'Can't Breathe' Or 'Can't Breathe At All'
June 5, 2017
Dr. Jeff Clawson, Brett Patterson
Perhaps the most influential agents of change for the MPDS® are the actual users. From Proposals for Change (PFC) to rapid input regarding the newest beta version, users provide the real-life feedback so necessary for quality protocol evolution.
Case in point: MPDS v13.0 contained changes to the ECHO-related, INEFFECTIVE BREATHING section of Case Entry. These changes were inspired by PFCs that detailed actual cases where EMDs did not select an ECHO code because the caller’s description did not EXACTLY match the quoted phrases in this section of the Protocol. In other words, the patient was actually in dire straits but, because the description did not match the Protocol phrase exactly, the EMD did not code the call as ECHO.
In reality, these phrases were taken from actual calls, which is why they are placed as quotations. However, they were never meant to be exact or absolutes. So, after considering the related PFCs, the Council of Standards voted to make a couple of changes to clear things up. First, the phase “… or reasonable equivalents …” was added to the directive at the beginning of the section, and this has worked out very well. Additionally, to more directly address one of the PFCs, the phrase “Can’t breathe at all” was changed to read “Can’t breathe (at all).”
But while the intent of the later change was actually to allow more discrepancy on the part of the EMD, it has apparently opened the gates a little too wide. Several high-volume agencies have reported spikes in the number of ECHO-level calls and have provided data that links the complaint of “Can’t breathe” alone to the volume increase. Additionally, there is field data to suggest that most of these patients are not as sick as the “Can’t breathe at all” group. In fact, many of them are reported to be 1st party callers speaking in full sentences, while stating, “I can’t breathe.”
In response to this excellent feedback, the Academy’s Rules Group, a working sub-group of the Council of Standards, is in the process of addressing this issue by removing the parentheses from this phrase and addressing the issue here, in print.
The intent of the INEFFECTIVE BREATHING section, and its link to the ECHO code, is to capture the most acutely ill patients that can benefit from the immediate response of the closest available trained responder who, in many cases, is not part of the standard EMS response team (e.g., HAZMAT units, ladder trucks, police, etc.). Patients with INEFFECTIVE BREATHING, as the term strongly suggests, are not breathing adequately to sustain life. And it is expected that while emergency callers have predictable tendencies in their descriptions of these patients, there is bound to be some variation. Therefore, EMDs should be encouraged to consider not only the caller’s vernacular, but also the scenario and any additional clues it may provide. Certainly, if the caller describes a patient using one of the listed terms, and there are no obvious circumstances to the contrary, INEFFECTIVE BREATHING must be assumed and the appropriate code assigned. But if the exact term or phrase is not used, and the EMD strongly suspects INEFFECTIVE BREATHING, caution must always err in the patient’s favor. 1st party callers offer direct, audible assessment of their breathing status.
Likewise, a same or similar INEFFECTIVE BREATHING term may be used when it is obvious the patient is not in severe distress, most commonly when 1st party callers are involved. This is most likely when the 1st party patient states “I can’t breathe” but is otherwise speaking in complete sentences without obvious distress. Again, the goal here is appropriate triage in the best interest of the patient, not simple word matching by the EMD.
The Academy owes a great deal of gratitude to the EMDs and their agencies who take the time and effort to provide the feedback so important to the evolution of the MPDS. In this case, the feedback is being used to “fast-track” this change into ProQA® and make it available to users as soon as possible, perhaps even by the time of this printing. In the meantime, EMDs and ED-Qs should consider the phrase “Can’t breathe” with discretion when it is offered alone or without further clarification, meaning it is no longer a mandatory, ECHO-level phrase in and of itself.
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
Special thanks to the Central Communications Center for Alberta Health Services in Edmonton, Alberta, Canada; the Toronto Paramedic Services Communications in Canada; the Alameda County EMS Authority in San Leandro, California, USA; and the Oakland Fire Department in California, USA; and the various IAED™ National Q clients who submitted their concerns and supportive data to facilitate this important change in the MPDS.