Priority Medical DispatchIs the Standard of Care
By W. Ann Maggiore, JD, EMT-P

Dispatch liability has moved to the forefront of EMSlitigation. Second only to EMS vehicle accidents, dispatchliability has produced not only frequent, buthigh-cost lawsuits that merit serious attention fromthe EMS agency’s risk management. Although EMS agencies frequentlyspend a great deal of time and effort on other risk managementendeavors, they would do well to consider how well theirdispatch is performing because this is the critical link between thepatient and the responding EMS units.

Gone are the days when dispatcherswere only clerks. “What dispatchers oughtto be seen as is air traffic controllers, butwhat they do is 10 times as stressful. Everytime the phone rings, it’s the equivalent ofsomebody in a crisis,” says Jeff Clawson,MD, the designer of an EMS priority dispatchsystem to help dispatchers fill theirrole as the first link in the EMS system.Clawson has been an expert witness in anumber of lawsuits involving dispatcherrors and has generally shown that theproblem could have been averted with apriority dispatch system.

The public will not tolerate understaffing, budget problems or any other excuse for a failure of the system set up to save lives.

The concept of emergency medical dispatchis not new. Clawson developed hisprotocols for the Salt Lake City FireDepartment in 1978, and the Departmentof Transportation, in developing dispatchrecommendations, borrowed heavilyfrom those protocols in 1981. However,the concept was slow to catch on,despite its effectiveness. EMS agenciesremained skeptical and hesitant to spendthe money it took to make dispatch a keylink in the EMS system. The problems ofimplementing priority dispatching systemsincluded the cost of training, resistancefrom police agencies that were providingdispatch services to EMS andgeneralized resistance to change.

Consider the several lawsuits leveledagainst the city of Chicago in late 2001.In July, a jury awarded $2.7 million overa dispatch error. Then, within only twomonths at the end of the year, juries hitthe city with two more huge EMSdispatch-related verdicts—one for $50million and the other for $3.06 million.1,2 These verdicts sent a clear message:The public will not tolerateincompetence when they dial 9-1-1.

In May 2002, another wrongful deathsuit was filed against the city of Chicagobecause of a 17-minute response time toa battered 31-year-old woman, who laterdied. A $2.7 million settlement followed,to the family of a teenager whodied during an asthma attack while waitingfor a delayed ambulance. The message:The public will not tolerateunderstaffing, budget problems or anyother excuse for a failure of the systemthat is set up to save lives. The cost ofthese verdicts would have paid for additionalsalaries, training and equipment toprevent the catastrophes that led to themin the first place.

A number of states have initiated someform of priority dispatch program withvarying levels of effectiveness. Given theavailability of the EMD programs, it isclear that inadequate risk managementprograms led to these disastrous verdicts.

In Prince George’s County, on Sept.26, 2002, a jury awarded $1.7 million inyet another dispatch disaster. The juryawarded the plaintiff $95,000 in punitivedamages. Punitive damages are strictly forpunishment and are generally awarded byangry, disgusted juries. This case involveda dispatcher who was on a personal phonecall. The caller dialed 9-1-1 five separatetimes, but couldn’t get an answer.Ultimately, the dispatcher sent BLSinstead of ALS to a heart attack call, andthe crew had a 22-minute response time.

Another suit against the city andcounty of San Francisco in 2002 furtherillustrates that juries will not hesitate tohold public agencies responsible forerrors in dispatching.3 In a 22-pageopinion, the Court of Appeal of the FirstDistrict of California overturned a summaryjudgment granted in favor ofdefendants by the trial court andimposed liability on the city and countyfor failure to train its dispatchers.

In that case, a woman died from anasthma attack after a call to 9-1-1 reacheda dispatcher who had not received trainingin the emergency response protocols. Theplaintiffs alleged that the city’s and county’sfailure to train the dispatcher resultedin the patient’s death due to a delayedresponse time. The appellate court analyzedwhat duty the dispatcher owed thecaller, finding not only that the dispatcherhad a duty to the caller, but also that the dispatcher’s duty was that of reasonablecare. (The immunity statutecited by the city provides immunityfor all but grossly negligent care.)The court went on to say that theduty was owed to the caller withrespect to the "manner in which the[9-1-1] emergency procedures wereimplemented."

The plaintiff alleged that thecaller was on the phone with thedispatcher for longer than five minutes.The dispatcher was a trainedparamedic who knew that asthmacan be fatal, but she took an undueamount of time on the phone tryingto determine the precise nature ofthe patient’s problem.

In this case, communication withthe caller was difficult because hespoke mostly Chinese, although abystander with medical training alsogot on the phone. The dispatcherhad not been provided with trainingin the priority dispatch protocolsbeing used by the city. She thenreceived misinformation fromanother member of the dispatchteam that the call had to do with adrug overdose. The dispatcher firstsent a police unit while asking aparamedic unit to stand by for a“Code 2” response—even thoughshe had information that the patientwas having trouble breathing.

When police arrived, they confirmedthat the patient was havingdifficulty breathing and theresponse was upgraded to a “Code3.” The ambulance arrived at thewrong door. So the crew had toreturn to the unit for furtherinstructions and then had to drivearound the block to the correctentrance. The time between the firstcall and the arrival of police was 10minutes, and the total actual EMSresponse time was 20 minutes.

An even more recent Californiacase, however, found that no statuteimposes direct liability on publicentities that employ emergency dispatchersfor injuries attributable inpart to a dispatcher’s failure or delayin responding to a 9-1-1 call.4

The court further found thatvicarious liability is limited to casesinvolving gross negligence in badfaith. In this case, plaintiffs allegedthat their three-year-old child sufferedan electric shock whilebathing and that a delay in dispatchcaused a prolonged EMS response.The court disapproved of the previousCalifornia decision and foundthat a broad cloak of immunity protects9-1-1 dispatchers from all butthe most egregious acts.

Prevention is the hallmark of aneffective risk-management program.Although the development of a prioritydispatch program may proveexpensive and time-consuming, someform of priority dispatching is now,without question, the standard ofcare for EMS agencies nationwide.

Political issues may hinder thedevelopment of these programs, particularlywhen the dispatch agency isnot within the control of the EMSchain of command. Another politicalissue has arisen over the ownership ofthe protocols and whether the programan agency chooses to institute isthe most updated version or simplythe least expensive.

However, one thing is clear: Asthe verdicts and settlements painfullydemonstrate, it is essential thatdispatchers be regarded as part ofthe patient-care response that isEMS. “You can’t have a medicaldispatch program by just trainingand throwing protocols in front ofpeople, then just shutting the barsand letting the animals feed,” saysClawson. Instead, emergency medicaldispatch programs require theinvolvement of EMS medical directors,a high level of dispatcher trainingand continuous evaluation ofprogram performance. EMS agenciessimply cannot afford to havephones unanswered, dispatchersrefusing to send ambulances topleading callers or even the innocenterrors of sending an EMS unitto the east side of town when theemergency is on the west side.Ultimately, it’s far less expensive—and much better for patient care—to do it right. JEMS

W. Ann Maggiore, NREMT-P, JD, isan attorney and paramedic inAlbuquerque, N.M. She has been a fulltimeparamedic, an assistant fire chiefand a state EMS administrator.Currently, she practices law full-time,defending physicians, police and EMSpersonnel against lawsuits. She is a frequentlecturer on EMS legal issues andholds a clinical faculty appointment atthe University of New Mexico School ofMedicine. Contact her via e-mail atwamaggiore@btblaw.com.

REFERENCES

1. Gant v. City of Chicago,97L03579, Cook County, Ill.
2. Cooper v. City of Chicago, 1997,Cook County, Ill.
3. Ma v. City and County of SanFrancisco, 115 Cal. Rptr. 2d 544(2002).
4. Eastburn v. Regional FireProtection Authority et al. Cal.Sup. Ct. No. BCV05011.