Jeff Clawson, M.D.
In 1989, the newly formed Academy subscribed to a national newspaper clipping service, and for one year, we received so many articles of Emergency Medical Vehicle Collisions (EMVCs) that I couldn’t fit them all into a cabinet drawer. These were just the ones that made the news, such as fatalities, rollovers, lawsuits, and horrible outcomes. I had hoped, that in coming years, the number of incidents (in the news and not) would decline, particularly those resulting from the unnecessary use of lights-and-siren. I was not expecting the clippings to eventually fit inside a manila envelope but, perhaps, a number that would free space for other topics in the same cabinet drawer.
My optimism was based on the Academy’s process in protocol to identify which emergency calls require the use of lights-and-siren and those that don’t, in addition to local discretion to develop policy reflecting our recommendations. We garnered the full support of the National Association of EMS Physicians and the National Association of State EMS Directors, which issued a joint statement (1993) that, in part, advised: 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.
In broad terms, the use of lights-and-siren can be particularly dangerous and often without the intended result to save a clinically significant amount of time.
Crashes involving emergency vehicles, including ambulances, are still a substantial problem nationwide. According to the National Highway Traffic Safety Administration (NHTSA), between 1992–2011, there were:
- an annual estimated mean of 4,500 motor vehicle traffic crashes involving an ambulance. (This does not include fire or police vehicles.)
- an annual mean of 29 fatal ambulance crashes and 33 fatalities (occupants and non-occupants of all vehicles involved).
- an estimated annual mean of 1,500 injury crashes involving an ambulance and 2,600 injured persons (ambulance occupants and occupants of all other vehicles involved).
Not all the accidents were a direct consequence of unnecessary lights-and-siren use; however, we can say the judicious use of warning lights-and-siren in the initial response and subsequent transport of patients likely will result in a more balanced system of appropriate care with minimization of iatrogenic (caused by medical examination or treatment) injury and death. If you don’t go HOT, you’re obviously less likely to be involved in, or create, an accident. And if you don’t go at all, you can’t get hit.
Emergency Medical Technician Legal Bulletin, Med/Law Publishers, Fall 1991, Vol. 15, No. 4
James E. George, MD, JD and Madelyn S. Quattrone, JD
Above All-Do No Harm
The following newspaper story was written by Scott Richardson, a staff writer for The Pantagraph, and appeared on the front page of this Bloomington, Illinois, newspaper on December 29, 1989:
“The city of Bloomington has reached a tentative settlement of nearly $5 million with a former cheerleader who was partially paralyzed in a crash between a pickup truck and a Fire Department ambulance last year.
If the proposal is approved at a scheduled hearing January 10, Sharron Rose Frieburg, 18, of rural Saybrook will get an immediate cash payment of $500,000, according to court papers filed yesterday by her attorney, James Ensign of Bloomington.
She would get three more cash payments, one of $25,000 in 10 years, one of $50,000 in 20 years and one of $100,000 in 30 years.
The proposed settlement also calls for her to get $2,000 each month for the next 10 years and $3,000 per month for each month after that for as long as she lives.
All payments would total $4,975,687 if she lives to her expected life span, Ensign said.
Miss Frieburg is mentally and physically disabled. Using a quadpod cane, she can walk only a short distance unassisted. She cannot talk and needs more surgery to improve motion of her arms. She is not expected to ever be able to work, Ensign said.
Miss Frieburg was an honor student when she left home March 26, 1988, to attend a movie in Bloomington with Mark Embry. As they were headed south at Center and Locust streets, Embry’s pickup was broadsided by the eastbound city ambulance which was transporting a man with a sprained ankle to Brokaw Hospital.
Miss Frieburg was in a coma until August 1,1988, and was brought home later that month after the family’s insurance company said it would not pay for any more hospital care because of a policy clause stating the firm would not pay for extended care when a patient has recovered as much as the company’s doctors think likely.
Since early this year, Miss Frieburg has been attending a program that combines education with therapy for the severely disabled.”
Everybody would certainly agree on the tragic proportions of this case. It is difficult to understand why transporting a patient with a sprained ankle would result in a motor vehicle accident with such a catastrophic outcome. Nonetheless, stories like this occur many times a year throughout the United States.
Why is it that emergency vehicle drivers let themselves fall victim to motor vehicle accidents which could have frequently been avoided in retrospect? Maybe it is the fact that running “RLS” (red-light-and-siren) is such an intoxicating experience that it blurs the normal judgment process which would ordinarily guide the emergency vehicle driver when driving “COLD” (non-emergency status) as opposed to running “HOT” (emergency status).
No Good Samaritan Immunity
Emergency care vehicles should be driven with due regard for the safety of other motorists on the highway as well as the safety of the patient-passenger in the vehicle. Defensive driving skills should be high on the list of EMT priorities. Emergency care vehicles must be operated in accordance with appropriate state vehicle codes and regulations. Such laws and regulations govern not only the physical characteristics of the emergency vehicle, but also the manner in which they must be operated.
New Jersey law (N.J.S.A. 39:4-91), for example, describes the appropriate operation of emergency vehicles: “The driver of vehicle upon a highway shall yield the right of way to any authorized emergency vehicle when it is operated·in response to an emergency call·and when an audible warning bell, siren, exhaust whistle or other means is sounded·and when the authorized emergency vehicle is equipped with at least one lighted lamp displaying a red light visible under normal atmospheric conditions from a distance of at least 500 feet to the front of the vehicle.”
It is important for EMS personnel to note that the above statute does not give the emergency vehicle an absolute right of way. On the contrary, the right of way is qualified and can not be forcefully taken by the emergency vehicle driver if the motorist does not voluntarily give it up. New Jersey law (N.J.S.A. 39:4-91) further 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, not shall it protect the driver from the consequences of his reckless disregard for the safety of others.”
Thus, the emergency vehicle driver must be aware of the fact that he has only a qualified emergency right of way and can not be unreasonably aggressive with other motorists if they do not relinquish the right of way to the emergency vehicle. EMTs often complain about motorists who do not get out of the path of their emergency vehicle in responding to an emergency call. Despite their anger, the only appropriate response for the EMT is to take the obstructing motorist’s license plate number and report them to the police. It is then the responsibility of the police to enforce the penalty provisions of the motor vehicle code for a motorist who does not yield the right of way to an authorized emergency vehicle.
EMTs must also understand that their emergency vehicle has to exhibit the necessary visual and audible signals in order to function in a authorized fashion. The reason for this requirement is obvious. It would be unreasonable to expect motorists to yield the right of way if they were given no visual or audible notice that the right of way was requested.
A further problem exists for EMTs with regard to the issue of what constitutes an emergency call. There are generally two tests that determine whether an emergency call exists. The subjective test attempts to determine what the driver actually believed. The objective test looks to all the facts to determine whether the driver’s belief was reasonable.
A determination of whether an emergency call exists often involves a combined subjective and objective analysis. If an EMT drives a vehicle as if an emergency exists, he must have reasonable grounds for so driving.
For what length of time can the EMT drive the vehicle as if an emergency exists? Generally speaking, the driver can assume an emergency exists from the time of dispatch until the time of arrival at the scene, unless the driver has actual notice or should have reasonably known that an emergency did not exist. Obviously, a large measure of how reasonable it is for the driver to assume an emergency exists will depend on the specific information given to the emergency vehicle driver and squad at the time of dispatch. Since dispatch of emergency vehicles is almost always recorded on audio tape, it will be easy to reconstruct these facts if they are questioned at a later date.
What happens from the time of departure from the scene until arrival at the hospital? Whether an emergency exists depends on the patientâs clinical diagnosis and condition at the time of pick-up from the scene. The run to the hospital may not be an emergency if the patient looks well and his vital signs are stable. However, a non-emergency run may deteriorate into a true emergency en route to the hospital.
A significant part of the decision about whether an emergency exists may rest on the shoulders of the EMTs who are with the patient in the vehicle. This decision must be responsibly exercised when it comes to driving the emergency vehicle. EMTs should always drive with reasonable restraint in order to avoid creating a new emergency. Above all, the emergency vehicle driver should do no harm. He should not make a controlled situation become uncontrolled and he should not make a bad situation worse. The guiding principle of medicine which governs the actions of all physicians is to have the physician conduct himself so that he does not make the patient’s condition worse by virtue of his intervention. Obviously, since physicians as well as EMTs are human, there are occasions in which errors in judgment occur and a situation is aggravated. This is unfortunate, and, under the right circumstances, may result in a lawsuit for negligence.
Medical Priority Dispatch System (MPDS)
An interesting article entitled “Running Hot,” was written recently by Jeff J. Clawson, M.D., in the July, 1991 issue of the Journal of Emergency Medical Services (Vol. 16, No. 7).
Dr. Clawson is President of Medical Priority Consultants, Inc., of Salt Lake City and is the Medical Director for Gold Cross Ambulance, the Salt Lake City Fire Department and the Salt Lake County Fire Department. He also serves as the medical-dispatch consultant for the cities of Los Angeles and Cincinnati. He is chairman of an NAEMSP subcommittee writing a position paper entitled, “RLS Use in Emergency Medical Vehicle Response and Patient Transport.” Dr. Clawson originated the medical priority dispatch system in 1976.
Dr. Clawson developed the MPDS concept from 1976 to 1979. It was developed with the acknowledgment that “the vast majority of people who request mobile aid are not in a life-threatening situation and, in most cases, the aid received at scene does not have a significant effect on the patient’s eventual outcome.” Dr. Clawson observes that the main objective of MPDS is to “send the right thing to the right person in the right way at the right time.” Dr. Clawson observes in his article that an official of the American Ambulance Association was once quoted as saying, “Red-lights-and-sirens never saved anyone’s life in the history of the world.” Dr. Clawson takes pains to point out that running “RLS” should not be confused with “saving significant time.” Everybody in EMS wants to save significant time whenever possible. However, this should never be at the expense of causing injury and damages which could have been avoided.
Dr. Clawson described the benefits of a medical priority dispatch system (MPDS). He notes: “In systems using a comprehensive MPDS, complete with a functioning dispatch quality-assurance program, we are starting to see some fascinating science regarding the appropriateness of sending BLS units “COLD,” or non-emergency status, when there is strict compliance to dispatch interrogation protocols. The City of Houston Fire Department recently submitted an abstract study to the Society for Academic Emergency Medicine on the ability of the cityâs MPDS to spare paramedics from non-ALS responses. The city of Los Angeles, one of the largest metropolitan area in the world, implemented an MPDS in November 1988. And, in March of 1990, Los Angeles implemented a tiered-response system based on the MPDS code; suddenly, after decades of full RLD response in an EMS system handling approximately a quarter of a million runs each year, 29% of those calls were initially dispatched as a solitary responding vehicle “COLD.” I have been working with Los Angeles for more than two years, and, to my knowledge, the city has never received a formal citizen complaint regarding this mode of response. Similarly, neither the Salt Lake City Fire Department after nearly twelve years of MPDS use.”
Dr. Clawson then revealed some startling statistics regarding the motor vehicle hazards of running “RLS.” It has been estimated, observed Dr. Clawson, “that as many as 12,000 emergency-medical-vehicle-accidents (EMVAs) occur each year in the United States and Canada as a direct result of RLS use. In addition, because of what we call the “wake effect” of emergency units, disrupting, confusing and startling other drivers, up to five times as many accidents are caused by units responding RLS that don’t physically involve the emergency vehicle itself.”
Dr. Clawson noted that “In 1983, Salt Lake City’s Fleet Management department reported that the EMVA rate had dropped 78 percent in that city as the result of MPDS, and it was estimated that the number of EMS vehicles traveling Salt Lake City streets with RLS was safely reduced by 50 percent through the use of the system.”
Dr. Clawson has commented that more and more people are learning about the “maximal-response disease” and the fact that every ambulance, fire truck, and rescue vehicle does not have to respond “HOT.” Dr. Clawson says, “The blind use of RLS may actually be killing more people than it saves. While we may worry about getting into trouble for not responding or transporting RLS, I predict that, in the not-too-distant future, any use of RLS will be subject to sensible justification and standardization or be considered negligent by the courts.”
Dr. Clawson and other individuals and organizations feel strongly about this. It is their opinion that “the medically unjustified, arbitrary or blanket use of RLS is a negligent process that runs contrary to the current medical-dispatch standard of care.” Thus, the MPDS approach to medical dispatching is creating a new legal standard of care for both dispatching and for safe driving of emergency medical vehicles.
Dr. Clawson refers to two recent national organization position papers to support his conclusion. In 1989, the Position Paper on Emergency Medical Dispatching was adopted by the National Association of EMS Physicians:
“Dispatch prioritization is an essential element in any EMS system for it establishes the appropriate level of care including the urgency and type of response.”
“These priorities must reflect the level of appropriate response including types of personnel (ALS vs. BLS vs. First responder), response configurations (numbers and type of vehicles responding) and mode of response (red-lights-and-siren vs. Routine).”
“The appropriate prioritization of the type, number and manner of responses is essential to effect an appropriate reduction of responding vehicles traveling red-lights-and-siren and therefore unnecessary vehicle accident.
Dr. Clawson next referred to a document entitled Standard Practice for Emergency Medical Dispatch, published in 1990 by ASTM, a national standards-setting organization: “This (standard) practice may assist in overcoming some of the misconceptions regarding emergency medical dispatching. These include the uncontrollable nature of the callerâs hysteria, lack of time of the dispatcher, potential danger and liability to the EMD (emergency medical dispatcher), lack of recognition of the benefits of dispatch prearrival instructions and misconceptions that red lights, siren and maximal response are always necessary.”
Dr. Clawson concludes his article by saying: “I believe that the careful, trained and knowledgeable use of the most up-to-date medical priority dispatch protocols results in a safe and efficient dispatch, care and response process for any EMS system. Measured, medically approved, preplanned responses (as opposed to the shotgun, hurry-up-and-wait approach still present in many current EMS systems) has become the new national standard of care.
We agree with Dr. Clawson and the need for a well-disciplined and thought out medical priority dispatch system (MPDS). Achieving MPDS in suburban and rural areas without a centralized dispatch system may be slower in coming. However, MPDS definitely fits within a setting which already operates off of a centralized dispatch system.
Whether the dispatch system is state of the art MPDS or less structured and divided, the ultimate determination of appropriateness of response will be decided by the intelligence and maturity of the EMT driving the emergency vehicle. In the unfortunate event that an accident takes place at any point in the prehospital EMS encounter, the ultimate decision regarding reasonable and prudent conduct by the EMT driver will be decided upon by the facts of the case as well as the general principles outlined above.