V5

Ambulance Vehicle Operator:

Driver Behavior and Performance Checklist (D1)

Teri L. Sanddal, Director of Research

Nels D. Sanddal, President and CEO
Critical Illness and Trauma Foundation

With

Nicolas Ward and Laura Stanley

Western Transportation Institute
College of Engineering
Montana State University

A report prepared for the

Office of Research, Development and Technology

Research and Innovative Technology Administration
U.S. Department of Transportation
400 7th Street, S.W., Room 2440
Washington DC 20590-0001

April 6, 2010
Driver Behavior and Performance Checklist (D1) Disclaimer

DISCLAIMER

The opinions contained in this report are those of the authors and may not, necessarily, reflect the
opinion or position of Montana State University.

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Driver Behavior and Performance Checklist (D1) Acknowledgements

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the leadership, support and assistance of the staff from the
Western Transportation Institute who provided the overall guidance for the broader project titled
Driver Safety Research Program: Phase I Feasibility Study.

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Driver Behavior and Performance Checklist (D1) Table of Contents

TABLE OF CONTENTS
1. Introduction ..............................................................................................................................7
2. Methodology ............................................................................................................................8
3. Literature Review...................................................................................................................10
4. Results ....................................................................................................................................11
5. Conclusions ............................................................................................................................22
6. Recommendations ..................................................................................................................23
7. References ..............................................................................................................................24

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Driver Behavior and Performance Checklist (D1) List of Tables

LIST OF TABLES
Table 1: Curriculum Source and Hours ....................................................................... ….11
Table 2: States Requiring EVOC………………………………………………………...13

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Driver Behavior and Performance Checklist (D1) Executive Summary

EXECUTIVE SUMMARY

This report is part of a pilot study to examine the potential of using aftermarket data collection

devices to examine crash risk factors in rural EMS services and the potential role of feedback

provided by these devices to reduce unsafe driver behaviors. This report satisfies the specific

requirements of Task 1: Analyze EMS Tasks and Performance Standards. The purpose of this

task is to define the functional requirement for EMS driving so that unsafe driver behaviors can

be defined and identified in collected data. The Driver Behavior and Performance Checklist that

is embedded within this document represents, arguably, the first comprehensive attempt to

provide a set of performance measures that cover the broad range of safe ambulance operations.

The checklist is divided into three operational phases, those being: administrative, pre-response

and response. Testing and refinement of the tool is essential to improve its validity and

reliability. As those two parameters are improved, the tool should receive wide-spread

dissemination.

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Driver Behavior and Performance Checklist (D1) Introduction

1. INTRODUCTION
Ambulance crashes are too common in our national transportation system, especially in rural

areas. The total number of ambulance crashes including minor “fender benders” per year has

been estimated at 6,500.2 Vehicle performance standards, improper maintenance, variable

operator training, and improper safety restraint use have been noted as contributing factors.1 The

occupational fatality rate from ambulance crashes is four times the U.S. average when compared

to other occupations.3 Emergency medical personnel are at a higher crash risk than other first

responders including law enforcement officers and firefighters.1 The volunteer nature of the

workforce.4–6, inadequate screening of vehicle operators7–8, inadequate vehicle operator training

7–14
fatigue and distraction 2,7,11,16, poor knowledge of driving laws17, poor vehicle design 7,11,15,18,

and inadequate policies and procedures have been linked to the increased crash rates. Little is

known about ambulance crashes in general and rural ambulance crashes specifically.1.-2.

This report is part of a pilot study to examine the potential of using aftermarket data collection

devices to examine crash risk factors in rural EMS services and the potential role of feedback

provided by these devices to reduce unsafe driver behaviors. This report satisfies the specific

requirements of Task 1: Analyze EMS Tasks and Performance Standards. The purpose of this

task is to define the functional requirement for EMS driving so that unsafe driver behaviors can

be defined and identified in collected data. In the absence of existing driving performance

standards for EMS, this report presents the conclusions of an effort to generate a “Driver

Behavior and Performance Checklist” based on a review of existing Emergency Vehicle

Operations Course (EVOC) training curricula and an analysis of crash reports in the popular

press

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Driver Behavior and Performance Checklist (D1) Methodology

2. METHODOLOGY

The driving measure checklist was derived as result of an extensive literature review describing

the frequency and characteristics of ambulance crashes that served as a precursor to this project.

That literature review was augmented by the analysis of 466 consecutive ambulance crashes

reported in the popular press along with a comparison of EVOC training materials and state

requirements for EVOC training among ambulance drivers.

The literature search was conducted in a stepwise process. The purpose of the search was to

identify published literature that describes the frequency, epidemiology, etiology, typology, and

cost of ambulance crashes generally and rural ambulance crashes specifically.

The popular press (newspaper and television) reports are captured on a website

www.EMSNetwork.org. Media crash reports were downloaded and abstracted to identify

common characteristics between and among the crashes. Data were further stratified by urban

and rural to determine any characteristics unique to rural events. An example of differences

between urban and rural crash characteristics derived from the dataset is that while rollovers

occur with similar frequency between the two cohorts, most urban rollovers are as a result of

being struck broadside by oncoming traffic. In contrast most rural rollovers are caused by

leaving the roadway with overcorrection contributing too many crashes.

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Driver Behavior and Performance Checklist (D1) Methodology

The crash and driver characteristics that were identified in the literature review, the crash

database analysis, or as discussion points in the EVOC training curricula were examined to

determine if different organizational or individual behaviors could have avoided crashes. Only

systemic (those contributing to several crashes), rather than singular issues, were addressed in

the checklists. Wherever available, existing standards (e.g. National Fire Protection Association),

guidelines (e.g. DOT EVOC) and protocols (e.g. State of PA use of red lights and sirens) were

used to help define the desired driving behaviors.

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Driver Behavior and Performance Checklist (D1) Literature Review

3. LITERATURE REVIEW

A detailed literature review of ambulance crashes served as a precursor to this project and was

published in a peer-reviewed journal1. At the onset of this project that review remained the most

comprehensive analysis of peer-reviewed and trade journal articles pertaining to ambulance

crashes and served as one of three basic information sources used in the construct of the checklist

contained in this report.

An additional review and comparison between and among the three primary EVOC training

curricula20-22 was also completed. This analysis helped to identify similarities and differences in

training content and approaches that could lead to inconsistent driving behavior in the industry.

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Driver Behavior and Performance Checklist (D1) Results

4. RESULTS
The literature review from the previous study helped to define some broad characteristics of
ambulance crashes and identified broad differences in the etiology and outcome of rural crashes.
Of primary note, according to various published sources rural crashes occur with greater
frequency, are more likely to involve running off the road and result in injury or death more
often than urban crashes. From these broad characteristics the need for forward scan, passing,
and off-road recovery training among other foci were identified as issues to be addressed.

There are three primary EVOC training programs in use across the United States. These include
documents produced by the U.S. Department of Transportation20, the United States Fire
Adminstration21, and the National Safety Council22. A high degree of variability is noted
between these documents in terms of content and philosophy. Table 1. illustrates that the
differences between the courses in terms of content, approach and time commitments.

Table 1: Curriculum Source and Hours

Lesson # DOT Hrs USFA Hrs NSC Hrs

1 Introduction 1 Introduction .5 Self Appraisal NS

2 Legal Aspects 1.5 The Problem 1.5 Inspection NS

3 Communication 1.5 Motivation .5 Safety Cushion NS

4 Amb. Ops .5 Personnel 1 On The Road NS

5 Inspection 2 Legal Aspects 1 Spec. Considerations NS

6 Navigation 2 Physical Forces 2 Emergency Driving NS

7 Maneuvers 3 Maintenance .5 Final Test NS

8 Special Issues 3 SOP 1

9 Safety 1.5

10 The Run 1 NS = Not Specified

Total Hrs. (Estimated) 17 (Estimated) 8 (Estimated) 4

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Driver Behavior and Performance Checklist (D1) Results

Perhaps more significant than the variation in content and approach to the training, there were
subtle nuances noted in the philosophical approach to the training. An example of the differences
is noted below.

USFA21: “The emergency vehicle driver must possess fine coordination in

controlling his vehicle and reacting to traffic problems. He cannot drive
faster than traffic permits, nor should he drive faster than his ability to stop
in an emergency allows”. (p. 1).

DOT20: “This course will not cover pursuit driving or high-speed operation of an
ambulance. The U.S. Department of Transportation recommends operating
at or below the posted speed limits and getting to the scene safely”. (p. 7).

The former training program suggests that if the operator has enough skill then driving above the
speed limit is acceptable behavior while the latter clearly states that following the posted speeds
is preferred. In spite of the admonition of DOT to drive within the posted speed limit and in
disregard for research showing limited time savings in using red lights and sirens1-- seldom do
ambulances responding to an emergency scene do so within posted speed limits.

Perhaps more disturbing than the variability in training programs is the infrequency with which
states require EVOC training prior to operating and ambulance. Table 2, adapted and updated
from a survey conducted by the Minnesota EMS Regulatory Board in 2002, illustrates the
number of states not requiring such training -- even in the face of issues of patient and provider
safety.

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Driver Behavior and Performance Checklist (D1) Results

Table 2. States Requiring EVOC Thirty-one reporting states and territories

State EVOC Required? noted not requiring EVOC training for
Alabama Yes. Montana No. ambulance drivers. Of those answering in the

Alaska No. Nebraska Yes. affirmative several noted very minimal

Arizona No. Nevada No.

requirements. Using a gross definition of rural
as falling below the mean population density
Arkansas No. New Hampshire No.
of 86.2 persons per square mile, a higher
California No. New Jersey No.
percentage (48%) of states defined as rural by
Colorado No. N. Mariana Islands Yes.
this gross definition require EVOC training
Connecticut Yes. New Mexico Yes.
than the percentage in the more densely
Delaware Yes. New York No.
populated states (32%). (States highlighted in
District Columbia Yes. North Carolina No.
Table 2, fall below the mean population
Florida Yes. North Dakota No.
density by 2007 census estimates). However,
Georgia No. Ohio No.
in more urban settings with large corporate
Hawaii Yes. Oklahoma Yes.
response agencies training may be required at
Idaho No. Oregon Yes. the municipal or agency level. No data on
Illinois No. Pennsylvania Yes. these training requirements are available.
Indiana No. Rhode Island No.

Iowa Yes. South Carolina No

The proposed Driver Behavior and
Kansas No. South Dakota Yes.
Performance Checklist was developed
Kentucky Yes. Tennessee No.
following the examination of the extant
Louisiana No. Texas No.
literature, EVOC training programs, and
Maine No. Utah No.
ambulance crash database through an expert
Maryland No. Vermont No.
consensus process. It is designed to address
Massachusetts No. Virginia Yes. common characteristics known to contribute
Michigan No. Washington No. to ambulance crashes. It is broken into three
Minnesota Yes. West Virginia Yes. discrete phases, those being administrative,
Mississippi Yes. Wisconsin No. pre-response and response.
Missouri Yes. Wyoming Yes.

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Driver Behavior and Performance Checklist (D1) Results

Driver Behavior and Performance Checklist

Administrative Phase Measures

Scenario Definition Behavior Standard Source

Driving record A driving Employers will No persons with Agency policies.

record complete a records of DUI,
Driving Records
background background suspended
check is driving check on license,
completed all employees vehicular
prior to hiring (paid or volunteer) manslaughter or
any at the time of other infractions
personnel. It employment and that could
is updated annually jeopardize the
annually. thereafter. public’s welfare
shall be allowed
to operate the
ambulance.

Emergency vehicle All new hires A written exam All persons will State’s drivers
operation laws will be will be be expected to manual.
required to administered at pass the exam
take a time of hire and with a score of
written with every 85% or higher. Company policy.
examination recertification
covering the period thereafter
laws, rules that measures the
and individuals
regulations knowledge of
pertaining to emergency
emergency driving laws, rules
vehicle and regulations,
operations in including
the state. company policy.

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Driver Behavior and Performance Checklist (D1) Results

Scenario Definition Behavior Standard Source

Emergency vehicle All new hires The individual will All persons will DOT EVOC
operation will be complete all be expected to Training
capabilities required to required written pass the Curriculum or
either furnish and skill examination and equivalent
proof of objectives skill
successful demonstration
completion with a score of
of the 85% or higher.
NHTSA
EVOC
course or
successfully
complete
such a
course prior
to being
allowed to
drive any
emergency
vehicle

Emergency vehicle All new hires Vehicle specific Prior to the Company policy
operations check-off will be check-off forms operation of any
required to will be developed vehicle in the
be checked for each vehicle in fleet a
off in all the fleet that the supervisor will
vehicles they employee will have completed
will be operate. the operational
operating to checklist with
ensure the new
familiarity operator.
with controls
and
operational
nuances

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Driver Behavior and Performance Checklist (D1) Results

Pre-Response Phase Measures

Scenario Definition Behavior Standard Source

Shift exchange At the Driver/ operator Checklist should DOT EVOC

checklist beginning of with, or without include, as a training manual.
each shift his/her partner minimum:
(paid completes and headlights, turn
services) or files a indicators, back-
an a standardized up lights, side
scheduled safety report. lights, warning
basis lights, siren,
(volunteer audible back-up
services) an warning, tire
ambulance tread
safety depth/wear, and
checklist is all fluids.
completed.

Adjust seat At beginning Adjust seat to a Brake and gas DOT EVOC
of shift and position of pedals can be training manual
as maximum driving easily reached
necessary, control and and arms are
driver/ comfort. slightly flexed
operator when hands are
adjusts seat. in a 9-3 o’clock
position.

Adjust mirrors At beginning Driver sits in Mirror DOT EVOC

of shift and properly adjusted placement training manual
as necessary seat and adjusts should include a
driver/ LH mirror, and portion of
operator directs another to ambulance and
adjusts side adjust RH mirror provide for the
view mirrors to proper position. widest additional
(May be an coverage.
electrical
adjustment on
some vehicles)

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Driver Behavior and Performance Checklist (D1) Results

Scenario Definition Behavior Standard Source

Fastens seat belt Prior to any Driver fastens Driver/ operator State driver’s
vehicle own seatbelt and visually scans manual
movement ensures others other occupant
all occupants are fastened. positions or asks
must have for verbal Model lights and
occupant confirmation siren response
safety (In some prior to vehicle protocol
restraint instances movement.
systems prehospital
secured. personnel may NFPA 1500
choose not to Driver/ operator 6.2.5
wear safety displays
restraints in order increased
to facilitate care in vigilance when
the back of the rear provider is
ambulance. Such unsecured, by
incidents should slowing the
be minimized and vehicle and
the unbelted stopping at all
occupant should intersections.
inform the driver)

Response Phase Measures

Scenario Definition Behavior Standard Source

Hand Position During the Hands in 9-3 Arms are slightly DOT EVOC
entire driving position flexed when training manual.
episode, throughout hands are in a
drives with sequence except 9-3 o’clock
two hands as necessary to position.
on the operate various
wheel. controls or the
radio.

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Driver Behavior and Performance Checklist (D1) Results

Scenario Definition Behavior Standard Source

Lights and siren use. Determines if Activates lights Reads back Model lights and
(Response to scene) a true and sirens dispatch siren response
emergency (manual, wail or information to protocol
exists yelp) if indicated. ensure
understanding.
SAE J1849

Downgrades as
indicated upon
receipt of
additional
information from
first responders
at the scene.
Does not, under
any
circumstance,
proceed more
than 15 MPH
above posted
speed limit.

Lights and siren use. Determines if Activates lights Follows protocol Model lights and
(Patient transport) a true and/or lights and concerning siren response
emergency sirens (manual, lights and siren protocol
exists. wail or yelp) if use during
indicated. patient
transport. Does SAE J1849
not, under any
circumstance,
proceed more
than 15 MPH
above posted
speed limit.

Speed limit If not Obeys speed Speedometer State Driver’s

operating limits reading does not Manual
with warning exceed posted
lights and/or speed limit.
warning
lights and
sirens abides
by speed
limit and
other traffic
laws.

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Driver Behavior and Performance Checklist (D1) Results

Scenario Definition Behavior Standard Source

Changing Lanes- Signal intent Check side view Activation at State Driver’s
town to change mirrors, engage least 100’ before Manual
lanes prior to turn indicator, lane change.
and during complete lane
lane change change, turn
indicator off.

Changing lanes – Signal intent Check side view Activation at State Driver’s
country or highway to change mirrors, engage least 300’ before Manual
lanes prior to turn indicator, changing lanes
and during complete lane
lane change change, turn
indicator off.

Turning – in town Checks to Check side view At least 100’ State Driver’s
ensure turn mirrors, engage before turning Manual
can be made turn indicator,
safely. complete turn,
indicator off.

Turning – country or Checks to Check side view At least 300’ State Driver’s
highway ensure turn mirrors, engage before turning Manual
can be made turn indicator,
safely. complete turn,
indicator off.

Following Distance Maintains a Maintains a Scans are DOT EVOC

safety zone forward scan of continuous course
around the the distance
vehicle traveled in 10
seconds,
maintains a 2
second following
distance of the
closest vehicle
traveling the
same direction in
front of the
ambulance.

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Driver Behavior and Performance Checklist (D1) Results

Scenario Definition Behavior Standard Source

Overtaking/passing Looks in Checks oncoming Declines to pass State Driver’s

another vehicle – both rear traffic lanes to if yellow line or Manual
country or highway view mirrors; ensure sufficient no passing zone
activate turn space to safely indicators are
signal complete passing evident, or if
maneuver, checks insufficient
side view mirrors, vehicle spacing.
engage turn
indicator,
complete turn, Activates turn
indicator off. indicator at least
300’ before
passing.

Completes pass.
Turns off
indicators

Intersection travel As If light is green Slows to posted NRPA 1500

approaching slows vehicle to speed if
(Green light)
intersection, normal posted operating with
foot off gas, speed or less, lights and sirens
positioned visually scans all
over brake directions and
proceeds through
intersection

Intersection travel As If light is red Bring vehicle to NFPA 1500

approaching slows as complete stop, 6.2.8
(Red light or any
intersection, approaching proceeds only
other stop signals)
foot off gas, intersection. after visual scan
positioned Brings vehicle to and all traffic
over brake complete stop. yields.
Visual scan in all
directions.
Proceeds through
intersection.

Unguarded railroad As Brings vehicle to Bring vehicle to NFPA 6.2.11

crossing approaching complete stop. complete stop,
intersection, proceeds only
foot off gas, after visual scan
positioned and determines
over brake no trains are
approaching.

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Driver Behavior and Performance Checklist (D1) Results

Scenario Definition Behavior Standard Source

Backing Always has a When parking Waits to back NFPA 1500

spotter ambulance until spotter is in
during attempt to leave a place, follows
backing forward egress spotters
procedures. route. If backing is guidance in side
unavoidable, view mirror. If
enlists partner, if not visible
not engaged in repositions
patient care, or spotter.
another first
responder (fire,
law enforcement)
to guide backing
procedure.

Against traffic flow Used only Confirms that Visually scans NFPA 1500
when a true there is no lane for
emergency oncoming traffic oncoming traffic.
exists, there prior to entering
is no other opposite traffic
access route flow. Ensures that
to the scene, all warning
and vehicle devices are on.
is being Changes audible
operated signal (e.g. air
with both horn).
lights and
sirens

Compromised Changes When operating Alters speed DOT EVOC

driving conditions driving on icy or other when training program
procedures conditions where compromised
accordingly the coefficient of driving
friction is reduced, conditions are NFPA 1500
or where visibility encountered.
is impaired by
snow, rain, or
smoke, the driver
will slow to a
speed that will
allow for safe
response or
transport.

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Driver Behavior and Performance Checklist (D1) Conclusions

5. CONCLUSIONS

Driving an ambulance represents a hazardous operational environment. While most training

programs prepare prehospital care providers well for the clinical aspects of their job such as

opening an airway or controlling bleeding, they lack detail and specificity relative to driving

operations. External courses such as the Emergency Vehicle Operations Course20 provide

additional training and skill building opportunities. However, the need for strong company

policies concerning emergency vehicle operations and, in particular, those pertaining to the use

of lights and sirens when responding to a scene or transporting a patient to the hospital are

critical to the safety of the vehicle operator, the patients they serve and the general public1.

While the Driver Behavior and Performance Checklist passes the “sniff test” relative to face

validity, actual validation of the instrument has yet to occur. Some portions of that validation

may occur during an ambulance instrumentation project currently in progress by WTI, CIT and

American Medical Response. Additional refinement and additions will need to be made to the

checklist following that project and as others attempt to implement the checklist across a variety

of settings.

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Driver Behavior and Performance Checklist (D1) Recommendations

6. RECOMMENDATIONS

All EMS agencies should adopt and enforce strict policies concerning vehicle operations. These

should include administrative aspects that are enforced during the hiring and orientation phase, a

pre-response program to ensure appropriate readiness of vehicles and personnel, and an

operational phase to ensure safe procedures are used at all times during the response to and from

an emergency scene. The Driver Behavior and Performance Checklist is one way of contributing

to a culture of operational safety. The adoption of the model lights and siren protocol contained

in the article titled: Contributing Factors and Issues Associated with Rural Ambulance Crashes:

Literature Review and Annotated Bibliography1 is another essential step in the process.

The Driver Behavior and Performance Checklist should be validated and refined as necessary to

serve as a tool by which appropriate driving behavior can be taught, coached and measured. As

refinements are made, they should be shared with the trade and scientific literature.

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Driver Behavior and Performance Checklist (D1) References

7. REFERENCES
1. Sanddal ND, Albert S, Hansen JD, Kupas DF. Contributing factors and issues associated
with rural ambulance crashes: Literature review and annotated bibliography. Prehospital
Emergency Care. 2008;12(2):257-267.
2. Sanddal, TL, Sanddal, ND, Ward, N, Stanley, L. Ambulance Crash Characteristics
Defined by the Popular Press: A Retrospective Analysis. Western Transportation
Institute. 2009. Bozeman MT
3. Zagaroli L, Taylor A. Ambulance driver fatigue a danger: Distractions pose risks to
patients, EMTs, traffic. Washington, DC: Detroit News Washington Bureau. 2003;1-8.
4. Levick NR, Swanson J. Managing risk and reducing crashes: Implementing a driver
performance-measuring device in ground ambulances. Prehospital Emergency Care.
2005;9(1):108.
5. Institute of Medicine. Quality through collaboration: The future of rural health. 2005.
Washington, DC: National Academies Press.
6. Thompson, A.M. (1993). Rural emergency medical volunteers and their communities: A
demographic comparison. Journal of Community Health, 18(6), 379-392.
7. Cheng, C.L., Collins, J. & Eaddy, S. (2001). A comparison of rural and urban emergency
medical systems (EMS) personnel: A Texas study. Prehospital and Disaster Medicine,
16(3), 117-123.
8. Custalow C, Gravitz C. Emergency medical vehicle collisions and potential for
preventive intervention. Prehospital Emergency Care. 2004;8(2):175-84.
9. Kahn C, Pirrallo R, Kuhn E. Characteristics of fatal ambulance crashes in the United
States: An 11-year retrospective analysis. Prehospital Emergency Care. 2001;5(3):261-9.
10. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency
medical services: A hidden crisis. Annals of Emergency Medicine. 2002;40(6):625-32.
11. National Association of EMS Physicians and the National Association of State EMS
Directors. Use of warning lights and siren in emergency medical vehicle response and
patient transport. Prehospital and Disaster Medicine. 1994;9(2):133-6.
12. Pratt SG. NIOSH Hazard Review. Work-related roadway crashes: Challenges and
opportunities for prevention. Washington, DC: Department of Health and Human
Services, Centers for Disease Control and Prevention, National Institute for Occupational
Safety and Health.
13. Ray AM, Kupas DE. Comparison of crashes involving ambulances with those of similar-
sized vehicles. Prehospital Emergency Care. 2005;9(4):412-15.
14. Larmon B, LeGassick T, Schriger D. Differential front and back seat safety belt use by
prehospital care providers. The American Journal of Emergency Medicine.
1993;11(6):595-9.

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Driver Behavior and Performance Checklist (D1) References

15. Lindsey JT. The effects of computer simulation and learning styles on emergency vehicle
drivers’ competency in training course. 2004. Doctoral dissertation, University of South
Florida.
16. Barishansky RM. Next generation ambulance puts safety first. Emergency Medical
Services. 2005;30:34.
17. Erich J. Wheels of fortune. Every time you hit the streets, you take your life in your
hands—how can you improve your chances? Emergency Medical Services.
2000;29(11):43.
18. Whiting J, Dunn K, March J, Brown L. EMT knowledge of ambulance traffic laws.
Prehospital Emergency Care. 1998;2(2):136-40.
19. De Graeve K, Deroo K, Calle P, Vanhaute O, Buylaert W. How to modify the risk-taking
behaviour of emergency medical services drivers? The European Journal of Emergency
Medicine. 2003;10(2):111-6.
20. Curriculum Development Group. Emergency Vehicle Operation Course (Ambulance):
National Standard Curriculum. Washington, D.C.: U.S. Department of Transportation,
1995.
21. US Fire Administration. Emergency Vehicle Driver Training. Emmitsburg, Maryland:
Federal Emergency Management Agency, 1996.
22. National Safety Council. Coaching the Emergency Operator 3: Ambulance. Itasca IL:
National Safety Council, 2007.

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