PAIS BUILD ON PRE-HOSPITAL CARE
July 30, 2014
By Audrey Fraizer
Phoenix (Ariz.) paramedic Bill Toon had barely settled in for the swing shift on Aug. 10, 1974, when a young mom in a full-flail panic called the fire department’s new emergency number to report that she had just pulled her 2-year-old son from the family swimming pool. The toddler wasn’t breathing, and he was turning blue.
The calltaker quickly obtained the address and phone number then asked if the child was still in the pool.
“We’re trying to give him mouth-to-mouth,” the mother tells the calltaker, who responds, “All right. I want you to stay on the line. I have a medic that is going to give you some help while I send someone. Stay on the line.”
Toon takes over the call, and asks the mother to describe the boy’s appearance and how long he might have been in the pool. Toon urges her to calm down then asks if anyone else is with her. She says her parents are trying to revive the child.
Toon says, “OK, here’s what I want you to do to make sure they’re doing [CPR] right.”
After about 30 seconds and bringing the child inside the house, the frantic mother loudly tells Toon, “He’s not breathing at all!”
“OK, calm down, ma’am,” Toon firmly tells her. “Listen, you’re going to have to listen to me in order to help him now, OK?”
Toon quickly moves through the instructions over the phone, and the mother repeats them to her father who is delivering mouth-to-mouth. About 40 seconds later, the child starts to moan. Ten seconds after that, desperation officially turns into elation as the boy coughs up the cup or so of water that flooded his lungs.
“He’s starting to cry,” the mother says.
“If he’s crying, he’s breathing,” Toon responds. “Just let him cry, all right. He’s going to be OK now.”
Toon, when asked to recall the incident, said in those days Phoenix Fire only had a single paramedic unit. At the moment of that specific call about the boy, the ambulance was so far away that chances were slim to none it would reach the scene in time to save the boy, he said.
“I began to give the caller a crash course in CPR because the only real chance the child had of being saved was for his family to do the saving,” Toon said. “I talked them through the resuscitation process, and in a few minutes, I heard the child begin to cry. That was a pretty sweet sound for everyone involved.”
There were other examples of paramedics giving advice over the phone to someone caught in a desperate situation back then, but the 3-minute, 8-second “Baby Fell in Pool” is the first known recording of basic life support (BLS) provided to a caller over the phone while awaiting the arrival of field response. Toon’s advice was expert although ad hoc; he was among the first crop of firefighters trained in paramedic rescue to offer in the dispatch center what he knew from his experience evaluating and treating patients at the scene.
And that’s where the major difference lies between BLS, given in the field, and Dispatch Life Support (DLS), provided from the communication center.
“This is a very important point to make,” said Brett Patterson, Academics & Standards associate and Medical Council of Standards chair for the International Academies of Emergency Dispatch® (IAED™). “While these first calls were awesome to hear, and the celebrated ones saved lives, we actually learned more about what not to do. Responders ad-libbing made mistakes, simply forgetting important things that they would normally see.”
As the Salt Lake City (Utah) fire surgeon, Dr. Jeff Clawson was mindful of 9-1-1 center operations, especially as they related to state and national efforts to coalesce standards for emergency medical services. In 1966, the National Academy of Sciences of the National Research Council, released the report “Accidental Death and Disability: The Neglected Disease of Modern Society,” which gave incredibly low marks to the United States’ ambulance services and led to major reform in pre-hospital treatment.
Clawson had worked his way through medical school as a paramedic with Gold Cross Ambulance Service in Salt Lake City at the same time a number of cities were training firefighters to take on roles previously reserved for doctors. In 1971, Jim Page, a founding figure in EMS, coordinated paramedic rescue services through the Los Angeles County (Calif.) Fire Department. At the time, EMS was a mere child and, according to an article published in EMS Magazine (Founding Fathers of EMS, Aug. 1, 2007), built by individuals taking personal and professional risks to develop systems they believed would save lives. They—and this is also important to point out—“allowed the next generation to build on a foundation with clinical, operational, and administrative improvements that helped EMS survive and thrive.”
Clawson is cited in the same article as one of those pioneers.
In the late 1970s, Clawson revisited a U.S. Department of Transportation plan—never fully realized or implemented—to bring pre-hospital care to the earliest point possible by establishing guidelines for emergency medical dispatch. He put his protocols into motion at the Salt Lake City Fire Department (SLCFD) Alarm Center to reduce the number of Code 3 medical runs and the number of fire department-related vehicle accidents.
That initial motivation—reduction in the number of Code 3 medical runs—comes as a surprise to most people in emergency communications, Patterson said.
“Many people think Pre-Arrival Instructions (PAIs) were the impetus for the protocol, when it was actually ambulance triage,” he said. “It was an issue in Salt Lake and everywhere else.”
Clawson had borrowed his protocol design from a senior physician he worked with at Charity Hospital in New Orleans, La. He turned the doctor’s so-named “cookbook” of recipes for handling patient flow (triage based upon severity and resources) into processes for providing standardized care during step one of the pre-hospital setting.
He introduced the medical dispatch system he created at home in his spare time on 8-inch by 5-inch cards with an intra-department memo (dated June 4, 1979) requesting feedback from dispatchers as well as EMTs and paramedics to help fine-tune and maintain the system at a high level.
The original set of protocols contained 29 sets of cards. Each caller complaint was listed in alphabetical order, as they are today, and reflected either a symptom (e.g., abdominal pain, burns, cardiac/respiratory arrest) or an incident (e.g., electrocution, drowning, or traffic injury accident).
The protocols were scripted and per Clawson’s instructions, the script must be followed word-for-word to determine “exactly what happened”—the reason for the call and the appropriate response. The core card contained three color-coded areas: Key Questions, Pre-Arrival Instructions, and dispatch priorities.
Clawson sent out the first revisions, based on the feedback provided on medical dispatch feedback reports, in an intra-department memo dated Nov. 27, 1979. The reports were the predecessor of the well-known Proposal for Change (PFC) form.
“Dr. Clawson was always concerned about feedback from users,” Patterson said. “He knew from the start that in order for the system to work effectively for dispatchers and field responders, he needed the constant vigilance of people relying on them in the pre-hospital setting.”
The first PAIs released in the cardset were ballooned boxes with instructions connected with lines that flowed from one instruction to another. Some of those lines branched, depending on the next instruction, or looped back to earlier instructions. The result was accurate but so difficult to follow that Clawson nicknamed the renderings “Uncle Squiggly.” They resembled methods English teachers used to help students conjugate complex sentences. For example:
°Penetrating wounds of globe
·Contact lens problems
·Lay patient down
·If chemical, flush immediately with H-2O for 10 min.
Key Questions: Type of problem
·Is eyeball leaking or cut?
·Most can be transported via personal auto
·Ambulance 10-40 for severe ocular trauma
For many, the protocols weren’t love at first sight. Leaving first aid to what was then considered a bunch of lower-tier office staff invited trouble and widened the opening for liability.
“You have to keep in mind who was managing many dispatch centers back then,” said Ross Rutschman, a co-designer of Treatment Sequence Protocols—the forerunner of today’s PAIs. “That was law enforcement and, therefore, any medical aid to be given over the phone was low priority. Also, keep in mind that this is well before computers, so many calltakers were treated as clerks, kept busy typing up police reports and doing other office tasks that came with the job.”
While Rutschman, Page, Clawson, and other dispatch sentinels could see as plain as day that remote life-saving instructions were logical, necessary, and even long overdue, “Back then, CPR had barely been accepted as viable treatment itself,” Rutschman said. “The thought of teaching someone to do it over the telephone was seen as very radical.”
There were claims that the Academy was practicing medicine over the phone.
“The answer was clearly no, and still is,” Clawson said. “The dispatcher is not making a diagnosis. The dispatcher using the Medical Priority Dispatch System (MPDS) stays on the phone with the caller and instructs or coaches the caller to do something positive for the patient during the response time lag that proves fatal in so many cases.”
By using appropriate Key Questions, the dispatcher is able to identify the mechanism of injury and the presence of priority symptoms, and respond to the symptoms with PAIs designed to accomplish three goals:
1.Provide immediate assistance through the caller when certain emergency conditions are present
2.Protect the patient and caller from potential hazards
3.Give bystanders correct information and protect the patient from well-meaning bystanders inadvertently giving incorrect treatment
In 1988, Clawson established the National Academies of Emergency Dispatch (now the IAED) to become the certifying and standard development organization for both the MPDS Protocol and the EMD certification curriculum. The Academy was set up to evolve the protocols and provide a forum for the future of EMD.
The PAIs were always a hair’s breadth away.
Over time, Clawson hired Mike Smith to convert the PAI algorithms into what we know today as the Panel Logic Sequence. Detangling the lines allowed the panels to easily adapt to the digital age and morph into today’s ProQA—the most widely used emergency dispatch software in the world. Smith’s work is still regarded as the single most important invention to transform the delivery of PAIs in a safe and consistent manner.
“That was a watershed event in the ability to expand the PAIs to handle gender, age, and, in time, related condition instructions easily,” said Rich Saalsaa, one of the architects of ProQA. “This led to the ability to track the actual usage of the protocol, and eventually, the ability to add quality assurance and quality improvement processes.”
Post-Dispatch Instructions (PDIs)
In contrast to the complexity of situations PAIs are designed to handle, PDIs are given to callers dealing with specific incidents requiring a range of instructions with very basic, simple advice for mild or minor injury situations. They provide instructions of what to do and, in some cases, what not to do while the ambulance is on the way to the scene. Over time, PDIs and PAIs have become so common that callers sound surprised, even angry, when told by dispatchers from a non-MPDS call center that they don’t provide first aid instructions over the phone.
A high-wire act
Asked to define PAIs in one sentence, Greg Scott, IAED operations research analyst, said, “PAIs are used in low-frequency, high-risk events that dispatchers rarely encounter. But when they do, they must handle them in a highly compliant manner.
“They are precisely worded and meant to be read verbatim for very good reasons,” he continued. “They maintain the proper order of care and eliminate unintentional but critical errors. Dispatchers working without scripts, for example, can too easily omit an important instruction when the rescuer and patient cannot be seen, or assume something is logically being done when it is actually not. Careful, well thought out, and time-tested wording is critical to remote caller understanding.”
The evolution of emergency medical dispatch in the United States and abroad has been a movement to bring logic and order to emergency responses that were basically, “Send everything you have as fast as you can,” Scott said.
That’s why PAIs are the centerpiece of the MPDS-scripted calltaking method, Scott said, noting that they have been field-tested. PAIs continuously debunk the tired, old criticism that pre-arrival instructions is beyond the providence of dispatching and would open centers up to the real and likely risk of being sued if an incident were to be made worse, not better, by dispatchers intervening.
“In just over 30 years, EMD has fully inhabited its potential as the critical link to the best possible outcomes in an emergency,” Patterson said.
Spinning in unison are methods of interrogation and caller instruction evolving into tightly-scripted steps known today as PAIs.
“They have allowed dispatchers to offer immediate and successful Dispatch Life Support well ahead of the field responders arriving at the scene,” he said.
Similar to the main body of protocol—Chief Complaints—the PAIs are every bit as dynamic in meeting the challenges of medical discovery and technology. The innovations have also received their fair share of resistance.
But that’s not a bad reflection of the protocol or us, Patterson said.
“The greater insult would be a medical and dispatch community ignoring the changes, particularly in recent years with the release of diagnostic tools in the MPDS,” he said. “As the standard-setting organization, we expect scrutiny and our response is always backed by the research that goes into protocol development.”
For example, the North American release of MPDS v12.1 in March 2012 generated several inquires regarding Protocol 28: Stroke (CVA) and the required Stroke Diagnostic (Dx) Tool. Initial pushback focused on the extra time it added to the call (an average of 34 seconds) and the potential impact on local response options for stroke patients.
According to a subsequent IAED Official Statement addressing the concerns:
The Academy’s Council of Standards has evolved and approved the new Stroke Diagnostic (Dx) Tool in an effort to better predict the outcome of stroke early on in the EMS response, not only to enable early hospital notification in the interest of prompt and effective patient care, but as a study methodology to measure and improve the outcomes of stroke patients. The new protocol was released and used extensively in the U.K. for about a year prior to its release in North America, with excellent results and positive feedback.
In short, Patterson said, the stroke predictability and subsequent hospital notification were found to be well worth the seconds spent administering the tool.
“It took time, but it’s now recognized as universal, DLS standard of care that enables better outcome studies in the interest of patient care,” he said.
Literally thousands of well-documented anecdotes over 35 years are now being supported by actual science showing irrefutably that PAIs have had a revolutionary impact on dispatch, Patterson said. Coming to be was a slow, sometimes halting evolutionary journey that began with field responders sitting around in the dispatch center offering or being asked to talk to callers while crews were en route.
“Back then, it was literally paramedics saying, ‘Why not? Nothing else is going on,’” Patterson said.
The ambiguous wording of instructions or giving them out of order was immediately seen as problematic to the effort, he said.
Those early efforts had an important lasting upside: “They gave us a full appreciation of and commitment to the specifically worded protocol interrogations and instructions dispatchers use today,” Patterson said.
Rutschman said there are many great EMS systems in the world that became great because of the EMD program.
“The trained, certified EMD is truly recognized now not only as a medical professional but as the most pivotal person in the EMS system,” he said. “In many cases, it doesn’t matter how fast we get there, how good the paramedics are, or how good a hospital is. If there’s a lapse of care between the incident occurring and someone arriving at the scene, it doesn’t matter how good the paramedics or hospital is, damage has been done.”
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