Journal of the Formosan Medical Association (2018) 117, 283e291
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
Original Article
Ambulance traffic accidents in Taiwan Po-Wei Chiu a, Chih-Hao Lin b,*, Chen-Long Wu c,d, Pin-Hui Fang b, Chien-Hsin Lu b, Hsiang-Chin Hsu b,d, Chih-Hsien Chi b a
College of Medicine, National Cheng Kung University, Tainan, Taiwan Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan c Department of Environmental and Occupational Health, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan d Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan b
Received 25 October 2017; received in revised form 13 December 2017; accepted 17 January 2018
KEYWORDS Ambulance traffic accident; Motorcycle; Occupational safety; Emergency medical services; Emergency medical technician
Background/Purpose: Ambulance traffic accidents (ATAs) are the leading cause of occupationrelated fatalities among emergency medical service (EMS) personnel. We aim to use the Taiwan national surveillance system to analyze the characteristics of ATAs and to assist EMS directors in developing policies governing ambulance operations. Methods: A retrospective, cross-sectional and largely descriptive study was conducted using Taiwan national traffic accidents surveillance data from January 1, 2011 to October 31, 2016. Results: Among the 1,627,217 traffic accidents during the study period, 715 ATAs caused 8 deaths within 24 h and 1844 injured patients. On average, there was one ATA for every 8598 ambulance runs. Compared to overall traffic accidents, ATAs were 1.7 times more likely to result in death and 1.9 times more likely to have injured patients. Among the 715 ATAs, 8 (1.1%) ATAs were fatal and 707 (98.9%) were nonfatal. All 8 fatalities were associated with motorcycles. The urban areas were significantly higher than the rural areas in the annual number of ATAs (14.2 7.3 [7.0e26.7] versus 3.1 1.9 [0.5e8.4], p Z 0.013), the number of ATAassociated fatalities per year (0.2 0.2 [0.0e0.7] versus 0.1 0.1 [0.0e0.2], p Z 0.022), and the annual number of injured patients (who needed urgent hospital visits) in ATAs (19.4 7.3 [10.5e30.9] versus 5.2 3.8 [0.9e15.3], p < 0.001). Conclusion: The ATA-associated fatality rate in Taiwan was high, and all fatalities were associated with motorcycles. ATAs in a highly motorcycle-populated area may require further
* Corresponding author. Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Shengli Rd., North District, Tainan City, 70403, Taiwan. Fax: þ886 6 2359562. E-mail address:
[email protected] (C.-H. Lin). https://doi.org/10.1016/j.jfma.2018.01.014 0929-6646/Copyright ª 2018, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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P.-W. Chiu et al. investigation. An ambulance traffic accident reporting system should be built to provide EMS policy guidance for ATA reduction and outcome improvements. Copyright ª 2018, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).
Introduction Emergency medical service (EMS) personnel respond to medical emergencies and various types of disasters. Exposures to dangerous environments and hazardous processes inherent in these emergency responses could engender occupational injuries.1 Ambulance traffic accidents (ATAs) are the leading cause of occupation-related fatalities and account for approximately 8% of nonfatal injuries among EMS personnel.1,2 The rate of motor vehicle incidents among EMS workers is almost 20 times higher than that among other workers.1 ATAs involve more people and more injuries than incidents involving similar-sized vehicles.3 ATAs may delay the transportation of patients on the ambulance and lead to significant equipment repair expenses and manpower shortages.4 Ambulance drivers may face legal liability, and persons involved in ATAs could experience long-term psychological burdens.5 Occupational safety among EMS personnel, especially in Western countries, has been discussed in several studies; however, the ATA situation in Asian countries has rarely been reported.1,4,6e10 EMS systems in Asian countries are very different from the so-called Franco-German model and Anglo-American model, not only in the prehospital protocols but also in the cultural and socioeconomic aspects.11e14 In Asian cities, the response time of ambulance and the transport time from the scene to the hospital are usually much shorter than those in America or European countries.12,15 The dense population and narrow roads in Asian cities may also contribute to the high risk of incidents among ambulances. Many Asians use motorcycles as their main mode of transportation.16 The motorcycle ownership rates in Asian countries are considerably high.16e18 In 2012, there were 1.5 persons per motorcycle in Taiwan, overwhelmingly exceeding the motorcycle density in the United Kingdom and the United States (47.4 and 118.7 persons per motorcycle, respectively).19 Traffic accidents involving motorcycles are 26 times more likely to have mortalities than those involving motor vehicles.20 Hence ATAs in Asian countries, compared to those in Western countries, may have a distinct pattern. The goal of this study is to use the Taiwan national surveillance system to analyze the characteristics of ATAs and to assist EMS directors in objectively developing policies governing ambulance operations.
Methods Study design and setting This is a retrospective, cross-sectional and largely descriptive study using Taiwan national surveillance data on traffic accidents from January 1, 2011 to October 31, 2016.
Taiwan is located in East Asia. The population of Taiwan was estimated at 23.5 million in 2017, spread across a land area of 36,197 km2, which makes the population density rank 17th in the world.21 There were 21.6 million vehicles in Taiwan, including 7.9 million motor vehicles and 13.7 million motorcycles. Half of Taiwan’s adult population uses motorcycles as their primary mode of transportation.16 The use of helmets for motorcycle riders and passengers is mandated by law, which was enacted in 1997. The motor vehicles in Taiwan are driven on the right side of the road, with the drivers sitting in the left side of the vehicle. The EMS system in Taiwan started in the 1960s. The public EMS system is fire-based, generally free of charge to users, and responds to prehospital emergencies. Interfacility patient transfers are usually carried out by private ambulances and are chargeable. As of 2017, there are 572 fire stations, 1188 ambulances and 14,033 emergency medical technicians (EMTs) in governmental fire departments, responsible for approximately 1.1 million ambulance runs annually.22 The average response time of ambulances in major cities is generally less than 5 min.12,14,21 During the deployment from the fire stations to the scenes, and during the transportation of patients from the scenes to the hospitals, the ambulances usually use sirens and flashing lights and are legally unrestrained to almost all traffic codes, such as speed limits or traffic-light controls. The traffic accident data were obtained from the national surveillance system of the National Police Agency of Taiwan. Ground traffic accidents that had any fatalities within 24 h or any victims needing an urgent hospital visit were enrolled in the surveillance system; crashes of aircrafts or ferries were not enrolled. The surveillance system of traffic accidents contains data including the locations of the traffic accidents, the roadway information (such as the roadway type, the intersection type, the type of roadway surface, and any vision obstruction), the environment information (such as the weather, the light condition, the date, and the time of day), the driver information (such as gender, age, alcohol use, and driver license information), the parts of vehicles involved in the crash, vehicle types, and any use of protection devices. An ATA was defined as a traffic accident in which at least one ambulance was physically involved. Fatal ATAs were defined as ATAs that had any fatality within 24 h. Nonfatal ATAs were defined as ATAs that did not have any fatality within 24 h but had at least one victim, other than the patients already on the ambulances, needing urgent hospital visits. The patients already on the ambulance prior to the traffic accident were not enrolled in the national surveillance system and thus were not included in our study. The surveillance system only follows up injured patients for 24 h; fatalities that occurred more than 24 h since the traffic accidents were not enrolled in the system.
Ambulance traffic accidents in Taiwan The EMS data were obtained from publicly accessible information of the National Fire Agency of Taiwan, which includes the number of ambulance runs and the number of fire stations. There was no motorcycle ambulance in Taiwan during the study period. Air ambulances, ferry ambulances, or private ambulances were not included in the EMS data system. Data on populations and sizes of areas were obtained from publicly accessible information of the Ministry of Interior of Taiwan. The EMS data and population data used in this study were retrieved in 2017.23,24
Comparison of ATAs in areas Taiwan has 6 major cities (Taipei, New Taipei, Taoyuan, Taichung, Tainan, and Kaohsiung) and 12 major counties (Hsinchu, Miaoli, Changhua, Yunlin, Chiayi, Pingtung, Taitung, Hualien, Nantou, Yilan, Penghu and other islands, and Keelung).25 The population in each of the 6 cities is more than 1.5 million, while that in each of the 12 counties is lower. We defined the cities as urban areas and the counties as rural areas. We then performed a comparison analysis on urban and rural areas, regarding their populations, the sizes of areas, the population density, the number of ATAs per year, the number of fatalities in ATAs per year, the number of injured patients in ATAs per year, the number of annual ambulance runs, the number of fire station, the fire station density, the ATAs rates, the number of ATAs per fire station per year, the number of ATAs per thousand km2 area per year, the number of ATAs per million populations per year, and annual number of ambulance runs per fire station. We also performed a comparison analysis for areas with high ATA rates, moderate ATA rates, and low ATA rates. ATA rates were defined as the number of ATAs over the number of ambulance runs in a certain area during a given period. The ATA rate of each city/county was calculated; then, all 18 cites/counties were ranked by their ATA rates. The top 25% ranking of cities/counties were defined as areas with high ATA rates; the lowest 25% ranking, areas with low ATA rates; and the others, areas with moderate ATA rates.
Statistical analysis Categorical variables were expressed as the number and proportion. Continuous variables were presented as the mean standard deviation (SD) and range, and their differences were evaluated using two-sample t-tests or oneway ANOVAs. Statistical analyses were performed using SPSS 17.0 statistical analysis software (SPSS Inc., Chicago, IL, USA). All statistical tests were performed at a two-sided significant level of 0.05.
Ethical consideration Data related to individual identification were removed. The study protocol was reviewed and approved by the Institutional Review Board of National Cheng Kung University Hospital (A-ER-106-147).
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Results During the study period, there were 1,627,217 traffic accidents in the national surveillance system of Taiwan, which caused 10,927 deaths and 2,176,476 injured patients.24 Among these traffic accidents, 715 ATAs caused 8 deaths within 24 h and 1844 injured patients. For ATAassociated casualties, the 24-h fatality rate was 0.4% (8/ 1852). Compared to overall traffic accidents, ATAs were 1.7 times more likely to lead to death and 1.9 times more likely to lead to injuries among patients. Among the 715 ATAs, 8 (1.1%) ATAs were fatal and 707 (98.9%) were nonfatal. Among the 1844 injured patients in ATAs, 1043 (56.6%) patients needed urgent hospital visits and 801 (43.4%) patients did not. There were 6,147,495 ambulance runs in Taiwan during the study period; thus, on average, there was one ATA for every 8598 ambulance runs.23
Basic characteristics Table 1 summarizes the basic characteristics of fatal and nonfatal ATAs, including the roadway type, the roadway pavement, the roadway surface, the intersection type, vision, the time of day, the weather, and the light condition. All 8 fatal ATAs and 529 (74.8%) of the 707 nonfatal ATAs occurred on urban roads. Five (62.5%) fatal ATAs and 463 (65.5%) nonfatal ATAs occurred at four-point intersections. Five (62.5%) fatal ATAs occurred in the evening (2 [25.0%] from 4pm to 8pm, and 3 [37.5%] from 8pm to midnight), while 347 (49.1%) nonfatal ATAs occurred in the daytime (199 [28.1%] from 8am to noon, and 148 [20.9%] from noon to 4pm).
Drivers and impact areas Table 2 demonstrates the driver characteristics and the impact areas of vehicles involved in ATAs. There were 8 ambulances and 9 non-ambulance vehicles involved in the 8 fatal ATAs. All ambulance drivers in the fatal ATAs were males and all had undetectable levels on alcohol inhalation tests. Among the 9 vehicles involved in fatal ATAs, 8 (88.9%) were motorcycles and 1 (11.1%) was a motor vehicle. Five (55.6%) motorcycles had front impact in fatal ATAs. There were 708 ambulances and 808 non-ambulance vehicles involved in the 707 nonfatal ATAs. Thirteen (1.8%) nonfatal ATAs involved only one ambulance and no other vehicles. One (0.1%) nonfatal ATA involved 2 ambulances. Among the 708 ambulance drivers in nonfatal ATAs, 681 (96.2%) drivers were males and 690 (97.5%) had undetectable levels on alcohol inhalation tests. Regarding the impact areas, the data for 37 (4.6%) of the 808 nonambulance vehicles were missing. Among the remaining 771 non-ambulance vehicles involved in the nonfatal ATAs, 488 (63.3%) vehicles were motorcycles and 283 (36.7%) vehicles were motor vehicles. In nonfatal ATAs, 145 (20.5%) ambulances and 110 (38.9%) non-ambulance motor vehicles had impacts at the middle part of the front area, while 283 (58.0%) motorcycles had frontal impacts.
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Table 1 The basic characteristics of ambulance traffic accidents (ATAs).
Roadway type State road Provincial highway Rural road Township road Urban road Village road Dedicated road Others Roadway pavement Asphalt Cement Gravel Others Roadway surface Iced Oiled Muddy Wet Dry Intersection type Three-points intersection Four-points intersection More than four-points intersection Straight Others Vision Obscured by constructions Obscured by parked vehicles Obscured by other obstruction No obstruction Time of day 0 ame4 am 4 ame8 am 8 ame12 am 12 am to 4 pm 4 pme8 pm 8 pm to 0 am Weather Rainy Cloudy Sunny Light condition Daylight Dawn or dusk Dark but lighted Dark
Fatal ATAs NZ8
Nonfatal ATAs N Z 707
0 0 0 0 8 (100%) 0 0 0
1 (0.1%) 34 (4.8%) 38 (5.4%) 19 (2.7%) 529 (74.8%) 71 (10%) 3 (0.4%) 12 (1.7%)
8 (100%) 0 0 0
703 (99.4%) 2 (0.3%) 0 2 (0.3%)
0 0 0 0 8 (100%)
0 0 2 (0.3%) 81 (11.5%) 624 (88.3%)
2 (25%) 5 (62.5%) 0
115 (16.3%) 463 (65.5%) 33 (4.7%)
1 (12.5%) 0
77 (10.9%) 19 (2.7%)
0 0 0 8 (100%)
5 (0.7%) 3 (0.4%) 5 (0.7%) 694 (98.2%)
0 0 1 2 2 3
(12.5%) (25%) (25%) (37.5%)
29 (4.1%) 68 (9.6%) 199 (28.1%) 148 (20.9%) 156 (22.1%) 107 (15.1%)
0 1 (12.5%) 7 (87.5%)
71 (10%) 70 (9.9%) 566 (80.1%)
4 (50%) 0 4 (50%) 0
487 (68.9%) 11 (1.6%) 206 (29.1%) 3 (0.4%)
Characteristics of fatalities and injured patients Table 3 shows the characteristics of the fatalities and the injured patients in the ATAs, including gender, injured parts, and use of protection devices. Among the 8 fatalities, 6 (75.0%) fatalities were male and 6 (75.0%) were under the age of 30. All fatalities were associated with
motorcycles: 7 (87.5%) fatalities were motorcycle riders and 1 (12.5%) was a motorcycle passenger. Among the 1043 injured patients who needed urgent hospital visits, 675 (64.7%) patients were male and 356 (34.1%) were between 20 and 29 years old. Among these patients, 472 (45.3%) patients were associated with motorcycles; 97 (9.3%) were ambulance drivers and 143 (13.6%) were ambulance passengers. Six hundred and three (57.8%) patients had multiple injuries; 787 (75.5%) were using helmets or safety belts. For the 801 injured patients who did not require urgent hospital visits, 739 (92.3%) patients were male and 619 (77.3%) were ambulance drivers. The information of injured parts for those patients was unavailable.
Comparison analysis on areas Table 4 illustrates the comparison analysis between urban (6 cities) and rural areas (12 counties). Between the urban and rural areas, there were statistically significant differences in the population (millions), the population density (millions per thousand km2 area), and the number of annual ambulance runs (thousands) (2.7 0.7 [range 1.9e3.9] versus 0.6 0.3 [0.1e1.3], p < 0.001; 2.8 3.6 [0.8e9.9] versus 0.6 0.7 [0.1e2.8], p Z 0.048; 123.0 32.8 [87.1e173.7] versus 26.3 12.9 [4.4e50.5], p < 0.001, respectively). The urban areas were significantly higher than the rural areas in the annual number of ATAs (14.2 7.3 [7.0e26.7] versus 3.1 1.9 [0.5e8.4], p Z 0.013), the number of ATA-associated fatalities per year (0.2 0.2 [0.0e0.7] versus 0.1 0.1 [0.0e0.2], p Z 0.022), and the annual number of injured patients (who needed urgent hospital visits) in ATAs (19.4 7.3 [10.5e30.9] versus 5.2 3.8 [0.9e15.3], p < 0.001). However, there were no statistically significant differences in the number of ATAs per million ambulance runs, the number of ATAs per million population per year, the number of fatal ATAs per million ambulance runs, the number of nonfatal ATAs per millions ambulance runs, the number of ATA-associated fatalities per million ambulance runs, or the number of injured patients (who needed urgent hospital visits) in ATAs per million ambulance runs. Table 5 shows the comparison analysis of the low-ATArate areas, the moderate-ATA-rate areas, and the highATA-rate areas. The ATA rates (defined as ATAs per million ambulance runs) for the 18 cities/counties were 114.1 42.9 (range 53.8e224.7). Five (27.8%) cities/ counties were categorized in the low-ATA-rate areas (Keelung, New Taipei, Pingtung, Tainan, and Taoyuan), 8 (44.4%) in the moderate-ATA-rate areas (Hsinchu, Nantou, Chiayi, Miaoli, Penghu and other islands, Taipei, Yunlin, and Kaohsiung), and 5 (27.8%) in the high-ATA-rate areas (Taitung, Yilan, Changhua, Hualien, and Taichung). Among the three groups (the low-ATA-rate, the moderate-ATA-rate, and the high-ATA-rate areas), there were statistically significant differences in the ATA rates (76.1 11.0 [53.8e80.7] versus 115.4 10.8 [90.7e120.5] versus 194.2 37.9 [131.7e224.7], p < 0.001, respectively) and annual number of ATAs per millions population (3.3 0.5 [2.3e3.7] versus 5.2 1.3 [3.7e5.9] versus 8.7 1.8 [6.5e11.4], p < 0.001, respectively). However, there were
Ambulance traffic accidents in Taiwan Table 2
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The characteristics of drivers and the impact areas of vehicles involved in ATAs.
Gender of driver Male Female Age of driver (years) 19 20e29 30e39 40e49 50e59 60 Driver license Appropriate license Inappropriate license Unknown Alcohol use of drivers Undetectable on alcohol inhalation tests Alcohol levels 0.8 mg/L Unavailable Impact part of motor vehicle Middle part of front Right part of front Left part of front Right part of body Left part of body Middle part of rear Right part of rear Left part of rear Unknown Impact part of motorcycle Front Rear Right part of body Left part of body
Ambulances involved in fatal ATAs NZ8
Other vehicles involved in fatal ATAs NZ9
Ambulances involved in nonfatal ATAs N Z 708
Other vehicles involved in nonfatal ATAs N Z 808
8 (100%) 0
7 (77.8%) 2 (22.2%)
681 (96.2%) 27 (3.8%)
582 (72%) 226 (28%)
1 3 0 3 1 0
(37.5%) (12.5%) (0%)
1 (11.1%) 2 (22.2%) 6 (55.6%) 0 0 0
1 (0.1%) 243 (34.3%) 267 (37.7%) 118 (16.7%) 71 (10%) 8 (1.1%)
91 (11.3%) 272 (33.7%) 167 (20.7%) 96 (11.9%) 82 (10.1%) 100 (12.4%)
7 (87.5%) 1 (12.5%) 0
8 (88.9%) 1 (11.1%) 0
689 (97.3%) 4 (0.6%) 15 (2.1%)
716 (88.6%) 62 (7.7%) 30 (3.7%)
8 (100%)
7 (87.5%)
690 (97.5%)
772 (95.5%)
0 0
1 (12.5%) 0
0 4 (0.6%)
9 (1.1%) 10 (1.2%)
0 0
0 0
1 (0.1%) 13 (1.8%)
0 0 1 (11.1%) 0 0 0 0 0 0
145 (20.5%) 133 (18.8%) 100 (14.1%) 127 (17.9%) 91 (12.9%) 16 (2.3%) 43 (6.1%) 20 (2.8%) 33 (4.7%)
5 (55.6%) 0 2 (22.2%) 1 (11.1%)
0 0 0 0
4 (0.5%) 14 (1.7%) n Z 283a 110 (38.9%) 29 (10.2%) 45 (5.8%) 32 (11.3%) 27 (9.5%) 25 (8.8%) 2 (0.7%) 13 (1.7%) 0 n Z 488a 283 (58.0%) 23 (4.7%) 104 (21.3%) 78 (16.0%)
2 2 1 1 2 0 0 0 0 0 0 0 0
(12.5%) (37.5%)
(25%) (25%) (12.5%) (12.5%) (25%)
a. The data for 37 (4.6%) of the 808 non-ambulance vehicles were missing. Among the remaining 771 vehicles involved in nonfatal ATAs, 283 (36.7%) vehicles were motor vehicles and 488 (63.3%) vehicles were motorcycles.
no statistically significant differences among the three areas regarding the number of ATAs per year, the annual number of ambulance runs, the population, the area, the population density, the number of fire stations, the fire station density, or the number of ambulance runs per fire station per year.
Discussion To the best of our knowledge, this study is the first work to systemically describe the ATA situation in Asian countries. In Taiwan, all fatalities and almost half of the injuries in ATAs were associated with motorcycles. Our study results may imply that ATAs in a highly motorcycle-populated area could have a distinct pattern and merit attention.26e28
Motorcycle accidents are one of the leading causes of mortality in many developing counties.26,27 For ATAassociated casualties, the 24-h fatality rate in Taiwan (0.4%) is almost four times of the fatality rate in the United States (0.1%).27,28 Motorcycle accidents, compared to vehicle accidents, are known to have a higher mortality rate.16e18,20,26 Ambulances are larger and heavier than most civilian vehicles. Thus, motorcycle accidents involving ambulances could be even more severe. Traditionally, ambulance structures and outfits are considered to be as strong as possible to protect the ambulance drivers and passengers. However, since ATA-associated fatalities in high motorcycle-populated areas are more likely to involve motorcyclists, rather than ambulance occupants, the strategy of ambulance design should be justified.29 This
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The characteristics of fatalities and injured patients in ATAs.
Gender Male Female Age 19 20e29 30e39 40e49 50e59 60 Casualty characteristics Ambulance driver Ambulance passenger Motor vehicle driver Motor vehicle passenger Motorcycle rider Motorcycle passenger Pedestrian Other Injury part Head Neck Chest Abdomen Waist Back Upper limb Lower limb Multiple injury Protection devices Use of helmet or seat belt No use of helmet/seat belt Unknown
Fatality NZ8
Injured patients (need urgent hospital visits) N Z 1043
Injured patients (needless for urgent hospital visits) N Z 801
6 (75.0%) 2 (25.0%)
675 (64.7%) 368 (35.3%)
739 (92.3%) 62 (7.7%)
2 (25.0%) 4 (50.0%) 2 (25.0%) 0 0 0
144 (13.8%) 356 (34.1%) 206 (19.8%) 113 (10.8%) 91 (8.7%) 133 (12.8%)
9 (1.1%) 261 (32.6%) 277 (34.6%) 133 (16.6%) 93 (11.6%) 28 (3.5%)
0 0 0 0 7 (87.5%) 1 (12.5%) 0 0
97 (9.3%) 143 (13.6%) 259 (24.8%) 57 (5.5%) 388 (37.3%) 84 (8.1%) 10 (1.0%) 5 (0.5%)
619 (77.3%) 5 (0.6%) 124 (15.5%) 4 (0.5%) 46 (5.7%) 2 (0.3%) 0 1 (0.1%)
4 (50.0%) 0 0 0 0 0 0 0 4 (50.0%)
116 (11.1%) 17 (1.6%) 48 (4.6%) 4 (0.4%) 11 (1.1%) 10 (1.0%) 87 (8.3%) 147 (14.1%) 603 (57.8%)
Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable
7 (87.5%) 0 1 (12.5%)
787 (75.5%) 34 (3.3%) 222 (21.3%)
696 (86.9%) 15 (1.9%) 90 (11.2%)
idea is important, especially given that ambulance standards or regulations could be lacking in many developing countries.30 We suggest that, should the body structures of ambulances provide sufficient protection and resilience, the surface rigidity of ambulances may be reduced to lessen the impact forces on motorcycles in traffic accidents.31 Bumpers on light trucks and vans (LTVs) are higher than those on civilian cars, and the excess number of deaths in motor vehicles could result from the tendency of LTVs to override the door sill in angle collisions or the front bumper of motor vehicles in head-on collisions.32 The bumper works as the main energy-absorbing structure for vehicles but could also lead to pedestrian injury.33 In our study results, 5 (62.5%) ambulances in fatal ATAs had frontal impacts, thus we suspect that frontal ambulance bumpers might contribute to the fatalities of motorcyclists. We have not found studies that have determined the protection effect of bumpers for ambulances. However, since the bumpers in ambulances are similar to those in LTVs, a height-matching standard for ambulance bumpers may be considered.34
The use of helmets is crucial for motorcyclists’ safety.35 Helmets generally do not restrict the hearing ability or visual acuity of motorcyclists in ordinary environments.36 However, the effective distance of ambulance sirens or warning lights could be disturbed multifactorially.37 The impact of helmets on the motorcyclist’s alertness to ambulance sirens or warning lights should be examined. Helmets, especially those with built-in earphones for streaming music, should be adjusted to the different frequencies, volumes, or locations of the projecting devices of ambulance sirens and warning lights. Most of the ATAs (87.5% of fatal and 86.4% of nonfatal ATAs) occurred in road intersections. Currently, almost all ambulance runs in Taiwan use sirens and warning lights and are generally unrestrained to traffic codes. However, only less than 20% of ambulance users needed advanced life supports or urgent cares.38 Time saved with use of sirens and warning lights during ambulance transport is rather limited, especially in urban or highly populated areas.39 The “pop-out” effect of ambulance sirens and warning lights in busy urban intersections could be less obvious to
Ambulance traffic accidents in Taiwan Table 4
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Comparison analysis of ATAs in urban areas and rural areas. Urban Areas NZ6 mean SD (range)
Rural Areas N Z 12 mean SD (range)
P value
Population (millions) Area (km2)
2.7 0.7 (1.9e3.9) 1818 936.9 (271.8e2953)
