The EMS community is still in the midst of figuring out how it will handle the contemplated retirement of the venerable General Services Administration ambulance specification (KKK-A-1822-x), the release of the National Fire Protection Agency (NFPA) ambulance standard, the responsibility of individual states to regulate ambulances, and a number of other forces that are affecting ambulance design and construction.
To understand what the ambulance of the future might look like, it’s important to understand the history of current designs. Before the 1970s, we used car-based ambulances. Since the 1970s, the ambulance world transitioned from car-based ambulances to ones that resembled a box vehicle or van on a light truck chassis.
The patient care compartment was built using expertise derived from and evolved with the recreational vehicle (RV) and motorhome industries. So what we began to deploy was a modified RV box that was built using a frame, particle board and some sort of applied surface material, such as Formica.
Since transitioning the chassis, these ambulances have continually been upgraded and redesigned. They have become bigger and heavier, and they’ve had more customization, cabinetry, and bells and whistles bolted on since they were originally created. They’ve changed so much in the past 40 years. How will they further transform in the next 40?
Changing the Future
Until now, the ambulance industry has been driven by externally imposed standards. If we continue to be pushed by external forces, we may not change much. Anything better will probably cost more, and there’s tremendous push-back to additional government-imposed “standards” (unless those standards are backed by substantial evidence). And with much of the prehospital community staying largely un-involved in matters of public policy, financing of EMS and research focused on safety and work environments, there’s not much pressure from within to force changes on a national level.
A number of factors make this an ideal time for innovation in ambulance design and construction. First, the role of the ambulance service in the community is changing. “One call, one haul” isn’t necessarily the only paradigm for our business as we move forward. Second, vehicle design and construction is changing all the time, and environmental constraints have already begun to impact our vehicle choices. Conventions, such as defense (DEF) standard, regeneration and corporate average fuel economy (CAFÉ) standards, and other regulations, are now part of the fleet planner’s considerations.
Is the ambulance of the future a box that’s built like a motorhome and bolted on a truck chassis with a bunch of aftermarket systems screwed on? I, for one, hope not. Future ambulances (or mobile care platforms) should be purpose-built. An ambulance intended to comfortably move patients from one healthcare facility to another should be built on a different chassis than one that must respond to a car crash or rescue scene on a mountain.
For example, the military has already purpose-built an ambulance to protect patients and medics in a high-threat environment. If that organization can think outside the box by using a boat-shaped hull instead of a flat bottom to better protect staff, why can’t we?
What to Consider
The following suggestions can help ensure your ambulances of the future are truly forward-thinking.
Consider your workflow. Future ambulances should be built with workflow in mind. Medics should not have to move to one corner of the ambulance to talk on the radio, another corner to retrieve a cold pack and someplace else to grab a sheet or blanket. Who says there has to be cabinets? The U.S. Navy Medical Department, serving the Marine Corps, developed a mobile trauma surgery facility that has no interior cabinets. Equipment and supplies live in fabric drop-downs, which take up far less space, are easier to inventory and restock and don’t have sharp corners to hurt crew if they bang into them while moving.
Eliminate movement during transit. There has to be a way to eliminate the need to climb in to the back of the ambulance to find whatever piece of equipment is needed. While there has been some work on “pass through compartments” for commonly used packs, why can’t all of the EMS equipment be equally accessible from both inside and outside the ambulance? I wonder how many knee injuries could be prevented if we eliminated climbing in and out” with heavy equipment.
Ensure the safety of your employees. If providers must move around in a moving ambulance, we need to ensure they’re safe doing so if the ambulance stops suddenly or experiences potentially harmful maneuvers or physical forces. Consider designs in other industries, such as roller coasters, in which we subject passengers to high G forces while traveling at high speeds on several axes. We expect them to get off the ride safely. If we can do that, we should be able to build a seat that will protect EMTs and paramedics moving around a 100-square-foot work area.
Automate lifts. A few bariatric ambulances have automatic lifts, so why can’t we do this for a ramp or lift system for every ambulance? For example, let’s consider ramps, platforms and a stretcher that can load itself.
Remember your human cargo. I believe we need four-door cabs. More than half the time one of the ambulances in my system rolls, it has more than two people in it. Regardless of who it is, whether it’s students, interns, observers or physician fellows, somebody always has to sit in the back. This is one of the worst places to be in a collision, even when we think all dangerous objects are safely secured in place. Being safely belted into a cab that has had to meet federal motor vehicle safety standards is always better than being “in the box” that doesn’t currently have to meet the same crash worthiness testing as the cab/chassis.
Consider the mid-motor chassis. Wake County EMS has had recent experiences with medium-duty trucks, and we found those trucks to be lacking in ride quality and reliability. Some fleet managers believe the Isuzu, Iveco and other blunt-nosed, mid-mount chassis are the most reliable and easy to maintain. They also permit the four-door cab without making the ambulance impossibly long. You can see these vehicles all over most cities because they’re popular with a variety of service companies. Their chassis are also light enough to carry an ambulance, without the spine-jarring impact of today’s 24,000-pound medium-truck chassis.
How to Make the Transformation
If we stretch our imaginations, we might consider a transformational vehicle that could be driven around configured in a small, efficient, aerodynamic package and could reconfigure itself on demand. It could reconfigure itself as a transport vehicle, a small clinic or some other related need. In the meantime, consider the following examples of ideas for the ambulance of the future.
Workflow engineering: A team of human factors and industrial engineers could look at workflow, layout and safety in the common ambulance environments that exist today. These varied environments include inter-facility, recumbent transfer, the 9-1-1-emergency response, critical care, and community paramedicine treat and release environments. These engineers could use their expertise to help us design workflows without the distraction of historical precedent.
Focus on safety: Another group of engineers should conduct research and help us build safe vehicles that can withstand the forces that might kill the crews inside it. (No, I don’t think that a 20,000-pound static load test for the roof of the box is sufficient. I’ve never seen a water tank jump on top of an ambulance before, but I have seen many that were T-boned at intersections.)
Systematic design: Ambulances need to be designed as integrated systems instead of a series of products bolted together. Do we need all of those wires connecting the monitor to the patient? For example, you can send ECG data wirelessly. And although nobody has figured out how to wirelessly send defibrillation energy, how about an engineered solution that allows the monitor to be secured out of the way, with defibrillation cables built into the vehicle? If all the physiological data were available on a wall-mounted screen, or a heads-up display, one of the dozen 25-pound missiles in the patient compartment could be eliminated.
Device integration: It would be helpful to have multiple computers—physiological devices, lab and imaging devices, ePCR reporting and navigation systems—integrated into one device. In the future, we should have one computer that provides recordkeeping, communications, network connectivity, driver feedback and vehicle telematics. That same computer might do lab work and record vitals, being reliably networked.
Some of these might seem far off in the future, but a two-year project in the United Kingdom, called Healthcare on the Move, might be a positive first step the U.S. should consider. Funded by the government’s Engineering and Physical Sciences Research Council and involving the Royal College of Art, the program has prototyped a variety of vehicles that could change the face of mobile health care delivery. These vehicles include “leave behind” silicone walled patient treatment modules, seats with paramedic packs built in to them (to allow medics to step from the vehicle with their pack already loaded), ultra-thin wall-mounted monitors, and all-wheel drive, off-road capability.