Search Terms: Medical professional, medical profession, emergency medical dispatching, EMD protocol, performance, professional standing, EMD's role, prehospital care providers, medical control physicians, governmental authority, professional certification, medical protocols, emergency medical dispatcher (EMD), nonvisually, lack of direct patient access, similarities, interrogative skills, the 60-second dilemma, four commandments, compliance, essential elements, basic life support provider, paramedical practice methods, peripheral brains, protocols, remote assessment, out-of-hospital providers, the EMD/EMS partnership, JEMS, 1996
Journal of Emergency Medical Services (JEMS), May 1996
The EMD as a Medical Professional
There is probably no medical profession other than emergency medical dispatching in which the core time for patient evaluation and decision making is routinely around one minute, and more is potentially at stake on a case-by-case basis. Unfortunately, the emergency medical dispatcher (EMD) is not generally accepted as a professional by EMTs, paramedics and other members of the medical team. Thus, EMDs occupy a somewhat ambiguous roles within the medical profession and public safety agencies.
Early in the history of emergency dispatching, dispatchers were seen as little more than public safety clerks. Early functions essentially consisted of identifying the emergency's location, determining which unit should respond, then notifying the units of the call and tracking their progress.
In 1978, the first comprehensive emergency medical protocol tool was developed, and EMDs were born, ushering in a new era of EMS delivery (1). Since then, the EMD protocol and process has evolved as the EMD's performance has been shown to be an effective adjunct to emergency medical care (2). This formal dispatch method-radical at the time-had redefined the EMD‚s role and professional standing (3,4).
One of the difficulties EMDs have in gaining acceptance as medical professionals is that the rest of the medical profession isn't clear on the EMD's role and whether the EMD's tasks are truly medical. Most prehospital care providers are directed and regulated by medical control physicians and some form of governmental authority (5,6). In contrast, EMDs are typically hired, trained, managed and paid by law enforcement, fire or ambulance agencies. They have limited or no medical direction and little or no government regulation. In many areas, the EMD's practice lacks adequate medical control and management. No quality improvement is undertaken, and the dispatchers lack professional certification (7). However, properly trained EMDs performance is based on medical protocols similar to other medical professionals except in two ways: a lack of direct patient contact and the decision-making time frame.
EMDs essentially practice their profession via remote control, dealing nonvisually with someone who is generally not the patient. The lack of direct patient access requires EMDs to rely heavily on interrogative skills. However, with tested protocol-driven questioning, EMDs can successfully elicit the necessary information to dispatch appropriate personnel with adequate information (8).
Unfortunately, in addition to the physical constraints, there exists system-imposed time limits on emergency medical dispatching. "The 60-second dilemma" was a phrase coined several years ago to emphasize that in today‚s high performance EMS systems, the EMD has only 60 seconds to interrogate (i.e., evaluate the situation) and render a decision (i.e., provisional diagnosis). Very few, if any, medical professionals are required to consistently perform the evaluation and decision-making part of their patient care process in 60-seconds. Even more astounding is that there is no scientific rationale for the 60-second time frame.
The 60-second time interval should be used as a goal or objective to strive for in most situationsųnot a rule or absolute upper limit. In most medical situations, the time to dispatch should not be treated as a ticking time bomb, since the majority of incidents are not escalating in any appreciable way, whether life-threatening or otherwise. With this in mind, 75 to 90 seconds is more a reasonable goal for most calls of a non-time-life priority basis, and some places are instituting just that. As Thera Bradshaw, past-president of the National Emergency Number Association recently said, "It's time we start doing it right, not just fast."
Fortunately, the similarities between EMDs and other medical professionals are more prominent. In fact, the individual practice of a physician-managed EMD closely resembles the emergency medical model. (see Table 1.)
The elements of medical care cross over easily and are equally relevant to both groups. For example, the primary survey must be as consistent and complete for the EMD as for the hands-on medical provider. No one can afford to abort or supersede this evaluation, no matter if other findings seem obvious. The importance of this is reflected in the EMD's term for the dispatch primary survey: the "Four Commandments." Like an EMT who checks the airway but not breathing and circulation, an EMD who doesn't not always ask these four questions risks missing essential information. As with an EMT's secondary survey, the answers provide relevant information regarding patient care, scene safety and response choices. Omissions in this information-gathering process can result in sending the wrong response and providing the wrong treatments. Table 2 outlines the essential areas the interrogation covers.
Perhaps this point can best be made by asking yourself, "When you or a family member are taken to the emergency department, do you want the emergency physician to perform a complete or incomplete evaluation?" Keeping in mind that each of the interrogation questions may lead to a different evaluative conclusion, different treatment, different information relay or different advice, EMDs cannot assume answers to questions they never asked. It is true that "a thing not looked for is seldom found."
Compliance to the EMD protocol ensures all essential elements will be "found," and clarification or expansion of the protocol will be accomplished only when necessary. In fact, EMD training directs that "dispatch personnel will follow all protocols per se, avoiding freelance questioning or information unless it enhances, not replaces, the written protocol questions and scripts."
The EMD as an ALS Professional
It is widely believed a trained EMD is essentially a basic life support-level provider. Reacting to this notion, an EMD once stated in a self-mocking tone, "that's right, we're sub-basic life support life forms." This belief, however, is incorrect. The basis of the core curriculum for EMD training, specially the "dispatch priorities" is, in fact, ALS-level.
What has confused most casual observers is that the EMD appears to perform BLS-type tasks, such as CPR, the Heimlich maneuver and airway control. However, the EMD is not required to perform the BLS skill but instruct it on the fly. In fact, the majority of the information in the EMD curriculum is derived from the knowledge base of emergency physicians and nurses. For example, the commonly taught dispatch rule, "A previously healthy child found in cardiac arrest is considered to have a foreign body airway obstruction until proven otherwise," cannot be found in Karen and Hafen's EMT text, Nancy Caroline's paramedic text, or the basic text by American Academy of Orthopedic Surgeons. Most paramedics eventually learn this "rule" from emergency department physicians.
This level of knowledge is why it is necessary for ALS-level personnel (paramedics, RNs and MDs) to train EMDs. No EMD training program should use non-ALS personnel as instructors (9). The use of specific EMD protocols to aid in the provision of a complete and comprehensive "remote" assessment of the patient in combination with on-the-fly bystander training requires that the EMD process information or "think like" ALS personnel.
Medical and Protocol Models of Practice
With all this knowledge, then why shouldn't EMDs routinely practice their medical routines as doctors do-without formal protocol in hand? After all, the practice of medicine by physicians appears to be safe without the use of well-defined protocols. The answer lies in a very important distinction between physician and "paramedical" practice methods, which can be illustrated by comparing the "medical model" of medical practice with the "protocol model" of evaluation and care. Physicians are allowed by law to deliver medicine in the way they deem best because of years of rigorous education and training and even more years of supervised post-doctoral practice. The sole practitioner in his or her office working from years of experience, perhaps best illustrates the medical model of practice. In contrast, the new physician or intern with approximately 10,000 hours of medical training and experience on his or her first day is hardly an amateur, but a professional who relies on routine access to pertinent additional information. Pockets are stuffed with all kinds of helpers: Harriet Lange's Pediatric Handbook, the Washington Manual of Therapeutics, the Surgical Manual, and a plethora of drug company-provided neonatal and gestational cardboard calculators. Such "peripheral brains" are commonly used by medical professionals to ensure complete and accurate medical treatment under demanding time constraints. They are called protocols.
Compared to that, the typical paramedic has 1,000 to 1,500 hours of training and the EMT had 120 to 200 hours of training. The current minimum amount of training for an EMD is 24 hours. Thus, it's easy to see that an EMD may need a "peripheral brain" that outweighs him or her. It need not be a big peripheral brain but simple be well-designed, medically sound and kept up-to-date.
The EMD and other out-of-hospital providers, therefore, use the protocol model of medical practice. The protocol model is the backbone of the EMD's permission from responsible medical authority to "practice" dispatch life support medicine. As such, compliance to the protocol model significantly enhances the EMD's method of practice by:
For example, physicians and nurses use a protocol model for resuscitations and trauma codes. The white board found in every major trauma room lists an orderly series of actions, tests and treatments that must be accompanied in rapid but standardized resuscitative efforts-in essence, a protocol.
The EMD/EMS Partnership
The time has come when we should start thinking of EMDs as medical professionals and, in every sense of the word, medical colleagues, who care for the patient when other medical professionals can't. They must receive the tools, training and time to perform their jobs well. Doing it right is even more important than doing it fast. This fact should be understood and embraced by public safety management and medical control.
Rather than decry the formal use of protocol as somehow demeaning, punitive, robotic or even non-medical, it is important to understand they are the tools to both field practitioners and EMDs. They speed up and improve the evaluation and decision-making in both EMD and traditional medical practiced.
Non-EMD can help the professionalization process in a number of ways. Ask about them in pre-hospital care surveys. Recognize them as part of the EMS team in papers and articles. Routinely list them as part of the medical control span of responsibility. Include them in consideration of EMS funding issues as well as for reasonable parity in pay.
EMDs can demonstrate their professionalism to their medical colleagues by seeking on-going medical dispatch education to keep current as their relatively new profession and protocol evolve: certifying and recertifying; being customer service-oriented, rather than complaint-driven and reactive in attitude, and maintaining and demonstrating a high respect for the human conditions entrusted to them, whether minor indecision on the part of the caller, or outright terror at the scene. Such actions by those in responsible positions within public safety, EMS, and the medical community as well as by EMDs themselves, will ultimately place the imprimatur of "medical professional" on the EMD, where it should have been all along.