As an industry that’s frequently scrutinizing helicopter crashes, we don’t always view our ground transportation as unsafe. If ambulance safety comes up at the station, EMS providers often blame the public for their inadequacies as drivers and lack of respect for the power of the red lights and sirens that we wield.
Professionally, we need to evaluate what we can do to prevent ambulance collisions and what’s within our power. Reducing collisions within our service would protect us, our crews, our patients and the communities we serve. By thoroughly understanding ambulance operations, the physics of driving and high-risk factors for collisions, we can decrease the financial, physical and emotional costs of ambulance collisions.
The pre-operational check offs are an important aspect of ambulance operations and should be performed regularly. Unfortunately, a lack of oversight allows complacency to set in, and check boxes may be “pencil whipped.” The pitfalls that occur are the potential to overlook low fluids, tire pressures or other mechanical issues.
Potential solutions to complacency include variety. For example, a station can change the units that are used or the crew assignments to ensure some degree of checks and balances. Changing the crew assignments can allow different crew members to work together and help reduce provider complacency.
Beyond the unit check off, any sounds or motions that appear to be out of the ordinary should be reported to the vehicle maintenance department promptly. Many departments have a standard operating procedure (SOP) that addresses how to report vehicle maintenance issues accordingly.
It’s imperative for providers to be familiar with their service area. Even if they don’t know every single road in the area, they should understand the potential hazards that may exist in different areas. This can vary in urban and rural areas. Some hazards may include poor road conditions, or weather conditions that may affect road conditions, bridges, ramps and sharp curves.
Urban settings provide unique hazards. Most cities have at least one interstate, which generally has a great deal of traffic at peak times. Traffic poses risks to providers even if they aren’t transporting emergently. This is where defensive driving techniques truly play a critical role.
Sometimes, what a driver may perceive as a safe following distance for an ambulance, other drivers may see as a space to change lanes. Being aware of the vehicles around you and their intent is crucial.
Large volumes of traffic comes the inevitable decay of roads, which may cause potholes and other bumps or hazards. Older cities also have brick, cobblestone and trolley track obstacles that may require reduced speeds and better control of the steering wheel. Providers should also be aware of potential flooding areas from sewer overflow, inadequate drainage or other problems.
Rural areas have comparable issues in different forms. Although rural areas may not have as much traffic volume, they tend to have more roads and lower road-maintenance budgets. Because of road deterioration and poor drainage, water and ice are frequent hazards.
Many rural areas may also have gravel or dirt roads that alter stopping distances and curves. The sharp and frequent curves in rural areas can prove to be extremely hazardous, especially when the driver is unfamiliar with the terrain and/or potential wildlife. Most ambulance collisions in rural areas involve fixed objects, such as embankments, trees, etc.
Bridges present unique problems in most settings. Single-lane or multiple-lane bridges still have minimal room for error. Single-lane bridges are extremely narrow and the slightest slip on snow, ice or rain can put the unit into the structure. Conversely, multiple-lane bridges are typically more than one lane because of anticipated traffic. This means the slightest error due to weather conditions can cause the unit to strike another vehicle. Ramps leading onto bridges or roads may also become slick. Although some pieces of equipment may increase traction (e.g., chains), it’s still recommended that the vehicles travel at slower speeds. Drivers using chains generally have to operate the vehicle at speeds under 35 miles per hour.
The Physics of Driving
EMS providers should have a thorough grasp of the physics of driving. Not only is it important to know about centrifugal force, inertia, kinetic energy and traction, but it’s also important for providers to understand how those laws relate to the act of driving and their effect on other crew members or patients.
Providers who have been in a head-on collision with the cabinets while working in the patient compartment are intimately familiar with centrifugal force. This is the force that pulls away from the center.1 It’s often felt on hard curves or sudden swerves. Drivers must pay close attention to this force to avoid career-altering injuries after being thrown around in the back of an ambulance.
Newton’s first law of motion, known as the law of inertia, states that an object in motion remains in motion unless acted on by an outside force. This law explains why everything, and everyone, shifts forward when the brakes are abruptly applied. By gradually increasing and decreasing the speed of the ambulance, we provide a smoother ride for our patients and a more efficient environment for our crews.
Traction is directly correlated to the friction between the vehicle and the driving surface. Good traction is what allows the ambulance to stop accordingly. Traction is affected by many things, including weight, speed, ambulance condition and driving surfaces.
As far as vehicles go, ambulances are larger than a passenger car or sport utility vehicle. This increased weight automatically increases the required stopping distance and decreases the traction available. Speed is also a critical factor: The faster the unit goes, the less traction it has. The friction necessary to acquire appropriate traction comes from having tires with good treads and brake pads in good condition. Even if the first three principles are covered, driving surfaces can be potentially problematic. Skidding, hydroplaning or sliding can be caused by gravel, dirt roads, rain, snow or ice. When you’re driving on these surfaces, speed is the biggest factor you can control.
Vehicle Collisions & EMS
The majority of ambulance collisions occur at intersections during the day with clear skies and minimal weather hazards.2 Providers must have a thorough understanding of vehicle crash data in the U.S. to understand ambulance collisions.
According to the National Highway Traffic Safety Administration (NHTSA), 85% of weekday drivers wear their seatbelts.3 This figure should be 100% for EMS providers considering our area of expertise and experience with unrestrained drivers. We should be setting an example for the citizens we serve The research about seatbelts saving lives is overwhelming, and we as a profession should be on board.
Virginia Tech has done some analysis for the Department of Transportation (DOT) to evaluate high-risk behaviors contributing to vehicle collisions. This research identified several high-risk behaviors, including eating, drinking alcoholic beverages, reaching for objects and texting. Driving under the influence of alcohol is prohibited by all state legislation and all ambulance provider SOPs. Drivers who have been drinking alcoholic beverages are 4.1 times more likely to be involved in a collision.4 However, several of the other listed activities are common within EMS.
Eating on the road is common in EMS. Providers often eat when they can because they’re unsure of their next opportunity. Some ambulance services may have their providers post at intersections; therefore, they may not have a choice but to eat in their unit. Regardless of the cause for eating while driving, drivers who do so are 1.6 times more likely to be involved in a collision.5
So what’s the solution? Is this just an accepted risk? The answer depends on the operational confines of your EMS system. However, regardless of the system, EMS providers can take actions to reduce the opportunities of driving while eating. Perhaps only one of you, the passenger, should be eating at one time. That does place an unfortunate burden on the driver, but this task can generally be switched to allow each person a chance to eat. You may get a cold meal every other meal stop, but you will be much safer and decrease your chances of a collision.
New technology (e.g., mobile data terminals, GPS devices and ePCRs), as well as older technology (e.g., radio communication, use of red lights and sirens and use of PA systems) can all be hazards within themselves. The data from Virginia Tech suggests that reaching for an object while driving causes a driver to be 8.8 times more likely to be involved in a collision.6
How can we possibly control these variables? After all, we may have to drive with lights and sirens and use equipment. The first solution is to pass these duties to the passenger of the vehicle. This works en route to a scene but becomes more challenging when transporting from a scene or interfacility.
Inputting coordinates into a GPS device, as well as having familiarity with the service area, will limit adjustments. Lights should be applied prior to engaging the vehicle, and sirens should be adjusted minimally. The driver should perform radio communication only when the vehicle is in park, prior to leaving or on arrival. Again, it may not be possible to eliminate these activities while operating an ambulance, but it is possible to minimize them.
According to NHTSA, 6% of drivers nationwide have been seen manipulating a handheld electronic device.7 Many states have outlawed distracted driving, which includes the use of handheld electronic devices in any format while operating a vehicle. Unfortunately, anecdotal experience has suggested that EMS providers in many communities feel some sense of immunity because of the professional courtesy that many law enforcement agencies provide ambulances.
However, we shouldn’t allow this courtesy to impede the safety of ourselves, the patients we care for or the citizens we serve.
Texting while driving causes drivers to be 23 times more likely to be involved in a vehicle collision.6 As EMS providers, we respond to motor vehicle collisions that involve texting. We should be models of proper driving techniques for the citizens in our community to observe.
A major role the other crew members play is the backer. They should exit the vehicle and assist the driver in backing up the vehicle. The average driver operates in reverse for approximately one mile per year; yet, 25% of all commercial vehicle collisions can be attributed to backing.8
Because of their size and their potential lack of focus on vehicles, children are most often struck while a vehicle is in reverse. Some services have attempted to reduce this problem by incorporating drive-through bays and requiring providers not to operate in reverse unless all other options have been exhausted. Even in systems that don’t have these policies in place, using a backer can greatly reduce the incidence of collisions while backing up.
Driving a vehicle requires several capabilities. Three necessary factors stand out: visual acuity, cognitive ability and physical aptitude. Drivers must have the ability to see all hazards within the various fields—in front, in behind and on each side. The driver’s cognitive recognition must transfer to a physical command, such as turn the wheel or brake. This process generally occurs within seconds; however, distractions can delay the visual and cognitive process, which may ultimately delay the physical response.
In today’s EMS systems, the driver’s compartment contains a variety of distractions. Other crew members can take the burden of these distractions from the driver by taking on navigation or other tasks, so the driver can focus on driving.
Red Lights & Sirens
The use of red lights and sirens is one of the most dangerous aspects of our job. According to NHTSA, 70% of ambulance collisions occur while running with lights and sirens.2 This should indicate the inherent danger associated with responding emergently. Providers should evaluate the risk vs. benefit for transporting with lights and sirens to see whether the time saved will make a difference one the patient’s outcome. Although some patients who are transported by EMS are suffering a time-sensitive emergency, many require minimal monitoring, observation and care that can be provided either on scene or at the hospital.
Data indicate that the time saved by using red lights and sirens, although statistically significant, isn’t clinically significant.9 This means that the time saved doesn’t make a difference in the clinical outcome of most patients. One problem with a large amount of the data regarding emergent transportation is that it’s been collected primarily from urban systems. So the question is, does driving with lights and sirens make an appreciable difference in rural settings? Because the distance is longer, the time saved should increase proportionally. However, the problem is that traffic decreases in rural settings. To date, the answer is unclear about whether emergent transportation makes a difference in rural settings.
As patient advocates, it’s our responsibility to do what’s in the best interest of our patients. Many providers transport patients emergently because they believe the best thing for the patient is rapid transport to definitive care. However, this can cause harm to some patients. Some studies indicate that red lights and sirens can induce stress in acute coronary syndrome patients, thereby increasing the workload on the heart.10 The provider must weigh the benefit gained by the decrease in time of transporting compared with the potential harm of transporting emergently.
Cardiac arrest patients have the lowest likelihood of benefiting from lights and sirens. Additionally, treating a cardiac arrest patient should revolve around continuous compressions, which is difficult to do in a moving vehicle with red lights and sirens. EMS providers should evaluate the likelihood of the benefits to a cardiac arrest patient by transporting the patient emergently.
Some systems have begun selectively transporting with lights and sirens based on specific patient criteria. Effective use of a lights-and-sirens protocol can create a safer environment for EMS providers, patients and the general public. Providers using that type of protocol are 5.6 times less likely to use lights and sirens.11
According to a report from Western Transportation Institute in 2010, 31 states and territories reported not requiring some form of emergency vehicle operator course (EVOC).12 In 1995, NHTSA disseminated a provider and instructor manual, which included a curriculum for EVOC.13 A major issue with the EVOC course is a lack of uniformity across the U.S. regarding length and quality.
EMS providers are required to earn certifications to ensure they’re proficient in skills we use minimally—ACLS and BLS. Why don’t we place more emphasis on safety? It appears that safety education stops at the “scene safe, BSI” portion of the National Registry of Emergency Medical Technicians skill sheets. Recently, the National Association of Emergency Medical Technicians developed an eight-hour course with a complete emphasis on safety. The EMS Safety Course discusses emergency vehicle safety and scene operations, as well as other topics to develop a culture of safety within EMS. Ultimately, we must get beyond our indestructible attitudes to ensure we arrive safely, so we can perform our public safety duties.
Training doesn’t need to be as formal as a certification course. Although driving an ambulance is something we do every shift, it’s still important to review the local, state and federal regulations that guide ambulance practice. Research indicates that EMS providers have a poor knowledge of laws pertaining to emergency vehicle operations.14 Beyond legislation, providers need to be intimately familiar with local SOPs regarding ambulance operations.
What’s the one piece of equipment that’s used on every EMS call? That’s right, your ambulance. It doesn’t matter how much oxygen you administer, how many IVs you start or how many airways you control if you never make it to the patient’s side. Vehicle operation is a part of our daily jobs, so it’s imperative we regularly train on the various techniques to combat the associated complacency that occurs without oversight and training. JEMS
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10. Weber U, Reitinger A, Szusz R, et al. Emergency ambulance transport induces stress in patients with acute coronary syndrome. Emerg Med J. 2009;26(7):524–528.
11. Merlin MA, Baldino KT, Lehrfeld DP, et al. Use of a limited lights and siren protocol in the prehospital setting vs. standard usage. Am J Emerg Med. 2011 May 11. [Epub ahead of print].
12. Sanddal T, Sanddal N. April 6, 2010. Ambulance Vehicle Operator: Driver Behavior and Performance Checklist (D1). In Western Transportation Institute. Retrieved, Oct. 24, 2011, from www.westerntransportationinstitute.org/documents/reports/4W2008_Final_Re....
13. U.S. Department of Transportation. (1995.) Emergency Vehicle Operator Course (Ambulance). In National Highway Traffic Safety Administration. Retrieved, Oct. 24, 2011, from www.nhtsa.gov/people/injury/ems/Participant%20Manual%201995%20EVOC.pdp.
14. Whiting JD, Dunn K, March JA, et al. EMT knowledge of ambulance traffic laws. Prehosp Emerg Care. 1998;2(2):136–140.
This article originally appeared in December 2011 JEMS as “Deadly Driving: Tips to ensure a safe ride for you & your patient.”
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