Minimizing the Damage

   On April 3, 2009, an ambulance from Virginia's Carilion Clinic Patient Transportation was involved in a collision on Interstate 81 outside Lexington. Though the incident revealed some opportunities for improvement, the agency's overall culture of safety helped minimize what could have been far more serious consequences. Here service leaders review what went right and some lessons learned.

   The evening began like any other: in at 8 p.m. for a 12-hour shift. The crew checked and readied their unit for the night in a mixed 9-1-1 EMS and ALS ground transport base. Just before 6 a.m., they responded to a local tertiary care hospital to transport a patient with facial fractures and an intracranial bleed to the University of Virginia Medical Center for definitive care. The ambulance's occupants included the driver, the attendant in charge (AIC), the patient and the patient's brother, who was sitting in the front passenger seat. It would be a 2½-hour transport by ground.

   For the first 80 miles, the transport was uneventful. The weather was moderate, and traffic light. Suddenly, crew members found themselves in a downpour, and the driver noticed traffic beginning to stop ahead of him secondary to an MVC. The ambulance was in the left-hand passing lane on a moderate uphill grade. There was a tractor-trailer in front of it, and another one next to that. To avoid striking the truck in his lane, the driver began braking and attempted to merge to an open area on the right shoulder. However, as he transitioned across the right-hand lane, the ambulance began to hydroplane, then struck the rear of the tractor-trailer in that lane. The impact caused a significant crushing deformation to the front, causing both air bags to deploy.

   Belted in the rear-facing captain's seat, the AIC was uninjured. The patient, restrained with the typical three cross-belts plus two shoulder straps, remained secured to the stretcher. The stretcher, however, dislodged from its brackets and became airborne. It landed at a 45-degree angle facing the bench seat, with the patient landing on his left side.

   The AIC checked the patient first and determined there were no new injuries sustained during the accident. He then spoke to the front-seat passenger, who had been properly belted and was uninjured as well. Next the AIC checked the driver. He, too, had been properly restrained, but his left leg was pinned underneath the dashboard, and he could not move.

   The AIC's personal cell phone was damaged during the impact. The ambulance's cell phone and radio were inaccessible due to the vehicle damage-they had been rolled up under the engine housing, pinned against the floor of the cab. The AIC was able to obtain the driver's cell phone to call our communications center for assistance. The crew relayed their exact location and the status of their injuries. This enabled our communication center specialists to activate our post-accident/incident plan, dispatching appropriate resources to assist.

   After the arrival of crews from several EMS agencies and two fire departments, all four occupants were transported to Carilion Stonewall Jackson Hospital for evaluation. The driver was subsequently airlifted to Carilion Roanoke Memorial Hospital, a level 1 trauma center, for additional treatment and surgery of a suspected abdominal injury, fractured left leg and injuries to the ligaments of the left knee. The original patient was evaluated and subsequently discharged for continued transport to the UVA Medical Center. The front-seat passenger and AIC were treated and released from the local ED.

Lessons Learned

   Overall, the crew performed well: The AIC was seated in a rear-facing seat, a much safer position than a side-facing seat. On the bench seat, there would have been a significant chance of injury from the rapid deceleration and/or the stretcher striking his lower legs when it became dislodged. Per policy and our agency's culture of safety, everyone was belted in their seats.

   Our agency had just recently begun using the two shoulder straps on the stretcher in addition to the three customary lateral belts. We credit this for mitigating potential injuries to the patient. Equipment was secure in its proper location, reducing the potential for additional injuries from secondary impacts during the collision. The crew also did a good job of maintaining situational awareness and knew their exact location upon calling for help. The AIC exhibited leadership by triaging the occupants of his unit and providing the initial situational report.

   There were opportunities for improvement as well. A cardiac monitor-defibrillator, out of service for scheduled maintenance, was sitting loose on the bench seat during the transport. Upon impact, it broke through the safety net at the end, striking the bulkhead 14 inches from the captain's seat. It left an indentation of its shape on the cabinetry (see photo).

   Our team decided to utilize this event to educate our employees on the importance of our safety initiatives and policies aimed at enhancing safety. We had the ambulance towed to our main office and placed in the parking lot so our employees could look at the damage and discuss safety issues with one another. We held an informal "hot-wash" the day of the event and a formal debriefing in the days that followed. We encouraged them to ask questions and brainstorm better ways to transport safely.

   What we saw in our experience was that seat belts work, crumple zones in the frame rails work, shoulder straps on our patients work, reducing head-strike potential works, air bags work, boxes with welded tubular structural frames work, and sitting in the captain's chair while AIC is the safest place to be in the back of the unit. Carilion's commitment to safety helped minimize the damages to our crew and their passengers in this accident. We hope to continue to share that message, and the lessons we learned, with our employees and partners in the industry moving forward.

   Safety doesn't just happen by accident-it takes a constant, conscious commitment throughout an organization.

Kevin W. Peters, NREMT-P, is the safety and compliance officer at Carilion Clinic Patient Transportation. He serves on the NFPA Technical Committee for ambulance standards and is active with the EMS Safety Foundation. Reach him at kwpeters1@carilionclinic.org.

Charles A. Coffelt, BS, NREMT-P, is currently the director of EMS, ground transportation and the communications center for Carilion Clinic Patient Transportation in Roanoke, VA. He has served continuously in Virginia EMS for 16 years. Contact him at cacoffelt@carilionclinic.org.