BY CONNIE PIGNATARO
MOTOR VEHICLE CRASHES make up a large part of the calls many fire departments respond to on a daily basis. According to the National Highway Traffic Safety Administration (NHTSA), there are more than five million motor vehicle crashes in the United States every year. In 2011, more than 1.5 million people were injured in motor vehicle crashes, and nearly 30,000 people died in those crashes.1
Although we have seen a steady decrease in crash-related fatalities over the past six years, with 2011 showing a 60-year low in the number of deaths, 2012 is estimated to show a 7.1 percent increase in the number of crash-related fatalities. The cause for the increase is unknown at this time, but one contributing factor could be the estimated increase in the number of miles traveled in 2012.2
Considering the anticipated rise in vehicle crashes, fire EMS will need every resource to get crash victims, especially those with critical injuries, to the hospital quickly. To do that, we must first be able to locate the accident. Fire departments rely on witnesses or victims to call 911 for help and to convey their locations. Of the 30,000 calls made daily to 911 for EMS in the United States, 5,000 are for vehicle crashes.3 But sometimes, the victims are unable to call for help and there are no witnesses when the crash occurs.
In November 2011, a passerby found a nine-year-old girl trapped in the passenger seat of a vehicle that had crashed 40 hours earlier in Cove City, North Carolina. She was still alive but injured. The driver, her father, had been killed in the crash, and the girl had no way of contacting anyone for help.4 Two months earlier in Graves County, Kentucky, a passerby found a man with life-threatening injuries two days after he had crashed over a guardrail into a creek. A female passenger in his car was pronounced dead at the scene.5 And in September 2011, the family of a 67-year-old California man found him after he had plunged 200 feet off a cliff five days earlier. He suffered multiple broken bones and a dislocated shoulder.6
It is unknown if those who had died in these crashes would still be alive today if they had been found sooner. It is also unknown if those who did survive would have had improved outcomes if found earlier. What is known is that, in general, quick access and treatment of the post-crash patient reduce deaths and disabilities from injuries sustained in motor vehicle crashes. For example, quick treatment and transport of a patient exhibiting signs and symptoms of a mild to moderate brain injury are likely to result in a full recovery whereas there is a higher probability of permanent disability or death if treatment and transport are delayed.7
AUTOMATIC CRASH NOTIFICATION
A resource that is becoming increasingly popular and is more frequently used is automatic crash notification (ACN), also known as “automatic collision notification” or “automatic crash response.” When a vehicle equipped with ACN crashes, an instant notification of the crash, in most cases triggered by air bag deployment, is sent to the telematics service provider (TSP) answering point. The TSP advisor then contacts the local Public Safety Answering Point (PSAP) or 911 system, and help is on the way without a witness or victim picking up a phone.
A majority of car manufacturers offer some level of ACN services. One of the more basic forms is available through Ford, which offers Ford SYNC® 911 Assist™. Currently, two million vehicles are equipped with this feature. This service uses the driver’s Bluetooth®-enabled mobile phone, which must be linked to the vehicle through a one-time setup. Once set up, it will be connected with SYNC 911 every time the driver enters the vehicle with the phone turned on.
Although the service is free, it has limitations. It will activate only if an air bag is deployed or, in some vehicles, if the emergency fuel pump shut-off is activated. The service will then send an urgent message to the local PSAP that the vehicle has been in a crash. The line remains open for hands-free communication between the victims and the 911 operator. If no one in the vehicle is able to speak, the PSAP location information received from the mobile phone carrier linked to the system will be used as the response location.8 Locating the crash is the first step in getting crash victims the help they need to survive with the best outcome. A recent study suggests that rapid treatment and transport without delay to the most appropriate facility led to a six-percent reduction in fatalities.9
Like Ford SYNC 911 Assist, OnStar®, available in General Motors (GM) vehicles, will also activate with air bag deployment. Unlike Ford, the latest OnStar system will activate in a moderate to severe crash even if the air bags have not deployed. These crash sensors are mounted throughout the vehicle. The system is embedded in the car, so no customer-provided mobile phone is required. All calls are routed to OnStar advisors, who receive the vehicle’s exact global positioning system location and additional crash data such as Delta V (change in velocity over time), direction of impact, if there were multiple impacts, if the vehicle had rolled over, and if there is the potential for severe injuries. The OnStar advisor may be able to verbally offer this information to the local PSAP.10 These additional features have become known as Advanced ACN (AACN) and were first offered by GM in 2003.
In Troutman, North Carolina, an AACN-equipped vehicle was responsible, in part, for the successful rescue of a crash victim. A driver lost control of his vehicle during the middle of the afternoon on Interstate 77. The Troutman 911 system received the call from OnStar immediately following the crash.
“(Dispatchers) got no cell phone calls on this,” says David Tomlin, firefighter for Troutman Fire and Rescue. “It was all from OnStar. They told us where the vehicle was and advised [of] multiple impact points.”
Because this was a busy highway and no other calls came in, responding firefighters had doubts that this was a real crash and thought that someone in the vehicle may have accidentally hit the emergency button.
“Then OnStar advised that the vehicle could be off the roadway. If we did not know that we should be looking for it in this particular area, we could have easily passed by it,” says Tomlin.
They found the patient unconscious in his vehicle, which was wedged in between the banks of a small stream, approximately 300 feet down a ravine.
“The information they gave us on the accident was right on,” says Tomlin. “If it wasn’t for OnStar, I don’t know how long the person would have been down there. I was amazed at the accuracy of the (location) information that was given to us. Without a doubt, OnStar made a huge difference in this instance.”
Car manufacturers are realizing the tremendous benefit that ACN/AACN provides, and many of them offer it to their customers. It is believed that “the effect of ACN on road traffic mortality could be anywhere from 1.5-15 percent of road traffic deaths.” (3)
BMW offers ASSIST™, Mercedes offers mbrace™, Toyota offers Safety Connect®, and Lexus offers Lexus Enform® with Safety Connect. All but Ford SYNC 911 have call centers or TSPs that receive the notifications from the vehicles.11 But by far, the leader in providing this service is OnStar.
“We are the world’s largest TSP with 5.5 million subscribers in the United States and about 6.5 million subscribers total,” says George Baker, global emergency services outreach manager for OnStar. “We receive more than 3,000 automatic crash response calls a month, totaling approximately 38,000 a year.”
Once AACN is activated, the vehicle places a call to an OnStar call center, and a window pops up on the advisor’s screen with all the sensor information, the GPS location, the subscriber information, and the number to the PSAP serving this location. According to Baker, there are approximately 6,500 PSAPs in the United States and Canada. OnStar keeps an updated database of all the PSAP primary and secondary phone numbers and jurisdictional boundaries.
The advisor immediately speaks to the victims in the vehicle, if they are conscious, to assess injuries and provide any necessary prearrival instructions/first-aid information. At the same time, the local PSAP is being contacted and advised of all the information gathered by OnStar. This information is dispatched to first responders, who use the information to make better decisions relative to requesting helicopter transport, additional extrication equipment, or more personnel.
According to Baker, OnStar emergency advisors go through an extensive and comprehensive training program. Candidates must complete six weeks of new hire training and demonstrate significant experience at handling nonemergency calls. After completing four additional weeks of emergency advisor training, they are required to complete the International Academies of Emergency Dispatch (IAED™) Emergency Medical Dispatch (EMD) Certification. Candidates round out their final week of training with cardiopulmonary resuscitation (CPR) certification and OnStar’s Emergency Medical Dispatch (EMD) process course.
“We recently announced that we have achieved the designation of Accredited Center of Excellence (ACE) with the IAED™,” says Baker. “This is the first nonemergency service private company in history to receive this accreditation. We consider it an honor to be among the five percent of all agencies that use this system of protocols to have achieved accreditation.”
As technology grows, so will the ability to provide fire EMS with more detailed information about crash victims. TSPs have gone from informing firefighters of a crash with air bag deployment and its location to providing them with information on multiple impacts, crash severity, and if the vehicle may have rolled over.
The Centers for Disease Control and Prevention (CDC) has recognized the importance of vehicle telematics. It has determined, through its National Expert Panel on Field Triage, that AACN with a high risk of injury should be considered as one of the criteria for making transport decisions. This is the first time this recommendation has been made. (11) Even in its recently revised Guidelines for Field Triage of Injured Patients, it states, “Advanced automatic collision notification shows promise in improving accuracy of field triage of patients involved in motor-vehicle crashes. Further effort is required to integrate this technology into trauma and EMS systems and evaluate its effectiveness.”12
Determining the high risk of injury is done by running AACN details through algorithm software called URGENCY. In 1996, the NHTSA began looking at how to improve recognition of time-critical injuries on crash scenes. After several studies, the URGENCY algorithm was born. URGENCY‘s goal is to minimize undertreating those needing to go to a trauma center and overtreating those who do not need transport to a trauma center.13
Past research has shown that some crash victims, as well as first responders, are not even aware of certain injuries, especially those internally such as to the liver and thoracic aorta, until diagnosed in a hospital or until it is too late. For them, AACN and URGENCY could provide an automatic indication of a high risk of severe injury with immediate transport recommended. (9)
Ensuring that severely injured patients are transported to a Level I or II trauma center is critical and has a significant impact on the outcome of the patient. The National Study on the Costs and Outcomes of Trauma (NSCOT) evaluated the care of moderately to severely injured patients and found “a 25 percent reduction in mortality for severely injured patients who received care at a Level I trauma center rather than at a non-trauma center.”14
Currently, OnStar uses its Injury Severity Prediction (ISP) algorithm, a version of URGENCY, which is based on the work of the CDC National Expert panel. It has the capability to inform the PSAP if there is a high probability of severe injury.
To determine a high probability of severe injury, all the crash information is plugged into the ISP algorithm such as Delta V, principal direction of force, number of impacts, and vehicle type. If the ISP determines that the victims involved have a >20 percent risk of having a severe injury, then the OnStar advisor will contact the vehicle occupant to determine age (those >55 years have an increased risk of severe injury), gender, number of vehicle occupants, and number of patients. (14)
The CDC believes that AACN shows promise in improving the outcomes of crash victims by providing the precise location of the crash, thus decreasing responders’ response time. It can also predict the likelihood of a serious injury and assist with transport decisions, thereby decreasing the time it takes to get the victim to the trauma center, which in turn decreases death and disability. (14)
In the future, the CDC would like TSP advisors to be able to convey more information to the PSAP such as Glascow Coma Scale via voice transmission of the injured victims; probability of the need for extrication; and real-time communication among TSP, PSAP, fire EMS, emergency medicine, and trauma surgery. (14)
In an effort to continue to improve the outcomes of crash victims, local fire departments, local PSAPs, TSPs, and car manufacturers will need to continue to collaborate to standardize the way information is communicated. Further studies and research will continue to improve AACN and the information it gathers so the technology can be seamlessly integrated into trauma and EMS systems.
ENDNOTES
1. U.S. Department of Transportation. National Highway Traffic Safety Administration (NHTSA). “Fatality Analysis Reporting System General Estimates System 2011 Data Summary.” August 2012. http://www-nrd.nhtsa.dot.gov/Pubs/811755DS.PDF.
2. U.S. Department of Transportation. NHTSA. “Early Estimate of Motor Vehicle Traffic Fatalities for the First Nine Months (January–September) 2012.” December 2012. http://www-nrd.nhtsa.dot.gov/Pubs/811706.pdf.
3. American College of Emergency Physicians. “Automatic Crash Notification and Intelligent Transportation Systems: Implications for the Emergency Physician.” Policy Resource Education Paper. September 2009. http://www.acep.org/Clinical-Practice-Management/Automatic-Crash-Notification-and-Intelligent-Transportation-Systems.
4. Rubio, R Francis. “9-year-old girl trapped in car for almost 2 days after wreck,” Digital Journal. Nov 15, 2011. http://digitaljournal.com/article/314475.
5. Lex18.com. “Man Found Alive in Car Two Days After Crash.” Sept, 21, 2011. http://www.lex18.com/news/man-found-alive-in-car-two-days-after-crash#_.
6. Huffington Post Los Angeles. David LaVau, “California Man, Found Alive Days After Car Crashed Off Cliff, Survived by Eating Leaves.” Sept 30, 2011. http://www.huffingtonpost.com/2011/09/30/david-lavau-california-man-car-crash-survivor_n_988931.html.
7. Champion, Howard R. “Reducing Highway Deaths and Disabilities with Automatic Wireless Transmission of Serious Injury Probability Ratings from Vehicles in Crashes to EMS.” ESV Paper 406. Retrieved Mar 15, 2013. http://www-nrd.nhtsa.dot.gov/pdf/nrd-01/esv/esv18/cd/files/18esv-000406.pdf.
8. Ford SYNC 911 Assist: Non-Subscription Emergency Service Available in 2 Million Vehicles Provides Peace of Mind. Media.Ford.com. Retrieved April 2. http://media.ford.com/article_display.cfm?article_id=34208.
9. Rauscher, Stefan; Messner, George; Bauer, Peter. “Enhanced Automatic Collision Notification System – Improved Rescue Care Due to Injury Prediction–First Field Experience.” Retrieved Mar 17, 2013. http://www-nrd.nhtsa.dot.gov/pdf/esv/esv21/09-0049.pdf.
10. OnStar. “OnStar and the Emergency Services Community. Automatic Crash Response.” Retrieved Marc4, 2013. https://www.onstar.com/web/portal/publicsafety.
11. Seekins, Tom; Blatt, Alan; Flanigan, Marie. Montana Automatic Crash Notification Project. Characterization of Pathways for Delivery of Crash Telemetry Data to Montana. July 8, 2011. http://www.mdt.mt.gov/other/research/external/docs/research_proj/crash_notification/options_memo_jul11.pdf.
12. Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report. Recommendations and Reports / Vol. 61 / No. 1. Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage, 2011. Jan 13, 2012. http://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf.
13. Augenstein, Jeffrey; Digges, Kennerly; Ogata, Sandra; Perdeck, Elana; Stratton, James. “Development and Validation of the URGENCY Algorithm to Predict Compelling Injuries.” Retrieved Mar 22, 2013. http://www-nrd.nhtsa.dot.gov/pdf/nrd-01/esv/esv17/proceed/00051.pdf.
14. CDC. Recommendations from the Expert Panel: Advanced Automatic Collision Notification and Triage of the Injured Patient. 2008. http://www.cdc.gov/injuryresponse/pdf/AACN%20Report_FINAL-a.pdf.
● CONNIE PIGNATARO is a lieutenant for Oakland Park (FL) Fire Rescue. In 2011, she was the first female to be promoted as an officer in Oakland Park. She has a bachelor of applied science degree in public safety administration. Pignataro was introduced to the field of fire rescue as a volunteer for her local Community Emergency Response Team (CERT) in 1998. She enjoyed this experience so much that she decided to make a career change. She went back to school, and in 2002, she joined Oakland Park Fire Rescue.
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