Nightmare On EMD Street
May 13, 2020
I hope you are doing well! During the month of October, we sent daily Halloween-themed EMD questions to everyone as part of our “Nightmare on EMD Street” game. The winner from each agency got a Halloween bucket full of yummy candy and spooky prizes! We had one question in particular that stumped a lot of people, and they were wanting to understand the why behind it.
The question was, “A male has been electrocuted while doing electrical work in an abandoned home. He isn’t breathing. Which CPR pathway do you take—Ventilations 1st or Compressions 1st?” Many EMDs got this incorrect, thinking that they should take Ventilations 1st as they are more familiar with the lightning strike being Ventilations 1st and therefore associating it with electrocution as well. So, the question is … why do we go Compressions 1st for electrocution and Ventilations 1st for lightning strike?
We would appreciate any help or resources that you can provide!
Valarie Turner, ENP
Larimer Emergency Telephone Authority
Loveland, Colorado (USA)
The answer has to do with the “Lightning Strike Arrest Theory” explained in the Additional Information section of P15. While an electrocution arrest is usually sudden and lasting, lightning strike tends to stop the heart initially, but the undamaged cardiac muscle restarts, only to arrest again because of the long-lasting respiratory arrest. In essence, it's thought that cause of the cardiac arrest is actually respiratory in nature, therefore we use the V-1st pathway.
It’s really a best guess scenario as the issue is difficult to study/replicate and, even if we could, such trials would be unethical in humans. I’m certainly not volunteering!
Hope that helps.
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
I had an employee on a call with a 2nd party caller reporting a 37-year-old female with chest pains. Nowhere on the chest pains card does it ask if she is pregnant; yet, she is of child-bearing age. Critical EMD Information says not to give the person an aspirin if they are pregnant; yet, how would you know unless you ask a freelance question? If someone can answer or give me some direction, I would appreciate it—thank you!
911 Communication Center Manager
Billings 911 Communications Center
Billings, Montana (USA)
The simple answer is the clinicians on the Standards Council didn’t think we needed to ask the question, so we didn’t include it in the protocol.
As you may remember, pregnancy was not a contraindication to the dispatch administration of aspirin until recently. It’s not that we didn’t know aspirin could be problematic during pregnancy—we did. But we also knew that gestational window for potential aspirin-related complications is very small, and the odds of a single dose being problematic is extremely low. If fact, the only reason this came up for debate again was because callers were offering that the patient was pregnant and that their doctor had told them not to take aspirin (although not specifically referring to a single dose in the presence of heart attack symptoms).
So why do we now include pregnancy as a contraindication? Although the risk of complications is extremely low with a single dose, the risk of actual heart attack in this age range is also quite low, and the emergency physicians we consulted with typically said that because the infarction risk was low, they would likely withhold aspirin until more definitive diagnostics were available, or until advised by a cardiologist.
So, rather than ask a question about pregnancy for every female in cardiac age range with heart attack symptoms, we decided not to ask the question and only stop the aspirin instructions if the caller offered that the patient was pregnant. In essence, the low probability that the caller will offer that the patient is pregnant, coupled with the extremely low odds of complications from a single dose, justified not including a question that would most often be answered no or be already obvious when yes.
So … this question came up in EMD class about the Heimlich (Protocol D: Choking (Conscious) – Adult/Child/Infant/Neonate), and I didn’t have an answer for it (nor did I see anything in the Principles book). Our instructions say (Panel 5 in the cardset), “In one quick motion, jerk hard, up and into the stomach,” but the training I (as well as the Canadians I’m teaching this week) have been through taught it should be “inward and upward”—to get under the diaphragm before pushing upward. Can you share why the instructions are in the opposite order?
Priority Dispatch Corp.™
The instruction states to do this in one quick motion; it's not a two-step process.
I suppose the order could be changed, but I have not heard of any difficulties understanding the instruction, and I wouldn’t want to create any.
"… hard, into and up into the stomach” doesn’t sound right and seems a bit more complex.
“… hard, inward and upward into the stomach” seems problematic as well.
I say don’t fix it if it ain’t broke, but if there is a demonstrable problem, we could have the research team do some testing with lay folks and see how it is being interpreted.
I’ve been going back and forth since you sent this. At first, I agreed: Don’t fix what’s not broken …
But do we really know it’s not broken?
Much of what is in the MPDS® is expert consensus-based because when it was originally designed, there was no such thing as evidenced-based dispatch research. All we had in the beginning were problems that needed solving, limited experience, and a motivated and passionate medical director in Salt Lake City (Utah, USA) that was soon to become an inventor. As the protocol evolved, more and more people used it, and user feedback became an important part of that evolution. Both remain important inputs today.
More recently we have developed specific ways to study the protocol, and we have an entire research team devoted to just that. In addition, other organizations are conducting, publishing, and evaluating dispatch-specific research, giving us more tools for protocol evolution based on science.
The instruction we are referring to has been used ever since I can remember, and I started using the MPDS over 30 years ago. So while I don’t know of any science behind the format of the instruction, its application in likely tens of thousands of cases over so many years without any related problems reported does give us some degree of confidence.
The answer to your question is no, we really don’t know, with scientific certainty, that it’s not broken. However, the confidence level is high because of its impressive track record. With that said, science is all about asking questions and testing theories. The overall question then becomes what do we devote our scientific resources to?
I appreciate the insight—one of the reasons I love working with the Academy is how we continue to evolve over time.