Butler County EMS in El Dorado, KS, has been seeking ways to revamp safety throughout the agency. Chad Pore, the county's EMS director since 2014, analyzed the design of the ambulances in the fleet and wanted to get away from the big-box format.

Then Pore met Ronald Rolfsen, special advisor for the prehospital medicine division/ambulance department at Oslo (Norway) University Hospital. Pore was intrigued about Oslo's use of low-top SUV-like vehicles for its ambulances. Now he's found a way to bring to America an innovative vehicle design that already is in use in Europe.

Butler County EMS hopes to take possession of the first low-top ambulance in the United States in July.

"We have worked to improve the overall safety and efficiency of our organization," Pore says. "I feel we've taken a step no one else in the U.S. has taken because we received approval to build the first low-top Sprinter ambulance in the U.S."

Over the last two years, Pore has worked with Rolfsen on the design and safety benefits of the low-top Sprinter. The conversion that Osage Ambulances in Linn, MO, will create on the Mercedes low-top Sprinter shell is based solely on promoting safety for both the crew and the patient.

"I've been looking for a long time for ways to increase safety, and I looked to the vehicle as the first line in that mission," Pore says. "[Rolfsen] asked me why we use high-top Sprinters. I said we want the medics to be able to stand up. He said we want them to sit and be safe during transport. So he showed me their designs and how everything is reachable to treat the patient from the seat."

Pore says the low-top ambulance costs approximately $120,000–$130,000, while the box-type ambulance is $180,000–$200,000. Because of the costs and safety enhancements, Pore says it was not difficult to convince Butler County commissioners to approve the low-top model.

"We have a forward-thinking commission," Pore says. "The commissioners allow us a lot of freedom. They were already used to the Sprinter because of a 2014 demo we use. We initially asked for two low-tops, but the commission said 'Let's do the first one and make sure it's what you really want.' We talked a lot about the safety side with the commissioners, and they asked a lot of questions. One question was, 'Aren't people going to be uncomfortable standing up?' That's the point. This forces them to sit down and stay buckled in; thus the liability decreases for the agency."

The trick for Butler County was that no manufacturer in the United States had ever converted a low-top vehicle into an ambulance.

"We asked a bunch of manufacturers if they would design one for us, and they all said no," Pore says. "Getting Osage to do it was trickier than getting the commission to approve it. One, Osage had not done something like this before, and two, they're very strict about following safety standards. They want to make sure everything they do has been tested or meets their standards. For the seat, they would only use one that has been crash-tested. We needed to make sure Osage could still meet the quality they're committed to. Osage doesn't want to build it and have us get it and not like it. But I know our department will like it because of the safety concerns that are addressed."

Rolfsen was given permission to share a complete set of drawings Oslo has used for its low-top Sprinters with Butler County. Pore shared those with Osage.

Pore says the low-top ambulance will bring the patient and crew closer together in the back of the ambulance while the medic can remain seated with a seat belt.

"One big thing we are doing is eliminating the traditional bench seat," Pore says. "It will have one forward-facing seat, and Osage is building a cockpit around it. The radio, oxygen, medicine and blood pressure kit will be on the opposite side by the medic. On the street side we are eliminating the cabinets on the lower part. That will help us slide the stretcher over more. The monitor will be on the street side, across from the crew member. Whether the patient is critical, stable or has minor injuries, the crew member should have no reason to get up."

Pore says working with Rolfsen has been enlightening.

"A lot of ambulance companies are putting in forward-facing seats that rotate," Pore says. "But Ron asked, 'Do you have that in your personal vehicle?' He is very good at paying attention to detail. I walked around with him at a conference, and he analyzed all the products for safety, pointing out safety issues on various products such as seat belts, down to a plastic piece that affects the belt bunching up, that I had never thought about."

Rolfsen is all about safety, and particularly ensuring that the crew remains seated.

"Safety is the No. 1 issue," Rolfsen says. "First, you should sit either forward- or rear-facing. Sideways is suicide. There is no scientific support that sideways is safe. You're not supposed to stand in the ambulance; you're supposed to sit down with your seat belt on. With the low-top, you can reach the patient and equipment easily. The roof also gives access to hang infusion bags and oxygen outlets. It can all be accessed from the seated position. All seats should have three-point seat belts, and the patient should have restraints for the hips and shoulders."

Rolfsen says the driver has all controls for lights and sirens on the steering wheel for easy access. There also is a hands-free radio and microphone behind the mirror. The partition wall is moved back, and there is 10 inches of space that holds the driver's jacket, helmet and bag securely behind the driver seat. Additionally there are ice-breakers and seat belt cutters in the front and back compartments.

Small equipment is moved to the passenger side, where the medic is seated, and more cabinets are installed overhead.

"Most of the equipment is on the outside, and medics can access it from the inside and the outside with cabinets on both sides," Rolfsen says. "All the heavy stuff is placed as low as possible. The only thing on the side of the patient is the monitor and defibrillator. Paramedics can reach both. And the cabinets on that (street) side hold stuff you don't need during the ride. It's equipment the medics can access from the outside when they arrive at a call."

Overall, Rolfsen says, he believes having the ambulance built on one solid chassis is the best way to keep patients and crew members safe.

"I would rather buy an ambulance chassis with all the safety features already built in," Rolfsen says. "It is more stable when you're in crosswinds. It absorbs better in an accident."

Pore says Butler County wanted to move away from the box-type ambulances due to concern over increased injuries sustained in accidents.

"When you look at the number of ambulance crashes, you have to ask why we have big ambulances," Pore says. "When the crew is standing, it's not safe for them. The Sprinter low-top is one solid vehicle. We are trying to improve the safety of everyone involved—the driver, the patient and the medic."

While proceeding on the low-top Sprinter ambulance, Osage is also converting a medium-top Ford Transit for Butler County. It is expected to be completed in late May and will have the same interior design as the low-top Sprinter.

"It's only 6 inches taller than the low-top," Pore says. "We are having them design the interior the exact same way as they will for the low-top, with a few tweaks."

Butler County also is focusing on better driver training.

"Firefighters and law enforcement go through extensive driver training," Pore says. "In EMS we hand the keys over, on the first day on the job, for a big-box ambulance. At Butler we do put medics through a class, but we're trying to improve our driver training. These are inexperienced big-box drivers. It's easier to put a driver into the Sprinter low-top because it's more like an SUV. It's more like a traditional personal vehicle."

The county is also emphasizing overall safety with all of its personnel while waiting for the new ambulances.

"We are getting people into the habit of buckling in," Pore says. "Our vehicle policy is to buckle in. When the new vehicle comes in, before we put it in the fleet and onto the street, we will put the crew in the back, buckle them in and run scenarios—one, to make sure the design works, and two, to show them they can still manage their patient. It's a way to get them in there and doing it themselves versus us telling them what to do. It will help get them to understand the importance of buckling in and that they won't have to stand up to take care of their patients. They will experience firsthand that they can stay buckled in, and it will not impact patient care. We will run scenarios for a month or two in the ambulance bay. Our crew understands safety, and they are willing to give it a try, even if some are not keen on the low-top design."

Pore says obtaining seat belt alarms also is up for discussion.

"We've talked about it, and we're still having debates," Pore says. "The question is, do we need to force that? We're not sure yet if we're going to do that."

The decals on the new ambulance also will be strategically placed.

"In Europe they don't cover the whole window all the way to the edge," Pore says. "Doing that makes the window stronger. But then it's harder to break out if you're in an accident and need to break out a window."

Enhanced Communication

Another benefit of getting away from the squad bench is enhanced communication between provider and patient.

“The most important thing is to communicate with the patient,” Rolfsen says. “In a patient-provider situation, in some cases, 90% of communication is nonverbal. When people are sick or injured, they retire, want to be smaller, go inward. How do we communicate with children? We get on the same eye level. When we place a patient on a stretcher in the ambulance we must place the chair beside the stretcher so that the provider can see the patient’s face. Probably more than 90% of patients can be seated at a 20-degree elevation. With this design medics can reach the patients from the knee up to the face. If you are sitting in a captain chair in a traditional ambulance, you communicate with the patient’s head, and the patient communicates with the back door.”

Susan E. Sagarra is a writer, editor and book author based in St. Louis, MO.