MAKE THE RIGHT CALL
January 5, 2017
By Josh McFadden
In March 2016, every caregiver’s worst nightmare came true for Sonia Melendez. Minutes after leaving a Chicago, Ill., mall, Melendez noticed that her 18-month-old granddaughter, Aureliana Colon, was choking. Melendez immediately pulled her car to the side of road and frantically called 911. However, the grandmother was too hysterical to speak, so she handed the phone to a bystander who had pulled over to lend a hand.
Handling the call
The good Samaritan spoke with a dispatcher and waited on the phone until paramedics arrived. Fortunately, the child survived and was out of the hospital in a few days. Of course, when it comes to a choking call, there are many possible challenges to address. Let’s examine a few turns this call could have taken and how you would handle each scenario.
In Case Entry, the caller reports that the child was sitting in her car seat, choking. The 18-month-old girl had been sucking on her pacifier when the choking began. The caller also states that the girl’s eyes have rolled back into her head and she appears unconscious. She is not breathing or coughing at all. The caller says the grandmother told him the child was choking on some candy.
Steps to follow
Based on the information you have, you know the Determinant Code should be 11-E-1C, COMPLETE obstruction/INEFFECTIVE BREATHING. Axiom 1 on Protocol 11: Choking, helps you make this choice. The Axiom reads, “Victims of COMPLETE airway obstruction are unable to speak, breathe, or cough.” You dispatch the call appropriately and then give Post-Dispatch Instructions: “I’m sending the paramedics to help you now. Stay on the line and I’ll tell you exactly what to do next. Do not slap her on the back.” Having all other necessary information, you must move to the appropriate Pre-Arrival Instructions. Your choice will depend on the patient’s age and whether she is conscious. Because the caller reported the patient is not conscious, you can eliminate the use of Protocol D: Choking (Conscious) – Adult/Child/Infant/Neonate. Also, because you are working with an unconscious 18-month-old, you must use Protocol B: Airway/Arrest/Choking (Unconscious) – Child 1–7 yrs.
This protocol has 18 panels. The panels you cover and the instructions you give are contingent on the answers the caller provides. For example, Panel B-2 has you instruct the caller to “Lay her flat on her back on the floor/ground and remove any pillows” and then to “Kneel next to her and look in the mouth for food or vomit.” You will then ask a critical question: “Is there anything in the mouth?” If the answer is yes, you move to Panel B-13, where you tell the caller how to clear the airway by cleaning out the child’s mouth and nose. At this point, because the baby is obviously not breathing, you’ll go to Panel B-3 without giving instructions; Panel B-3 will then send you to Panel B-5 to begin compressions and then go back to mouth-to-mouth instructions after CPR is administered.
Suppose the only information you have from the third-party caller is that a woman had pulled her car over on the highway because a baby inside was choking.
Steps to follow
After obtaining the location of the caller/patient, you must ask Case Entry Question 3c: “Is she breathing or coughing at all?” If the caller isn’t sure, instruct him to check and find out. If the caller reports that the patient is breathing, you know it is a PARTIAL obstruction. It is essential here to instruct him not to slap the baby on the back, because, as Axiom 2 on Protocol 11: Choking states, “PARTIAL obstruction can be made more life-threatening by attempted intervention in the breathing patient.”
Case Entry Question 4 asks, “How old is she?” In this scenario, let’s say the caller asks the grandmother and reports that the baby is 6 months old. The first two Key Questions to ask here are, “Is she completely alert?” and “Is she breathing normally?” Assuming the answers to these Key Questions are “no” and “yes” respectively, the calltaker would skip Key Question 3 “Is she able to cry?” since it is only asked if the patient is alert and breathing normally and would move on to Key Question 4 “What did she choke on?” If the caller isn’t sure what the baby is choking on, you will select Determinant Code 11-D-2U, Not alert.
Next, give your Post-Dispatch Instructions and appropriate Pre-Arrival Instructions. In this scenario, you would use Protocol D since the baby, although not alert, is conscious.
This time, assume Grandmother Melendez calls in herself. During the Case Entry Questions, you learn that her 2-week-old granddaughter has a complete obstruction and is unconscious. She doesn’t know what the baby is choking on. You know to immediately dispatch a Code 11-E-1U. You have provided Post-Dispatch Instructions and go to Protocol N: Airway/Arrest/Choking (Unconscious) – Newborn/Neonate < 30 days. If you determine from Panel N-2 questioning that there is nothing in the baby’s mouth, how would you handle this situation?
Steps to follow
After determining that nothing is in the baby’s mouth, you would go from Panel N-2 to Panel N-5, giving instructions and moving past Panel N-4. However, if there was something in the baby’s mouth, the correct panel flow would be N-1, N-2, N-13, N-3, and then to N-5. Once in N-5, this panel instructs you to tell the caller, “Listen carefully and I’ll tell you how to do chest compressions. Make sure the baby is flat on its back on the ground. Place 2 fingers on the breastbone, right between the nipples.” Next, move to Panel N-6, where you will tell the grandmother how to give the compressions to her newborn granddaughter. After clearly giving the instructions, ask, “Do you understand me so far?” If the grandmother says that she does not, give clarification and reassurance. If she understood your directions, you would head back to Panel N-4 and instruct her to give the baby five puffs of air. Next, you would go on to Panel N-8 and continue CPR and mouth-to-mouth.
From this point, follow Protocol N until emergency responders have arrived on the scene.
As with other Chief Complaints, when dealing with a choking call, you’ll often be talking to frantic, panicked callers whose loved one is in a life-or-death struggle. Even third-party callers will experience a great deal of stress as you instruct them on how to assist in the emergency. Thus, it’s vital that you provide excellent customer service by reassuring the caller, clarifying instructions, speaking calmly and directly, and behaving in a professional way.
Here are some ways in which you can help callers make it through this difficult situation and provide patients the help they need1:
• Use repetitive persistence.
• Repeat phrases verbatim with a steady tone of voice.
• Say, “Listen to me carefully so we’re sure to do it right.”
• Use the caller’s name if possible.
• Give reassurance by telling the caller that if the patient can talk or cough, the airway is open and enough oxygen should be getting to the brain.
• Use a positive tone.
• Do not alter the wording from the protocols.
• Never use an offensive command.
• Refrain from inappropriate behaviors such as ignoring the caller’s concerns or demeaning, judging, or insulting the caller.
• Don’t use offensive or confrontational language.
It is essential that you maintain control of the call. Callers will look to you to take charge and tell them exactly what to do. Recognize that in moments of extreme stress, some callers may lose control of their emotions and say hurtful things to you. Never take these things personally. Keep your own emotions in check and commit to complete professionalism.
The holiday season brings family and friends together for parties, celebrations, and festivities. Where there are groups assembling for social events, there is often food and drink. While we look forward to these happy times, there’s always the risk of choking. When you picture a full room of people talking and laughing, all while eating their favorite meal or downing their favorite beverage, it’s easy to see why choking is a common hazard.
The American Academy of Pediatrics reports that hot dogs top the list of foods that cause the most choking incidents. One person every five days dies from choking on this popular food. Hot dogs are the leading cause of choking deaths for children 14 and under.2 Carrots, apples, and grapes are good for you, but they are second, third, and fourth, respectively, when it comes to choking hazards. Nuts, peanut butter, marshmallows, gum and hard candy, and popcorn round out the top nine. Other foods to watch out for are chips, cheese, pretzels, raisins, and ice cubes.
Food is hardly the only culprit when it comes to choking. Deflated balloons, batteries, bolts, coins, crayons, jewelry, doll accessories, toys with small parts, small office supplies, and bottle caps are other common sources for choking.
Children are especially susceptible to choking. One reason could be that children have airways one-third the size of an adult’s. Between 2001 and 2009, an average of 12,435 children 14 and younger were treated annually in U.S. emergency rooms for choking problems.3 Another study, this one published in the journal Pediatrics, revealed that 34 children per day are admitted to the ER due to choking issues.4 In Canada, choking and suffocation are blamed for nearly 40 percent of all unintentional deaths among babies under the age of 1.5 In Europe, an estimated 2,000 children 14 and younger choke on a toy each year, and 50,000 children in this age range have some sort of choking episode annually.6
The elderly also are prone to succumbing to choking hazards, largely because of dentures or difficulty swallowng. In 2016, the National Safety Council reported that 4,684 people died from choking in 2013. Of this total, 2,751 were older than 75.7 J
Clawson J, Dernocoeur K, Murray C. Principles of Emergency Dispatch. Fifth Edition. International Academies of Emergency Dispatch; Salt Lake City, Utah. 2014.
Hutton L. “Top 9 Choking Foods.” Family Education. Sandbox Networks, Inc. 2012. http://life.familyeducation.com/slideshow/safety/65468.html (accessed Aug. 8, 2016).
“Recent Statistics on Choking.” Be Smart Don’t Choke. BC Children’s Hospital & Pedagogy Department. 2016. http://dontchoke.ubc.ca/saving-lives/recent-statistics/ (accessed Aug. 8, 2016).
See note 3.
See note 3.
See note 3.
“Choking Prevention and Rescue Tips.” National Safety Council. 2016. http://www.nsc.org/learn/safety-knowledge/Pages/safety-at-home-choking.aspx (accessed Aug. 8, 2016).
What Is Moral Injury?
Causes and effects of moral injury in the dispatch environment
AED Use In Infants
Emphasis should be on ventilations and compressions initially