Brett Patterson
Brett:
Caller advises they have non-chewable low-dose aspirin; what instructions would be given?
Do we tell them to take with a mouthful of water?
Eric Gerald Fahler
Lebanon County 9-1-1 Deputy
Lebanon, Pennsylvania (USA)
Eric:
“Non-chewable” means enteric coated, which means a firm coating is applied designed to get the aspirin through the stomach and dissolve in the gut. Essentially, it protects the stomach from the long-term effects of acetylsalicylic acid (aspirin). It is prescribed for patients on long-term ASA therapy.
This coating is not terribly hard and can be chewed. We actually tested this on several folks in the Salt Lake City (Utah, USA) office, and there were no resulting broken teeth or complaints.
Swallowing an enteric coated aspirin delays absorption, and this is not optimal in the potential heart attack setting. Advise the caller to chew the aspirin as per the MPDS® instructions. If they refuse, swallowing it is probably better than nothing, although the medics will likely provide a "chewable” on arrival.
Your question is also addressed in the ASA FAQ section of Principles of EMD. You will find your question and answer on page 6.21.
Brett Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
Brett:
We’ve several employees asking what to do when the reporting party states they have taken an abortion pill and are now bleeding. I want to give them direction on what path to take, but it seems it may vary depending on how far along they are, whether they are bleeding heavily, cramping, or have passed anything. It’s a frustrating call for most of my calltakers, and I’m looking for direction on how to best equip them to take these calls.
Heidi Partlow
CQI Supervisor
Valley Regional Emergency Communications Center (VRECC)/West Region
Modesto, California, USA
(Editor’s Note: The question included a transcript of a call, for an example, in which Brett made the following comments placed in parentheses for purposes of discussion.)
CEQ3: “She’s having extremely bad pain.” (No clarification by EMD.)
Caller volunteers: “She’s having an abortion." (Again, no clarification by EMD.)
EMD moves to P26 then shunts to P21 when vaginal bleeding is discovered.
EMD asks P21 KQ 1a (EMD does not shunt to P24 for Yes answer and does not ask KQ 1ai; no codification as to what has passed.)
(Situation finally clarified by caller) EMD asks “When did they give her the pill?” (Freelance, no benefit.)
EMD stays with P21.
Heidi:
There are several issues with this call that all stem from not knowing what happened on Case Entry. We need to clarify at Case Entry to get on the right track. In this case, the EMD went to P26 with no information other than non-descriptive pain.
This was a call for an intentional, pharmaceutical abortion with vaginal bleeding and pain (still don’t know where). Once this information is known, P24 becomes obvious, and KQ1 dictates the correct pathway.
MISCARRIAGE if fetus or tissue less than 24 weeks gestation.
THREATENED MISCARRIAGE if bleeding or bleeding and cramps less than 24 weeks gestation.
STILLBIRTH if greater than 24 weeks and purposeful/induced by physician.
Simply put, if prior to 24 weeks, pill or no pill, it’s a MISCARRIAGE (fetus or tissue) or THREATENED MISCARRIAGE (blood or blood and cramps). If after 24 weeks, STILLBIRTH, unless SIGNS of LIFE are present.
Brett
Brett:
Thank you for your reply. I do agree with your findings (Q-wise). We seem to get these calls more often in the past year than we have before, and my calltakers are just unsure of where to go. So, digging more at Case Entry 3 as far as asking where the pain is and when she took the pill? And/or has the fetus already passed? Or if it is known she took the pill we just go to Protocol 24 and go from there? My calltakers are wanting to go to Protocol 21 (or on this call Protocol 26).
When choosing from the drop-down should the EMD choose “MISCARRIAGE situation” or just “Pregnancy/Childbirth/ Miscarriage”?
On KQ 1 if the RP is not having abdominal pain/cramping—just bleeding—what would be the appropriate choice if it is known they took an abortion pill? I think this is where they are getting off track and not choosing “threatened.”
They do follow the DLS Links, but it seems as though many of the instructions are not applicable to this particular situation and don’t seem appropriate, unless we’re looking at this wrong. For example, “I’m sorry” or even mentioning the term “baby” may be uncomfortable.
Again, thank you for all your input and guidance on this. I’m just hoping to be able to put out a training bulletin on what to do and how to handle these types of calls better.
Heidi
Heidi:
My point: EMDs need to know what happened. Simply knowing this woman was prescribed a pill to terminate and is now bleeding and cramping is enough. If she was prescribed a pill to terminate pregnancy, she is pregnant. And if now bleeding, cramping, or passing tissue or delivering a fetus, P24 is appropriate. P24 will ask about gestation and provide the appropriate answer options:
If she is just bleeding, or bleeding with cramps, and is less than 24 weeks, THREATENED MISCARRIAGE, by definition.
If fetus or tissue and less than 24 weeks, MISCARRIAGE, by definition.
If fetus and greater than 24 weeks, and purposeful termination by a physician, STILLBIRTH, by definition.
Protocol 21 is for vaginal bleeding when not pregnant, or for POSTPARTUM Hemorrhage ONLY, meaning no other problems (baby born <= 8 weeks and the only complaint now is mother bleeding).
Please note: Some of the instructions may not be appropriate—“(I’m very sorry. There’s nothing we can do for the baby)” has recently been placed in parentheses to make it optional, so simply don’t read them if not appropriate.
Recommendations:
Always clarify what happened and get on the right train at the right station before the train leaves. This may help: https://iaedjournal.org/art-and-science/.
Learn these four DLS definitions:
MISCARRIAGE
THREATENED MISCARRIAGE
STILLBIRTH
SIGNS OF LIFE
Let me know if I can be of further assistance.
Brett
Brett:
I’m trying to get an answer for one of my dispatchers. As are many areas of the country, our state is fighting an opioid crisis. One of my dispatchers recently took a call for an opioid overdose. While following PAI Q for administering Narcan, the caller advised that the dose was expired.
It is my understanding that expired drugs really don’t have any different effects—they just may be less effective due to the drug’s half-life. In this case, wouldn’t it be worth the shot to try the expired Narcan until EMS can arrive? I could not find anything in the protocols that addresses expired drugs.
Tim Coale
Communications Center Manager
Worcester County Department of Emergency Services
Snow Hill, Maryland (USA)
Tim:
You are absolutely correct. While an expired drug may have lost some potency, it is safe and appropriate to give in an emergent situation unless clearly damaged. In fact, we recently removed the section of Protocol P that stopped administration instructions due to particles or discoloration in an auto-injector.
Thanks for the great question and all the best with the efforts of your team.
Brett
