Hot off the Press

Note: This editorial reflects the opinion of Jeff Clawson, M.D., creator of the police, fire, and medical emergency dispatch protocols used throughout the world. It does not necessarily reflect the views of the National Academies of Emergency Dispatch.

A national story CNN broadcast on its website (For CNN story click here ) did a major disservice by suggesting that 20 percent of the people calling 9-1-1 do not deserve an ambulance relative to the reason they called. The “20 percent” reflects the average number of calls that, perhaps, do not fit the professional definition of a life-threatening emergency. The reporter, Parija Kavilanz, turned the 20 percent figure into a statement of 9-1-1 abuse. This is an inaccurate application of the statistic.

Specifically, Kavilanz wrote: The National Fire Protection Association, which tracks 911 call volume annually, said fire departments nationwide responded to about 15.7 million total medical aid calls in 2008. Using that data, the National Academies of Emergency Dispatch (NAED), said about 20 percent of the calls are classified as non life-threatening and don't require a paramedic.

That insinuates these are not emergencies; that these people don’t need our attention.

This is neither what I said nor even remotely suggested during our 30-minute interview over the phone. These are true emergencies to the people calling and they do require assistance. My point: we need to handle these calls better.

First, the 20 percent is not simply “non-emergencies;” the 20 percent we talked about refers to lower level, non-life threatening situations most of which are clearly worthy of a call to 9-1-1 (I’ll give some examples below). The 20 percent CNN’s Kavilanz referred to in her report are what we call ALPHA-level response codes in the Medical Priority Dispatch Protocol System (MPDS). While she correctly reported that these do not require paramedics, the context she used strongly suggested that they don’t need EMS ambulance responses at all, which is wholly incorrect. They generally do need an ambulance (and therefore should call 9-1-1), just not one staffed with more highly trained and equipped paramedics (Advanced Life Support personnel). However, they do require basic emergency evaluation and care, then transport by EMTs (Basic Life Support personnel)-the minimal amount of training needed to be on an ambulance or first responder unit.

I also told her during our 30-minute interview that the number of these calls has gone up-but only proportionately to all calls to 9-1-1, which began to raise significantly both locally and nationally around 1990. In other words, the 20 percent today is the same 20 percent then but of a larger overall number of 9-1-1 calls due to the increasing number of calls made to 9-1-1. People are not abusing the system more now than in the past and true intentional abuse to 9-1-1 for medical help is quite low.

There is another medical 9-1-1 code level that, to date, has been basically overlooked within the United States, called the OMEGA tier. It is a smaller subset of the ALPHA calls that truly do not need emergency response and transport-this constitutes about 6 percent of all 911 calls, leaving the remaining 13 percent ALPHA calls for non-emergent transport. This special protocol is used universally in the U.K. and in several places in Canada and Australia. Currently only Richmond, Va., has a fully functioning OMEGA system in the United States. The OMEGA system requires careful evaluation and a referral to a more appropriate healthcare entity: Nurse Advice Lines, Poison Control Centers, Suicide Help Lines, scheduled doctors appointments, and other health/social agencies. In no case is the caller told, “This is not an emergency, we’re not coming, have a nice day.”

While the 9-1-1 systems in the United States talk-the-talk of too many “non-emergency” calls, they do virtually nothing to really provide any alternative, much less a safe and reliable alternate care path, for these myriad of people who have a real need, even though it is not ultimately life threatening nor requiring an ambulance transport to the most expensive healthcare place on earth-the Emergency Room. Most 9-1-1 system administrators still believe it is “un-American” not to respond, and, more than not, continue to over respond (too many vehicles and personnel). Most still respond lights-and-siren to even clearly minor cases, placing the driving public (and tragically themselves) at great risk (15,000 to 20,000 emergency medical vehicle accidents each year in the United States). Now that’s not exactly helping healthcare in America today.

Let me provide you with some examples of these ALPHA-level cases and you judge for yourself whether a call to 9-1-1 might be appropriate:

Burns to less than 18 percent of the body; Chest pain under age 35 (breathing normally); Just choked - but is not apparently still choking; Post-seizure now unconscious (breathing effectively); Drowning but now alert and breathing normally; Moderate eye injuries; Fainting episode and alert (under 35 - with cardiac history); Broken knee; Sick with new onset of immobility (some of these are actually strokes); Fall with a broken shoulder; Focal seizures (alert); Non-trauma-caused back pain (can’t get up due to pain).

Another continuing public safety myth is the misunderstanding of addressing 9-1-1 abuse by chastising the public through media articles or advertising campaigns “to only call for emergencies.” The approach just doesn’t work. You cannot reeducate the entire American public to change their emergency reaction habits learned over a lifetime-especially when their only real-life practice tries are the one to two (average) times a citizen calls 9-1-1 in their lifetimes (the ubiquitous cell phone is likely changing that figure). As a matter of fact, most people who are 45 years old or younger have been told since childhood to call 9-1-1 “if you or mommy needs help.” Kids and most of the lay public don’t know exactly what an emergency is (nor can they), but they know when they need “help” and that’s when they call-exactly as trained, mind you.

In the early 1980s, Detroit, having just hung their 9-1-1 shingle out, felt they were being overwhelmed with 9-1-1 calls. The city allocated $3.5 million for a public ad blitz that included TV ads, radio spots, and billboards, advising basically, “Don’t call unless it is a real emergency.” After the three million plus bucks were gone, on review, calls to 9-1-1 went up nearly six percent! Remember that famous Gary Larson cartoon that asked “What Do Dogs Hear?” First panel:  Don’t eat the food.” Second panel: “Blank, blank, blank, FOOD.” The individuals so targeted never think they are the uncaring or stupid ones abusing 9-1-1 as the advertising states.

We need safe and efficient processes in the 9-1-1 center that accept all calls, whatever they may be (within reason), but then direct the callers to the most appropriate mobile or non-mobile healthcare or “helpcare” entity-without just sending an ambulance or paramedics in a knee-jerk reaction.