Running Hot

Pushkin.

Hello, Hello everyone. This is the first of what are going to be a couple of episodes in this mini season from my colleague Ben Adaph Haffrey. Ben is the guy when you're hiking through the wilderness who says let's go this way and there's no trail and you think, oh, I'm going to get eaten by bears, and then no, you find some lost civilization and large piles of glittering gold. Ben started telling me this story and I stopped him halfway through and I said, oh, Ben, this is a spandrel.

Walk me through. No, you really do walk me through what we're looking at here. I'm talking with my wife Julia Conrad, who happens to share an apartment with me on quite a noisy street in Brooklyn.

This is a log that you created. Although I am represented in it, I think it looks like we only did it for one day. Of how many times we heard the siren and where we heard it. Wow, what a day.

Julia and I live opposite this grocery store that's all local, small batch whatnot. So instead of getting just one delivery a day, they get like fifteen, sometimes from trucks bearing I assume one sprig of artismal basil next door there's a noisy playground and crucially a fire station, a really active fire station. What happens is the grocery store trucks block traffic, which means the fire trucks can't get out, and so sirens all the time. This, for me, as

First, I have to say I never understand your way of doing Google sheets because the color coding seems to just be aesthetic. It's not actually representing anything in the data.

I don't need this in it. I could get enough of this in my job. I don't hear from you. I will confess that the spreadsheet, consisting of mauv baby blue, puked green, a cheery yellow, and several pleasingly varied shades of red, isn't even complete because it does not count the times we heard the siren in the middle of the night when there is no one on the road. Maybe you didn't realize this, but emergency vehicles will sometimes run their lights and sirens even if there's seemingly no

As we say, it's not a firetruck unless it's got.

A key siren. According to a helpful chart from Yale University, one hundred twenty three decibels is just two decibels lower than the point at which quote pain begins. This would all be fine, except I kind of need my ears for my job, and this is why I began the log. The log has fields for all relevant data date, time, branch of emergency service. Location in the house from which we have heard the siren.

Well, there's really just two possibilities. You're either in the front of the house or the back of the house. But actually some of these entries are logged for front and back, so that's when you know it's a really big siren.

There's also a field for reporter Ben slash Julia and another for notes and then what is the final column.

The final column is called dog question mark.

This is the only field that matters. You See, there's a dog in my neighborhood who howls almost every time the siren goes off, and he sounds like this, a dog who, by the standards of people on my block is practically famous. Have you heard a dog who howls every time the sirens go off? Yeah? I have.

I mean they're pretty consistent with it.

They're they're dedicated to their.

Howling.

I think I feel like my wife has heard the dog.

But there's a guy, Kevin that lives after that garage right there, and he does so he's talked about this dog here. Yeah, what does he say? Oh, he's ready to do something about it.

It starts really low and guttural.

I thought it was like a wearwolf or something.

Oh.

I decided to take a two pronged approach to my siren problem. Planet I had to see if I could. I proved that the sirens in my neighborhood were dangerously unnecessarily loud, and Plan B. I needed a sympathetic face for my cause. Nobody really cares about podcasters, but everybody cares about dogs. And I had to assume that that dog was howling along with the siren because he was, like me, in serious pain. So find the dog, stop the siren. It'd be that simple, except the dog was

We're going to take you into the noise troom.

What's the noise troop?

Oh?

Okay, no, see when you get there.

Sarah doctor Bronze Aft, is an eighty nine year old environmental psychologist who has been called the noise Queen of New York City. She's done major noise studies worked for five mayors. She grew up in Brooklyn and lives in a lovely tidy apartment on the Upper East Side someone was jackhammering the street outside the building, and yet you couldn't hear a thing. Double glazed windows. Of course, she took me to her noise room. The noise room sounds possibly like the opposite of what I mean.

Let me tell you it is a very quiet room. This is quiet.

Wow. How did you get it so quiet? Oh?

Did I help make it quiet? Answer? Yes, I did have a role and making it quieter than it would have been. Can you see the cooling units?

Yep?

Are they all closed?

Yep?

Who do anythink made that request?

Bronze Aft started her work during the golden age of noise control the nineteen seventies, when the EPA began regulating noise. Her early work demonstrated that noise isn't just annoying. They can get in the way of kids learning in school, and she just kept going from there. When the city updated its noise code in two thousand and seven.

In fact, it was my suggestion that they updated, it carried quite a bit of weight. However, the literature that they were depending upon was it was older. So today we have much more solid literature on the link between noise and health. That's critical, and that includes mental health. As well in learning that.

All checked out for me. Of course, the sirens are too loud, but it can take a while for the research to make its way into policy. Now we have research linking even small changes and overall noise to significantly increased risk of heart disease, to say nothing of stress, poor sleep and its associated elements, and crucially the effective noise on easpirated podcasters.

Now you mentioned sirens, all right, that deals with safety, That deals with getting someone to the hospital on time. However, the sirens in Europe are less offensive, are less intrusive. Europe mean people aren't dying, aren't they. The point is, if Europe can have quiet at once, you could come up with a method of quieting the sirens and still be as effective. I have not seen a study I has shown that if you have a less offensive intrusive siren that more people die.

Have you no? So here?

I am, I'm a data person. Show me the data.

I left that meeting full of hope. There's no doubt that sirens are dangerously loud. I just need to find the data to back this up and figure out a new solution. Like Arlene said, I went straight to the library and started digging around. But the more I saw about how clear it is already that these sirens are crazy, the less I believe that that data was going to

I have like four jobs because it doesn't everyone. And I'm like, right now, I'm at the Barrion County Health Department.

Jonathan Byer, former EMT and now medical director for the Barrion County Health Department.

I am not speaking on behalf of the Barian County Health Department.

Buyer was a boy scout, scrupulous. The reason he was speaking to me is because, in his capacity as the EMS medical director of the Baryon County Medical Control Authority, he is responsible for the ambulances of Barrion County, and that means he's thought a lot about the noises that those ambulances make and he's arrived at a very controversial position.

There is no evidence that lights and sirens helps anybody. There's plenty of evidence that it hurts people.

No evidence that lights and sirens helps anybody. This, even to me an inveterate complainer about sirens, was a huge surprise.

I started life as a paramedic before I got demoted to doctor. I was a paramedic for eleven years. And when I was a paramedic in the Philadelphia area, we responded lights and sirens for everything. Like you called nine to one, we just let you know, there we go. When I got here to Michigan, they had two sets of priorities, Priority one in Priority two.

A lot of ems across the country has a similar kind of tiered into system, a way to rank every incoming nine to one one call based not on its importance but on its time sensitivity. In Barryon County, they would tag a call with priority one or two, depending on what the issue was.

There are more calls for service than there are ambulances, so we have to find some way to prioritize them.

Except the system wasn't really working.

And a lot of these triggers for things were like, if you ever complained of shortness of breath in any way, shape or form, it made it a Priority one. The problem is shortness of breath or do you feel like you're having trouble breathing? An incredibly subjective question, and so the medics were coming to me complaining. It's like, why are we getting Priority one dental pain because the person's like, I have a toothpain. Oh yeah, it's making hard to break.

So you only have a certain number of ambulances, but if a full half of your calls are coming in as urgent, how do you fix the problem? How do you get all those ambulances where they need to be. Well, an easy way is to get more places faster, which theoretically you can do very easily if you're exempt from all typical traffic laws, precisely why we have sirens. But it's a little more complicated than that.

So when you drive your car, you're used to things like red lights. Everyone's going to stop. Once something interferes with that, the chances of an accident increase.

Specifically, it increases your chance of an accident by over fifty percent, which is crazy. This is according to a peer reviewed twenty nineteen study published in the Annals of Emergency Medicine. The risk is even higher when transporting a patient than when initially responding. But either way, the chance of an accident is a lot higher when you're using lights and sirens than if you're not. Also, these are

I started going, why are we responding to dental pain priority one? So myself and I have a residency program here, and I had a couple of my high performing medics and another EMS position and myself. We spent a couple of weeks going through hundreds of these determined codes, going does that really need priority one?

So there's the accident's risk. But also, and this is really surprising, using lights and sirens doesn't actually save that much time on your route to the patient. For decades now, studies have shown that lights and sirens seem to save on average between forty two seconds and three minutes and forty eight seconds. It's about one and a half minutes of savings if you're in a city, and a little over three and a half minutes if you're in the country.

On average, yes, it's about forty five seconds or three minutes.

And there are that's not a critical that's not a critical interval most of the time for.

Most disease process. Cardiac arrest is one that I would put in the that's the time makes sense because in cardiac arrest, for every every minute that you go without CPR being done, there's about a ten percent increase in mortality and decrease in survivable brain function coming.

That's huge. Yeah, serta's huge. But heart attacks are actually one of the few exceptions, not the rule, and yet they are the exception on which the rule is largely based. So all of these factors led Buyer to do something big. He restructured the tears.

I tell the medics, and this is how I presented it is consider lights and sirens a medical therapy. Right, there's for every medicine that you give, there is an indication and there's a contraindication.

Right.

If I were going to say I'm going to give you up an effort, well, why would I give you epin effort and the benefits have to outweigh the risks. So I wanted to think of lights and sirens that way. It is a high risk procedure. When are we going to do it when the risks are outweighed by the benefits.

They ran through their data on all the calls that they had responded to Priority one lights and sirens, and they reassessed whether those really needed to be lights and sirens.

So cardiac arrest, people choking, respiratory arrest, things where seconds could make a difference, yep, that is worth the risk to try to get someone there quicker. But other things like well she fell and broke her hip, Okay, that's an emergency and that person needs to get to a hospital. I don't doubt that is the three minutes going to make a difference in that person's outcome.

No, So with all this data, Buyer and his team changed how the calls were coded.

I wiped out about fifty percent of the Priority one calls in burying down.

Let that sink in ambulance lights and sirens and Barrion County were sounding half as often as they had before. Now even I was wondering, could you really know that this switch was putting anyone at risk? Well, eventually they followed up on the people the ambulances had picked up in the field to see how the hospital coded the patients as they came in. So if you went to someone as a priority too not that urgent, and they showed up to the hospital as a priority one, that

When I instituted the change, I didn't really have much of a problem. Nine to one one didn't have a problem with this because it just was a difference in coding for them.

It didn't affect them.

The medics themselves really liked it because the medics were like, yep, most of these things we were going on are not priority on board.

The paramedics are on board. Smooth sailing, except what ended.

Up happening and I'm not exactly sure how this got out. It went through all the proper channels on my side, like medical control in the hospital in the county, so that was okay, But it started getting publicized, and I don't exactly know how, but it started showing up on the hospital Facebook page about Burian County medical Control is killing people with slow responses, and oh boy.

Unbeknownst to Bayer, word had gotten out to the people who call ambulances big problem.

Hey, if you're drive in Barrian County, you won't see as many lights and sirens as you're driving. Ambulances will be using them only for time sensitive cases like a heart attack.

The local news began doing man on the street interviews.

Literally, they were out on the bluff overlooking Lake Michigan, just interviewing people walking by, going what do you think about ambulances coming to your house slower?

And of course people explode over what did they say?

It's like, I can't believe this, and you know that this is terrible. Of course I won't ambulance there fast. And the hospital started getting a lot of flack, some of it was very nasty. So people started on Facebook attacking the hospital. Oh this is Lakeland just killing patients again? You know, just very bad vitriol.

At the time, though Bayer was blissfully unaware any of this was happening. Other jobs were keeping him very busy. But then one morning he got a call.

I'd done a six p to two am shift and at eight am I got a call from the administrative assistant to the CEO of the hospital. Hi there, doctor Buyer, It's eight am. What are you doing at eight thirty? I'm like, and I'm still swaking up because again I've had four hours of sleep, and she's like, doctor Hamill. At that point, the CEO of the hospital would like to speak to you.

Buyer gets dressed in hurries to doctor Hamill's office.

And I'm met by them in the hospital attorney and being shown this Facebook page and they're like, what did you do? This is terrible?

Buyers stunned, and then he begins to lay out the case against Sirens in a very doctor buyer way.

I try to explain what I had done. Is have you ever taken physics?

Buyer explained his move, maybe a little inefficiently, by using the equation for velocity distance divided by time changed to solve for time or Tea. It amounted to this, If you're trying to get time down and you can't reduce the distance between you and a patient by putting more ambulances on the street, because it's expensive, the easiest way to get it done is to increase your velocity, which

I showed him some of the studies. He's like, your science is sound. You may you go next time, do a press conference. Oh I had a press conference, which is what you saw.

Online Buyer confronted the outrage masses.

And once that went out, all complaints disappeared in six weeks and I've heard not a thing since then. In fact, now we are considered we right now are the leader in Michigan for the lowest rates of lights and sirens use in the state of Michigan.

For ems. Things worked out for buyer in the end. But I'm interested in that initial freak out because it reveals a basic assumption people make, myself included. Everything is urgent, so we accept this social loophole where you can break all known traffic laws provided you possess a device that emits the loudest, shrillest sound imaginable. What kind of world

If you would have asked eighteen year old Jeff when I first drove lights and sirens. I would have said that they are always life saving and we absolutely need to use it. But I'm not eighteen anymore.

Jeff Jarvis the chief Medical Officer for the Metropolitan Area EMS Authority in Fort Worth, Texas, an emergency medical service that serves over a million people in Fort Worth and fourteen surrounding cities. He's been a paramedic since the nineteen eighties. He served around New York City in Austin. So eighteen year old Jeff who's made his decision to begin to be a paramedic. So let me ask you. Let me

Oh?

Of course? And did that have an effect on your becoming a paramedic?

It did. I thought it was the coolest thing ever.

In nineteen seventy two, NBC began airing a television show called Emergency. That's got an exclamation point at the end. By the way, the theme song is the music they'd play in my version of Hell. The show is about Johnny and Roy, two young paramedics working out of fire Station fifty one in Los Angeles, except they're not paramedics in the beginning that.

Special training program.

Remember we were talking about it a couple of days ago.

Yes, sir, the para something or other paramedics. The series begins in a world where there basically aren't any paramedics, which was our world fifty three years ago. Fifty three years in nineteen seventy one, there were a slim twelve paramedic units in the entire country and it was kind of a Wild West situation. Details varied from place to place, but in some areas it was illegal to give someone medical care if you weren't a doctor or a nurse.

People at dying at the scene, people who could stay alive if there was somebody on the spot who knew what to do.

Look, if that.

Bill passed the legislature today, do you know how many people we'd have ready for the job?

Six men for six and a half million people.

I learned about emergency in a brilliant essay by UCLA emeritis law professor Paul Bergman, where he traces the profound influence the show had not just on par metics, but on lawmakers too, by dramatizing just how urgent every single nine to one call is.

We almost head him back.

Damn it, we almost head him back.

If you could have been defibrillated the moment they pulled him off the wire. This is from the first episode, right after a maintenance man gets electrocuted and eventually dies. The doctor and nurse, who by the way, are of course romantically involved, are talking.

Somebody should have been there with a machine in their bucket, not somebody The paramedics again.

Call him paramedics a rescue team. That doesn't matter.

Cal if somebody with the right equipment and trained to use it.

Had gotten to this man in time, he'd be alive.

Now, I won't use this situation that justify setting amaters out to practice medicine on the street, trained amaters trained by you, and doctors like you, amateurs, Dixie. I spent twelve years in school and residency and I'm still learning my trade.

It's a doubleheader pilot, and both episodes are full of these situations that dramatized the resistance to paramedics, which was very real. But the show argues that we need paramedics and why do we need them because there are so many accidents where if only someone had been there in time, we could have saved.

Them, including myself, and thought it could possibly be a success.

Well, or arm may not function as well as it used to, but at least it'll be your own.

You're getting out here as fast as you did.

Made the difference, Randy, to have around, doc, you gotta give.

Us a try.

Bergmann, the law professor, talked to the legends of ems and he heard all these emergency references. Dug through California hearings on the Paramedic Act, and he found emergency references letters from senators emergency references. In the early years of the show, forty six states legalized paramedicine. To be clear, this was a movement that was already in process, but emergency was a big part of establishing the cultural expectations

But you can't ask someone not to die while you're trying to find out what's wrong with him. And they do die, gentlemen, on the way from where it happens to my hospital.

This is from the second part of the pilot episode, when the skeptical doctor has come around.

They die by the hundreds every year, not from mortal wounds, but neglected wounds, not from incompetence or indifference, but from time, from lack of time. I'm in favor of more doctors, more hospitals, and better equipment. And I'm also in favor of this bill until those other things come along, because it will save lives, maybe a dozen lives, maybe a thousand, maybe just one.

He's looking directly into the camera, those thirty million viewers, and who knows which one time, time time, And if you succeed at convincing people that every situation is urgent. They're going to come to expect lights and sirens every time they call nine one one, And how many of the calls in emergency do they respond to with lights and si.

Absolutely, so think about it this way. On Emergency, every call was a life threatening emergency. Now I say that knowing the first call they went on was not but in the team the first episode of the pilot, but the vast majority were life threatening emergencies. So sure people got that that notion and expectation that that's what would happen.

Sirens are all over the show. You may recall that the literal theme song of Emergency features sirens, and I think a lot of this time sireen obsession is due to the fact that early ems departments were part of fire departments, and a fire is a very specific kind of emergency. If you don't contain it, it spreads. So every fire is an urgent situation, and according to FEMA, anecdotally, firefighters use their sirens way more often than the police.

Sometimes that three or four minutes is clinically valuable. Most of the time it's not.

Jeff Jarvis did a massive study on lights and sirens using something called the ESO data set, a national collection of emergency calls with unbelievably granular data attached.

Seven and a half million records. Five point nine million of those were non Wollown responses. We analyzed every one of those and calculated the proportion that used lights and sirens, and eighty five point eight eighty six percent of them responded to the scene with lights and sirens.

Oh my, God.

The fundamental question we ask is of those responses where you use lightcense sirens, how many of them did we do something potentially life saving? And what we ended up finding is six point nine of those nine one one lights and sirens responses, did we do something even vaguely potentially life saving? And we were rather generous with our description of what potentially life saving is.

So this is crucial. Paramedics are responding with lights and sirens to around eighty six percent of calls when only seven percent of them are resulting in a vaguely potentially life saving intervention, So why were they urgent? That means that in the United States, we're using lights and sirens somewhere between eighty percent and ninety percent more often than we need to. The question I have that I can imagine people who are skeptical might ask, is, well, how

Most folks are using some type of emergency medical dispatch where there are scripted questions, and they will give each type.

Of call.

A number and a letter, and the letter is called the determinant and it goes from your echo level calls which are most likely to be life threatening down to Omega level calls which are not very likely at all to be life threatening. And those criteria have been evaluated multiple times with multiple data sets. Again, they're not perfect, but they are pretty accurate. For example, there is a

And how many do people run hot to all of them?

It's just dangerous, and it's dangerous, and it's not really doing what we think it is. So it seems like it is an intervention whose time has come and gone.

So I want to play for you again a very specific moment from the pilot episode of Emergency and the speech that doctor gave to the legislature about why we need ems.

I'm in favor of more doctors, more hospitals, and better equipment, and I'm also in favor of this bill until those other things come along.

But those other things have come along. More doctors, advances in the ways we take nine to one one calls, better in more emergency rooms, better in more emergency medicine, better, and more paramedics to use Buyer's formula. We have reduced distance. Paramedic units are all over the place now in a way they just weren't in the world of emergency. But it seems to me like in our minds and on TV, it's as if nothing has changed since the nineteen seventies.

There is in emergency departments everywhere I see as there's this concept called alarm fatigue, where when everything is an alarm, nothing is an alarm. To paraphrase, The Incredibles, the Car Chain movie. So you just get immune to these sirens that are not doing the job.

So Jarvis, like Buyer, reduce the use of lights and sirens. He cut them by about a third. Did their response time increase, Yes, by a median of six seconds, and in the vast majority of cases by less.

So it's turning out it's not making that much of a difference in we're being much safer.

And this I realized this is purely in the realm of hypothesis, but it seems to me common sensical that were lights and sirens reserved for truly emergency use, you would see a more potent reaction to them, and likely then it would it could it could possibly decrease response times.

So I'll put my scientist hat on and say that's an interesting hypothesis that needs to be tested. I will put my realist in my pragmatic public health hat on and say, absolutely, giddy up. I absolutely think you'll see that.

I like that hat. That's a very stylish hat. You're all right, So here it is. Lights and sirens are a tool that currently seem to be way overused, and that overuse has real consequences. Most of all, for our burnt out, overstretched first responders who go to work to save lives and wind up responding to everything as if it's a crisis, wearing themselves out and losing their hearing

Well, I guess it.

Was like the first time we heard him howling at sirens, because he didn't seem particularly distressed by it. Like a lot of times his tail wags and he does get quite a reaction from like the neighbors, like the neighborhood, Like everyone usually turns around and stops and like laughs and was there, like I've never heard that before.

It turns out Davy is starting a movement.

His dog walker always like posts like sends us emails like describing their walk. So you know, sometimes Davy has gotten his his co his co partners in walking the other dogs to start to howl with him.

But he's always the first towler.

It's definitely always the first howlur. But I think he has taught some of the other dogs like how to maybe start doing this, so.

Their owners must be thrilled. Jen is a psychologist, Joe is a composer for film and television, so together they're experts on mammalian behavior and sound. So I'm inclined to believe their analysis of Davy's views on the sirens subject. He's not in distress, which means he's not going to be the poster child for my anti siren campaign. But I hadn't given up yet. Do you share this view of Davy's howl origins or what? So?

There's there's another theory, which this is the one I think I if I had to choose one that I would like to believe the most, it is. It is that the sirens harken back to a lost dog who has been separated from the group, and they are howling to reconnect with the pack like a like a call and answer from a lost dog. That's one of the series, And that Davy is saying, we're over here. Come on, lost buddy, this is where we are.

He is a very nigh early dog.

It loves to hang.

Jen and Joe are very neighborly people. I'm glad to know them now, even if their dog is a huge disappointment. My anti Siren cusade, seeing as he really love sirens. But it makes sense. It goes back to that evolutionary theory Malcolm was talking about at the top of the episode, the idea of the spandrel and the things in our bodies and our worlds that we think we're selected for but actually are just there and maybe not doing us a whole lot of good. Davy's howl isn't quite a spandrel,

Get add free episodes of Revision's history by subscribing to Pushkin Plus. Sign up on the show page on Apple Podcasts, or at pushkin dot fm, slash plus. Pushkin Plus subscribers can access ad free episodes, full audiobooks, exclusive binges, and bonus content for all Pushkin shows.