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I think it might be helpful as we are discussing this to be able to explain how the current 911 system works. As it exists now, calling 911 for an ambulance se

by ctenev 11y ago

I think it might be helpful as we are discussing this to be able to explain how the current 911 system works. As it exists now, calling 911 for an ambulance sets off a chain of 9 human-to-human information transfers and averages over an hour for you to get to the hospital and be treated by a doctor. Many articles and research papers are out there showing the inefficiencies of the current system. Current 911 system STEP 1: You call 911 STEP 2: Cellular service carrier connects you to an operator (4.5% busy signal rate) STEP 3: Operator with no medical background takes your basic information and location STEP 4: Operator types that info into a processing/relay system STEP 5: EMS Dispatcher reads the relayed info STEP 6: EMS Dispatcher radios paramedics to go to scene [Steps 1-6: average of 3.9 mins] STEP 7: Paramedics type address into dashboard GPS system STEP 8: Paramedics drive to scene [Step 7-8: average of 9 mins] STEP 9: Paramedics treat, stabilize, and package you STEP 10: If advanced procedure or medication is needed, paramedic must call a designated physician in a local emergency department to gain approval. STEP 11: Nurse or other employee answers phone and then finds a physician who is concurrently taking care of other patients in the ER STEP 12: ER doctor hears your case from the paramedics STEP 13: ER doctor approves advanced procedures or asks for clarifying information [Step 9-13: average of 14.9 mins] STEP 14: Paramedic transfers you to the hospital STEP 15: Paramedics drop you off at an ER (may not be the same ER who approved the advanced procedure) [Step 14-15: average 12.2 mins] STEP 16a (CRITICAL): In critical situation, paramedic with 2 years of training and no access to your medical records tells what they know about your case to an ER physician STEP 16b (URGENT/EMERGENT): In noncritical situation, paramedic tells the ER triage nurse about your case STEP 17: ER triage nurse tells the treating nurse assigned to you about your case STEP 18: Treating nurse tells an MD about your case STEP 19: You wait for an MD [Step 15-19: average 24 mins] STEP 20: An MD finally sees you As physicians who worked in the emergency departments of the world’s leading medical institutions we were able to see first hand the inefficiencies of the current emergency care system leading to poor patient outcomes and avoidable costs. TLDR - 1) 911 is an outdated system in many ways 2) there is room for improvement.

FireBeyond 11y ago
This is an overly 'exaggerated' flowchart. Whilst there are many flaws with the 911 system, there are also several fallacies (though not universal): STEP 2: <1% busy signal is a goal of and attained by a large number of PSAPs. 3: Many PSAPs have their dispatchers trained to the EMT level. 4 through 6 are happening concurrently, not as a single step flow. 6: Many PSAPs have a goal that the initial unit dispatch is within 60 seconds of call reception. 7: I've not seen a system yet that relies on ALS units punching an address manually into a TomTom. AVLS (automatic vehicle location system), and mobile data terminals pull the exact information that is entered into 911 (which whilst still prone to error, is an issue with Call9, too) and use GPS which is linked into maps + county GIS overlays. 8: Highly dependent on location. My county has an average 6min response time. 10: Most advanced procedures and medications are governed by offline medical control ("here's our protocol for using this drug / treatment. Indications, contraindications, dosing regime") - the goal is that the need to contact a physician is the exception, not the rule. If the time taken for 'online medical control' is 14.9 minutes I'll be at the hospital already, because that's where definitive care happens. I, as a medic, am not going to wait on hold and have a leisurely chat with a physician for nearly quarter of an hour on scene. This is a gross distortion of reality. If I do need to call the ER doc, there will be one available, or the charge nurse will know that one needs to be found, now. 16a: at an SNF if we need access to medical records, we can get them. If a patient uses the same healthcare system, they're available at the hospital. Pretending like we're stabbing in the dark and shrugging our shoulders is devaluing the care that paramedics and EMTs do down to the 'ambulance driver' stereotype. Both are trained in patient assessment and history taking, even if not medically qualified to the same level as a physician. In 16b: In a non-critical situation AND there are insufficient resources, then triage is the most appropriate care situation. If you're non-emergent and there's capacity in the ED you're going to a bed. 17/18: As opposed to... what? Unless Call9 claims to be the sole definitive (and remote) care provided, there's going to be a transfer of knowledge. Your example has it taking a quarter of an hour to get to the patient, an undefined amount of time treating, stabilizing and packaging the patient, supposedly before requiring an online sign-off and discussion with a physician lasting another quarter of an hour before finally loading the patient for another nearly quarter hour trip to the hospital, while some paramedic with no situational awareness gives a nurse a hand off to relay to the physician. What really happens on scene in a cardiac arrest: BLS providers show up first, AED, CPR, bag patient, potentially with advanced airway, LMA, etc. ALS shows up, determines quickly whether to stabilize on scene or load-and-go, CPR still in progress. A call is made to the hospital, with no discussion with a physician, only the charge, giving pertinent information, and ETA. "Code Blue, Ambulance, Bed A3, 4 minutes out." RT, IV, pharmacy, imaging, are all ready. A team is ready to continue CPR. Physician is there. All staff with the exception of the physician move patient from gurney to bed, begin work, while physician gets information from ALS, and then begins directing the code.
- tpeck 11y ago
  You seem to know your stuff and work in a great system. . There's a lot here in these comments, and I'll do my best to sum up my thoughts succinctly: We've done A LOT of user research including days of time on the back of ambulances, days of sitting in nursing homes and watching how a typical 911 call (not a Call9 call) works, countless conversations and late nights with world-leading experts in EMS care, and years of being an EM doc on the receiving end. . Paramedics are NOT just ambulance drivers. They are some of the most valuable members of our society (and surely undervalued/underpaid). But THE reason I left my job to pursue Call9 with my team, is because I have felt if only a trained EM doc could have been in the field, than many of my patients with unfortunate outcomes could have decreased morbidity/mortality. With Call9, we can do that, and save patients who are not otherwise being saved.
- nickpsecurity 11y ago
  Even if exaggerated, his flow is closer than yours for our area in terms of delay. The last accident with a family member of mine had very competent ambulance and team get to use within 5-10 minutes. I got to the hospital and registered before they arrived without speeding. There was another long delay before she was in a room with nurses talking to her. Several got the same information. The overall difference between "event is happening" and "a doctor is seeing her" was in the 30min-1hr range. If it was more serious, the consequences of delays might have been more serious. So, you and your team seem to be very competent with no tolerance for BS that endangers those you care for. But be careful not to project what you do onto the whole system. The system varies in efficiency, how much people care, steps in between, and so on. A whole spectrum. An outfit like yours might have less need for this service but I've experienced many that could use it. That doesn't even count the whole "help less competent people in a nursing home assess a potentially, deadly situation" part. I'm totally with them on that.

by ctenev 11y ago

FireBeyond 11y ago

This is an overly 'exaggerated' flowchart. Whilst there are many flaws with the 911 system, there are also several fallacies (though not universal): STEP 2: <1% busy signal is a goal of and attained by a large number of PSAPs. 3: Many PSAPs have their dispatchers trained to the EMT level. 4 through 6 are happening concurrently, not as a single step flow. 6: Many PSAPs have a goal that the initial unit dispatch is within 60 seconds of call reception. 7: I've not seen a system yet that relies on ALS units punching an address manually into a TomTom. AVLS (automatic vehicle location system), and mobile data terminals pull the exact information that is entered into 911 (which whilst still prone to error, is an issue with Call9, too) and use GPS which is linked into maps + county GIS overlays. 8: Highly dependent on location. My county has an average 6min response time. 10: Most advanced procedures and medications are governed by offline medical control ("here's our protocol for using this drug / treatment. Indications, contraindications, dosing regime") - the goal is that the need to contact a physician is the exception, not the rule. If the time taken for 'online medical control' is 14.9 minutes I'll be at the hospital already, because that's where definitive care happens. I, as a medic, am not going to wait on hold and have a leisurely chat with a physician for nearly quarter of an hour on scene. This is a gross distortion of reality. If I do need to call the ER doc, there will be one available, or the charge nurse will know that one needs to be found, now. 16a: at an SNF if we need access to medical records, we can get them. If a patient uses the same healthcare system, they're available at the hospital. Pretending like we're stabbing in the dark and shrugging our shoulders is devaluing the care that paramedics and EMTs do down to the 'ambulance driver' stereotype. Both are trained in patient assessment and history taking, even if not medically qualified to the same level as a physician. In 16b: In a non-critical situation AND there are insufficient resources, then triage is the most appropriate care situation. If you're non-emergent and there's capacity in the ED you're going to a bed. 17/18: As opposed to... what? Unless Call9 claims to be the sole definitive (and remote) care provided, there's going to be a transfer of knowledge. Your example has it taking a quarter of an hour to get to the patient, an undefined amount of time treating, stabilizing and packaging the patient, supposedly before requiring an online sign-off and discussion with a physician lasting another quarter of an hour before finally loading the patient for another nearly quarter hour trip to the hospital, while some paramedic with no situational awareness gives a nurse a hand off to relay to the physician. What really happens on scene in a cardiac arrest: BLS providers show up first, AED, CPR, bag patient, potentially with advanced airway, LMA, etc. ALS shows up, determines quickly whether to stabilize on scene or load-and-go, CPR still in progress. A call is made to the hospital, with no discussion with a physician, only the charge, giving pertinent information, and ETA. "Code Blue, Ambulance, Bed A3, 4 minutes out." RT, IV, pharmacy, imaging, are all ready. A team is ready to continue CPR. Physician is there. All staff with the exception of the physician move patient from gurney to bed, begin work, while physician gets information from ALS, and then begins directing the code.

tpeck 11y ago
You seem to know your stuff and work in a great system. . There's a lot here in these comments, and I'll do my best to sum up my thoughts succinctly: We've done A LOT of user research including days of time on the back of ambulances, days of sitting in nursing homes and watching how a typical 911 call (not a Call9 call) works, countless conversations and late nights with world-leading experts in EMS care, and years of being an EM doc on the receiving end. . Paramedics are NOT just ambulance drivers. They are some of the most valuable members of our society (and surely undervalued/underpaid). But THE reason I left my job to pursue Call9 with my team, is because I have felt if only a trained EM doc could have been in the field, than many of my patients with unfortunate outcomes could have decreased morbidity/mortality. With Call9, we can do that, and save patients who are not otherwise being saved.
nickpsecurity 11y ago
Even if exaggerated, his flow is closer than yours for our area in terms of delay. The last accident with a family member of mine had very competent ambulance and team get to use within 5-10 minutes. I got to the hospital and registered before they arrived without speeding. There was another long delay before she was in a room with nurses talking to her. Several got the same information. The overall difference between "event is happening" and "a doctor is seeing her" was in the 30min-1hr range. If it was more serious, the consequences of delays might have been more serious. So, you and your team seem to be very competent with no tolerance for BS that endangers those you care for. But be careful not to project what you do onto the whole system. The system varies in efficiency, how much people care, steps in between, and so on. A whole spectrum. An outfit like yours might have less need for this service but I've experienced many that could use it. That doesn't even count the whole "help less competent people in a nursing home assess a potentially, deadly situation" part. I'm totally with them on that.