Ambulances & Vehicle Ops, Operations, Patient Care

Rig Safety 9-1-1: What you need to know about ambulance safety & standards

Issue 10 and Volume 33.

What is it that we need to know about ambulance safety? How do we digest the information that_s put forward by manufacturers? Does KKK-A-1822 compliance mean the ambulance can endure a crash? What_s safe and what isn_t? What works and what doesn_t? And where do we go to find out?

A Disconnect
Since the 1960s, when we left the Cadillac and went into the “box,” we essentially lost the safety oversight of the automotive industry. What has been the status quo in the ambulance vehicle industry since then hasn_t matched what_s standard in the automotive and transportation industry.„

Extensive data now highlights some of the strengths and weaknesses of how we address the transportation safety aspects of EMS. Data currently demonstrate that per mile traveled per vehicle, ambulances are one of the most hazardous vehicles on the road.

Concept vehicles are on the market, but where are the data and automotive safety oversight to support these modifications? Automotive safety experts have raised serious concerns about the safety of these vehicles built outside the purview of technical experts in occupant protection and vehicle crashworthiness.

Would you dare to administer medication that was demonstrated by clinical experts to be unacceptably toxic? Would you use equipment that had been known for 10 years to be unsafe or, worse yet, lethal? No. So why aren_t we holding ourselves to the same standard when it comes to the vehicles we ride in every shift?

A Shift in Standards
It might come as quite a surprise, but neither the KKK Ambulance Specification nor the Ambulance Manufacturers Division (AMD) Standards are standards of occupant crash protection or vehicle crashworthiness. In fact, in some areas, they even conflict with current technical automotive safety engineering practices.„

KKK- or AMD- compliance doesn_t demonstrate that an ambulance is crashworthy or will protect occupants in the rear patient compartment in the event of a crash. Although KKK and„AMD default to the Federal Motor Vehicle Safety Standards (FMVSS), these standards have a special exemption for ambulances. So once we_re positioned in the rear compartment, just 600 mm (2 ft.) behind the seating reference point of the„driver_s chair, the FMVSS are largely exempt from protecting us. Thus, our safety choicesƒsuch as effectively securing equipment, wearing lapbelts and applying safe vehicle operationsƒare paramount.

Bigger isn_t always better. The rest of the world is moving toward compact vehicles that offer fuel economy and lower price tags. These ambulances are designed by automotive safety experts and create an environment in which providers can easily reach patients and equipment while belted and which are demonstrated to be crashworthy. Fortunately, what has historically been considered safe is being challenged in the U.S., and in a fashion that_s strongly driven by data and evidence.„

The new Subcommittee on EMS Transportation Safety of the National Academies Transportation Research Board and the interdisciplinary Ambulance Transportation Safety Task Force are holding an Ambulance Safety Summit in November. Also, the non-profit EMS Safety Foundation has taken a delegation to Europe to look at„
safety practices at RETTmobil and will share highlights from its trip at the 2009 EMS Today Conference and Exposition and via Webinars. These are two examples of how organizations with technical experts are contributing to enhance our understanding of safer ambulance transport.„

The importance of this issue is highlighted by the recent National Fire Protection Association focus on ambulance vehicle safety standards. Essential to the development of such vehicle standards is the need for input from transportation, automotive safety, injury and impact biomechanics, and human factors technical experts and data. Creating a standard takes time, even years, and it_s imperative to have access to the best safety information available while these processes are underway.

Where We_re Going
When it comes to crash safety, the accepted standard is dynamic crash testing, not static pull tests. In the automotive world, crash testing is related to real-world injury data. The mechanism and data on how injuries occur in crashes is fed back into the development of the testing, and as a result, to the safety enhancements of the vehicle and, importantly, the standards.„

Although dynamic crash testing is the method to test the occupant safety of a vehicle, not all dynamic crash tests are the same. Without standards for how tests should be conducted, some of these tests can be meaningless or misleading. Intrusion into the patient compartment cannot be determined from simple deceleration testing (sled tests). Although being thrown against the bulkhead is a serious hazard, intrusion into the patient compartment is one of the real risks that we face (see crash photo).„

For optimal safety, current data suggests a compact vehicle, a well-designed interior with minimal possible injury hazards, forward- and rear-facing seats, and patients secured in over-the-shoulder belts in the longitudinal direction on the stretcher. Also, crashworthy, energy-absorbing features should be designed to addressalloccupants, not just those in the front. All essential equipment should be accessible and effectively secured. Manufacturers should ensure there are no head strike hazards present in the head-impact zone. Squad-bench occupants should wear the lap belt low over the pelvis and avoid using four- or five-point harnesses on side-facing seating. Many serious crashes are frontal crashes, and such harnesses have been shown by the world_s leading automotive safety engineers to be highly hazardous when seated sideways.

Other aspects important to the overall safety of the vehicle are enhanced stability control, scientifically proven enhanced visibility markings, and operations policies designed to optimize fleet safety performance, such as the ANSI/ASSE Z.15 Standard. We can learn a lot about fleet safety management from commercial fleet operations and the Federal Motor Carrier Safety Administration.

Independent studies demonstrating the effectiveness of aftermarket safety devices are rare. One such device that has been independently validated has demonstrated significant safety benefits in the EMS environment. This device monitors operator safety performance and provides immediate auditory feedback. Study results demonstrate a 1,000-fold improvement in safety proxies and a major decrease in crash rate and severity, as well as an improvement in vehicle maintenance expenses and response times.

In the absence of meaningful federal standards, our challenge is to identify best practices in vehicle safety. Watch for„new developments in vehicles, technology, policies and standards that will save lives, time and money. First, be sure your purchases pass muster with independent safety experts and have been through meaningful testing. Our providers, patients and the public deserve the„safest and most efficient vehicles available.„JEMS

Nadine Levick, MD, MPH, is an emergency physician, clinician and researcher. She has won many national and international awards for her studies in ambulance safety. She has published a large majority of the engineering literature in the field. She also conducted the world_s first federally funded vehicle-to-vehicle ambulance safety crash tests and established the EMS Safety Foundation( Contact her at[email protected]

1.„Levick NR: “Emergency Medical Services: Unique Transportation Safety Challenge.” Transportation Research Board.

2.„Levick NR, Grzebieta R: “Ambulance vehicle crashworthiness and passive safety design: A comparative evaluation.” SAE International. 2008.

3.„Ambulance Manufacturers Division. Public Comment. July

4.„Federal Motor Vehicle Safety Standardƒ
DOT NHTSA, FMVSS 49 CFR Parts 571, 572 & 589 Docket no. 92Ï28; notice 7, Item S6.3 (c)

5.„National Fire Protection Association: NFPA News.„12(6): 12Ï13, 2008.„

6.„Richardson SA, Grzebieta RH, Zou R: “Development of a side facing seat and seat belt system for the Australian„Army Perentie 4 x 4.” International Journal of Crashworthiness. 4(3): 239Ï260, 1999.

7.„Safe Practices for Motor Vehicle Operations. ASSE/ANSI Z.15. 2006.„

8.„Levick NR, Wiersch L, Nagel ME: “Real world application of an aftermarket driver human factors real time auditory monitoring and feedback device: An emergency service perspective.” International Technical Conference on the Enhanced Safety of Vehicles. 2007.„„