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An EMS Epidemic

In the last few days, we have lost two of our best and brightest paramedics in Texas, due to motor vehicle collisions. Fayette County paramedic Michelle Otto died instantly when her car was struck by another car in the Texas Hill country. The second collision occurred in the pre-dawn hours of Oct. 10, when an ambulance from Marble Falls was returning from Austin. The driver, paramedic Eric Hanson, was dead at the scene. His partner, Kyla Wilson, was transported to a local trauma center in critical condition. The driver of the pick-up truck that veered into the path of the ambulance was also killed.

Motor vehicle collisions, such as these two in Texas, are the greatest risk for serious injuries and death for police officers, EMS personnel and firefighters. Unfortunately, this phenomenon has not been well studied. Several people, including Nadine Levick, MD, Valerie DeFrance and Sue Roundy, have been trying to get our attention about the growing trend in ambulance collisions for years. It is time we listen.

When taking a hard and fast look at ambulance collisions, here are issues we need to consider:

How effective and comprehensive is emergency vehicle operations education? I am sure that every EMS service has some sort of orientation for emergency vehicle operators. But does it adequately prepare personnel to react in emergencies?

When I was a paramedic in the 1970s, we were sent to the Texas Department of Public Safety Academy in Austin for emergency vehicle operations instruction. We would drive old highway patrol cars that looked like the car the Blues Brothers drove throughout Illinois. It was part classroom and part practical. We drove on the skid pan, learned to avoid hazards and learned about high-speed operations. This training still helps me. Although it only snows or ices in Texas every few years, my instincts developed in those classes come into play, and I am able to drive safely in that kind of weather.

Are the majority of our EMS drivers young? Without a doubt, the average age of our EMS workforce in the United States is lower than in the Commonwealth countries and other first-world countries. In addition, many people are hired as EMTs and, by definition, must drive so the paramedic can attend to the patient. Thus, in many instances, we have people between the ages of 21 and 29 driving emergency vehicles.

Insurance statistics have shown that drivers under 25 years of age are at an increased risk to be in an accident, due to either inexperience or carelessness. It would be interesting to study ambulance accidents by looking at the age of those involved in accidents.

Ambulances are becoming larger and more complex. It is now commonplace for ambulances to be placed on a commercial diesel chassis. Ambulances are now, essentially, commercial trucks with air brakes, altered aerodynamics and unusual centers of gravity.

It took me some time to get comfortable driving and operating a fire engine. I feel that the transition time to these new ambulances is much longer, when compared to traditional Type I, Type II and Type III ambulances. Also, new employees need experience on a test track to get used to the performance characteristics of these vehicles.

Response times are not as important as once thought. It is unfortunate that we place so much emphasis on response times. There is a finite time interval to drive from point A to point B. Using lights and sirens can shave a few seconds off of the response. Driving over the posted speed can shave a few seconds off the response. But both red lights and siren usage and driving over the speed limit SIGNIFICANTLY increases the likelihood of a collision. The time saved is not clinically significant. So, why place employees at risk?

Jeff Clawson, MD, recently told me that in Salt Lake City, Utah, they stopped lights and sirens response for certain categories of calls, such as motor vehicle collisions, falls, etc. They found no detriment in terms of patient outcome, and, interestingly, one engine company actually improved their response times, when they limited lights and siren responses.

People don't respect emergency vehicles. My wife and I were recently driving west on Flamingo Street in Las Vegas, when the LVFD and a MedicWest ambulance were responding to a call. Nobody, and I mean nobody, pulled over. Both emergency vehicles had to drive in the oncoming lane to get by. Likewise, people do not slow down when emergency vehicles are parked on the scene, which puts all responders at serious risk.

We need to work with law enforcement to make a concerted effort to educate people about what to do when an emergency vehicle approaches. More importantly, police must start citing people for not pulling over or not slowing or changing to a different lane when approaching a parked emergency vehicle.

We need to better understand shift work. The Marble Falls accident happened at 5:45 a.m. This is a time when most people's circadian rhythm calls for sleep. I am not saying that was the reason that this accident happened, but it may have been a factor. This accident happened when it was dark and the road, which is quite hazardous even in good weather, was wet. We need to look at the impact of shift work on critical skills such as driving and patient care.

In the past, I have been extremely hard on the helicopter EMS industry in regard to their safety record. However, it appears that 2006 will be a much safer year. Recommendations from the National Traffic Safety Board and industry-initiated programs appear to be positively impacting the horrible accident rates we saw in the first part of this decade.

I think we need to look at some of the practices the helicopter EMS industry has applied to ground ambulance operations. One of these is called Crew Resource Management (CRM), which was developed by NASA in 1979 and has been widely adopted in the aviation industry. The CRM model focuses on the elements of human effectiveness.

The three primary components of effective crew management are safety, efficiency and morale. Specific factors related to aircrew performance are categorized and serve as the basis for training and research. These factors include materials, organization and individual and group process variables associated with performance. Examples of outcomes that result from these input variables are safety, efficiency and customer satisfaction.

I think we need a standardized emergency vehicle operators' course. Not only should this course be educational, it should also be used to screen out those whose driving skills are incompatible with safety. We also need to further look at the role of "black boxes," so management can monitor ambulance operations. This will also provide needed data for research.

Perhaps, we should not give the nature of an emergency call until the crew is a minute or less from the scene. Knowledge that the call is "bad" or involves a child can affect our emotions and adversely affect our decision-making skills. For example, it is standard practice in air medical operations to not tell the pilot the nature of the call so that he or she will not be biased when making a determination whether the flight is safe to attempt.

I am certainly not an expert in this area. But, there are many who are. It is time in EMS where we embrace a culture of safety. We write over and over in our textbooks that crew safety comes first. How often we forget this admonition when we are behind the wheel of an ambulance.


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