CHEST PAIN, BURN, OR BREATHING PROBLEM?
July 6, 2016
By Brett Patterson
I ran into what I thought was an interesting medical call the other night.
I took a call from a steel mill requesting assistance for a patient who inhaled steam and was having chest pain and a burning sensation but no difficulty breathing. I originally picked Protocol 10: Chest Pain (Non-Traumatic), just from hearing the chest pain, but prior to asking any questions from that card I debated on using Protocol 8: Carbon Monoxide/Inhalation/HAZMAT/CBRN, for inhalation hazard, and, possibly, Protocol 7: Burns (Scalds)/Explosion (Blast), although the caller presented no information involving burns, just the sensation. I also considered Protocol 6: Breathing Problems, but the caller said he had no breathing problems. The steel mill has a nursing staff and BLS ambulance.
I talked to co-workers, and we decided to ask for your take on the call. Thanks again for your help. I look forward to hearing your advice. I guess I should tell you I just ended up using the Chest Pain Protocol (Protocol 10).
Butler County 911
Butler, Pa., USA
If the caller/patient knows the offending inhaled agent is steam, the mechanism of injury (thermal burn to the face caused by a hot gas) fits the definition of SIGNIFICANT FACIAL BURNS (Protocol 7) and is exactly why the definition and associated code was created. The internal airway burns caused by such an injury may not initially cause difficulty breathing, but these patients are at significant risk of subsequent airway swelling that may be life threatening. Two such real-life cases sparked (pun) the definition and code mentioned above.
Academics & Standards Associate
Medical Council of Standards Chair
I do agree that although the third-party call from the security company at the steel mill stated the patient wasn’t in any distress, there was potential for that patient to decline quickly with airway burns. I should have gone with my gut and away from the chest pain card. I will hopefully have others learn from my mistake!
Thanks again for getting back to me.
We are a county communication center in Iowa, and we are EMD certified through the Academy. Most of the time we are staffed with a single dispatcher on duty. If a critical call that needed EMD came into the center, and the dispatcher on duty was inundated with calls and radio traffic, is it permitted to transfer the caller needing EMD to an adjoining county that we know is also EMD certified through the Academy to conduct or continue with the protocols needed? This would allow our dispatcher on duty to concentrate on the radio and additional calls coming into the center. If this is permitted, should there be an agreement between the centers to provide this backup service to each other? Also, would there be liability risks? We’re just trying to think outside the box for smaller centers like ours that want to provide EMD.
Delaware County 911 Communications
Manchester, Iowa, USA
First let me commend you on your proactive insight into these potentially litigious scenarios. I am not an attorney, but I am familiar with some of the related legal concepts, namely foreseeability, abandonment, and the Emergency Rule, all of which can be referenced in the legal chapter of your “Principles of EMD” textbook.
As you have shown with your insightful inquiry, an inundation of emergency calls overwhelming a single EMD is foreseeable and is therefore not “excusable” under the Emergency Rule concept in civil law. In other words, if the potential is obvious and predictable, your agency is obligated to prepare for it. If your agency does not have contingency plans, there is potential liability.
Not providing Pre-Arrival Instructions, or transferring a caller to an agency that does not provide the expected standard of care, can potentially be considered patient abandonment, as doing so transfers the caller/patient in need from a higher level of care to a lower level of care. By transferring a caller to an agency certified in EMD when you are inundated, you have prudently avoided abandoning the patient/caller. This is sound practice and is commonly referred to in the field as mutual aid.
As you may know, many (and hopefully most) EMS/fire/police agencies have mutual aid agreements in place for field operations. These are plans/policies/procedures that direct employees with specific actions that have been preapproved should such circumstances arise. When properly applied, these actions can be defended when they are based on the current standard of care, pre-approved by the appropriate people, made available in writing, and everyone is properly trained.
Therefore, my advice is to gather the involved stakeholders, i.e., representatives from both agencies’ communication centers’ clinical field operations and medical control, and create sound policy/procedure regarding this issue, i.e., when and how to transfer calls. Such policy/procedure should be formalized in writing and then signed off by medical control. Importantly, make sure everyone involved is properly trained and updated on a regular basis, keeping in mind that related occurrences may not be frequent, so related action should be practiced.
I hope this response helps to answer your questions. I have copied an EMS attorney colleague to see if he may have anything to add.
Great response! I concur with your recommendations for stakeholder involvement, development of a formal written policy, medical control approval, and continuing training as good strategies for reducing liability exposure.
Douglas M. Wolfberg
Page, Wolfberg & Wirth LLC
The National EMS Industry Law Firm
Mechanicsburg, Pa., USA