INTRODUCTION

This case study is based on a call handled at the Emergency Services Telecommunications Authority, Victoria. The Authority handles 42,000 emergency ambulance calls per month in an area of 237,629 km², with a population of 6 million.

The third party caller was the mother of a patient who was in labor with her first baby and had an undiagnosed true footling breech presentation. The patient was at home alone in an isolated rural area. This breech case was the call taker's first in six years of ambulance calltaking. He had taken many childbirths calls over the years, but this one was special because he had just experienced the birth of his first child, and he felt a lot more confident that he would be able to manage childbirth calls. It turned out that was only part of the reason.

First person EMD case report

At the time of this call, the Medical Priority Dispatch System (MPDS) protocol version in use was version 11.3. I determined the address, the on scene phone number, and the problem. As the caller was a third party talking to the patient, I was a little hasty in following my case entry and key questioning protocol sequences:

Call Taker(CT) – You're not sure? Are you there with her now?

Mother (M) – No I'm on the phone with her, I'm an hour away.

CT – Oh, you're an hour away. Okay. And she's in labor, how old is she?

M – She's 24.

CT – 24. All right. And she's conscious?

M – Beg your pardon?

CT – She's conscious, you're talking to her?

M – Yeah she's conscious, but she's coming out feet first.

CT – Okay, how many weeks pregnant is she?

M – She was due on the 16th (overdue).

CT – Due on the 16th. The baby's not out yet, though?

M – It's not all out, but there's a foot out.

I felt so anxious about getting a response on the way that I really rushed some of these questions, and although they were not verbatim, I was satisfied I understood the situation well enough. Using MPDS protocol 24 (Pregnancy/ Childbirth/Miscarriage), I coded the case 24D1- BREECH or CORD, and immediately sent it to the dispatcher. Our response was a single advanced Life support (ALS) crew lights-and-siren ("HOT").

At this point I was telling the mother that she would need to hang up so I could call the patient in labor to provide pre arrival childbirth delivery instructions. But then I recalled being present for my wife's labor only 1 month before, and after helping her through most of the day in active labor, her mother came in to help us both through one of the most exciting but potentially dangerous experiences in our lives. It was at this time that I changed my mind and told the caller we would conference the call so that we could do this together. I knew that it was so hard seeing my wife in labor in a hospital surrounded by midwives, and how scary that was for us, I couldn't imagine how scared this patient would be, so conferencing the call was the right choice.

A student paramedic was listening to my calls to gain insight in the 'non-visual' environment of emergency medical calltaking. I turned to that paramedic who was sitting beside me and said, "We wouldn't normally do this. This is interesting… I've never done one of these, in 6 years I've never done one of these." Luckily, the caller was on hold while I was conferencing the call, so she was unaware that this was my first breech birth experience.

The patient was past her due date for delivery, hundreds of meters from the nearest neighbour, and a cousin who was a nurse was reported to be en route but about 20 minutes away. The estimated time of arrival of the nearest ambulance was also about 20 minutes. The statistics for footling breech delivery in a modern first world hospital are forbidding, with a 2 – 4 times normal perinatal mortality. I was hoping they would arrive to give the patient and the newborn every chance, and I'm pretty sure all of my colleagues in the control room had their fingers crossed, too.

When I connected to the patient and conferenced the call, I went straight into the Pre-Arrival Instructions –

CT – I should have you both on the line now, is that right?

Patient (P) – Yep.

M – Yep.

CT – Okay, good. All right, now "P," you can see, you can feel a foot coming out, or two feet, is that right?

P – I can see two feet, they're out.

CT – The feet are out. Okay. Are you having pains?

P – (A little breathless) Umm, not at the moment, no.

CT – No, all right. Just stay nice and calm for me, okay?

P – Yep (puffing).

CT – So you can just feel it, yeah?

P – No, I can see them, they're out.

CT – You can see them. Okay.

M – Did you say they were blue before, love?

P – Yep (crying).

CT – All right now, I want you to try and prepare a soft area on the ground, no more than 30cm from your bottom.

P – Yep.

CT – And use something clean and soft.

P – Yep.

CT – This is to put the baby on when it comes out, okay? Do you understand me?

P – Yep.

CT – Have you got a towel or something there?

P – Yep.

CT – Good, okay, this could be a very difficult delivery, okay? So listen carefully, and I'll tell you exactly what to do next.

P – Yep.

CT – Are you lying on a bed or on the floor?

P – No, I'm sitting on the toilet.

CT – Okay, I want you to jump off the toilet onto the floor for me okay? I don't want you on the toilet. We don't want the baby to come out into the toilet, okay?

P – Okay, I'm on the floor.

At this point I had reached the protocol sequence for beginning the actual BREECH Delivery instructions. But there was a small problem: at that time our pre-arrival instruction protocols were scripted only for a second party – someone with the mom who would be performing the delivery – not for delivery with the mom alone, and no one around to help. As I read the instructions to the mom from my computerized protocol script, I was careful to modify the language of the instructions just enough to account for the mom's situation, slowing down to make sure I got it right.

Carefully, I worked through the pre-arrival instruction sequences; I got the patient off the toilet and sitting on the floor towels. In between the pains, I checked access into the house, kept up the words of reassurance to both parties, positioned the patient for pushing, and let the about-to-be grandmother coach her daughter.

Bit by bit the feet became legs, buttocks, abdomen, chest, and finally the head. Next came instructions for drying and wrapping the baby, and after what seemed like a long time, the first baby cry could be heard! At this point the nurse arrived, with congratulations all round. Then, the arrival of the ambulance, a final check that all was well, a "Thank You" from the patient, and the call was terminated – 18 minutes of hard work for all.

The patient kept in touch with me, and after the birth of her second child, she sent a letter that is quoted in part (as it was written) below. It is a reminder of the lasting impression we leave with members of the public who rely on us as the first health providers "on scene."

Dear Paul, It's almost two years to the day since your voice guided me through the birth of my precious little girl, without your help and guidance on that day I'm not sure we would have such a happy or healthy outcome so I just want to express my thanks to you. I have listened to the CD of our phone call a million times and all I can do is smile as I say some pretty stupid things to you about your wife being lucky to have been in hospital for her birth etc., then I cry because I know the outcome could have been so different. I cry because my partner did not get to witness the birth of his first born, I cry because I scared the hell out of my mother but above all else I cry because a complete stranger chooses to do an amazing job every day with little to no recognition to the contribution he makes. So I thank you, for being the person to answer that call, for staying calm even when I know it was probably difficult to hear, for allowing my mum to be a part of the call and for keeping us both in check while my feet first little lady appeared. 'A' is now the proud big sister to another baby girl, 'Z' was born in January safely in hospital this time, we learnt from our past experience and got there in time. I'm happy to report she was also a drug free quick labor and they are the best of friends. 'A' is still a very full on independent little girl, she loves riding the quad bike with her dad, helping me clean, helping with her sister and climbing and jumping on or in everything she possibly can. She made a fast and full on entrance and I think she will live life in the very same way. I tell everyone I know the importance of ambulance subscription and the help 000 can provide, with people like you manning the phones I know we are in good hands. So thank you again, I only wish there was some way to repay the gift you have given us in the help you provided that day, you're a very special man and you do an amazing job.

The response was, as you would expect, that I was just doing my job. This case illustrates several key learning points:

• Follow the protocol – it works even in these rare situations;
• Be prepared to think laterally – the conference call helped all three of us on that line—and draw on your own experiences when empathizing with the caller;
• We should never think we have heard it all before, in this business there will always be a call that will surprise us;
• We all have or will have at some stage taken a call that will leave a lasting impact on someone's life, whether it be a successful resuscitation, a baby delivery, or just someone vomiting or who has fallen and injured a hip. What is important to always remember is although on rare occasions people do take the time out to write to us about their experience, nearly everyone who places an emergency telephone call will have a lasting impression of the service we all provide.

This case has become one of our truly classic training cases; many people have heard and shared this call over the years to demonstrate the power of protocol, a little quick thinking, and life experience.

A true footling breech at full term is most unusual. One or two feet may present if the breech has flexed knees, but a footling breech with both hips and knees extended is very rare. The neonatal death rate in all breech births is between 2 and 4 times higher than a normal vertex delivery.