A recent, well-publicized crash involved an ambulance that was allegedly travelling 83 miles per hour “against traffic,” which I have assumed means “in the wrong lane of the highway.” It was reported that the driver has been charged criminally with vehicular homicide or whatever they call that particular crime in the state where it allegedly occurred.
Response to this event within the EMS community has been, to me, interesting. I’ve been following responses on a variety of blogs, podcasts, chats and Facebook. Some say such things as, “You don’t know how it is out here unless you’re an EMS dude/gal, so you have no right to talk about it.”
Wow. Most adults are drivers and know the basic rules of the road, so why not? This is a public act done in a public place, so everybody has the right to talk about it.
More interesting to me have been the, “We don’t do enough training on driving” responses. Although I agree with that concept in general (I think that our industry’s approach to this core EMS competency is abysmal, at best), I disagree that this is a training issue involving driving skill.
What I see in this (and so many similar) situations are issues of ethics, leadership, maturity, organizational culture and selection of personnel. The failure, as I see it, involves the driver of the vehicle—but only a little bit. No, I’m not one of those, “It’s everybody’s fault except the guy who did the act” apologists. This driver did what he did, and he’s ultimately accountable. But how did a person with character so deficient that he knowingly made a decision to drive at a reckless speed, in the wrong lane of travel, wind up behind the wheel of a large vehicle, without oversight (human or mechanical) such that it was possible for him to take the life of another human being?
Some other human beings made that possible, and they’re as accountable as the driver. Some had the chance to intervene and stop the reckless behavior and didn’t. Some could have built systems to prevent such an occurrence but didn’t. The list goes on.
So why, I have to ask, does the EMS community allow this and all the other knowingly dangerous behaviors to occur? Are we so into “running it like a business” that we’re able to accept loss of life and limb as a cost of doing business? Are today’s EMS executives, managers and supervisors as uncaring about the safety of their employees as the mining executives of the last century? Do we need an outside agency (the government) to require that we clean up our houses by force of law?
Do we need a Federal Aviation Administration to tell us that 24-hour shifts may be dangerous to crews, patients and the community? Or can we be like much of the hospital community, in which the voluntary accreditation agency provides the motivation to remove life-threatening hazards? Maybe we can do it ourselves, because we are moral, ethical, concerned leaders who know what’s going on, and we’re willing to push for these issues to be addressed just because it is the right thing to do.
So what pushed me to the “writing point” where I felt the need to put pencil to paper?
First, there was a podcast on EMS Garage during which the discussion led to the notion that in some parts of the country, there are actually EMS “leaders” that either actively or tacitly encourage “fast driving.” The theory is that if they require prudent driving, they won’t be able to “meet response performance requirements” or some other agency will report better “stats” than they do, thereby forcing them out of business.
Second, there was the “Don’t criticize us if you haven’t walked a mile in our shoes” thread. OK, maybe somebody writing out there wasn’t an EMS provider, but I am and have been for a long time. So I’ll claim my right to speak and do my best to bust this safety thing open.
Third, I care about the safety of EMS folks. Over the past couple of years, I’ve been becoming increasingly concerned. I attended the National Association of Emergency Medical Technicians rolled out its new “Taking Safety to the Streets” course, became an instructor and started teaching. I came in contact with Kip Tietsort and the Escaping Violent Encounters/DT4EMS crowd and learned what they’re trying to do. In my own service, I experienced a graphic reminder of the potential for harm in EMS, after employees suffered a series of career-ending or career-modifying injuries and a vehicle wreck illustrated that there’s a great potential for death or injury—even in routine EMS work.
Fourth, as National EMS Management Association president, I’m on the distribution list for the EMS Culture of Safety Project. I’ve been privileged to read and comment on the draft reports that are being circulated as project volunteers, staff and the EMS community come together to address this safety thing. We have issues that are deep and complicated, and we need to sort those out. But there are also things, such as excessive speed, that routinely slap us in the face, briefly get our attention and then are forgotten until the next time.
Come on now. This stuff has got to stop. In much of the U.S., EMS has moved away from organizations that are “social clubs that run ambulance calls.” Unfortunately, it sounds as though there are some areas where this attitude is maintained. And worse … where “organizational preservation” is more important than safety.
In a 2006 white paper, the Institute for Healthcare Improvement discussed the importance of leadership in creating a culture of safety by stating, “Leadership is the critical element in a successful patient safety program and is non- delegable. Only senior leaders can productively direct efforts in their health care organizations to foster the culture and commitment required to address the underlying systems causes of medical errors and harm to patients.”
Yet it has been alleged that in some EMS agencies, the leadership, far from encouraging safe driving and other behaviors, at best condones unsafe behaviors and at worst, encourages them. Can it be?
It’s time for EMS leadership behavior to change. If your approach to safety in your EMS agency is to rely on luck, please remember that according to former Secretary of Homeland Security Tom Ridge, “Luck is not a strategy.” For too long, and in too many EMS agencies, the primary human resources consideration has been “meat in the seat,” or its EMS version, “a pulse and a patch.”
Many important considerations, including content of pre-service programs, hiring standards (or lack thereof), field training programs (or lack thereof) and standards for retention and promotion have been ignored, avoided or minimized because of the belief that higher standards would result in an insufficient pool of credentialed personnel to meet the operational needs of the agency. Personally, I’d rather have fewer EMS units on the road, knowing that the people on those trucks were quality individuals with good clinical skills and who are persons of character, integrity, maturity and good judgment.
EMS Industry Assessment
So here are some things I think that we need to look at as an industry. Before we do so, we either need to develop some EMS scholars to do the necessary research or we need to borrow from existing academic disciplines, starting with psychology and industrial engineering.
1. Develop assessment tools that assess maturity and judgment with sufficient reliability and validity, so that we can exclude thrill seekers who aren’t sufficiently controlled to safely function within our environment.
2. Require, somehow, an in-depth course in ethics and ethical management for every EMS leader. Maybe a certification. Ensure leaders know that they’re responsible for system performance, not individual drivers. If your drivers aren’t getting lost en route to calls and your system doesn’t meet whatever standard you adopt, it means either a) you need more units on the street or b) you need to position them differently. It’s you the leader, not the people, in the trucks.
3. Develop a model code of ethics for EMS personnel that includes safety issues and effective driver-passenger interaction. Make it an ethical obligation for every EMT and paramedic to drive and otherwise act safely, and for every passenger attendant to “call out” their driver for unsafe practices.
4. Make sure that your field training and evaluation program (orientation, whatever you call it) includes plenty of time behind the wheel under the direct visual supervision of a qualified instructor. How much is enough? I don’t know (need some research), but an hour or two isn’t enough. If the first time a new employee drives your ambulance is to a call, as part of a two-person crew, I submit that your program is negligent per se. A field training officer (FTO) can’t monitor, evaluate and provide feedback to a driver while the FTO is in the back of the truck providing patient care.
5. Examine mechanical options for vehicle control and vehicle feedback. I have concerns about mechanical speed limitation devices (i.e., governors) for vehicles that have to be able to safely operate on interstate highways, but I think I may be able to get over that. If we can’t depend on our people to drive within safe parameters, perhaps we can train our vehicles to stay within those parameters.
6. Take existing driver-monitoring systems to the next step. Many of our vehicles are equipped with GPS, and some of the “black box” systems provide minute-by-minute monitoring of vehicle speed and other telematics. My personal in-vehicle navigation system, commercially available for about $100, knows the speed limit of every road segment in the U.S. How about we couple this technology to something that would immediately notify a supervisor every time a vehicle exceeded the speed limit? After-the-fact monitoring (via downloading and reporting) is nice, and not enough EMS agencies have even this capability. but by the time the 100+ mph driving is discovered, the harm may have been done.
7. Instead of counting Band-Aids and 4x4s during ambulance inspections, state EMS offices should concentrate their limited regulatory efforts at a higher level, on things that matter to the citizens their efforts are supposed to protect. Next time you make a change in those state EMS rules, add requirements that will help to keep EMS personnel safe, including driver feedback and monitoring systems. If an EMS agency’s policies, procedures and practices encourage fast driving (for example, the SOG manual says that a driver who doesn’t arrive in X minutes has to write a report to explain why), suspend that agency’s license until it changes that practice and undergoes a thorough safety practices audit.
8. Develop, procure and require the use of high-quality driving simulators that can be used to test driver judgment. Individuals who can’t qualify and who make poor decisions shouldn’t be allowed on the road until their judgment and ethical performance meets a standard of acceptability. Hey! They do it for Ice Road Truckers. Why not EMS? This includes all aspects of driving: city, highway, backing, tight spaces, etc. The airline industry has figured out that they can’t afford to do enough training in the air in real airplanes, so they developed simulators that are sophisticated to provide a valid teaching and testing environment. We need to do the same.
Finally, EMS leaders need to stop accepting the notion that financial constraints justify not doing what’s necessary to keep our people, our patients and our communities safe. Sir Winston Churchill once said, “It’s not enough that we do our best; sometimes we have to do what's required.”
What’s required is that we do what must be done to ensure our people operate our vehicles in a safe manner, regardless of cost. If we can’t do it, then we don’t deserve the privilege of serving our communities. If you’re one of those who are more concerned with “meat in the seat” than with safe operations, you deserve to have some other agency serve your community. You may have to do things that are risky or distasteful, such as educating your elected officials that you need more money, or that it’s not possible to run a quality, safe, quick EMS system on only the revenue you can generate from ambulance transportation. But doing things that are risky or distasteful are what good, ethical leaders do. So … it’s time to step up.