Just recently, a story came out about how dispatchers at the LAFD are too slow when it comes to directing 911 callers to begin CPR. The story was picked up by print, Internet and television news outlets from all over the U.S., and it even created some talk radio buzz.
In defense, the LAFD claimed that some software issues needed to be addressed with the vendor.
Apparently, according to the LAFD, dispatchers cannot simply send units to a particular call — even if it is obvious from the caller that serious help is needed immediately. It seems that the dispatchers are forced to run algorithmically through a series of questions generated and required by the software in order to triage the call. Only after the computer has sufficient information can a rescue unit be dispatched.
The 911 call recording released in connection with this story is pretty compelling. The caller tells the dispatcher that the victim's skin is changing color before his eyes; that he is not breathing normally; that, while it appears he is breathing, there is no chest-rise and he is "very pale" and "very cold."
Even the newest graduate of a basic first-aid class knows that the caller is describing someone who needs medical attention STAT! Does the victim need CPR? Maybe, maybe not. I can see how that part might still be unclear, but the person turning blue needs paramedics.
"Are the paramedics on their way?" the caller asks in a voice trembling with anxiety and fear.
The dispatcher answers calmly, "Until I get through getting the information that I need, we're gonna have to wait until that happens."
Really? In 2012, that's the answer?
The real story
By itself, the story is rather damning, and the coverage did not cast a favorable light on an already beleaguered department. However, while everyone is focused on the fact that the caller did not receive CPR instructions sooner, there is a much bigger and more serious picture here, and everyone seems to be missing it.
This story shines a spotlight on a critical and universal problem, not just in Los Angeles, but in countless 911 systems across the country: lack (or total absence) of dispatcher discretion — or worse, of human discretion.
"Are the paramedics on their way?"
"Until I get through getting the information that I need, we're gonna have to wait until that happens."
What happened to the days when the trained dispatcher asked intelligent questions in response to each individual caller and acted quickly based on training and experience?
What happened to the days when certain key words or phrases, like "difficulty breathing," led to an immediate dispatch of resources with one hand while the phone was still in the other? (That's a metaphor; I know they wear headsets.)
The idea of withholding the dispatch of resources because all of the boxes were not checked is positively insane to me! Have we really adapted to a world filled with exciting technological advances by forfeiting common sense?
EMS systems all across the country have spent hundreds of millions of dollars to integrate more "efficient and cost-effective" systems, ostensibly to improve resource management and response times.
Like too many other aspects of life in 2012, the consumer more readily believes what appears on paper or a screen rather than what is plainly visible by simply looking at it in real life and in real time.
I have to tell you, the first draft of this column went into excruciating detail about system changes in response to shrinking budgets and growing 911 call volumes. It was painful.
Fortunately for you, I cut that all out because I can sum up my point simply and in a way that every EMS provider who ever lived will understand and agree: Toys are good, but people are better.
No computer will ever recognize the helplessness in a frightened mother's voice. No algorithm is necessary to know that if someone is not breathing, has no pulse, is short of breath, is unconscious, fell 20 feet or is bleeding uncontrollably, it does not matter how old they are or what their history is or how long it's been going on — get responders rolling.
You can ask the supplemental questions and communicate the relevant information to the responding units as needed. If it takes four and a half minutes to tell the caller to initiate CPR, at least the paramedics will already be on the way.
When software prevents the dispatching of resources, the problem is not the software; the problem is the system. When the toys of EMS tell the people of EMS what to do, stories like this one will give way to stories of lost lives and lost hope, and EMS will take yet another step in the wrong direction.
About the author
David Givot, Esq., graduated from the UCLA Center for Prehospital Care (formerly DFH) in June 1989 and spent most of the next decade working as a Paramedic responding to 911 in Glendale, Calif., with the (then BLS only) fire department. By the end of 1998, he was traveling around the country working with distressed EMS agencies teaching improved field provider performance through better communication and leadership practices. David then moved into the position of director of operations for the largest ambulance provider in the Maryland. Now, back in Los Angeles, he has earned his law degree and is a practicing Defense Attorney still looking to the future of EMS. In addition to defending EMS Providers, both on the job and off, he has created TheLegalGuardian.com as a vital step toward improving the state of EMS through information and education designed to protect EMS professionals — and agencies — nationwide. David can be contacted via e-mail at email@example.com.
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Kevin BieseckerTuesday, October 16, 2012 12:38:44 PMSounds like Emergency Medical Dispatch in all of its glory.
Tuesday, October 16, 2012 1:37:42 PMWhoa! Let's reserve judgement on Emergency Medical Dispatch (EMD) for the this one. I co-managed the consolidated Emergency Communications Center in Chesterfield County, VA for 3+ years and we used the APCO (Association of Public Safety Communications Officers) with great success. NOTHING in our dispatch protocols prohibited the 911 Call Taker from quickly entering the call for service into the Computer Aided Dispatch System (CADS) for dispatch by the appropriate Radio Operator (Fire or EMS or Law Enforcement) once they had a confirmed address and enough information to give it a Dispatch Call Type.
If one of our dedicated and professional Emergency Communications Officers (ECO) had taken this call, this is how it would have gone down:
ECO working a Call Taker (CT) position answers the 911 call from the citizen. Immediately, the ANI/ALI (Automatic Number Index/Automatic Location Index) information for the phone number and location for the citizen caller appears on their CADS screen.
The CT quickly confirms that the number is correct as is the location of the caller. (This is protocol because s*#t happens--computers have been known to be wrong!--and wireless phones have changed everything). If the information on the screen is correct, the CT does not have to do any keyboard data entry; if additional information can be added to better locate where Fire & EMS need to go, they would enter it.
For this situation, the CT would have entered Call Type "Priority 1 Heart Attack" and "hit' the send button for the call to route over to the Fire & EMS Radio Operator. (Our Center Performance Goal for this part of the process to be completed--from time the CT picked up the 911 call to "hitting" the send button--is 45 seconds).
The call "pops up" on the Radio Operator's CADS screen and the RO quickly scans the information to ensure that they've got enough info to get the call out to the appropriate Fire & EMS station to alert the responders. (In our Center, the CTs and ROs are all in the same room. If the RO needed more MINIMUM REQUIRED info to dispatch the call, he/she would stand up and ask across the room to the CT for the needed information. (Who, by the way, is still on the phone with the original caller getting more information from the caller and working their way down the EMD algorithm be better define the call type and provide the caller with Pre-arrival instructions, like directing the caller in how to perform CPR).
Once the RO has ensured they have enough to dispatch, they hit their "send button" and the call goes out. (Center Performance Time Goal for this part of the process--from time call appears on RO CADS screen and the RO dispatches call to Fire & EMS Station--is 45 seconds.
So all total, no more than 90 seconds should transpire for the entire process to be completed. The CT is expected to continue to update the Notes for the call in CADS even after they've sent the call for the RO to dispatch, and vice versa. I've seen call dispatch records on many occasions, similar to this one, were the only comments entered by CT in the Notes section prior to hitting their Send Button were: Man not breathing, turning blue. By the time the call was "closed out" there might be over 100 lines of additional text notes, entered by both the CT and the RO for the call.
I'm sure that the ECC in Chesterfield County still has a very dynamic Quality Assurance and Improvement Program, just like we did "back in my time". Every Priority 1 call type for Fire, EMS, and Law Enforcement gets a "minimum level" review to ensure that those Performance Goals were met (45 seconds and 45 seconds respectively), that the correct Call Type was used for the call, and that the appropriate resources were recommended for the call by CADS (based upon the call type entered). For any call that "fell" outside of those parameters, an audio tape of the entire 911 call is pulled from the taping system and reviewed in its entirety by the QA Coordinator, who then sits down with the CT or RO to give them feedback and guidance on how they need to improve their performance the next time they handle such a call.
It's been 13 years since I had the honor of working with the women and men of the ECC in Chesterfield County and I have many cherished memories of that time. And, I still believe it's the toughest job in all of Public Safety!
Brett PattersonThursday, October 18, 2012 8:52:53 AMThis article is based on the false assumption that dispatching EMS resources at LAFD requires lengthy clerical input and, apparently, that assumption is based on the rather inappropriate comments a dispatcher made to a frightened caller during the call cited in previous stories regarding poor CPR start times in LA. It seems logical that an author with seemingly high qualifications would research the actual protocol used in the call to determine if the dispatcher's comments were on target before printing such an opinion. In other words, does it actually take minutes to dispatch resources in LA to critically ill patients due to some software requirement or could these problems have some other source, perhaps even a human one?
The protocol being used at the LAFD is the Medical Priority Dispatch System (MPDS). This protocol, developed by the International Academies of Emergency Dispatch, is being used by some 44,000 certified Emergency Medical Dispatchers in nearly 2600 EMS communication centers worldwide. The protocol contains a very clear and concise fast-track for critically ill patients that enables nearly immediate dispatch for patients in life-threatening distress, including those patients who are changing color and have ineffective breathing. Could it be that non-compliance to protocol, or the human factor cited as being absent in this case by the author, is the actual culprit?
A primary reason for using protocols in dispatch, in a compliant manner, is to decrease the type of variance cited in this article. The freelancing expressed as "human discretion" actually increases variance, and human variance has a long and negative history in EMS dispatch, especially with regard to dispatch delays.
Rarely is human error a special-cause variation in the workforce. In other words, we should certainly not blame an individual in haste when a bad outcome occurs. Far more often there is a process problem and the same types of errors can be found throughout the system. A less critical and far more effective approach to such problems is to utilize a sound quality improvement process to first ensure compliance to protocol, then measure the effectiveness of that protocol's processes, i.e., how long does it take to dispatch the right resource to a critically ill patient, and then improve the protocol or process as warranted. In reality, this is being done all over the world using the MPDS, and this particular process takes less than a minute, when done correctly.
Of course, anyone with a history in large EMS systems can tell you that implementing a sound QI process can be politically challenging due to the shear number and types of players involved. However, it can and has been done. As for the "human factor," it is absolutely essential in EMS dispatch, just not for the reasons cited in this article. While we can and should reduce the variance associated with freelance dispatching, we will always need the care and compassion and ability to "override" protocol in special-cause situations that only a human being can provide.
Brett A. Patterson
IAED Academics, Standards, & Research.
Andre BaumannThursday, October 18, 2012 9:16:12 AMWell done! If we would send ALS based on the fear in peoples voices, we would need 20 more ALS Units and still miss many cardiac arrests
Herb BrockettWednesday, October 31, 2012 1:12:08 PMRead the responses! The EMD system does allow common sense and rapid dispatch. This is likely an individual problem. The EMD process also brings huge benefits to the public and EMS providers by allowing a dispatched resource to be diverted to a higher risk incident without risking legal action. The whole move to EMD was a major step forward in service to the public.
Herb BrockettWednesday, October 31, 2012 1:19:46 PMThank you Brett, ...well said.
Bobby EugeneMonday, November 05, 2012 5:36:08 PMNot an individual problem, but an organizational one primarily due to micromanaging Chiefs who do not people smarter than them making decisions.