Search Terms: Don't ask permission, Jeff Clawson, pre-arrival instructions (PAIs), dispatch life support, permissive questions, legal consent, permission camp, inappropriate inaction, failure to provide, dispatcher malpractice, stop-gap emergency provisions, informed consent, telephone treatment, determined negligence, liability, Dispatch, 1991, ethic of emergency medical dispatch

Dispatch, the official National Academy of Emergency Medical Dispatch, Winter 1991
Jeff J. Clawson, M.D.

As the father of five girls (three teenagers and four year old twins) you don't know how painful this title was for me to pen. Obtaining permission is a necessary part of responsible life, ie. "Can I borrow the car?"·"Would you like to go to the prom?"·"Will you marry me?" It implies that a rational adult has a right to say yes or no-in essence, exercise self determination. However, the world of emergency medical dispatch is different. Everyone we deal with is not rational, healthy, or calm.

In 1975, the first documented Pre-Arrival Instructions (PAI's) were given, establishing the prototype for an entire branch of medical dispatching science that would evolve over the next 16 years into Dispatch Life Support (DLS).

As an offshoot of PAI's some EMDs and dispatch centers require the caller to consent to receive and perform PAI's for the benefit of the patient. One prominent system in the Pacific Northwest qualifies the provision of PAI's with the permissive questions "Do you want to do CPR?" and "Do you want to help?"

In case you're wondering what the official position of the NAEMD is, read the title of this article again.

Why should we ask the caller's permission to help the victim? This notion is probably built on the medical process to obtain formal consent prior to treating or operating on a patient. Here the similarity ends, In the medical world, the patient is asked for his/her personal verbal permission to go forward based on a calm, informed description of the pros and cons of the recommended treatment.

Question: What is wrong with this picture as it relates to medical dispatching?

Answer: Literally everything.

First, since when do we ask a bystander, even an interested or committed one, whether they want to "help" the patient? Honest to God, didnât they just call and ask for help? Just like we don't let the caller dictate by request what the specific mobile response will or won't be, likewise we shouldn't ask for their opinion on the appropriateness or lack of treatment for the person needing it. As Steve Martin would say, "Who's the Barber here?"

Second, in regards to legal consent, who has the right to deny emergency care to a critical unconscious or dying person? Not a relative, child, or even a spouse. Ask Page, Lazar, Ayres, or Shanaberger. If they agree, then how about a perfect stranger?

Third, the "permission camp" incorrectly surmises that an individual calling to elicit help for another might not want to help. Not only does this appear overwhelmingly false, it is a negative approach, just when firm, in-charge, professional leadership based action is most needed.

We can't physically make anybody do something over the phone they donât want to do. (The PAI for telephone imposed arm twisting has yet to be developed). Yogi Berra reportedly once said, "If people don't want to come out to the ball park, how are ya gonna stop Îem?"

Then why suggest such inappropriate inaction to the caller as one of their choices? There are 3 possible generic end actions to dispatch instructed PAI's: 1) the caller does as instructed; 2) the caller says they are doing as instructed but don't; 3) the caller refuses. They always have the third option and we "can't stop "em".

It has been our experience that when unprimed callers refuse to help, they usually have a fairly good reason to defer (the patient is obviously or long dead, they fear infection, or involvement in 3^rd party situations).

Paramedics and EMTs don't ask people in the street is they want help. If the patient doesn't, they will usually say so. Likewise, the EMD shouldn't ask someone who has no right express the unspoken will of the patient if they "want to help." If they really don't they will decline or just not perform. I consider the failure to provide PAI's when appropriate and possible to do so "dispatcher malpractice." Asking permission is merely deferring this failure.

I have literally heard dispatchers who were by policy expected to deliver PAI's, misuse a "permission" discussion to in essence talk the caller out of helping. Trained EMD's using medically sound and time-proven safe protocols should feel confident that their decisions, advice and instructions are not only needed by wanted.

We don't answer the phone in the dispatch center by saying, "9-1-1 do you want help?" Why then start the "help" portion of our later message in a similarly weak way?

It is the official position of the NAEMD that PAIâs 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.