On driving lights and sirens

[medicdan]

Particularly in light of the recent EMSA crash, I have been re-thinking lights and sirens driving considerably. I would like to share some of my thoughts/rants, and get your responses. We've had pieces of this discussion before in different places, but i'm discussing a new approach.

I will start by saying I am not a particular fan of driving with L&S… I work mainly PB (ALS) and my company has fairly few (or little) policies regarding driving. We do not have Road Safety, and it seems management does not care much what we do as long as nobody complains and there are no collisions.

I am aware of the considerable risks that come with L&S, the high rates of collision and significant damage and the minimal cost savings. With that said, I generally drive to all emergencies with L&S, and modulate my speed/rush based on dispatch complaint (drivers make the priority decision here, not dispatch). Once we get the patient into the truck, I leave my partner (medic) to decide how they want to get to the hospital, but find myself disagreeing more often recently. More on that in a minute.

One of our managers (an experienced instructor in his own right) strongly believes, and shares broadly his belief that unless a team of RNs and MDs swarm around our patient when we arrive at the ED, or the patient receives some critical diagnostic or treatment within 3-5 minutes of arriving, we shouldn’t have been using L&S on the way in. Especially when working ALS, that makes a lot of sense.

I recognize some EDs have particularly lazy staff, and this tenant stems from the quality (and accuracy) of our radio/triage report, but it resonates deeply with my thinking. We can do whatever we think is prudent on the way to scene, provide whatever assessment or treatment we need, then realistically look at how fast we need to get to the hospital.

This is where I disagree with my medic partners—they like lights in, and I am reluctant. I absolutely trust them to make decisions that are in the best interest of the patient, realize that I do not always understand their motives, and always honor their requests (within reason), but just do not think it’s worth the risk for what I see as low priority patients. When I push their thinking after the call, I frequently get shallow excuses with no mention of patient acuity. When we are done with our paperwork 10 minutes later and say goodbye to the patient, they haven’t been seen yet by a tech or RN, let alone an MD.

I don’t want to debate who’s in charge on a PB truck… that’s a different issue… but differing opinions on patient priorities, and whether we are really doing the right thing rushing patients, and developing more formal decision matrices for L&S use patient loaded.

There are some services to my knowledge (Boston EMS comes to mind) that have policies that call for ALL patients to be transported L&S, even if they are going to the waiting room, ostensibly to maximize unit availability (boingo/TOTWTYTR can you confirm/deny?) Does anyone have data on whether the cost of adding trucks is more than increased crashes, or does that boil down to driver training? Do we have a panacea for emergency vehicle driver training? What do services with the lowest collision rates do? Is it a function of EVO or other drivers? Conditions? Type/size of vehicles?

 

[Shishkabob]

My current agency has a robust driving system. We have road safety, like you, and while they don't force a strict level each month, they want everyone atleast level 5 or above. Calls are dispatched PMD, in an attempt to not run LS to non-emergent calls. Obviously this has flaws in it, but in a busy system, I've run LS 2 times each shift for the past few shifts, while most of my calls are non-LS. They also have a 5 week long driver training program, one week in class, and 4 weeks in the field, just driving. They have policies, such as not forcing cars in to traffic (If we come up to a red light, and can't get in to oncoming lanes, we shut off lights, hang back a bit, and once it turns green, go again)


They still have a number of collisions during the year (all sent to incident review boards), but that's going to happen in a very busy system with a lot of trucks, and idiot civilian drivers on the road.



On the way back to the hospital, it's the crews decision, and I personally only do it in time sensitive things, such as MI/CVA or airway issues. (Cardiac arrest are non-LS transports, if they even get transported)


I'm all for LS response to the scene for calls that call for it, because honestly, people who call 911 suck at giving info, and a stubbed toe can and has turned in to a cardiac arrest. Back to the hospital? With all that Paramedics can do today, it's not preferable the vast majority of the time, but as I stated, there's a few times where it is required.

 

[R99]

Depends entirely on how sick patient is and how much traffic.

Lets be fair, theres nothing better than going the down the main in the rush hour with lights and siren screaming, going as hard down on the air horn and two tone making as much noise as possible, it's great, its a good thing to do anybody mental who tell you different.

 

[medicdan]

Lets be fair, theres nothing better than going the down the main in the rush hour with lights and siren screaming, going as hard down on the air horn and two tone making as much noise as possible, it's great, its a good thing to do anybody mental who tell you different.

Actually, I like many things more than this... it's not particularly exciting or enticing to me... but will do it if necessary. Just because we can do something doesn't mean we should...

 

[abckidsmom]

Depends entirely on how sick patient is and how much traffic.

Lets be fair, theres nothing better than going the down the main in the rush hour with lights and siren screaming, going as hard down on the air horn and two tone making as much noise as possible, it's great, its a good thing to do anybody mental who tell you different.

Buckle your seatbelt, man. And get ready to consider other people's viewpoints. You are about to hear a lot.

 

[abckidsmom]

I worked in an urban system that was a public utility model operated by AMR. We had something called the 12 standards that I have been unable to find in a google search. Anybody know what I'm talking about?

Anyway, OP, I agree with you 100%, and while I can't discount that it is FUN to drive with lights and sirens, I'll say it's also FUN to ski, it's FUN to blow stuff up, and it's FUN to throw rocks.

All of the above are activities that carry risk, and the risk should me managed in the best possible way. Like with skiing, you follow the rules of the slopes, and the only one who gets hurt when you crash into a tree is you. With fireworks, you don't do them during a drought, not inside the house, and not without sober adult supervision. With rock-throwing, you aim away from people.

Sadly, with ambulance driving, you are aiming INTO people who are busy following the rules, going with the flow of traffic, and you and ONE other emergency are not worth risking all of those people.

 

[R99]

Even the most professional ambos I know are at heart a wee bit of a siren junkie

We take driving and driving safely very seriously and have strict laws about how long we can drive for as well as a comprehensive driver training program. Lights and siren responses are used when appropriate and safety is always paramount. Doesn't mean it doesn't brighten the day a bit to play mobile christmas tree, come on lets be honest with ourselves

The fire boys go to every job with lights and siren, ambo dont. Their fire truck weights in at thirteen metric ton, snorkels and the like even more, our hunk of crap van is about 2500kg.

 

[Medic Tim]

Boston area services run L/S for everything in my experience. I did some ride time there as a student.

Where I work we are dispatched to code 1(l/s) or code 2( no l/s) calls. We have restriction of 20km/h over the posted limit to a max of 120km/h.(the highway speed limit is 110km/h). this is usually slower than the flow of traffic.

I find a run l/s to the hospital very rarely. even with cardiac pt's. we are 10-15 min from the hospital on most transports and you might save 1 min if you are lucky going l/s as most of it is highway driving. our driving is monitored by AVL so big brother is always watching.

 

[Shishkabob]

I worked in an urban system that was a public utility model operated by AMR. We had something called the 12 standards that I have been unable to find in a google search. Anybody know what I'm talking about?

Yup.

Smooth braking
Constant rate acceleration
Rear tire concept
Rear space cushion
Side space cushion
Rear view mirror use
Eye movement pattern
Looking far ahead
4 second following distance
12 second lane change
Signalling turns and exits
Speed control

who are busy following the rules, going with the flow of traffic,

You know that's just not true

 

[exodus]

Even the most professional ambos I know are at heart a wee bit of a siren junkie

We take driving and driving safely very seriously and have strict laws about how long we can drive for as well as a comprehensive driver training program. Lights and siren responses are used when appropriate and safety is always paramount. Doesn't mean it doesn't brighten the day a bit to play mobile christmas tree, come on lets be honest with ourselves

The fire boys go to every job with lights and siren, ambo dont. Their fire truck weights in at thirteen metric ton, snorkels and the like even more, our hunk of crap van is about 2500kg.

I would rather never run code, it's dangerous and most of the time benefits very little. L


---
I am here: http://maps.google.com/maps?ll=34.068410,-117.852668

 

[Rettsani]

We can not decide how we reach the Patient, whether we drive with or without blue lights and sirens. This decides for us, the dispatcher. ^_^
Only when we have take the patient in our Rescue Vehicle, we had to do our own decision. If the patient's condition allows it, I prefer clear without blue lights and siren to drive.

We have for all rescue vehicles a regular driver training on the traffic training ground. In addition, we are taught about dealing with special and rights of way.

 

[Meursault]

How much of the pressure to respond quickly to calls comes from the public or from municipalities? Do you think your managers feel it's medically important to have good response times, or that it's good customer service, or that it's necessary to keep the contract/get good funding?

 

[Shishkabob]

How much of the pressure to respond quickly to calls comes from the public or from municipalities? Do you think your managers feel it's medically important to have good response times, or that it's good customer service, or that it's necessary to keep the contract/get good funding?

My agency complies with the time standards as, no matter how incorrect and misguided, that's how civilians grade an agency on how good they are at their job.

However, they're pushing to get away from response times and making the civilians realize that there are much better ways to grade an agency, such as patient outcomes.




Any time a news agency runs an article about 'slow response times' and putting 'lives at risk', I want to punch the "journalist" for not digging deeper and seeing the delay in care is due to people calling 911 for inappropriate reasons and demanding transport.

 

[Rettsani]

Good question next. From the pressure we got nothing on the ambulance with. We have 11 fire and rescue stations in the city, all vehicles at the Fire an Rescue Stations to be routed through a central control center.
If I get the message on my Pager then I know I must in 3 minutes be outside and 8-10 minutes be at the patient. :unsure:

 

[EMSLaw]

How much of the pressure to respond quickly to calls comes from the public or from municipalities? Do you think your managers feel it's medically important to have good response times, or that it's good customer service, or that it's necessary to keep the contract/get good funding?

I think it's the former, really. At least for the large majority of ambulance calls - your sick person jobs, lift assists, random aches, pains, and sniffles.

For the first... forty-five or so years of its existance, my service operated under a system where rigs were stationed at various locations throughout town. The crews were at home. They would be toned out, and the driver would either have the ambulance at his home, or would go pick it up. He would meet his crew, and they would go to the call. Response times in our area averaged approximately 12-15 minutes.

Six or seven years ago, that response time suddenly became unacceptable. For some reason, a sub-eight minute response is now the expected standard. So, the crews stay at our station when on duty.

While I haven't crunched the numbers, and it would require poring through a huge number of old run sheets, I suspect that evidence would show that the difference in response time was not medically significant. But public and political perception required that we respond faster.

I consider myself a mature, sober individual. I drive as safely as I can, and I expect my crew to do the same. There are times when I will put the hammer down - a serious call involving a child, for instance. And yes, there is a thrill to driving with lights and sirens. But as I've said (frequently) to some of our newer, younger drivers - we don't do anyone any good if we wreck our ambulance getting to the call.

The issue, like so many other things that plague EMS, comes down to public education. The purpose of the ambulance is to deliver emergency medical care, and safe transportation to the hospital. Expecting EMTs to magically appear at your door in five minutes because you have a sniffle is not realistic, and expecting that will put a lot of people, including the ambulance crew, everyone on the road, and - in my area - a large number of deer, in deadly peril.

 

[rmabrey]

I normally don't mind driving LS to scene cause I understand dispatchers work with what they have. I mind driving lights and sirens in a rainstorm to an ED for a patient that has neck pain, that told dispatch they were seen, treated, and discharged, and want to go to another ED.................especially when its the dispatch manager taking the call.

We rarely go lights and sirens to the ED. Only severe trauma, some CVA's, MI depending on how long they've been symptomatic. If we get ROSC we transport cold, if we lose them again, still cold.

Sent from my Desire HD using Tapatalk

 

[OrlandoRMAMedic]

I know we all have our examples of abuse of the system. The one that I have had recently was a 23 y/o male c/o difficulty breathing. We responded with L/S. He walked down the 3 flights of stairs and met us at the truck as we were arriving on scene. He explains that he cannot breathe through his nose (that was his difficulty breathing) and his girlfriend had just left (just before he called 911) to take their daughter to the walk-in clinic for the same thing. He said his mother told him to call 911 and go to the hospital by ambulance instead of going with his girlfriend and daughter.

SMH

 

[the_negro_puppy]

We are told whether or not to go L&S to the job depending on the AMPDS code.

It is up to us if we want to go L&S to hospital. We rarely do, i've been L&S to hospital less than 10 times in 2 years on an emergency ambulance.

 

[Localmotion34]

In my old county in NC we had to provide WRITTEN justification in our report for going LS with a patient in the back to the hospital.

Going to the scene, we used the "carding" system, where B-D levels we went LS to the scene. Once we had the patient, it had to have been VERY serious to go LS.

When i worked in NJ, EVERY ambulance I ever saw was going LS TO the patient, and with the patient in the back. Even ankle pain, they would run emergency traffic to the hospital. Ri-dic-u-lous.

I told my drivers that unless the patient was dying, we were NOT using LS going to the hospital with a patient in the back. On the rare days I would get a Medic for a stable patient, they would hop in and I swear to you, we would be running NO LS, and their chase vehicle would still have the lights on. We'd be stopped at a light, and again, they would leave their lights on. After two rides like that I was overrode by our chief and had to use LS for everything.

I am glad I got out of that system before someone got killed, and I would have been paying out a lawsuit for the rest of my life.

 

[Tigger]

In the Boston area it seems like everyone gets transported L&S to the ED, which I think is ridiculous. It's convenient maybe, but not justifiable. The reasons I hear absurd...

"he has a trach in!"
"we don't have medics, what if she gets worse?"
"the traffic is going to be brutal and the Bruins are on!"