Table 5.

Illustrative Quotes Theme Two. Nb quotes have been condensed for readability.

Theme 2: Identifying and responding to deteriorating patients Sub Theme – Clinical support for the call-taker role
Q14	P02	“… any concerns … we’re supposed to flag to either a floor walker or a team leader first, and then ask permission if we can flag it to … a clinician… now they go into what’s called a clinical [hunt], and if one’s available they’ll answer… But quite often they’re not available… So, you’re then told put a warning on, but that doesn’t help if the patient is potentially in cardiac arrest. You’ve got a crew that’s on a category two call that’s nearby but aren’t going to get diverted because this isn’t as high a priority because it’s still a cat two as well”.
Q15	P10	“…and then it goes back to what we said earlier about having to raise somebody (get the attention of a floor walker, or supervisor), them not knowing what you mean and then having to get a clinician, and then … at least a 15 minute period there when potentially you might get a duplicate call, “Oh, yeah, patient’s not breathing now.”
Q16	FGP12	“Yeah, I think it's definitely something that we ought to look into because it is too hard for us to try and get hold… (of the) clinicians…”.
Q17	FGP12	“The difficulty is, though, I mean I don't know what it's like at ****, but … the clinicians really don't like communicating with the EMDs (call-takers). We have no direct line of communication…”.
Theme 2: Identifying and responding to deteriorating patients Sub Theme – Key clinical features described during the EMS call
Q18	P07	“…the biggest thing that comes to mind is the ineffective breathing problem (patients contacting EMS with difficulty breathing that then proceed to OHCA and the difficulty assessing ineffective breathing), … that's the call that I've always had go to a cardiac arrest…the most common thing that changes, is ineffective breathing goes to unconscious and that's CPR”.
Q19	P09	“…when someone's agonal breathing they really do tell you, … he's had this God-awful noises, it's something that they will bring up, not something that you have to ask of them”.
Q20	P08	“…so assessing breathing for us is probably one of the biggest challenges there are, as EMDs (call-takers). It’s one of the hardest things”.
Q21	P02	“If they’re predominantly conscious and keep passing out, they’re awake…. If they’re predominantly unconscious and wake up occasionally before passing out again, I just leave it unconscious…”.
Q22	P04	“…unconscious isn't always dangerous unless it's blocking an airway. So people faint”.
Q23	P02	“quite often a patient that’s going into cardiac arrest, the caller will give a description of a colour change. “He’s not conscious, he’s barely breathing, and he’s going blue.”
Theme 2: Identifying and responding to deteriorating patients Sub Theme – Acting on call-taker intuition
Q24	P06	“We all seem to have gut feelings of when things don’t quite sit right… a caller will say something and it’s just like, that’s not quite right. So then you have to seek clinician advice for it”.
Q25	P08	“…I said earlier, when you can hear the little catch in the back of someone’s throat when they’re explaining something to you that makes you feel like the person is very scared”.
Q26	P09	“…it's like this gut instinct that you get, which is a bit difficult to try and like get everyone to get on the same page”.
Theme 2: Identifying and responding to deteriorating patients Sub Theme – Opportunities to monitor for change
Q27	P05	“So if you're looking at someone's conscious level gradually deteriorating, or the respiratory effort going down, it's things like that that the system isn't very well set up for”.
Q28	P06	“I tend to use … unconscious protocol when you’re dealing with an unconscious patient. And one of the instructions is, “Look at them very carefully and tell me exactly what you see and hear them doing.” So I tend to use that even if I’m not in that part of the protocol, just to see what they’re going to say. Because sometimes they’ll say something and you’re a bit like, “I need more information there.” But you can’t ask for it. So I tend to use that, because it is scripted somewhere else.”
Q29	P11	“once you’ve coded the call, as long as there’s no instructions to be delivered but you have to stay on the line, it’s then more freelance…if you had a burning question that you needed to get in but weren’t allowed at the time, you can then get it in then in that sort of discussion at the end…”
Q30	P07	“…with a patient that's got breathing problems … Once I've gone through my instructions and before I consider putting the phone down, I’ll just check in again and be like … how is their breathing? And if at that point they go, oh well, it’s got so much worse, then okay, that's where I'm going to consider staying on the line or making a cat warning (upgrading) if that's necessary…”.
Q31	FGP11	“it's not a requirement for them (call-taker) to check in, that's a really good point, maybe it should be a requirement to check in more often or really that skill of knowing to check in more often should be taught…”.
Q32	P12	“…I try to concentrate on each call as they come through, and, regardless of whether there’s calls waiting, you know, if I need to stay on the phone for a little bit longer then… then I do…”.
Q33	P12	“…EMDs (call-takers) need to be brave enough to upgrade something to a cat. one, if they think it needs a cat. one without worry that they're going to be [complianced] (fail an audit) or that the dispatcher's going to come down on them or whatever … it's not very nice when you've been on the phone with somebody for 20 minutes and they've taken a turn for the worst and you have to cat. one it and then … they've not been able to arrive within time (target times) but at the end of the day we've got to take care of the patient we've got, so…”.
Theme 2: Identifying and responding to deteriorating patients Sub Theme – Managing caller behaviour
Q34	FGP12	“..they want to tell you what they want to tell you, they're not always listening to the question and they sometimes panic answer. I've had quite a few that will say no, the patient's not breathing when it becomes quite clear when they tell you what the problem is that the patient is breathing or they could actually be the patient themselves”.
Q35	P01	“… how to calm that caller and how to deal with that caller is all down to you, you know?”