Bells and Whistles

   It's not exactly news to anyone that ambulance travel with lights and siren is associated with an increased collision risk and is unlikely to save meaningful time for most patients. In the name of everyone's safety, then, regulating jurisdictions have an interest in defining the circumstances under which calls can be answered or patients transported in emergency mode.

   Pennsylvania has done this at the state level with official guidelines addressing ambulance services' lights and siren use. It devotes three pages of its statewide BLS protocols to the whens and hows of utilizing what commonwealth EMS medical director Doug Kupas, MD, views as a discrete-and often unnecessary-medical intervention.

   "Lights and siren use is a medical treatment, and should be viewed as a medical treatment," says Kupas, who has studied the subject for more than 15 years. "With everything we do in medicine, we weigh the risks and benefits, and I think lights and siren should be the same. They should be used only when the benefit of saving that 45 seconds to 2-3 minutes most studies show you save with them would truly be lifesaving for the patient."

   Those circumstances are pretty rare, Kupas told attendees of the ambulance safety conference that preceded the National Association of EMS Physicians' annual meeting in January. In Pennsylvania they're spelled out; patients should get an L&S ride only by meeting one of the following criteria:

• Systolic BP < 90 mmHg (or < 70 plus age times two for patients under 8), or respiratory rate > 32/min. or < 10/min.;
• Inability to establish or maintain a patent airway, or upper airway stridor;
• Severe respiratory distress (which may include pulse oximetry < 90%, retractions, stridor or respiratory rate > 32/min. or < 10/min.);
• Cardiac arrest with persistent ventricular fibrillation, hypothermia, overdose or poisoning (other cardiac arrest patients don't typically get L&S);
• Anatomic or physiologic criteria for triage to a trauma center;
• Motor portion of GCS < 5, recurrent or persistent seizure activity or acute stroke symptoms of onset within three hours;
• Pediatrics with upper airway stridor;
• When the most highly trained practitioner believes the patient's condition will be worsened by a delay.

   In responding to calls-per state data, 40%-plus of Pennsylvania's ambulance crashes occur during lights-and-siren responses to scenes-the guideline defers to EMD criteria, but notes the inappropriateness of L&S use for various common situations.

   As opposed to a mandatory protocol, it should be noted, Pennsylvania's lights and siren language is a guideline-a best practice services are encouraged but not required to adopt. They can ignore it, or go even further, as did one service that requires supervisor notification with every L&S transport.

   That kind of restriction may well save lives, and no one will hold it against you. It's a myth, Kupas suggests, that EMS callers expect noise and flash with their responses, and will be aggrieved if you roll up otherwise.

   "A good way to illustrate that," he notes, "is the number of calls we get where people say, 'Don't use lights and siren near the house.' Many of our services have gotten to a point of essentially never transporting with lights and siren, and they've not had complaints. I honestly think what a patient and their family expect is a feeling that they're in good, competent hands. If what they get is providers excited and running around and a hair-raising lights-and-siren trip to the hospital, I don't think that inspires confidence."

Other Measures

   While Pennsylvania's statewide protocols have been in place since 2004, other safety-based efforts are newer. Under new guiding EMS legislation passed last year, known as Act 37, the state will also start certifying ambulance operators.

   "We provide and require continuing education for all other levels of providers in the EMS system, but we've never had any requirements at the vehicle operator level," says Kupas. "We recognize now that probably the biggest safety issue for EMS providers is risk of injury from a motor vehicle crash, and so this is an opportunity to have that kind of education requirement. We're really using the same kind of pattern we do for the rest of our providers."

   With that, the state EMS office has full access to the Pennsylvania Justice Network, or JNET, a state law enforcement resource that provides real-time information on citizens' driving offenses. That means officials can stay current on providers' off-duty vehicular malfeasances. And if a provider screws up badly enough to get their license suspended, they'd better let their company know before it's found out some other way.

   "We have a responsibility to ensure we have responsible people driving emergency vehicles and delivering patient care," Kupas says. "We want to be aware if there's somebody who may not be a responsible individual performing those roles. It gives us an opportunity to address any offenses and make alterations in providers' privileges based on that."