February 8, 2016
By Brett Patterson
The following question was submitted anonymously:
A calltaker received a call for a male that fell less than 10 feet (from a tractor). He was unconscious, on his side, and was breathing but ineffectively. The calltaker selected Protocol 31 for Unconscious, but opted not to use Protocol C instructions because the calltaker was concerned about patient movement with a questionable neck injury. So, the calltaker instead stayed on the line and monitored without moving the patient.My thought was Protocol 17 first for the best mechanism, which was a fall. More importantly, while I understand the calltaker’s thinking, I’m more inclined to think airway management is more key with regard to instructions. Now the sticky point is the patient was breathing, albeit ineffectively. It’s interesting because staff members in our communication center are either EMTs or paramedics, so sometimes we tend to overthink these things as street providers. This particular calltaker works regularly on the street, which was why the calltaker was thinking don’t further damage a possible spinal injury. I asked the calltaker the response if arriving on this scene as the first EMT. The calltaker said that if the patient wasn’t breathing, the EMT would immediately move him, but in the given situation the EMT would have stabilized the patient before moving.
There are several issues here, some of which you have mentioned, i.e., protocol selection and suspicion of spinal injury. However, if the patient had INEFFECTIVE BREATHING (a defined term in the MPDS), these other points are actually moot because ProQA will recommend immediate PAIs regardless of whether the EMD chooses Fall or Unconscious/Fainting.
Let’s talk about protocol selection first.
We know that the Not Alert and Unconscious Determinant Descriptors in the Falls Protocol contain a relatively high number of cardiac arrest outcomes. In the case of ground level or falls under 10 feet, we know that this is because these cases (unconscious or not alert) nearly always have a medical etiology; the caller simply noted the fall and not the preceding medical event (classic “chicken or the egg first” question). A related Rule on the Falls Protocol states: “Always consider that the patient's fall may be the result of a medical problem (fainting, heart arrhythmia, stroke, etc.).”
The likelihood of serious traumatic injury from a short fall is low, while the probability of a more serious, underlying medical cause is high when medical signs and symptoms are present. However, as you point out, the mechanism of injury is important here, so LONG or EXTREME falls are obviously the exception. This case smells very much like a medical case, and I would have gone with “Suspected MEDICAL Arrest” at Case Entry, or 31-E-1, as either would lead to PAIs. Do you know the patient’s outcome? You said that the EMD selected Protocol 31 and the patient had INEFFECTIVE BREATHING, which should have linked from P31 KQ1 directly to PDIs and then ABC-1. However, the EMD elected to link to Panel X-3 and monitor the patient due to concerns about spinal injury, which is not an option for INEFFECTIVE BREATHING on P31, or anywhere else in the protocol.
Rule 3 on the Falls Protocol (which is repeated on other TRAUMA protocols), states: “The head-tilt is the only recognized method of airway control in the PAI dispatch environment. When presented with a TRAUMA patient described as not alert with INEFFECTIVE BREATHING, the EMD should protect life over limb and open the airway.” Exacerbation of a spinal injury after the insult is rare and, when it does happen, it is usually the result of rotation or flexion of the neck rather than extension. With this and the far more concerning INEFFECTIVE BREATHING in mind, the protocol directs us to PAIs to protect life over limb.
The responder that took the call stated that, in the field, she would have addressed the airway immediately, but only after stabilizing him. The latter is not advised as a coordinated instruction in the MPDS for two reasons. First, a “log roll” is very difficult to instruct effectively in the non-visual realm of DLS, even if multiple rescuers are present. I actually reviewed a recording of a paramedic/EMD attempting to do this for a little girl that was hit by a car and was gurgling, face down, in the street. The caller was even a police officer and the attempt was, at best, a cluster of misguided misunderstanding. This leads to the second and perhaps most important reason for not doing this at dispatch; it takes too long when the patient is not breathing effectively. We know, especially in cases of cardiac arrest, that the patient’s chances of survival decrease exponentially with every second lost without intervention, which makes this instruction very risky, as opposed to the relatively low risk of exacerbating a spinal cord injury.
So, in summary, I think the EMD was wise and prudent in selecting the MEDICAL protocol, and I’ll bet this man didn’t simply fall off his tractor but rather had a preceding medical event. However, the decision not to follow protocol at that point and provide PAIs, as the DLS Link directs, was inappropriate, for the reasons mentioned above. As you know, the protocol does provide for monitoring only when the victim of trauma is unconscious with effective breathing, but it links to PAIs when unconsciousness is associated with INEFFECTIVE BREATHING.