By Brett Patterson
Brett:
My question is about choosing the ECHO Determinant on Protocol 6: Breathing Problems (which is only during Case Entry). Is it possible for a first-party caller/patient to have an ECHO Determinant if the offered answer to “Tell me exactly what happened?” is “I can’t breathe”? I know the protocol specifies very particular phrases in this section to qualify an event for an ECHO response (i.e., “Can’t breathe at all”), but is this possible on a first-party caller/patient?
Upon continuing to the Key Questions, this patient is able to answer all questions without obvious shortness of breath (if any, only abnormal breathing). Is it appropriate then to downgrade the event from an ECHO (chosen on Case Entry by the calltaker based on the offered answer of “I can’t breathe”) to a DELTA or even a CHARLIE? Is it possible to diagnose a first-party caller/patient to have INEFFECTIVE BREATHING despite the non-difficulty of answering all Case Entry and Key Questions or is this more suited for a second-party caller and only having administered the [Agonal] Breathing Detector to the patient?
Thank you in advance,
Mike Guasch, EMD
Central Communications Centre
Alberta Health Services
Edmonton, Alberta, Canada
Mike:
We included the ECHO code on Protocol 6 for just such circumstances. Most commonly, patients with severe asthmatic or congestive heart failure exacerbations may present with ECHO-level breathing difficulty, and some actually arrest while on the phone. We have a call played in the EMD course in which the first-party caller was in extreme distress, but the dispatcher did not appear to take note and tell the responders that she was alone. They knocked on the door; she didn’t answer, and they left. Her boyfriend found her later that day, dead.
We have changed the INEFFECTIVE BREATHING qualification in the Medical Priority Dispatch System (MPDS) v13.0 to include “reasonable equivalents” because EMD-Qs were taking these quotes too literally. Obviously, not everyone expresses distress exactly the same way.
As for the downgrade, keep in mind the old legal adage, popular with plaintiff’s attorneys: “asked and answered.” When the caller provides the information that was asked of him/her, and that information clearly prompts a code in protocol, the code then becomes appropriate. Your scenario seems very clear. The patient meets INEFFECTIVE BREATHING criteria by definition; however, he or she also answers questions without difficulty and this illustrates effective breathing. We must keep in mind, however, that not all cases are this black and white, so to err on the side of caution is prudent.
We know that difficulty breathing codes are full of over-triage. However, we also know that these codes are full of very sick patients. The challenge is to safely separate the two without significant under-triage, and this is very difficult to do. We have made significant progress through research, but we still cast a large net in order not to miss sick patients. The good news is that while the DELTA-level difficulty breathing patients are significantly over-triaged, the ECHO-level patients on this protocol that are over-triaged are far less in number, and probably do not have a significant impact on EMS system resources.
Finally, I would like to comment on the use of the Agonal Breathing Diagnostic Tool (ABDxT). We have had a significant problem with EMDs using the ABDxT to confirm that a patient is not breathing and thus delaying CPR, which significantly impacts survival. Your mention of using the tool to confirm that a patient is breathing effectively is what the tool was actually designed for. If at Case Entry the caller says that an unconscious patient is breathing, but the EMD doubts this because of the scenario, or for any reason, using the ABDxT is appropriate. However, the ABDxT should not be used when the caller reports INEFFECTIVE or UNCERTAIN BREATHING associated with unconsciousness, unless it is reasonably clear that the patient is breathing effectively and the EMD simply wants to confirm effective breathing. As Dr. Jeff Clawson says, “Use it when you are unsure, not when the caller is unsure.”
Using the ABDxT on a conscious patient to “rule out” INEFFECTIVE BREATHING is not what the tool was designed for. However, there is consideration of using some form of the tool to measure respiratory distress and help us with the ongoing challenge of safely reducing the over-triage associated with the difficulty breathing codes. But this concept is still in the research stage, so we will have to stay tuned ...
Thank you for your excellent questions.
Brett Patterson
Academics & Standards Associate
Medical Council of Standards Chair
Brett:
Thank you very much as always for an excellent, thorough, and articulate response to my question. I will make sure to share this Q&A with our organization and peers. We are eager to learn the changes to version 13.
Mike
