Partners in Stress

Some systems are built to inspire conflict. Democrats and Republicans. Boston Red Sox and New York Yankees. 9-1-1 dispatchers and field crews. 

Almost everyone who has worked in emergency services for longer than the pandemic has heard a bit of snippy, sarcastic radio traffic or in-person communication. A circa-1980 conversation between a dispatcher and a paramedic in the Midwest highlights the issue:

Paramedic (slamming a cold Big Mac with one bite taken on the desk): Well, I hope you had a hot lunch. 

Dispatcher: Well, yes, I did. Thank you very much.

Of course, you can’t see the facial expressions or hear the tone of voice. If you could, it would inspire you to pull your children behind you for protection.

Our three organizations—FirstWatch, the International Academies of Emergency Dispatch, and EMS World—set out to learn about the current state of dispatch and field crew relations. We started by inviting respondents to answer a survey asking dispatchers about the kinds of things field crews do that cause them stress, and vice versa. We asked field crews what dispatchers could do to decrease their stress and vice versa. We also asked both groups what they could do to improve the relationship. We interviewed some of the respondents to get an in-depth perspective. 

We got responses from 73 dispatchers and 156 EMTs/paramedics. The results were enlightening.

Views From the Dispatch Center

Emergency dispatcher comments to the survey did not paint a glowing portrait—quite the contrary. An overwhelming majority—84.9%—clearly indicated the relationships between dispatchers and responders traveled a bumpy road, with lots of potholes.

They are partners in stress.

Emergency dispatchers don’t complement the EMS chain of command—at least that’s their view from inside the communication center. An attitude of dispatch happening outside the EMS circle, rather than alongside, culminates with “some officers and firefighters seem[ing] to think it is OK to belittle and be smart-alecky, thinking it’s cute or garners them points with other officers,” according to one survey respondent.

Or, in a more negative perception, “[Field crews] are condescending and treat us like we’re stupid.”

A failure to understand—or even try to understand—the process followed inside a center is a prevailing roadblock in creating solid relationships, according to the survey: “Partners in the field want to question everything from dispatch. They don’t understand how it works.” A lack of two-way communication and underappreciation of dispatch confounds the situation. Field crew perception that dispatch is “out to get them” adds to the “confusion, inconsistency, and disruptions in service.”

Stress spinning off from frustration, impatience, and snarky behavior, however, does not diminish the shared belief in the importance of their work. The survey made that clear. Respect, acknowledgement, appreciation, collaboration, and realizing “our job duties are very different but equally valuable” go a long way to patch up grievances and pave a smoother road to successful working relationships: “We are a team.” “We complement one another.” “Be patient.” “Remember dispatch is [your] coworkers. We don’t send them to calls to be jerks, we are doing our job and asking they do theirs.”

The lack of comradery—while not universal—is rooted in change, or so it seems. Consolidation. Expectations. Moving at a pace without the “wiggle room” to understand what the other is doing.

Suzanne Fitzgerald, EMD, head trainer for learning and development with the South Western Ambulance Service NHS Foundation Trust (SWASFT) in Bristol, England, started her EMD career 19 years ago in a county dispatch center. The crew would go on a call, give dispatch feedback, and greet each other by name in the hallway. Over the years the small county centers merged into larger and larger centers, to the point where SWASFT now provides services for a fifth of England (six counties and the Isles of Scilly), employs more than 4,000 staff members, and manages 96 ambulance stations, three clinical control rooms, six air ambulance bases, and two hazardous-response teams. 

Fitzgerald attributes the fracture in working relationships to growth and size, not the people doing the jobs. She compares it to growing up in a small town that morphs into a metropolis.

“It’s not so much a friction between people but a loss of connection,” she says. “As time goes on and things get bigger, people stop knowing each other so well.” 

Rather than calling quits to connections, Fitzgerald suggests using technology to bridge the gap between communications and field crews. For example, an online photographic yearbook—like the ones U.S. schools produce for their students—could tag names to faces. The names and faces would appear on the dispatch and ambulance screens on every call and subsequent assignment.

“I could walk by someone in the hub and give a hello if I knew we’ve communicated over the radio,” Fitzgerald says. “I would know the face—simple as that.”

The connection extends inside SWASFT’s two communication hubs, she says. While COVID restrictions have interrupted the development of closer ties between veteran and new dispatchers, she looks forward to conversations about the part of dispatch that isn’t taught or subject to certification.

“EMDs are professionals. We are experts in helping others,” she says. “It’s important that we develop trust: trust in our callers. Trust in our responders. Trust in each other. These are the types of conversations we need to have.”

Melissa Sawyer, EMD, senior communication specialist for Northwell Health in New Jersey, learned firsthand about trust in EMS following an auto accident that nearly claimed her life. In 2004 the then-17-year-old Sawyer was ejected from her car and declared clinically dead when the ambulance crew arrived. She credits the EMT for both saving her life and guiding her choice of a career. After a year in recovery, she signed up for EMT training.

“I heard my calling and answered it,” she says. “I knew this is what I had to do.”

Five years on the road with a private ambulance company, and Sawyer applied for a dispatch position at Northwell Health. Inside operations were new to her, though she quickly settled into the concept of helping before the EMT shows up. She specializes as a flight follower and radio operator. 

From experience on both sides of emergencies, response and dispatch, Sawyer understands the components of good working relationships. The EMT perspective lends to providing crews the details of the situation they’re walking into. The dispatcher perspective sharpens her situational awareness—what she can sense about an incident or individual even if not directly told.

Sawyer’s team’s shared situational awareness takes into consideration the needs of response. She leaves a space to discuss their concerns: Fatigue. COVID. Behavioral situations they might encounter.

“I know what it’s like not to know what’s going on,” she says. “I also know the stress of not physically being there to help. The big cheese happens with the PAIs [prearrival instructions]. They’re huge when it comes to helping the patient before EMTs arrive and letting them know more about the patient’s condition.”

The stress levels attributed to COVID for dispatch and response personnel add to the importance of trust, she says.

“People are dying while on the phone over and over again,” she notes. “Nothing prepared us for this. We’re doing our best, knowing what we do betters the chances of our patients.”

Mike Fallow, EMD, emergency communications officer with Alberta Health Services in Canada, also worked the street before going into emergency dispatch. He is a volunteer firefighter for the Peace River Fire Department, now going on 17 years. The combined experience, he says, contributes to his understanding of the two-way partnership.

“It’s a matter of trusting that the other knows their job,” Fallow says. “EMS reacts to what it sees. Dispatchers react to what we hear or ask. We have the protocol to guide us. It would be impossible to help people without all of this working together.”

While patience, trust, and mutual respect go a long way in repairing and improving working relationships, actions also contribute to the harmony. 

Several dispatchers recommended inviting crews to stop in the communications center to put faces with voices. Ride-alongs in the ambulance, crews spending an hour in dispatch, training and education, and allowing time to ask questions and voice concerns while not in the heat of the moment were also cited as potential game-changers. Others suggested speaking at a normal rate and repeating information slowly and calmly, without letting emotions or an exasperated sigh get in the way.

Then there’s the matter of addressing the root problem. Rather than ignoring a troublesome situation, go to the source. “Ask them what their issues with dispatch are and work on fixing/addressing those issues,” urges one respondent. Oversights and taking the other for granted tarnish relationships. For example, to decrease stress on crews, “Check to see if there is something they need from dispatch they aren’t getting, then work to make sure they have what they need.”

Collaboration, however, is the clincher. No one is alone, and no one works in isolation. Commonality comes through doing the best for the patient and, in doing so, valuing each other’s expertise. “Realize we are all on the same team,” one reply said. “We complement each other. Respect should be the default.”

Views From the Ambulance 

An overwhelming 90% of EMS respondents to the poll conducted by EMS World and the Journal of Emergency Dispatch answered “yes” to whether the dispatchers they worked with sometimes caused stress. That’s not surprising, given the nature of the work.

“Anyone who denies there is tension between communicators and EMS field providers is naïve or not being honest,” says Kevin Collopy, BA, FP-C, CCEMT-P, NRP, CMTE, clinical outcomes manager at AirLink/VitaLink Critical Care Transport at New Hanover Regional Medical Center in Wilmington, N.C. “Despite everyone’s best efforts, there is always going to be that gap between the reality and the ideal, from both perspectives.”

Common friction points cited in the survey responses included attitude and professionalism (37% of responses), improper or inaccurate dispatching (30%), lack of understanding of EMS work (12%), and poor communication (11%). 

New EMS hires at AirLink/VitaLink spend an entire day side-by-side with the service’s telecommunicators to get a look inside the shift of a dispatcher, says Collopy—the unpredictability, the need to multitask and handle multiple calls simultaneously, the scattered and inaccurate information, and above all the emotional stress that comes with the job.

“There is so much information overload,” says Collopy. “A new call comes to our communications center every 27 seconds. Telecommunicators are frontline providers but often forgotten about. They hear the screams, the gunfire, the shouts for help, and the terrifying periods of silence.”

Annual crew resource management training is developed by AirLink/VitaLink staff, and transfer center meetings are attended by operations leaders to keep lines of communication open between dispatch and field personnel, Collopy says. In safety meetings communicators learn aspects of EMS such as scene size-up, the logistics of patient care, and the extreme unpredictability in homes and communities that can interfere with even the best-planned call.

“If we talk about improving communications with each other, we have to embrace the idea that we can always make the working relationship more effective,” says Collopy. “Nobody should take these discussions personally. We have to respect both paradigms. Quality management should improve the entire call.”

According to our survey, 1 in 5 respondents felt dispatchers understanding EMS work more fully would lead to decreased stress. This was followed by reducing crew favoritism and improving staging practices (17%), providing clear and concise communication (15%), better attitude and respect (10%), and offering complete and correct call information (9%).

At Falck USA, which provides ALS and BLS service in 10 states with a total force of more than 4,000 EMS providers, improving working relationships with 9-1-1 call-takers is top-of-mind with corporate leadership. A dispatch officer (DO) sits in the dispatch center to handle any issues of communication, crew resource management, or dispatch protocol.

The DO is an experienced EMS provider with a solid understanding of communications and EMS field work, explains Brooke Burton, NRP, FACPE, quality division chief for Falck USA. All crew reassignments must first go through the DO for approval. In addition, a dispatch committee meets regularly to discuss protocols and priorities and implement training in areas such as radio etiquette.

“So much comes down to communication styles,” says Burton, adding that emerging technology such as automated key replies (“525 has arrived on scene,” etc.) go a long way to ease stressful exchanges while facilitating the flow of critical data. Furthermore, a section of EMT and paramedic curricula should be devoted to EMD training and the nuances of radio communication, Burton says.

No matter how large the service and how sophisticated its communication systems, much of the difficulty between EMS personnel and telecommunicators arises from basic human interactions.

Northwell Health Center for EMS is the largest hospital-based ambulance service in the New York metropolitan area. Northwell’s EMTs and paramedics provide care to more than 120,000 patients annually throughout the five boroughs and Long Island. Their communication center and EMS crews delivered critical lifesaving treatment and transport services at the U.S. epicenter of the COVID outbreak in 2020.

“Human communication is challenged when we’re only communicating with one of our senses,” says Jonathan Washko, MBA, FACPE, NRP, AEMD, assistant vice president for Northwell’s Center for EMS, SkyHealth, and centralized transfer center. “When we can’t ‘read the room’ and observe physical reactions, voice inflection over the radio becomes tremendously important and can easily be misinterpreted. This is only heightened during times of extreme duress.”

With an advanced emergency medical dispatch certification and as a member of his system’s medical dispatch review committee, Washko meets monthly to address issues related to the medical triage system and improving the working relationship between communicators and EMS personnel. This gives field providers and other stakeholders feedback into the system and how to mitigate operational issues that arise. “The mission is loop closure,” says Washko. 

New EMTs and paramedics spend time in Northwell’s communications center as part of their initial orientation, Washko explains, adding that Northwell dispatchers are compensated on the same level as paramedics and are valued members of the organization. Training on emotional intelligence is a requirement for transfer center staff. Supervisors monitor the radios in real time, and there is a zero-tolerance policy for infractions. Field providers and communications staff are encouraged to pursue leadership positions on the “other” side.

“We do want a degree of inherent healthy tension in that exchange,” Washko says of the dispatch-field crew interchange. “That comes with the job and heightens performance. But there is a limit to it. It’s all about building relationships and breaking down those barriers.”

Mike Taigman is an improvement guide for FirstWatch and adjunct instructor at the University of California San Francisco and the University of Maryland Baltimore County. He is author of Super-Charge Your Stress Management in the Age of COVID-19.

Audrey Fraizer is managing editor of the Journal of Emergency Dispatch, published by the International Academies of Emergency Dispatch.

Jonathan Bassett, MA, NREMT, is editorial director at EMS World. Reach him at jon@emsworld.com.