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Screened & Examined: The Hazards of Cell Phones and 911

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000461262.82857.8d
Screened & Examined

Dr. Ballardis an emergency physician at San Rafael Kaiser and the medical director for Marin County Emergency Medical Services.

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Smart phones are amazing, life-changing devices. They can be used to pay bills, provide directions, and check drug-drug interactions. They can read you a story, light your way on a dark path, and calculate a NIHSS score. And they can even — get this — be used to make phone calls! Surprisingly, though, it's in this last capacity that smart phones (indeed, all cell phones) can be dangerous.

Most people know that dialing or texting while driving is dangerous, but few (myself included till recently) realize that simply choosing to use your cell phone to call 911 (as opposed to a landline) might also be perilous because the EMS response could depend on the type of phone used to initiate it. The bottom line: Use a landline to call 911 if available.

Last year, 24-year-old Jordan Soto had a medical emergency at her home in Santa Barbara. The Santa Barbara Independent reported that the family member who found her unconscious called 911 from a cell phone. A fire station was less than a mile from the home, but the EMS response was delayed 20 minutes because it was routed from the California Highway Patrol to EMS dispatch. The process created confusion and delay, and paramedics were sent to the wrong address. Potentially valuable minutes were lost, and Ms. Soto died. Her parents filed a wrongful death suit against the California State 911 Advisory Board, the CHP, and the city of Santa Barbara.

We know that minutes matter in EMS responses. A number of studies have linked EMS response time to emergency calls to improved outcomes. (Health Econ 2013;22[7]:79; Prehosp Emerg Care 2012;16[1]:142; Ann Emerg Med 1996;27[6]:700.) And in a handful of situations including anaphylaxis, trauma with exsanguination, narcotic overdose, and cardiac arrest, even 60 seconds can make a difference in outcome. Cardiac arrest is by far the best studied. Nichol, et al. concluded that a one-minute increase in response times for cardiac arrest victims leads to an eight percent decline in survival rates within one day of the event.

Data from King County, WA, which has been dubbed the best place in the world to have cardiac arrest, supports this estimate. An analysis showed a 67 percent chance of survival if CPR and defibrillation (or other advanced life support intervention) were started immediately among patients with out-of-hospital cardiac arrest from ventricular fibrillation. The survival rate dropped by 5.5 percent for each minute that passed without these. The survival odds were 12 percent if nothing had been done 10 minutes after cardiac arrest. The odds were zero in another two to three minutes. (Ann Emerg Med 1993;22[11]:1652.)

Any delay in getting a cardiac arrest patient into the EMS system can have disastrous consequences. This includes any hesitation in getting calls to the EMS dispatch center, where staff is trained in giving bystanders instructions on how to perform CPR.

An important second bottom line: Always communicate your location first when calling 911! It turns out that emergency response systems have not yet fully adapted to the wireless revolution. Approximately 70 to 80 percent of 911 calls are made from wireless phones, and the way the calls are processed is often archaic.

If a 911 call is made from a landline, the 911 system uses the telephone number to identify the address and route the call to the Public Safety Answering Point (PSAP, or dispatch center) responsible for that area. After initial screening, the call would then be passed to trained medical dispatchers who would follow standard protocols and initiate an EMS response. If the same call were made from a wireless phone or device, however, it would most likely end up being routed without an originating address to a regional PSAP. Regional PSAPs in California are staffed by the California Highway Patrol rather than trained medical dispatchers. The caller is queried, the address determined, and the call is then transferred to the correct PSAP. This transfer process takes time, often at least a minute and sometimes longer.

Once a phone call reaches the correct PSAP, the location data that the PSAP automatically obtains from the call may not be accurate, and depends on the physical space in which the call was made and the call's duration.

PSAPs often will receive only Phase I data, which is restricted to the telephone number of the originating call and the location of the cell tower transmitting the call. These data give a rough idea of location, but are not very helpful in directing help to the exact position of an emergency. Most smart phones on smart networks are also capable of sending Phase II data, which includes the latitude and longitude of the caller down to 50-300 meters, known as XY routing. The accuracy of these data, however, can be skewed if calls are made from inside a building or if the call is dropped or cut short. This is because the Phase II location, like the “Location Services” on your iPhone, depends on satellite technology. The more pings sent to the satellite, the better the accuracy. In most cases, and certainly if a call is made indoors, XY location will not be available for 30 seconds or more. And, for indoor calls, the 30-second estimate is generous at best.

This is an understudied field, but some data do exist about the proportion of Phase I versus Phase II 911 calls. A telecom industry-funded group, Find Me 911, published data obtained from the Federal Communications Commission indicating that only 10 percent of Washington, D.C., 911 calls made between January and July 2013 generated Phase II location data. Statewide data from March 2013 published by the California Chapter of the National Emergency Number Association showed just a 45 percent rate of Phase II information delivery across five counties. And, even more ominously, the data trend shows a significant decline in Phase II delivery since 2008. The reason for the decline is not clear, but it may be due in part to a higher volume of 911 wireless calls and greater interference during indoor calls.

The location that a PSAP receives from a wireless phone cannot be assumed to be reliable. A nationwide survey of PSAP dispatchers found that only 18.7 percent expressed “a great deal of confidence” in the location data they receive from wireless carriers. Are you concerned yet? Concerned that salvageable EMS patients become unsalvageable because of defects in 911 responses? Wondering what is to be done?

How about a third bottom line? Do not pocket dial 911. FCC Commissioner Michael O'Rielly has said wireless 911 misdials are becoming an emergency themselves. It is estimated that approximately half of all 911 calls are misdials. The reasons for the misdials can range from meddling children to phones jostled in backpacks to rogue buttocks, but the result is the same. National FCC estimates put these mistaken calls at 230,000 each day. Obviously, this volume of calls puts a significant strain on the ability of PSAPs to respond to the true emergencies.

While the FCC, states, and the telecom industry work on technological solutions to the wireless 911 dysfunction, a truly reliable next generation system is years, maybe decades, away. Interim data-mapping programs may help bridge this implementation gap. The Routing on Empirical Data (RED) Project was successfully started in California to do this before it lost funding. Public education can also help.

The FCC is also said to be aware that most PSAPs currently lack the technical capability to receive texts, photos, and videos. This will change eventually because it is a federal priority that cell phones can be used to text 911, and a California law went into effect Jan. 1 requiring that 911 text receipt technology be implemented at PSAPs. If you dial 911 by mistake, stay on the line, acknowledge the error, and answer the dispatcher's questions. (http://www.fcc.gov/guides/wireless-9-1-1-services.)

We should all do our part to prevent unintended wireless 911 calls. One man's misdial could lead to another's EMS response misadventure. Put your phone on airplane mode when you hand it to junior to watch SpongeBob, lock your phone keypad before you put it in your pocket, and disable functions that auto-dial 911.

A little bit of pocket hygiene could save someone's life.

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