these vehicles stand out in low light from as far away as 500 feet.

The European fashion influence doesn't stop there; their uniforms are also in similar bold, highly visible colors and highlighted with retro-reflective material. These uniforms make providers stand out on the roadside, day or night.

Purpose drives evolution, and our purpose is the same as in Europe: to assess and treat patients, and to safely transport them from bedside or roadside to a definitive care facility. In terms of ambulance safety, their system is superior. European patients, providers and the public are far safer from the injuries and fatalities that can occur in and around ambulances. We have a lot to learn from Europe and about ourselves. We have the data, we have the technology, and we have the resources required to make EMS safer in the U.S. We need to look into the future, be open to change and be part of that change.

1. Rettmobil. www.rettmobil.org/index.php?lang=en
2. CEN-European Committee for Standardization. European Standard for Road Ambulances: CEN. 1789, 2007.
3. Mercedes-Benz Sprinter USA. www.mbsprinterusa.com/about/features.
4. CDC. Ambulance crash-related injuries among emergency medical services workers--United States, 1991–2002. CDC MMWR Morb Mortal Wkly Report. 2003;52:154–156.
5. Levick N. Safety strategies for EMS fleets: What works? PowerPoint presented at American Society of Safety Engineers, San Antonio, Texas.


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