Breathing Normally

Brett Patterson

Brett Patterson

Best Practices

Brett Patterson


A question I hope you can help me with:

Caller is continuously relaying the EMD questions to a patient who is next to him.

"Is she breathing normally? <question is relayed to the patient, who gives an extensive and clearly audible answer>

Caller: "No, she's not."

"Does she have difficulty speaking between breaths?" <again, question is relayed, and the patient answers extensively in full sentences>

Caller: “Yes, she is having difficulty speaking between breaths.”

In this case, the answer given does not seem to correlate well with the situation on scene. Should the EMD err in favor of this patient and choose "Yes" when prompted for difficulty breathing between breaths? Or should the EMD choose "No" as this is clearly the case?

Universal standards 17 suggest that the question to which an answer is already clear, need not be asked. But it does not handle the situation where the question is asked but the answer is quite clearly not true.

I'm inclined to err in favor of the patient, who might be forcing us to get an ambulance sent but doesn't need one. But it doesn't feel quite alright to do so …

Hope you can help me out here.

Thanks in advance,

Harm van de Pas, M.D.

Medical Director

Regional Ambulance Service Brabant MWN

Brabant Noord Dispatch Center, Netherlands

Hello Harm:

These situations put the EMD in a difficult spot.

We recently added a Rule to Case Entry (v13.1) that allows some EMD discretion when dealing with first-party callers and INEFFECTIVE BREATHING terms, but this was restricted to first-party callers where assessment is more obvious. With second-party callers, once an answer has been given, no matter what we hear in the background, we are placed in a bit of a quandary. In a court of law, the opposing attorney refers to this as “Asked and answered!”

What we advise is to enter what the caller has answered. However, if the answer is obvious before the question, there is no need to ask the question. If the patient is speaking in full sentences and we know absolutely that the full sentences are being spoken by the patient, then there is no need to ask about difficulty speaking between breaths.

I was recently asked if the results of the Breathing Verification Diagnostic Tool could be used to downgrade a call in which an ECHO-Level code was selected due to the use of an INEFFECTIVE BREATHING term at Case Entry. This seems straightforward and prudent when the EMD is using the tool in good faith to monitor the patient’s breathing in Case Exit. However, the potential for EMDs to use the tool to confirm INEFFECTIVE BREATHING because they doubt INEFFECTIVE BREATHING is very concerning.

So while your scenarios are innocent enough, and likely clinically accurate, we don’t want EMDs to get in the habit of “testing” the caller’s answers or doubting the integrity of the caller. These practices have proven to be very dangerous over the years.

Ideally, we need to develop reliable evaluations/diagnostics that can substitute for the questions we have consistent over-triage issues with. If we can crack those alertness and difficulty breathing nuts, we’ll take specificity to new heights in dispatch.

Brett Patterson

Academics & Standards Associate

Chair, Medical Council of Standards

International Academies of Emergency Dispatch®

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.