Priority System relays emergency instructions before ambulance arrives

Sun-Sentinel; Fort Lauderdale, Florida; September 1991   added 10/15/01
Chele Caughron, Sun-Sentinel staff writer  http://www.prioritydispatch.net/medical/articles/prioritysystem1.htm

Jeff J. Clawson was an ambulance driver when he first realized the important role dispatchers play in medical emergencies.

Now a doctor and medical director for the Salt lake County Fire Department in Utah, Clawson has designed a system to help dispatchers do even more.

He refers to his creation, the Medical Priority Dispatch System, as sort of a recipe file for dispatchers to give medical instructions over the telephone before an ambulance ever arrives at the emergency scene.

"The dispatcher is indeed the first first responder," Clawson said. "They can guide the person through the do's and don'ts."

Palm Beach County Fire-Rescue as well as dispatchers in Boca Raton, Delray Beach, and Boynton Beach now use Clawson’s system to aid people who call 911 with a medical emergency.

For example, if a person calls to report that someone is having trouble breathing, he will be asked the following questions:

• Is he alert and able to talk?
• Is he choking?
• Is he pale, sweaty or changing colors?
• Does he have any heart problems?
• Does he have asthma?

The instructions callers are given depend on the answers dispatchers receive.

"The dispatcher can have a profound effect with just a nickel's worth of information," Clawson said. "The protocol is actually a manual computer."

In the past, many departments prohibited their dispatchers from giving medical instructions over the telephone. Local governments did not want to take the risk of a dispatcher giving out false or inadequate medical advice and the lawsuits that might follow. Other department officials simply did not think dispatchers could handle giving out medical information.

"The dispatcher initially was like a clerk," Clawson said. "What dispatchers ought to be seen as is air traffic controllers, but what they do is 10 times as stressful. Every time the phone rings it's the equivalent of somebody in a crisis."

The flip cards in Medical Priority Dispatch System are prepared to cover nearly any kind of medical call: back pain, choking, diabetic problems, drowning, electrocution, overdose, gunshot wound, stroke.

"Dispatchers personally don't see themselves as medical personnel, but what they do is medical in every sense of the word. They just do it in 60 seconds," Clawson said. "The system prioritizes the actions of the dispatcher so the dispatcher minimizes and maximizes actions."

Clawson, who is also president of the National Academy of Emergency Medical Dispatch, said he came up with the idea for the system in 1978 and developed it in his basement in Salt Lake City. The doctor had a hard time pitching the life-saving medical recipe cards, however.

"Initially it was very controversial. We couldn't give it away with a $100 bill glued to it," Clawson said. "Since that time things have gone 180 degrees."

Now the Medical Priority Emergency System is considered one of the standards for emergency medical dispatchers, area dispatch supervisors said.

The Politics of Emergency Medical Dispatch

NENANEWS, June 1995
Michael G. Petricca  http://www.prioritydispatch.net/medical/articles/politics1.htm

On November 30, 1994 at 12:13 p.m., the Webster City Police Department Communications Center received a 9-1-1 call from a distraught mother whose infant baby’s heart had stopped beating. At the time the baby’s heart was being monitored by an apnea monitor.

Immediately two well-trained telecommunicators implemented Emergency Medical Dispatch (EMD) techniques. Telecommunicator Rick Mortenson, who initially received the call, determined the problem, calmed down the mother, and began instructions on how to initiate CPR. Glenda Ubben, another telecommunicator and the department's communication training officer, performed back-up duties by handling associated radio traffic.

The good, calm, professional approach displayed by these two individuals resulted minutes later in the baby being revived by its mother, and a potential tragedy was averted. Shortly thereafter, ambulance crews arrived and the baby was transported alive to the local hospital for a short stay.

Unfortunately, instances like this do not occur routinely across the United States and the levels of professionalism exhibited in call handling at E9-1-1 Communication Centers dramatically fluctuates. For example, if this call had come into the Webster City Police Department one year earlier, the dispatcher would not have given any medical information to the mother, but would have just dispatched the local ambulance and paramedics. In all likelihood, CPR would have been delayed approximately 5 minutes, which is the difference between life and death. In rural locations, arrival time can be as high as 30 critical minutes, which is certain death for individuals who need CPR or emergency medical care.

In February 1994, the Hamilton County E 9-1-1 Service Board and the Webster City Police Department split training expenses to implement Emergency Medical Dispatch. The training was held on-site in the City Council Chambers with several other jurisdictions from Northwest Iowa participating. This approach was beneficial for all the agencies because it provided quality training with very low travel expenses.

The Influence of Politics

Emergency Medical Dispatch, like any new program, has its skeptics and many of those opinions were aired prior to our program being implemented. Opinions were voiced through the entire spectrum of the EMS. Fire and Public Safety Agencies, including the telecommunicators themselves. However, the program proceeded with the Hamilton County/Webster City system now having a responsive way to assist the community.

There is no way to escape the influence of politics in any setting, whether it is in the public or private sector. There are several misconceptions about EMD, how it works and why or why not communities should implement. The following are several misconceptions that may arise when proposing an EMD program.

Misconception #1-Liability

Many opposed to EMD believe that if the communication center dispatcher gives medical advice over the phone and an error occurs, the agency is liable. This issue has plagued everyone in public safety for many years and has caused many departments to just say "no" to EMD. The basic fact is that there has never been a pre-arrival instruction-related lawsuit filed against the EMD professional who was certified and followed the protocols for their system.

It is believed that the communication centers that do not provide EMD training are actually the ones at risk. There are lawsuits on file against agencies who have declined to give advice or medical assistance over the phone. Dr. Jeff Clawson, consultant from Medical Priority, Inc., who oversees a nationally acclaimed EMD program, states, "There are no demonstrated lawsuits against those agencies using Medical Priority Dispatch protocols. Conversely, multiple agencies not providing this kind of service have been sued." In addition he states, "Basically across the nation, however, there have not been very many lawsuits filed."

It is Dr. Clawson's opinion that those administrators who decline to implement EMD do so as an administrative decision using the fear of lawsuits as an excuse.

Misconception #2-The Need for Multiple Dispatchers

There is a real concern that for a communication center to successfully implement an EMD program, there must be multiple dispatchers on duty around the clock. The belief is that a single dispatcher cannot give pre-arrival instructions without the aid of another dispatcher to handle multiple calls and radio traffic. What must be realized is that dispatchers working alone will prioritize radio and phone traffic if they are properly trained. The can excel in this environment if given a chance. This has been the case in our department where dispatchers work alone one-half of the time in a 24-hour period.

Misconception #3-EMS Response Delays

Individuals who are not familiar with EMD may believe that an EMD program will delay the response time of E9-1-1 calls. This assumption may cause debates over which is important, EMD or the E9-1-1 system. The reality of EMD is that with a quality EMD program, the first event to occur is the dispatching of the EMD provider. To ensure that this occurs, a strict set of policies and procedures must be in place and a review board must be established. In our case, we have established a peer review board that meets on a monthly basis. A medical doctor sits on this board with representatives from the EMS community and dispatching staff. This group reviews 10% of the EMS calls each month and then relates their findings back to the telecommunicators. With this process there is two-way communication between those in the field and the dispatching staff, with oversight from the medical community.

Having a peer review board like this has resulted in respect for the telecommunicator from those out in the field. The EMS personnel now realize what it takes to be a telecommunicator and the many tasks they must perform. In essence, what this board establishes is a quality control mechanism which evaluates the performance of the EMD program.

Misconception #4-Hospital Instead of Communication Center

Those exploring the feasibility of implementing an EMD program will undoubtedly be confronted with the question, "Can't the local hospital take these calls?" The belief is that the nursing and paramedic staff can handle these calls more professionally than a telecommunicator. The true answer to this question is yes, the hospital can receive these E9-1-1 calls, but there are many drawbacks:

1. Conducting an E9-1-1 call transfer to a local hospital takes extra time. With a life threatening call, this is impractical and causes added stress to the caller as he waits for the call to be transferred and answered at the local hospital.
2. Once the call transfer is complete, trained staff must be located within the hospital. There is no data which states that a nurse, paramedic, or doctor can give better instructions than a certified EMD telecommunicator. Experts in the field believe that the telecommunicator can do this job better due to the fact that they have better phone skills.
3. Many hospitals do not want the extra burden of receiving E9-1-1 calls in addition to normal hospital phone traffic.
4. The EMD originally interrogating the caller has assessed the situation and is now prepared to give the correct and appropriate pre-arrival instructions. A nurse who receives the call must start all over again. Time is lost as well as continuity and rapport.

With our EMD program we explored this possibility and decided it was better to stay in-house with an EMD program, due to these problems. In addition, our hospital administration also agreed that our community would be better served by keeping EMD at our PSAP.

Conclusion

It is our experience in Webster City/Hamilton County that the implementation of EMD has increased the professionalism of out E9-1-1 public service answering point. All too often we spend too much time, effort, and money on the people in the field and forget how important the telecommunicator really is. We take great pride in the fact our telecommunicators can take a frantic caller and make the necessary decisions to resolve the situation in the most appropriate way. This is a lot better than simply advising the caller that help is on the way and then terminating the call.

The political experience in our community with EMD was a healthy one. The issues were researched and a quality program was initiated. I hope everyone in the NENA family has the same experience.

Michael G. Petricca is Chief of Police in Webster City, Iowa, where he heads a police department with 14 sworn and 6 civilian employees. He is also an adjunct professor in the Law Enforcement Department of the Iowa Central Community College and State Chairman of the Federal Narcotics Multi-Jurisdictional Task Force. Petricca is a past president of the Iowa Chapter of NENA, and currently serves as NENA’s First Vice President.