A Tip of the Helmet – Cleveland says “No”

Social Media in EMS - A Tip of the HelmetIt was reported this morning in the Cleveland Paper the Plain Dealer that Cleveland EMS will start rejecting minor calls for service unless the system is able to handle it. Writer Mark Puente reports:

“This is a huge step for Cleveland,” EMS Commissioner Ed Eckart said. “This is a step back from a long-standing culture in this city.”

And indeed a long standing culture in America on whole.  I have a call into the Commissioner to get more details on the nuts and bolts of this move as I would love to know how we all can enact this kind of common sense in our own EMS systems.

Now before everyone starts wringing their hands about what is going to happen, take the time to read through the comments on the story, many of which claim to be written by local responders.

As you start to write your comment about the referred ankle pain that could be presenting as a silent MI, keep in mind that as you transport that “maybe” call, the actual crushing chest pain that IS an MI is waiting longer for a transport.  We need to stop worrying about what might be and focus on what is.

The issue of liability for reducing immediate response is countered by the liability of explaining to the family of a deceased person that their ambulance was delayed because of system abusers.  We call it triage.  No one thinks twice about ignoring minor injuries in an MCI, why is it suddenly an issue when that decision is moved into the control center?  If we let the call taker take the calls and the triage system deems it non-emergent, then let it be non-emergent.

For so long we as an industry have striven for an 8 minute goal only to see the nation expect that 8 minutes for everything.  Cleveland says no more.  Cleveland.  No offense to the system there, I’m learning more about it now, but if you went to a conference and asked which EMS system in the Nation is out ahead of the others, Cleveland is not in my top 3.  Until now.

A Tip of the Helmet to Commissioner Eckart and the Cleveland EMS system for breaking free and doing the right thing.  I hope to learn more about their research and system savings in the near future.  I will most certainly pass that along if I can get it.  Do you have a question you’d like me to ask the Commissioner?  Post it below and I’ll ask him.

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81 thoughts on “A Tip of the Helmet – Cleveland says “No””

  1. Softy get that coat off! If you think the stag party fancy dress is excess ask Mark about carnage 3000 students all in matching fancy dress on one pub crawl!

  2. I agree with you the system needs reform there has to be a better way to do it and prevent system abuse. The question I have is can we trust dispatchers to make the right priority decision? I mean 2 weeks ago we were all up in arms about 2 dispatchers that let someone die because they wouldn’t step into a room to evaluate a person, but now everyone is rejoicing at the idea that instead we let them make those decisions from a different building entirely. I am in favor of a system where you send a medic or a pa out to those low priority calls first to see if they are in need of higher care, but too often dispatch has been way off on the nature of the call or have shown lack of care or training (the fdny dispatchers or the Iowa 911 dispatcher that left the call center unattended for over an hour in which a 911 call went for over a half hour without an answer). I just have lost faith in the dispatch system for the moment. I don’t know that they are capable at this point to take on such a task. I just think we should wait to celebrate this as God’s gift to burnt out ems providers.

    1. Not a gift to the burnt out responder at all, more of a realization that we do triage all the time, yet dispatch is mandated to push those calls out, some not even completely coded, just to reach a magical response time. In the perfect dispatch system things will be miscoded, but until we give them the responsibility and experience, all that will happen is they will hear “I need an ambulance” and hit the tones for the “unknown medical aid, more to follow.” there, they mee ttheir goal and it’s all the same. But when they take the same BS call fro mthe same abuser over and over and over again, they are the ones who can benefit the system best by recognizing the abuse, CODING the call based on the patient’s information and FOLLOWING that code. I get sent on 26A1 severe Resp Distress, simply because someone is crying that they fell down and hurt their foot. This is done to get the call out of the center before 4 minutes. Imagine when that call is CODED, based on the patient’s information, a non emergent fall that we funnel them to the proper care, not a 6 person lights and sirens response. I too want to learn more about what Cleveland is doing and how they got around the knee jerk legal arguments so many in this business hide behind. Thanks for reading and even more for your comment!

      1. I agree with the idea of having non emergent responses for those calls definitely. I think for me I just have a distrust for dispatch in my area, as we have been sent out on 3 different difficulty breathing calls in the last 4 months in which the person was supposedly alert and talking to dispatch and then the first responder or we arrive 2 minutes later to find a person in full cardiac arrest. Then there have been the ones that were dispatched as heart attack possible code, and we find it to be a guy who rolled his golf cart down the hill to be awake and talking to dispatch. I am totally in favor of this kind of dispatching in theory, I just want to watch how it works in Cleveland first before I pass total judgment. Thanks for the interesting info.

          1. Agreed. And more importantly, I hope to learn what training, policies or procedures are in place so we can gauge the success or failure accurately. From some emails I’m getting from folks in the region, this is news to them as well. More to follow, thanks for reading.

          2. ** I have a wonderful response to this, but then my computer crashed, so; I am trying again. **

            I am just a lonely 9-1-1 Dispatcher here, but I have a strong voice.

            As Happy mentioned before 9-1-1 dispatcher are mandated to get the calls in the CAD within a certain time frame – every centre in different. In my centre I have 30 seconds to get a fire/medical call put into CAD in a per-alert status for Dispatch uses to dispatch the crews. In that 30 seconds I need to get a verifiable address, phone number, and chief complaint while still talking to the caller in a friendly, compassionate, and controlling manner.

            Every time a call comes into a 9-1-1 centre the goal is to correctly triage the call based on what the caller has told us; sometimes the callers lie to use, but we have to assume the caller is giving us the correct information and not trying to abuse the system. I know there is abuse of the 9-1-1 system, and especially EMS.

            Sometimes there are errors made when we are triaging the call for help, but with the correct training hopefully we are able to minimize those errors. The medical cards are designed so that non-medically trained personal are able to triage a call correctly – the cards use terms that anyone can understand.

            Every centre is different, some centre use medically trained personal while other use non-medically trained to triage the calls. My centre uses primarily non-medically trained personal to triage calls, and we do this for many reason but because years ago we found that the medically trained personal were trying to diagnose the patient while on the phone with them . Now, I have been on the phone with the person who is calling about chest pain, who is alert, breathing normally, no cardiac hx, and no medication used in 12 hrs and triaged the call correctly, and while the medics were responding to the call the caller has gone into cardiac arrest. No one has control of what happens once the phone is hung up, so there is no one to blame.

            I won’t comment on the 9-1-1 Dispatchers who may have abandoned their posts, because I don’t know all the facts. However they may lose their jobs, and be prosecuted to the full extent of the law.

    2. Many services use an EMD system now. it is a script designed to triage 911 calls. Yes it has flaws, but overall, it is a good system. If a service uses this system, their dispatchers are free from liability as long as they stick to the script. It is not up to the dispatchers to make the call, It is up to the system.

    3. This is very true. As a firefighter paramedic, I know how common it is to arrive at a scene and have it have absolutely nothing in common with what we were dispatched out to. I wish it were only occasional that we were sent to the wrong address or wrong suite number. As a citizen I witnessed a car wreck and called it in to 9-1-1. The driver went head on with a car that was turning with a green arrow and was altered. The dispatcher heard him yelling in the back ground that he was fine and asked if that was the patient. I said yes and she told me since he was denying injury she wasn’t sending anyone. You know what? She didn’t send anyone. A passing by fire engine from a neighboring community stopped to help and had the guy transported to the local hospital. As they were getting ready to leave a community aide, not even a police officer came by in response to my call. Over 30 minutes had passed since I made the call. People no matter how smart and trained can not make decisions on triage and patient priority without SEEING the patient. That is just common sense. I do not think this will go well for Cleveland. A better way must be sought. I remember reading years back of fast response units being used in major cities in Australia. Medics on motorcycles that could maneuver through gridlock faster then ambulances to stabilize the seriously injured or cancel the ambulance if it was not needed. This may be a better idea.

  3. Ed Eckart is a horrible man. Please learn more about him before you sing his praises. He is psychotic and is running the division into the ground. The only reason he’s doing this whole thing is because we are laying people off and reducing the amount of ambulances. He disciplines us for nonsence. We in the field found out about this in todays paper. There is no protocol in place and we havent been told about not taking people to the ERs of their choice. If u want legitimate info on Eckart, u may contact me if u like.

  4. Well this kind of call handling is usual in many larger cities of Germany. If the patient has a minor problem the “911 (112) dispatcher” connects him with the dispatch center for the general practitioner service. The patient can make an appointment at the 24h open doctor’s practice and if he is not able to walk the gp will visit him at home. Also as a paramedic you can call this service if you see no need for transporting the patient to an ED.

    1. It sounds lovely, Mathias. Unfortunately, in the US the “24h open doctor’s practice” is the Emergency Room, and medics are the home visit.

  5. Softy get that coat off! If you think the stag party fancy dress is excess ask Mark about carnage 3000 students all in matching fancy dress on one pub crawl!

  6. I agree with you the system needs reform there has to be a better way to do it and prevent system abuse. The question I have is can we trust dispatchers to make the right priority decision? I mean 2 weeks ago we were all up in arms about 2 dispatchers that let someone die because they wouldn't step into a room to evaluate a person, but now everyone is rejoicing at the idea that instead we let them make those decisions from a different building entirely. I am in favor of a system where you send a medic or a pa out to those low priority calls first to see if they are in need of higher care, but too often dispatch has been way off on the nature of the call or have shown lack of care or training (the fdny dispatchers or the Iowa 911 dispatcher that left the call center unattended for over an hour in which a 911 call went for over a half hour without an answer). I just have lost faith in the dispatch system for the moment. I don't know that they are capable at this point to take on such a task. I just think we should wait to celebrate this as God's gift to burnt out ems providers.

  7. What an interesting article and comments in the Cleveland Plain Dealer! There seems to be a lot of tension there between EMS and the Fire Department. And I LOL’ed when one commenter said the merger wouldn’t happen because the Fire Union was too powerful! I’m surprised they don’t want to get their hands on all those new members and that new EMS money.

    I love the idea of triaging out the calls, however. We’ll have to watch how it goes, see how the dispatchers’ judgement call matches with the reality the medics find when they get there. Most horrible EMS abuse single call division I can recall: Man got tossed out of a local casino due to talking to the machines and acting weird–turns out he has history of schiz. Man taken to hospital near his home. Man makes total sense, oriented, not having AH or VH, gave the FF/EMS no trouble, etc. etc. Finally says out loud, “Well, I had to get home…” I took several deep breaths, and managed not to ruin the hospital ER’s Press-Gainey score or cause injuries that would need the care of a trauma center. He left the ER ambulatory.

    Hey, can we triage out the “ambulance=get out of jail free card” calls?

  8. Ed Eckart is a horrible man. Please learn more about him before you sing his praises. He is psychotic and is running the division into the ground. The only reason he's doing this whole thing is because we are laying people off and reducing the amount of ambulances. He disciplines us for nonsence. We in the field found out about this in todays paper. There is no protocol in place and we havent been told about not taking people to the ERs of their choice. If u want legitimate info on Eckart, u may contact me if u like.

  9. Not a gift to the burnt out responder at all, more of a realization that we do triage all the time, yet dispatch is mandated to push those calls out, some not even completely coded, just to reach a magical response time. In the perfect dispatch system things will be miscoded, but until we give them the responsibility and experience, all that will happen is they will hear “I need an ambulance” and hit the tones for the “unknown medical aid, more to follow.” there, they mee ttheir goal and it's all the same. But when they take the same BS call fro mthe same abuser over and over and over again, they are the ones who can benefit the system best by recognizing the abuse, CODING the call based on the patient's information and FOLLOWING that code. I get sent on 26A1 severe Resp Distress, simply because someone is crying that they fell down and hurt their foot. This is done to get the call out of the center before 4 minutes. Imagine when that call is CODED, based on the patient's information, a non emergent fall that we funnel them to the proper care, not a 6 person lights and sirens response. I too want to learn more about what Cleveland is doing and how they got around the knee jerk legal arguments so many in this business hide behind. Thanks for reading and even more for your comment!

  10. Many services use an EMD system now. it is a script designed to triage 911 calls. Yes it has flaws, but overall, it is a good system. If a service uses this system, their dispatchers are free from liability as long as they stick to the script. It is not up to the dispatchers to make the call, It is up to the system.

  11. Well this kind of call handling is usual in many larger cities of Germany. If the patient has a minor problem the “911 (112) dispatcher” connects him with the dispatch center for the general practitioner service. The patient can make an appointment at the 24h open doctor's practice and if he is not able to walk the gp will visit him at home. Also as a paramedic you can call this service if you see no need for transporting the patient to an ED.

  12. I agree with the idea of having non emergent responses for those calls definitely. I think for me I just have a distrust for dispatch in my area, as we have been sent out on 3 different difficulty breathing calls in the last 4 months in which the person was supposedly alert and talking to dispatch and then the first responder or we arrive 2 minutes later to find a person in full cardiac arrest. Then there have been the ones that were dispatched as heart attack possible code, and we find it to be a guy who rolled his golf cart down the hill to be awake and talking to dispatch. I am totally in favor of this kind of dispatching in theory, I just want to watch how it works in Cleveland first before I pass total judgment. Thanks for the interesting info.

  13. Agreed. And more importantly, I hope to learn what training, policies or procedures are in place so we can gauge the success or failure accurately. From some emails I'm getting from folks in the region, this is news to them as well. More to follow, thanks for reading.

  14. What an interesting article and comments in the Cleveland Plain Dealer! There seems to be a lot of tension there between EMS and the Fire Department. And I LOL'ed when one commenter said the merger wouldn't happen because the Fire Union was too powerful! I'm surprised they don't want to get their hands on all those new members and that new EMS money.

    I love the idea of triaging out the calls, however. We'll have to watch how it goes, see how the dispatchers' judgement call matches with the reality the medics find when they get there. Most horrible EMS abuse single call division I can recall: Man got tossed out of a local casino due to talking to the machines and acting weird–turns out he has history of schiz. Man taken to hospital near his home. Man makes total sense, oriented, not having AH or VH, gave the FF/EMS no trouble, etc. etc. Finally says out loud, “Well, I had to get home…” I took several deep breaths, and managed not to ruin the hospital ER's Press-Gainey score or cause injuries that would need the care of a trauma center. He left the ER ambulatory.

    Hey, can we triage out the “ambulance=get out of jail free card” calls?

  15. This entire debate highlights the larger issue, which is a broken healthcare system. The comments from Germany sound progressive and amazing. Dare to dream huh? Until this country has healthcare that is accessible to everyone we will continue giving taxi rides to the ER. I’ve been in this business for 9 years and the majority of our calls are bs rides to the hospital. We aren’t even allowed to refuse transport on scene. Having said that I absolutely wouldn’t trust the dispatchers in my area to triage calls. Does anyone out there remember scene size-up? Remember that, in your basic class? Just last week I was on an intermediate truck and the 22 year old paramedic on the second truck in tried to push a late night transport off on me–I refused. When I got back in the truck I told my partner the man would code on the way–they transported non-emergent. He coded and died as they moved him off the cot at the local bandaid hospital. How did I know this–experience. On scene experience that could never be replaced by someone on the phone. I still LOVE a hot ripping call, but I don’t forget that this job is about helping people. Unfortunately in the rural south that is often poor uneducated people who still deserve my help even when it’s not emergent. Back to our system is broken and we pay the price–what I’m being paid is criminal. I work 100+ hours a week to pay the bills. The bottom line for me is I take a deep breath, get over myself and say how can I help this human being–often it’s social work. If I ever lose my ability to have compassion and empathy for the unfortunate souls I encounter I need to find that
    Wal-Mart greeter job. Triage is for mass caualty not the sick lonely old lady whose d-mn cats got tangled in her home O2 again. Be grateful you have a job in this economy and it’s not boring as crap stuck on an assembly line or trapped in an office. Do any of you honestly want dispatchers triaging your family members over the phone?

    1. Absolutely I want dispatchers triaging my family members, they already do. What I want them to do is triage based on the resources available and send the appropriate response to my home, based on that triage. If the patient tells the truth (I know they don’t always) we can put them in the right place in line. What was the chief complaint of that late night transport? Likely an emergent complaint. If my mother calsl in with a sore elbow, please do not send an ambulance. If she demands one, tell her one will be sent after all the emergencies are handled. If she lies to get a quicker response, let the crews on scene document it and re-triage her on site.
      It may take a year or two, but they will stop calling when we stop taking them at the drop of a hat. Keep up the good work and keep those medics honest!

    2. I trust the Dispatchers in my 9-1-1 Centre to triage and dispatch the correct resources to any of my family emergencies.

  16. carolinagrl–I dig your compassion for the people. Thinking of them as folks who need help is one of the ways this RN does not blow up the Press-Gaineys. However, there’s a point where the people have to have some responsibility not just for their health, but for the services they use and the money/resources those services cost. Assuring health care for everyone, and detaching the responsibility for the cost/use of resources, is a sure ticket for abuse. Also, the patient is not always right. If you accept the idea that everything the patient does is righteous, and never allow yourself a little slack for being annoyed, you can become a very angry person.

    The Europe model, which HM and his British bud have also discussed, has the advantage of putting experienced eyeballs on the patient and making the call about what the patient needs. That’s quite a bit different from trying to judge it on the phone, even for a dispatcher who is paramedic trained. That would be the best way.

  17. Respiratory distress–but he’s not wheezing he’s fine—OMG. It shook the kid up which is good. This idea may work in some systems but not where I’m located. Extremely poor rural area with only a few trucks and they aren’t all ALS. We don’t even have first responders. I don’t know what the answer is but I try to keep it simple at the level I’m working. I’ve had people climb out of the back of the truck and thank me for the ride more than once. It sucks. Again I signed up for this and they’re job security. A job I truly love even on the worst day.

  18. This entire debate highlights the larger issue, which is a broken healthcare system. The comments from Germany sound progressive and amazing. Dare to dream huh? Until this country has healthcare that is accessible to everyone we will continue giving taxi rides to the ER. I've been in this business for 9 years and the majority of our calls are bs rides to the hospital. We aren't even allowed to refuse transport on scene. Having said that I absolutely wouldn't trust the dispatchers in my area to triage calls. Does anyone out there remember scene size-up? Remember that, in your basic class? Just last week I was on an intermediate truck and the 22 year old paramedic on the second truck in tried to push a late night transport off on me–I refused. When I got back in the truck I told my partner the man would code on the way–they transported non-emergent. He coded and died as they moved him off the cot at the local bandaid hospital. How did I know this–experience. On scene experience that could never be replaced by someone on the phone. I still LOVE a hot ripping call, but I don't forget that this job is about helping people. Unfortunately in the rural south that is often poor uneducated people who still deserve my help even when it's not emergent. Back to our system is broken and we pay the price–what I'm being paid is criminal. I work 100+ hours a week to pay the bills. The bottom line for me is I take a deep breath, get over myself and say how can I help this human being–often it's social work. If I ever lose my ability to have compassion and empathy for the unfortunate souls I encounter I need to find that
    Wal-Mart greeter job. Triage is for mass caualty not the sick lonely old lady whose d-mn cats got tangled in her home O2 again. Be grateful you have a job in this economy and it's not boring as crap stuck on an assembly line or trapped in an office. Do any of you honestly want dispatchers triaging your family members over the phone?

  19. Absolutely I want dispatchers triaging my family members, they already do. What I want them to do is triage based on the resources available and send the appropriate response to my home, based on that triage. If the patient tells the truth (I know they don't always) we can put them in the right place in line. What was the chief complaint of that late night transport? Likely an emergent complaint. If my mother calsl in with a sore elbow, please do not send an ambulance. If she demands one, tell her one will be sent after all the emergencies are handled. If she lies to get a quicker response, let the crews on scene document it and re-triage her on site.
    It may take a year or two, but they will stop calling when we stop taking them at the drop of a hat. Keep up the good work and keep those medics honest!

  20. Carolinagrl brings up an excellent point. The distances, less trained personnel (both in number and training level), resources spread further apart, and lower call volume of the rural area present a totally different problem from the congested metropolitan area. I don’t think a one size fits all would solution work. What works in Cleveland might not work in Carolina.;-) We need to be open to all kinds of ideas regarding encouraging proper use of precious EMS resources.

  21. carolinagrl–I dig your compassion for the people. Thinking of them as folks who need help is one of the ways this RN does not blow up the Press-Gaineys. However, there's a point where the people have to have some responsibility not just for their health, but for the services they use and the money/resources those services cost. Assuring health care for everyone, and detaching the responsibility for the cost/use of resources, is a sure ticket for abuse. Also, the patient is not always right. If you accept the idea that everything the patient does is righteous, and never allow yourself a little slack for being annoyed, you can become a very angry person.

    The Europe model, which HM and his British bud have also discussed, has the advantage of putting experienced eyeballs on the patient and making the call about what the patient needs. That's quite a bit different from trying to judge it on the phone, even for a dispatcher who is paramedic trained. That would be the best way.

  22. Respiratory distress–but he's not wheezing he's fine—OMG. It shook the kid up which is good. This idea may work in some systems but not where I'm located. Extremely poor rural area with only a few trucks and they aren't all ALS. We don't even have first responders. I don't know what the answer is but I try to keep it simple at the level I'm working. I've had people climb out of the back of the truck and thank me for the ride more than once. It sucks. Again I signed up for this and they're job security. A job I truly love even on the worst day.

  23. Carolinagrl brings up an excellent point. The distances, less trained personnel (both in number and training level), resources spread further apart, and lower call volume of the rural area present a totally different problem from the congested metropolitan area. I don't think a one size fits all would solution work. What works in Cleveland might not work in Carolina.;-) We need to be open to all kinds of ideas regarding encouraging proper use of precious EMS resources.

  24. I dunno. I work in a rural, underserved, poverty-stricken area, and we see abuse of the system day and night. If anything, keeping rural EMS units in service where one truck covers 96 square miles and is 25 miles from the nearest ER is more important than an urban ghetto where abuse is high but there are five or six hospitals within 15 minutes, and at least one is a trauma center.

    I respectfully disagree with the “job security” line. I’ve heard that a number of times, and I do not agree that allowing (and perhaps unknowingly encouraging) abuse helps any of us. Money is tight, and many public safety workers are under attack right now for their modest salaries and their still-intact retirement plans. We are seeing layoffs of police and fire in our area due to no money. So far, EMS has not been affected, but we have been threatened.

    As our call volume increases, we aren’t getting more trucks and paramedics, we’re being forced to do more with the same money or with less. I’m not asking for a huge decrease in calls (and I don’t think we’ll see that anyway) but we should be active in trying to curb the abuse and at least stay where we are. I’m still a firm believer that spotlighting the abuses of EMS and creating a positive public education campaign would make inroads into some of the problems we face now.

    Great discussion. I am watching the Cleveland EMS proposal closely. This will be interesting to follow.

  25. While I completely understand your perspective, although not necessarily in full agreement with it, I would like to specify a particular section of your post:

    The issue of liability for reducing immediate response is countered by the liability of explaining to the family of a deceased person that their ambulance was delayed because of system abusers. We call it triage. No one thinks twice about ignoring minor injuries in an MCI, why is it suddenly an issue when that decision is moved into the control center? If we let the call taker take the calls and the triage system deems it non-emergent, then let it be non-emergent.

    MCI triage and over the phone triage are vastly different things. When you are at an MCI, you are triaging the actual patient that you can look at, touch, and speak with versus over the phone triage where in my experience you are talking to the actual patient only approximately 30-50% of the time. I think that makes a really big difference when attempting to triage a call.

    We need to stop worrying about what might be and focus on what is.

    I completely agree with this although from a different perspective. I have tried to stress this to a number of dispatchers who would hold units “just in case”, and when “just in case” never happened it only created a bigger backlog. I think simply placing low priority calls on hold is a mistake that will see unintended consequences of elongated wait times and the potential for a critical backlog that may very well be blamed for a lost life, whether justified or not. If you have the resources, I say use them for what they are intended for.

  26. I dunno. I work in a rural, underserved, poverty-stricken area, and we see abuse of the system day and night. If anything, keeping rural EMS units in service where one truck covers 96 square miles and is 25 miles from the nearest ER is more important than an urban ghetto where abuse is high but there are five or six hospitals within 15 minutes, and at least one is a trauma center.

    I respectfully disagree with the “job security” line. I've heard that a number of times, and I do not agree that allowing (and perhaps unknowingly encouraging) abuse helps any of us. Money is tight, and many public safety workers are under attack right now for their modest salaries and their still-intact retirement plans. We are seeing layoffs of police and fire in our area due to no money. So far, EMS has not been affected, but we have been threatened.

    As our call volume increases, we aren't getting more trucks and paramedics, we're being forced to do more with the same money or with less. I'm not asking for a huge decrease in calls (and I don't think we'll see that anyway) but we should be active in trying to curb the abuse and at least stay where we are. I'm still a firm believer that spotlighting the abuses of EMS and creating a positive public education campaign would make inroads into some of the problems we face now.

    Great discussion. I am watching the Cleveland EMS proposal closely. This will be interesting to follow.

  27. Dallas tried this, or at least a similar system- triage via RN.

    Somebody died, and now they don’t do it anymore.

    Let me know when to start the stopwatch on Cleveland.

    (Not saying I hope it fails spectacularly. I just think it will.

  28. It sounds lovely, Mathias. Unfortunately, in the US the “24h open doctor's practice” is the Emergency Room, and medics are the home visit.

  29. No hand-wringing here. It’s so phrigid that phrozen phalanges would phlutter to the phosty ground if had-wringing were even attempted.

    Although I have strong feelings on this issue, methinks it best to withhold my views and remain open-minded whilst you attempt to obtain further information. I look forward to your follow up with the Commissioner!

    Right now I have to find a warm place for my tootsies.

  30. While I completely understand your perspective, although not necessarily in full agreement with it, I would like to specify a particular section of your post:

    The issue of liability for reducing immediate response is countered by the liability of explaining to the family of a deceased person that their ambulance was delayed because of system abusers. We call it triage. No one thinks twice about ignoring minor injuries in an MCI, why is it suddenly an issue when that decision is moved into the control center? If we let the call taker take the calls and the triage system deems it non-emergent, then let it be non-emergent.

    MCI triage and over the phone triage are vastly different things. When you are at an MCI, you are triaging the actual patient that you can look at, touch, and speak with versus over the phone triage where in my experience you are talking to the actual patient only approximately 30-50% of the time. I think that makes a really big difference when attempting to triage a call.

    We need to stop worrying about what might be and focus on what is.

    I completely agree with this although from a different perspective. I have tried to stress this to a number of dispatchers who would hold units “just in case”, and when “just in case” never happened it only created a bigger backlog. I think simply placing low priority calls on hold is a mistake that will see unintended consequences of elongated wait times and the potential for a critical backlog that may very well be blamed for a lost life, whether justified or not. If you have the resources, I say use them for what they are intended for.

  31. Dallas tried this, or at least a similar system- triage via RN.

    Somebody died, and now they don't do it anymore.

    Let me know when to start the stopwatch on Cleveland.

    (Not saying I hope it fails spectacularly. I just think it will.

  32. Just walked back in from a working full arrest–dispatch said he was moving and talking right as we pulled up. NOT! I rest my case. Seriously educating the public is absolutely needed. Part of what I try to do when the opportunity comes up; and I go out of my way on my on time to do this. I firmly believe I’m an advocate for my patient especially when they don’t have the ability to do it. If I can spend the little extra time to get social services or the family of an old person involved in their care maybe they don’t need to call again, at least not non-emergent. I agree with we have to better utilize our resources but the reality for me is that little old man who just died. I guess dispatch would have left him holding. I could make myself crazy with the larger issues that I can’t fix. I show up and do the best I can for those who need me and that includes the people who seem to not really “need” an ambulance.

  33. No hand-wringing here. It's so phrigid that phrozen phalanges would phlutter to the phosty ground if had-wringing were even attempted.

    Although I have strong feelings on this issue, methinks it best to withhold my views and remain open-minded whilst you attempt to obtain further information. I look forward to your follow up with the Commissioner!

    Right now I have to find a warm place for my tootsies.

  34. Ok, I have a few questions …

    — How many Dispatcher does Cleveland plan to have on duty every day to handle calling back their pending Bravo, Alpha and Omega calls every 10 minutes? [I can tell you from personal experience that in my centre there is no way we would be able to call those pending calls back every 10 minuets – we are just too busy during the day.]
    — How long on average do their ambulance spend in hospital once they arrive at the hospital?
    — The article states Cleveland is decreasing their resources from 18 to 15 units. Will those 15 units be all ALS, or a combination of BLS and ALS units? Also, are those 15 units staffed 24/7 or is that 15 unit at the peak of the day? Will there be any peak unit coming on duty throughout the day to compliment and assist those 15 units?

    That is all I have for now …. I may have more.

    I like the basic idea of not dispatching lower priority calls when the city is busy. I would like to know more before I make my final decision.

  35. Just walked back in from a working full arrest–dispatch said he was moving and talking right as we pulled up. NOT! I rest my case. Seriously educating the public is absolutely needed. Part of what I try to do when the opportunity comes up; and I go out of my way on my on time to do this. I firmly believe I'm an advocate for my patient especially when they don't have the ability to do it. If I can spend the little extra time to get social services or the family of an old person involved in their care maybe they don't need to call again, at least not non-emergent. I agree with we have to better utilize our resources but the reality for me is that little old man who just died. I guess dispatch would have left him holding. I could make myself crazy with the larger issues that I can't fix. I show up and do the best I can for those who need me and that includes the people who seem to not really “need” an ambulance.

  36. I think thats great… i wish we would do that out here… lots of BS calls, it will be level 1 and we will go on a code 2 for some BS drunk or a sore throat and then a critical call will come down and there will be no units available.

  37. ** I have a wonderful response to this, but then my computer crashed, so; I am trying again. **

    I am just a lonely 9-1-1 Dispatcher here, but I have a strong voice.

    As Happy mentioned before 9-1-1 dispatcher are mandated to get the calls in the CAD within a certain time frame – every centre in different. In my centre I have 30 seconds to get a fire/medical call put into CAD in a per-alert status for Dispatch uses to dispatch the crews. In that 30 seconds I need to get a verifiable address, phone number, and chief complaint while still talking to the caller in a friendly, compassionate, and controlling manner.

    Every time a call comes into a 9-1-1 centre the goal is to correctly triage the call based on what the caller has told us; sometimes the callers lie to use, but we have to assume the caller is giving us the correct information and not trying to abuse the system. I know there is abuse of the 9-1-1 system, and especially EMS.

    Sometimes there are errors made when we are triaging the call for help, but with the correct training hopefully we are able to minimize those errors. The medical cards are designed so that non-medically trained personal are able to triage a call correctly – the cards use terms that anyone can understand.

    Every centre is different, some centre use medically trained personal while other use non-medically trained to triage the calls. My centre uses primarily non-medically trained personal to triage calls, and we do this for many reason but because years ago we found that the medically trained personal were trying to diagnose the patient while on the phone with them . Now, I have been on the phone with the person who is calling about chest pain, who is alert, breathing normally, no cardiac hx, and no medication used in 12 hrs and triaged the call correctly, and while the medics were responding to the call the caller has gone into cardiac arrest. No one has control of what happens once the phone is hung up, so there is no one to blame.

    I won’t comment on the 9-1-1 Dispatchers who may have abandoned their posts, because I don’t know all the facts. However they may lose their jobs, and be prosecuted to the full extent of the law.

  38. I think many of us are encouraged by the possibilities here, but Cleveland will have to do this right the first time or it will set the entire concept back for years. Especially now this it is here on the blog (which has become pretty high profile), I am sure a lot of other outlets will be picking it up (or already have), and a lot of eyes will be on Cleveland. After reading through these comments, it is clear that they will need adequate and well-trained personnel doing triage, and have a well-designed triage process. Too few people and/or a clunky procedure will spell doom. I hope for the best, but fear a crash and burn. Please do this right, Cleveland.

  39. I trust the Dispatchers in my 9-1-1 Centre to triage and dispatch the correct resources to any of my family emergencies.

  40. Ok, I have a few questions …

    — How many Dispatcher does Cleveland plan to have on duty every day to handle calling back their pending Bravo, Alpha and Omega calls every 10 minutes? [I can tell you from personal experience that in my centre there is no way we would be able to call those pending calls back every 10 minuets – we are just too busy during the day.]
    — How long on average do their ambulance spend in hospital once they arrive at the hospital?
    — The article states Cleveland is decreasing their resources from 18 to 15 units. Will those 15 units be all ALS, or a combination of BLS and ALS units? Also, are those 15 units staffed 24/7 or is that 15 unit at the peak of the day? Will there be any peak unit coming on duty throughout the day to compliment and assist those 15 units?

    That is all I have for now …. I may have more.

    I like the basic idea of not dispatching lower priority calls when the city is busy. I would like to know more before I make my final decision.

  41. Does Cleveland deploy ALS fire engines as well as ambulances and if so, will they get dispatched right away or will they wait too?

  42. I think thats great… i wish we would do that out here… lots of BS calls, it will be level 1 and we will go on a code 2 for some BS drunk or a sore throat and then a critical call will come down and there will be no units available.

  43. I think many of us are encouraged by the possibilities here, but Cleveland will have to do this right the first time or it will set the entire concept back for years. Especially now this it is here on the blog (which has become pretty high profile), I am sure a lot of other outlets will be picking it up (or already have), and a lot of eyes will be on Cleveland. After reading through these comments, it is clear that they will need adequate and well-trained personnel doing triage, and have a well-designed triage process. Too few people and/or a clunky procedure will spell doom. I hope for the best, but fear a crash and burn. Please do this right, Cleveland.

  44. Does Cleveland deploy ALS fire engines as well as ambulances and if so, will they get dispatched right away or will they wait too?

  45. whiskey108’s comments were apparently precursor to this:

    Cleveland Police And Firefighters Laid Off
    More than 100 Cleveland firefighters, patrolmen and EMS workers are on the unemployment line after layoffs took effect Monday.

    http://www.fox8.com/news/wjw-layoffs-txt,0,1562158.story

    This is a very bad circumstance under which to implement dispatch-level triage and expect success, as it indeed seems that it is being implemented for the wrong reasons, to compensate for a resource shortage instead of establishing intelligent resource management for the betterment of the taxpayers. Ugh.

  46. whiskey108's comments were apparently precursor to this:

    Cleveland Police And Firefighters Laid Off
    More than 100 Cleveland firefighters, patrolmen and EMS workers are on the unemployment line after layoffs took effect Monday.

    http://www.fox8.com/news/wjw-layoffs-txt,0,1562

    This is a very bad circumstance under which to implement dispatch-level triage and expect success, as it indeed seems that it is being implemented for the wrong reasons, to compensate for a resource shortage instead of establishing intelligent resource management for the betterment of the taxpayers. Ugh.

  47. Hallelujah!! Finally, a system attempting to bring some common sense back into a field that largely waved bye bye to THAT concept decades ago!!

    “We need to stop worrying about what might be and focus on what is.”

    Perfect! Couldn’t have said it better myself!

  48. Wow that’s scary. What are they thinking? To clarify on my rant from last night; I have a lot of respect for the job dispatch does. I spent 8 LONG hours in dispatch a few months ago when I took this job. Not for me! I realize they, for the most part, do the best they can with what they get. Still there is just no way they can truly assess a scene from the phone. I have seen people prosecuted for ems abuse in another county but it’s not an option here. The guy I’ve taken twice in the past week (our worst) has restraining orders against him at the hospitals in the area–anybody beat that? They still force us to transport him– now to an ER a hour away. It’s ridiculous but there is nothing I can do. So instead of getting p-ssed at my boss or the system, I try to focus on the patient. He’s mental and if he had stayed at home this week he might have died from hypothermia, dehydration, or starvation. It’s all relative and patients like him remind me to be very grateful for the life I have.

    1. “It’s ridiculous but there is nothing I can do.” There is everything you can do. From referrals at the ER to reporting suspected abuse to using the system to your advantage. Who calls you for this person? What is their chief complaint? Is there a resource in the community you can call to help him? A church group, non-profit, perhaps a municipal agency that can send someone by to check on him? Adult Protective Services should always be notified in cases where a person is unable to care for themselves. It is not he job of emergency services to shuttle the mentally ill from home to hospital whenever they skip off their meds or refuse to medicate all together. It is our job to assess and treat appropriately, then transport if additional care is indicated. If he does not fit into your treatment protocols (which are likely diagnosis based) then why are you taking him 1 hour to an ER. If he has a condition which warrants ambulance transport to a hospital, he goes to the nearest appropriate facility.
      I am not in your system so I make general observations from my own rural experiences of being an hour from the nearest ER so abusers with 3 hour round trip times were standard.

      But don’t feel like the system is against you, you ARE the system. If you stand up for your patient by getting him the treatment or support he needs, instead of an automatic transport, he gets healthier and doesn’t call anymore. Problem solved. It really is that easy.
      In SF we had a person who specialized in Social Care who wandered the City looking for our regular 911 abusers and when we found them he came and put them into the system. It worked so well the folks who make money on all the homeless in SF got him shut down. now all our regulars are back on the streets and calling us day in and day out.
      Watch for the premiere of Chronicles of EMS where one of our regulars gave permission to talk on camera about how she abuses 911 using our code words to get her ride across town coded as an ALS 6D3. In Cleveland she would still get a response, but we need to stand up and find solutions to our respective problems.

      Remember, you ARE the system. We have the power to change things, and we will. Thanks for reading.

  49. Hallelujah!! Finally, a system attempting to bring some common sense back into a field that largely waved bye bye to THAT concept decades ago!!

    “We need to stop worrying about what might be and focus on what is.”

    Perfect! Couldn't have said it better myself!

  50. Wow that's scary. What are they thinking? To clarify on my rant from last night; I have a lot of respect for the job dispatch does. I spent 8 LONG hours in dispatch a few months ago when I took this job. Not for me! I realize they, for the most part, do the best they can with what they get. Still there is just no way they can truly assess a scene from the phone. I have seen people prosecuted for ems abuse in another county but it's not an option here. The guy I've taken twice in the past week (our worst) has restraining orders against him at the hospitals in the area–anybody beat that? They still force us to transport him– now to an ER a hour away. It's ridiculous but there is nothing I can do. So instead of getting p-ssed at my boss or the system, I try to focus on the patient. He's mental and if he had stayed at home this week he might have died from hypothermia, dehydration, or starvation. It's all relative and patients like him remind me to be very grateful for the life I have.

  51. “It's ridiculous but there is nothing I can do.” There is everything you can do. From referrals at the ER to reporting suspected abuse to using the system to your advantage. Who calls you for this person? What is their chief complaint? Is there a resource in the community you can call to help him? A church group, non-profit, perhaps a municipal agency that can send someone by to check on him? Adult Protective Services should always be notified in cases where a person is unable to care for themselves. It is not he job of emergency services to shuttle the mentally ill from home to hospital whenever they skip off their meds or refuse to medicate all together. It is our job to assess and treat appropriately, then transport if additional care is indicated. If he does not fit into your treatment protocols (which are likely diagnosis based) then why are you taking him 1 hour to an ER. If he has a condition which warrants ambulance transport to a hospital, he goes to the nearest appropriate facility.
    I am not in your system so I make general observations from my own rural experiences of being an hour from the nearest ER so abusers with 3 hour round trip times were standard.

    But don't feel like the system is against you, you ARE the system. If you stand up for your patient by getting him the treatment or support he needs, instead of an automatic transport, he gets healthier and doesn't call anymore. Problem solved. It really is that easy.
    In SF we had a person who specialized in Social Care who wandered the City looking for our regular 911 abusers and when we found them he came and put them into the system. It worked so well the folks who make money on all the homeless in SF got him shut down. now all our regulars are back on the streets and calling us day in and day out.
    Watch for the premiere of Chronicles of EMS where one of our regulars gave permission to talk on camera about how she abuses 911 using our code words to get her ride across town coded as an ALS 6D3. In Cleveland she would still get a response, but we need to stand up and find solutions to our respective problems.

    Remember, you ARE the system. We have the power to change things, and we will. Thanks for reading.

  52. Please believe those are exactly the questions I asked. The answers I got last night were he’s been doing this for years, people have tried to help him, he’s not that crazy, blah blah blah. The individual I was speaking with said my job wouuld be in jeapardy if I ever tried to refuse anyone. Also threatened another guys job because we only took him half an hour away. Nice huh? I’ve gotten myself into trouble repeatedly over the years standing up for patients and trying to get them help. Nursing homes make me lose my mind, several years in transport work makes me pray I drop dead one day. There’s probably more to the story with this policy of taking absolutely everyone no questions asked. I haven’t been here long enough to hear all of it yet. Instead of respecting our abilities and transport decisions they have FTO’s call back no transports the next day to try and catch us trying to turn them away. I’m pretty sure I would get fired for that. For that matter I’ll probably get canned if they spot this blog. Like I said before life for a female EMT-I in the rural south is an exercise in CYA and frustration. I have to stay focused on doing what I can to help the individuals I encounter and try to let the rest of the b-llsh-t go. That social care person sounds like an excellent idea, kind of what I try to do when I get the chance. It makes way to much sense though huh? LOL. I would kill to be working in a place with progressive anything. It would be nice to have support and training instead of backstabbing and constant job fear. Oh well enough whining. Kind of down about a guy we lost last night. It was a cluster–huge cluster. First one I’ve worked with this county and WTF was my major reaction. I’ll definetly be tuning in to Chronicles. It lets me know there’s hope out there.

    1. Hey grl, sounds like a tough spot to be in. But while profit is the goal of EMS we can never really give people what they need, the truth. Sounds as though your company is using resources to try to nail you in a gray area instead of helping your with your situations. not a new scenario in the slightest.
      Hope is out there, believe me. Things will always seem to get better right before a new policy comes down the pipeline to ruin your day. That’s just the way it is.
      From what you have written on this message board, there is nothing they could fire you for, we don’t know where you are, who you are or what days you worked, aside from your last comment about a “cluster” “last night.’ Don’t let them frighten you. Carry a copy of the HIPAA rules with you and if they press you, ask them to show you where in the laws you are wrong.
      Supervisors HATE it when you also ask them specifics about protocols. Learn yours backwards and forwards, then follow them. If you do what is right, you’ll never be wrong.
      nothing in the laws says you can’t get your patient help outside of the EMS system.

      Hang in there.

  53. Please believe those are exactly the questions I asked. The answers I got last night were he's been doing this for years, people have tried to help him, he's not that crazy, blah blah blah. The individual I was speaking with said my job wouuld be in jeapardy if I ever tried to refuse anyone. Also threatened another guys job because we only took him half an hour away. Nice huh? I've gotten myself into trouble repeatedly over the years standing up for patients and trying to get them help. Nursing homes make me lose my mind, several years in transport work makes me pray I drop dead one day. There's probably more to the story with this policy of taking absolutely everyone no questions asked. I haven't been here long enough to hear all of it yet. Instead of respecting our abilities and transport decisions they have FTO's call back no transports the next day to try and catch us trying to turn them away. I'm pretty sure I would get fired for that. For that matter I'll probably get canned if they spot this blog. Like I said before life for a female EMT-I in the rural south is an exercise in CYA and frustration. I have to stay focused on doing what I can to help the individuals I encounter and try to let the rest of the b-llsh-t go. That social care person sounds like an excellent idea, kind of what I try to do when I get the chance. It makes way to much sense though huh? LOL. I would kill to be working in a place with progressive anything. It would be nice to have support and training instead of backstabbing and constant job fear. Oh well enough whining. Kind of down about a guy we lost last night. It was a cluster–huge cluster. First one I've worked with this county and WTF was my major reaction. I'll definetly be tuning in to Chronicles. It lets me know there's hope out there.

  54. Hey grl, sounds like a tough spot to be in. But while profit is the goal of EMS we can never really give people what they need, the truth. Sounds as though your company is using resources to try to nail you in a gray area instead of helping your with your situations. not a new scenario in the slightest.
    Hope is out there, believe me. Things will always seem to get better right before a new policy comes down the pipeline to ruin your day. That's just the way it is.
    From what you have written on this message board, there is nothing they could fire you for, we don't know where you are, who you are or what days you worked, aside from your last comment about a “cluster” “last night.' Don't let them frighten you. Carry a copy of the HIPAA rules with you and if they press you, ask them to show you where in the laws you are wrong.
    Supervisors HATE it when you also ask them specifics about protocols. Learn yours backwards and forwards, then follow them. If you do what is right, you'll never be wrong.
    nothing in the laws says you can't get your patient help outside of the EMS system.

    Hang in there.

  55. I can’t believe anyone with any time in EMS would not applaud this. My rural dept runs around 3,000 calls a year. I’d guess 2,000 are total BS I need a ride calls. You cannot “educate” the majority of the people calling 911, as #1 they could care less. They want a ride. Could this lead to problems? Sure! Anything you do could have a negative consequence associated with it. Now if we could get the government to place and enforce welfare co pays, I’d think about staying in EMS. Great site glad I found it.

  56. I can't believe anyone with any time in EMS would not applaud this. My rural dept runs around 3,000 calls a year. I'd guess 2,000 are total BS I need a ride calls. You cannot “educate” the majority of the people calling 911, as #1 they could care less. They want a ride. Could this lead to problems? Sure! Anything you do could have a negative consequence associated with it. Now if we could get the government to place and enforce welfare co pays, I'd think about staying in EMS. Great site glad I found it.

  57. How much of this is budget/personnel cuts or to the bad publicity the EMS commissioner got from the city on how much EMS resources are wasted on bogus calls. Now just two years ago the press did a story on Cleveland could not get enough quality EMS folks. The press ran a few stories on EMS abuse, especially in Cleveland, like this award winning journalistic video: http://www.youtube.com/watch?v=tVrGEJCPZVw

  58. How much of this is budget/personnel cuts or to the bad publicity the EMS commissioner got from the city on how much EMS resources are wasted on bogus calls. Now just two years ago the press did a story on Cleveland could not get enough quality EMS folks. The press ran a few stories on EMS abuse, especially in Cleveland, like this award winning journalistic video: http://www.youtube.com/watch?v=tVrGEJCPZVw

  59. This is very true. As a firefighter paramedic, I know how common it is to arrive at a scene and have it have absolutely nothing in common with what we were dispatched out to. I wish it were only occasional that we were sent to the wrong address or wrong suite number. As a citizen I witnessed a car wreck and called it in to 9-1-1. The driver went head on with a car that was turning with a green arrow and was altered. The dispatcher heard him yelling in the back ground that he was fine and asked if that was the patient. I said yes and she told me since he was denying injury she wasn't sending anyone. You know what? She didn't send anyone. A passing by fire engine from a neighboring community stopped to help and had the guy transported to the local hospital. As they were getting ready to leave a community aide, not even a police officer came by in response to my call. Over 30 minutes had passed since I made the call. People no matter how smart and trained can not make decisions on triage and patient priority without SEEING the patient. That is just common sense. I do not think this will go well for Cleveland. A better way must be sought. I remember reading years back of fast response units being used in major cities in Australia. Medics on motorcycles that could maneuver through gridlock faster then ambulances to stabilize the seriously injured or cancel the ambulance if it was not needed. This may be a better idea.

  60. This is very true. As a firefighter paramedic, I know how common it is to arrive at a scene and have it have absolutely nothing in common with what we were dispatched out to. I wish it were only occasional that we were sent to the wrong address or wrong suite number. As a citizen I witnessed a car wreck and called it in to 9-1-1. The driver went head on with a car that was turning with a green arrow and was altered. The dispatcher heard him yelling in the back ground that he was fine and asked if that was the patient. I said yes and she told me since he was denying injury she wasn't sending anyone. You know what? She didn't send anyone. A passing by fire engine from a neighboring community stopped to help and had the guy transported to the local hospital. As they were getting ready to leave a community aide, not even a police officer came by in response to my call. Over 30 minutes had passed since I made the call. People no matter how smart and trained can not make decisions on triage and patient priority without SEEING the patient. That is just common sense. I do not think this will go well for Cleveland. A better way must be sought. I remember reading years back of fast response units being used in major cities in Australia. Medics on motorcycles that could maneuver through gridlock faster then ambulances to stabilize the seriously injured or cancel the ambulance if it was not needed. This may be a better idea.

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