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Journal of Emergency Medical Services (JEMS), July 1989
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
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.
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.
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.
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.
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.
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:
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:
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)"
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.
National Academy for Professional Driving
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
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
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