ZERO RESPONSE TIME CREATING A MODERN MEDICAL DISPATCHING PROGRAM
The woman is frantic. Her fourmonth-old son has been in commlsions for five minutes. She doesn’t know what to do. She called the fire department and was assured that an ambulance was on the way. She sits in anxious silence, watching her son’s frail body twist and shake. Her panic increases.She dials 9-1-1 again, desperately crying for help.
“We’re on the way, ma’am,” the dispatcher says in a calm manner.
“What can I do?” she shrieks into the phone. “Tell me what to do!”
“I’m sorry, we can’t give you any medical advice, ” the dispatcher says. “Please try> to remain calm; we’ll be there as soon as we can.”
The woman hangs up. She stares through the silence at her trembling son. The seconds squeeze by like molasses. She waits and waits….
Television shows like “Rescue 9-1 -1 ” to the contrary, the preceding scenario is played out all too often in many U.S. communities. Unless a community employs emergency medical dispatching (HMD) and pre-arrival instructions (PAI), the delay between the time the initial emergency call is made and first responders arrive can be life-threatening; it also increases the caller’s panic and hysteria and adds to the chaotic and uncontrolled scene first units find when they arrive.
“Even under the best conditions, our typical response times are between three and five minutes,” says Terry Lou, senior dispatcher for the San Jose (CA) Fire Department and a member of its EMD development team.
Based on the concept that the dispatcher is the first prehospital care contact the public has, dispatchers operating under the pre-arrival instruction program—after getting the basic required information relative to the incident—give medical instructions to the caller so the caller can help the victim before the fire department arrives on the scene, Lou explains. Dispatchers give instructions for a variety of conditions such as bleeding, difficulty in breathing, chest pains, and seizures, enabling the caller to stabilize a sick or injured person and minimize further injury. More comprehensive instruction sequences pertaining to major emergencies such as choking or cardiac arrest lead the caller through the Heimlich maneuver or CPR. The dispatcher even can direct the caller in the actions to take when delivering a baby.
The PAI program generates more specific details concerning the medical emergency to the en-route responders than those a caller usually provides in a 9-1-1 call. The dispatcher relays the caller’s responses to his/ her medical questions to the responding firefighters and paramedics, allowing them to preplan the course of treatment while still en route and to make sure that they will have on hand all needed equipment. A properly trained EMD dispatcher on the line can help fire departments and paramedic agencies achieve virtually a “zero” response time. The dispatcher’s medical training and expertise are on the scene immediately, enabling the caller to perform first aid or other therapeutic functions as instructed.
THE SAN JOSE PROGRAM
When the San Jose Fire Department (SJFD) dispatch operation was moved into a new communications center it shares with the police department, the SJFD committed itself to creating a customized EMD program that would allow it to better serve its community. The EMD/PAI, the first one in Santa Clara County, officially went on line in August 1991.
The SJFD conducted extensive research among dozens of California fire departments that already provided EMD, but it decided to create its own program from scratch. The emergent program is based on the State of California EMS Training Guidelines for Emergency Medical Dispatch. Designing its own program precluded any restrictions that may have arisen had existing, copyrighted PAI systems been used. It also allowed the program to be customized to the specific needs of the department and community.
Working in close consultation with the city attorney’s office, the SJFD formed a project team to research, develop, and implement the EMD program and its attendant training curriculum. The team consisted of Cindy Obos, fire communications instructor; Terry Lou, senior dispatcher (then assigned to the Training Unit); and Gary Galasso, fire engineer, and Susan Salinger, firefighter, who are also certified paramedics for a private EMS provider.
Lou established a Northern California PAI Task Force that allowed user and nonuser agencies to network, pose questions, address common issues and concerns, and offer possible solutions. Also invited to serve on the committee were two city attorneys, to field legal questions; several county EMS directors; and representatives from the Poison Control and local trauma centers. Before developing the PAI cards, or protocols, the development team attended a 48-hour “Training the Trainer” course, presented by Medical Emergency Training Systems (METS) and sponsored by the Stockton Fire Department and San Joaquin County EMS. The team also contacted dozens of fire agencies statewide to ask about their EMD programs, to get ideas for devising the San Jose system. In addition, the project team frequently consulted with Dr. Philip Harter, Santa Clara County’s medical director, who was the final link in approving the PAI protocols.
All the agencies contacted provided information about their systems, associated programs, and lessons learned. The San Jose team ultimately decided to base its cards on the systems used by the Stockton, Los Angeles, and Orange County fire departments.
Card system. Formatted into an open-book card file system, the cards are divided into two groups—simple PAI cards, for initial complaints, and treatment sequence cards (TSC) that offer detailed, flow-charted instructions for procedures such as performing the Heimlich manuever, administering CPR, and facilitating emergency childbirth. Key questions on the initial PAI cards often refer the dispatcher to one of the TSCs, depending on the caller’s responses.
Academies. After the card system was finalized, a series of PAI academies was designed to train the department’s 30 civilian dispatchers. Seven 40-hour academies were held over a five-month time span. “As much as we thought we’d ‘fine-tuned’ the protocols prior to the academies,” Lou notes, “the dispatchers ‘fine-tuned’ them even more. With each academy came new revisions. We now have what we believe is the best protocol system we’ve seen so far.”
Quality Assurance (QA) Board. The project team’s responsibility didn’t stop once the program was activated and introduced. Early in the research stage, the members had attended an EMD conference, sponsored by Medical Priority. Here, they recognized the importance of maintaining a Quality Assurance Board to monitor and review the effectiveness of the PAI program. As soon as the training academies were completed and the program activated, the department established an 11-member QA Board, comprised of dispatchers, firefighters, paramedics, and the county’s EMS medical director. The board meets monthly to review tapes of PAI calls, evaluate the quality of the card system, and address the concerns of the dispatchers using the cards.
“You can’t have a good pre-arrival instruction program without quality assurance,” stresses Fire Engineer/ Paramedic Galasso. “We’re looking for consistency and progressiveness. We must be consistent with what’s going on relative to medical care outside our dispatch center.” To ensure that the PAI program remains current, the protocols are continually reviewed and updated to reflect any changes in medical practice and prehospital care procedures. “We’re just hitting the tip of the iceberg with our QA Board, and it’s going to be real interesting to see how we will achieve these goals,” says Galasso.
Critical Incident Stress Management. Along with the QA Board, another support program vital to an effective EMD/PAI program is critical incident stress management (CISM>7 administered by counselors from the local employee assistance group and dispatchers specially trained to support dispatchers experiencing the kinds of stress associated with their functions. EMD/PAI system dispatchers become more intimately involved in the incidents by keeping oftenhysterical callers on the phone so they can provide medical instructions. Complementing the firefighters’ CISM team, the dispatchers’ CISM team is trained to act as peer counselors and to participate in critical incident stress debriefings.
PROMOTING AND ACTIVATING THE PROGRAM
After the PAI cards had been developed and the training academies had been completed, the department began a two-month “shakedown” period, during which the dispatchers became familiar with the new system and how it affected their jobs and gathered statistics related to the system’s use to present to the senior staff.
A public education program promoted the EMD/PAI program. Information packets were sent to the local news media, and site demonstrations were offered. Brochures and a 10minute video informed area hospitals, care homes, and allied public safety agencies about the new program offered in San Jose.
Several television and radio stations interviewed the department. Overall, however, media response to the new program was disappointing.
The subdued media response, Lou believes, could be due to the widely held misconception shared by the media and the public—and reinforced by television shows—that all of the nation’s public-safety agencies provide PAI and that, consequently, help is always at the other end of the phone line. In fact, he stresses, only a small percentage of communities offer this service.
During the first six months of San Jose’s program, six babies were delivered via PAI and at least one cardiac arrest was revived through telephone CPR and transported to the hospital with an active pulse. The performance impact on dispatchers has been minimal: While all TSC calls and occasional other PAI calls require the dispatcher to remain on the phone until firefighters arrive (generally between three and five minutes after the call is received), the average time spent giving callers PAI during the first 10week period was 78 seconds.
Despite some initial trepidation about the new aspect of their jobs and some concerns over the added level of stress, SJFD dispatchers unanimously have embraced the program. Since they no longer are restricted to merely receiving and relating information between caller and responder and now are actively involved in aiding the patient, they have become a direct part of the system. “I didn’t realize how incredible the program could be until the first time I had to help a woman whose aunt was not breathing,” recalls Dispatcher Robert Meineke. “Two cycles of rescue breathing, for which instructions were given over the phone, were enough to get the woman breathing on her own again until the fire crew arrived on the scene. That type of call reassures me that the program is making a big difference for the department and. especially, for the citizens of San Jose.”
“We’ve gotten a lot of positive feedback from the line firefighters, who now walk into a scene that’s calmer and where people already have done something to help,” adds Fi refi gh ter/Paramedic Sal i n ger.
The San Jose Fire Department sees a vast potential for the EMD/PAI program. Galasso predicts that it will be used countywide within the next two years. The county already has indicated its intent to make San Jose’s program a template for the county. “I think it’s going to be a turnkey operation for most agencies—especially if San Jose can help these agencies put on an academy for their instructors,” he adds. “Fifty-one percent of the county is San Jose,” he stresses.
“Therefore, a majority of the population of Santa Clara County expects to receive pre-arrival instructions for medical emergencies. There might be a legal precedent now for other agencies to follow suit.”
“San Jose has established a new standard for prehospital care in Santa Clara County,” agrees Lou. “Once the general population of the county realizes and understands what the citizens of San Jose have, I can foresee the public exerting pressure on their communities to provide the same standard of care. We’re talking about a program that can save lives over the phone before firefighters and paramedics get there.”*
