INTRODUCTION

While teaching a Medical Priority Dispatch System (MPDS®) refresher course in Canton, Illinois, USA, at the Canton County Sheriff's Office Dispatch Center, I was asked an interesting question by a student: "What do you do when a second party caller doesn't know the answer to your questions?"

The student's question was inspired by a recent investigation request from the 911 center's local fire department involving a case dispatched as a BRAVO-level response to a fall patient.

Emergency medical dispatchers (EMDs) use the MPDS to assign response determinant codes to incidents based on answers obtained from callers during the 'Key Question' interrogation process. These codes are extremely valuable for several reasons:

1. They provide field administration and medical directors with a standardized system for prioritizing calls, with the flexibility for assigning customized local responses.
2. The frequency of the codes can be reviewed for operational quality improvement (QI) and quality assurance (QA).
3. They provide an opportunity to optimize and reduce the unnecessary use of field resources.
4. They provide the EMD with direction in providing the correct pre-arrival and post-dispatch instructions.

CASE

The MPDS includes six response (priority) levels that represent the level of acuity respectively (ECHO–highest acuity, DELTA, CHARLIE, BRAVO, ALPHA, and OMEGA—lowest acuity). An "ECHO" level is indicative of a patient that requires immediate lifesaving measures. "OMEGA" is the lowest priority level and typically does not require care via the use of the pre-hospital 9-1-1 system (i.e., means other than an ambulance and emergency department may be better care for these patients).

This particular case was assigned a dispatch code of 17-B-3G— an intermediate priority level response type—based on the caller's description, which was incomplete as to the cause of the fall and how far the patient fell.

Upon arriving at the scene, the fire department responders discovered a 56 year old female patient who had indeed fallen; however, she had no injuries and was in need of nothing more than a lift assist. The fire crew was concerned that multiple field units were sent lights-and-sirens to a non-emergency case without injuries when a lower priority level response would have sufficed.

Management and Outcome

A review of the audio recording of the case revealed that the Emergency Medical Dispatcher (EMD) began by verifying the address and telephone number and continued with the following interrogation sequence:

Case Entry

Calltaker (CT): Okay, tell me exactly what happened?

Second Party Caller (SPC): I am with a patient that fell to the ground. She may be injured.

CT: How old is she?

SPC: 57

CT: Is she awake?

SPC: Yes

CT: Is she breathing?

SPC: Yes

Key Questions

CT: How far did she fall?

SPC: I don't know?

CT: What caused the fall?

SPC: Don't really know, just came in and found her.

CT: Is there any serious bleeding?

SPC: No

CT: Is she completely alert?

SPC: Yes

CT: What part of the body was injured?

SPC: She is not complaining of any injuries.

CT: Is she still on the floor (ground)?

SPC: Yes

DISCUSSION

Based purely on the answers given, the determinant coding was actually correct, but this coding overlooks a key fact: the caller was a second party, meaning he/she was right there with the patient. In that context, some of the caller's answers appear odd or incomplete.

Given that the caller is second party ("with the patient"), and the patient is completely alert, it is surprising that the caller was unable to answer the Key Questions. The underlying issue may be that the EMD did not prompt the caller to obtain the information from the patient using an enhancement or clarification those specific Key Questions.

When using the MPDS protocols, the answer choice of "unknown" is offered for a variety of reasons:

1. The caller is not with the patient (3rd party or 4th party).

2. The patient is not able to relay the appropriate information to a 2nd party caller due to an altered mental status (see below example).

3. The emergency dispatcher (ED) has appropriately restated the question and the caller still does not understand the question.

4. After obtaining an answer of "unknown", the ED clarifies or enhances the Key Question, but the caller still has no further information.

5. There are safety issues preventing the caller from obtaining the required information.

If the EMD has taken the appropriate steps to clarify the information, an answer of "unknown" to one or more Key Questions may represent a more serious underlying condition. EMDs must have a high index of suspicion that the underlying cause may be medical in nature; in other words, if a second-party caller cannot provide the information even after clarification or prompting, the patient is likely unable to answer the questions; thus, the true cause of the fall could be cardiac, circulatory, or neurological, as opposed to a simple accident trip or slip. Under those circumstances, the EMD would certainly want to assign the BRAVO level priority to get a more rapid response.

An example would be a case in which a woman walks into a room and finds her mother on the ground. The daughter finds that the mother fell but does not know how she fell. During Key Question interrogation, the caller clearly indicates that her mother cannot remember the cause of the fall.

In this example, the coding of a 17-B-3G is appropriate EMD, since there would be a specific reason for the answer of "unknown" despite the second-party caller.

In the case outlined here, however, there was no such specific reason.

What we can learn from this case is that EMDs must clarify and enhance the protocol Key Questions when the information provided by the caller is vague or ambiguous, especially when the caller is second party and near enough to the patient to gather more information. Not doing so may lead to a final code that is not representative of the patient's true condition, and generally leads to assigning a higher response level than may be necessary. With complete information, including the knowledge of a ground-level fall with no dangerous cause—as the fire department responders found upon arrival—an ALPHA-level coding could have been assigned.

During emergency situations, the caller may genuinely not know the answers to all of the Key Question, even when they are ready and willing to obtain information from the patient, or the caller may simply need a little more prodding, in the right way, from the EMD. Through good caller management technique, including enhancing the questions where necessary, the EMD can obtain the most complete information available.

EMDs may need training on the use and purpose (as listed above) of the "unknown" selection choice in the dispatch protocol. Such training need not always be formalized classroom instruction. It can be delivered in various less-formal formats such as training bulletins, one-on-one audio playback sessions, and other instructional platforms. Regular case review must also be administered to ensure that final determinant codes compliant with protocol rules and performance standards.