Art And Science
February 28, 2019
A Chief Complaint may be described as the reason a caller is seeking help. The Chief Complaint may or may not be accurately expressed by the caller for various reasons including a tendency to self-diagnose, a lack of knowledge concerning clinical or situational priorities, multiple/concurrent problems, or emotional distress, among other factors.
Case Entry Question 3, “Okay, tell me exactly what happened,” was designed to solicit a complete complaint description from the caller that can then be interpreted by the trained EMD to determine an accurate Chief Complaint and, ultimately, select an appropriate Chief Complaint Protocol.
The objectives associated with determining an accurate Chief Complaint include the discovery of any potential safety issues, any significant Mechanism of Injury (MOI), and the identification of priority symptoms and/or conditions that can be used to select a Chief Complaint Protocol. The selection of an appropriate Chief Complaint Protocol then helps to meet the primary objectives of the MPDS®: Safety, response allocation, patient care, and information for responders.
Understanding exactly what is happening, or has happened, at a given scene is essential to accomplishing the above objectives. For this reason, Case Entry Question 3 is perhaps the most important question in the MPDS. Because callers may not understand the EMD’s objectives or priorities, they may not initially provide a complete or accurate Complaint Description, making a second or clarifying attempt at asking this question mandatory. Most often, simply repeating the phrase “… tell me exactly what happened” is enough to obtain the information necessary to identify a Chief Complaint. However, if this does not work, rephrasing or otherwise attempting to find out exactly what triggered the call for help is compulsory. Cutting the caller off at Case Entry Question 3 is self-defeating as an inaccurate result is far worse than sacrificing a few seconds to get it right.
The Chief Complaint Selection Rules, found primarily on the Case Entry Protocol but also on various Chief Complaint Protocols, are designed to guide the EMD by setting some basic priorities. In particular, once a Chief Complaint is identified, these Rules ensure that safety, MOI, and Priority Symptoms are always considered when selecting a Chief Complaint Protocol. In other cases, a Rule may ensure a specific condition or situation is addressed accordingly on a specific Chief Complaint Protocol, i.e., that hazardous materials are addressed on Protocol 8: Carbon Monoxide/Inhalation/HAZMAT/CBRN, or that the apparently non-breathing seizure patient is evaluated on Protocol 12: Convulsions/Seizures before response assignment and caller instruction.
Our first Case Entry Rule is perhaps the most easily understood because safety is always our first priority. If the caller’s complaint description identifies any safety issues, the EMD must choose the Chief Complaint Protocol that best manages those issues. This applies even to those cases where another Chief Complaint Protocol may seem more appropriate for the caller’s concern, or even the patient’s care. A basic premise is introduced here: More than one Chief Complaint Protocol may address a safety issue, a mechanism of injury, or a Priority Symptom. All EMDs should be familiar enough with the MPDS to know the basic functions of each protocol.
Our second Case Entry Rule is designed to identify specific MOIs addressed by the MPDS. This is because significant MOIs can cause undiscovered (occult) injuries that may not be noticed by the caller or patient but require a certain level of response to address the potential injury. The classic example is LONG or EXTREME falls. While a caller may be concerned about a particular injury, perhaps a broken leg that Protocol 30: Traumatic Injuries (Specific) would address, Protocol 17: Falls is most appropriate because it will prioritize the call based on the MOI alone, if necessary.
In MEDICAL cases, Case Entry Rule 5 was designed to establish priorities when multiple complaints are expressed in the caller’s complaint description. Generally speaking, we want to know the primary reason the caller decided to call for emergency help. This is called the foremost symptom. In many cases, knowing why the caller is seeking help right now is enough to determine the Chief Complaint. Second, we want to make sure Priority Symptoms are not missed because lay callers may not understand their clinical significance. For instance, while a patient’s belly may hurt worse than her chest, the chest pain is obviously the clinical priority in the pre-arrival environment.
However, in order to appropriately apply these Rules and ensure the selection of an appropriate Chief Complaint Protocol, we must first obtain a complete complaint description, and then formulate an accurate Chief Complaint that we can apply our Rules to. To do this, we must consider the clinical and situational scenario presented to us and also have a thorough knowledge of the content and capabilities of our Chief Complaint Protocols. Let’s illustrate this concept by using a few examples.
A very emotional mother dials 911 after her 12-year-old son is exposed to a known allergen, say peanuts. Her Chief Complaint description includes both difficulty breathing and allergic reaction. If we strictly apply Case Entry Rule 5 to the complaint description alone when considering a Chief Complaint Protocol, we might select Protocol 6: Breathing Problems and, therefore, miss Key Questions and instructions very important to this case. However, if we consider this scenario clinically, we understand that the difficulty breathing is being caused by an allergic reaction. If we consider the scenario’s physical circumstances, we note that the child was exposed to a known allergen. With this information, we can now formulate an accurate Chief Complaint: allergic reaction. And, knowing that Protocol 2 will address both the allergic reaction and the priority symptom of difficulty breathing, we can apply our Rules and select an appropriate Chief Complaint Protocol—Protocol 2: Allergies (Reactions)/Envenomations (Stings, Bites). This example clearly illustrates the basic premise we made earlier: More than one protocol may address a particular Priority Symptom—we are not always limited to a Chief Complaint Protocol with the same name as the Priority Symptom.
Let’s look at another scenario that’s not so cut-and-dry. An elderly man calls and states: “My wife just fell in the kitchen.” With this information alone, an EMD may initially think about the fall (MOI) when considering which Chief Complaint Protocol to select. However, because we know nothing about the circumstances of this fall, the prudent EMD asks again, “Tell me exactly what happened” to which the caller replies, “She was in the kitchen doing the dishes, and I heard her fall from the living room. Now she’s not responding to me!”
In this case, the complaint description contains a mention of fall. However, the complete scenario—the sudden, unexplained collapse of a previously normal patient—strongly suggests sudden cardiac arrest. The trained EMD understands that a ground level fall is very unlikely to cause unconsciousness, but the sudden collapse and unresponsiveness is highly indicative of cardiac arrest, followed by stroke or seizure. So, while the complaint description made mention of possible TRAUMA, the Chief Complaint is most likely MEDICAL.
Let’s look at one more case. A 65-year-old man calls and, in answer to Case Entry Question 3, states: “I was just watching television when I got this terrible, ripping pain between my shoulder blades. And when I tried to get up, I felt faint and had to sit back down. It’s really hurting badly now.”
In this case, the patient’s foremost complaint is ripping back pain, but there is also the mention of a Priority Symptom. However, the EMD understands that this sort of non-traumatic back pain, coupled with the patient’s age, fits the definition of SUSPECTED Aortic Aneurysm addressed on Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma). Additionally, the near-fainting symptom, also suggestive of aneurysm, is addressed in the CHARLIE level of Protocol 5. Therefore, in this case, the caller’s complaint description matches the Chief Complaint determined by the EMD—non-traumatic back pain. And the Chief Complaint Protocol selected, Protocol 5, addresses both the SUSPECTED Aortic Aneurysm and the associated Priority Symptom of near fainting.
One of the most misunderstood concepts of the MPDS is the application of the Chief Complaint Selection Rules. Specifically, the literal interpretation of the Rules versus their actual intent, i.e., the “the letter versus the spirit of the law.” And nowhere is this more apparent than in the selection of a Medical Chief Complaint Protocol, especially when Priority Symptoms are involved.
In v12.2 of the MPDS, the wording of the “Chief Complaint Selection Rules” was altered slightly to differentiate the caller’s complaint description from the actual Chief Complaint determined by the EMD. This was done because the caller’s chosen description of events doesn’t always accurately reflect the Chief Complaint and, subsequently, there is a tendency for EMDs to select a Chief Complaint Protocol based on keywords heard in the complaint description, rather than considering the entire description as a whole. Let’s call this tendency the “trigger finger” approach to Chief Complaint Protocol Selection.
Perhaps the most common and notable example of the trigger finger approach involves the selection of Protocol 31: Unconscious/Fainting (Near), when unconscious, fainting, or near fainting are not even part of the complaint description. How does this happen? It happens when the EMD’s interpretation of the complaint description is incorrectly decoded based on the perceived notion that all forms of a decreased level of consciousness (a Priority Symptom) are best handled using Protocol 31. And this is quite simply not the case.
While it is certainly true that unconsciousness, fainting, and near fainting are all forms of decreased level of consciousness, it is not true that all remaining forms of decreased level of consciousness are appropriately addressed using Protocol 31. In fact, many MPDS Chief Complaint Protocols address varied levels of consciousness, while also addressing the multi-varied complaints associated with a decreased level of consciousness.
Protocol 31 is designed to deal with the unconscious state, when no specific cause is addressed on another protocol (think anaphylaxis, seizure, diabetic problem, stroke, and the many TRAUMA protocols where the Unconscious Determinant Descriptor and associated DLS Links appear). It also deals with the episodic events of fainting and near fainting, both of which are specific medical events. What it was not designed to do is deal with more specific causes of decreased level of consciousness that are addressed on other Chief Complaint Protocols, like the ones mentioned above.
So why does this inappropriate Chief Complaint Selection process continue to happen? The most likely culprit is a trigger finger approach that relates all non-traumatic level of consciousness issues with Chief Complaint Rule 5: “If the complaint description appears to be MEDICAL in nature, choose the Chief Complaint Protocol that best fits the patient’s foremost symptoms, with priority symptoms taking precedence.”
When read literally, this Rule seems to direct the caller’s mention of any Priority Symptom to the Chief Complaint Protocol associated with that mention. Literally, all MEDICAL Complaint Descriptions that include chest pain should be handled using Protocol 10, any MEDICAL complaints involving breathing problems require the use of Protocol 6, all MEDICAL bleeds should be taken care of with Protocol 21, and all MEDICAL patients with any decreased level of consciousness should be handled with Protocol 31. However, when presented this way, most would agree that this is not an absolute, nor was it intended to be. In fact, these conditions sometimes relate directly to more specific Chief Complaint Protocols and are far better addressed as such.
So, what is the purpose of these Chief Complaint Selection Rules? How do the Priority Symptoms so sought after in Dispatch Life Support fit into the process of Chief Complaint selection?
The intent of these Rules is to guide EMDs with regard to their interpretation of a caller’s complaint. In other words, the Rules regarding Chief Complaint Protocol selection are there to help us select a Chief Complaint Protocol after translating a caller’s complaint description into a Chief Complaint. They were never designed to literally take a caller’s words or impression and translate that directly into a Chief Complaint Protocol selection. The human interpretation of a caller’s complaint description is, and always will be, a fundamental EMD process. “Press 1 if you’re choking” is simply not an option.
In other words, the trained EMD must listen carefully and clarify, when necessary, the answer to Case Entry Question 3, then use that information, both clinically and circumstantially, to formulate an accurate Chief Complaint. Once this is done, the EMD can use the Chief Complaint Selection Rules, along with a thorough understanding of the MPDS, to select a Chief Complaint Protocol appropriate for the case. To do this, the EMD must be familiar with the ability of various protocols to deal with that circumstance, both in terms of addressing Priority Symptoms in Key Questioning and coding, and in DLS Links and instructions.
Let’s get back to some examples.
The son of a cancer patient calls to report that he is no longer able to care for his ailing mother. He says her condition is worsening. Her generalized pain is unbearable and not responsive to the powerful medications she is taking. She is lethargic and not responding well to commands. She is very weak and now unable to ambulate with or without assistance.
Given this complaint description, what is the actual Chief Complaint? Is it pain or the inability to ambulate? Is it a decreased level of consciousness, fainting, or near fainting? Or, is he reporting the deteriorating condition of a cancer patient, for which no specific Chief Complaint Protocol is titled? For most of us, Protocol 26: Sick Person (Specific Diagnosis) is a logical, even intuitive, choice. But what about that change in level of consciousness? And what about our Chief Complaint Selection Rule? How does that Priority Symptom fit in?
The answer is simpler than it appears. Yes, this caller is reporting a Sick Person. Yes, the patient has a change in her level of consciousness. And yes, Protocol 26 addresses this change in level of consciousness through questioning, coding, and instruction. Just like that, we have addressed the caller’s complaint with appropriate questioning, we have assigned an appropriate Determinant Descriptor (26-D-1 or 26-C-1, depending on the answer to “Is she alert?”), and we will provide appropriate instructions to monitor the patient until arrival.
Now let’s take that same patient in an unconscious state. Yes, she has been ill. But she has now become unconscious, which is likely the reason for the call, and this we can easily clarify. What have we done here? We have listened to the complaint description and formulated a Chief Complaint of unconsciousness.
Unconsciousness, as an episodic event, is a clear Chief Complaint, especially when expressed without a specific cause. And in the absence of a specific cause better addressed elsewhere in the protocol, Protocol 31: Unconscious/Fainting (Near) best addresses this complaint under these circumstances.
In summary, the process needed for selecting the most appropriate Chief Complaint Protocol for a given case requires more than recognizing keywords in a complaint description and loosely applying a Protocol Rule. In fact, hurrying through Chief Complaint identification is the mother of incorrect selection. Key to the process is the EMD’s ability to understand why the call is being made, which literally means listening to the complaint description, clarifying when necessary, and determining exactly what happened. A complete complaint description must always be required to contain enough information to generate an accurate Chief Complaint.
Understand that the actual Chief Complaint may or may not be literally aligned with the complaint description. The art in this process is knowing just how much information is needed to correctly synthesize the description into a usable Chief Complaint. With this information, the trained EMD, equipped with some basic knowledge about what protocols are available and what the capabilities of those protocols are, can then select a Chief Complaint Protocol using the Chief Complaint Selection Rules to make sure the key factors provided are addressed by the protocol selected.
EMDs are not the only communication center staff selecting Chief Complaint Protocols. ED-Qs do this every time they make a judgment, in hindsight, about the appropriateness of an EMD’s Chief Complaint selection in a given case. The simple fact is that even ED-Qs sometimes disagree on which protocol is appropriate for a given case. This is inevitable because of the incredible variation of Chief Complaint descriptions that we are all responsible for first interpreting as Chief Complaints and then, based on that judgment, selecting just one of a relatively small number of Chief Complaint Protocols.
In my position with the Academy, I am asked to weigh in on Chief Complaint Protocol selection decisions on a daily basis, and this is often instigated by a disagreement between EMDs, or between ED-Qs, or a combination of both. In fact, this article is a result of many of those discussions. The point is that when even the experts disagree, the need for education and improvement becomes obvious, and that is the intent here. And while this article is sure to generate some debate, my hope is that those ensuing discussions will be productive and will hopefully spawn improvements to the way we approach Chief Complaint Protocol selection, thereby decreasing the variance we work so hard to eliminate in our quality improvement processes.