EMS use of red lights and sirens is a dangerous sacred cow
The evidence tells us that not using red lights and sirens should be the rule – and using them should be an infrequent exception
By Douglas M. Wolfberg, Esq.
Few cows are more sacred in EMS than the ones that flash, wail and yelp. The use of red lights and sirens is an inseparable part of everyday EMS life. It’s as if RLS use is encoded in the DNA of EMS responders. It’s seemingly part of who we are.
When we’re dispatched for an emergency, RLS gets switched on as a standard part of response operations. But in this era of evidence-based medicine, everything we do must be viewed through the critical lens of "does it work?"
Like every practice, procedure, policy and protocol in EMS, RLS use must be safe and have a proven benefit to patient care. And the practice should be curtailed if it doesn’t.
The EMS graveyard is full of the corpses of other sacred cows that have not withstood the test of time. MAST trousers are long gone. The use of long spine boards is being curtailed in many systems. Protocols for airway management are always in a state of flux based on the latest science.
Yet, these aspects of EMS are viewed as clinical, where the use of RLS is looked at as operational. Why should we view RLS use differently than any other aspect of EMS?
Shouldn’t virtually everything we do be subject to the same test? That is, if it doesn’t help us help patients, why should we continue to do it?
Does it work?
It is imperative to first properly frame the question. When we ask "does it work," we must define what it means "to work." Something works in health care (and I hope by now we have satisfied ourselves that EMS is health care and not merely public safety) if it is safe and reduces morbidity and mortality.
More specifically, in this post-reform era of health care, something works if it satisfies one or more of the "Triple Aims" of improving the patient experience of care, improving the health of populations and reducing the cost of health care.
Having spent many years working in the provision of EMS, I know from personal experience that RLS "works" to clear traffic and warn drivers, pedestrians and others that an ambulance is approaching in emergency mode.
And RLS "works" by showing the public that we are treating their emergency calls seriously. RLS "works" when we show our public officials that we are meeting their response time expectations and being accountable.
But even though RLS "works" for those purposes, the real question is whether those purposes ultimately serve the larger purposes of benefitting patients.
Where is the evidence?
The hard evidence about whether RLS use helps patients is severely lacking. No studies of which I am aware have ever directly linked the use of RLS to improved patient outcomes.
In fact, the National Association of State EMS Officials concluded that "no evidence-based model exists for what mode of operation (lights and sirens) should be used by ambulances … when dispatched … or when transporting patients ."
Most studies only link RLS use to time. While some studies have found that time saved with RLS use is operationally significant, there is no evidence that RLS use is clinically significant.
In other words, if RLS use reduces response time or transport time by six minutes, the extra six minutes typically wouldn’t make a difference in the care or outcome of the patient. Although the response time debate is beyond the scope of this article, most studies and publications I’ve seen suggest that EMS response times generally make much less of a difference than the public believes.
Response times are driven more by public perception of quality service and by local officials believing that response time performance is the primary mechanism for holding their EMS systems accountable.
Why do we respond RLS?
So, if RLS hasn’t been shown to benefit patient care, why is their use so prevalent in EMS? The answers are a mix of cultural, operational and political realities.
RLS use is certainly engrained in the EMS culture, given its long association with police, fire and other public safety services. Although interestingly NASEMSO said, "EMS providers are at a greater risk of death on the job than their police and firefighter counterparts, with 74 percent of EMS fatalities being transportation related .")
Operationally, there is a logic to using warning devices to alert traffic that an ambulance on an important mission would like to clear an intersection or overtake other vehicles. In some cases, RLS is used because that’s what dispatchers tell us to do when calls are dispatched hot.
RLS use can have political roots as well, often being necessitated by response time performance standards that are part of local EMS system design. Local officials tend to look at response times as a strong indicator of EMS system performance. And the public wants us to treat their emergencies as, well, emergencies.
Therefore, there are strong public expectations of RLS use as part of regular EMS system operations.
As with any patient-care practices in EMS, however, we must always look at the safety of what we do as an integral part of the analysis in whether our customs and practices "work." Ambulances are being designed to be more crashworthy. The use of active and passive restraints to protect EMS crewmembers is becoming more prevalent.
Awareness of responder safety after tragic events like 9/11 is at an all-time high. Yet, the simple fact is that twice as many ambulance crashes involve RLS use. So why does our profession seem to turn a blind eye when it comes to the safety issues associated with RLS? .
In one study, RLS was found to be in use in 80 percent of all crashes involving ambulances . This same study went on to conclude that an "essential issue verified in the analysis of these data is the fact that the use of lights or sirens often places the responding ambulance and the civilian population at risk."
The authors went on to note that EMS personnel may assume that using RLS "give[s] them license to disregard certain rules of the road," a particular risk when civilians are "clearly under-informed on how to respond to visual and/or audible signals from emergency vehicles."
Another study found that most crashes (60 percent) and most fatalities (58 percent) involving ambulances occurred during emergency use when RLS was activated .
Reevaluate the use of RLS
As an attorney, I must mention that where there are more ambulance crashes, there will be more lawsuits, settlements and payouts by EMS agencies and local governments. In that sense, reducing RLS use can have a direct impact on reducing legal liability for EMS providers and EMS agencies.
A few facts are uncontestable. No evidence links RLS use to better patient care or improved patient outcomes. RLS use is associated with markedly higher rates of ambulance crashes and higher rates of EMS provider fatalities than non-RLS operations.
With no proven clinical benefit and well-established risks to providers and the public, RLS practices need to be reevaluated as a daily part of EMS operations. This leads me to making these six recommendations.
1. Start with dispatch
All EMS systems should be using validated dispatch protocols and trained dispatchers. The number of local PSAPs and EMS systems not employing emergency medical dispatch protocols and trained EMDs still amazes me.
If your dispatch agency tells you to run everything hot, you and your dispatch agency are walking on a liability minefield. It’s only a matter of time until your organization experiences a catastrophic loss.
2. Set policies
Whether or not your dispatch agency is up to par with its dispatch protocols, your EMS agency can — and should — have its own policies and training when it comes to RLS use and other aspects of ambulance safety.
In the absence of any evidence that RLS use improves patient care or protects providers (in fact, the evidence establishes the contrary — that RLS use endangers EMS personnel), your agency’s polices should make non-RLS use the rule and RLS use the infrequent exception.
3. Train personnel
Because RLS use is an engrained part of EMS culture, changing our RLS mindset will take time, training and a cultural change. But effective training of emergency vehicle operators is a key to reducing RLS use and improving operational safety for EMS workers.
4. Make RLS part of clinical QA programs
Just as 100 percent of certain clinical cases — cardiac arrest or STEMI activation — undergo review in many EMS quality improvement programs, the use of RLS needs to be integrated into EMS clinical QA programs.
Personnel should document when RLS is used either in the response phase or during patient transport. The appropriateness of RLS use should be subject to retrospective review as with any other aspects of our care.
5. Educate decision makers
Work with your local officials to educate them why quality prehospital emergency health care doesn’t necessarily go hand in hand with RLS. When local officials are properly educated on the risk that RLS adds to their liability, and that the benefits of RLS use have not been shown to outweigh those risks, public demand for hot responses can start to cool.
6. Embrace new technology
Just as vehicle-to-infrastructure (V2I) technology has allowed emergency vehicles to communicate with traffic signals, newer vehicle-to-vehicle (V2V) technologies will allow emergency vehicles to communicate directly with other vehicles to request lane access, pass safely, and alert traffic to the presence of emergencies.
EMS systems should stay abreast of this technology so that RLS use can hopefully become a thing of the past as newer, safer technologies emerge.
RLS use involves proven risks and unproven benefits in EMS. It is a major factor in causing injuries and deaths of EMS workers. RLS use creates liability risks for EMS agencies and local governments. Recognizing the risks and changing EMS culture to reduce those risks is an imperative for all EMS systems in the United States.
Running lights and sirens is not an inevitable part of every EMS response. It is time to put that sacred cow out to pasture.
About the author
Doug Wolfberg is a longtime former EMS provider who also worked as a county EMS director and as a state and federal-level EMS administrator prior to attending law school. Doug is an EMS attorney and founding partner of Page, Wolfberg & Wirth, the nation’s leading EMS industry law firm.
1. National Association of State Emergency Medical Services Officials (NASEMSO), Emergency Medical Services: Considerations for Toward Zero Deaths: A National Strategy on Highway Safety. August 19, 2010.
2. NHTSA Fatal Analysis Reporting System (FARS), 1992-2010, NHTSA Office of Emergency Medical Services, April 2014 presentation.
3. Sanddal, et al., Ambulance Crash Characteristics in the US Defined by the Popular Press: A Retrospective Analysis. Emergency Medicine International, Vol 2010, Article ID 525979 (2010).
4. Kahn, et al., Characteristics of Fatal Ambulance Crashes in the United States: An 11-Year Retrospective Analysis. Prehospital Emergency Care, Vol. 5, No. 3 (July/September 2001).
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