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Ocean City Department of Emergency SeruicesCommunications Division

6501 Coastal HighwayOeean City, Maryland 21.842

Crltical Incident Og OOF

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c on october 3, 2009 Pco III ]o Ann Eurbage notified captain Eric Peterson of timestamp disgepancies in the CAD repoft for Incident 09-04966. She also contactedDivision Supervisor Guiton via telephone to report same.

o The Investigatlon of this incident was prompted by Captain Petersont memo toChief Bafton notifying hirn of the time stamp issue. trnvestlgatlon was not promptedby any complaint from OCFD or oubide party having intercst.

. October 5, 2009, per request of OCFD Career Division, tape recordlng of the 911emergency telephone call related to the incldent was produced and given to same.

o Internal Critical Incident Investigation conducted and completed by October 6,2009. The facts of the case are as follows:

-n The Initial call for service was received at L7221:17 hours. Burbage answeredthe incoming call and stayed on the line with the caller for 7 minutes 10seconds obtaining information before turning the call over to Blue to handleCPR instruction. The complainant was not able to provide a correct addressfor her location fior a period of two minutes. One an accurate location wasprovided questions conceming the patient were then asked. The complainantreported that her brcther-in-law was unconscious in his boat docked in backof the rcsidence. She dld advise that he was breathlng but unconscious.

n At L7:23:60 Burbage advises the complainant tlrat she is''...going to sendparamedlcs.'

I While speaking to the complalnant who was panic-stricken, at 17:25:00Burbage states oMam... Marn... Mam...I need the answers to these questionsand the paramedlcs ane on their way."At 17:25:43 hourc Burbage announed the Emergency Medicat Call fur anunconscious subject and dispatched Paramedic I or 1-l and C47 to the call.At 17:26:07 Paramedic 1 and C47 acJcnowledgd the call.At 17:26:09 the complainant advised that the patient was not breathing andagked Burbage to tell her what to do. Burbage advlsed her to get him out ofthe boat and flat on hls back, Untif Blue takes control of the cail thecomplainant @ntinues to request information to help the patlent and tellsBurbage to hurry,At 17226224 Burbage advise Paramedic 1-1 and C47 that she is upgradlngthe call to CPR in Progress and the subject has stopped breathlng.

L7226256 Paramedic 1 advises they are responding.17t27t22 Paramedic 1-1 advises they are respondingAt L7t27:25 can hear Burbage telling Blue to take over the call to provideCPR instruction to the caller.

n Engine 16 announces that they are on 4 at L7:27:5A hours.E At 17:28:02 Chief 51 tells Burbage that the call !s a Silent Alarm response.

Burbage replies with, *10-4, I'm trying to get it now, she's scrcamin, in myear so we're tran#erring call takerc."

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AttT:28;22 Blue takes over the cail and provides CpR Instruction.L7:28t39 Burbage announces the call as a silent alarm for cpR in prcgress,

Paramedic 1 arrivs at L7229:33Faramedic 1-1 arrives atLT:29137Chief 51 advises that he is responding at L7zZ9:SSAt 17:30:32 the telephone cafl is terminated.At L7t32:32 c47 advises that he has command arrd Engine 16 is on sceneChief 51 is on scene at 17:33:58AILT:44252 command advises that evefihing is under control and thepatient is being transported to,$lantic.

r November 10, 2oo9, meeting was afrended by Director Theobald, DivisionSupervisor Guiton, Chief Barton and Chlef Larmore.

o November L2,2009, Mrs, Jacquetlne Rehmann, widow of the deceased, made arequest via email for a copy of the 911 telephone call related to the case,

o November L4,2009, recording was produced per Rehmann's request and sentcertified mail, Package contalning the cD was reeived by comptainant on

November 19, 2009 at 1511 hours.r Direcftor Theobald attempted to contact Mrs. RehmaRR several tlmes after the CDwas received with negative results. Messages were left on Mrs. Rehmann's voicemail however no calls were ever retumed.

r JanuErY 13,20LO, Director Theobald met with City Solicitor Guy Ayrcs to discussthe facts of the case.

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There is no current national standard for processing an Emergenqr Medicalcafl br seruice. PrioriW Dispatch, our Em6rgency t'iedical Dispatctr protocolprovider, does not commit to a standara procesiing flme.Tfie following is an excerpt from the Emeipency turimuei FrofessionalMagazine:

CaII hocasing TbneRoryw defined, the callprocessing time is tke elqsedtimefron themoment an eftrergency call is received at the g-I-I center, mfit the closestcnailoble responfur crew(s) has been notifiedwith all incidentinfornetion neceswryt to respond rhe National Fire protectionAssociation (IWPA) has pub lisFwd a di spatch stwdard for t)- I - I errdemergency call proceffing ttwt covvrsfire adfiItfi slte Ihe stmdardstat:s: ',Ninety-fu9-ryrcent of emergenqt &spatching sltolt be cornpleted

, within 60 seconds.' Yet, otEresent, noresearih or etrptrtul dda;tcist to.,!:i' "

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.MpIWtqrn slwrfud,

{s*4 tirW s/ro?dar4 or,,even tefi#twetly what ttwt\here is no establisledcorrwction between slprter

(Nerage cal! :Froce syig.time s

_wd favorable case outcames.

In fact,gJ

- Iery,EB ("W&liEffi&b'iHiffifur agg,ryils crcross ttie eoith$, " -*ytsatltft'p6ri'iFh\ avast mqjority oltheir cases ate,not,life . ,.,,r

tlrdatening qtd even not time+ritical. In reality, ffie perceptian tlwt

r€qrorrse tactics reslt in perhqs lwn&eds of lawwits a yeq.

Ddamking C,all-hocasing TimeI*tbfirst consider how processing time is being meanred. olderteclwologies, ircluding nary computerized disptch systems still in use,do rct always time*tmnp cases as initiate{ * ,ott ed, until the qd*essor exact location has b-eenverifiedin the system,s master streetsfile. Thatdiseowfis a Mbstattial mown of elrysed-time, incfuding tte ttnie it takesthe call taker to qtsrver the phone, ta enter the ad&ess ir location ln the$yten mdverify it electronically. Afuess verfication alone, cwt easilytalre one mimrte or more when a confusvd eailer lws dificutty providingan eract locatior+porticululy if enhared g-I-I im,{used or ovato{te,

seconds cotmt or seconds swe lives is true only in a wattjlactton of totatreported coses of spcifu hrcident twes rTere is alnost ienaffiy ia^nnside for agencies tlwt plaee a disproportiorute value on time ad speed:inflaible and obitrry fime stoMs may cause g-IJ mll takeri to tafuhasty slrcrtarc with esablished protocol md procedures, irureMngefors, mdjeoprdiztng tlrc $ety of aresporae. Witness thediscorcertingfact thst tlare se iamerous tau,wits agoinst dispatchagercies for respony;time & lays fue n

failweto piper ly reiord ard

verify the corect d*ess af an incideni accidentidi to Imrried

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Since there is no established standard for call processing we must use our ownpensonnel as a berchmark to evaluate whethenthe call taking process relatedto this incident was handled within an acceptable amount of time. Afterrunning a cAD call Taker Average Time [eport the average time forprocessing the described catls ar€ as foilows:

IINCONSCIOUS FAINTING 000:01:33BREATIIING PROBLEMS 000:01:36IIEART PROBLEI\,IS AICD 000:02:07CARDIAC OR RESPIRATORY ARREST 000:02:59

JEMS.COM article states:

Response tirru stersderds - &n atban rnyth?No tmiversally accepted response-time system requirenent exists,Irowever, in urban ffeas, the most widely used qnbulance response-timestwtdudis eight miwtes @d sg secords (g:s9),with g0%cinpliwece

reliability - measned on afractile, not emerage, basis (Fracitereqtonse time weamrement includes a reliabilityfactor atdmea&sres elltine interuals between the fime the semice receivedenottgh information toinitiete a response md the time aproperly eryippedand-st@edambulqtee wrives on seene,)

lltis s:51 tsget is consistefiwith the reryorae tine recommerded by theNational Fire Protection Associationwhin adjasted to include call-'processing time. (NFPA 1710, ss,3.s.4.2, reEtires cannnmittes to'prwidefor the mival of anALS within qn miwtere sponse time to 9 A %o of inc idcnts,r*ffi1:rc.P,A:,,WErffi:Itfrd:Wffiiil r; "dd;;;; a recent suraey of the 200 mostwwlotrs cities in anericafotd thst more than tfuei,.qAffturs fTrQ ofthe wrwy respondenys re?nrt a ttrget of g:s9 or less uttng *e jr*tittrneqsurement methd (Februay 2005 JEMS)