Tuesday, January 13, 2009

What's with the lights?

This is might seem a little bit off topic, but I thought that I would get other people's perspectives (including those of you who have worked in pre-hospital EMS), and I will bring it back to an ethical issue.

Why do AMR rigs drive with lights and sirens on?

At least in Seattle, Medic One provides first responder care to patients. The premise of using lights and sirens is that rapid arrival on scene of an incident will help to decrease mortality in emergent situations (although even this premise is debated). Since telephone triage is not 100% effective, unless it is absolutely clear that there is not a life threatening situation, Seattle Fire responds with lights and sirens going. And when it is clear that a life hangs in the balance, Medic One comes along with similar displays to encourage the motorist (as well as pedestrian and bicyclist) to move out of the way. Once on scene it is determined that the patient does not need ACLS certified transportation to the hospital, AMR (a private company providing ambulance transport in Seattle) is summoned. At this point someone (a paramedic or firefighter, occasionally via telephone conversation with a physician) had determined that a life threatening emergency does not exist and that the patient does not need to be transported post-haste to the nearest emergency room. Yet, AMR will arrive on scene with lights and sirens going.

For anyone that has witnessed the number of near miss accidents of been in an emergency vehicle rushing through a busy city, it is apparent how dangerous it is for the operators of the emergency response vehicle, let alone the citizenry. Despite this, someone has decided that it's okay for AMR to drive as fast as possible to a non-emergent scene. How does one balance the ethics of this response with the danger it exposes everyone too?

Just as a clarification: this is not to say that certain AMR rigs do not transport critically ill patients. Indeed, AMR in Seattle has pediatric critical care and adult critical care vehicles that provide inter-hospital transport (and occasionally from the helipad at Harborview to another hospital). Usually this is done without use of lights and sirens, as even though the patient is sick, they are already receiving appropriate care.

I have some ideas behind this, but wanted others to weigh in first.


  1. It doesn't make sense to me to endanger the lives of AMR drivers and everyone else on the streets with the rigs flying through the city at excessive speeds to respond to a non-emergent situation.

    However, I can see an argument for the lights and siren as they allow the rig to take the right of way through traffic and intersections. It is important to respond as quickly as is SAFELY possible so that the FD can be freed up to respond to other calls.

    I think that the AMR rigs should obey speed limits and drive cautiously in non-emergent situations, but still use siren and lights to get the right of way through traffic.

  2. Lights & sirens... They pose a threat to many, but there are many times where a patient is greatly benefited from them. I guess if I would to use the ulilitarianism point of view - I would have to agree that lights & sirens are not in the interest of the greater good.

    However, I believe it is more the that. A few things come to mind - history, contracts, and negligence.

    Lights & sirens (L&S) were respected and used by staff only in emergency. The symbol is much greater then the actual act and with the society we live in, it seems that every classifies as an "emergency" (or else potential lawsuit...)

    Next, AMR has a contract with king county to arrive in 9 min 59 seconds to a call. Sometimes that means L&S from Northgate to West Seattle. Due to our rapid L&S response King County is one of the best places to have emergency. Although the true life or death calls are not as frequent - there are times when the L&S make the difference.

    Lastly, we are all self-absorbed to extent. We get in our car, on our bike or out for a stroll and blast our tunes (I am as guilty as the next person), but then in we no longer are aware of our surroundings. We depend on one sense to do the work of what two did before. Then we wonder why there are more accidents - it can't be partly our fault, can it? :-)

  3. Hi David,
    Your concerns are absolutely valid yet thanks for taking pause for other opinions before turning off the reds on the AMR cars. I speak from experience that the AMR driving record speaks to the fact their drivers do a pretty safe job getting around town to help us Medics out. Noisy yes and safe...yes.
    In the mix are a few other points to consider. Their expeditious response serves the Customers better by reducing out of service time for the limited resources of Medic Units and Fire Units that have Triaged the scene as you correctly described. It is not uncommon to be at the scene of an "Aid" response for a non life threatening case when fate directs that a more distant Unit must respond as a "fill-in" simultaneously only blocks away for a Fire or Cardiac Arrest.
    AMR also takes the initiative to slow go to Aid and Medic incidents in a team effort to help keep more of your SFD rigs in service. Sometimes if I am coming from, say, West Seattle on Medic 32 to a breathing problem on Capitol Hill as Medic 1 and 10 are O.S. I will arrive, spot the rig safely, unsnap my seat belt, get out, wave at the AMR van up the road and grab the kits before going inside. If our advanced care isn't necessary, quickly the AMR staff is coming through the door with their gurney. Let me repeat, they arrived slowly and safely and in service until they got our official request to respond.
    I have to mention the fact that traffic in Seattle is awful and getting worse for varied reasons. There are many long episodes of virtual gridlock throughout the city. One could debate the fact that not using the Emergency Lights and Sirens to get definitive care for the sick and injured would be silly, if not disastrous.
    I have pondered your point many times, why can't the SFD go and evaluate the folks, determine that they are sturdy enough to wait for a non- emergent vehicle then leave and return to the "In Service" status quicker? The answer is obvious that the Doctors and Lawyers get real serious heartburn in fear of an abandonment issue if problems arise. So...we wait.
    Let me add that the Seattle Model for pre hospital care is still light years ahead of the National picture regarding long term survivorship post Cardiac Arrest. The team players in those endeavors aside of the SFD includes the Medical Community like Harborview Medical Center, the wonderful Citizen Customers that get schooled up in the use of CPR and AMR ambulance staffing that works hard to help us so we can help you.

    Support your local Pipe and Drum Band

  4. One of the commentors brings up a good point that it would seem lights and sirens do not benefit the greater good, if one life is saved while many lives are put at risk. It looks like a conflict b/w beneficence and nonmaleficence. But we're used to seeing nonmaleficence with regard to the PATIENT, not to society in general.

    I drove a private BLS ambulance for a while (Tri-Med, not one of those AMR guys!) and this is what I think. It is good to get to the scene quickly. We (the private BLS) were actually the first to arrive on-scene a few times. None of these occasions were a true emergency (eg, pt needed CPR), but if they had been, it would have been good to get there fast. Sometimes it is also good to get to the hospital quickly (eg, patient goes into labor, stops breathing, codes, etc). But this needs to be balanced with nonmalificence for the general public. I think that lights and sirens DO save time, and I think the added danger to the public can be balanced by putting a competent, cautious driver behind the wheel of the ambulance. L&S doesn't give you the right to go "as fast as you want," it lets you go 10 mph over the posted speed limit (which everybody else does, anyway), which should automatically increase the driver's paranoia 10-fold for other people on the road.

    That being said, as a private BLS, we would also sometimes drive L&S to the scene, and then stand around with the stretcher for a while, waiting for the FD and medics to finish up. In these cases, it didn't seem to do the patient any good by getting there quicker, which tips the balance more towards maleficence to the general public.

    But the issue here is limited information. When we were dispatched, we didn't know whether we would be first on-scene or standing around (more often the latter, unfortunately). So we drove quickly, for the chance that we would get there in time to really make a difference for the pt. But we also drove safely, and did everything we could to make sure nobody got hurt.

  5. I am under the impression that it is the SFD that requests a private ambulance to respond priority or routine. Neither the AMR dispatchers or drivers have any part of that decision.

    That said, I think the rationale is that FD units want to return to service.

    AMR also transports with the seattle PD, and rarely respond priority to these calls, because they are not requested to .

    Another fun fact... AMR policy dictates that drivers may not exceed the posted speed limit by more than 5mph while going code 3 in the city limits.
    Thus, if a unit is truly going "as fast as possible" that driver is individually in violation of policy.