# Dispatcher sends wrong agecy to wrong location, woman dies.



## Grady_emt (Aug 8, 2008)

Here in Fulton County FulCo)/City of Atlanta (CoA) there are two ambulance services and 3 PSAP centers.  Grady EMS (GEMS) is the ALS 911 provider for the City of Atlanta in central Fulton County.  Rural Metro (RMA) is the ALS 911 provider for North and South Fulton County (two separate operations for RMA).   

When you call 911, if it is an Atlanta address or pings off a cell tower in the city limits, then the call is kicked to Atlanta PSAP.  Atlanta determines if EMS is needed and forwards the call to Grady EMS PSAP who continues the call taking process.  The Atlanta operator is "eavesdropping" on the call, and when cued by the GEMS call taker will initiate APD/AFD response as needed based on the call triage.

Fulton County operates the PSAP for the unincorporated/incorporated areas of FulCo outside the COA and will initiate RMA/FulCo Fire as needed, or forward the call to the municipality involved for FD dispatch (Alpharetta/Johns Creek/Milton/Roswell etc…). 

Grady EMS was dispatched by FulCo as well until last June when GEMS began their own call taking to cut out the 3rd party that was involved, and to eliminate the delay in the dispatch process.  RMA is still dispatched by the county.

On Saturday 8/2/08 around 1300hrs a FulCo call taker/dispatcher took a call for a woman in respiratory distress at 602 * Wales * Drive in the newly formed City of Johns Creek, north of Atlanta.  The woman called from a cell phone that pinged off a tower on Jones Bridge Rd.   The dispatcher put the call in the CAD as 602  Wells  Drive in the CoA, nearly 27 miles and 2 municipalities from the cell tower that the call originated from.  She then forwarded the call to GEMS Dispatch over the computer to be dispatched to a GEMS Unit.

GEMS was dispatched and could not locate the address on the street.  GEMS Comm. Supervisor called Fulton County back to confirm the address and she still said it was in the CoA.   Another GEMS dispatcher Googled the Apt Complex name and discovered it was off of Jones Bridge Rd (where the cell call originated).  It was 1338 when FulCo FD engine arrived, and after 1400 before the first RMA unit arrived on scene after the mix up.  Johns Creek PD had been onscene for nearly 10 minutes before FD with and AED doing CPR and had ROSC x2.  The pt was transported to a local ER at 1418 and pronounced dead at 1501

AJC Article about the situation   (AJC may make you log in, use emtlooking@gmail.com as the email address, and oleoff04 as the password)
http://www.ajc.com/metro/content/metro/atlanta/stories/2008/08/06/emergency_0807.html

WSBTV’s excellent report so far:
http://www.wsbtv.com/video/17114604/

Tape of the 25 minute call released by FulCo (edited by FulCo to 19:23to "remove dead air time")  
http://www.ajc.com/multimedia/content/multimedia/video/index.html?clip=92670


----------



## mikeylikesit (Aug 8, 2008)

this is unfortunate, it puts a bad light EMS but mostly EMD's. how bad do you think they feel?


----------



## Grady_emt (Aug 16, 2008)

Just a few updates in the two weeks since this incident.  The dispatcher was fired, and is in the process of appealing her firing.  Her personell file was released to the media, 2,100 pages with several past suspensions and warnings for insubordination, sleeping at work, verbal conflicts with co-workers and one review said that she should be removed from the console as she was failing to grasp the entire process. 

The county 911 director has been re-assigned to the EMA manager pending an internal and external audit of the county 911 system.


----------



## Chimpie (Aug 16, 2008)

Grady_emt said:


> Her personell file was released to the media, 2,100 pages with several past suspensions and warnings for insubordination, sleeping at work, verbal conflicts with co-workers and one review said that she should be removed from the console as she was failing to grasp the entire process.



And the reason she wasn't let go long before this is.......?


----------



## Flight-LP (Aug 17, 2008)

because she hadn't actually killed someone yet.......................


----------



## MagicTyler (Aug 17, 2008)

Its times like this I wonder why LEO arn't at least emt-b certified... That 10 minutes could have saved her life...


----------



## KEVD18 (Aug 17, 2008)

right up until you mentioned the info regarding her service record, i wasnt planning on joining the lynch mob. mistakes happen. humans are fallible and therefore capable of mistakes. expecting any human being to have a perfect operational record is, in a word, ridiculous.

that being said, this dispatcher should have been canned long before this. a mistake can happen. a long stream of mistakes isnt fair human error, its blatant incompetence.


----------



## BossyCow (Aug 18, 2008)

Flight-LP said:


> because she hadn't actually killed someone yet.......................



My guess is a manager who took 'progressive discipline' a little too literally.


----------



## Grady_emt (Aug 19, 2008)

A direct quote from the AJC article linked below:

"In April 2003, Conteh was suspended for falling asleep at her desk so deeply that she tumbled from behind her console and scraped her left ear as she fell. Conteh explained she was leaning over to pick up paper when she fell, according to the file.

She filed a worker's compensation report on her injury. Her superiors did not buy her story.

She also had several screaming matches with co-workers and had to be sent to anger management classes as recently as last year.

She had numerous incidents of mishandling calls, beginning with a string of six errors from December 2006 to January 2008 that resulted in a three-day suspension.

And Conteh was twice spared from being fired. The first time was in April 2004, when she again fell asleep at her desk.

After an appeal, she kept her job, but was moved from a morning shift to an afternoon shift, records show. Another attempt to fire her a year later fizzled

She also had several screaming matches with co-workers and had to be sent to anger management classes as recently as last year."

http://www.ajc.com/metro/content/me...911_operator_history.html?cxntlid=inform_artr


----------



## Jochempeiper (Aug 25, 2008)

Yeah, I feel bad for the pt's family. We ran a code a while back, and the way that the streets are laid out they are REALLY confusing. Their are 2 streets of the same name on different parts of the town, anyways, we had alot of trouble trying to find the address and when we got there, CPR was in progress, needless to say we kept him in V-tach and V-fib throughout the 20 minutes working it on the scene and transporting.


----------



## snaketooth10k (Aug 26, 2008)

I think advice dog says it best


----------



## p3medic (Aug 26, 2008)

Cell phones can be problematic because you don't get an exact call location as with a land line in a system with E-911.  We had a call yesterday for someone stabbed in a park, the call was dispatched to another section of my city.  I couldn't picture a park there, however there is another street in my district thats name sounds similar to the street the call was reported to be on.  I pulled up the call on the CAD at the station, and sure enough, the cell tower the call came from was one street away from the street in my district, not the street several miles away.  Anyway, no real harm done, we were rolling up to the call by the time the dispatcher got our message and corrected the address.


----------



## KEVD18 (Aug 26, 2008)

Jochempeiper said:


> Yeah, I feel bad for the pt's family. We ran a code a while back, and the way that the streets are laid out they are REALLY confusing. Their are 2 streets of the same name on different parts of the town, anyways, we had alot of trouble trying to find the address and when we got there, CPR was in progress, needless to say we kept him in V-tach and V-fib throughout the 20 minutes working it on the scene and transporting.



just two? there are FIVE washington streets in boston.


----------



## keith10247 (Aug 26, 2008)

I guess it is a good thing dispatchers in my county are pretty good at correcting their mistakes.  I have been dispatched to a box number that is 1 off from my first due (my due is 15 and they dispatched us on a 14 box)...twice.  While the numbers are close together, the stations are not!  It can be about a 20+ minute drive with lights & sirens.  

While off duty, I will see our station get called for the same box number.  I always say "WTF?" but within about 30 seconds after our lights flip on, they correct the situation, dispatch the proper unit, and put us in service.


----------



## Granola EMT (Aug 27, 2008)

There is a good reason that AREA FIMILIARAZATION is a part of ANY FTO phase. The streets in one city of the county I work in are the worst ever and mistakes happen a lot, but with a little knowledge of the area a lot of bad mistakes can and should be avoided. That is very unfortunate that the patient died due to a crappy dispatchers mistake. We get sent to the wrong street/address a lot. I.E; 6th st S instead of 6th ave S. ect. . We've even been sent to the wrong county... Thankfully it hasn't resulted in loss of life or limb... 

" Canyon dispatch -medic 5. Conforming the location is 612 6th st N. Not 612 6th ave N?"  "Medic 5 - canyon. Sorry I loaded the wrong address. I'll change the location on the MDC...."


----------

