Emergency Medical Dispatching
What is Emergency Medical Dispatch(EMD)?
In 2011 Governor Tomblin Signed into law House Bill 2013 giving an unfunded mandate to all 911 Centers statewide to begin providing Emergncy Medical Dispatching (EMD) by July 2013. This is were a 911 Dispatcher will provide a caller with pre arrival instructions and/or medical treatments over the phone while a caller awaits local medical responders to arrive. We are in the process of implenting a program provided by PowerPhone, Inc. and will have our program up and running with 6 months.
In most modern EMS systems, the Emergency Medical Dispatcher will fill a number of critical functions. The first of these is the identification of basic call information, including the location and telephone number of the caller, the location of the patient, the general nature of the problem, and any special circumstances. In most EMS systems, the telephone remains almost a singular point of access for those needing assistance.
There are general exceptions to this rule. Most of them still involve 9-1-1 calls, but using new alerting mechanisms upstream from the 9-1-1 call. While these new applications are not directly monitored by the EMD, the EMD nevertheless remains the primary point of contact into the dispatch system.
The next area of responsibility involves the triage of incoming calls, providing expert systematized caller interrogation, using the script provided by the Emergency Medical Dispatch system, in order to determine the likely severity of the patient's illness or injury, so that the most appropriate type of response resource may be expedited. All calls are prioritized by medical symptom/condition acuity. This process may be further complicated by panic-stricken callers who scream, cry, or make unreasonable demands. The trained EMD uses interpersonal and crisis management skills to sort through these distractions, taking control of the conversation, calming the caller, and extracting the necessary information. This inquiry begins with the obvious questions regarding whether the patient is conscious or breathing. The questioning will continue until the EMD is able to qualify a potentially life-threatening condition, at which time the closest appropriate response resource (such as a paramedic-staffed ambulance service) is notified to initiate pinpointing the call location. When this occurs, the EMD will continue the questioning, attempting to gather additional relevant information, useful to determine response speed, the type of resources dispatched, or the type of equipment that the paramedics will bring to the site when they arrive. In most cases, this 'pre-alert' function will not be required, and the resource will simply be dispatched when all of the required information has been gathered. Ultimately, the decision on how to proceed, or when to interrupt the established process, requires the judgment of the EMD handling the call. Otherwise, the manner in which this questioning proceeds is often governed by protocols, or by decision-support software.
The third function is the selection and assignment of the most appropriate type of response resource, such as an ambulance, from the closest or the most appropriate location, depending on the nature of the problem, and ensuring that the crew of the response resource receive all of the appropriate information. The EMD is responsible for the management and work assignment (physicicans and supervisors provide work direction) for all of the response resources in the EMS system. In many cases, the EMD is responsible for multiple response resources simultaneously, and these may include ALS, BLS, or some mix of skills, ambulances, 'fly-cars', and other types of resources. In a quiet, rural setting, such resources may be at a fixed point, in quarters, most of the time, while in other cases, such a surban settings, all or many of the resources may be mobile. It is not uncommon, in a large urban centre, for an EMD to manage and direct as many as 20 response resources simultaneously. It is the job of the EMD to analyze the information and ensure that it leads to the right resource being sent to the patient in the shortest appropriate time. This requires a constant level of awareness of the location and status of each resource, so that the closest available and appropriate resource may be sent to each call. Particularly in larger, urban settings, the mental demands and stress level may be comparable to those of an air traffic controller, and 'burn-out' rates may be quite high. This has been eased somewhat in recent years through the use of Automatic Vehicle Locating (AVL), permitting the EMD to monitor the location and status of all assigned resources using a computer screen instead of by memory.
The EMDs next priority is to provide and assist the layperson/caller with pre-arrival instructions to help the victim, using standardized protocols developed in co-operation with local medical directors. Such instructions may consist of simple advice to keep the patient calm and comfortable or to gather additional background information for responding paramedics. The instructions can also frequently become more complex, providing directions over the telephone for an untrained person to perform CPR, for example. Examples of EMDs guiding family members through assisting a loved one with the process of childbirth prior to the arrival of the ambulance are also quite common. The challenge for the EMD is often the knowledge level of the caller. In some cases, the caller may have prior first-aid and/or CPR training, but it is often just as likely that the caller has no prior training or experience at all. This process may still consist of a symptom-based flip-card system, but is increasing automated into the CAD software.
The EMD is generally also responsible for providing information support to the responding resources. This may include callbacks to the call originator to clarify information. It may involve clarifying the exact location of the patient, or sending a bystander to meet the ambulance and direct paramedics to the patient. It may also include requests from the EMS crew to provide support resources, such as additional ambulances, rescue equipment, or a helicopter. The EMD also plays a key role in the safety of EMS staff. They are the first with the opportunity to assess the situation that the crew is responding to, will maintain contact on the scene in order to monitor crew safety, and are frequently responsible for requesting emergency police response to 'back up' paramedics when they encounter a violent situation. EMDs are often responsible for monitoring the status of local hospitals, advising paramedics on which hospitals are accepting ambulance patients, and which are on 're-direct' or 'divert'. In many cases, the EMD may be responsible for notifying the hospital of incoming patients on behalf of the response resource crew. Paramedics who are working on patients or driving an ambulance are rarely able to make a detailed telephone call. As a result, the EMD will relay any advance notification regarding patient situation or status, once in transit.
Finally, the EMD ensures that the information regarding each call is collected in a consistent manner, for both legal and quality assurance purposes. In most jurisdictions, all EMS records, including both patient care and dispatch records, and also recordings of dispatch radio and telephone conversations, are considered to be legal documents. Dispatch records are often a subject of interest inlegal proceedings, particularly with respect to initial information obtained, statements made by the caller, and response times for resources. Any or all may be demanded by a criminial court or civil court,, a public inquiry, or a Coroner's Inquest, and may have to be produced as evidence. It is not uncommon in some jurisdictions for EMDs to be summoned to court, in order to provide evidence regarding their activities. As a result, there is frequently a legal requirement for the long-term storage of such information, and the specific requirements are likely to vary by both country and jurisdiction. Additionally, medical directors will frequently rely on information provided by EMDs for the purpose of medical quality assurance for paramedics; in particular analyzing conversations between paramedics and dispatchers or physicians, analyzing the paramedic's actions and judgments in the light of the information that they were provided with. As a direct result of these two factors, there is a requirement for all call information to be collected and stored in a regular, consistent, and professional manner, and this too, will often fall to the EMD, at least in the initial stages.