Hello,
I recently took a call for an opioid arrest, which I took the ECHO Fast Track for, went through KQ and began CPR instructions. While coaching the caller and waiting for the crew to arrive I suddenly realized—"I don't know if there's a defibrillator on scene, and I haven't given any instructions to the caller regarding collecting one."
My training covered an earlier version of ProQA® without the ECHO Fast Track so the specifics about it were new to me. Looking back over the call through ProQA with my team leader, we confirmed that the ECHO Fast Track for opioid arrest doesn't deliver any instructions regarding fetching a defibrillator. I know that Protocol C is supposed to prompt the caller to fetch a defib "and tell me when you have it," but that card simply just did not come up on ProQA.
My team leader seemed to think this was deliberate but couldn't think of any reason why this would be the case. On reflection, there's no PDI on CC23 to collect a defibrillator, even for not alert patients, so one would assume there's a link between the two ideas. Is there a particular reason why patients in opioid arrest should not have defibrillator intervention? If the caller offers that there's a defib on scene for a patient in opioid arrest, should we specifically advise against its use?
Thanks in advance!
Sean Bailey
EMD
South Western Ambulance Service
U.K.
Hi Sean,
While there is no clinical contraindication, the clinical benefit of an AED for opioid arrest is minimal compared to ventilations and Narcan administration, simply because of the narcotic overdose mechanism.
Narcotic overdose arrest is most often the result of respiratory depression followed by respiratory arrest, and this must be corrected before the heart can be successfully resuscitated. Compare this to sudden cardiac arrest where the presenting rhythm is often ventricular fibrillation that precedes hypoxia (there is oxygen in the tank at the time of the sudden arrest). This is where the AED shines as it can reverse the ventricular fibrillation provided there are no impeding factors like massive heart damage or severe/prolonged hypoxia.
Regards,
Brett A. Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
Hello,
Just looking for a bit of clarification on the fall card. For the second question “How far did s/he fall?”:
Ground level would be typically from standing, sitting, from bed, or falling on stairs.
Less than 10 ft/3m (1 story) would be like falling off a ladder or from a tree, etc.
Fall down (not on) stairs would be them falling down several steps whether it is 5 steps or a flight of steps ... correct?
The confusion some of my employees are having is if someone fell down stairs, is that a series of small falls and which options should they choose? I told them it would not be ground level unless they fell “ON” the steps like it mentions in Axiom 3.
Am I correct?
Elvita Lewandowski, CMCP
Dispatch Training Supervisor
Ottawa County Central Dispatch
West Olive, Michigan (USA)
Elvita,
To answer your first question, yes, a ground-level fall is a person who falls while standing, and they were not standing on something like a ladder, box, or porch that was above ground level but less than 10 ft.
For the second part, falling down stairs is typically seen, as you point out, as several very short falls. The body never picks up the momentum to have hidden injuries when they suddenly stop at the end of the fall. Falls down a flight of stairs can create serious injuries, but these are typically caught with the safety nets in Protocol including Priority Symptoms and Body Area Classifications. I have included Brett Patterson on this email—the Chair of the Medical Council of Standards. He may have other points on this question.
Brian Dale
President
Priority Dispatch Corp.™
Elvita,
I agree with Brian and will add some clarification and relate it directly to Protocol.
Ground level: From standing on ground to the ground standing on, including falls from a chair, bed, or sofa where feet can normally touch the ground. This includes falls directly on stairs (lands where fell).
Less than 10 ft: From a position above ground but below 10 ft, not including the standard bed/chair/sofa positions mentioned above (not a bunkbed). Please note that your examples of falling from a tree or ladder MUST be further qualified by the height of the tree or ladder.
Fall down (not on) stairs: A fall down stairs where the patient ends up below where s/he fell on the stairs. Note this option has its own BRAVO-level code that is response-assigned locally. It differs from LONG FALLs and EXTREME FALLs due to inertia factors Brian has mentioned. A fall directly on stairs should be categorized as Ground level.
LONG FALL and EXTREME FALL: These falls are qualified by the heights listed in their dispatch definition.
Brett
Brett,
Yes, you are correct when saying if they fell off a ladder or out of a tree it would need to be specific to how far that fall was because that can then place it in the LONG FALL, EXTREME FALL, or less than 10 ft. fall category.
Thank you for the clarification. This is how we have explained it, and I wanted to be sure I am not on the wrong path.
Have a wonderful day,
Elvita
Brett,
On Protocol 26, KQ 2, when asked “Is he breathing normally?” the caller responded, “No, he’s … no … because he is in so much pain.” We are familiar with the “hurts to breathe” law of chest or back pain. Does that extend to all protocols, even when no mention of back or chest pain?
Sincerely,
Megan Craig
Training Manager
Deschutes County 9-1-1
Oregon, USA
Hi Megan:
I think the intent of the law is notable here. Remember, this is a law, not a Rule, and is there to make a point, not to direct an action.
Rather than being related to normal/abnormal breathing, the law is telling us that pain in the chest is chest pain. This is why the law is located where it is.
In the example you cite, it seems the caller is telling us the patient’s breathing isn’t normal because the patient is in pain. However, I have not heard the call so my assumption may be problematic. If this is the case, the answer to “Is he breathing normally?” is “No.” The caller clearly said no. As Dr. Jeff Clawson often states, from the perspective of the plaintiff’s attorney, “Asked and answered!”
If the caller says “It hurts to breathe,” one might clarify where it hurts when he breathes. If it hurts in the chest, it’s chest pain, and that is the intent of the Rule.
Either scenario may create some over-triage, but both decisions are safe and, fortunately, not encountered terribly often.
I will make one more point here. Note that on some protocols we ask “Is he breathing normally?” while on others we ask “Is he having difficulty breathing?” We ask the latter when pain is a likely factor and the former when dealing, primarily, with medical maladies. Protocol 26 is primarily medical, but pain may well be a factor, as is evident in your scenario. But this we accept in the interest of safety, and we continue to look for ways to adjust incrementally to reduce over-triage.
Brett
