EMD, Staging Errors End In Man’s Death-Updated

A series of EMD, priority assignment and ambulance staging mistakes by Toronto dispatchers and paramedics ended with the death of a man from what the coroner says was a heart attack. It took paramedics 38 minutes to finally arrive in the hallway of an apartment building where Jim Hearst had collapsed. Another tenant reported Hearst’s condition, but mentioned that, “he might be drunk.” That remark ended the dispatcher’s standard EMD questioning–for some reason–and for the call to be classified as a lower priority. The responding paramedic crew stopped about two blocks away from the building and waited for police, who didn’t arrive for another 29 minutes. Five employees were given unpaid suspensions of from 10 to 17 days, city EMS officials said, and will receive additional training. Read more about the incident here, and an editorial after the break. Update: Download (pdf) a just-released ministry report on the incident, with a timeline and recommendations.

Editorial

The provincial report on the response delay is full of dates, times, personnel IDs and other specific facts. But it’s perhaps better to read the report, digest it and then ponder exactly what happened, taking a much wider view. When you do, you can spot a basic flaw in the EMD system and the system of policies and procedures that have been set up by Toronto’s EMS system.

That flaw is: strictly following a set of procedures can send you down a path filled with mistakes. EMD or any other set of protocols must be accompanied by an intelligent, free-thinking person who can interpret what is occurring, and pursue questions that are outside of or beyond the protocol. Even though the investigation focused on how policies and procedures were followed, or not, it also revealed how the dispatch and EMS personnel were thinking “inside the box,” and failed to use common thinking about the situation. I should also note that there were mistakes of notation by the calltaker, and of inexperience by the ambulance crew.

Read the investigative report, analyze it without using any type of EMD protocols, and decide if you would ask questions differently and reach a different result for what was entered in CAD. Sometimes an incident is much more simple than it appears when protocols are used.