Buckle Up: How to Decrease Ambulance Worker Fatalities

By Barnabas Odeyomi

Thursday, February 16, 2006, the weather was clear and the roads were dry. The crew had left Fordyce headed to Carthage in northeast Dallas County, Texas, never to return again. According to the State Police’s accident report, James Goodman, an Emergency Medical Technician (EMT) and Timothy Clowers, a Paramedic, were responding to a medical emergency when the 7 p.m. accident occurred. The driver of the ambulance lost control while negotiating a curve. The accident report indicated that neither of the men were wearing seat belts. The vehicle overturned several times before striking the tree, ejecting them both. Goodman was married with two children. Clowers was single.

A similar tragedy happened a year earlier on February 19, 2005.

Paramedic Christopher Clingan was killed along with two fellow Emergency Medical Service (EMS) providers when their ambulance was hit by a train. Two of the men were thrown out the back door as the ambulance spun around. The driver also was ejected, but the stroke patient on the cot, who was strapped on, stayed inside and alive, later recovering from her stroke. Another six inches, and the train would not have hit the ambulance.

Dale Clingan, Christopher’s father lobbied for mandatory seatbelt use by people in ambulances for their protection. However, Clingan said he heard all kinds of excuses, including that the providers can’t always reach their patients if they’re buckled.

“That’s why I think they should also be making changes in the back. They need to make the environment safer,” he said.

A study published by EMSWorld in 2015 revealed that four in five EMS providers in the back of the ambulance were unrestrained at the time of a serious crash. It was also found that whether ambulance occupants wear seat belts or not significantly predicts the severity of occupant injuries and fatalities. Furthermore, unrestrained providers are doing more than just getting injured – they also risk injuring their patients. EMS workers don’t fail to buckle up their patients. Investigations show that at the time of a crash, 96% of patients were buckled.

Although the annual fatalities of Emergency Medical Service workers have reduced significantly since 2006, the Bureau of Labor reported that in 2014, per 100,000 EMTs, 10 were killed while performing their duties. This number is brought into perspective when compared to the average number of fatalities per 100,000 for all workers in the same year–3.3.

EMT fatalities aren’t like college exams where it is desirable to be whole standard deviations above the average. That’s why work is being done on Hopkins’ Homewood campus to reduce the number of EMT fatalities on duty each day.

The Mechanical Engineering Senior Design Project is the capstone design project for MechE seniors, intended to give them some practice and experience in the art of engineering design. Students working in teams of 2–4 select a small-scale design problem from a preset list provided by the department. Teams apply for three of those projects and must write about early ideas convincing the department that they are the right team for the job.

Senior MechE majors Theophilus Moss, Joonghyun (Peter) Ahn, Oritsetimeyin Moju and Kyle Candela took on the challenge of redesigning the interior of a specific set of ambulances for greater safety. Professor Nathan Scott oversaw their project, which started in August 2015.
Nine weeks into the project, the young mechanical engineers were fully immersed in the challenges of real-world engineering. They sorted through vehicle safety regulations and consulted healthy industry professionals and EMT’s. On top of it all, they only had $5,000 to finance their project.

An important part to providing this safety was first understanding the interior of the back of an ambulance. Everything in an ambulance is there to stabilize the patient. Whether the patient has a broken leg or is in cardiac arrest, the ambulance has to be equipped for any situation. This is one reason why a Type I ambulance can cost up to $160,000. There are four major ambulance types- Type I to IV. Types I to III are van-based with different variations in form and purpose. For example, Types I and III have box like frames while Type II are vans with a raised roof. Type IV includes non van-based utility vehicles, such as motorcycles, all-terrain vehicles, and bicycles.

To add to the challenge, the group was working with the Johns Hopkins pediatric intensive care unit (PICU). A PICU ambulance has specialized equipment, like smaller cots with straps that accommodate children, a cardiac monitor with built in defibrillators, tiny blood pressure cuffs, and various solutions and medication at appropriate children doses.

The patient lies on the cot with his head oriented toward the front of the vehicle. There’s a service bench to the side of the cot with space for two or three EMTs facing the patient. Then there’s one seat at the head of the cot, called the airway seat, where an EMT is able to access the patient’s airway (mouth and nostrils).

The critical safety issue with these seats are the seat belts.

“All they currently have is a seat belt when seated but they often have to get up to grab equipment and supplies and to take care of patients,” said Ahn.

This is ironic, because it’s expected that EMTs should know better than to take off their seat belt and jeopardize their own safety while trying to save others. However, Moju explained, that isn’t necessarily their concern – rather, the most important objective is accessing the equipment on the opposite wall. “They have equipment on the opposite wall from where the EMTs sit. The wall has most of their equipment and most of the solutions they need and the patient is right in front of that wall,” he said.

Does this mean a design flaw is keeping EMTs from working most efficiently and maintaining their own safety? The group had to take several other factors into consideration before reaching a conclusion.

New Safety Regulations

In the bid to increase safety for EMT workers, the group had to be familiar with current safety regulations. The National Institute for Occupational Safety and Health (NIOSH) is responsible for conducting research and making recommendations for the prevention of work-related injury and illness. Their regulations act as guidelines and not mandates. NIOSH works closely with the Occupational Safety and Health Administration (OSHA) in the U.S. Department of Labor to protect American workers. OSHA goal is “to assure safe and healthful working conditions for working men and women; by authorizing enforcement of the standards developed under the Act; by assisting and encouraging the States in their efforts to assure safe and healthful working conditions; by providing for research, information, education, and training in the field of occupational safety and health.” OSHA has developed guidelines that recommends minimum training and personal protective equipment for EMTs. This guide is intended for employers of EMTs.

The guidance and recommendations issued by NIOSH and OSHA are often used by other agencies responsible for developing and enforcing workplace safety and health regulations. The recommended guidelines are not enforced, therefore not all states or agencies follow all the guidelines.

Jim Green, the head safety engineer for NIOSH, and considered a leading engineer for ambulance safety in the US, mentioned the goals for revising the ambulance crash safety standards. They included working with end users to ensure designs meet needs, incorporating changes into a few ambulance national standards, providing patients with the same level of crash protection as passenger vehicles, developing system specific standards for publication to be referenced nationally or internationally and ensuring all proposed standards are based on actual test data.

Furthermore, OSHA has acknowledged the tension that exists between the need to provide treatment and the need to protect EMTs. The hope is that in working with EMTs, NIOSH and OSHA will be able to base new regulations on actual test data that will allow EMTs to both be able to provide treatment while maintaining their safety.

The group of seniors got valuable guidance from experts in the field. Mark Van Arnam is the CEO of one of the largest ambulance production companies on the east coast, American Emergency Vehicles. He also sits on the regulations board for safety of ambulances on the National Institute of Occupational Safety and Health (NIOSH) board. He partially sponsored the seniors’ project. According to Mr. Van Arnam, the new regulations that they’ve just recently voted in, which will be implemented in 2016, requires EMT workers to be seated at all times. The extent to which these new regulations will be enforced is uncertain, because in the end, the employer (usually an individual state or someone like Van Arnam) decides what guidelines to implement and how to enforce the rules.

“Everyone that we spoke to that’s an expert in the field readily brought up a couple of accidents that took place before we met them,” Moju said.

Dr. Green talked about a crash in which an EMT wasn’t buckled in and instinctively held on to the infant, positioned themselves to take the impact and lost their life. This saved the baby.

“The trouble that comes with the Heroic Complex is that (and this comes into a design problem with us) they see themselves in a very self-sacrificial light already, but we’re worried about their safety,”

After a couple conference calls, he paid the group a visit at Hopkins. He highlighted the problem of EMTs putting their lives on the line for the benefit of others. This problem was termed the Heroic Complex. It’s the idea that EMTs consider themselves as heroes, which is not necessarily a false statement.

According to Moju, “The trouble that comes with the Heroic Complex is that (and this comes into a design problem with us) they see themselves in a very self-sacrificial light already, but we’re worried about their safety. We’re coming up with ways so that you don’t have to stand up, you can still be safe and still make sure that that person survives, but they’re still quite reluctant to the idea, because they think of the most tragic situations where, had they been buckled in, and that baby goes flying, then they’re gonna have the memory of an infant flying around the cabin, you know, experiencing all kinds of trauma.”

In the designing process, the seniors had to keep in mind the heroic and self-sacrificial nature of the EMTs. In doing so, they could design something that would not restrict the EMTs’ ability to protect and serve the patient, as apparently the current layout of an ambulance does. At the same time, they would design something that kept the EMTs safe while performing their heroics. “We have to make sure that whatever we produce can accommodate the worst situations…nothing is foolproof–but we can at least give it a shot,” Moju said.

A few weeks into the project, the group had been brainstorming ideas on how to keep the EMTs safe, including while standing. However, the new NIOSH regulations that would require all EMTs to remain seated, changed their approach. In Moju’s words, “the regulation is what’s driving the innovation.”

This is a reality that existing professionals have faced while working on increasing safety for EMTs. According to Ahn, there have been safety engineers who’ve developed systems to solve the problem. However, some of these innovations were not commercialized because they did not fit the current regulations.


In the bid to decrease the amount of time EMTs stand up, Ahn said: “we’re bringing some of the supplies and equipment closer to them, because right now the space in the ambulances are very confined and also it’s not very optimized for the EMTs.”

Another innovative idea was the use of modular pouches that keep essential items near the EMTs. “We are planning on developing modular pouches that can be attached to the walls near them that will hold the supplies that they can reach,” Ahn said.

The group also developed an innovative approach to validate the claim that EMT workers were not seated at all times as required. They wanted to gain more familiarity with the operational habits of EMTs in the back of the ambulance but were initially faced with a problem. The group could not record what went on in the back of the ambulance because of patient privacy laws.

Referred to as a visionary, Professor Scott proposed that the team should record and blur out video footage of the general movements to protect EMT identity. However, there was resistance from employers to that idea because recording footage who infringe upon privacy laws. Adapting to the situation, they designed a system that used pressure sensors to record sitting and standing times. “What we’re gonna do is that over every journey we’re going to monitor how frequently the person is sitting or standing,” Moju said. “And then what we’ll do later is cross check what type of call it was, what solutions they were using and from there we can prioritize what substances and what solutions we should put closest to them, optimizing the situation.”

The project, which commenced in August 2015, is a two semester project that ends with a presentation in May 2016. According to Candela, the end goal is testing plans and products, but not marketing.

“Our project is actually one of the more impactful projects of all, because we’re providing the EMT workers with safety, “ Ahn said.

When asked about the impact of their project, Moss spoke similarly: “Any systems we create, if massively successful can potentially be implemented in emergency vehicles worldwide.”

Footnote: EMT, EMS and Paramedics are used interchangeable.