A NEW AGE IN DISPATCH
October 19, 2015
By Audrey Fraizer
There’s never been anything like it.
Medical Priority Dispatch System (MPDS) version 13.0 is the newest wonder of the emergency communications world released initially in the North American English (“the Mother” language) version in the fall of 2015, after years of research, testing, and the resolute persistence of the boards and councils of the International Academies of Emergency Dispatch (IAED) and the patience and hard work of the producers at Priority Dispatch Corp. (PDC). Translations into the other 16 language and dialect systems are in the release cascade process as usual.
“This is a moment for the EMS history books,” said Jeff Clawson, M.D., inventor of the MPDS and principal author of the classic dispatch text “Principles of EMD”—now in its fifth edition. “Version 13 captures the best pre-arrival care available to support and improve our proven standards of excellence in caller, bystander, and responder safety.”
MPDS v13.0 brings several new dimensions to EMD since the original release of MPDS in 1979. Now found in 3,000 communication centers worldwide, the latest and greatest version of MPDS enhances an EMD’s role as an integral and critical component in the patient care chain of survival, and the Academy fills the gaps with regard to both dispatch research and the formulation of standards based on expert consensus and actual user input.
MPDS v13.0 is available in cardset form and PDC’s ProQA Paramount version 5.1, the software engine of the IAED protocols. However, the MPDS cardset has become increasingly problematic to update and navigate in comparison to software.
“The ability to put all things we think are valuable in protocol is difficult in the cardset,” said Brett Patterson, Chair, IAED Medical Council of Standards. “An increasingly sophisticated protocol complicates manual cardset navigation. It is much more intuitive and simply easier to follow in software.”
All the right stuff
New elements to the protocol system include a Fast Track to “hands-on-chest”; clearer definitions, Rules, and Axioms; and additional patient PAIs and PDIs.
Patterson called the “hands-on-chest” Fast Track a “significant” addition to an EMD’s toolkit, and it’s intended for patients who are initially and obviously described as being in cardiac arrest in the Case Entry sequence. A DLS Link from Case Entry to PAIs was introduced in MPDS v12.2, but the new Fast Track feature in v13.0 has already proven to further reduce hands-on-chest time, which translates into lives saved.
Using the Fast Track, the EMD simply types in an “o” (for “obvious”) in the “Tell me exactly …” field to bypass all remaining Case Entry Questions. The Fast Track immediately recommends a 9-ECHO-1 response activated by a single click followed by a question about the availability of an AED. The EMD makes sure the patient is flat on his or her back and begins PAIs for chest compressions.
“This is perhaps the single most important change to v13.0,” said Patterson, who has spent the past year traveling around the country promoting getting hands-on-chest faster. “The latest research clearly illustrates the vital role EMDs have in providing lifesaving PAIs to people calling 9-1-1.”
In addition to changes reducing the time to compressions, MPDS v13.0 also limits the use of the AGONAL BREATHING Detector that, according to extensive case review, was clearly being overused.
“While this diagnostic tool was designed to confirm that reported breathing actually is occurring, all too often EMDs were using it to confirm the absence of breathing, which delays time to hands-on-chest,” Patterson said.
Patterson cautions EMDs to use the detector only to confirm reported breathing that the scenario makes questionable, and not to use it when the caller reports UNCERTAIN or absent breathing.
Dr. Clawson simplifies this point by saying: “Use the AGONAL BREATHING Detector when you are unsure, not when the caller is unsure. If the caller is unsure, that’s the same as uncertain, which equals ‘not breathing.’”
Patterson adds, “EMDs should never hesitate to start compressions when they think the patient may be in cardiac arrest. It’s far better to start compressions on a patient who does not need them than to delay compressions for a patient who does. In most cases, the alive patient will object to the compressions, and EMDs need to know that’s OK.”
Patterson said EMDs should never hesitate to start compressions when the status of the patient’s breathing is questionable. “For every minute of delay, the patient’s chance of survival drops 5–10 percent,” he said.
To aid in the quality improvement aspect of rapid intervention for sudden cardiac arrest, MPDS v13.0 includes real-time feedback by displaying hands-on-chest times for the EMD at the end of every cardiac arrest case.
“We know that EMDs appreciate feedback, and this feature not only provides that, it emphasizes the rapid intervention goal we seek,” Patterson said.
Dr. Clawson adds that while efficient protocol is essential to this effort, a cultural change must take place in communication centers worldwide that encourages erring on the side of the patient and starting CPR as soon as possible.
“The goal needs to be rapid recognition of absent or agonal respirations followed by immediate chest compressions,” Dr. Clawson said. “This basic intervention simply improves survival.”
The Academy relies on its members to get the message across.
“The Academy needs your help,” Patterson said. “We rely on patient care-oriented EMDs to spread the word.”
But that’s just the tip of the proverbial protocol iceberg.
MPDS v13.0 also contains a new option for a “Compressions Only” pathway to provide agencies a choice between the current Compressions 1st pathway and the new Compressions Only pathway. Local Medical Control must authorize the option.
Patterson explained that the choice would most likely fall to local demographics.
“We suspect that rural systems with longer response times may elect to continue with the Compressions 1st pathway to provide ventilations at about 10 minutes and beyond after arrest,” he said. “Urban systems with shorter response times may elect to eliminate ventilations altogether and use the new Compressions Only pathway.”
Take an aspirin
MPDS v13.0 contains new Axioms for use of the Aspirin Diagnostic & Instruction Tool to clarify true aspirin allergy and whether it is advisable to take expired aspirin or a higher aspirin dosage. “The Principles of EMD” includes a section of frequently asked questions (FAQs) that will be expanded in the book’s fifth edition.
The Aspirin Diagnostic & Instruction Tool has generated more questions than the Academy ever anticipated when it was released.
“Nothing has been more controversial in protocol than this,” Dr. Clawson said. “It’s truly amazing the concerns we’ve had about this. It took us by surprise, since the risks are so small and yet the benefits are so great.”
More to come
The work to update the MPDS into version 13.0 was a long process, starting in 2010. The interim release of version 12.2 in September 2012 featured the DLS Link to PAIs and a modified CPR sequence to complement recommendations of the American Heart Association (AHA) for emergency cardiovascular care.
The Academy is so intent on early recognition of breathing status indicating possible cardiac arrest that in addition to these protocol changes in versions 12.2 and 13.0, it has launched a comprehensive program to teach EMDs about prompt recognition of agonal breathing and the importance of prompt and uninterrupted chest compressions. EMD-certified instructors attended several-day courses at both NAVIGATOR 2013 in Salt Lake City and NAVIGATOR 2015 in Las Vegas.
Curriculum materials to complement the version 13.0 release have been in development since the Medical Board of Curriculum met in October 2012, shortly after the release of MPDS v12.2.
Over the past three years, Curriculum & Instructional Design Manager Greg Spencer and his team developed the EMD course manual, EMD certification exams, EMD course PowerPoint presentations, a new Advanced EMD CD, and the Automated Update Guide.
In their world, nothing goes unattended, and Spencer’s group works closely with the Academy’s Medical Board of Curriculum to identify the elements that must be addressed, as well as when they are to be introduced, reinforced, mastered, and extended.
The Academy is also researching protocol outcomes between the new and past version in accredited communication centers to measure the effect of these changes and incorporate the results to further improvement efforts.
Don’t expect the process to come to any sort of standstill. This is a system that relies on internal and external research, technology, expert advice, and—perhaps most importantly—the hundreds of Proposals for Change submitted by the international community of MPDS users.
“Every time we complete a version that we think is perfect, someone finds something else,” Patterson said. “It’s wonderful to have so many people looking at the unified protocol so closely, in so many centers and so many countries.”
Watch the Fast Track process at http://www.prioritydispatch.net/hands-on-chest-case-mpds-v13.
Other major enhancements to MPDS include:
• The instructions for taking a pulse have been revised based on published Academy research. Changes include directing the caller to use two fingers, taking appropriate time to detect the pulse, notifying the EMD when s/he has detected it, and counting beats out loud.
• A new Protocol P: Epinephrine (Adrenaline) Auto-Injector Instructions has been added for patients experiencing an extreme allergic reaction or anaphylactic shock. These instructions include positioning the patient, removing the packaging, and using the epinephrine (adrenaline) injector.
• Two new ECHO-level Determinant Codes have been added to Protocol 14: Drowning/Near Drowning/Diving/SCUBA Accident to address drowning victims either currently underwater or just out of the water and in cardiac arrest. In conjunction with these additions, a new Protocol K: Person in Water has been added, which provides instructions for ice rescue, person in water, swift water, and floodwater incidents.
• Protocol 8: Carbon Monoxide/Inhalation/HAZMAT/CBRN and Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt now include an Additional Information section on Chemical Suicide. Additionally, new Case Exit Panels X-7a and X-7b have been added to instruct callers and bystanders to avoid (further) contamination at the scene of a chemical suicide.
• Protocol 18: Headache has been modified to address the possibility of stroke or other serious brain conditions. The Stroke Diagnostic Tool has been added to this Protocol.
• Protocols Q: Narcan/Naloxone Nasal Administration Instructions (Panels 1–5) and R: Naloxone Auto-Injector (Evzio) Instructions (Panels 1–4) have been added for patients in need of an antidote for narcotic drug overdose, when available. The EMD will select either Protocol Q or Protocol R depending on the medication device available (nasal spray or auto-injector, respectively). These instructions include preparing the delivery device, administering or injecting the medication, and monitoring the patient to ensure recovery.
• Protocol 24: Pregnancy/Childbirth/Miscarriage has been modified to redefine the range of months/weeks for the 2nd and 3rd TRIMESTERS and the MISCARRIAGE and premature birth definitions. New Rules and Axioms, a DLS Link to F-25, and a specific PAI pathway have been added for patients with cervical cerclage (stitch). The DLS Link for MISCARRIAGE has also been redirected to a new Protocol G: Miscarriage (Panels 1–9). Instructions on Protocol F have also been modified throughout to improve patient care.
• The Sinking Vehicle (1st Party) Protocol has been renamed Protocol L: Vehicle in Water as it now includes additional instructions for a vehicle in floodwater. In addition, the sinking vehicle instructions have been extensively revised to suggest further alternatives for escape and to address other factors such as children in the vehicle.