It was a few hours after dark on Nov. 28, 2003, when a motorist on U.S. 63 called 911 and reported what he thought was a car that had gone off the highway between Broadway and Stadium Boulevard. With little solid information to go on, a 911 operator classified the call as an accident with unknown injuries and dispatched Columbia police to investigate. Police spent about 20 minute searching with headlights and flashlights, but found nothing.
The next morning, a frostbitten Jerad Miller crawled up a 60-foot embankment from the creek bed he had crashed into the night before on his way home to Jefferson City after shopping at Columbia Mall.
His passenger, Joseph Stenger, was dead.
All 911 calls for medical emergencies are routed to the city-operated Public Safety Joint Communications Center in downtown Columbia, but what happens next is not as simple as identifying the nearest fire or ambulance crew. Operators at the 911 center use sophisticated computer software that tells them which questions to ask and, based on the answers, decides what sort of response is appropriate.
But the city and county fire departments, as well as ambulance services operated by Boone Hospital Center and University Hospital, have their own protocols for responding to medical emergencies.
The Boone County Fire Protection District responds to all medical situations relayed from 911; the Columbia Fire Department is more selective.
The pre-established response protocols of these agencies are integrated in the computer programs used by dispatchers to prioritize calls and decide which fire or ambulance service to send. For serious emergencies, 911 dispatches both fire and ambulance crews to get help on the scene as soon as possible. But some calls, such as accidents with unknown injuries, fall into a gray area because dispatchers often lack enough information to know whether the incidents are serious enough to warrant an emergency response.
This difference in protocols highlights what some see as a weakness in the local emergency response network: While 911 calls are routed through a central command post, there are differences in the ways the two fire departments and two ambulance services respond.
John Purves, who retired last fall after 20 years as a city firefighter and as a member of the Professional Firefighters Union, remembers talking with other firefighters after the fatal accident on U.S. 63. He said they were bothered by the response and wondered why the Fire Department, which he said has night vision equipment and powerful lights, wasn’t dispatched.
Nine times out of 10, a 911 call reporting an accident with unknown injuries will turn out to be nothing, Purves said, but the call should generate an automatic Fire Department response.
“If they’re not sure, send everybody,” Purves said. “Why not?”
Purves said he understands that administrators have to manage resources and that it’s not practical to send fire, police and an ambulance crew to every call. But as a firefighter, he said, “I’d go every time.”
Battalion Chief Steve Sapp of the Columbia Fire Department said city fire does not respond to crashes with unknown injuries. The reasons: safety and resource management.
“We certainly don’t want to run emergency equipment in a non-emergency situation,” Sapp said. Emergency responses with fire engines, he said, are “one of the most dangerous times for our firefighters and for the general public.”
Secondly, Sapp said, “if we can keep that equipment in quarters and prevent them from going on a non-emergency call, it is certainly beneficial to someone who may call with a true emergency.”
After the U.S. 63 incident, Sapp said, the Fire Department re-examined its policy on not responding to accidents with unknown injuries. Fire officials talked with Columbia police, Sapp said, and decided the policy was sound.
The Fire Department uses a tiered response system that relies on 911 dispatchers and computer software to prioritize calls. In addition to accidents with unknown injuries, city fire also does not respond on an emergency basis to calls classified as “man down, unknown problem.”
The 911 center logged 891 such calls in 2004: 260 for “man down, unknown problem” and 631 for accidents with unknown injuries.
Fire Chief Bill Markgraf said his department stopped responding a few years ago to calls the computer coded “man down, unknown problem” because of too many calls that involved homeless people sleeping along roads. The decision not to respond, he said, eliminated hundreds of runs by his department.
Jeff Clawson of the National Academies of Emergency Dispatch, which developed the computer programs used in Boone County, said the majority of 911 centers respond to “man down, unknown” on an emergency basis.
Jim McNabb, director of the Columbia-area 911 center, said “man down, unknown problem” calls are typically for someone down on the ground who appears to be unresponsive. These calls often turn out to be a person sleeping, intoxicated or otherwise not in need of medical attention, he said.
McNabb explained that his agency is simply a purveyor of information to user agencies. The fire departments and ambulance services make their own decisions on how they will respond to different types of calls — or whether they will respond at all.
The Joint Communications Center has to keep current on changes the user agencies make in their protocols.
“Depending on who that responder is, we have to present the information differently,” McNabb said. “For very valid reasons, they all have different responses.”
He added that 911 operators “have to remember and do more than you would if everyone was doing the same thing.”
The city Fire Department’s policy of not immediately responding to “man down, unknown problem” and accidents with unknown injuries contrasts with the practice of the Boone County Fire Protection District, which responds on an emergency basis to all medical situations relayed by 911.
Rob Brown, chief of staff for the Fire District, said his agency temporarily stopped making emergency runs for 911 calls classified man down and accident with unknown injuries after the two codes were adopted in 2001. The district later decided to treat those types of calls as emergencies, Brown said, because there were times when people weren’t getting medical care soon enough.
The Fire District operates with “kind of a no-regret policy” that errs on the side of the patient, Brown said. “We find almost on a weekly basis that we’ll be told there’s no injuries, and we’ll get on the scene and find someone injured.”
Brown said police or an ambulance crew will sometimes respond to non-emergency calls with unknown injuries and find that a person needs urgent medical care. He cited an accident in February involving a “serious trauma patient” on Interstate 70. “Several crucial minutes” passed, Brown said, before a city police officer arrived and determined the accident warranted a response from an ambulance and a city fire crew.
Brown said the sophisticated computer coding system put in place several years ago is better suited to urban areas larger than Columbia where there’s a higher volume of calls and, therefore, a greater need to screen and prioritize responses.
Don Stamper, who served on the Public Safety Joint Communications Committee during his tenure as Boone County presiding commissioner and is a former manager of ambulance service at University Hospital, said the ideal structure of Columbia’s emergency medical system would center on an autonomous center making decisions and setting consistent protocols for various agencies.
Like others with experience on the front line of emergency services, Stamper said he doesn’t think the current system is broken. But he does see room for improvement.
“In the best of all worlds concerning policy differences,” Stamper said the various agencies who respond to medical emergencies would be following the same protocols. “They literally should have identical policies.”
The relative autonomy of the fire departments and ambulance services reflects the local political landscape of separate city and county governments and a county Fire District that is its own political entity.
“The way it is now, each agency may have a different opinion,” Brown said. “We’ve worked for years to say that the best thing that could happen in Columbia and Boone County would be to consolidate the government, have one fire and rescue department. Over the years, many people have rebuffed that idea for reasons like loss of control.”
There needs to be “a more thorough look at policy and how policy’s arrived at,” Stamper said. He realizes there will always be judgment calls and human error, but believes a centralized set of protocols is what’s missing most.
“It needs to be there,” he said. “It won’t happen until leaders of the community step up to the plate and request it.”
Man down, unknown problem
It was 3:38 p.m. on July 15, 2004, when a Boyd Lane resident in northeast Columbia called 911 to report that her next-door neighbor was lying on the sidewalk beside a lawn mower. “I tried to wake him up, and he’s asleep,” the caller reported. “I don’t know if something’s wrong with him or what.”
The caller provided her address, but the operator wanted the location of the man on the sidewalk. Once she had that information, the 911 operator confirmed that the man was outside. Before the operator could ask another question, the caller began speaking again.
“It sounds like he’s snoring, but I couldn’t wake him up,” she said on a recording of the dispatch provided by 911 officials. “Uh, but he lives at the house over here. And I tried knocking on the door over there to see if his mom and dad were home, but they aren’t home.”
Forty-nine seconds into the call, the operator asked her third question.
“So, does it seem like there is something medically wrong, or he’s just sleeping?”
As she continued to gather information from the caller, the 911 operator dispatched a Boone Hospital Center ambulance housed in a county fire station at Prathersville, about six miles from Boyd Lane, for “man down, unknown problem.”
As medics responded non-emergency, without lights and siren, the dispatcher relayed additional information to the ambulance crew: “For a subject in his early 20s. He is laying on the sidewalk. Caller states it sounds like he’s snoring, but she is unable to wake him. He is still breathing. There’s a lawn mower beside him. Also, a law enforcement (officer is) en route. Do you want fire to assist you?”
Columbia Fire Station 5 is located about seven blocks from the address where Ray Gilpin, a recent graduate of Rock Bridge High School, had collapsed while mowing his family’s lawn. The medics told 911 they didn’t need additional help from city firefighters, and firefighters would have no way to hear the radio traffic about the medical emergency that was unfolding a short distance away; radios used by the Fire Department don’t pick up the frequency that’s used to dispatch ambulances.
It was 3:44 p.m. when the caller contacted 911 a second time, this time to report the man was no longer breathing. The additional information left no doubt there was an emergency, prompting the 911 operator to dispatch an engine from Station 5. Four minutes and 17 seconds after the second call, a city Fire Department crew arrived — 54 seconds ahead of the ambulance from Prathersville.
Ten minutes and 46 seconds elapsed between the first 911 call and the arrival of an emergency crew.
Gilpin, 21, died the next morning in Boone Hospital Center of complications from an inflamed heart and seizure disorder.
His parents, Carol and Raymond Gilpin Sr., said their son was diagnosed with juvenile myoclonic epilepsy after he had his first seizure in August 1999 and was taking medication for the condition. The Gilpins said doctors told them their son had a seizure. They were told that his weight and an obstructed airway caused his heart to fail and his brain to hemorrhage, though they don’t know if that happened in front of their house or on the way to the hospital.
The Gilpins learned about the response to their son’s emergency from the 911 caller, a neighbor.
“I don’t want another set of parents to go through what Raymond and I have gone through,” Carol Gilpin said.
After a review of the Boyd Lane call, 911 managers cited human error on the part of the dispatcher for failing to use the computer program designed to prioritize medical calls as emergency or non-emergency and decide which agency will respond.
Joe Piper, administrative coordinator for the 911 center, said details of the review are confidential but confirmed that the dispatcher was disciplined.
Initially limited to phones with Columbia prefixes, 911 service was extended to all of Boone County in 1986 and “enhanced” so that every call could be traced to a given address. In 1993, an automated Computer Assisted Dispatch system went on line for both fire and medical calls.
By 1999, an increasing volume of calls had prompted emergency managers to look for more sophisticated computer software that would help dispatchers prioritize and code incoming calls.
Doug Westhoff, assistant chief of the Fire District, was director of Boone Hospital ambulance service in 2001 and participated in an emergency medical dispatch panel that evaluated which computer software was best suited to local needs.
In the end, Westhoff said, the decision was made to add a program called Medical Priority Dispatch System, or ProQA. The idea, he said, was to better “match the right assets to the right classification of patient.”
The Computer Assisted Dispatch software divides calls into 33 categories. The addition of ProQA, which is used just for medical calls, created 387 codes. For example, “sick person” is broken down into 29 codes, each one for a specific problem such as earache or toothache — even a request to have a ring cut off. It guides dispatchers through a series of questions that become more specific. The information is fed back into the computer, which decides how to code the call and, consequently, which agency or agencies will be dispatched.
The operator answering a 911 call relies on the accuracy of the caller’s information. “There is a need for callers to provide as much information as possible,” said Ralph Lee, director of Boone Hospital Center ambulance service. He added that that might be something the public needs to be better educated about.
“In the winter, it gets even worse,” Lee said.
Drivers will see a car go off the road and will call 911 to report it, Lee said, but they won’t stop to check on the vehicle or get more information.
Piper said ProQA was necessary to help prioritize calls based on urgency. “Not everything needs to be dispatched immediately,” he said. “If it’s not an emergency, why should it be dispatched immediately?”
The Fire District makes use of the codes provided by ProQA, but doesn’t screen or prioritize medical incidents except on unusually busy days when there is bad weather or a significant event such as a presidential visit, Brown said.
“We don’t do it every day, because in a state of normalcy there should be enough resources to be able to handle those calls,” Brown said.
He estimated that the Fire District responds to an average of 12 calls a day, about 20 percent of which tend to be life-threatening.
He could not provide a figure on how often the Fire District receives incorrect or inadequate information for medical calls.
“It’s not an epidemic,” he said. “It’s not out of control. But it happens too frequently for us to be comfortable.”
Part of the problem, Sapp said, is that different people have a different definition of a “true emergency.”
“We have to look at what constitutes an emergency,” Sapp said. “That’s what ProQA is designed to help us do.”
The operator who answered the 911 call from Ray Gilpin’s neighbor did not use the ProQA software, 911 officials said, and miscoded the incident as “man down, unknown problem” instead of a medical emergency.
Clawson of the National Academies of Emergency Dispatch is credited with developing the first computer program designed to prioritize 911 calls while working for the Salt Lake City Fire Department in the 1970s. His system, which evolved into the leading product of its kind, led to the formation of the emergency dispatch organization, which monitors and updates medical response protocols.
Clawson said emergency management centers must use the software correctly in order for it to be effective.
“That’s important, because what we found is you can put a protocol in place, you can train operators to use that protocol, but if you don’t do quality assurance and case review then you just go on doing what you did before that protocol was in place,” he said.
The National Academies of Emergency Dispatch has a 20-point process for accreditation, which includes certifications for 911 operators, a weekly review of 911 calls and the appointment of a medical director to oversee operations. Clawson said that accredited sites have a better than 90 percent accuracy in coding calls, while those that are not accredited have about 50 to 75 percent accuracy.
Becoming accredited, Clawson said, “really isn’t hard. You either make a full-time commitment to having a quality assurance program or not.”
Of about 2,900 centers that use the dispatch software, 71 are accredited, Clawson said.
In November, the Public Safety Joint Communications Committee, which includes representatives from emergency services agencies, directed the 911 center to pursue accreditation four years after it began using the ProQA software.
Assistant City Manager Paula Hertwig Hopkins, the city’s representative on the committee, said she is “completely supportive” of the accreditation process, which she characterized as an “enormously challenging project.”
It can take anywhere from several years to less than 10 months to become accredited, Clawson said. “If you pull out all the stops, you can probably be accredited in about nine months to a year,” he added. “There has to be a track record showing compliance.”
Having several protocols for 911 operators can present difficulties, Clawson said. “It is certainly a hindrance to have each agency behaving differently,” he said. “One will likely do it right. One will likely do it sort of right, and one may do it completely wrong.”
“A dispatcher can kill you just as fast as a paramedic,” Clawson added. “They just do it sooner — by remote control.”
Asked specifically where the city stands in the accreditation process, Joint Communications director McNabb outlined the requirements and said the city is “working toward achieving that goal.”
McNabb said the current average accuracy in coding medical calls is 82 percent, and the center has never been below 75 percent accuracy. He emphasized that medical calls make up less than 5 percent of the calls that come into the 911 center.
“Our compliance has continually increased, and we currently have a quality improvement process in place that measures our compliance on a monthly basis,” McNabb said. “Our goal is to minimize as many mistakes as possible, but you can’t forget the human element. Mistakes are going to happen.”