Epigastric Pain Could Mean Something Else
January 14, 2020
My team keeps me on my toes. Here is question that I would love your take on:
I was reviewing a lesson for Protocol 1: Abdominal Pain/Problems and was curious as to why Rule 1 (shown below in the graphic) does not indicate the use of the Aspirin Diagnostic and Instructions Tool. Should we attempt to use the diagnostic from the icon at the top of the ProQA® screen? (Whitney Mercado, EMD)
Thanks for being there,
Chief Communications Officer
Longview, Texas (USA)
Hi Teri (and Whitney):
First of all, if the pain or discomfort described sounds like Heart Attack Symptoms denoted on Protocol 10, use Protocol 10.
The 1-C-5 & 6 codes for abdominal pain are safety nets to make sure we get an ALS, face-to-face evaluation for patients in cardiac age range with epigastric pain (heart attack until proven otherwise). However, we know that the risk of cardiac arrest for these patients is much lower than patients complaining of chest pain.
In the male patients over 34 with abdominal pain, the risk of cardiac arrest is about 0.1%, and females over 44 is about .06%, while the cumulative number for the Protocol 10 codes for patients over 34 is .27%. So we assume the heart attack risk for the abdominal pain patients is much lower and wait for a more definitive evaluation before aspirin is indicated. Additionally, because abdominal pain may indicate a surgical or hemorrhagic risk, the predicted low risk of heart attack is weighed against a moderate risk of aspirin administration.
Thanks for the great question,
Brett A. Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
Which Chief Complaint card should be selected when a caller states they had to have brain surgery and their scalp has come unattached at the surgical site and requires reattachment? No injury or cause, no bleeding.
Davie County E911 Communications Center
Mocksville, North Carolina, USA
A surgical wound, while purposeful, is traumatic. If the complaint is an issue with the wound and not bleeding, Protocol 30: Traumatic Injuries (Specific) works fine. I will assume the patient’s brain surgery was greater than 6 hours old here, but the Protocol does ask about this—30-A-3 or, if sooner and alert, 30-B-1.
In the past year there have been a lot of fentanyl overdoses. In our center we would go to the Overdose Protocol (Protocol 23) first and then if not breathing go into the PAIs. Panel 4 of the CPR pathway directs Overdose/Poisoning situations to follow the Ventilations 1st pathway. I have two questions about this.
First is, if the caller comes in and finds patient down and not breathing and then advises “I think she/he overdosed” but they do not know how long they have been down, why wouldn’t we just go to the Compressions 1st pathway? Even for hanging, for instance, why not just go into compressions if we do not know how long they have been down for?
Also, with fentanyl being big and the different types of fentanyl out there such as fentanyl, carfentanil, and U4, wouldn’t doing mouth-to-mouth ventilations cause a possible issue to where you could have two patients?
I think that if they meet either one or both criteria then we should only do compressions only.
Finally, I think it could be questionable about what path to take—ventilations or compressions—if it is not witnessed and we do not know how long they have been down.
Name withheld upon request
Unfortunately, your agency is not alone with regard to high volumes of narcotic overdose calls. The problem is truly of epidemic proportions. To put things in perspective, have a look at this article from British Columbia, Vancouver, Canada:
But back to your questions.
OVERDOSE is in the Ventilations 1st pathway because the cause of death is likely respiratory in origin and, if in arrest, the patient has likely used up all oxygen reserves and has built up too much carbon dioxide. Your point about time down is noted, but scene estimates are generally unknown or unreliable, which is why we do not discriminate with sudden cardiac arrest patients either. If the cause is likely respiratory in origin, the current standard of care assumes ventilations are needed. And if sudden cardiac arrest is the complaint, the standard assumes oxygenated blood is present and focuses on compressions, at least until advanced airway adjuncts can be applied. In summary, the current standard of care cardiac arrest of suspected respiratory etiology is ventilations with compressions.
I understand your concern regarding potential contamination when providing Mouth-To-Mouth (M-T-M) in narcotic OVERDOSE cases. However, this concern is anecdotal and unsupported by the evidence. Most of the pushback on this actually comes from providers rather than lay rescuers, who are generally willing to help. And if the rescuer does not want to provide M-T-M, a Refused M-T-M pathway is readily available.
We added some related precautions to v13.1 when paranoia about contamination from fentanyl and its analogs was high but have since removed the instruction to try and administer Narcan without touching the patient. The reason for this is based on evidence that came to light following some rather exaggerated media reports early on. Here’s a link to an article authored by an expert in this field and recently printed in the Journal that details this journey and provides specific references. Please see page 20.
Importantly, after dealing directly with these
emergencies for many years now, and also providing M-T-M instructions in the
MPDS® for nearly 40 years, we have never had a report of disease
transmission or narcotic contamination with any serious consequence. This fact,
when considered with the compelling science, is why the current standard of care
continues to be ventilations with compressions when arrest is of suspected
I have a question regarding Protocol 29: Traffic/Transportation Incidents, Key Question 5 “Are there any obvious injuries?” What is the purpose behind asking “obvious” injuries as opposed to asking if there any injuries in general?
Because there are often multiple patients, traffic considerations, and safety concerns, Protocol 29 is a scene-oriented protocol. Rather than prioritize by specific injury, the Protocol evaluates potential injuries by looking at the mechanism of injury and other important scene factors. And because the caller is often looking at the entire scene, asking about obvious injuries, or injuries that may be noted at a glance, serves to include any injuries in at least the BRAVO-1 code, once the DELTA-level has been ruled out. When no injuries are reported, or when a 1st-party caller is the only patient, a more detailed assessment may qualify the ALPHA and OMEGA codes.
About the Author:
Brett Patterson is Academics & Standards Associate and Chair of the Medical Council of Standards for the International Academies of Emergency Dispatch (IAED). His role involves protocol standards and evolution, research, training, curriculum, and quality improvement. He is a member of the IAED College of Fellows, Standards Council, Rules Group, and Research Council.