In light of the dizzying pace in which technology has impacted prehospital medicine, I propose that the emergency medical dispatch (EMD) algorithms and lengthy questioning does not demonstrate measurable improvement in patient outcomes.
Rather, I propose that the delay encountered during interrogation procedures lengthens response times and provides prehospital responders with just enough information to create situation bias and, in some cases, provider apathy. This silently incentivizes the providers to find a reason to disprove the call type through their assessment, rather than perform a critical examination.
In Malcolm Gladwell’s book, Blink: The Power of Thinking Without Thinking, radiologists who are asked, “Where does this film display a compound bone fracture?” are far less accurate in their diagnosis than radiologists who are asked, “What is wrong with this film?”
When those physicians are prepped with a leading question, they are far more likely to find what the question leads them to believe is already there. This same bias occurs in prehospital medicine, specifically for common call types such as “trouble breathing” or “chest pain.” Elimination of patient-specific complaints will encourage providers to use their critical thinking skills rather than a telephone-based assessment by an emotionally charged layperson.
Since the inception of modern-day EMS, 9-1-1 has increased the use of computer-based, pre-formatted, closed-ended questions to better specify and control emergency response dispatch assignments. Call categories are broken down into Alpha, Beta, Charlie, Delta and Echo categories, with Alpha responses requiring the least sophisticated and least number of personnel and equipment, and Echo responses indicating the life-threatening events requiring multiagency responses.
Specifically, EMD caller interrogations focus on progressively more in-depth questions that dictate how, when and how much emergency response personnel and apparatus respond to an incident. This type of telephone triage allows the closest and most appropriate resources to be sent to each caller.
Although there are many “flavors” of EMD, the typical progression begins with the calltaker asking the caller which type of service they require: police, fire or ambulance. Some new protocols use generic questions (“Tell me exactly what happened”), which relies on the calltakers’ critical listening and thinking skills to select which service (or services) to dispatch or, if no emergency exists, to transfer to the appropriate outside agency (public works, highway roads, social services, etc.)
Typically, these questions begin as simple “yes/no” responses and then drill down qualitative specifics. “Is the patient breathing?” spurs additional questions: “Normally?” To ask the layperson medical questions during a time of personal crisis lends itself to false results exacerbated by emotions and confusion.
To assess what is considered “normal” breathing, the observer must inspect and assess rate, depth, effort and consistency for at least one minute. Imagine one’s critical inspection ability as their loved one experiences a medical emergency. Again, remembering the power of suggestion, callers are more likely to answer “No” to the question of breathing normally. Because the 9-1-1 calltaker asked it, it’s probably important!
Using either method of direct, closed-end or subjective questioning rarely results in accurate on-scene information. Even in the case of medical facilities speaking directly with a 9-1-1 center, the prevalence of jargon or institutional-specific terms often fail to translate into the pre-defined categories the computer offers.
Although the growth in popularity of computer-aided dispatching has accurately fine-tuned the dispatching of resources, it creates an atmosphere where the call type can significantly deviate from the real emergency. The benefits of over-triage are well documented and certainly err in the side of patient care and advocacy, however they frequently cause providers to assume that commonly used call types (chest pain; trouble breathing) will turn out to be vastly different than the on-scene observation. When reading the calltaker notes provided, it is not uncommon to find information that directly contradicts the dispatch type or suggests that the call type is just a technicality and hence a poor representation of the call.
Example: A900 and M900 are dispatched for “trouble breathing” at 123 Main Street. When reading the call notes, the providers discover that the “trouble breathing” is actually ankle pain and the sole reason for breathing problems is the anxiety of the patient.
This example of incongruence occurs with increasing frequency. In conclusion, the inaccurate data given by callers, the inflexibility of the call types and provider complacency does not serve the callers or the providers well. Eliminating the lengthy interrogation procedure and dispatch units with generic call types such as medical, trauma or cardiac arrest, and emergency or non-emergency, will reduce inbound call times and encourage providers to think critically without relying on preformatted data.
As we continually move forward through the information age, it would be prudent to ensure that we are collecting actual valuable information, not just simply more data points. Vendors are apt to provide dozens and dozens of data point and information bits, but simply gathering all of that information, merely for the sake of gathering them, lengthens the calltaking process, creates provider bias and does little that shows an objective and demonstrable benefit to the patient.
We as an EMS system have been loath to accept new practices and our desire to collect meaningful data is markedly behind most major industries. We must continue to strive to collect meaningful, accurate and useful information—not simply collect data points for their own sake.