Cardiac Arrest – Anatomy of a System Failure

Dave Statter ( recently posted a story about a cardiac arrest that occurred in Ocean City, MD. It’s a sad story with an unhappy ending. In fact, there’s only one redeeming quality about this story. It’s a perfect example of a system failure.

  • The dispatcher who answered the 9-1-1 call “froze” and was unable to effectively process the call.
  • There was an unacceptable delay in dispatching the call: approximately 4 minutes and 26 seconds.
  • Total response time for the first responder from call received (17:21:38) to patient’s side (17:27:50) was documented as 6 minutes and 12 seconds on the run sheet, even though the news story suggests that a fire station was only a mile and a half away.
  • Even this documentation is suspect considering that a Critical Incident Report from the Ocean City Department of EMS indicates that 7 minutes and 10 seconds into the call they switched dispatchers to handle CPR instruction. If first responders were at the patient’s side in 6 minutes and 12 seconds, why would they need to give CPR instructions?
  • Internal documents discussing the case attempt to gloss over the issue by suggesting that there’s no evidence based standard for call processing or response time intervals.
  • The dispatcher was unable to distinguish between agonal respirations and effective breathing, even though the caller stressed that the breathing was abnormal.
  • The dispatcher asked the caller to take the patient out of the boat prior to starting CPR.
  • The pre-arrival instructions, when they were finally given, were antiquated (mouth-to-mouth rescue breathing as opposed to “hands only” CPR for untrained lay rescuers).
  • The dispatcher sounds annoyed with the caller (stating “she’s screamin’ in my ear!”) as if the caller wasn’t completely justified in becoming impatient.
  • Internal documents refer to the caller as “panic stricken” in an apparent effort to stigmatize the caller and avoid responsibility.
  • Once paramedics arrived, the automatic CPR device malfunctioned.
  • The manufacturer of the automatic CPR device was able to determine that the equipment had not been properly maintained.
  • The EMS Incident Report is poorly written (I tried to figure out when or if the patient was shocked but I gave up) and suggests there was a problem with the patient’s airway en route to the hospital (tracheal tube replaced with a King).

In reading (and listening) to this story one is left with the sick feeling that the chain-of-survival is horribly broken in Ocean City, MD. Worse than that, one senses that officials in Ocean City, MD are oblivious to their duty to protect the public.

Imagine that your wife, husband, mother, father, sister, brother, daughter, or son will experience a sudden cardiac arrest in your jurisdiction sometime in the next 365 days. Then design a system to save their life.

Spare the bereaved families of the dead your lame excuses. They pay your salary and they deserve a heck of a lot better than that. I don’t think they expect perfection. Just an honest effort.

At the very least, the surviving spouse in this case deserves what she tearfully asks for in her interview with the news media: acknowledgement.

See also:

Left waiting: Alexandria man in cardiac arrest waits for EMTs in Ocean City


  • It’s about time the media criticize an agency over poor cardiac arrest performance. When Altanta fixed their dispatching problems their survival rate went from 0% to 33% (slide 48)

  • Jim Jones says:

    Let me preface by saying that I have learned that there is always more to the story than is known. Dispatch centers, PSAPs, for the most part are controlled by law enforcement agencies. The goals of these centers, both stated and unstated are usually far different from those of EMS and fire agencies. Law enforcement is normally a reactive response whose actions do not affect the immediate outcome for the caller having the emergency. EMS and fire on the other hand are normally active response whose actions have an immediate affect on the outcome for the caller. They are also more time dependant than law enforcement responses. Dispatchers are rewarded more for correctly handling law enforcement calls than EMS and fire. Dispatchers on the whole are underpaid, understaffed, under supervised, and under trained for the work they perform. That and given tools such as Dr. Clausen’s EMD which gives a false sense of compentency are some of the causes of tragedies such as this. This is not to say that responsding personnel do not have the obligation to also be competent. This includes checking their equipment.

  • Tom B says:

    You’re right, Jim Jones. There is always more to the story. However, what what we know about this story is pretty bad. We can’t allow ourselves to get used to things that would outrage members of the general public if the facts were known. The citizens expect us to work together to solve problems that hinder our ability to save their lives. Are the citizens choosing to have an under-trained and under-staffed dispatch office geared toward law enforcement with the full knowledge that it could cost them their lives one day? “That’s the way it’s always been done” isn’t good enough and we have to confront issues that weaken the chain-of-survival in every community. There are explanations but there are no excuses.

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