The hazards of ambulance transportation are coming under closer scrutiny by safety advocates who are pushing for more crash research, better safety features and more uniform guidelines to lead to a safer ride for medics and the 100,000 patients treated in ambulances each day.
"It's going to cost you a fortune not to fix this problem," Dr. Nadine Levick of Harlem Hospital, who has conducted the nation's only full-body crash tests of ambulances in the United States, told a conference of ambulance operators recently. "You're already paying out $500 million a year trying to get this problem paid for."
There are several indications the industry is starting to recognize the gravity of the problems that lead to 6,500 ambulance crashes each year.
Investigators from the National Institute for Occupational Safety and Health and the National Highway Traffic Safety Administration are closely scrutinizing a handful of ambulance crashes to determine whether they can identify any trends that could translate into better safety recommendations.
An interagency committee on emergency medical services, which includes NHTSA, the General Services Administration and ambulance manufacturers, has devoted a subcommittee to review ambulance design.
The American Ambulance Association, a trade group that represents mainly private ambulance operators, is trying to develop "best practices" for ambulance operations.
Levick said the industry has shown a "collaborative spirit" by donating vehicles and other resources to her research.
Members of the industry agree one of the best ways to ensure better outcomes is to undergo an intensive evaluation program like the one offered by the Commission on Accreditation of Ambulance Services. The commission scrutinizes everything from whether the service carries adequate medical equipment to whether it has a regular schedule for vehicle maintenance that it actually meets.
"They have to be able to show on paper and in their operations that they do what they say they do," said Meredith Hellestrae, executive director of the group, which started accrediting ambulance services in 1990.
Of the estimated 12,000 ambulance agencies nationwide, 72 of them have completed the accreditation process, she said, and 19 of those are in Michigan. The exhaustive process, which has taken agencies as long as five years to complete, and the expense, which can be higher than $15,000, might keep some agencies from applying.
"It doesn't do any good to save a life and kill them in the process," said John J. Russell, president of Cape County Private Ambulance Service of Cape Girardeau, Mo., who is considering accreditation.
Here are some other possible solutions being discussed:
Vehicle design
NHTSA says it would take years, if not decades, to come up with a crash test standard for ambulances.
Manufacturers are reluctant to demand more regulation, but a few of them are subjecting their vehicles to more rigorous standards than the industry norm in an effort to gain a competitive edge.
"It's ironic that the crew does everything right to treat a patient and that person or the crew is killed in a crash," said Bill Litteer of Livonia, N.Y., a sales manager for American LaFrance Medicmaster. "It will continue until the government steps in and requires new standards or the consumer demands changes. Either the government comes up with stricter mandates or the consumer requires it and starts shutting out the manufacturers with bad safety records."
NHTSA is preparing a guide that will suggest some basic questions ambulance buyers should ask before choosing a vehicle, but it won't have specifics about how the vehicles' safety records compare to others because that information isn't documented.
Levick is touting the design of an ambulance sold in Europe -- the Volvo S80 -- because its tight interior allows medics to reach everything they need and treat a patient while still being strapped in to protect their own safety.
Maintenance
Ambulance services should have routine maintenance of vehicles to ensure that brakes, tires, suspension and other systems aren't worn out to dangerous levels on the high-volume vehicles.
They should consider allowing medics to sideline a vehicle without supervisory permission if they are concerned an ambulance is unsafe to drive, said Larry Anderson, chief executive officer of Battle Creek-based LifeCare Ambulance Service, who heads a team of ambulance operators looking at ways to improve driver records.
Restraint systems
Gurneys should have shoulder belts, in addition to straps across the waist and legs, that would keep patients from shooting forward in a crash.
Regulators should evaluate whether lap belt systems on squad benches adequately protect side-facing occupants in a collision.
"What I want them to do is establish protocols that mandate that people buckle up in the front, and when they can, buckle up in the back," NHTSA Administrator Dr. Jeffrey Runge said at the start of a two-day conference on EMS safety last week with state public health officials.
Though the state officials were trying to come up with ways to get medics to promote safety in the community, there was limited acknowledgement that they should do more to ensure their own safety.
Ambulance operators should mandate their employees use seat belts in the rear compartment as well as the driver's cab unless a patient is in immediate need of life-saving measures.
Technology
A combination of computer programs can contribute to better service and less chaos on the streets.
For example, in Pinellas County, Fla., the ambulance service there links an automatic phone number indicator with an automatic location indicator so the dispatcher knows exactly where the call is coming from, and then cross references that information with an automatic vehicle location system that allows the dispatcher to locate the closest ambulance and give it directions to the patient using global positioning systems.
The county also uses a "black box" type of driver monitoring system to determine whether its employees are driving too fast, taking corners too roughly or braking too hard.
Chuck Kearns, executive director of the Florida authority, said the year before he installed the driver monitoring system he had 19 incidents that involved property damage of more than $1,000. A year later, he had only one.
Research
"Until research is conducted that says here is the problem, here is the scope of the problem and this is how people are being injured, there is no way to take the next step because anything else is based on speculation," Maguire said.
"You can say we need better seat belts, but if the people who are dying are dying because IV (intravenous) poles are being jammed in their heads and oxygen bottles are flying around in the backs of ambulances and killing them, seat belts aren't going to do anything."
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