Search Terms: Medical miranda, extending priority dispatching, Jeff Clawson, dispatch priority protocols, police mentality, advanced life support (ALS), priority card system, necessity to ask, arriving scene officer, four commandments, medical dispatch, tiered response system, pre-arrival instructions, direct communication, rational discussion, law enforcement, law enforcement agencies, 20 questions game

Journal of Emergency Medical Services (JEMS), March 1985
Jeff J. Clawson, M.D.

"Dispatch, Patrol Car 15. Call city fire and have them send their paramedics over here right away." How do most paramedic providers respond? They send over the paramedics, of course. And why not? The police ordered it, didn't they? But how did they assess the need for paramedics? If this is a trauma case, what will ALS personnel add to the victim's definitive care? Do they really mean they need advanced life support?

Since the advent of dispatch priority protocols, the practice of sending paramedics on request is finally disappearing, It makes sense. Often law enforcement officers don't clearly understand that paramedics aren't just better EMTs, but that they offer specific additional treatment adjuncts. That they add little to the treatment of most non-critical trauma is not usually perceived.

We have instructed our EMTs that a request for "paramedics" means that "emergency medical help is needed." Tell us what you've got and we'll apply dispatch protocol and send the appropriate medical personnel. Unless every officer carries a set of 32 priority cards in his pocket, he can't possibly request, on a consistent basis, the correct personnel and response configuration in a multi-unit, tiered response system. Yet the "ham-on-rye" practice of "ordering" paramedics happens every day in every part of North America.

In case you're wondering, this is not, in any way, an ill-thought our slap at "police mentality." Let me illustrate. Suppose police arrive first at the scene of a car vs. tree accident in which it is obvious that a woman is pinned in the wreckage. The officer immediately radios his dispatcher to request the fire department to "send the paramedics." The officer attends to the victim while awaiting the arrival of a nearby paramedic unit. As it pulls up a few minutes later, the officer yells, "She's trapped in the car. Bring your jaws-of-life." Everything's okay so far you say? Wrong! Ask the bewildered paramedics who reply, "We don't have the jaws. They're on Rescue-12 near the freeway entrance four miles from here." Access to the victim is delayed an additional seven minutes.

To the officer in this case, "paramedics" meant "extrication"-not advanced life support. Had the officer indicated to dispatch what the problem was, Rescue-12 would have been initially dispatched to extricate. Even if every unit had heavy extrication capability, how many police officers were told at morning report that your jaws were down for repair or that your MAST suit hadn't been returned yet by LifeFlight. This "what if" case happened to us and it helped to make a very important point with our police administration who likewise want the best, most efficient care for their citizens.

From our experience in Salt Lake City, we can suggest some relatively simple solutions. If law enforcement doesn't understand new necessities and capabilities based on our recent evolution in medical dispatching they can't possibly be expected to mysteriously adapt to our needs. We have to rationally explain our improved methods to them. And if I know the caliber and professionalism of the majority of law enforcement agencies, they'll come through. But not until you take the effort to meet, discuss, and plan with them-not just sit back and complain about the "damn cops."

Our meeting with the city police administration was, to their credit, generated by them to ask about what they referred to, not comically, as our "20 questions game." During that meeting, we described the priority card system and the necessity to ask a minimal number of questions to ascertain the appropriate response, whether paramedic/engine, EMT/engine, private BLS ambulance, or combinations of the above. It wasn't surprising to us that the "damn cops" understood the first time. They didn't squirm, change the subject, or call "King's X." They merely stated, "What specifically do you want our scene officers to relay to you on each case?"

Well, what would you want dispatch to know if the answers to a generic set of questions could be relayed from each first arriving scene officer? Simple, start with the "Four Commandments" of medical dispatch: 1) chief complaint, 2) age (approximate), 3) status of consciousness, 4) status of breathing. "Anything else?", the police major asked. Yes! If the case is medical, does the victim have chest pain? If the case is trauma, is uncontrollable hemorrhage present? "No problem," he replied, "Is that all?" Well, if any additional information or special circumstances are appropriate or apparent, such as the need to respond red light-and-siren, relay them to us. End of meeting.

To accomplish this, we decided upon a two-part approach. First, we would present a mandatory four-hour in-service to all patrol personnel. This meant three sessions to catch all 375 city police officers. These were scheduled immediately. The four-hour training sessions included a description of the fire department's tier response system, and how the response mode and configuration are determined through interrogation. Copies of all dispatch priority cards were given to each officer and the important priorities on appropriate cards were reviewed. Pre-arrival instruction example tapes were played. A brief explanation of another area of EMS directly applicable to police activities, Salt Lake City's unique EMS Abuse Ordinance, was given. In addition a number of very interesting questions were posed by some very savvy officers.

The second phase of the solution involved the introduction of the "generic" questions plus three additional "optional" questions for either medical or trauma printed on a card to be carried by all city police officers. This card we have affectionately entitled, "Medical Miranda" (see Figure 1).

The subsequent result has been better initial information and fewer relays of questions between police and EMS. The problems have not disappeared but some important ground has been broken. We also found out that "the other guys," in this case the "cops," were just as interested in good citizen and, therefore, patient care as we were. As usual, the answer lies in direct communication and rational discussion followed by as game plan involving some definitive methods to effect the necessary instruction and, as a result, the desired change.

We feel that the simple instruction of a "Medical Miranda" approach to extend the concept of priority dispatch to law enforcement has significant potential to improve information secured from the scene and to effect appropriate allocation of our medical response resources in every case possible.

MEDICAL MIRANDA

Appropriate response of EMTs or Paramedics

depends on you to relay the following minimal

information to Medical Dispatch through your

Dispatcher:

1. Patient complaint or type of incident
2. Approximate age
3. Conscious: yes/no or alert?
4. Breathing: yes/no or difficulty?

Medical case and age over 35:

IS CHEST PAIN PRESENT?

Trauma/injury case:

UNCONTROLLED HEMORRHAGE?

Response mode:

RED-LIGHTS-AND-SIREN