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<b>REACHING FOR REFORM:</b>  Santa Barbara County EMS medical director Dr. Angelo Salvucci warned that patients have been “dying at an unacceptable rate” because of routing issues between cell phones and the state’s 9-1-1 system.

Paul Wellman

REACHING FOR REFORM: Santa Barbara County EMS medical director Dr. Angelo Salvucci warned that patients have been “dying at an unacceptable rate” because of routing issues between cell phones and the state’s 9-1-1 system.


State Urged to Fix Fatally Flawed 9-1-1 System

Lawsuit Filed Over Santa Barbara Woman’s Death After Routing Snafu


The problem of cell phone compatibility with the statewide 9-1-1 system has some emergency responders seriously distressed and has prompted a wrongful-death lawsuit and two prominent Santa Barbarans to testify about the matter in Sacramento in the same week.

The issue emerged publicly after the parents of 24-year-old Jordan Soto ​— ​who died from a medical emergency in January ​— ​filed a lawsuit last week alleging the system is to blame for their daughter’s death. The suit was filed against the State 9-1-1 Advisory Board, California Highway Patrol (CHP), City of Santa Barbara, and its police department. Medical Director for Santa Barbara County Emergency Medical Services Angelo Salvucci and former Santa Barbara fire chief Warner McGrew made the trip to the state capitol to urge the 9-1-1 Advisory Board to give more attention to the incompatibility issue.

Last January, Soto’s relative called 9-1-1 after finding her collapsed and unconscious. Even though the family’s residence on Tinker Way is less than a mile from a fire station, the call was routed 30 miles south to a Ventura California Highway Patrol dispatcher because it was made on a cell phone. The call was then transferred to the Santa Barbara dispatch center. The lawsuit alleges that the family member had provided the accurate address to the Ventura dispatcher, but the Santa Barbara dispatcher gave the emergency response team the incorrect address. The first responders spent several minutes searching for what turned out to be a nonexistent location on the wrong street.

A city dispatcher takes an emergency call.
Click to enlarge photo

Paul Wellman

A city dispatcher takes an emergency call.

“The dispatcher in the old days could tell exactly where a call is coming from,” said Orange County–based attorney Mark Peacock, who is representing the Sotos in the civil action. Landlines have street addresses embedded into their transmission signal so there is no confusion about where the responders should go. Plus, a landline call would have gone straight to the Santa Barbara dispatch center, saving a small amount of time. But 80 percent of 9-1-1 calls today are made on a cell phone, according to Dr. Salvucci.

“This is something that should be fixed yesterday,” said former fire chief McGrew, who is a family friend of the Sotos. “This is a big deal.” In Santa Barbara, many cell phone calls are taken at the Ventura CHP dispatch center, which is the regional location that covers wireless calls from Moorpark to Santa Barbara.

A potential remedy was the RED (Routing on Empirical Data) project, which sought to reduce busy signals on wireless 9-1-1 calls by analyzing call data from involved agencies, including the state 9-1-1 division and law enforcement agencies. The RED project would map all wireless calls in a given cell-tower sector to determine which dispatch jurisdiction they came from and then send them to the appropriate local dispatch center. It was implemented in 2008 but was later terminated reportedly for financial reasons.

Representatives for the defendants named in the lawsuit, which was first reported by the Santa Barbara News-Press, said they could not comment on pending litigation, though some offered a glimpse into how the system works. Santa Barbara Police Lieutenant Jim Pfleging explained when dispatchers take a call, they receive information on how far the caller is from the cell tower. Dispatchers then might receive a rough estimate about the latitude and longitude of the caller. “When [CSI] first came out, everyone thought you could drill down to the single piece of nothingness … that isn’t the case,” Pfleging said, adding that several factors such as weather and type of cell phone also come into play.

Despite the problem in pinpointing their location, cell phones have proved very useful in reporting drunk drivers and disseminating Amber alerts, Police spokesperson Sergeant Riley Harwood said. “The technology evolves so rapidly, and agencies will always be one or two steps behind the curve when it comes to keeping up with advances in technology,” Harwood added.

Salvucci believes fixing the problem has been a low priority, and he’s written letters to state officials offering to help secure funding for a wireless optimization service like the RED project. Salvucci found it disconcerting that the 9-1-1 state advisory board had no idea when new cell towers are constructed, where the calls are routed, and how many are misrouted every day. Brad Alexander, a spokesperson for the Governor’s Office of Emergency Services, said he could not comment on the matter.

Salvucci said that for a patient suffering from cardiac arrest, the likelihood of survival decreases by 10 percent for every minute of delayed treatment. About 1,000 individuals suffer heart attacks in Santa Barbara and Ventura counties every year. Salvucci said dispatchers, EMTs, and firefighters try their best to save lives but are unnecessarily delayed by this dilemma. He added that the responders suffer the collateral damage because they see what could have been done had they been dispatched sooner.

A concept dubbed the “chain of survival” by the American Heart Association says that if your heart stops, multiple medical interventions have to take place for you to survive. “When that first link is broken, everything else we do is worthless,” Salvucci said. “That link fails across the state thousands of times a day.”

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