Altered Level Of Consciousness On Protocol 26: Sick Person

Hello, 

I am reaching out for clarity on whether an IAED^™ Journal article from over a decade ago is still accurate/correct. It is titled "The Safety Net In Protocol 26," published July 29, 2015. 

I am an Ambulance Communications Officer from Canada, and our dispatch center launched the MPDS^® in 2025. I have been searching for best practices/answers/direction regarding KQ 1 on Protocol 26: Sick Person (Specific Diagnosis). This article answers my questions perfectly; however, I have been informed that it is probably out of date and no longer accurate. I would immensely appreciate a response from you on the current status of this article. 

Now for my specific question: 

KQ 1 "Are they responding normally (completely alert)?" 

If the caller states "No, they are [any of the specific approved Altered LOC descriptors]", is the EMD expected to select "No" (coding a 26-D-1) or are they expected to select the specific Altered LOC descriptor provided by the caller (26-C-1)? 

This article from 2015 clearly states anytime the caller answers with a “No,” regardless of what descriptors are used, the EMD should be selecting “No” and coding a 26-D-1. 

Current direction from anyone I have talked to or contacted about this is that the EMD should select the Altered LOC descriptor anytime it is provided by the caller, including when the caller advises “No” to this question. 

Thank you for the work you do. I look forward to a response.

Name withheld 

Hello, 

Thank you for reaching out with your question. 

All clients must exercise discretion when referencing older articles, as protocols are likely to have changed since they were written. And this one is under significant research review right now regarding this very issue. 

When a caller provides a description that matches one of the ALOC answer options, it is reasonable for the EMD to select that specific ALOC option. We know from years of evaluating cases, that callers will answer both ways: “Yes, but he is confused” or “No, he is confused,” even though the patient’s level of consciousness is the same—“confused.” 

We also know that a caller will often mention one of the ALOC conditions within their response to TMEWH. When this happens, the EMD may use this information, along with everything else known, to make an informed decision on Protocol 26 KQ 1 regarding how to proceed. They may consider the KQ obvious, or, if the caller provides evidence that the question needs to be asked, by all means ask. As the lawyers say, “That’s already been asked and answered.” 

The primary objective of the ALOC is to capture patients who should not be in the ALPHA- or OMEGA-level response. 

I hope this helps. Please do not hesitate to reach out if you have any questions. 

Bryon Schultz Academics, Subject Matter Expert-Medical, ARC International Academies of Emergency Dispatch^® 

Hi Bryon, 

Thank you so much for your prompt response. I really appreciate you taking the time to confirm this, as it has been a contested topic at my center. 

As a follow up question, the list of ALOC descriptors includes things like “confused” and “lethargic,” which do seem perfectly reasonable as CHARLIE-level responses, but also “unresponsive” and “semi-conscious.” We have calls in which a caller simply responds “No” to KQ 1 and receives a DELTA code, and then we have calls in which a caller responds “No, they’re unresponsive,” and they only receive a CHARLIE-level response because they provided more detail to the calltaker. 

I have a hard time wrapping my head around this, particularly when the difference between a DELTA and a CHARLIE is the most significant (lights-and-siren response/potentially holding 60 mins). Is this because the MPDS assumes that if the patient had a significantly decreased LOC, it would be caught at TMEWH and be handled on Protocol 31: Unconscious/Fainting (Near) anyway? 

Is it ever reasonable for the EMD to select “No,” even if the caller provided an approved ALOC descriptor, because the EMD feels like the call should be coded as a DELTA?

Is it ever reasonable to shunt from Protocol 26 to Protocol 31 if the response to KQ 1 is that the patient is unresponsive? 

Thanks again for your time. 

Hi, 

Great question. Unresponsive is identifying a patient who is awake but not responding to the caller. Semi-conscious, historically a rather uncommon response from a caller, generally means the patient is awake and responding, but not appropriately, or in another more common description, lethargic or slow to respond. 

We appreciate how agencies are having to manage high call volumes, which puts more stress on the EMD to ensure they are sending the appropriate response and resources. 

Keep in mind that Protocol 31 is not for a complaint of “not alert.” Protocol 31 is for a person who fainted, nearly fainted, or is unconscious now (non-trauma). 

Absolutely, an EMD can select no to KQ 1 when the caller gives a “No, but (fill in the blank)” if they feel that this patient requires a DELTA-level response. They are acting on the patient's best interests and erring on the side of the patient. 

If the patient becomes unconscious, it would be appropriate to shunt to Protocol 31. 

We always want the EMD to follow all the Laws of Emergency Dispatch: First, do no harm. 

When in doubt, send them out. I hope this helps, 

Bryon 

Dr. Jeff Clawson adds: 

Years ago, in looking at a very large MPDS database from the London Ambulance Service, we were examining ambulance patients who were reported by dispatch to be in cardiac arrest for every code in system. What we found was fascinating, as most of the time these cardiac arrests were found exactly where we predicted—in ECHO and DELTA codes and mainly in Protocol 9, Protocol 31, and Protocol 6 cases. We created a column that showed the percentage of all cases in that code compared to those found later to be in arrest or who arrested after scene arrival of the medics. This was called the Cardiac Arrest Quotient (CAQ) that we have used over the years, and which can provide additional information to assist agencies in not over-assigning responses to all CHARLIE codes and even some DELTA codes. 

The surprise was that we found only any significant numbers of arrests in only three lower-level codes: 17-O-1, 17-A-1, and 26-A-1. P-17 made sense as often a fall is a “chicken or the egg” conundrum as to exactly what was the initial underlying cause of a ground-level fall, and we have adjusted the logic in that protocol since. However, the 26-A-1 was even more unexpected, although we have always said that “Sick Persons” are a collection of unholy conditions often masquerading as just “sick.” I have warned about this for years, and tell folks, these are not usually the kind of patients that should be triaged out of the system or sent to non-quality controlled or non-RN-trained nurse lines. 

The finding led us to do a further unpublished study with London wherein we identified the list of KQ Answer Choices mentioned in the initial question above, as all were actually things callers said in cases that made it to the ALPHA-code tier but should have been coded as obviously Not Alert on QA review. When callers stated any of these terms, often the EMD immediately “threw” the clarifier at them and they paused then said things like, “Well, I guess not.” In essence the EMD had virtually talked them out of saying these patients were not alert, even though all these words (now answer choices) are synonyms for an altered level of consciousness (i.e., not exactly “alert”). 

We then did a research change to the Determinant Code section only in London making all these a new CHARLIE-level code “Altered Level of Consciousness” which, after that data was combed, resulted in 50% less CAs in the ALPHA level. It wasn’t all of them, but a significant chunk. And London then decided not to triage these out, so to speak. We are currently doing a study to publish the actual outcomes of all 15 of these answer choices that should shed some significant light on which ones work best and even which ones might actually need to be DELTAs. We then may be able to expand this method to other protocols—in the near future. 

With 26-A-1, as I told the docs and ambulance management of London back then, when you are dealing with “Sick Persons,” nonvisually ... be afraid, be very afraid! And, at least, be careful! 

Onward, through the ALOC fog ... Doc