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    Help Delayed Is Help Denied: The Fatal Flaw in China’s 911

    A 120 dispatcher’s work protocol is simple but veterans point to systemic problems that plague response time.

    Editor’s note: Alone, in the dark, and in grave distress, Junjun, a 20-year-old Henan University student in Zhengzhou dialed emergency services on May 17 pleading for an ambulance. It was two hours later when help finally arrived.

    The delay proved fatal. After 13 days in the ICU, Junjun died from a cerebral hemorrhage. On June 3, her father posted on Weibo, China’s microblogging platform, an ICU admittance slip and an 8-minute audio recording of the emergency call his daughter made, which detailed the emergency dispatcher’s nonchalant and unprofessional attitude.

    The outrage that followed prompted an official investigation and on June 6, the dispatcher was sacked and four others were disciplined.

    Eight minutes

    Junjun’s roommate Wu Wen occasionally thinks about how, after studying exclusively on the Henan University campus in Kaifeng for the first two years, classes were suddenly relocated to the provincial capital of Zhengzhou at the end of 2021.

    And since the city was locked down soon after, students had little time to get familiar with the area. Two weeks before the tragic incident, they ordered a cake online, but because Junjun didn’t know her way around, Wu had to pick it up.

    The memory leaves Wu solemn. “If I had explained the way to her clearly back then, would all this not have happened?”

    Around noon on May 17, Wu recalls rushing back to the dormitory to look for Junjun, who was about to miss her mandatory COVID-19 test. “She wasn’t the type to try and avoid testing,” says Wu.

    Wu found Junjun in the dorm, where her roommate was bedridden, twitching, and moaning in agony. Wu immediately called the head of their class to come help.

    At 12:15 p.m., the class head dialed 120, China’s medical emergency number. Three minutes later, an ambulance was dispatched, which arrived on the scene within ten minutes.

    But on May 30, after struggling in the ICU for more than ten days, Junjun passed away. That’s when Wu learned from her roommate’s father that the class head wasn’t the first to dial 120: Junjun had called emergency services herself nearly two hours before Wu found her in agony in the dorm.

    From the recording of the conversation, Wu realized that Junjun made the first call to emergency services at 10:27 a.m. At the time, she could barely speak in complete sentences.

    Yet, with great effort, she managed to mumble to the dispatcher a few keywords: “Henan University’s Zhengzhou campus” and “Dorm number 711.” She also repeatedly moaned, “My head hurts.”

    All Junjun got in response was apathy.

    During the 8-minute recording, the dispatcher said a few times, “I can’t help you if you’re going to be like this,”; “Come on now, you’re a grown woman in her twenties at university,”; and “I feel like there’s nothing wrong with you.”

    Junjun was also repeatedly asked for a specific address. The dispatcher even proposed to add Junjun on WeChat so she could send her exact location via GPS. Junjun didn’t respond.

    Her family later found that she’d instead shared her position in her dorm’s group chat. They supposed that since she was falling in and out of consciousness, it took all of her strength simply to tap the screen, but ended up sending her location to the wrong contact.

    The phone call ended. Junjun lay in darkness for more than an hour. In the meantime, the dispatcher tried calling back 11 times. But Junjun was no longer able to pick up.

    The eldest daughter of her family, Junjun was an obedient girl who never caused her parents any concern. Her friends all remember her small gestures of kindness.

    She was always considerate of others: when choosing a cake for her 20th birthday, she kept in mind her roommate’s allergies; and once, she accompanied another roommate who wasn’t feeling too well to the hospital and waited with her until 11 p.m.

    She had a lot of plans too. A cousin on her father’s side says Junjun had agreed to be her bridesmaid for her wedding in October. She was in her third year of college, and was intent on testing into a graduate program, but hadn’t yet decided where. She figured she had plenty of time.

    One night, while Junjun was still fighting for her life in the ICU, Wu had a dream. She saw Junjun’s round, sweet face. She had come back from the brink and, with a smile, told Wu that she was planning to take time off to recover. Her plan was to return to school a few years later.

    “I believed that all good dreams were prophetic. It never occurred to me that it wasn’t,” says Wu, letting out a soft cry.

    When Junjun’s father posted the traumatic recording on Weibo, it immediately sparked outrage online. In the days that followed, Zhengzhou’s health commission announced a probe into the handling of Junjun’s call to the emergency services.

    The investigation found that the dispatcher not only “misjudged the condition of an emergency patient” but was also “unable to deal with complex situations.” It also noted a failure in the chain of command.

    But veterans point to larger systemic problems that plague emergency service dispatchers across China.

    60 seconds

    In theory, a 120 dispatcher’s work protocol is simple.

    They must answer an emergency call by the third ring, ask the caller for their symptoms and address, and try to ascertain their condition.

    The entire conversation is supposed to take no longer than one minute. After obtaining this essential information, the dispatcher assigns an ambulance based on proximity and the level of the call’s emergency.

    Once an assignment is handed out, the ambulance should respond within three minutes. Should the specific circumstances permit it, the dispatcher may provide remote guidance and support to the caller.

    It all comes down to those first 60 seconds.

    Fang Yining, 41, is a 120 dispatcher in a third-tier city in southern China with over 20 years of experience.

    Once, he received a call from an elderly woman whose husband complained of tightness in his chest and palpitations. Straight away, he asked: does he have a history of cardiovascular or cerebrovascular disease? The woman was very cooperative and told him that he’d just had bypass surgery the year before.

    After obtaining their address, he instructed the man to lie down and refrain from moving, and also recommended that he take either a nitroglycerin tablet or a traditional medicine called Suxiao Jiuxin Wan (Rapid-Action Heart-Saving Pill). Simultaneously, he sent a dispatch order on his computer. “All that, in 60 seconds,” says Fang.

    Emergency heart problems no longer cause him stress. Nuisance calls, however, are an unending pain.

    Jurong, a city in the coastal Jiangsu province, receives 2,300 to 2,400 emergency calls a month, almost 60% of which aren’t really emergencies. Meanwhile, Haikou, capital of the southern Hainan province, receives 500 calls a month, of which only around 100 actually require an ambulance.

    “If someone calls 120 to say that a car accident has taken place — say, at a certain school — how can you tell if it’s genuine?” asks Fang.

    First, he continues, one must listen to the sounds in the background. Usually, you can tell if the caller is inside or outside, and typical noises on the street differ from those just after a traffic accident.

    Second, following a traffic accident, the 120 service usually gets multiple calls. “If only one person is calling, then there’s reasonable doubt,” he says. He underscores that the job really is all about accurately ascertaining the severity of a situation and allocating appropriate resources.

    Says Fang: “Otherwise, you could pick someone at random off the street to do it. Who doesn’t know how to answer the phone?”

    Last year, he received an emergency call from a mother whose child was choking. He was just about to instruct her to perform the Heimlich maneuver when he suddenly recalled a conversation with a friend a few days earlier about how children these days grow up so fast, while referring to their own child, who already weighed 45 kg in second grade.

    Fang had another idea: he asked the mother to take a seat, and lay her son face down, with his abdomen pressed against her knee, just above the navel.

    Before the ambulance arrived, the child had already successfully coughed up a rib blocking his esophagus. Afterwards, their family visited the emergency center to show Fang their gratitude.

    He was immediately struck by how thin the mother was, while her son appeared to weigh around 30 kg. “If I had acted according to the standard protocol, that mother wouldn’t be able to perform the maneuver on him, and he may have choked to death,” says Fang.

    A dispatcher at a prefecture-level city in the eastern Zhejiang province says that in urgent cases, “the caller often can’t clearly tell you where they’re located, but we should dispatch, even without enough details. We always have the police for further assistance.”

    In Junjun’s case, what infuriates Fang most is that “the dispatcher ignored the young woman’s condition and callously decided that nothing was wrong.” He says, “And why did she waste several minutes nitpicking over which campus the girl was at?”

    Pulling out a map app on his phone, Fang searched for Henan University’s Zhengzhou Campus. Pointing at the map, he says: “The university only has one campus in Zhengzhou.”

    Fang says that in life-and-death scenarios where time is of the essence, “Just get the location as best you can, put aside the detailed questions, and send out the damn ambulance.”

    Dispatchers also need to adjust their line of questioning. “If the caller has difficulty speaking, they need to ask simple yes-or-no questions, rather than open-ended ones that require lengthy answers,” says Fang.

    22 days

    A broad look at the recruitment notices of emergency centers across the country shows that China is not particularly demanding about the academic qualifications of 120 dispatchers.

    Applicants don’t require backgrounds in medicine, though some centers indicate that they prioritize candidates who have clinical or nursing experience. “People with proper degrees in medicine aren’t willing to do this kind of work — they feel that it doesn’t make use of their expertise and that the salary is too low,” rues Fang.

    The monthly wages offered to dispatchers in third- and fourth-tier cities vary between 2,500 to 3,500 yuan ($370 to $520). These wages are slightly higher in top-tier cities.

    Recruitment data for Guangzhou in 2021 shows dispatchers earn an average of 3,500 yuan per month during their first year of employment (including a trial period), which approximately doubles when on the permanent payroll.

    There’s no universal model or list of evaluation criteria for dispatchers’ pre-employment training — this is left to the discretion of individual centers or dispatch stations.

    According to Zhengzhou’s emergency center website, when training new dispatchers, the head of the dispatch section “personally devises a training program” that includes theoretical knowledge, familiarity with maps, and drills. The head is also one of the key people in charge of employee evaluations.

    In all, it takes 22 days.

    Fang believes 120 dispatchers should undergo at least six months of training before taking calls. When he began, he spent two months doing just one thing: memorizing the map of the city.

    Today, some emergency centers allow dispatchers to go on duty after two weeks of training. Fang says many people think this job is just like working in a call center. “How much training do you need for that?” says Fang.

    The dispatch station where Fang works only began teaching and evaluating basic first aid such as CPR and the Heimlich maneuver in 2017. He’s unsure if today’s young dispatchers can take advantage of the crucial time window between an ambulance being dispatched and arriving at the spot to provide instructions over the phone.

    Performance evaluations generally only take into account the length of calls and the speed at which ambulances are dispatched. Some centers inspect dispatchers’ call logs monthly. As long as 90% of the calls are limited to 60 seconds, the dispatcher gets a pass.

    Fang says anything other than that is difficult to quantify. For example, inspectors can randomly listen in on calls. “But the workload is untenable. 100-200 calls a day — they couldn’t possibly listen to all of them. If they hear something problematic, but the caller didn’t complain, then the matter is usually dropped,” he explains.

    Therefore, dispatchers who aren’t incentivized by any practical performance criteria, who don’t have any kind of medical expertise, and haven’t received relevant training are only really capable of sending ambulances whenever they get an address.

    One dispatcher from the coastal Zhejiang province says that “when in doubt, we just send the ambulance, even if the caller doesn’t end up needing it.”

    A doctor working rotations at an emergency center in Ningbo, Zhejiang confirms. “In the past four months that I’ve spent here, ambulances are sent out about 70-80 times a month. About a dozen times it’s called back early, or nobody ends up getting in,” says the doctor.

    Some emergency centers have therefore introduced a new evaluation criterion: the frequency of wasted trips. Sending out ambulances that come back empty is considered wasteful. Some dispatchers have shared on social media that their employers even penalize them for it — docking their pay by up to several hundred yuan, for instance.

    Fang quite pessimistically believes that the problems facing emergency dispatching are here to stay. “It will happen again,” he says.

    44 years

    Some believe that the US Medical Priority Dispatch System (MPDS), conceived in 1978, could be a useful model for China. In the past few years, dozens of Chinese cities, including provincial capitals, have already adopted it.

    The MPDS sorts common urgent medical symptoms into 33 categories, such as choking, cardiac or respiratory arrest, and childbirth. Every category has its own protocol of interactions.

    Dispatchers must ascertain the nature of the caller’s condition in three to six questions. The call is then attributed one of six levels of severity, for resource allocation purposes. In cases where it is impossible to be sure, the call is treated as “most severe” by default and an ambulance is sent immediately.

    Dispatchers also receive standardized training and accreditation that allows them to respond better. This accreditation is valid for two years. Dispatchers must continually train, and have their accreditations renewed.

    Shan Dongdong, a dispatcher at an emergency center in Beijing, contributed to the Chinese localization of the MPDS handbook ten years ago. She writes: “The MPDS imposes standardized requirements that ensure that every caller can receive the same emergency services, regardless of their dispatcher’s background.” Today, MPDS is used in more than 3,000 emergency centers around the globe.

    In Henan, where Junjun’s incident occurred, Sanmenxia was the first city to adopt the MPDS. It allowed dispatchers to provide prompt CPR guidance to the family of a young man who had gone into cardiac arrest after suffering an asthma attack, saving his life.

    It remains to be seen though, to what extent the MPDS method can improve China’s 120 dispatch system.

    Back in Zhengzhou in the days following his daughter’s death, Junjun’s father had trouble sleeping. He spent a lot of time at night sitting up and sifting through his daughter’s phone.

    He always felt his daughter, who had flown the nest to study in the city, would be safe and live an uneventful life, and that there was no need to call regularly.

    Now, however, his last memory of her will forever be tied to that harrowing eight-minute recording.

    Reporter: Li Xiaofang.

    Junjun, Wu Wen and Fang Yining are all pseudonyms.

    A version of this article originally appeared in White Night Workshop. It has been translated and edited for brevity and clarity, and published with permission.

    Translator: Lewis Wright; Editors: Zhi Yu and Apurva.

    (Header image: Comstock/VCG)