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Chapter Overviews
Chapter 1: The
First, First Responder
Emergency Medical Dispatch is the jewel upon which the watch movement
of public safety turns.
—F. Hurtado
Overview
This chapter lays the groundwork for understanding the complex role of
the Emergency Medical Dispatcher (EMD) as the "first, first responder."
EMDs have the potential to make the difference, literally, between life
and death, through proper application of the principles described in this
book. The EMD's specialized skills and equipment can minimize the risks
faced by field personnel and enhance the quality of patient care.
This chapter describes the many purposes of emergency medical dispatch.
It includes the broader historical and anecdotal perspective and research
collected since this book's first edition. It also summarizes the reasons
the EMD system has become the national standard for emergency medical
dispatchers.
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Chapter 1
Subheadings
- The International Standard
- Impact on Quality Patient Care
- Impact on the EMD
- Impact on Prehospital Providers
- Impact on Equipment
- Impact on the Community at Large
- Profile of EMD Duties
- Misconceptions and the Facts about EMD
- Medical Control and the EMD
- The Spock Principle
- Traditional Roadblocks to Change
- The EMD as a Medical Professional
- Summary: A New Era in EMS
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Chapter 1 Case Studies/Reports
- Time Interval: Vehicle-at-Scene to Patient-Access
- My First Experience with Emergency Medical Dispatch, by Don McCoy
- Bill Toon Recalls Giving the First Recorded Pre-Arrival Instructions
- A Failure to Communicate
- The "Time Standard" Dinosaur at Dispatch, by J. Clawson, M.D.
- Does It Take More Time or More Control Staff?
- Statistical Information from EMVC Study
- Patient Care Routines for EMD and EMS
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Chapter 2: Basic
Telecommunication Techniques
Remember not only to say the right thing in the right place, but, far
more difficult, to leave unsaid the wrong thing at the tempting
moment.
—Benjamin Franklin
Overview
Few people are really talented at telecommunication. Even for those who
are, it requires practice and dedication to organize and process multiple
simultaneous tasks. The basic roles and responsibilities of an EMD include
telephone interrogation, radio dispatch, prioritizing responses to emergencies
that compete for time and resources, logistics coordination among crews
at various settings, resource backup, and long-distance lifesaving via
pre-arrival telephone instructions.
Dispatch centers vary. Some assign different people to each function;
others have only one person to perform all functions. Some centers are
handled by volunteers. Regardless of the setup, the EMD must always strive
to behave in the most professional manner possible.This chapter outlines
basic telecommunication techniques for radio and telephone operations.
It includes tips for beginners and experienced dispatchers. After all,
a professional knows there is always more to learn.
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Chapter 2
Subheadings
- Six Roles of Telecommunication
- Specific Telephone Techniques
- Strategies for Good Telecommunication
- Special Caller Situations
- Inappropriate EMD Activities
- Communication and Coordination Between Agencies
- First-Party Gone-On-Arrival Situations
- Dispatch Overload
- Mass Casualty Incidents
- Summary
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Chapter 2 Case Studies/Reports
- Five Tips for Working with Children
- An Example of Second-Guessing the Caller
- Creating a Policy for Gone-on-Arrival
- Confidentiality in Emergency Medical Despatch, by Brett Patterson
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Chapter 3:
Structure and Function of Priority Dispatch
Everything should be as simple as possible, but not simpler.
—Albert Einstein
Overview
This chapter describes the theories and concepts underlying the Medical
Priority Dispatch System®. It is the basic anatomy and physiology,
the underlying machinery, of priority dispatch.
The goal is to provide a clear map of priority dispatch to anyone involved
in system implementation, on-line use, and management. These people need
to understand what EMDs do and why.
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Chapter 3
Subheadings
- Basic Priority Dispatch Anatomy
- Principles for Getting Started
- Understanding ECHO Determinant Practice
- Principles Related to the Dispatch Protocol
- Quantity vs. Quality: A Lesson in Understanding Priority Symptoms
- Safety Features
- Understanding Determinant Terminology
- Avoiding Response Code Confusion
- Telephone Instruction Theory
- Case Completion Theory
- Summary
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Chapter 3 Case Studies/Reports
- Medical Miranda—Extending Priority Dispatching to Law
Enforcement
- Breakdown of Caller Party
- Analysis of Caller Party in Traffic Incident Cases
- Complaints vs. Chief Complaints
- Chief Complaints by Protocol Type
- "Sick Person" Call
- Chest Pain Call: Quantity vs. Quality
- An Example of Response Configuration—How One System Does It
- Tualatin Rural Fire Protection District Priority Dispatch Implementation Study
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Chapter 4: Dispatch
Life Support
I get by with a little help from my friends.
—Lennon and McCartney
Overview
Dispatch Life Support is the body of information and methods used by EMDs
to help callers deal with a wide range of patient and scene circumstances.
The scripted protocols enabling this crucial exchange of information lead
the EMD through a verifiable, comprehensive process that eliminates the
chance of inadvertent omissions of vital information.
The procedures include some variations from hands-on cardiopulmonary
resuscitation. These have been carefully modified and approved by the
Academy's Council of Standards to enable the EMD to transmit material
safely via the unique telephonic setting.
The Pre-Arrival Instructions found in the current Medical Priority Dispatch
System® (MPDS) represent a quantum leap in development and design over those
described in the first edition of this book.
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Chapter 4
Subheadings
- Standards That Work
- Who Should Give Pre-Arrival Instructions?
- Pre-Arrival Instructions
- Unique Concepts of Dispatch Life Support
- National Standard of Practice
- Example of a Dispatch Life Support Protocol
- Protocol Y: Tracheostomy
(Stoma) Airway/Arrest/Choking (Unconscious)
- Protocol Z: The AED Support
Protocol- Protocol X: The Exit Protocol
- Danger Awareness
- Summary
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Chapter 4 Case Studies/Reports
- Example of Tendency to Follow PAIs Verbatim
- What's Wrong With "Telephone Aid" (excerpt from NIH position paper on EMD)
- Automated External Defibrillators (AEDs): Background, Research, and a New Protocol, by Robert Sinclair, Ph. D.
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Chapter 5: Caller
Management Techniques
You can only see a thing well when you know in advance what is going
to happen.
—John Tyndall
Overview
The EMD's objective is to gain control of each telephone call so the situation
can be handled efficiently—while obtaining the caller's confidence
and conveying a consistent impression of compassion. Of all the EMD's
tasks, controlling telephone interrogation can be one of the most trying,
but also at times the most rewarding. This chapter describes a series
of predictable caller behaviors that can interfere with the EMD process
and innovative ways to handle them effectively.
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Chapter 5
Subheadings
- Don't Shoot the Messenger
- Hysteria Threshold and Repetitive Persistence
- The Bring the Patient to the Telephone Problem
- Re-Freak Events
- The Nothing's Working Phenomenon
- The Relief Reaction
- The Paramedics Aren't Coming Notion
- The Gap Theory
- Customer Service is Patient Care
- Summary
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Chapter 5 Case Studies/Reports
- Phoenix Call—Baby Not Breathing
- Rules for Applying Repetitive Persistence
- The Use of Repetitive Persistence, by Jose Estavenall
- Phoenix Call—Baby Fell in Pool
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Chapter 6: Medical
Conditions
When you have eliminated the impossible, whatever remains, however
improbable, must be the truth.
—Arthur Conan Doyle
Overview
This chapter guides the EMD through an assortment of ailments underlying
the priority dispatch decisions that have to be made. This chapter focuses
on medical conditions. It shares information about physiology (how the
body functions) and pathophysiology (how the body gets sick); prehospital
needs and considerations; and "the pearls" involved in providing
out-of-hospital care for sick people. The specific identification of the diseases underlying many of these
medical problems is difficult to do even in a fully equipped hospital.
Learning and applying the concept of priority symptoms (rather than diagnosis)
and mastering the dispatch (rather than EMT, QAO, or paramedic) objectives
for each Chief Complaint is a paramount goal of this chapter.
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Chapter 6
Subheadings
- Protocol 1: Abdominal Pain/Problems
- The Age Factor in Chest Pain
- Protocol 10: Chest Pain (Non-Traumatic)
- Protocol 19: Heart Problems/A.I.C.D.
- What Constitutes a Cardiac History?
- The Aspirin Diagnostic and Instruction Tool
- Aspirin Questions and Academy Answers
- Protocol 26: Sick Person (Specific Diagnosis)
- Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma)
- Protocol 2: Allergies (Reactions)/ Envenomations (Stings, Bites)
- Protocol 20: Heat/Cold Exposure
- Protocol 23: Overdose/Poisoning (Ingestion)
- Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt
- Protocol 13: Diabetic Problems
- Protocol 12: Convulsions/Seizures
- Protocol 18: Headache
- Protocol 28: Stroke (CVA)
- Protocol 33: Transfer/ Interfacility/Palliative
Care
- Protocol 35: Health Care Professional Admission (UK only)
- Summary
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Chapter 6 Case Studies/Reports
- Ten Year Incidence of Myocardial Infarction Among 2,282 Men and 2,845 Women at Risk
- Death Rates From Acute Myocardial Infarction
- Poison Control and the EMD, by J. Clawson, M.D.
- A Call to Remember, by Franz Malcher
- Excerpt from a Hanging Case in the United Kingdom
- Should Pediatric Febrile Seizures Be Treated Over the Phone?
- Using EMD for Acute Stroke Identification—Official Academy
Position Statement, by Robert Sinclair, Ph.D., and J. Marler
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Chapter 7: Trauma
Incidents
When you're confused, beat up and hurting, nothing feels as good as
some calm, capable, credible, concerned person paying attention.
—Alan Brunacini
Overview
Many dispatchers perform their jobs without basic emergency training or
practical experience with emergency medical problems. EMDs, as part of
the emergency medical team, need a special familiarity with medical principles.
Murder, mayhem, and a meaner society places the EMD electronically at
the scene of many difficult and sad situations.
The purpose of this chapter is to introduce information related to this
element of emergency care—trauma (or injury).
This chapter is valuable for EMDs who have training and experience in
prehospital care; it is essential for those who do not. Information is
presented from the dispatcher's perspective, not that of field personnel.
There are important differences.
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Chapter 7
Subheadings
- The Mechanism of Injury
- Protocol 30: Traumatic
Injuries (Specific)
- Protocol 21: Hemorrhage/Lacerations
- Trauma Due to Assault
- Protocol 4: Assault/Sexual Assault
- Protocol 27: Stab/Gunshot/Penetrating Trauma
- Protocol 17: Falls
- Protocol 3: Animal Bites/Attacks
- Protocol 16: Eye Problems/Injuries
- Protocol 7: Burns (Scalds)/Explosion
- Protocol 22: Inaccessible Incident/Other Entrapments (Non-Vehicle)
- Protocol 29: Traffic/Transportation Incidents
- Protocol 34: ACN (Automatic Crash Notification)
- Summary
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Chapter 7 Case Studies/Reports
- Short by a Measure:
Burn Size Assessment, by Hammond and Ward
- The Energy Within,
by Brian Dale
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Chapter 8: Time-Life
Priority Situations
Listen to the newborn infant's cry at birth—see the death struggles
in the final hour—and then declare whether what begins and ends
in this way can be intended to be enjoyment.
—Soren Kierkegaard
Overview
Critical priorities are estimated by outcome to be about 5 to 10 percent
of the emergencies that are telephoned in to EMS systems. That adds up
to a large number of people worldwide needing time-critical or lifesaving
assistance every year. The Medical Priority Dispatch System® identifies
nine situations in which a problem poses an immediate time-critical or
life-risk possibility to the patient. Some are medical in nature, others
are due to trauma.
Time- or life-critical calls represent some of the closest emotional
ties the EMD will have with callers. This can generate a lot of pride—but
sensations of frustration as well. Clearly, priority dispatch (especially Dispatch Life Support) has an
impact on patient survival. The EMD can make a difference! However, there
are losses. In cardiac arrest of all types, the average save rate is less
than 1 in 10. To win is to beat the odds! The EMD should not expect to
save every life. Priority dispatch provides the potential to save lives,
but does not guarantee success every time. EMS is a best-efforts ball
game; the win/loss score must not be allowed to define the quality of
those efforts.
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Chapter 8
Subheadings
- Protocol 24: Pregnancy/Childbirth/
Miscarriage
- Protocol 9: Cardiac or Respiratory Arrest/Death
- Protocol 11: Choking
- Protocol 14: Drowning (Near)/Diving/SCUBA Accident
- Protocol 6: Breathing Problems
- Protocol 15: Electrocution/Lightning
- Protocol 8: Carbon Monoxide/Inhalation/
HAZMAT/CBRN
- Protocol 31: Unconscious/Fainting (Near)
- Protocol 32: Unknown Problem (Man Down)
- Summary
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Chapter 8 Case Studies/Reports
- Making a Difference in Wales, by Robert Bevan
- I Think My Wife Has Died
- Choking on a Marshmallow
- Hendon Case
- Percentage of DELTA Codes in Unknown Problem Cases
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Chapter 9: Scenarios & CDE
Practice what you know and it will help to make clear what now you
do not know.
—Rembrandt
Overview
In this chapter, each of the various types of priority dispatch protocols is demonstrated
in full, from Case Entry (initial assessment), Key Questions (ongoing
assessment), through dispatch of resources and, where applicable, Dispatch
Life Support to case completion. The protocols chosen for demonstration
are:
1. The Trauma protocol, 7: Burns (Scalds)/Explosion (Blast).
2. The Medical protocol, 23: Overdose/Poisoning (Ingestion).
3. The Time-Life protocol, 31: Unconscious/Fainting (Near).
4. The SHUNT protocol, 22: Inaccessible Incident/Other Entrapments (Non-Vehicle).
The Academy's method of continuing dispatch education (CDE) is highlighted
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Chapter 9
Subheadings
- Trauma Incidents
- Medical Conditions
- Time-Life Priority Situations
- SHUNT Situations
- Continuing Dispatch Education
- Summary
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Chapter 9 Case Studies/Reports
- New Methods in Continuing Education
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Chapter 10: Stress
Management in Dispatch
Dispatchers' First Rule of Randomness:
Emergency calls will randomly come in all at once.
—Unknown
Overview
Dispatching is very stressful work. Anyone who has done it knows vividly
how the hot seat feels. Shifts that begin with a bang and never slow down
can leave the EMD feeling drained and slightly bruised, if not totally
battered. On the other hand, in slow times, waiting hours for a call can
be hard in its own insidious way.
This chapter addresses stress and its negative effects. It focuses on
the stressors unique to the dispatch office and offers the EMD an understanding
of the way stress can build to unhealthy levels.
It also describes various strategies to recognize and cope with stress.
Half the battle is learning to admit that over-accumulations of stress
exist. The other half is learning to manage stress appropriately.
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Chapter 10
Subheadings
What is Stress?
Stressors Unique to the EMD
Signs and Symptoms of Distress and Burnout
Managing Distress and Avoiding Burnout
Critical Incident Stress
Summary
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Chapter 10 Case Studies/Reports
- Four Hallmarks of Distress
- Diagnostic Criteria for Major Depressive Episode
- The Seven Most Stressful Calls
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Chapter 11: Legal
Aspects of EMD
The point is, while your dispatching personnel express anxiety over
the possibility of liability for providing such a service, we may well
see the day when a municipality faces allegations of negligence for not
providing such a service.
—James O. Page
September 28, 1981
OVERVIEW
This chapter summarizes legal issues surrounding EMD and the Medical Priority
Dispatch System®. First, a common framework is provided through the
presentation and definition of relevant legal terms and principles. Certain
areas of medical dispatching which have tended to attract legal attention—"dispatch
danger zones"—are presented in full, along with recommendations
for minimizing vulnerability to lawsuits. Several hallmark legal case
call transcripts are presented and evaluated.
Since the inception of priority dispatch, many states have generated
regulations, certifications, and immunity statutes in support of the concepts
that have evolved into the standards of priority dispatch and Dispatch
Life Support.
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Chapter 11
Subheadings
- Legal Terms and Definitions
- Dispatch Danger Zones
- Insurance Aspects of EMD
- Emergency
Vehicle Collisions
- Development of State
Regulations for EMD
- Two Simple Safeguards
- Summary
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Chapter 11 Case Studies/Reports
- The Maximal Response Disease, by J. Clawson, M.D.
- DeLong vs. County of Erie, Findings
- Archie Case
- Lam Case
- Dale Case
- Follow the Protocol and Avoid Liability, by J. Clawson, M.D.
- Caller "Refusal to Provide Dispatch Life Support"
Example
- Please Don't Ask Permission, by J. Clawson, M.D.
- Brooke Hauser Case
- Ellis Case (partial transcript)
- Boff Case
- Hendon Case
(partial transcript excerpt)
- BLS Response Times: 1997 (HOT) vs. 1998 (COLD)
- From Dumb to Dumber, by James O. Page
- EMD Risky Business, by Fred Hurtado
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Chapter 12: Quality
Management
We must touch his weakness with a delicate hand. There are some faults
so nearly allied to excellence that we can scarcely weed out the faults
without eradicating the virtue.
—Oliver Goldsmith
Overview
This chapter reviews essential functions that constitute a comprehensive
and effective quality management program. Unlike various other EMD programs
that may include training and the discretional use of a set of interrogation
guidelines, priority dispatch is a structured systems approach to Emergency
Medical Dispatching. Priority dispatch includes the most advanced quality
management process in EMD as well as in EMS and public safety in general.
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Chapter 12
Subheadings
- Eleven Components of a Comprehensive Program
- Prospective Activities
- Concurrent Processes
- Retrospective Evaluation
- Compliance Improves Determinant Correctness
- Does Compliance Improve the Caller's Emotion?
- Review and Steering Committees
- Data Collection, Analysis, and Feedback
- Quality Management Improves Compliance
- Suspension, Decertification, or Termination
- How EMD Works Best
- Necessary Infrastructure
- On-Line Use
- The Feedback Process
- Risk Management
- The Goal of Quality Management
- Summary
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Chapter 12 Case Studies/Reports
- EMD Entry-Level Selection Criteria
- Academy Minimum Case Review Standards
- A Real Tough Time Breathing
- Los Angeles City Fire Department Protocol Compliance Data
- The Impact of a Comprehensive Quality Management Process on
Compliance to Protocol
- Guidelines for Risk Management in an EMD Quality Assurance Program
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Chapter 13: The
Evolution of EMD
The art of progress is to preserve order amid change and to preserve
change amid order.
—Alfred North Whitehead
Overview
The genesis of EMD processes used by medical dispatchers to interrogate
callers and determine the need for Dispatch Life Support and system response
was occurring in several locations simultaneously in the 1970s. At that
time, new pressures resulting from increased availability and use of 9-1-1
in the EMS and public safety environment served as the catalyst needed
to change inefficient and unsafe dispatch practices. The growing demand
for modern emergency medical services has continued to fuel this process.
This need to evolve has effectively called the question to choose between
either a disarrayed, every-system-for-itself future versus a unified standard.
Using a scientific method-based evaluation and change process, the National/International
Academy of Emergency Medical Dispatch grew to manage a full range of medical
dispatch standards as the preeminent professional organization for EMD
worldwide.
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Chapter 13
Subheadings
- The Critical Selection
of an EMD Program
- Evolutionary Dead End—Protocols
Without Process
- The Evolution of Organized
Standards for EMD
- The DNA of Dispatch—Origins of the College of Fellows
- Gene Sharing and Protocol Sharing—The Unified
Protocol Model
- Birth of the Pre-Arrival
Instruction Grid
- Summary
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Chapter 13 Case Studies/Reports
- How I "Discovered" the Protocols, by J. Clawson, M.D.
- Unstructured Discretionary Interrogation Case
- Frequency of Questions Asked, CBD versus MPDS: Sheffield Study
- Factors Resulting in EMD Evolutionary Dead Ends
- Birth of the Pre-Arrival
Instruction Grid, by Michael Wayne Smith
- National Academies
of ED Organization
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Appendix
Information is the reduction of uncertainty.
—Bill Gates
National Academy Mission and Goals
Our mission is:
"To advance and support the Emergency Medical Dispatch
professional, and to ensure citizens in need of emergency, health, and
social services are matched safely, quickly, and effectively with the most
appropriate resource."
Our goals are:
"To use and promote the fundamental principles of a
scientific method in the pursuit of the mission."
"To advocate a single, scientifically defensible protocol which becomes the
unifying standard under which all professional Emergency Medical Dispatchers
practice."
"To advance professionalism within the dispatch community by establishing
and promoting an ethics policy as well as minimum standards for curriculum,
instruction, certification, recertification, and accreditation of centers."
"To provide opportunities for members to improve themselves and their
organizations through facilitation of communication, providing comprehensive
information resources, and creating high-quality training and continuing
dispatch education through seminars, publications, and other media designed
to meet our members' needs."
"To establish and promote a collegial, research-based culture that welcomes
the expertise of many disciplines through the creation of standard
committees, task forces, and subgroups that reach out to other
organizations and advise the Academy."
"To be recognized as the authoritative, independent voice that represents
the Emergency Medical Dispatcher and enhances the profession."
Appendix
Subheadings
Appendix
SUBHEADINGS
- Appendix A: The National Academy of EMD Ethics Policy
- Appendix B: Protocol Information
- Appendix C: Legal Documentation
- Appendix D: Emergency Numbers Around the Globe
- Appendix E: Acute Myocardial Infarction Data
- Appendix F: EMSA Data
- Appendix G: Derbyshire Ambulance Services Data
- Appendix H: 9-1-1 Transfers to the Utah Poison Control Center
- Appendix I: National Institutes of Health EMD Position Paper
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- Appendix J: EMD for Children NHSTA Position Paper
- Appendix K: Unnecessary Lights-and-Siren Use
- Appendix L: Model EMD Legislation & Rules and Regulations
- Appendix M: Modified Cardiopulmonary Resuscitation (CPR) Instruction Protocols for Emergency Medical Dispatchers: Rationale and Recommendations
- References
- Glossary
- Index
- Quality Assurance Forms
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rights reserved.
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