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Saturday, June 17, 2000

911 Error Slipped Through Safety Nets

By April E. Moorefield STAFF WRITER

Greenville County's 911 system worked "perfectly" three weeks ago when an EMS crew on its way to treat a gunshot victim ended up in Travelers Rest instead of at the Greenville residence where a man lay dying.

Where the breakdown occurred was when an EMS dispatcher apparently disregarded safety nets in the computer dispatching system that are designed specifically to eliminate such errors, officials said.

"It should have been caught and it wasn't," Greenville County 911 Director Ralph Inman said.

James Dorriety, who oversees the county's EMS, said Friday he is still evaluating the situation and will decide if disciplinary action should be taken against the dispatcher once his investigation is complete.

EMS officials said it was 911 computer glitches combined with human error that put paramedics at the front door of a home in Travelers Rest on May 31 instead of on Cox Street in Greenville where an unconscious Christopher Glover was bleeding heavily from two gunshot wounds.

Records show the county's 911 system properly delivered the call.

The computer screen for the county's dispatching system showed it as coming from 6 Cox Street in Greenville.

Once the call arrived, a variety of safety nets should have prevented any confusion that might have arisen over the dozens of duplicate road names scattered throughout communities in Greenville County, said Del King, the county's 911 system coordinator.

Four were missed.

"What does Cox Street turn off of? Paris View Drive?" the EMS dispatcher asked, according to a recording of the 911 call.

"You turn off of Goldsmith, off of Hammett and come around in front of Pioneer Chemical," the woman answered. "Please ..."

"Listen to me," the dispatcher responded. "Calm down. We've got somebody on the way."

First, it was a Greenville address and telephone number that appeared in the window in the right corner of the EMS dispatcher's screen that provides information on the incoming call, King said.

That window provides a name and address, as well as a list of agencies that provide that address with police, fire and medical services.

A second master terminal in the dispatch center also showed the 911 call coming from a Greenville address, King said.

When both of those went unnoticed, the dispatcher had another opportunity to recognize a problem when she validated the address with the county's database, King said. The address of 6 Cox St. in Greenville wasn't listed, so the computer changed it to 6 Cox St. in Travelers Rest.

At that point, the conflict over streets the dispatcher was cross- referencing with the caller became critical, King said.

Last month alone, 911 dispatchers answered 30,022 calls. Since the beginning of the year, they've answered an estimated 135,000.

"Our dispatchers do a good job, and I have the utmost respect for them," Inman said Friday. "But this is something that should have been caught."

County deputies whose dispatchers were operating with a system that uses the same database of addresses arrived on the scene in less than two minutes.

The ambulance didn't get there until 12 minutes later.

Dorriety said then the delay was the result of a series of technical problems that contributed to human error.

"There wasn't enough human communication to clarify the information before this was caught," Dorriety said after the incident.

Inman said the safety nets are there so such blunders don't occur. He and Dorriety are now working as part of as special task force formed to streamline all EMS procedures. The task force will take a close look at the EMS dispatching system, Inman and Dorriety said.

With such expansive growth in Greenville County, Inman said it would be impossible to ensure the county's database is constantly up to date.

"We could hire 20 people for six months, and I can assure you every address wouldn't be in the system," Inman said. "But the telephone company will tell you Greenville County has the highest volume of service orders of anywhere else in their system. The numbers are staggering. There is no way to maintain it 100 percent."

That's why training for dispatchers is critical, he said.

Greenville County Coroner Parks Evans has said he doesn't believe the 10-minute delay in emergency medical care for Glover was a factor in his death.

But in a vast majority of cases, time is critical, said Dr. Richard Miller, director of trauma surgery services for the Greenville Hospital System.

"Time is absolutely of the essence," Miller said. "They key is stopping the bleeding as soon as possible." And often, it is impossible to tell someone is bleeding internally until they are evaluated in an emergency room, he said.

That's when seconds count.

In an emergency room trauma bay, doctors can quickly crack open a patient's chest and clamp off a major artery to stop bleeding, he said. That can't happen in the field.

And by the time such a move becomes necessary, the situation has already reached life and death proportions. Patients can lose up to 30 percent of their blood volume before their blood pressure ever begins to show signs of dropping, Miller said.

-- (, June 17, 2000

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