Q&A: What is the future of 911 dispatch?

Jeff Clawson, 'father of emergency medical dispatch' speaks about the evolution of 911 dispatch and where the industry is headed

Updated June 2015

As the inventor of the Priority Dispatch System and co-founder of the International Academies of Emergency Dispatch, Jeff Clawson is widely known as the father of emergency medical dispatch. In the 1970s, Clawson’s pioneering work in developing a system for interrogating 911 callers and giving prearrival instructions led to the transformation of dispatchers from “clerks” into professionals who send the right level of response to callers—and save lives.

As an EMT in Salt Lake City in the late ’60s, Clawson’s first experience with medical dispatch went like this: An emergency call would come in to the ambulance station’s seven-digit phone number, he’d answer it, and then head out to respond. Before he left, he would switch the phone to ring at the home of the husband and wife who owned the ambulance company.

A thing or two has changed since then. 911 became ubiquitous nationwide. Clawson became an emergency medicine physician and an advocate for dispatchers as a vital part of emergency response. Today, the International Academies of Emergency Dispatch protocols (the Medical, Fire and Police Priority Dispatch Systems) are used in nearly 3,000 EMS, 403 fire and 242 police call centers around the world.

Clawson is CEO/medical director of Priority Dispatch Corp., which develops and licenses the caller interrogation software (brand name: ProQA) that’s integrated into computer-aided dispatch (CAD) systems. Clawson is also medical director and head of research, standards and academics at the International Academies of Emergency Dispatch, which develops standards of care and practice in EMS/public safety telecommunications, accredits 911 call centers, and offers training and continuing education for 911 communications specialists.

Clawson spoke with Best Practices about the evolution of 911 dispatch and where he sees dispatch headed in the future.

What were people’s attitudes toward dispatch and dispatchers when you started in EMS?
In the ’70s, we believed dispatch couldn’t figure anything out. Dispatchers were clerks; they were remote. They were at the lowest rung in the pecking order of public safety. You had someone who was untrained, other than in-house orientations. We called it ‘sitting with Nellie.’ You sat with your supervisor and learned how she did it. You learned to make the same mistakes that Nellie made. There was no continuing education.

We also believed everything had to go lights and sirens, so the system was depleted and mismatched from the get-go. If you were sending three units with lights and sirens on a cat bite, and five minutes later grandpa had a heart attack in the same area, he didn’t get help in time and he died. Nobody was the wiser, except the dispatchers.

Where did you get your inspiration for protocols for dispatchers?
It came from several different places. I was an EMT at a BLS service in Salt Lake City, and I used that to pay my way through medical school. In 1975, I did a thesis on ambulance response in Salt Lake City. I made a recommendation that some better order to dispatch should be looked at in the future.

Then, when I was in my first year as an emergency medicine resident at Charity Hospital in New Orleans, I had a very personal experience dealing with a giant outpatient clinic. We saw tons of people, some of whom had charts 3 feet thick. These people were born, treated and died at Charity Hospital. When they came in, trying to figure out what to do seemed overwhelming. You had to reinvent the wheel as far as tests and labs with everybody who came in.

I told this to a resident, and he said, ‘What you need is a protocol.’ He showed me a bunch of 5x8 cards for handling various situations, such as high blood pressure. The cards were basically a decision tree. But I was dismissive of it. I said, ‘You mean a cookbook?’ I thought that as a doctor, I was smarter than a cookbook. And the resident said, ‘Cookbook, my ass. You can’t survive at Charity Hospital without one.’ The very first time I used it, I got through clinic twice as fast. I had a tenth as much stress, and I was able to spend time listening to patients rather than reinventing the wheel with every one.

I didn’t think much of it until I got back to Salt Lake City and became the medical director in ’76. Every time somebody said something went wrong with a call, it always went back to the communications center and the dispatcher. If it goes wrong at communications, it goes wrong everywhere down the line.

We were sending three vehicles, lights and sirens, on every call. That was crazy. We didn’t do that in the emergency room. A clerk or a nurse triages patients at the front desk; you decide if people are living or dying. If somebody isn’t doing OK, they get rushed to the front of the line. If they have a broken arm, they might get three hours of TV therapy. I went to the fire department and asked, ‘Why aren’t we doing something similar and triaging patients at the time of the call?’ It all came together. They needed a protocol, too.

Does the public still believe that lights and sirens is the appropriate response for every call?
That’s a myth that has been perpetuated by public safety, especially by the fire service. They say that the public expects you to send everything lights and sirens and to overwhelm with resources, but that actually isn’t the case. We have done surveys in Salt Lake City regarding dispatch, one that we published in the journal of the National Academies [National Journal of Emergency Dispatch]. We asked, ‘If you had an emergency such as choking or a heart attack, would you expect a vehicle to come lights and sirens?’ The vast majority said yes. Then we asked, ‘If it wasn’t a life-threatening emergency, would you expect responders to come lights and sirens or drive following the rules?’ More than 70 percent said, ‘We don’t expect them to come lights and sirens.’

My experience spending five years on an ambulance is that people were actually embarrassed about the lights and sirens. They were thinking, I don’t need the neighbors to know. I just need Granny taken to the hospital. But public expectation has been a very convenient excuse for public safety, especially high-ranking public safety, for demanding more resources. Yet when you ask the consumers, they’ll say, ‘I don’t need three units.’ Or, ‘Why was a cop car coming to my house?’

You’ve referred to dispatchers as the ‘first, first responders.’ What do you mean by that, and why is it relevant today?
If dispatchers know what to do, you have a zero-minute response time. If they don’t know what to do, that caller may be given a life sentence while waiting for the appropriate care that can’t possibly get there in time. I can look out the window and see places in the Salt Lake Valley that are almost rural. It may take somebody 10 to 15 minutes to get there. If you have a child choking to death, the brain doesn’t last that long.

Why is a protocol superior to, say, dispatchers with EMS experience asking questions based on their medical knowledge and experience?
With our protocols, any question 911 dispatchers ask has to satisfy one or more of the following four objectives:

  • Sending the right personnel—ALS, BLS, hazmat, extrication, air medical, fire, boats.
  • Determining the presence of conditions at the scene requiring telephone advice or instructions. That’s separate from giving instructions; the goal is to determine if somebody needs instructions.
  • Providing information for responders. In essence, the dispatcher is the scene commander until someone arrives at the scene. All of the information responders get is through dispatch. A protocol never has a bad hair day. It does what it needs to do every day. Nothing gets forgotten.

The fourth is to provide for the safety of everyone involved at the scene—the patient, the caller, bystanders and the responders.
A lot of people don’t think you need a protocol. Some people think that to be a dispatcher, you need to be an EMT or a paramedic, and then you have the necessary knowledge. The trouble is that the knowledge of street providers varies, and that knowledge is oblique to what people do.

With the protocol, there is an objective reason for asking every one of the questions. Just offering guidelines doesn’t work. A guideline is a ‘you may’; a protocol is a ‘you shall.’ There is a huge difference between the two. The Academies’ protocol is used in 43 countries and in 17 languages and dialects, with very few variations. It’s the same in Berlin as it is in Salt Lake as it is in Qatar and Sao Paulo. Australia has some bad snakes and spiders, so there are a few variations for them!

You got your start in EMS as an EMT for Gold Cross Ambulance in Salt Lake City. How did you get that job?
I was a science nerd at the University of Utah going to get a degree in vertebrate paleontology. My mom would remind me that summer was coming up and I needed to get a summer job.

There was a job board at an old Army barracks nearby, and I told the person at the desk that I was interested in something
science-related. She said, ‘What’s your major?’ It was like something took over my body. Instead of saying paleontology, I said, ‘Premed.’ She said, ‘Oh, we’ve been holding a job for somebody just like you. How would you like to be an ambulance driver?’ It scared me. I used to pass out when I got blood drawn, but I knew the experience would tell me if I could go into medicine.

What was JEMS’ role in creating the National Academies of Emergency Dispatch?
When I was a fire surgeon with the Salt Lake City Fire Department, I made a presentation to the federal government regarding prearrival instructions and dispatch protocols. It was 1980, and we’d been doing it in Salt Lake City for about a year. I had a draft of the presentation called “Medical Priority Dispatcher: Strengthening the Weak Link.” [The JEMS article was called “Dispatch Priority Training: Strengthening the Weak Link,” published in February 1981.] I was planning on publishing it in another journal, the Annals of Emergency Medicine.

I went to a conference that Jim Page was holding in Snowbird, Utah, called EMS and the Fire Service: Born of Necessity. I introduced myself, told him about what we were doing, and he said, ‘If you publish it in that other journal, 10 people will read it. If you publish it in JEMS, thousands of people will read it.’ It changed my mind. I sent the article to JEMS, with my home address listed in it. A week after it hit the streets, I came home and my mailbox was stuffed so full of envelopes they were falling onto the porch. I’ve been told that before or after, they never had that much reader response to anything.

The very first letter I got came from a medical director/ER physician at Illinois Masonic in Chicago. I’ve read his letter so many times I have it memorized. It said, ‘Recently, Chicago Fire Department has come under fire for ineptness and lack of training in dispatch. Rather than reinvent the wheel, can we get this program in Chicago?’

I started working on the weekends out of the fire department, using the typewriter, answering letters and preparing manuals for other agencies, including key questions and prearrival instructions. Through ’85 and ’86, it became evident that everyone wanted information about dispatch, but I was becoming overwhelmed. So I started the North American EMD Network, which became the National Academy of Emergency Medical Dispatch in 1988.

In the beginning, there were misconceptions about what dispatchers could and couldn’t do. People said, ‘People are hysterical. They don’t listen. Dispatchers don’t know what to do. You’ll get sued.’ Every one of those things has been debunked. Dispatchers have saved thousands of lives over the years. Sometimes it’s as simple as telling people to remove the pillow that every well-wisher has put under Grandpa’s neck, opening his airway.

This interview will be published during 911 Education Week and National Public Safety Telecommunicator Week. How important is the dispatcher to emergency response?
The dispatcher is the lifeline, and the earliest link in the chain of evaluation and care. It’s very important in terms of response—who goes, when they go, if they go, how fast they go. All has to be quantified by the dispatcher. The dispatcher is the jewel upon which the watch of public safety turns.

In the old days, the attitude among responders was that dispatch didn’t give much information. We referred to it as being the black hole of public safety space. Now they provide much richer information for the responders, including helping to ensure the safety of everyone involved.

We are constantly developing protocols to help dispatchers be more useful. Several years ago, we developed protocols for stuck accelerators and pandemic flu. At the end of last year, as a result of the mass shootings in Arizona, Aurora and elsewhere, the Academy put out the ‘Active Assailant’ protocol and distributed it to any 911 call center that wanted it.

For the Active Assailant protocol, we worked with the National Tactical Officers Association. With these shootings, they generally happen in one place once. The dispatchers may never have experienced one before they get the big one. They don’t have experience with it, so they have to rely on the protocol. It’s unfolding rapid fire. They may be talking to somebody at the school or the theater. Dispatchers can provide active information about what’s going on to responders, and to people on scene about what not to do, how to create a lockdown and how to not get yourself killed. It can make things worse if dispatchers tell them to do the wrong thing.

What does the public need to know about the dispatcher’s role?
They need to know that the dispatcher asks exactly what they need to know and no more. The dispatcher knows what to ask and when to ask it. Rely on the dispatcher and expect them to tell you what to do. If they don’t tell you what to do, you don’t have a good dispatch system. And there’s a patchwork out there.

There’s a lot of talk about abuse of the 911 system. Do you think the use of 911 needs to be reformed, or do we need to change our attitudes about what 911 should mean to the average citizen, even if it isn’t what public safety officials think is an emergency?
It’s an urban legend that there is tremendous abuse. There are cases of it, and that group of people will always be there.
Public safety people tried to reform the system using billboards, radio, advertising and TV, to tell people not to call 911 except in cases of emergency. But that actually works just the opposite. Detroit in the early ’80s spent $3.5 million getting that message out, and in the end calls to 911 went up 5.5 percent. The reason is if you say, ‘Don’t eat the food’, what people hear is ‘Blank, blank, blank FOOD.’

People call 911 because they were told to call when you don’t know what to do. You tell little kids, ‘If mommy needs help, call 911.’ We don’t teach them what an emergency is. People call because they need help. If they knew what to do, they wouldn’t be calling us. Of course, the health care system has something to do with this. 911 is a portal because people don’t have an availability of other resources—a place where they can go and get help, get transport, and not have to make an appointment for six weeks from now.

Instead of telling people to not call 911, we need to have dispatchers who know what to do when they call. If you get somebody who has a hangnail, they may get transferred to a nurse. If you get a kid who chewed on a poinsettia leaf, they go to poison control. For that to happen, the 911 system has to change, in terms of getting people to the right place at the right time, which may be an urgent care clinic, a dentist, a doctor’s appointment or rape crisis. 911 doesn’t provide any social support, which is what many people really need.

911 shouldn’t chastise you. We should tell them, ‘You got to the right place,’ or, ‘We will get you to the right place,’ and not be limited to sending an ambulance to take you to the most expensive health care place on earth, an emergency department.

How do Omega calls fit into this?
Omega calls are a subset of the lowest acuity (Alpha) tier of the Medical Priority Dispatch System. Once a center is accredited and we know their decision-making process is accurate and safe, the Academy will allow them to use the Omega protocol, which can result in a referral rather than response.

If you send an ambulance, you can be pretty sure you are staying out of trouble. But if you make the decision to do something else, you better be sure that what you determined was the problem is accurate. It’s waste vs. risk.

We have the Omega protocol being used in England; Australia; Montreal; Richmond, Va.; Louisville, Ky.; and Fort Worth, Texas. Typically, Omega calls are referred to a nurse with certified special training from the International Academies of Emergency Dispatch. In the Omega world, you also have to create a network of primary care physicians and others who are willing to accept these patients who aren’t taken to the emergency department. It takes a village.

Do you expect the number of 911 call centers and EMS services that use Omega to grow?
Everybody should have it. That would be making the best, most efficient use of the array of their resources, instead of just taking everybody to the emergency department. They would be arranging for them to get the care they should have gotten if they were health care management experts. It’s going to get nothing but bigger. More and more dispatch centers are using quality assurance to get higher levels of compliance, more accurate decision-making and, based on that, they are becoming accredited, which sets up a perpetual quality assurance system.

How many 911 call centers are accredited?
The first was the Albuquerque Fire Department in 1993. Today, there are 166 Accredited Centers of Excellence, but it’s expanding exponentially. Once they’ve gone through the process, very few let it lapse. They realize there’s a continuous improvement system built into it.

Dispatch quality assurance is different from quality assurance in every other part of EMS and public safety. We have an audio recording of every call, so we know exactly what happened. Paramedic quality assurance is retrospective—we review the medical record they wrote down, but we don’t know what happened sequentially. In dispatch, you know. It’s like having instant replay. We can listen to it, review it, share it with the dispatcher who took it and offer feedback.

You can listen to the call to know if they asked the question according to the protocol, or if there was a breakdown in the interpretation of the answer. For example, if I ask a caller, ‘Do you have chest pain?’ and the answer is, ‘Well, um … it just … um,’ then the answer is yes. They have chest pain.

Many volunteers contribute their time to the boards and councils of the International Academies of Emergency Dispatch. Why are people so passionate about this approach to dispatch?
It gives dispatch a professional face and name. You might have a billion-dollar system, but if you have a person who doesn’t know what to do when answering the phone, it’s not going to be much help. People have to be trained, educated and re-educated. The Academy provides a suite of things that make up a comprehensive, well-oiled machine at dispatch: certification, training, curriculum, recertification, recertification testing, continuing education and quality assurance.

What would you tell someone who wants to be a dispatcher?
It’s a very honorable profession. It takes a certain type of person who has a certain type of disposition. They need to care about people and treat people with good customer service. And it takes lifelong learning.

The initial learning is still fairly short. The certification course, the national standard, is 24 hours, but 24 hours does not a medical professional make. That got started because in 1978, I asked the fire chief if I could have three days for training dispatchers, he said OK, and that got set in cement. Now you can’t change it or you’d have people screaming about overtime.

Three days makes a very high-powered initial orientation. But your continuing dispatcher education needs to be ongoing forever. Dispatchers are professionals. They need to take responsibility for their ongoing training just like any person in medicine. A dispatcher can kill you just as dead as a paramedic.

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