A Profound Impact:

The Rest of the Story

How one agency started a crusade to make
ambulances safer for patients and providers
By Jeff Czyson, BA, EMT-P, & Brian LaCroix, BS, EMT-P

hirty years ago, when we first became

EMTs, we often stood in the backs of
speeding ambulances, believing the only
way to treat our patients was to put ourselves at risk. We didnt think much about
the fact that we should be wearing seat beltslet
alone designing safer ambulances.
Of course, we also didnt always wear gloves, balked
at the idea of female paramedics and shared patient
information with little regard for privacy. Those are
all things we wouldnt dream of doing today.
Some things have changed for the better, while in
other ways our profession is stuck in conventions we
think need to be shaken up. At Allina Health EMS,
we decided to focus on caring for our patients and
providers by embarking on a journey to make our
ambulances safer for everyone.

The Motivating Factor

In January 2014, on a snow-covered two-lane highway
in rural Minnesota, one of our ambulances was transporting a stable medical patient. About 30 minutes
after midnight, a small SUV, traveling in excess of 60
mph, crashed into this rig head-on. EMT Tim Daly,
who was driving a cautious 37 mph due to road conditions and visibility, suffered bilateral lower extremity
fractures and spent three months in a wheelchair with
multiple surgeries to his legs and feet.
Paramedic Brian Nagel was unrestrained while
caring for the patient in the back of the ambulance
when the collision occurred. The impact threw Nagel
violently into the bulkhead, causing a severe traumatic brain injury and rendering him unconscious for
seven days. Months and months of rehab and recovery
followed and continue today. The driver of the SUV
later died in the hospital.

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NOVEMBER 2016 | EMSWORLD.com

After dealing with the effects of this fatal crash

one of the toughest challenges in any of our careers
we realized we needed to learn more about what happens when ambulances crash and how we could try
to prevent another tragedy.
According to the Office of EMS at the National
Highway Traffic Safety Administration, which analyzed nearly 20 years of ambulance crash data, 4,500
motor vehicle traffic crashes involving ambulances are reported to law enforcement in the
United States each year. Thats an
average of 12 ground

Editors note: For the

background to this
story, see EMSWorld.
com/12095290.

ambulance crashes per day, with about 30% of those

resulting in injury.
While we would like to say otherwise, its probably
not a surprise that NHTSAs research showed that
84% of EMS providers in the backs of these ambulances were not belted. Its also not surprising that
when providers properly secure patients to the cot
with seat belts and shoulder straps, those patients
are at much lower risk of injury.
NHTSAs data, which is available at EMS.gov,
confirmed that our own crash experience was not
unique and motivated us to do everything we could

to help build a safer ambulance and create a safer

working environment for our caregivers. So, what
did we do about it?

Challenging Assumptions
First we researched our ambulance chassis options.
Its common knowledge that the patient compartments of a 1980s ambulance and one rolling out of
the factory today are virtually identical. We, as an
industry, have failed to advocate for safer patient
compartments, and manufacturers have had little
incentive to produce them on their own.
Think about the sheer volume
of purchases that drives
improved safety for

Authors Brian LaCroix

(left) and Jeff Czyson
(right) are pictured
with the newest Allina
Health EMS ambulance,
a Type III Sprinter
manufactured by
Crestline. Following
a significant crash in
December 2014, the
Allina Health EMS team
embarked on a two-year
effort to design a new
patient compartment
that is safer for both
patients and providers.

EMSWORLD.com | NOVEMBER 2016

47

consumer autos: Annually there are

approximately 7.7 million automobiles sold in the United States. The
mere 6,000 ambulances sold each year
have resulted in little to no research
and development for these vehicles in
which we spend our days (and nights)
and where our patients receive both
emergent and nonemergent care. We
set out to use the information available and develop a process to find what
worked for our providers and patients.
We initially explored larger ambulances because we assumed bigger had
to be safer. We were wrong. Unrestrained caregivers are likely to be
injured regardless of vehicle size. In
addition, the public we strive to protect is placed at greater risk when colliding with a larger vehicle. With this
realization, we focused our efforts on
finding a nimble, crashworthy chassis
with a strong service record and the
ability to carry a module. We consulted friends across the U.S. and the
European Union; after our research,
we embraced the Sprinter.

Team Priorities: Safety,

Ergonomics, Economics
We assembled a design team of mechanics, supervisors and caregivers with
various experiences, sizes and shapes.
This group developed a list of desired
features and specifications for the new
ambulance. Bench seats and lap belts
were out, forward- or rear-facing seats
with shoulder belts were in. Safety, ergonomics and economics, in that order,
became the teams focus. We wanted
clinicians to be seated and restrained
while providing care in the moving
vehicle, so we had to design a patient
compartment that made that possible.
Weighty equipment was positioned
so it was easily accessible when using
good lifting technique. HVAC and
electrical components were placed
so our mechanics could access them
without the need for time-consuming
disassembly. And controls were lowprofile to reduce protrusions into the
work space.
After compiling the list of desired
characteristics, we solicited vendors

48

willing and able to build a single Type

III Sprinter with no assurance of additional purchases. This was a big ask,
but to their credit, five manufacturers
stepped up. Each brought us a sample
of its existing work, and our design
team evaluated them thoroughly.
Three manufacturers stood out, and
we submitted our specifications and
wish list for each of them to build one
ambulance.
These three manufacturers knew
we planned to select one of them to
work with moving forward; however, it
quickly became evident that we simply
could not get everything we wanted.
Component testing, engineering
challenges and inexperience with the
Sprinter chassis made this a challenging build. The result was three vehicles,
each with a very different application
of our requested features. As expected
with a brand-new design, each required
some follow-up work, but we placed all
three new ambulances in service during the summer of 2015.

Allina Health EMS encourages its crews to sit down

and buckle up, something its team kept in mind when
designing the patient compartment. Controls for all
module functions are located on both the curbside and
street-side walls. The monitor/defibrillator is shown
swiveled to be within reach of a caregiver positioned in
the airway seat. This chair also contains a child seat and

Communicating to Win
Hearts and Minds
Our leadership team recognized these
vehicle designs were radical departures
from the ambulances Minnesota EMS
providers have been working in for
more than 30 years. To address this we
invested a great deal of time and effort
in communicating why the change was
necessary.
Our employees showed patience,
understanding and even appreciation
for this pursuit despite some obvious
trepidation. Members of the team
delivered presentations during mandatory staff meetings, shared blueprints
and plans, and established avenues
for communication. When the ambulances were placed in service, we asked
caregivers and mechanics to provide
direct feedback and share ideas for further change or improvement. If someone expressed a dislike, we expected
specific input so each issue could be
addressed appropriately.
In addition to communicating with
our staff, it was important to share
our efforts with our state EMS regu-

NOVEMBER 2016 | EMSWORLD.com

will rotate 180 to be forward facing for a third member

of the crew between calls. All seats have three-point seat
belts. Cabinet storage is located at the bulkhead and in
the rear corners of the vehicle. This photo illustrates the
openness of space as a result of eliminating overhead
cabinetry. The Ferno iNTRAXX system allows for
reduced cabinetry and more ergonomic function than
reaching up and around for supplies behind a door.
Removal of overhead cabinetry is expected to reduce
head and neck injuries, as the space above each seat is
now open all the way to the ceiling.

The Stryker Power-LOAD system provides

stretcher retention for greater patient and
caregiver protection in a crash and will also
help reduce musculoskeletal injuries from
repetitive lifting. Lights in the opened
doors illuminate the ground in the loading
area to identify sure footing.

Ferno SafePak
pouches are
shown on the wall
of the ambulance.
These pouches
are removable,
function well
in extreme
temperatures,
come in various
shapes and
sizes, and can
be positioned
anywhere the rail
is installed.

Ferno iNTRAXX rails are positioned on the wall

for the mounting of various equipment, allowing
flexibility in positioning supplies within reach of
a seat-belted caregiver. Brackets hold equipment
and supplies securely in a crash. Also pictured is
a movable mount for a laptop or tablet computer
and a seat that rotates to be forward-facing or at a
45 angle toward the stretcher. The stack below the
monitor contains a trash receptacle, two drawers for
supplies and a pull-out work surface.

EMSWORLD.com | NOVEMBER 2016

49

latory board. Since this was a dramatically

different design, some parameters simply
didnt apply any longer. One example was
the requirement for an attendant walkway of not less than 12 inches between the
stretcher and fixed bench. We no longer
had a fixed bench, and the rotating seat left
11 inches depending on which points you
measured from. The board embraced the
need for innovation to improve the EMS
care environment for our patients and clinicians. In fact, our regulatory board created
a work group to explore the KKK, NFPA
and CAAS ambulance standards and recommend one for future inclusion in Minnesota regulations.

Finding the Right Fit

Once the prototype ambulances were
placed in service, one design and manufacturerCrestline Coachstood out as the
best solution for our needs. The Crestline
model was also displayed at a number of
EMS conferences. The favorable responses
from our fellow EMS professionals, as well
as the shared feedback and additional ideas,
have been invaluable.
Most important for us was the feedback
we received from caregivers and patients.
A handful of patients provided unsolicited
comments noting how comfortable the
ride felt compared to other ambulances.
As we moved the vehicle between many of
our divisions, our process benefited from
greater exposure and feedback, including
e-mail messages from 41 employees sharing
specific likes and dislikes. This information was highly valued by the design team
and incorporated into updated specs for the
ambulances we would order.
We focused on communicating with
Crestline about lessons learned during the
build process along with recommendations
for future adjustments and have ordered 13
ambulances, which are currently in production. Another nine will be produced in 2017,
and nine more in 2018. The first of our 2016
ambulances was delivered in September.
The ambulance we selected has a
Freightliner Sprinter 3500 chassis with a
144-inch wheelbase. The module is able to
be remounted. All seats are forward-facing
with three-point seat belts except for the
seat at the head of the stretcher, which
rotates to face the rear. A short stack is posi-

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NOVEMBER 2016 | EMSWORLD.com

Throughout the planning process, the Allina

Health EMS ambulance redesign committee
worked with the vendors to identify and
place key design elements. Pictured here is
one of the initial design schematics for the
new interior.
tioned in front of the curbside seat which
will hold the cardiac monitor on a swivel
mount, letting it be reached and viewed
from multiple seating positions.
Most sidewall cabinetry has been
removed in favor of the Ferno iNTRAXX
storage system. Stretcher retention and
loading assistance was achieved with the
Stryker Power-LOAD system. Low-profile
controls are placed on both sides of the
module, while hard surfaces are angled,
rounded or padded to reduce any impact.
These ambulances are built to meet or
exceed the CAAS Ground Vehicle Standard,
which includes the crash safety requirements of SAE (the Society of Automotive
Engineers) International.

Equipment and Behavior

Changes for a Safer Ride
The 2014 crash had a galvanizing effect on
our staff and leadership, and we committed
to building a culture of safety within our
agency. In addition to studying the equipment available and making it as safe and
easy-to-use as possible, we also set out to
educate our staff and the public about the
need to strike a balance between quick service and safety.
Even if paramedics or EMTs are foolish
enough to consider themselves capable of
driving 90 mph safely, our ambulances are
not capable of performing well at those
speeds. We taught our crews that these
heavy vehicles operating at payload capacity are incredibly stressed, which runs the
risk of compromising performance or even
leading to catastrophic failure.
Second, we helped identify any less-thansafe driving behaviors by installing driver

alert and modification technologies from

Road Safety and Geotab. These devices give
real-time audio feedback about speed, braking and other factors. An annoying buzz or
beeping alarm sounds when the ambulance
exceeds preset parameters. The only way a
driver can stop the bothersome noise is to
slow down. Our speed problem came under
control almost overnight.
Additionally, we communicated to our
providers data from NHTSA that confirms
the importance of restraint use for both
patients and providers. And of course our
design team committed to ensuring the new
ambulances made it easier for caregivers
to address patient needs while remaining
restrained in the patient compartment.

Whats Next?
We remain vigilant in our support of the
culture of safety at Allina Health EMS. We
will continue to communicate the best practices of safe driving and advocate for the
use of restraints for patients and providers.
We will also continue to give our providers
the safest equipment possible to support
them in doing their jobs. While many of the
features weve included in these new ambulances are not unique, industry experts have
expressed to us that the combination is.
We hope others will demand safety and
ergonomic features in their vehicles and
share innovative ideas. If you have ordered
the same vehicle design for several years, its
time to explore what is out there and seek
innovation. The cost of this pursuit may
also leave you pleasantly surprised.
Furthermore, by insisting on these features, we can push manufacturers to invest
in further research, development and testing. We owe no less to the safety of our
patients and providers.
A B O U T T H E AU T H O RS
Jeff Czyson, BA, EMT-P, is the director of
operations for Allina Health EMS, based in St.
Paul, MN. In his three decades in EMS, Jeff
has served in a number of roles at the local
and state levels.
Brian LaCroix, BS, EMT-P, is the president/
EMS chief for Allina Health EMS, based in
St. Paul, MN. Allina Health EMS serves a
population of more than a million people
with a team of more than 600 caregivers,
responding to more than 260 requests for
service every day. Brian also serves on the
board of the National EMS Management
Association (NEMSMA).