The first side-loading ambulance in production in the U.S. will soon debut in Gibson County, Ind., with a service goal of putting the crew in a better position to survive a crash without compromising patient care.
SJC Industries Corp., manufacturer of McCoy Miller, Marque and Premiere brands, built the ambulance on a Ford E-450 cutaway cab and chassis. The Premiere Side-Load ambulance was purchased by the Gibson County Ambulance Service and includes a side-loading patient compartment that has the patient riding in a sideways position and the crew facing either forward or backward on either side of the patient.
Fred Schimmel, senior design engineer for SJC says the side-loading configuration was his idea, “based on my experience as a medic in the field and my involvement with National Institute for Occupational Safety and Health (NIOSH).”
Equipment and cabinets are designed to place supplies within easy reach of providers while restrained in a five-point harness. The new design eliminates rear patient loading, with a compartment now in the rear for exterior storage.
So far, Ferno is the only manufacturer to develop a cot for the new configuration. A version of the StatTrac cot has been modified and tested for use in the ambulance. “We’ve done all the testing required by KKK-A-1822F and AMD Standard 0004 to help ensure crash safety,” says Jim West, Ferno director of Global Strategic Accounts.
According to SJC, the side-load configuration offers a safety advantage because the seats can slide toward the patient and providers can remain secured in their seats while giving care and accessing equipment. SJC also states that they believe the configuration is safer for the patient because by being positioned laterally, the force in a frontal impact collision will be evenly distributed along their entire body length.
Some industry experts are concerned, however, that the patient could be injured if the ambulance is T-boned because the patient’s head and feet are positioned close to the vehicle’s large sliding doors and have less of a buffer zone to protect them from intrusion into the compartment.
According to Nadine Levick, MD, MPH, executive director of Objective Safety and a passionate proponent of ambulance design safety, the government doesn’t currently require crash testing for ambulances or intrusion tests for the patient compartment.
“The only test that was done [on the Premiere side-loading ambulance] was conducted by NIOSH to gather information on injury numbers on the crash dummies and cot mount,” says Schimmel.
The company also refers to side-intrusion testing conducted by two of its competitors. However, experts state that extrapolating results based on the testing of another manufacturer’s vehicle isn’t appropriate. Nearly two dozen ambulance manufacturers build bodies to their own structural integrity standards, making it almost impossible to say that they all will perform the same in a crash test.
Gibson County Ambulance Director Dan Alvey faced some red tape before he could put the new ambulance in service. He had to obtain waivers from the Indiana State EMS Commission to change the ambulance specifications to include side-loading ambulances and address the Commission’s concern regarding patient headroom.
Some agencies are concerned that the lack of sufficient space for an attendant at the head of the patient may inhibit proper airway management, stating that it could be difficult to directly visualize the trachea or maintain a bag-valve-mask seal while en route to a hospital. SJC contends that those who use the King ET tubes will still be able to intubate a patient from the side. Other intubations may require the ambulance to be stopped. In those cases, “access to the patient is possible by simply opening the side door and standing in the door well or on the street to perform endotracheal intubation,” the company states in a prepared fact sheet.
The side-load and unload aspect also requires sufficient space at emergency departments to off-load the patient from the side. At facilities with ramps and spaces designed for side-by-side ambulance parking, this configuration may dictate that the patient be off-loaded prior to parking the ambulance between two other ambulances. According to SJC, the side-load ambulance requires 4–6 feet for patient loading and unloading.
—Teresa McCallion, EMT-B
National Drug Shortage
Bob Bauter, director of clinical services for the Monmouth Ocean Hospital Service Corporation (MONOC), knew he had a problem in early September when the ALS service was down to just 60 vials of 50% dextrose (D50) and had no date for a delivery of fresh meds.
That was a real problem, considering the New Jersey area MONOC serves uses about 25 injections of D50 each week.
EMS agencies nationwide are being forced to more closely monitor drug supplies because of a critical shortage of pre-filled syringes of such meds as D50, epinephrine 1:10,000 and nalaxone. The shortages were the result of Amphastar Pharmaceuticals stopping production on some drugs this past December because of an FDA requirement that companies file new applications for “grandfathered drugs.”
In early August, Amphastar claimed it would start rolling out the drugs again on a timetable going into October, but the damage had already been done.
“We’re speaking about the three most important drugs used for EMS that are out there. For us to find ourselves with a drug—that is, the premiere one for cardiac arrest—on back order for months at a time, says a great deal about our lack of preparedness,” says Parkland Memorial Hospital (Texas) emergency physician Ray Fowler, MD, FACEP.
The shortage has forced agencies to better track supplies and demand. It’s also made them consider alternative treatments, such as using D10 instead of D50. Fowler is also calling on the industry to devise a plan to ensure this type of shortage doesn’t happen again.
—Richard Huff, NREMT-B
Bedbugs are Back!
Bedbugs have made headlines worldwide in the past. But they’ve become more prevalent recently, partly because of increased international travel and decreased use of pesticide, which kept their numbers low until pesticide use was banned in the U.S. in 1972.
It’s unlikely EMS providers will encounter bedbugs as a primary complaint, because their bites are seldom a serious problem. And although the insects feed on blood, often from multiple hosts, no evidence shows they spread any diseases or infections.
Because bedbugs are large enough to see with the naked eye—reddish brown, oval, flat and about the size of an apple seed—ambulance crews should look for any bugs after transporting a patient with suspected bites. JEMS Medical Editor Edward T. Dickinson, MD, NREMT-P, FACEP, says routine cleaning of ambulance surfaces, seating and benches should be sufficient. Crews should also carefully examine linen stacks and other soft materials in the patient care area.
The Human Impact of Dynamic Deployment
In theory, dynamic deployment is an efficient way to dispatch ambulances. But, often, ambulance services fail to consider the very real and significant human impact that this “practice” may have.
Dynamic deployment involves geographically deploying ambulances based on projected demand by the time of day. Ambulances may not always respond from fixed stations, but instead may be “posted” on street corners, in parking lots or in other public locations. Unfortunately, dynamic deployment often places field providers in uncomfortable and sometimes unbearable conditions that management may fail to fully consider.
Field providers may be forced to sit in cramped vehicles for extended periods of time or be expected to endure extremely hot or frigid temperatures in ambulances with poor air conditioning systems. Other times, crews are stationed at facilities that don’t have designated areas for them and may be left standing for hours on end.
Although your providers can seek refuge at a local coffeehouse or other businesses during normal business hours, the 24-hour nature of EMS often means crews may be stuck without a suitable place to stretch their legs or use the restroom. As a result, EMS providers in some systems that practice dynamic deployment are experiencing a host of back, neck and knee problems, which could lead to workers’ compensation claims and to a general feeling of dissatisfaction.
Few current laws speak directly to this practice. The Fair Labor Standards Act provides that employees must be paid for all time for which they are “engaged to wait.” So, EMS providers must be paid for all “post” time. The Americans with Disabilities Act and similar state laws require employers to provide a “reasonable accommodation” for individuals with mental or physical disabilities; providers with legitimate mental or physical limitations may ask for accommodation.
Ambulance services that have a union may have other considerations. Unless management rights clearly give the agency the power to unilaterally change to a dynamic deployment model, such a change may be subject to collective bargaining. If so, both sides should negotiate for reasonable working conditions, and employers should carefully balance their performance objectives with the best interests of their employees. EMS agencies should consider posting crews at locations with restrooms and other amenities. Services can speak with local health-care facilities, fire departments or even regular businesses, which may welcome an EMS crew at their site, and ask whether crewmembers could utilize a designated room while “on post” in that area.
EMS agencies that take into account the concerns of field staff will increase acceptance and reduce the level of disharmony in the workplace. This approach may also reduce the risk of workplace injury or disability claims and external complaints (or even lawsuits) related to poor patient care caused by unhappy field providers. It’s in an agency’s best interest to consider the “human impact” of dynamic deployment. Good communication with field staff and inclusion in the process of developing and adjusting the dynamic deployment system is key to success and can translate to improved job performance and greater overall satisfaction. JEMS
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information.
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This article originally appeared in October 2010 JEMS as “New Ambulance Design Hits the U.S. Streets: Indiana adopts first side-loading ambulance.”