A Fresh Outlook on Ambulance Design

I liked the MedTec design, 2 rotating captains chairs with all the radios and controls mounted where the bench used to be, doesn’t require the user to get out of his seat and walk across the floor to the next seat. Since we do most if not all of our care at the cot-side this makes mire sense to reduce the amount of moving we have to do. Add a wireless headset to interface the radios and talk to the driver, oh man, that’s sexy.

Kelly,
Up here at [redacted] Ambulance Service in [redacted], Maine we’re switching our Hortons to a new setup without a bench seat, in its place is a single seat that locks in three positions, forward facing, at a 45 degree and a 90 degree angle to the patient, they whole box has been redesigned so that you can do everything but manage the airway from that seat. Everything in the box is secured down but is still easily accessible. The latest units that we have taken delivery of are also outfitted with multiple airbags in the patient compartment. Our company has designed this setup without impacting provider comfort, there’s still plenty of head room out back (for most people) and plenty of leg room up front. As with anything in this trade of ours it will just take time for people to start utilizing these safety features.

By “no room,” what do you mean?

There’s more headroom than just about any other type of rig, including the big Type III boxes. As far as foot room, the first generation Sprinter conversions had none. Anyone with feet bigger than a little girl couldn’t put them flat on the floor between the bench and cot.

However, the current chassis layouts offer far more foot room than the previous versions. I have no problem maneuvering my size 12 clodhoppers between the cot and bench in The Borg’s Sprinters, and the McCoy Miller and Crestline conversions pictured offer a good deal more foot room than that.

As far as mechanical breakdowns, I couldn’t say. Our VP in charge of such things, who is known as a fleet management guru in EMS circles, seems to be satisfied with them. I do know that you only have to change the oil half as often, they get 50% better gas mileage, the tranny is a sealed Allison that only requires servicing every 100k miles, and there are Sprinters all over the world still running strong with over 500k miles. There are a few in Britain with over a million miles.

Is it possible you got a lemon, or that your fellow EMTs are just brutally hard on a rig? We’re known to do that, you know.

Anon,

“Currently in the set up that the Borg has, try putting yourself, a first responder, and the patient in the back working a CPR and you too would be griping about the space.”

Why are you still transporting codes? They encourage us to work them entirely on scene. I transported my first code in 6 years just last month, and that’s only because I couldn’t see leaving her in front of the altar in the middle of church services with 500 people speaking in tongues.

“The cot and the bench seat are so close together that if you have an obese patient you ain’t moving from head to toe unless you are crawling on the bench seat. Patients complain about not being able to move their right arms because it is up against a cabinet. Try transporting a claustrophobic patient, it isn’t fun.”

Yeah, I have the same gripe. The Borg’s rigs could be laid out better. Still, the Careflite unit has much more room than ours do, on the same chassis. The Borg had one of our Sprinters on display at Expo. I didn’t have a tape measure to do exact comparisons, but the Careflite Sprinter has noticeably more room, and a center-mounted cot. Look at the pic. There’s a lot of room between the cot mount and cabinetry.

We’ve got a few Type III Sprinters in the fleet, although I’ve yet to work in one. Don’t you think that may solve the complaints about lack of space?

“Most of them have requested a box unit instead of a Sprinter. I have even shown up on scene and had family be mad as a wet hen because they requested a box unit and we showed up in a Sprinter. I fully understand their complaint also because the Sprinter doesn’t allow for their family member to be transported in a position of comfort.”

That’s all about managing expectations. On a PST, I can see the patient’s point, and that can be handled with something as simple as special dispatch instructions for that patient.

On an emergency call, tough titty. This ain’t Burger King, and they don’t get to have it their way. They call for prompt, professional emergency care, and we deliver it. It’s asking a bit much to specify what kind of ride you get, as well.

“As for repair, from what the mechanics have said, it isn’t cheaper. From what one of the mechanics told me the engine is Mercedes and they are designed to burn so much oil every 600 miles.”

You actually listen to our mechanics? OUR mechanics??? DuDe, what have you been smoking? Next you’ll be telling me all our dispatchers know what they’re doing, too, and the folks in MSC actually know how to read! *grin*

Your opinion is not supported by research. Not even a little bit.

And there are plenty of major EMS systems in the U.S. who only transport SCA victims if/when they get a return of spontaneous circulation. All of which, by the way, adheres to current AHA guidelines as well.

Statistically speaking, for prehospital sudden cardiac arrest, the victims either gets ROSC in the field or not at all. The percentage of victims who regain a pulse in the ER is actually pretty low, and there is nothing that the Emergency Department can do for the patient, within the context of medical arrest resuscitation, that cannot be done by paramedics in Grandpa’s living room.

And if a patient is in cardiac arrest because of a massive MI, that patient is highly unlikely to be resuscitated anyway. Even if he were, and the arrest happened right there in the ER, the patient ain’t going to the cath lab until he gets a pulse back, anyway. And if we or the ED staff manage to get a pulse back, the amount of Epi we gave and the trauma done by chest compressions are likely to make your whole “time is muscle” argument moot.

So basically, that shoots down your entire argument, but I’ll give you half a point for the weak attempt at sarcasm.

Thanks for playing.

I probably am a bit lucky in that regard. Since 2005, The Borg’s percentage of SCA victims that survive to hospital discharge neurologically intact has risen from a little over 7% to over 21%, in just five years. The only thing we did different after 2005 was working our codes on scene, and de-emphasis of early intubation. Packaging and transport just interferes with quality CPR.

Before I worked at The Borg, I worked for a large national company that allowed us to work asystole on scene and not transport. As far as I know, I was the only medic who didn’t transport most of my SCA victims. Most of the other medics transported, even though they didn’t have to. Old habits die hard, I suppose.

Before that, I worked for a small Mom-and-Pop service as a field supervisor and education director, and I was the one that wrote our medical protocols. I haven’t routinely transported cardiac arrest victims since 2000.

I’ve read the arguments listed here-and you know as a student is “required to be belted in at all times” while in the back of a truck- its almost damned near impossible to do any patient care belted in a box- so any improvements that can be made whether it be in a redesigned box type unit or one of the Sprinters-will be welcomed by this paramedic student- I hope to see a truck that the patient can be accessed from both sides of the cot-so that we don’t have to violate the first rule we’re taught in Basic- “never stand over a patient” while trying to start a line or hook up monitors etc.

Kelly,

As for transporting because I was the student riding out with the Borg. I agree with working the entire thing on scene. But when you have newer Paramedics doing what more seasoned Paramedics tell them to do………….there ya go. One CPR showed asystole and after approximately 25 minutes went to PEA, old time medic said you gotta go. The newer medic (1 year experience), just prior to the rhythm change, had asked about calling it on scene. As for the second transport it was an MVC, we arrived to find the patient not responsive. Old timer pulled the patient out of the vehicle and off to the hospital we went.

As for the request of the units none of it has happened on an emergency as far as I know. Mainly because most of us do everything in our power to leave the Sprinters for the BLS and Skills trucks. And yes I listen to OUR mechanics, matter of fact they have worked on my vehicle, and it runs like a charm. I don’t know what kind of mechanics you have over there and what they are smoking, ours are decent.

As for dispatchers and MSC that is a story for another day. Though I can say dispatch here does have a few bad apples but generally speaking it ain’t so bad. It helps having them dispatch out of the same city.

This ambulance looks like it is a lot more safe the person in the back. Only time will tell if this catches on nationwide. It would be awesome if we could get rid of the traditional bench seat. It is so unsafe.

As a now retired “old Dinosaur” Medic (PreRegistry) The configuration looks plausible. There were a couple of reasons for the old bench seat. 1. The bench seat was a place to put a second patient in a multicasualty incident, and 2. Depending on manufacturer, it was either a “catchall” for ugly and seldom used equipment required to be carried, or it hid the backboard cupboard from outside. The old bench seat really needs to go the way of the old pontiac/cadillac lowboy ambulances. The cupboard under the bench was seldom, if ever, easily accessible when you really needed to get into it, and generally you needed to be a weight lifter to get it open and keep it open to get something while hurtling down the road anyways.
With todays modern protocol you need an ambulance for each critical patient and the days of transporting 2 for 1 SHOULD BE OVER, so the design just makes sense. To the young whippersnapper medic who made the snide remark “Where we going to take our naps without the bench seat?”. all I can say is…Real Medics can sleep sitting up…with the lights on!

Mark, preach it brother!

The only thing I’d add is that a real medic can not only sleep sitting up, but knows to open their eyes, turn their head and say “Clear right!” when the brakes are applied.

And real medics can sleep with their eyes open, too. Comes in really handy at long staff meetings.

I’d like to see an EMS specific rollover test between one of these Sprinter based vehicles and your standard F450-with-a-big-box-on-the-back Ambulance. The narrow wheel track and high roofline of the Sprinter just make me concerned at a gut level (though, as implied, there’s no actual evidence to back that up on my part) that they’d be more prone to tipping over than your dual-rear-wheel rig of today.

I just got my basic, and I’ve now been in the back of an ambulance all of three times now, so I’m hardly any sort of expert on the system, but even with that minimal experience (all in a big box truck) I can see that’s there’s room for improvement in layout.

Up here in Québec, Can, that kind of ambulance (type II) is forbidden. To be able to drive code 3, the ambulance need to be double-axled, so de facto type I or III.

A couple of MVA happened when an ambulance in overweight because of the staffing of a transfert team (attending medic, MD, RN, RT, driving medic, and obviously the patient) rolled over. The CSST (worker’s security office) with the coroner stated that either they change for bigger ambulance, or drive 20% UNDER the speed limit with a type II.

Were I work, we have big and bulky type III. I did my student ride along on a small type II (Demers Mirage). My preference? as a rather tall guy, the type III all the way.

As for the seating configuration, my main concern would be, if you seat forward, you have to twist your back every time you want to talk, or do care to the patient. A multitude of back injuries to happen, compared to the 1/100 000 chance of beeing in a MVA.

By “dual axle,” do you mean dual rear wheels?

Because there’s at least one coach manufacturer who makes a Type II Sprinter with dual rear wheels.

From what I’ve read on the net, it seems like many ambulance drivers are 18 years old, fresh out of high school. You think that might have any bearing on the number of wrecks? Maybe more extensive driver training, or a higher age limit might help. Personally I would be in favor of better training, ala Finland.

1) A lot of this could be avoided if people would slow the f*** down.

2) I’m not convinced that this is an ideal lay out. We still have to transport two patients frequently, so we need the bench. As to mounting equipment, it should be done, but it’s not easy to find the ideal spot in each ambulance for each piece of gear.

Maybe a Type III Sprinter would be the answer, but I haven’t seen any on the road in any industry.

Again, watch and soon you’ll see this layout…..

How widespread are these becoming? I am looking forward to moving to N.E. and I know in many places there, they try to stay up with the newest, latest & greatest. I really am hoping to see the inside of one of these for many many hours

I’ve worked in all 3 types of ambulances, and vastly favor the Type I boxes we had at the vollie squad when I started. We run Type III’s now, which are similarly roomy in back, but cramped in the cab. At the paid service where I worked, I used a mix of Type II’s and Type III’s, including some single-axle boxes we called “mini-mods”. I also did radio installation work for ten years or so, and explored the insides of some Type II Sprinters I put communications gear in. They seemed (to me, at least) to combine the worst of all types – they had the cramped cab of the Type III van cutaways, and the cramped rear of the Type II vans. I hope they’ve improved.

My wife saw Nadine Levick speak at a conference the year before last, and came home with feelings similar to mine (and TOTWTYTR’s, it sounds like) regarding ambulance safety: The ergonomics are important, both for convenience and safety, and improvements there are welcome…but the biggest improvement would be to train our drivers to stop crashing the damn things.

One of the things I dislike most about the Sprinter configuration in your photos (and also the Type II Fords I used to run) was the lack of exterior cabinets. The modular rigs have the best storage layout – IMHO, patient packaging gear should be outside, patient care equipment should be inside.

Nice post, AD.

here’s an honest question, though. Do those NFPA standards actually make you safer?

I’m sure some of them do, but they seem to become more unwieldy with each new one that is adopted. Such is the nature of regulations – they only become more complex and expensive to implement, never easier or cheaper. Now, NFPA is looking at formulating ambulance standards, when the KKK specs could simply be revised.

Seems to me they’re reinventing the wheel, and if new NFPA regs price a new apparatus out of the reach of many departments, forcing them to stretch the service life of an older rig… have they made you safer?

Bigger rig doesn´t mean less safety. Look at a lot of ambulances in Germany. Ambulances with a box and the same safety as the one above. The only question is how you built it.

I agree with you, with one small caveat.

Depending on the airframe, a number of procedures may be done on scene prior to loading in the aircraft, simply because the medic won;t have access to those areas once the patient is loaded. I know that is true of The Borg’s BK 117′s, and may well be true of other smaller aircraft.

Sometimes, some of the minor packaging and treatment steps can be done en route, provided your patient module gives you enough room to maneuver and reach the areas in question.

But for the most part, yes, the whole “Type II ambulances don’t have enough room for me to do my job” is a pretty weak argument.