An EMD Milestone

Protocol 41: Caller in Crisis (1^st party) is a milestone in Emergency Medical Dispatch. It is structured consistent with the other protocols, based on 45 years of building protocol experience, and designed specific to suicide.  

Why a milestone?

“This is a protocol long overdue,” said Brett Patterson, Medical Council of Standards Chair, International Academies of Emergency Dispatch^® (IAED^™). “We are looking at the patient from a clinical perspective. This is science-based. Not everyone is dangerous.” 

Patterson emphasized his participation as part of a collaborative team of mental health experts, such as Jim Marshall, 911 Training Institute Co-founder and Chief Executive Officer, and IAED/Priority Dispatch Corp.^™ (PDC^™) protocol experts, including Patterson and Darren Judd, PDC Implementation MTPS Protocol Expert, Protocol Implementation & Client Support, and Brian Dale, PDC President. The protocol’s release also relied on the expertise of PDC’s Protocol, Translation, Curriculum & Instructional Design team, which—among other responsibilities—managed the protocol’s frame of logic.

Caller in Crisis

Protocol 41 is set for special release in 2024 and is for first-party callers who: 

• Express intent and have the means to immediately cause severe harm or death to themselves at any moment (IMMINENT SUICIDE POTENTIAL).
• Intend to carry out a suicide plan without being actively involved in the event (INTENDING SUICIDE).
• Have thoughts, ideas, or ruminations to end one’s life without expressing active intent (SUICIDAL IDEATION).
   

IMMINENT SUICIDE POTENTIAL implies the presence of a weapon, such as a gun to the head, or fatal action, such as standing on a ledge ready to jump. SUICIDAL IDEATION implies thoughts that cover a range of contemplations, wishes, and preoccupations with death and suicide, without an actual plan. In contrast, INTENDING SUICIDE involves an actual plan and the method to carry it out.   

Protocol 41 has been in the works since 2018, beginning with collaboration between Marshall and Ivan Whitaker, former PDC Executive Director of Client Success and Implementations. The Protocol is based on Marshall’s LifeBridges Program. Marshall, upon encouragement from his sister, an emergency dispatcher, combined his clinical knowledge and professional counseling to establish training in the 911 center for trauma situations. Marshall’s training turned into action and protocol. 

“Too often, public systems respond as if a mental health crisis and danger to self or others were the same; they’re not,” said Whitaker at the genesis of Protocol 41 development. “Whatever we can do to help, I couldn’t help but get behind.” 

Protocol 41 is in many ways unique among the protocols.

It is not the same as Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt. Protocol 25 goes beyond suicide to include mental health conditions such as depression and emotional and hysterical reactions to an incident. EMDs can apply Protocol 25 to first-, second-, and third-party callers. Protocol 41 is specific to suicide and designed for first-party callers only. It is intended for people reaching out.

“It was not a matter of if you take this type of call, but when,” said Marshall during a Dispatch in Depth podcast.¹ He credited Dr. Jeff Clawson’s invention of protocols to developing his mental health training to provide science-based training and resources that meet or exceed the profession’s demands. As said by Jay Scott, Partner Engagement Director, 911 Training Institute, “[like the EMD Protocol] the 911 professional should never be tasked with the burden of clinical responsibility. We remove the clinical burden and create pathways relating to the caller.” 

Patterson’s responsibility was making Protocol 41 consistent with the protocol system. The format was adapted to the behavioral health needs of the individual. The protocol also represents a departure from the accustomed organization. “It’s bigger than a breadbox,” he said. “It’s a new thing. The permeations are rich. It covers all the bases [concerning suicide], and there are so many bridges.”

The bridges diverge depending on the specific section required to address the caller’s situation (intent, plan, or ideation). Nuances about mental health are unique to the Protocol. Language reflects terminology advised by mental health experts. For example, “commit” is never used because it conveys a crime. “Intending” is used instead of “threatening.” In contrast to other protocols, Protocol 41 asks rather than tells.

“We are working with the caller and not telling them what to do,” Judd said. “We’re here to help and de-escalate the situation before response arrives while keeping in mind the safety of others.”

Protocol 41—and its unique differences from other protocols—presented a challenge for Audrey Gonzalez, PDC Logic Design & Proofreading Manager, Protocol, Translation, Curriculum & Instructional Design. “There was nothing like this,” said Gonzalez, who was responsible for building the logic of Protocol 41. “We were going from the ground up. A lot of the questions are new to the Protocol.

Logic design can be defined as creating pathways to achieve the desired outcome. Gonzalez started with the list of Determinant Codes and then worked back through the Key Questions to make sure the different questioning sequences would gather all the information needed to arrive at the correct Determinant Code. Gonzalez said a central question was, “‘Multiple Determinant Codes may qualify, but which should take priority?’ Identifying potential conflicts is part of what we look at.”

Irena Weight, Vice President of Protocol, Translation, Curriculum & Instructional Design, took responsibility for the logic of Protocol V: Separate/Distance from Means. She and Gonzalez worked from cardset-style drafts of Protocol 41 for visual illustration when applying logic and flagged their recommendations for medical discretion.

Patterson said their assistance is invaluable. “Much of what we do relies on experts, and we never want to leave out the brilliance in logic. They are another set of eyes, brilliant in the logic world, making sure we get this right.”        

Factors promoting Protocol 41  

International demand underscores the need for emergency services worldwide that meet callers’ needs and, in turn, curb overreliance on police intervention. Civilian responders have proven they can handle a mental health situation without police, who are often ill-equipped to handle it effectively. Their presence can exacerbate feelings of distress.

“Back in the day, you sent a police officer or an ambulance, and that was not the right response,” Judd said. Often, the ambulance crew waited for law enforcement’s arrival and their permission to assist the patient. As Patterson and Judd emphasized, “Success incorporates different response models,” including crisis intervention teams, community paramedics, and, when necessary, police backup and collaboration.

Emergency Dispatchers stumbled over what to say.

“We heard that again and again,” Judd said. “They are the first line of help. There is no one-size-fits-all reason they called. It could be medications, loneliness, or depression. The Protocol discovers the reason for their call to send them the correct response.” 

The call is a critical moment in a person’s life, as well as a critical moment in the life of an Emergency Dispatcher. In a medical emergency, such as a sudden out-of-hospital cardiac arrest, seconds count, as does how the EMD interacts with the caller, like providing over-the-phone CPR instructions. The EMD attempts to create an alliance with the caller to encourage compliance and respond correctly, as in all medical emergencies. 

The “right words” are not as important as the concern demonstrated in the Emergency Dispatcher’s tone of voice, nonjudgmental approach, and ability to form a trusting relationship. It asks a lot to create an instant bond with a stranger with injurious intent. However, Judd said, “It is their job to build a relationship with the caller to gain their trust. They must engage the caller. They’re not going to get anywhere if they don’t.”

In addition, the Emergency Dispatcher knows they did everything they could to help the caller. “Dispatchers understand the why from what science teaches us,” Marshall said. “They are not grasping in the dark. We have created pathways in relating to the caller.”

Finally, a call for help is not a criminal offense. A mental health emergency is a physical condition often requiring medical treatment, like other conditions such as diabetes or high blood pressure.² The stigma, a negative stereotype, commonly accompanies a person with a mental health condition. They are assumed to be aggressive and someone to be avoided. The effects on the individual can include the reluctance to seek help or lashing out at the inequities of care.

Protocol 41 and the training required to use the Protocol promote understanding. It humanizes the caller. “The telecommunicator is given the means to understand how to relate human to human in a mental health crisis,” Scott said. “They are the conduit to provide the necessary help now.” 

Protocol 41 basics

Once Protocol 41 is chosen on Case Entry in ProQA^®, an “Emotional Control Tool” provides the EMD with quick access to a reference guide on caller management for times when the caller might become irritated, angry, ambivalent, etc. This tool provides EMDs with statements to assist in bringing the caller back into the conversation and playing an active role in working with the EMD. For example, if a caller’s voice reveals inappropriate, out-of-control, or raging anger, the guide provides these tips: 

• Remember to do your own CAD Breathing.
• Speak calmly and confidently.
• Empathize: “I’m sorry you’re so upset.”
• Join with caller (using name if known): “I want to do my best to understand …”
• Ask: “Can you slow down just a bit and speak a little softer?”
• If anger is directed at you: “I’m really trying to help you. Please work with me, okay?”
• Affirm: “Thanks for working with me. That’ll help us do our best together.”

The first question the EMD asks on Protocol 41 is if the caller is functionally alert. If not, the EMD assumes a potential clinical perfusion issue and shunts to Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt and follows the script that includes questions to determine if this was an actual suicide attempt. If so, and the source is reported (such as carbon monoxide poisoning), the EMD shunts to the specific protocol. 

The second question on Protocol 41, “Are you thinking of killing yourself,” is there to discover if the caller is in imminent danger to themselves—planning or contemplating suicide. While the question might seem abrupt, the EMD is not putting ideas into the caller’s head. The EMD is attempting to build trust to elicit truthful answers and prevent the crisis. “The EMD is showing concern,” Judd said. 

If the answer is yes, the EMD begins asking a series of further questions to determine what the person has done, what the person plans to do, and whether the person intends to harm others—a series of jurisdictionally-approved questions, such as the means for a person threatening imminent harm.  

Pre-Arrival Instructions are set up for the EMD to separate the caller from any means of suicide, whether that be a weapon, drug, roadway, railway, or even distance them from a ledge if the need arises.  

Post-Dispatch Instructions remind the caller that response is part of the team, and they are coming to the scene in the interest of supporting the individual. The EMD encourages the person to separate from the means. The call ends with the EMD thanking the caller and asking them to “Please follow any instructions.” 

“The Protocol is one of making it right,” Patterson said. “It must be free of critical errors due to the potential magnitude of emotional crisis. We want future revisions to enhance the Protocol, not correct it.” 

Training required

Implementation requires a four-hour self-paced training course through the IAED’s online College of Emergency Dispatch. The IAED recommends at least one or two of the center’s internal staff attend the 911 Institute’s three-day Emergency Mental Health Dispatching (EMHD) course, which provides additional insight into the methodologies behind the Protocol and how to navigate the various mental states encountered during the phone call. Course completion provides an EMD-H credential. More information is available through the 911 Training Institute,  https://www.911training.net/. 

The self-paced course and Protocol 41 will be released simultaneously. Protocol 41 will be released in North American English and then translated into additional languages. The Protocol is only available through ProQA. It is not available in cardset form.

Marshall looks forward to seeing the effect of a Protocol that reflects his training and passion to assist Emergency Dispatchers in building self-reliance in a career that always demands the resources, particularly protocol, to perform their work effectively.

“Protocols represent what needs to happen,” Marshall said. “We have Emergency Dispatchers with the dedication, intelligence, and willingness to do all they can for calls involving suicide. We’re trying to achieve this by giving them the tools they need and deserve.” 

Sources

¹ AEDR Editorial Team. “Principles of Emergency Mental Health Dispatching with Jim Marshall and Jay Scott.” Annals of Emergency Dispatch & Response. 2023; June 6. https://www.aedrjournal.org/principles-of-emergency-mental-health-dispatching-with-jim-marshall-and-jay-scott (accessed Oct. 26, 2023).

² “Navigating a Mental Health Crisis.” National Alliance on Mental Illness. https://www.nami.org/Support-Education/Publications-Reports/Guides/Navigating-a-Mental-Health-Crisis (accessed Oct. 26, 2018).