Emergency Medical Dispatch: A Changing Profession   added 10/14/01

It's 1958, and screams from the back yard propel you outdoors, where you find your 10-year-old son, Orville, lying under a large tree with an obviously broken leg. With his pleas to not be left alone ringing in your ears, you run into the house and dial the phone number for a nearby mortician, who also provides transport to the local hospital. He promises he'll be there as soon as he puts the last touches on the late Mrs. Jones, so you hang up and go back to comfort Orville while you wait for the mortician to arrive.

Fast-forward to 1998: An adult Orville has just fallen off the roof of his house, where he was trying to adjust a new satellite dish. A vigilant neighbor dials 911 on his cellular phone, and a skilled medical dispatcher leads him through a series of pertinent questions, verifies the address that's showing on the computer screen, and assures him that help is on the way. As the neighbor's phone disconnects, he hears the comforting sound of a siren in the distance.

Evolution of Dispatch

The first 3-digit emergency number was introduced in Britain in 1937 as the "999" system.¹ Not wanting to rush into anything, the United States took its time following suit. In 1957, the National Association of Fire Chiefs recommended using a single number for reporting fires, but the idea went unnoticed until 1967, when President Lyndon Johnson's Commission on Law Enforcement and Administration of Justice proposed a single number for law enforcement emergencies. On January 12, 1968, AT&T (Bell System) announced that 911 would be the universal emergency number. The first call to 911 was placed on February 16, 1968, in Haleyville, AL.¹

Today, approximately 85% of the United States (90% of the population) is covered by the 911 system, and 99% of the adults in those areas know they should call 911 for an emergency.

Dispatch As a Profession

Sewell began his career in 1983 as a police, fire and EMS dispatcher in the city of Pelham, AL, where, as the sole dispatcher in the center, the manner in which he handled calls was purely at his own discretion. His goal was primarily to get the basic information, hang up the phone and send what he thought was appropriate help.

"When I started working for Shelby 911 in 1990, one of my goals as assistant director was to see that people who called 911 had the same level of service that was the standard of care in the nation," says Sewell. Knowing he could provide that care with enhanced training, Sewell enrolled in a 3-day EMD training course from Madison, CT-based PowerPhone.

"I knew that dispatchers were no longer just taking information and hanging up the telephone," he says, "and it's well known that dispatchers can provide additional help to both patients and responders when they stay on the phone to give prearrival instructions."

Sewell is no longer the only medical dispatcher at Shelby County 911, and the center is now limited to fire and medical emergencies only. However, dispatchers are still cross-trained in law-enforcement dispatch techniques, says Sewell.

"If you take a call, you need to know what to do whether you're dispatching the call or not," he says.

Training aside, what are the characteristics of a good dispatcher?

"Obviously, an alert person who has learned to react to and recognize the need of the person who calls," says Sewell. "Someone who is willing to be trained, someone who cares about the person on the other end of the line, and someone who stays cool in stressful situations. I've found that the dispatchers who are most nervous and don't stay calm are those who don't have standard operating procedures to follow. If you have a written plan, you do a lot better."

Philip Salafia, Jr., president/CEO of PowerPhone, believes it boils down to old-fashioned common courtesy.

"We don't have time to be nice to each other anymore," says Salafia. "Well, 911 is a pinnacle of customer service. When I hear dispatchers say, 'People call me for the stupidest things,' I tell them, when an elderly lady calls to say her cat is in a tree, remember that the cat may be what's keeping her alive. You don't ask her, 'When's the last time you saw a cat skeleton in a tree?' You have to be kind."

When you speak about what makes a good dispatcher, the age-old argument invariably arises about whether a medical background, such as EMT/paramedic training, makes better dispatchers.

"Absolutely not," says Salafia. "You need step-by-step protocols and CPR certification. Dispatchers simply need confidence, and that comes through training."

According to Geoff Cady, manager of Access Management Solutions for Medical Priority Consultants in Salt Lake City, UT, there are two schools of thought: Sometimes EMTs and paramedics make good dispatchers, and sometimes they don't.

"Jeff Clawson [founder of the Medical Priority Dispatch System] will tell you that sometimes EMT and paramedic training puts an emergency medical dispatcher at a disadvantage," says Cady, "but their training can also be good in helping them determine the problem. For example, when an EMD asks a caller, 'What's the problem? Tell me exactly what happened,' most people say, 'I've got some indigestion, my back hurts a little, and I have a funny feeling but I can't tell you exactly what it is.' A dispatcher who has absolutely no medical background, because they have no orientation toward medical pathophysiology or disease process, would say that sounds like an upset stomach. Someone with medical training, however, might say, 'I was told once that heart attacks sometimes present as indigestion and back pain, so I'm going to choose the card for chest pain.' Selecting the right chief complaint is where past medical experience is a positive."

Where past training becomes a negative, says Cady, is when the individual believes that because of his prior training, he does not need to follow the protocol or ask all of the questions because he already knows the diagnosis.

"It also sometimes happens that those EMS-trained individuals have a predisposition to believe that certain complaints are not valid," says Cady. "A dispatcher might decide that 'the complaint is coming from Bob Jones over on the other side of town and he probably just wants a free meal at the hospital, so I won't ask him if he has chest pain.' Or that dispatcher might say, 'Bob, you don't have chest pain, do you?' and interject bias into the assessment by changing the syntax of the question. By following a protocol, we drastically reduce the possibility of a preconceived notion about the caller's integrity. Someone with no medical training other than the EMD program is much more reliant on the protocol."

Most paramedics make good dispatchers, says Cady, because they're used to following protocols and realize that they enhance their ability to provide care. EMTs, on the other hand, are not so accustomed to following advanced protocols and have just enough training to get them in trouble. In addition, EMTs and paramedics are used to working in a visual environment, which is very different from the nonvisual environment of the dispatch center.

"In the nonvisual environment of EMDs, they have to assume certain things," Cady adds. "For instance, EMDs are often talking to a second-party caller, who has to look at the patient and make determinations. One of our priority dispatch cards says, 'The first direction the EMD gives a lay person for managing a patient's airway is: If there's a pillow or anything behind his head, please remove it now.' If someone is unconscious or unresponsive, most people will put a pillow behind his head because they think it makes him more comfortable, but it actually obstructs his airway. The EMD has to assume the pillow is there, and the card is one of the tools that helps compensate for the fact that he or she can't see the patient.

"As a paramedic, I wanted to believe I could rely on my own wits, and using a structured protocol process takes away your judgment and turns you into an automaton," Cady continues. "In reality, you use your judgment every time you have to figure out which chief complaint to go to and, after asking the questions, know how to interpret the answers."

Emergency medical dispatch is slowly becoming recognized as a profession say Sewell and Salafia, but many systems are reluctant to provide dispatchers with adequate pay and training.

"Our philosophy is that the person who answers the phone in a police, fire or medical emergency is truly the first person at the scene, and we have to build on that person," says Salafia. "Unfortunately, many EMS personnel directors believe it's a job that simply involves answering the phone and they should therefore be paid clerical wages. That's a mistake. We have to invest in these frontline people. We held a 40-hour program for a large agency a couple of years ago and insisted that the personnel who were rewriting job specifications for the dispatchers attend the class. After hearing some tapes of actual 911 calls, they walked out amazed at the demands placed upon dispatchers."

"If someone is interested in becoming a medical dispatcher, I would suggest checking with their local department to find out the procedures for doing so," says Sewell. "I believe pay and recognition are getting better, but, over the years, I don't feel the communications operators have received the recognition they deserve. Agencies are beginning to recognize how vital dispatchers are and how important EMD training is. Here in Alabama, a new law has gone into effect saying that if you provide ALS services to the community, you can't renew your drug license unless your dispatchers are EMD-trained. That's a big step in the right direction."

Legal Implications

Mistakes could be reduced to a minimum with adequately trained medical dispatchers and protocols that meet or exceed National Highway Traffic Safety Administration (NHTSA) standards, says Salafia.

"It's antiquated thinking when administrators say 'We're exposing ourselves to more liability when we give prearrival instructions,' because it's not true," he says. "When a 911 emergency call is handled incorrectly, there are at least two things that will almost certainly happen: Someone is going to get hurt; and someone is going to get sued as a result."¹

As a liability representative for VFIS Claims Management, Inc. of York, PA, Steve Forry, EMT-P, has seen the results of badly handled calls more times than he cares to remember.

"An ultimate goal of mine is to get the word out to people that if a call starts out wrong, it seems to go bad from there on down," he says. "We have to send the right people in the right vehicles to the right patient, using the right response mode at the right time. That's the goal of any priority dispatch program."

It sounds so logical, yet many systems administrators remain reluctant to invest the necessary time and money in EMD training.

"The main barrier, as I see it, is that people are afraid to accept the additional liability of becoming a priority dispatch center," says Forry, "but the medically driven protocols make so much sense to good patient care. If something does what it's supposed to do and requires fewer vehicles running red lights and sirens where they're not needed, we're all for it. In our business, probably 60%-70% of the claim dollars we pay out at one time are directly related to emergency vehicle collisions. That is very inappropriate, very unprofessional, and nine times out of 10, the claims that come across my desk are for injuries that are more serious than the calls they were responding to."

Forry hesitates to place blame on the dispatch centers, although he believes that many EMS systems continue to dispatch all ambulances with red lights and sirens on any calls to 911.

"Unfortunately, the more you do that, the more chance there is for it to go wrong," says Forry. "You're usually going above the posted speed limit; you're going through intersections and red lights; you're passing people in no-passing zones; and you're confronting traffic in oncoming lanes. Without red lights and sirens, you don't do that. In the insurance industry, we have a saying, 'With frequency, comes severity.' The more small accidents you have, it's only a matter of time until the big one."

With 28 years in EMS, Forry says he's known of numerous paramedics, EMTs and firefighters who were jailed for emergency vehicle collisions-some on felony charges, which means the end of an EMS career.

"Another problem is volunteers responding in their private vehicles," says Forry. "In one incident, a volunteer heard a dispatch on his radio saying, 'Respond for a head-on collision: people entrapped, people in the roadway, children involved, wires down.' As he headed for the scene, he was involved in an accident in an intersection 3 blocks from the incident and later went to jail for 2-10 years for his involvement. Ironically, the ambulance service that arrived at the call that had sounded so bad signed off six patients against medical advice.

"If we're sending every call down the road red lights and sirens, the dispatchers aren't doing their job," Forry continues. "This doesn't abate any responsibility on the emergency vehicle operator, of course. If they're told to respond red lights and siren, it's not the dispatcher's fault if they have an accident-it's the driver's responsibility."

Untrained medical dispatchers are, however, responsible for mishandling calls, says Forry.

"In one instance, a dispatch center told a caller, 'Ma'am, you aren't in our area. Call this number.' The next dispatcher told her the same thing. Some 35 minutes later an ambulance finally arrived at the location, only to find the victim dead from a cardiac arrest at age 43. The courts and jury agreed with her family that this was negligence-the dispatch center did not do that which is expected of a 911 center in an emergency-and awarded the family $3 million."

In another precedent-setting case, an ambulance responding to a hospital red lights and siren with a patient who had a sprained ankle went through an intersection at a high rate of speed, hit another vehicle and made an innocent driver a brain-traumatized quadriplegic.

"A jury awarded the family $4.97 million," says Forry, "and the city deserved that. We can no longer afford to operate with the fly-by-night, 'you call, we haul' mentality. We're being called to a different level of expectation, and we should only be sending the right people in the right response mode to the right patient."

EMS, fire and law enforcement agencies can avoid costly lawsuits by offering prearrival instructions only in the context of strict procedural protocols, says Salafia.

"If clear, competent protocols are put into place allowing dispatchers to respond to each type of emergency with standard, predetermined instructions, liability and legal costs may actually be reduced," he says.¹

Not only will these agencies benefit under a structured system, he adds, but the public will receive the immediate assistance it has come to expect when calling 911.

Protocol Controls

A few years after its inception, Jeff Clawson, MD, began to realize that the Medical Priority Dispatch System (MPDS) he had created in 1978 could not be managed by a single person, says Geoff Cady.

"He knew that it needed an expert body of members who could collect information about what was happening in the evolution of remote or telephonic triage, and it should be a collaborative effort of getting these people together to discuss what they had discovered about MPDS use in their own systems," Cady explains. "Thus, in 1988, the National Academy of Emergency Medical Dispatch (NAEMD) was created as a users' group of the MPDS. It is a nonprofit organization that is responsible for the medical management and evolution of the protocol. Several boards and councils review the medical literature to make certain the protocols comply with national standards in areas like CPR, the Heimlich maneuver and emergency childbirth.

"Among them is a group called the Council of Standards," Cady adds, "which takes user recommendations that are research-based and looks at the syntax of the protocol (how the questions are worded), the organization and number of questions, and what end point is reached by how those questions are answered. Users may submit a form called Recommendations for Change, which is then reviewed by the Council of Standards committee. There were more than 200 changes in the last updated protocol and more than 1,000 changes since its inception."

The Council of Standards will be meeting in September to look, among other things, at what role the NAEMD should play in forwarding the profession of emergency medical dispatching, says Cady.

"The Academy is also responsible for accreditation of EMS communications centers," he says. "That process certifies that the dispatch agency is complying with or exceeding all national standards related to EMD."

Computer-Aided Dispatch

"In the early days of priority dispatch, we had a recordkeeping CAD system with flip cards that dispatchers went through to determine prioritization," says Maloney. "The flip cards were on the side, and the CAD system was just for tracking and times. Then, we decided to computerize the cards and bring them into the CAD system, so today we have a fully integrated system where medical triage is part of the call-taking process.

"In San Diego, when a 911 call comes in, the user immediately begins to enter information into the CAD system," explains Maloney. "At some point, it automatically triggers the priority dispatch system and a new screen comes up taking the caller through a highly structured series of questions to determine the priority of the call and the chief complaint. That automatically feeds back into the CAD so we know what to do: Do we go fast? Do we send one ambulance or two? Do we send an ambulance with a fire truck? Do we go at all?"

Mapping systems, which show the dispatcher where an incident is, which emergency vehicles are closest to the scene and how they should get there, are a recent advent in CAD systems, says Malone. But although mapping wasn't available prior to 1992, almost all of today's CAD systems include maps, he says. Dispatch maps are very simple and attuned specifically for dispatcher use, and most vendors now supply maps along with underlying data that go with the CAD system.

One place where CAD systems have had a major impact are rural areas. In some parts of the country, street names are replacing box numbers and fire-code signs to enable emergency responders to locate specific addresses more easily.

"Without a mapping system in some rural areas, you're out of luck," says Maloney. "Acadian Ambulance Service in Louisiana services about three-quarters of the state and operates out of one dispatch center for the entire area. You can imagine the folks in Lafayette aren't familiar with the whole Atchafalaya Basin-they rely on the mapping system to get there."

For economic reasons, in particular, strategically placed dispatch centers are becoming quite common in some areas, says Maloney.

"In the private ambulance sector, it isn't efficient to operate individual dispatch centers," he says, "so most of the largest companies like American Medical Response and Rural Metro have established centralized dispatch centers. Some cover half a state out of one center, but to do that you have to have a sophisticated system."

It's also important to remember when doing centralized dispatch that medical protocols may vary between counties, says Maloney, so the CAD system has to be able to regionalize its medical advice based on the address that is put into the system.

"Also, in Acadian's case, one parish may have an 8-minute response time and a 10- or 15-minute standard in another," Maloney adds. "So the CAD system has to adapt to those changing contractual assignments, as well."

In spite of modern-day, advanced technology, cellular phones have created a major headache for CAD users due to the difficulty in identifying a caller's exact location.

"When cellular systems first came into place, there was no thought given to what would happen if you called 911 on a cellular phone," says Maloney. "Initially, if you were out of range when you called 911, you'd get 911 in your home state. That got sorted out, but the dispatch centers still can't identify a 911 cellular caller unless they're in an area with enhanced 911. The FCC has mandated that all cellular providers must provide E-911 by a certain date, but CAD systems will still be key because the cellular providers can't really tell where you are. They can give a position, like a latitude/longitude coordinate of where the user is, but if you don't have a CAD system, how would you know what that means? It's critical to have a mapping CAD system to place the caller on a map using those coordinates."

Are CAD systems affordable for rural and small-systems providers?

"I think so," says Maloney. "The technology we use is very expensive, but companies are starting to offer different mechanisms to get into the technologies. For example, if Duluth, MN, couldn't afford a $1 million CAD system, they could rent one on a monthly basis, or pool their resources with several other agencies to create a joint dispatch center."

Future of Dispatch

As far as CAD systems are concerned, Maloney doesn't foresee a lot of changes.

"We've advanced computer-aided dispatch to the point that we're using a lot of the most current technologies: mapping, automatic vehicle location, mobile data technology and Medical Priority Dispatch," he says. "I'm not sure there won't be changes yet to come, but I think the most significant changes have already taken place. All we're really doing now is augmenting existing systems with great information, but we aren't advancing the technology. We're just using technology to advance the science."

As creator of a priority dispatch system, Salafia is adamant about the importance of EMD training and certification in the integrated atmosphere of fire, EMS and law enforcement. A hit-and-run accident with people hurt and gasoline all over involves all three disciplines, he says, and dispatchers must be trained to immediately identify the problem and send out appropriate resources.

"The National Institute of Statistics says that 87% of police officers who are killed or injured are killed or injured prior to the arrest phase," he says. "When we look at that statistic, we have to examine how they were sent to the scene. We lost three firefighters who were dispatched to a dumpster fire-a routine call, but the dumpster was full of batteries, and when the firefighters arrived, the batteries exploded and the firefighters were killed by flying shrapnel. So we have to take an investigative and journalistic approach to dispatch: who, what, when, where, why, how, plus weapons. And to ask the right questions and give proper prearrival instructions, dispatchers must have the ability to jump from a fire incident, to a police incident to a medical situation using an integrated approach to give prearrival instructions in all three disciplines."

It's obvious that funding and managed care will greatly impact the future of dispatch. In states like California, it's already happening, says Forry.

"Kaiser Permanente of California is now in the process of bidding the entire state of California, as well as parts of Oregon and Washington, to a single ambulance contractor, who will subcontract with ambulance services that have what we call 'alternative patient transport systems.' Right now, if a call comes in for someone who needs to go for an MRI, the service sends out an ambulance with two EMTs to transport the patient to the MRI machine. Well, she doesn't need any care-she needs transportation in a van with one EMT. Another thing that will happen, without a doubt, is that a patient who calls 911 with a diabetic emergency won't necessarily get carted off to a hospital. That person may just need to get his insulin regulated or need to remember to eat after taking insulin, so the managed care organizations are saying, 'We aren't going to transport you to a hospital. We'll take you to your family doctor, and we'll send a Ford Taurus around to pick you up.'

"In reality, less than 5% of the patients we respond to in the entire United States ever meet the definition of a life-threatening emergency," says Forry. "If you get a patient who has crushing chest pain, diaphoresis and shortness of breath, he's fixing to die and needs all the EMS the system can send. But the patient who hurt his back three days ago and now wants to go to the hospital needs a van with a stretcher and an EMT, and that's it."

Geoff Cady agrees.

"At our company, we asked ourselves if there was a way from the communications center that we could hand off a caller who didn't need the traditional EMS response," he says. "Was there a way to take a number of the chief complaints coming in, ask a couple of additional questions and determine that it was safe to refer them somewhere else?

"At Medical Priority Consultants, we use the Delta, Alpha, Bravo, Charlie scenario, with Delta being people who are dying and Alpha representing people who don't need ALS intervention but, because our system traditionally sends an ambulance, they'll get a BLS ambulance to the hospital. Jeff Clawson recognized that the Alpha cases really didn't warrant ambulance transport but they probably needed to see a medical professional at some point. He determined what those presentations would be and developed the Omega protocol, which is the fifth determinant that is even lower priority than Alpha."

Patients who fall into the Omega category are now referred to medical call centers, which, says Cady, are primarily staffed by nurses. With the right clinical decision support technology and further advancement of EMD, however, he believes there will be an expanding role for EMDs, as well.

According to Cady, several cities are currently exploring the idea of adopting the Omega protocol, including San Diego, Salt Lake City, New York City, and large communities in Florida, Tennessee, Texas and Massachusetts.

"We've talked about expanded-scope medicine for some time," Cady adds, "although we haven't seen much of it yet. But we recognize that there are advantages to having mobile fleets and have looked at whether we could use physician assistants or nurse practitioners to go to patients' homes instead of taking them to a hospital. It's possible that some day, if we aren't sure at the end of the dispatcher's clinical interrogation as to whether this patient needs an ambulance, we'll dispatch a provider in a vehicle that can carry the necessary equipment, who gets on scene and completes the assessment. That information, possibly done on a handheld computer, will then be amended to the original question/answer sequence at the EMD level and we'll begin to build a longitudinal patient record."

There's no question this will create some stakeholder issues, says Cady: Paramedics don't want EMDs to take over their responsibilities; nurses don't want paramedics to get in their way. In the long run, says Cady, anything that prevents EMS going on unnecessary calls leaves more time for them to engage in preventive activities.

As we approach a new century, Cady believes there are still myriad changes to come.

"I predict that EMD's professional status will increase, but it has to be with the realization that responsibility and accountability go along with that," he says. "Their ability to multitask and use sophisticated computers and phone/radio systems will be a big part of their job responsibilities."

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