WHICH PROTOCOL FITS THE EMERGENCY?
December 3, 2014
By Jeff Clawson, M.D.
I am a deployment manager for the Northern Communications Center in Alberta for Alberta Health Services EMS Communications and Deployment. I would like to take a moment of your time to see if you can answer my question or if you can better direct me to another department. We are utilizing the Medical Priority Dispatch System (MPDS) 12.2 with an upgrade to ProQA Paramount this fall. We recently reviewed an event in which a caller had a seizure on the roof of the house and then fell 10 feet to the ground. I am seeking direction on which protocol best handles this situation. This does not happen very often; however, I am certain this question must have a greater frequency with the Academy.
Perhaps this question and answer could be answered and posted on the Academy’s website for others to review and consider as well.
Thank you for your time and assistance with this perplexing situation.
EMS Dispatch, Communications and Deployment
North Communications Center
Alberta Health Services, Alberta, Canada
Thank you for your question, which I am deferring to Brett Patterson, of the Academy’s Academics, Standards, and Research Division and Chair of the Medical Council of Standards.
You are correct regarding this being a rare event, and also that the Academy is often privy to these rare occurrences simply because of the volume of MPDS users worldwide—2,954 and rising. Coincidentally, I responded to a similar question a few days ago where it was reported that a man was struck by lightning and subsequently fell from a rooftop. I tend to remember these cases when I’m thinking that I’m having a bad day!
Your question relates to the Chief Complaint selection Rules on Case Entry, specifically Rule 2 regarding mechanism of injury, and also the built-in fail-safes of the MPDS that safeguard the EMD when multiple Chief Complaints are initially present. Protocol 17: Falls is most appropriate because of the mechanism of injury (LONG FALL), and the potential for serious, underlying injuries. Note that the first question on Protocol 17 relates to the height of the fall, which helps to qualify the potential medical “shunt” to Protocol 31: Unconscious/Fainting (Near), which is qualified by (ground level) when either “Dizziness” or “Fainted/Nearly Fainted” is determined to be the cause of the fall. The rationale is fairly simple, and it applies to your seizure case as well.
Ground level falls are not likely to cause life-threatening injuries from a prehospital standpoint, especially when the patient is alert. If the cause of the ground level fall is medical in nature, the protocol automatically shunts the EMD to Protocol 31 to evaluate the medical cause, which is often more serious than the fall itself. In fact, many of these cases actually turn out to be cardiac arrests, simply because the caller only witnessed the fall, and not the prior loss of consciousness. If the cause of the fall is unknown, the Unconscious/Arrest or Not alert determinant codes on Protocol 17 provide the appropriate fail-safe. However, LONG or EXTREME falls have the potential to cause very serious, or occult (hidden), injuries that may not be recognized by the caller or even the responder, so knowing the mechanism of injury and coding the call appropriately is paramount.
With that said, the Post-Dispatch Instructions (PDIs) from protocols, other than the one chosen for the case, are always available if needed, and this practice is permissible and encouraged in the ED-Q scoring standards. In the case you describe, the EMD should code the call on Protocol 17, provide any applicable PDIs, and then consult the PDIs from Protocol 12: Convulsions/Seizures, if necessary. Note that Protocol 12 has direct links to PAIs should the patient arrest, as does Protocol 17.
I hope this response answers your question. I think your question and this answer would benefit other EMDs. Please do not hesitate to contact me directly if you have any additional protocol questions.
Academics & Standards Associate
Medical Council of Standards Chair