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Journal of Emergency Medical Services (JEMS), February
Dispatch Priority Training: Strengthening the weak link
In the last ten years, the EMS response in this country has undergone an incredible evolution. Improvement has been the general trend, exemplified by the move from untrained mortuary services and first aid vehicles, to EMT ambulances, and finally ALS paramedic systems. Responders' expertise has been upgraded, and the fact that EMTs now receive hundreds of hours and paramedics over a thousand hours of intensive emergency training indicates the importance of such training in EMS. But at the center of this well-trained, specialized, and expensive EMS configuration÷deciding whether or not to respond, who responds, and how they respond, is the emergency dispatcher, who likely has not been given even a single hour of emergency medical instruction. For many years, emergency dispatchers have remained the weakest link in the EMS chain of response.
In November, 1976, the Department of Transportation developed a program for converting EMTs into dispatchers. However, this type of training program was applicable neither to the EMS in our area nor to many other systems of which we were aware. Most fire and law enforcement agencies operating EMT and paramedic services function with an established corps of dispatchers, many of whom have significant seniority and accrued benefits. This is the case in our system, and thus replacement of these dispatchers with EMTs or paramedics is neither economically nor occupationally feasible.
In addition to the problem, those few dispatchers who have completed EMT training courses lack the concurrent field experience necessary to make this classroom education relevant to dispatch application.
In order to upgrade the emergency medical expertise of the dispatcher the concept of the Emergency Medical Dispatch Priority Card system was developed. This reference system became the core of a 25-hour training course used to educate and certify dispatchers as EMDs (emergency medical dispatchers) throughout the state of Utah. The entire course was outlined in instructor teaching format and was elapsed-time referenced for accuracy in course scheduling.
Emergency Medical Dispatcher (EMD) Training Course
The 25-hour course consists first of a three-hour review of basic dispatch techniques, equipment, regulations and code. The role of the EMD is then explained and the Medical Dispatch Priority Card System introduced. At the system's core are the general concepts of key questions, pre-arrival instructions, and dispatch priorities (determinants and response). The "Four Commandments" of medical dispatch (age, chief complaint, status of consciousness and breathing) are reinforced as an absolute baseline of information obtained and relayed on every call.
The EMD trainee is taught how to assist in coordinating EMT-paramedic en route rendezvous and relaying information between agencies and units lacking common radio frequencies. Since function of the EMDs is also to prevent needless delays within the system, their leadership role in the area of unit logistics is stressed. For example, the EMD is often in the position to determine that available ALS units are so distant from the victim that, in the interest of time, EMTs at the scene would be better advised to transport immediately to the nearest emergency department.
A significant improvement necessary to every medical dispatch system today is the provision of pre-arrival instructions. To prepare the EMD for the role of giving life-saving instructions to the caller, the trainees are certified in basic life support (American Heart Association) on the second day of the course.
The heart of the course, however, is the physician-taught review of each medical symptom or incident-type priority card. This includes a basic review of the problem involved, discussion of the additional information section of the cards, the significance of each key question, and a brief explanation of the pre-arrival instructions. The medical (as opposed to political or geographical) priorities of dispatching are stressed for each caller complaint.
The introduction of the non-red-light-and-siren response concept for many calls previously felt to be dire emergencies by untrained dispatchers is an important learning experience for the EMD trainees, and a highlight of the course. For example, after explaining that abdominal pain and fever in a 17-year-old-male (felt to be appendicitis) is not a prehospital medical emergency, and requires neither a red-light-and-siren nor paramedic response, dispatchers often respond, "Why, after all these years, werenāt we told that before?"
The importance of obtaining symptoms rather than diagnoses is stressed (for example: chest pain vs. heart problem). The physician also discusses how to adapt and localize the dispatch priorities to meet different agencies' needs, and he demonstrates how to calculate and establish varied levels of response (see Figure 1) and explains benefits of the dispatch system.
A practical session of medical interrogation ends the course, using tape recordings of caller/dispatcher interactions. Each class member relates his or her approach to the caller using the key questions and selecting the appropriate determinant and response.
A final examination of 25 items is administered and those passing this requirement receive state certification and a uniform insignia. Recertification requirements are currently being developed by the Utah State Bureau of EMS. It is anticipated that revisions of State Paramedic Rules and Regulations will require EMD certification of all dispatchers in ALS provider agencies by 1982.
The Priority Card System
Each dispatch office is provided with a flip-card file containing 30 sets of two 8" x 5" cards (Figure 2). Each caller complaint (typed as either symptom or incident) is listed in alphabetical order for quick reference. The index of cards reflects either a symptom of an incident categorization of problems rather than a diagnosis-oriented system. If diagnosis is used as the index, the dispatcher must "diagnose" or, even worse, accept the callerās diagnostic opinion before selecting the appropriate card. With diagnosis clearly the most difficult of all medical skills, requiring the least medically trained individual in the system to diagnose as an initial step for response selection is foolish at best.
The core card contains three color-coded areas: key questions, pre-arrival instructions, and dispatch priorities, subdivided into "determinant" and "response".
The key questions are the minimum amount of interrogation necessary to adequately establish the correct level of emergency medical response (i.e., EMTs versus paramedics, red-light-and-siren mode or not). Use of all the key questions assumes the idealistic concept that all information asked for is available and accurate.
Pre-arrival instructions are given: a) to assist the caller in preventing the patient from further injuring himself, and b) to enable the caller to do as much as possible to help or resuscitate a victim in a life-threatening situation. The instructions range from basic head-tilt airway maintenance to phone-instructed CPR. Also included are control of hemorrhage by direct pressure, treatment of small burns, eye flushing, removing pillows from behind the heads of unconscious victims, and prehospital obstetrical do's and don'ts.
While key questions and prearrival instructions remain basically constant from one locality to another, the dispatch priority section of each card must reflect a given agency's varied ability to respond, ranging from single-unit volunteer squads to the multiple-level response of metropolitan fire departments. Dispatch priorities become necessarily more complex for more sophisticated systems. Each problem should be studied carefully before responses assigned. Certainly these breakdowns are medical control decisions and should be made by emergency or advisory physicians in every case.
The determinant subsection reflects lines of separation for different preplanned levels of response. For example, in an urban ALS system, chest pain in a 10-year-old should not evoke the same level of response as in a 57-year-old, just as hives without dyspnea should require a less urgent response than when dyspnea is present. For many emergency medical systems, localization of the dispatch priority section will require an unprecedented justification of response modes and unit selection.
To date over 100 public safety and private agency dispatchers have been trained and certified as EMDs by the Utah State Bureau of Emergency Medical Services. Participating agencies were surveyed both prior to training and one year after the course was administered. A comparison of these surveys showed that five of the six paramedic provider agencies in Utah are now using the Dispatch Priority Card System. In addition, the chief dispatchers of each agency indicated that the training course was "very useful" to the dispatch corps.
The survey also showed that, as compared with the time prior to the implementation of the course and card system, there are now fewer red-light-and-siren runs. Concurrently, the ratio of EMT to paramedic runs has increased, with the use of paramedics being limited more to life-threatening problems. The State Bureau of EMS also reports that the EMD course is the most enthusiastically accepted program that they now offer.
Finally, the National Highway Traffic Safety Administration of the Department of Transportation has adopted the EMD Priority Training Course as a national program and standard.
Many dispatchers are performing in the role of Emergency Medical Dispatcher without the benefits of either basic emergency training or practical emergency experience in the problems that constitute their daily routine. In order to correctly utilize them as members of the emergency medical team, it was necessary to upgrade the dispatchers' skills by the development of the Emergency Medical Dispatch Priority concept and an associated statewide EMD training course and certification program.
The benefits of the utilization of this system are far-reaching. Through dispatch-specific education and practical experience, the EMD is able to more accurately interrogate the caller, cull more pertinent information, and make more sensible decisions about EMS responses. The system allows for preplanned responses, safer responses (fewer units responding in the red-light-and-siren mode), fuel and energy savings (smaller units and fewer units used when possible) and it saves paramedic teams for true advance life support emergencies. It was for these reasons we devised this program.
Figure 1-Determining the Response
*Note: In rural areas distance can replace true medical need as an index of emergency response.
Figure 2-Categorization of Caller Complaints