The caller provided his address and urgently detailed that someone had collapsed outside his home. He needed help – now.
Knowing the victim had collapsed triggered a new protocol in Juneau that called for the telecommunicator to expertly assess the situation using a simple three-step script known in the field as “no, no, go” to ask: Is the patient conscious? Is the patient breathing normally? If the answer to both is no, the script requires a critical question: “Are you willing to do CPR?”
“I can walk you through it,” the telecommunicator added firmly.
“Absolutely,” the caller responded. “I need you to walk me through it.”
Just a month earlier, step-by-step CPR instructions may not have been available to 9-1-1 callers – and not just in Juneau. Across the complex network of sites in Wisconsin that receive emergency calls, from centralized dispatch centers to sheriff’s offices to police departments, protocols for providing CPR instructions varied – or didn’t exist at all. The result was that in aiding the nearly 6,000 victims of out-of-hospital cardiac arrests in Wisconsin each year, less than half of the state’s 9-1-1 call centers were providing callers with step-by-step instruction in CPR.
“Many telecommunicators had to sort of sit there and say, ‘The ambulance is on the way. Just be calm. Hang on,’ leaving many telecommunicators feeling helpless,’” says Marc Cohen, executive director of the Wisconsin Emergency Medical Services Association (WEMSA).
Today that is changing thanks to work that WEMSA is leading statewide. Funded through a three-year, $582,000 AHW grant designed to help community-academic partnerships change systems to improve health outcomes, WEMSA and the Medical College of Wisconsin Department of Emergency Medicine are changing how the statewide 9-1-1 dispatch system operates, equipping them with the protocols and skills to save lives.
The approach is based on a simple fact: When it comes to cardiac arrest, every minute matters.
“The sooner you can start CPR, the better chance the patient has for survival,” says Jason Liu, MD, MPH, associate professor at the Medical College of Wisconsin, an EMS medical director, and the project’s primary academic partner.
Every minute a person’s heart is not beating, their risk of death increases by 10 percent. Even in the most efficient emergency medical services response times, victims who receive their first CPR compression after the responder arrives have low survival rates.
“In less than 10 minutes without CPR, there are minimal chances of survival. You’re dead,” says Cohen.
"In less than 10 minutes without CPR, there are minimal chances of survival. You're dead." - Marc Cohen
This reality makes the role of the bystander critical to survival. While important efforts are underway to introduce the general public to CPR – including teaching CPR in all Wisconsin schools –
WEMSA’s effort is more akin to creating expertly-trained CPR coaches who are available right when you need them.
“The telecommunicators who are answering 9-1-1 calls are often the first point-of-contact for help,” says Liu.
“They are the true first responders,” says Amanda Bates, who not only serves as WEMSA’s education director, but is also a firefighter paramedic and trained as an emergency medical dispatcher, or telecommunicator.
“So we are giving dispatchers throughout the state the tools they need to be able to get CPR started, which then can potentially make a difference in the chance of survival,” explains Liu.
Evidence bears out the importance of this approach. In Seattle, where a concerted effort to promote dispatcher-assisted CPR began more than a decade ago, the rate of bystander-provided CPR is routinely among the highest in the nation, exceeding 70 percent. The survival rate for out-of-hospital cardiac arrest is often touted as one of the highest as well.
In Wisconsin, a 2015 AHW-funded project in Milwaukee County led by Dr. E. Brooke Lerner, a professor and epidemiologist, provided similarly impactful results on a local level. Following the implementation of a countywide dispatcher-assisted CPR program, the rate of bystanders providing CPR nearly tripled, from 19 percent to 52 percent, and the cardiac arrest victim survival rate nearly doubled from 10 percent to 19 percent.
“It was based on that data that Dr. Lerner saw there was evidence we could scale this up and bring this around the state,” says Cohen.
Working with Liu and Nicole Fumo, a program manager in MCW’s Comprehensive Injury Center, WEMSA has now collaborated with agencies like the American Heart Association, the Wisconsin EMS Advisory Board and other statewide first responder associations to make statewide reach a reality.
The work was given a boost prior to its launch when, in 2017, Wisconsin Act 296 was passed, putting into law a requirement that by May 1, 2021, all dispatch centers in Wisconsin must either provide evidence-based CPR instruction over the phone, or have a protocol in place to identify and transfer appropriate calls to a center that can provide CPR instruction. And while the law specified that the script and protocol must be evidence-based, it didn’t specify a single source.
That is where the AHW funding filled a gap. To change the way the dispatch system was operating, the WEMSA-MCW team had to develop an evidence-based protocol, script, and quality assurance and improvement strategies that each center could easily implement, regardless of their size or budget. And then they had to make the change in protocol actually happen, developing a training curriculum that will not only launch the new protocol in each dispatch center, but is available for continuing education and training long after the program starts.
Along the way, they've found that the work has another benefit.
“For the telecommunicators, the program is much bigger than just coming in and teaching them how to give instructions over the phone,” says Bates. “It’s about empowering them.”
The training sessions not only cover CPR in depth, they teach each telecommunicator how to break through – and manage – what is often a crisis situation on the other end of the phone line.
“Telecommunicators have to get control of a situation that they are not present at,” she explains. “The number one barrier they encounter is panic. So we teach them the assertiveness needed to take control, to give firm directions, and to give the caller confidence and reassurance.”
Since then, Cohen and Bates have been putting on the miles, travelling region-by-region to provide in-person training to shifts of telecommunicators. So far, they have completed training in three of Wisconsin’s seven healthcare emergency readiness coalition (HERC) regions, training more than 150 telecommunicators. The project will complete its reach to all seven HERC regions, training as many as 500 people, by 2021.
The result will be a 9-1-1- dispatch system that is working to save lives statewide. For each member of the project team, the work it takes to change an entire system is time well spent.
“I love this part of what I’m doing. We’re putting the education and information in the hands of those who can get it to those in need,” says Cohen. “You really see it make a difference.”
Liu echoes the sentiment. “This is the most rewarding work,” he says. “We are implementing best practices across multiple systems throughout the state, and it’s going to last. It’s going to be impactful long after this initial training effort is done.”
In Juneau, the impact is easy to see: On their first call following the protocol change, they saved a life.
For information and resources on dispatcher-assisted CPR training, visit wisconsinems.com.