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Though considered a commonly used and understood Chief Complaint Protocol, Protocol 26: Sick Person (Specific Diagnosis) has occasionally become a heavy-handed catch-all.
EMDs frequently use Protocol 26 as a familiar fallback to handle confusion surrounding a patient’s symptoms. For instance, in response to the Case Entry Question, “Okay, tell me exactly what happened,” perhaps the caller gives an ambiguous description: “My mother has been sick for days, and now she isn’t doing great” or “My uncle had dialysis, and now he won’t get out of bed.” At times, the caller may only refer to a known patient diagnosis such as “My brother has liver problems, and last time he had an episode like this, he almost died” or “My aunt is undergoing cancer treatment, and now she can’t stand up.”
These physical backgrounds are important insights for a medical professional to begin assessing the patient’s care, but these descriptions do not address the critical information the EMD requires to assign the appropriate priority level and emergency response. With no clear Chief Complaint Protocol to match these varying descriptions and
no mention of Priority Symptoms at Case Entry, the simple solution might be for the EMD to go to Protocol 26 to address myriad “sick” symptoms, which is a valid pathway in some cases. However, the EMD must understand the purpose of the Sick Person Protocol to use it compliantly and consistently.
Priority-Level pitfalls
Underresponse, Priority Symptoms
The first thing the EMD must understand is that the event prompting an emergency call may or may not be associated with a patient’s diagnosis. Though callers may feel they’ve explained the situation when describing the patient’s medical history, the EMD may need to do a bit more digging for dispatch purposes.
EMDs mustn’t fear looking for more information to correctly assess the needs at the scene. This may be as simple as repeating the initial Case Entry Question as a reiteration or clarification: “I understand the patient has a diagnosis of liver failure. Please tell me exactly what happened.” Doing so may prompt the caller to give information that would warrant a higher response level than generalized “sickness.”
Axiom 1 on Protocol 26 reminds the EMD, “When the caller gives dispatch a previous disease or a current diagnosis, it may be because the caller does not know what is actually causing the patient’s immediate problem.” Asking the caller to clarify the event that prompted the call enables the EMD to prioritize and send the right help. As stated in Axiom 2, “A complete interrogation obtains symptoms that can be correctly prioritized.” To stay on track, the key is for the EMD to seek clear symptoms of the current event, not identify generalized sickness.
The most significant error in overusing Protocol 26 is the potential for ignoring Priority Symptoms, which are defined as “abnormal breathing, chest pain/discomfort (any), decreased level of consciousness, or SERIOUS hemorrhage.” These symptoms are indicators of a serious circumstance that may warrant a higher response. However, Protocol 26 is not intended for that use. A “Sick Person” is defined as “a patient with a noncategorizable Chief Complaint who does not have an identifiable priority symptom.”
In recent years, Ross Rutschman, Senior IAED™ International Program Administrator, observed a confusing and concerning trend when analyzing communication center data: At times, EMDs would select “unconscious” at Case Entry and then continue Key Questions on Protocol 26 rather than going directly to Protocol 31: Unconscious/Fainting (Near) or another appropriate Chief Complaint Protocol, depending on the cause of unconsciousness.
Nearly all centers reviewed had at least a few cases where reported Priority Symptoms of “unconsciousness” or “not breathing” were incorrectly handled on Protocol 26. This is a violation of Chief Complaint Selection Rule 5: “If the complaint description appears to be MEDICAL in nature, choose the Chief Complaint Protocol that best fits the patient’s foremost symptom, with consideration given to priority symptoms.”
To deter EMDs from making an error in prioritization, ProQA® now has a built-in Rule reminder for a patient recorded as unconscious and breathing: “When the patient is not conscious but breathing, the most likely code is 31.” If the EMD continues to select Protocol 26 as the Chief Complaint, a pop-up box populates, saying “This Chief Complaint isn’t normally selected for unconscious patients. Please select a more appropriate Chief Complaint or, if you’re sure, continue,” urging the EMD to reconsider the appropriate path.
The potential for underresponse is one reason EMDs shouldn’t consider Protocol 26 to be a comfortable safety net. Brett Patterson, IAED Medical Council of Standards Chair, explained the concern behind this misuse: “Protocol 26 catches unconscious patients from going into the ALPHA level, but those callers have given us some troubling statements, and we’re trying to catch that earlier and assign the appropriate priority response.”
Overresponse, emotional misdirection
At times, a caller’s passionate plea for help in a dire battle against a disease can weigh heavily on the EMD’s heart. However, EMDs must be careful to focus on the patient’s current need rather than respond to a compassionate misdirection. Axiom 3 on Protocol 26 warns that “Complaints such as cancer, leukemia, chronic illness, stroke, dehydration, infection, meningitis, etc. may incorrectly elicit an emotional response from EMDs since these diagnosis-based terms sound serious. The caller’s ‘diagnosis’ may have nothing to do with the actual reason the patient needs help now.” The EMD must act logically in the best interest of the patient and for the best utilization of responders and resources sent to the scene, regardless of the severity of the patient’s diagnosis.
Safety net shunts
Another misconception is that Protocol 26 is a safe interrogation pathway to use as a baseline to choose a more specific Chief Complaint Protocol as more information is made known. In the past, Protocol 26 contained more shunts to redirect the EMD; however, research showed that patients who had “discovered” symptoms reported in later questioning, such as abnormal breathing, were less immediately ill than those who described abnormal breathing as part of the initial complaint at Case Entry.
In MPDS v14, only two shunts remain to redirect the EMD if the caller confirms the patient is bleeding or vomiting blood (Protocol 21: Hemorrhage (Bleeding)/Lacerations) or if the caller describes chest pain (Protocol 10: Chest Pain/Chest Discomfort (Non-Traumatic)). A new Rule 2 was added to Protocol 26 in MPDS v14 to clarify this direction: “The EMD should remain on Protocol 26 for symptoms other than chest pain/discomfort (HEART ATTACK symptoms) ‘discovered’ in Key Question 4 (e.g., abdominal pain, back
pain, or headache).”
ALTERED LEVEL OF CONSCIOUSNESS
As mentioned previously, a sick patient who is reported “unconscious” at Case Entry should be handled on a different Chief Complaint Protocol (i.e., 31, 9, 11, 12, 13, 14, 15, or 23); however, the level of consciousness in a sick patient can be another source of confusion on Protocol 26. If a sick person has been described as “conscious” during Case Entry (without other Priority Symptoms), the EMD should proceed to Protocol 26 to ask the following Key Question: “Is s/he responding normally (completely alert)?” If the caller answers “No,” the EMD should continue questioning and then select the 26-D-1 Determinant Code “Not alert.”
However, if the caller offers certain descriptors as defined, the EMD should complete the Key Questions and then select the 26-C-1 Determinant Code “ALTERED LEVEL OF CONSCIOUSNESS.” These descriptors include “combative, confused, dazed, delirious, disoriented, incoherent, lethargic, non-/unresponsive, not acting normal, not acting right, not aware, not thinking right, not with it, out of it, semi-conscious, slurred speech, or won’t respond.”
If, at any point during the call, the caller reports that the patient loses consciousness, is no longer responding normally, or is not completely alert, the EMD should select the 26-D-1 Determinant Code. As the ALTERED LEVEL OF CONSCIOUSNESS definition states, “All other not fully awake states should be considered not alert.” In certain cases, Rule 4 reminds the EMD to take into consideration the baseline condition of the patient: “Patients who are normally not completely awake should be considered alert in the dispatch environment.”
Unknown and NON-PRIORITY Complaints
BRAVO-level
After ruling out the presence of Priority Symptoms (or variations of affected consciousness or breathing), Protocol 26 covers a wide range of unknown or NON-PRIORITY Complaints. As Rule 3 explains, “This Chief Complaint should be used for patients with an ‘unknown problem’ who are with or near the caller (2nd party).” If the caller’s description does not match any of the specific diagnoses listed in the CHARLIE-level Determinant Descriptors, the BRAVO-level Determinant Descriptor “Unknown status/Other codes not applicable” is an appropriate selection for situations where the caller lacks much information. For example, 26-B-1 may be used if a caller is reporting an unfamiliar person who has suddenly become ill in a public setting.
ALPHA- and OMEGA-level
Similarly, the ALPHA-level Determinant Descriptor “No priority symptoms (complaint conditions 2–12 not identified)” is appropriate for a specific condition that is not covered in the other 11 common ALPHA-level NON-PRIORITY Complaints (e.g., complaints of nausea, vomiting, dizziness, or fever). An additional 27 NON-PRIORITY Complaints are listed in the optional OMEGA-level Determinant Descriptors for added coverage of patient symptom possibilities.
However, as stated in Rule 1, “OMEGA codes should not be selected if the caller (especially 3rd/4th party) cannot personally verify the patient’s condition and/or cannot provide for the alternate care/referral needed for the patient as an OMEGA disposition requires. In some circumstances, this may occur even with 1st and 2nd party callers.” An example of this would be recommending that a patient with a toothache arrange an appointment with their dental care provider or suggesting that a case of gout be handled by a regular physician.
Know your own stats
Current statistics from the IAED Data Center show that the usage of Protocol 26 has varied between 10 to 15% of the total call volume in the last 10 years. The current statistics for 2023 show 684,030 calls handled on Protocol 26, which comprises about 11% of the 5,961,232 total calls so far this year. If a center’s average use of Protocol 26 is notably higher, it may be necessary to review call data to look for trends: individuals, shifts, or broad misuse that can be addressed through specific training and greater frequency of review. Individual EMDs may analyze their own statistics by using ProQA Reports. Doing so will improve accuracy in call prioritization, including proper handling of Priority Symptoms, which could make a significant difference in patient outcome.
