Ground Ambulances
Ground ambulances are the primary means of prehospital patient transport and the most common vehicle used for interfacility transport. As with selection of any vehicle for neonatal-pediatric transport, consideration of the potential advantages and disadvantages of the mode of transport is important.
Ground vehicles offer many advantages over air ambulances. More ground ambulances are routinely available to serve a given geographic area. Although the scope of services (critical care, advanced life support, and basic life support) and availability of ground ambulances may be limited in many rural areas, urban and suburban areas usually have large numbers of ground vehicles in their service areas. If an ambulance breaks down, other ambulances are likely to be available for backup. Parts and maintenance also are more readily available, so that a disabled ambulance can be back in service without extensive delays. Diesel fuel or gasoline also is more readily available than aviation fuel.
The ground ambulance can operate in weather conditions that often restrict safe air operations. Thus, transport team members determining the mode of transport will have a reliable vehicle that should be readily available in a wide range of weather situations.
The transport environment of the ground ambulance may be more userfriendly and functional for the transport team than other vehicles. The cabin usually is larger than cabins in aircraft, and many vehicles are able to accommodate 2 to 4 transport team members and 1 or 2 patients, depending on the configuration of the vehicle. There also are fewer restrictions to the size, weight, and amount of equipment that can be taken on a ground transport. Unlike aircraft, especially helicopters, there usually are not significant weight issues in ground transport for the amount of equipment that can be carried or the location of the equipment during transport.
Another advantage is that the transport team can easily “pull over” and interrupt a transport in an emergency situation to facilitate patient assessment and intervention. If necessary, the ground ambulance also can be easily diverted to the closest hospital if the patient's condition deteriorates or supplies have been exhausted.Ground ambulances provide door-to-door service, with no need for a helipad, landing zone, or runway. The patient or incubator is secured on the stretcher, which is then secured in the ambulance for transport directly to the receiving facility. The patient does not need to be moved from vehicle to vehicle. Keeping transfers between vehicles to a minimum is always desirable.
Many health care professionals believe that it is easier to educate personnel for ground transport than to educate them for air-medical transport. Medical personnel can be oriented more quickly to ground safety procedures and to the location and proper use of supplies and equipment. However, medical personnel unfamiliar with the world of “mobile medicine” may still find this environment most challenging.
In times when cost, use, and reimbursement are important issues, the ground ambulance remains the most affordable vehicle to operate. The approximate cost of a medically configured ground ambulance is $150 000 to $350 000, depending on the manufacturer and model selected. The annual maintenance and fuel costs might range from $10 000 to $25 000 per vehicle. Costs vary depending on annual use of the vehicle. Compared with the costs for helicopters and airplanes, the ground ambulance costs considerably less to operate, purchase or lease, maintain, and insure.
There are 3 basic types of ground ambulances. A type I ambulance is a modular or box-type unit mounted on a conventional cab and chassis. Unless specifically modified, a passageway does not connect the crew and patient compartments. Type II is a standard van in which the body and cab are continuous. A type III ground ambulance is a larger modular-type vehicle with a walk-through between the cab and the patient compartment.
A decision about the type of ground ambulance for a transport system should be based on numerous factors. Most important are safety, expected patient population, and the maximum number of transport team members and patients to be transported at one time. In addition, it is important to consider the amount, type, and size of medical equipment that will be taken on transport.
Although there are many advantages to the ground ambulance, there also are limitations. Ground vehicles have a high potential for a rough ride because of the type of vehicle suspension, narrow wheel base, high center of gravity, and bad roads. The bouncing and vibration may be painful or potentially detrimental to certain patients, including those with vertebral fractures and other orthopedic injuries as well as the neonate with potential for intraventricular hemorrhage.
Another common problem is the possibility of motion sickness for the patient, family member, and transport team members. This usually is a result of various factors, including a confined space, poor ventilation, sideways seating, poor road conditions, a lack of visual references (the horizon), and a loss of orientation to the direction of travel. The smell of gasoline or diesel fuel may be an aggravating factor for people experiencing motion sickness. Medication to prevent or alleviate motion sickness may be beneficial. Transport team members should, however, be concerned about the potential adverse effects of any medication taken, especially drowsiness. Optimal vehicle ventilation, visual fixation on a distant object, and other nonpharmaceutical approaches have proved helpful.
In any mode of the transport, vehicle configuration should ensure the safety of not only the patient but also the transport team personnel. This is especially important in ground ambulances because of recent data showing that an increasing number of fatalities in ground ambulance crashes occur in the occupants in the rear of the ambulance.
If possible, transport team leaders should meet with ground ambulance vendors to build an ambulance to the specifications of the team. Size and layout of the ambulance will depend on the transport team's personnel, discipline of practice and number of transports performed. The traditional box ambulance has its advantage of being large, allowing transport personnel to move about to tend to the needs of the patient; however, this is also a detriment, because a team member may have to unbuckle seat belts and safety restraints to move closer to a patient. The typical box ambulance configuration has a side-facing bench seat. Ambulance crash studies looking at frontal impacts have shown that even with safety restraints, a rear compartment occupant in a side-facing bench or seat can experience more significant forces more than an occupant sitting in a frontward- or rearward-facing seat. These serious forces can result in serious neck injuries and possibly death as a result of the head continuing to move laterally as the occupant's body is belted in place.This risk of rear occupant hazards has brought about a new philosophy looking at smaller ambulances, such as the Mercedes Sprinter. Being more economically affordable and fuel efficient, these ambulances can be ergonomically configured so that medical providers can reach for equipment and tend to a patient without having to unbuckle restraints and move around. This ambulance unit, used in Australia and by 1 ground ambulance provider in the United States, has front-facing seats that are tested to 20 g and can only be swiveled to the side and folded up when not in use. Furthermore, by reducing cabinets and obstructions in head strike zones and minimizing the chance of ballistic projectiles in an ambulance crash, this ambulance design can eliminate potential devastating injuries.
Ground ambulances have significant time, distance, and access constraints. They may be unable to proceed into remote or restricted areas. Their speed is limited, and traffic congestion, construction zones, detours, inclement weather (eg, rain, floods, fog, ice, and snow), and inaccessible terrain can delay or halt ground transport.
With lengthy trips or long distances and prolonged out-of-hospital times, there may be a greater risk of patient complications and fatigue of the transport team members. When the number of ground ambulances is limited, the dispatch of one unit on a distant transport may cause other areas to be underserved temporarily.Ground ambulances should have a well-defined and well-documented vehicle maintenance plan to prevent a vehicle failure during the transport of a critically ill patient. Ambulance manufactures typically provide recommendations for service intervals either in miles or in time (usually months). For example, checks of the lights, signals, warning systems fluids levels, tire pressure, wipers, brake pedal travel, air condition and heating systems and monitoring of the engine condition should be done on a daily basis. Oil and filter changes, checks of the suspension, engine belts, alternator tire and break wear and battery load should occur at 3000-mile intervals. At the 6000mile mark, the suspension, differential, fuel filter, brake rotors, and brake pads should be inspected. Replacement of the belts, fuel filters, air filters, and transmission fluid should be performed at the 9000-mile service checkup.
Because ambulances undergo more vehicle operational wear and tear than a standard truck or utility van, a more aggressive preventative maintenance plan should be used. Detailed maintenance histories and monitoring can identify vehicle component or system failures after a particular time of usage. Parts can be replaced prior to the time onset rather than waiting for a break down during an emergency transport. Furthermore, the maintenance needs will depend on the ambulance service area: an ambulance operation that services a mountainous area will have very different issues than one that operates in the desert.
Overall, although ground ambulances have their limitations, they remain the dominant vehicle in patient transport and often the preference for critical care transport.