Brett Patterson

Brett Patterson

Greg Scott

Greg Scott

Best Practices

By Brett Patterson and Greg Scott


I have an issue concerning a patient with a compound fracture just above the ankle, although unsure whether it was tibia or fibula. The patient’s bleeding was described as “not very much. . .just a drop.” Using Protocol 30: Traumatic Injuries (Specific), the Determinant Level would be an ALPHA, since the lower leg is listed as a “Not Dangerous Body Area.” Our final code was a 30-A-1. The ambulance, however, upgraded to a DELTA sighting, as described:

The response was upgraded due to it being a compound fracture (open fracture). Any open fracture will require immediate ALS intervention through appropriate treatment and pain management that must be performed. My concern is that an open fracture was dispatched as a non-emergent BLS response via EMD criteria. This should never have occurred and I would recommend reviewing the EMD process as it relates to appropriate EMS intervention requirements. If a BLS crew had been dispatched, ALS assistance would have been requested once an assessment was completed. This would have delayed ALS and also committed unnecessary resources to a single event.

Could you provide the Academy’s reasoning for running “COLD” and only responding BLS, which seems to contradict the ambulance company?

Carl Jaklic Supervisor,

Quality Assurance & Training

Mercer County Department of Public Safety Mercer, Pa., USA


Jeff Clawson, M.D., Brett Patterson, and I have reviewed your question. Dr. Clawson has written the official opinion below.

  1. We agree that coding as a 30-A-1 is correct.
  2. The prehospital care of lower leg fractures has been a BLS COLD level response for 32 years per the MPDS response matrix list. Also, a HOT transport is not clinically necessary for this type of case. In my personal experience (JC), I have treated a few dozen of these types of injuries in the ER and many of them came in via private vehicle, with only splinting and contamination protection being compromised.
  3. The case at hand is not a new concern. These types of cases were considered in the development of Protocol 30. The argument, if presented to the Council of Standards, in our opinion, would not be persuasive as it was written; however, anyone can provide a Proposal For Change (PFC) to the Academy, once approved by the Dispatch Review Committee and signed by the medical director. It will receive formal evaluation.
  4. The issue of pain management per se is an ALS treatment. However, whether the fracture is open, partial, closed, deformed or not, has no bearing on the need for analgesics. The level of pain of any injury, regardless of where it is, may warrant pain meds. Having four fingers dislocated might be more painful than the injury in this case.
  5. Unless the EMS system wishes to send an ALS unit on every fracture or soft tissue injury called in, ALS will not be at the vast majority of these types of calls in a tiered ALS/BLS system. It is much more common that in special cases of severe pain, ALS is later dispatched, or much more commonly, the patient is simply transported to the care center in nearly the same amount of time as the response of an ALS unit.
Please let us know if you have any further questions or concerns regarding this case.

Gregory Scott

Operations Research Analyst

National Academies of Emergency Dispatch (NAED)