1964 Superior Pontiac Rescuer

After EMS Expo last October, I wrote about the new Sprinter chassis designs featuring forward-facing attendant seats, manufactured by Miller Coach and Crestline Coach.

At EMS Today 2011, I saw quite a few more ambulances on display with forward-facing attendant seats. There were also a number of rigs built on the Sprinter chassis, including a couple of Type III conversions.

I’ve said before that I am intrigued by the inherent advantages of the Sprinter chassis design. Given the current economic climate and the inexorable rise of fuel prices, I’m betting a great many more fleet managers are going to give them a serious look.

They’re cheaper to maintain, last far longer, and sip diesel compared to other ambulances on the market. For a light-to-medium duty ambulance fleet, they probably make the most sense of all the available options. If you’re a medic working in a System Status Management system, particularly if you’re on the tall side, you’ll quickly fall in love with the legroom and headroom of a Sprinter.

Still, they have their detractors, and most of the complaints seem to center on the lack of foot room and storage space in the patient module. Our Borg Sprinters are fairly well laid-out, but they still offer less-than-adequate foot room between the bench seat and the cot. Most of our guys working in them have been spoiled by spending their careers in Type I boxes, and they bitch mightily about the lack of room.

Frankly, the argument doesn’t wash. Given half a chance, most of them would give their eye teeth for a flight medic position, wedging themselves into a BK117 every day:

Roomy, ain't it?

I’m a big boy, and I have no trouble working in a Sprinter. Granted, working in a van is a bit of an adjustment when you’re used to working in a box, but it can be done. Frankly, if declining reimbursement and increasing fleet costs meant a company’s choosing between smaller, more efficient ambulances and pay raises for its employees…

… this employee will choose the cramped ambulance, thank you very much.

The gripe about Sprinters being top-heavy is a legitimate one, but I’ve had the opportunity to drive these things a few times now, and if one drives them within our low-forces driving standards, they’re quite manageable. Most ambulance accidents could be avoided by simply slowing the hell down, anyway.

The folks at Miller Coach Company had at the show a new design based on the Sprinter chassis, a Type II conversion with a stretched wheel base and their reclining, forward facing seats:

Yes, it's a stretch Sprinter.

Plenty of cabinet space and foot room between seat and cot.

I'm digging the fold-down desk space...

Miller Coach’s design demonstrates that the Sprinter chassis affords plenty of room with the right module layout. I can’t quite remember how many more cubic inches of space this new design has, but from looking at it, there is plenty of room to dock my cardiac monitor, multiple IV pumps and transport ventilator, with enough room between the foot of the cot and the rear doors to secure a balloon pump. There’s as much cabinet space as the wide-body Type I boxes that The Borg uses for CCT rigs now.

Of course, there is still the issue of a relatively narrow footprint, being top-heavy. The solution to that would be a Type III conversion based on the Sprinter chassis; wider footprint, plenty of room in the back, while maintaining the ease of maintenance and most of the fuel savings.

Looks like the folks at Medix Specialty Vehicles were already thinking along those lines:

Medix 142 Type III Sprinter, owned by Trappe Fire Company.

As TOTWTYTR noted in his blog post on the subject, ambulance design hasn’t come very far in thirty years, but ambulance construction has made huge strides. In terms of HVAC, electrical systems, forward-facing attendant seats and structural integrity of the module itself, today’s rigs are a far cry from your daddy’s ambulance, even if they do still sport a similar profile and layout.

While there is still a viable market for the heavy duty chassis behemoths, I think that as more EMS agencies – public or private – start to feel the economic crunch, these Sprinters are going to become much more popular.

Looks like they’ve got the potential to represent a new era in ambulance design.

It had a 460 cubic inch gasoline engine, worn-out tires, brakes and suspension, and steering so loose I looked like a little kid driving one of those coin-operated toy cars you used to find in front of supermarkets.

I drove it like I stole it.

I can vividly remember hurtling down twisty country roads at oh-dark-thirty in the morning with my foot buried in the carburetor, pulling on gloves as I drove. Officially, the fastest any of us ever drove it was 85 mph, because my boss allowed us to exceed the legal limit by no more than 15 mph, and that’s as far as the speedometer went, anyway.

Unofficially, we were once clocked by a State Trooper at 130 mph, en route to the hospital with my very first trauma code as a paramedic.

It took age and hard-won experience to realize just how foolish we were back then. I lost a partner in an ambulance rollover in 1996, and attended plenty of other funerals in the years since.

It’s a dangerous business, driving an ambulance. That’s one reason I don’t bristle much at being called an ambulance driver. According to NHTSA crash data, ambulances are involved in 3,200 crashes per hundred million miles traveled. That’s 4 times as often as motorcycles, 8 times as often as cars and light trucks, and 15 times as often as heavy trucks.

And some of you guys chided me for buying a bike for my daily commute!

After 17 years in an ambulance, I wear paranoia like a second skin. If you think a motorcycle rider is invisible to inattentive drivers, you’ve obviously never driven an ambulance or fire truck.

Nowadays, we have sophisticated accelerometers that measure pitch and yaw in ambulances, and record driving habits of individual EMTs. We have drive cams, and engine governors, and fancy reflective paint jobs, and agencies are starting to take a long, hard look at the risks of lights and siren responses and transports. God knows the vehicles themselves are safer and more sophisticated.

And of course, none of that matters much unless the individual EMTs at an agency buy into the idea of a safety culture, a fact I alluded to in this column.

Some of my fellow Borg drones would rather run a red light than risk a 50% force count on their driving record, and we still have a few that will talk on a cell phone while driving Code 3 – even though they know they’ll be summarily banished from The Hive if caught.

Gradually, thanks in no small part to people like Nadine Levick, industry leaders have begun to pay more than lip service to provider safety, particular within the realm of ambulance transport. But one thing that has lagged behind is the ambulance design itself.

Greater structural integrity of ambulance modules, padded cabinetry, gee-whiz lighting systems and psychedelic paint schemes will only be of limited benefit as long as we still have unbelted providers working in the back of rigs, or sitting on side-facing bench seats. Modern restraint systems were designed for front-facing occupants. They’re far less effective when the provider is turned to one side.

That’s why I was intrigued to hear of Careflite’s new custom ambulances that eliminated the side-facing bench seat. Careflite’s CEO, Jim Schwartz, was at EMS Expo, and lectured on the egregious lack of safety standards for providers working in the back of an ambulance:

“The United States has more safety standards in place for the transport of cattle on a truck than it does for crew members in the back of an ambulance…”

True, and utterly inexcusable.

Careflite’s new rigs were built by Crestline Coach, developers of the Herb Tarlek/Ralph Furley paint scheme.

Their rigs, built on the increasingly popular Sprinter chassis, feature pivoting bucket seats equipped with 4-point restraint systems that are designed to be locked into the forward-facing position whenever the vehicle is in motion.

The interior was redesigned for maximum ergonomics, placing everything within reach of a belted occupant. Gone are any heavy equipment cabinets that open inward, minimizing the chance of ballistic projectiles in an ambulance crash. Every piece of equipment has its place, and a hard mount to dock it to. That’s an important feature, all by itself. After my ex-partner’s fatal crash, we found IV catheters and alcohol preps underneath the ceiling light fixtures. Crap flies everywhere in a rollover.

Last year, The Borg bought forty-something new Sprinter ambulances. From  a fleet-management standpoint, they’re a no-brainer: 50% better (or more) fuel economy, leg room and headroom to spare, substantially decreased maintenance costs, longer service life, and a lower overall price tag make it a very attractive option for a light-duty ambulance fleet.

Some of our kids, primarily the younger ones spoiled by working in large, roomy boxes for their entire careers, gripe about the lack of room in a Sprinter, but truthfully they’re far roomier than any Type II rig I’ve ever worked in, and the headroom in back and legroom up front can’t be beaten. If you’re a big guy working 12 hour shifts in a SSM system, they’re much more comfortable than our current Type I Chevys.

Currently, The Borg still uses Type I boxes for their critical care transport trucks, so I don’t work out of the Sprinters that often. In the configuration that we ordered, there simply isn’t enough room for our critical care equipment. That may change, however. Rumor has it that we have a couple of Type III Sprinters in the fleet, presumably being used as a test bed for future CCT rigs.

Just looking at the Careflite rig displayed at EMS Expo, however, I see no reason we couldn’t fit all of our critical care gear in that rig, and have room to spare. There’s a rack to hang my ventilator, room for poles to mount IV pumps on, a dock for my cardiac and vital signs monitors, and floor tie-downs suitable for mooring an IABP or something of similar size. A neonatal transport isolette would fit in there as well.

The Crestline-built rig of Careflite’s was a single seat version set up for Critical Care Transport, but Careflite’s web site boasts photos of their new rigs with a dual seat configuration as well.

Across the exhibit hall floor, coach maker Miller Coach Company had a competing version on display that boasted a dual seat configuration, with reclining seats that allow transport of a second supine patient, if necessary.

Al Miller of Miller Coach, demonstrating their new forward-facing configuration.

The McCoy Miller rig featured a more conventional cot placement and cabinet layout, but for my tastes, I think I’d prefer the Crestline Coach rig built for Careflite. It makes very efficient use of available space.

Still, either rig demonstrates that an ambulance without a side-facing bench seat has definite potential. Only time will tell if they are truly safer, but placing providers sitting forward is probably a good start.

But hey, that’s just my opinion. What do you guys think? In which rig would you rather work? Do you think you can adapt to working in a rig without a bench seat, or a side-facing seat at all?

One thing’s for sure, though. If these designs take off, that’s gonna spell the death of the old “Armor All the bench seat when your paramedic partner pisses you off” trick.

Enjoy.

I’ve said before that I believe EMS 2.0 should mean a leaner, more efficient version of prehospital care than what we have now, with the future equivalent of an EMT-Basic as the default EMS provider for most communities. Paramedics will be a relatively few, exquisitely trained providers capable of providing what we have always professed EMS to be, but so rarely is: an extension of the Emergency Department into the field.

To do that, we’re going to have to re-educate the general public and public officials about the capabilities and limitations of EMS, and probably the Emergency Department as well.

We’ve done a pretty fair job of educating the public about the capabilities of EMS, despite the fact that quite a few of my patients seem to think I drive a smaller version of a mass transit bus, only with Bandaids and free morphine. Where we have monumentally failed is in educating the public about what EMS cannot do.

That isn’t a failing unique to EMS. The public has totally unrealistic expectations of the capabilities of medical care in general.

Despite what you see on House, the best doctors are not unredeemable Vicodin-addicted assholes, nor are they geniuses with encyclopedic knowledge of every disease pathophysiology ever identified. I’ve never seen an episode of ER that showed the legions of people in the waiting room with toothaches, or demanding work excuses or inappropriate antibiotics for their viral syndromes. Despite what we saw on Emergency, 95% of our cardiac arrest patients stay that way despite our best efforts, and the camera never showed Johnny Gage showing up on a call at oh-dawn-thirty with dragon breath and his uniform shirt tucked into his underwear.

And before you comment on his bed head, everyone’s hair looked like that in the 70′s.

I watched Rescue 911 for years, and yet to this day, I’ve never been invited to a patient’s “new” birthday party. On the other hand, I have been subpoenaed invited to attend the lawsuit one filed against me to commemorate the day I saved his life.

In fact, if you want to see the most realistic medical show on television, just watch Scrubs. The medicine is generally correct if not terribly exciting, but the interpersonal relationships are spot-on.

#1 Dinosaur’s First Law states “The art of medicine consists in amusing the patient while nature cures the disease.” She may have cribbed the quote from Voltaire, but the reason she considers it her First Law of the Dinosaur is that nothing has come along in the 200+ years since Voltaire’s death to prove it demonstrably untrue.

So, if we’re going to re-invent EMS, we must first start with dispelling some of the dogma in EMS – not just in the care we provide, but in system design as well. So now I’ll channel my inner Al Gore (although, hopefully, without the blandness), and speak some Inconvenient EMS Truths. Actually, there are a number of Inconvenient EMS Truths, but I’ll confine this post to the biggie, the one that affects everything from EMS system design, to trauma triage guidelines, to the justification of EMS helicopter transport:

Inconvenient Truth #1: Very few of our calls are actually all that time-sensitive.

That admission alone can utterly transform EMS, folks.

With the exception of stroke, evolving MI, hypoglycemia and severe respiratory distress, very few of our calls require a rapid EMS response, and for most of those categories, prompt response usually only has the potential to effect morbidity, not mortality. I’ll even include multi-systems trauma in the category of calls that are not all that time-sensitive.

Most current research on trauma deaths indicates a trimodal distribution of trauma mortality: death within minutes due to neurological or vascular causes; death within hours due to hypoxia or hypovolemia; and death within days or weeks due to sepsis, Multiple Organ Dysfunction Syndrome, or other complications.

Of those three identified categories of trauma death, EMS has the potential to positively impact only one: those who would die within hours due to hypovolemia or hypoxia. Funny thing is, the outcomes in those patients don’t seem to reflect much difference between the patients who made it to surgery within the Golden Hour and those who made it in the Aluminum Afternoon.

And if you look at the reasons that middle group die – hypoxia and hypovolemia – one might argue that a good, old-fashioned EMT-Intermediate trained under the 1985 curriculum would be the most appropriate EMS provider for them.

That is, unless you pay attention to Ken Mattox’s research supporting permissive hypotension, and the studies that show poorer outcomes in trauma patients who are intubated. Then, you might say that the best EMS provider for a critically injured trauma patient is someone who can plug the holes, apply oxygen, and make an intelligent decision as to appropriate receiving facilities. That provider would be an EMT-Basic, pretty much the same critter as envisioned in the EMS White Paper way back in 1966.

We’ve built an entire belief system based on the myth of the Golden Hour, and extrapolated from it our own proprietary myth of the Platinum Ten Minutes. Nowadays, that Platinum Ten Minutes has more relevance to maximizing Unit Hour Utilization than to patient care, although your system’s managers will be loathe to admit it.

Most urban EMS systems in this country operate on an artificially contrived response time standard of eight minutes or less. Read the municipal ordinances that govern such things, and you’ll often see it actually required by law that the EMS system in a given area  arrive at the scene of emergency calls in eight minutes or less, 90% of the time.

Ask the city council members or lawyers as to why it’s written that way, and you’ll get a chorus of blank looks, much like you’d get if you asked a chimpanzee to perform calculus.

You may find an occasional one that will bloviate on and on about how the standards were derived, but – and primate experts and political commentators will back me up on this – the only thing worse than a chimp that can’t do calculus is a pompous chimp who pretends otherwise.

I’ll tell you what that eight minute response time standard is based on:

See that fourth link there, the one about Early Advanced Care?

Yeah, that one. For as long as I’ve been teaching their courses, the American Heart Association has stated that ALS care within eight minutes of arrest improves survival rates. That is what we’re basing that response time standard upon. There are only two problems with that:

1. That number is based less upon science than conjecture, and the only two interventions proven to improve survival to hospital discharge are early and uninterrupted chest compressions, and early defibrillation – both BLS interventions. The benefit of ALS is, at best, theoretical. Now, with the advent of things like post-ROSC induced hypothermia, that may indeed change. But for now, there is precious little evidence to support the efficacy of ALS in cardiac arrest.
2. It’s a chain. Take out any of the first three links, and the best ALS care in the world is essentially meaningless. Fact is, the only meaningful response time standard is four minutes or less. If you can’t meet that standard, then the next best bet is just as reliably derived by using the Magic Eight Ball as it is by copying the ambulance ordinance from the next town over.

While we’re on the subject of time, and its overstated importance in what we do, let’s look at lights and siren transport, shall we?

I’ve often said that twin water-cooled .50 caliber machine guns and a snowplow bumper would be more effective than lights and siren, and I was only half-joking. Lights and siren usually don’t buy you that much time, but throwing a burst of armor-piercing rounds into the Prius plodding along at 45 mph in the left lane would improve my job satisfaction by an order of magnitude.

In a North Carolina study, lights and siren response saved an average of 43.5 seconds. In Syracuse, NY, it was 1 minute, 46 seconds. In Minneapolis, it was a whopping 3.02 minutes. Yet, as I’ve pointed out earlier in this post, unless those time savings represent, consistently, the difference between a four minute response and something more than four minutes – on the 1% of EMS calls that involve cardiac arrest – then the end result is simply rapid conversion of money into noise and diesel fumes.

When it comes to the benefit of transporting with lights and siren, I’ll refer you to this quote from an article by Bryan Bledsoe, another EMS heretic who does a much better job than I at questioning EMS dogma:

“…Pennsylvania researchers studied a county-wide, single-provider, private EMS system that used 11 ALS ambulances. Annual call volume for the service area was 14,000, and the county population was approximately 90,000. A medical protocol was developed, and carried on each ambulance, that provided medical criteria for lights and siren transport. A total of 1,625 patients were entered into the study. Based on the medical protocol, 92% of patients were transported without lights and sirens, while 8% were transported with lights and sirens. No adverse outcomes were identified as being related to non-lights and siren transport.”

From later in the article, comes this:

“Do the benefits of lights and siren transport outweigh the possible risks? Again, this must be a local decision. A recent study estimated that the fatality rate for EMS personnel is 12.7 fatalities per 100,000 EMS workers annually, which compares with 14.2 for police, 16.5 for firefighters, and a national average of 5.0 during the same time period. Most fatalities were due to traffic accidents.⁷ Some industry experts have estimated that there are 12,000 ambulance-related crashes annually in the United States, causing nearly 120 deaths.”

It’s pretty clear that, despite what we tell the public, despite what we tell ourselves, that the vast majority of EMS calls aren’t a life-or-death struggle set to the ominous ticking of a clock. It’s time we stopped pretending otherwise, and started doing research to determine exactly what calls are that time-sensitive, and what is the optimum response time standard for those types of calls.

And while we’re at it, start the long and arduous task of educating John Q. Public that, should he call an ambulance for the knee pain he’s had for a month, he can expect an ambulance in roughly the same time frame he can expect his cable television installer – some time next Thursday, between the hours of 8:00 am and 5:00 pm.

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That’s all the preaching I’ll do for now. There may be Inconvenient Truths to come, unless my ADHD kicks in and I – Hey guys, let’s all go ride our bikes!