Ocean City Department of Emergency Seruices

Communications Division
6501 Coastal Highway
Oeean City, Maryland 21.842

Crltical Incident Og OOF

;

c on october 3, 2009 Pco III ]o Ann Eurbage notified captain Eric Peterson of time
stamp disgepancies in the CAD repoft for Incident 09-04966. She also contacted
Division Supervisor Guiton via telephone to report same.
o The Investigatlon of this incident was prompted by Captain Petersont memo to
Chief Bafton notifying hirn of the time stamp issue. trnvestlgatlon was not prompted
by any complaint from OCFD or oubide party having intercst.
. October 5, 2009, per request of OCFD Career Division, tape recordlng of the 911
emergency 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 answered
the incoming call and stayed on the line with the caller for 7 minutes 10
seconds obtaining information before turning the call over to Blue to handle
CPR instruction. The complainant was not able to provide a correct address
for her location fior a period of two minutes. One an accurate location was
provided questions conceming the patient were then asked. The complainant
reported that her brcther-in-law was unconscious in his boat docked in back
of 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 send
paramedlcs.'
I While speaking to the complalnant who was panic-stricken, at 17:25:00
Burbage states oMam... Marn... Mam...I need the answers to these questions
and the paramedlcs ane on their way."
tr At 17:25:43 hourc Burbage announed the Emergency Medicat Call fur an
unconscious subject and dispatched Paramedic I or 1-l and C47 to the call.
U At 17:26:07 Paramedic 1 and C47 acJcnowledgd the call.
E At 17:26:09 the complainant advised that the patient was not breathing and
agked Burbage to tell her what to do. Burbage advlsed her to get him out of
the boat and flat on hls back, Untif Blue takes control of the cail the
complainant @ntinues to request information to help the patlent and tells
Burbage to hurry,
tr At 17226224 Burbage advise Paramedic 1-1 and C47 that she is upgradlng
the call to CPR in Progress and the subject has stopped breathlng.
E L7226256 Paramedic 1 advises they are responding.
n 17t27t22 Paramedic 1-1 advises they are responding
E At L7t27:25 can hear Burbage telling Blue to take over the call to provide
CPR 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 my
ear so we're tran#erring call takerc."
 I AttT:28;22 Blue takes over the cail and provides CpR Instruction.
n L7:28t39 Burbage announces the call as a silent alarm for cpR in prcgress,
I Paramedic 1 arrivs at L7229:33
I Faramedic 1-1 arrives atLT:29137
n Chief 51 advises that he is responding at L7zZ9:SS
D At 17:30:32 the telephone cafl is terminated.
tl At L7t32:32 c47 advises that he has command arrd Engine 16 is on scene
n Chief 51 is on scene at 17:33:58
n AILT:44252 command advises that evefihing is under control and the
patient is being transported to,$lantic.

r November 10, 2oo9, meeting was afrended by Director Theobald, Division

Supervisor Guiton, Chief Barton and Chlef Larmore.
o November L2,2009, Mrs, Jacquetlne Rehmann, widow of the deceased, made a
request 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 sent
certified 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 CD
was received with negative results. Messages were left on Mrs. Rehmann's voice
mail however no calls were ever retumed.
r JanuErY 13,20LO, Director Theobald met with City Solicitor Guy Ayrcs to discuss
the facts of the case.
 There is no current national standard for processing an Emergenqr Medical
cafl br seruice. PrioriW Dispatch, our Em6rgency t'iedical Dispatctr protocol
provider, does not commit to a standara procesiing flme.
Tfie following is an excerpt from the Emeipency turimuei Frofessional
Magazine:

CaII hocasing Tbne

Roryw defined, the callprocessing time is tke elqsedtimefron the
moment an eftrergency call is received at the g-I-I center, mfit the closest
cnailoble responfur crew(s) has been notifiedwith all incident
infornetion neceswryt to respond rhe National Fire protection
Association (IWPA) has pub li sFw d a di spatch stwdard
for t)- I - I errd
emergency call proceffing ttwt covvrsfire adfiItfi slte Ihe stmdard
stat:s: ',Ninety-fu9-ryrcent of emergenqt &spatching sltolt be cornpleted
, within 60 seconds.' Yet, otEresent, noresearih or etrptrtul dda;tcist to
.MpIWtq
.,!:i' "
. ,*tt rn
{s*4 tirW s/ro?dar4 or,,even tefi#twetly what ttwt
slwrfud, \here is no establisledcorrwction between slprter
(Nerage cal! :Froce syig.time s
_wd favorab le case outcames. In fact, " I
gJ -
ery,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
seconds cotmt or seconds swe lives is true only in a wattjlactton of totat
reported coses of spcifu hrcident twes rTere is alnost ienaffiy ia^nn
side for agencies tlwt plaee a disproportiorute value on time ad speed:
inflaible and obitrry fime stoMs may cause g-IJ mll takeri to tafu
hasty slrcrtarc with esablished protocol md procedures, irureMng
efors, mdjeoprdiztng tlrc $ety of aresporae. Witness the
discorcertingfact thst tlare se iamerous tau,wits agoinst dispatch
agercies for respony;time & lays fue n failwe to piper ly reiord ard
verify the corect d*ess af an incideni accidentidi to Imrried
r€qrorrse tactics reslt in perhqs lwn&eds of lawwits a yeq.

Ddamking C,all-hocasing Time

I*tbfirst consider how processing time is being meanred. older
teclwologies, ircluding nary computerized disptch systems still in use,
do rct always time*tmnp cases as initiate{ *
,ott ed, until the qd*ess
or exact location has b-eenverifiedin the system,s master streetsfile. That
diseowfis a Mbstattial mown of elrysed-time, incfuding tte ttnie it takes
the call taker to qtsrver the phone, ta enter the ad&ess ir location ln the
$yten mdverify it electronically. Afuess verfication alone, cwt easily
talre one mimrte or more when a confusvd eailer lws dificutty providing
an eract locatior+porticululy if enhared g-I-I im,{used or ovato{te,
Since there is no established standard for call processing we must use our own
pensonnel as a berchmark to evaluate whethenthe call taking process related
to this incident was handled within an acceptable amount of time. After
running a cAD call Taker Average Time [eport the average time for
processing the described catls ar€ as foilows:

IINCONSCIOUS FAINTING 000:01:33

BREATIIING PROBLEMS 000:01:36
IIEART PROBLEI\,ISAICD 000:02:07
CARDIAC 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-time
stwtdudis eight miwtes @d sg secords (g:s9),with g0%cinpliwece
reliability measned on afractile, not emerage, basis (Fracite
-
reqtonse time weamrement includes a reliabilityfactor atdmea&sres ell
tine interuals between the fime the semice receivedenottgh information to
initiete a response md the time aproperly eryippedand-st@ed
ambulqtee wrives on seene,)

lltis s:51 tsget is consistefiwith the reryorae tine recommerded by the

National 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 miwte
idcnts,r*ffi1:rc.P,A:,,W
re spon se time to 9 A %o of inc
Erffi:Itfrd:Wffiiil r;
"dd;;;;
a recent suraey of the 200 most
wwlotrs cities in anericafotd thst more than tfuei,.qAffturs fTrQ of
the wrwy respondenys re?nrt a ttrget of g:s9 or less uttng *e jr*titt
rneqsurement methd (Februay 2005 JEMS)