Emergency Medical Dispatching

by Gary Allen

Part I

Emergency medical dispatching has become a significant part of an effective emergency response, but it's still unclear what the standards will be, who will provide training and whether a national EMD standard is possible.

Amidst these procedural questions is a subcurrent of competition among companies, pending litigation and politics that clouds the issue of improved medical care. For an agency thinking of tackling EMD, these difficulties may seem to outweigh the benefits. But forearmed with information, the task of implementing EMD can be successful.

EMD was born during a wave of attention that emergency medicine received 15 years ago by agencies that realized the call for help was the first critical step in supplying medical aid. They recognized a dispatcher can play a crucial role by determining the type of problem, classifying the incident for an appropriate response and-in a rather radical departure from previous practices-giving first-aid instructions via the telephone. Two concepts evolved: tiered response and pre-arrival instructions--together they constitute emergency medical dispatching.

"People little understand EMD, what it really is and what it really does," says Carl Van Cott, Chairman of the EMS Committee for the Associated Public Safety Communications Officers (APCO). "And everybody wants one, but nobody knows what it is."

Tiered response is based on the concept that different types of incidents may require different levels of response, either by equipment (engine only vs. engine and EMS unit) or medical expertise (EMT vs. paramedic). The result is a reduction in Code 3 responses and the number of emergency vehicle accidents, while still dispatching the appropriate resources.

Pre-arrival instructions are based on the concept that dispatchers are the victim's first medical contact and can provide basic first-aid via telephone, by asking specific questions and giving the caller instructions. The questions and instructions--protocol in medical parlance--are predetermined, given in a structured sequence, and specially designed to be effective when given to a third party over the telephone. The result is a dramatic decrease in the time it takes to begin administering emergency care.

Tough Start

Devising an EMD program takes an enormous amount of time, energy and money to either purchase a commercial program or devise one from scratch. The final program must bridge the wide gulf between diverse disciplines--medicine, law enforcement, fire and emergency communications agencies, state and federal law--and still provide effective emergency medical care.

"You can't have a medical dispatch program by just training and throwing protocols in front of people, then shutting the bars and letting the animals feed, says Dr. Jeff Clawson, who is medical director for the Salt Lake City Fire Department, president of Medical Priority Consultants (MPC), a publisher of EMD protocols, and considered the nation's authority on EMD.

Van Cott agrees. "It's not simply purchasing a set of cards and putting those cards in the dispatch center. That's not what EMD really is, or what it takes to get one. That understanding has not been fully publicized yet."

EMD programs presume extensive involvement by medical authorities, a high level of training by the dispatchers and emergency response personnel, and a continuing evaluation of the program's effectiveness. All of these requirements can destroy an agency's determination to develop an EMD program before it's even established.

The First Attempts

Clawson recalls that in 1976 the U.S. Department of Transportation (DOT) began looking at ways to improve medical care on the highways. They developed a plan to train EMTs as dispatchers. "Their heart was in the right place," says Clawson, but the program never really succeeded.

In 1982 interest in EMS increased, and the DOT developed a curriculum. "It was pretty much developed in a vacuum," says Clawson, and the DOT didn't take advantage of the few dispatch experts there were at the time.

A more troubling problem was that the DOT borrowed heavily from the protocols Clawson had previously developed for Salt Lake City in 1978 and they used his name on the finished product. "If they really wanted to do it, they should have come to the people who created it," says Clawson.

Instead, Clawson says the DOT took the 1981 edition of the protocol and made a "lateral mutation" out of it. "They didn't even realize what they had done in damaging it, because they didn't understand what it was supposed to accomplish in the first place and how it was built," he says.

Since then, the DOT protocols have been copied, modified and exchanged among agencies to the point where they're barely recognizable from the original. The result is a hodge-podge of questions and instructions that largely offset the ability of EMD to perform effectively. Clawson estimates there are 4,000 modified versions of his company's protocols throughout the U.S. and argues for a national standardizing body. "Only that way can we have a protocol that has integrity, that's state-of-the art, follows medical science and we can compare data among agencies."

Despite being dated, the DOT material is still important--it has focused attention on dispatching as a part of EMS, and has served as a model for other EMD systems. "Everyone will eventually have to meet the real DOT standards," predicts David Cole, director of sales for Powerphone, a national dispatcher training institute, much as federal requirements changed ambulances staffing. "The same thing will eventually happen with dispatching. As soon as enough lawsuits get initiated over this, then obviously agencies will do something."

Another Friend

EMD also found unlikely friends at the American Society of Testing and Materials (ASTM). ASTM sets standards for everything from the size of pea gravel and building bricks, to the octane of gasoline and the thickness of plastic pipe.

APCO's Van Cott explains that ASTM is really more a process than an entity. "They simply have a management mechanism established that allows for the evolution of full consensus standards through a democratic process."

How did such a group get involved in setting EMS standards? Van Cott says ASTM established an EMS committee about five years ago and characteristically gave it the arbitrary designation F-30. Its EMS Communications subcommittee began work on standards for emergency medical dispatch and produced Standard F12.20.90.

"The standard is called Emergency Medical Dispatch and it addresses those functions that must be taken care of to effectively manage the dispatch of ambulances," Van Cott says. It's an outline of procedures for what should be in place administratively, managerially, and quality assurance-wise to dispatch ambulances in an efficient and effective manner, he says.

But, Standard F12.20.90 did not go as far as recommending a set of EMD protocols. "It simply says there should be a written protocol that is medically derived and followed on a routine basis in the dispatch center," explains Van Cott. That leaves a lot of room for agencies to purchase or devise their own protocols.

Will ASTM ever take on the task of preparing such protocols? "Highly unlikely," Van Cott says, "because there's too much need for local input. You can't write a protocol at a national level and expect it to function on a local basis.

Part II

As emergency medical dispatch (EMD) began to prove its worth, a number of companies sprang up to offer canned protocols and training programs. But instead of a healthy, competitive, market, it's become a battlefield of vendors who insist their product is the best.

Mention the name Dr. Jeff J. Clawson and lightening immediately begins to crackle. He stands out among the nation's EMD experts, both in knowledge and criticism. Clawson is president of Medical Priority Consultants (MPC), a company he founded in 1988 to market the EMD protocols he developed. He is also medical advisor for the Salt Lake City Fire Department, technical advisor for the weekly CBS television show Rescue 911, and an expert witness in at least ten medical dispatching lawsuits.

In 1979 Clawson began working to reduce the number of Code 3 runs Salt Lake City ambulances were handling. The dispatchers became the focal point of those efforts and resulted in a series of procedures for questioning callers reporting a medical emergency. "It was a very controversial thing in the beginning," Clawson says. "We couldn't give the protocols away with a hundred dollar bill attached to them. And now people are practically in a state of panic if they don't have some sort of protocol."

The system, called "Medical Priority Dispatch System" (MPDS), continued to evolve as Clawson worked single-handedly to market the system. With no secretary or support staff, Clawson typed the manuals, designed the cover, packaged and mailed the products-"the whole nine yards," he says. His family life suffered and stress began to take its toll as he fought to keep up marketing MPDS and still attend to his full-time job.

In 1987 Clawson formed Medical Priority Consultants (MPC) to market the materials and now serves as its president. The current 10th edition of the protocols consist of a training program, a set of cards and other printed material to implement a complete EMD program.

By any objective standard, the MPC's protocols are considered the most polished, thoroughly researched and best supported EMD system in the country. And the costs reflect this: $395 for a card set, $25 for audio cassettes, and $49.50 for student textbooks. Recently, the MPDS material has been transferred to a self-standing computer program, allowing dispatchers to quickly access the information with just a few keystrokes on an IBM-PC.

Clawson assigned his copyright claim to MPC and the company retains a Salt Lake City law firm to defend its claim. Company officials routinely flash letters from their attorney warning that MPC, "will not tolerate any infringement on its copyright." One source says that MPC has sent letters to agencies it feels has violated its copyright, with a request for a $400 per-dispatcher licensing fee.

But Clawson says the copyright is vital to maintain the integrity of the protocols. "If it wasn't important to do it, I wouldn't want to do it," he says. "Only through the ability to control [the protocol] can we assure ourselves that we have a scientific protocol and process."

He concedes the conflicts involved in protecting a medical procedure by copyright. "You're always in a sort of rub between what's the greatest way to disseminate the greatest good, but also not allowing material that's damaged or inappropriate or outdated to remain in the domain," Clawson says.

He says the MPDS system has been defined by non-EMS medical experts as the most complex, comprehensive medical protocol in the entire field of medicine-quite a statement, considering the complexities of medicine. When dispatchers or untrained medical personnel start to change the protocol, Clawson says they "can significantly damage the protocol."

"That's what happened to the DOT stuff", he says. "They took the 1981 protocols--which is about our third edition--and made a lateral mutation out of it."

Clawson recalls visiting a comm center in North Carolina and noticing their card set was missing some cards. He looked closer and found they were the 1981 edition of his cards. "They literally had been functioning for a 10-year period, thinking they were state of the art." Clawson says the agency apparently copied the EMD cards from another agency and didn't realize they were long out-of-date.

All this is why Clawson is working to transfer responsibility for protocol maintenance to a separate body, similar to the way CPR protocols are now handled by the American Heart Association. "That's the goal of the what we call the National Academy of Emergency Medical Dispatch," which, like the American Heart Association, determines what the content of the protocol is.

"It's not Jeff, it's not so-and-so. It the College of Fellows of the National Academy," Clawson explains. "Only through that way can we have a protocol that has integrity, that's state-of-the art, that follows medical science and that we can compare data with."

"And that's not the goal of Powerphone, not the goal of APCO, not the goal of any of the others," says Clawson, "because their goal is limited to the training of the protocol aspects, where ours is the implementation of comprehensive systems, even up to and including accreditation."

To critics who say Clawson is only out for money, he says, "I've got employees here that need to take home a paycheck, but they have a vision of working for a company that has a corporate goal of helping people. As soon as we stop doing that, I'd just as soon go do something else."

"I mean, I'm in this for the fun of it and what I think the impact can be."

APCO Enters the Scene

When the Associated Public Safety Officers (APCO) introduced their "criteria-based" EMD program during 1990 APCO conference, it began treading in deep and murky waters.

At that August, 1990 debut in Boston, Gary Broughman called the EMD program "one of the most important new programs" the association had undertaken for public safety. At the time, Broughman headed the APCO Institute, which handles the association's training programs. But shortly after the program's introduction, Broughman departed APCO amidst a cloud, leaving EMD training in limbo.

Joe Nassar, a former APCO national president, picked up the pieces of the EMD program until the APCO Board found a full-time director to take Broughman's place. Nassar says at least six train-the-trainer EMD sessions were held after August, but apparently EMD training has waned lately.

Originally APCO formulated two options for an EMD program--develop one from the DOT material, or acquire a program from another provider with existing material. They quickly realized that the develop-it-yourself option was not a very good one, according to Broughman.

So APCO went looking for a program to adopt. They considered at least two--the fully-developed system offered by Medical Priority Consultants and a new concept being pushed at the time by King County, Washington.

King County's program was built around a new, untested and sometimes controversial concept of allowing dispatchers to ask questions based upon the caller's response to prior questions. Existing programs usually require dispatchers to ask one series of questions without deviation.

Dr. Christie Ann Horton is medical advisor to King County, Oregon's EMS program and helped develop the EMD methods. "We developed our own program because there wasn't any place out there that could prove to us that their system worked," Horton says.

"Criteria-based dispatching was born out of listening to how dispatchers were making [dispatching] decisions." says Horton. "In fact, dispatchers had these criteria ideas in the back of their minds already, but had not formalized them."

She surveyed dispatchers, who told her, "We're professionals. You don't have to tell us exactly how to ask the questions. Why don't you give us a set of criteria as to how you want us to send people?" She consulted legal experts, hospitals staffs and EMS personnel. All of this input was considered as the program evolved.

Horton says she likes the system because, "It leaves the dispatcher to come up with ideas on their own for getting information. They don't get focused in one little area." Instead, Horton says, "It keeps them more open-minded. It encourages their thought process."

King County began training dispatchers for the criteria-based system in mid-1990. They hadn't implemented the program as APCO began its search for an EMD program, but the lack of experience or measurable results didn't factor into APCO's decision.

The decision also wasn't influenced, apparently, by the possible negative effects of creating another set of EMD standards. "Look, we don't need more protocols," Clawson pleaded with APCO at a Portland meeting. "We need more trainers."

At that meeting, Clawson presented a formal EMD proposal from his company. After an evaluation, the APCO board voted to adopt the MPC system. But according to Clawson, Broughman overruled the board and awarded the contract to King County. To Clawson, Broughman's reason was obvious. "You're a non-medical person who's been given the reins and told-make money for the institute."

As for Broughman, in late 1990 the APCO Board apparently decided the Institute needed new direction and Broughman left as its director. In a confusing move, he joined Powerphone, an independent dispatcher training institute.

On March, 8, 1991 APCO hired Kevin Duffy, a 18-year law enforcement veteran, training supervisor and masters degree candidate, to head the APCO Institute. Duffy says he's not tied to past events. "When I was hired, one of my first tasks and priorities was to get [the program], as it had already been done, finished and on the road, which is what I'm doing."

Duffy admits the program was delayed "a little bit" when the director's position was vacant. But now, "We're right where we want to be." As for outside criticism of the program and its origin, he says, "We're confident that what we have is a good, viable program, and will work."

Duffy is straightforward about possible competition with Clawson and Medical Priority Consultants. "We don't feel at all upset with Dr. Clawson's program. I think it's a very good program. We don't want to be at odds with them at all."

With Broughman gone, would APCO reconsider its decision to adopt King County's system? Duffy says, "No. It'd be silly for us to go back and start over."

Clawson admits he's asked APCO to reconsider their decision and remains hopeful. And Duffy remains flexible. "I'm one of these kind of people that thinks anything can happen in the future. But right now, it's getting the program out."

Meanwhile, Nassar says New Jersey is moving to specify APCO's EMD program as the the minimum standard of medical training its public safety dispatchers, he says. "I would imagine that within the next two years we'll see a similar, wide-spread endorsement of [APCO's EMD program] by many of those same states that have adopted the other APCO training programs," Nassar predicts.

APCO prices its EMD program at $195 per student for the course and all manuals, and $150 per set of guideline cards. Instructor training prices have not been set, says Duffy, because the cost of materials hasn't been determined.

Early results from King County are positive, Horton says. "The paramedics are beginning to treat the dispatchers with a lot more respect, and the dispatchers are treating the medics with more respect. But Clawson is more reserved. "It's going to have its day in court. It's going to have its time to show whether it works or not."

So the APCO EMD program continues, caught in a crossfire of internal politics, business competition and personality clashes.

APCO Institute president Duffy says, "We're ready to do what we've promised to do."

Powerphone's System

David Cole, director of marketing for Powerphone, a nationally-known training institute, says his company's philosophy on EMD is somewhat different. "Emergency medical dispatch is, in our opinion, just one facet of an entire picture that you must address as a whole."

"Pre-arrival instructions, for example, are not something particular to emergency medical dispatch," Cole says. "You run into problems by trying to isolate emergency medical dispatch away from everything else." He cites a hit and run incident, where the driver is hurt, gasoline is spilling onto the road, and the other driver is getting away. To meet this situation, Powerphone offers a police, fire and medical cards that provide structured questions for the dispatcher to ask, and pre-arrival instructions to give.

Cole lauds the EMD protocols developed by Dr. Jeff Clawson of Medical Priority Consultants. "But it has one major flaw, and that is, it's not compatible with any law enforcement or fire service dispatch program." Cole also thinks well of APCO law enforcement training program. "But, to throw in a little bit of fire and a little bit of medical is crazy," he says.

Cole says Powerphone used the Department Of Transportation (DOT) cards as the basis for their EMD system. "What we did was take the [DOT] protocols and break it into quick tabs, in the form of a reference manual," Cole says. "We've spent five years evolving them. We have utilized the expertise of national standards, where they exist, particularly in regard to the medical," says Cole.

But the DOT material, upon which Powerphone bases its cards, has a cloudy origin. DOT's material was created in 1982 from material borrowed-without permission-from Clawson's existing EMD cards. Clawson says the result was a "poor product," and says that the DOT cards are is thoroughly out of date.

"Now the 10th edition of the (protocol) is out and there are people like Powerphone who are trying to sell the 1981 protocols," Clawson warns. "They don't know what they're getting is a Model T Ford when they could have the current, latest Infiniti."

But Cole defends his system as low-priced and effective. "We have the DOT protocol available for $49.95," Cole says-much less than competing systems. "Everyone will eventually have to meet the real DOT standards," Cole says confidently.

"The protocol is public domain and everyone should be allowed to get it. You shouldn't have to have it licensed and spend $500 to purchase a set of cards or something like that."

Part III

If all this sounds confusing, join the crowd. The in-fighting is significant even though the biggest marketing battles have yet to be waged. The winner so far: Medical Priority Consultants, who still wields the best set of protocols, backed up with 10 years of experience and a director of national stature.

EMD is becoming popular, if only to help stem the rising tide of litigation against public safety agencies for mishandling medical calls, says David Cole of Powerphone, a national training institute. "The reasoning is this: most agencies tend to change their protocol and policies as the result of liability, as bad as that sounds," he says.

"It's not because there's a better way," Cole says. It's just that most changes occur as the result of a lawsuit, he says.

Cole says that liability in the comm center isn't universally recognized. He says the CBS television show "Rescue 911" has helped to foster the feeling that public safety agencies can do no wrong.

"People expect, of course, that when they dial 911 they're going to get through immediately, help's going to arrive immediately and always solve the problem," Cole says.  "It is the standard of expectation now.

Contrary to some administrators' feelings, "Emergency medical pre-arrival instructions don't increase liability, they decrease it," Cole says. "You're not going to kill a dead person by giving them CPR, but you may have a person die on you if you don't try."

The Future

The popularity of emergency medical dispatching stems primarily from the desire to curb the rising tide of lawsuits alleging negligence in medical calls,

David Cole of Powerphone, a national training institute, says that liability in the communications center isn't universally recognized. The CBS television show "Rescue 911" has helped to foster the feeling that public safety agencies can do no wrong.

"People expect that when they dial 911 they're going to get through immediately, help is going to arrive immediately and always solve the problem," Cole says.  "It's the standard of expectation now."

Instead of being pro-active, Cole says, "Most agencies tend to change their protocol and policies as the result of liability, as bad as that sounds." But this after-thought approach just doesn't attack the main objective--supplying better medical care to citizens.

Some administrators might feeling that becoming more involved in EMD will increase their liability if something goes wrong. Cole disputes this, saying, "Emergency medical pre-arrival instructions don't increase liability, they decrease it."

"You're not going to kill a dead person by giving them CPR, but you may have a person die on you if you don't try."

Cole also explains the complicated situation when lawyers compare your agency's medical dispatching to similar jurisdictions in the area. More pointedly, if they compare how you currently handle callers reporting police and fire emergencies.

If you now give pre-arrival instructions to fire and police callers, you could be setting a standard of performance a plaintiff's attorney will emphasize. "So you set your own standard and didn't meet it," Cole says. "So, then it becomes how many zeroes on the check."

The Future

The current EMD situation is hardly clear. But put your spectacles to the crystal ball of the future and things become even more hazy.

APCO's Carl Van Cott says future EMD systems will be medically directed. In his home state of North Carolina, the Board of Medical Examiners has already ruled that EMD can't be practiced without a medical director. "I would think that other regions or states will start taking a look at it in the same manner. This will bring some degree of control over it," he says.

Consultant Joe Nassar, working on APCO's EMD program, sees a long period of evolution for EMD. "Certainly the work that was done by Jeff Clawson was pioneering in this area and others are now developing the same types of material. But to say that this thing can be cast in concrete--I don't see that happening for years and years and years."

Nassar thinks that EMD will remain under the control of telecommunications, "With oversight and support from emergency medical services." He predicts more consolidation of emergency communications services, so dispatchers won't be a direct employee of the police, fire or EMS agencies for which they dispatch

"I don't think you'll see it totally supervised and managed by the emergency medical field. I think it'll be a joint effort."

Nassar believes that APCO program will set the pace in EMD. "I would imagine that within the next two years we'll see a similar, wide-spread endorsement of the training effort by many of those same states that have adopted the other APCO training programs."

Is a national standard for EMD protocols possible? "Only if everybody will adopt and use it," APCO's Van Cott says. "It's apparently like ice cream. Some people want to eat vanilla, some people want to eat chocolate. Some want to use Clawson, some people say they want to use APCO. I can't tell you whether chocolate's better than vanilla."

Dr. Jeff Clawson, who heads Medical Priority Consultants, feels the federal government should not play a role in setting a national EMD standard. "Why do we need the federal government, who never does anything expertly," he asks. "They're too slow and everything is too cumbersome to come up with a leading edge standard."

Instead, he believes the federal government should fill a support role. "Their ability to fund this sort of stuff or help with it is invaluable."

Clawson is disappointed that states have not played a more important role in EMD. "There not one single state in America that requires dispatchers to be EMD certified. Yet, would you want an uncertified paramedic or EMT or physician working on your mom?"

Clawson echoes others when asked about EMD in the next decade. "The lawyers, the plaintiffs' attorneys are going to drive, to a great extent, what happens in the next decade."

He also says one of the "sleeper" issues for EMD will be emergency medical vehicle accidents, going red light and siren when it's not necessary.

"If I told you there could be as many as 75,000 emergency medical vehicle-related accidents in the U.S. and Canada per year, would that cause you to sit up?" Clawson asks.

Tying It All Up

Exactly where does all this leave the nation's 25,000+ public safety agencies? Mostly searching for help in a sea of information and misinformation.

For now, the choices are clear if you know exactly what you want. If you want just a medical system, then the program from Medical Priority Consultants fits the bill. If you prefer a combined police/fire/medical system, then Powerphone has the program. And if you're not sure, you might just wait to see how APCO's programs develop in the next year.

The sad news is that the competition has forced everyone into propriety methods that lock out the possibility of a national standard. Even the national dispatcher organizations such as APCO and NENA don't have the clout to form a consensus.

In the meantime, an agency's liability increases and the quality of emergency medical care is in a stall.

For more information on emergency medical dispatching, contact:

Powerphone, (800) 537-6937

Medical Priority Consultants, (801) 363-9127

APCO Institute, (904) 322-2500

copyright 1990-1994 911 Dispatch Services, Inc.