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Medical Call Review for 5161 Chaplain Way 2/6/2010

Ron Roth, MD Final 2/15/10
Medical Director, City of Pittsburgh, Department of Public Safety
Medical Director, Allegheny County Emergency Operations Center

Information generated for this document was obtained from review of
recorded call taking, dispatching and callback audio files from the Allegheny
County Emergency Operations Center (EOC), review of patient care records
(PCR) generated by City of Pittsburgh Paramedics, discussion with
administration from the EOC and City of Pittsburgh Bureau of EMS and
personal knowledge of the event. This review focuses specifically on the
medical aspects of this call, recognizing that there were certainly other
factors including road conditions that contributed to this tragic event.

During the evening of 2/5/2010 and continuing throughout the early morning
of 2/6/2010 the region was blanketed with nearly 2 feet of snow in short
period of time. The poor road conditions resulted in challenges to emergency
vehicles responding to calls. In addition, the number of requests for EMS
services more than doubled the average number of calls for a similar time
period. As a result, EMS call prioritization was initiated along with call
holding and callbacks.

During the time period from 2/6/2010 2:09 through 2/7/2010 7:56 there were
4 individual events generated at the EOC for 5161 Chaplain Way.

As an overview, each of the calls from 2/6/2010 was initially processed as
medium priority abdominal pain calls. The third call (P000183) was upgraded
after additional information was obtained. With respect to the emergency
medical dispatch (EMD) process, the calls were appropriately screened by
the call takers and entered into the CAD computer using our EMD software
ProQA. The call takers and software appropriately identified the patient at
This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

5161 Chaplain Way had abdominal pain without priority symptoms (altered
mental status, shortness of breath, fainting or suspected aortic aneurysm.)
The calls were coded as ABD2 (with scale ranging from 0–highest to 3-lowest

Because of the high call volume and long turnaround time for ambulances
due to the weather, calls were being held in a pending queue and prioritized
for dispatch. This is a standard procedure for EMS dispatch. When call
volume exceeds resources, calls with higher priorities (more likely to have
time sensitive medical conditions) such as heart attacks, shortness of breath,
falls outside with the potential for hypothermia, are dispatched prior to calls
coded with lower priorities. In general, this system works well to mitigate
short term time periods when demand exceeds available resources. The
system does work for longer term events but has limitations as identified by
this specific case.

Call backs by paramedics/physicians enhance this process and serve as a
safety net for the short term (several hours.) However, during the declared
weather emergency, the system was required to perform the call
screening/holding function for over 24 hours. Since this was a unique event
for all parties involved, there was no previous knowledge on how to handle
this type of event. As a result, the existing procedures for managing pending
and repeat calls, call backs and unit dispatching were less effective.

EMS units were dispatched for every request for assistance from 5161
Chaplain Way. Unfortunately, there were time delays between the request
and response of the EMS providers. For calls P0033 and P0073 the delays
were less than 2 hours. While not desirable, the delays were appropriate
based on the number of calls in the pending queue, many with higher
severities. The third call, call P00183 shows a greater than 9 hour delay
from request to dispatch. This occurred during the peak of requests for EMS
responses. During this time, the pending queue always had higher priority
(E0 and E1s) calls awaiting responses. Numerous call backs occurred
(patient to EOC and EOC to patient) during this time period. Each time the
call was correctly identified as patient with chronic abdominal pain without
priority symptoms.

Unfortunately, what appeared to be underappreciated by some parties is the
fact that this was the third request for service by the same person for the
same complaint. In addition, most if not all, were unaware of the details of
the previous call. This may have occurred for several reasons. The CAD

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

screen does identify previous calls to the same address but requires an
operator to drill down to additional an additional screen to pull up the details.
While call takers and dispatchers may be proficient in this process, the
paramedics/physicians doing call backs are probably less likely to use this

Each call was seen as an individual request for assistance. Knowledge gained
on previous calls was not communicated at the time of the next request. As a
result we made the same request over and over (can you walk to the
ambulance?) It was clear from the first call that the patient would not walk to
the ambulance and identified by the second call that he could not walk to the

Limitations with respect to the call back function for the EOC paramedics
5061/5062 contributed to the communications problems. The current system
of documenting call backs on paper works well when the system is not
overwhelmed. However, during the first day of the winter emergency, the
system required rapid processing of a large number of calls and formal paper
documentation was for the most part abandoned. With multiple people
making call backs over multiple shifts, information obtained on one call back
was not communicated to other personnel making call backs over the
extended time period. While paramedics/physicians can document in CAD,
this function is rarely used due to lack of training. In addition, the function of
using the M[space]period(event#)comma to enter information appears to be
less desirable then entering information directly from the event entry screen.
(This is as per TCOs working the room that day.) There apparently is no alert
function when M[space]period(event#)comma is used. Therefore, important
call back information may not be seen by the TCOs in a timely manner.

The call back areas can accommodate two personnel, each with a phone, city
computer and CAD. They are in close proximity to the EMS and Fire
dispatchers which is a great advantage. Adding personnel to the area
(physicians/district chiefs) without adding phones and computers may
actually reduce efficiency. The physicians had no access to CAD except via
paramedic 5061. In addition, the same phones used to make call backs, were
used to recruit additional personnel for the field, take call offs and other
administrative duties. Often phones and personnel were not available for call

During the event, it was difficult for the call screeners to track calls once
they left the pending queue. Once a call was dispatched, the call screeners

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

made the reasonable assumption that EMS contact occurred. There should
be a mechanism for feedback to the call screeners if a call is cancelled.

Asking patients to walk to the ambulance is a relatively unusual request.
However, during this event, field providers and TCOs realized that medic
units were becoming stuck in the snow as they ventured deep into
neighborhoods. This often put the medic unit out of service for hours. Asking
callers to walk to the truck became a viable alternative that worked on many
calls. As can be expected, there were patients that could not walk to the
ambulances and alternate methods schemes had to be developed. In some
cases the medics were able to walk to patient or a district chief 4WD vehicle
or Response 5 was summoned.

Use of the Fire first responders in fire vehicles was suggested as a resource
for these difficult cases. Indeed, first responders were sent on the highest
priority calls (E0s.) In addition, first responders were sent on E1 calls
deemed by call screeners to have a time sensitive emergency. The first
responders were a valuable resource during the winter emergency. The call
on Chaplain were coded as an E2, the patient did not have a time sensitive
emergency and therefore did not meet the threshold to receive a first
responder dispatch.

On the surface, it seems difficult to understand that on 3 occasions there
were EMS units in the vicinity of the patient’s home and patient contact
never occurred. Because of road conditions, hazards and terrain it appears
that EMS crews were only able to get within one quarter mile of the home.
The first call (P00033) was initially held due to limited unit availability.
Several callbacks were made by the EOC paramedic prior to the dispatch of
Medic 5.

Medic 5 was dispatched but became stuck in the snow near the Elizabeth
Street Bridge. Medic 5 requests the district chief in his 4WD vehicle and asks
if the “the patient can walk across the bridge, we can begin treating him.”
The dispatcher contacted the district chief and provided him with the detail.
The district chief went en route from Bloomfield (he was with another unit
that was stuck and 2 public works vehicles) and the crew related that they
would be digging themselves out from snow.

The EMS dispatcher, after talking to the caller told EMS that:

• The patient was unable to walk to them

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

• The caller said to just cancel

• They would call back later should he hurt any more

• TCO explained that he told the caller that it would be the same
situation later, but they said to cancel.

EMS accepts the disregard and cancels the district chief’s response. The EMS
documentation on their PCR CCR# 5339 reflects the above conversation.

The actual conversation between the EMS dispatcher and the caller differs
somewhat from the information relayed to EMS.

The EMS Dispatcher on call back spoke to the girlfriend of the patient.

• The medics are at the East Elizabeth bridge, they are unable to get to
the house

• The medics want to know if it is possible for the patient to walk to
them. Girl friend says no, he is in too much pain.

• Medics are stuck and they cannot make it

• I don’t know what else you want me to do because they cannot get to
you. Girl friend says well maybe later

• Dispatcher says so you want to cancel?

• Dispatcher relates that the situation will still be bad later.

The call is entered as cancel per caller. There is no documentation that the
medics became stuck or that the patient could not walk to the paramedics.
The option of waiting for the district chief to attempt to reach them was
never offered. The call is removed from the CAD screen.

The second request for assistance occurred slightly less than an hour after
the first cancellation. The call is held by the district chief because of limited
unit availability. The district chief is aware that this is a repeat call. Medic 8
is then dispatched to the call. They are told that this is a return call. They are
not made aware that a previous unit responding to the call became stuck.
Medic 8 becomes stuck and tells the dispatcher that “if he wants a ride to
the hospital, he is gonna have to come down to the truck.” On call back, the

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

caller says he will walk to the truck and he just needs a few minutes to get

At 6:22 the caller calls 911 and states that he cannot make it across the
bridge. He cannot even walk steps. The caller states they can come back
later. Again the call taker says do you want to cancel the call. The caller
inquires if they will come back later. The call is cancelled. I do not have the
audio file relating the cancellation of the call.

Once again, the documentation states that the call was cancelled by the
caller. The TCO does note that the caller is unable to walk to the corner.
There is no mention of the road conditions.

In review, the comments made by the paramedic were inappropriate “if he
wants a ride to the hospital…” however they were not relayed to the caller.
As a system we did not use options such as using the district chief’s vehicle,
walking to the house or keeping the call in the pending queue until the roads
were plowed.

The third call for assistance occurred approximately four and a half hours
after the previous cancelation. The initial complaints are similar, abdominal
pain. There are no priority symptoms identified. Again the call is held due to
lack of unit availability. At this point in time, higher priority calls are being
held and there are over 30 calls in the pending queue. Multiple call backs
occurred and the caller is appropriately identified as a patient with chronic
abdominal pain with no acute symptoms. At 20:15, 9 hours after the third
request, the call is upgraded because of an additional call relating that the
patient is short of breath.. The call taker nicely verbalizes the events of the
day with the caller including the multiple calls, multiple cancelations and
inability to walk to the truck. The call lasts greater than 10 minutes. The TCO
is concerned that narcotics have depressed the patient’s respirations. The
patient’s breathing is confirmed and pre-arrival instructions are provide that
include watching the patients respirations. None of this information is added
to the active event or relayed to EMS. Of note, a call back was made four
minutes prior to this call and apparently no priority symptoms were
identified. Audio for this call back is not available.

Medic 7 is given the call. There is no mention provided that this was a repeat
call or that road conditions were bad. When the medics ask about road
conditions, they are initially told there have been no units to Chaplain.

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

Several units walk on each other trying to give reports. Medics are also told
to check a second address on Chaplain.

The dispatcher tells the medic unit that one patient does not want to walk
down, the other, they were to check out. It is unclear which patient was
being referenced by this statement. The dispatcher clarifies that the man
with abdominal is now walking down to them. Twenty two minutes later the
crew states that they have not seen the guy. The callers girlfriend calls back
and states that there is a medic unit outside but her boyfriend took his pills
for insomnia and pain pills and that she can’t wake him up. The TCO confirms
that he is breathing. The caller’s tone is not excited and she seems to
suggest he has taken his pills and has gone to sleep. The CAD
documentation states that he went to sleep and she cannot get him up to go
outside to the medic truck.

A call back is made to the home by the emergency physician, apparently on
a non-recorded line. The physician questions the caller about her boyfriend’s
status including breathing. At the end of the conversation, the physician is
convinced that the patient took his prescribed medications and went to
sleep. In addition, this was normal occurrence with this patient.

The call taker then tells the medics that the gentleman went to sleep and
they were going to cancel for now.

The fourth and final event for 5161 Chaplain Way occurred the following
morning. This call was for a DOA.

During one of the callbacks, it was learned that the patient had a history of
pancreatitis. The patient’s complaints were consistent with pancreatitis but
not exclusive to that diagnosis. In general, pancreatitis is a serious medical
condition precipitated by a variety of causes including alcohol, gall bladder
disease, medication, and a variety of other entities. In relatively rare
situations, complications of acute pancreatitis can result in life threatening
conditions. At the time of this report, the findings of the Medical Examiner
were not available.

On three separate CAD events, EMS is dispatched to 5161 Chaplain Way.
Each time the paramedics are told to cancel by the EOC. The paramedics are
not privy to the conversations between the TCOs and the callers or the
details from previous events. It was reasonable to ask the caller to walk to
the ambulance on the first call. It is not reasonable to ask the caller to walk
to the truck on subsequent calls after he refused on the first call. (Never the

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

less, he agrees to attempt to walk to the truck on calls 2 and three.) On the
first call, the EOC cancels the call prior to additional resources arriving on the
scene. With respect to the second call, we ask the caller to walk to the truck
and when he cannot, the EOC cancels the call. On the third call once again
we ask the patient to walk to the truck. He apparently agrees but then
decides to go to sleep. At this point it seems reasonable by all parties (caller,
TCO and EMS) to cancel the call.

In summary, there was not one specific event that precipitated this tragedy.
During a weather emergency with a prolonged period of high call volume, we
repeatedly sent ambulances to an address that they could not reach and
apparently did not mitigate that situation. There was an overreliance on
having the caller walk to the truck by all parties involved. Calls were
prematurely cancelled prior to system invoking additional resources (District
Chief, Response 5, and Public Works) to reach the patient. Information
gathered by one party (TCO, dispatcher, 5061/5062, field providers, District
Chiefs and the physicians) was not documented, transmitted or easily
available to other parties.


1. Improve the process and workspace for call backs made by

a. Consider additional phone lines and CAD terminals

b. Limit other administrative calls into 5061 and to the district chief

c. Record all phone lines

d. Ensure all call screeners are able to view previous calls from the
same address and merge relevant information.

e. Re-evaluate the documentation required by persons doing call

i. Must be streamlined

ii. Visible by all parties (Dispatch, call takers, other call

1. Call screener documentation should appear in CAD

2. This will require training

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

iii. Create an electronic template for call screeners

f. Place an EMS district chief at the EOC as soon as possible. At
peak times, limit his duties to call and unit assignment. Other
duties such as call offs and call ins could be done off site.

g. Consider CAD triggers to alert the TCOs when a call has been
held for greater than 1 hour. This trigger should occur at hourly
intervals. The EMS Dispatcher should notify the appropriate EMS
district chief.

2. Re-evaluate operations at the call taking / dispatch positions

a. Review information that should be documented including road
conditions, specifics about the case, road hazards or conditions

b. Evaluate how calls from the from the same address are reviewed
and documented in the current event

c. Review how specific calls are cancelled

i. The decision to cancel because there is a perception that a
unit cannot reach an address should not be made without
input from the EMS district chief.

ii. Consider holding calls versus cancelling them with special
notation/coding in CAD. This will require re-education of
the EOC staff.

3. Re-evaluate EMS response to unplanned major events

a. Early mobilization of additional units/personnel and equipment

b. Consider mutual aid sooner and alternate assets, (PANG)
realizing that other agencies may be having similar issues and
may not be available

c. Use of the Bureau of Fire first responders to evaluate higher
priority calls

i. First responders are currently dispatched to E0 calls

ii. Consider first responders dispatch to specific E1 and E2
calls that are identified by call screening

This is a confidential document generated as part of the Continuous
Quality Improvement program for the City of Pittsburgh Department of
Public Safety and the Allegheny County Emergency Operations Center

iii. On specific calls, allow first responders to evaluate calls
and leave the scene versus waiting for EMS

1. Unfortunately, this might be considered

2. We would have to consider a “disaster exception”

3. This would require tight coordination through
medical command

4. Recognize the limitations of a first responder

d. Ensure that all parties are aware of the availability and
capabilities of alternate vehicles such as Response 5, PANG
units, and district chiefs vehicles.

i. The district chief at the EOC should control the dispatch of
these vehicles.

ii. TCOs, call screeners and field personnel should avoid
cancelling calls due to inability to access patients

iii. Develop patient access protocols to assure all efforts are
made to make patient contact before any event is

4. Ensure that all parties understand the call screening process

a. Consider “Levels of Emergency”

i. Low levels would allow call screening and holding but all
requests for service would be honored

ii. At the highest level of emergency, low priority calls would
calls would be canceled after appropriate screening.

b. Develop a brief monograph to train call screeners