Have you ever had an emergency situation in your office? What if a patient collapses in the hygiene chair, during an extraction, or while sitting in the reception area? While CPR is part of your license renewal, do you have any idea what systems go into motion when your designated person dials 911? Here are interesting facts, procedures, and likely questions you need to be ready to answer in the event of a true emergency.
“911…WHAT’S YOUR EMERGENCY?”
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Photograph by Nathan Zak
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Millions of calls are made to 911 every year in the United States. Some of these calls are “true” emergencies such as heart attacks, major accidents, strokes, shootings, stabbings, and unconscious people. Others range from people asking directions to lonely people calling to chat with the dispatchers. Some people have called with false information, sending emergency equipment on a wild-goose chase, and, while the fire station was empty, they have stolen everything that wasn’t secured at the station!
Most major cities in the United States now offer prearrival instructions for emergencies including childbirth, CPR, and choking. The dispatchers are no longer merely answering the phone, obtaining an address, and hanging up, but are truly becoming a lifeline to those in need. Many lives have been saved by a dispatcher giving instructions over the phone to a person with no medical training, talking a person through delivering a baby or performing CPR until trained medical personnel arrive. Many dispatchers for the fire department are firefighters and paramedics who have undergone specialized training to be able to obtain relevant information from a frantic caller and provide the proper assistance, while at the same time dispatch the appropriate emergency equipment.
Most of us will go through life never calling 911 or requiring emergency assistance. However, in a clinical environment, with anxious patients and many taking medications, you and your staff should be ready to respond with oxygen, CPR, and emergency equipment to take proper care of a patient until an ambulance arrives. What is going on behind the scenes at the 911 operator’s desk, the fire station, and at the hospital actually directing the ambulance and its personnel? What happens when you call 911?
We teach our front desk staff to dial that number, but we may be unable to explain what occurs after the system is activated. Some of us tell our children to dial it in case of emergency, but then we do not allow them to actually practice, so as not to bother the dispatchers. We should have an understanding of the process ourselves to be able to explain it to them. What constitutes an emergency? When do we point to a staff member and tell them to dial 911?
As previously stated, most emergency medical services (EMS) systems are utilizing a dispatch method to obtain as much relevant information as possible and relay that information to the responders. In this day of potential terrorist activities, it is imperative that the responders know what they are headed into. If there has been a toxic gas detonation and multiple people are affected, the responders must be prepared or risk injury themselves. If a witness calls in information about a mo-tor vehicle collision, it is important to determine if it involves a Mini Cooper or a school bus to ensure that ap-propriate resources are sent. Is it on a highway or a side street? Are power lines down, causing other potential problems? Responders are given information prior to arriving on the scene so they may be ready to handle the situation and know what they are facing.
Dispatchers are trained to ask several questions based on the situation. One of the first questions is the address of the emergency. Placing your address next to every office phone will help adults, as it is common to forget information in times great stress. In addition, there may be times when a nonstaff person is designated to make the 911 call.
If your office is in a single-story, multiple-office professional building, knowing the suite number is vital. If you are in a high-rise building, along with providing the floor and suite number, an elevator must be secured, security notified, or a staff member placed on the first floor directing the EMS crew.
A system similar to caller ID is utilized when a call is placed from a home or office that allows the dispatcher to see the address to which the number is assigned. However, it is important to remember that most cities do not have the technology in place to identify the location when a caller is using a cellular phone. In that instance, the address, suite, floor, or other information will have to be given. Other questions dispatchers ask include whether the patient is awake, breathing, bleeding, or has a pulse. If it is a call about a person who is choking, the instructions are based on whether the person is awake. If someone calls in about a woman in labor, decisions are made based on several factors, including the gestational age and how many other children the woman has delivered.
Once the dispatcher obtains information about the situation, responders are sent to the address that the caller provides. Depending on the emergency, a fire engine or truck may respond along with the ambulance. In lots of cities, a fire apparatus generally responds with the ambulance if the call is related to a heart at-tack, shooting, unconscious person, or a motor vehicle collision on a major roadway, or if the response time of the ambulance is greater than a certain amount of time. Other EMS systems may have their own policies regarding which apparatus is sent to assist. It can be based on time, available resources, or other factors.
The national average response time is 5 minutes from the time the 911 call is received until the emergency responders arrive on scene. However, in an emergency situation 5 minutes can feel like a lifetime. Emergency dispatchers are able to provide assistance over the phone and help the caller until the responders arrive. Sometimes the only help they can offer is a kind word when a loved one has died, but at least the caller doesn’t have to face the situation alone. (These dispatchers are truly a lifeline for many callers.)
Actual response time varies depending upon the setting: rural versus urban versus suburban. Some areas have cross-trained law enforcement officers to respond to medical emergencies along with the ambulances, as the officers are more likely to be on the road already and thus may have a quicker response time and be able to provide care until paramedics arrive.
So the first responders have arrived…now what? Paramedics and emergency medical technicians have received specialized training enabling them to provide emergency medical treatment en route to the hospital, as necessary. They frequently have to work under constraints that most people cannot fathom. I would be very upset if they had to come to my house and I had dishes in the sink! These medics respond to homes that haven’t seen a dustpan in years, if ever. I have heard stories about homes that were so cluttered with papers and belongings that there was only an 18-inch wide path through waist-high trash to get through the house. And, apparently, once this occurs, small creatures like to make their homes there, but that’s another story.
Medics have been shot at, beat up, and otherwise had their lives threatened. One medic, whom I know personally, was attending to a young man in the middle of the street. He had been shot several times and left for dead. The medic was checking for a pulse when he heard a voice from behind that instructed him get up slowly and move away from the patient. When the medic turned around, he had a gun pointed to his head.
Family members, screaming and crying over a loved one the medics were trying to save, have manhandled others. It’s incredibly difficult to work in cramped, dirty, potentially violent situations, but these responders do it every shift and come back for more, I’m sure reluctantly some days.
It is important to remember that first responders work under a set of guidelines or protocols that generally allow them to treat the patient without having a doctor present to give orders. Some areas have the medics contact the hospital they are affiliated with or transporting the patient to and obtain further orders. Several cities use a medical control office to obtain these orders. Staff members in medical control have a set of protocols that allow them to provide orders to the responders without having to contact a physician. Physicians are available if needed for a consult or further orders. For the most part, the medical control staff is not mandated to contact a doctor but may choose to do so based on the situation. When I worked in the local medical control, I frequently contacted a physician if I had a critical or dying child or if there was a patient who had a pulse return after the medics performed CPR. I know that these patients were incredibly labile and I wanted to be sure they received every option possible.
Decisions about where to transport a patient are multifaceted. Some decisions are based on the patient’s condition. Ideally, paramedics transport patients in cardiac arrest to the closest facility; however, some hospitals have been known to refuse critical patients if their emergency departments are overloaded. The medics must then scramble to find an available facility. Just think, the medics are careening down the road, sirens blaring, performing CPR, starting IVs, establishing secure airways, and now attempting to find a place to take the patient. How frustrating!
For patients who are more stable, the decision about a destination facility could be based on several things. Some departments allow the patients to decide where they want to go, which can be great for the patient but can have bigger implications for the community. If the patient requests to be transported to a facility that’s across town, that ambulance is taken from its usual area or district, which requires other emergency responders to cover the calls until the equipment returns. It may not seem like much if only one ambulance is involved, but if 50% of the equipment is out of its own district and covering other areas, problems could arise.
Many hospitals are now working to be designated as a specialty facility, such as a stroke center, heart center, trauma center, burn center, etc. While the patient might really want to go to a specific hospital, the medics may feel that it would be in the patient’s best interest to go to another facility. In order for a hospital to be specially designated, trained teams have to be in place to receive patients with those specific ailments or injuries. The facilities may also need to have special equipment available to care for those patients. Medics are trained to identify the patients who might benefit from a special facility and will transport the patient there to ensure he or she receives the best possible care.
Emergency responders are becoming primary healthcare for a growing segment of our population. The in-ability to obtain health insurance or to pay for doctor visits has caused an increase in the number of calls to 911 for nonemergent situations. In the past, ambulances were actually hearses, and society didn’t just call them on a whim out of fear that they would be transported…and not to a hospital! Now people are calling 911 for problems that could be handled at home or by their primary physician. Patients have arrived in the emergency room who needed their earrings removed, had back pain for a year, and knee pain from a football injury in 1962. Many emergency response systems have policies regarding transporting patients to a hospital. Many operate under the philosophy of “you call, we haul,” which means that no matter what the reason is for calling 911, someone’s going to be transported to the hospital. This causes issues with “real” emergency calls holding in the dispatch centers because the ambulances and other responders are tied up elsewhere. This is also causing issues within the community emergency departments, as they are unable to refuse to register patients for treatment. As more and more people lose their health coverage, the community emergency departments will need to find a way to care for the increasing patient volume. Many emergency departments have developed fast-track or nonemergent care areas to address these patients who really should be seen by a primary physician but do not have one. Even these changes may not help as health insurance costs increase and fewer people are covered.
Emergencies are bound to happen. Practice with your staff and hold mock emergency drills. Designate someone to check your emergency kit regularly for expired drugs and used items. Be sure your oxygen tank is full and that you have masks appropriately sized for adults and children. Put your full office location next to the phone. Attend CPR classes as a group and use that time to really train together.
Perhaps some of the information I’ve provided will help you understand why the dispatchers ask questions that may not make a whole lot of sense at the time, and why the EMS system functions the way it does.
The next time an ambulance or fire apparatus comes up behind you, move over to the right and let it pass. It could be your family or friend it is on its way to help.
Ms. Rivera has been working for 14 years in various settings at one of the largest level 1 trauma hospitals in the country: neonatal, burn unit, triage nurse in the emergency room, and the medical control office. She can be reached at (214) 590-8735 or sriver@parknet.pmh.org.
