1. Telephone CPR Troubles From A Dispatcher’s Perspective
FINAL
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

2. 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

3. 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.

4. Article Available

5. Article Available

6. 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

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

8. 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?

9. Discover
Analyze
React
Engage
Access
Talk
The bystander’s Chain

10. 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

11. 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

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

13. 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

14. 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)

15. 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

16. 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

17. 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”

18. 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”

19. 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”

20. Bystander
Reluctance

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

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

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

24. 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

25. Bystander
Coaching
Play me

26. 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

27. 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

28. The MPDS™/ProQA™ dilemma

29. 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.

30. 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

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

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. The Extra Reassurance Tab

39. 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

40. 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™

41. 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

42. 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