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Journal of Emergency Medical Services (JEMS), July 1989
Robert Elling, NREMT-P

Dispelling Myths on Ambulance Accidents

The word myth often conjures images of two-headed creatures and goddesses who play with human lives in a supernatural world. But there are also myths in EMS.

These can take the form of rumors or just misconceptions, and although there is no proven truth to the myths, they seem to get passed along from generation to generation and accepted without question.

In the case of the misconceptions that surround ambulance accidents, allowing these myths to be propagated can ultimately impact our ability to save lives.

The funny thing about dispelling myths is that it usually just requires using a little common sense. The sad fact is that most people only pay close attention to issues when they have personal interest in them. For instance, knowing that there are a large number of ambulance fires each year in this country would probably not impress you unless you had the unfortunate experience of watching a $75,000 vehicle roast.

All it takes if for someone to tune into the problem, collect data and inform others of the magnitude of the problem.

Donāt learn by experiencing the trauma of an ambulance. Rather, become aware of the variables involved, such as road conditions and visibility. This will help identify high-risk behaviors that contribute to these accidents.

Assuming your ambulances are adequately maintained, the way to decrease the number of accidents is to minimize the number of human errors that occur. This goal can be attained by changing the behavior of the ambulance driver, using strategies that include: providing education for both the ambulance operator and the public by emphasizing risk factors; conducting driver behavior-modification classes; modifying existing laws, rules, regulations; developing agency standard operating procedures; and increasing the visibility and audibility of ambulances.

The following is a series of myths held by some people about ambulance accidents and specific data that corrects the misconceptions.

The data presented represents the 48-month period from Jan. 1, 1984, through Dec. 31, 1987. During that time, the number of ambulance accidents reported to the police in New York State increased by 28.6 percent. In the period studied, 1,412 ambulance accidents occurred, resulting in six fatalities. Injuries were sustained by 1,894 ambulance occupants.

Each of the charts presented in this article represents aggregate data from four annual reports produced by the NYS Department of Motor Vehiclesā accident database. A specific run was performed using the database to isolate ambulance accidents from those involving other types of vehicles.

The specific categories of information that appear in the charts were taken verbatim from the DMV reports. For simplicity, the percentages were rounded up to the nearest whole number. Those totals that do not equal the total injuries or accidents cited earlier are a result of incomplete information having been entered into the database.

None of these figures include "non-reportable" accidents with minor vehicle damage estimated to be under $600 or without personal injury.

Myth #1: Ambulance accidents occur in bad weather with poor visibility

Fact #1: The majority of ambulance accidents occur on clear days with good visibility

The data:

Weather Conditions Number of Accidents Percentages

Clear 792 56

Cloudy 220 16

Rain 259 18

Snow 51 4

Sleet/Hail/Freezing Rain 13 1

Fog/Smog/Smoke 1 1

Other 5 0

Unspecified 71 5

While it is obvious that the weather on most days was either clear or cloudy, the data does show that only a small percentage of accidents occurs in inclement weather. This may be attributable, in part, to the extra effort drivers make to reduce their speed and adjust their driving habits during poor weather.

Myth #2: Most ambulance accidents occur on dark roads or at dusk when the driver has difficulty seeing other vehicles.

Fact #2: The majority of ambulance accidents occurs in daylight.

The data:

Light conditions Number of Accidents Percentages

Daylight 825 70

Dawn 17 2

Dusk 35 3

Dark (lighted road) 261 22

Dark (unlighted road) 22 2

Unspecified 12 1

Surprising, 92 percent of these accidents occurred in either in daylight or on a lighted road at night. The more widely traveled roads in New York are lighted, and the majority of ambulance calls in a typical community occurs during daytime hours. Yet the number of accidents remains low in conditions of poor visibility.

Myth #3: Most ambulance accidents occur when trying to pass a vehicle that refuses to yield to the right of the road.

Fact #3: The majority of ambulance accidents occurs when making turns or when broadsided at an intersection.

The data:

Manner of Collision for Two-Vehicle Accidents Number of Accidents Percentages

Rear End 231 21

Left and Right Turns 128 12

Right Angle (Lateral) 447 41

Head On 15 1

Side Swipes/Overtaking 224 21

All Others 37 3

Although the driver of a vehicle with its windows closed and radio on cannot usually hear the ambulance approaching until it is directly behind the car, the largest percentage of collisions occurs in an intersection, not when overtaking an automobile. In addition, the percentage of head-on collisions is actually very small, which refutes the myth that passing on the left or entering into oncoming traffic is the foremost hazard in ambulance driving.

Myth #4: Most ambulance accidents occur on wet or snowy roads.

Fact #4: The majority of ambulance accidents occurs on dry roads.

The data:

Roadway Surface at Time of Accident Number of Accidents Percentages

Dry 891 63

Wet 352 25

Muddy 4 0

Snow/Ice 78 5

Slush 12 1

Other 3 0

Unspecified 74 3

Even when ambulance drivers use extras caution on wet roads, a significant number of ambulance accidents occur. But reduced road grip is also difficult to detect on dry roads. As a result, it is imperative to drive cautiously to compensate for a possible error in judging the road grip you do have. It is generally recommended that drivers reduce normal speed by one-fourth for rain, one-half for snow and three-fourths for icy surfaces.

Drivers should not be lulled into a false sense of security when traveling on dry roads. The statistics show that dry roads do not ensure safety and that drivers must always be alert and cautious.

One useful technique that defensive drivers practice is keeping a four-second following distance on dry pavements when all other conditions are good. To determine this distance, watch the rear bumper of the vehicle just ahead as it passes a stationary marker, such as a tar strip, sign post, or telephone pole, and count "one thousand and one, one thousand and two, one thousand and three, one thousand and four." As you say "four," your front bumper should reach that marker. If you reach it before that point, reduce your speed by one or two mph and the recheck your distance. When conditions are not good, increase your following distance to six seconds or more. See Figure 1 for driver reaction and vehicle braking distances in a light, two-axle truck.

Myth #5: Most ambulance accidents occur while backing the vehicle into a tight spot.

Fact #5: As in Fact #3, the majority of ambulance accidents occurs on the roadway in an intersection.

The data:

Location of Accident Number of Accidents Percentages

On Roadway at Intersection 824 70

On Roadway, Not at Intersection, and

Off Roadway 348 30

Intersections clearly present a hazard to the ambulance driver and the crew. The overwhelming number of accidents that occurs at intersections strongly suggests that other drivers do not hear or see an ambulance until it is too late to stop their vehicles. A "rolling stop," or the practice of slowing as you enter an intersection in the hope that you could stop in time if another driver was in your path, is reckless. It is not possible to stop a moving 11,000-pound (or heavier) vehicle traveling more than 35 mph in time to prevent an accident.

Ambulances are considered lightweight trucks. As vehicle weight increases, the vehicle braking distance also increases. Thus, an ambulance will travel much farther than a car when braking. Do you know what your ambulance weighs? Figure 2 illustrates ambulance types and weights.

An informal survey of fully equipped Type III ambulances produced an average actual vehicle weight of 10,450 pounds excluding the patient and crew (1). Such an average implies that many services are routinely overloading their ambulances. Patient and crew safety is jeopardized, as the handling and braking of the vehicle are affected when the gross vehicle weight is exceeded.

It is recommended that drivers come to a complete stop at a stop sign or red light, make eye contact with all other drivers and then proceed with caution. In a case in which the ambulance actually has the green light or there is not stop sign, defensive driving would dictate momentarily moving the right foot off the accelerator to cover the brake and slowing the vehicle until clearing the intersection. This will help reduce the reaction time required to move the foot to the brake pedal, should the driver need to stop the vehicle.

While many ambulance accidents do occur when ambulances are backed up without a spotter, these accidents are often minor in nature and frequently are not reported to the police.

Myth #6: Because ambulances have lights and sirens, the traffic signal device does not present the ambulance driver with a major hazard.

Fact #6: Locations where traffic signaling devices exist present the greatest risk for an ambulance accident to occur.

The data:

Traffic Control at Accident Sites Number of Accidents Percentages

None 424 30

Traffic Signal Device 745 53

Stop Sign 94 7

Flashing Light 8 1

Yield Sign 8 1

Officer/Guard 5 0

No Passing Zone 18 1

Other 26 2

Unspecified 84 6

Since 60 percent of the accidents occurred at stop signs or traffic lights, it is obvious that the intersection is a dangerous place.

An emergency vehicle should not attempt to assert the right of way through an intersection against a traffic signaling device. In New York State, statistics show that 70 percent of reported ambulance accidents occurred in intersections and frequently resulted in serious injury or death.

A typical intersection scenario might involve a passenger car traveling at 35 mph approaching an intersection where the driver has a green light. At this time, the vehicle is 116 feet from the intersection. An ambulance traveling 45 mph on an emergency run in nearing a red light, 200 feet from the same intersection. The shortest distance between both vehicles would be 252 feet apart.

The light on the emergency vehicle likely will not attract attention because it is often obscured at intersections. The other alternative is that the ambulance siren will alert the oncoming automobile driver. But numerous studies have shown that the sound of an ambulance siren cannot actually project over a long distance or overcome other traffic and ambient sounds. Since the siren is also non-directional, it may bounce off buildings and tree, making it confusing for other motorists to pinpoint the vehicle's location.

In a 1986 study by Tom Precut, it we found that a typical wail siren mode measured for sound levels at a 45-degree angle to the siren speaker cannot be heard by the automobile driver in the above scenario (2). Thus, the driver can neither see nor hear the ambulance approaching the intersection.

The automobile in this case is beyond the point of no return. Even if the driver were to recognize a siren, it would not be possible for him to stop the vehicle without sliding through the intersection. The ambulance is also past that point. At 45 mph, the ambulance, which is a much heavier vehicle and traveling 66 feet per second, will cross into the path of the oncoming car, and the vehicles will collide.

Many ambulance services do not have a standard procedure for the use of lights and sirens. The following recommendations might be helpful in establishing such procedures, but need to be tempered by local vehicle and traffic laws.

Routine Driving (Code II): Any call other than an emergency run should be considered a Code II or routine response. All Code II runs should be made using headlights only-no sirens, beacons, or flashers. During Code II response, an ambulance should be safely driven and not subject to any emergency vehicle privileges under the stateās vehicle and traffic laws.

Emergency Driving (Code III): Should be limited to "true emergency" runs that are defined as situations in which there is a high probability of death or serious injury. Implementation of emergency medical dispatcher protocols can help reduce the number of Code III responses bases on predetermined medical interrogating and response procedures.

Once on the scene, the decision to run Code III to the hospital must be based on whether the patientās status is critical or unstable. The patientās status is, of course, a medical judgment call. A patient with a fractured tibia shouldnāt require a Code III ride to the hospital, as the ride then potentially becomes more dangerous than the original injury. All Code III runs should be made using headlights, emergency lights and siren as required by state laws.

The emergency driving (Code III) section of any procedure should include the following criteria:

    • The first arriving certified first responder, EMT, or advanced EMT should be responsible for determining the response status for any additional ambulance vehicles going to the scene of the call.
    • Ambulance service vehicles should not exceed posted speed limits by more than 10 mph.
    • Ambulance service vehicles should not exceed posted speed limits when proceeding through intersections with a green light.
    • Ambulance service vehicles approaching a red light, stop sign or railroad crossing must come to a complete stop before proceeding with caution.
    • When traffic conditions require ambulance service vehicles to travel in the oncoming traffic lanes, the maximum speed should be 20 mph.
    • When ambulance service vehicles use the medium (turning lane) or oncoming traffic lane to approach intersections, they must come to a complete stop before proceeding through the intersection with caution.

Safety Equipment

One other element that directly affects the outcome of ambulance accidents is the safety equipment used in the vehicle. While ambulance personnel are assumed to be extremely safety-conscious, that is not always the case.

The safety equipment used by all the 4,876 occupants who were involved in the ambulance accidents studied is listed in Figure 3. The total number of injuries given in this figure is less than those previously cited due to incomplete accident documentation.

It was expected that the statistics would be more dramatically in favor of restraining devices than they actually show. However, few EMTs wear restraining devices in ambulances for a number of reasons. Further analysis of the data showed that 37 percent of the occupants were injured. Although 58 percent of those injured were wearing an adult restraining device, compared with 42 percent who wore no restraint at all, the most serious injuries occurred in the victims who did not wear restraints. Patients wearing a restraining device had a 5 percent chance of having a major injury, compared with those who did not wear a restraining device, who had a 10 percent chance of suffering a major injury.

Gov. Mario Cuomo of New York State signed into law the nation's first automobile seat-belt law, which went into effect on Jan. 1, 1985. This law requires all front-seat passengers in motor vehicles to be restrained either in safety seats or safety belts. An exemption to the law was provided for those drivers and passengers with a physically disabling condition that would prevent the use of these safety devices. For the purpose of the law, the term "motor vehicle" specifically excluded those vehicles that are "authorized emergency vehicles," including ambulance vehicles.

The overwhelming evidence in favor of using automobile passenger restraining devices is testimony that all ambulance services should incorporate into their standard operating procedures the following points:

    • All operators and front-seat passengers of ambulance service vehicles must use seat belts when the vehicle is in motion.
    • Any patient on a stretcher must be secured at all times when the vehicle is in motion or the stretcher is being moved.
    • All EMS personnel in the patient compartment must use seat belts when not attending to a patient and when the vehicle is in motion.
    • All non-EMS personnel in the patient compartment must use seat belts when not attending to a patient and when the vehicle is in motion.
    • Whenever possible, if a child is taken along to the hospital and the childās own restraining device is available, he should be placed in the device and belted into the ambulance seat.
    • If the child is the patient, he should be appropriately secured onto the stretcher with straps or a child seat.

The National Highway Traffic Safety Administration estimates that 200 children's lives were saved by child safety seats in 1987 (3). In addition, proper use of child restraints could save an additional 500 children's lives and prevent between 39,000 to 108,000 injuries each year.

It is unrealistic to expect the public to use seat belts if those in health-care professions fail to do so. The people of the community will notice when an ambulance drives by without a belted-in crew or a volunteer EMT drives his personal care while unbelted. Managers have known for years that it is not what you say that counts. Since it is what you do that people remember, present a good role model for your community.

Fire department personnel should also be aware that the National Fire Protection Association recommends that "drivers shall not move fire department vehicles until all persons on that vehicle are seated and secured with seat belts or safety harnesses in approved riding positions (4)"

Summary

There appears to be self-perpetuating trail of misinformation surrounding the issue of ambulance accidents. As with all problems, we must first acknowledge that a problem does exist and clearly distinguish the facts from the myths. The intent of this article was to clarify some of those misconceptions by using an analysis of one stateās four-year experience with ambulance accidents.

The next step in solving this problem is to create driver education programs that modify the behavior of ambulance drivers, adjust their attitudes about driving an emergency vehicle and make them fully aware of the hazards encountered in driving an ambulance.

In addition, consider adjusting the agency standard operating procedure so that all ambulances must come to a complete stop at all stop signs and red lights to minimize the number of accidents that occur in the intersection.

Readers who would like to learn more about this subject should contact their state EMS offices to determine if they offer emergency vehicle operator courses or continuing education programs that deal with ambulance driving. New York State has developed a network of 90 instructors who are qualified to teach the Ambulance Accident Prevention Seminar, a nine-hour classroom-based ambulance driver "attitude adjustment" program.

Two other organizations that have developed driving courses geared specifically for ambulance driving are:

Failsafe Driving Inc.
Alvin F. Davenport, President
2529 San Pablo Ave.
Pinole, CA 94564

National Academy for Professional Driving
Dick Turner, Chairman
1001-A South Interstate 45
P.O. Box 649
Hutchins, Tx 75141

References

  1. Elling R, Guerin R: Ambulance Accident Prevention Seminar Student Workbook. NYS EMS Program publication. December 1988.
  2. Staff Report, "Exploring the intersection illusion." Mechanical Engineering . February 1986.
  3. EMS Week: Your Time to Shine Planning Guide. U.S Department of Transportation, National Highway Traffic Safety Administration booklet. May 1988.
  4. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program. 1987 Edition.

 

Figure 1-Driver Reaction and Vehicle Braking Distances in a Light, Two-Axle Truck

Miles Per Hour Driver Reaction Vehicle Braking Total Stopping

Distance* Distance* Distance*

10 11 7 18

15 17 17 34

20 22 30 52

25 28 46 74

30 33 67 100

35 39 92 131

40 44 125 169

45 50 165 215

50 55 225 280

55 61 275 336

60 66 360 426

*All distances given in feet.

Figure 2-Ambulance Types and Weights

Ambulance Type Maximum Gross Vehicle Weight Average Manufacturer

Curb Weight

Type I 11,000 lb. 8,630 lb.

Type II 9,000 lb. 7.065 lb.

Type III 11,000 lb. 8,860 lb.

 

Figure 3÷Safety Equipment Used in Accidents Studied

Device Major Injury Minor/Moderate Injury No Injury

No Restraint 62 561 820

Lap Belt 22 357 498

Harness 4 135 209

Lap Belt/ 22 336 500

Harness

Child Restraint 1 5 19

Helmet 4 9 0

Unspecified 29 256 1,027

Total 144 1.659 3.073

Response Letter JEMS October 1989

Hit or Myth

Robert Elling's July article, "Dispelling Myths on Ambulance Accidents," was excellent and long overdue. His dissection of the emergency medical vehicle accident (EMVA) data in New York state by outlining six myths of ambulance accidents was compelling. And his very readable commentary on this little studied problem in EMS specifically and public safety in general was also valuable.

The problem of EMVAs has been present since the invention of red lights and sirens. Yet, little data is available regarding this appalling problem. The very mention of these accidents causes most EMS administrators to briskly change the subject.

I have been interested in this problem for some years and would like to offer the theory that emergency responses actually cause many more accidents between private vehicles than accidents involving ambulances, fire trucks or police cars. We at Medical Priority Consultants call these "emergency vehicle-related accidents" and estimate that this previously unidentified phenomenon represents many times more the number of accidents identified by any official statistics. Nevertheless, according to my math, the problem is approaching immense proportions on a national and international basis.

I was pleased to see Mr. Elling state that, "Implementation of emergency medical dispatcher protocols can help reduce the number of Code III (red-lights-and-siren) responses based on predetermined medical interrogating and response procedures." Certainly everyone "responsible" for patient care and responder safety should read and re-read Mr. Elling's article and then heed his words.

Jeff J. Clawson, MD
Medical Priority Consultants, Inc.
Salt Lake City, Utah