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Call9 (YC S15) Delivers On-Demand Doctors in Emergency Situations (techcrunch.com)
81 points by katm on July 20, 2015 | hide | past | favorite | 85 comments

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.

So many good questions/points. Responding to each: 1. This would be an ideal world, but it just isn't the case. Nor do I think its a feasible solution to train nursing home nurses to be as knowledgeable about pathophysiology as physicians. Subtleties of acute cardiac syndrome (heart attacks, etc) are difficult to recognize, and it takes a few years of residency after medical school to be able to quickly recognize and act on them. There are many great nurses that can too, but that usually comes with lots of experience in critical situations (especially in the ICU, ER, and PACU). Nursing home nurses just don't have the same exposure to critically ill patients. 2. Which county? Those are great times. A word of caution when interpreting response times - they often start the clock at the time of dispatch, not the time of the patient calling 911. A lot of Call9's value is cutting out the inefficiencies between the 911 call and the dispatch. 3. Administering aspirin (ASA) is very significant. Anti-platelet therapy (e.g. aspirin) has been shown to decrease the mortality of heart attack patients significantly, and the earlier you give the aspirin, the sooner it works. As for nitroglycerin ('nitro'), the medication that dilates the blood vessels on the hearts surface and allows for better oxygen delivery to heart muscle as its dying in a heart attack, it is extremely dangerous to self administer nitro in certain situations that can only be interpreted if you have an EKG - in one of our patients, we in fact identified this issue and purposefully held the nurses giving off this medication which could have killed the patient. As for the nursing home, this situation happened in, the nurses are well trained and I've been happy with their level of care and concern for their patients. 4. I too think a proactive response makes sense. Good point about the utility of these diagnostics - we surely have cases where they are useful in facilitating the care of patient in an emergency. But they are extremely useful in preventing unnecessary hospitalizations - another key value of Call9. In this way, we do practice urgent care too. . Thanks for your comments - seems like you've been in the field and know your stuff.

Thanks for the thoughtful reply!

I agree, the ideal world and the real world are two very different things. Though still, given the length of your average RN course (or even LPN, since as we're talking real world, many nursing facilities are supervised by one RN over many LPNs) versus EMT... certainly it "should" be better. You do make a very good point about the nature of chronic versus acute patients.

2. Thurston (http://www.co.thurston.wa.us/medic1/stats.htm) - I'm not entirely sure about the measurement of response time, would have to clarify with a dispatchers.

3. Thank you for calling out this. Agreed, ASA is very significant, and should not be discounted. I meant that emergently it's not going to improve patient condition, but I should have acknowledged that's only one part of the treatment plan. NTG, too, at least here, is typically administered or assisted by BLS with numerous contra-indications (brady/tachycardia, hypotension, etc), but most patients I have seen are instructed by their physician to self-administer with symptoms "similar to previous cardiac event". I'm presuming right ventricular infarction on your example patient?

As said elsewhere, I would like to see a service like this succeed, and apologize if I come off 'skeptical' in some of my comments!

This whole thread looks like tempest in a teapot. They provide emergency physicians on call for nursing homes (and maybe other facilities) that already have nurses and other healthcare providers in them. So any analogy to 911 is beside the point.

Their 911 claims (and the people who attack them on HN) - all this could easily be just viral marketing. :)

I worked 911 in NYC and LA. The incompetence of Nursing Home Staff is often quite astounding.

It was common to arrive for a call of "general illness" only to find the patient in respiratory failure or cardiac arrest with no CPR in progress.

I see this as providing a fast way for clueless staff to up-triage patients.

Telemedicine can potentially add value in many settings, like here http://nyti.ms/1fyWXeK. What I disagree with is their misleading marketing as an alternative to 911.

For regular people, this service is like a family doctor visit on Skype. Sometimes it can be handy, but it remains to be seen how this impacts outcomes statistically. (I wouldn't use this myself.)

For healthcare facilities, like nursing homes, this is like providing a doctor on call via telemedicine. Many hospitals already do this with radiologists or neurologists for example.

What is misleading is their marketing jump from these potentially useful scenarios to advertising as an alternative to 911 for the general public, and even claiming that they are faster than 911 when in fact they are a gatekeeper to 911.

While not wanting to paint with too broad a brush, many nursing/assisted living facilities have as a first priority the avoidance or at least dilution of liability. For example, in one facility, the management, the building owner, and the nursing provider will likely be three separate business entities. I can easily imagine that "call 911" is start and end of their approach to emergencies. If the patient dies, well there are probably 10 more people on the waitlist for that room.

Absolutely. I saw this time and time again. Things that were done to minimize liability, rather than patient's best interest - and that should never be acceptable. The least reason of which is financial, but people and their families are paying four, sometimes five digits a month for places whereby anything more than taking vitals is handled by 'do nothing, call 911', all the while charging for 'round the clock nursing care'.

Yeah. Anything that can be done to limit the damage of "ignorance and/or incompetence" is always a good thing.

My pet hate is always "Do you have a history on the patient or what's been going on?" was almost invariably answered with:

a) "No, this is my first day", or

b) "No, I just got on shift"

Oh. Good.

Ditto. 15 mins response times are old statistics.

"Since the 1970s, arriving within eight minutes 90% of the time has been the gold standard for determining the quality of an EMS system."

"NFPA 1710 states that first responders and BLS units must arrive on scene within a four-minute timeframe 90% of the time for all incidents. The ALS crew that must respond within eight minutes."

Source: http://www.jems.com/articles/2012/02/great-ambulance-respons...

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?

If I may clarify some of the misunderstandings of what happens in a typical emergency. If a patient is clutching their chest, we're calling our ambulance service, not doing an EKG. However, the great majority of heart attacks don't present with crushing chest pain. If they did, Emergency Care would be easy, and EM docs wouldn't have had to do 11 years of schooling to recognize and treat these subtleties. The patient that the TechCrunch article is referring too had a subtle tachypnea (slightly elevated respiratory rate because the dying heart muscle causes the blood to become acidic and so the body compensates by blowing off Co2) and a vague abdominal discomfort with a lot of confounding factors like constipation. This patient would not get an EKG in the overwhelming majority of nursing homes in the country, and it's not their fault! It's just because the system doesn't allow for the evaluation the patient may need. Also - an EKG is quite easy to do - this is a non-issue.

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.

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)

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.

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.

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

Wait. The facility shares PHI (protected health information) with Call9? Have the facility residents consented to this?


If this information is provided and accurate, this is awesome. I love it. :)

Too much time is taken while care providers ask each other vague questions about "do you know what he/she has?" when in my head I'm thinking "You should KNOW this. Or have it readily available!"

I think you're confused or just being overly cynical. The process, as described, is exactly like traditional 911, but your first point of contact is a physician who can, if needed, immediately dispatch an ambulance (just like in your first scenario). If deemed appropriate (by a emergency physician trained to deal with life threatening situations), an EKG can be requested and the nurse can be guided through the process. If I'm in an emergency medical situation, I would absolutely want to connect with an emergency physician first and I'm sure there are many other people who feel the same way.

I think it might be helpful as we are discussing this to be able to explain how the current 911 system works.

As it exists now, calling 911 for an ambulance sets off a chain of 9 human-to-human information transfers and averages over an hour for you to get to the hospital and be treated by a doctor. Many articles and research papers are out there showing the inefficiencies of the current system.

Current 911 system STEP 1: You call 911

STEP 2: Cellular service carrier connects you to an operator (4.5% busy signal rate)

STEP 3: Operator with no medical background takes your basic information and location

STEP 4: Operator types that info into a processing/relay system

STEP 5: EMS Dispatcher reads the relayed info

STEP 6: EMS Dispatcher radios paramedics to go to scene [Steps 1-6: average of 3.9 mins]

STEP 7: Paramedics type address into dashboard GPS system

STEP 8: Paramedics drive to scene [Step 7-8: average of 9 mins]

STEP 9: Paramedics treat, stabilize, and package you

STEP 10: If advanced procedure or medication is needed, paramedic must call a designated physician in a local emergency department to gain approval.

STEP 11: Nurse or other employee answers phone and then finds a physician who is concurrently taking care of other patients in the ER

STEP 12: ER doctor hears your case from the paramedics

STEP 13: ER doctor approves advanced procedures or asks for clarifying information [Step 9-13: average of 14.9 mins]

STEP 14: Paramedic transfers you to the hospital

STEP 15: Paramedics drop you off at an ER (may not be the same ER who approved the advanced procedure) [Step 14-15: average 12.2 mins]

STEP 16a (CRITICAL): In critical situation, paramedic with 2 years of training and no access to your medical records tells what they know about your case to an ER physician STEP 16b (URGENT/EMERGENT): In noncritical situation, paramedic tells the ER triage nurse about your case

STEP 17: ER triage nurse tells the treating nurse assigned to you about your case

STEP 18: Treating nurse tells an MD about your case

STEP 19: You wait for an MD [Step 15-19: average 24 mins]

STEP 20: An MD finally sees you

As physicians who worked in the emergency departments of the world’s leading medical institutions we were able to see first hand the inefficiencies of the current emergency care system leading to poor patient outcomes and avoidable costs.

TLDR - 1) 911 is an outdated system in many ways 2) there is room for improvement.

This is an overly 'exaggerated' flowchart. Whilst there are many flaws with the 911 system, there are also several fallacies (though not universal):

STEP 2: <1% busy signal is a goal of and attained by a large number of PSAPs.

3: Many PSAPs have their dispatchers trained to the EMT level.

4 through 6 are happening concurrently, not as a single step flow.

6: Many PSAPs have a goal that the initial unit dispatch is within 60 seconds of call reception.

7: I've not seen a system yet that relies on ALS units punching an address manually into a TomTom. AVLS (automatic vehicle location system), and mobile data terminals pull the exact information that is entered into 911 (which whilst still prone to error, is an issue with Call9, too) and use GPS which is linked into maps + county GIS overlays.

8: Highly dependent on location. My county has an average 6min response time.

10: Most advanced procedures and medications are governed by offline medical control ("here's our protocol for using this drug / treatment. Indications, contraindications, dosing regime") - the goal is that the need to contact a physician is the exception, not the rule.

If the time taken for 'online medical control' is 14.9 minutes I'll be at the hospital already, because that's where definitive care happens. I, as a medic, am not going to wait on hold and have a leisurely chat with a physician for nearly quarter of an hour on scene. This is a gross distortion of reality. If I do need to call the ER doc, there will be one available, or the charge nurse will know that one needs to be found, now.

16a: at an SNF if we need access to medical records, we can get them. If a patient uses the same healthcare system, they're available at the hospital. Pretending like we're stabbing in the dark and shrugging our shoulders is devaluing the care that paramedics and EMTs do down to the 'ambulance driver' stereotype. Both are trained in patient assessment and history taking, even if not medically qualified to the same level as a physician. In 16b: In a non-critical situation AND there are insufficient resources, then triage is the most appropriate care situation. If you're non-emergent and there's capacity in the ED you're going to a bed.

17/18: As opposed to... what? Unless Call9 claims to be the sole definitive (and remote) care provided, there's going to be a transfer of knowledge.

Your example has it taking a quarter of an hour to get to the patient, an undefined amount of time treating, stabilizing and packaging the patient, supposedly before requiring an online sign-off and discussion with a physician lasting another quarter of an hour before finally loading the patient for another nearly quarter hour trip to the hospital, while some paramedic with no situational awareness gives a nurse a hand off to relay to the physician.

What really happens on scene in a cardiac arrest: BLS providers show up first, AED, CPR, bag patient, potentially with advanced airway, LMA, etc. ALS shows up, determines quickly whether to stabilize on scene or load-and-go, CPR still in progress. A call is made to the hospital, with no discussion with a physician, only the charge, giving pertinent information, and ETA.

"Code Blue, Ambulance, Bed A3, 4 minutes out."

RT, IV, pharmacy, imaging, are all ready. A team is ready to continue CPR. Physician is there. All staff with the exception of the physician move patient from gurney to bed, begin work, while physician gets information from ALS, and then begins directing the code.

Even if exaggerated, his flow is closer than yours for our area in terms of delay. The last accident with a family member of mine had very competent ambulance and team get to use within 5-10 minutes. I got to the hospital and registered before they arrived without speeding. There was another long delay before she was in a room with nurses talking to her. Several got the same information. The overall difference between "event is happening" and "a doctor is seeing her" was in the 30min-1hr range. If it was more serious, the consequences of delays might have been more serious.

So, you and your team seem to be very competent with no tolerance for BS that endangers those you care for. But be careful not to project what you do onto the whole system. The system varies in efficiency, how much people care, steps in between, and so on. A whole spectrum. An outfit like yours might have less need for this service but I've experienced many that could use it.

That doesn't even count the whole "help less competent people in a nursing home assess a potentially, deadly situation" part. I'm totally with them on that.

You seem to know your stuff and work in a great system. . There's a lot here in these comments, and I'll do my best to sum up my thoughts succinctly:

We've done A LOT of user research including days of time on the back of ambulances, days of sitting in nursing homes and watching how a typical 911 call (not a Call9 call) works, countless conversations and late nights with world-leading experts in EMS care, and years of being an EM doc on the receiving end. . Paramedics are NOT just ambulance drivers. They are some of the most valuable members of our society (and surely undervalued/underpaid). But THE reason I left my job to pursue Call9 with my team, is because I have felt if only a trained EM doc could have been in the field, than many of my patients with unfortunate outcomes could have decreased morbidity/mortality. With Call9, we can do that, and save patients who are not otherwise being saved.

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...

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.

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.

"With a doc there immediately, we can encourage bystanders to do CPR immediately and again save lives not otherwise being saved."

That definitely helps. But is not unique to Call9. Call 911 and you'll get dispatcher-assisted CPR. Counting compressions with you, talking you through the process.

That is true. But there's a difference in being able to see the patient vs. having a bystander explain the situation verbally. There's no question that a dispatcher brings value to the CPR process - I think that we can bring more.

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

FWIW, I work in a cardiology department and "Sudden Cardiac Death" and "Sudden Cardiac Arrest" are used interchangeably. You even hear the term "sudden cardiac death survivor": http://eurheartj.oxfordjournals.org/content/25/8/623

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.

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

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. :-/

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.

“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 ;-)

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).

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.

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).

FWIW, Washington state is exceptionally good at treating cardiac arrest. See table 4 here: 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.

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'. :)

Toronto is more than 4x the population of Seattle and 2x the area though. And Alabama is a often rural state. It would be interesting to compare survival rates based on equal distances to a hospital.

How can you claim to get an ambulance to the scene faster than 911 (on a practical scale)? 911 / the ambulance are first responders.

We don't claim to - we do. Here's a great graphic on what happens when you Call 911: http://www.nyc.gov/html/911reporting/html/anatomy/call.shtml Our first step enters into this process later on in the schema, saving time.

It does, but it's a little disingenuous, too. You say things like "The ambulance dispatcher knows our location" - you mean, the location of all the facilities you service" (which isn't a stretch, most EMTs could probably recite the street address of every nursing home in their service area in their sleep).

A dedicated line gets you "Oh, this is Call9".

They still need to get pt demographics. ALS/BLS. The dispatcher still needs to find you an available ambulance. Dispatch it. Get the crews out and on the road.

Yes, the infographic breaks up a lot of that information, but the call receiving time is in many locations mandated to be within 60 seconds of reception to unit toned. And your service doesn't cut that to zero by virtue of "we have a dedicated line to an ambulance service".

And if they don't have that? Because that WILL happen. "Ambulance Co B, respond in place of Ambulance Co A, no units available".

"Call 911." And you've burned that time because you need to go back to the start.

Actually, from my understanding, this is more like an ER doctor acting as the ambulance dispatcher. Instead of waiting on a minimally trained phone operator to get you an ambulance, you can have an actual doctor figure out what's going on while you wait. Seems like a big improvement to me, you get to a doctor first rather than last.

Good point trisomy21. Amazingly, it take 64 minutes on average to see an MD after calling 911! With Call9, you see one immediately.

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)

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. :)

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.

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.

Thanks! (although I'm not sure who this is - text me outside of HN if you want to stay anonymous). . Those Sn/Sp numbers are in collection - I don't have hard data for you yet. But you'll be sure to know when I do.

"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.

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.

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

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?

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.

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


Interesting service.

My first question is what differs Call9 from any medical first responder?

My second question: Thinking long term. Where do you forsee the barriers of our reactive emergency services in the U.s. from making traits of Call9 more standard.

Great question - Call9 is different because we immediately put you in touch with an emergency doc, even as the first responders are trying to get to you. By the time EMTs get to the site, we have already begun triaging. And, when first responders do arrive, our physicians help make decisions based on their extensive medical expertise.

Right now, when EMTs get to the site, they don't know anything about the patient. With Call9, EMTs can begin work right away upon arrival.

As for long-term, we want this kind of service to reach everyone - that's certainly our end goal. But traditional emergency services have to completely alter their business and operational models to offer what Call9 offers.

> Right now, when EMTs get to the site, they don't know anything about the patient.

This is completely not true. You really need to stop lying when advertising an emergency medical service that affects lives. Nothing personal.

Most EMTs and paramedics are trained to 'disregard' physicians on scene (notwithstanding common sense - am I going to listen to a trauma doc? Am I going to listen to a podiatrist?) - this is somewhat different.

When Call9 has a private transport arranged by the ambulance service, whose medical license do the EMTs and paramedics operate under? The county/hospital associated therewith? The ambulance service? Your physicians? And depending on the answer to that, what does the County MD have to say about that? Or the DOH EMS section for that matter?

If your ambulance service's EMS personnel are operating under county auspices, and that county has a medical protocol, how does that mesh in with instructions from your physician? What happens if your physician's instructions differ from the county protocol?

Because that could and will be an issue. An instruction from your physician could lead to a paramedic losing their job (and has happened, when physicians have instructed the on-scene medic to do procedure X when the paramedic is not authorized to do so). Do you have a clear policy for this?

"Right now, when EMTs get to the site, they don't know anything about the patient. With Call9, EMTs can begin work right away upon arrival."

This is, as someone else noted, a very hand wavy, dismissive and inaccurate description. You have access to patient history from facilities, and that is a fantastic resource.

But to say that when I roll up on scene that all I know is "Go to address X for sick person" is not remotely true.

"You'll be seeing a 65 year old male with sudden onset left arm numbness, shortness of breath, shoulder pain with no known cause, and no relief. Pt has a previous cardiac history and has taken prescribed nitro with no relief. Pt caregiver states that they have been in good health with no recent illness." is a sample 'short report' I might get en route. There's a good amount of detail there.

What's happening on the back end?

Two 911 operators listen to the call, the Call Receiver works through a flowchart to determine base complaint and appropriate response. In tandem, the Dispatcher begins assigning unit(s) and dispatching them over the air. After the initial tones to get the units rolling, whilst the call receiver continues to gather more information, the dispatcher is preparing a short report to give more detailed information to the responding units.

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.

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.

I think the EMS system does what it can for our patients, and paramedics save lives. As an ED doc and resident, I served as med control for EMS and saw first hand all of the difficulties they have with an outdated system created in the late '60s. Like most industries, there is lots of room for improvement, and being scared of change should not hold us back from exploring how we can save even more lives and help more people.

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.

That is definitely not the case.

The system does no such thing. Criteria-based dispatch is a powerful tool. Many counties also require Fire/EMS dispatchers to be trained as EMTs.

Expert systems help ask the appropriate questions to establish the base complaint, and the level of service needed, the response level, lights/sirens, what-have-you.

See: http://www.kingcounty.gov/healthservices/health/ems/communit...

It's great to hear that some counties require fire/EMS dispatchers to be EMTs, but wouldn't it be better if the dispatcher was an actual emergency physician? I don't actually see this as disrupting 911 as much as it is disrupting the traditional dispatch system.

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.

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.

So you would rather speak to a dispatcher who is, at best, trained as an EMT first instead of an actual emergency physician? All the next steps (dispatching an actual ambulance) are exactly the same in the Call 9 model and the traditional 911 model.

Why not just call an ambulance?

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.

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)".

So you can get an ER doctor as the first point of contact instead of the last.

Good idea for patients, terrible awful business model.

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

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?

Are they insured?

We insure ourselves and our physicians.

Was that difficult, being an emergency service?

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.

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

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.

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

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

'Murica, your shit is beyond repair.

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".

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