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Home > Health & safety > Staying healthy > Wheels of Fortune

Wheels of Fortune
Every time you hit the streets, you take your life in your hands—how can you improve your chances?

In April, an 18-year veteran of the Chicago Fire Department was killed when his hook-and-ladder, responding to a call, collided with a landscaping truck. Thirteen others were injured.

In June, a motorcyclist, just 21, died in a collision with an ambulance headed to a house fire in Central Islip, NY.

In August, three EMTs were injured when their ambulance hydroplaned into a stand of trees in Alachua County, FL.

That same month, three people were killed in Raleigh, NC, in a collision with an ambulance transporting a police officer who'd been shot breaking up a domestic dispute. Those are but a fraction of this year's still-rising total. The injuries—and the deaths—continue to mount.

Every year, when looking at the glaring number of accidents involving emergency vehicles, the EMS industry vows to do better—to build safer vehicles, to better train its drivers, to raise everyone's levels of caution and awareness. Yet the accidents still happen. Providers and civilians alike still die. What in heaven's name will it take to stop them?

The answers are as many as the causes of the problem—and a large part of the problem, clearly, is that there is no single cause. A variety of factors contribute to emergency vehicle accidents and the injuries and fatalities that accompany them.

Such as provider carelessness: The Chicago firefighter, in violation of his department's policy, wasn't wearing his seat belt. He was completely ejected from his vehicle.

Such as the urgency that surrounds emergency calls: The northbound Central Islip ambulance responding to the fire made a left turn in front of the southbound motorcyclist, who, unable or unwilling to yield, broadsided it.

Such as faulty maintenance: The Alachua County ambulance, according to the Florida Highway Patrol, had worn tires that led to its driver losing control on the wet road.

Such as a simple lack of safe, courteous and legal vehicle operation by other drivers. In Raleigh, the car whose occupants died was making an illegal turn.

A Big Problem

According to the National Highway Traffic Safety Administration (NHTSA), there were more than 6.3 million motor vehicle crashes in 1998, the last full year for which statistics have been compiled and analyzed.¹ Among those, there were almost 3.2 million injuries and more than 41,000 deaths.² The good news for most Americans is that with more than 2.6 trillion total vehicle miles traveled (VMT), that breaks down to just 1.6 fatalities and 122 injuries per 100 million VMT, the lowest rate on record. (By contrast, in 1966, there were 5.5 fatalities per 100 million VMT.²)

At first glance, rates involving emergency personnel seem comparably low. There were 28 people killed in ambulance crashes in 1998, 20 in fire vehicle crashes and 94 in police vehicle crashes.³ That's a total of 142 deaths in collisions involving emergency vehicles.

NHTSA doesn't track injuries from emergency vehicle crashes, and there has been relatively little research that has. However, if the data that does exist is compared in similar terms, the picture for EMS providers gets considerably more grim.

One study on the subject examined all collisions involving vehicles from the Houston Fire Department's EMS Division in 1993. The HFD had 51 ambulances in operation that year, and conducted 180,000 vehicular responses that covered more than 2.6 million miles.⁴

Their injury rate was calculated at 0.64 per 100,000 miles driven—or, to use NHTSA's denominator, 640 per 100 million VMT. If it can be assumed that Houston's is typical of a major metropolitan EMS agency, and that their drivers are no better and no worse than any other city's, then it appears that individuals in ambulances are at an injury risk more than five times greater than that of civilians.

Moreover, the Houston numbers showed a rate of 32.43 accidents for every million miles driven. The national rate was just 2.42, meaning the collision risk for ambulances is more than 13 times greater than for civilian vehicles.

Human Factors

Logic tells us that if ambulance accidents keep happening despite all the training, technology, protocols and best efforts an entire industry can wield against them, there must be some basic overriding human causes at work. So it should surprise no one to learn that the biggest single contributing factor to emergency vehicle accidents is human error. It may be surprising, however, to learn that it's the ambulance drivers, not their civilian counterparts, most often at fault.

"The overwhelming majority" of such accidents, says Rick Patrick, Director of EMS Programs for York, PA-based VFIS Insurance, are caused by human error or negligence on the part of the emergency vehicle operator. "It's the No. 1 liability in emergency services, hands down," Patrick says.

VFIS insures more than 13,000 emergency organizations nationwide—more than 40% of the entire market—and has done extensive tracking of accident rates and causes among its clients. What they've discovered, says Patrick, is that while driver training has improved dramatically in recent years, driver education is still lacking. In other words, people know what they should do, but not why they should do it, or what can happen if they don't. And without this essential context, mere training may not be enough.

"There's a big difference between education and training," Patrick says. "I think we're at the point where we're training emergency vehicle operators, but the question is, are we educating them to the consequences that come with poor driving habits?"

Those consequences can be severe. In a worst-case scenario, a driver who operates an ambulance negligently could find himself facing criminal penalties for manslaughter.

"Our educational institutions are doing a better job of educating people on the importance and responsibility of operating an emergency vehicle today than they were 10, 20 years ago," says Patrick. "Hopefully the younger folks coming out have a better understanding of vehicle safety—as long as they're not coerced into bad habits through peer pressure."

That kind of 'coercion'—cutting corners because everyone else is doing it, or abandoning safety measures because colleagues may make fun of you—is one of the many human factors that can lead to drivers making mistakes.

Others, the experts say, are more fundamental. Some ambulance operators were bad drivers—aggressive, impatient, easily distracted—long before they became EMTs. Some are old enough and have been driving long enough that bad habits have become ingrained. Some, after going years without an accident, are lulled into false senses of security and relax in their commitments to caution. And some become intoxicated by the unique circumstances of driving an ambulance. Falling prey to that desperate power and life-or-death responsibility is a condition Patrick calls 'sirencide.'

"It's a phenomenon that's basically defined as being hypnotized by the siren," he says. "You start going faster and faster and faster, not even realizing what you're doing. It requires controlling that adrenaline response, controlling the associated excitement of the situation. It's a learned experience—it's not an ability you naturally have, to be calm, cool and collected when you're responding to a child who's near drowning, or an accident with entrapment or something like that.

"Unfortunately, too many people let their guard down, and they let it down at the time when they're exercising certain privileges granted by law. They come up on an intersection, the light's red, and they know that when granted the right of way, they can proceed through it with due caution. However, a lot of times, they go into it with a commanding-type attitude and basically demand the right of way."

Closely related to this phenomenon is another basic human emergency response: tunnel vision. Studies have shown that when under stress, drivers tunnel: They focus too much on what's directly in front of them, and stop scanning from side to side and utilizing their peripheral vision. Potential hazards, however, don't stop coming from all directions just because you're preoccupied with one.

"Tunneling is basically a very fast narrowing of the focus," says Ken Mills, PhD, of the research organization Profile Associates, who has conducted extensive research into the phenomenon in police pursuits.

Mills has found that any driver who operates under even mild stress—police, fire and ambulance drivers and even civilians in certain trying situations—can experience the phenomenon. And it certainly applies to EMS: While ambulance drivers don't have a single pursuit subject (like a fleeing felon) on which to focus, the overall stress of their situations on the road—rushing a critically injured person to a hospital, or racing to some bloody accident scene—can cause the same tunneling effect. It's a defense mechanism of sorts, part of the body's overall physical and emotional "emergency" response that also includes an increase in heart rate and the release of adrenaline.

"When somebody gets aroused—that is, the sympathetic nervous system gets fired up—it restricts the field of view very quickly," says Mills. "When the adrenaline starts to rise and an officer is in a pursuit, or somebody's in an ambulance and the siren's going, the person tends to focus only on the center of the scene.

"Now, if you're on the tundra chasing dinner, or if you are dinner, that's a very adaptive response. It lets you focus on the threat. If you're driving, though, threats come from all over the scene. When you're racing down a four-lane divided highway on an emergency call, and there are radios and sirens going, you're less likely to be observant at intersections and things like that."

The good news is that this tendency can be overcome with proper driver training. Learning to combat tunnel vision, and in a greater sense, learning to stay cool and drive defensively even while responding to a critical call, will not only help drivers avoid making mistakes, it will allow them to recognize other people's mistakes—i.e., a driver pulling out, a jaywalking pedestrian, a dog crossing the road—before it's too late to compensate.

Other People, Other Factors

Even the safest and most aware driver, however, can't compensate for every potential human hazard out there. Sometimes accidents are simply unavoidable. If a less-than-vigilant pedestrian steps from behind a bush directly into the path of an ambulance traveling 60 miles an hour, no amount of driver scanning is going to help them.

Part of the problem is that many civilian drivers are only vaguely aware of how to defer to an emergency vehicle. Laws vary by state, and for most people, it's been a long time since Driver's Ed. Some will pull to the right and stop. Others will stop right where they are. Some, if they're in the left lane, will pull to the median. Others will just slow down. Many, with windows up, music blasting, or engaged in conversation, may not even notice an ambulance trying to pass them.

"If people are seldom approached by an emergency vehicle, how can we expect them to know what to do when we come blowing up behind them, lights on and siren blaring?" asks Patrick. "Then we start playing with the siren, and then we lay on the air horns, and we're right on their bumper. What are they going to do? They jerk-react. It's 'Oh, my God, what do I do now?' not 'Gee, what did I learn when I was 16 that I'm supposed to do now?'"

Patrick emphasizes that ambulance drivers must give other motorists the chance to get out of the way.

"Given the opportunity, most people will yield us the right of way," he says. "Unfortunately, many emergency vehicle operators do not give them the opportunity. They come right up on their bumper and do those things I just said. Then the other driver has this jerk-reaction. They could hit somebody head-on, they could hit somebody on the side of the road, they could just stop suddenly."

Other things ambulance drivers can do to increase everyone's safety are more basic. First, the ambulance has to be maintained. In the Florida hydroplaning accident, the Alachua County Fire Rescue ambulance incurred an estimated $65,000 worth of damage—a high price to pay for bald tires, and one that could have been substantially higher had someone been killed.

Closely related to that is awareness of surroundings and circumstances: If you're driving on a wet road, be aware that hydroplaning can occur. If you're responding through hairpin mountain turns, don't corner at 70 mph. If you're transporting around the time of last call, be aware that inebriated drivers will be leaving bars. With emergency vehicles as with passenger cars, defensive driving is safe driving.

As well, seat belts and restraint systems for passengers in back save lives in ambulances just as in other vehicles. A 1987 analysis of more than 100 ambulance accidents in Tennessee found that the variable most closely associated with injury was use of safety belts or other restraints.⁶ Darkness and intersections also appeared to pose an increased risk.

And the risk is higher: A study of mobile intensive care units in Belgium found that 66% of collisions occurred while the MICUs were using lights and siren.⁷ An American study mirrored that result, finding that 69% of ambulances involved in fatal crashes were running L&S.⁸ It has also been estimated that as many as 12,000 emergency vehicle accidents occur each year as a direct result of the use of lights and siren, and that five times that many could be caused by emergency vehicles that are not themselves involved in the accident.⁹

The time saved by using lights and siren, however, may in many cases be negligible. In one study conducted in a major metropolitan setting, response times using L&S, from the location of dispatch to arrival at the scene, averaged just 106 seconds faster than those done from the same places at the same times of day without.¹⁰ In a smaller-town setting, L&S transports from accident scenes to the ED averaged just 43.5 seconds faster than those done without.¹¹ The first study concluded that the time saved is rarely likely to be relevant, while the second concluded that except in extreme cases, L&S transport is not warranted.

This notion is not new; as long as three decades ago, some agencies were limiting their "hot" responses. In 1994, the National Association of State EMS Directors (NASEMSD) and the National Association of EMS Physicians (NAEMSP) issued a joint position paper stressing that "the use of L&S should be reserved for those situations…in which response and transport times have been shown to improve a patient's chances for survival or quality of life."

Responding L&S to calls that aren't life-threatening "just seems kind of crazy," says Jeff Clawson, MD, medical director and CEO of Medical Priority Consultants of Salt Lake City, UT, and a leading researcher on the subject. "When a person comes into the ED, we don't take our gloves off and sprint down the hall just because somebody enters the door," he notes. Clawson is a major proponent of limiting L&S responses through priority dispatch, a process by which calls have their severity assessed by a dispatcher using a standard template of questions and then prioritized accordingly.

Use of lights and siren is "linked at the hip with dispatch procedures," Clawson says. "If you can determine what the call is and determine that it doesn't need paramedics, then it may also not need lights and siren."

Still other studies have found that red flashing lights alone seem less effective for alerting other drivers of an ambulance's presence than other color combinations, and that in terms of visibility and response by other drivers, lime yellow may be preferable to more-traditional emergency vehicle colors.¹²

Liability

A mistake you make while driving not only could take an innocent life, it could also cost your insurer or your city millions of dollars. The city of Bloomington, IL, discovered this the hard way.

Bloomington authorities agreed to a settlement of almost $5 million for a 1988 accident that left an 18-year-old honor student partially paralyzed.

Sharron Rose Frieburg was riding in a pickup truck that was broadsided by an ambulance using L&S to transport a man with a sprained ankle. The collision left Frieburg in a coma for more than four months; upon regaining consciousness, she was left severely disabled and unable to work again.

"It's dramatic," acknowledges Clawson, who has studied the case. "If you see her, you'll never forget that this happened because of a sprained ankle response."

It has been reported that among volunteer organizations insured by Glatfelter Insurance Group, the parent company to VFIS, there are 25 claims for automobile-crash liability for every malpractice claim against an EMS provider.¹³ While information about total payouts for accidents and settlements is kept confidential, it seems safe to estimate that it totals millions nationally each year.

It's also not unheard of for ambulance drivers who are egregiously negligent to face jail time if the accident they cause is severe enough.

"There are many EMTs, paramedics and firefighters in jail right now for crashes they've been involved in where they've killed somebody," warns Rick Patrick, "and just as many are waiting to see what's going to happen with their court cases."

In one recent case, a New York City ambulance driver pleaded guilty to criminally negligent homicide for a 1998 crash that killed three children.

Anne Lamberson, who was on a non-emergency call, admitted to driving at an excessive speed and running a red light without due caution before hitting a Nissan containing Angela Morak and her family. Morak's children, aged 7, 5 and 2, were killed; her sister, aged 9, was critically injured. Under her plea, Lamberson received five years' probation instead of a possible four years of prison on each count. A lawsuit was subsequently filed by the children's father.

"There's nothing that poses a greater liability, personally, professionally and to an organization, than driving an emergency vehicle," notes Patrick.

How Hurt Happens

In the 1998 NHTSA data, the bulk of the deaths resulting from ambulance crashes (17 of 28) were among occupants of the other vehicles involved; only two ambulance drivers and seven ambulance passengers were killed (the other two were pedestrians).³ That's not necessarily surprising; when two vehicles collide, the larger one usually wins. But the NHTSA data didn't examine injuries, and plenty of anecdotal evidence suggests that drivers, passengers and patients are at high risk of injury when an ambulance crashes.

Research that may shed light on what happens inside a crashing ambulance is being conducted by a team of scientists under a grant from the group Emergency Medical Services for Children. While the group initially set out to study pediatric transport, it has discovered that many of its findings can be applied to anyone who travels in the back of an ambulance.

"Although our study was focused on the safety of children, we've clearly identified that everyone's safety is related," says lead researcher Nadine Levick, MD, of the Division of Pediatric Emergency Medicine at the Johns Hopkins Children's Center. "The work we're doing is totally applicable to any other form of transport in an ambulance vehicle."

Levick's team began by looking at how children were transported in ambulances and how ambulance interiors were configured. After examining more than 200 pediatric transports, they concluded that the potential for injury not only to children but to all occupants should the vehicle crash was "alarmingly prevalent."¹⁴ They found that more than a quarter of the patients in the study were transported unrestrained on the vehicle's bench seat, and more than a dozen types of EMS equipment were left unsecured or minimally secured.

These findings resulted in the release of a set of guidelines for the transport of children in ambulances, but the work of Levick's team was just beginning. Support for her program was so great—she's received an estimated million dollars' worth of in-kind contributions, including many donated ambulances—that her team moved on to recreating actual ambulance crashes.

"We'd been working very hard on the background epidemiology, identifying what crashes were causing what injuries and fatalities, so that when we modeled the environment, we could model the risky environment," Levick explains. "There are numerous different types of vehicles, so we tried to identify what would give us the most bang for our buck. We realized that the head-on was an important test to conduct. Many injuries and fatalities are associated with head-on impacts. So we determined to conduct the head-on impact and the side-on impact.

"Somewhere along the way, we had to tell our engineers what to put in the vehicle. So we actually put together a team of field workers and asked them to monitor ambulances carrying children to hospitals. We wanted to know how many occupants were in the vehicle, what size the occupants were, what equipment was there. That's what people don't do, you know? Even when they do automotive tests, they put the crash-test dummies in, but they don't go out there and look in the street and say, 'How many people are in the vehicle? Where are they sitting? What other things are there?' We wanted to identify what was there and properly conduct real-world testing."

That study was presented in May to the American Academy of Pediatrics, to great acclaim. "Had we not looked, we wouldn't have thought there should be a spot where it's safest to secure a stroller," says Levick. "There are plenty of places you can put a stroller in an ambulance, but where's the safest spot? I hadn't even thought about strollers, but that makes sense—they're going to be there.

"We realized there was a strong interplay between all the occupants and the equipment. If a child is perfectly well-restrained but the equipment isn't, it could strike the child. Or if the child's perfectly well-restrained and the occupants aren't well-restrained, they could strike the child. To study this properly, you can't just put a crash test dummy on a gurney and test the gurney. You've got to test the whole environment."

That led to a series of crash and component tests that is ongoing and will extend into 2001. The findings are expected to have relevance well beyond pediatrics: Levick hopes to determine what types of crashes are the most dangerous and to identify specific mechanisms of injury. This knowledge will have obvious safety applications to anyone who rides in the back of an ambulance, where lifesaving pieces of equipment can become life-threatening projectiles in a crash.

"Where is the best spot for the oxygen cylinder, and how do you best tie it down?" she asks.

"Where is the best spot for the defibrillator? There might be a range of good spots. Our goals now are to determine what are the safer practices. Clearly, everything's a compromise and a balance in the rush of an ambulance trip. But it seems to me it's not fair to expect the paramedic in the field, who's focused on patient care issues, to have to start calculating out his own automotive safety parameters."

Building It Better

Levick's team isn't the only one trying to improve the ambulance environment. The General Services Administration (GSA) and the American Society for Testing and Materials (ASTM) are both working on new specifications for ambulance design, and the American Ambulance Association is drafting a series of recommendations to be released next year.

The GSA's standard, KKK-A-1822, is the official government standard for ambulance design and construction and has been the definitive word on the subject since 1974. The revision currently being drafted is hoped to be ready for release by the first of the year.

"The K Spec incorporates a number of different types of requirements," explains Mel Globerman, Chief of the Engineering and Commodities Management Branch of the GSA's Office of Vehicle Acquisition and Leasing Services, Automotive Division. "It covers design requirements, performance requirements, functional requirements, and bottom line, many user-specified requirements."

It's a flexible document, he emphasizes, that allows tailoring to the needs of individual departments while at the same time ensuring minimum levels of quality and safety. While adherence to the K Spec is not mandatory under law, many jurisdictions require it of their ambulances, and it is widely accepted as the industry benchmark.

"We use this document to procure hundreds of federally owned ambulances every year," notes Globerman, "but we also produce it so that anyone outside the federal government can cite it and use it to give themselves a level of assurance. If they're buying a vehicle that conforms, it's going to intrinsically provide a high level of performance, safety, durability and ease of maintenance."

Safety-related changes and updates in the forthcoming revision will include:

• Standards for testing weight distribution, both front-to-rear and laterally;
• Required anti-lock brakes (which are already required by law);
• Daytime running lights;
• The prohibition of swing-down IV hangers that can cause injury;
• Testing requirements for bench-seat belts and litter fasteners and anchorages;
• Improved exterior/warning lighting systems, including moving from a dark red to a hot pink.

"I call it road-flare red," says Globerman. "It's brighter, and you can get more usable light through the lenses. Just by a slight lightening of the color, you get more efficient output, more usable light and more attention-getting capability."

In a separate safety-related matter, the GSA is also concerned about emergency vehicles outfitted with the Firestone ATX, ATX II and Wilderness AT tires that have been so much in the news of late.

"These would typically be smaller vehicles used for administrative or fire chief response, or EMS response vehicles," says Globerman. "Not likely ambulances, obviously, but these tires are frequently used for law enforcement. It could be a fire chief responding in a Ford Explorer, it could be an EMS chase vehicle. It cuts across the whole spectrum of emergency services."

The ASTM is also in the process of updating its previous ambulance standard, which is less widely referred to than the K Spec.

"In some ways it's a compendium of a lot of other ASTM standards," says Paul Roman, Chairman of the ASTM's Committee F30 on EMS' Subcommittee on Equipment and Its Uses. "But in more ways than not, it's a freestanding document that encompasses everything you'd want to have when purchasing or speccing out an ambulance. It doesn't conflict with the K in a lot of ways, though there are some differences.

Like the GSA, the ASTM subcommittee is closely monitoring Levick's findings, the results of which will be reflected in both standards.

"We're staying in touch with what she's doing," says Roman. "As she gets to the point of real solid documentation of some of the things we all suspect and believe are true, and once we get more empirical data we can put into the form of a standard with some statistical validity behind it, I think you'll see those things begin to come into our standard."

Better Living Through Technology

Some of the dangers of ambulance transport may eventually be reduced by improving technology. Several new products and systems hold promise in that regard:

• Global positioning satellite system technology reduces response time not only by decreasing the time crews spend lost, but also through a procedure called systems status management that allows agencies to circumvent congested areas and other traffic problems.
  
  "It's done by relocating ambulances to high call-volume areas around or encompassing high-traffic areas, which allows for a more expeditious response time," explains Patrick. "If you're closer and don't have to go through all that traffic, you don't need to use your lights and siren like you normally would; thus you reduce the risk of a collision occurring." Fewer miles traveled also means less wear and tear on an agency's fleet.



• Dispatch priority systems, as described earlier, can minimize the number of lights-and-siren responses to situations that ultimately don't require them. The key link is the dispatcher, who must assess the gravity of calls using a standard set of medically developed guidelines.
  
  According to Patrick, "Essentially what they're doing is deciding on a hot or cold response. What they do is teach dispatchers how to screen calls at the 9-1-1 center. It's a great risk reduction tool from our standpoint."
  
  Clawson's work indicates that in Salt Lake City, implementing priority dispatch reduced the number of lights-and-siren responses by 50% and the number of accidents involving emergency vehicles by an impressive 78%.⁹
  
  "In essence, you're managing your resources, and you're risk-managing resources also," says Clawson. "You put people at a much greater risk going lights-and-siren. It increases your chance of an accident up to 20 times."



• Black box systems such as DriveCam (see sidebar) and others monitor forces on a vehicle that can show if it's being operated unsafely. They typically record turn ratios, G-forces from braking, accelerating, etc.; some even have video capability.
  
  Sunstar EMS of Pinellas County, FL, recently installed RS3000 on-board computers from Camarillo, CA-based Road Safety International that not only monitor G-forces, braking distances and the like, but also such user-defined characteristics as the use of seat belts and turn signals and a spotter while backing. The RS3000 gives an audible warning to drivers who exceed predetermined parameters, giving them a chance to correct themselves immediately; it can also identify problem drivers to higher-ups through a feature called exception-based reporting.
  
  "If they deviate from the parameters, it generates a report for me," explains Scott Springstead, Sunstar's Operations Supervisor. "I don't have to scan through reams of data—it gives me a red flag, which is very handy."
  
  Studies by Road Safety estimate that the average fleet saves more than $1,300 per vehicle in maintenance fees each year with the computers, and between $300 and $1,300 a year in fuel.



• Radar systems can alert drivers to unseen hazards in backing or turning.



• Safety transmitter systems warn drivers with radar detectors of an ambulance's approach using police radar bands. Drivers receive the same alert they would if a police cruiser were approaching and will thus slow down for the ambulance.



• Preemption systems can be used by an ambulance approaching an intersection to turn the traffic light green before it gets there. With cross traffic stopped, navigating the intersection becomes much safer.



• "The modern ones today can be activated manually by audio from the siren, or by infrared or by visual from the revolving lights," notes Patrick. The range is roughly 200 feet.



• Harness systems can provide protection for those in the back while still allowing them the freedom to tend to patients. Wearers' movement is governed by cables on a series of reels; in an accident, the reels lock up, holding the wearer in place.

Driver Training

As the number of accidents mounts, so do efforts to combat them with more extensive driver training. Among the many programs and approaches available, how can an agency tell which ones work best?

The standard for most of the industry is still the Emergency Vehicle Operators Course (EVOC) developed by NHTSA.

The National Safety Council (NSC) offers CEVO (Coaching the Emergency Vehicle Operator) courses that were designed especially by Princeton, NJ-based FLI Learning Systems. FLI conducts separate CEVO courses tailored to the specific needs of the three primary types of emergency drivers: ambulance, fire and police. They are presented throughout the year at various locations around the country, and a revised CEVO-II ambulance course was just unveiled last year.

"The success of this program is based on discussion," says course instructor Bill Waslick, Vice President of Health and Safety Programs for FLI. "That's the trick: They're not sitting there listening to somebody; it's very interactive. A lot of courses say they're interactive, but they're still based on somebody up front lecturing. That doesn't go over well, and all of us know that."

The main point CEVO tries to drive home, Waslick says, is the same one Rick Patrick makes: You just never know what other drivers will do upon encountering an ambulance. Therefore, be prepared for anything.

"The first thing you learn, when you do the research and drive the ambulances and ask the drivers what's going on, is that you can't predict how others are going to react," he says. "Just because you have your lights and siren on doesn't mean that people are going to yield to you. There are many, many examples of other people stopping right where they are and of people going through traffic lights because they don't know where the siren's coming from. You get the adrenaline flow on the part of the other driver hearing the siren, and you get the adrenaline flow from the ambulance operator. There are a lot of factors involved." The CEVO course also features a "train the trainer" facet that teaches attendees how to impart the skills they learn to others back in their departments. A CEVO-II ambulance course will be held in Detroit on November 29 (248/557-7010).

VFIS developed the first emergency vehicle driver training course and now offers one that's a highly detailed mixture of classroom study and track testing of actual skills.

"Nothing can replace real time on the street with an ambulance," says Patrick. "We want them to go out there and learn how these vehicles maneuver. We have a point system for brushing and knocking over cones, crossing imaginary lines, those types of things, and we get them used to that before they go on to real-time driving on a street with an approved driver trainer."

An often-overlooked component of driver training, Patrick adds, is the skills update—something few agencies require and few resources offer.

"This is all just the beginning of the driver education and training process," he emphasizes. "Right now, we are unaware of any state that requires refresher training from a regulatory standpoint. But we encourage people to refresh at minimum every three years."

Conclusion

Driver, passenger or patient, traveling in an ambulance puts you at a much greater risk than in other types of vehicles. Accidents, injuries and fatalities all happen with striking frequency to emergency vehicles. And despite increased recognition and efforts to combat the problem in recent years, it shows few signs of abating.

While many factors contribute to this phenomenon, the most vexing—and certainly the most difficult to address—is human error. Not only errors by other drivers, who often have neither the knowledge nor the inclination to yield to emergency vehicles, but also errors by the ambulance drivers themselves.

Given the urgency and responsibility that come with driving an emergency vehicle, ambulance operators often fall victim to an adrenaline response that leads them to drive less safely than they should. Involved training and intense education are among the keys to avoiding this—and avoiding it is vitally important, as a mistake a driver makes while on duty can lead to an expensive judgment against his or her agency/city/insurer, and even to personal criminal liability.

Other protocols and procedures have shown some promise in reducing the dangers as well. Using seat belts and restraints, minimizing lights-and-siren responses, and utilizing such new technology as black box systems have all been demonstrated to make the ambulance response environment safer. Additional research is underway that will shed further light on ambulance accidents and the damage they do.

Sidebar — Dealing With Death: How One Driver Faced the Unthinkable

1. "Traffic Safety Facts 1998: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System." U.S. Department of Transportation/National Highway Traffic Safety Administration, 1999
2. Ibid, NHTSA, p. 15.
3. Ibid, NHTSA, p. 94.
4. Biggers WA, Zachariah BS, Pepe PE. Emergency medical vehicle collisions in an urban system. Prehospital and Disaster Medicine, 11(3): 195-201, 1996.
5. Clawson, J. Limiting lights and siren provides safer transport. Medical Priority Consultants, Salt Lake City, UT.
6. Auerbach PS et al. An analysis of ambulance accidents in Tennessee. JAMA 258(11): 1487-1490, 1987.
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• Annals of Emergency Medicine, National Association of Emergency Physicians
• Emergency Medical Services for Children
• Emergency Response Safety Institute
• Emergency Vehicle Operators Course (EVOC) Participate Manual (PDF), National Highway Traffic Safety Administration
• Journal of the American Medical Association, (JAMA)
• Journal of Prehospital and Disaster Medicine
• European Journal of Emergency Medicine, European Society for Emergency Medicine
• National Safety Council
• Prehospital Emergency Care, National Association of EMS Physicians
• Protecting Emergency Responders on the Highways, Cumberland Valley Volunteer Fireman's Association
• State and National Fatality and Injury Data, National Highway Transportation Safety Administration

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Updated 08.07.06