First Party Gone-On-Arrival
A New Danger Zone in Dispatch
By Dr. Jeff J. Clawson

First party callers are usually easier to deal with than other callers who often are more remote from the patient. First party (patient) callers constitute approximately 10-15% of all EMS callers. However, one challenge to dealing with these usually straightforward patients is the fact that there may be no one to watch over them during the response interim or to come to the door on arrival. Every patient has the potential to do three things after their evaluation by the EMD. They can get better, get worse, or stay the same.

First party callers are no exception. If they get worse and suffer a decrease in level of consciousness, become too weak to shout or ambulate, or just outright collapse, the situation is dramatically altered for the EMD and the responders. What should the EMD do if the arriving crews report back to dispatch that nobody appears to be at home, the doors and windows are locked, and a call back from dispatch goes unanswered? Only breaking in will answer the question of whether the patient is actually "gone-on-arrival" versus incapacitated or dead. What to do?

Several recent legal cases have pointed out the problems that exist when contact is lost with first party callers. Since so many of these cases have been reported and resulted in lawsuits, this new type of EMS and dispatch "Danger Zone" needs to be addressed.

Case in Tennessee: On March 24, 1993, a 45-year-old male called 9-1-1 from home to report he was having "real bad chest pains." The dispatch case transcript revealed the following interrogation and advice:

911 Calltaker: 9-1-1

Simmons: uh, yes... uh... this is Tony Simmons. I’m in... uh... uh... Concord Hills.

911 Calltaker: Uh, huh.

Simmons: I’m having these real bad chest pains...

911 Calltaker: Okay, you need an ambulance?

Simmons: ... and I’m here by myself. And I don’t know if it is... this is indigestion or what.

911 Calltaker: Well, it doesn’t pay to... to wonder. Okay, I’m gonna connect you down to the ambulance service so... a... they can talk to you about it. Okay, so we’re gonna get somebody started.

911 Calltaker: (unintelligible) answers the paramedics, so they can put you on the phone, too.

911 EMS: Emergency Medical Services.

Simmons: Yes, I’m Tony Simmons. I’m up in Concord Hills.

911 EMS: Uh, huh.

Simmons: I’m here by myself and I started just a little while ago having these real bad chest pains. And I don’t know if it is some indigestion or what. But I’m not feeling very good.

911 EMS: Okay. How old are you?

Simmons: I’m 45.

911 EMS: 45. Okay, and you’re at {address on screen verified}?

Simmons: That’s right.

911 EMS: Okay. I’ll get somebody out there. Have you ever had any chest pain or a heart attack before?

Simmons: No. Never have.

911 EMS: Okay, I’ll get somebody out there to you.

Simmons: Thank you.

Simmons then called his secretary at work to let her know he wasn’t coming in and asked her to notify his wife. The paramedics arrived to find no one apparently at home. After a walk around check of the residence revealed no signs of an occupant except a dog barking in the house, the dispatcher was requested to call back and reported to the crew, "Patient probably went by POV." Dispatch also tried calling a local hospital to determine the possible whereabouts of the patient, to no avail. Simmon’s wife came home half an hour later to find him dead. A lawsuit resulted.

Case in Chicago, Illinois: About 8 a.m. in October, 1995, a 26-year-old female called 9-1-1 to report a severe asthma attack:

Kazmierowski: I need help.

911 Calltaker: What happened?

Kazmierowski: I’m having an asthma attack.

911 Calltaker: What?

Kazmierowski: It’s so bad.

911 Calltaker: What?

Kazmierowski: Is this 9-1-1?

911 Calltaker: Do you need an ambulance?

Kazmierowski: Yeah.

911 Calltaker: I’ll connect you. Hold the line. After two rings, a fire department dispatcher takes the call. Kazmierowski can be heard wheezing and struggling to breathe.

Fire/EMS Dispatcher: Fire Department.

Kazmierowski: Oh, God. I need an ambulance.

Fire/EMS Dispatcher: Fire Department.

Dispatcher repeats, "Fire Department," seeming not to hear the caller.

Kazmierowski: I need an ambulance–forty-five twenty Greenview.

Fire/EMS Dispatcher: Forty-five two oh Greenview?

Kazmierowski: Forty-five two oh. I can’t breathe.

Fire/EMS Dispatcher: What floor are you on?

Kazmierowski: I’m on the third floor. Please come up.

Fire/EMS Dispatcher: Yeah, we’ll be over. What’s your phone number?

Kazmierowski: I think I’m going to die — hurry!

Fire/EMS Dispatcher: Just let me read it out.

The dispatcher read back the telephone number to the caller and the call was disconnected. The paramedic ambulance crew entered the apartment building and knocked on the front door; they also heard a dog barking. After the paramedics failed to get an answer, a neighbor opened his apartment to let them knock on her back door. Still no answer. A call back to the residence went to an answering machine.

After 15 minutes the crew left having never attempted to open the door, which was unlocked at the time. Kazmierowski’s boyfriend found her lifeless on the bed later that afternoon. At a recent EMS conference, a former employee of the City defended their performance in this case on the premise that the paramedics had no legal responsibility to attempt to open the door if the patient didn’t open it on request. After an initial Appellate Court ruling that the City was immune from damages, in an unusual move the Illinois Supreme Court agreed to review the case.

Case in Texas: On July 25, 1996, a 55-year-old female with post-recurrent polio syndrome was in her motorized wheelchair gardening in a field adjacent to her house when she hit a depression in the dirt and the cart overturned. The caller historically had trouble breathing when not sitting up. She called 9-1-1 from a mobile phone on the cart, obviously in distress and vaguely stating what was later interpreted as, "Help. I’m… I’m…a field, I’m dying."

The initial calltaker thought she said, "Help. I’m… I’m… ill, I’m dying," after which the caller did not speak. Five minutes later the line went dead. The calltaker, using enhanced 9-1-1, called back but only got the answering machine. They immediately called the fire/ambulance department to respond and had also sent a deputy sheriff. Interestingly, the sheriff’s calltaker stated in a very caring tone to the ambulance EMD, "When people say that [I’m dying], they usually are." Another call was received from the residence but no one spoke and the line went dead again.

After multiple searches inside the house failed to locate the patient, a multi-person circumferential search (of a disputed distance) around the caller’s semi-rural residence was also unsuccessful. After law enforcement’s inquiry of a neighbor, no one was found and the patient was assumed to have left with her husband. Later he came home and found her dead, 50 yards from the house and partially hidden in some relatively tall weeds.

In the resulting lawsuit the jury found for the various dispatch and public safety defendants, based partially on the fact that a reasonable attempt to locate a patient cannot be defined by how much further out an unsuccessful search should be extended. We call this the "just a little further would be better" philosophy, which seems nice on the surface but would obviously be difficult to use as the basis for an objective standard of practice. In this case, while the parties agreed the search was not optimal, the jury determined that a reasonable effort had been made before leaving the scene.

Case in Georgia: On July 6, 1986, the following call was received at a large public safety dispatch center. Obviously this case involved a first-party caller who only produced grunting noises throughout the entirety of the call. The calltaker apparently did not recognized the caller had a major problem and on several occasions threatened the caller (judgment danger zone). The following is a partial transcript:

Dispatcher: Hello?

Caller: (grunting)

Dispatcher: Hello? What's your address?

Caller: (grunting)

Dispatcher: Hello? What's your address?

Caller: (grunting)

Dispatcher: Do you need a police out? Cause if you're playing on the ph... if you're playing on the phone, officer's gonna come and take you to jail.

Caller: (grunting) Time passes as the dispatcher continues to ask caller for information.

Dispatcher: Do you need an ambulance out?

Caller: (grunting)

Dispatcher: Do you need a police out?

Caller: (grunting)

Dispatcher: Hello? I'm gonna hang up if you don't tell me what's the problem.

Caller: (grunting)

[For more complete transcript of this case, see Hendon Case, Principles of EMD, 2nd Edition Chapter 8: Time-Life Priority Situations, pp 390-393.]

This call, an amazing 55 minutes long, had an equally amazing ending. Upon successfully tracing the call, the fateful decision to only send a police unit was made. According to case depositions, on arrival the police team found a car in the driveway, but after a careful walk around the outside could see no evidence of anyone in the locked house. The older, more experienced officer mentioned enroute that he had responded to this location in the past and that the occupant was an alcoholic. He then recommended leaving. The rookie officer, however, insisted that more be done, even suggesting they break in. The older officer then called dispatch and asked, "Do you still have the RP [reporting party] on the line?" The dispatcher replied, "Yes, but he’s refusing to come to the phone." Upon hearing the dispatcher’s misinterpretation of the facts, the officers drove away.

Nearly a day later, the patient’s son found him lying in the house, critically ill from a massive stroke. Upon regaining some ability to speak the caller recounted how he had actually called 9-1-1 several hours before the call transcribed here, but was hung up on. The patient apparently was not currently a drinker nor a derelict, but was a recently retired superior court judge for the region. Not surprisingly, a lawsuit followed.

It is always wise to exercise caution in ruling out a serious problem that may be preventing the patient from answering the door. Retrospectively, calls resulting in a non-answering patient at a residence likely involve first-party callers (otherwise someone else would have answered the door). This should be a warning sign that increases the responsibility to rule out serious patient deterioration before giving up. In any first-party case involving a reasonable chance of patient deterioration, such as the patient with chest pain, it is advisable to stay on the line with the patient. Any subsequent inability of the patient to meet the arriving units would then be clearly known.

Creating a Policy for Gone-on-Arrival
In the absence of a national standard policy, it isimperative that every communication center has awritten local policy regarding what to do, who tocall, and when to leave the scene in first-party, possibly“gone-on-arrival” cases. Law enforcement notificationand response is the norm in these situations.Never assume that a first-party caller patient “hasleft” until that has been reasonably established basedon an in-place policy. In such a policy the followingshould be considered for inclusion:

1. Call-back several times on the verified callbacknumber. Establish a minimum number ofcall backs. With call waiting and call messaging,what appears to be a “not home” may be a“non- (or can’t) answer” for a variety of reasons.

2. Verify that any callback number that is notanswered is indeed a correct number. Evenenhanced phone systems may contain errorsthat can be corrected by a standardized tape ordigital playback procedure.

3. Crews should not be advised to break inunless a clear policy is in place and/or theyhave legal authority or the approval of lawenforcement.

4. Responders have a responsibility to exercisedue regard in determining that a first-partycaller is indeed gone. A well-articulated policystatement to this effect will set forth areasonable process, as well as a reasonable limit,to such searches.

5. Animals impeding (or apparently impeding)entry or access should not alter theresponsibility to locate the patient. When itis obvious that additional help in the form oflaw enforcement or animal control is required,do not hesitate to request it. Again, a reasonableattempt to isolate or bypass the animal isrequired. Leaving because of hearing barks orhowls without actually seeing the animals mayadd the embarrassment of learning later thatthe pet was a miniature poodle named “Fluffy.”

6. Certain critical determinant codes that are tobe given an extra level of regard, or thatwarrant a legal break-in, should be explicitlylisted (i.e., 10-C-1, Chest Pain with abnormalbreathing). Essentially, the clinical ranking of adispatch determinant code can strongly suggest(or discourage) that a patient who appears to beinitially stable, could later deteriorate.

Jeff J. Clawson, MD: Widely recognized as the "Father of EMD," he is a founder of the Academy and inventor of the Medical Priority Dispatch System™.