Accidental Or Intentional?

Brett Patterson

Brett Patterson

Best Practices

Brett Patterson


Derick Aumann here from New Hampshire. I was looking to clear something up that has been a long-standing policy here.

On Protocol 23: Overdose/Poisoning (Ingestion) Key Question 1, “Was this accidental or intentional?” we have treated the overdose cases as intentional. There is some discussion that these should be treated as accidental. The person intended to get high; they did not intend to overdose.

Just curious on your thoughts. Thank you, Derick Aumann, NRP Quality Improvement Supervisor New Hampshire Department of Safety Bureau of Emergency Communications Concord, New Hampshire, USA

Hi Derick:

Thank you for the great question.

OVERDOSE is a DLS-defined term designed to differentiate an intentional act from an accidental one (POISONING). This code separation allows for a safe referral to a poison control center for accidental ingestions without priority symptoms (23-O-1) and ensures a physical response and face-to-face evaluation when there is intent to harm. And the latter is where the confusion lies.

Certainly there is intent when someone partakes of recreational drugs to get high. However, the intent is to get high, not to harm oneself—the overdose is actually accidental. The call is being made because the patient accidentally took too much of the drug. Essentially, it’s akin to a patient accidentally taking too much medication, with the obvious difference being the recreational drug is often illicit, or illegal. However, this is not always the case as prescription drugs cause many overdoses. Please note my use of lowercase for accidental “overdose.” This is common layperson terminology, which is probably the source of at least some of the confusion.

Unfortunately, accidental narcotic overdose is becoming rampant in cities across North America. I suspect this is why this question of intent has become more frequent. After some discussion, the Academy’s Rules Group has proposed some minor protocol modifications to clear up the confusion and make the coding process more intuitive. While I can’t be very specific because the enhancements are in draft form and have not formally been approved, the changes involve adding the intent to harm oneself to the OVERDOSE definition, the ProQA® answer choice, and perhaps to the Key Question itself in the form of a clarifier.

So forgive me for the long answer to your short question, but I wanted to explain why it’s important to ask: “Was this accidental or intentional?” Once we know the purpose of this question, we understand why it most often needs to be asked, and we also know when it needs to be clarified.

In summary, when asking “Was this accidental or intentional?” we want to know if the patient accidentally took something, or accidentally took too much of something (POISONING), versus intentionally taking something with the intent to harm oneself (OVERDOSE). In DLS, an accidental overdose is defined as POISONING in an effort to separate self-harm intent and provide an appropriate response or referral. Once this distinction is understood, the purpose of the Key Question becomes clear.

Hope that helps. Brett Patterson Academics & Standards Associate Chair, Medical Council of Standards International Academies of Emergency Dispatch®


I have a continuous positive airway pressure (CPAP) question. If a patient is unconscious and is on a CPAP, how is this addressed? I’ve read the forum, and it has more about vent patients than CPAP patients. Should the calltaker err on the side of the patient and treat as if the patient isn’t breathing? Should they remove the CPAP and check the breathing diagnostic without the CPAP (since sometimes it’s used for sleep apnea)? Start chest compressions whether the CPAP stays on or not?

I’m familiar with the CPAP in the field but not for in-home use. We had a call with a patient on CPAP with a cancer history. The agonal breathing tool was used, and they indicated the patient was breathing normally; however, that wasn’t the case. I’m just wondering what the Academy’s position is on this. I always believe in erring on the side of the patient. This one is a bit tricky. Do you foresee the Academy addressing this in any future updates?


Johnna Howell

Central Emergency Medical Services

Fayetteville, Arkansas, USA


I could use a little help from medical direction for this one.

Michael Spath

Chair, ED-Q Council of Standards



First of all, I have included Brett Patterson in this email. My knowledge of CPAP is not as complete as his, but I will provide you the basics here and let Brett add or subtract from my comments.

When dealing with CPAP patients, it is important to remember the patient has to be breathing (initiate a breath) for the device to function. It is not a ventilator, so if the person is unconscious but breathing, I would leave the unit in place and functioning. If the patient is not breathing, or the breathing is ineffective, I would remove the device and start CPR as appropriate. If the EMD is not sure if the unit is functioning, or believes the patient is crashing and their breathing is ineffective or agonal, I would remove it and get back to basics.

Let’s see what Brett has to say.

Brian Dale

Associate Director of Medical Control and Quality Processes



I agree with Brian. If there is any doubt, remove and assess. If there is no doubt, either way, it doesn’t hurt to leave it on. If we know the patient is not breathing and we are doing compressions only, it certainly won’t hurt to leave it on. If we are certain the unconscious patient is breathing effectively, then leave it on. But again, remove and assess if there is any doubt.


Hi Brett:

Why isn't shoulder pain considered a chest pain symptom in addition to other areas of the body such as neck, jaw, upper back, chest, and arms?

Angela Stronach, EMD

Queensland Ambulance Service

Brisbane, Queensland, Australia

Hi Angela:

The Heart Attack Symptoms listed in the MPDS® are not strictly limited to exclude the shoulder; it’s just that the areas listed are much more typical for cardiac-related pain. Just as important as the location is the pain description. If a caller reported shoulder pain as heaviness or crushing or aching pain that was non-traumatic, I would certainly err on the side of safety and classify that as a Heart Attack Symptom. However, the shoulder is a complicated joint where musculoskeletal pain with movement is much more common, unlike the more typical pressure-like chest to jaw to upper arm radiating pain associated with cardiac ischemia.

I hope that helps, and thanks for asking.