ADVERTISEMENT
The Patient Compartment Reimagined
POLICY: Ambulance compartments developed around priorities of patient transport and equipment storage, not provider safety or working ergonomics.
STRATEGY: Reimagining configuration of the box could enable improvements in ergonomics as well as safety.
VISION: Less bending, twisting and contorted weight-bearing for providers can reduce injuries.
You don’t have to be in a crash to get hurt in the back of an ambulance. Just working as intended in a patient compartment can take a physical toll through difficult ergonomics and user-unfriendly design.
No designer or builder ever set out to provide an inhospitable box, of course. The ergonomic problems we face today developed inadvertently as we grew our mobile workplaces around function, with little regard for form.
“Ambulances were originally designed to put grandma in the back and take her to the hospital,” notes Jonathan Olson, MBA, MHA, NREMT-P, chief of operations for North Carolina’s Wake County EMS. “We’d sit back there and watch grandma and talk to her, and then we’d get to the hospital and unload her. But we’ve evolved from that point to where we are now basically rolling emergency rooms where we’re required to do things we can’t do sitting in the chair we used to talk to grandma from. And that’s happened without much focus on the safety of folks who work in the back of the truck. We’ve never really changed the design to accommodate paramedic safety.”
Our work environments have roots in the GSA’s Triple-K specification. But that was created as a purchasing spec, not a safety or design spec (it’s now due for retirement in 2015). And EMS has since become exponentially more complex, adding ever-more equipment and procedures within the same little space.
“Over the last 40 years,” adds Wake’s chief, Skip Kirkwood, MS, JD, EMT-P, “the business of paramedicine has evolved such that there’s lots of care that goes on in the back of that ambulance. The design that was settled upon in 1968 hasn’t been right for quite some time.”
Measuring the Problems
Your own musculoskeletal woes may testify to that, but there’s scientific literature too. A 2005 study from the U.K. found more than 40% of providers’ higher-frequency tasks required postures that needed corrective measures.1 Three years later Israeli researchers documented that medics often undergo nonneutral back postures, including twists greater than 20 degrees and sitting with the back flexed between 20–45 degrees.2
Those authors heard providers describe much discomfort: 74% said the paramedic’s seat was located inefficiently for performing clinical tasks; 77% said the vertical distance between the bench and stretcher was too great; 86% needed to steady themselves when their vehicle moved; 94% found the bench seat uncomfortable.2 In a separate article last year, the same team proposed an ergonomically improved design that would raise the interior roof height, replace the squad bench with new seats with better restraints, add an adjustable work-surface design and suspended utility cabinet, and move the monitor.3
That might reduce back flexion, but it’s not all we might consider. Last year Kirkwood and Olson got to experiment with reimagining the patient compartment in ways that could potentially reduce various common problems. Starting with a stretcher and four blank walls, they reconsidered all we know and commonly accept about things like seating and storage. They could move, place, mount and hang things wherever they wanted.
“There are some significant provider-patient needs that we can’t currently accommodate,” says Olson of current compartment designs. “We’ve tried within our fleet over the years to move things around and make them more provider-safe while providing better patient care, which means getting closer or in a better perspective to the patient on the cot. We think we’ve gone as far as we can go with that. It’s more functional now, but it’s not where we should be as an industry. To me that’s why we need to sort of blow up this whole idea of we’ve known as an ambulance for 40 years in the United States and start over.”
Starting Over
In reenvisioning the patient compartment, some areas Olson and Kirkwood considered were:
• The bench seat—This, they concluded early in the process, is something we could lose. “It takes up a lot of space, and it’s not functional,” says Kirkwood. “If you sit on it, you’re facing the right direction to work on the patient while you’re sitting still, but it’s also the right direction to get really hurt when the ambulance is in motion.” It’s also a difficult position for right-handed providers to perform basic procedures like starting IVs.
• Access to equipment—EMS depends on portable equipment, but current designs don’t always make it easy to get to.
“Generally, on any sort of complex call, crew members have to enter and exit the ambulance to get what they need,” says Kirkwood. “If you’re outside the truck and need something like the traction splint, you have to climb back up into the truck, make a 180-degree turn, dig through a toy box, find the tool, then make another 180-degree turn and climb back down. It’s hard on the back, it’s hard on the neck, it’s hard on the head, and it wastes a lot of time.”
Better would be mounting portable equipment in a way that it’s easily reachable when you’re restrained in transit, but also when you’re working outside the truck. One novel way to do that might involve turning the entire curbside wall into a series of swing-out doors on which items could be hung and secured. Items you could never find under the squad bench would be accessibly displayed for work, inside or out-.
• Cabinetry—Ambulance vendors have typically offered limited cabinet configurations, and EMS agencies have structured their inventories to accommodate the cabinets they had. This is precisely backward.
“We need to design cabinetry for the needs of the organization,” says Olson. “One thing you see now, especially in the fire apparatus industry, is that they start with a blank sheet and ask, ‘What do you want to put where?’ Then they engineer how to best place things and mount them, and when it comes time to take that piece of equipment off, you can get to it easily and ergonomically.”
As an organization evaluates what its equipment needs really are and what its crews commonly use, there may be different ways to store it in the rig.
Changing the Mold
Ambulance ergonomics are a complex interplay, and solutions aren’t always as simple as they seem. Powered devices that make lifting and carrying patients easier, for example, are themselves heavier and harder to carry. Safety and function and comfort in the EMS world often involve trade-offs.
Still, it seems worth spending some time revisiting the back of the ambulance. Beyond the well-discussed issues of crash safety, its working ergonomics are ripe for improvement too.
Says Olson: “We have come to the time where, as an industry, we have to take seriously changing the mold we’ve used for ambulances for 40 years in the United States. We have to focus on ergonomics, on provider safety, and on patient care.”
References
1. Ferreira J, Hignett S. Reviewing ambulance design for clinical efficiency and paramedic safety. Appl Ergon, 2005 Jan; 36(1): 97–105.
2. Gilad I, Byran E. Ergonomic evaluation of the ambulance interior to reduce paramedic discomfort and posture stress. Hum Factors, 2007 Dec; 49(6): 1,019–32.
3. Byran E, Gilad I. Design considerations to enhance the safety of patient compartments in ambulance transporters. Int J Occup Saf Ergon, 2012; 18(2): 221–31.
