By Douglas M. Wolfberg, Esq.
Few cows are more sacred in fire service based EMS than the ones that flash, wail and yelp. The use of emergency lights and sirens is an inseparable part of everyday EMS life.
It's as if lights and siren use is encoded in responders' DNA. It's seemingly part of who we are.
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 fire and EMS, lights and siren 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 this scrutiny. 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 lights and sirens is looked at as operational. Why should we view this differently than any other aspect of EMS?
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 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 that lights and sirens clear traffic and warn drivers, pedestrians and others that an ambulance is approaching in emergency mode.
They work by showing the public that we are treating their emergency calls seriously. They work when we show our public officials that we are meeting their response-time expectations and being accountable.
But even though lights and sirens work 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 lights and sirens use helps patients is severely lacking. No studies of that I am aware have ever directly linked their use 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 their use to time. While some studies have found that time saved with lights and sirens are statistically significant, there is no evidence that their use is clinically significant.
In other words, if using lights and sirens reduces response time or transport time by six minutes, the extra six minutes typically wouldn't make a difference in the patient care or outcome. 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 hot?
So, if lights and sirens haven'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.
Lights and sirens use is certainly engrained in the fire and EMS culture. Although interestingly NAEMSO 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, they are used because that's what dispatchers tell us to do when calls are dispatched hot.
Lights and sirens have political roots as well, often being necessitated by response-time 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.
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 practices work.
Awareness of responder safety is at an all-time high. Ambulances are being designed to be more crashworthy. The use of active and passive restraints to protect EMS crewmembers is becoming more prevalent.
Yet, the simple fact is that twice as many ambulance crashes involve lights and sirens use. So why does our profession seem to turn a blind eye when it comes to the safety issues associated with lights and sirens? 
Re-evaluate their use
In one study, lights and sirens were found to be in use in 80 percent of all crashes involving ambulances.  This same study concluded 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 said that EMS personnel may assume that using lights and sirens "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. 
As an attorney, I must mention that where there are more ambulance crashes, there will be more lawsuits, settlements and payouts by fire departments and local governments. In that sense, reducing lights and sirens use can have a direct impact on reducing legal liability.
A few facts are uncontestable. No evidence links lights and sirens use to better patient care or improved patient outcomes. They are associated with markedly higher rates of ambulance crashes and higher rates of EMS provider fatalities than operations not running lights and sirens.
With no proven clinical benefit and well-established risks to providers and the public, lights and sirens practices need to be re-evaluated 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 fire department can — and should — have its own policies and training when it comes to lights and sirens and other aspects of ambulance safety.
In the absence of any evidence that lights and sirens improve patient care or protects providers, your department's polices should make not using lights and sirens the rule and their use the infrequent exception.
3. Train personnel
Because lights and sirens use is an engrained part of EMS culture, changing our mindset will take time, training and a cultural change. But effectively training emergency vehicle operators is a key to reducing lights and sirens use and improving operational safety.
4. Make them 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 lights and sirens needs to be integrated into EMS clinical QA programs.
Personnel should document when lights and sirens are used either in the response phase or during patient transport. The appropriateness of their 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 pre-hospital emergency health care doesn't necessarily go hand in hand with lights and sirens. When local officials are properly educated on the risk they add to their liability, and that the benefits of their 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 technology has allowed emergency vehicles to communicate with traffic signals, newer vehicle-to-vehicle 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.
Running lights and sirens is not an inevitable part of every EMS response. It is time to put that sacred cow out to pasture.
1. National Association of State Emergency Medical Services Officials, 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).
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. He is an EMS attorney and founding partner of Page, Wolfberg & Wirth, the nation's leading EMS industry law firm.