Fire Dept. Begins Overhaul of Medical Emergency System

The Los Angeles Fire Department, facing stiff criticism that its responses to medical incidents have been “inadequate” in many cases and “seriously mishandled” in others, is revamping its emergency medical dispatching system according to the prescription of a Salt Lake City doctor.

The expert is Jeff J. Clawson, 41, creator of the “Clawson’s protocols,” a system of priority medical dispatching that enables fire dispatchers to determine the seriousness of emergency calls and to send the appropriate level of aid.

The program is expected to be in place in Los Angeles by January.

In the meantime, the Fire Department has modified its dispatch procedures and now sends engine companies on many low-level medical incidents. It also plans to equip fire engines with automatic defibrillators for thousands of heart attack calls received each year.

But adapting Clawson’s system to Los Angeles conditions is viewed by city officials as a key step in efforts to improve poor response times by overhauling the city’s emergency medical system.

Specific Questions

The protocols provide specific questions for dispatchers to ask to determine a caller’s trouble, so they can then send either paramedics on critical incidents or firefighters trained as emergency medical technicians on less-serious calls.

For the most part, the Fire Department has overburdened paramedics with virtually all medical calls for years, according to an audit report by the city administrative office issued earlier this year.

The report noted that paramedics responded to most of the 200,372 emergency medical dispatching incidents last year, and as a result they were sometimes busy with “first aid” and unavailable for life-threatening calls, such as heart attacks.

Response times in hundreds of heart attack cases exceeded American Heart Assn. survival standards, which call for cardiopulmonary resuscitation within four minutes and for use of drugs and defibrillation within eight minutes, the report said.

“We also encountered instances where OCD (Operations Control Division) call-takers seriously mishandled calls,” the report said, without being specific.

The auditors favored Clawson’s protocols to help cut response times. And they suggested that the nearest on-duty firefighting unit should respond to low-level calls, leaving paramedics for the life-threatening events.

When the Fire Department offered its own three-year trial emergency medical system plan in May, officials also embraced the Clawson protocols.

Clawson was hired last month under terms of a one-year $115,000 contract to assess the city’s dispatching system, train its fire dispatchers, establish a quality-control program and, along with the Fire Department, see that his protocols are implemented.

Clawson has developed his priority dispatching system over the last 10 years, while serving as medical director of the Salt Lake City Fire Department. As a medical student at the University of Utah, he got a first-hand view of emergency response by driving an ambulance.

He developed a quick-reference card file, listing 32 complaints and incidents alphabetically arranged from “abdominal pain” to “unknown problem (man down),” with key questions, pre-arrival instructions and recommendations on what level of aid to send.

Clawson does not claim to be the originator of priority dispatching, which Phoenix started a decade ago, but he has been active in installing his protocols in dozens of cities throughout the country, including Salt Lake City, Stockton and Aurora, Colo.

Essential Step

“I invented the format--the concept of the key questions, the formalization of tiered (priority) response, and (I) helped formalize pre-arrival instructions,” he said.

Clawson views his personal training of 69 Los Angeles fire dispatchers and officers--beginning soon--as an essential step in revamping the system.

“The dispatchers are facing tremendous call loads,” he said. “They lack one thing. They lack the training on what to say, what to ask, and . . . how to put that together. That’s done through the use of protocols.”

Dispatchers are taught to first determine four facts: the victim’s chief complaint, age and whether he or she is conscious and breathing. Then, the dispatchers refer to Clawson’s card file under the appropriate heading for specific questions to ask.

For example, the protocol card for Stab/Gunshot Wound asks: “Assailant still present? Police notified? Location of wound? Alert? Uncontrollable bleeding? Time of injury? Stab or gunshot?

Under pre-arrival instructions, the dispatchers are told to tell a caller to: “Remain safe if assailant is nearby. Have victim lie down and calm them. DON’T DISTURB SCENE OR MOVE WEAPONS. Apply direct pressure on extremity wounds. Keep victim warm. Elevate legs if uninjured.”

Four Levels of Response

Clawson’s system has four levels of response. The medical technicians take the first two non-emergency categories, designated as “Alpha and Bravo.” Paramedics handle the other two: “Charlie,” when time is less important from a life-saving standpoint, and “Delta,” when time is critical.

Clawson teaches three rules of medical dispatching: “Do no harm. When in doubt, send them out. Let’s not be in doubt so damn much.” The third rule is, “Really a glib way of saying, ‘We want trained individuals functioning as dispatchers,’ ” he said.

Clawson tells dispatchers to answer the phone in three rings, empathize with the caller, take charge of the conversation by asking direct questions to obtain specific information, be courteous but firm and learn to listen.

Hysterical Callers

And Clawson tells his students how to control hysteria.

Dispatchers have historically responded to unpleasant, uncooperative or hysterical callers by just sending someone out, Clawson says. While sympathizing with medically untrained dispatchers who do that, he says it is “no longer acceptable” to shift the problem to someone else.