Fire Dept. Dispatching in ‘Dire Need of Revision’
Breakdowns in the way the Los Angeles Fire Department dispatches emergency medical crews have been tied to at least three recent cases in which patients died. The system, according to an internal review, is in “dire need of complete revision.”
Fire Department dispatchers--the public’s first link to paramedic services--are regularly failing to ask callers scripted medical questions that can mean the difference between sending the right and wrong personnel in life-and-death situations.
In a July report by the department’s top quality assurance commander, firefighters in four cases were criticized for “grossly inappropriate dispatches” that “potentially led to negative patient outcomes.”
Battalion Chief Michael Bowman did not detail those cases in his report. But other records and interviews show that three of the incidents ended in death. Fire officials say there is no evidence that the fatalities could have been averted had dispatchers acted properly.
Still, the report to Fire Chief William R. Bamattre suggests that the mistakes are not isolated and are opening the city to possible lawsuits. According to the report, wrong medical help may have been dispatched to an estimated 160 patients during a recent span of less than 60 days, the same period in which complaints arose about the incidents involving deaths.
Firefighters are “dispatching inappropriately, thereby increasing the risk of liability to the department and reducing the quality of patient care,” Bowman warned. He cited earlier reports dating back to 1997 that dispatchers were not following scripted questions designed to elicit vital information on a patient’s condition.
Based on medical research, the questions--also called “protocols"--appear on flip cards mounted next to each dispatcher’s phone.
Numbering in the dozens, the questions begin with basics: location, the chief complaint and whether a person is breathing and conscious. From there, they become more intricate, depending on the nature of the problem. Some calls may require only a few inquiries, while others may require many as dispatchers work to identify the trouble.
These protocols were mandated after the 1987 death of a Chatsworth woman. In that highly publicized case, firefighters failed to ask crucial questions.
Since then, the mandated protocols have been reduced to guidelines and Fire Department dispatchers have been given wider leeway, contributing to inconsistencies and mistakes, some fire officials say. Battalion Chief William Cody, whose earlier studies warned of inadequacies, said the tougher rules “kind of fell by the wayside.”
Chief Bamattre and department medical director Dr. Marc Eckstein said the problems cited in the latest report represent a small percentage of the more than 300,000 emergency incidents handled each year.
“Our people do an excellent job,” Bamattre said.
Despite the earlier critical reports, Bamattre said he does not recall being told until recently that firefighters were straying from dispatch procedures. The chief said his subordinates should have alerted him to the problem and also “should have corrected it.”
After receiving the July report, Bamattre said he ordered new training and an interactive computer program requiring dispatchers to ask standardized questions in a specific order.
“I think we should do everything we can,” the chief said.
The proposed overhaul is expected to take months, with the goal of obtaining national accreditation--evidence that the department is adhering to high standards. A number of cities already have achieved the standards required for accreditation, a relatively new process.
To get there, dispatchers have to ask the scripted medical questions more than 90% of the time. Los Angeles firefighters, on average, do not ask key questions in 48% of their calls, according to several Fire Department studies.
Dispatchers Not to Blame, Chief Says
While acknowledging problems, Bamattre and other fire officials said there is no evidence that the three recent deaths resulted from poor dispatching.
One of those who died was a 59-year-old man who suffered a heart attack Feb. 9 in San Pedro. The second was a 13-year-old girl who collapsed at her Sherman Oaks school and went into cardiac arrest. In both cases, documents show, investigators concluded that more personnel could have been dispatched.
The third death, however, drew the most critical response from the department.
Sandie “Sam” Hugle, a well-liked, churchgoing man from Inglewood, had worked for the city of Los Angeles for 20 of his 56 years. Nearing retirement from his job in the Sanitation Department, he was looking forward to returning to his home state of Tennessee. He once drove trash trucks. For the past few years, he had been working in a Northridge refuse yard.
On March 16, he arrived early in the morning as usual. Sitting at a break-room table about 6:15, Hugle slouched in his chair and complained to his friend and co-worker, Art Sanchez, that he was feeling ill. Sanchez noticed that Hugle was having trouble breathing. Another worker said someone was calling 911, which promptly transfers such emergency medical calls to the Fire Department.
Believing everything would be fine, Sanchez headed out to his job.
But things only deteriorated, as a tape of the call to the Fire Department reveals:
“We’ve had an employee suffer a diabetic seizure. What we believe to be a diabetic seizure,” says the caller, who did not see the event.
“Yeah, what happened to him, sir?” a dispatcher responds. “Was he shaking real bad?”
“I didn’t actually witness it,” the caller says. “This is a, this has got about 100 employees here and one of the employees came up to me and said that he is on the ground, uh, uh, shaking and foaming at the mouth.”
The dispatcher asks: “OK, you don’t know how old he is, or anything like that?”
After checking, the caller says: “About 50-something.”
The dispatcher inquires about gender and then asks: “Is he breathing at this time, do you know, sir?”
Caller: “Yes, he’s breathing.”
Dispatcher: “OK, so the seizure is over then, huh?”
Caller: “It seems to be. I guess.”
The dispatcher, verifying the address, says: “OK, they’ll be right there.”
But they weren’t.
In fact, there was a series of foul-ups that began when the dispatcher failed to follow the scripted protocols, according to a Fire Department investigation.
“The call-taker asked questions in no organized manner as should have been done,” the probe found.
As a result, the dispatcher underestimated the severity of the problem, sending two firefighters who were not paramedics--without lights and siren--into the field. The investigation concluded that there should have been a full emergency response by at least two paramedics in an ambulance and four firefighters on an engine.
Moreover, investigators said the dispatcher failed to ask crucial questions to help the first rescuers find the city refuse yard. They ended up at a train station about a half-mile away.
When the firefighters finally arrived, more than 10 minutes after the call, they radioed dispatchers that Hugle was unconscious and needed paramedics. Moments later, they were on the radio again, asking for even more help because Hugle was in cardiac arrest.
About 20 minutes after the 911 call, the paramedics arrived, taking more than twice the average time to get there.
Hugle was pronounced dead at a Northridge hospital an hour after the ordeal began.
That afternoon, Sanchez returned to the yard and heard the anger over the delayed response and the grief for his fallen friend. “Everybody was upset,” he said.
Hugle’s remains were returned to Tennessee, where his widow, Gloria, now lives.
She said she knows little of the events leading to her husband’s passing--or of any mistakes.
“They called 911 and got the ambulance there,” she said. “That’s all I know.”
The dispatcher was later “counseled” and given a “notice to improve.”
In recent years, the Fire Department has repeatedly trained and counseled its dispatchers to follow the scripted procedures.
But, according to the July report, there has been “no improvement in the dispatcher compliance rate.”
On a recent morning at the Fire Department dispatch center, the uneven use of the questions was evident.
With its banks of computers and video screens, this is where desperate callers are transferred after dialing 911. At the consoles are veteran firefighters and paramedics, each answering about 7,800 emergency calls a year.
About 9:30 a.m., a dispatcher is on the phone with a man whose 64-year-old wife is having abdominal pains, which would not normally prompt an emergency response by paramedics.
But the dispatcher, quickly flipping through the protocol cards, asks a series of questions in the exact order they appear. Within seconds he hits on the right one.
“Is she taking any medication?” the dispatcher asks.
“Yes,” the man replies. “I think she’s suffering some sort of reaction.”
The situation, according to the cards, requires an emergency response, which he orders.
At another phone, a dispatcher is more loosely following his script. He says he has memorized many of the questions.
A caller on a cell phone reports that a man in the Valley broke his collarbone when his bicycle hit a pothole. The dispatcher keeps his eyes mostly on his computer monitor, not the flip cards.
The dispatcher asks for a telephone number where he can call back should they be cut off, an important detail. Hesitating, the dispatcher types in a number without double-checking it. The protocols require that callback numbers be verified.
A reporter, listening in, suggests that the dispatcher may have gotten the number wrong. Skeptical, he replays a tape of the call. Realizing his error, he explains that his mind momentarily wandered.
Still, the dispatcher says he has reservations about being forced to stick too closely to scripted questions under the proposed automated system.
“I’ll do it but it’s not going to make the person calling in happy,” he says, because of all the questions they’ll have to answer.
That’s one reason Bamattre is not a “big fan” of the scripts. He said callers don’t always give good information and it can take too long to work through the questions.
‘Time We Started Doing It Right’
Not everyone, however, agrees that the scripts complicate dispatches.
“That’s dinosaur thinking,” said Dr. Jeff Clawson, the nationally recognized expert who will help the Fire Department upgrade its dispatch procedures. “It’s time we started doing it right, not just fast.”
The chief said the way to achieve better service is to push ahead with a controversial pilot program in the San Fernando Valley called “1 + 1.” Under the plan, two-person paramedic teams would be split so there would be enough rescuers for every station to have at least one. In theory, this will improve response times and lead to more precise diagnoses at the scene.
“There’s less responsibility of the dispatcher to assess calls,” Bamattre said, and “you’ll be sending paramedics to a majority of calls.”
But the plan is strongly opposed by many paramedics and emergency room nurses, who say it will dilute the quality of medical care. They contend that it is better to work in teams, with each paramedic backing up the other. A special hearing of the mayor-appointed Fire Commission is scheduled Thursday to discuss the pilot program and other matters.
Although the controversy over dispatching has been less contentious than the proposed paramedic plan, it is no less important.
The use of scripted questions grew out of the 1987 death of Ziporah Lam, 42. Among other things, she complained about feeling faint and having chest problems.
Family members made three calls, during which dispatchers failed to ask basic questions and twice refused to send an ambulance. When paramedics finally got there nearly a half-hour later, Lam was in cardiac arrest.
Her death sparked a City Hall inquiry that found fire dispatchers were seriously mishandling calls.
David Lam, a computer retailer in Ventura County, placed the final call for help after his mother’s heart had stopped. He says he had hoped that, through subsequent reforms, something lasting would come of her death.
“Our goal,” he said, “was to make sure that nothing like this ever happened again.”
Times researcher Vicki Gallay contributed to this story.