RARE ENCOUNTERS OF THE PROTOCOL KIND
March 19, 2015
By Audrey Fraizer
Protocol is built on probability.
No system, no matter how robust, can cover every possibility, and that’s why the protocol systems are so dependent on user feedback, statistical evidence, experience, and trending to provide the best immediate chain of questioning and instruction for incidents more likely to happen and the array of possibilities within an incident type.
At least that’s until a call potentially provides an exception to the rule, illuminating an occasion by the very event to modify a specific protocol or set of Pre-Arrival or Post-Dispatch Instructions (PAIs/PDIs).
For example, the caller could be describing an unusual clinical presentation that does not have a reciprocal Determinant Descriptor in the Medical Priority Dispatch System (MPDS).
“We change the protocols when it’s possible the same can happen again,” said Brett Patterson, IAED Academics and Standards Associate and Medical Council of Standards Chair. “We don’t want our EMDs caught off guard. We want something in protocol that backs them up in even the most unusual situations.”
Patterson and IAED Co-Founder Jeff Clawson, M.D., discussed “Rare EMD Encounters” during their co-hosted NAVIGATOR 2014 presentation. The session gave insight into rare dispatcher situations, including specific clinical diagnoses; advanced, portable medical equipment; dangerous scenes; and unusual patient presentations to MPDS use.
But not only was the full house treated to their perspective but, also, to present and future changes in protocol based on the unique events.
The first call Patterson played as an example resulted in a new BRAVO Determinant Descriptor in Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt. The caller was reporting that his wife had hanged herself in the family barn. Screaming in the background nearly obscures the caller’s voice.
“Who’s making all the noise?” the EMD asked.
“My wife,” replied the caller. “She’s not hanging anymore. She’s yelling and foaming at the mouth.”
She is also begging her husband to breathe for her, through her mouth.
The caller’s answer and the plea to help in breathing caught the EMD off guard since the wife’s status—alert but difficulty breathing—did not fit an existing Determinant Descriptor in Protocol 25.
“We hadn’t had that type of patient,” Patterson said. “It was not the norm. She had crushed her windpipe, which resulted in the respiratory distress. She was alert.”
Patterson said the unusual situation and clinical presentation met the “could happen again” criteria and, consequently, a Proposal for Change was approved by the Medical Council of Standards. The new Determinant Descriptor will be added to a future version of the MPDS.
A second call opened to the sound of a rapid-firing gun and terrified screams, with a frantic caller reporting an unknown shooter opening fire at a shopping mall.
“There is blood and glass everywhere!” she cried.
Although shaken, the caller was able to answer questions and follow safety instructions despite her inability to leave her hiding place.
It was an incident that, as Patterson said, “will probably never happen in your life,” but it did hasten development of the Academy’s Active Assailant (Shooter) Protocol in the Police Priority Dispatch System (PPDS).
Dr. Clawson explained that Protocol 136 came about in response to several similar incidents.
“The Police Council of Standards jumped on the idea and developed the protocol in cooperation with the NTOA [National Tactical Officers Association],” he said. “While we might not be able to stop this type of incident from happening, we can help in stopping further death and mayhem when it does happen.”
Protocol 136 was released shortly after the Sandy Hook incident and made available to all emergency communication centers, not just PPDS users. It provides responding law enforcement officers with immediate notification of the event, followed quickly by critical scene safety information. PAIs give callers Evacuation or Lock Down Instructions based on their ability to leave the area undetected by an assailant and the protocol aids in gathering information pertaining to the assailant’s actions.
A third call that Patterson played resulted in the development of an Axiom in MPDS Protocol 9: Cardiac or Respiratory Arrest/Death, and led to further discussion of related changes in the upcoming release of MPDS v13.0.
In this incident, a 16-year-old boy had collapsed in the school gym during a volleyball game. The boy [Brock] was unconscious and unresponsive to pain, but his age in relation to potential cardiac arrest caught the dispatcher off guard.
She did not initially grasp that his “gasping breaths every five seconds” was an AGONAL (dying) respiratory pattern. She chose Protocol 26: Sick Person and valuable minutes into the call asked about the availability of an AED.
“She had used the AGONAL Breathing Detection tool, and he had stopped breathing,” Patterson said.
The AED was retrieved but never used. A school nurse provided CPR. The boy did not recover.
“This was a tragic case,” Patterson said. “Unnecessary use of the tool delayed the treatment of a possible cardiac arrest. EMDs should use the tool when they are unsure, not when the caller is unsure.”
Since breathing may be difficult for callers to determine in unconscious patients, the Academy added several descriptions that qualify as INEFFECTIVE BREATHING on Case Entry for clear recognition. A new definition for UNCERTAIN BREATHING was also added to MPDS v13.0: “A situation where a 2ndparty caller is uncertain, unsure, indefinite, or ambiguous when asked if an unconscious patient is breathing.”
If a 2nd party caller (who can actually observe the patient) is uncertain whether the patient is actually breathing, the calltaker should consider the patient to be NOT BREATHING until proven otherwise.
Brock’s Law was developed in reference to the AED that was available but not used: The presence of an AED does not ensure its use; an EMD does.
Patterson said this type of situation emphasizes the need for greater awareness.
“We are responsible for the tools that can help,” he said.
Circulatory support devices
Patterson also discussed a new Axiom in Protocol 9 relating to externally worn circulatory support devices.
Physicians prescribe the devices (e.g., LifeVest Wearable Defibrillator) to patients following a sudden cardiac arrest. The devices monitor the patient’s heart and, if a life-threatening heart rhythm is detected, the devices can deliver a shock to restore normal heart rhythm.
While circulatory support devices are not new, the portable varieties are relatively recent additions to the market, potentially placing EMDs in unfamiliar territory.
“The EMD needs to know about the option [type the patient is using],” Patterson said. “If the device is attached to the heart by catheter, compressions could tear the muscle and cause hemorrhage. The wearable defibrillators provide loud audible warnings. They require no bystander intervention.”
In response, the Academy added Axiom 5 to MPDS v12.2, addressing the external defibrillators in context to providing CPR.
“The standard of care is CPR,” Patterson said.
According to the Axiom: It’s appropriate when advised by the machine or when no warning is audible.
Available to a larger audience
The Continuing Dispatch Education (CDE) series offers Rare EMD Encounters (CDE 57).
More information is available at www.prioritydispatch.net