What are the real risks in our EMS practice? A look at the areas of physical danger, as well as those with the highest liability risk, is in order. Risk is defined in Black's Law Dictionary as "a degree of hazard; a specified contingency or peril; exposure to loss, injury, disadvantage or destruction; and the element of uncertainty in an undertaking." This article will explore the different types of risks—physical and legal—that EMS personnel face, and it will provide tips to lower the uncertainty.
The Leading Cause of Risk
EMS vehicle crashes remain the most prevalent cause of morbidity and mortality for our patients as well as for EMS responders. They also cause the most expensive claims and lawsuits. A look at the EMS list servers will find almost daily references to serious EMS vehicle accidents.
In 2009, 207 serious accidents were reported to the EMS Network. In those crashes, 191 EMS providers were injured and five were killed, while 39 patients were injured and nine killed. In other vehicles involved in these crashes, 119 people were injured and 20 were killed. Driver-related factors contributing to these devastating accidents include fatigue, straying out of the lane and excessive speed. Failure to wear restraints while working in the patient compartment both contribute to the severity of injury, as does the design of ambulances that ultimately cause injury.
The tireless work of Nadine Levick, MD, MPH, to improve the safety features of ambulances keeps trying to push the industry towards safer vehicles. Risk management tools include having priority dispatch systems reduce unnecessary Code 3 responses, being well rested, keeping speed down, implementing better vehicle design and paying attention to the road.
Air ambulance transportation fares even worse. "EMS helicopters have the worst fatal crash record in aviation, and it is the setting in which EMS crews are most likely to die on the job," said Ira Blumen, program director for the University of Chicago Aeromedical Network, in a hearing before the National Transportation Safety Board. Interestingly, in Canada, where two pilots are required, and there are much more rigorous standards for flying in inclement weather than in the US, there were almost no crashes. Overuse of helicopter transport is currently being closely examined by leaders in the EMS and aviation industry to reduce the risk of flying.
Patient Handling Incidents
Patient handling incidents also rank high on the list of risks. According to VFIS Education Specialist David Bradley, BS, NREMT-P, patient handling incidents are the most common injury claims from patients as well as the most common cause of disability for prehospital healthcare providers under the age of 45. Strains and sprains of the back, knee and shoulder are extremely common, and Worker’s Compensation claims place a burden on the EMS agency.
Risk management tools include staying in good physical condition, training in equipment use and good body mechanics, having impeccable maintenance of equipment and providing solid documentation if a patient handling mishap occurs. Use additional personnel when needed to lift extremely heavy patients or to move patients from difficult locations. It's also critically important for EMTs to be focused on the task of moving a patient and to be aware of hazards, such as lawn sprinklers, uneven pavement, small rugs and weather-related issues.
As for legal risks, patient refusals and "no loads" are a high-risk activity. A lack of understanding by EMTs of the informed consent/informed refusal process has led to numerous lawsuits by patients who deteriorated after being examined by EMS and left behind. Over-reliance on refusal forms, "EMS initiated refusals" and end-of-shift fatigue lead to failures to transport patients who should be transported. It is important for EMTs to remember that a family member cannot consent or refuse transport for their loved one, and that a person who is impaired by drugs, alcohol, trauma or illness may lack decisional capacity to refuse transport.
Today's EMTs have tools to assess a patient's decisional capacity, such as pulse oximetry and glucometry, but the best tool in the box is still the ability to talk to our patients and documenting how they process information. Risk management tools include a thorough patient assessment, evauation of a patient’s mental status and decisional capacity, following protocols including contact with on-line medical control, and careful documentation. Courts have upheld patient refusals even when the patient goes downhill after refusing transport if EMS has carefully documented efforts to transport the patient. These calls can be frustrating and can take a lot of time, but the best patient care results from taking the time to do the proper assessments.
Worth a mention—yet not in the highest liability category—is clinical error. Such airway issues as misplaced endotracheal tubes remain a quality assurance concern. An incomplete or poorly performed patient assessment can lead to cavalier attitudes and the failure to discover subtle signs that a patient is heading for trouble.
EMS is a risky business, but the risks of our profession can be reduced by using tools that are available to us as providers as well as managers. Education is our best defense to the uncertainty we face daily in our work. Keeping physically and mentally healthy can greatly reduce stress, exhaustion and lack of focus, thus reducing errors.