DLS STANDARD OF CARE: VENTILATIONS & CHEST COMPRESSIONS

By Jeff Clawson, M.D.

Hello Brett, 

One of our dispatchers recently handled a 9-E-3 call involving an 18-year-old female (Hanging Now). At the Protocol C Pathway Director, the dispatcher correctly chose Ventilations (V) 1st followed by Chest Compressions. Although the caller complied with and carried out all instructions, the patient did not survive.

Our EMS division is concerned by the fact that EMD Protocol directs dispatchers to initiate ventilations and the potential for fluid exchange. It is my understanding that they are considering eliminating ventilations altogether in the dispatch environment and going with compressions only. Obviously our medical director would need to approve of this, but I am nonetheless worried about these changes and the potential effect it would have on our dispatchers and citizens. I would greatly appreciate your input on this subject.

Sincerely,

Scot Swindall

Shift Supervisor/ EMD-Q

West Metro Fire Communications

Lakewood, Colorado, USA

Hi Scot: 

Nice speaking with you today. To summarize our conversation:

MPDS v.13 includes a “Compressions Only” pathway for victims of suspected cardiac arrest. The “Compressions 1st” option will remain, which essentially provides compressions for the 1st 6 minutes (about 10 minutes into the cardiac arrest sequence), followed by a 100:2 compressions to ventilations ratio. Your medical director will need to select and authorize the pathway of his/her choice.

The current standards (2015 AHA ECC CPR Guidelines Update) recommends compressions only for untrained laypersons. Trained rescuer guidelines recommend 30:2 (compressions to ventilations). And they state that “compressions only” is reasonable in the dispatch environment.  Then there are BLS, ALS, and in-hospital guidelines. However, it is very clear that the dispatch guideline is for suspected cardiac arrest, and is not intended for arrest with a respiratory etiology, or for kids.  For this reason, the Ventilations 1st Pathway will remain in the MPDS for v.13.  As a side note, the Academy’s Medical Council of Standards has a subcommittee, Resuscitation Council, made up of resuscitation experts and researchers familiar with the dispatch environment. This group reviews the current research and AHA/ILCOR guidelines and “translates” them into the dispatch environment.  As such, the MPDS maintains and exceeds the current standard of care in the DLS environment.

Although the concern about disease transmission from patients to rescuers is common, actual disease transmission is not. The reality is that the incidence of disease transmission via rescue MTM is minuscule; we at the Academy have actually never heard of such a case in 35+ years of the MPDS. A call to 911 is, as seen by our courts, an implied call for help in which we are obligated to provide a standard of care, and CPR is the standard of care. If the caller refuses to do MTM, a “Refused MTM” Pathway is available. But there are no plans to change the DLS standard of care based on the potential for MTM disease transmission.

I have attached some material on the MPDS initiative regarding High Performance CPR and cardiac arrest survival you mind find useful.

Brett A. Patterson

Academics & Standards Associate

Medical Council of Standards Chair

Brett,

This is perfect! Thanks for your prompt and personal response to my questions.

Scot

Brett, 

Great answer!  One thing I think you need to clarify in an addendum to him is that, while their medical director can select one of the two pathways for Compressions arrests, they cannot opt out of Ventilations 1st for hanging or any other variation that is not supported by the protocol.  That would “void the warrantee” and violate the protocol license agreement, and is simply not allowed with in the unified protocol system—however, PFCs are… Doc

Hi Scot: 

I forwarded this e-mail to Dr. Clawson as we keep a record of FAQs to use in other replies and occasionally publish in the FAQ section of our Journal. Although I believe I explained this to you on the phone, Doc pointed out that my e-mail may not have been clear about the distinction between medical control authorization of the Compressions 1st or Compressions Only Pathways, versus the completely separate issue of using the Ventilations 1st Pathway for the suspected etiologies listed there. While the science currently supports either the Compressions 1st or Compressions Only Pathway for suspected, sudden cardiac arrest, it is unified in a 2:30 approach for a respiratory etiology. Just to be clear, use of this protocol pathway is not a locally-defined decision, but rather the current, international standard of care contained in the MPDS. A local omission of this pathway would constitute a violation of the agency’s license agreement and degrade the integrity of the Unified Protocol concep.

Thanks, Brett

See the link at www.emergencydispatch.org/downloads/Unified_Protocol_IAED.pdf

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