Dispatch 2 of 2 from APCO 2023
This first installment of a multi-part “Words Matter” series for the JEMS is a bookend to my previous dispatch (pun intended!) at the start of the 2023 Association of Public Safety Communications Officers conference in Nashville. APCO is one of several national emergency telecommunicator trade groups, alongside the National Emergency Number Association (NENA), whose Washington, D.C., legislation and advocacy event I attended earlier this year (“NENA Goes to Washington”), and the National Association of State 911 Administrators (NASNA). As my first report from the 2023 APCO show noted—and by its end, I had resoundingly confirmed—there is no shortage of overlaps between the discussions taking place in the hallways and boardrooms throughout this event, and those that take place at events focus on ambulance services, fire services, mobile integrated health services, and co-responder programs nationwide.
Among the key takeaways from my visit was the essentiality of accelerating efforts to put these already-aligned professions in a room together so that they can cross-pollinate ideas and see for themselves the noteworthy similarity of their politics. Will there be specialized distinctions among them? Naturally. For example, at an ambulance services conference, one will see more focus on healthcare devices like laryngoscopes and clinical decision support software; at a fire conference, more focus on flame-retarded materials, extraction devices, and the ability to see through heat and smoke; and so on.
A dispatch conference featured some fascinating tools and technologies, though most could be seen at any public health or safety event; again, consider the natural overlap. One that stood out was from a tech company that has previously announced collaborations with a major private ambulance provider. It showcased a real-time approach to language translation that (as someone who has in-laws that primarily speak Spanish) presented a showcase of the real value of artificial intelligence to enhance emergency response and patient care. Which of course fits the theme, not only of my focus here—but of the conference itself and so much of our profession: the need and ability to communicate.
The title—“Words Matter”—has a triple meaning:
- Communication is at the heart of so much of Mobile Medicine, and public health and safety more broadly. This includes the ability to communicate with one another on the line, known as interoperability. As Mike Taigman and Marianne Gausche-Hill noted during their session at the 2023 EMS Administrators Association of California conference, interoperability is not just technical in nature. It also means forging relationships, to know who to call when help and understand the methods by which others are able to assist. This is one reasons why I believe having too many trade associations that don’t exchange insights may be a practice that actually detracts from patient care and operational readiness.
- The ability to communicate with patients during moments of extreme stress—bedside manner is a baseline, but of late, leaders like Alexandra Jabr and Peter Antevy have also advocated vociferously for a deeper understanding of how to converse during sensitive times more generally…including to deliver terrible news, like telling a loved one that their person died.
- Finally, the importance of communicating accurately with the public. Kevin Collopy of New Hanover Regional Medical Center in Wilmington, N.C., recently posted on social media, decrying a news article from the Chicago area about ambulance transport fees being raised to pay for new fire stations. There may be good cause for needing new fire stations, but Collopy’s frustration highlights a worthy point: there certainly is no obvious connection between raising medical fees to pay for a building; if there is one—and the community that approved the measure clearly agreed—clearly public engagement would go a long way.
A theme throughout this series will be the implications for promises made to, and promises made by, public health and safety agencies—because these details matter. Consider: at APCO 2023, I spoke with a woman who works in the Virginia 911 system. After a session where the worthy and urgent topic was how Public Safety Answering Points (PSAPs) engage with callers who have autism, or where the person in need of help has autism (even if it’s not yet clear whether the caller is a patient, a victim, or simply in distress)—her chief concern was to discuss text-to-911. That’s what was on her mind, and she mentioned that in her community, the resounding response has been that text-to-911 is “too slow,” as she put it. Are there situations where text-to-911 may be helpful? Of course. The most frequently cited examples, in this author’s experience, are when the caller is in the back of a vehicle (e.g., if a rideshare has gone bad) or hiding in a closet (e.g., cases of domestic abuse).
These cases are obviously critical and should be abided as such. But to the person who spoke with me, the question comes down to whether the focus is on the edge cases, or the majority of cases, because the available funding at any given moment is limited. As readers of this column will recall from past installments, this is where the late Carnegie Mellon professor Lave’s “Iron Law of Government” comes in: “When government gets involved, everybody loses.” Innovation requires investment, but if investment in the new versus the current are out of balance, a bubble sets in and, eventually, pops.
If the resultant effect is inconvenience, the fallout may be minimal—some grumbling, perhaps some people choose to move on from the organization. What if the promise is critical to patients and their families…for example, that end-of-life medical orders will be made available to dispatchers during a cardiac arrest call?
Is it possible to make that happen? Lots of people would have to fall into place that do not exist today, but far be it from this author—whose Day Job is as a technologist—to determine whether something thing is possible or not. However, is it possible today? No, for both technical and legal-regulatory reasons, including privacy protections and workflows (including the fact that most patients in arrest do not call 911 from their own phones…). If the promise points to an aspirational future, then what a wonderful goal! But if the public does not understand that the concept is “future-state,” then Responders will be the ones who bear the risk. As the New York Times wrote: “The suit alleges that they also disregarded a New York State MOLST — medical orders for life-sustaining treatment — form and his spouse’s explicit instructions…”
On July 20th, three weeks ahead of APCO, two companies issued a press release that reads, in part: “This partnership will eliminate this hurdle, integrating the… Exchange…directly into the… platform. This enables direct delivery of advance directive information to 911 and first responders based on matching a caller’s phone number to their ACP and PMO forms. Launched July 12, 2023, this innovative integration promises to be a game-changer, providing more personalized and efficient emergency response and a significant reduction in unwanted or unnecessary medical procedures and hospital admissions.”
One company spokesperson at APCO 2023 was unfamiliar with the patchwork of rules that apply to advanced directives, including that some states restrict Mobile Medical professionals from using them as advertised. For example:
- In Pennsylvania (see page 4): “EMS will honor an Out-of-Hospital Do Not Resuscitate Order, as prescribed by Pennsylvania statute but the required statutory form and procedure is different from the POLST. Consequently, EMS may honor a POLST only upon receiving an order from a medical command physician.” Therefore, a PSAP cannot provide such information to EMS agencies in Pennsylvania because the Responders are unable to legally honor it; the order must come from medical command, and receiving contravening instructions could pose a liability risk.
- In Idaho, the advanced directive registry is run by one company and there is no way for another company to give PSAPs such details since they lack access to the forms.
- In Arizona: “…Certified health care institution caregivers MUST perform necessary CPR and first aid when appropriate before the arrival of emergency medical services (EMS). …In Arizona, it had become disturbingly commonplace for EMS to arrive at a care institution eight minutes after receiving a 911 call to find an unresponsive resident and no one performing emergency care. This bill became law in Arizona on September 29, 2021.”
- In California, there is currently no POLST registry. There were two pilots: one was in San Diego, powered by a company and run through San Diego Health Connect HIE. The other was in Contra Costa County, and involved another company, the Alameda-Contra Costa Medical Association, the Contra Costa County Fire Protection District, and the local pilot’s main clinical contact was at Sutter Delta Medical Center. The pilot’s duration was about three years. According to a Contra Costa County budget document, implementation of one company’s system was proposed in 2021, several years after the pilot officially ended. Meanwhile, a 2021 law created the legal structure for a statewide approach to sharing end-of-life medical orders in California. According to Manifest Medex, California’s largest HIE: “AB133 would enact the California POLST eRegistry Act, which would require the Emergency Medical Services Authority to establish a statewide electronic POLST registry system for the purpose of collecting a patient’s POLST information and disseminating that information to an authorized user. The bill would require the authority to promulgate regulations necessary for the operation of the POLST eRegistry.”
The details of each state’s requirements are beyond the scope of public advertisements, but still: Words matter. Cell phone coverage is unevenly distributed, so carriers publish maps that highlight where coverage is and isn’t available, managing expectations. The fine print at the bottom of a commercial might say, “Not available in all areas.” When an announcement promises that “our partnership enables first responders to provide the proper response to individuals in need while respecting their advance directives and portable medical orders,” but it leaves out where or when…should the public think anything other than “now”?
Should the public assume that “first responders” refers to Dispatchers but not Police, Police but not EMS, EMS but not Fire—or should someone who reads the announcement on social media (as I did), thrilled at the idea that their medically frail loved one will be safe when things go sideways, assume “all of the above”? The statement is written in the present tense and makes no distinctions about who will (or won’t) know the patient’s critical wishes during a life-or-death moment.
A CEO should absolutely be excited if a collaboration “extends our interoperability…reaching frontline healthcare providers when it matters the most.” But shouldn’t there be an accompanying caution that says, “except in California, Arizona, Idaho, and Pennsylvania”? My mind returns to the lady who said text-to-911 won’t do the trick because it’s “too slow.” We have a choice when it comes to serving her: Abandon all hope of using text-to-911, which eliminates the value to those who need it (even if infrequently). Or invest in ways to make it better, faster, better suited to the mission. But if we simply gloss over “The Real,” all we’re doing is courting disappointment…and flirting with legal disaster. Words matter, if only to empower us to ask the hard questions.