red lights and sirens: do we need them?

Red Lights and Sirens: Red Lights and Sirens: Do We Need Them?Do We Need Them?

Michael D. Curtis, MD, FACEPMichael D. Curtis, MD, FACEPEMS Medical DirectorEMS Medical Director

Saint Michael’s Hospital – Stevens PointSaint Michael’s Hospital – Stevens PointSaint Clare’s Hospital – WestonSaint Clare’s Hospital – Weston

ObjectivesObjectives

Define the problems related to using Define the problems related to using red lights and sirens in EMSred lights and sirens in EMS

State the conclusions of research on State the conclusions of research on the value of red lights and sirens in the value of red lights and sirens in EMSEMS

Develop an understanding of the Develop an understanding of the conceptual framework for balance in conceptual framework for balance in the use of RL&S in EMSthe use of RL&S in EMS

Discuss steps industry leaders can Discuss steps industry leaders can take to reduce the toll on our industrytake to reduce the toll on our industry

PerspectivePerspective

Primum Non NocerePrimum Non Nocere – Above all, do no – Above all, do no harm!harm!

Origins of RL&S TransportOrigins of RL&S Transport ““Back in the day” when ambulances were Back in the day” when ambulances were

merely transport vehicles and few if any merely transport vehicles and few if any interventions were performed in the fieldinterventions were performed in the field

A practice adopted from law enforcement A practice adopted from law enforcement and fire services without question as to and fire services without question as to safety and efficacysafety and efficacy

PerspectivePerspective

The Culture of RL&S in EMSThe Culture of RL&S in EMS "...loose interpretation of what "...loose interpretation of what

constitutes an emergency has constitutes an emergency has essentially given [EMV operators essentially given [EMV operators permission] to operate their vehicles as permission] to operate their vehicles as they see fit while carrying victims who they see fit while carrying victims who are essentially stable by anyone's are essentially stable by anyone's definition."definition."

Paul S. Auerbach, MD, Paul S. Auerbach, MD, et alet alJAMA 1987;258:1487Ð1490

Excerpted from: Prehospital and Disaster Medicine, April-June 1994

My PerspectiveMy PerspectiveLike so many therapeutic interventions Like so many therapeutic interventions throughout the history of medicine that throughout the history of medicine that have landed on the scrapheap of good have landed on the scrapheap of good intentions, the widespread use of red intentions, the widespread use of red

lights and sirens in EMS should be lights and sirens in EMS should be abandoned, their use being restricted to abandoned, their use being restricted to

the very few cases in which the the very few cases in which the potential benefits may outweigh the potential benefits may outweigh the

associated risks – for they have largely associated risks – for they have largely proven to be proven to be

‘not helpful and potentially harmful’ .‘not helpful and potentially harmful’ .

Characteristics of Characteristics of Fatal Ambulance CrashesFatal Ambulance Crashes

Kahn, Pirrallo & KuhnKahn, Pirrallo & Kuhn US NHTSA FARSUS NHTSA FARS 1987-19971987-1997 339 Ambulance crashes339 Ambulance crashes 405 fatalities & 838 other injuries405 fatalities & 838 other injuries Emergency Mode of Travel (RL&S)Emergency Mode of Travel (RL&S)

60% (202/339) of all crashes60% (202/339) of all crashes 58% (233/405) of all fatalities58% (233/405) of all fatalities

Prehospital Emergency Care 2001; 5:261-269

Characteristics of Characteristics of Fatal Ambulance CrashesFatal Ambulance Crashes

Kahn, Pirrallo & KuhnKahn, Pirrallo & Kuhn In most fatal ambulance crashes:In most fatal ambulance crashes:

Traveling in the “emergency mode” (RL&S)Traveling in the “emergency mode” (RL&S) The ambulance is the striking vehicleThe ambulance is the striking vehicle The crash occurs at an intersectionThe crash occurs at an intersection Occupants of other vehicles are more likely to die Occupants of other vehicles are more likely to die

or suffer serious injury than occupants of the or suffer serious injury than occupants of the ambulanceambulance

Rear compartment occupants are more likely to be Rear compartment occupants are more likely to be injured or die than front compartment occupantsinjured or die than front compartment occupants

The ambulance drives have poor driving historiesThe ambulance drives have poor driving histories


Ambulance Crash Injuries Among Ambulance Crash Injuries Among US EMS Workers 1991-2002US EMS Workers 1991-2002

Based on NHTSA FARS dataBased on NHTSA FARS data 300 Fatal Ambulance Crashes300 Fatal Ambulance Crashes 82 deaths in the ambulances82 deaths in the ambulances

27 EMS workers27 EMS workers Most EMS worker deaths in front Most EMS worker deaths in front

compartmentcompartment Lack of restraint use cited in many of Lack of restraint use cited in many of

the EMS worker deathsthe EMS worker deaths 275 deaths of others (in vehicles or 275 deaths of others (in vehicles or

pedestrians)pedestrians)MMWR 2003; 58:154-156

Occupational Fatalities in EMS:Occupational Fatalities in EMS:A Hidden CrisisA Hidden Crisis

Maguire & Hunting, Maguire & Hunting, et alet al Death rate among EMS workers 12.7 Death rate among EMS workers 12.7

per 100,000 workersper 100,000 workers More than twice the National Average More than twice the National Average

(5.0)(5.0) 14.2 per 100,000 for Police14.2 per 100,000 for Police 16.5 per 100,000 for Firefighters16.5 per 100,000 for Firefighters

Highest risk occurs in transportation Highest risk occurs in transportation related incidentsrelated incidents 9.6 per 100,000 EMS workers9.6 per 100,000 EMS workers

Ann Emerg Med. 2002;40:625-632

Legal RisksLegal Risks

Colwell & Pons, Colwell & Pons, et alet al Claims Against a Paramedic Claims Against a Paramedic

Ambulance Service: A Ten-Year Ambulance Service: A Ten-Year ExperienceExperience

Denver: 1984 – 1993Denver: 1984 – 1993 82 Claims against the EMS Agency82 Claims against the EMS Agency 11 Lawsuits11 Lawsuits

J Emerg Med 1999; 17(6):999-1002


Colwell & Pons, Colwell & Pons, et alet al Frequency of Named Parties (N=82):Frequency of Named Parties (N=82):

100% Paramedics involved100% Paramedics involved 46% The City of Denver46% The City of Denver 20% The Department of Health and 20% The Department of Health and

HospitalsHospitals 4% The Physician Medical Director4% The Physician Medical Director

J Emerg Med 1999; 17(6):999-1002


Colwell & Pons, Colwell & Pons, et alet al 59 of 82 (72%) ambulance crashes59 of 82 (72%) ambulance crashes

6 lawsuits6 lawsuits Run status not known in 10 runsRun status not known in 10 runs 29/49 (59%) emergency use (RL&S)29/49 (59%) emergency use (RL&S) 5/49 (10%) non-emergency use5/49 (10%) non-emergency use 20/49 (31%) not on a call 20/49 (31%) not on a call

J Emerg Med 1999; 17(6):999-1002


Colwell & Pons, Colwell & Pons, et alet al 6 Lawsuits went to trial6 Lawsuits went to trial 5/6 (83%) due to ambulance crashes5/6 (83%) due to ambulance crashes 36/59 (61%) property damage claims36/59 (61%) property damage claims 23/59 (39%) personal injury claims23/59 (39%) personal injury claims Rate: 1 claim per 5,084 patient Rate: 1 claim per 5,084 patient

transport runs (0.197 claims per transport runs (0.197 claims per 1,000)1,000)

J Emerg Med 1999; 17(6):999-1002


Colwell & Pons, Colwell & Pons, et alet al Total payout: $579,956Total payout: $579,956

Max per claim: $150,000 (Gov’t Max per claim: $150,000 (Gov’t Immunity)Immunity)

Three lawsuits from ambulance Three lawsuits from ambulance crashes with personal injury paid out:crashes with personal injury paid out: $32,000$32,000 $100,000$100,000 $150,000$150,000

J Emerg Med 1999; 17(6):999-1002

CostsCosts

In excess of $500 Million Annually*In excess of $500 Million Annually* ““A conservative estimate”A conservative estimate” ““Could be 10 times or more higher”Could be 10 times or more higher”

Nadine Levick, MD, MPHNadine Levick, MD, MPH Personal Conversation Personal Conversation

* http://www.objectivesafety.net/LevickAAAM2005.pdf

Code 3 vs. Code 2 StudiesCode 3 vs. Code 2 Studies Hunt & Brown, Hunt & Brown, et al et al

Small Urban Setting – Transport PhaseSmall Urban Setting – Transport Phase Annals of Emergency Medicine Annals of Emergency Medicine 1995;25:507-5111995;25:507-511 RL&S transport time savings average 43.5 sec vs. RL&S transport time savings average 43.5 sec vs.

without RL&S (N=50)without RL&S (N=50) RL&S transport not warranted, except in rare RL&S transport not warranted, except in rare

circumstancescircumstances Brown & Whitney, Brown & Whitney, et al et al

Medium Size Urban Setting – Response PhaseMedium Size Urban Setting – Response Phase Prehospital Emergency Care Prehospital Emergency Care 2000;4:70-742000;4:70-74 RL&S Response time savings average 1 min 46 secRL&S Response time savings average 1 min 46 sec Statistically significantStatistically significant Clinically relevant in very few circumstancesClinically relevant in very few circumstances

Code 3 vs. Code 2 StudiesCode 3 vs. Code 2 Studies

Ho & Casey Ho & Casey Major Urban Setting – Response Phase (N=64)Major Urban Setting – Response Phase (N=64) Annals of Emergency MedicineAnnals of Emergency Medicine 1998;32:585-588 1998;32:585-588 Average time savings 3.02 minutes (38.5%)Average time savings 3.02 minutes (38.5%) Statistically significantStatistically significant

Ho & Lindquist Ho & Lindquist Rural Setting – Response Phase (N=67)Rural Setting – Response Phase (N=67) Prehospital Emergency CarePrehospital Emergency Care 2001;5:159–162 2001;5:159–162 Average time savings 3.63 min (30.9%)Average time savings 3.63 min (30.9%) Statistically significantStatistically significant

The Effectiveness of Lights and The Effectiveness of Lights and Sirens During Paramedic TransportSirens During Paramedic Transport O’Brien, Price & AdamsO’Brien, Price & Adams Prospective case-control observationalProspective case-control observational

Simultaneous Code 3 ambulance transport Simultaneous Code 3 ambulance transport vs. Non-Code 3 observer vehicle (OV)vs. Non-Code 3 observer vehicle (OV)

Convenience sample of 75 runsConvenience sample of 75 runs Do RL&S save time?Do RL&S save time? Does the time savings result in clinically Does the time savings result in clinically

significant interventions at the significant interventions at the destination hospital?destination hospital?


The Effectiveness of Lights and The Effectiveness of Lights and Sirens During Paramedic TransportSirens During Paramedic Transport O’Brien, Price & AdamsO’Brien, Price & Adams Setting:Setting:

University of Louisville School of MedicineUniversity of Louisville School of Medicine Jefferson County KentuckyJefferson County Kentucky 365 square miles365 square miles Annual run volume: 36,000Annual run volume: 36,000 Suburban single-tier third serviceSuburban single-tier third service Ambulance makes Code 3 transport decisionAmbulance makes Code 3 transport decision Observer vehicle follows but obeys all traffic Observer vehicle follows but obeys all traffic

lawslaws


The Effectiveness of Lights and The Effectiveness of Lights and Sirens During Paramedic TransportSirens During Paramedic Transport O’Brien, Price & AdamsO’Brien, Price & Adams Ambulance vs. OVAmbulance vs. OV

Mean Ambulance transit time 666 sec Mean Ambulance transit time 666 sec (11:6)(11:6)

SD 203 secSD 203 sec Mean OV transit time 896 sec (14:56)Mean OV transit time 896 sec (14:56)

SD 269 secSD 269 sec Mean Difference 230 sec (3:50)Mean Difference 230 sec (3:50)

SD 126 sec (Range 23 sec to 13 min, 3 sec)SD 126 sec (Range 23 sec to 13 min, 3 sec) Statistically significant (p<0.0005)Statistically significant (p<0.0005)


The Effectiveness of Lights and The Effectiveness of Lights and Sirens During Paramedic TransportSirens During Paramedic Transport O’Brien, Price & AdamsO’Brien, Price & Adams Ambulance vs. OVAmbulance vs. OV

Average distance traveled was 8.8 milesAverage distance traveled was 8.8 miles Statistically significant correlations Statistically significant correlations

between the transit time difference and:between the transit time difference and: Number of stop lightsNumber of stop lights Traffic intensityTraffic intensity Distance traveledDistance traveled

No differences based on the time of dayNo differences based on the time of day


The Effectiveness of Lights and The Effectiveness of Lights and Sirens During Paramedic TransportSirens During Paramedic Transport O’Brien, Price & AdamsO’Brien, Price & Adams Hospital InterventionsHospital Interventions

81% (61/75) received none81% (61/75) received none 5% (4/14) received critical interventions that 5% (4/14) received critical interventions that

could not be accomplished by the paramedics could not be accomplished by the paramedics before hospital arrivalbefore hospital arrival

Re-intubationRe-intubation One being prepped for intubationOne being prepped for intubation IV + D50 for a hypoglycemic after failed IV in the fieldIV + D50 for a hypoglycemic after failed IV in the field Diazepam for child in status epilepticus - difficult to Diazepam for child in status epilepticus - difficult to

start IVstart IV Remaining interventions felt to be non-criticalRemaining interventions felt to be non-critical


The Effectiveness of Lights and The Effectiveness of Lights and Sirens During Paramedic TransportSirens During Paramedic Transport O’Brien, Price & AdamsO’Brien, Price & Adams ConclusionsConclusions

There was a statistically significant time There was a statistically significant time savings with RL&S transportsavings with RL&S transport

The use of RL&S added little to the care of The use of RL&S added little to the care of those patients who received successful those patients who received successful interventions by paramedics in the fieldinterventions by paramedics in the field

Few clinically relevant interventions were Few clinically relevant interventions were accomplished at the hospital during the time accomplished at the hospital during the time saved by RL&S transportsaved by RL&S transport

Paramedic ALS interventions significantly Paramedic ALS interventions significantly reduce the need for RL&S transportreduce the need for RL&S transport


A Question of BalanceA Question of Balance

System Performance

Goals: Response Time

Public Expectations: “When it’s my emergency!”

Safety:

The Provider’s The Patient’s The Public’s

The needs of the patient


Number Needed to Treat (NNT)Number Needed to Treat (NNT) The number needed to treat a specific The number needed to treat a specific

disease with a given therapy in order to disease with a given therapy in order to prevent one additional deathprevent one additional death

The inverse of the ‘risk difference’ between The inverse of the ‘risk difference’ between alternative therapiesalternative therapies

The absolute change in risk due to the The absolute change in risk due to the interventionintervention

Related to the characteristics of the disease Related to the characteristics of the disease and the characteristics of the treatmentand the characteristics of the treatment


Number Needed to Harm (NNH)Number Needed to Harm (NNH) The number of times a specific therapy The number of times a specific therapy

is given before it causes an adverse is given before it causes an adverse outcomeoutcome

The inverse of the ‘risk difference’ The inverse of the ‘risk difference’ between alternative therapiesbetween alternative therapies

The absolute change in risk due to the The absolute change in risk due to the interventionintervention

Related to the characteristics of the Related to the characteristics of the treatment alonetreatment alone


Number Needed to Treat vs. HarmNumber Needed to Treat vs. Harm Example: Fibrinolytics for AMI vs. Example: Fibrinolytics for AMI vs.

PlaceboPlacebo 3% absolute risk reduction of death from 3% absolute risk reduction of death from

AMIAMI 1% absolute risk increase of fatal 1% absolute risk increase of fatal

intracranial hemorrhageintracranial hemorrhage NNT = 1NNT = 1÷ 3% = 33÷ 3% = 33 NNH = 1÷ 1% = 100NNH = 1÷ 1% = 100 Thus, for every 3 lives we save with lytics, Thus, for every 3 lives we save with lytics,

one life will be lostone life will be lost


NNT vs. NNH Across the Spectrum of NNT vs. NNH Across the Spectrum of Prehospital Emergencies Prehospital Emergencies

Likelihood of RL&S to Reduce Avoidable Adverse Patient Outcomes

NN

T &

NN

H

Number Needed to TreatNumber Needed to Harm


Consider this…Consider this…

If an ambulance crashes while If an ambulance crashes while responding to a call, and no harm responding to a call, and no harm

comes to the patient for whom it was comes to the patient for whom it was summoned as a result of the ensuing summoned as a result of the ensuing delay, then the consequences of the delay, then the consequences of the

crash were realized for no gain.crash were realized for no gain.



If I am correct in believing that RL&S are If I am correct in believing that RL&S are generally ‘not helpful and potentially generally ‘not helpful and potentially

harmful’, then it would seem reasonable harmful’, then it would seem reasonable to limit their use to the few situations in to limit their use to the few situations in which the potential benefits outweigh which the potential benefits outweigh the potential harm, and if that is not the potential harm, and if that is not

clearly known, then the laws of clearly known, then the laws of probability favor not using them, until probability favor not using them, until better information becomes available.better information becomes available.



If I am correct in believing that RL&S If I am correct in believing that RL&S is ‘generally not helpful and is ‘generally not helpful and

potentially harmful’, then it would potentially harmful’, then it would seem reasonable to conclude that seem reasonable to conclude that

the premise of improved emergency the premise of improved emergency vehicle driver education is at best a vehicle driver education is at best a

double-edged sword.double-edged sword.

NAEMSP Position StatementNAEMSP Position Statement

Few published data on effectiveness of RL&S in Few published data on effectiveness of RL&S in reducing response [or transport] timesreducing response [or transport] times

RL&S should be reserved for situations in which RL&S should be reserved for situations in which patient welfare is at stakepatient welfare is at stake

RL&S during response and transport should be RL&S during response and transport should be based on situational and patient problem based on situational and patient problem assessments and the Medical Director should assessments and the Medical Director should participate in the development of related participate in the development of related policiespolicies

Crashes should be evaluated by EMS system Crashes should be evaluated by EMS system managers and medical directorsmanagers and medical directors

Prehospital and Disaster Medicine, April-June 1994


EMS dispatch should use a priority EMS dispatch should use a priority reference system to identify which calls reference system to identify which calls warrant RL&Swarrant RL&S

Except for suspected life-threatening, Except for suspected life-threatening, time-critical cases or cases involving time-critical cases or cases involving multiple patients, RL&S response by more multiple patients, RL&S response by more than one EMV usually is unnecessarythan one EMV usually is unnecessary

The utilization of emergency RL&S should The utilization of emergency RL&S should be limited to emergency response and be limited to emergency response and emergency transport situations onlyemergency transport situations only



All agencies should institute and maintain All agencies should institute and maintain emergency vehicle operation education emergency vehicle operation education programs for vehicle operatorsprograms for vehicle operators

Scientific studies evaluating the Scientific studies evaluating the effectiveness of RL&S under specific effectiveness of RL&S under specific situations should be conducted and situations should be conducted and validatedvalidated

Laws and statutes should take into Laws and statutes should take into account prudent safety practices by both account prudent safety practices by both EMS providers and the monitoring publicEMS providers and the monitoring public


Thought Provoking?Thought Provoking?

Should we – the leaders of the EMS industry Should we – the leaders of the EMS industry – seek legislative reforms to regulate the – seek legislative reforms to regulate the appropriate use of RL&S?appropriate use of RL&S? Stopping at red lights Stopping at red lights Driver training and certificationDriver training and certification Driver background checksDriver background checks Technological innovations to promote safetyTechnological innovations to promote safety Priority Medical DispatchingPriority Medical Dispatching Written policies for emergency medical vehicle Written policies for emergency medical vehicle

operationsoperations Others?Others?

Thought Provoking?Thought Provoking?

Even if we master and solve Even if we master and solve thisthis problem, our work will not be doneproblem, our work will not be done The issue of safety in our industry goes well The issue of safety in our industry goes well

beyond the issue of RL&Sbeyond the issue of RL&S We also need to master the issues of We also need to master the issues of

occupational safety and health among EMS occupational safety and health among EMS workersworkers

We also need to master the design We also need to master the design specifications of ambulances as they specifications of ambulances as they pertain to the safety of the EMS work pertain to the safety of the EMS work environmentenvironment

A ‘Must See’ PresentationA ‘Must See’ Presentation Dr. Nadine LevickDr. Nadine Levick

Wisconsin Division of the American Wisconsin Division of the American Trauma SocietyTrauma Society

2007 William H. Perloff Trauma Care 2007 William H. Perloff Trauma Care Conference: Reality TraumaConference: Reality Trauma

November 9-10November 9-10 Holiday Inn – Stevens PointHoliday Inn – Stevens Point For further information or to receive the

application, contact Lynne Sears at [email protected], 608-265-0372 or the WATS website at www.wats.cehss.org.

Questions?Questions?

http://www.bobomania.com/music/moodies/qob/images/A%20Question%20Of%20Balance%20(small).gif

Thank You!Thank You! Contact Information:Contact Information:

Michael D. Curtis, MD, FACEPMichael D. Curtis, MD, FACEPEMS Medical DirectorEMS Medical Director

Saint Michael’s Hospital – Stevens PointSaint Michael’s Hospital – Stevens PointSaint Clare’s Hospital – WestonSaint Clare’s Hospital – Weston

[email protected]@ministryhealth.org

red lights and sirens: do we need them?

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