October 2, 2020
With my understanding of the Medical Priority Dispatch System™ (MPDS®), the medical concern takes precedence. The following scenario was highly debated amongst our team, and I would like to get an expert's opinion of the right process to follow.
Scenario: Geriatric patient in a skilled nursing facility experienced a ground-level fall and hit their head; the patient is awake but not verbally responding after the fall.
Case Entry Rule 2 states to “choose the Chief Complaint Protocol that best addresses the mechanism of injury.”
Case Entry Rule 5 states “If the complaint description appears to be MEDICAL in nature, choose the Chief Complaint Protocol that best fits the patient’s foremost symptom, with priority symptoms taking precedence.”
The debate we are having is whether to use a trauma protocol or a medical protocol.
The Falls Protocol (MPDS Protocol 17) makes sense since the patient fell and hit their head, but there is now a priority symptom, with the patient being altered.
The patient may have potentially had a CVA (cerebrovascular accident) and fallen. Due to that reason, I would argue that the Stroke Diagnostic Tool would better help evaluate the scenario and give the responding crew better information.
Thank you for your time.
Sacramento, California (USA)
Great question, Ivan.
You have described a classic “chicken or the egg” dilemma, which is often dependent on the actual Chief Complaint description. This dilemma is particularly important when dealing with a fall resulting in cardiac arrest because even a few moments delay in CPR may adversely affect the patient’s outcome. However, in this scenario, we have a bit more time to actually address both possibilities.
If the Chief Complaint is fall, use Protocol 17 to address the mechanism of injury and any subsequent injuries; the Not alert DELTA driver adequately addresses the response. If stroke is suspected as the cause of the fall, it is quite prudent to use the Stroke Diagnostic Tool and report the results to the responders.
Your mention of the potential medical cause is well noted and appreciated; we need more of this! If the Chief Complaint description is highly suggestive of cardiac arrest, stroke, diabetic problem, etc., and the subsequent fall is known to be ground level, I always encourage EMDs to go with the cause and then use the Target Tool to address any injuries. In most cases, injuries from a ground-level fall are not as serious as the underlying cause, especially when dealing with cardiac arrest.
We know that there is a high incidence of cardiac arrest in the 17-D-3 (Unconscious) code, so it is prudent to take the cardiac arrest pathway when the scenario strongly suggests sudden collapse resulting in unconsciousness, even if the caller is reporting only the fall they have witnessed. I have attached a couple of related articles that may be of interest and education.
EMD is a very dynamic and diverse environment making black-and-white answers to Chief Complaint selection questions challenging, but this is really for the best. If our world was governed by strict rules that do not allow for thoughtfulness and experience, we could simply automate our role— “Press 1 if you’re choking.”
Editor’s Note: Brett discusses Chief Complaint selection in an article published in the Journal of Emergency Dispatch. Click https://iaedjournal.org/art-and-science
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
A question was raised recently on which protocol to use for an injury from a pellet/BB gun. Would it be shooting or the assault card?
Quality Assurance Coordinator
Orlando Fire Department
Orlando, Florida (USA)
Coincidentally, this topic was recently debated on the True 2 Q Facebook page, and the answer I’m about to give you is not as simple as I prefer.
First of all, we need to know “exactly what happened.” Namely, was the shooting accidental or intentional? This is because I’m going to throw two more Protocols in the mix, Protocol 30: Traumatic Injuries (Specific) and Protocol 16: Eye Problems/Injuries, either of which might be appropriate if accidental and superficial.
Protocol 27: Stab/Gunshot/Penetrating Trauma was designed for penetrating injuries as its title suggests. It can be used if accidental or intentional, or if the injury is penetrating or if unknown if penetrating. However, many times BB gun injuries are reported as accidental and superficial, in which case P30 or P16 may be appropriate. If intentional and superficial, P04 (Assault/Sexual Assault/Stun Gun) is appropriate.
As always, err on the side of safety and worst-case scenario when circumstances are unknown, i.e., assume intentional unless accidental is known and assume penetrating unless superficial is known and offered. This information is best obtained by getting a clear and complete answer to “Okay, tell me exactly what happened?"
My agency is trying to prepare training for MPDS 13.3, and we came across the new rule and need some clarification and possibly a good example for when this would come up. Is this new rule stating that when a patient is considered not alert by the caller (not necessarily the patient) but there is information that patient is responding somehow, awake, and talking in some fashion that the calltaker should use the Aspirin Diagnostic Tool? Any example, additional information, etc., that you could provide would be appreciated.
Regional Communications Duty Officer
Quality Improvement Unit
Training and Development Division
Broward Sheriff's Office
Fort Lauderdale, Florida (USA)
You are likely aware that we have significant over-triage in the "Not alert” Determinant Codes in the MPDS. This is likely due to the lay public’s lack of understanding the term in its clinical sense, i.e., poor perfusion. Anyway, this Rule change is the result of user requests following incidents where aspirin was not given to patients because of the alert criteria in the Critical EMD/EFD/EPD Information (CEI) when, in fact, it was obvious to the EMD the patient could safely take an aspirin, i.e., patient is awake, talking, responding, and quite obviously maintaining her/his airway.
You may recall that in earlier versions of the MPDS we had an "INEFFECTIVE BREATHING and Not alert" DLS link criteria to PAIs. This meant that anytime a caller used a term that qualified a patient for INEFFECTIVE BREATHING, and the patient was reported to be not alert, the Protocol directed the EMD to PAIs where the caller would then be directed to lay the patient down. This became problematic because many of these patients were not only conscious, they were having respiratory distress and did not take kindly to being laid down. The link is now limited to unconscious patients.
The point is that while some not alert patients should not have anything by mouth because of the risk of aspiration, other patients, who are clearly maintaining their own airway (awake, talking, and responding), will not be compromised by chewing a single aspirin, and that therapy may prove to be very beneficial.
As for the practicality of this Rule, if a patient is reported to be not alert and we only know the patient is conscious, do not advise aspirin. However, if it is clear from the call the patient is awake, talking, and responding, and the patient otherwise meets the aspirin criteria, advise its administration.
Brett Patterson is Academics & Standards Associate and Chair of the Medical Council of Standards for the IAED. His role involves protocol standards and evolution, research, training, curriculum, and quality improvement. Prior to working with the IAED, he spent 10 years working in the Pinellas County EMS System, Florida. He answers members' protocol questions in the Journal FAQ column.