By Ben Welsh, Kate Linthicum and Robert J. Lopez
7:24 PM PDT, October 5, 2012
It was 25 years ago when Ziporah Lam's family frantically called 911 over and over, telling Fire Department dispatchers that the Chatsworth mother was in pain, with tingling arms and hands. Dispatchers variously diagnosed her ailment as the flu, food poisoning or an anxiety attack — and did not send help.
"Sir," one dispatcher told her husband in the midst of the drama, "we don't come out for people that aren't feeling well — OK?"
Only after Lam's son called back to report his mother was foaming at the mouth and choking was a paramedic ambulance sent. By the time it arrived nearly 30 minutes after the first call, Lam was in full cardiac arrest. She later died.
Lam's death was a seminal moment for the Los Angeles Fire Department. It made national headlines and prompted a drive to reform the LAFD's 911 system. Dispatcher training was improved and new standardized procedures for assessing medical emergencies were adopted.
When problems persisted, the department pledged to secure an independent accreditation of the dispatch center to ensure it met professional standards.
Today, the center still is not accredited and it continues to be plagued by performance deficiencies, according to recent reports and interviews.
Last month, The Times reported on systematic delays in a crucial dispatcher duty: getting callers to begin CPR on cardiac arrest victims. The Times also examined 2011 cardiac arrest cases and found that the agency failed by a wide margin to meet a national standard that rescue units be alerted within one minute on 90% of 911 calls.
Advances have been made since Lam's death, but many of the LAFD's current dispatch center troubles reflect shortcomings in quickly and consistently handling calls that have persisted for years, according to a review of public records and interviews with experts and department officials.
In a statement to The Times, Fire Chief Brian Cummings acknowledged the "urgency of this issue" and said he is committed to improving dispatcher performance in cardiac arrest calls. He also vowed, once again, to seek accreditation for the dispatch center.
The LAFD's struggles partly reflect a long-running debate in the profession about the best way to assess medical emergencies over the phone. With a limited number of highly skilled paramedic ambulance teams available, assessing the seriousness of each call for help is critical. That is especially true at the LAFD, where budget cuts in recent years have stretched resources thin. The department has 89 paramedic ambulances and handles more than 700 medical calls a day.
How consistently, accurately and quickly LAFD dispatchers evaluate the 911 calls they receive has been a recurring concern at City Hall. Studies dating to the late 1970s warned that dispatchers lacked adequate training and should be required to use tightly scripted medical questions — known as protocols — when processing calls.
After Lam's death in 1987, fire officials implemented a new call-handling system developed by a Utah physician, Jeff Clawson, that now is used by dispatch centers around the world.
Under Clawson's system, dispatchers were given color-coded flip cards with scripted questions designed to methodically elicit information on the caller's location, the nature of the emergency and whether victims were breathing and conscious. The answers guided dispatchers toward decisions about whether to send EMTs with limited first aid skills or paramedics authorized to administer drugs and perform advanced life-saving procedures.
But the cards failed to fully resolve the problems.
A few years later, an LAFD study found that dispatchers did not ask key questions in nearly half the 911 calls they handled. And The Times reported in 2000 that at least three patients died in heart attack and cardiac arrest incidents after dispatchers strayed from the standardized questions.
Fire officials again vowed to fix the problem by obtaining accreditation and meeting statistical targets in eight different categories. Cities with accredited dispatch centers include San Diego, San Jose and Miami-Dade County.
LAFD officials acknowledged in recent interviews that they never completed the accreditation process because they lacked the staff needed to analyze how dispatchers handle thousands of 911 calls. Cummings said he now plans to assign several additional firefighters to the task.
As part of the package of reforms approved in 2000, the department also promised to purchase a high-tech version of Clawson's system that tracks dispatcher compliance with call-handling protocols by requiring them to enter callers' answers to medical questions into computers.
Officials said the upgrade would increase accountability and speed up call handling, but it only became operational in 2008.
Now, that upgrade is being faulted by the department for exacerbating delays in getting CPR instructions started.
An LAFD study of 166 cardiac arrest calls received last October found that CPR was started just 31% of the time. And it took an average of 4 minutes and 12 seconds to get chest compressions going in those cases — after the point at which brain death typically begins.
The study partly blamed the delays on a question dispatchers are required to ask. The answer relies on often panicked callers to judge whether victims are breathing. Changes to the Clawson software were needed, the study concluded.
Clawson told The Times the LAFD has it wrong. Echoing past criticisms of LAFD dispatchers, he said the problem is city firefighters not consistently following his scripts when they take 911 calls.
"It never has a bad hair day," Clawson said of his software program. "People who follow it by the numbers don't have these types of problems."
Cummings has acknowledged his dispatchers sometimes "jump to a conclusion about a call as opposed to listening to what's being said and following a script." But he said his dispatchers do a "tremendous job" overall.
The San Francisco Fire Department uses the same Clawson program as the LAFD. Dr. Clement Yeh, the agency's medical director, said it is effective and user-friendly. "We've had some spectacular successes with this," Yeh said.
Still, many experts agree that gauging whether a patient is breathing can be difficult. One reason is that cardiac arrest victims sometimes gasp in ways that can be mistaken for normal breathing.
Like the LAFD, Houston officials have struggled with the problem. They recently rewrote in-house dispatching software to try to deal with the issue.
Houston dispatchers now ask callers "Are they breathing normally?" rather than "Are they breathing?"
David Persse, a physician who is the Houston Fire Department's medical director, said the new approach is an improvement, but not perfect because it still depends on the subjective judgment of callers.
"They don't have a medical background," Persse said. "They're nervous, they're scared."
Los Angeles fire officials now are pursuing a new round of reforms. Procedures allowing dispatchers to more quickly start CPR instructions will take effect shortly, they say. And the LAFD's medical director, Dr. Marc Eckstein, said that within a month the department will streamline other rules to ensure the closest fire engine and paramedic ambulance are immediately sent on critical emergencies, like cardiac arrests.
The LAFD must improve its dispatch center performance, Cummings said in an email to The Times. "I am committed to seeing this accomplished."
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