Surprising facts are learned about even a relatively uncomplicated system when a small “piece” or component of that system is removed or not working as it should be. Without being privy to the discussions, the nation’s football fans will probably never fully understand the thrust of the many closed-session talks between owners and on-field umpires and referees leading up to recent "lockout" of National Football League (NFL) officials. It is now clear, though, that the owners reached the erroneous conclusion that experienced referees are not needed in the football “system.”
The principal “components” of a professional football game include: (a) the players, of course; (b) the coaches and owners; and (c) the fans, certainly – not only those in the stands, but also the much larger number watching the game on television. If asked last year, many fans might have discounted the value of the referees; however, a very different answer would be given during the current season.
Most Emergency Medical Services (EMS) systems cannot simply shut off an essential support function – as the NFL tried to do. However, various vital components of all types of systems, both electronic and mechanical, sometimes fail of their own accord – or must be interrupted for upgrade or repair. During even a temporary cessation of a support function, the goal is to continue providing services and to keep the disruption virtually invisible to the end user. As with any other change, permanent or temporary, several steps must be taken for the change process to be successful.
The Starting Lineup – Computer-Aided Dispatch For individual components of computer-aided dispatch (CAD) operations, for example, planners must begin by thinking through and documenting every step of the process needed to stay operational. Planners must work through the loss and/or malfunction of each part of the entire system to create many seemingly small plans that can be combined into what is sometimes a surprisingly large “playbook.”
In today’s high-tech world, interruption of the current support system often means falling back on earlier technology. When a CAD system fails and EMS assignments cannot be quickly and easily entered into a computer, pen and paper are usually the most obvious and sometimes only “replacement parts” immediately available.
The screens of most CAD systems may initially have been designed to emulate existing paper forms, but it is unlikely that this is still the case. In today’s much more complicated high-volume support systems, it is often necessary to reduce, to the absolute bare necessities, the services provided to the end user(s).
In the case of CAD, there are a series of questions that must be asked as well as a parallel series of answers – many of those answers, though, lead to additional, but different, sets of follow-up questions. The end result is or should be an improved and, usually, more complete understanding of the medical emergency the caller might be reporting. For software programs with built-in logic that prompts the next question, even while answers are being recorded, this is a relatively simple matter – but does not always seem so on paper. When switching to paper, therefore, the decision “tree” may have to be shortened to maintain the speed necessary to cope with a major emergency of any type.
The Backup Quarterback – Pen and Paper Paper backup forms should be upgraded to make the flow of the paper version – of a standard “form” of various types, for example – more like that of the on-line version. By doing so, the operators working with the paper will become acclimated more readily if and when a breakdown occurs. The ultimate goal is to make the paper process as similar as possible to the electronic process.
It is not enough, therefore, simply to emulate the computer screens on paper and pack all of the backup components into a handy nearby box marked “break seal in case of emergency.” Staff members and supervisors must be trained and exercised to promote a full and complete understanding of, and comfort with, such materials. For working purposes, this means that procedures that have been written but not trained functionally do not exist.
The final step in the process is review. Any loss-of-service event or incident should be written up as an after-action report in a format similar to that of any other major response event that occurs in the field. By enumerating the positive as well as negative lessons learned, planners can revisit and improve the backup plans previously developed. Similarly, every time the system is changed – to accommodate an upgrade of the CAD software, for example – the plan must be reviewed and modified as needed.
In short, by recognizing – as early as possible – that support services play a significant role in the successful operation of a system, and that detailed planning is critical to operational success when (not if) essential services are unavailable, leaders and managers can provide the guidance necessary to make not only the system as a whole but also each and every one of its vital components operationally successful at all times.
________________________ Joseph Cahill is a medicolegal investigator for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as the citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Prior to that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s Paramedic Program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.