Last month's International Firefighter and EMS Safety Stand Down was designed to draw attention to the line-of-duty deaths and reinforce the safety message. A stand down places safety at the forefront for a day and takes a serious look at fire department and ambulance operations.

The number of deaths per 100,000 people in EMS operations is now approaching the number in fire service operations. The rate for EMS providers is now 12.7 deaths per 100,000 workers; the fire service rate is 13.5. The causes of EMS fatalities include electrocution and needle sticks (4%), homicide (9%), cardiac event (11%), and the overwhelming transportation accident (74%).

The National Highway Traffic Safety Administration's Center for Statistics and Analysis and Dr. Les Becker looked at fatal and non-fatal crashes from 1988 to 1997. During that time, there were 305 fatal and 36,693 non-fatal ambulance crashes, compared to 166 fatal and 29,790 non-fatal fire truck crashes. Almost all of the fatal fire truck crashes involved unrestrained passengers. The EMS vehicles had 80% front-seatbelt compliance. To put the fire and EMS numbers in perspective, there were 1,113 fatal and 183,371 non-fatal police vehicle crashes during that time.

When you examine the numbers for seatbelt use in ambulances, 90% of front-seat passengers are restrained; in the back seat, five of the people were restrained and 531 were unrestrained in crashes that resulted in injuries. One study asked EMS providers how often and under what circumstances they did not wear their seatbelts. The EMTS and paramedics reported not wearing their seatbelts while responding to cardiac-arrest 82% of time, chest pain 63% of the time, shortness of breath 38% of the time, and trauma 41% of the time. ems providers are doing a better job taking care of the patients than themselves. In one study, there were 531 patients included in the crash statistics, and very few were unrestrained in crashes. Most of the serious injuries in the back of the ambulance are to ems providers.

Odds are 6.5 times more likely that you'll be injured if unrestrained. You are 2.6 times more likely to be injured running with lights and siren, and 5 times more likely to be injured in the rear compartment of the ambulance. Looking at these numbers, policies shouldn't allow family members to ride in the back of the ambulance. With more than half of the fatal injuries occurring to the non-restrained passengers in the patient compartment, these are injury rates not seen since firefighters rode the tailboard on an engine.

Several groups are taking a new look at ambulance designs and standards to improve safety. The ambulance safety subcommittee of the Federal Interagency Committee on ems is bringing the issue to the forefront by holding a serious discussion on the safety of ambulance operations this summer. NHSTA's commercial division is likely to adapt its experience in the trucking industry to the ems division. There also is a call for the National Fire Protection Association's apparatus committee to create a new standard for ambulances.

While the General Service Administration's KKK standard is the most commonly used ambulance design standard, many researchers considered it the bronze standard. The more detailed ASTM standard may offer more construction and design elements related to safety. Many suggest that the astm standard holds the silver to a yet-to-be-created gold standard that would include things like seam wielding versus spot welding, reinforcement in the ambulance box, and specific arrangements of cabinets to reduce head trauma.

But improving ambulance standards isn't the only concern. An ambulance will be involved in a crash approximately every 42,000 calls. There may be as many as 60,000 wake collisions or crashes not involving the emergency vehicle but associated with emergency response. Sixteen percent of emergency workers are cited by law enforcement in ambulance crashes. A fire department paramedic in the Midwest who caused a crash that killed a young woman was sentenced to two years in prison. Still, departments don't prepare people to drive an ambulance like they do a fire truck.

There is a misconception that a larger vehicle may be more dangerous. While that is true when the physics of an accident are applied, the miles placed on an ambulance and the increased frequency of response place it at risk more often. A patient onboard may distract the driver and facilitate riskier behavior.

What are we really doing to focus on ambulance operations? The Emergency Vehicle Operations Course has been around for many years; however, it and programs like it aren't often used for ambulance operations. EVOC highlights how to react to a skid and other defensive driving techniques. New technology using the Skidcar system teaches drivers how to avoid getting into a skid in the first place. Some training centers have placed ambulances and fire trucks on the Skidcar platform to simulate control techniques and skid avoidance. Other techniques and procedures, such as recovering from blowouts, over-corrections, and icy road conditions also can be simulated in a much smaller space.

Serious consideration needs to be given to applying other engineering controls as well. Speed regulators or governors are effective to regulate the urge to speed the vehicle above the manageable stopping distance. A black box from a company called RoadSafety or DriveCam measures braking, speed and handling. Drivecam captures simultaneous video of the crew in the cab and of the roadway ahead. This technology has long been employed in the trucking industry and to some extent in the private ambulance industry. Black box usage has been shown to reduce brake wear, alignment issues and lost employee time, and it has contained the depreciation of ambulance for resale. These programs can be used in a non-punitive fashion to educate and coach drivers. The data from these devices also can help in accident reconstruction and analysis of the incident.

Even the best of driver training and technology can't account for all drivers in the organization. A collaborative approach between the union and management needs to ensure enforcement of organization polices when it comes the operation of the vehicle. If coaching and education can't curb bad driving behavior, then sanctions need to be available to front-line supervisors. The fire service needs to start looking more closely at the people who are being hired and behind the wheel. The private ambulance insurance carrier Thomco has provided its clients with a screening tool designed to eliminate potentially aggressive or risky drivers.

As with most fire agencies, the ambulance industry has been a common source of applicants. It is imperative that the fire service not assume the private ambulance risk when it comes to hiring personnel with bad driving habits or aggressive driving behaviors. VFIS has some of the best prepared educational packages available for ambulance operations. The material has some chilling audio tape of a crew from Oklahoma being struck on the freeway. Several new textbooks will be on the market shortly dealing specifically with the safety aspect of vehicle operations.

The fire service leadership needs to take a strong role in making the streets safe when fire and ems apparatus are responding. We need to take action by hiring the right people and educating, training and coaching them. The near-miss reporting systems should become part of a monthly routine. The scene safety rule of not becoming a victim while providing rescue services to the public needs to be reinforced. The fire or ems chief needs to align patient, passenger and driver safety with the same thoroughness as scene safety.

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Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.

Online Tools

www.respondersafety.com

ResponderSafety.com focuses on roadway safety of public safety workers. It has a material available for responders and a listserv that notifies responders of crashes or injuries in the roadway.

www.emsclosecalls.com

EMSClosecalls.com is a site dedicated to sharing the stories involving close calls in EMS operations.

www3.thomcoins.com

Thompson Insurance, doing business as Thomco Insurance, has an excellent newsletter and training materials.

www.vfis.com

VFIS is the largest insurer of emergency services providers and has numerous training packages and information.