Telephone CPR Troubles From A Dispatcher’s Perspective FINAL1.25.2016 The Great Disconnect Telephone CPR Troubles From A Dispatcher’s Perspective Ryan Caiazzo, EMD-Q, EMT Manchester Grand Hyatt | San Diego, CA Seaport G | Wednesday, December 9, 2015

My Perspective Dispatcher in Newark, NJ for 13 years Urban environment/low socio-economic population HIGH violence, culture of indifference LOW bystander participation; high refusal rate EMS system: BLS, ALS (no first responders); call “stacking” Primary healthcare providers for community Advocate of the MPDS/ProQA™ Processed over 1,000 cardiac arrest PAI calls

Scope The premises of this presentation focuses only on those OOHCA cases that are VIABLE arrests (not obvious deaths) where a bystander/caller who is with the victim and has accessed a 911/999 system where a trained EMD is authorized to give scripted medical CPR instructions.

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Myths & Misconceptions Nearly all callers will perform CPR OOHCA is easy to recognize EMDs have protocols that address EVERYTHING All EMDs can “ad lib” or freelance Most callers are cooperative CPR refusals come mostly from bystanders who encounter strangers in OOHCA

The good ol’ chain Early Defibrillation Early Recognition Early Compressions Early Defibrillation Definitive Care Early Reporting ALS

Rethinking the Chain Does the “chain” tell us the full sequence of events? Are there more links in the chain than we thought? How might other links in the chain effect the way lives are saved?

Discover Analyze React Engage Access Talk The bystander’s Chain

The EMD’s Chain Get Location Find out Situation Code/ Prioritize Get Callback Find out Situation Recognize OOHCA Code/ Prioritize Early Dispatch The EMD’s Chain

The Recognition Chain With the patient? Obvious Death? FIRST PAI Patient Awake? Patient Breathing? Obvious Death? FIRST PAI AED Available? The Recognition Chain YES NO I Don’t Know I can’t tell YES NO I Don’t Know I can’t tell Agonal YES NO I Don’t Know I can’t tell

The Bystander-Dispatcher Chain Instruct Caller Caller Performs EMD Coaches Caller Feed-back Handoff The Bystander-Dispatcher Chain

Handoff Discover Analyze React Engage Access Talk Get Location Get Callback Find out Situation Recognize OOHCA Code/ Prioritize Early Dispatch With the patient? Patient Awake? Patient Breathing? Obvious Death? FIRST PAI AED Available? Instruct Caller Caller Performs EMD Coaches Caller Gives Feedback Handoff

Patient Access Issues 3rd party callers 4th party callers Patient is on the bed Patient is in a dangerous situation Patient is bariatric Patient is inaccessible (locked door)

Sticky wickets Patients on hospice, palliative care, DNR Seizures and Overdoses mimicking OOHCA “Just send the ambulance” Responder “cry wolf” fatigue “Trained rescuers” Protocol issues & shortcomings

Sticky wickets (cont’d) Language Barriers Multiple calls from same scene/home Traumatic arrests Scene chaos/emotional callers Agonal/Ineffective Breathing determinations Dispatcher doubt new protocols updates (“If they don’t say yes…” PAIs on very alive people

Bystander Reluctance Things EMDs hear every day “I don’t know this guy” “She’s already dead” “Just send the ambulance” “I don’t want to get HIV/AIDS” “I might hurt her” “I can’t deal with this” “My card is expired”

Bystander Reluctance Things EMDs hear every day “It’s too late” “She’s already dead” “There’s vomit, I’m not touching him” “Let the professionals do it” “I think she breathing ok” “I’m not a doctor”

Bystander Reluctance Things EMDs hear every day “I’m not doing this 600 times” “By the time I do all of that, they’ll be here” “I’m not trained” “I’m not allowed to help/touch the patient” “It won’t work” “I don’t want to be sued”

Bystander Reluctance

An EMD can’t force an unwilling caller to perform CPR…

But an EMD can “sell CPR” to a reluctant caller who just needs assurance and encouragement.

Pool A Pool B Callers who are adamant about refusing, EMDs cannot reach… Callers who are reluctant, we can teach

Encouragement I’ll talk you through everything You don’t need to do Mouth-to-Mouth You will not be liable CPR is the only way you can try to save the victim You can do this and I’m going to help you You will not hurt the patient

Bystander Coaching Play me

The MPDS™/ProQA™ dilemma Used in 3,000 call center in over 40 countries, the MPDS™ is the must robust, comprehensive telephone medical protocol… Source: IAED

The MPDS™/ProQA™ dilemma It is the official position of the NAEMD that PAI’s are stop-gap emergency provisions that do not require informed consent of the provider (caller) and that delaying or confusing telephone treatment by asking permission is considered contrary to the ethic of emergency medical dispatch and may result in determined negligence or liability for the dispatcher and center advocating uninformed inaction. —Principles of Emergency Medical Dispatch

The MPDS™/ProQA™ dilemma

The MPDS™/ProQA™ dilemma “Freelancing” is banned by multiple standards. “If it’s not in the script, you must omit” mantra. The protocol provides no guidance to EMDs for reluctant callers in CPR situations.

The MPDS™/ProQA™ dilemma Universal Protocol Standard 1: All questions will be read exactly as written in the protocol script, allowing only for the specific script variations defined in these standards… MPDS 9a Medical Standards

The MPDS™/ProQA™ dilemma DLS Standard 2: Pre-Arrival Instructions are to be read only as written. MPDS 9a Medical Standards

The MPDS™/ProQA™ dilemma The medical dispatcher is responsible for offering help to those in need but should not attempt to force help on those not willing. —Principles of Emergency Medical Dispatch

The MPDS™/ProQA™ dilemma “We can’t physically make anybody do something over the phone they don’t want to do. (The instruction for telephone-imposed arm twisting” has yet to be developed.) —Principles of Emergency Medical Dispatch

The MPDS™/ProQA™ dilemma EMDs cannot, and should not, force a caller to do anything over the phone. Encouragement is warranted; badgering is not. It is ultimately the caller’s choice to continue their involvement—or not. —Principles of Emergency Medical Dispatch

The MPDS™/ProQA™ dilemma I’m not putting my job on the line for going outside the protocol. There’s nothing that says I should talk them into doing it. We have a script that says to put away the family pets and turn on the outside lights, but we don’t have a script that tells me to try to get Mrs. Jones to do chest compressions on her husband because she’s scared she’s going to hurt him, even though he’s technically already dead. —Rudy Rodriguez, EMD

The MPDS™/ProQA™ dilemma “I’m just a robot. They beat it into us ‘follow the script, follow the script, follow the script... You can’t blame dispatchers for not going above and beyond because the robot doesn’t have the authority to do it. It’s not there.” —Rudy Rodriguez, EMD

The Extra Reassurance Tab “Hidden” and out of the way, but in the protocol.

The Extra Reassurance Tab

All we need is a few buttons… “HIV” “Hurt Patient” “Scared” “Let Medics Handle” “Won’t Work” “Don’t Know How” General Reluctance Reluctant Caller Canned Phrases

Conclusions Telephone CPR does not always go smoothly When callers give bad information, we get bad results EMDs are placed in challenging situations Many callers decline or refuse to do CPR The Chain of Survival has many more links EMDs are limited in encouraging callers under MPDS™/ProQA™

Recommendations EMDs need robust training in recognizing and handling OOHCA situations PSAPs who can’t afford a protocol need to be provided with a non-proprietary, consensus-based PAI protocol A training audio case study lab should be established EMDs must be allowed in protocol and in practice to encourage reluctant callers to perform CPR

Recommendations Assertiveness training for EMDs is needed Protocol, Policy, or Practice Educate people in the community about what EMDs do, what they will ask, how CPR has changed Reward/Recognize EMDs for good faith efforts Track data and outcomes

ryancaiazzo@gmail.com