Toronto Paramedic Services has one of the largest communications centres in Canada. Approximately 135 Emergency Medical Dispatchers (or EMD's) are employed and work together on 6 different platoons on rotating schedules of 12 hour shifts. Like Paramedics, EMD's are there to answer your call for help 24/7, 365 days per year.
Your co-worker approaches you with difficulty breathing. She has asthma and doesn't have her inhaler. Someone tells you to call 9-1-1 - so you do. What happens next when you're in a large, urban area like Toronto?
9-1-1 calls in the City of Toronto are routed to the Toronto Police Communications Centre and are answered by a 9-1-1 police operator “Emergency, do you require police, fire or ambulance?" Depending on your emergency, your call will travel across the city to Toronto Fire Services or Toronto Paramedic Services - Central Ambulance Communications Centre (CACC). Though it may seem simple enough to call for an ambulance and get one, your call sets in motion a series of events to get you the right help, to the right place, all within minutes. Emergency Medical Dispatchers (EMD's) are trained professionals who are accredited by the International Academy of Emergency Dispatch and they are the beginning of the chain of first responders. EMD's are responsible for answering and dispatching all calls for emergency medical aid within the City of Toronto's boundaries. On an average day, more that 700 calls for help are directed to Toronto CACC. To handle that call volume, EMD's use a Medical Priority Dispatch System (MPDS) on a series of CAD (computer aided dispatch) screens. Your emergency will change hands several times between the time that you place your initial call and the patient is ultimately seen at the hospital.
Toronto Ambulance, where do you need us?"If you are calling from a landline (also known as a hardline), we will receive the address and phone number of where you are calling from known as ANI/ALI (Automatic Number Identification / Automatic Location Identification). This includes home telephones that receive E9-1-1 service, pay phones and some business lines. You will always be asked to confirm the location of the emergency. When calling from a cell phone, our information is not as accurate. We are provided with the number you are calling from and the location of the cell tower you are closest to. It's very important to know exactly where you are, especially when using a cellular phone. Other types of phone lines can use the Internet such as VOIP or Magic Jack which have increased in popularity over the recent years. It is very important to have your current address up to date with these services because a representative from the provider will handle your initial call. There is no ANI/ALI.
In a diverse city like Toronto, we encounter many people who speak a variety of languages. Our call receivers have access to a service called Language Line, which provides interpreter services 24/7 in 170 languages. We also liaise with Toronto Police Communications to use TTY services for the hearing impaired.
“Tell me exactly what happened?" Part of our job is to triage patients over the phone and tell the Paramedics that are responding what is happening. Is the patient awake? Is the patient breathing? Based on what the emergency is, EMD's use 33 protocols in MPDS to ask questions relating to the patients' condition. These include calls for chest pain, difficulty breathing, abdominal pain and traumatic injuries; however, they also include questions that we ask for the safety of the caller and the emergency responders such as traffic accidents with hazards present, assaults and patients with possible psychiatric concerns that are behaving violently. When all questions have been answered, a priority will be assigned to the emergency and it will be sent via CAD (also known as VisiCAD) to the EMD responsible for that particular area of the city. The call receivers' job does not end there. We will re-assure you and give you instructions on what to do until help arrives. MPDS protocols are very thorough in providing detailed instructions for various emergencies. EMD's can tell you how to control bleeding, how to deliver a baby, how to use an EpiPen for someone having an allergic reaction and even how to do CPR or the Heimlich maneuver. In the case of emergent patients, we will stay on the phone until help arrives. Based on the information, your emergency will be assigned a priority:
Echo - The highest priority for patients that have agonal (dying) breathing or who are unconscious and not breathing. Paramedics, police and the fire department are all sent to provide immediate care.
Delta - A high priority where Paramedics usually use their lights and sirens. This is for patients with a potentially life threatening condition or symptoms.
Charlie - Moderate priority. Based on the information provided, the patient MAY have a pre-hospital emergency.
Bravo - A lower priority emergency. Though there may be pain or injury present, the patients' condition is not deemed immediately life threatening.
Alpha - A low priority call. These patients may or may not require ambulance transport to hospital. In some cases with low acuity patients, the EMD will transfer your call to a registered nurse at Telehealth Ontario who can assist you with suitable options that may not include ambulance transport to the emergency department. Examples are: lower abdominal pain, a cut finger, a child with something stuck up their nose, flu symptoms and back pain. A registered nurse can provide a more in depth assessment over the phone and if they believe an ambulance is required, one will be sent. In many cases, callers/patients are directed to a family doctor, clinic or an ER visit within 24 hours.
Courtesy Call - Some patients may not be injured but require help. For example; an individual who has fallen/slipped but can not get up under their own power.
Non-Emergency Transfers - Toronto Paramedic Services does not have a fleet of Paramedics dedicated to transferring patients for appointments. The types of “transfers" that we do accommodate now are unstable patients or those who require immediate transport to another hospital for specialized care.
When the priority has been assigned, your call changes hands to a Dispatcher.
At Toronto CACC, the city is split into 4 quadrants.
- Northwest (District 1)
- Northeast (District 2)
- Southwest (District 3)
- Southeast (District 4)
A quadrant dispatcher is assigned at the beginning of their shift and remains in the position for 12 hours. Dispatchers use five computer screens to monitor emergency calls and coverage in their assigned quadrant and throughout the city. These screens include one for mapping in the assigned quadrant, one for mapping the city, one for tracking ambulances and resources assigned to their district, one for using dispatch software (Optima) and the last is Avtec, which is a computer based, touch screen phone and radio system.
Dispatching is often fast-paced and EMD's need to think and act quickly. We are constantly assessing and prioritizing emergency coverage, emergency calls, Paramedic requests and needs as well as that of our fellow quadrant dispatchers and the rest of the city. Dispatchers are responsible for the deployment of emergency coverage and emergency call assignment for approximately 25 ambulances in each quadrant on any given day. Using VisiCAD, they can track and deploy the Paramedics and when doing so, this remotely sends each assignment to the station, the mobicad in the ambulance, the pagers assigned to Paramedics and their portable radios. Dispatchers have the help of AVL (automatic vehicle location, much like GPS) in each ambulance to give them up-to-date information on the location of each unit.
When a call receiver processes a call and assigns a priority, VisiCAD automatically sends that call to the appropriate quadrant dispatcher. Depending on the priority, the dispatcher will select an appropriate resource to send. We also use Optima, which is dispatch software that aids in selecting appropriate resources. It is the responsibility of the dispatcher to ensure that Paramedics receive their assignment and respond in a timely manner. If a higher priority call arises in the same area, the dispatcher may reassign the Paramedics if they are responding to a lower priority. Most communication is done via vehicle installed (trunk) or portable radios.
Other duties that dispatchers are responsible for are ensuring the safety of Paramedics, taking patient notifications from Paramedics and notifying the appropriate hospitals, ensuring that Paramedics are assigned a meal break location, administrative duties such as status updates, paging, sending help if a Paramedic becomes ill or injured on the job and liaising with other quadrant dispatchers, as well as supervisors in operations and communications.
Once the Paramedics arrive on the scene of an emergency call and assess their patient, they will assign that patient a CTAS level (Canadian Triage and Acuity Scale) similar to call Priority based on actual patient assessments and condition. They will then contact the Hospital Destination Coordinator.
PSA (Patient Safety Advocate)
This position is staffed by a senior dispatcher on day shifts only. (Soon to be staffed 24hrs a day.) The PSA will monitor ambulance response times and delayed dispatch times. When there is a high volume of emergency calls and limited resources available, the PSA will contact the scene and advise them of the delay and reassess the patient's condition. During a busy weekday, emergency call volume can be very high and at times, ambulances are not available immediately. The PSA will stay updated on patient's conditions and re-triage low priority calls appropriately by remaining in direct contact with quadrant dispatchers.
Hospital Destination Coordinator
The City of Toronto has 14 hospitals with emergency departments and also utilizes 5 hospitals within the GTA. The Destination Coordinator is responsible for monitoring the status of those hospitals and distributing patients evenly so that one or two hospitals do not get overloaded with ambulance patients. Using PDS (Patient Destination Software), the Destination Coordinator (HDC) will assign a hospital destination to Paramedics using their location, the CTAS level assigned to the patient and any special services required.
Toronto has 2 regional trauma centres, 4 regional stroke centres and several designated cardiac cath labs. Some hospitals specialize in other areas and it is the HDC's responsibility to ensure that Paramedics are directed to a hospital that meets the needs of their patients' condition. The HDC will also take patient notifications from Paramedics to notify the emergency department and will be the liaison to hospitals with regard to multiple patients from a MCI (multiple casualty incident).
Hospital Clearing Coordinator
Upon a patient's arrival at the hospital, Paramedics go through a series of events to transfer the care of that patient to hospital staff. It is the HCC's responsibility to monitor and track the time that our Paramedics spend in the hospital. Paramedics are in radio or telephone contact with the HCC regarding their patients offload status, which is reflected in their potential availability for another emergency call. Many Paramedics spend hours in ED's monitoring their patients because there is no hospital bed or staff to take over patient care. Offload delay causes a chain effect of reduced resources for emergency calls and deployment, delayed or non-existent breaks for Paramedics and an all-over strain on the system. The HCC will be notified when Paramedic crews are delayed, require a clean up or uniform change, as well as when the patient transfer of care to hospital staff is complete. They will then become potentially available as a resource if the need arises. The HCC is in close contact with quadrant dispatchers who may need a crew for an emergency call.
The tactical desk has many uses and is manned by at least one dispatcher, depending on the event. TAC desk is used for MCI's or large events that cannot be handled on a regular quadrant desk due to the potential for large volume and multiple patients. The dispatcher and the Paramedics assigned to each event will be on a special radio channel dedicated to them. They also have VisiCAD and Avtec, including joint emergency channels with Toronto Police and Toronto Fire Services.
Out of Town Dispatcher
This position monitors ambulances from other services that are travelling within Toronto's boundaries. They receive notification about these vehicles from other CACC's and the Paramedics are required to switch their radio channel to notify the OOT that they are travelling in Toronto CACC's area. The dispatcher is also responsible for monitoring the availability of these units in case the need arises to have them respond to emergency calls in Toronto. OOT will also direct out of town unit to appropriate Toronto hospitals using PDS and track their call times manually and provide that information to the appropriate CACC. This position routinely takes overflow emergency calls while monitoring two radio channels.
Also known as Senior Dispatchers, 1 Desk has various responsibilities. While they do not actively dispatch emergency calls, they are responsible for our Critical Care Transport Unit (CCTU) and monitoring other dedicated emergency channels. Senior dispatchers are responsible for deployment of resources at start of shift, matching up Paramedics to make full crews, rostering of Paramedics to vehicles and administrative duties. They also monitor quadrant dispatchers and aid in decision making and contact with other allied agencies. 1 desk monitors Paramedic meal breaks and attempts to make arrangements if a break is not provided.
Roles and Staffing in CACC
Hospital Destination Coordinator
Hospital Clearing Coordinator
Out of Town
SCS (Systems Control Superintendent)
Senior Dispatcher/1 Desk
Duty Officer (Deputy Commander)
**A note from the dispatcher**
I have been an EMD with Toronto for 10 years. Prior to this, I was a police dispatcher. Securing a job with TPS (formerly known as TEMS or Metro) CACC was a realized dream for me, although not acquired easily. Being a dispatcher isn't just answering a phone and sending an ambulance. I spent 6 weeks in training to become a Call Receiver and another year solely taking emergency calls. It takes 3 months to train a dispatcher, sometimes longer. All of the book smarts in the world cannot make you a good & effective dispatcher. I have had the opportunity to watch and work alongside some incredible people that are masters of their craft; people that make it look easy. We all work together for 12 hours and become a family. It is under stressful conditions that we create organized chaos and make the best of what can be a really lousy day.
We don't see the victim that was hit by a car but we are the first ones to hear the terror and helplessness of the person calling 9-1-1 at the height of their emergency. We don't go to scenes of chaos or freezing temperatures or unthinkable cruelty but we know our friends and colleagues ARE and we empathize with them - we are humans first. Dispatchers aren't a voice in a box and Paramedics aren't green dots for emergencies. Over the years, I have worked with the same names and voices but could not put a face to some of them because that's how our job is. When that voice calls a "Paramedic needs assistance", a call for help, my heart is in my throat because that is my FAMILY - those are my people!
I love my job. I love being busy, thinking on my feet, multi-tasking and organizing a completely hopeless mess. I work side-by-side with people that I trust and respect. I enjoy the sometimes inappropriate banter because we're all a little dark and need that release. My hope is that my voice can provide comfort - whether it's to a citizen in need of help or a Paramedic that knows I've got their back. I think that's a pretty sweet gig.