Administration and Leadership, Major Incidents, Operations, Patient Care

Why EMS Should Employ High-Reliability Organization Characteristics

Issue 6 and Volume 38.

JEMS founding publisher Jim Page, often called the father of modern EMS, came in my office one day and told me about a sharp physician, Daved Van Stralen, MD, a former Los Angeles paramedic who was working in the Loma Linda University School of Medicine Department of Pediatrics. Page said Van Stralen was “onto something big,” called high-reliability organization (HRO) processes, that I “needed to pay attention to.”

So I contacted Dr. Van Stralen, discussed the concept with him and attended an HRO conference where I was blown away. I heard representatives from the U.S. Navy, NASA, offshore gas industry and major airlines vividly explain how the following can stop an unsafe process before it gets out of control: A careful consideration of predictable risks, a system of defined corrective actions and the empowerment of any employee or responder in a high-hazard environment to take action.

Dr. Van Stralen and retired U.S. Navy Rear Admiral Thomas Mercer honor us this month with the first of two articles they agreed to author for JEMS on the principles of HRO, so I won’t go into great detail here. But I did want to give you an example of how HRO principles can affect your decision-making processes and actions at a high hazard scene, because I experienced it personally.

As an EMS operations director for a large, progressive, high-performance EMS service in Pennsylvania, I was alerted one day to a highway incident were three of my crews were. It involved an overturned tanker truck that was leaking Freon. The hair on my neck stood up when I heard the word Freon because, early in my EMS career, I treated a young boy who had huffed Freon from cooking spray PAM through a toilet paper tube packed with toilet tissue. He did it to get a “buzz.” He inhaled an excessive amount and excited his heart so much that he lapsed into v fib that couldn’t be reversed. He died two days later.

Freon Toxicity
Freon is the trade name for a group of man-made chemicals called chlorofluorocarbons (CFCs). CFCs contain chlorine, fluorine and carbon and are often found in air conditioners and refrigerators. The manufacturing and use of Freons is restricted and is gradually being phased out. People are usually exposed to Freon by accidentally or deliberately breathing it in.

High concentrations can reduce the activity of the central nervous system, cause weakness, an irregular heartbeat, convulsions and death. In addition, high concentrations can cause severe abdominal pain, vomiting (including vomiting of blood) and loss of vision. People who take medications used by asthmatics may face a greater risk and should avoid too much exposure.
The Material Safety Data Sheet (MSDS) on Freon notes that inhalation of high concentrations of its vapor is harmful and may cause heart irregularities, unconsciousness or death. Intentional misuse or deliberate inhalation can be fatal.(1)

Immediate effects of overexposure by inhalation may include central nervous system depression with dizziness, confusion, incoordination, drowsiness or unconsciousness. Gross overexposure can cause death from v fib that often starts as an irregular heartbeat during the early stages of exposure. It often presents with a strange sensation in the chest, “heart thumping,” apprehension, lightheadedness, feeling of fainting, dizziness and weakness, and it sometimes progresses into loss of consciousness and death.

According to the National Institutes of Health, most symptoms are a consequence of inhaling Freon. It also notes that Freon vapors are heavier than air and pose a threat of suffocation if trapped in enclosed or low places and that inhalation may cause dizziness, headache, confusion, incoordination and loss of consciousness.(2)

A tanker truck carrying CFCs can also present a significant hazard to emergency responders who will not find Freon or CFCs in their standard Emergency Response Guidebooks.

Enacting HRO Principles
So I called my crews on an operational channel and asked how far they were from the leaking product. They said they were told by incident command (IC) to stay 1,000 feet away from the tanker and that it was spewing a “rather harmless” gas/refrigerant.
The Department of Transportation Emergency Response Guidebook, which we’re all are supposed to know and use, doesn’t specifically list Freon or CFCs. However, it does list in Guide 115 that:  “Gases: Flammable (including refrigerated liquids) as extremely flammable, lighter than air” and that “some may be irritating if inhaled at high concentrations.”(3)

The Guidebook also doesn’t truly describe the effects of Freon or CFCs. However, under “Evacuation,” it does state that “during a large spill,” incident commanders should consider “initial downwind evacuation for at least 800 meters (1/2 mile).” That is 2,640 feet—1,640 feet further than where my crews were positioned.

I opened the massive Railroad Hazardous Material binder that I carried with me at all times and confirmed that excessive inhalation of Freon could result in irreversible v fib. I then called my crews and asked them to alert the IC that Freon was involved and that “6202” (my county ID number, which indicated that it was their ops director on the line) recommended that the evacuation/positioning zone be extended to 1/2 mile.

They reported back that the IC “felt they were not in danger and felt no need to move their vehicle position.” I responded that I would be en route to their location.

With the Railroad Hazardous Material binder under my arm, I responded to the scene, presented the specific sections relative to the true hazards of Freon to the IC and he agreed to move my crews to the 1/2-mile perimeter. I should mention that I politely told him that, regardless of his decision, I was going to reposition my paramedics outside the stated hazard zone. I told him they would be available to “attempt to resuscitate” his personnel if they were exposed to the high Freon concentration and “needed to be resuscitated.”

Was I insubordinate, arrogant or disrespectful? You may feel that I was. But in reality, I was educated to a level that could have been validated and should have been respected by command. I was, in fact, practicing a key aspect of HRO. I was stopping an obvious dangerous condition before it could harm or kill emergency responders. My IC colleague knew it from the facts presented and, in fact, joked with me about my “subtle sarcasm” and moved the perimeter to the recommended half-mile distance.

Did I win, or did a HRO proactive win? Actually, HRO won and potentially saved 30 lives. I simply presented the hazards of CFC inhalation. A high reliability organization must not rely on only one source of data when detailed information on a hazard isn’t immediately available, or if it isn’t very informative during an emergency decision-making process. Read EMS & High Reliability Organizing: Achieving safety & reliability in the dynamic, high-risk environment and practice its important principles. It’s really common sense, not rocket science, and may save you, your crews or others in your community.


1. Thompson L. (1999–2013). What are the dangers of inhaling Freon. In EHow. Retrieved May 1, 2013, from
2. DuPont. (Nov. 4, 2002). Material Safety Data Sheet: Freon. In DuPont. Retrieved May 1, 2013, from
3. U.S. Department of Transportation: Emergency Response Guidebook: A guidebook for first responders during the initial phase of a dangerous goods hazardous materials transportation incident. Claitor’s Law Books and Publishing; Baton Rouge, La., 2008, p. 176–177.