Dealing with urgency.

Urgency characterises OHCA calls so call-takers provided their perspectives on how they handled this overriding influence in the phone interactions. The call-taker’s experience of OHCA calls is aptly described in the quotes below from Deb;

… you’re knowing that if you don’t get this right, by the time the crew gets there, they’ve got nothing to work with (Deb)

… after a cardiac arrest, as soon as you see that pop up [that the patient is being taken to hospital], it’s just exciting. I mean, you don’t know what the results gonna be but they’ve got a chance … if I get like a lot of positive feelings after, it’s usually more based on who the people on the scene were. So sometimes you get people who are super helpful, work together, and it’s just like, wow, you feel so good about humanity. But if it was really difficult and people struggling to follow your instructions. Or maybe you’re struggling to get information, it can be a bit draining. You kind of feel like you could have done more, could you have said more to get there, to encourage them. (Deb)

Deb’s statements indicate the high level of investment call-takers had in OHCA calls. They were acutely aware of the importance of cooperative teamwork between the call-taker and the caller/bystanders to achieve survival outcomes.

Call-takers commented on the distinction between OHCA and other medical emergencies, where OHCA required immediate intervention from the bystander, and thus gave the call-taker a set process to implement with the caller;

We’re all just kind of treading water with most of those [other] jobs … We’re stopping it getting worse, until someone can take them to hospital and fix them or fix them on scene. Whereas cardiac arrest is one of the few jobs we can step in very quickly and change an outcome. (Cody)

Call-takers exhibited keen awareness of the time-critical nature of OHCA calls and that rapid intervention was imperative;

This is not about preserving or being gentle and careful with him. This is a very vigorous thing we’ve got to do and we’ve got to do it quickly. Time now is of the essence. (Cody)

When call-takers became aware that the call was an OHCA emergency, they switched into a heightened mode;

I hate to say it, they all have a little bit of a thrill to them, because you get that adrenaline spike … you’re amped up … your heart rate’s up, you’ve got that adrenaline … and you’re pounding through the call. (Alex)

Along with switching into a different mode, call-takers commented that they would change their voices to indicate urgency, although this could vary depending on the caller’s situation;

I think it also depends how old the patient is. So if it’s a newborn, you’re a little bit more harsh on the caller, you need to say ‘right now’, ‘we need to get this sorted’. Whereas if it’s someone, they found dad and they think he might have been there a little while, you’re a bit more like, ‘okay, we’re gonna get him on the floor’ … a bit slower for them. (Kerry)

Call-takers spoke about the skills required to handle OHCA calls effectively. They had to be adept at multi-tasking while on the call;

You’re clicking, you’re moving, you’re making sure the mapping, you’re probably listening to somebody saying, you’re doing 87 things at once. (Alison)

I think we put a lot on our call-takers to expect them to do all of these other things and arrange all these other resources. Or [the call-taker has to] ask other people to arrange these other resources whilst they’re still trying to control a scene and have a system and follow a protocol. (Cody)

Cody referred to the fact that call-takers must, while initiating CPR, also be looking to see if there are any first responders or defibrillators close to the patient that could be brought in for assistance.

Scene management was also critical to the handling of the urgent OHCA call. Call-takers had to ensure the scene was accessible and safe for the paramedics. They also had to be alert to factors that would impact the emergency. Alison provided a scenario here;

Do we need to be addressing bleeding before even touching cardiac arrest? So sort of taking that time to determine the situation as a whole. Because we can get very ‘okay they’re not conscious, they’re not breathing’… moving [quickly], and then you’ve not asked any more questions, because you’ve gone [on to CPR]. (Alison)

Critical thinking was a skill that many of the call-takers mentioned as necessary for the swift resolution of any obstacles that occurred during the call, especially when it came to barriers to commencing CPR. Prim pointed out that there were no visuals for call-takers, so listening became a sharpened skill;

They [paramedics] say when they go to scene, they assess, everything’s visual. They’ll look at coloured skin, they’ll feel, they’ll touch, they’ll speak. For us, it’s purely audio. So everything we hear becomes an absolute sixth sense almost. We actually go, ‘that doesn’t sound right’. And we pick up things that most people wouldn’t even think to hear for or listen to. So [that’s] our skill set and what we hear that people aren’t saying. (Prim)

Call-takers discussed the balancing act they had to perform in managing callers’ expectations and needs but also not giving them false hope;

We’re not meant to say how far away the ambulance is. It’s the dynamic environment, everything can change. Generally speaking, on those calls, because you’ve got multiple crews attending, I feel like we should be [able] to give a realistic expectation to say ‘the ambulance is organised, help is on the way’. It’s sometimes a bit unfair. If the ambulance is 30 minutes away, we need to be able to say, ‘hey, they’re 30 minutes away but we’re going to do this’ and set realistic expectations and realistic points of measurement. (Jane)

Call-takers outlined the difficulty of their position—to know when there were ambulance crews heading to the patient, but to be limited in the reassurance they could give the caller, as per the call centre policy. At the same time they knew this was the one piece of information that could have positive benefits for the initiation or continuation of bystander-CPR.

Staffing.

As part of their heightened awareness of the urgency of OHCA calls, call-takers expressed concern about whether the call centre had the capacity, that is, the quantity of staff to handle an increased volume of emergency medical calls. A shortage of staff on a shift impacted on call-takers’ sense of control over their abilities to provide immediate attention to OHCA calls;

… understaffed in regards to our work volume has gone up quite significantly … they’re [managers] just sort of playing catch up at the moment by recruiting a lot of new people. Just because the workload’s gone through the roof. (Buddy)

For call-takers, watching the call queue grow, and knowing that they might not be answering an OHCA call in a timely manner, was a source of stress and frustration;

… we sit there watching the triple zeros across the bottom of screen. And then like five minutes later, cardiac arrest. You’ve already lost your window. You know, how long have they waited with triple zero? (Charlotte)

Charlotte raised the issue of surge capacity (not currently available at SJWA), so that non-call-taker staff at the ambulance headquarters could assist in peak periods;

There’s no one to bring in to answer the calls. Other places have a surge capacity where people [other roles in the headquarters] … could be trained up. They should be trained up as call-takers. … bring in anyone and everyone to answer those triple zero calls. (Charlotte)

The standardised protocol.

When it comes to managing OHCA calls, the overwhelming attitude about the dispatch system, MPDS, was positive. Call-takers pointed out that the standardised protocol equipped them with a set of steps to follow verbatim, thus providing structure to handle this critical emergency;

I find cardiac arrest actually the easiest because that’s when the protocol actually works. And you follow it, word for word. (Charlotte)

Cody pointed out that this structure meant that callers were assured a consistent service;

So at least this gives a level playing field to everyone who calls up. Whoever they get who answers the phone, it’s not luck that you’ve got someone that has got the background knowledge that knows what’s going on. (Cody)

The phrasing in the script for OHCA calls also enabled swift progression to CPR and to instil urgency in the caller;

The scripting within MPDS is very deliberate. It’s very to the point. And the way that it is written does help convey that sense of urgency that you really need to get across to a caller. (Alex)

The computer interface.

When it came to processing OHCA calls, participants were generally positive about ProQA [29], the computer software package that accompanied MPDS. However they also acknowledged that not all call-takers found the system to be user-friendly. Several commented that the more recent recruits tended to favour ProQA whereas longer-serving call-takers found it harder to adapt from previous methods of manually entering case records.

Participants commented on the system enabling navigation between different parts of the OHCA call process;

I find the ProQA system pretty awesome for me because … I like being more structured in a way. And everything’s there as long as I’m clicking in the right [place] and following the right processes. It does make it a lot easier. (Buddy)

Deb pointed out that the system for OHCA allowed for a scenario where call-takers could move quickly to CPR instructions, and fill in other patient details (on their computer screens) once the caller had commenced compressions;

It’s a pretty good system. So it allows us to jump straight ahead. So we don’t have to get every detail beforehand, that we can get to those compressions very early on, which I think is great. (Deb)

However some call-takers found that navigation through ProQA could be cumbersome;

[what] I find very frustrating with MPDS is the multiple windows that you’re jumping in and out of. Because we’ve got our call card on one. You try and update the crew as well, because the Fast Track doesn’t give the crew an age. And they need to know what age the patient is that they’re going to. So you’re jumping between MPDS and then your call card as well. (Jane)

Call-takers pointed out that ProQA provided a systematic record of their actions in the OHCA call which meant that they were protected in the event of an investigation;

… it’s also a system that protects us. If we follow it as our role and our job and our policy, well we’re governed by that. So if there is any reason as to why … you know, things go to coroner’s court and all that sort of stuff. ‘What did she do?’ Because they go from the first phone call to the ambulance to the ambulance attendants. So it’s a whole research thing. ‘Did we follow ProQA? Yes, done.’ (Prim)

This, in fact, was a positive aspect of using a standardised protocol and system for call-takers because they felt safeguarded by it.

Out-of-hospital cardiac arrest recognition.

The issue of timely recognition of OHCA during the call received much attention from the participants, raising issues about the callers mistaking ineffective breathing for effective breathing and the difficulty in using a breathing diagnostic tool in MPDS. In the following excerpts, call-takers spoke about the uncertainty in determining an OHCA if the caller was not clear about the symptoms.

Prim outlined a common scenario where call-takers could pick up clues of ineffective breathing even if the caller said the patient was breathing;

… for example, if someone’s called up and … someone’s not breathing effectively, to the layman person, they’ll be like, ‘oh, you know, they’re snoring or they’re making a gasping [noise], they sound like a fish’. All these words to us are very important, but to them, they’re still breathing. Because according to the caller, they’re taking breaths in, but they don’t realise that it’s not sufficient. (Prim)

To alleviate some of these issues, many participants expressed taking a precautionary approach of treating uncertain statements of breathing as ineffective in order to trigger an OHCA response, even if the evidence was inconclusive;

I would rather organise a dual response [two ambulances] or send it out as that response. And then start CPR and then go oh, ‘actually, no, wait, hang on’. (Alison)

Prim highlighted the importance of call-taker experience in being able to detect the, sometimes non-verbal, signs of OHCA;

‘They’re dead’ or ‘they’re not awake’, ‘they’re not breathing’. They don’t use words like that … ‘they’re asleep, but they’re not responding’… so you have to use your experience, going, ‘okay, so what are we going to do with this information? Are we going to go down the path of they’re unconscious and assess, or [are we] going to find out more there and then?’ … what I think is with cardiac arrest specifically, in this role, the more you do it, the more you pick up on what people say and what you hear. And it’s more so what you hear that gives you the [conclusion], this is going to be a cardiac arrest, and then you start moving in that direction. (Prim)

Charlotte referred to the need for call-takers to overcome hesitancy in their assessment of a patient’s breathing as this could waste time;

… it’s that ambiguity and that hesitation that we have sometimes and maybe checking the breathing [again] when they’ve clearly given you one of the statements that you could just go into CPR. So I think that a lot of it is around training and education. (Charlotte)

Participants commented on the need for call-takers to do more probing in order to elicit the right information that could help to rule out or determine an OHCA;

… we prioritise based on the questions we ask … But like they say, we’re only as good as the information provided. It’s also up to us to make sure we get the right information given to us … so push for more if you’re not happy. (Prim)

The MPDS dispatch system has a breathing diagnostic tool which call-takers can employ to assess if a patient is breathing effectively. This tool was frequently raised as a challenge to use with callers, as call-takers had to ask the caller to “say ‘now’ every time s/he takes a breath in starting immediately”. Cody specified how the phrasing of the instructions could be changed to clearly instruct the caller to check the patients’ inhalations;

Some of the scripting in the breathing assessment tool is difficult and people forever misunderstand what you want them to do. ‘Okay I want you to tell me every time they take a breath starting now’ [call-taker]. ‘What’ve I got to do?’ [caller] … So probably a preamble of ‘okay, I’m going to see how their breathing is. What I want you to do is look at them closely. Watch the chest or the tummy rising and falling. Tell me when you’ve got that’ [call-taker]. ‘Yep, yep, I can see it now’ [caller].’ Okay, now tell me every time they take a breath’ [call-taker]. Something like that. (Cody)

Cardiopulmonary resuscitation.

One of the challenging aspects of managing OHCA calls was when callers were resistant to initiating CPR. Call-takers were trained in how to encourage the caller to commence CPR and each had their individual approach to providing reassurance to the caller;

Reminding them that we’re doing this together … saying, ‘if you don’t know how to do it, that’s okay, I’m going to be here with you. I’m going to tell you’. Those kind of statements so that they don’t think they’re on their own. And that it’s okay to try. Like I had one today where they were scared, they’re gonna get blamed if something’s wrong. (Deb)

For call-takers, it was sometimes difficult to gauge when they should push the caller and when to accept the caller’s refusal. Call-takers showed understanding for refusal in certain circumstances;

If they refuse to do CPR, we can’t force them, we just have to try … and that I thought was kind of nice, because she’s obviously in her 90s. I think she had quite bad COPD [chronic obstructive pulmonary disease] and a few other health issues. And he’s obviously thought, ‘I just want her to go peacefully’, as opposed to dragging her on the floor and doing CPR. (Kerry)

The participants commented on how initiating CPR was not only important for the patient but also for getting the caller to focus on an action rather than the panic they may be experiencing;

… because they’re actually doing something. You know, ‘I’m helping’ or ‘I’m saving this person’s life’ or whatever. It kind of shifts that focus away from ‘oh my God, my loved one’s dying’ or ‘this person is dying’. (Buddy)

In this excerpt, Kerry proposed that commencing CPR has a potential benefit to the caller of knowing they tried to save the patient rather than being a helpless onlooker;

Just sort of doing something, even though it obviously doesn’t do that much. But at least you’re trying something. And I also think sometimes we do CPR more, also for the person calling as well. Because if your loved one does die, wouldn’t you like to think you tried to do something? … So they can be like, ‘I did everything I could to save them’ rather than just staring at the person. (Kerry)

In terms of the dispatch system, call-takers noted the difficulties in reciting a long set of CPR instructions to the caller. Call takers provided full “telephone-CPR” instructions, however if the caller was experienced in CPR or a medical professional then call-takers generally felt confident to let them handle CPR by themselves with support to ensure cadence and depth. The length of the instructions meant that callers sometimes missed information;

… the biggest stepping stone for me is just bang!… heaps of instructions straight out, like in a stressful situation, you know? … they’re probably not listening. (Buddy)

Some call-takers found their own strategies to deal with the quantity of CPR instructions, such as breaking the instructions into smaller components;

So I read it all out and then I do it in a way that they can understand the second time. I read it and be like, ‘now move the sheets from blah, blah, blah’… it’s like a step-by-step thing, rather than ‘get them on the ground’. (Kerry)

The procedure of moving the patient on to the floor for the commencement of compressions was identified as another challenging aspect of the CPR phase of the call because the MPDS script could not account for all the possible obstacles to achieving this. Again, call-takers had to exhibit critical thinking to rapidly resolve the issue;

I tried to work with them and brainstorm if there were any ideas they had, that we could use to get him onto the floor. So sometimes you do have to divert, you do have to kind of think on the fly. (Alex)

All participants found the phrasing of instructions in MPDS for positioning the patient to be helpful, especially the fact that these instructions could be broken down into steps;

… those instructions are really good. I’ve had a few people that were absolutely just refusing to try and move them and ‘I can’t move them. I can’t move them’. But then when I’ve told them the step-by-step process, they’ve been able to do it. So I guess maybe it’s just putting it into like a bite-sized chunks for them. (Kerry)

Another aspect of CPR that was raised was how call-takers instructed callers to maintain the quality of CPR once it had commenced. Due to space limitations, this is detailed in S3.

Defibrillator retrieval.

The existence of public access defibrillators received considerable attention because call-takers felt that the system around using them needed improvement. Several call-takers mentioned that connecting with other emergency services, that is, the police and fire departments, could help in getting defibrillators to the scene of an OHCA in a timely manner;

I suppose having a bigger resource pile for our second crews and things … using WA POL [police] and Firies [fire department] and things like that, because we don’t look very far beyond the first responder schemes. Our first responders that are set up by the organisation are fantastic but there’s 101 other defibs and people out there, first-aid-trained, that we never use … some sort of alert system for cardiac arrest for the police or firies. (Cody)

In the above quote Cody refers to SJ-WA’s first responder scheme which uses an app to alert registered first-aid-trained citizens to nearby emergencies, however this app does not connect with other emergency services.

Call-takers expressed the need for in-room assistance, i.e., teamwork within the call centre, when it came to locating and organising a public access defibrillator;

I would make more emphasis on getting defibs to scene. So at the minute, some people in the room are really good at, if you see a colleague on a resus, I will, for example, click on the resus [case record], see if there’s any defibs nearby. If there’s one nearby, got a phone number, I’ll say ‘I’m going to call for the defib’. (Kerry)

As with CPR, call-takers displayed concern for the callers and bystanders when it came to encouraging defibrillation, that is, not wanting to put a bystander in danger by asking them to race off to find a defibrillator; and questioning whether it was better to focus the bystander on doing compressions;

… there’s a defib 100 metres down at the [petrol station], someone needs to go and get that. They don’t want to leave that person. There’s two people, … How far do we send them? Or how much should we push them to do that? … you’re putting these people in a stressful situation in another stressful situation … trying to get one of them to leave the home or leave the resus. (Suji)

Caller compliance.

The key to successful management of an OHCA call was ensuring that the caller answered all questions clearly and promptly and complied with call-takers’ instructions, in order for CPR to be immediate and effective. This was identified as a challenging aspect of OHCA calls;

… controlling of the call is harder than going through the MPDS system of the cardiac hands-on-chest and everything. Getting them to comply is the hard part. (Suji)

To ensure compliance, call-takers had to be able to handle a range of emotions and behaviours from callers;

And it is about that call management. I think if you take the time to make sure your emotion is managed and understand that even if the person is aggressive, or yelling at you, ‘okay, this is an extremely stressful situation for that person, how can I be of assistance to them?’ Not matching or trying to override them. ‘How can I help the caller to help the patient?’ Because I think taking that time makes the rest of the call a lot easier. (Alison)

Calming some hysterical callers required patience from the call-takers who had to try an array of strategies and skills to take control;

We call them screamers. They’re on the call, and they’re just that high. And no matter what you say, no matter what you do, no matter … my training, my experience, I’m going to give it to you, and they just don’t listen or they don’t stop because they’re just that upset … You can’t bring them back so … you ask [for] someone else. ‘Will you give the phone to someone else?’ and get them away, or ‘you shut the door’, all those sorts of things. (Prim)

You just have to be very firm. Almost to the extent that you have to say, ‘shut up’ without using that word. Try and get their stress level down. For me, one of the best things to do is try and get their name because then you can just say, ‘okay Emma, okay Emma, okay Emma’… just reiterate ‘you have to do this, you’re doing the best thing that you can’ … while you’re waiting for the crew to get there. (Suji)

Apart from the highly emotional callers, call-takers also had to be alert to those who appeared compliant;

They’re [OHCA callers] actually usually the most compliant callers. They’re one extreme or the other, they’re off the Richter and it’s really hard to get control of them. Or they’re just compliant. The only thing you’ve got to be careful of if they’re really compliant, is that you can hear them doing something … So a lot of what we have to do is make sure that we can either hear them doing it or get them to acknowledge that they understand and are doing it. (Charlotte)

Charlotte raised the issue that call-takers do not only rely on what callers tell them but what they can hear happening.

Call-taker empathy.

While call-takers spoke of the difficulties of dealing with emotional callers, they also exhibited much empathy for the caller and patients’ situations, as part of their commitment to fulfilling the demands of their role. Therefore, blame for the challenging situation was not directed at the callers;

… you can’t expect the caller in that moment of panic to be problem solving. (Deb)

Alex noted that his role was not just about achieving a survival outcome for the patient but actually supporting the caller through the call;

If we can help the caller and make them feel that they’ve done everything that they could to help dad. To help mum. To help their brother, their son, their daughter. If we help them through that process, I think that’s just as important as what the outcome for the patient is. (Alex)

Along these lines, participants cited compassion as integral to how they handled the caller, especially when the caller was tending to a loved one;

So I want to display the compassion to that caller that I would expect if I was the caller or one of my family’s the caller. (Jane)

As part of their empathy for callers, participants were aware of the significance of this phone call in the callers’ lives;

This is a normal day for us but for the people calling in this is a very abnormal day. This is probably a situation they’ve never ever been in, and hopefully never going to be in again. (Cody)

Especially in the case where it is likely the patient would not survive, call-takers stated that callers’ wellbeing would then become their primary concern;

… at least you’ve got the caller to do CPR, so you’ve helped them with their healing process, because now they know they’ve tried everything, and you were there for them when they needed to do [something] in that moment. And so it’s almost like a way to think about it. If the patient dies, there’s still possibly some good that can come out of it. (Kerry)

Downtime and debrief.

The intensity during the OHCA call, where call-takers had to exercise complete concentration to work swiftly and definitively to get the caller to commence resuscitation, followed by an abrupt end to the call, could be a taxing experience, both mentally and emotionally. Call-takers spoke about the importance of self-care, in taking a few moments to calm down after the call had finished, as part of their coping mechanisms;

I think sometimes you do need a moment, at the end of call. Just a breath … settle that, take a moment and move on. And sometimes we don’t always have the luxury in our room to be able to do that. And sometimes, at the end of the day, I might just take a moment to go ‘cool that happened’. We all have different triggers for what bothers us more. (Alison)

Alex spoke about the strange nature of OHCA calls when a call-taker drops in and out of a critical moment in the caller’s life;

… and we go into these really intense periods where we have to stay calm. We have to stay in control … we’re doing everything we can to maintain the scene and keep them going and keep them focused. … that snapshot in a person’s life. And then it’s just done. Fine, hangs up. And there’s another call waiting. It’s a very strange, surreal way to look at life and death. (Alex)

Call-takers expressed the need to have downtime and debrief as part of organisational policy, as they had seen done for paramedics;

Sometimes, some big cases, they’ll have debriefs [for the ambulance crews] here at SOC. And we won’t get released from the room to be a part of it because it’s too busy for us. Well you pulled in a road crew off when it’s busy. (Deb)

Call-takers advised that there was a policy in place where, if a call-taker took a distressing OHCA call, then this would trigger the organisation’s support team to check-up on the employee via email or phone. However call-takers said implementation of the policy tended to be inconsistent and they did not always have the opportunity to talk to the team during their shift if it was busy.

Call-taker wellbeing.

OHCA calls had the potential to impact call-takers’ sense of wellbeing. They pointed out that cardiac arrest calls tend to “hit you a little bit harder” (Alison) than other calls;

… just the way that a caller talks about a patient or there’s something about it that just niggles at you a little bit. And that can be hard. (Alison).

In the following quote, Deb describes the potential effect of an OHCA call on the call-taker, due to experiencing the high-pressured first moments of a patient’s cardiac arrest;

… just because you’re not there doesn’t mean it’s not connecting [with you]… obviously they’re not all [like that] but you do have just a much higher exposure to trauma. And, you know, you might not be there at that hanging that turns into a resus. But you’re hearing the mum’s scream when she finds her child. You’re hearing all that first stuff. (Deb)

Over time in the job, call-takers said that they developed their own coping mechanisms, however, some call-takers felt that;

we’re not checking in on people after they take so many horror calls. Not really looking after them. St John does this concept of self-reporting to wellbeing and support and they do some notifications [call-taker sent a generic email from support team]. But we know we’re in an industry where we won’t self-report. We’re not traditionally the kind of people that will go and ask for help. (Charlotte)

Charlotte noted that, in emergency services, seeking help was not always part of the culture. Cody saw this as an area that needed improvement;

I think the follow up of ‘you’ve just taken a cardiac arrest, are you okay?’ Because … they are still not nice calls and the impact … we don’t know what’s going on in their family at the time … I think … that touching base with ‘okay, do you want more information about this?’ … ‘no worries I’ll get clinical onto it, and we’ll let you know how this worked and what the crew found’. (Cody)

Several call-takers also referred to the fact that taking calls could be triggering in terms of reminding them of past or potential traumas with their own loved ones. In relation to PTSD, Suji suggested that support was required, not only for the immediate call, but also for holistic wellbeing maintenance;

… it should be mandatory for everybody to go and see a psych. Like maybe once a year, once every six months. And the reason I say that is because I’ve had a couple of friends from work that have left because they’ve ended up with PTSD or issues with the job. (Suji)