April 2, 2018
How do you prioritize calls?
For police and fire communication centers, anything in progress is a top priority. An active shooter situation is dispatched immediately, and the same goes for an explosion at a fertilizer plant. Anything life threatening in EMS takes top priority, whether a sudden cardiac arrest or a baby on the way.
These same types of incidents—high priority—can be low or high frequency.
Sudden cardiac arrest (SCA) is the largest cause of natural death in the U.S.—about 383,000 adult deaths each year—and is responsible for half of all heart disease deaths.1 SCA, however, is a low-frequency 911 call. Statistics put it as low as one percent.
Active shooter mass incidents (commonly defined as four or more people killed, excluding the shooter) increased dramatically from one incident to 20 incidents during the period between 2000 and 2015.2 Although a relatively low-frequency occurrence, an active shooter incident demands the highest priority.
So, what does sudden cardiac arrest have to do with active shooter incidents, especially in relation to emergency dispatch?
They make the heart pound faster, particularly if unprepared.
“It’s a real issue in EMS,” said Brett Patterson, Academics and Standards Associate and Chair, Medical Council of Standards, International Academies of Emergency Dispatch® (IAED™). “You certainly get comfortable with the more frequent types of calls. Unfamiliarity can cause apprehension. It’s something you’re not used to working with all the time.”
Understand the ‘why’
Familiarization requires training, and training requires more than simply memorizing the script, Patterson said.
The unified protocol concept (script) and systems approach distinguishes the IAED protocols to, among other reasons, standardize care no matter where it is used. However, an actual incident involving a seldom used protocol is not the time to practice. In addition, patient-driven events—such as childbirth—might require starting the PAIs at a section of the scripted sequence you’ve never needed (e.g., breech, cord wrapped around baby).
“You don’t want to go searching to find out where you are in the process,” Patterson said. “You need training and practice. You have to understand the goal of that protocol.”
As an example, Patterson cites a call he took in 1991 while working in dispatch in Pinellas County, Florida (USA). The 18-year-old caller was pregnant, in hard labor, and home alone with her two-year-old daughter. The delivery went quickly—twins, one weighing 1.5 pounds and the other weighing 1.7 pounds. An ambulance was on the way, but what could be done until paramedics arrived on scene?
“I remembered the goal of the protocol,” Patterson said. “Keep them breathing and warm. I focused on that. Focusing on understanding the basic need of the patient is what’s needed in these types of situations.”
Focus, he said, also keeps an emotional response at bay. As a result, the EMD conveys confidence. Patients understand their role and what you expect of them.
Supply the right tools
Megan Craig was introduced to the Medical Priority Dispatch System™ (MPDS®) when she started at Deschutes County 9-1-1 (Bend, Oregon, USA) in 1998. Similar to other new hires, she attended an initial training that included instructions on how to use the cardset.
“There was very little continuing education or explanation behind the protocol,” said Craig, now the center’s Training Coordinator. “This could make it unnerving to be on certain types of calls and not understand the best way to process them.”
Providing the tools for a deeper understanding of the protocol and ProQA® has since become a major goal, so regardless of the outcome, she said, “We know we’ve done everything we could for that situation, and the callers received excellent care.”
An initial challenge was where to go for the tools. Craig recalls talking to other EMDs, finding instructions online for choosing the correct Chief Complaint, and developing scenarios based on these with her teammates. She now uses the Academy’s Advancement Series and rotates through all the protocols for training lessons, all in the interest of practicing the protocols in preparation for the “what-ifs.”
Craig also sends out weekly emails summarizing call compliancy, congratulating emergency dispatchers for their efforts (even if the outcome is not always what they had hoped), and providing a pop quiz.
“I am thankful to work at a center where people want to do a good job,” she said. “We offer a high level of care, and we’re proud of that.”
Despite a gregarious, outgoing personality, the voice of EMS is where Chad Hicks plans to stay. It’s his niche. He identifies with the attention the profession demands.
“I’m a stickler for detail,” said Hicks, who is an emergency dispatcher and trainer at Deschutes County 9-1-1. “It’s something I got from my dad. He always said, ‘Anything worth doing, is worth doing right.’”
The life and death consequences of what emergency dispatchers say, hear, and relay to response is why he tries to tap into the motivation of the newcomers he trains. It’s not only for accuracy’s sake.
“You have to want to do this,” said Hicks, who left private industry for public service. “If it’s just a job, something to get through each day, it’s probably not right for you.”
Realizing the potential to help is central, he said, to mastering protocols and proficiently handling high-priority/low-frequency situations. Hicks’ most memorable call, in fact, was not one he answered directly. He was training when a call requiring the use of childbirth PAIs came through to his trainee. He acted in an oversight position, guiding the trainee’s actions.
“Pregnancy doesn’t happen here at the center that often, and it’s really hard to navigate the CAD and at the same time walk through the protocol while trying to keep the caller calm,” he said. “I let her do it, and we heard the baby’s first cries. This is something I don’t think either of us will ever forget, and we did it as a team.”
Retaining the specifics of a low-frequency call takes repetition for new and seasoned emergency dispatchers alike, Hicks said. The emergency dispatcher must understand the sequence of events (why the steps occur in that order) and practice protocols and PAIs in a no-stress training environment.
“Calls are the luck of the draw,” he said. “When the call comes in is past the time to learn. Without practice, it’s like having a plan to fail. My goal is to be the best, and I want the same for my trainees.”
Prepare for randomness
The unpredictability factor is the impetus behind Heidi DiGennaro’s roll call training at the Harford County Department of Emergency Services, Forest Hill, Maryland (USA). DiGennaro is a shift manager at the tri-accredited center (fire, police, and medical ACE) and entering her 25th year in emergency communications.
Roll call training is the 30-minute period overlapping shift change, and during that time, supervisors summarize events of the previous shift, give position assignments, and provide a training exercise. DiGennaro favors the latter and over the years has created scenarios of the unpredictable. She scours the news, takes suggestions, dramatizes little used protocols, and plain relies on her imagination to develop the situations involving active shooters at shopping malls, explosions, teenage parties gone wild, bar fights, and airline crashes.
“Set up a scenario, and work through it like a tabletop exercise,” she said. “Be outlandish, go crazy because you never know. ‘What if a boat hits a bridge when a train carrying hazmat is on it, and the boat breaks the bridge?’ Sounds unusual, especially if you have no waterways, but what about overpasses? What if a tanker hits a highway bridge abutment and breaks the overpass with cars on it? Can that happen? Create the discussion.”
Engaging the emergency dispatchers motivates them, which is critical for unpredictable events, DiGennaro said.
“That first five minutes of the incident is crucial,” DiGennaro said. “That’s when the call is make-or-break. We are the front line. We are the ones who will set the initial tone for the call. The field doesn’t know the call exists when we are making decisions on what to do from the first telephone or first radio call. We must be prepared.”
Give your best
While agency policy may be helpful in these situations, Patterson said, “You can see how difficult it would be to create a policy that covers every possible situation.”
More often, policies are created to change response plans or suspend PDIs/PAIs during unpredicted, high call volumes. In addition to the consideration of policy, however, Patterson said agencies might be comforted to know that doing your best, given certification, training and experience, is always considered in a court of law. In addition, he said predictable spikes in call volumes—which can happen during high-priority and low-frequency events—are generally not considered under the Emergency Doctrine.
“An agency is obligated to prepare for what is predictable,” he said.
- “CPR Statistics.” American Heart Association. 2014; Sept. 3. http://www.heart.org/HEARTORG/CPRAndECC/Whatis%20CPR/CPRFactsandStats/CPR-Statistics_UCM_307542_Article.jsp# (accessed Nov. 29, 2017).
- “Mass Casualty Shootings. 2017 National Crime Victims’ Rights Week Resource Guide: Mass Casualty Shootings Fact Sheet,” 2017. https://ovc.ncjrs.gov/ncvrw2017/images/en_artwork/Fact_Sheets/2017NCVRW_MassShootings_508.pdf (accessed Nov. 28, 2017).
What is the best indication of preparedness in a communication center for an active shooter incident at a shopping mall?
Disaster preparedness and management policies?
Resource allocation procedures?
What about the caller having chest pains at the same time but in a different place than an active shooter? What can you do for him?
Providing appropriate assistance to secondary high-priority callers—for situations not related to the major incident—is every bit as significant as response to a major event.
“A center can’t put everything else on hold for one event,” said Kevin Anderson, Director of Communications, American Medical Response (AMR) Northwest. “You have to attend to the non-emergent callers and what they need.”
Anderson speaks from experience: 30 years in EMS, including EMT and supervisory and management positions with AMR Portland, Oregon (USA), communication center. He has been in the field responding to mass casualty incidents, including directing response to a mass shooting at a shopping mall, and, most recently, voluntarily providing aid at the mass casualty shooting in Las Vegas, Nevada (USA).
“People in EMS want to fix things,” Anderson said.
Even at times when the event is more than they’ve ever been through.
Five years ago, on Dec. 11, 2012, communication centers in the Portland, Oregon, metropolitan area handled 22 minutes of chaos when a 22-year-old shooter opened fire on shoppers at the Clackamas Town Center. The number of 911 calls soon overwhelmed the Clackamas County emergency system, subsequently routing the overload to outlying dispatch centers, including AMR Portland.
Anderson was “very proud” of everyone at the center who responded to the shooting. He also acknowledges the 40 secondary calls they ran at the same time, reinforcing a perspective he finds integral for management during crisis.
“Pump the brakes,” he said. “We all want to help. Everyone wants to go to the shooting, but there has to be dispatchers waiting for that minor chest pain call from the nursing home.”
The second mass casualty incident in his experience was directly related to his job in Portland. Anderson and his wife, Elaine, were among the thousands clapping and dancing to country music when hell broke loose on the Las Vegas Strip (Oct. 1, 2017). They heard the shots. They were 30 yards from stage right, opposite the side where bullets first hit.
“I was convinced shots were on the street,” Anderson said. “No crack by the side of my head. Nobody moved. Nobody knew what was going on.”
Four minutes into the shooting, Anderson realized the terror was coming from within the venue. He and Elaine fled toward an exit. The first victim in their path was a man concertgoers were dragging across the grass, his head wrapped in a shirt to staunch the blood from a head wound. Anderson helped lift him into a car in a line of vehicles coming from the adjacent parking lot. Elaine stayed to comfort the man’s wife.
So it went for the next two hours after the gunfire stopped. Anderson looked for silhouettes on the ground, placing the wounded on wheeled containers and rolling them to waiting vehicles and carrying the deceased to an alley alongside the venue. He lost sight of Elaine who, he later learned, was sequestered at Hooter’s Restaurant. He mustered the strength people expect from EMS.
“I remember being very scared and angry,” he said. “People are hurt, dying, and screaming, and there is absolute chaos. No one in this type of situation stays the coolest cucumber, but people in EMS are looked upon as the voice of reason, and that’s what I knew I could do to help. I was trying to be calm for them, at least on the surface.”
Anderson went home and returned to work two days later. He told the emergency dispatchers what had happened, from his perspective, and it wasn’t an easy story for them.
“This was beyond what anyone had heard,” he said. “I could tell that in their eyes. What would happen to me? This is not only about preparation. It’s also about recovery.”