Ambulance driver fatigue a danger
Distractions pose risks to patients, EMTs, traffic

By Lisa Zagaroli, and April Taylor / Detroit News Washington Bureau
Monday, January 27, 2003

Emergency medical technician Anne Lamberson thought she was doing her job when she got a priority dispatch, stepped on the ambulance's accelerator and tried to make it to the scene as quickly as she could.


But by speeding through stop signs and a red light and entering a Brooklyn intersection without pausing, she was in violation of nationally endorsed ambulance driving practices and state traffic laws. A New York law required drivers of ambulances to slow down and check for other drivers and pedestrians before proceeding through lights and intersections.

Lamberson smashed into a car driven by hairdresser Angela Igwe, a Nigerian immigrant who was driving her four kids home to Coney Island.

Igwe's sons Akintunde Morak, 2, and Olusegun Morak, 5, and her daughter, Damilola Morak, 7, were killed in the Sept. 30, 1998, crash. The mother and another daughter, Ibironke Morak, 9, were seriously injured.

Though Lamberson had only been on the job four months, hers was not a mistake reserved for rookies. It involved a predictable scenario.

Many of the 6,500 ambulance crashes a year that injure an estimated 10 people a day and kill at least two people a month are due to unnecessary speeding, insufficient driver training, driver exhaustion from long work hours, and inadequate dispatch procedures, according to a four-month Detroit News investigation. Those factors, coupled with inadequate safety regulations and design precautions in the patient compartment, lead to unnecessary risk in vehicles meant to get people out of harm's way, The News found.

Increasingly, ambulance drivers are being held at fault for crashes, particularly if they are using their lights and sirens. The chaotic setting of a medical station on wheels driving alongside flustered and oblivious motorists is more often being seen as the very reason drivers should use extra caution rather than haste when rushing to help the sick and wounded.

This is a problem not just for ambulance passengers but for other motorists, too, because occupants of the vehicle that's hit are most likely to die in the crashes.

The ambulance was the striking vehicle in 74 percent of fatal crashes, according to an 11-year analysis published last year in Prehospital Emergency Care. It found that intersections were the site of more than half of the deadly accidents.

Although there isn't enough analysis of ambulance crashes to determine the severity of the problems, each factor can have a snowball effect in an inherently chaotic setting, researchers say.

"It is difficult to imagine a ground-based vehicle with more potential distractions than an ambulance," said Brian J. Maguire, associate graduate program director of the emergency health services department at the University of Maryland Baltimore County.

A driver has to decide whether to proceed through intersections on busy streets "with a vehicle full of screaming patients and family members" in a driver's compartment crammed with multiple radios, a computer screen and input console, separate controls for emergency lights and sirens, while monitoring police, fire and emergency medical services' radio frequencies, Maguire said.

"If distractions account for 20 to 30 percent of crashes in the relatively sedate environment of a passenger car, they may account for a larger percentage of ambulance crashes," said Maguire, who is writing a dissertation about on-the-job risks of EMS workers.

Though other motorists often contribute to the crashes by failure to yield to the emergency vehicles, it is for that very reason that paramedics are expected to use special caution, rather than haste, when driving, safety experts say.

"An ambulance crash violates the medical profession's first duty -- to do no harm," Medical College of Wisconsin researchers, led by Christopher A. Kahn, wrote in the fatality analysis. "Not surprisingly, crashes are an increasing source of public concern and litigation."

Speed a factor

Most lawsuits against ambulance companies are settled out of court because the driver committed at least one violation that would be difficult to defend, said Billy Rutherford, president of American Integrated Training Systems, one of the few companies that trains instructors to teach ambulance driving safety.

"A lot of times you find out they were using excessive speed even when there was no patient emergency, or they did something else wrong and caused the crash. And then everything goes downhill from there," said Rutherford, who has been deposed several times as an expert witness on both sides of ambulance crash lawsuits. "That's why it is extremely important for people to not use excessive speed and to learn to operate that ambulance safely and obey the traffic law. A lot of people got in that business because they want to drive fast and put on lights and sirens."

Local agencies struggle with how fast is too fast.

Commissioners in Delaware County, Ohio, decided to stop ambulances from speeding during emergency runs after the county had to pay $650,000 to settle a wrongful death lawsuit stemming from a crash involving a speeding ambulance.

In that Sept. 1, 1998, incident, driver Mark Schlauder saw a plume of black smoke, flipped on his lights and siren, passed a car on a blind curve at 71 mph in a 45 mph zone, and encountered stopped traffic. He slammed into a car and killed its passenger, 81-year-old Mae Lowe. Schlauder never made it to the fire, which turned out to be a controlled burn of debris.

But the resulting policy against speeding, which Delaware County initiated last January, slowed average response time to seven minutes, eight seconds, down from five minutes, 55 seconds.

Paramedic Tom Calland told commissioners that worrying about the speed limit made it difficult for medics to concentrate on driving. So in March, the commissioners revoked their decision and gave back permission to abide by the state law that allows drivers to determine how fast they should be moving.

Prior violations

Forty-one percent of ambulance drivers involved in fatal accidents had prior citations on their driving records, a rate similar to that of the general public, according to the 11-year ambulance fatality report.

"Keeping in mind the EMS system's obligation to public safety, it is reasonable to require a higher level of competence for ambulance operators compared with the general public," Kahn and other researchers concluded.

Though some states like Michigan allow ambulance companies to be notified about a change in one of their driver's records, only a few companies take advantage of the service.

Terry Schoens, 30, of Pahokee, Fla., a police dispatcher who volunteered as a firefighter, died Oct. 23, 1998, when the ambulance he was riding in slammed into a parked dump truck. The driver of the ambulance, Michael J. Lee of West Palm Beach, had compiled 11 citations on his driver's record since 1989, including unlawful speed five times, careless driving twice, and operating a motor vehicle in an unsafe condition once.

In a separate incident, Michael A. Lee of Flint had multiple violations on his record before he was hired by the Flint Fire Department as an emergency medical technician. He crashed two ambulances, one carrying a patient, in one 24-hour shift in March 2001.

Flint Fire Chief Dandre Williams said experience can be a big factor.

"It's a lot of information to process when you're first starting out as a driver," Williams said. "It's just pure adrenaline. All of a sudden you get these lights going, you're hyped up, and you're thinking about the incident, so in a way it's overload."

Long hours

Though adrenaline might keep drivers alert when they're running emergency calls, some ambulance services do only nonemergency transports that might leave some medics even more vulnerable to fatigue.

EMS, or emergency medical service, was built largely on the model of fire departments, which often allow workers to pack all their hours into two or three long shifts. It tends to work with firehouses because many of them only get a few calls and the employees can sleep when they're not fighting fires. Employees love it because they can work another job on their days off to make up for low medic pay, or earn considerable overtime.

Nonemergency transports, such as patients who need to be moved from one hospital to another in a reclined position, have appointments stacked the entire shift, and offer little opportunity for sleep for their employees.

Paramedic David T. Carkin said that at one point he worked 44 consecutive shifts during which he was asked to work at least three extra hours beyond the 24 he was working every Monday, Wednesday and Friday. There was no way to tell how rested medics were when they came to work.

"I got a lot of money, but I was exhausted," said Carkin, who was seriously injured in an ambulance crash in Virginia in 2001 when a driver who had been up most of the night volunteering at a firehouse fell asleep and ran the ambulance off the road, killing his partner Joseph "Neal" Sherman. "You had to make a conscious decision to be fresh for your work.

"And you know the people who didn't do it, we would have to pick up the slack for them in the middle of the night. I have worked with people who just didn't take care of themselves. I've run transports with them and would stick them up in the passenger seat and let them sleep if they were not an essential part of the transport."

Sam Bryant, a firefighter paramedic in Amherst, Va., said it's not unusual for him to be awake 20 hours of his 24-hour shifts.

"I don't count on anything as far as rest goes," said Bryant, whose part-time job as a flight paramedic for the Virginia State Police requires him to have eight hours off from his full-time job before he comes into work.

In September, an American Medical Response ambulance transporting a man complaining of chest pains and breathing problems crashed on Interstate 76 in Akron, Ohio. Police cited ambulance driver Jennifer Lape, 25, with failure to control a vehicle after she told them she fell asleep.

AMR spokesman Eric Berthel declined to discuss Lape's or the company's hours of operation, but said, "We do not make it a policy to force any employee to work any more hours than they'd like to.

"If an employee comes in and they haven't had any rest, hopefully they would let somebody know that."

W.H. Bill Leonard, an insurance underwriter for ambulance services, said Medical Transportation Insurance Professionals has stopped insuring private providers in Philadelphia because of a horrible loss ratio there.

"If they have a work force that is not full-time and they allow people to moonlight, we won't even consider it. We know they're a candidate for a crash," he said.

Leonard said he believes another factor in ambulance crashes is that EMS providers who compete for contracts promise certain response times, like eight or nine minutes, and treat everything like an emergency.

Lamberson, the EMT whose high-speed crash killed three children in Brooklyn, has said she was dispatched on a "priority" call. Although Lamberson's account remains in dispute, the patient she was rushing to help had complained of severe back pain.

The crash devastated both the family of the children killed and that of Lamberson, who had decided to become a medic when her own 3-year-old son died of a brain tumor. She pleaded guilty to criminally negligent homicide and was sentenced to five years of probation.

"That's not what was supposed to happen that night," Lamberson, an Irish national, said in an interview with the British newspaper The Mirror. "We were supposed to help someone."

Ambulances at a glance

Q. Are all ambulance services the same?

A: No. Some are private providers, some are housed in fire departments, some are connected to another service like a hospital, some are run by municipal governtment. No studies have been done that show whether one type of service is more effective than another.

Q. What's the difference between an emergency medical technician and a paramedic?

A: Though titles vary from state to state, typically the beginning level is made up of first responders who have basic first aid and emergency training.

Basic emergency medical technicians, or EMTs, typically have about 150 hours of training that allows them to administer oxygen, treat wounds and immobilize spines. Advanced training might allow them to administer IV fluids, intubate patients and monitor heart conditions.

Paramedics would have an additional 1,200 hours of training and be qualified to do a number of more aggressive treatments and administer drugs.

Michigan has 389 first response services, which aren't allowed to transport patients but can help until an ambulance arrives; 175 basic life support services, which must have at least one EMT and one first responder on board an ambulance; 20 limited advanced life support services, which have at least one basic EMT and one EMT with advanced training; and 172 advanced life support services, which have at least one paramedic and one EMT.

Q. Do companies hire people just to drive ambulances?

A: No. That job category was phased out years ago. Now, everyone on board has to be at least an EMT.

Q. Are all ambulances the same?

A: No. One type is a conversion truck cab and chassis with a separated box and cab. Another is a van type with integrated cab and body. A third type is a cutaway van with an integrated cab and body. There is not enough in-depth analysis of ambulance crashes to know whether one kind holds up better in a crash.