Help! There's Not A Protocol For This!

Becca Barrus

Becca Barrus

CDE Medical

*To take the corresponding CDE quiz, visit the College of Emergency Dispatch.*

Although the Medical Priority Dispatch System™ (MPDS®) covers a large number of medical emergencies, there’s simply no way it can cover every single possible scenario. The Protocols are built on the binary of “yes” and “no” questions in order to keep emergency response calls as concise as possible to get the patient the right help in the right place at the right time. But life isn’t concise, and humans (and their imaginations) are so varied that conditions and situations have to be put into as broad of categories as possible.

For the most part, the calls you take as an Emergency Medical Dispatcher (EMD) will fall under one of the MPDS Chief Complaints. But life being what it is, you will also undoubtedly take at least a handful of calls that don’t fall neatly into one Chief Complaint or another. What happens if someone calls reporting multiple overdose arrests? Multiple births? What if your caller has been the victim of an acid attack?

“These . . . situations that are difficult if not impossible to ‘protocolize’ [are] where talented and experienced EMDs empathize, improvise, and shine,” wrote Brett Patterson, the IAED’s Academics, Research, and Standards Associate and Chair of the Medical Council of Standards. “Protocols are based on probabilities, and not everything is reasonably probable. For that reason, EMDs need to be familiar with the Protocol’s goals and objectives.”

How can you best handle unusual or challenging emergency medical calls while still being compliant with the Protocol?

The basics

The MPDS is specific to pre-arrival emergency needs. Often when doctors, nurses, and other field providers take MPDS courses, they lose sight of that fact and can get stuck trying to give the patient care over the phone that they would typically give in a hospital or on scene as a paramedic. That is not the role of an Emergency Dispatcher! Your role is to pass on relevant information to the responders and provide instructions that will keep the patient safe and stable until those responders arrive.

For most unusual calls, asking the caller to tell you again exactly what happened can help you get a better mental picture of the situation and help you focus on the symptom that’s worrying the caller or patient the most. They’re called “priority symptoms” for a reason! Abnormal breathing, unconsciousness, chest pain, and serious hemorrhages always take precedence. If it’s due to TRAUMA, pick the Chief Complaint that best addresses the mechanism of injury. How did it happen? Are there scene safety issues to take into consideration?

Take acid attacks, for instance. There isn’t an MPDS Chief Complaint regarding acid attacks specifically. If a patient reports accidentally burning themselves with cleaning chemicals, you will respond differently than if they report that someone threw a corrosive fluid at them. Even if it’s the exact same substance and you end up giving the exact same Pre-Arrival Instructions (PAIs), you will treat the second example as an assault because of the mechanism of injury.

Words matter

Aside from reassuring them that help is on the way, there’s no script for what to say to comfort someone because it’s individually tailored to each experience. Sometimes the perfect thing to say to a caller comes through instinct. Sometimes it comes through experience. Sometimes it comes from a combination of the two. What if nothing comes to mind in the moment? You can never say “Someone is coming; help is on the way” too many times.

If all else fails, ask for help! Even if you don’t feel like you have the expertise or knowledge necessary to improvise the best help for the patient, someone else on the floor will. 

“If something is out of the ordinary, our EMDs know to raise it with the team leader,” said Laura Hayes, Education Developer for East Midlands Ambulance Service (EMAS) NHS Trust in Nottingham, England. “We also have a team of clinicians, including midwives and a doctor, on hand to take over the call. They can give clinical advice.”

Again, the midwives and doctors in your center have a different role than you do, and they are a great resource to utilize when a call is especially baffling.

Real-life examples

“Entrapment is a very rare call,” said Adele Litchfield, Education Developer for EMAS. “We once got a call from somebody who’d been trapped underneath a load of gravel poured on them by a lorry. Picking the Sub-Chief Complaint was difficult because it wasn’t quite a collapsed building, but it wasn’t a confined space either. The EMD taking the call went with ‘inaccessible terrain situation,’ and our team of auditors supported them.”

The calltaker identified the patient’s most critical issue—being trapped underneath gravel—and went from there. If the patient didn’t get help as soon as possible, he was at risk of suffocating due to the weight of the materials on top of him. Thus, a DELTA-level Determinant Code was chosen, and the EMD was praised for quick thinking.

Another example from EMAS is a call about a patient in labor in a birthing pool. Since the MPDS doesn’t have instructions for water births, Stephanie Pett, Education Director with EMAS, advised the patient to get out of the pool and onto the center of a bed or on the floor.

“The caller made it clear that the patient refused to get out of the birthing pool, so I reiterated to them that I don’t have any instructions to navigate a water birth,” Pett said. “Because of this, I then remained on the line and continually monitored the patient and updated my CAD notes accordingly until the crew arrived.” 

A more common example is callers who can’t, for whatever reason, get a patient onto the floor to perform CPR. Craig Sturgess, an emergency dispatcher for the Welsh Ambulance Services NHS Trust (Wales), handled just such a call. The patient’s wife called 999 when she found her husband collapsed in the bathroom, wedged between the toilet and tub. He was not conscious, and whether he was breathing was unclear.

The MPDS called for Sturgess to instruct the woman to get the patient on his back in order to start CPR. When she said she couldn’t get her husband on his back, Sturgess instructed her to go find someone to help—a neighbor, a passerby, anyone. The woman was hesitant to leave her husband, but Sturgess reassured her with an unscripted but touching gesture. 

“Leave the phone next to him by his head so I can speak to him,” he said.

Once the patient’s wife was gone, Sturgess talked to and reassured him, despite the patient’s unconscious state. He said things like, “Sir, if you can hear me, we are coming as quickly as we can for you, okay?” and “Your wife is coming back,” until a couple of neighbors arrived to help.

Although the patient did die, Sturgess was able to move forward knowing that he had done all he could do to help.

In all of these scenarios, the EMDs followed the MPDS to the letter, and then enhanced the spirit of the Protocols by remaining on the line to keep first responders up-to-date on the patients’ conditions and provide reassurance to the caller. As Patterson pointed out, the role of the EMD is to provide pre-arrival care, and sometimes that care is as simple and human as being a comforting voice on the other end of the line.

You don’t have to be a perfect EMD to be an effective one. You don’t have to run the entire communication center by yourself. Learn as much as you can and ask questions when you need to. Like Patterson said, this is your time to shine! Follow the principles and you can’t go wrong.