The Ambulance That Went to the Wrong Street

What happened, in the times that matter

A five-person roofing and gutter shop, a gutter replacement on a house set back on a wooded lot. At 3:00 pm on a Wednesday in October, a tech stepping from the top of an extension ladder onto the low roof edge loses his footing and falls about 10 feet onto a wooden deck. He lands on his left side. He is awake and talking, says his neck and back are fine, and his left lower leg is bent where it should not bend.

His partner called 911 at 3:02 pm, giving the address on the work order, which was correct. The dispatcher said an ambulance was about 8 minutes out. It arrived at 3:22, twenty minutes after the call, after driving to the right address on the wrong street, finding no house there, and being redirected by the dispatcher on a second call from the crew.

The tech was transported and admitted; the office reported the admission to OSHA within the 24 hours 29 CFR 1904.39 requires. Twelve minutes of extra waiting on a deck with a broken leg is miserable rather than dangerous. The same twelve minutes with someone not breathing is the difference that CPR and an AED exist to cover, and the shop could not count on the next one being a leg. So the owner wanted to know exactly where the twelve minutes came from, and wanted the answer before changing anything.

The care, briefly, because it was right

The partner did what the shop's card says for a fall: he checked that nothing on the roof was about to come down on them, told the tech not to move, asked about neck and back pain, numbness and tingling (none), and did not straighten or move the leg. He put a folded tarp under the tech's head only after the tech said his neck felt fine and asked for it, covered him with a jacket against the cold, and stayed beside him. See related: Falls From Ladders and Possible Spinal Injury. Nothing in the delay traced back to the care, so the review moved on to the call.

Candidate one: the address was wrong

The first suspicion was the simplest, that the partner read the wrong number. He had not. The work order said 410 Maple Lane, the partner said 410 Maple Lane, and the county's property records list the parcel at 410 Maple Lane. The dispatcher's read-back, which the partner remembered, matched. Ruled out.

Candidate two: the dispatcher sent it to the wrong place

The owner asked the county's emergency communications office for the call record. Whether a 911 center releases its records to a caller, and how, varies by state and county; this one released a call summary on a written request after about two weeks. The summary showed the dispatcher entered 410 Maple Lane, and the dispatch system placed it where the county's address map puts 410 Maple Lane. The ambulance was dispatched to exactly the address given. Ruled out, and the summary held the real clue: the dispatch point sat on Maple Lane itself, at the front corner of the parcel.

Candidate three: the map was right and the house was not where the map said

This one held. The lot is a deep, narrow parcel. Its front edge touches Maple Lane, and that is where its address comes from, but there is no driveway on Maple: a steep wooded slope and a creek run along that edge. The house sits at the back of the lot and is reached by a 600-foot gravel private lane off Ridge Road, a different street that wraps around behind it. The mailbox is on Ridge Road too.

So the ambulance did what it was told and arrived on Maple Lane, at a wooded slope with no house in view. At 3:13 the crew radioed the dispatcher; the dispatcher called the partner back. The partner, who was kneeling by the tech on the deck and had not thought about the road at all, said "we're at the back, come up the gravel lane," which did not help until the dispatcher asked "the gravel lane off what street?" At 3:16 the ambulance turned around, drove the long way around to Ridge Road, and found the lane. It reached the deck at 3:22.

From the times on the call summary: the expected arrival was about 3:10 (3:02 plus 8 minutes), and the actual arrival was 3:22, so roughly 12 minutes of the delay belonged to the wrong street.

A second, smaller gap: the caller was also the caregiver

The callback at 3:13 cost another three minutes, and the reason is worth separating from the address. With only two people on site and one hurt, the partner was the caller and the caregiver at once. When the dispatcher rang back, his attention was on a man with a broken leg, and his answer described the property the way he saw it from the deck ("at the back, up the gravel lane") rather than the way a driver on Maple Lane needed to hear it.

The customer was home. She had come out onto the deck a minute after the fall and stood watching. Nobody gave her a job. Had she been asked to walk out to Ridge Road and stand at the lane, the ambulance would still have gone to Maple first, because the call had already sent it there, but the dispatcher's callback would have found a person on the right street who could say "I'm standing at the lane entrance, across from the red barn." The shop's review counted that as about three of the twelve minutes, and the rule that came out of it is in the next section.

The part that stung: the shop already knew

The review's most useful finding was not in the 911 record. It was in the tech's own work history. When the crew first came out to quote the job three weeks earlier, his navigation app had taken him to Maple Lane too. He had driven around, found the Ridge Road lane, and mentioned it at the shop ("that Maple one is actually off Ridge"). Nobody wrote it down. The work order still carried only the mailing address, with no field for where the driveway actually was.

The information that would have saved twelve minutes had been in the building for three weeks. A phone-based location fix probably would have helped the dispatcher too, since wireless 911 calls usually carry an estimated caller location, but its accuracy varies, and dispatchers properly act on the spoken address when the caller gives one confidently. The fix had to be in what the caller said, and in where somebody was standing.

What the shop changed

Two rules came out of the review, and the shop built both into its systems rather than into a memo. The general method for a 911 call from a job site belongs to its own card (see related: Calling 911 From a Job Site So They Find You); these are the two pieces this case added.

An "access from" field on every property. At booking, the office asks one question: "Is your driveway on the same street as your address?" When the answer is no, or the house is down a private lane, the field gets the access street, a landmark and the lane entrance's coordinates from the map app. Techs who find a mismatch on site update it the same day. The field prints at the top of the work order, above the address.

Meet at the street, every time. On any 911 call from a job site, someone goes to the point where the ambulance will leave the public road: the curb, or where a private lane meets the street, with truck flashers on, and stays there until the ambulance is in sight and following. On a two-person crew that is the customer if they are home, or the caller once the patient is safe to leave for a minute; the patient's care comes first. Standing out of the travel lane, in a high-visibility vest after dark or in rain, because the person waving down an ambulance on a rural road at dusk is hard for any driver to see.

The opening line of the call was rewritten to put the access street first. It is the one thing the shop now has every tech say out loud at each safety meeting:

DISPATCH: 911, what's the address of your emergency?
TECH:     410 Maple Lane - but the driveway is NOT on
          Maple. Come in from Ridge Road. Gravel lane
          across from the red barn.
DISPATCH: Access from Ridge Road, gravel lane, red
          barn. What's going on there?
TECH:     A man fell off a ladder, about ten feet.
          Awake, leg's broken, not moving him.
          Someone will be at the lane on Ridge with
          yellow flashers.
DISPATCH: Okay. Stay on the line with me.

The tech says the access street twice in the first exchange on purpose, and asks for nothing until the dispatcher has repeated it back.

How they checked that it worked

The owner did not wait for another injury to test it. He ran a drill at the next safety meeting with one person playing the dispatcher and the work order from the Maple Lane job in hand; the drill never dials 911 or contacts the real dispatch center. Each tech gave the opening line cold. Three of five put the access street first on the first try; the other two did on the second. Then the office pulled every active customer and asked the booking question of the ones with long drives or rural parcels: 9 of the shop's regular properties turned out to have a driveway on a different street from the address, and all 9 now carry an "access from" line.

Five months later a tech with a deep forearm cut on a job down a private lane gave the access street in his first sentence, and his partner was at the road with flashers when the ambulance turned in. The call summary the owner requested that time showed the ambulance arriving 7 minutes after the call, inside the dispatcher's estimate. One case is not proof of a system, but it is the case the shop built the system for.

What would have changed the conclusion. Had the call summary shown the dispatcher mistyping the address, the fix would have been the read-back, which the shop already did. Had the property had a driveway on Maple, the meet-at-the-street rule alone would have saved most of the time. It took both the access field and the street guide to close this particular gap, because the guide has to know which street to stand on.

References

• 29 CFR 1904.39, reporting in-patient hospitalizations to OSHA.
• American Red Cross, First Aid/CPR/AED participant materials (current edition); hands-on certification is what makes a responder.
• Your county or regional 911 authority, on requesting call records and on how wireless caller location is handled.
• See related: Calling 911 From a Job Site So They Find You; The Injury Response SOP; The Remote Job Emergency Plan SOP; Falls From Ladders and Possible Spinal Injury.