Encouraging Reasonable Judgment

Jeff Clawson, M.D.

Jeff Clawson, M.D.

Brett Patterson

Brett Patterson

Ask Doc

Greetings Brett,

Hope you are managing to stay safe and well.

We often get questions from our EMDs about the identification of the Case Entry INEFFECTIVE BREATHING listed “Turning blue or purple.”

A caller may call for a patient who is vomiting and add in the Complaint Description that a part of their body (fingers, toes, hands, feet) is blue. With this should they be selecting 6-E-01 in Case Entry?

For example, consider a patient with a history of cerebral palsy presenting with cyanosis of the feet. There is no suggestion of breathing problems at all. The patient had seen a doctor earlier in the day who advised he should go to the hospital because of concerns about blood circulation to his feet.

We understand that “Turning blue” or “Turning purple” is an INEFFECTIVE BREATHING statement. Should any mention of blue or purple always be coded as ECHO, regardless of the Complaint Description?


Name withheld


We all know that INEFFECTIVE BREATHING is a dispatch-defined term meant to capture very, very sick patients who are at imminent risk of cardiac arrest. Dr. Jeff Clawson has accurately and descriptively referred to these patients as those who are “circling the drain.” In many systems these calls generate an ECHO-level response that includes personnel not routinely assigned to all medical calls. These responders are supposed to be reserved for cases where patient outcome may depend on their response and rapid intervention.

Whether the severe distress we generally associate with cyanosis is related to respiratory function or not, we are talking about severely compromised patients here who are either in obvious, severe distress, or are unconscious or barely conscious at the time of the call. We also know the patient circumstances described in your scenario do not meet these criteria, and I think our EMDs do as well, intuitively. Additionally, we have been given good rationale for the extremity cyanosis and have been informed that the patient is not in distress.

The elephant in the room is the caller has offered key words included in the dispatch definition of INEFFECTIVE BREATHING so, the question becomes: Do the terms alone, apart from the patient’s actual condition and circumstances, warrant the selection of an ECHO-level Determinant Descriptor? We do not think so.

If we force absolutes in an effort to decrease variance among EMDs (and ED-Qs), we risk losing valuable judgment and exacerbating over-triage, unnecessarily. However, if we allow for rational consideration of the facts on a case-by-case basis, we impart education and feedback into the QI process and eventually improve EMD judgment. In short, sticking to absolutes in QI processes discourages rational thought and promotes a lack of confidence in our QI personnel and protocol we depend on. Conversely, allowing and encouraging reasonable judgment based on obvious factors promotes thought, education, and quality.

I will extend this advice to other areas of similar concern with a different example recently presented to me. The case involved a sick person and was clearly a MEDICAL case. When asked about bleeding during Key Questioning on Protocol 26, the caller noted a minor, weeping wound on the patient’s shoulder. While shunting to Protocol 21 is intuitively inappropriate to most of us here, it may be argued such an action is correct based solely on the Yes answer to the Key Question. A shunt to Protocol 21, however, produces inappropriate questions and instructions and an inaccurate code that may mislead  potentially inappropriate responders.

In order to continually improve the protocols we work with, we need to be sure the output we analyze is actually the output of the tool and not the variance associated with calltaker freelancing. However, inaccurate or inappropriate output can also be associated with poor judgment or, more accurately here, the fear of being punished for using good judgment. In reality, these sorts of exceptions can help us maintain accurate data when good judgment provides a safety net for atypical calls that predictive tools cannot always address.

In short, we expect our EMDs to be well-trained and capable of good judgment. Our protocol and guidance should enable this, not discourage it.

Thanks, as always, for your thoughtful questions and insights.

Brett A. Patterson

Academics & Standards Associate

Chair, Medical Council of Standards

International Academies of

Emergency Dispatch®