
Call9 (YC S15) Delivers On-Demand Doctors in Emergency Situations - katm
http://techcrunch.com/2015/07/20/call9-delivers-on-demand-doctors-in-emergency-situations/
======
FireBeyond
A few comments (which aren't necessarily a complaint about your product) from
a firefighter/paramedic:

1\. Nursing home staff should be able to recognize typical and atypical signs
of cardiac arrest ('should' being a key part of this).

2\. My county's 911 service (serving 300,000 people) has the following
response times: 6.0min for BLS (Basic Life Support) services, 6.1min for ALS
(Advanced Life Support). 15 minute response times would be... a whole new
world.

3\. Impending cardiac arrest, I'd be curious as to what the 'difference made'
would be. Administering ASA (aspirin)? Not emergently significant. Nitro?
Typically self-administered, and again, I'd question the quality of a nursing
facility that didn't feel comfortable administering such drugs based on vitals
and symptoms alone, without needing the assistance of an ED physician
(granted, several in our area as a policy/liability concern will immediately
phone 911 as their 'treatment plan' for these situations - but similarly,
these same facilities would be on the low end of the bell curve for utilizing
a service like Call9).

4\. Similarly, a nursing facility that wasn't vigorous in training and
utilization of CPR/AED (because that's the number one hope for an arrest
patient, high quality chest compressions - in the absence of tele-EKG for
administering cardiac drugs for certain arrhythmias and dysrhythmia - again,
if your 911 arrival time is 15+ minutes, perhaps...)

I can definitely see a use case for anything that moves from "proactive" (nor
necessarily in a positive, often actually a negative sense) ED / 911 visit
called by a skilled nursing facility. Indeed any increase in the use of a
community outreach / service for high risk patients is a good thing.

I did read that you are indeed going to supply EKG and US to clients, and this
helps - but I'd be curious about the value of some interventions. A
presentation of impending cardiac arrest should be a first call to 911 (I
realize your example presented with constipation and stomach pain). And in the
context of having to talk a nurse through an EKG, what interventions do you
really expect them to be able to reliably perform (start an IO/IV)? I am
intrigued though, to see how this could grow, but it seems to me that your
target might want to be 'urgent care' as much as emergency medicine.

Of course, where 911 response truly is that slow (and I know that it can be in
several parts of the country), then anything that helps the patient's
prognosis cannot be a bad thing.

~~~
uber_for_cats
Look their own sales pitch in the article is the death knell for this startup.

Protocol with 911:

* Person has suspected heart attack symptoms.

* 911 is called, short triage on the phone.

* Ambulance is dispatched.

Protocol with this new startup:

* Person has suspected heart attack symptoms.

* Skype with doctor, short triage on Skype.

* Doctor quickly trains nurse (conveniently available on site) to take EKG (presumably while patient is grasping his chest).

* Nurse takes first EKG in her life.

* Doctor reads EKG, and calls 911.

Who in their right mind would call a gatekeeper instead of 911 in an
emergency?

~~~
Jessdonig
Hi, this is Jessica from Call9. Just wanted to address a few points here:

1) When you call 911, you talk to a gatekeeper. That gatekeeper is a phone
dispatcher, not a doctor. Talking to a doctor is not a delay in care--it's the
reason people call 911 in the first place.

2) Since Call9 works with facilities such as nursing homes and has access to
patient information, using Call9 actually saves time in the dispatch process.

3) As described in the article, it's not always that clear to the person
calling 911 has "suspected heart attack symptoms". In the given example, he
presented with abdominal pain. That is why having the doctor be the first
point of contact is so important.

~~~
civil2
Your doctor is a gatekeeper to 911, so you have an additional gatekeeper. I
think you will find that anyone in the general public experiencing an
emergency is going to call 911, not your service.

Your service might be useful in non-emergencies. It's basically like a family
doctor visit on Skype. There are a number of companies offering this, but it's
not clear how this helps with outcomes. (For example,
[http://nyti.ms/1fyWXeK](http://nyti.ms/1fyWXeK))

For healthcare facilities, like nursing homes, you are basically providing a
doctor on call via telemedicine. That is already heavily used. Many hospitals
employ radiologists, neurologists, etc who can view diagnostic images and data
remotely and provide consultation to the medical staff on site.

What I think is dishonest (and could cost lives) is advertising your service
to the general public as an alternative to 911, and especially claiming that
it is faster than 911.

~~~
ctenev
These are interesting points. I think that it’s important to clarify a major
differentiating factor between Call9 and other telemedicine providers: not
only do we have an ER doctor directly interfacing with the patient
immediately, but we also have on-site healthcare staff who are prepared to
perform diagnostic tests and immediate medical interventions under a doctor’s
direction. This is different than a consult where a doctor can only virtually
advise, but cannot intervene; it is also different that calling a doctor for a
specialty consult or a second opinion.

It is true that putting a doctor first in the process adds another step before
calling 911. But it is a meaningful interaction that improves the quality and
efficiency of the medical care (both by having an ER doctor assess the
patient, and by having information ready so that the 911 call can go faster).
It’s not about cutting out steps, but reorganizing the system to optimize care
and save lives.

------
brandonb
Very cool! I think this could help with sudden cardiac arrest, where the heart
stops pumping blood effectively and death happens within minutes--faster than
an ambulance can arrive.
[http://my.clevelandclinic.org/services/heart/disorders/arrhy...](http://my.clevelandclinic.org/services/heart/disorders/arrhythmia/sudden-
cardiac-death)

The survival rate of sudden cardiac arrest is 8%, and it kills about
350,000-400,000 people in just the US. It's our #1 killer.

The difference between a life saved and a life lost is whether non-medical
bystanders can intervene and perform CPR or use an AED within the first couple
of minutes.

~~~
tpeck
SCD (sudden cardiac arrest) is a great example of when having a highly trained
healthcare professional at the scene early can save lives. It's been well
shown that there's a 'bystander effect' when it comes to CPR, which can keep
the brain oxygenated in SCD and keep people alive before the ambulance
arrives. The bystander effect, is that CPR is often not done when it needs to
be (even by those who have been trained in CPR) because they are fearful of
doing something wrong. With a doc there immediately, we can encourage
bystanders to do CPR immediately and again save lives not otherwise being
saved.

~~~
FireBeyond
SCD is sudden cardiac death, not arrest - death as the result of 'loss of
heart function'.

~~~
tpeck
Sorry - let me explain myself. The term SCD is often used as analogous to SCA
(sudden cardiac arrest). In this context, SCA is a more proper term - good
catch. The only difference between the two is that the SCA didn't get treated
in time and so the patient expired.

~~~
FireBeyond
I figured something along those lines, with "SCD (sudden cardiac arrest)" in
your original comment. Always happy to clarify and get clarification!

------
DanBC
This looks fascinating.

i) do you have plans to gather data? Correct research would be tricky, but
have you considered collaborations with researchers / statisticians? It'd be
fascinating to see some robust numbers after a year

ii) in England a considerable amount of 999 calls are either alcohol or mental
health related. You've limited the "custer base" to schools and care homes and
etc, but how will you handle such calls? For example: you get a call for
someone who has engaged in severe (requiring surgery and hospital admission)
self harm but who has no suicidal intent. Do you have procedures for that kind
of call?

Thanks for patiently answering questions! HN is sometimes somewhat hostile.
:-/

~~~
tpeck
i) A group from University of Arizona is actually doing a prospective study on
our patients. The have IRB (Institutional Review Board) approval to collect
data and will see our impact on the patients as we move forward. After we
proved concept, we were confident enough in our product to let them in and see
what we're doing. I stay out of their way, so I don't have details on how the
study is structured, what data they're collecting.

------
semerda
“In a few years, people are going to be using Call9 instead of calling 911,”
says Tenev.

I doubt it. I would never put my life in the hands of an insurance like app
which may or may not work; say where data is not available. You can call 911
over all cell network even if yours is not available/no sim/unregistered
phone.

I hope Call9 understands the emergency side of the business esp around PSAP?
Otherwise it won't scale and will be liable should their technology fail to
save a life.

A problem with mobile phones is location. Unlike a home phone which is tied to
your physical home address, how will the emergency personnel know where you
are if you pass out before telling them the address? Cell tower location find
can be up to 100m away from you. Satellite requires 3+ direct satellite
triangulation.

Then there is the routing issue. So the app connects to a Physician in a
hospital? But hospitals don't own Ambulances. Ambulance companies are private
in the USA. So a hospital will in turn contact the Ambulance company.
Additional piping that can be avoided with a better model. Say; if Call9
connected directly with an Ambulance company that is running a Home Visit
Program (HVP) ie. Paramedicine, then use the EMT to triage the situation using
industry Protocols/ICD. Then, Call9 would be starting to solve Hospital
Readmission Penalties/Rates. That's a big fish worth $$$ per patient and thus
a great disruptive business model.

Now of course this is all easier said than done since the red tape to get this
going is the major hurdle. The technology part is easy. I've been down this
rabbit hole ;-)

------
uber_for_cats
It looks like this product introduces an extra delay before an ambulance is
called - terrible idea. When you have a heart attack, you want an ambulance,
not an Uber driver (UberFIRST-AID) or a Skype call with a doctor (this
startup).

~~~
tpeck
We get an ambulance to the scene faster than 911, which is a great benefit of
using Call9 - I completely agree that it would be a terrible disservice to
cause a delay in emergency response. Because we have a direct line to an
ambulance service dispatcher, we don't first need to go through a central
call-center like other 911 emergencies. Therefore, we save time by a) not
having to explain if its a medical vs. police/fire emergency, b) not
explaining our location - they know it already, c) having the doctor tell them
if advanced life support is needed vs basic life support.

~~~
FireBeyond
This doesn't necessarily seem like it's a guarantee - firstly, from my
experiences working private ambulance, most are built and staffed to operate
at or near capacity, as idle ambulances don't make money.

Depending on the location, when you dispatch ALS/BLS ambulances this way,
whose medical license are the EMTs and paramedics working under? Does the
county medical protocol director like/want this?

In cases of cardiac arrest, you're going to typically want more than an EMT
and a medic on an ambulance. CPR is, as you know, a man-power intensive
activity.

The three things you mention are not really problems in a 'modern' PSAP. "911,
what are you reporting?" "Confirmed cardiac arrest". Even without that, in
most areas around here criteria-based dispatch is used to determine ALS/BLS
with an erring towards ALS if there's any question.

In my county (Washington state), the protocol states (and is met with 94%
reliability that from call reception for EMS, dispatchers should have toned
the appropriate unit(s) with 60 seconds of call reception, and those units
should be en route within 2 minutes of that (even for in quarters response).

~~~
brandonb
FWIW, Washington state is exceptionally good at treating cardiac arrest. See
table 4 here:
[http://jama.jamanetwork.com/article.aspx?articleid=182614](http://jama.jamanetwork.com/article.aspx?articleid=182614)

SCA survival rate of 16% in Seattle, vs. 3% in Alabama or 5.5% in Toronto.

Still a long ways to go, even for the best regions.

~~~
FireBeyond
Very true. As objectively as possible, I realize we're at the 'leading edge',
and there are a lot of improvements, both here and elsewhere, to be made.

But then again, I'm sure Call9 would rather be compared to 'how we fare versus
the best EMS systems in the country, not the worst'. :)

------
lbhnact
Hi Tim, congrats on the launch from back here in Boston! I had a couple of
questions on what I'll call 'sensitivity' and 'specificity' in your early
work:

Sensitivity: What's the OR, relative delta, or NNT in calls for changing
prehospital acuity or intervention to a higher than initially suspected level?

Specificity: How often does the early contact result in a less intense, on-
site, or diverted response?

So many questions! Would love to hear what you're finding.

(edit: copy)

~~~
civil2
So much misleading medical marketing in the article and this thread, by the
time this thread is done, he's going to have his medical license pulled. :)

~~~
lbhnact
Well, like usual on HN I don't read the actual linked content and probably
won't here as well. For my own peace of mind, I'll recuse myself from reading
the website and it's likely necessary launch rhetoric. You're right that HN
suffers from less than rigorous medical analysis more often than I would
usually like, but there are usually at least a few penetrating questions on
the medical threads I read.

However, I have met Tim before and can attest to his interpersonal candor on
problems with EMS, and the reputation for rigor of his medical training. In
short, I think he's a smart, hard working guy who is legitimately committed to
solving a real problem.

Given my own experience (as an EMT, working in the ED as an admin and medical
student, and as a federal emergency response officer in a previous life), I do
think solutions along the lines of higher fidelity information on scene will
be useful for patients and providers.

There will need to be piles and piles of evidence before we can conclude that
products like this will provide the outcomes we want in our health system. In
the meantime, I'll try to appreciate the obstacles I know this team has
overcome to get as far as they have.

~~~
tpeck
I still don't know who this is writing this, but I thank you for the
sentiments!

We've done our best to research the stats and present a thoughtful
representation of the current state of EMS. We have many official and
unofficial EMS advisors who have spent tireless hours to make sure this is
true. I assure you, nothing on our site or in our advertising is meant to be
misleading - the 911 system is antiquated and could benefit from an overhaul.
Like many large systems, there are a lot of good, smart people involved, but
change is difficult. We hope to work from the outside in, and save
lives/improve outcomes in the process.

Research and academic integrity is important to me and my Call9 colleagues.

------
carterehsmith
"The team has a group of 130 doctors standing by"

I think that this is not a startup, but a psychology experiment that needs to
find out just how gullible we are.

~~~
tpeck
Hahaha. I like this comment. We have 130 physicians who will do part time
calls - we also have full time docs. But the benefit of the part time model is
that Emergency Medicine docs have never had a model to make extra income for
clinical work in which they can only work a couple hours at a time. As an EM
doc, when I go to work now, I have to stay there until I'm done usually 10-12
hours later.

------
xiaosongmu
Hey HN! XiaoSong here (cofounder/CTO at Call9). Would love to answer any
questions people might have about the product.

~~~
scott_karana
Are there any liability aspects if a nurse or other practitioner _doesn 't_
call 911, in favour of calling you? Or does your product also alert ambulance
services, while simultaneously providing advice?

~~~
xiaosongmu
If the patient needs an ambulance, the Call9 doctor can easily order one. One
advantage of this system is that the doctor can prep the EMTs on what they
need to know as they're en route to the emergency. The TC article elaborates
on this a bit.

~~~
scott_karana
Cool. That sounds sensible. Good luck! :-)

------
trisomy21
This is really interesting. I know it's not a replacement for it, but 911
seems so inefficient and outdated to me today. I'm excited to see how this
company progresses. Small improvements here can really save lives.

~~~
uber_for_cats
It's not going to seem so outdated when you or one of your loved ones has a
heart attack, and the ambulance is rushing him to the hospital where an
interventional cardiologist is going to unblock his/her heart arteries in an
operating room.

~~~
trisomy21
Well, one of the reasons why the medical response aspects of 911 feel so
outdated and inefficient to me is because the system has to treat all calls as
if they are life threatening heart attacks, when most often they are not.

~~~
uber_for_cats
Right, so this startup introduces an additional delay / filter before 911 is
called. I would not want that for my loved ones in an emergency.

~~~
tpeck
Surely your right to not use our product. But, we've already saved lives,
decreased transport times, identified conditions in patients that otherwise
would have been ignored (because we have doctors doing the assessment, not
bystanders/nurses/EMS). The way the system works is that there are many triage
steps before a patient ever sees a doctor - we've flipped that model and put
the physician (who is ultimately the one making the medical decision) as the
first step rather than the last. To us (and our patients), it just makes
sense.

------
tcook
Why not just call an ambulance?

~~~
xiaosongmu
Most people don't realize this but there are a lot of inefficiencies with the
current 911 system that jeopardize the safety of patients. It takes on average
over an hour to see an MD from the time you call 911. In that time, a lot of
triage and diagnostics, and even treatment can happen. We cut down that time
drastically.

Additionally, a very large portion of 911 calls come from patients who should
not be going to the emergency room. Going to the emergency room is always
exposing yourself to risk (such as hospital infections), not to mention
unnecessary stress and pain. For the elderly, or very young patients, or very
ill patients, this undue (and often unnecessary) stress can have very
detrimental effects on the patient. Call9 can prevent that portion of calls
from going to the hospital.

So with call9, we either A: provide safer, better service on top of
traditional 911, or B: we skip the emergency room altogether.

~~~
FireBeyond
This confuses me. These aren't necessarily benefits to your service.

If the patient needs an ER visit, you are getting one, however it is
initiated.

Community-outreach / in-call? Absolutely. I love that aspect of your service.

Your "A" and "B" benefits seem to be the same, not an either-or. The safer
route in A comes from skipping the emergency room in B where applicable and
appropriate.

I do like that you cut the waiting time to see an MD, regardless of the
situation. Diagnosis is an important first step. But I'm curious about the
'medical kit' provided. Because diagnosis is limited to cases that don't
require (for example) lab services, and for non-emergent cases, great.
Prescribe the appropriate medication or treatment regime. For anything else,
the outcome is likely to be the same - not much is changing in that "golden
hour" (with all caveats thereto) in terms of definitive care.

I realize I may be coming across as cynical or skeptical in many of my
comments, but I really do wish you success and would be very happy to talk
with you further. I'm just raising some of the thoughts and questions that
come to my mind as a first responder and, as I'm sure anyone will agree,
anything that alleviates pressure on the 911 system is "A Good Thing(TM)".

------
mattmireles
Good idea for patients, terrible awful business model.

~~~
tpeck
How so? Would love to address this question and your concerns. What is your
perception of how our business model works?

------
qq66
Why not dispatch the ambulance as soon as the call is received, and call it
back a few seconds later if the doctor determines it's not an emergency?

------
ngoel36
Are they insured?

~~~
tpeck
We insure ourselves and our physicians.

~~~
ngoel36
Was that difficult, being an emergency service?

------
mangeletti
DO NOT visit call9.com

If you were curious, like me, why Call9 didn't use call9.com, don't visit that
domain to find out. It will redirect you to a malware website.

IMHO, Call9 should attempt to acquire the call9.com domain (or sue for it),
since it clearly serves no decent purpose.

~~~
tpeck
use callnine.com !!! we're surely working on this

~~~
mangeletti
Ah, good deal. One more thing:

The "Request Access" button doesn't function properly on Firefox, due to the
use of... an <input type="text" ...> there (not sure what the purpose of this
is, but surely you could get by with just a <strong> or something.

~~~
tpeck
thanks for this. we'll work on it right away.

------
yuvadam
> "In a few years, people are going to be using Call9 instead of calling 911"

'Murica, your shit is beyond repair.

------
jbob2000
This is dangerous for one reason and one reason alone: It conflates the
message of "Medical emegency, call 911". We've had that drilled into our heads
and drill it into our children's heads.

Now, you want people to question that in a time of emergency? "Crap! Mom is
having a heart attack! Should I call 911 or use Call9? It's supposed to be
better! Shit, where is my smartphone, all I have is this landline. Crap, my
smartphone is upstairs, I'll just use my tablet. Wait, I don't have Skype
installed on my tablet. Dammit, I'll just call 911".

