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Patient Care

A Profound Impact

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Allina Health EMS experienced its worst-ever ambulance crash in the early morning hours of Saturday, January 18, 2014. This is our story.

Snow was falling at an ever-increasing rate, and it was getting harder to see markings on the road. A short time earlier, when paramedic Brian Nagel and EMT Tim Daly had been dispatched to the medical call, there was a stiff breeze, but the snow was fairly light. Now it was coming down at a fast clip, and the large flakes were reflecting in the headlights, limiting visibility to just 30 yards or so.

There was such a fast accumulation of snow that Daly, who was driving the 2012 Ford Type-III ambulance, reported riding close to the shoulder so he could hear the rumble strips in the pavement to be certain of his position on the road. Nonetheless, the experienced EMS provider was in control, maintaining speeds of approximately 35 mph while en route to the hospital some 10 miles away.

This event was unfolding in what we call our Wright County Division. The 9-1-1 geographic service area of Allina Health EMS spreads far and wide across Minnesota. One million people live within the areas we serve, which include urban centers such as the Mall of America and the Minneapolis-St. Paul International airport, as well as more rural areas like Wright County, about an hour west of Minneapolis.

Brian was in the back of the rig and had just given his patient some medication. He had been seated on the squad bench earlier in the call, but was now standing to reach the sharps container to dispose of the syringe and call his report into the receiving hospital. He tells us he also remembers leaning from the patient compartment into the cab, asking about the noise he heard while Tim was riding the rumble strips.

Through the wall of falling snow, Tim saw headlights coming toward him fast. In the millisecond he had to react he tried to maneuver the ambulance away from the oncoming vehicle. Many credit his action with making the outcome of the crash less devastating than it might have been. There was a thunderous crash, followed by deep silence, then everything went dark.

The patient, safely belted on the cot, including shoulder restraints, remained conscious and alert throughout, and sustained no serious injuries—in fact, the patient became the source of much information in the aftermath of the incident. For example, it was through the patient that we learned that neither Tim nor Brian responded to calls for help for a period after the impact.

While Brian has no memory of the aftermath of the crash, Tim remembers being dazed and hearing nothing. “It was a deafening silence,” he recounts. In addition, everything went black. The violence of the impact had sheared the battery cables on the ambulance and the engine went dead. No lights, no motors, no radios. Now, beneath the dark, cloud-filled skies, the road was being buried, as were the wrecked vehicles and the four souls within them, under a blanket of heavy snow.
Later we learned that at the time of impact our ambulance was traveling at 37 mph. The vehicle that struck us was driving in excess of 60 mph.

The Response

Tim recalls struggling through the smashed ambulance cab—as the firewall had been pushed in 18 inches and entrapped his feet. He had suffered bilateral fractures to his lower extremities—unknown to him at the time—but he made it back to Brian and the patient to do whatever he could until more help arrived. It was then that Tim discovered Brian unresponsive with a head injury.

In a strange twist, while Tim was making his way out of the cab, the patient had retrieved Brian’s cell phone from his cargo pants pocket and called 9-1-1. In our dispatch center in St. Paul, emergency medical dispatcher Jennifer Stewart quickly determined that the caller was a patient in the back of one of our own ambulances and began providing prearrival instructions.

Word of the ambulance crash spread quickly. In addition to our crews who were dispatched to the scene to help treat and transport their own colleagues and the driver of the other vehicle, personnel from six different agencies joined in the response.

We know from existing research that responding and caring for a severely injured coworker is highly stressful and challenging for EMS providers. Nonetheless, everyone did an exceptional job. We will always be grateful for the outstanding performance of our responding crews and the support we received from neighboring EMS and fire agencies, local and state law enforcement, and hospital staff.

The Call

Some 1,600 miles from the crash scene, my cell phone rang around midnight. I was in Tucson, AZ, attending the annual meeting of the National Association of EMS Physicians. It was a dreadful call to receive from Operations Director/Deputy Chief Kevin Miller.

“There’s been a crash,” he said. “It’s still evolving, but here’s what I know: Two employees hurt, Tim Daly and Brian Nagel. Tim is conscious and being treated locally. Brian is unconscious, intubated with a head injury, and being transferred to a Level 1 trauma center 30 miles away. Helicopters can’t fly due to weather, so he’s going by ground. The patient is OK, but the driver of the other vehicle sustained multi-system traumatic injuries.” (That driver later died from injuries sustained in the crash.)

Being miles away from home, there was nothing I could do directly. Besides, I knew my leadership team were handling things. My primary thoughts shifted to notifications. Tim had made contact with his wife himself, but Kevin reported that Brian’s family hadn’t yet been informed of the crash.

Brian Nagel was 30 years old at the time and single. Our records showed he listed his parents as his next-of-kin. They were semi-retired and living part-time in Florida. I told Kevin I would call them.

Six years earlier, we had added an EMS chaplain to our staff. Soon after he joined us I asked Rev. Russ Myers to help research and create a line-of-duty-death protocol. It was one of those things I knew we should prepare for with hopes of never having to use it. The exercise of creating that SOP was helpful that night. As odd as it may sound, I had practiced the conversation I was about to have with these complete strangers, telling them their son was critically injured and might die.

I woke the Nagels in the middle of the night, 3 a.m. Florida time. Few of us had ever met Terry and Jill Nagel before, but we would come to know them well in the months to come. They are a remarkable family.

Later that day, we got an update about the condition of our guys. Tim was OK but in for a long recovery, which would include multiple surgeries. As for Brian, all we knew was that he had safely been transferred to the ICU at the Level 1 trauma center at North Memorial Medical Center in a Minneapolis suburb. He was intubated and unresponsive, and his prognosis was far from clear. The rest of our crews, including those who’d responded, were doing OK, and word was spreading quickly among the Minnesota public safety community.

This was the beginning of a key lesson in crisis communications. Our line-of-duty-death protocol called for an in-person notification of family by myself, our chaplain, operations director, etc. Looking back, that concept seems somewhat nostalgic and completely naive.

Within about an hour of the crash, a complete set of dispatch audio tapes were posted on a website called mnpoliceclips.com. Soon after, the site had received hundreds of hits, and the link was reposted by dozens of well-intended and concerned people via Facebook, Twitter and other sites. In the age of social media, smartphones and a tech-savvy public, the idea that any of us can “control the message” is an outdated concept. The best we can hope for is to stay abreast with the communication, which will be happening all around us at warp speed.

Another lesson learned has to do with privacy. It’s not that we broke any rules regarding HIPAA or other privacy considerations, but we didn’t obsess about them. We knew that our staff wanted to know what was going on, and they deserved to be kept informed. We also knew social media was abuzz, often with incorrect information. Beyond our own agency, there was a large group of hospital and public safety colleagues who had a genuine concern for our crew. And of course there were the media, both local and national, who were interested in information about the crash.

With all of that in mind, our leadership team agreed on one golden rule: We would only share information with explicit approval from our crew and/or their families. Early on I called Tim and asked what he was comfortable with us sharing. He gave me the green light to let folks know what was going on with him and his road to recovery. As for Brian, that was part of a conversation I had with his parents and his sister in the ICU about 18 hours after the crash.

My memory of that first meeting with Brian’s family is still emotional and raw. There was clearly a sense of shared sadness and angst for what the future held. We talked about the organization’s commitment to see things through no matter what the outcome. Brian’s mother also asked some challenging questions: “Was he standing? Was he wearing a seat belt? How does that work in the back of an ambulance anyway?”

During that meeting, almost as an afterthought, Jeff Czyson, our operations director, asked the family if they had heard of Caring Bridge, a website where families can post updates about ill or injured loved ones. Jeff explained how it works, and within a couple of hours Brian’s sister Amanda had created a page about the crash. When I awoke the next day, I looked at the site and was amazed to see 200 visits from overnight. Within days the number would balloon to several thousand, eventually reaching nearly 100,000 visits from people all around the world.

As far as sharing information, the Nagel family was clear: “Yes, we want people to know what happened, and we need their prayers.”

We decided to be proactive and used the Allina Health EMS Facebook page to communicate with our own internal staff and the broader community. The media picked up on it and over the next few days often simply reposted our Facebook updates.

That Sunday, less than 24 hours after the crash, members of our senior leadership team and I visited the ambulance bases that were most impacted. We didn’t really have an agenda, but as our chaplain put it, “It’s being present that matters most.” Many people showed up just to be together and share the experience. Plenty of tears were shed.

We discovered right away that people wanted to do something. Working with our union partners from the International Association of EMTs & Paramedics Local 167, we created a family liaison schedule. Dozens of Brian and Tim’s co-workers signed on to help. Support came in many forms, from a round-the-clock uniformed staff member at the hospital, to dog sitting and making meals. Keeping vigil and supporting the family at the hospital was great therapy for all.

The Long Road

Tim Daly was discharged from the hospital after a few days, but spent the following three months in a wheelchair and had multiple corrective surgeries on his feet and lower legs.

Brian remained unconscious for seven days. On day seven, he recalls not being able to see well because, among his multiple injuries, his eye was severely damaged. But he remembers the blurry image of the wall in his hospital room…and hearing his mother’s voice. When he woke up, it was like the sun finally shining after a very dark period.

He was discharged to an inpatient rehab center and spent months in recovery. Like many patients with traumatic brain injury, Brian reports having experienced some strange occurrences when he was unconscious and in the days after he awoke. He remembers dreaming that he and his father were living in Nicaragua, a place he has never been to before or since. He says he thought they were “hiding out” there until something terrible blew over. Weeks and weeks of rehab followed.

In March, a fundraiser was held at a local fire department where Tim Daly serves as a volunteer firefighter. It was the first time that most people had seen Tim and Brian since the crash—Tim in his wheelchair, and Brian wearing a cervical collar and baseball cap covering his head wounds. It was a glorious day.

Healing

Tim returned to full duty late last year. Brian is back at work continuing the re-entry process, hopefully returning to the streets soon. Both continue to face the challenges of a long recovery. As friends and co-workers, we are committed to standing beside them as they do so, with a deep sense of gratitude to have Tim and Brian with us.

And as an organization, we’ve committed to making ongoing safety improvements. It’s an essential part of our responsibility to our patients, our clinicians and our community.

After the Crash: Lessons Learned

As you might imagine, the ambulance crash we experienced caused us to do some soul searching that is still going on 18 months after. As is often the case, facing a catastrophe has given us the opportunity, and the responsibility, to emerge stronger. Here are some of our take-aways.

There’s no such thing as too much preparation. For any organization, “be prepared” is probably the most important lesson. It seemed like we had prepared for an event like this years in advance, and we put pretty much every bit of that planning into action after our crash.

Think before acting, then act thoughtfully. Following any major or catastrophic event, there is typically a call for sweeping and rapid change. After our crash, such a call came not just from street-level clinicians, but from all levels within the organization, that we must take steps to prevent and/or minimize similar future events. As much as we felt compelled to take immediate action, we realized that what actually needed to occur was planned, multi-stage change.

Secure, secure, secure. Early on we spread word of the “three S’s” of the patient compartment: Secure your patient, secure your equipment and secure yourself. This was done via safety messages developed by our Safety Committee.

Treat prior to transport. We encouraged clinicians to, for example, initiate IV therapy and other procedures prior to transport, procedures they may have been doing during transport. We also recommended they position and secure equipment they may need during transport so they could remain seat-belted, and if they had to get up and move about the patient compartment, to buckle up once they sat back down.

Keep emergency contacts current. Keeping updated emergency contact information can seem like a lot of work, but these contacts can be crucial when you need them.

Modify driving behavior. Electronic driver monitoring/feedback systems have proven to be very effective. We think of them not as a “gotcha” device, but as safety adjuncts, much like the technologies that help airline pilots fly safely.

Rethink speed. Speed is dangerous. While it was not the case in our crash, we know that 70% of all ambulance crashes occur while operating in an emergency mode. We have begun routine reviews and revisions of the protocols under which ambulances drive code 3.

Expect that social media will play a huge role. Think through your crisis communication plan in an era of social media when you can’t control the message.

Review SOPs. Examine long-held practices with fresh eyes and understand what rules you might be willing to break. These have all been the subject of important conversations within our organization.

Involve medical directors. The National Association of EMS Physicians (NAEMSP) has endorsed the idea that medical directors need to get involved and lead safety issues, including response protocols, and have issued a position paper on the subject. In part the paper states, “Shorter response times are not without cost; inappropriate use of lights and sirens carries established, significant safety risks for EMS providers and the public alike. Most important is the proper triage of calls to determine which ones require rapid ‘lights and siren’ responses and which ones can be handled in a timely, but safer fashion.” Our own medical director, Dr. Charles Lick, plays a key role in our safety initiatives.

Consider the ambulance design itself. Last year, we initiated plans to redesign our ambulance fleet with a focus on provider safety. We formed a multi-disciplinary committee that includes front-line providers, mechanics, union leaders and managers. We wanted to get everyone’s perspective as we took this first step toward a significant vehicle change. Everyone had a say. We had folks who were tall and short as well as light and heavy to get a feel for comfort, clearance and safe ergonomics, along with efficient patient care.

Make safety improvement an ongoing effort. Over the past 18 months, our Safety Committee has continued reviewing and debating the above issues and more, from creating cultural changes to trialing the use of helmets. Like most quality improvement practices, this will be a never-ending exploration.

Building a Better Ambulance

In 2014, there were just 5,884 U.S. domestic ambulance sales. Contrast that to the more than 60 million cars produced in this country each year. Safety research and development is time-consuming and expensive, so you can imagine how difficult it can be to get the manufacturers to spend a lot of
R & D money for fewer than 6,000 units per year. But we are making progress as an industry.

At Allina Health EMS, we have learned from our European colleagues and others and redesigned the patient compartment of our rigs. The bench seat is gone, replaced by forward-facing crew seats with four-point restraint systems. We want to be near the patient and within reach of most equipment that might be needed to provide patient care, while remaining belted in. An important goal is to limit the need to ever stand in the back of a moving ambulance.

We had three manufacturers accept the challenge and, this summer, we have taken delivery of three different designs—variations on this theme. They are all based on the Mercedes Sprinter chassis and are currently being tested in the field. We expect we will make a selection on the final design and manufacturer and begin standardizing our new fleet with a much safer ambulance in the coming year.

Implementing a Safe Driving Culture

Allina Health EMS operates a fleet of nearly 100 vehicles, mostly ambulances, but also wheelchair vans and operations vehicles. We respond to about 260 requests for ambulance service each day, and drive more than 4 million miles every year (many of those miles driving Code 3).

Long before this crash we launched a focused effort on driving safety. In 2011 we hired a new fleet director, Gary LeLoup, an experienced fleet manager from the trucking industry. One of the first things Gary did was to install informatics (black box) devices in all of our vehicles. The primary purpose of the devices was to help us track mileage so we could get vehicles in for maintenance rotations in a timely manner.

However, an additional data point that we began to better understand was the speed that some of our people were driving. Informatics allowed us to track certain aspects of driver behavior in real time and, on a whim, Gary set up his pager to alert anytime someone was driving more than 90 mph.
One day he called me to explain what he had done and added, “My pager sounds like a popcorn popper going off.” Our blissful ignorance had ended, and we knew we had a problem that needed immediate attention.

At first I set up my own pager the same way. For several weeks, whenever I received an alert about high-speed driving, I started personally calling crews to give them some real-time coaching about expectations for safe driving. This was very effective, as word quickly hit the street that careless drivers were getting a call from the chief, sometimes in the middle of the night. But in an organization of nearly 600 staff members, it was only a short-term solution. The long-term solution meant changing a culture of “driving fast.” We launched a comprehensive education program and engaged the technology of Road Safety and Geotab.

It’s important to note here that our January crash had nothing to do with an ambulance driving at high speeds. As reported, our rig was traveling just 37 mph when it was struck by the car that crossed the snowy center line. But we were implementing a culture of driving safety across our organization.

Hear Brian LaCroix tell this story in person at EMS World Expo in Las Vegas, NV, September 15–19. In “Ambulance Safety: A National View & A Personal Perspective” Brian will co-present with Noah Smith, a project manager for the federal Office of EMS at NHTSA, to deliver a compelling safety message. Noah will give the national perspective and the results of the NHTSA investigation into the Allina Health EMS crash. Brian will tell the personal story of the consequences of the crash. Register today at EMSWorldExpo.com.

Brian LaCroix is the president/EMS chief for Allina Health EMS, based in St. Paul, MN. Allina Health EMS serves a population of more than 1 million people with a team of more than 600 caregivers, responding to more than 260 requests for every day. Brian also serves on the board of the National EMS Management Association (NEMSMA).

 

 

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