Priority Medical Dispatch
Is the Standard of Care
Dispatch liability has moved to the forefront of EMS litigation. Second only to EMS vehicle accidents, dispatch liability has produced not only frequent, but high-cost lawsuits that merit serious attention from the EMS agency’s risk management. Although EMS agencies frequently spend a great deal of time and effort on other risk management endeavors, they would do well to consider how well their dispatch is performing because this is the critical link between the patient and the responding EMS units.
Gone are the days when dispatchers were only clerks. “What dispatchers ought to be seen as is air traffic controllers, but what they do is 10 times as stressful. Every time the phone rings, it’s the equivalent of somebody in a crisis,” says Jeff Clawson, MD, the designer of an EMS priority dispatch system to help dispatchers fill their role as the first link in the EMS system. Clawson has been an expert witness in a number of lawsuits involving dispatch errors and has generally shown that the problem could have been averted with a priority dispatch system.The public will not tolerate understaffing, budget problems or any other excuse for a failure of the system set up to save lives.
The concept of emergency medical dispatch is not new. Clawson developed his protocols for the Salt Lake City Fire Department in 1978, and the Department of Transportation, in developing dispatch recommendations, borrowed heavily from those protocols in 1981. However, the concept was slow to catch on, despite its effectiveness. EMS agencies remained skeptical and hesitant to spend the money it took to make dispatch a key link in the EMS system. The problems of implementing priority dispatching systems included the cost of training, resistance from police agencies that were providing dispatch services to EMS and generalized resistance to change.
Consider the several lawsuits leveled against the city of Chicago in late 2001. In July, a jury awarded $2.7 million over a dispatch error. Then, within only two months at the end of the year, juries hit the city with two more huge EMS dispatch-related verdicts—one for $50 million and the other for $3.06 million.1,2 These verdicts sent a clear message: The public will not tolerate incompetence when they dial 9-1-1.
In May 2002, another wrongful death suit was filed against the city of Chicago because of a 17-minute response time to a battered 31-year-old woman, who later died. A $2.7 million settlement followed, to the family of a teenager who died during an asthma attack while waiting for a delayed ambulance. The message: The public will not tolerate understaffing, budget problems or any other excuse for a failure of the system that is set up to save lives. The cost of these verdicts would have paid for additional salaries, training and equipment to prevent the catastrophes that led to them in the first place.
A number of states have initiated some form of priority dispatch program with varying levels of effectiveness. Given the availability of the EMD programs, it is clear that inadequate risk management programs led to these disastrous verdicts.
In Prince George’s County, on Sept. 26, 2002, a jury awarded $1.7 million in yet another dispatch disaster. The jury awarded the plaintiff $95,000 in punitive damages. Punitive damages are strictly for punishment and are generally awarded by angry, disgusted juries. This case involved a dispatcher who was on a personal phone call. The caller dialed 9-1-1 five separate times, but couldn’t get an answer. Ultimately, the dispatcher sent BLS instead of ALS to a heart attack call, and the crew had a 22-minute response time.
Another suit against the city and county of San Francisco in 2002 further illustrates that juries will not hesitate to hold public agencies responsible for errors in dispatching.3 In a 22-page opinion, the Court of Appeal of the First District of California overturned a summary judgment granted in favor of defendants by the trial court and imposed liability on the city and county for failure to train its dispatchers.
In that case, a woman died from an asthma attack after a call to 9-1-1 reached a dispatcher who had not received training in the emergency response protocols. The plaintiffs alleged that the city’s and county’s failure to train the dispatcher resulted in the patient’s death due to a delayed response time. The appellate court analyzed what duty the dispatcher owed the caller, finding not only that the dispatcher had a duty to the caller, but also that the dispatcher’s duty was that of reasonable care. (The immunity statute cited by the city provides immunity for all but grossly negligent care.) The court went on to say that the duty was owed to the caller with respect to the "manner in which the [9-1-1] emergency procedures were implemented."
The plaintiff alleged that the caller was on the phone with the dispatcher for longer than five minutes. The dispatcher was a trained paramedic who knew that asthma can be fatal, but she took an undue amount of time on the phone trying to determine the precise nature of the patient’s problem.
In this case, communication with the caller was difficult because he spoke mostly Chinese, although a bystander with medical training also got on the phone. The dispatcher had not been provided with training in the priority dispatch protocols being used by the city. She then received misinformation from another member of the dispatch team that the call had to do with a drug overdose. The dispatcher first sent a police unit while asking a paramedic unit to stand by for a “Code 2” response—even though she had information that the patient was having trouble breathing.
When police arrived, they confirmed that the patient was having difficulty breathing and the response was upgraded to a “Code 3.” The ambulance arrived at the wrong door. So the crew had to return to the unit for further instructions and then had to drive around the block to the correct entrance. The time between the first call and the arrival of police was 10 minutes, and the total actual EMS response time was 20 minutes.
An even more recent California case, however, found that no statute imposes direct liability on public entities that employ emergency dispatchers for injuries attributable in part to a dispatcher’s failure or delay in responding to a 9-1-1 call.4
The court further found that vicarious liability is limited to cases involving gross negligence in bad faith. In this case, plaintiffs alleged that their three-year-old child suffered an electric shock while bathing and that a delay in dispatch caused a prolonged EMS response. The court disapproved of the previous California decision and found that a broad cloak of immunity protects 9-1-1 dispatchers from all but the most egregious acts.
Prevention is the hallmark of an effective risk-management program. Although the development of a priority dispatch program may prove expensive and time-consuming, some form of priority dispatching is now, without question, the standard of care for EMS agencies nationwide.
Political issues may hinder the development of these programs, particularly when the dispatch agency is not within the control of the EMS chain of command. Another political issue has arisen over the ownership of the protocols and whether the program an agency chooses to institute is the most updated version or simply the least expensive.
However, one thing is clear: As the verdicts and settlements painfully demonstrate, it is essential that dispatchers be regarded as part of the patient-care response that is EMS. “You can’t have a medical dispatch program by just training and throwing protocols in front of people, then just shutting the bars and letting the animals feed,” says Clawson. Instead, emergency medical dispatch programs require the involvement of EMS medical directors, a high level of dispatcher training and continuous evaluation of program performance. EMS agencies simply cannot afford to have phones unanswered, dispatchers refusing to send ambulances to pleading callers or even the innocent errors of sending an EMS unit to the east side of town when the emergency is on the west side. Ultimately, it’s far less expensive— and much better for patient care— to do it right. JEMS
W. Ann Maggiore, NREMT-P, JD, is an attorney and paramedic in Albuquerque, N.M. She has been a fulltime paramedic, an assistant fire chief and a state EMS administrator. Currently, she practices law full-time, defending physicians, police and EMS personnel against lawsuits. She is a frequent lecturer on EMS legal issues and holds a clinical faculty appointment at the University of New Mexico School of Medicine. Contact her via e-mail at email@example.com.
1. Gant v. City of Chicago,
97L03579, Cook County, Ill.