Jeff Clawson, M.D.

Jeff Clawson, M.D.


By Jeff Clawson, M.D.

Dr. Clawson:

Wellington Free Ambulance in New Zealand is considering adding new material to the guidelines for the field responders. The aim could be to assist responders to call communications for the provision of advanced dispatcher-assisted instructions in cases of high risk childbirth using Pre-Arrival Instruction (PAI) Protocol F.

The directive would be significant in terms of recognition for the Medical Priority Dispatch System (MPDS) system and the advanced childbirth instructions that are now provided by EMDs. In short, this would be a good win for Emergency Medical Dispatchers (EMDs) and patient care here!

Thanks again,

Ruth Lloyd

PDC Implementation Specialist

Australia/New Zealand

Wellington, New Zealand


That is certainly “earth shattering” news—field responders being directed to call EMDs for instructions! It certainly is an amazing win for the respect of EMDs and recognition of the MPDS. You don’t see this sort of thing happening in EMS-land every day. This is not a brand-new phenomenon since after the release of MPDS v11.2 in 2004, this has occurred sporadically in several countries, which have had communication centers using the MPDS High Risk Delivery PAI protocols to advise crews at scene.

These very special protocols became a necessity after the International Academies of Emergency Dispatch (IAED) encountered an increasing number of different types of what we call “high risk” delivery cases in which critical care fell completely outside the scope of the then current protocol, not to mention what any other 9-1-1-like centers could or would do.

This High Risk Delivery protocol is actually a group of nine protocols designed to address a host of different critical problems occurring in the early moments of a 9-1-1 call. On a per 9-1-1 center basis, these appear to be rare occurrences, but pose significant clinical as well as ethical problems if not dealt with accurately and immediately by EMDs. Response time can be, and is often, lethal, or brain damaging, in such cases. The Academy has adopted a policy statement regarding the EMDs’ involvement in such difficult situations (see Principles of EMD – 4th Ed. page 8.5):

The International Academies of Emergency Dispatch considers situations necessitating the provision of these instructions to be an extremely High Risk-Inherent Situation Case (HiRISC) and believes that the trained EMD, EFD, or EPD (or other agency), making a good-faith attempt to provide these instructions, should not be held responsible for any bad outcomes. This should not be considered a legal interpretation, but a strong official opinion of the Council of Standards and Board of Trustees of the IAED.

This list of special delivery PAI sub-protocols includes: Footling Breech, Frank Breech, Arm or Hand Presentation, Shoulder Dystocia, Prolapsed Cord, Ruptured Cord, Cord Around Neck/Body, Amniotic Sac Encasement, and Fundal Massage for serious post-partum hemorrhage.

In less than a year [after the release of v11.2], Louise Ganley, now the clinical support representative at the U.K. Office of PDC, then told me that they provided this service for their operational staff at Great Western Ambulance Service in Bristol, U.K. She stated, “It became very apparent that this was a good thing to do after one of our EMDs, who was awarded dispatcher of the year in Dublin, provided PAIs for a breech and successfully delivered the baby who was presenting feet first, cord around the neck, and was successfully resuscitated, all before the crew arrived on scene.”

Tracey Barron, research & studies officer for IAED, formerly of South East Coast Ambulance Service in the U.K, added that their road staff “… were always advised to call in to dispatch during an ‘unusual’ birth so we could provide these PAIs. We did this from v11.2 onwards. While it was never part of their formal clinical training, any member of road staff that set foot in control was shown the instructions and advised to call in.”

In 2008, Dr. Andrew Bacon, medical director for the Melbourne Ambulance Service, Australia, shared this encouraging experience with the Academy. “I reviewed the first breech delivery call brought to my attention today. It was a first-party caller, isolated location, no one else on scene, 20 minutes to the nearest ambulance. I think she was a first pregnancy, undiagnosed breech at 38 weeks, who earlier had rung the hospital and been told not to come in too early in the labour. Two feet had presented in the bathroom, and the patient herself was on a mobile phone. The EMD adapted the script beautifully to a first-party caller. The call started with the patient’s mother ringing in from a suburb an hour away. The EMD goes to conference call, kept both mother and daughter on the line and worked through PAI-F. Twenty minutes later the baby is out, breathing, and all is well. It makes all the reviewing of (the protocol) drafts (as a member of the Council of Standards) so worthwhile. Cheers.”

Several other similar cases have been shared with the Academy since this special protocol set has been available to EMDs.

When the initial High Risk Pregnancy/Delivery Standards Committee met, it became very apparent that even medical practitioners like myself, an emergency physician and previous field responder, as well as emergency or general floor hospital nurses, are not experienced in how to actually deal with these situations, since we rarely, if ever, do. We had the experts present to the Committee that they knew, and they very quickly realized that just how to tell someone else how to actually accomplish these feats non-visually was very much more difficult than simply and physically doing it in person.

It makes perfect sense that an EMD, with the correct PAI tools, should be able to provide help to scene responders as well as lay callers, rather than simply leaving them to reinvent this “rare” type of wheel. It would also seem that this dispatch-to-EMS crew advice should be formally incorporated by many more, if not all, EMS systems utilizing the MPDS to safely dispatch.

If the goal is to help people, then regardless of the origin of that care, even if it’s from an EMD armed with these advanced protocols, these life-improving instructions should not only be provided here and there, but actively embraced by all.