search terms: Emergency medical dispatching, life and death, hot calls, Rock Island, pre-arrival instructions, 911 calls, severity, do no harm, risk of accidents, wake effect, emergency dispatcher, difference in emergency medical services, standardized instructions, quad-city times, newspaper articles, Jeff Clawson, advantages

Quad-City Times
Carie Dann, Quad-City writer

Life and Death

Case one: A customer began choking while eating at a Rock Island restaurant. They called 911, and a Rock Island emergency dispatcher, using a description from witnesses, quickly determined the customer had a complete airway obstruction that needed immediate attention.

Another man in the restaurant had seen American Red Cross posters ĪWhat to do if an adult is choking." Using his limited knowledge and verbal directions from the dispatcher, he administered abdominal thrusts, dislodged the food from the choking manās throat and averted a tragedy before paramedics arrived.

Case two: a 10-year-old boy called Davenport 911 and frantically said his mother couldn't breathe. Their house was on Davenport's far-west edge.

In the background, the woman moaned for several minutes, then became still. "She's turning blue," the boy said. The dispatcher told him help was coming.

By the time emergency vehicles arrived 10 minutes into the call, the boy's mother had gone into cardiac arrest. She died.

The two calls, which actually occurred, illustrate the difference in emergency medical services in the Quad-Cities-a difference that will become even more striking in the next few weeks.

The city of Rock Island uses a system called emergency medical dispatching, or EMD. The dispatchers, sitting in their control center downtown, use standardized instructions to talk callers through emergency, life-saving procedures. (They also handle 911 calls from Milan and the area west of Milan).

It's just like on TV "rescue" shows.

Within days, the rural Scott County dispatcher center will also upgrade to emergency medical dispatching, making pre-arrival instructions available to the 15,000 Scott County residents living outside of Davenport, Bettendorf and Le Claire. (Each of those three communities has its own separate dispatching center.)

But if you live anywhere else in the Quad-Cities, you aren't talked through emergency procedures, because no other city had certified its dispatchers to provide EMD. Dispatchers will ask what the problem is, verify your address and send emergency vehicles. Treatment does not begin until emergency personnel arrive-sometimes, a delay of five minutes or more.

Pre-arrival instruction is gaining support in the emergency medical services profession. Both the American College of Emergency Physicians and the National Association of EMS Physicians have endorsed EMD as the "standard of care."

"With enhanced 911 and all that technology sitting there, it seems silly not to pass along life-saving information during the 3-to-6-minute response time. It's been shown that a person on the phone can be talked through CPR, and other procedures, effectively," said Dr. Scott Ludwig, director of emergency medical services at Illini Hospital, Silvis. (Illini is the resource hospital for city of Rock Island emergency services, overseeing training and quality assurance.)

"Rescue 911" and other shows have made EMD so public," said Jan Gaylord, head dispatcher in Rock Island. "I'm surprised the citizens haven't said this is what they want."

The reason for public silence may be lack of awareness. Probably the majority of citizens assume that if they call 911, a dispatcher will provide pre-arrival instructions.

Emergency medical dispatching was developed in 1967-77 by Dr. Jeff Clawson, an emergency medicine physician in Salt Lake City. He and a group of about 50 other medical and public safety experts constantly monitor the protocols and implement improvements when necessary.

"Salt Lake City, at the time, was fairly apolitical. It was a place where germination of the idea was possible," he said. "If I had been in New York or Los Angeles, it wouldn't have gotten 10 feet off the ground."

About 4,000 municipalities are using his system, licensed under the name Medical Priority. It is used in all 50 states, every Canadian province and eight other countries, and has been translated into four foreign languages. (Some cities are using EMD programs based on Clawson's system; Scott County dispatchers were trained at Scott Community College, which offers a program similar to Medical Priority.)

The dispatcher has a book with flip cards providing medical instructions. The cards used÷and the pre-arrival directions given-are based on the patient's chief complaint, such as shortness of breath, a cut, chest pain, unconsciousness or numerous other signs and symptoms.

Some people question whether giving pre-arrival instructions increase a city's liability, but actually the opposite is true, Clawson said, because EMD is endorsed as the national standard of care. In several instances, not having EMD has increased a municipality's risk of being sued by a patient, particularly when neighboring cities do offer the service. Medical Priority-trained dispatchers using his system have never been challenged in a dispatch negligence lawsuit, he said.

Scott County's rural residents are about to become the second group of Quad-Citians to benefit from pre-arrival instructions. The center's 10 dispatchers each have completed 25 hours of training, and the Scott County Sheriffās Department, which operates the dispatch center, has received a go-ahead from the county health department and board of supervisors.

They'll go on line as soon as one last administrative detail is completed, regarding liability for the county medical director.

"Our target date is Saturday, but we have the ability to start up on very short notice," said Art Miller, communications coordinator for the Scott County sheriff's office. "What we'll offer that we cannot offer now is instruction in what to do for the patient until ambulance and fire arrive."

For a few years, the county dispatch center has transferred some 911 calls to a hospital emergency room, where nurses gave callers advice over the phone. But the hospital workload increased to the point that some callers waited several minutes to talk to a nurse. (Also, emergency medical dispatching is based on standardized answers, whereas advice given by nurses could vary from person to person or hospital to hospital, potentially increasing the likelihood of a lawsuit being filed by a patient.)

"The first minute is crucial when a person is having a heart attack, difficulty breathing or other serious health problems," said Gloria Isham, head dispatcher for the Scott County center. Each shift has two or three dispatchers, which should be enough to handle the call load without waits, she said.

While the flip cards will be used on every 911 call, only about 5 percent of the calls are true medical emergencies requiring pre-arrival instructions, Isham said.

"We're ready to go. We're excited," she said. "I think it will be very rewarding. In the past, if there were a farm accident, for example, and someone severed his arm, common sense says to put direct pressure on it to stop the bleeding. But we couldnāt tell them that. It was a helpless feeling."

Dispatchers will continue with ongoing training with Dr. Richard Vermeer, the EMD medical director. He and Scott County's emergency medical services coordinator, Denny Coon, will also listen to tapes of every call in which pre-arrival instructions were given, to provide quality assurance.

"Anytime we can provide prompt medical service to an individual, it enhances the probability of survival," Sheriff Mike Bladel said. "It will also be better for the officers at the scene, because they'll be dealing with people who are more calm. Fire, ambulance and law enforcement will have a better idea of what they're getting into, because of information from the dispatcher."

Sharon Ennis, executive director of Medic EMS, Scott County's main paramedic ambulance service, mentioned two other advantages: the capability to send the closest available ambulance to a 911 call; and diverting first-available ambulances to more serious calls, and sending backup ambulances to less serious calls.

The optimal solution would be forming one dispatch center for emergency medical calls, instead of the four presently in operation in Scott County, she said. "It would help if we got rid of the boundaries for service areas and looked at ourselves as one county. We need to base our decisions on what's best for the patient."

Emergency medical dispatching is not a "taxing and funding issue," Clawson said. Cost to train dispatchers is $250 for the Medical Priority course and $465 for the flip cards.

Ennis said, "The thing that sticks in my mind is that call with the 10-year-old boy in west Davenport. It was 10 minutes of no intervention. We'll never know, but pre-arrival instructions could have changed the outcome."

ADVANTAGES

Here are the advantages of medical priority dispatching:

    • Provide pre-arrival instructions, which can improve patient outcome, particularly when emergency response times are longer, as on rural calls answered by volunteer services.
    • Decrease the risk of collisions involving emergency response vehicles and citizens, by reducing the number of calls on which multiple rescue units are sent.
    • Calm people at the emergency scene, which helps law enforcement officers and medical personnel.
    • Relay more patient information to medical personnel en route to the scene.
    • Decrease health-care costs by reducing the number of vehicles and personnel dispatched to non-emergency calls, reducing the number of non-emergency patients transported to hospital emergency rooms, and reducing the number of accidents involving emergency response vehicles.
    • Reserve advanced-care teams for true emergencies.
    • Improve dispatcher morale.
    • Decrease stress and burnout among emergency medical services providers.

 

EMD makes a difference in Rock Island

Emergency medical dispatching has made a difference in the city of Rock Island, head dispatcher Jan Gaylord said.

"Weāve had numerous saved lives because of pre-arrival instructions," she said.

The city added EMD six years ago after dispatchers completed training developed by Medical Priority out of Salt Lake City, which originated the system in the late 1970s.

It's not just saved lives, said Dr. Scott Ludwig, director of emergency medical services at Illini Hospital in Silvis, which oversees Rock Island's emergency medical services. "It may be an instance of decreasing the severity of an injury," he said.

Rock Island Fire Department supplies the city's 911-response paramedics, with two ambulances at two stations. The fire department also covers emergency medical calls in Milan and an area west of Milan.

Usually, it takes them a maximum of 5-6 minutes to arrive at an emergency scene. During that time, dispatchers give standardized instructions to the caller.

"CPR is used most. Usually, friends and family will do anything they can to help the patient," she said.

(In Rock Island County, East Moline, Moline and Silvis each has a separate dispatch center, as does the sheriff's department, which dispatches calls for unincorporated areas in Rock Island County and a few small towns. None of them has emergency medical dispatching.)

Gaylord said pre-arrival instructions help not only the patient, but also the caller.

The city's 12 dispatchers also are able to give paramedics a head start en route to the call. They can ask about a patient's medical history and it they're taking medication, and relay the information on the radio.

 

Condition should merit (hot) calls

Although the city of Rock Island offers pre-arrival instructions for 911 calls-and rural Scott County will add that service-neither dispatch center is using what developer Dr. Jeff Clawson calls "the most important component" of emergency medical dispatching.

He is a proponent of medical priority dispatching: sending emergency medical vehicles at a high rate of speed, using red lights and sirens, only when it is merited by a patient's condition, instead of on every call.

Reducing the number of calls with vehicles running "hot" cuts down on the injuries, fatalities and property damage from accidents involving emergency vehicles, he said.

With medical priority dispatching, dispatchers determine the severity of the emergency based on a caller's information. If it is a true medical emergency, ambulance and fire trucks activate the sirens and lights. If it is not a true emergency-and that's 75 percent of all 911 calls-the vehicles travel the speed limit. Sometimes, a fire truck is not needed for calls, and only an ambulance goes.

Occasionally, a dispatcher may tell the caller he needs a taxi, not an ambulance. Listen to a police scanner, and youāll hear those types of calls (all actual)-baby with earache, infected mosquito bite and a child with a bean stuck in his nose.

As it is, ambulances and fire trucks now respond with sirens, red lights and high speed, even for the taxi-type calls. Clawson said that violates the first rule of emergency medical services: "Do no harm."

The main benefit of priority dispatching is reducing the risk of accidents involving emergency vehicles, he said. Based on statistics, it is a concern:

    • Between 12,000 and 15,000 emergency vehicles are in accidents every year in the United States, or about 35 a day.
    • Thereās also the "wake effect," which occurs when an emergency vehicle causes an accident but is not physically involved in the crash. These happen five times more frequently, which adds up to about 75,000 accidents a year involving emergency response vehicles.
    • Every 4.5 days, one person is killed in an ambulance or emergency vehicle accident.

Studies show that only 5 percent of 911 calls are of such life-threatening nature that a lights-and-siren response can be justified.

"Generally speaking, red lights and sirens don't do a whole lot, except cause confusion and excitement, and injure and kill people," he said. "Used correctly, in life-threatening emergencies, theyāre appropriate."

Even though the concept of priority dispatching is simple, itās not always easy to implement. Because it reduces the number of calls to fire departments and ambulance service respond, it may reduce the number of employees need to staff the services. And that can make it a heated political issue.

But it doesnāt have to be perceived as a threat, Clawson said. "In Salt Lake City, it reduced our emergency vehicle responses by 33 percent and reduced red lights and sirens by 50 percent. Our fire chief said that that was good, because instead of going on calls, they could improve training, fire prevention and public education. Thatās the right answer."

Medical priority dispatching can also cut health-care costs. Currently, emergency personnel respond to the non-emergent patients (the "taxi-type" calls) and sometimes transfer them to hospital emergency rooms, where health care is expensive. But dispatchers ferreting out minor emergencies and advising patients to see their physician cuts down on unnecessary emergency room visits.

Later this year, the National Association of EMS Physicians is expected to release a paper calling for limiting the use of red lights and sirens.

"Medical priority dispatching represents a significant change in prehospital care," Clawson said. "People fear change, but change is the way the future reveals itself."