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Florida report confirms how low we set 911 center standards

When you don't teach call-takers to do more than read a script, people die

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Read IAED critique of 911 call

(PLEASE NOTE: This post focuses on the work of the 911 call taker involved in the Polk County (FL) Fire Rescue incident where 76-year-old Lorretta Pickard died. Because I’m focusing on 911 does not excuse or take away from the importance of the responsibility of the first firefighters on the scene who failed to initiate a rescue attempt.)

911 in the United States is in serious trouble. A group that sets standards and provides protocols for a large number of 911 centers describes the work of the 911 call-taker who talked with 76-year-old Lorretta Pickard in her final moments as “quite good”. If your standard is based mostly on whether the call-taker can read a script, I guess that evaluation may be true. If your standard for 911 shoots a little higher, as mine does, it’s hard not to come to the conclusion that 911 read and typed Lorretta Pickard to death. My belief is the 911 center did only the minimum to try to urge the disabled woman to leave her home. This left Lorretta Pickard waiting for firefighters from a station about 15-minutes away. Firefighters who never mounted a rescue attempt.

This official evaluation of the call–released publicly on Monday–tells me the bar is set enormously low for 911, not just in Polk County, but across the country. Here’s why I come to that conclusion.

Lorretta Pickard could walk, she was just scared

First, let’s deal with a myth that has surrounded this tragic incident from the start. Based on many comments to STATter911 and elsewhere, there are a large number of people who believe Lorretta Pickard was so disabled she couldn’t get out of the house by herself. The family has confirmed to reporters this is not true. In addition, here are Pickard’s words to the 911 call-taker.

911 call-taker – “So, it’s pretty much hard for you to get up without assistance.”

Lorretta Pickard – “Oh, usually I can, but I don’t know I guess I I’m scared. My husband wouldn’t leave me if I couldn’t get up and go to the bathroom and stuff.”

If you listen closely to the entire conversation, there are at least 10 other times that Pickard dropped clues or indicated directly she can, in fact, move about the house (she actually did so during the call). Pickard’s biggest issue was that she was frightened. Pickard also indicated she needed two hands to use her walker and that meant–because she didn’t know how to operate the speaker phone option–she couldn’t stay on the phone with 911 and walk.

Despite all of this information available to the 911 call-taker, she never made it clear to Lorretta Pickard that help was almost 15 minutes away and that it was urgent they work on getting Lorretta Pickard out of the house right now.

Report acknowledges the key point about 911 but does nothing with it

Emergency Services Consulting International (ESCI), the firm Polk County contracted with for the report, really only had one critical comment about the performance of the call-taker.

Despite this valid and crucial point, ESCI never listed it as a key factor in its report. There’s no indication that I could find that ESCI even talked with Pickard’s family about the woman’s mobility issues. It’s as if no one even realizes or accepts the fact that if 911 was able to convince Lorretta Pickard to get over her fear and leave the house, none of us would ever have heard of this story.

The call-taker evaluation was handled by the protocol providers 

A separate evaluation of the call-taker was handled by the International Academics of Emergency Dispatch (IAED) Fire Standards Council. All that was published Monday is the executive summary, which you can find here.

Here’s how IAED describes itself on its website:

The IAED is a nonprofit standard-setting organization promoting safe and effective emergency dispatch services worldwide. Comprising three allied Academies for medical, fire, and police dispatching, the IAED supports first responder-related research, unified protocol application, legislation for emergency call center regulation, and strengthening the emergency dispatch community through education, certification, and accreditation.

IAED provides the call-taker protocols used by many 911 centers. Polk County Sheriff’s Office operates the 911 center and uses IAED’s protocols via Priority Dispatch Systems. Three-years-ago, the 911 center became an Emergency Fire Dispatch Accredited Center via IAED:

The Sheriff’s Office is now recognized as the 32nd Emergency Fire Dispatch Accredited Center in the world. The IAED awarded the accreditation because PCSO demonstrated compliance to the Fire Priority Dispatch System and its “20 Points of Excellence,” which are international standards for emergency fire dispatch.

IAED says the call-taker “was quite good”

In it’s report about the 911 call from Lorretta Pickard, IAED determined, while the call-taker’s performance “was not perfect, it was quite good given the extraordinary circumstances that presented themselves.” The call-taker was also “strongly commended” for her empathy and interaction with Lorretta Pickard.

Both call-taker & caller are victims

I’ll be the first to admit the call-taker didn’t fail Lorretta Pickard. My belief is the call-taker, like Mrs. Pickard, was a victim. They were both victims of the poor training, low standards and even lower expectations that have infiltrated too many of the nation’s 911 centers.

The document IAED submitted about the Polk County incident just lays this all out in black and white and confirms my long held beliefs about 911.

It’s all about the script

IAED believes one of the key problems is that Lorretta Pickard, because of her disability that required the use of a walker, couldn’t follow “the Trapped in Structure Fire instructions”. That Pickard failed to follow those instructions is an absolute fact. But what IAED’s investigation fails to consider is the possibility that relying mostly, if not solely, on its Trapped in Fire Instructions script was the real failure. (For the record IAED, in its review, did praise the call-taker for using “independent thought” and “non-protocol driven methods in a couple instances.)

IAED and most jurisdictions are great believers that the path to success in a 911 center is the protocol/script. The biggest problem with that thinking is when the words the call-takers are reading off a computer screen or flip chart fail to solve the problem, people like Lorretta Pickard sometimes die.

In the last dozen years that I’ve been writing about 911 issues on STATter911, I’ve heard regularly from the current generation of 911 center employees. From all over the country they tell me they’re taught to read the script verbatim, or else. They are told it’s all about liability and the 911 center will be sued and lose if they go off script and something bad happens. In many places 911 workers don’t know what to do without the script or the computer. That’s because there are a lot of 911 centers that don’t provide adequate training and knowledge to give employees the ability to apply critical thinking and even common sense, allowing them to do the job at a higher level than just being a script reader. As I’ve written before, there’s a great similarity in the required skill at some 911 centers and the telemarketing companies that hound us every day. Employees at both are told to stick to the script.

IAED report fails to address very important issues 

What might have helped Lorretta Pickard was not in the IAED protocol. The IAED executive summary (that’s all that was released) focuses almost exclusively on the whether the call-taker complied with protocols. The report doesn’t address the skills well-trained 911 workers had when I answered 911 calls in the 1970s. These include an intimate knowledge of the jurisdiction’s geography, the ability to actively listen, a thorough understanding of the organization(s) the center dispatches for and the ability to use all of those skills to help people in trouble.

I’ve listened to Lorretta Pickard’s 911 call multiple times and have taken many notes. Here are some of the things I thought were very poorly handled:

  • The call-taker didn’t ask if anyone was still in the house until 1:46 into the call, missing many cues from Pickard that she was inside the home that was filling with smoke. Shouldn’t “Are you still in the home?” have been one of the initial questions asked? (The IAED report did acknowledge the call-takers failure to pick up on early cues that Pickard was still in the house.)
  • It wasn’t until 2:21 into the call that the call-taker finally read the script about exiting the home.
  • The call-taker didn’t start telling Pickard what to do to protect herself (I assume this is the Trapped in Fire Instructions) until about 4:15.
  • Most important, is the call-taker seemed to accept, with almost no probing questions, that Pickard didn’t have the ability to move about or get out of the house by herself. There were many clues in the conversation this wasn’t the case (Pickard’s family has also confirmed this). Apparently there’s no script that encourages people to push themselves, even if it’s extremely difficult, to find a way out.
  • The call-taker never advised Pickard the reality of her situation. Pickard was never told the closest fire station is about a 13 to 15 minute response time to her home and that if she can get you out before firefighters arrive, that would be a much better option.
  • Despite clues that Pickard was scared and that staying on the phone seemed to be Pickard’s priority, 911 never told Pickard it was more important for her to exit the home than stay on the phone.

Looking at this list, we should be greatly alarmed and disappointed that the people who set standards for 911 ignored most of these points when deciding the call-taker was “quite good”.

The December report got it right

What I’ve written is also supported by the findings of Polk County’s internal report completed in December, a few weeks after the fire. The Polk County Fire Rescue battalion chief who wrote that report wrote “the occupant attempting to self-rescue on this call, or at least try, was extremely important.

A critique of the key moments

The IAED executive summary doesn’t provide a transcript with a detailed critique of the 911 call, so I made one myself (ESCI has a partial transcript in its report, but no simultaneous critique). I realize I’m just an old guy who did this job before there were computers and do-or-die scripts. My evaluation is based on what I believe any of the people I worked with 40-years-ago would have done if they were on the phone with Lorretta Pickard. These comments are made knowing that many, if not most, 911 workers today would be unable to react to Lorretta Pickard in the manner I suggest. That’s because there’s apparently no script for it.

(NOTE: What’s in quotes below are direct quotes from the recording. Other items are just paraphrased or the activity is described. My comments are in red. “911” is the call-taker. “LP” is Loretta Pickard. You can follow along with the recording that’s at the top of this post. This is not a complete transcript and only covers what I believe are key points in the call.)

:00 Call taker (911) gets name, address and phone number (all bleeped)

:23 Lorretta Pickard (LP) – “I think my house is on fire and I’m here alone and I’m in a walker.” Indication LP’s in the house that’s totally missed by 911.

:33 911 says she has a couple of questions.

:42 911 asks again for a name. Doesn’t inquire as to why LP is so out of breath.

:47 911- “Can you spell your first name?” Why is this so important right now? Is that more of a priority than determining if someone is in the burning home?

1:00 LP – “Hurry up. I have a house full of smoke”. A second clear indication LP may be in the house.

1:21 911- 911, for at least second time, says talking to LP is not delaying paramedics and then corrects it to firefighters. In fact, 911 is delaying a possible self-rescue.

1:27 911 – “I am sending the fire department to help you now, stay on the line.”

1:30 911 – “Stay on the line and I will tell you exactly what to do next.” 911 still hasn’t figured out LP is in the house, but 911 is going to tell LP what to do next.

1:32 911 – “Okay, how many floors or stories are there?” Wasn’t 911 was going to tell LP what to do next? 911 is asking about the construction of the building, but has never asked LP is she or anyone else is in the house and totally missed all the clues that was the case.

1:44 LP – “What should I do?”

1:46 911 – “Is anyone trapped inside the building?” Even without the many clues that LP has provided about being in the house, this question should have been asked long ago.

1:49 LP – “Well, I am inside the house. I don’t even know if I can get out.” Finally!

1:54 911 – “I have them coming as quickly as possible. Okay?” No, it’s not okay. The firefighters are 13 minutes away and 911 still hasn’t told LP to leave her home.

1:59 911 – “How many?” LP – “Just me. My husband is at the ball game. I can’t get anyone. I tried his cell phone.”

2:08 911 – “Okay. Exactly where are you located?” LP – “Uh.” 911 –  “No. Inside the home. Exactly where are you located inside the home.” LP – “Right now I am in the living room.” It’s 20 or so seconds since 911 realized LP is in the house and still hasn’t told her to get out.

2:19 LP – “Smoke’s getting bad.”

2:21 911 – “Okay, if it’s safe to do so, leave the building, close the doors behind you and remain outside. Do not try to put the fire out. Do not carry anything. Do not carry out anything that’s on fire.” LP – “(unintelligible) if I wanted to. I am on a walker and can’t hardly walk.”  It took 2:21 for 911 to tell LP to get out of her burning home. Note that LP doesn’t say she can’t walk. 

2:58 911 – “Okay Is anyone injured?” LP – “No, I’m the only one here. I’m not injured.”  LP has already said she’s the only one there. This is one of many indications of poor active listening skills by 911 in just the first three minutes.

3:07 LP – “Eyes full of smoke, lungs. I can’t get out the door.” Why isn’t 911 asking what does she mean she can’t get out the door? Are there steps to climb? Is it she just can’t walk that far or walk at all? Is it that she can’t see the door? Is it a deadbolt without a key?

3:14 911 – “What is the best entrance of the building to get to you?” Possibly this is a minor point, but shouldn’t the question be, “What’s the best door of your house for firefighters to use to get to you?” 

3:35 911 – “Okay, I have them coming. Okay, they’re coming as quickly as possible. Lights and sirens, okay.”

4:03 911 – “I am going to be right here until they get right there with you. Okay?” LP – “Okay.”

4:15 911- “Okay, If it is safe to do so stay low to the floor, close the door immediately. Uh (pause) Cover.”  LP sounds like she responds that she can’t or I am not getting down to the floor honey. LP then says “I will sit on my walker, that’s the lowest I can get.” Is this a clue LP can get to the walker or the walker is with her?

4:40 LP – “Oh, what was that?” 911 – “What’s going on?”  LP – “I don’t know. It hit me on the head. It’s like a drop of water or something. I don’t know.” No response from 911. Just typing.

4:45 LP – “I’m sorry. I know I shouldn’t be panicking.” 911 – “No, that’s okay. This is a very hard situation to be in, but I am going to be with you until they get right there with you. Okay? Just let me know when they’re there. I am seeing now how close they are to you. Okay? They’re coming as fast as they can.” 911 doesn’t tell LP where the firefighters are or how much time is will take for them to get to LP’s home. At this point in the call, firefighters are still about 10 minutes away. A reality check about the time for the firefighters to get there might have been good motivation to get LP moving and out of the home. She got to that living room table somehow.

5:03 LP is crying, coughing and breathing heavy.

5:14 911 – “I will stay on the line with you as long as I can.”  LP – “Okay.” 911 –  “Alright, I am going to stay on the line as long as I can. Just let me know when they get right there with you.”  It’s hard not to think this is giving LP a false sense of security instead of having her deal with the danger she’s in. What about working with her to find a way out?

5:58 LP – “I don’t know what’s dripping on me.” 911 – “Okay, I have updated them and let them know. Okay, so now let’s just … We are waiting for them to get there. They’re coming as quickly as possible.”

6:28 911 – “Okay, just let know what’s going on. Okay?” LP – “Got to get where I can sit down”. More clues that LP may be able to move on her own.

6:38 LP – “The walker, got away from me.” 911 – “Okay.” More clues about LP’s mobility. No questions about this from 911. Just almost constant typing.

6:44 LP – “Okay I’m sitting down. My feet are hurting.”  911 – “Okay.” More clues that there is mobility. Still no reaction from 911 on these important points. Just typing.

7:02 911 – “They’re coming as quickly as possible.” 911 continues to repeat this, but offers no help.

7:19 LP – “I’m sorry.”  911 – “No, It’s okay. Just. Just let.” LP – “I feel like a big baby.” 911 – “No, it’s okay. Is the smoke still in the home?” LP – “Yes.” 911 – “It’s still filling up? Okay, but you don’t see any flames at this time?” LP – “I can’t go outside to see.” 911 – “Yes, but there’s no flames in the home that you can see?” LP – “No. Not in the house. (unintelligible) smoke.” 911 – “Okay.” LP – “But there’s all kind of noise on the roof. I think it’s on the roof.” Once again, 911 doesn’t ask why LP can’t go outside. I’m guessing that question isn’t on the script 911 has been reading from. 

8:43 911 – “Okay. I’m going to be right here. Okay?” LP – “Okay.”

8:49 911 – “Alright, they’re still coming as quickly as possible.” At this point firefighters are still about 6 minutes away.

9:02 LP – “I’m back in the woods.” 911 – “Yes. They just have a little ways to get to you. They do have to make it a little ways to get to you, but they are coming as quickly as .. as … The quickly …The quickest way that we can get them there in the time that they’re responding.” LP – “Okay.” 911 – “Everything is lights and sirens right now. They, they know that it’s serious, to come quickly”. LP – “Okay.”  This is the first time that 911 even acknowledges that it will take firefighters a little while to get to LP.

9:26 For the next 32 seconds all you hear is 911 typing and LP breathing heavy. At 9:58 LP cries and coughs again.

10:02 911 – “Okay honey. Are you still in the living room?” LP – “I am in the living room and kitchen. Kind of in-between.” Another clue LP moved or is mobile.

10:11 911 – “Is there any like dish towel or anything in there that you can wet and put it over your face to help not breathe in the smoke?” LP – “If I thought I could get up.” How about urging her to try?

10:26 911 – “Okay. What, so where at are you sitting on now?” LP – “Dining room chair.” 911 – “Dining room chair. Okay.” Clearly she moved form living room to dining room.

10:36 911 – “And your walker is away from you?” LP – “It is right here. I can reach it. But I don’t know if can get up with being on the phone.” 911 – “Okay. I understand.” I think this is an important clue to what is going on. LP has made a priority of staying on the phone over using the walker. 911 should have challenged this. It takes another minute (at 11:35) for 911 to get back to this crucial point.

10:46 LP – “It’s hard for me to get up. I usually do okay. I just sit in my chair and watch TV and stuff when he’s gone.” Why doesn’t 911 say, “I know it’s difficult, but the firefighters are still more than four minutes away. It’s important for you to get out, so can you try? The answer, of course, is there is apparently no script for that.

10:58 LP – “I just kept hearing these noises, so I went to investigate and keep seeing the smoke.” Yes another clue she can get around.

11:06 911 – “So, it’s pretty much hard for you to get up without assistance.” LP – “Oh, usually I can, but I don’t know I guess I I’m scared. My husband wouldn’t leave me if I couldn’t get up and go to the bathroom and stuff.” Finally, a probing question from 911 on the most important issue. If 911 wasn’t clear before this is confirmation that the reason LP isn’t moving out of the house is she’s sacred and can actually do more than wait there and die.

11:35 911 – “Is there any way. Do you know how to put me on speaker phone so you can have both hands for your walker?” It sounds like LP replies that she should know how “but I don’t.” 911 – “I’m sorry?” LP – “Every time I try to do the speaker phone I get .. here they come. I hear them. I hear the sirens.” 911 – “Okay. Stay on the line until they get right there with you. Okay?” LP – “Okay.” Refer back to 10:36. It appears 911 understands that LP was worried that she couldn’t hold the phone and use her walker. She needed two hands for the walker and couldn’t do that and stay on the phone without the speaker turned on. A well trained call-taker would have said it’s more important for you to leave the house than to remain on the phone with me. LP hears the sirens but the firefighters are still about three minutes away from reporting on the scene.

13:00 LP is coughing and clearly having more difficulty breathing. She mumbles a few unintelligible words.

13:27 911 – “Do you know your husband’s phone number?” LP – “(unintelligible), but I don’t know it.” 911- “Or a neighbor or anything?” LP – “Friend. (unintelligible). They live at (unintelligible). Let me think.” Discussion continues about trying to reach a friend of LP’s and 911 says the supervisor is going to call him..

14:33 911 – “Do you still hear the sirens?” LP – “No.” 911 – “They may have cut them off because they are getting closer. Because I see that a unit is closer to you now. Okay?”

14:43 911 – “I do see a unit is closer to you now.”

15:04 911 – “Okay. They’re there uh with you, okay? So, do you know if your door is unlocked? You don’t know? LP – “Yes, it’s unlocked. Tell them to hurry.” 911 – “Okay. I’m letting them … I am updating them now, okay.”

15:28 LP can’t even see inside.

19:04 LP says she sees fire/flames.

19:53 LP advises she is on fire and there is not further contact.

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