The hidden problem with ambulances | Andrew Garrett | TEDxFoggyBottom transcript

I'm not sure if I'm not supposed to talk till I get on the red dot. Morning everybody. They're very strict about the dot. Good morning everybody. How you doing? My name is Andy Garrett. I've been an EMS physician for the better part of two decades. Right now you're thinking to yourself, "I didn't realize that was a thing." And you wouldn't be wrong. Our numbers are small, but they're growing. EMS is actually a subspecialty of medicine where we focus on the quality of care that we deliver to patients before they get to the hospital.

It's distinctly different, but entirely complementary to emergency medicine which we tend to do in hospitals. I've been involved in EMS my entire adult life. Like so many in the audience, I started as an EMT when I was in college. My first real job was as a US Park Ranger in Yellowstone National Park, and my favorite and best job ever. Along the way I've had a lot of different response jobs. Uh and the journey has brought me to the point where now I'm fortunate to be a middle-aged physician who gets to think about EMS all day long, all the time.

A couple of the journeys A couple of the stops on the journey have been I got to work as a tactical medicine physician on a SWAT team in Massachusetts. I got to fly full time for 3 years in Los Angeles, moving sick kids around Southern California. An incredible opportunity. And then I came to DC in 2010 and I was fortunate to work with the National Disaster Medical System where I led the nation's civilian disaster medical response teams.

And even found myself over at the White House for a year on the National Security Council working for President Obama. But probably the most important thing I've done in my career is I landed here in 2018, and I've been fortunate to be the program director and medical director for GW's Emergency Health Services program. And I know there's a couple of you out there, so represent. Um suffice to say I've had a lot of lights and sirens in my life, and that's going to be a theme we're going to talk about today.

What do EMS physicians do? Our job, like I said, we focus on pre-hospital care, but we're interested in the quality of care being delivered to patients in all the settings before they get to the hospital. Examples of that include, like on the top line, what's public access to defibrillation look like? That's a main way we save lives in the community. Likewise with CPR. Similarly with the ability of members of the public to stop the bleed in traumatic injuries.

Also, we work with 911 and dispatch centers to make sure that when you call 911 to get help, that the phone the phone advice you're getting over the phone is reliable and safe and helping the situation until about 8 minutes later, professional EMTs and paramedics land at your side. And we certainly focus on that part cuz we want well-trained clinicians helping you make your journey to the hospital. Right? So, in that vein, see what I did there?

There's a procedure that we do in EMS, commonplace, that actually increases the likelihood of a bad outcome of your patient by up to threefold in some circumstances. Right? Emergency services do it all the time all over to the all over the world to the tune of about 10 million times a year, and we've been doing it for decades. Very high-quality research has shown that this intervention does not benefit most of our patients most of the time.

Anyone guess on what that is? Inappropriate lights and sirens use. And that's what we're going to talk about today. This is a significant public health emergency that's happening right in front of our faces and about which we've done little to mitigate for quite some time. In communities all over the place, including the one you're sitting in right now, lights and sirens use is so prevalent among EMS that you barely notice it anymore.

Right? But we tolerate it because we assume it's achieving a greater good, that the poor unfortunate soul in the back of the ambulance is going to benefit from that time saved by being rushed as fast as they can to the hospital. But lights and sirens use comes at a cost. Increased speed, driving the wrong way down a one-way road, maybe not coming to a complete stop when you go through a red signal. We get away with it most of the time.

But sometimes we don't. That's not the trip you expected to have when you get loaded in the back of an ambulance, right? The gut punch here is that although we do lights and sirens use all the time on ambulance transports, 95% of the time those lights and sirens aren't going to have a clinically significant impact to the care of that patient, either in EMS or in the hospital. This is a story about risk. Sorry for the scientific looking slide up here, but work with me here.

So, this is about risk to us in the back of the ambulance, it's about risk to your patient, it's about risk to you as the public, as a pedestrian, as a cyclist. Ambulance crashes occur fatally about 25 times a year in the United States. And unfortunately, there's about 2,500 injuries from ambulance crashes that occur in the United States as well. Right? So, if you're an EMT or paramedic, you're five times more likely than your non-medical counterparts to be involved in any kind of traffic accident, not necessarily one where someone dies or even gets hurt, but just to be involved in an accident.

And something we really have a hard time measuring is this thing called wake effect crashes. You've all seen it where an ambulance goes ripping through traffic, and then the traffic has to recombobulate itself to figure out how to get back on the road, or maybe they pull to the left or pull to the right. Those accidents don't necessarily involve the ambulance, but it involves the public. And we think again that those happen at a rate of about four times ambulance crashes, but it's almost impossible to measure.

Let's look at some numbers here. So there's been some high-quality studies, for example, Watson et al. that have looked at what's the odds ratio, adjusted odds ratio for you public health people, that's the percentage increase of times that something will happen if you do something. If you look at two different phases of response, ambulances is going from headquarters or wherever they're sitting to the patient, and then from the patient to the hospital.

If you look at that first part, lights and sirens use is associated with a 1.5 increase in ambulance crashes, not necessarily injuries or fatalities, just crashes. If you look at the second part of that, from treating patient on the scene transporting them to the hospital, that adjusted odds ratio doubles to almost three. That's three times the risk of being involved in an ambulance crash if you're driving in an ambulance going from the scene to the hospital.

Okay. We keep doing it, so is it worth it? I'm here to tell you the answer is probably no. There's been a lot of good studies out there that have looked at this. And they find that using lights and sirens saves you a little time, no question, somewhere between one and three minutes. Let's call it three minutes for the sake of argument. Time saved versus driving without lights and sirens. Turns out the time saved, that one to three minutes, is clinically relevant only about 5% of the time because most patients in EMS aren't that sick.

But here we're talking about the heart attacks, the stroke patients, folks who you really are okay with them driving a little bit faster than for the sprained ankles, right? So the real kicker is though they've looked at that three minutes that's saved and followed them when they get to the hospital. And it turns out that even if you drive lights and sirens and save that three minutes, people in that category, in that 5%, don't typically receive life-saving interventions in that three minutes that was saved, in that first three minutes when they get to the hospital.

So we kind of have to question everything here. And to look at the numbers a little bit, 75% of ambulances use lights use lights and sirens when they're responding to you when you call 911. And 25% of them use lights and sirens when they are taking you or your loved one to the hospital. And ladies and gentlemen, as a public health person, we've got ourselves a denominator problem because there are 40 million calls for EMS annually in the United States.

So, these numbers are incredibly big. I only showed you two videos, but this goes on all day long every day. So, what the actual Why are we doing this? We have a intervention that we know is marginally useful to the patient at best and is actually dangerous. I'm going to answer it in one word. Tradition. There's an inextricable relationship between EMS and the fire service that goes back a long way. Back in the 1970s when EMS was just starting to become a thing in the United States, um we found that EMS was very much a secondary mission for the fire departments.

But, now flash forward to 2025. If you look on the left side of the chart here, there are almost 24 million calls for fire department EMS service in the United States, far exceeding fire incidents over there at about 1.3 million. So, although it was sort of a secondary mission back at the in the last century, now it's the primarily what they do, right? So, another aspect of this too is measuring quality in a fire department typically relies on response time.

And response time is pretty easy to modify. You just drive faster, right? And that's where the lights and sirens comes in. So, when EMS really was blossoming in the United States 1970s, 1980s, when it was becoming a thing, when it used to not be a thing before that, it was only a good idea 50 years ago, when EMS was blossoming, we sort of started absorbing that mindset that speed was the indication of quality for an EMS service.

But, it turns out that in EMS, if the metric you're using to measure quality is how fast you get there, you're measuring the wrong thing. Everything we do in EMS, whether it's how you drive or the care you're providing at the bedside or on the street, really needs to be measured against one thing, patient outcome. How did they do? How did your patient do based on what you did? Right? The value we bring to the community as EMS isn't the speed which we move.

It's the life-saving resources we deliver to the patient's side. Okay? So, what's a medical director to do? What do I do as a medical director? As a medical director of EMS services, and I'm the medical director for the campus EMS system that you're sitting in the system for it right now. I'm the medical director for a federal law enforcement agency. We write the protocols. We approve the protocols that determine what our EMTs and or paramedics can deliver to you as the public to hopefully save your life and reduce suffering.

Right? I want EMTs and paramedics in the services I oversee to think about the decision to flip the switch and use lights and sirens the same way you would think about any other medical decision. Maybe it's to give epinephrine to someone having an allergic reaction. Maybe it's to use the defibrillator or the AED to shock someone who's having a heart attack. Why? Because everything we do in health care has pros and cons, risks and benefits.

I want our providers being engaged clinicians. I want them making the decision to use lights and sirens. I want them to do it purposefully the way they would do any other intervention because they're introducing risk to the care of their patient if they indiscriminately drive quickly if that patient doesn't need it. The time saved by using lights and sirens, as I sort of mentioned before in a different paradigm, may potentially impact about one out of 20 transports we do.

For the other patients, what we call routine response, driving with the flow of traffic, is probably the most responsible way to move from point A to point B, especially when we're taking a patient in our care on a stretcher from the scene to the hospital. It's okay to drive without the lights and sirens and get your patient there 3 minutes later in 95% of cases. What do we need to do? We need to figure out how to optimize making sure, remember right care, right patient, right time, we need to work with dispatch to improve those systems, lean on the evidence we've got, lean on the best practice we have to better identify those patients who deserve to be in that 5% club, who merit the additional risk from driving faster to get them to the hospital that much quicker.

Let's talk about it in terms of money. So, ambulance crashes are obviously a bad thing even if nobody gets killed or injured. But when ambulance crashes do occur, frequently it's the public that gets injured. And that can cost the agency anywhere from tens to hundreds of thousands of dollars to up to tens of millions of dollars if you're a big city like Los Angeles, just paying for the liability of hitting another person.

That money can often be used in a much better way buying other things like supplies and power lift stretchers and all the other good stuff that comes along with EMS in 2025. We also know that in many communities, especially in rural America, ambulances and people to staff those ambulances are an incredibly precious commodity. When you're involved in an ambulance crash, that ambulance and potentially the staff who got injured are now off line.

Replacing an ambulance can cost anywhere from 100 to 100,000 dollars to a quarter million dollars depending on what you want. Right? And think about the incalculable toll to those individuals who get hurt or injured and their family. Not to mention that they're off line as a resource to their community. Okay. Culture change needs to happen here, right? And I won't tell you that it's not happening. Good things are starting to go forward.

We need to leverage the growing evidence base of physician scientists and public health researchers who have looked at this issue, who are looking at ways to utilize lights and sirens more safely so that it actually directly impacts the outcome of the patient, not just because that's how we used to do it last year, or that's how we do it in the fire department. I'm not saying lights and sirens are a bad thing. I'm just saying they need to be used much more judiciously.

And at least 22 other professional stakeholder agencies wouldn't argue with me. And this includes stakeholder agencies like the American College of Emergency Physicians, the National Association of EMS Physicians, the National Association of EMTs. That's kind of a who's who list representing EMS at the national level in the United States and internationally in some cases. And they have all signed a position statement agreeing that we need to do a better job with more judicious and evidence-based use of lights and sirens in our communities to protect against unnecessary injuries and illness injuries and death.

Okay? We also need to follow the example of those communities that are steering into the skid, that are leaning forward and tackling this issue. Places like Austin, Texas, places places like Salt Lake City and Seattle have taken on the political challenge to change the culture in their community. It's hard. Politicians get impacted when people think the ambulances are coming fast enough. So you have to really get buy-in in your community.

And you also have to train the responders. We have to do this as a whole community. And we also need to talk to our responders. Right? If you survey EMTs and paramedics, turns out that half of them think we should be using less lights and sirens. That shouldn't surprise you. I will tell you, driving lights and sirens is fun. And it's a big attraction for people that work in fire and EMS and law enforcement. I'm not going to lie to you that it is.

But it's also our lives their lives on the line. We We it's dangerous. We do it anyway. We know it's dangerous. Also, be an informed consumer. What can you do as the public? Most people are not even tracking on this as an issue. We just assume that what's happening with our lights and sirens providers in our community is just the way it's supposed to be done. I'm here to tell you we don't necessarily know the answer to that question, if it's the right way to do it.

But it's okay to think forward. The esteemed physician, researcher, scientist, author Atul Gawande made this statement, "Culture strangles innovation at the crib." And I would argue that if you look in all of health care, not just pre-hospital pre-hospital care, but all of health care, that there's no issue that sort of exemplifies that quote as well as what we're talking about here. Right? Tradition over evidence. It's time to slow our responses down to do the right thing for our communities and our patients and our providers and the rest of the public.

Okay? Thanks for your time today. Be safe.