Optimizing dispatcher-bystander dyadic collaboration in emergency medical communication to improve cardiac arrest response
Article information
The concept of the dyad occupies a central role in medical practice, describing a reciprocal and productive relationship between two individuals, typically a nurse and a patient or a patient and a caregiver, both sharing a therapeutic goal in a collaborative environment [1]. Dyadic relationships are also present in educational settings, with a student working closely with a preceptor or mentor, resulting in a reduction in student anxiety, as well as an enhanced learning experience and increased task efficiency. In both cases, a dyadic interaction develops within a supportive framework characterized by respect, empathy, mutual support, cultural sensitivity, and effective communication [2]. As described by Brown [3] in 2016, mutuality, which is made up of reciprocal transactions, mutual influence, and a sense of common purpose, represents a valuable social capital and may enhance outcomes and satisfaction for service users and healthcare professionals.
This editorial discusses the concept of the dyad between callers and emergency medical communication center (EMCC) dispatchers during emergency calls, examining the main issues and how to maximize this collaborative interaction in order to optimize outcomes in cardiac arrest victims (Fig. 1).
Enhancing the dyadic relationship in emergency medical communication. Images were created with artificial intelligence generative technology, DALL-E (OpenAI) and ChatGPT-4 (OpenAI), on June 12, 2024. The authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
DYADIC RELATIONSHIPS DURING EMERGENCY CALLS
Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is an essential element in optimal cardiac arrest response [4]. Rapid detection of cardiac arrest and prompt initiation of resuscitation maneuvers significantly improve patient outcomes, with two meta-analyses reporting a higher rate of shockable rhythms at emergency medical service (EMS) arrival, return of spontaneous circulation, and favorable neurological status at hospital discharge associated with DA-CPR [5,6].
In out-of-hospital cardiac arrest (OHCA), where every second counts, the interaction between EMCC providers and bystanders marks the beginning of a collaborative effort aimed at providing prompt CPR to the victim. A dispatcher-bystander dyad occurs in a collaborative context, where both parties work together to manage a critical situation: the telecommunicator provides pre-arrival instructions, while the bystander follows their guidance to perform CPR. Mutual trust and effective communication are the core elements of this dyad, which is made even more difficult by the lack of face-to-face contact and the caller's emotional distress. EMCC providers must be trained to quickly identify a cardiac arrest and overcome all the potential barriers that may delay or prevent resuscitation attempts. A series of factors hampering the provision of bystander CPR have been identified. Analyzing 295 OHCA emergency calls, Aldridge et al. [7] identified one or more barriers to DA-CPR initiation in 97% of emergency calls, mostly related to bystander physical inability (65%), communication gaps and language barriers (54%), and emotional distress (46%).
Notably, younger age (<45 years), male sex, higher level of education, and higher social status have been identified as common bystander characteristics indicating an increased willingness to perform CPR [8]. These findings may be related to physical factors and to greater access to information and new knowledge about cardiac arrest and EMS response via public education campaigns [9,10]. Conversely, lower socioeconomic status, often indicating a lower education level, ethnic and racial disparities, and marginalized communities are associated with lower rates of bystander CPR, calling for an equal and inclusive approach by EMCC dispatchers [11].
COMMUNICATION ISSUES AND LANGUAGE BARRIERS
Clear and concise communication is essential during an emergency call. A series of factors involved in increased willingness to perform telephone CPR have been hypothesized, including use of a simplified interview with fewer questions and early reassurance that EMS vehicles are already on the way [12]. A linguistic study on 424 cardiac arrest calls showed a greater bystander willingness to perform CPR when call-takers use words of futurity or obligation (“We are going to do CPR” or “We need to do CPR”). Using terms of willingness (“Do you want to do CPR?”) may result in delayed or denied CPR, probably because the caller is not able to fully comprehend the situation and make important decisions [13]. Redundant questions and nonessential assessments must be avoided, in order to reduce the time until first chest compression [14]. Dispatcher-assisted instructions should consist of straightforward messages explaining to a layperson how to perform CPR, avoiding technical language and limiting the risk of misinterpretation [15]. All these elements, aimed at using everyday language, may improve dyadic interactions between the caller and the clinician.
Linguistic barriers and cultural differences, mostly related to ethnic minority groups, may also pose a significant challenge, requiring more time before cardiac arrest recognition and initiation of chest compressions, and lower willingness to perform CPR under EMCC provider guidance [16]. Similarly, elderly callers may have communication difficulties related to generational gaps, different cultural levels, or comprehension problems due to hearing difficulties. Training call-takers to handle language barrier situations by simplifying questions and information and avoiding every form of prejudice, may help overcome communication gaps and disparities, enhancing caller comprehension and cooperation [17].
EMOTIONAL DISTRESS
Witnessing a cardiac arrest scenario is an extremely distressing event. An emergency call may become impossible due to confusion or panic, as the caller may be unable to cooperate, provide the required information, or perform CPR following telecommunicators’ guidance. A recent retrospective study on OHCA emergency calls observed that 32.2% of bystanders were emotionally stressed (i.e., crying, screaming, or not paying attention). Emotional stress was found more frequently in women, among relatives of the victim, and when the caller was alone [18].
Through an emphatic approach, EMCC providers must acknowledge the callers’ emotional distress, using reflective listening techniques, such as paraphrasing and summarizing, or calling them by name to convey understanding and help them feel heard. Constant reassurance that emergency teams are on the way and instructions on how to perform CPR maneuvers may empower cardiac arrest witnesses, shifting their focus from distress to action and giving them a sense of control over a chaotic situation. Interestingly, Chien et al. [19] found that a high emotional state was not a barrier to OHCA identification; additionally, uncooperative and highly emotional callers who were reassured by dispatchers started chest compressions in a shorter time compared with calmer callers. It is possible that a caller's emotional distress is a result of understanding the seriousness of the situation, which is why they are more responsive to the need for lifesaving maneuvers. Despite the dramatic nature of an OHCA, awareness of the situation can help foster human interpersonal and cognitive factors, including communication and team collaboration [20]. Providing effective support in cases of emotional distress not only enhances the overall experience but also increases trust in the whole emergency medical response system.
PHYSICAL BARRIERS
A bystander's physical inability has been described as one of the most prevalent obstacles in performing effective DA-CPR, mostly related to the impossibility of moving the patient to a hard surface [21,22]. A significant number of cardiac arrests occur in a private location, witnessed by an elderly person alone with the victim who is not strong enough to reposition them. Physical limitations represent a common barrier to the prompt initiation of compressions due to the difficulty of repositioning a cardiac arrest victim on the floor in 27% to 48% of cardiac arrests [7,21]. Soft surfaces may absorb up to 57% of the compression depth [23]. Notably, a systematic review and meta-analysis on mannequin studies investigating the optimal surface for delivering chest compressions found no significant differences between placing the patient on the floor or on rigid surfaces [24]. Dispatcher-assisted CPR instructions should weigh the risk of physical fatigue due to the increased compression effort required to overcome the effects of soft-surface compression against the difficulty of moving a victim to a firm surface.
Simulated studies reported that chest compressions performed by older people, particularly women, are often suboptimal in terms of depth and number [25,26]. Despite new communication strategies currently implemented in several EMCCs, such as video calls offering more effective DA-CPR instructions, older people often encounter difficulties in using technological support tools, such as activating the speaker function on their mobile phones [27]. Telecommunicators’ training and protocols should consider dedicated CPR instructions targeting older people with physical limitations.
CONCLUSION
The interactions between emergency dispatchers and bystanders represent a peculiar example of a mutual relationship in a critical time-dependent situation. Although it may appear asymmetrical or unidirectional, the engagement between EMCC providers and bystanders represents a dyadic relationship, which plays a pivotal role during an emergency call and strengthens the initial links in the chain of survival. In a continuum of care, EMCC dispatchers offer guidance and support throughout the emergency call, coordinating the arrival of rescue teams on the scene and giving ongoing CPR instructions. Active listening, common trust, and clear and effective communication by EMCC personnel empower bystanders, playing a vital role in achieving improved outcomes for cardiac arrest victims.
Notes
Conflicts of interest
Guglielmo Imbriaco is a member of the Scientific Committee of the Italian Resuscitation Council and a board member of Aniarti, the Italian Association of Critical Care Nurses. The authors have no other conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.