Red Lights and Sirens: Do We Need Them?

1. Red Lights and Sirens: Do We Need Them? Michael D. Curtis, MD, FACEP EMS Medical Director Saint Michael’s Hospital – Stevens Point Saint Clare’s Hospital – Weston

2. Objectives • Define the problems related to using red lights and sirens in EMS • State the conclusions of research on the value of red lights and sirens in EMS • Develop an understanding of the conceptual framework for balance in the use of RL&S in EMS • Discuss steps industry leaders can take to reduce the toll on our industry

3. Perspective • Primum Non Nocere – Above all, do no harm! • Origins of RL&S Transport • “Back in the day” when ambulances were merely transport vehicles and few if any interventions were performed in the field • A practice adopted from law enforcement and fire services without question as to safety and efficacy

4. Perspective • The Culture of RL&S in EMS • "...loose interpretation of what constitutes an emergency has essentially given [EMV operators permission] to operate their vehicles as they see fit while carrying victims who are essentially stable by anyone's definition." • Paul S. Auerbach, MD, et al JAMA 1987;258:1487Ð1490 Excerpted from: Prehospital and Disaster Medicine, April-June 1994

5. My Perspective Like so many therapeutic interventions throughout the history of medicine that have landed on the scrapheap of good intentions, the widespread use of red lights and sirens in EMS should be abandoned, their use being restricted to the very few cases in which the potential benefits may outweigh the associated risks – for they have largely proven to be ‘not helpful and potentially harmful’ .

6. Characteristics of Fatal Ambulance Crashes • Kahn, Pirrallo & Kuhn • US NHTSA FARS • 1987-1997 • 339 Ambulance crashes • 405 fatalities & 838 other injuries • Emergency Mode of Travel (RL&S) • 60% (202/339) of all crashes • 58% (233/405) of all fatalities Prehospital Emergency Care 2001; 5:261-269

7. Characteristics of Fatal Ambulance Crashes • Kahn, Pirrallo & Kuhn • In most fatal ambulance crashes: • Traveling in the “emergency mode” (RL&S) • The ambulance is the striking vehicle • The crash occurs at an intersection • Occupants of other vehicles are more likely to die or suffer serious injury than occupants of the ambulance • Rear compartment occupants are more likely to be injured or die than front compartment occupants • The ambulance drives have poor driving histories Prehospital Emergency Care 2001; 5:261-269

8. Ambulance Crash Injuries Among US EMS Workers 1991-2002 • Based on NHTSA FARS data • 300 Fatal Ambulance Crashes • 82 deaths in the ambulances • 27 EMS workers • Most EMS worker deaths in front compartment • Lack of restraint use cited in many of the EMS worker deaths • 275 deaths of others (in vehicles or pedestrians) MMWR 2003; 58:154-156

9. Occupational Fatalities in EMS:A Hidden Crisis • Maguire & Hunting, et al • Death rate among EMS workers 12.7 per 100,000 workers • More than twice the National Average (5.0) • 14.2 per 100,000 for Police • 16.5 per 100,000 for Firefighters • Highest risk occurs in transportation related incidents • 9.6 per 100,000 EMS workers Ann Emerg Med. 2002;40:625-632

10. Legal Risks • Colwell & Pons, et al • Claims Against a Paramedic Ambulance Service: A Ten-Year Experience • Denver: 1984 – 1993 • 82 Claims against the EMS Agency • 11 Lawsuits J Emerg Med 1999; 17(6):999-1002

11. Legal Risks • Colwell & Pons, et al • Frequency of Named Parties (N=82): • 100% Paramedics involved • 46% The City of Denver • 20% The Department of Health and Hospitals • 4% The Physician Medical Director J Emerg Med 1999; 17(6):999-1002

12. Legal Risks • Colwell & Pons, et al • 59 of 82 (72%) ambulance crashes • 6 lawsuits • Run status not known in 10 runs • 29/49 (59%) emergency use (RL&S) • 5/49 (10%) non-emergency use • 20/49 (31%) not on a call J Emerg Med 1999; 17(6):999-1002

13. Legal Risks • Colwell & Pons, et al • 6 Lawsuits went to trial • 5/6 (83%) due to ambulance crashes • 36/59 (61%) property damage claims • 23/59 (39%) personal injury claims • Rate: 1 claim per 5,084 patient transport runs (0.197 claims per 1,000) J Emerg Med 1999; 17(6):999-1002

14. Legal Risks • Colwell & Pons, et al • Total payout: $579,956 • Max per claim: $150,000 (Gov’t Immunity) • Three lawsuits from ambulance crashes with personal injury paid out: • $32,000 • $100,000 • $150,000 J Emerg Med 1999; 17(6):999-1002

15. Costs • In excess of $500 Million Annually* • “A conservative estimate” • “Could be 10 times or more higher” • Nadine Levick, MD, MPH • Personal Conversation * http://www.objectivesafety.net/LevickAAAM2005.pdf

16. Code 3 vs. Code 2 Studies • Hunt & Brown, et al • Small Urban Setting – Transport Phase • Annals of Emergency Medicine 1995;25:507-511 • RL&S transport time savings average 43.5 sec vs. without RL&S (N=50) • RL&S transport not warranted, except in rare circumstances • Brown & Whitney, et al • Medium Size Urban Setting – Response Phase • Prehospital Emergency Care 2000;4:70-74 • RL&S Response time savings average 1 min 46 sec • Statistically significant • Clinically relevant in very few circumstances

17. Code 3 vs. Code 2 Studies • Ho & Casey • Major Urban Setting – Response Phase (N=64) • Annals of Emergency Medicine 1998;32:585-588 • Average time savings 3.02 minutes (38.5%) • Statistically significant • Ho & Lindquist • Rural Setting – Response Phase (N=67) • Prehospital Emergency Care 2001;5:159–162 • Average time savings 3.63 min (30.9%) • Statistically significant

18. The Effectiveness of Lights and Sirens During Paramedic Transport • O’Brien, Price & Adams • Prospective case-control observational • Simultaneous Code 3 ambulance transport vs. Non-Code 3 observer vehicle (OV) • Convenience sample of 75 runs • Do RL&S save time? • Does the time savings result in clinically significant interventions at the destination hospital? Prehospital Emergency Care 1999; 3:127-130

19. The Effectiveness of Lights and Sirens During Paramedic Transport • O’Brien, Price & Adams • Setting: • University of Louisville School of Medicine • Jefferson County Kentucky • 365 square miles • Annual run volume: 36,000 • Suburban single-tier third service • Ambulance makes Code 3 transport decision • Observer vehicle follows but obeys all traffic laws Prehospital Emergency Care 1999; 3:127-130

20. The Effectiveness of Lights and Sirens During Paramedic Transport • O’Brien, Price & Adams • Ambulance vs. OV • Mean Ambulance transit time 666 sec (11:6) • SD 203 sec • Mean OV transit time 896 sec (14:56) • SD 269 sec • Mean Difference 230 sec (3:50) • SD 126 sec (Range 23 sec to 13 min, 3 sec) • Statistically significant (p<0.0005) Prehospital Emergency Care 1999; 3:127-130

21. The Effectiveness of Lights and Sirens During Paramedic Transport • O’Brien, Price & Adams • Ambulance vs. OV • Average distance traveled was 8.8 miles • Statistically significant correlations between the transit time difference and: • Number of stop lights • Traffic intensity • Distance traveled • No differences based on the time of day Prehospital Emergency Care 1999; 3:127-130

22. The Effectiveness of Lights and Sirens During Paramedic Transport • O’Brien, Price & Adams • Hospital Interventions • 81% (61/75) received none • 5% (4/14) received critical interventions that could not be accomplished by the paramedics before hospital arrival • Re-intubation • One being prepped for intubation • IV + D50 for a hypoglycemic after failed IV in the field • Diazepam for child in status epilepticus - difficult to start IV • Remaining interventions felt to be non-critical Prehospital Emergency Care 1999; 3:127-130

23. The Effectiveness of Lights and Sirens During Paramedic Transport • O’Brien, Price & Adams • Conclusions • There was a statistically significant time savings with RL&S transport • The use of RL&S added little to the care of those patients who received successful interventions by paramedics in the field • Few clinically relevant interventions were accomplished at the hospital during the time saved by RL&S transport • Paramedic ALS interventions significantly reduce the need for RL&S transport Prehospital Emergency Care 1999; 3:127-130

24. A 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

25. A Question of Balance • Number Needed to Treat (NNT) • The number needed to treat a specific disease with a given therapy in order to prevent one additional death • The inverse of the ‘risk difference’ between alternative therapies • The absolute change in risk due to the intervention • Related to the characteristics of the disease and the characteristics of the treatment

26. A Question of Balance • Number Needed to Harm (NNH) • The number of times a specific therapy is given before it causes an adverse outcome • The inverse of the ‘risk difference’ between alternative therapies • The absolute change in risk due to the intervention • Related to the characteristics of the treatment alone

27. A Question of Balance • Number Needed to Treat vs. Harm • Example: Fibrinolytics for AMI vs. Placebo • 3% absolute risk reduction of death from AMI • 1% absolute risk increase of fatal intracranial hemorrhage • NNT = 1÷ 3% = 33 • NNH = 1÷ 1% = 100 • Thus, for every 3 lives we save with lytics, one life will be lost

28. A Question of Balance • NNT vs. NNH Across the Spectrum of Prehospital Emergencies Number Needed to Treat Number Needed to Harm NNT & NNH Likelihood of RL&S to Reduce Avoidable Adverse Patient Outcomes

29. A Question of Balance • Consider this… If an ambulance crashes while responding to a call, and no harm comes to the patient for whom it was summoned as a result of the ensuing delay, then the consequences of the crash were realized for no gain.

30. A Question of Balance • Consider this… If I am correct in believing that RL&S are generally ‘not helpful and potentially harmful’, then it would seem reasonable to limit their use to the few situations in which the potential benefits outweigh the potential harm, and if that is not clearly known, then the laws of probability favor not using them, until better information becomes available.

31. A Question of Balance • Consider this… If I am correct in believing that RL&S is ‘generally not helpful and potentially harmful’, then it would seem reasonable to conclude that the premise of improved emergency vehicle driver education is at best a double-edged sword.

32. NAEMSP Position Statement • Few published data on effectiveness of RL&S in reducing response [or transport] times • RL&S should be reserved for situations in which patient welfare is at stake • RL&S during response and transport should be based on situational and patient problem assessments and the Medical Director should participate in the development of related policies • Crashes should be evaluated by EMS system managers and medical directors Prehospital and Disaster Medicine, April-June 1994

33. NAEMSP Position Statement • EMS dispatch should use a priority reference system to identify which calls warrant RL&S • Except for suspected life-threatening, time-critical cases or cases involving multiple patients, RL&S response by more than one EMV usually is unnecessary • The utilization of emergency RL&S should be limited to emergency response and emergency transport situations only Prehospital and Disaster Medicine, April-June 1994

34. NAEMSP Position Statement • All agencies should institute and maintain emergency vehicle operation education programs for vehicle operators • Scientific studies evaluating the effectiveness of RL&S under specific situations should be conducted and validated • Laws and statutes should take into account prudent safety practices by both EMS providers and the monitoring public Prehospital and Disaster Medicine, April-June 1994

35. Thought Provoking? • Should we – the leaders of the EMS industry – seek legislative reforms to regulate the appropriate use of RL&S? • Stopping at red lights • Driver training and certification • Driver background checks • Technological innovations to promote safety • Priority Medical Dispatching • Written policies for emergency medical vehicle operations • Others?

36. Thought Provoking? • Even if we master and solve this problem, our work will not be done • The issue of safety in our industry goes well beyond the issue of RL&S • We also need to master the issues of occupational safety and health among EMS workers • We also need to master the design specifications of ambulances as they pertain to the safety of the EMS work environment

37. A ‘Must See’ Presentation • Dr. Nadine Levick • Wisconsin Division of the American Trauma Society • 2007 William H. Perloff Trauma Care Conference: Reality Trauma • November 9-10 • Holiday Inn – Stevens Point • For further information or to receive the application, contact Lynne Sears at lsears@uwhealth.org, 608-265-0372 or the WATS website at www.wats.cehss.org.

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

39. Thank You! Contact Information: Michael D. Curtis, MD, FACEP EMS Medical Director Saint Michael’s Hospital – Stevens Point Saint Clare’s Hospital – Weston mike.curtis@ministryhealth.org