Search terms: Red lights and siren (RLS), hot, maximal response disease, Sharron Rose, Jeff Clawson, emergency medical vehicle accidents, ambulance accidents, wake effect, potential danger and liability, Bloomington Illinois, blind use of lights and siren, JEMS, July 1991, cold, medical priority dispatch protocols, saving significant time

JEMS, July 1991, Guest Comment
Jeff J. Clawson, MD

Running "Hot" and the case of Sharron Rose

Recently, a gentleman from a Michigan EMS system asked me to render my professional opinion regarding his city's current EMS unit-response philosophy. As I understood from his letter, his system's medical directors had verbally directed the local ambulance service to response "emergency status" to all unscheduled calls. I assumed this meant that all ALS units were being dispatched red-light-and-siren (RLS, or "HOT") to the scene. This mode of dispatch, he said, was based on the medical assumption that such calls represented "presumed life-threatening emergencies."

After significant thought regarding the possible interpretation of my opinion that might not be appreciated by other members of his system, I decided to respond in writing in the follow manner.

The Medical Priority Dispatch System (MPDS) concept was initially developed from 1976 to 1979. Its specific intent was that-from an emergency medical standpoint-the vast majority of people who request mobile aid are not in a life-threatening situation and, in most cases, the aid received at scene does not have a significant effect on the patient's eventual outcome. Since EMS evolved primarily out of public safety and not out of the medical community, the amount of medical expertise and confidence in medical decision-making in the public safety community was largely absent. This resulted in the perpetuation of old fire- and police-response traditions in EMS, or the "maximal response disease," as it has recently been described.

The main objective of MPDS is to "send the right thing to the right person at the right time." To my knowledge, not a single article has been published in this century that proves or even strongly indicates that the use of RLS saves lives. I will agree that a strong correlation does exist between early defibrillation of V-fib (in less than 600 seconds) and any time saved in delivering that response. Early reversal of choking and complete airway obstruction also pose good arguments for this practice. A weaker extrapolation can similarly be made for critical trauma patients and the "golden hour." However, as one official of the American Ambulance Association was once quoted as saying, "Red-lights-and-sirens never saved anyone's life in the history of the world." He may be right.

Please do not confuse "saving significant time " with "RLS response," as no published data prove that RLS response does save significant time. In an unpublished study conducted in Salt Lake City, it was demonstrated that fire pumpers and paramedic-staffed engines responding within their initial-response districts in urban or suburban area experienced a 9-percent to 28-percent reduction in response times. Reductions depended on the time of day and concentration of semaphores, or visual signaling apparatuses, encountered. It was found that the maximum saving occurred during rush hour, when emergency vehicles traveled in the direction of main flow and when there was a traffic light at every block. It is interesting to note that the average time saved in these in-district responses was approximately 30 seconds.

In systems using a comprehensive MPDS, complete with a functioning dispatch quality-assurance program, we are starting to see some fascinating science regarding the appropriateness of sending BLS units "COLD," or non-emergency status, when there is strict compliance to dispatch interrogation protocols. The City of Houston Fire Department recently submitted an abstract study to the Society for Academic Emergency Medicine on the ability of the city's MPDS to spare paramedics from non-ALS responses. The city of Los Angeles, one of the largest metropolitan areas in the world, implemented an MPDS in November 1988. And, in March of 1990, Los Angeles implemented a tiered-response system based on the MPDS codes; suddenly, after decades of full RLS response in an EMS system handling approximately a quarter of a million runs each year, 29 percent of those calls were initially dispatched as a solitary responding vehicle "COLD." I have been working with Los Angeles for more than two years, and to my knowledge, the city has never received a formal citizen complaint regarding this mode of response. Similarly, neither has the Salt Lake City Fire Department after nearly 12 years of MPDS use.

The use of RLS is not without significant hazard. It has been estimated, for example, that as many as 12,000 emergency-medical-vehicle accidents (EMVAs) occur each year in the United States and Canada as a direct result of RLS use. In addition, because of what we call "wake effect" of emergency units disrupting, confusing and startling other drivers, up to five times as many accidents are caused by units responding RLS that donât physically involve the emergency vehicle itself. Does the number 75,000 get your attention? It should, if you, too, believe that the prime rule of emergency medical dispatch÷as for medicine itself-should be, "First, do no harm."

In 1989, I subscribed to a national newspaper clipping service, and for one year, I received so many articles of EMVAs that I couldn't fit them all into a cabinet drawer. And these were just the ones that made the news, such as fatalities, roll-overs, lawsuits and horrible outcomes. Then there was Sharron Rose. Her story caught my eye: In Bloomington, Ill., nearly $5 million and the quality of life of a talented, beautiful 18-year old girl, Sharron Rose Frieburg, were lost because of a "sprained-ankle" run (see Editor's note).

In 1983, Salt Lake City's Fleet Management department reported that the EMVA rate had dropped 78 percent in that city as a result of the MPDS, and it was estimated that the number of EMS vehicles traveling Salt Lake City streets with RLS was safely reduced by 50 percent through the use of the system. Were any Sharron Roses saved by these changes? I guess we will never know.

The "loyal opposition" (i.e., attorneys such as Sharron Rose's) are learning about the "maximal-response disease" and the fact that every ambulance, fire truck and rescue vehicle does not have to respond "HOT." The blind use of RLS may actually be killing more people than it saves. While we may worry about getting into trouble for not responding or transporting RLS, I predict that, in the not-too-distant future, any use of RLS will be subject to sensible justification and standardization or be considered negligent by the courts.

Finally, after reading about hundred of unnecessary EMVAs, it is my opinion that the medically unjustified, arbitrary, or blanket use of RLS is a negligent process that runs contrary to the current medical-dispatch standard of care. In 1989, the National Association of EMS Physicians took the following significant stands in their Position Paper on Emergency Medical Dispatching:

  • "Dispatch prioritization is an essential element in any EMS system for it establishes the appropriate level of care including the urgency and type of response."
  • "These priorities must reflect the level of appropriate response including types of personnel (ALS vs. BLS vs. First responder), response configuration (numbers and types of vehicles responding) and mode of response (red-lights-and-siren vs. Routine)."
  • "The appropriate prioritization of the type, number and manner of responses is essential to effect an appropriate reduction of responding vehicles traveling red-lights-and-siren and therefore unnecessary vehicle accidents."

In 1990, ASTM, a national standards-setting organization, issued its national document, Standard Practice for Emergency Medical Dispatch, which clearly states:

"This [standard] practice may assist in overcoming some of the misconceptions regarding emergency medical dispatching. These include the uncontrollable nature of the callerâs hysteria, lack of time of the dispatcher, potential danger and liability to the EMD [emergency medical dispatcher], lack of recognition of the benefits of dispatch prearrival instructions and misconceptions that red lights, siren and maximal response are always necessary."

Perhaps these documents should be considered "Plaintiff's Exhibits #1 and #2," because that is what they will likely be used for in future EMVA negligence suits.

I believe that the careful, trained and knowledgeable use of the most up-to-date medical priority dispatch protocols results in a safe and efficient dispatch, care and response process for any EMS system. Measured, medically approved, preplanned responses (as opposed to the shotgun, hurry-up-and-wait approach still present in many current EMS systems) has become the new national standard of care.

I left the gentleman from Michigan with the thought that I was confident that his system÷as an early leader in EMD training with progressive medical control-would be able to recognize inevitabilities of response "science" in the near future. Let's hope his system, as well as many others, realize its importance before it's too late for the next Sharron Rose.

Editor's Note: The following new story that appeared on the front page of the Bloomington, Ill., newspaper, The Pantagraph, on Dec 29,1989, illustrates just how costly the practice of running red-light-and siren really can be in terms of lives and dollars.

 

Ambulance involved

Tentative settlement reached with crash victim
By Scott Richardson

Pantagraph staff

The City of Bloomington has reached a tentative settlement of nearly $5 million with a former cheerleader who was partially paralyzed in a crash between a pickup truck and a Fire Department ambulance last year.

If the proposal is approved at a scheduled hearing Jan. 10, Sharron Rose Frieburg, 18, of rural Saybrook will get an immediate cash payment of $500,000, according to court papers filed yesterday by her attorney, James Ensign of Bloomington.

She would get three more cash payments, one of $25,000 in 10 years, one of $50,000 in 20 years and one of $100,000 in 30 years.

The proposed settlement also calls for her to get $2,000 each month for the next 10 years and $3,000 per month for each month after that for as long as she lives.

All payments would total $4,975,687 if she lives to her expected life span, Ensign said.

Miss Frieburg is mentally and physically disabled. Using a quadpod cane, she can walk only a short distance unassisted. She cannot talk and needs more surgery to improved motion of her arms. She is not expected to ever be able to work, Ensign said.

Miss Frieburg was an honor student when she left home March 26, 1988, to attend a movie in Bloomington with Mark Embry. As they were headed south at Center and Locust streets, Embry's pickup was broadsided by the eastbound city ambulance which was transporting a man with a sprained ankle to Brokaw Hospital.

Miss Frieburg was in a coma until Aug., 1, 1988, and was brought home later that month after the family's insurance company said it would not pay for any more hospital care because of a policy clause stating the firm would not pay for extended care when a patient has recovered as much as the company's doctors think likely.

Since early this year, Miss Frieburg has been attending a program that combines education with therapy for the severely disabled.