Chapter 22 Brian J. Maguire Ambulance crashes and the resulting injuries, fatalities, and liability have elevated the discussion of ambulance safety to an urgent level. This chapter includes an introduction to the issue and an exploration of the factors related to crashes, and concludes with recommendations for ways in which EMS professionals, medical directors, and agency administrators can help mitigate this serious problem. Transportation-related events result in high rates of injury and fatality among EMS professionals. These events include ambulance crashes, EMS personnel being struck by moving vehicles, and air ambulance crashes. The vast majority of these events are ambulance crashes (Figure 22.1). Maguire et al. found that transportation-related events cause 59% of all EMS occupational fatalities [1]; there are about ten transportation-related fatalities per year among EMS personnel in the US [2]. According to the National EMS Memorial Service, 21 EMS personnel died in 2012; nine of the fatalities were from ambulance crashes [3]. Figure 22.1 The author, in jeans, was an ambulance service administrator in New York City; he is pictured at the scene of a crash of one of his ambulances in 1994. The two paramedics in the vehicle were responding to an emergency call at the time of the collision. When the fire department arrived the medics were found hanging upside down from their seat belts. They were extricated and transported to the hospital. Fortunately both were discharged later that day with no more than minor injuries. Reproduced with permission of Richard Zarrillo. Kahn et al. studied the characteristics of fatal ambulance crashes in the United States involving 89 ambulance occupant fatalities and 592 non-fatal ambulance occupant injuries during one 11-year period. They found that most crashes and fatalities occur during emergency use and that most of the fatal and serious injuries among ambulance occupants occurred in the patient compartment [4]. Maguire et al. found that the rate of transportation-related occupational injuries for EMS personnel is more than 30 times higher than the national average; 9% of all EMS occupational injuries are secondary to transportation-related events; and 20% of (crash-related) cases resulted in 31 or more lost work days [2,5,6]. Saunders and Heye found an overall collision injury rate of 22.2 EMS worker injuries per 100,000 emergency (lights and sirens) responses [7]. Gershon et al. found nine collision-related injuries among 197 EMS field personnel in one year; they noted that the resulting injuries were “particularly severe and resulted in extended loss of work time” [8]. Every year 15 Australian paramedics are seriously injured in crashes [9]. Crashes involving ambulances on public roads in the US produce twice as many casualties as the national average [10]. Evidence also suggests that civilians make up a large portion of the victims. Kahn et al. found that “the greatest burden of serious injury and death fell upon persons not in the ambulance,” with 89 fatalities among ambulance occupants but 316 among non-ambulance occupants [4]. Sanddal et al. found that “persons in other vehicles involved in collisions with ambulances were the most likely to die as a result of crashes” [11]. Maguire et al. described 25 ambulance occupant fatalities in the US between 1994 and 1997; eight were described as EMS personnel, and 68% of the fatalities were non-EMS personnel including patients, family members, and friends [1]. The risks associated with ambulance crashes extend beyond injuries and fatalities. For example, the proportion of EMS agency lawsuits that relate to ambulance crashes has been reported to be between 45% and 100% [12–14]. While grieving for lost colleagues and civilians or coping with catastrophic medical bills, companies are simultaneously attempting to cover lost workdays and train replacement workers. It is conceivable that these stresses cause further distractions, which may lead to more deaths, crashes, injuries, costs, and lost workdays. In a state-wide study, Weiss et al. found that there were more ambulance injuries in the urban environment, but the severity of injury was greater in rural environments [15]. For all vehicle crashes, the injury fatality rate is “almost three times higher in rural areas” [16]. Elling examined New York State data between 1984 and 1987 and found that 1,894 ambulance occupants were injured in 1,412 ambulance collisions [17]. Becker et al. found a significant difference in risk of fatality or serious injury between restrained and unrestrained ambulance passengers [18]. Ray and Kupas found that the highest-risk locations for ambulance crashes are at intersections and traffic signals [19]. The same authors found that “operator error was the most common cause of crashes” [20]. Maguire found an average of over 70 injuries and fatalities per year in ambulance crashes that involved at least one fatality on major roads in the United States [10]. Clawson et al. found that ambulance “wake-effect” collisions may occur with greater frequency than collisions involving ambulances [21]. Therefore, there may be over 140 people killed or injured in ambulance-related collisions every year. With a reported 31 million EMS calls in the US during 2004 [22] and 37 million calls in 2010 [23], the risks to personnel, patients, and the public are growing. Although insufficient data exist to quantify factors contributing to ambulance crashes, Haddon’s Matrix provides a logical approach to categorizing and describing factors that seem likely to contribute to the risks [24]. In Table 22.1, the matrix is adapted to identify factors related specifically to ambulance crashes [25]. Human factors include fatigue, poor driver training, distractions, stress, poor driving skills, and diesel fume exposure. Vehicle factors include poor maintenance before the event, and protruding objects, sharp corners, and unsecured equipment during the event. Examples of environmental issues include both the ambulance’s environment at the time of the event and the environment (culture) of the agency. For example, poor visibility and hazardous road conditions relate to the crash environment while inadequate agency policies and/or enforcement of policies (e.g. related to speed or seat belts) are examples of inadequacies in the agency culture, as is insufficient support for research and prevention. Table 22.1 Haddon Matrix for emergency vehicle collisions Joseph Neal Sherman was a 25-year-old paramedic. He was killed in an ambulance crash on March 16, 2001 [26]. The night before the crash, his partner had worked the overnight shift at a volunteer fire department. At the time of the crash, Neal was caring for a patient in the back of the ambulance. His partner fell asleep, veered off the road, and struck a guardrail [27]. The vehicle rolled 300 feet, flipping over several times before landing upside down in a ditch. The other three ambulance occupants were injured. Neal was killed; he left behind a wife and an unborn child. A growing body of literature links fatigue to a host of occupational risks, including crashes. Dawson and Reid found that “moderate levels of fatigue produce higher levels of impairment than the proscribed level of alcohol” [28]. Arnedt et al. found that 21 hours of wakefulness produces impairment of the same magnitude as a 0.08% blood alcohol concentration (BAC) [29]; the legal limit for commercial drivers in the United States is 0.04% BAC [30]. A 2007 report by the International Association of Fire Chiefs noted that sleep deprivation is an important factor contributing to injuries within the fire service; several studies were cited noting that alertness and postural stability decline during extended shifts, leading to increased worker stress and more crashes [31]. The National Highway Traffic Safety Administration (NHTSA) National EMS Advisory Council, Safety Committee, noted that “poor sleep and fatigue among EMS workers represent potential threats to patient care, provider wellbeing, and the public’s health” [32]. NHTSA notes that “fatigued drivers were twice as likely to make performance errors as compared to drivers who were not fatigued” [33]. Patterson et al. found a “3.6 greater odds of safety compromising behavior among fatigued respondents versus non-fatigued respondents” [34]. Studnek and Fernandez found that the odds of involvement in an ambulance crash within the past year were significantly higher for those reporting sleep problems [35]. In one survey, “almost half (48%, n = 29) of paramedics answered yes to having nodded off or fallen asleep whilst driving” [36]. The JEMS 2012 survey of 200 cities found “85.9% of respondents (are) working 24-hour shifts” [37]. Although long shifts may be less problematic for workers in slower areas who may be able to have extended sleep periods, it is likely a significant problem for busier units and systems. Anecdotal evidence suggests that many ambulance driver training programs (perhaps thousands) exist in the United States. These programs range from a short orientation to courses of over 40 hours, incorporating classroom presentations and discussion, driving practice on a dedicated track, and field internship with a driver-training mentor. However, no research was found that demonstrates efficacy or any difference in outcomes between these various programs. Larmon et al. found that seat belt usage is low among EMS providers working in the patient compartment. They noted that the following issues may account for the low usage: Johnson found that two-thirds of EMS respondents “reported not wearing their seatbelt on the squad bench while treating patients” [39]. Maguire and Porco found that at least four of 13 EMS workers injured in collisions were not wearing restraints [40]. Proudfoot reviewed 25 fatal ambulance collisions resulting in 27 fatalities and found that 22% of EMS workers killed while riding in the patient compartment were not wearing restraints, and 26% who died while driving the ambulance were unrestrained [41]. Becker et al. found that “restrained ambulance occupants involved in a crash were significantly less likely to be killed or seriously injured than unrestrained occupants” [18]. So it is shocking to find that “most states do not require patients of any age to be restrained in ambulances” [42]. Emergency medical services personnel are confronted with many distractions while driving ambulances. These include “multiple radios, a computer, and warning system controls, in addition to all the usual controls found in a typical vehicle. The driver of the ambulance may be expected to operate several devices while driving on busy streets with a vehicle full of distraught patients and family members” [10]. NHTSA estimates that distractions account for 20–30% of passenger car crashes [43,44]. Saunders and Heye found that a major cause of ambulance crashes in an urban environment was “inattention” [7]. In 2003, Maguire reported that “the crashworthiness of ambulances is largely unknown. The integrity of vehicle structures, the vehicle’s ability to protect occupants from fatal and serious injuries, the vehicle’s ability to prevent occupant compartment intrusion or ejection of passengers, and the vehicle’s ability to prevent or reduce injuries from occupant impact with interior surfaces (especially sharp cabinet corners, IV holders, and oxygen ports) probably varies significantly from manufacturer to manufacturer. The compatibility of structural crash performance with occupant restraint systems is also largely unknown” [10]. Levick and Yannaccone evaluated ambulance patient compartments under crash conditions and demonstrated the need for special testing to be done for the ambulance patient compartment [45]. Although the US nationwide ambulance fleet has been largely converted to diesel, nothing is known about the effects this may be having on the EMS workforce. Mills et al. describe an increased coronary risk associated with diesel fume exposure [46]. The Environmental Protection Agency reports that short-term exposure can cause neurophysiological symptoms (e.g. lightheadedness, nausea) [47]. Kilburn found that workers exposed to diesel fumes had “significantly impaired reaction time” [48]. Any intervention designed to improve the health of the population should be subject to the same rigorous scientific evaluation as an intervention designed to improve the health of an individual. We would never consider administering a drug that had not gone through rigorous scientific evaluation. Sadly, we are not much further along than “grandma’s home remedies” when it comes to interventions designed to save the lives of paramedics. Years of well-intentioned interventions have resulted in a variety of unproven solutions, including possibly thousands of driver training programs. Many of these courses could, for all we know, be increasing the risks of collisions, injuries, and fatalities. In all the literature, only two papers were found that describe interventions to reduce ambulance collisions, with one focusing on outcomes and the other on process. The first is a 1997 paper by Maguire and Porco that describes a bimodal intervention. The authors concurrently introduced a standardized driver training program and a change in department policy. The pre- and posttest evaluation found that the ambulance collision rate changed from one collision per 1,146 calls during the 12 months before the interventions to one collision per 2,940 calls during the 12 months after the interventions [40]. Levick and Swanson described an 18-month evaluation of 36 vehicles in a metropolitan EMS group using an “onboard computer-monitoring device.” “In >1.9 million recorded miles, performance improved from a baseline low of 0.018 miles between penalty counts to a high of 15.8 miles between counts. Seatbelt violations dropped from 13,500 to 4” [49]. Before we begin any efforts to improve ambulance safety we must first and foremost accept that ambulance crashes are largely preventable. We have both the responsibility and the ability to drastically reduce the number and severity of ambulance crashes. We can no longer delude ourselves by thinking “accidents” are unavoidable. Instead we must use the tools and abilities we have to make the changes necessary to reduce the risks for ourselves, our employees, our patients, and our communities. Using the four Es of injury prevention: Education, Engineering, and the Enactment and Enforcement of risk reduction policies
Ambulance safety
Introduction
Risks to providers
Risks to others
Legal risks
Other considerations
Contributing factors
Human/host
Vehicle/agent
Environment
Pre-event (preinjury)
Fatigue
Poor driver training
Impaired hearing
Alcohol/substance abuse
Non-use of seat belts
Distractions
Stress
Poor driving skills
Diesel fume exposure
Smoking
Speed
Poor maintenance
Poor design
Inappropriate tires or tire pressure
Lack of functional seat belts
Lack of driver’s compartment airbags
Poor visibility
Hazardous conditions
Urban vs rural
Inadequate agency policies and/or enforcement
Inadequate funding for research and prevention
Event
Employee’s health
Resistance to energy
Protruding objects
Sharp corners
Unsecured equipment
Lack of vehicle restraining walls/rails on roadside
Post-event
Employee’s health
Priority given to other’s care over self-care
Presence of hazardous materials
Availability of ambulances
Trauma center
Fatigue
Poor driver training
Passenger restraint
Distractions
Ambulance structural design
Diesel fumes
Recommendations
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