1. #1
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    Thumbs down DCFD: Crew misses dispatch; Patient dies

    Family: Woman Dies After Waiting For Ambulance
    Officials: Crew Members Did Not Hear Dispatch


    POSTED: 12:42 am EDT April 19, 2006
    UPDATED: 5:52 am EDT April 19, 2006


    WASHINGTON -- A 39-year-old woman's family says she died after waiting more than an hour for an ambulance, and a fire official says crew members did not hear the dispatch.

    Cassandra Bailey, 39, was waiting for an ambulance at the Capitol Hill Dialysis Center on N Street Southeast on March 14, where she went there three times a week for dialysis, according to Antonio Evans, a friend, and Brenda Bailey, Cassandra's sister.

    Brenda Bailey and Evans said they arrived at 5:25 p.m. and were told that an ambulance had been called. When the ambulance did not come, the family said, a worker at the center called again.

    "She said, 'I have to complain because it's been over an hour since I've called for them, and they haven't arrived yet,'" Evans said.

    The family said that more than an hour went by before a fire truck and EMT workers finally arrived, followed by an ambulance, but Bailey died minutes after arriving at the Washington Hospital Center.

    Fire officials admit that mistakes were made, NBC 4 reported.

    "Apparently, the crew members did not hear the dispatch. Clearly, the dispatch was made. For whatever reason, they didn't hear it," said Alan Etters, of D.C. Fire and EMS.

    The department said that changes have been made to ensure that ambulances are dispatched properly. An investigation continues.

    Bailey's family members said they want assurances that a situation of this kind will not happen again.

    "If the ambulance had gotten there, say, when I got there, I think she would still be here in her place," Brenda Bailey said.

    There is no word on how long the internal fire department investigation will take.

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    Question Charlie Foxtrot

    "Apparently, the crew members did not hear the dispatch. Clearly, the dispatch was made. For whatever reason, they didn't hear it," said Alan Etters, of D.C. Fire and EMS.
    How many foul-ups had to occur for this to happen. How do entire companies miss a dispatch (and, from the sounds of it, multiple units -- at least an engine and an ambulance)? If companies are dispatched for a run and never ackknowledge, doesn't someone from communications check on why?

    I know the whole "let's hear both sides of the story" routine. However, we already have someone from DCFD admitting that the dispatch was missed -- so something did go terribly wrong here.

    Of course, the flip side of this is that if I call for an ambulance and it doesn't show up -- even in the largest of cities -- I'll be calling again long before the one-hour mark.

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    Quote Originally Posted by cozmosis
    How many foul-ups had to occur for this to happen. How do entire companies miss a dispatch (and, from the sounds of it, multiple units -- at least an engine and an ambulance)? If companies are dispatched for a run and never ackknowledge, doesn't someone from communications check on why?

    I know the whole "let's hear both sides of the story" routine. However, we already have someone from DCFD admitting that the dispatch was missed -- so something did go terribly wrong here.

    Of course, the flip side of this is that if I call for an ambulance and it doesn't show up -- even in the largest of cities -- I'll be calling again long before the one-hour mark.
    You took the words right out of my mouth coz. There are so many variables here. Did the call ever get dispatched? "Officials" say yes. So did the call actually go out over the airwaves, or was this recorded in the dispatch center prior to the transmitter? Was the crew in a dead spot and didn't get the radio signal? We all have radio problems from time to time. Or, was the crew just plain not paying attention and missed the broadcast? It will be interesting to see where this takes off to. Either way, you have to feel for the family of this lady.
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    Isn't it standard practice to acknowledge you have received the call?

    In most organizations, you must confirm you have received the call, either verbally or by hitting a button on the console, and then acknowledge when you arrive on scene. If you don't acknowledge the call in a timely manner, the dispatcher will call you to verify you have received it and have responded.

    As someone said, many things had to go wrong for this incident to happen.

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    This is an interesting case in the eyes of a dispatcher. Here in Memphis, if a station does not acknowledge a run on the vocal, we'll call that station on the phone to see if they got the run. If a piece of apparatus is "on the air" and they don't answer the radio, we'll send someone else in their place and try to find the original company who didn't answer the radio. It boils down to the fact that we have to keep up with all of our active calls at all times. If we let something slip by, we can get written up.
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    Unfortunately, it seems "slipped by" may be an understatement here...
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    Is this an in house full time company, paid on call, volunteer? I guess there could be several variables why they missed the dispatch. None the less our dispatch requires aknowledgement of dispatch from companies and arrival time. If aknowledgement isn't recieved a secondary company is dispatched. While the circumstances aren't fully known it seems the dispatch droppped the ball.

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    Somthing like this happened in DC when I was little. My family was visiting the National Zoo and were in the gorilla house place when an elderly gentleman collapsed with a heart problem and fell down some stairs. As my dad was a Lt. on a Rescue Squad and I was only like 5 he went over and helped out, and 911 was called. The engine, ambulance, and cops didn't come for 45 minutes to an hour later. Luckily the guy survived.

    Not badmouthing the DCFD in anyway, they are a great bunch of guys and I have met a few on a couple of occaisions. Just throwing it out there.
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    It's was a failure of the system. It's not just the ambulance crew's fault, it's dispatch and it's whoever was listening to the radio that day. Someone should have picked up on that no one was responding. Now I don't know how or what system is used for dispatch in the DC area however, it has to be some sort of voice or computerized system, even Locution type programs have to be acknowledged.

    I hate to see when things like this happen because I am sure no one intentionally meant to do it but, it happens and well let's face it when the media and the uninformed persons hear this they are always quick to point fingers. I feel for the family and anyone involved because I am sure they will live with this for rest of their lives. Hopefully everyone can take something from this and hope it doesn't happen again.
    Last edited by savoy6; 04-20-2006 at 02:44 AM.

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    Quote Originally Posted by savoy6
    It's was a failure of the system. It's not just the ambulance crew's fault, it's dispatch and it's whoever was listing to the radio that day. Someone should have picked up on that no one was responding. Now I don't know how or what system is used for dispatch in the DC area however, it has to be some sort of voice or computerized system, even Locution type programs have to be acknowledged.
    We used a computerized dispatch for the ambulance company I work for, there are times in which we just don't recieve the call, due to whatever reason. There are also times in which our system just fails and we are unable to respond within the given time. There have been nights where a telephone pole has been knocked out, and we are unable to alert a station about a call, and we have to send anotehr ambulance, running emergency to alert the crew at that station that A: they have a call to run
    B: that the other crew now needs to set up a watch

    And there are other things, but it's going to add into a delay, even worse when we don't realize it immideately. I think the worst delay I've had has been about 32minutes due to the above problem. The phone line was knoced out, we were the only rig available, and were unable to be alerted until another squad cleared up. Thankfully it was only for a minor laceration, but these things happen..at least it's not on a regular basis. The other question I have is, even if this person could have recieved medical attention on time, would it still have had the same outcome, or would it have been different?
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    PFD, I agree, a phone line or a pager or whatever method that department uses could have had a malfunction. I was basically trying to make two points, one being that if the call was put out, why was there no follow-up and two it's a very difficult situation to all those involved because sometimes the media and public are quick to judge because they are unaware of the above listed circumstances.

    It's just a unfortunate situation.

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    It's just a unfortunate situation.

    No, it's an unacceptable situation.

    "Hey whoops, we lost your call, sorry!" isn't good enough.

    It's the dispatch center's responsibility to track that a call has been answered, and if it hasn't re-dispatch it or cover it as their protocols indicate.

    (And as a side note...I'd go as far as if a station that is supposed to be staffed fails to answer by both radio & phone tries by both the dispatcher and a dispatch supervisor if there is one, it gets bumped up to a full Fire / EMS / Police Officer-Needs-Assistance level emergency response since something is very wrong at that point)

    It's the administration's responsibility to make sure the dispatchers have the proper tools to perform the job -- the right protocols, a CAD that can handle their City's needs, sufficient personnel for anticipated call volumes, electricity, phones, radios, etc. And back of my head questions if this was a "slip through the cracks" type problem with their CAD system...something the administration would be on the hook for...so it's easier to say the company missed the call.

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    My old dept had nothing hard and fixed. If the dispatcher didn't hear them responding in about 1 minute they would call them.

    However my current department and as recomended incidentally by NFPA (I can't recall the standard this minute) requires a postitive acknowledgement of the alarm to the dispatcher. Our Housewatchman must acknowledge within 20 seconds or the dispatcher will be calling via the Voice Alarm.

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    I dont know about anywhere else (so far) except for Malahat VFD, FireComm based out of Nanaimo who took over dispatch from Duncan Fire Dispatch will, once a page is made, wait 3-5 minutes before sending a 2nd page, and they identify it as a "Second page". If there is no answer they will automatically dispatch the next nearest station, which for Malahat is either Mill Bay or Shawnigan Lake, each about 10-15 minutes away. Not the greatest way perhaps, but it works better than nothing at all.

    To try and answer a question that was asked, to my knowledge DCFD is 100% career staffed. Not absolutely certain, but am reasonably so. And if you look at the city FD map, there are more stations here than I could ever shake a stick at. Someone is always close by.

    So the real question comes back to the dispatcher: If no one answered, was there a 2nd page, and if so, why was another unit not sent as backup?

    Purely from a technical point of view, it would be nice to get some solid answers. DCFD seems to be drawing a lot of bad press in the past few weeks. That can only mean that there are things in the background that aren't so good out here. Whatever it is, I hope they will be able to pull up their socks and get back to doing what we do... Helping out good people when things go bad for them.
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    I know our dispatch will be hollering on the radio if we're not up within a couple of minutes. And at that point they will retone, and send the next closest resource as well. Nothing hard and fast that I am aware of but an open incident with no response will get their attention. And our dispatch is not the best nor the brightest either. Too much reliance on computers instead of people in this case maybe?

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    Quote Originally Posted by BirkenVogt
    Too much reliance on computers instead of people in this case maybe?
    Maybe? No, almost certain. Here, there isn't a day that goes by when I don't hear

    "..All squads currently on air, monitor Fire Dispatch Frequency, the CAD is down.."

    Without the CAD running in our dispatchers office, they have no idea what is going on in the city unless they are listenting to a fireground frequency.
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    PFD, you must be from right around the corner...our CAD's always down, too.

    I must say, though, I think our dispatchers do a great job of juggling all the calls and keeping track of all the incident/command traffic. Gotta be a rough job.

    But, like many of you....if we don't respond "en-route" quickly, they'll come back and check on us, if still no response, they dispatch the next unit.

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    This sounds like a definite failure at the dispatch level...basic and simple fact, if the units had recieved the dispatch and been able to respond to the call, they would have done so. No mention is made of the crew being uinable to respond for any reason, which would have been a news story in it's own right had it been the case

    If the call was dispatched, and it wasn't acknowledged by the company the dispatcher should have attempted to contact the company, ascertain if they were responding or had missed the dispatch, and if necessary, dispatched the next closest available unit to cover the call.

    In every locality around the Richmond area, acknowlegement of the call is required, and an unanswered call will result in the dispatcher trying to contact the station (Or unit if it's in the district). If the dispatcher is unable to contact them, the next due company is dispatched to cover the incident. At the same time, steps would be taken to determine why the dispatched company didn't answer up. (And get them assistance if needed)

    My bet is that a similar protocol is in place in DC...this protocol just wasn't followed. The big question is, of course, 'Why?'.

    If the call was never dispatched in the first place, that is another set of problems of an equally serious...if not MORE serious...nature.

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    At my POC we have 5 mins to acknowledge the call..............then it is an auto retone. Where I work FT there are "flags" on CAD, units can use verbal, MDT, or SIMS to be enroute. At the pre-set limit the "reverse video" changes color on the CAD screen alerting us that the unit is not enroute. If this happens the unit is tried on the air and if there is no response then the station is called to verify they got the run, if it is a single company then another is dispatched until the original is found. It is NOT that hard.
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    Montgomery County Fire Rescue Services in Montgomery County, MD (right outside of DC) Dispatch Protocols state that a response check is made @ 1 minute from dispatch, the unit is replaced @ 3 minutes, and "failed" @ 5 minutes.
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    I'm starting to wonder if this call was amongst many others that were being taken at the same time, if this one was dispatched and just forgotten about.
    Last edited by pfd4life; 04-20-2006 at 02:20 PM. Reason: I'm a retard with grammar.
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    We are required to carry our portable's at all times while on duty, so even if the voc alarm fails we still receive the calls. You would think in a city like DC the officer sould have a radio near by just to be aware of what's happening in the district?

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    Quote Originally Posted by pfd4life
    I'm starting to wonder if this call was amongst many others that were being taken at the same time, if this one was dispatched and just forgotten about.
    If that was the case then the call was still recorded by the 911 Center and if not logged in and sent to be dispatched falls on the call taker for the error.

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    Every riding position in D.C. has a portable radio, hence all personnel have a radio. Each station has an alerting system. A watchman is posted at the "watchdesk" 24/7. The facts have yet to be released pending further investigation. You may feel free to speculate.

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    Quote Originally Posted by OffBase
    You may feel free to speculate.
    Thanks for your permission It's seeming to be that everything is pointing more and more at the dispatchers.
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