Dispatcher FAILED to send EMS after 911 call...

[EMTDoc]

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Ok so this is my first time starting a thread on SDN and I am posting this thread because something happened today that just absolutely pissed me off.

So now I am wondering how many of you have had to deal/see a situation where a low level employee has made an f'ed up decision that negatively effects a pt/pt.s care? Especially a decision that they don't have any right/skill/knowledge to make.

If you would like to read what situation I dealt with, the story goes like this:

I work as an EMT at a local Urgent Care and today while I was at work, an adult male came in with new onset diabetes and a blood glucose of over 500 (our meter doesn't read anything higher than that, it just says 'hi'). So, as the UC is not equipped to care for, or admit the patient, the doctor asked the nurse to call 911, and since she was starting a line the task was passed on to me. Before I called, I got down all the pertinent info, pt. name, location, and diagnosis (Dr said it was DKA, but diagnosing this based on the blood sugar alone and no labs is a whole other issue), etc. Either way, I get on the phone with the dispatcher and the conversation went fine, I thought... Well 15 minutes later EMS is still not there, when they are normally in there within 5 minutes every other time we have called, to take the pt to the ED. Instead a cop shows up and says that the EMS has not yet been dispatched or even received a call because the dispatcher did not know if it should be code 2 or code 3 transport. 😱 WTF?!?!

As you can imagine a few nurses involved got pissed off that 15 minutes after 911 was called, EMS was not even dispatched, but instead we get a cop who probably knows jack squat about a glucose of >500. Well... He pulls me aside as I was the one who called and asked me what went on in the conversation because the call he got from the dispatcher was a little weird, so I told him what I said. When the dispatcher asked which code, 2 or 3(lights and sirens), I said the Dr did not specify, so the cop said it was my fault, although I'm pretty sure he was just trying to stand up for his dispatcher.

SO.. What I get out of the conversation is, the dispatcher felt that she had to send a cop out to verify that we needed an ambulance even though I called 911 asking for transport to the hospital.... ummm was she ******ed!! Yes we need an ambulance and screw the cop for trying to make me the scape goat! Another physician was standing right next to me as I made the call and backed me up that I in no way mishandled the call/situation. Regardless of what code transport it should be, EMS should be dispatched on medical calls, yet she didn't even dispatch them code 2, which I would think is at least the bare minimum when a medical facility requests EMS.

Either way EMS finally arrived >30 minutes after the initial call. This was not because they were busy, only because the dispatcher wasn't sure why a medical facility wanted EMS to respond for a glucose of >500.

Now the patient did not need code 3 transport, only code 2 (non-lights and sirens). However, that is not the problem. The problem is, where the hell does this dispatcher get the idea that when the DR at my facility is requesting an ambulance that she should only have EMS respond if she feels like it!

Luckily, this extra 30 minutes did not make a difference on this pt, but one day we could have an pt having a MI and what is this dispatcher going to do, send a cop first to make sure its an MI???

I would love to make a report, and the physician on duty agreed so the word was passed on to our medical director. I think the dispatcher should be fired.

Sorry for the long post/rant...

Does anyone have any experience dispatching that could comment on the way the dispatcher handled the situation, and if she was even following protocol or if she was just making it up as she goes?

 

[FIREitUP]

tl;dr. Take home message: ppl r dumb?

 

[MisterVeil]

Having worked in EMS, I would definitely say the dispatcher was in the wrong and should be fired. There is simply no excuse for not dispatching anybody to a call.

Couldn't the dispatcher have contacted the hospital again if she was freaking out that much? Either way, it is not your fault, for sure.

 

[Hammergin]

I'm volunteering with an ambulance corps and we have had similar issues. Most of ours are related to 2 issues: #1) The person who calls in the 911 does not accurately provide the patients symptoms and #2) The police officer dispatcher is not trained in professional medical dispatching and thus does not know when to have a paramedic (ALS) dispatched in addition to volunteer EMTs. In short, these things happen and the best way to avoid them is to have set protocols in place that are followed on all sides.

In your case, it sounds like the dispatcher was really negligent. It's called abandonment when a 911 is placed and no one responds.

 

[apumic]

OP, I'd be p*ssed too. That's pretty ridiculous.

We had a similar case awhile back, where I was part of an on-site EMS team at a large event. We were outfitted as an onsite volunteer BLS unit staffed w/ RNs, MDs, EMT-Ps, EMT-Is, and EMT-Bs. During the event, an older man strokes and goes into seizure-like activity. We immediately called 911, removed him from the event area, and began what limited treatment we could provide for his condition in that location. Considering the size of the facility and that all calls from our facility are mandated Code 4 (assuming an authorized person calls it in) unless specified otherwise to the dispatcher (i.e., all local stations report for possibility of a mass cas incident, full lights/sirens), the response should have been within 5 minutes. Instead, EMS arrives 25 minutes later. The patient died during transport. We were protected from any litigation but the city EMS sure wasn't....

 

[exptherainbow]

How did the patient get to urgent care in the first place?

 

[EMTDoc]

How did the patient get to urgent care in the first place?

He walked in. Although it was new onset diabetes and he was hyperglycemic, I am not convinced that he was in DKA, however, the Dr was after just looking at his glucometer reading of 'hi'. No chem panel was drawn or anything like that, but who am I to question his diagnosis on the fly. The on duty MD calls it DKA, then until another MD says otherwise, thats what I have to go with.

The patient died during transport. We were protected from any litigation but the city EMS sure wasn't....

Did any litigation result from this and what was the outcome?

 

[Mbeas]

this has to be shared

 

[MeowMeowCAT]

I am surprised that there is so much doubting and questioning that is involved when a 911 call is made, especially from a place like Urgent Care. I always thought the general idea was to assume the worst and over react, and then worry about the "level" of emergency later.

 

[TTigers70]

Its ridiculous you'd be expected to give it a code in the first place. A lot of our calls come in with a brief synopsis ("55 year old male complaining of chest pains") and we adjust accordingly. I don't get what the big deal is in treating a call like a 3 vs a 2; EMS arrives a little sooner? Don't understand how the dispatcher would justify holding a crew up because he/she didn't want lights and sirens.

 

[JustMeditate]

You wanna see a real f***ed up situation?

http://abcnews.go.com/WNT/US/story?id=1823994&page=1

Bottom Line: We need better training for 911 Operators.

 

[jeffro1080]

this has to be shared

[YOUTUBE]http://www.youtube.com/watch?v=cXf0yIRcdnI[/YOUTUBE]

 

[FirefighterDoc]

At the fire dept, we run "hot" (lights and sirens) to all calls we go on. If someone is calling 911, theyre getting an ambulance right away. The question I have is if you called 911, or a private ambulance company.

In the area I work all 911 calls go through a big dispatch center for a 4 town area. There are no codes. Everyone goes "hot"

I did a short private stint at a private ambulance company and all the Urgent care centers here call them to transport to the hospital as opposed to the city fire depts. In fact thats one of the few times that some privates actually get to run lights and sirens, because they usually dont. With privates, sometimes they dont have trained dispatchers and it is run more like a business.

If in fact that was the 911 dispatcher ( which Im thinking may in fact be the case because they sent the PD) then this was a definite breach in PT. care.

 

[MicroBrewer87]

At the fire dept, we run "hot" (lights and sirens) to all calls we go on. If someone is calling 911, theyre getting an ambulance right away. The question I have is if you called 911, or a private ambulance company.

In the area I work all 911 calls go through a big dispatch center for a 4 town area. There are no codes. Everyone goes "hot"

Well the research shows that going hot to everything is not more effective than going cold so many places are coding the calls to determine different tiers of response. Less time spent lights and sirens is safer for providers and bystanders. Some places are being progressive with this kind of thought process and coding systems for calls.

The issue I see in your story OP is was the guy symptomatic? 911 is not equipped to handle the phone call of blood sugar over 500 with no other signs of distress (the public doesn't call 911 and give laboratory results as their chief complaint, its respiratory distress or chest pain, etc.) Not that I'm saying the guy wasn't sick but I could see how the dispatcher was confused by just a blood sugar over 500. I still think they botched it by not sending anyone at all but I see where the error could have happened. I'm sure if the guy was in full blown DKA huffing and puffing away and really really sick you wouldn't have had a problem...but it doesn't sound from your original post that he was that sick at the time.

The service I work for we respond to an Urgent Care center occasionally for calls that 911 deems low priority, but sometimes require ALS interventions (sometimes because the nurses or doc's do something on scene like give different meds, etc.). Its just that 911 is ill-equipped to handle calls like that from medical facilities.

 

[BigRedBeta]

He walked in. Although it was new onset diabetes and he was hyperglycemic, I am not convinced that he was in DKA

First off, initial management of DKA vs HHS is not significantly different enough to bother with semantics. Second, ketones on the breath or Kussmaul respirations probably are reliable enough to differentiate the two. While there are other possibilities that could result in hyperglycemia, assuming that the story fits for a new onset DM, it doesn't seem unreasonable to set the diagnosis as DKA without further lab workup. Either way, the physician at the urgent care center did the right thing in expediting transfer to definitive care without dicking around waiting for other labs - his plan just got sideswiped by a lackluster dispatcher who was overthinking. Now to be fair to her, while DKA and HHS are emergencies, generally, it's better to be deliberate in treatment than overaggressive. Moving too fast in these patients can have devastating consequences, and a delay of 30 minutes (depending on what sort of interventions your facility is capable of) probably didn't result in any sort of negative impact on the patient.

 

[EMTDoc]

First off, initial management of DKA vs HHS is not significantly different enough to bother with semantics. Second, ketones on the breath or Kussmaul respirations probably are reliable enough to differentiate the two. While there are other possibilities that could result in hyperglycemia, assuming that the story fits for a new onset DM, it doesn't seem unreasonable to set the diagnosis as DKA without further lab workup. Either way, the physician at the urgent care center did the right thing in expediting transfer to definitive care without dicking around waiting for other labs - his plan just got sideswiped by a lackluster dispatcher who was overthinking. Now to be fair to her, while DKA and HHS are emergencies, generally, it's better to be deliberate in treatment than overaggressive. Moving too fast in these patients can have devastating consequences, and a delay of 30 minutes (depending on what sort of interventions your facility is capable of) probably didn't result in any sort of negative impact on the patient.

Right. I agree it is mostly just semantics, but I just wasn't convinced. The pt did not have Kussmaul respirations, was not vomiting, and was even joking with EMS when they arrived. If it weren't for a liability issue I'm sure the pt could have got a ride from a friend.

The issue that I have is not so much any negative consequences the pt might have experienced because an extra 30-40 minutes did not make a difference particularly in his case, but more the fact that after calling 911 and specifically requesting an ambulance she decided not to send EMS. Even sending an ambulance code 2 I think would be the bare minimum.

Pretty much, even if the dispatcher was confused over the "glucose >500, probable DKA" complaint, where is it ok to just not send ANYONE. For this pt it did not too much of a difference overall, but I don't think she has the right to decide not to send EMS when the MD at my facility specifically requested one, even if she is confused over the complaint.

 

[tabascosauce]

this has to be shared

 

[Hoody]

Pretty much, even if the dispatcher was confused over the "glucose >500, probable DKA" complaint, where is it ok to just not send ANYONE. For this pt it did not too much of a difference overall, but I don't think she has the right to decide not to send EMS when the MD at my facility specifically requested one, even if she is confused over the complaint.

I thought they sent a cop?

and someone should have called the ambu crew back....why wait 30-40 minutes when you know they come in 5?

 

[apumic]

I thought they sent a cop?

and someone should have called the ambu crew back....why wait 30-40 minutes when you know they come in 5?

That does seem a bit odd to wait that long, although I can see it happening if the UC was busy. You probably don't want to call back until probably a good 10 min has passed (since traffic could be slowing them down or whatever -- at least in my metro area) and 10 min can slip to 30 in a heartbeat if something comes in unexpectedly (e.g., elderly gentlemen comes in w/ his wife who has fallen and needs an x-ray to rule out a hip fracture, but, unknown to UC staff, has high BP and has an AMI or CVA while waiting for her and suddenly the staff's attention is diverted from a sky-high blood sugar to something that "seems" more urgent). (This seems more likely in a small UC than a larger ED, where we would have the staff to handle both situations simultaneously w/o problems, but in a small UC you may only have 1 tech, 1-2 RNs, and an MD on at any time, along with a tech who does the imaging. I've seen small UCs where the single critical care tech does both the tech and unit secretary jobs. In a situation like I described that tech could easily get distracted on the other case and not realize transport hadn't arrived as expected until things had calmed down 30-40 min later.)

 

[EMTDoc]

I thought they sent a cop?

and someone should have called the ambu crew back....why wait 30-40 minutes when you know they come in 5?

They did send a cop, but only a cop. This was not apparent initially because due to our location (2 blocks from the police department the cop showed up first which is what usually happens when we call 911 from the UC) he showed up about 10 later, and didn't disclose that no ambulance was dispatched until after he had spoken to the Dr in length. So with everyone focusing on the pt and the cop there, we assumed that EMS might just be a little tied up and still on their way until the cop got on his radio and requested one. Then the fact that no one from EMS was dispatched yet became clear.

 

[Hoody]

rule #76: no excuses...

If a crew usually takes 5 minutes to show up and its minute 7+ and dudes having a MI, I'm calling back. Whats the worst they are going to say? "Um, dude, truck is on the way!"

If non-symptomatic dude with a BS > 500 is chillin' in a chair and crew is not there after 15 minutes, I'd call back. Most especially if cop has arrived and says "hey, confusion about the ambulance request..."

multitask. and dont forget about your patients. at my place of work, patient is my responsibility till he's locked and loaded, in the hands of EMS. So, yeah, I'd stay on top of it...blaming dude that didn't send EMS might backfire in a court. just sayin....

 

[EMTDoc]

rule #76: no excuses...

If a crew usually takes 5 minutes to show up and its minute 7+ and dudes having a MI, I'm calling back. Whats the worst they are going to say? "Um, dude, truck is on the way!"

He wasn't having an MI....

Also, I think you're missing the point. The time it would have taken EMS to respond is not an issue. I'm not going to split hairs over an extra 5 minutes if they were on their way for a guy who is conscious and joking with us when the dispatcher stated during the call that EMS was on their way.

However, I do take issue with not sending EMS at all when specifically requested by our on-duty physician after calling 911. If the dispatcher had doubts on this, I worry about all the people she will be talking to in the future where that half hour might a huge difference.