The response and transport phases of EMS care often fails to receive appropriate attention. That is, until a crash occurs. However, there's a new strategy for reducing injuries and fatalities in ambulance accidents.

First, it is important to review some realities of ambulance operation. Whether career or volunteer, ambulances drivers tend to be younger members of a department and have less driving experience. Ambulance and utility vehicles tend to be the first departmental vehicles that new employees drive. Ambulances are almost certainly the first vehicles driven by newer employees under emergency conditions.

So, it's no wonder that ambulances crash, especially during emergency-response conditions. It is, in fact, testimony to emergency driving training programs that more crashes do not occur. These factors and others have contributed to the development of what can be characterized as the bad-driver hypothesis of ambulance crashes.

There is little doubt that lack of emergency driving experience and excess speed, combined with weather hazards, poorly designed intersections and unpredictable responses by other drivers, contribute to ambulance crashes. The good news here is that an accumulating body of data and experience suggests rather strongly that black box interventions in ambulances may be effective in calming the ambulance operator's driving behavior. These black boxes contain inertial sensors and collect data on vehicle operation. The Road Safety On-Board Computer System is an example of these devices. When accompanied by management scrutiny of black-box output and sanctions when necessary, operator behavior has been shown to change. Remarkably, these devices have been in existence since the early 1980s. Yet only quite recently has any review of them been published in the peer-reviewed traffic-safety literature.

But focusing only on the driver completely neglects half of the equation. There is little doubt that the behavior of ambulance occupants (EMTS and accompanying family members) and their contributions to crash injuries has been overlooked. It is well established that the use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor-vehicle crashes.

Seatbelts seem to be used by front-seat occupants of ambulances. Furthermore, a recent study by John Studnek at the National Registry of Emergency Medical Technicians of self-reported front-seat restraint revealed that providers from EMS organizations with seatbelt-use policies were more likely to report seatbelt use than those from organizations lacking such policies. Organizational policies are effective in promoting front-seat restraint use. Additionally, 86.7% of almost 30,000 respondents said that it had been more than a year since the last time they did not use a seatbelt in the front seat of the ambulance.

Are ambulance occupants using seatbelts when occupying the patient compartment? The best answer is that very little is known. Almost 20 years ago and based upon a sample of 148 cases, Richard T. Cook and colleagues asked ALS providers to estimate the amount of time that they believed that they needed to work unrestrained in the patient compartment. Overall, these providers believed the necessity of not wearing restraints to provide adequate patient care to average 41% when looking at a wide range of types of calls. For cardiac arrest, these providers reported 75% perceived non-restrained time, for trauma, 56% and for seizures, 51%. By patient severity category, class I (high) severity patients 70% and class III (low) severity patients 14%.

Baxter Larmon surveyed 900 public, private, and volunteer pre-hospital care providers. He defined rarely using a seatbelt as less than 5% of the time and always using a seatbelt as more than 95% of the time. Almost 80% of the respondents reported that they rarely wore a seatbelt in the back compartment during an emergency run and almost 60% reported that they rarely wore a seatbelt in the rear compartment during a routine run. In contrast, this same group reported a range of use of 75% and 80% for front-seat seatbelt use during non-emergency and emergency conditions, respectively. Reasons reported for not using belts in the rear compartment included inhibiting patent care (67.9%), restricted movement (34.7%) and inconvenience (15.1%).

Failing to wear a seatbelt in the patient compartment harbors serious consequences. My research team examined those consequences. Our principal research findings are displayed in the chart below. If involved in a crash, the risk of a fatality versus no injury for ambulance rear occupants was more than five times greater than for front-seat occupants. Unrestrained ambulance occupants involved in a crash had nearly four times greater risk of fatality than did restrained ambulance occupants. Unrestrained ambulance occupants involved in a crash had nearly six and a half times greater risk of suffering an incapacitating injury than did restrained ambulance occupants. Interestingly and somewhat inexplicably, ambulance occupants traveling during a non-emergency were nearly three times more likely than occupants traveling during an emergency to be killed if involved in a crash.

So, what can be done? Engineering approaches such as the black box can be effective in calming vehicle operators. But how can the behavior of technicians in the patient compartment be influenced? Part of the issue is one of normative values. Most pre-hospital care providers and many officers, supervisors, managers and chiefs believe that traveling unrestrained is essential and incidental to providing appropriate patient care.

How long does it really take for an experienced, competent provider to establish an intravenous line? Despite historical pronouncements to the contrary in the EMS research literature, the duration is typically quite short, perhaps several minutes. The reality of EMS is that the moments where time is of the essence are relatively few and far between. This of course is one of the best-kept secrets of the EMS mystique. A competent provider can place monitoring leads on a patient without inflating scene time.

If particular pre-hospital care activities are performed on scene in a swift and timely fashion there is less rationale for unrestrained providers during transport. And it is likely that patient safety is actually enhanced by performing interventions on scene rather than in the rough-and-tumble environment of an ambulance in motion or by asking the vehicle operator to pullover to the side of the road to perform a procedure.

So, here's a new approach to provider safety. This approach features integrating optimal patient care with optimal provider safety. It includes preplanning ALS and BLS activities to occur during natural lulls and when possible (which it quite frequently is) and performing ALS skills early in the time sequence of a call when the provider is already out of the vehicle. Simultaneously optimizing provider and patient safety will require fundamentally retraining field providers to maximize their efficiency when on scene so that procedures en route become the exception rather than the rule, and on-scene times are not inflated.

This approach does not advocate “stay and play.” Also, this approach will not be appropriate for every patient. But the next step in increasing the safety of EMS providers in the back of a moving transport vehicle is to shift the norm from hardly wearing seatbelts to only riding unrestrained when life-saving care is truly prevented by the use of seatbelts. Those times have been and will continue to be relatively rare.

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Les R. Becker, Ph.D., NREMT-P is a retired career paramedic from the Prince George's County (Md.) Fire/EMS Department, an associate research scientist with the Pacific Institute for Research & Evaluation. He coordinates medical simulation activities in the ALS program of the Maryland Fire Rescue Institute. He holds several adjunct faculty appointments in area community colleges.