EMS Errors/Dangerous Places

Interesting online article at Slate.com about ambulance errors.

Ambulances Can Be Dangerous Places

Here’s two excerpts:

In 1999, the Institute of Medicine published its report To Err Is Human, which estimated that up to 98,000 patients may die each year because of the mistakes of doctors, nurses, and other hospital workers. But few published studies have tried to quantify or even characterize the injuries to patients that take place before they reach the hospital. How frequent and how serious are the mistakes that take place in ambulances—and are there simple changes that could help prevent them?

Based on what we know about hospital-based medical error, ambulances may be one of the more dangerous places to be a patient. Studies have shown that medical error is more common when conditions are variable, like in the emergency room, than it is in other parts of the hospital. The problem likely has little to do with experience or skill. Instead it’s about the lack of predictability: Doctors and nurses make more mistakes when they work under changing conditions. Think about that and compare the working conditions of paramedics and EMTs with an operating room. Before surgery, an entire staff is prepped with information about a patient’s condition, medical history, and the anticipated plan of action. On an ambulance run, there is no plan. Paramedics and EMTs have to improvise as they encounter the obese, frail, terrified, combative, near-dead, stoned, violent, and newly born. And they have to deliver care in a cramped space with relatively few resources.

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Thought-provoking article, although I would have to disagree with its assumption that ambulances are more dangerous than hospitals. I think in EMS, we have less ways to make errors. In many ways, while our scenes are all varied, the situations are often common — MI, Stroke, CHF, asthma, hypoglycemia, etc — and since we have general protocols we follow, the medical care is often routine to us (by routine I don’t mean cookbook), even under the most trying circumstances. Difficult situations are after all our norm. Another critical point in our favor is that we are the ones deciding on and providing the care. There are no misunderstandings when one person is both drawing up the drug and delievering it.

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At my monthly EMS meetings we often talk about the problems of quality assurance. As the number of patient runs increases, and as people charged with QA, whether ambulance service employees or hospital clinical care coordinators have increasing demands on their time, QA inevitably suffers. I recently heard the laments of a fellow paramedic who works for another service complain that his service posted spread sheets detailing employee compliance with filling out billing information — everything from getting the patient’s signature to their next of kin’s name — but nothing has been done to QA the front of the form or discover compliance with taking regular vital signs, giving ASA for chest pain, etc.

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If there are major errors in EMS, they are most likely system errors. If you were to ask me what is the most dangerous part of being in an ambulance, I would say it is traveling in an ambulance lights and sirens.

Check out this site to view daily ambulance crash logs:

Ambulance Crash Log

Check out these articles from the Detroit News:

Unsafe Saviours

From USA Today:

Speeding to the rescue Can Have Deadly Results

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For our regional council medical advisory committee, I have been researching lights and sirens protocols to the hospital. Some very interesting items.

1. The National Association of Emergency Medical Services Physicians (NAEMSP) Position Paper on the issue. Use of Warning Lights and Siren in Emergency Medical Vehicle Response and Patient Transport

2. A Merginet Article: Curtailing Emergency Driving Saves Money and Lives

3. A Pennsylvania Regional Council’s Newletter Discussing Issue and the new PA regs.Lights and Sirens Use: It is a Big deal to EMS Services!

4: A PA Service’s Policy/ Foxwell EMS: (PA): Emergency Response Policy

5. A disccusion group arguing merits/drawbacks of transport AMI patient’s lights and sirens. Lights and Sirens Transport of AMI Patients

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People are just used to lights and sirens being a part of the EMS system even when they are largely unneccessary. This part week they sent us lights and sirens for the 12 year old violent psych, police on scene. The next was also lights and sirens for the 9 year old misbehaving on one of the floors at a pyschiatric hospital. What is wrong with these pictures? Cops on scene and a patient in a psychiatric hospital and they need an ambulance lights and sirens to save the day? In both cases as expected the scenes were well under control before we arrived.

One of the protocols listed above recommends that lights and sirens not be used for cardiac arrests except in cases of trauma, persistent vfib, hypothermia, or drug overdose. I did a code a week ago — an old woman found face down against the steering wheel of her car outside a doctor’s office. She was cold, but still limber. Asystole on the monitor. We worked for a little bit, then since we were already in the ambulance started to the hospital. I told my crew I wanted to go on a priority 2. They revolted. They called me all sorts of names and insisted on going lights and sirens. They said I was crazy. But the lady was dead. Driving fast in fact made CPR harder to do effectively. I am hoping for a sea change in the way we use lights and sirens.

Until there is that sea change, ambulances will continue to be dangerous places.

2 Comments

  • Ted says:

    I work in Australia. We have very few accidents with our vans. Generally they seem to be smaller than American vans. The old ones we had were under braked. The Mercedes we have now are good. I have been a Paramedic for 20 years. I know (and our training reinforces) that I am noo good in a bent (or worse) van. The attendant calls the shots If I say priority 2 its a priority 2. No one hassels the driver to go faster than they feel is safe. I would like to seem more regular checks of my driving to ensure I am up to speed.

  • Anonymous says:

    The evidence, from solid research, is that driving slower sans lights and sirens, provides just the same level of care and same patient outcomes as driving like a fucking nut. I was reading this other blog, written by a street medic, that talked about racing to a call at 90 mph. That’s just fucking stupid. Really fucking stupid. I hope I never end up needing help in that system, because the medics won’t make it to me while they care for the child they just ran over or while another unit responds because the first rolled into a ditch.

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