Rural Ambulance Crash:
Literature Review
This document was prepared for the U.S. Department of Health and
Human Services, Health Resources and Services Administration, Office
of Rural Health Policy under HRSA contract # 250-03-0022.
On this page:
Foreword
EMS professionals face many risks – exposure to infectious
diseases, violence, hazardous scenes, and oncoming traffic, to name
a few. However, none of these risks compares to the potential for
death and injury that is associated with driving an ambulance. Every
year dozens of EMS providers are killed and many more seriously
injured in ambulance crashes. Rural EMS providers are at even greater
risk because when the ambulance they are driving or riding in crashes,
there is a greater likelihood that they will be killed or sustain
a serious injury than is the case in urban areas.
There is a high degree of variability among EMS agencies when it
comes to emergency vehicle operations training. Some agencies require
such training during initial training, others may provide it as
an option for continuing education, but many, many others do not
require it at all. In a rural environment, where the dangers are
high and the frequency of use is low, it is imperative that emergency
vehicle operators be given all of the skills that they need to survive.
This document is not an emergency vehicle operations training program;
there are many of those available. Contact your State or Commonwealth
EMS agency for information concerning the location and availability
of such training.
Marcia K. Brand, PhD
Associate Administrator for Rural Health, HRSA
This report is a review of the published research pertaining to
ambulance crashes with a special emphasis on the rural environment.
It is provided to give the reader an understanding of the magnitude
of the risk that rural ambulance operators face every time they
respond to an illness or injury. Armed with this knowledge, it is
our hope that local EMS leaders in rural America will understand
the need to screen prospective drivers, to implement training strategies,
to adopt and enforce policies pertaining to warning light and siren
responses, and to look for potential technological adaptations to
improve driver performance.
If your agency does not have a policy pertaining to emergency vehicle
operations, we hope that you will adapt, adopt, and enforce the
sample that is provided in this report.
An ambulance crash that kills or maims a crew member can devastate
a rural EMS agency. At a time when the sustainability of many volunteer
EMS agencies is in doubt, such a tragedy can result in the loss
of a critical health care resource within the community –
that of timely, safe, and effective emergency medical care. We hope
that this paper will be a call to action for your rural EMS agency.
Nels D. Sanddal
Director Rural EMS and Trauma Technical Assistance Center
INTRODUCTION
Unfortunately, ambulance crashes are relatively common. A lack
of vehicle performance standards, maintenance, and proper safety
restraint contribute to the human toll caused by at least 6,500
ambulance crashes a year (Zagaroli & Taylor, 2003). A study
conducted in 2002, documented that the occupational motor vehicle
fatality rate for emergency medical personnel was four times the
national average for other occupations (Levick & Swanson, 2005).
Rural ambulance crashes are of great concern. They are usually
much more severe than urban crashes because rural ambulances travel
at higher speeds and thus there is greater potential for harm if
a crash occurs. Further, the roadway typology, with narrower roads,
few dividers, limited lighting, and no shoulders, in addition to
slower emergency response times in the event of an ambulance crash,
can make an already dangerous crash scene worse (Weiss, Ellis, Ernst,
Land, & Garza, 2001). Ambulance crashes occurring on rural roadways
are more likely to result in death to emergency medical personnel,
the patient, and occupants of other vehicles. When a rural crash
does not involve fatalities, there are often significant delays
associated with the continued transportation of the initial patient.
Often times, multiple ambulances must be dispatched from surrounding
communities, resulting in transportation delays for the original
patient as well as the “new” patients resulting from
the ambulance crash itself.
Little is known about ambulance crashes in general and rural ambulance
crashes specifically. This paper will review the current literature,
discuss the implications for rural emergency medical service (EMS)
agencies and personnel, and provide a sample policy or protocol
that could be adapted for use in most communities.
LITERATURE SEARCH AND SELECTION
The literature search was conducted in a step-wise process. The
purpose of the search was to identify published literature that
describes the frequency, epidemiology, etiology, typology, and cost
(human and fiscal) of ambulance crashes generally and rural ambulance
crashes specifically.
The primary database selected for the literature search was MEDLINE
(1996-2007). A secondary search was conducted using Academic Search
Premier and Comprehensive Index of Nursing and Allied Health Literature.
A final search was conducted using ProQuest Dissertation International.
MeSH search terms used in MEDLINE included, ambulance; accident,
traffic; emergency medical technician; occupational health; and
rural in descending combination. The primary, secondary, and tertiary
searches yielded 31 articles on the subject. Of those, four published
in trade magazines and one appearing in a foreign medical journal
were not retrievable on-line. Staff reviewed the remaining articles
for relevance and, ultimately, included 26 in this review. A brief
annotated bibliography follows.
ANNOTATED BIBILIOGRAPHY
Barishansky, R.M. (2005). Next generation ambulance puts safety
first. Emergency Medical Services, 30, 34.
This descriptive article discusses the features of a “2nd”
generation ambulance design that “puts safety first.”
Among the updated design functions, are external cameras for better
driver visibility, improved seat placement and restraints systems
for rear crew members, safety cargo netting to reduce the possibility
of striking the bulkheads during a crash, more secure equipment
storage, turn and brake signal indicators in the rear compartment
to provide a visual warning of impending turns or stops, and changes
in exterior paint and lighting. Additionally, the new vehicles come
with “black box” monitoring and recording systems as
standard equipment. The author concludes that these modifications
may have an impact in both the avoidance of crashes and in the reduction
of injury in the event of a crash.
Calle, P., Fonck, K., & Buylaert, W. (1999). Collisions involving
mobile intensive care unit vehicles in Flanders, Belgium. European
Journal of Emergency Medicine, 6(4), 349-353.
(Full-text not available on-line.)
Centers for Disease Control and Prevention (CDC). (2003). Ambulance
crash-related injuries among emergency medical services workers–United
States, 1991-2002. MMWR: Morbidity and Mortality Weekly Report,
52(8), 154-156.
The authors analyze the Fatality Analysis Reporting System for an
11-year period and describe the attributes of 300 fatal crashes
involving ambulances that occurred during that time period. The
300 crashes resulted in 82 deaths among the 816 ambulance occupants
(patients and emergency personnel). There were an additional 275
deaths to occupants of other vehicles and/or pedestrians.
Although acknowledged to be an imprecise estimate, the authors conjecture
that 27 of the deaths were emergency personnel. The authors also
cite Maguire, Hunting, Smith, & Levick (2002) estimated fatality
rate of 12.7 per 100,000 EMS personnel; more than double the national
average of on-the-job motor vehicle related mortality. The significant
findings were: (1) the risk to unrestrained occupants; (2) one-third
of the fatalities occurred in the front seats of the ambulance where
seat belts were available, could have been used, but were not; and
(3) 22 percent of the workers killed were in working unrestrained
in the patient compartment. The report also illustrates three case
examples gleaned from the National Institute for Occupational Safety
and Health database. In each of the three case reports, the emergency
care worker who died was unrestrained at the time of the fatal event.
Custalow, C., & Gravitz, C. (2004). Emergency medical vehicle
collisions and potential for preventive intervention. Prehospital
Emergency Care, 8(2), 175-184.
The authors draw on a database from the Paramedic Division of
the Denver Health and Hospital Authority for a 9-year period. During
that time period, there were 192 moving collisions involving ambulances.
Thirty-nine of these resulted in injuries or death to 81 individuals.
These injuries were sustained by 18 emergency vehicle operators,
19 emergency medical providers who were not drivers, 27 civilian
drivers (including 2 deaths), 11 civilian passengers, and 2 patients
being transported.
While this article does not specifically discuss rural ambulance
crashes, it does provide insight into the vectors involved in a
crash, identifying the emergency vehicle driver, civilian driver,
and environment as each contributing, to some varying degree, to
ambulance crashes. The authors note that a disproportionate share
(91 percent) of the crashes occurred while the vehicle was operating
with lights and sirens. The study also noted that in 71 percent
of the collisions the emergency vehicle operator had a record of
multiple collisions.
The authors also note that crash-related vehicular claims constitute
the greatest liability risk for an EMS agency. They report that
in many States Good Samaritan laws exempt crashes involving emergency
vehicles.
De Graeve, K., Deroo, K., Calle, P., Vanhaute, O., & Buylaert,
W. (2003). How to modify the risk-taking behaviour of emergency
medical services drivers? European Journal of Emergency Medicine,
10(2), 111-116.
This article represents the first of several that have reported
the impact of “black boxes” on emergency vehicle driving
behavior. The black box is an electronic device that monitors, in
real time, several vehicle parameters such as speed, acceleration,
braking and cornering. It is designed to provide auditory feedback
to the driver when pre-defined limits are exceeded. The authors
of this seminal work reported only moderate change resulting from
the black box with ongoing feedback and performance monitoring.
Interestingly, the authors also note that the change from a Volvo
sports wagon to a more traditional ambulance vehicle resulted in
less aggressive driving behavior.
Eckstein, M. (2004). Primum non nocere–first do no harm:
An imperative for emergency medical services. Prehospital Emergency
Care, 8 (4), 444-446.
In this editorial the author reminds EMS providers that their
first responsibility is to “do no harm” and challenges
aggressive driving response tactics as violating that tenet. He
notes that compared to other vehicles, ambulances are 13 times more
likely to be involved in a crash and these crashes are five times
more likely to result in an injury. He notes that the cost of these
crashes exceeds $500 million annually. He suggests that alternative
deployment and response characteristics of EMS units may result
not only in fewer crashes, but also in better outcomes.
Erich, J. (2000). Wheels of fortune. Every time you hit the streets,
you take your life in your hands–how can you improve your
chances? Emergency Medical Services, 29(11), 43.
Several case reviews are included in this essay that outline various
factors, (emergency vehicle operator error, faulty maintenance,
the urgency of a potentially life-saving response, and poor driving
habits in the civilian population) involving emergency vehicle crashes.
After discussing each of these in some depth the author concludes
that “human error” is the most common and most difficult
factor to modify.
Hayes, T. (2003). The story behind the story. Interview by Mike
Taigman. Emergency Medical Services, 32(5), 28-29.
(Full-text not available on-line.)
Ho, J., & Casey, B. (1998). Time saved with use of emergency
warning lights and sirens during response to requests for emergency
medical aid in an urban environment. Annals of Emergency Medicine,
32(5), 585-588.
This prospective study examines the entire response continuum
(leaving the station or deployment area until arrival at the hospital).
The authors conclude that there is a 38.5 percent total time reduction
when lights and sirens were used in this urban environment with
a response distance of 0.20 – 8.00 (mean 2.3) miles. The authors
draw no conclusion about the importance of this time savings on
patient outcomes, but note that other studies have been very vague
about what conditions warrant such a time saving response. The primary
limitation of this study is that it is small, representing 64 emergency
responses.
Hunt, R.C., Brown, L.H., Cabinum, E.S., Whitley, T.W., Prasad,
N.H., Owens, C.F, et al. (1995). Is ambulance transport time with
lights and siren faster than that without? Annals of Emergency Medicine,
25(4), 507-511.
This is one the earliest of several studies that have looked at
the time savings of responding with lights and sirens, in this case,
specifically during the transport (rather than response) phase of
care. In this mid-size community of 46,000 people the average time
savings was 43.5 seconds. The authors conclude that such a minimal
time savings does not warrant a lights and siren transport except
under very narrowly prescribed circumstances. The authors do note,
however, that results of lights and siren transport need to be examined
in other venues, specifically mentioning rural environments where
transport distances may be much greater.
Hunjadi, D. (2005). From provider to patient. Emergency Medical
Services, 34(8), 157-160.
This personal account of the results of an ambulance crash that
occurred in rural Wisconsin provides the reader with details of
the physical, psychological, social, and economic toll that each
ambulance crash can have on those involved. The Emergency Medical
Technician (EMT) involved was providing care in the rear compartment
of an ambulance that skidded into the median on a rain soaked highway
and rolled. The EMT was in critical condition immediately following
the crash and currently is paralyzed below the waist. The economic
burden of ongoing medical care on his family has been only partially
covered by workers compensation due to the volunteer nature of the
EMS agency and to the fact that a 34-year-old family man does not
wish to go to a nursing home to live out his remaining years.
Kahn, C., Pirrallo, R., & Kuhn, E. (2001). Characteristics
of fatal ambulance crashes in the United States: An 11-year retrospective
analysis. Prehospital Emergency Care, 5(3), 261-269.
The authors provide a descriptive analysis of fatal ambulance crashes
over an 11 year period from 1987-1997, using data derived from the
U.S. Department of Transportation’s Fatality Analysis Reporting
System (FARS). The study’s hypothesis was “…that
there is no association between emergency use vs. non-emergency
use and other fatal ambulance crash characteristics…”
(p. 262). There was an inability to reject the null hypothesis for
most crash characteristics with only the relationship to an intersection
and the manner of the collision showing differences between emergency
and non-emergency use. However, the true value of this analysis
lies in the descriptive tables that describe seasonal, temporal,
atmospheric, and roadway characteristics in fatal crashes involving
ambulances. The authors also note that most ambulance crash fatalities
occur to those traveling in the rear compartment where the patient
may not be securely fixed to the chassis and where other occupants
are less likely to be wearing seat belts. The FARS data also revealed
that many emergency vehicle operators had poor driving histories.
Kupas, D.F., Dula, D.J., & Pino, B.J. (1994). Patient outcome
using medical protocol to limit “lights and sirens”
transport. Prehospital and Disaster Medicine, 9(4), 226-229.
The authors examine the outcome of patients following the implementation
of a protocol governing the use of lights and sirens during transport
of the patient from the scene to the hospital. The setting was a
rural/suburban county with a mixed EMT-P, EMT-B crew configuration.
There were 1,625 patients enrolled in the study. Of these 130 (8
percent) met the criteria for transport using lights and sirens.
Of the 92 percent of transports that did not involve the use of
lights and sirens, nearly one-half received some advance life support
intervention either prior to, or during transport. There were no
adverse events associated with the non lights and siren transports.
Based on these findings, the authors recommend the establishment
of protocols concerning lights and siren transport and the ongoing
medical oversight of those protocols. (The protocol used in this
study is similar to the one that is included as an appendix to this
report).
Larmon, B., LeGassick, T., & Schriger, D. (1993). Differential
front and back seat safety belt use by prehospital care providers.
The American Journal of Emergency Medicine, 11(6), 595-599.
This article was among the first to look at the behavior of safety
belt use among emergency medical personnel in ambulances. The self-reported
data indicated a high use (approaching 100 percent) of seat belt
use when emergency medical personnel are in the front of the ambulance.
This was at a time when the civilian seat belt use rate nationally
was reported to be 49 percent. However, when the emergency personnel
were in the rear compartment of the ambulance providing patient
care, the use rate fell substantially and approached zero, if the
patient was deemed to be in a “critical” condition.
The authors conclude that the findings point to a need for additional
training, investigation of which clinical conditions might warrant
the provider being unrestrained, and the need for ambulance redesign
to accommodate the needs of the emergency provider in the care of
the injured/ill patient.
Levick, N.R. (2005). An optimal solution for enhancing ambulance
safety: Implementing a driver performance feedback and monitoring
device in ground emergency medical services vehicles. Annual Proceedings
/ Association for the Advancement of Automotive Medicine, 49, 35-50.
This pre/post (repeated measures) comparison examined the pre-and
post-deployment of a “black box” in an urban ambulance
fleet. The black box (onboard computer-monitoring device) was placed
in the fleet without driver identification and without turning on
the auditory alert signal for a period of 3 months. A number of
vehicle operation parameters were measured during this “blind”
data gathering period. The second phase of the research began with
an orientation of all personnel to the system, the issuance of key
fobs for driver identification, and the activation of the auditory
alert signaling component of the black box. The auditory alert signal
was activated when the driver approached pre-selected speed, braking,
and vehicle handling parameters. When the auditory alert signal
threshold was exceeded, “penalty points” were also recorded
in each individual driver’s record. The linear distance interval
for auditory alert and penalty point awards went from a baseline
low of 0.018 miles to a post deployment high of 15.8 miles. Significant
improvements in front seat belt use were noted, going from 13,500
seat belt violations pre-deployment to four post-deployment. There
was also a substantial cost savings in maintenance costs, netting
enough to pay for the acquisition and installment of the black boxes
within a short time frame.
In a very brief discussion of the limitations of the study the
authors note that the technology should be further tested across
a broad spectrum of systems, including rural/volunteer agencies.
However, they also question whether additional research is warranted,
or even ethical, considering the dramatic results reported in this
paper.
Lindsey, J.T. (2004). The effects of computer simulation and learning
styles on emergency vehicle drivers’ competency in training
course. (Doctoral dissertation, University of South Florida, 2004).
The focus of this research is the impact of a driver simulator
on emergency vehicle operator’s performance as measured during
a subsequent hands-on driving course. In a comprehensive review
of the impact of simulation technology across both the medical and
broad vehicle operations field, the author notes that ambulance
drivers operate in an environment with multiple distractions, including
the patient care activity occurring in the back of the vehicle itself.
He notes that simulators provide a “safe” environment
for training emergency medical personnel without endangering themselves,
other crew members, the patient, or the public. While the long-term
impact of simulator training, coupled with hands-on experience behind
the wheel has not been measured, the author notes that the short-term
impact is substantial and represents both safety achievements and
cost savings.
Maguire, B.J., Hunting, K.L., Smith, G.S., & Levick, N.R. (2002).
Occupational fatalities in emergency medical services: A hidden
crisis. Annals of Emergency Medicine, 40(6), 625-632.
This article is based on data from multiple sources and extrapolates
the occupational fatality frequency, rate, and typology of on-duty
fatal events involving EMS providers. The primary findings include
a fatality rate of 12.7/100,000, more than double the average occupational
fatality rate of 5.0/100,000 and approaching the fatality rates
for law enforcement and firefighters. When stratified by cause,
transportation injury fatality rates for EMS workers was 9.6/100,000
for EMS personnel, exceeding transportation fatality rates for law
enforcement (6.1) and firefighters (5.7). The EMS rate is more than
four times the average transportation fatality rate for all U.S.
workers at 2.0/100,000. The article clearly supports the need for
safer driving practices across both rural and urban environments.
Maio, R., Green, P., Becker, M., Burney, R., & Compton, C.
(1992). Rural motor vehicle crash mortality: The role of crash severity
and medical resources. Accident; Analysis and Prevention, 24(6),
631-642.
This work examines the Michigan Accident Census database for a
1-year period of time. The unadjusted relative risk of dying in
a motor vehicle crash was 1.96 times greater in the rural area than
in an urban area when comparing Metropolitan Statistical Areas (MSA)
and non-MSAs. Much of the variation can be described by crash characteristics
and age of the occupant. Among the implications noted by the authors
is a discussion of the need for additional specificity in rural/urban
definitions.
National Association of EMS Physicians (NAEMSP) and the National
Association of State EMS Directors (NASEMSD). (1994). Use of warning
lights and siren in emergency medical vehicle response and patient
transport. Prehospital and Disaster Medicine, 9(2), 133-136.
This formal position paper by two prominent national organizations
concerned with emergency medical care discusses the risks associated
with emergency responses involving the use of warning lights and
sirens. The paper includes a series of 11 recommendations. Among
these recommendations are the need for judicious use of warning
lights and sirens based on the patient’s medical condition,
the need for close oversight by the EMS agency’s medical director,
and the need for a national reporting system for emergency vehicle
collisions. The paper was formally adopted in 1994 and reaffirmed
in 2002
O’Brien, D.J., Price, T.G. & Adams, P. (1999). The effectiveness
of lights and siren use during ambulance transport by paramedics.
Prehospital Emergency Care, 3(2), 127-130.
This study involves a convenience sample of 75 ambulance calls
that, in the opinion of the emergency medical personnel at the scene,
required the use of lights and sirens during transport to the hospital.
The same route was followed by a second vehicle traveling within
the normal transportation flow. The authors conclude that there
was a significant time savings using lights and sirens. The mean
times savings was 230 seconds. From these 75 runs, receiving physicians
conjectured that four may have clinically benefited from the time
savings. There is a correlation between the number of stoplights
encountered and traffic intensity with the total time savings. Likewise,
there is a relationship between distance traveled and time saved.
The authors conclude that lights and siren transports are warranted
under certain circumstances and that availability of advanced life
support personnel can reduce the frequency of such responses. The
patients enrolled in this convenience sample had emergencies of
a predominately medical etiology, and the findings may not generalize
to a more trauma oriented setting such as may be common in some
rural communities.
O'Connor, P., & Osborne, C. (1986). An EMT's guide to ambulance
operation. Emergency Medical Services, 15(2), 14.
(Full-text not available on-line.)
Pratt, S.G. (2003). NIOSH Hazard Review. Work-related roadway crashes:
Challenges and opportunities for prevention. Washington, DC: DHHS,
Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health.
This comprehensive analysis of multiple data sources describes
work-related motor vehicle crashes from a variety of perspectives.
While it does not specifically address ambulance crashes, it is
important to note that trucks (all types) account for 64.9% of all
fatal work-related crashes in rural areas. Ambulances, by the nature
of their design, would be captured in this category, again confirming
the high risk nature of rural emergency vehicle operations. Of note,
the report discusses in great detail the increased risk associated
with both driver fatigue and driver distraction. The report offers
employers a set of recommendations to reduce work-related crashes
including fatigue management, vehicle operations training, and graduated
implementation of driving responsibilities for young drivers.
Proudfoot, S. (2005). Ambulance crashes: Fatality factors for EMS
workers. Emergency Medical Services, 34(6), 71.
This article is a more focused summary of Ambulance crash-related
injuries among Emergency Medical Services workers in the United
States from 1991-2002 (CDC, 2003) as reported above. The conclusions
are more prescriptive, stressing the need for driver screening for
previous moving violations coupled with initial and ongoing training.
Ray, A.M. & Kupas, D.E. (2005). Comparison of crashes involving
ambulances with those of similar-sized vehicles. Prehospital Emergency
Care, 9(4), 412-415.
In this analysis of data from the Pennsylvania Department of Transportation
from 1997-2001, it was noted that road surface conditions and weather
factors were similar between the ambulance and other truck type
configurations. However, differences were noted in crashes at intersections
and traffic signals with ambulances being more likely to be involved
in such events. More people were involved in each ambulance crash,
with 3 or more persons in 84 percent of the events. There was also
a greater preponderance of ambulance crashes occurring during evening
and weekend hours. The authors conclude that additional driver training
and policies concerning the use of lights and sirens, including
enforcement of the “complete stop” rule at intersections
and traffic signals, could result in a reduction of ambulance crashes.
Ray, A.M. & Kupas, D.F. (2005). Comparison of rural and urban
ambulance crashes in Pennsylvania. [Research Forum Abstract]. Annals
of Emergency Medicine, 46(3), S113.
This poster presentation summarizes findings from the Pennsylvania
Crash Outcome Data Evaluation System database, which is a probabilistically
linked data set involving a number of separate data systems, for
the time period of 1997-2001. The analysis identified 1745 ambulance
crashes of which 311 occurred in rural areas. The authors noted
that rural crashes were more likely to involve snowy roadway conditions
and unlit nighttime roadways. Operator error was the most prevalent
contributing factor in both urban and rural crashes although it
was less often the cause in rural environments (75 percent rural
vs. 93 percent urban). Rural crashes were more likely to involve
striking a fixed object. Criteria for distinction between rural
and urban were based on the Pennsylvania Department of Transportation
Roadway Management System, in which rurality is based on traffic
volume and municipal population criteria.
Shanaberger, C.J. (1993). Field operations and written policy.
What you don't know can hurt you. Greater Houston Transport v. Zrubeck.
JEMS: A Journal of Emergency Medical Services, 18(11), 25.
(Full-text not available on-line.)
Shanaberger, S.J. (1987). Running hot. JEMS: A Journal of Emergency
Medical Services, 12(4), 75-76.
(Full-text not available on-line.)
Swanson, J. & Levick, N. (2005, March). Device improves ambulance
drivers’ performance: Cuts crashes and reduces costs for tires
and maintenance. EMS Insider.
This is an expansion of Swanson and Levick’s 2005 article
discussed above. It is illustrated with quotes from the authors
about both the methods of the deployment of the “black box”
technology, the procedures for providing feedback to the drivers,
and the early results of the project.
Vukmir, R.B. (2004). Medical malpractice: Managing the risk. Medicine
and Law, 23(3), 495-513.
This article provides a review and analysis of previously published
articles pertaining to the likelihood of medicolegal errors. The
author describes high risk encounters for emergency physicians,
and more germane to this discussion, notes that, in emergency medical
services, the most frequent area for the increased incidence and
recovery amounts in verdicts pertained, not to clinical care issues,
but rather to ambulance crashes. The author further notes that attention
to this high risk area could help reduce subsequent medicolegal
risk, reduce costs, and improve patient care.
Weiss, S.J., Ellis, R., Ernst, A.A. Land, R.F. & Garza, A.
(2001). A comparison of rural and urban ambulance crashes. American
Journal of Emergency Medicine, 19(1), 52-56.
A database comprised of information from mandatory reporting forms
required to be completed for all ambulance crashes occurring in
the State of Tennessee was analyzed for a 5-year period from 1993-1997.
This data set includes both fatal and non-fatal crashes. The primary
hypothesis of this study was “Rural vehicle accidents will
be more severe and have a higher rate of citations than urban accidents…”
(p. 52). Rural was defined as a population equal to or less than
the fifth largest county in Tennessee (Montgomery, population 102,000).
The authors analyzed characteristics including injury severity,
traffic citations, ambulance damage, other vehicle damage, ambulance
impact site, temporal, meteorological, and roadway conditions. They
also examined the number of people involved, the number of people
injured, and use of safety belts at the time of the crash. The primary
finding was that rural ambulance crashes were more likely to result
in injury and that the injuries sustained during the crash were
more likely to be severe. This finding was predominately attributed
to the point of collision, which was more likely to involve a frontal
impact in rural areas and a rear impact in urban.
Whiting, J., Dunn, K., March, J., & Brown, L. (1998). EMT knowledge
of ambulance traffic laws. Prehospital Emergency Care, 2(2), 136-140.
This research involves a survey of emergency medical personnel
at a statewide conference. The survey measured knowledge of specific
traffic laws pertaining to emergency vehicle operations in the State
of North Carolina. The sample size was 295. Out of a possible score
ranging from zero to five on the five question survey, the median
response was one correct question. Volunteer emergency medical providers
were twice as likely to miss the question pertaining to speed limits
than their paid counterparts. Emergency medical personnel who had
taken one or more emergency vehicle operations courses were more
likely to score above the median and more likely to answer questions
concerning yielding to traffic (same direction and oncoming) correctly.
The authors conclude that additional emergency vehicle operation
training is warranted.
Zagaroli, L. & Taylor, A. (2003). Ambulance driver fatigue
a danger: Distractions pose risks to patients, EMTs, traffic. Washington,
DC: Detroit News Washington Bureau, 1-8.
This newspaper article is based on a compilation of interviews
augmented by other facts and accounts of ambulance crashes. The
focus of the article is on the relationship between fatigue and
ambulance crashes. While the information is anecdotal in nature,
it is compelling. As an example, one person interviewed noted that
each of the 40 preceding 24-hour shifts that he normally worked
on Monday, Wednesday, and Friday had actually become 27-hour shifts,
which he noted left him exhausted. Other emergency personnel relate
similar stories of being awake for 20 hours of a 24-hour shift or
being expected to drive immediately after being awakened to an emergency
call.
DISCUSSION
There is an ever-increasing body of knowledge pertaining to crashes
involving ambulances. One of the first conclusions that can be drawn
from the extant literature is that driving an ambulance is a dangerous
process (CDC, 2003; Eckstein, 2005; Erich, 2000; Maguire et al.,
2002; NAEMSP & NASEMSD, 1994; Pratt, 2003; Proudfoot, 2005;
Ray & Kupas, 2005; Zagaroli et al., 2003). This finding is,
in and of itself, not surprising given the “emergency”
nature of the work. Of note is that in comparison to other “emergency”
responders, specifically law enforcement agents and firefighters,
emergency medical personnel are at greater risk of a fatal vehicle
incident then their public safety colleagues (Maguire et al, 2002).
The reason for this increased risk is unknown but could include
the fact that a large portion of the EMS workforce is volunteer
in nature (IOM, 2006; Thompson, 1993; Chng, Collins & Eaddy,
2001). Additional factors may include, inadequate screening of vehicle
operators for previous violations (Custalow & Gravitz, 2004;
Kahn, Pirrallo, & Kuhn, 2001), non-existent or inadequate vehicle
operations training (Custalow et al., 2004; Erich, 2000; Larmon,
LeGassick, & Schriger, 1993; Lindsey, 2004; Maguire et al.,
2002; NAEMSP et al., 1994; Pratt, 2003; Ray et al., 2005), fatigue
and distraction (Custalow et al., 2004; Erich, 2000; Pratt, 2003;
Zaragoli et al., 2003), poor vehicle design (Barishansky, 2005;
Custalow et al., 2004; DeGrave, Deroo, Vanhaute, & Buylaert,
2003; Pratt, 2003), and poor knowledge concerning driving laws (Whiting,
Dunn, March, & Brown, 1998).
A key factor in ambulance crashes is operations in an emergency
mode with warning lights and sirens engaged. Implicit in the use
of these warning devices is the fact that the ambulance is using
certain privileges that may include traveling above the speed limit,
expecting traffic to yield, and assuming the right of way at intersections.
Arguably, the most heavily researched aspect of ambulance response
is the time savings associated with the use of lights and sirens
and the degree to which those savings “might” contribute
to positive clinical outcomes. Several authors contend that the
time savings is not significant and is unwarranted in all but the
most extreme clinical circumstances (Custalow et al., 2004; DeGraeve
et al., 2003; Eckstein, 2004; Ho et al., 1998; Hunt et al., 1995;
Kahn, 2001; NAEMSP et al., 1994; Ray et al., 2005, Kupas et al.,
1994). O’Brien et al. (1999) concluded that the use of warning
lights and sirens did result in significant time saving (230 seconds)
and that there were at least 4 of 75 cases in which those time savings
resulted in improved clinical outcomes. Only Kupas et al. (1994)
specifically define the clinical conditions under which response
or transport might warrant the use of warning lights and sirens.
The reluctance of emergency care providers to wear safety restraints,
particularly while delivering care in the patient compartment is
also noted by several authors to contribute to the risk of injury
or death (Baker, Whitfield, & O’Neill, 1987; Barishansky,
2005; CDC, 2003; Custalow et al., 2004; Hunjadi, 2005; Kahn et al.,
2001; Larmon et al., 1993; Levik, 2005; Maguire et al., 2002; Maio,
Green, Becker, Burney, & Compton, 1992; NAEMSP et al., 1994;
Weiss et al., 2001). Ray & Kupas (2005), note that more individuals
are likely to be injured or killed in each ambulance crash than
in crashes of similarly sized commercial vehicles. They conclude
that this is due to multiple people (providers, patients, and family)
traveling unrestrained in the rear compartment. Limited discussion
is available in the literature about making ambulances more “user
friendly” to encourage restraint use for all occupants (Barishansky,
2005; Ferreria & Hignett, 2004).
Less is known about rural ambulance crashes, although several of
the studies have been conducted in communities of 100,000 or less
(Hunjadi, 2005; Hunt et al., 1995; Maio et al., 1992). Two studies
specifically compared rural and urban crashes (Weiss et al., 2001;
Ray et al., 2006). Weiss, Ellis, Ernst, Land & Garza (2001)
in their seminal work described and compared the characteristics
of rural ambulance crashes from a variety of factors. They concluded
that rural crashes were more likely to result in injuries and that
the injuries were more serious. This finding compares well to Pratt’s
(2003) work, concerning the incidence of fatal crashes in rural
areas and, in particular, with those involving “truck like”
vehicles. Ray et al. (2006), in the preliminary presentation of
their findings, concluded that rural crashes were more likely to
involve snowy roadway conditions and poorly lit night-time roads.
Both Weiss et al. (2001) and Ray et al. (2006) noted that, during
rural crashes, the ambulance is more likely to strike a fixed object
such as a tree, guard rail or signpost. While ambulance-specific
data are limited, additional information pertaining to rural driving,
in general, supports many of the findings pertaining to poorer road
design, longer travel distances, higher rates of speed, inclement
weather and road surface conditions (Maio et al., 1992; Baker et
al., 1987; Pratt, 2003; Moretti, 2005).
The economic impact of rural ambulance crashes is not known. However,
line-of-duty deaths are estimated to cost between $900,000 and $1.2
million per occurrence (National Safety Council, 2005; Rice, MacKenzie,
& Associate, 1989). These economic costs are increased by long
term economic costs of survivors and further exacerbated by psychosocial
impact (Hunjadi, 2005). The impact of a fatal crash in a rural environment
can be devastating to a volunteer EMS agency (Hunjadi, 2005). Additional
costs are evident in legal fees associated with injuries, fatalities
and property loss to civilians (Custalow et al., 2004; Vukmir, 2004).
One of the persistent challenges in answering any questions about
rural ambulance crashes is the application of a consistent definition
of rural. Some studies have used a non-Metropolitan Statistical
Areas (Maio et al., 1992), others have used highway department definitions
(Ray et al., 2006) and still others have more arbitrarily determined
the cut off in population density in their State (Weiss et al.,
2001). None of the research identified in this literature search
used definitions of rural that are more consistent with current
thinking in rural health care, such as Economic Research Service
Rural-Urban Continuum Codes (IOM, 2005).
The general findings for reducing crashes and improving outcomes
of crashes that do occur rely on three general strategies: education,
policy development, and technological applications.
Many authors suggest the need for additional emergency vehicle
operations training (DeGraeve et al., 2003; Eckstein, 2004; Erich,
2000; Kahn et al., 2001; Larmon et al., 1993; Lindsey, 2004; NAEMSP
et al., 1994; Pratt, 2003; Ray et al., 2005). Unfortunately, there
is a high degree of variability in emergency vehicle driver training
programs and little is known about the effectiveness of such courses
although the general injury prevention literature questions the
effectiveness of driver’s education courses. Additional study
of such courses is essential. Simulator training holds great promise
in augmenting traditional, “hands-on” courses (Lindsey,
2004). One challenge associated with this technology is ensuring
that rural and frontier EMS providers have access to such simulators.
Policy development, implementation, and enforcement have been shown
to have an effect on the “culture” of safety within
an organization. Standard policies concerning the use of safety
restraint systems and warning lights and sirens should be adopted
and enforced by all departments (NAEMSP et al., 1994; Pratt, 2003).
This intervention is immediately available to all rural EMS agencies
and does not require a large outlay of funds to implement. For that
reason, we have included the NAEMSP/NASEMSD policy on emergency
driving and a sample agency protocol that can be modified and adopted
by any service wishing to do so.
Technology has begun to have an impact on ambulance operations.
In particular the deployment of “black box” and “drive
cam” technologies hold great promise in creating a safer driving
environment (Barishansky, 2005; De Graeve et al., 2003; Levick,
2005; Swanson & Levick, 2005). Vehicle modification including
crash avoidance technologies also holds promise (Barishansky, 2005).
Intelligent transportation systems research also has the potential
to contribute to emergency vehicle safety such as the animal detection
and avoidance system created and tested by the Western Transportation
Institute (USA Today, 2006). As rural EMS agencies go through their
normal ambulance purchase cycle, new vehicles should have “black
box” or similar technology installed or services should consider
installing these in their existing vehicles. However, the effectiveness
of these devices is dependent on their consistent use and feedback
to all drivers.
Summary
Ambulances are a dangerous place to work. If you happen to work
in a rural environment, they are doubly dangerous. Findings from
a review of the extant literature suggest that there are educational,
policy, and technological interventions that can decrease the risk
of death and disability to rural and frontier emergency care providers
as well as the patients and public that they serve.
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Custalow, C., & Gravitz, C. (2004). Emergency medical vehicle
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Eckstein, M. (2004). Primum non nocere–first do no harm: An
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Erich, J. (2000). Wheels of fortune. Every time you hit the streets,
you take your life in your hands–how can you improve your
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Ferreira, J. & Hignett, S. (2004). Reviewing ambulance design
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Ho, J. & Casey, B. (1998). Time saved with use of emergency
warning lights and sirens during response to requests for emergency
medical aid in an urban environment. Annals of Emergency Medicine,
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Hunjadi, D. (2005). From provider to patient. Emergency Medical
Services, 34(8), 157-160.
Hunt, R.C., Brown, L.H., Cabinum, E.S., Whitley, T.W., Prasad, N.H.,
Owens, C.F, et al. (1995). Is ambulance transport time with lights
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Institute of Medicine. (2005). Quality through collaboration: The
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Jones, C. (2006). Systems warn drivers of deer in headlights. USA
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Kahn, C., Pirrallo, R., & Kuhn, E. (2001). Characteristics of
fatal ambulance crashes in the United States: an 11-year retrospective
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Kupas, D.F., Dula, D.J., & Pino, B.J. (1994). Patient outcome
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Larmon, B., LeGassick, T., & Schriger, D. (1993). Differential
front and back seat safety belt use by prehospital care providers.
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Levick, N.R. (2005). An optimal solution for enhancing ambulance
safety: Implementing a driver performance feedback and monitoring
device in ground emergency medical services vehicles. Annual Proceedings/
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Levick, N.R. & Swanson, J. (2005). Managing risk and reducing
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ambulance crashes in Pennsylvania. [Research Forum Abstract]. Annals
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Injury Prevention Center, the Johns Hopkins University.
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drivers’ performance: Cuts crashes and reduces costs for tires
and maintenance. EMS Insider.
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and Law, 23(3), 495-513.
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A comparison of rural and urban ambulance crashes. American Journal
of Emergency Medicine, 19(1), 52-56.
Whiting, J., Dunn, K., March, J., & Brown, L. (1998). EMT knowledge
of ambulance traffic laws. Prehospital Emergency Care, 2(2), 136-140.
Zagaroli, L. & Taylor, A. (2003). Ambulance driver fatigue a
danger: Distractions pose risks to patients, EMTs, traffic. Washington,
DC: Detroit News Washington Bureau, 1-8.
APPENDIX A: ACKNOWLEDGEMENTS
The Rural EMS Driving document was made possible by funds provided
by the U.S. Department of Health and Human Services (HHS), Health
Resources and Services Administration (HRSA), Office of Rural Health
Policy (ORHP); the Rural Emergency Medical Services and Trauma Technical
Assistance Center (REMSTTAC); and the Montana State University Western
Transportation Institute. Special thanks for producing this compendium
go to REMSTTAC staff, including Nels Sanddal, Director; Heather
Soucy, Program Support Specialist; Joe Hansen, Assistant Director;
and Teri Sanddal, Associate Director; and to members of the Rural
EMS Driving Workgroup at REMSTTAC.
A special acknowledgement is extended to Stephen Torgerson an intern
of Montana State University-Bozeman for his literature review and
expertise provided to make this document possible.
Nels D. Sanddal, MS, REMT-B, Co-chair
Director
Rural Emergency Medical Services and Trauma Technical Assistance
Center
Steve Albert, Co-chair
Director
Montana State University
Western Transportation Institute
CONTRIBUTORS AND REVIEWERS:
Drew Dawson, Chief, EMS Division
National Highway Traffic Safety Administration
Joseph D. Hansen, Assistant Director
Rural Emergency Medical Services and Trauma Technical Assistance
Center
Douglas F. Kupas, MD
Rural Committee
National Association of EMS Physicians
Tommy Loyacono, MPA
National Association of Emergency Medical Technicians
Jerry Overton, Executive Director
Richmond Ambulance Authority
Jacob L. Rueda III, PhD, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Chris Tilden, PhD, Director
Kansas Department of Health & Environment
Office of Local & Rural Health
Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center
APPENDIX B: REMSTTAC STAKEHOLDERS GROUP
Katrina Altenhofen, MPH, REMT-B
State Coordinator
Emergency Medical Services of for Children
Iowa Department of Public Health
Jane W. Ball, RN, DrPH
Executive Director (Retired)
EMSC National Resource Center
Trauma-EMS Technical Assistance Center
Bethany Cummings, DO
Rural Committee
National Association of EMS Physicians
Drew Dawson, Chief, EMS Division
National Highway Traffic Safety Administration
Tom Esposito, MD, MPH, FACS
Medical Director
Rural EMS and Trauma Technical Assistance Center
Blanca Fuertes, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Christian L. Hanna, MPH
Michigan Public Health Institute
Child and Adolescent Health
Bob Heath, EMS Education Coordinator
Nevada State Health Division
Intermountain Regional EMS for Children Coordinating Council
Marilyn Jarvis
Assistant Director for Continuing Education
Extended University
Montana State University
Douglas F. Kupas, MD
Rural Committee
National Association of EMS Physicians
Fergus Laughridge, Program Manager
Nevada State Health Division
EMS Bureau of Licensure & Certification
Tami Lichtenberg, Program Manager
Technical Assistance and Services Center
Rural Health Resource Center
Tommy Loyacono, MPA
National Association of Emergency Medical Technicians
Patrick Malone, Director
Initiative for Rural Emergency Medical Services
University of Vermont
N. Clay Mann, PhD, MS
Professor, Associate Director of Research
Intermountain Injury Control Research Center
University of Utah
Evan Mayfield, MS
U.S. Department of Health and Human Services
Center for Disease Control and Prevention
Office of the Commissioner
Charity G. Moore, PhD
Research Assistant Professor
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill
Carol Miller, Executive Director
National Center for Frontier Communities
Kimberly K. Obbink, M.Ed., Director
Extended University
Montana State University
Jerry Overton, Executive Director
Richmond Ambulance Authority
Daniel Patterson, PhD
AHRQ-NRSA Post-Doctoral Research Fellow
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill
Davis Patterson, PhD, Research Scientist
Battelle Centers for Public Health Research and Evaluation
Ana Maria Puente, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
International Health
Jacob L. Rueda III, PhD, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Kristine Sande, Project Director
Rural Assistance Center
University of North Dakota Center for Rural Health
Mary Sheridan, Director
State Offices of Rural Health
Idaho Department of Health and Welfare
Dan Summers, RN, BSN, CEN, EMT-P
Director of Education
Center for Rural Emergency Medicine
West Virginia University
Chris Tilden, PhD, Director
Kansas Department of Health & Environment
Office of Local & Rural Health
Robert K. Waddell II
Secretary /Treasurer
National Association of EMS Educators
Bill White, President
National Native American EMS Association
Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center
Jill Zabel Myers, Healthcare Consulting
Wipfli LLP
APPENDIX C: NAEMSP, NASEMSO POLICY ON DRIVING
USE OF WARNING LIGHTS AND SIREN IN EMERGENCY MEDICAL VEHICLE RESPONSE
AND PATIENT TRANSPORT
National Association of Emergency Medical Services Physicians (NAEMSP)
and the National Association of State EMS Directors (NASEMSD)
This paper was developed for NAEMSP by the Emergency Medical Response
Task Force: Jeff J. Clawson, MD, Chair; Robert Forbuss; Scott A.
Hauert; Fred Hurtado; Alexander E. Kuehl, MD; W.H. ABill@ Leonard;
Peter A. Maningas, MD; Joseph L. Ryan, MD; and Donald R. Sharpe.
It was reviewed and adopted to the position paper format by the
NAEMSP Standards and Clinical Practice Committee, Herbert G. Garrison,
MD, MPH, Chair.
Correspondence: Executive Director, National Association of EMS
Physicians, P.O. Box 15945-281, Lenexa, KS 66285-5945.
The position paper was approved by the NAEMSP Executive Committee
on 18 November 1993, and by the Executive Committee of the National
Association of State EMS Directors on 6 January 1994.
Published in Prehospital and Disaster Medicine, April-June 1994.
Abbreviations: EMS = emergency medical services; EMV = emergency
medical vehicle; L&S = lights and siren
Introduction
The use of warning lights and siren (L&S) by prehospital emergency
medical services (EMS) vehicles is a basic component of emergency
response and patient transport. This public-safety practice predates
modern EMS by 50 years.1 Despite the long-term reliance on L&S,
it is not a risk-free practice. There are many reports of emergency
medical vehicle (EMV) collisions during L&S responses and transports.2-4
These collisions often result in tragic consequences for the EMV
occupants and those in other vehicles, and may cause significant
delays to medical care for the patient the EMV was responding to
or transporting.5 While there is no systematic collection of EMV
collision data, some authors have suggested that the available information
underestimates the extent of the problem.6,7 In addition, to date
there have been few published analyses regarding the effectiveness
of L&S as a modality that improves response times or, more important,
patient outcome.
Despite the lack of data, it generally is accepted that the use
of L&S is a privilege granted to emergency medical responders
that should be reserved for those situations in which patient welfare
is at stake. To provide guidance to the states' EMS medical directors
and system managers, the National Association of EMS Physicians
(NAEMSP) and the National Association of State EMS Directors (NASEMSD)
endorse the following positions regarding the use of warning L&S
in EMV response and patient transport.
Position Statements
1. Emergency medical services (EMS) medical directors should participate
directly in the development of policies governing EMV response,
patient transport, and the use of warning lights and siren.
Emergency medical vehicle response policy decisions involve many
medical care and medical direction issues including patient outcome,
quality improvement, patient and emergency medical provider safety,
and risk management. Therefore, EMV response and patient transport
decisions should be guided, reviewed, and approved by the EMS medical
director.
2. The use of warning lights and siren during an emergency response
to the scene and during patient transport should be based on standardized
protocols that take into account situational and patient problem
assessments.
Written protocols and guidelines should delineate when to use L&S
during scene response and patient transport. These protocols should
be based on a reasonable identification of situations for which
a reduction in response and transport times might improve patient
outcome. The protocols should be developed in conjunction with local
emergency response practices and statutes and should receive approval
from the EMS medical director. Final protocols should be distributed
to all dispatch and EMS entities. Warning lights and siren protocols
should be enforced, and inappropriate use of L&S by EMS personnel
will be limited.
3. EMS dispatch agencies should utilize an emergency medical dispatch
priority reference system that has been developed in conjunction
with and approved by the EMS medical director to determine which
requests for prehospital medical care require the use of warning
lights and siren.
Sound dispatch prioritization systems establish a patient’s
level of severity, which then allows the determination of the type
of vehicle(s) that should respond and the urgency of that response.
Emergency medical dispatch centers should institute the protocols
and monitor adherence to them.
4. Except for suspected life-threatening, time-critical cases or
cases involving multiple patients, L&S response by more than
one EMV usually is unnecessary.
Guidelines for the multi-EMV L&S response should be outlined
in emergency medical response policies and dispatch procedures.
5. The utilization of emergency warning L&S should be limited
to emergency response and emergency transport situations only.
Alternative practices, such as returning to a station or quarters
using warning L&S or using L&S for Astaging or moving to
designated areas to stand-by for a response, should be discontinued.
Exceptions to such a policy would include extraordinary circumstances
such as a disaster, or situations in which patient outcome could
be affected.
6. All agencies that operate EMVs or are responsible for emergency
medical responders should institute and maintain emergency vehicle
operation education programs for the EMV operators.
Initial and continuing education of EMS personnel should include
instruction in safe and appropriate EMV driving techniques and should
take place prior to initial EMV operation. Knowledge and demonstrated
skill in EMV operation are prerequisites for all public-safety vehicle
operators.
7. Emergency medical vehicle-related collisions occurring during
an emergency response or transport should be evaluated by EMS system
managers and medical directors.
Such evaluations should include an assessment of the dispatch process,
as well as initial (at the beginning of the transport) and final
patient conditions.
8. A national reporting system for EMV collisions should be established.
Data are needed regarding the prevalence, circumstances, and causes
of EMV collisions, including related injuries and deaths, and "wake
effect" collisions. Collection of the information should start
at the State and local levels; the information collected should
include uniform data elements for tabulation and nationwide comparison.
9. Scientific studies evaluating the effectiveness of warning L&S
under specific situations should be conducted and validated.
These important research efforts should be supported by both public
and private resources.
10. Laws and statutes should take into account prudent safety practices
by both EMS providers and the monitoring public.
The major emphasis and focus should remain on the exercise of prudent
judgment and due regard by EMV operators. Laws and statutes also
should emphasize the motoring public's responsibility to clear a
lane or access way for EMVs.
11. National standards for safe EMV operation should be developed.
Such standards should mandate that EMV operators should approach
intersections safely and have a clear view of all lanes of traffic
before proceeding through. Standards also should set appropriate
speed limits for emergency responses and transports in urban and
rural settings, and for responses that occur under adverse road,
traffic, and weather conditions.
Discussion
The Risk of the Emergency Response
Response to and transport of emergency patients are integral components
of the EMS chain of care. Since the beginning of modern EMS, the
usual vehicle response mode has involved the use of L&S. Since
this type of response was consistent with the practices of other
public-safety agencies that use emergency vehicles (i.e., law enforcement
and the fire service), the practice was implemented initially without
question. As an understanding of EMS call histories and patient
outcomes has evolved, it has become evident that the use of L&S
by EMS vehicles is not necessary for every response or patient transport.4
There is risk associated with the use of warning L&S: emergency
medical vehicles running "hot" (with L&S) have been
involved in many collisions that have resulted in injuries and death
in a high number of cases.2,4,6 The monetary loss derived from EMV
collisions, including property damage, increased insurance premiums,
and liability payments in some venues, have eclipsed that of any
other negligence-related EMS problems.7,8 This situation exists
at a time when published data demonstrating the use of L&S in
response or patient transport is effective in improving patient
outcomes are lacking. In fact, the U.S. Department of Transportation
has reported that sirens may never become an effective warning device.9
Even if warning L&S eventually are shown to be useful in certain
time-critical situations (e.g., cardiac arrest or penetrating chest
injuries), it is unlikely that L&S will be proven beneficial
for each and every EMS response and transport.
Concern about patient welfare, combined with inadequate information
on a patient's actual condition, often pressures emergency medical
technicians and paramedics to rush to and from scenes in order to
"save lives." As Auerbach5 states, "...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."
Medical Director Involvement
Since EMS response and patient transport are prehospital medical
"tools," accountable EMS medical directors should be involved
in the development of emergency response and transport policies.10
Additionally, EMS medical directors should evaluate EMV collisions
for the medical correctness of the dispatch process, the patient's
condition on arrival at the scene, when the transport began, and
the patient's eventual outcome. For those medical directors who
may need assistance with this aspect of prehospital care, advice
is available from colleagues in NAEMSP, NASEMSD, and other EMS organizations.
Standardized Dispatch, Response, and Transport
Sound emergency medical dispatch protocols should be established
and used as the basis for determining those situations that would
benefit from the appropriate use of warning L&S. Research is
emerging that supports the concept that medically sound protocols
safely delineate which patients do and do not require emergency
advanced life support.11, 12 Such protocols, as well as proper emergency
medical dispatcher and EMV operator training, should be integral
parts of a local dispatch agency's emergency medical dispatch system.
The American Society for Testing Materials state in their Standard
Practice for Emergency Medical Dispatch document that "this
practice may assist in overcoming some of the misconceptions...that
red lights, siren, and maximal response are always necessary."13
Ideally, the use of L&S should be reserved for those situations
or circumstances in which response and transport times have been
shown to improve a patient's chances for survival or quality of
life. Examples of such situations include cardiac or respiratory
arrest, airway obstruction, extreme dyspnea, critical trauma, childbirth
and problems with pregnancy, drowning, and electrocution. In some
of these cases, a rapid response is important (e.g., cardiac arrest),
whereas in others rapid transport is necessary (e.g., breech birth).
Nevertheless, a large number of calls to 9-1-1 are for non-emergency
problems that require neither rapid response nor rapid patient transport.14,
15 Systems utilizing non-L&S response modes for such low-priority
calls have experienced few problems.16 This issue, however, requires
more in-depth study in order to determine the specific positive
and negative effects of L&S utilization on patient outcome in
the various types of high- and low-priority cases.
In the typical EMS model, once a patient is evaluated and provided
appropriate emergency treatment, transport by an EMV is initiated
to move the patient to a definitive care facility. Many patients
to whom EMS respond do not require L&S for patient transport.
However, many EMS systems do not have protocols governing L&S
use during patient transport, and few endorse contact with an on-line
medical control base-station for advice or consent on the use of
L&S transport.
Response of Multiple Emergency Medical Vehicles
The use of warning L&S by all EMV’s responding to a single
incident has been scrutinized in many systems, and many of those
systems have adopted a modified approach.12, 17 From a medical point
of view, the response of more than one unit utilizing L&S is
necessary only in those situations involving suspected life-threatening,
time-critical cases, or multiple patients. Likewise, the practice
of returning to a station or quarters using L&S so as to "be
in position" for the next call has no support in most responsible
public-safety communities.
The Emergency Medical Vehicle Operator
While prevention of EMV collisions will depend on the application
of sound dispatch protocols, dispatcher training, and direct involvement
of the EMS medical director in developing dispatch and transport
policies, attention also should be directed at the EMV operator.
Before a driver of an emergency vehicle takes the wheel, their driving
records should be carefully screened, and each should be trained
in the proper use of EMV’s. Rigorous education and control
of EMV drivers should reduce EMV collisions, create a more standard
approach and practice to EMV operation, and improve EMV longevity.
Fortunately, there are detailed instruction guides for proper EMV
operation.18, 19
Emergency medical services provider education should include instruction
in "low force" driving techniques. In addition, all personnel
operating EMS vehicles should be involved in agency quality improvement
programs including continuing education courses on EMV operation.
Some State laws require that EMV operators exercise what is called
"due regard." New Jersey law (N.J.S.A. 39:4-91) states
it "...shall not relieve the driver of any authorized emergency
vehicle from the duty to drive with due regard for the safety of
all persons, nor shall it protect the driver from the consequences
of his reckless disregard for the safety of others." Using
laws of this nature, a number of prosecutors recently have charged
and convicted ambulance operators of involuntary manslaughter.14
Most state laws, however, fail to place clear responsibility for
the use of L&S on the EMS operators themselves.20 While much
talk has ensued regarding the public's responsibility to "watch
out" or "get out of the way," EMS should not blame
the public for the problem of EMV collisions.
The EMS Profession
Responsibility rests with the EMS profession and local governments
to establish minimum standards for the safe operations of EMS vehicles
and to monitor the use of such standards. An example of such a standard
would be a formal policy stating that EMV’s should not exceed
the locally posted speed limit in urban settings, should not exceed
the speed limit by more than 10 miles per hour in rural areas, and
that EMV’s should not travel at any speed that is unsafe for
current road, traffic, or weather conditions.
Nationally, EMS-related organizations should work together in helping
to create standards that detail the positions in this document.
Organizations that should be involved in a effort to set standards
for emergency medical response and transport include the American
Ambulance Association, the American College of Emergency Physicians,
the Association of Public Safety Officers, the International Association
of Fire Chiefs, the International Association of Fire Fighters,
the National Association of Emergency Medical Technicians, the National
Association of EMS Physicians, the National Association of State
EMS Directors, the National Association of State EMS Training Coordinators,
the National EMS Alliance, and the National Fire Protection Agency.
Reimbursement
The reimbursement profiles of many EMS agencies contain an extra
charge for the use of warning L&S. This occurs because the Federal
Centers for Medicare and Medicaid Services (the Health Care Financing
Administration during the time of the study) reimbursement policies
recognize L&S use as a special circumstance. Insurance reimbursement
for "emergencies" also may be predicated on L&S use,
further perpetuating this problem. Unless these types of policies
and profiles are modified by the government, insurance companies,
and the EMS profession itself, adjustments in L&S use (as recommended
in this document) may be viewed as adversely affecting EMS reimbursement.
Therefore, without reimbursement policy modifications, the L&S
reform process may be slowed.
Emergency Medical Vehicle Collision Reporting
The amount of data available on EMV collisions in general is fragmented
and has not been obtained using any systematized or scientific format.4,
5 The Fatal Accident Reporting System (FARS) may underestimate EMV
collision occurrence and outcome. In 1990-1991, a national press
clipping service documented 303 EMV collisions in 1 year resulting
in 711 injuries and 78 deaths. (Clawson, unpublished data). The
number of fatalities discovered in this newspaper review eclipses
those reported by FARS involving EMVs for the same time period.
An acknowledged, but little-studied result of L&S use is the
"wake effect," in which use of L&S results in collisions
that involve only civilian vehicles and not the EMV itself. The
ratio of wake effect collisions to those actually involving an EMV
may be as high as five to one.6 However, this only can be adequately
assessed with a comprehensive EMV collision reporting system.
There are models for EMV collision reporting systems. The National
Fire Protection Agency has had in place a uniform process for reporting
and quantifying fire fighting-related collisions and injuries for
many years. Utah and Tennessee have "ambulance accident"
reporting systems. As Auerbach5 has reported about Tennessee's system:
"Before the requirement for accident reporting was imposed,
[EMV collisions] analysis would have been impossible. Prehospital
[EMV collision] data collection is essential if emergency medical
services physicians are to exert reasonable control and make knowledgeable
recommendations involving clinical care and professional regulations."
Ideally, the federal government will initiate a national reporting
system for EMV collisions. Any reporting system should be uniformly
structured. It should track the multiple different types of responding
agencies and vehicles, including both volunteer and fire-based first
responders (not just "ambulances"), and also provide a
mechanism for the identification and reporting of wake effect collisions.
Research
Regrettably, there currently are few published investigations of
dispatch protocols for L&S use. Also, there are no published
studies attempting to evaluate the effectiveness of L&S use
in terms of patient outcome. Worse still, there are no studies in
either refereed or public safety trade journals that demonstrate
that the use of L&S saves significant time over routine driving
methods. In 1987, Auerbach5 demonstrated that the mean delay to
hospital care after an EMV collision in Tennessee approached 10
minutes.
The use of warning L&S in EMS rests primarily on the unsupported
tradition that has evolved from police- and fire-response practices.
In some cases, these practices may adversely affect EMS patients
and providers. Therefore, a series of objective, well-structured,
scientific studies aimed at identifying both the positive and negative
effects of L&S use should be pursued.
Conclusion
In order to ensure that we "first do no harm," 20 sound
rationale and corresponding protocols and policies for the use of
warning L&S in EMV response and patient transport should be
developed and instituted in all EMS systems. All EMV operators should
be trained adequately and regulated. The judicious use of warning
L&S in the initial response and subsequent transport of patients
likely will result in a more balanced system of appropriate care
with minimization of iatrogenic injury and death.
References
1. DeLorenzo RA, Eilers MA: Lights and siren: A review of emergency
vehicle warning systems. Ann Emerg Med 1991; 20:1331-1334.
2. Elling R: Dispelling myths on ambulance accidents. JEMS 1989;
14:60-64.
3. Caldwell LH: Hard Lessons. Fire Command 1990; 57:20-21.
4. Sharpe D: Ambulance Fatality Accidents for 1988. Presented at
the 1990 Canada InterPhase Conference; Edmonton, Alberta, Canada.
5. Auerbach PS, Morris JA, Phillips JB Jr, et al: An analysis of
ambulance accidents in Tennessee. JAMA 1987; 258:1487-1490.
6. Clawson JJ: Ambulance accidents. JEMS 1989; 13:23.
7. Clawson JJ: Hit or myth. JEMS 1989; 14:8.
8. Page JO: EMS Legal Primer. Jems Publishing Co. 1985; 2.
9. Skeiber SC, Mason RL, Potter RC: Effectiveness of Audible Devices
on Emergency Vehicles. Washington, DC: U.S. Department of Transportation,
National Highway Traffic Safety Administration, Publication No.
DOT-TSC-OST-77-38, 1977.
10. National Association of EMS Physicians position paper: Emergency
medical dispatching. Prehospital and Disaster Medicine 1989; 4:163-166.
11. Kallsen G, Nabors MD: The use of priority medical dispatch to
distinguish between high- and low-risk patients. Ann Emerg Med 1990;
19:458-459.
12. Curka PA, Pepe PE, Ginger VF: Computer-aided EMS priority dispatch:
Ability of a computerized triage system to safely spare paramedics
from responses not requiring advanced life support. Ann Emerg Med
1991; 20:446.
13. Standard Practice for Emergency Medical Dispatch. American Society
for Testing and Materials Publication No. F1258-90. Philadelphia,
Pa., 1990.
14. Leonard WH: What a waste when a system fails. Ambulance Industry
News 1991; 1:6-7,22,44.
15. St. John DR, Shephard RD Jr: EMS dispatch and response. Fire
Chief 1983; 26:142-144.
16. Clawson JJ: Medical priority dispatch: It works! JEMS 1983;
8:29.
17. Clawson JJ: The maximal response disease: Red lights and siren
syndrome in priority dispatching. JEMS 1987;12:28-31.
18. Childs BJ, Ptacnik DJ: Emergency Ambulance Driving. Englewood
Cliffs, NJ: Prentice-Hall, 1986.
19. Solomon SS: Ambulance accident avoidance. Emergency 1985;17:34-35,44.
20. George JE, Quattrone MS: Above allÑDo no harm. Emerg
Med Tech Legal Bull 1991; 15:4.
APPENDIX D: MODEL LIGHTS AND SIREN
RESPONSE PROTOCOL
LIGHTS AND SIREN USE GUIDELINES
Adopted from Pennsylvania Statewide
Basic Life Support Protocols
Pennsylvania Department of Health
Bureau of Emergency Medical Services, November, 2006
Used with permission.
Criteria:
A. All EMS incident responses and patient transports. 1
System Requirements:
A. These guidelines provide general information and “best
practice” guidelines related to the use of lights and sirens
by EMS personnel during incident response and patient transport.
Ambulance services may use these guidelines to fulfill the service’s
requirement for a policy regarding the use of lights and other warning
devices as required by state regulation, or regions may use these
guidelines in establishing regional treatment and transport protocols.
Policy:
A. Use of lights and other warning devices:
1. Ambulance may not use emergency lights or audible warning devices,
unless they do so in accordance with standards imposed by state
regulation (relating to Vehicle Code) and are transporting or responding
to a call involving a patient who presents or is in good faith perceived
to present a combination of circumstances resulting in a need for
immediate medical intervention. When transporting the patient, the
need for immediate medical intervention must be beyond the capabilities
of the ambulance crew using available supplies and equipment.
B. Response to incident:
1. The EMS vehicle driver is responsible for the mode of response
to the scene based upon information available at dispatch. If the
PSAP or dispatch center provides a response category based upon
EMD criteria, EMS services shall respond in a mode (lights and siren
(L&S) or non-L&S) consistent with the category of the call
at dispatch as directed by the dispatch center. 2 Response mode
may be altered based upon additional information that is received
by the dispatch center while the EMS vehicle is enroute to scene.
2. L & S use is generally NOT appropriate in the following circumstances:
a. “Stand-bys” at the scene of any fire department-related
incident that does not involve active interior structural attack;
hazardous materials (see below); known injuries to firefighters,
or other public safety personnel; or the need for immediate deployment
of a rehabilitation sector.
b. Carbon monoxide detector alarm activations without the report
of any ill persons at the scene.
c. Assist to another public safety agency when there is no immediate
danger to life or health.
3. Special circumstances may justify L&S use to an emergency
incident scene when the emergency vehicle is not transporting a
crew for the purposes of caring for a patient:
a. Transportation of personnel or materials and resources considered
critical or essential to the management of an emergency incident
scene.
b. Transportation of humans or materials and resources considered
critical or essential to the prevention or treatment of acute illness/injury
at a medical facility or other location at which such a circumstance
may occur (i.e. transportation of an amputated limb, organ retrieval,
etc).
C. Patient transport:
1. The crewmember primarily responsible for patient care during
transportation will advise the driver of the appropriate mode of
transportation based upon the medical condition of the patient.
2. L&S should not be used during patient transport unless the
patient meets one of the following medical criteria: 4,5
a. Emergent transport should be used in any situation in which the
most highly trained EMS practitioner believes that the patient’s
condition will be worsened by a delay equivalent to the time that
can be gained by emergent transport. Medical command may be used
to assist with this decision. The justification for using this criterion
should be documented on the patient care report.
b. Vital signs
1. Systolic BP < 90 mmHg (or < 70 + [2 x age] for patients
under 8 years old).
2. Adults with respiratory rate > 32/min or < 10/min.
c. Airway
1. Inability to establish or maintain a patent airway.
2. Upper airway stridor.
d. Respiratory
1. Severe respiratory distress. (Objective criteria may include
pulse oximetry less than 90%, retractions, stridor, or respiratory
rate > 32/min or < 10 min).
e. Circulatory
1. Cardiac arrest with persistent ventricular fibrillation, hypothermia,
overdose/ or poisoning.
Note: Most other cardiac arrest patients should not be transported
with L&S. 6
f. Trauma
1. Patient with anatomic or physiologic criteria for triage to a
trauma center (Category 1 Trauma). Refer to Trauma Triage Protocol
g. Neurologic
1. Patient does not follow commands (motor portion of GCS < 5).
2. Recurrent or persistent generalized seizure activity.
3. Acute stroke symptoms (patient has Cincinnati Prehospital Stroke
Scale findings) that began within the last 3 hours. See Stroke Protocol
h. Pediatrics
1. Upper airway stridor.
i. When in doubt, contact with a medical command may provide additional
direction related to whether there is an urgent need to transport
with L&S.
3. No emergency warning lights or siren will be used when ALS care
is not indicated (for example, ALS cancelled by BLS or ALS released
by medical command). 7
4. Mode of transport for interfacility transfers will be based upon
the medical protocol and the directions of the referring physician
or medical command physician who provides the orders for patient
care during the transport. Generally, interfacility transport patients
have been stabilized to a point where the minimal time saved by
L&S transport is not of importance to patient outcome.
5. Exceptions to these policies can be made under extraordinary
circumstances (e.g., disaster conditions or a back log of high priority
calls where the demand for EMS ambulances exceeds available resources).
These exceptions should be documented.
D. Other operational safety considerations:
1. The following procedures should be followed for safe EMS vehicle
operations:
a. Daytime running lights or low-beam headlights will be on (functioning
as daytime running lights) at all times while operating EMS vehicles
during L&S and non-L&S driving.
b. L&S should both be used when exercising any moving privilege
granted to EMS vehicles that are responding or transporting in an
emergency mode. (Examples include, proceeding through a red light
or stop sign after coming to a complete stop or opposing traffic
in an opposing land-or one-way street)
c. When traveling in an opposing traffic lane, the maximum speed
generally should not exceed 20 miles per hour.
d. EMS systems are encouraged to cooperate with the dispatch centers
in developing procedures to “downgrade” the response
of incoming units to Non-L&S when initial on-scene units determine
that there is no immediate threat to life.
e. The dispatch category (e.g., “code 3,” “ALS
emergency”, etc.) that justifies L&S response should be
documented on the patient care report. The justification for using
L&S during transport should also be documented on the patient
care report (e.g., “gunshot would to the abdomen,” “systolic
BP<90,” etc.).
f. Seat belts or restraints will be securely fastened to the following
individuals when the vehicle is in motion:
1. All EMS vehicle operators
2. All patients
3. All non-EMS passengers (cab and patient compartment)
4. All EMS practitioners (when patient care allows)
5. All infants and toddlers (these children should be transported
in an age appropriate child seat if their condition allows). Children
should not be placed in cab passenger seat with airbag.
Notes:
1. These guidelines are secondary to and do not supercede the state
Motor Vehicle Code.
2. Dispatch centers/PSAPs and EMS regions are encouraged to have
medically approved EMD protocols that differentiate emergent responses
(for example, “emergency,” “code 3,” “red,”
“Charlie,” “Delta,” etc…) from a lesser
level of response (for example, “urgent,” “code
2,” “yellow,” “Alpha,” “Bravo,”
etc…) based upon medical questions asked by the dispatcher.
The dispatch category classification or determinant that justifies
L&S use should be documented on the patient care record.
3. Firefighters cross-trained as EMS personnel who respond in an
EMS vehicle to a fire station or fire incident in order to complete
a fire apparatus crew are considered an exception to this policy.
4. In most cases (up to 95 percent of EMS incidents), EMS personnel
can perform the initial care required to stabilize the patient’s
condition to a point where the small amount of time gained by L&S
transport will not affect the patient’s medical condition
or outcome. In previous studies and in most situations, L&S
transport generally only decreases transport time by a couple of
minutes or less.
5. Each of these criteria refers to an acute change in the patient’s
condition. For example, a patient who is chronically comatose would
not automatically require L&S transport because the individual
does not follow commands (criterion 2.g.1). Additionally, if the
patient improves with treatment and no longer meets the criteria,
L&S transport is not necessary.
6. The American Heart Association gives a class III recommendation
to L&S transport of patients in cardiac arrest. A Class III
indication is not helpful and is potentially harmful. Providing
CPR during L&S transport may increase the risk for injury to
EMS personnel. L&S may be indicated in some situations where
ALS is indicated, but not available or cancelled, because the ALS
crew can not rendezvous with the BLS crew prior to transport to
the closest appropriate medical facility.
Performance Parameters:
A. Review for correlation between dispatch classification/category
and documented mode of response to scene.
B. Monitor percentage of “911” calls using L&S during
response to EMS calls. Routine or scheduled transports should be
excluded. [Potential benchmark less than 50 percent of responses
with L&S].
C. Review for documentation of reason for L&S transport when
patient does not meet criteria listed in section A.13.b –
A.13.h.
D. Monitor percentage of urgent/emergent (“911”) calls
using L&S during transport. [Potential benchmark more than 90
to 95 percent of patients transported without L&S]
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