Threat Reduction

Strategies for reducing the dangers facing EMS providers

This article is from the supplement Ambulance Safety Solutions sponsored by ZOLL Medical Corporation


Expert sources: David Slattery, MD, FACEP, FAAEM, Assistant Professor, University of Nevada School of Medicine & EMS Medical Director, Las Vegas Fire and Rescue; Tim Crowley, EMT-P, Battalion Chief (Ret.) Las Vegas Fire and Rescue

   It's no great leap of logic to fathom: To reduce a risk, you have to identify the risk. The only problem, in the risk-abundant world of ambulance operations, is where do you start?

   Ambulances are not built to a federal crash standard. Their patient compartments can have sharp edges, head-strike hazards and unsecured equipment flying about in a crash. Providers are often unrestrained to deliver care and can become projectiles themselves in accidents. Crash, injury and fatality rates are high, associated with numerous factors that include lights-and-siren driving, operator distraction and encounters with other vehicles, particularly at intersections. There are a lot of elements of danger.

   What can we do about them? Increasingly, there are answers. Consider the following strategies for some key danger areas:

    Code 3 driving--The seconds you might save using lights and siren with a patient on board are rarely worth the risk they increase to you and everyone else. Increasingly, EMS systems are limiting their Code 3 transports.

   "There are very few scenarios where driving Code 3, and making a difference of a couple of minutes, really makes a difference in a patient's outcome," says David Slattery, MD, FACEP, FAAEM, EMS medical director for Las Vegas Fire and Rescue and a frequent conference speaker on ambulance safety issues. "But it does put our crews at risk, and that's something we need to work on."

   Organizations such as the National Association of EMS Physicians (NAEMSP) and National Association of State EMS Officials (NASEMSO) have published position statements that say Code 3 driving should be used only in life-threatening situations where patient outcome could be affected by delay. Systems that have restricted Code 3 driving via dispatch protocols and transport criteria, notes Tim Crowley, a retired EMS battalion chief for Las Vegas Fire and Rescue, have observed minimal effect on patient outcome. The advantages to the patient, the ambulance crew and other motorists far outweigh any need for speed.

   Las Vegas leaders are attacking the problem with educational emphasis on the risks and general lack of benefit of running hot, and may ultimately develop a protocol for it. For now they present the facts and leave transport-mode decisions to their providers. But the issue has a lot of relevance for the department. In 2003, a city fire truck responding to a call rolled over, leaving a captain paralyzed. A judge ruled the driver was going too fast for conditions.

   That was during a response to a call, where providers may have less discretion about their travel mode. But as tragedies have elsewhere, this one helped focus greater scrutiny on patient-transport modes, too. In particular, in Las Vegas and lots of places, hot cardiac arrest transports are getting an increasingly skeptical eye.

   When talking on the subject, Slattery poses audiences the case of an 80-year-old with terminal cancer going into asystolic cardiac arrest. Medics can't get return of spontaneous circulation in the field, but are told by medical control to transport. Would they go Code 3, or not?

   "Its usually about 50-50," Slattery says. "A lot of people say yeah, you have to, even though you have someone who clearly fits all TOR guidelines. That patient's dead, and it's well-based in evidence. But there is still a group of providers who feel compelled to drive Code 3, because they think they're at medico-legal risk if they don't. And actually it's just the opposite."

    Restraints--A classroom survey at EMS EXPO in 2008 found 98% of respondents had, at some point, stood in the back of an ambulance traveling Code 3. But even at low speeds, the forces on unrestrained providers can be perilous.

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