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

3. Perspective Primum Non Nocere – Above all, do no harm! Primum Non Nocere – Above all, do no harm! Origins of RL&S Transport 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 “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 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 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." "...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 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 Kahn, Pirrallo & Kuhn US NHTSA FARS US NHTSA FARS 1987-1997 1987-1997 339 Ambulance crashes 339 Ambulance crashes 405 fatalities & 838 other injuries 405 fatalities & 838 other injuries Emergency Mode of Travel (RL&S) Emergency Mode of Travel (RL&S) 60% (202/339) of all crashes 60% (202/339) of all crashes 58% (233/405) of all fatalities 58% (233/405) of all fatalities Prehospital Emergency Care 2001; 5:261-269

7. Characteristics of Fatal Ambulance Crashes Kahn, Pirrallo & Kuhn Kahn, 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 vehicle The ambulance is the striking vehicle The crash occurs at an intersection The crash occurs at an intersection Occupants of other vehicles are more likely to die or suffer serious injury than occupants of the ambulance 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 Rear compartment occupants are more likely to be injured or die than front compartment occupants The ambulance drives have poor driving histories The ambulance drives have poor driving histories Prehospital Emergency Care 2001; 5:261-269

8. Characteristics of Fatal Ambulance Crashes Kahn, Pirrallo & Kuhn Kahn, Pirrallo & Kuhn Most RL&S fatal crashes occurred: Most RL&S fatal crashes occurred: At intersections At intersections At an angle At an angle With another vehicle With another vehicle Most fatal RL&S crashes involved: Most fatal RL&S crashes involved: One fatality (84%) One fatality (84%) People who were not in the ambulance (78%) People who were not in the ambulance (78%) Mostly in other vehicles Mostly in other vehicles 9% were pedestrians or bicyclists 9% were pedestrians or bicyclists Prehospital Emergency Care 2001; 5:261-269

9. Characteristics of Fatal Ambulance Crashes Kahn, Pirrallo & Kuhn Kahn, Pirrallo & Kuhn Ambulance occupant deaths Ambulance occupant deaths Rear compartment > front compartment Rear compartment > front compartment OR 2.7 OR 2.7 Unrestrained/improperly restrained occupants Unrestrained/improperly restrained occupants OR 2.5 (compared to properly restrained) OR 2.5 (compared to properly restrained) OR 2.8 (rear vs. front occupants) OR 2.8 (rear vs. front occupants) Prehospital Emergency Care 2001; 5:261-269

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

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

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

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

14. Legal Risks Colwell & Pons, et al Colwell & Pons, et al 59 of 82 (72%) ambulance crashes 59 of 82 (72%) ambulance crashes 6 lawsuits 6 lawsuits Run status not known in 10 runs Run 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 use 5/49 (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

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

16. Legal Risks Colwell & Pons, et al Colwell & Pons, et al Total payout: $579,956 Total payout: $579,956 Max per claim: $150,000 (Gov’t Immunity) Max per claim: $150,000 (Gov’t Immunity) Three lawsuits from ambulance crashes with personal injury paid out: Three lawsuits from ambulance 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

17. Costs 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, MPH Nadine Levick, MD, MPH Personal Conversation Personal Conversation * http://www.objectivesafety.net/LevickAAAM2005.pdf

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

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

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

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

22. The Effectiveness of Lights and Sirens During Paramedic Transport O’Brien, Price & Adams O’Brien, Price & Adams Ambulance vs. OV Ambulance vs. OV Mean Ambulance transit time 666 sec (11:6) Mean Ambulance transit time 666 sec (11:6) SD 203 sec SD 203 sec Mean OV transit time 896 sec (14:56) Mean OV transit time 896 sec (14:56) SD 269 sec SD 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) Prehospital Emergency Care 1999; 3:127-130

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

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

25. The Effectiveness of Lights and Sirens During Paramedic Transport O’Brien, Price & Adams O’Brien, Price & Adams Conclusions Conclusions There was a statistically significant time savings with RL&S transport 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 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 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 Paramedic ALS interventions significantly reduce the need for RL&S transport Prehospital Emergency Care 1999; 3:127-130

26. 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

27. A Question of Balance Number Needed to Treat (NNT) 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 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 inverse of the ‘risk difference’ between alternative therapies The absolute change in risk due to the intervention The absolute change in risk due to the intervention Related to the characteristics of the disease and the characteristics of the treatment Related to the characteristics of the disease and the characteristics of the treatment

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

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

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

31. A Question of Balance Consider this… 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.

32. A Question of Balance Consider this… 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.

33. A Question of Balance Consider this… 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.

34. NAEMSP Position Statement Few published data on effectiveness of RL&S in reducing response [or transport] times 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 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 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 Crashes should be evaluated by EMS system managers and medical directors Prehospital and Disaster Medicine, April-June 1994

35. NAEMSP Position Statement EMS dispatch should use a priority reference system to identify which calls warrant RL&S 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 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 The utilization of emergency RL&S should be limited to emergency response and emergency transport situations only Prehospital and Disaster Medicine, April-June 1994

36. NAEMSP Position Statement All agencies should institute and maintain emergency vehicle operation education programs for vehicle operators 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 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 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

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

38. Thought Provoking? Even if we master and solve this problem, our work will not be done 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 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 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 We also need to master the design specifications of ambulances as they pertain to the safety of the EMS work environment

39. A ‘Must See’ Presentation Dr. Nadine Levick Dr. Nadine Levick Wisconsin Division of the American Trauma Society Wisconsin Division of the American Trauma Society 2007 William H. Perloff Trauma Care Conference: Reality Trauma 2007 William H. Perloff Trauma Care Conference: Reality Trauma November 9-10 November 9-10 Holiday Inn – Stevens Point 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.

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

41. Thank You! Contact Information: 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