Danger in the Back of the Ambulance



Ann-Marie Lindstrom | | Thursday, July 9, 2009

Instead of simply assuming running Code 3 saves lives, David Slattery, MD, medical director for Las Vegas Fire and Rescue and assistant professor and research director of the University of Nevada School of Emergency Medicine, would like to ask the question, "Why do we run Code 3?"

Slattery has EMS providers' safety in mind when he asks this question. He would like the industry to examine the issue as part of an overall look at safety in the back of the ambulance -- the patient compartment. He says critical-care patient procedures en route to the hospital, driving behavior, and inadequate ambulance design and safety standards all increase the risk of injury and death to providers and patients. EMS providers' risk of occupational death is two-and-a-half times higher than the risk for other American workers. And about 74% of those deaths are connected to transportation incidents.

Slattery is co-author of a recent literature-review study, "The Hazards of Providing Care in Emergency Vehicles: An Opportunity for Reform," published in the January issue of Prehospital Emergency Care.

The study was borne from a request to talk about the efficacy of using ZOLL's AutoPulse (mechanical chest-compression device). Slattery says he's a visual person, so he made a video of providers standing to administer CPR and manually ventilate a patient while an ambulance ran a Code 3 at 15 to 20 miles per hour on a closed course. A second video of seated, restrained providers using the mechanical chest-compression device and a mechanical ventilator dramatically demonstrated the differences in injury risk to providers. In the first video, the providers swayed as the ambulance turned and changed speed. They occasionally had to grab onto something to avoid falling. They were surprised to see how much movement they coped with. "They are focused on the scene of the battle" so they don't even notice what is happening to them, says Slattery.

Slattery says using more technology that allows "hands-off" patient treatment would allow providers to remain seated and restrained while working in the patient compartment. Plus, he says the automated devices for compressions and ventilation deliver more consistent results, quoting a study published in JEMS in 1991:

"In a study of the effectiveness of chest compressions performed on a manikin in a moving ambulance, manual chest compressions were only 22% effective (i.e., proper depth and rate) on highway trips, 33% effective on low-speed (15-mph) local runs, and 0% effective on high-speed (30-mph) local trips in truck-style (type I) ambulancesÚ.

"In a manikin study performed in a moving ambulance, paramedics were able to provide adequate ventilation (i.e., proper volume and rate) only 66% of the time with a bag-valve-mask in type II (van-style) ambulances and 25% of the time in type I (truck-style) ambulances."(1)

Riding unrestrained in the patient compartment becomes even more dangerous in the event of an accident, of course. Standing providers could be thrown around the patient compartment, injuring themselves on bulkhead-mounted cabinets and equipment. In one Las Vegas incident, an unsecured, used-sharps container was destroyed, spraying sharps throughout the space, says Slattery. There also have been cases of providers falling on patients, further injuring the patients.

Slattery feels some people have a false sense of security about their driving skills after undergoing driver training. He would like to see EMS adopt two ideas from the airline industry: crew resource management and a sterile cockpit. Crew resource management means anyone not actively involved in patient care should be constantly aware of what is happening on the road. Slattery says as many as 58% of responders admit to talking on a cell phone or text messaging en route to a scene. A sterile cockpit implies the driver's total concentration during critical times in the transport. That means during travel, no one in the ambulance will hold unnecessary conversations or talk on cell phones, for example.

Ambulance engineering and design need examination, too. Slattery says, "The back of an ambulance is usually not crash worthy." Future designs may want "to draw from the nautical industry" with more of the equipment secured as it is on boats and ships, he suggests. Redesigning compartments so a seated provider can reach supplies and equipment without moving around would help. Equipping patient compartments with sliding seats, so the providers can reach the patient while they remain restrained would allow for unrestricted patient care, in most cases, while still protecting the providers.

Slattery wants to "shine a light" on ambulance safety. It's time to reconsider what EMS does and how it does it. He'd like to see Code 3 runs "on the radar screen" for further discussion. He says in many cases, this risky protocol is unnecessary. In a typical urban environment, he says, running Code 3 may only shave off one to two minutes of transport time and says a well-trained, well-equipped, "advanced provider can deliver 90% of the care an [emergency department] ED can deliver." So, screaming through city streets with lights and sirens may put all the ambulance's occupants at risk without increasing the patient's chances of survival.

New technology and better engineering and design, along with updated protocols, could lower the risk of EMS job-related deaths and injuries -- without compromising patient care and, in some cases, improving it.

Read Dr. Keith Wesley's take on the study and what it means for field providers in"The Hazards of Providing Care in Ambulances."

Ann-Marie Lindstromis a freelance writer and contributing editor to JEMS.


1. Stapleton ER: "Comparing CPR during ambulance transport. Manual vs. mechanical methods." Journal of Emergency Medical Services. 16(9):63Ï72, 1991.

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