Back To The Start
July 16, 2020
We’ve recently had a couple calls where dispatchers had a call coded and were in the middle of PDIs when they went all the way back to call classification, changed the protocol, and then proceeded to ask the Key Questions for the new call type. In essence, they just started over. On one occasion, the calltaker realized she had initially chosen the wrong call type and started over, and on the second occasion the calltaker received new information and was simply confused as to what to do with it.
My question is this: Is it written somewhere, or is there any rule that says once you reach a certain point in a call you shouldn’t go back and start over? Universal Standard 17 seems to indicate that it’s okay to go back at any point if you realize a mistake has been made. Is this really the case? Or, if you are already in PDIs and realize a mistake, should the call just be manually updated to correct a previous mistake in protocol type? The difficulty is that it creates a lot of confusion for responders when we start changing the response and call type several times in the course of a call.
Hope that makes sense. Thanks for any clarity you can give.
Quality Assurance Supervisor
Weber Area Dispatch 911 and Emergency Services District
Ogden, Utah, USA
We want to prevent what Dr. Jeff Clawson has described as “protocol surfing,” where the EMD hears a symptom that is clearly not a priority in the case but changes protocols simply because the EMD does not understand the current path is sufficient and appropriate. A common example of this occurs when the primary complaint is not a fainting or near fainting issue, but the caller mentions a level of consciousness issue so the EMD switches protocols even though the current pathway handles the not alert patient appropriately, while better dealing with the primary complaint.
I would applaud an EMD for “starting over” when it is clear they didn’t get it right the first time but would explore why this happened. Changing direction is certainly appropriate when a caller offers new or updated information that warrants a change, but this is where it gets a bit muddy and why education and training are important. If, after choosing another Chief Complaint Protocol, say Protocol 26: Sick Person (Specific Diagnosis) based on a vague or non-categorizable complaint description, the caller offers symptoms clearly handled better on another protocol, and described by Rule/Axiom/Law/Definition as such, i.e., Heart Attack or STROKE Symptoms, allergic reaction, TRAUMA, etc., switch protocols. However, if the “discovered” symptom is not clearly benefitted by the use of another protocol, the symptom discovered is handled where you are, or a Rule tells us not to shunt, i.e., P26 Rule 2, stay where you are. Obviously, this can be somewhat subjective making education and training important. I would recommend the following article as a start:
As always, reviewing specific protocols and their intent and proper use helps EMDs know when, and when not, to use them.
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
After reading your insightful article, “Keep Them Awake?” from 11/28/2017, I found myself wondering a vital question about a scenario I've had many times.
case of a first party (alone) who exhibits a gradual decrease in consciousness
or makes statements like "I think I'm going to pass out" or "I
feel tired," should we be interfering with this? My concern is that if the
patient were to lose consciousness, we would have no one to maintain their airway.
I have the urge to keep the patient talking so they can continue to update me
with their symptoms and level of alertness. Letting them lose consciousness
worries me that their airway may be compromised.
I would appreciate your opinion and directive on this scenario.
Thank you in advance!
OnStar Emergency Advisor
I think it’s a great idea to keep a 1st party caller on the line and engaged, provided we are not asking a patient with severe difficulty breathing to talk. However, this is more about consoling, comforting, and monitoring than keeping alive, as Dr. Clawson points out in his article. Remember, speaking to someone is not likely going to stop the process that is causing the problem. Keeping someone awake by talking to them really only helps when sleepy, or sometimes encouraging them to fight exhausting difficulty breathing, and this really isn’t a good thing. There’s an old paramedic adage that asks, “When is it appropriate to intubate a conscious patient?” The answer, “When they allow it.”
But your 1st party concern is valid—airway is important. If the patient is alone, and you believe the patient is going to pass out, ask what position they're in. Optimally, lying on their side would be best, although we don’t recommend this “recovery position” when someone is there to assist because it isn’t hands-on like the airway maneuver we utilize, and the caller may leave the patient. But, if alone, lying on their side at least helps protect the airway if they should pass out.
Recently, some role-plays were being done on our site, and while practicing an overdose, we noticed an inconsistency with ProQA®. Fentanyl can be introduced to multiple different drug types, one being cocaine. When role-playing through a scenario for Protocol 23: Overdose/Poisoning (Ingestion), however, if you were to pick "cocaine" from "What did they take," it does not prompt whether or not fentanyl was mentioned. If we were to pick an opioid however, it does.
Is there any reason for not prompting for cocaine, as fentanyl can be found there as well?
Thanks for your insight!
Brand & Cultural Ambassador
Emergency/Stolen Vehicle Assistance | Concentrix
Oshawa, Ontario, Canada
(Feb. 27, 2020) While we appreciate that fentanyl is sometimes added to cocaine, this can also be the case with other drugs. So, after discussion with our Council of Standards Rules Group, we have decided to address this by Rule. The Rule will effectively advise the use of the Narcotics answer choice when more than one option applies. This will ensure that the Fentanyl/Carfentanil/U4 option displays, and the Narcan DLS link is recommended, when unconscious.
Thank you for bringing this issue to our attention and inspiring change to the MPDS®!
(May 27, 2020) I just wanted to follow up and make sure you've noted the new v13.3 Rule you and your team have inspired regarding narcotics taken alongside other substances. As you can see from the graphic below, the new Rule helps to ensure the Narcotics answer option is chosen in ProQA when substances in addition to narcotics are involved, thereby ensuring scene safety and an appropriate DLS response.