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When a massive explosion at a propane plant rocked the city of Toronto’s north end in August, sending huge fireballs high into the sky and thousands fleeing their homes, 34 ambulances and support vehicles were sent to the rescue, including Toronto Emergency Medical Service’s multi-patient emergency response vehicles (referred to as Emergency Support Buses).

“These Emergency Support Buses are used any time there is a chance of multiple casualties,” says Paul J. Harris, Operations Supervisor assigned to Special Operations, Toronto EMS. “We send the bus to the scene, and release ambulances back into the system to do regular calls.”

With 5.5 million people in the greater Toronto area, and a lot of tall buildings and highways, the potential for a mass casualty incident is high. Harris says the city has used multi/patient vehicles for 30 years. “In 1975, a local bus made contact with a train during rush hour. We had multiple patients requiring transport to hospital, and we realized that we couldn’t transport quickly enough. So, the commissioner at that time purchased an old transport bus which was retrofitted in-house.”

The makeshift model worked so well that Toronto EMS began buying professional models. They currently have three Emergency Support Buses in the fleet, the newest of which is a fifth generation vehicle built in collaboration with the engineers and production staff at Crestline Coach. “Every time we get a new bus,” explains Harris, “we change it according to things we learn over the years.”

The latest Emergency Support Bus is a customized model on a 40-foot low floor El Dorado National AXESS bus built in Riverside, California. Designed by Crestline to seat 13 patients or transport eight stretchers with access to oxygen outlets, 12-volt and 110-volt power, a diesel generator, a suction system and area lighting, the bus can also carry three wheelchairs, safely tied down.

Three custom-made seat bunks can be raised or lowered independently and quickly. Harris says it takes about 30 seconds to vary the seating arrangements. “At a recent apartment fire, the entire building was evacuated. We used the bus to treat on scene, for transport, and we also used it for days as an on-site walk-in medical centre.”

This versatility allows Emergency Support Buses to be used as public immunization clinics, briefing rooms, standby support at public events, holding centers, and even mobile command centers.

Harris says the vehicles often function as intensive care units for long-distance transport. “It’s not unusual for us to transport a sick child 120 miles from Toronto to London (Ontario). We need 110 volt power, specialized equipment, a large staff, and room to treat a patient in an incubator or on a heart-lung machine. With this bus, that’s no problem.”

The Emergency Support Bus has a Cummins ISL 8.3L Turbo Diesel 280 HP engine, and Allison B400R five-speed automatic transmission, air ride suspension, all-wheel ABS brakes and a 275-inch wheel base with four-corner kneeling capability which, Harris says, has taken the strain off the medics, who can now load a stretcher even without the ramp. “The low floor design is well suited for bariatric patient transport and is different from anything else. Several other large EMS services have contracted us asking us how it was built and who built it.

One of those inquiries was from the Winnipeg Fire and Paramedic Service (WFPS).

Emergency Support Buses can transport eight stretchers or seat 13 patients at a time.

When you’re pulling 12-hour shifts on the mean streets of greater L.A., you need a couple of things from your ambulance: 1) toughness and durability, and 2) enough comfort to get you through. Torrance-based Gerber Ambulance Service found both in the new Apex from Crestline Coach.

Gerber has added five of the vehicles since December, and plans to get more.

“What we liked from Crestline was the attention to detail and the durability of the product,” says Gerber Operations Manager Matthew Steeneken. “We were impressed by the powdercoating and the undercoating and a lot of other things that weren’t industry standard.

Built on Crestline’s AeroBody design, the Apex has an integrated roll cage and all-aluminum construction that contributes to better fuel efficiency and more available payload. It isn’t huge (body length: 151”; body width: 90”; interior height: 67”), but it optimizes operational space and offers options and floor plans usually seen on larger ambulances.

The Apex’s overall comfort, Gerber personnel have noted, extends to the cab.

“The configuration allows for the driver’s and attendant’s seats to actually recline,” Steeneken says. “I’ve never seen that. On a 139-inch wheel base, it doesn’t seem possible.”

An operations manager also notices the little things: Insulation, Door latches that can be released without using the handle, Heat and A/C along the roofline, running the length of the patient compartment.

All those little things add up big. Crews have noticed too, and can’t wait to get behind the wheel.

“Everybody wants their opportunity, and we’re trying to limit it right now to some of the better drivers, so they get a good breaking in,” Steeneken says. “The guys pretty much live in these things for 12 hours a day, and they really like to take full advantage of the equipment.”

At first glance, it’s clear the Mobile Primary Health Center is not the typical work area for paramedics. After all, it is a full size bus stationed at various places in Saskatoon, SK, with paramedics and nurse practitioners in it in their jeans. In fact, if it weren’t for the logos and larger-than-life sized photos of paramedics and nursing staff pictured on the bus, a passerby could easily mistake it for a tour bus.

Aside from the huge impact of the identifiable mobile health bus, as it’s referred to around Saskatoon streets these days, the MD Ambulance Care pilot project is causing quite the buzz across the country, representing strategic goals of emergency medical services and the future of EMS Canada. “As many of us know, EMS is no longer merely an ambulance. Paramedics have diversified in so many ways and community paramedicine is a natural progression,” says Jan Heibert, director of corporate services and special operations with MD Ambulance Care in Saskatoon.

Heibert has seen the project grow from infancy to practicality, and she says she’s seen the huge impact the mobile health bus had already had on the community.

“The trust that we have gained in our communities come in part from the time we take to listen to them. It is not a 15 minute appointment with time to only address the most important medical issue, rather time is taken to listen to many issues with discussion of options available to them. This has resulted in identifying healthcare services we can refer them to because as we talk the real health issues come to light,” she says.

In many ways, the project represents community paramedicine at its best. So many patients with limited mobility, who would not normally be able to receive care, can walk a couple of city blocks and step right into a clinic, an ambulance, a referral center and sometimes an informal counseling centre, all rolled into one.

The bus hit the streets of Saskatoon in late August 2008, with the vision to “create mobile community health care as a venue to generate health equity and close the disparity gap of those who are geographically, socially, economically, and/or culturally isolated.

Phase one of the strategic partnership between the Saskatoon Health Region, MD Ambulance Care and the Saskatchewan Ministry of Health – the Mobile Primary Health Center Team – focuses on the inner city population, including aboriginal, children, the elderly, immigrants, and refugees, as well as chronic disease management.

The reason for the focus is to bring health care to those who don’t normally receive it for a number of reasons.

The health bus is a converted RV that contains a fully equipped examination room. A team of paramedics and nurse practitioners provide the following services: health checks; blood pressure and blood sugar checks; chronic disease management; disease prevention; health education (for example, disease awareness, bike and helmet safety, smoking cessation, nutrition); wound care; and follow-up care.

Staff can also link patients who use the health bus with youth, addiction and mental health services; community-based organizations and programs; and other services provided in the community.

Shirley Isbister is the president of the Central Urban Metis Federation and she says her organization has nothing but praise for the mobile health bus. “It’s one of the most positive projects that’s come into the core area (of Saskatoon),” she says. “It’s an opportunity for people who don’t normally go for health care to stop in and get treated.

Isbister says the simple fact that no health care card is needed to receive treatment opens up a huge window for many living on the streets or in high-risk lifestyles.

“You don’t need your hospital card. You can just go in as ‘Jim Brown’ and receive the care you need,” she says. “In the core area there are a lot of homeless, high-risk lifestyle people and for a person to be able to go to that bus for service, it’s really important.”

The team working on the bus consists of a paramedic and a nurse practitioner, widening the range of service available to patients. This combination is proving to be very effective, according to staff working on the bus. “Working with nurse practitioners, I’ve learned a lot. I come from a background of nursing, so for me it’s nice,” said Debbie Oesch, an intermediate care paramedic working on the bus.

Heibert says the combination of the two professions has proven to be not only beneficial, but “necessary”.

“We have very similar visions in striving to bring the best to our communities. Even in this short time the staff have come together with ideas regarding health promotion, linking with other services and engaging in partnerships to better serve the client coming to the mobile health bus,” she says.

One of the health bus priorities is to have regular consultation with emergency rooms in the area. This helps manage ER return visits. For example, health bus staff can give IV antibiotics, write prescriptions, remove sutures and care for wounds.

Since the bus hit the streets, it’s had a positive response from the community, officials and representatives of special groups.

And the people living in inner city Saskatoon, where the bus is stationed, are not mistaking it for a tour bus, but more and more are quickly recognizing the bus for what it is: a treatment centre, a referral hub, and a place where they can come to just rest if it’s -40ºC outside.

“The trust we’ve built up is phenomenal. We have one client, who’s a drug abuser, and he first came in for sores, and just wanted a prescription and to get out. The next time he came in he sat with us and talked about his addiction,” Oesch recalls.

Aside from the general positive feedback from the Metis, aboriginal and high-risk population, Heibert says there’s also been a tremendous impact on the immigrant and refugee population.

“Many of these individuals are adjusting to a new life in a foreign country and are unfamiliar with access to health care. There was joy in their faces when they saw the health bus drive to their community,” she says. Because many newcomers don’t know how to access a family physician, the health bus staff has been there for them, and patients constantly give good feedback. As one way of measuring success of the Bus, a diary is kept by staff for patients treated:

October 24, 2008: “Tonight’s story involves a couple that came by for the flu shot, both are HIV positive. The young lady was an IV drug user and the guy I’m not sure about. The woman convinced her partner to come by for his first shot. Both have turned their lives around and are attending school to become addiction counselors.”

November 6, 2008: “A young woman brought to us from Infinity House. Initially we were called by a representative from Infinity House asking if we do pregnancy tests. Both client and representative arrived a short time later. Test results were positive. We also found out she is taking antibiotics that are contraindicated during pregnancy. Her response to the results went from crying to feeling confident about her options. She is going to keep the child and was setup to start prenatal care immediately.”

There are pages upon pages of these accounts of people being helped, and each one is written in a tone that conveys the hopefulness of the staff working on the bus. One thing that staff all emphasized when speaking about their new job is that they now have the time to understand patients a little more than in the traditional primary/emergency care setting.

“It’s a lot less adrenaline because most of the care is non-emergent,” says Paramedic Tanya Hibbert, who also works on the bus. “It’s more of a medical clinic… there’s less pressure.”

Also, instead of wearing uniforms, staff on the bus are outfitted in jeans and a health bus t-shirt, and while some members of the public were quick to question the casual dress code at first, Hibbert says the effectiveness of wearing casual clothing is evident.

“Wearing jeans and the health bus t-shirt, I get more respect from people in the bus than I ever did in my uniform,” she says.

Reliable, accessible and multi-faceted, it’s easy to see why the pilot project has gotten such positive response from across the nation.

Before deciding on the project, a lot of research went into community and primary health care. Community health care in several other places in the world was looked at, including United Kingdom, Australia and the provinces of Ontario and Alberta.

The health bus is also in tune with the EMS Chiefs of Canada’s recently released White Paper, which endorses “the future of EMS in Canada is providing mobile primary health care as defined by the needs of each community. The health bus goals include to: Strategically link traditional institutional health services with mobile community health care; re-define the provision of out-of-hospital care via a Mobile Primary Health Center Team; prepare for the demographic changes and health care complexities of tomorrow; and implement Treat & Refer protocols.

By partnering with the Saskatchewan Health Region and MD Ambulance Care, the project addresses needs of vulnerable populations, relieves some pressure on the health care system, and addresses demographic and health care trends as well as resources.

The bus is establishing new and creative health care delivery in core neighborhoods as well as decreasing fear and isolation within neighborhoods. This is done by creating a sense of trust among patients, something the health bus staff is seeing more and more.

Staff see many patients are warming to the notion of the bus and using it as a comfort, something Hibbert says is “restoring her compassion for people.”

The beginning

While the health bus is proving to be a successful pilot project, with other jurisdictions looking on closely, and showing interest in doing the same in their communities (in fact, Calgary has just launched a similar project), it wasn’t an incredibly smooth start. Like any brand new idea, it took a lot for people to focus in and get the right project on the go.

“From a project development perspective, it was difficult at times to keep structured with our process and to not get carried away with trying to do too much, too fast,” Heibert says. “We had to be cautious and understand that although the potential for this project was enormous, it was crucial to take bite size pieces in order to have success. We needed to find the partners that could help us make this work and look at a project that would demonstrate the potential of this kind of service.”

When it was initially thought of by Dave Dutchak, CEO and President of MD Ambulance Care, a concept of “providing health care and immunization by means of mobile community health bus” was presented, Heibert recalls.

“Although the concept was good, the timing was premature. The Saskatoon Regional Health Authority was not situated to approve funding for the project at that time,” she says.

Shortly after, MD Ambulance sent two of their senior management paramedics to the UK to attend a health care conference, and that’s when the idea was firmly planted in their minds.

“In the fall of 2007 we began researching the possibility of bringing a health bus to our communities,” Heibert says.

The biggest challenge, as with many new projects of this scope, says Heibert, was funding. Funding of the amount needed was unavailable from the SRHA, but finally the Ministry of Health division of Saskatchewan government started to show interest, and that’s what boosted the project and made it a reality.

“A true collaboration with the Ministry of Health, Primary Health in the SRHA and MD Ambulance Care Ltd. made this project possible,” Heibert says.

Pilot project getting local praise from the community and other health regions are watching closely.

Based on a new El Dorado National 40' low floor bus, this new innovative vehicle, custom built to meet the requirements of the City of Winnipeg Fire Paramedic Service is designed to accommodate the treatment and transport of several ambulatory patients or up to eight stretcher patients. This is the second vehicle of this type recently produced by Crestline. The first order, produced for the City of Toronto EMS, was delivered in February 2008. "Toronto EMS, the largest city- based Emergency Medical Service in Canada, really took the lead by expanding their Emergency Support Program and collaborated with us to develop this vehicle. Since then, the City of Winnipeg and other large urban services have indicated similar requirements in meeting the growing complexity of demands faced by EMS today." says Glenn Nicol, Crestline's Sales Manager.

These multi-patient emergency buses will be in use daily responding to a full range of mass incident calls such as fires, crashes, crime scenes or any emergency that occurs involving a large number of people. The vehicle also functions well as a mobile treatment centre for large community events.

With vehicles sold worldwide, Crestline has grown to become one of North America's most advanced manufacturers of custom built ambulances and emergency vehicles. Our commitment to quality is demonstrated in ISO 9001:2000 and Ford QVM certification, and KKK-A-1822 compliance. Since 1975, Crestline has led the industry with innovations such as the Aero Body - all aluminum aerodynamic ambulance body, O2toGo Oxygen loading system, Dual main cot designs, High Visibility Exterior Graphics and our exclusive CrestCoat exterior finish. Crestline is also an authorized dealer for ElDorado National, the undisputed leader in the commercial bus industry.

For further information, contact: Tim Morrow, president, at 888/887-6886 or 306/934-8844 or by e-mail at tmorrow@crestlinecoach.com.

In case you haven’t purchased an ambulance recently, they are significant investments. You don’t have to add too many bells and whistles or custom compartments to cross into the six-figure price range.

With that kind of cash outlay, you’d certainly want to do all you could to protect your investment, and one of the best investments you can make in the way of protection, along with maintenance, is to have a tough exterior finish. That is exactly what the new Crestcoat paint technology represents.

Day after day, our rigs are exposed to all sorts of road debris, environmental pollutants and highly corrosive and anti-icing / de-icing solutions (mainly salt). Once you chip your finish and the paint begins to delaminate and flake off, big-time rust and / or corrosion are just around the corner. Now you’re looking at body work and touch-up paint or, in a worst-fiscal-case scenario, having to replace the entire box.

Crestline Coach’s Crestcoat uses an industry-first breakthrough technology to produce one of the toughest and most resilient finishes I’ve ever seen. The finish is sprayed on as a powder and then baked onto the vehicle, which produces an amazing effect. Clearly, Crestline believes in this technology, as the company is standing behind it with a solid five-seven year warranty. Protect that big investment with a top-quality finish: Check out Crestcoat paint technology from Crestline today.

Crestline Coach calls it the "High Vis" — short for high visibility — and it was inspired by research showing more people are seeing fewer ambulances.

"In the U.S., there's about 6,500 ambulance accidents a year and in those you get about 10 serious injuries a day and about 36 fatalities a year," said Crestline's research and development engineer Kyle Kmshelniski.

Crestline, which sells ambulances worldwide, believes if emergency vehicles are more conspicuous that such statistics would go down, allowing ambulances to get where they're going.

Krushelniski said he began by researching what it is that makes objects visible. Taking colour, patterns, psychology and art into consideration, Kiushelniski came up with the High Vis colour scheme after about a year,

"You can imagine this parked beside a white snowy landscape or against a bright sky. The white basically washes out," Krushelniski said pointing to a picture of a traditional white-coloured ambulance.

"Whereas this," Krushelniski said referring to his purple and yellow creation, "has the colours to be able to stand out against vehicles or nature or snow or sky."

What makes the High Vis just that is the "retroflective" decals its fluorescent and contrasting checkerboard pattern is composed of — about 10 times brighter than reflective jogging gear, Krushelniski said.

Krushelniski said Saskatchewan ambulance regulations currently do not allow deviations from the traditional ambulance colour scheme used since the 1970s.

"They require an eight-inch orange stripe down a white-sided vehicle and that's it," Krushelniski said, making them similar in ap¬pearance to delivery vans and recreation vehicles.

Increased visibility of ambulances is doubly important considering stereos and better insulation of newer consumer vehicles can drown out wailing sirens Krushelniski added.

But he said he doesn't expect Saskatchewan to change it's ambulance restrictions overnight. Instead, Krushelniski said the first step in get ting the design on the streets is convincing in dustry insiders at trade shows that the High Vis is simply a safer way to ride.

Though it's basically the same as regular am bulances on the inside, Krushelniski said the High Vis will sell for roughly $6,000 more, due the innovation on the outside.

"They're less likely to be in a accident," said Krushelniski on how he'll make the hard sell. "They're going to be able to get to their patients sooner and get them to a hospital quicker," he said, adding the High Vis will also be available in blue and orange.

Firm eyes prototype purple, yellow paint to help vehicles stand out on roads

"One of the initiatives we're working very hard on now is to expand our presence in the U.S.," says Crestline CEO Tim Morrow, who points to unique innovations that he hopes will give Crestline an edge in the massive and highly competitive U.S. market.

One such innovation is an aerodynamic ambulance body design created by the company. With its integrated roll-cage structure that improves patient and crew safety, this streamlined design also provides better handling and improves the vehicle's fuel economy.

Crestline's high-visibility graphics use bright, contrasting colours and reflective elements to help reduce emergency vehicle accidents by ensuring the ambulances are visible even in the most difficult weather conditions. "No one else is doing something like this," says Mr. Morrow. "That's something we're quite proud of."

As a custom ambulance manufacturer, Crestline must cater to a range of geographic, climatic and operational needs.

Because of the need for this level of flexibility, a higher level of skill in production employees is essential. "They're not just an assembly line," says Mr. Morrow. "They need to think creatively, to be able to make changes based on customer needs. We're fortunate to have those skills in the Saskatoon workforce." "You might think we were geographically challenged being landlocked in Saskatchewan and that it would be difficult for us to export products," Mr. Morrow says. "We find the contrary. We have a relatively low cost of overheads and competitive cost of labour. We can live where we want to live, and work where we want to work, enjoying the growth and progressiveness of a city like Saskatoon and the lifestyle that it offers."

Crestline Coach's aerodynamic ambulance body sports unique safety features inside and our, including high-visibility graphics that help ensure ambulances are visible even in the most difficult weather conditions.

For motorists’ awareness, our High Visibility Emergency Decal Package uses prismatic decal materials, which are more effective than emergency lights in situations of limited visibility. Introduced in 2002, this customizable package consolidates the four factors of conspicuity which are fluorescence, color contrast, pattern and reflectivity, into one cohesive design. In addition, we have strategically placed reflectors and high visibility decals on the inside of the rear doors in order to heighten awareness that additional hazards are present when the doors are open and activity is imminent. We want you to be seen to be safe!

For the medics, we use safety-yellow components in our ambulances so their peripheral vision brings attention to potential obstructions. Yellow grab bars are standard in all of our vehicles, with the option of yellow doorway markings, running boards, and overhead door padding. Driver intention lights in the interior compartment immediately notify the medic of sudden vehicle movements, thereby reducing the risk of injury.

In 2000 we introduced our squad bench safety net. The materials, shape, stitching patterns and mounting mechanisms are designed to withstand extreme forces, and the mounting points are securely attached to incorporate the strength of the ambulance frame.

Our ergonomic portable oxygen system, 02 to Go, is a simple, low cost and effective solution to preventing medic injuries. Loading and unloading a large oxygen tank can be easily done via our secure ramp and tank carrier system.

Since 1984 we have been using thermoformed upholstery, which eliminates seams and minimizes bodily fluid contamination in the patient compartment.

For everyone from EMS management to EMS staff, Crestline’s AeroBody design is all-aluminum in construction, contributes significantly to fuel efficiency and combined with Crestline’s integrated roll cage structure, provides a robust vehicle body. Our AeroBody envelopes the only true roll cage in the industry!

These safety measures are regularly crash-tested in the real world (unfortunate, but a reality), and are second to none. A Paramedic from North East Mobile Health Services in South Portland, Maine says it best:

“You folks delivered 3 ambulances to us recently that were absolutely fabulous. Yesterday, after only approximately 1 week on the road, one of them was involved in a collision. The ambulance was struck from the rear by a large straight axle type commercial truck… I was quite impressed with how well the ambulance held up… I am grateful that the structural integrity of the ambulance held up so well. It quite possibly saved my 3 co-workers from being either seriously injured or even killed in the collision. Thank you.”

These highlight just a few of the numerous innovations in safety and design that Crestline Coach has focused on in order to maximize the safety of our medics working environment. As a company focused on research and development, we have provided the industry with plenty of truly innovative features to keep everyone safe. For more information, please visit www.crestlinecoach.com.

Crestline Coach is dedicated to R&D in the area of EMS vehicle safety.