An April 2014 report from the National Highway Transportation Safety Agency identified that EMS providers weren’t using safety restraints in 80% of investigated ambulance crashes.1,2
This single astounding fact was the stimulus for the Cranberry Township (Pa.) EMS (CTEMS) to develop what we wanted to be the safest ambulance in America—one that would focus on provider safety by addressing crash avoidance, and crash survivability.
We knew that our focus on crash avoidance could only be accomplished by changing many of the norms of ambulance design in the United States.
As for crash survivability, there had already been a few industry leaders who had researched and even implemented some of the same ideas that we were exploring.
Figure 1: Step-up distance
Our older ambulances required providers to step up at least 20″ to get into the patient compartment.
For provider comfort and safety, our new ambulances have two steps that require stepping up only 12″.
In early 2014, CTEMS developed a capital replacement program to help guide us through the large purchases we’d need to make in the next few years, including two new ambulances.
Historically, the organization had never purchased custom ambulances. The tradition was to run an ambulance until it could no longer be in service and then search for something similar—and make it as inexpensive as possible.
A team of CTEMS personnel, led by EMS Chief Jeff Kelly, was formed in mid-2014 to consider how to develop the new ambulance, what the costs of development might be, and, finally, how such a dramatic change would affect CTEMS.
We began by researching the chassis and vehicle construction to meet our needs. We spoke with and visited several manufacturers to observe and review their design and construction processes as well as to obtain their feedback and input.
We immediately recognized the Mercedes Sprinter as our likely chassis of choice. The Mercedes Sprinter has been a workhorse in the EMS industry in other parts of the world for some time. The height of the cab and spacious interior would also help us achieve our objective of crew comfort. It’s also been a mainstay in ground delivery vehicles, such as those operated by FedEx and UPS, for the past two decades.
We knew that not every manufacturer was excited about pushing the envelope. Many didn’t favor the Sprinter chassis nor would they necessarily embrace our “outside the box” thinking and specific design needs. This led us to Demers Ambulance in Beloeil, Canada.
Figure 2: Equipment storage and access
Jump bags, monitor/defibrillators and other equipment used to be stored within the ambulances. Exiting the patient compartment with the equipment could be awkward and even unsafe.
In our new ambulances, equipment is stored in an exterior side compartment that providers access after they’ve exited the cab or patient compartment.
We were impressed with the safety standards set by Demers, especially their pull testing and the enhanced safety design of their cabinetry. The Demers engineering team listened to our unique requests and offered significant technical assistance, feedback and constructive criticism when and where it was needed. We found it refreshing and encouraging that they were open-minded and able to offer viable solutions to help move our design forward.
Demers put us in touch with other EMS systems, including Durham County (N.C.) EMS (DCEMS). DCEMS director Skip Kirkwood, MS, JD, EMT-P, EFO, CEMS, explained their design and acceptance of the Demers Sprinter box platform. Our team was happy with the feedback from DCEMS and others, and we made the decision to move forward with the Sprinter chassis.
Patient Compartment Design
The next step in designing our safety-focused ambulance was to develop a patient compartment that was practical, functional, but most of all safe for the provider, patients and the public.
We spent countless hours taking measurements, doing call history research, and speaking with our crews to determine the needs of our organization and the community we serve. (See Figures 1 and 2, above.) We were careful not to make changes that would be so drastic they would cause pushback from the frontline staff.
Figure 3: Spine board access
Long spine boards used to have to be accessed from an outside rear compartment that could be difficult to access, especially for smaller providers.
In our new ambulances spine boards are kept in a slide-in compartment within the patient compartment that’s easy to access.
We looked at moving the long spine boards from an outside rear compartment to an easy-to-access slide-in configuration within the patient compartment to keep our crews from harm’s way when working at an incident. (See Figure 3, above.)
We wanted to develop a forward-facing seat that was easy for the provider to be restrained, but would also be practical. We explored exactly what needed to be within reach of a single pedestal-type seating arrangement so that all essential supplies could be accessed while keeping the crew member comfortable and safely buckled.
We discovered that for over 95% of our calls and subsequent transports, our personnel only needed a few items to be within an arm’s reach. We positioned our personnel and measured their arm length and reach to make sure to position the swivel seat in the best location, not necessarily the location that the manufacturer chooses. (See Figure 4, below.)
With the help of the Demers engineers, we designed a single pedestal seat that would swivel into the patient compartment, but could also be locked in a forward-facing position while traveling and treating the patient. This provided the safest alternative to the traditional bench seat, while also putting the EMT or paramedic in a practical position to treat patients.
Figure 4: Seating position inside the patient compartment
The traditional bench seat in our older ambulances didn’t allow for easy access to equipment nor allow providers to face forward during transport.
A single pedestal seat that swings into the patient compartment allows for provider safety while traveling and while treating the patient.
To achieve our goal of crash avoidance, we designed the units to be highly visible.
We chose the Euro Yellow Ral 1016 color for the exterior paint. Yellow is a proven safety color. The American and European EMS industries have adopted and used “high-visibility yellow” jackets and vests for the past 15 years. In addition, the Pennsylvania Department of Transportation found that yellow was easy on the eyes and caught the attention of drivers, alerting them earlier than white, green or red. During our research, we also learned that individuals who have any degree of color blindness are able to identify yellow.
Quality and placement, not quantity, was our primary lighting objective. (See Figure 5, below.) We placed dual-head LED lights on the rear of the vehicle that flash red when in emergency mode but switch to amber while in park, thus allowing the entire rear of the unit to appear like a highway service or construction vehicle.
We designed the emergency lighting placement to flash in optimal patterns and, more importantly, to all important areas in the front, rear and sides of the ambulance.
Figure 5: Lighting placement allowing for increased visibility
The dual-head LED lights on the rear of the vehicle flash red when in emergency mode but switch to amber while in park.
A light bar low in the front grill splashes light far ahead of the ambulance, alerting traffic well advance of the vehicle’s approach.
Cognizant that intersection and cross-traffic collisions are common in our industry, we carefully positioned emergency lighting to not just protect us when entering an intersection, but also alert traffic in advance of our approach. This was done with careful placement of a small, bright light bar low in the front grill to “splash” light on the ground far ahead of our ambulance so that vehicles approaching from side streets would be alerted much earlier than if we had used traditional flashing lights.
We increased the exterior visibility even further by adding the blue Battenberg markings all around the ambulance and by adding Department of Transportation-approved chevrons to the interior of all of the doors.
The research, design and procurement process reaffirmed to us that you can, and should, build an ambulance that’s not just safe for patients, but is also a more convenient and safe work environment for EMTs and paramedics. We learned that we could break from the mold of traditional thinking and work with a like-minded vehicle manufacturer to help us incorporate our ideas and needs into the final product.
In the end it was a team effort that included the research of the CTEMS team before the design, the willingness of Demers to build the ambulance, and the providers and community to embrace the degree of change that these ambulances offer.
1. National Highway Traffic Safety Administration (NHTSA) Office of EMS. (April 2014.) NHTSA and ground ambulance crashes. National Association of EMTs. Retrieved Aug. 13, 2016, from www.naemt.org/Files/HealthSafety/2014%20NHTSA%20Ground%20Amublance%20Crash%20Data.pdf.
2. NHTSA advances ground ambulance safety by tracking and investigating crashes. (n.d.) NHTSA Office of EMS. Retrieved Aug. 13, 2016, from www.ems.gov/newsletter/marapr2015/ground-ambulance-safety.html.