Airway & Respiratory, Ambulances & Vehicle Ops, Cardiac & Resuscitation, Operations, Patient Care

Patient Positioning 101: Time to rethink patient access in the back of ambulances

Gordon Graham, one of the most insightful risk managers and public safety consultants in the country, has a phrase that should be embedded in the brains of all emergency personnel and managers: ˙Predictable is preventable.Ó The reason is because EMS crews and their patients suffer too many needless injuries and deaths as a result of preventable hazards in the patient compartments of ambulances.

I think it’s time for some sweeping changes in the way we design and outfit our vehicles, and I know that many ambulance manufacturers feel the same way and are starting to do something about it, as you’ll see in this year’s ambulance showcase and innovations sections.

Some of the changes I’m recommending may require approval by governmental agencies or additional changes in the federal ambulance specifications. But I think it’s critical that we speak up as an industry and begin to make these changes happen.

First, we need to engineer air bag systems into all emergency response vehicles regardless of the size and shape of the vehicle. We must also ensure that there are no sharp edges or unsecured equipment in the cab. I’ve seen laptop brackets, loose flashlights and other gear in too many rigs lately. Crews and managers need to eliminate these preventable hazards.

We’ve done a pretty good job of adding reflective trim and side-fender mounted warning lights, but the rear of our units needs more attention. Many manufacturers are now recommending diagonal reflective striping on the rear of the ambulance body, a practice adopted decades ago by highway safety experts and highway departments.

But it’s the interior of the patient compartment that’s most in need of our attention. First and foremost, the location of the attendant seat at the head of the patient has to change to enhance functionality. I find it hard to believe that the folks who design and mount these seats have ever closely watched an EMS crew managing critical patients, flown in medical helicopters, watched„Grey’s Anatomy or been to the dentist.

˙Watched Grey’s Anatomy or been to the dentistÓ? Has A.J. lost his mind?

No, I’m serious. If you watch an anesthesiologist practice their craft (and I did recently), you’ll notice that they sit in an optimal position to access, visualize and manage their patient’s airway at all times. And they have all their airway, monitoring and suction equipment within inches of their eyes and hands. The same holds true for a dentist. Imagine if they tried to drill your teeth from a seat-belted position three feet away. (Ouch!)

In just about every ambulance built today, the attendant seat is attached to or pushed up against the action wall and fixed in location. We need to be able to adjust, elevate and lower the attendant seat to meet the needs of our crews and patients.

This leads me to the area in the patient compartment that needs our attention the most, the location of the primary stretcher and the need to be able to reposition it while in transit to access and treat our patients. The size and location of the ambulance bench seat hasn’t changed in 30 years, nor has the location and utility of the famous ˙CPRÓ seat (which is misnamed, because you’ll never see a provider seat-belted into this seat able to deliver proper chest compressions to a patient).

What has changed dramatically is the shape and height of stretchers when in their collapsed position on the floor of modern ambulances. The original squad bench height and interior designs were primarily designed around the Ferno Model 30 stretcher. But today’s stretchers are lower in design, and consequently lower to the floor of the patient compartment.

Therefore, the only way you can access your patient’s arm, airway, extremity or torso is to lean over (or down), or worse yet, unbuckle your seat belt and kneel down next to them.

In emergency departments, operating rooms and X-ray departments (and yes, even the dentist’s office), this problem is non-existent because the patient’s position is adjusted to the height required by the team or specialist taking care of the patient’s particular need. Further, medical helicopter seats are designed to meet the height of their stretcher, but ground ambulance seats and flooring designs are not. We need to rectify this.

Instead of totally re-engineering the interior of the ambulance patient compartment, I think it would be more prudent and efficient to have the stretcher rolled onto, and secured to, a platform that can be hydraulically elevated and lowered, shifted right or left, and moved forward or backward, to positions optimal for IV establishment, airway control, ECG electrode placement, hemorrhage control and CPR.

This isn’t a new concept. Many European ambulances have had this feature engineered into them for years, and the U.S. military’s most advanced field care unit, the new Stryker medical evacuation vehicle ambulance, has the capability of rapidly positioning four litter patients in this manner (

It’s time to change the paradigm of ambulance design, to examine what our hospital, aeromedical and military counterparts have done to make patient care and transfer safer and more efficient, and to incorporate those ideas into tomorrow’s ambulances.