Flat On Your Back

Becca Barrus

Becca Barrus

CDE Medical

Did you know that the spine supports about half the weight of the human body? Not only that, it’s flexible enough to allow for all kinds of movement and it helps protect vital organs and nerves. It’s got joints and fluid and connects to the ribs, pelvis, and arms. Is it any wonder that when someone’s back is hurting, they feel like the world is ending?

Unlike breaking a bone or losing an eye, back pain is something that 80% of people will experience at some point in their life. In 2021, participating agencies reported 62,338 cases of Back Pain to the International Academies of Emergency Dispatch® (IAED) Data Center, and 69% of those calls were triaged using an ALPA-Level Determinant Code. While not as commonly used as Protocol 26: Sick Person (Specific Diagnosis) or Protocol 17: Falls, back pain can indicate a more severe problem, so paying attention to everything the patient says is crucial. This CDE outlines what types of cases should be handled using Medical Priority Dispatch System (MPDS®) Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma) and which ones are better off using a different protocol.

First of all, you undoubtedly noticed the descriptors in parentheses—Non-Traumatic or Non-Recent. The first two Key Questions make sure you’re on the right track when it comes to cause and time frame: “When did this start/happen?” and then “What caused the back pain?”. If the caller mentions that they’ve had a fall within the last six hours, you’ll shunt over to Protocol 17: Falls. If they mention that they’ve experienced some other trauma within the last six hours (like picking up a heavy box), you’ll shunt over to Protocol 30: Traumatic Injuries (Specific).

On this Protocol, pain is sorted into two categories: traumatic and NON-TRAUMATIC. TRAUMA is defined as “a physical injury or wound caused by an external force through accident or violence.” If the caller states that their back hurts as a result of getting punched in the back or stabbed in the shoulder, you shouldn’t use Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma) at all. You should use Protocol 4: Assault/Sexual Assault/Stun Gun and Protocol 27: Stab/Gunshot/Penetrating Trauma, respectively. Those protocols are more equipped to handle potential scene safety issues and give appropriate PAIs.

As for the “NON-RECENT” part, it lets us know that the time frame of the initial injury matters. The Additional Information section of this Protocol says that a situation qualifies as NON-RECENT if “six hours or more have passed since the incident or injury occurred (without priority symptoms).” If the patient was hit by a slow-moving car a week ago and didn’t have any symptoms until they started having back problems today, the mechanism of injury isn’t as relevant as the pain itself.

Some causes of NON-TRAUMATIC back pain are a dissecting aortic aneurysm, a kidney stone, low back syndrome, pyelonephritis (kidney infection), or vertebral disc disease.

Not “just” back pain

Remember how the spine is in the middle of the body, adjacent to all kinds of organs, nerves, and joints? Sometimes a patient’s back pain isn’t only about the back. The other symptoms the patient is having in addition to back pain can point to problems much bigger than a thrown disc.

Abdominal aortic aneurysm (AAA)

Aneurysms happen when part of a blood vessel balloons out, causing the vessel’s lining to stretch and weaken. The aorta is an artery that runs from the heart through the center of the chest and abdomen and helps supply blood to the rest of the body. Aneurysms are dangerous by themselves, but an abdominal aortic aneurysm can be life-threatening due to the size of the artery and the potential to lose a lot of blood in a short time frame. If the lining stretches to the point that it breaks, the blood it’s carrying will spill out of the artery into the surrounding area, causing potentially lethal problems.

One of the symptoms of an AAA is back pain, often coupled with pain in the belly. It can also be described as a “ripping” or “tearing” sensation. But before you get ahead of yourself and select 5-C-1 “SUSPECTED aortic aneurysm (tearing/ripping pain) ≥ 50” though, there are a few other questions you’ll ask first. If the answer to “Is s/he completely alert (responding appropriately)?” is “no,” you’ll immediately select 5-D-1 “Not alert” because no matter what the official diagnosis ends up being, a not alert patient takes precedent. The same goes for a patient aged 50 years or older who the caller describes as “ashen” or “gray.” When the skin suddenly loses its usual color, that’s a sure sign there’s blood loss somewhere in the body that must be treated quickly with a DELTA-level response.

If the patient is alert, not ashen or gray, over the age of 50, and describes the pain as “ripping” or “tearing,” then you will use 5-C-1 “SUSPECTED aortic aneurysm (tearing/ripping pain) ≥ 50.”

Some patients might be aware of an AAA diagnosis, so if they inform you that that’s the case, you’ll use 5-C-2 “Diagnosed aortic aneurysm.”

ECNS perspective

The Emergency Communication Nurse System™ (ECNS™) handles a subset of the low-acuity ALPHA- and all the OMEGA-level medical calls by getting more information from the caller before sending an ambulance (if at all). Overall, the most frequently used protocols in the ECNS are Falls, Abdominal Pain, Back Pain, and Vomiting. If your center uses ECNS, what happens when you send a low-acuity Back Pain call to an emergency communication nurse (ECN)?

The first thing to note is that there are no OMEGA-level Determinant Codes on Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma) and only two ALPHA-level Determinant Codes. The case can only be passed on to the ECN once you, the EMD, determine that the patient’s complaint is best handled on either 5-A-1 “NON-TRAUMATIC back pain” or 5-A-2 “NON-RECENT (≥ 6hrs) traumatic back pain (without priority symptoms).”

Once the ECN is connected with the patient, they will verify that the problem is best handled on Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma) by letting the patient talk and tell them exactly what happened again. After the patient confirms that the problem is lower back pain and that they don’t have any other priority symptoms, the ECN will first confirm that it is safe to continue with more in-depth questioning by exploring the potential presence of any obvious immediate life-threatening conditions before asking them about allergies, current medications, and medical conditions. After that, the nurse will work through a list of possible conditions (the ECN doesn’t diagnose) from the most life-threatening to the least, only moving on to the next question after excluding the presence of the condition they are questioning the caller on.

If something was missed by the EMD or if something gets worse with the patient while they’re on the phone, ECNs can upgrade them back to dispatch by declaring an emergency. After upgrading the call, they’ll give the details back to dispatch and give the patient PAIs.

If, however, it truly is a case of NON-RECENT or NON-TRAUMATIC back pain, the nurse will give evidence-based interim self-care instructions and/or have them go to an alternate care destination like an urgent care facility or book an appointment with their regular doctor. The interim self-care instructions are there to assist the caller/patient in managing their symptoms until they get treated, and some centers will schedule a follow-up call in a few hours or the next day (depending on the severity) to see how the patient is faring.

Whether the patient ends up having an AAA or a case of sciatica, the way you handle the call will ensure that the caller gets the right care in the right place at the right time.