EMERGENCY MEDICAL DISPATCH
Looking Back, Looking Ahead
A Conversation with Dr. Jeff Clawson
by Randall D. Larson
| Photographs: (select thumbnail to view detail image) |
 With more and more PSAPs providing EMD, pre-hospital care now begins with the first call to 9-1-1. Medically- approved protocols provided by the dispatcher enable the caller to assist the victim immediately while emergency responders are en route. Medical Priorities Consultants |
 Dr. Jeff Clawson Randall Larson |
 In the time it takes paramedics to respond to a medical emergency, a patient's condition may worsen from recoverable to fatal. With the advent of dispatcher-assisted CPR and Pre-Arrival Instructions over the last decade, survival potential has increased. Medical Priorities Consultants |
 Coshocton, Ohio, paramedic enroute to an emergency call. The provision of post-dispatch medical instructions while units like this are responding have created a new and valuable concept: Dispatch Life Support. Ken Kerr |
This article can be found on
page 28 of the Mar/Apr 1998
issue of 9-1-1 Magazine.
Dispatch Life Support - encompassing Emergency Medical Dispatching, Priority Dispatching, and Pre-Arrival Instruction - is not a completely new concept in pre-hospital care. In 1975, the Phoenix Fire Department assigned paramedics to its dispatch center to provide emergency instructions to citizens by telephone. The U.S. Department of Transportation drafted EMD curriculum guidelines in 1976. The following year, Dr. Jeff Clawson of the Salt Lake City Fire Department created the first actual EMD program when he developed a set of key questions, pre-arrival instructions and dispatch priorities for a full range of medical emergencies which the dispatchers would provide over the telephone. Clawson's system has since evolved into the MPDS (Medical Priority Dispatch System), the nation's leading commercial EMD product, spawning in 1988 the National Academy of EMD for the purpose of maintaining and updating its medical protocols. The concept of Dispatch Life Support was defined the same year by the National Association of EMS Physicians. EMD systems from commercial providers like PowerPhone and APCO are also well-represented in the field, as are a number of home-grown EMD systems. With the advent of Managed Health Care, Dispatch Life Support will be more important that ever to retain the PSAP as the primary triage point for medical emergencies. In his original role as Medical Director for both the Salt Lake City Fire Department and Research & Standards at Medical Priority Consultants, and the Father of EMD, Dr. Clawson is in a unique position to see where EMD has come from and where it's going. |
Q What is your evaluation of where EMD has gone over the last twenty years? Has it really been successful?
In a relative sense, I think it's been quite successful, especially given the fact that it really changed a paradigm that the dispatchers were not clerks. They weren't just people who got an address. We had an untapped resource there. Dispatch evolves slower that other aspects of public safety. I think some reasons for that is that it's a hybrid in many places. People are employed in public safety, mainly by police departments, and yet they are considered to be medical people from the viewpoint of their performance and standards. That's a difficult role for them, because they have to wear multiple hats, and that makes it more difficult to be able to obtain the specific training and ongoing education that's required.
Q Have the major stumbling blocks in the path of EMD been paved over now, or are there still some obstacles to acceptance?
A number of them have tombstones now, but I think maybe we're still beating them to death! The medical-legal issues have never really surfaced. Those were boogiemen we were afraid of just like the Good Samaritan statutes - when someone finally looked, there'd never been a case in 48 states against a Good Samaritan, but we still passed laws to protect them. The same thing has occurred in medical dispatching. All the misconceptions have been debunked with the exception of the dispatcher's role in managing resources in such a way to reduce unnecessary light-and-siren and multiple vehicle responses. I think the genie's out of the bottle, and there's no stopping it now. Those changes are occurring but they haven't been fully accomplished because some of those require significant changes in management thinking.
Q What do you think are some of the biggest obstacles in selling a manager on this program?
Quality Assurance, especially in public safety, is something less exciting than street work, and to hire a person to do Quality Assurance case review, for example, sounds pretty boring. We need to convince managers of what quality assurance case review can do for them in their role of managing a system, and what it can do for the dispatchers in providing them with feedback on their performance. I think we've learned one very important thing in this evolution over the last 20 years, and that is that medical dispatching should function as a system of Total Quality Management and not as a series of events. That's what we did for about ten years - we trained people, gave them protocols, and just assumed they were doing the right thing with the protocols. We found that really wasn't the case.
Q How is this happening? Some agencies now claim to be doing EMD where they're really just performing what we would call telephone aid, with the illusion of priority dispatch. They've got a card set and they train the dispatcher, but their education ended that first 24 hours never to be seen again. The dispatcher is not held to any performance standard, they don't follow the protocol, and the protocols sit there as a high-priced coffee cup coaster. It's becoming more difficult to tell whether people do or don't provide EMD until you really get in and look at performance. There's no way to fake adequate performance.
Q What about agencies not yet doing EMD? How will they be impacted by these changes?
I think any agency that isn't doing EMD correctly is in big trouble. Not that lawsuits are happening by the basketful, because they're not. But you're still hanging your shingle out a country mile if you don't give adequate Pre-Arrival Instructions - and, in the future, manage your resources appropriately - because that's going to be the next area of medico-legal challenges regarding dispatcher performance.
Q How does the concept of Dispatch Life Support differ from the term you've just mentioned, "telephone aid?"
Dispatch Life Support is to dispatch what Advanced Life Support is to paramedics and Basic Life Support is to first responders. Within that science, then, it defines that in giving specific types of telephone instructions, especially in cases where time and life threat is critical, scripts must be used. Dispatchers don't function by the seat of their pants. It's not a free-form art. Time after time, case review has shown that dispatchers who function at a "telephone aid" level provide, again, only the illusion of Pre-Arrival Instructions, because they're done for the wrong patients, they're done incorrectly, the verification steps that even lead up to them were either insufficient or not done so that any instructions given may or may not be the right instructions.
Q You touched on this briefly - what do you feel is the need for Quality Assurance within EMD systems?
It's probably the spinal cord of it all. Bill Gates once said that "information is the reduction of uncertainty," and in a dispatch sense, uncertainty is a bad commodity. We don't want to be uncertain about the decisions we're making. And from a management standpoint, uncertainty results in an inability to manage our dispatch systems. The result is that dispatchers are just functioning on however they're feeling, not based on feedback that tells them what they did or didn't do. We try to be as zero-defects as possible in medicine, but there are always things to be learned.
Q How has the advent of Managed Health Care affected EMD and what considerations should EMD agencies take when dealing with HMOs and the like?
I think we've come full circle. If you go back into the `70s, a lot of the forces that were coming to bear on new EMS systems, especially in large metropolitan areas, resulted in priority dispatch systems evolving. I don't have a corner on it, there were a lot of people doing stuff and recognizing that "unless we start managing this thing it's going to eat us alive." Even in the mid-to-late 1970s, people like Bill Roberts in Dallas would say that the dispatch center's the key because that is the point at which we come the closest to what's happening with the patient, so if we can direct the patient in the right trajectory we get him to the best place. I think most people also understood that everybody who called 9-1-1 didn't have a critical emergency. The nature of that, over time, has been to try to re-educate the American public - or, in essence, to un-educate them from the best education that has occurred in public health since the turn of the Century: to call 9-1-1 if you need help. That was the failure. We were telling little kids, "if you need help - call 9-1-1." So the American public calls if they need help, and then we get mad at them when they call for something we don't think is a real emergency!
So now, we're back where we started - knowing that everybody didn't need an ambulance or a fire truck for everything. A lot of these people just needed to have someone tell them what was appropriate in caring for themselves, And that idea is back again, with Managed Care driving it. They come in and they control the money, and they say "we want medical care managed more efficiently and effectively." So what does that really say to us? They're starting to reach into the 9-1-1 system and saying "if someone calls 9-1-1, it's costing a bundle because we have to supply all these resources and send them in ambulances when it otherwise wasn't always necessary." So we're rethinking it.
The good news is that we can appropriately manage cases if we follow medical protocol. If we can then determine to a very, very high degree of accuracy what's the matter with the patient, then we can direct that patient potentially to non-mobile resources. High compliance to medically-approved, standardized protocols can safely do that incrementally. That's the paradigm now, with Managed Health Care pushing it. Actually, it's been nice to see public safety moving slowly back to the common sense thing that we were all saying in the `70s, that everybody didn't need an ambulance. Back then we created a system without dispatch management that couldn't literally make a differentiation. Now we can make that differentiation.
Q What has EMD evolved into? What would you describe is it's "State of the Art?"
What the evolution of EMD has really turned into is the evolution of the Unified Standard Protocol. We've been spending our time in a fire department or a comm center worrying about how to follow protocol, not how to build a protocol. That's an incredibly complicated science, and it has to do with logic systems, it has to do with testing and Quality Assurance of these protocols. It's not just something that's been scribbled on a page and then "whited out"overnight because something happened. You walk into a dispatch center and you see people with stickers and "white-out" on protocols and stuff that's handwritten, that's the dispatch equivalent of finding duct tape on the O-rings on the Space Shuttle! It's frightening.
What we have done is establish the National Academy of EMD. I just spent five days with the Standards Council going over 237 proposals for change to the MDPS. It was done in an organized format, with much discussion and voting on the changes to reach a consensus, determining the next version of the protocols based on input from literally thousands of centers using those protocols. This is where the Unified Standard Protocol comes in. You can't do comparative science if everybody is using a different protocol - it's impossible! If we thought that the American Heart Association was doing that with CPR protocols, we'd be absolutely astounded. It would make no sense. And yet, in the dispatch world, these protocols are being seen as, "well, if you have something, it's okay. If you kind of follow it sometimes, it's okay." Probably the greatest evolution of the dispatch process is really to become a system rather than a bunch of events. With a management system and a training system, there's a whole pie instead of a couple of slices.
Q Where do you see EMD going over the next decade? What will the future hold?
We're going to see a number of megatrends. We're going to re-examine what the dispatcher can actually accomplish from the dispatch chair. There are more skills that the dispatcher can master which have not heretofore been examined. Including some very specialized protocols and aspects of medical care that require the dispatcher's directing a caller to perform more evaluation, to go back to the patient and check them. I think we're going to see much more complex protocols written. Obviously, if those protocols are that complex, they are going to best reside in automated systems, so we'll probably see a trend away from card systems and into card/logic systems incorporated into CADs.
Continuing education goes hand-in-hand with that. If you're going to give dispatchers added responsibility and provide them with greater skills, you're going to have to train them more often and be more careful about it. I think that the parity for dispatchers to be trained at the level of police officers, paramedics, and firefighters is long overdue, and I think we're moving toward that. Yet still we see that, when it comes to the almighty dollar, the dispatcher is still somewhat down on the totem pole when it comes to retraining. There's still somewhat of a clerk kind of a view of these individuals, which is completely erroneous.
Q You have been involved with EMD from the very start. You've seen it evolve into a standard of care - and you've seen other companies sprout up that are providing this service. Personally, how do you feel about the direction this has gone? Do you feel that it's what you wanted to do when you first started out?
I think it's actually gone further than what I perceived. I can clearly say that. I don't think any of us quite had the vision of where it's gone today. I worked many years in public safety and the fire service, where there are no short-term goals. People get frustrated by their inability to create change immediately. Some of us once sat in the Holiday Inn in Butte, Montana, after the first dispatch class we ever taught outside the State of Utah, and we were complaining about the future. We guessed that in about nine years - that was 1981 - that there'd be a computer system that would run this card thing. And two of us who were there had Atari's!
We also believed that the medical dispatch goal, if we were going to be involved in this, would take about 25 years. To assess it's success of failure at anything less than a 25 year point would be incorrect and not far-sighted. That really helped me, over time, to look at the direction of EMD, even though the clock hands don't appear to be moving, and to keep providing information to people to make a difference. One of my favorite mottoes is: "change is the way the future reveals itself." And if people don't recognize that there is a need for these changes, then they become the antithesis of change. They become the wart on the wheel of progress. I think, in that sense, the management of change is our greatest challenge. I think we're going a pretty good job in medical dispatching in that way, but there's a long way to go.
