search terms: Failures in the EMS system, Public expectations of 911 systems, Need to determine the exact nature and urgency of the "emergency" request, Inadequate medical control, local protocols, and medical quality assurance , Lack of required emergency medical dispatching training, Need for appropriate driver training and examinations for operator/drivers of EMS vehicles, Law of Due Regard, Increased accident liability for the EMS industry, Need for new and improved safety standards for Emergency Medical Systems personnel

What a Waste When The System Fails
By W.H. "Bill" Leonard

Recently, I was asked to write an article for distribution to the EMTs and Paramedics in the State of New Jersey. The topic was "The use of Seatbelts and Crew Safety in the Patient Compartment of Ambulances in the 21st Century." Little did I know that I was going to be asked to comment on the tragic Code 3 intersection accident that killed one Paramedic and seriously injured three other EMTs and Paramedics.

The Death of a Pre-Hospital Care Provider I learned about Paramedic Leslie Gocek's death when contacted by the New Jersey State Police. They were requesting information on driving standards and safety requirements for EMS personnel. Shortly after being contacted by the Police Department, I was also contacted by the New Jersey State First Aid Council who requested that I do an article on this topic for their publication.

In reviewing the information regarding this accident, I looked at all aspects from the time the call was dispatched up to the fatal collision. I was emotionally taken back by all the failures that occurred within the New Jersey EMS system causing the untimely death of Leslie. I do not place the blame with any particular individual or agency, because I feel that failures in the whole EMS system contributed to this accident. I have never heard of a set of circumstances that demonstrated how modern EMS failed so dramatically.

Public Expectations of our 911 Systems Citizens are bombarded with reminders that help begins by dialing 9-1-1. It is one of the most visible images the public has of emergency services. 9-1-1 is a great asset in any community - but, is it being used properly by the public? Every year throughout the United States, there are numerous emergency vehicle accidents which occur when crews are responding to phoney calls for help from uncaring citizens who just want a trip to the hospital in a high priced taxi. Reducing the "exposure" to risk involved in emergency response includes effectively educating the public on the appropriate use of each community's 9-1-1 system.

In addition to public expectations on the appropriate time to dial 9-1-1, the public has been inappropriately conditioned to believe that emergency help can arrive within 3-4 minutes. It is reported daily by the news media and is promoted by emergency responders who are frequently quoted as saying, "we were there in 3-4 minutes." It is wrong to mislead the public that it is possible for access and response to the system to occur in an average of 3-4 minutes from the time of the accident. I suggest that in 99% of all emergency cases throughout the United States, it is humanly impossible to have an emergency first responder on the scene within 3-4 minutes from the actual time the emergency occurred. I challenge the EMS industry to lead the way and help educate the general public to the fact that it takes time to get the proper services to the emergency.

Actual Life Threatening Emergencies Our industry emphasizes that quality patient care includes a rapid response within the proverbial 4-6 minutes to assure that brain damage does not occur. However, this pressures EMTs and Paramedics to rush to the scene with hopes of saving a life. Nationwide statistics tell us that 40% of all ambulance requests are emergency in nature. Of those 40%, 20% are actual medical emergencies (which includes anything from a broken arm to a victim of full cardiac arrest or serious trauma). Of those, only 5% are life threatening. Many authorities conclude that actually less than 5%, and in some instances only 1%, of all ambulance calls require a Code 3 response which necessitates advanced life support procedures during the emergency transport to the hospital. Considering these statistics, wouldn't it be more appropriate to ask detailed questions of 911 callers to determine the exact nature and urgency of the "emergency" request?

Emergency Medical Dispatching On this particular call, the patient was an 88 year old woman with a past history of heart disease and high blood pressure. The first responders on scene documented on their patient care record that the patient was alert, conscious, and having no difficulty breathing. Her vital signs were within normal limits and stable. Upon arrival of the first responders the patient stated, "I just want to go to the hospital." The system failed to relay this pertinent patient information to the responding unit.

WHAT IF - the dispatcher would have taken time to ask a few simple questions about the patient's condition, medical history and age, and communicated that information to the crew en route to the call? WHAT IF - the first responders would have radioed this information to the paramedic crew responding to the call so they could have prepared themselves mentally prior to their arrival at the scene? Would this have changed the outcome?

There should be required emergency medical dispatching training for all dispatchers and system status controllers within EMS, so they can identify the type of medical emergency they are dispatching, notify the responding units, and relay pertinent patient and call information.

Medical Control After the paramedics assessed the patient, they determined that the patient was stable and needed to be transported to the hospital for further evaluation. WHAT IF - the operator/driver of the ambulance would have taken a few minutes to think and realize that the patient was stable and did not require emergency transport to the hospital? WHAT IF - the attending Paramedic with the patient would have ordered the driver to stop running Code 3 because the patient was stable. Would this have changed the outcome?

If the base station hospital was responsible for medical control and standard of care, why did they permit the paramedic to transport a stable patient Code 3 to the hospital? Nowhere in the medical journals, EMT or Paramedic training manuals, clinical protocols, or standing orders, does it recommend or require Code 3 transport of a patient that is in stable condition. What is the hospital's "legal responsibility" in this fatal accident? Is it possible someone in the Emergency Room had a mental lapse or just wanted to get off duty on time? In my opinion, this is the major cause of this entire accident scenario.

The protocols must mandate that ambulance crews must not drive Code 3 when it is not medically necessary to do so. And, the medical professionals at hospitals and trauma centers (i.e. ER physicians and base station RNs) must enforce those protocols. Ambulance crews must slow down, whether en route to calls or transporting, when patients are in a non-life-threatening condition.

Driver training Needless to say, our sympathy and compassion go out to the family of Leslie and other injured crew members. But what about the driver of the ambulance that caused the accident? I have a great deal of empathy for that person who was obviously a dedicated volunteer and supporter of the local EMS system. The system failed to ensure that the driver received the proper training and evaluation.

WHAT IF - the EMS industry had standardized training requirements for operators/drivers of EMS vehicles? Operator/drivers should be certified and given annual checks to demonstrate their skill level and driving proficiency. I would suggest a low "G-force" training program, that does not permit high speed driving or pursuit driving techniques in the curriculum. WHAT IF - EMS systems required biannual eye examinations of operators/drivers by a licensed ophthalmologist to verify peripheral vision, depth conception and color blindness? Is it possible the driver involved in this fatal accident had a peripheral vision problem? WHAT IF - it was mandatory that EMS and pre-hospital care agencies stop rotating operator/drivers and only employ operator/drivers who are specially trained to understand the high risk of emergency driving? The primary function of the operator/driver should be to drive the vehicle in a responsible manner for the safety of crew members, the patient, and the public. Would any of these improvements in the system changed the outcome of the accident?

Law of Due Regard All fifty states have certain exemptions for emergency vehicles when responding to emergency calls in addition to a law that is called "Due Regard." The law is designed for the safety of all persons using highways, streets, intersections and freeways. However, it does not protect emergency vehicle operators from the consequences of their actions when they arbitrarily exercise the "special privilege" of operating an emergency vehicle in the emergency mode.

WHAT IF - the State of New Jersey had a law requiring all ambulances, fire trucks and police cars to come to a complete stop, and wait for all traffic to clear before proceeding through those intersections which are controlled by a traffic control signal or stop sign? Was the ambulance operator/driver aware of the law of "Due Regard?" In 60% of all Code3 ambulance accidents, the collision occurred in the intersection.

The system also fails when police officers turn their backs on a speeding ambulances and do not cite the operator/drivers for excessive speed, reckless driving, or failure to follow the law of "Due Regard." The "good ole boy" approach of letting fellow emergency personnel "off the hook" must be discontinued. It is just as great a disservice to the system when law enforcement agencies fail to cite the public for "failure to yield" the right of way to an emergency vehicle!

Accident Liability In 1989, a considerable number of ambulance operator/drivers throughout the United States were charged with involuntary manslaughter. The EMS community must realize that the industry is becoming a target for lawyers who are going after the deep-pockets of insurance companies, and beyond, to your personal assets. Plaintiff attorneys argue that the "negligent driving" on the part of ambulance operator/drivers and their failure to follow the law of "Due Regard" are the cause of many ambulance accidents and the cost can be significant. In the numerous accidents I have investigated, the ambulance drivers frequently state that, "It was the other driver's fault and he/she was cited." However, in reality, the insurance company for the EMS provider still paid the claims presented by the other driver because the ambulance driver failed to follow the law of "Due Regard."

Insurance payments for intersection accidents involving ambulances driving Code 3 are generally in the half million to ten million dollar range. This does not take into consideration the heartache, consternation, and the pain and suffering experienced by the ambulance company employees, the patient, other drivers and their families; in addition to the financial responsibility of the EMS provider, their officers and the employees, if punitive damages are awarded to the plaintiff. Is the thrill of driving Code 3 worth jeopardizing your home, or worth the risk of personal bankruptcy?

Crew safety It is sad when EMTs and Paramedics state that, "I don't use the seatbelts when I am in the patient compartment because they restrict me from doing patient care." EMTs and Paramedics, of all people, who witness death and trauma on the highways of America every day, should not resist the use of seat belts whether they are in the cab or the patient compartment. WHAT IF - the crew members in this fatal accident would have worn their seatbelts? WHAT IF - the Department of Transportation, which has spent millions of dollars to upgrade EMS systems across the nation, had invested some of those funds in better crew safety and funded a program to develop a safety restraint system for crew members riding in the patient compartment? This is one of the most difficult and unanswered questions in the field today!

Through federally funded EMS programs such as the Highway Safety Funds (generated by gasoline tax dollars), our nation has spent millions of dollars in funding EMS systems for design, implementation, equipment, and training. Unfortunately, none of those dollars, to the best of my knowledge, has ever been spent on developing a safe working environment for the crew. If we can put someone on the moon, and make safety systems for our military people, surely there is someone with the intelligence and design ability to invent a harness system for the patient compartment of an ambulance which assures a safe and workable environment for EMTs and Paramedics.

Conclusion Many factors contributed to this fatal accident: public expectations of our 911 systems; lack of protocols for call taking and dispatching of units; lack of training for dispatchers and first responders; lack of direction from the base station hospital; inadequate medical control, local protocols, and medical quality assurance; need for beefed up operational policies and procedures; need for more training and evaluation of driver/operators including eye examinations; lack of attention by the emergency ambulance driver/operator to drive under the law of "Due Regard," crew failure to use seatbelts, and the lack of a safe work environment in the patient compartment for EMTs and Paramedics. Do any of these situations exist in your system?

It is my deep conviction that Emergency Medical Services agencies which provide high performance EMS in the 1990's, and the entire medical transportation industry, must provide the leadership and demand changes in our EMS systems to correct these problems. EMS is a vital element of the health care delivery system in this nation and it deserves more attention to safety than it is receiving.

There must be new and improved safety standards. There must be new and innovative concepts on how EMS responds and renders patient care. There must be greater financial support provided by local and state government agencies for pre-hospital care providers. There must be improved compensation structures for EMTs and Paramedics. EMS personnel must work harder to earn the respect which is due them, by always conducting themselves in a professional manner. We all must ask ourselves what can be done to help prevent this wasteful tragedy happening in the future. Reality tells us that accidents will happen. However, let's make sure that in each one of our services that we have done everything in out power to prevent it from resulting in the catastrophic loss that New Jersey experienced.


Author Biography: Bill Leonard is the Executive Vice President of A-Star Center for Safety and Risk Management. He has forty-one years of experience in the pre-hospital care industry as a patient care provider (as a first aider, EMT and Paramedic), as a member of numerous local, state and national emergency medical services committees and has provided safety and loss control services to the pre-hospital care industry.