WHEN SECONDS DO COUNT
January 23, 2015
By Audrey Fraizer
A home health aide answering the 9-1-1 callback realized her patient was in danger, but not to the degree that soon became apparent.
“She wasn’t certain about the patient’s breathing; it was questionable,” said Anthony Guido, EMT, EMD-Q, quality improvement coordinator at North Shore-LIJ Health System in Syosset, N.Y. “The EMD immediately went to the ECHO response.”
The ECHO-Level Determinant in the protocol systems signals an obviously life-threatening situation that demands instant response. Another unofficial way of describing it is that these are people that are “dying right now.”
In a medical emergency, the ECHO code is used when the caller volunteers indicators of ineffective breathing at any point during Case Entry. For example, the caller might tell the EMD that the patient is “barely breathing, fighting for air, or making funny [respiratory] noises (a sign of AGONAL breathing).”
The code accelerates the response of North Shore-LIJ Health System EMS.
“It becomes a very quick, calculated assignment,” Guido said. “The caller has confirmed the patient is not breathing or barely breathing. Everything and everyone goes into motion.”
Guido’s agency always sends a minimum of two units to an ECHO call—the two available medical resources that are closest to the scene and often coming from two directions to deflect time barriers resulting from traffic and other obstacles. In the meantime, the EMD begins immediate bystander instructions for chest compressions.
An EMS supervisor who was in the area when the ECHO was dispatched was on-scene in two minutes, 14 seconds, with paramedics arriving moments later. The bystander, who had started chest compressions, turned over care. The patient was transported within 14 minutes of the call.
Guido said the North Shore-LIJ Health System communication center sends response to about 850 medical calls each month, of which at least six are coded ECHO. Most of the ECHO-level responses involving cardiac arrest originate from skilled nursing facilities; some are callbacks to numbers provided through home medical alert systems, as was the case in the call profiled at the beginning of the article.
Guido said ECHO requires situational awareness; it is a low-frequency, high-risk operation that EMDs must be able to pick up on fairly quickly into the call.
“We train on the ineffective breathing status and drive home the reasons for using the ECHO code,” he said. “It’s like a NASCAR race. Using ECHO to shave 10 seconds is huge. The patient is going downhill fast and requires immediate medical attention.”
Best thing to happen
The ECHO-Level Determinant was “one of the most exciting” changes to the Medical Priority Dispatch System (MPDS) when introduced in v11.0, according to Brett Patterson, IAED™ Academics & Standards Associate and Medical Council of Standards Chair.
“ECHO-level dispatch is sent directly from Case Entry, and that provides the EMD with the means to dispatch earlier in the interrogation sequence,” Patterson said. “It is used when certain life-threatening conditions are clearly evident.”
The determinant gave dispatchers a code to use in situations when a non-standard responder could reasonably make a difference in the outcome of a dying patient. It provides agencies with the means to assign response-capable units that would not normally respond to typical EMS calls (i.e., AED-equipped police and fire vehicles, HAZMAT, snorkel, and ladder crews). ECHO-initiated crews must be, at a minimum, BLS trained and understand scene safety entry procedures.
For example, a non-standard responder trained in CPR and arriving at the scene within minutes of a call could make a difference for a patient in imminent arrest. In certain cardiac arrest situations, the prompt application of a defibrillator, or AED, can save a dying patient’s life. While in most cases CPR itself doesn’t reverse the patient’s cardiac arrest, it does prolong the window of viability needed for a successful defibrillation. To use an old farmer’s term, it’s like “priming the pump.”
The ECHO-Level Determinant exists only in Chief Complaints that also have DELTA codes, although not every protocol with a DELTA code has the corresponding ECHO-Level Determinant, and not all arrests are ECHOs. MPDS Chief Complaints with ECHO codes are 2, 6, 7, 9, 11, 14, 15, and 31.
Although the Academy designates the Chief Complaints that include the ECHO-Level Determinant, it’s up to the individual agency to determine exactly what response configuration is appropriate for each ECHO type.
The response process provides flexibility, Patterson explained.
“Agencies can make sure that the most appropriate and closest resources are being sent in the most effective way possible to give patients in their jurisdictions the best chance at survival,” he said. “Essentially, a response guideline in Miami-Dade County [Fla.] may not be the best for an agency in Merced [Calif.]. This is where agencies should pay close attention to the efficacy of their emergency response, especially with ECHO cases.”
Despite ECHO’s popularity, it’s not the easiest tier to understand.
For example, the opportunity to dispatch response early in the interrogation sequence (Case Entry) is not what defines an ECHO-Level Determinant.
ECHO codes in the MPDS have been designed to allow for “early recognition and closer response initiation based on extreme conditions of breathing” caused by potentially reversible factors. They are also to be used for “other dire circumstances as defined, such as person on fire.”
A patient given an ECHO-level designation does not necessarily require a different response from DELTA, according to Dr. Jeff Clawson, IAED co-founder.
“ECHO was differentiated from DELTA to encourage the local assignment of the absolute closest responder of any trained crew,” Clawson said. “It encourages the ‘ethical’ response of other specialty crews or responders who otherwise might be sitting or traveling close by while someone dies.”
How a call is prioritized is based on a pre-determined question protocol sequence, the answers and logic of which determine response levels. The Determinant Descriptor code is like the bar code on a cereal box. The same code exists on every box of that type/size of cereal. However, what we pay for that box is different at each different store. The code defines what it is, and the response assigned to that code in each jurisdiction is essentially the “price” (in manpower, equipment, and speed) that that department is willing to “pay” for that situation.
The process saves dispatchers from making decisions by the “seat of their pants”—trying to figure out what is taking place on the other end of the line and, from there, sending out the cavalry (lights-and-siren) for every call.
The MPDS, first created 35 years ago, was designed to give a medically correct orderliness to EMS response—not just sending everyone to everything, always, and in a big hurry, Clawson said.
“The MPDS has been proven over time to do what the priority levels were designed to do—send the right thing, to the right patient, at the right time, at the right speed, and do appropriate things over the phone to help the caller and patient, until the troops arrive,” he said.
A more detailed explanation of, and specific training in, the ECHO-Level Determinant that includes lessons in its application is available through the Academy’s EMD Advancement Series™.
The following descriptions, when volunteered by the caller at any point in the early interrogation period (Case Entry Protocol), qualify for an ECHO-Level Determinant:
• “Barely breathing”
• “Can’t breathe” or “Can’t breathe at all”
• “Fighting for air”
• “Gasping for air” (AGONAL BREATHING)
• “Just a little” (AGONAL BREATHING)
• “Making funny noises” (AGONAL BREATHING)
• “Not breathing”
• “Turning blue” or “Turning purple”
And/or when the following conditions exist:
• Not breathing at all
• Breathing uncertain (AGONAL)
• Complete airway obstruction in choking
Anthony Guido contributed to this article.