Priority Please

Brett Patterson

The Protocols are quickly learned by numerical position, and referred to as such, i.e., when I think Chest Pain, I think 10.

While we try to place the Determinant Descriptor codes in an acuity hierarchy, there is always some local variance concerning this order.

I have discussed this with several of my colleagues and would like to get some clarification.
I recently took a phone call for a 12-week pregnant female with a confirmed miscarriage (by the doctor, two days prior), which was stated in Case Entry.

At the beginning of the call the patient was awake and breathing.

After going through Key Questions, I went to the Miscarriage < 6-month DLS Link. I asked the G1 question, “Is the afterbirth out yet,” and the caller responded, “She is unconscious now.” I then asked, “Is she breathing?” and he replied, “Yes.”

I was unsure if I should reroute to the Case Exit Protocol and give airway instructions or focus on the hemorrhage by giving fundal massage instructions.

To me both are equally important, but in this case, what is the most appropriate PAI to give next (airway instructions or fundal massage)? And what is the best way to get there in ProQA® (from the G1 panel)?

Elizabeth Collins

Emergency Communications Officer

North Communications Center

Alberta Health Services, Canada

Hi Elizabeth:

Excellent question and difficult decision.

Our Protocol tells us that “The airway of an unconscious patient must be constantly maintained” and, yet, in this case, we suspect that bleeding may be the cause of the unconsciousness.

This is not unlike the cardiac arrest patient with severe hemorrhage. While CPR is obviously indicated, it is likely ineffective until bleeding is controlled. We recently rewrote the related Axiom to stress that both are important, but that when only one rescuer is available, CPR should be primary: “In cases of traumatic arrest associated with SERIOUS Hemorrhage, direct pressure on external wounds by a second rescuer, while CPR is initiated by a primary rescuer, may increase patient survival.”

I think in your case, however, because the patient is breathing, we should go ahead and stay on the MISCARRIAGE Pathway and do fundal massage.

If cardiac arrest is suspected, however, I would use the Sudden Arrest reset or Target Tool and get to CPR.

Unfortunately, we can’t be two places at once in the software so, if a second rescuer shows up, we should be able to provide simple airway instructions while we proceed with the scripted fundal massage instructions, keeping in mind that the Sudden Arrest reset or Target Tool is available if the patient stops breathing.

Difficult call.

Brett A. Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®

 

Brett:

One of my students asked why the seizure card is under convulsions instead of seizure. That one got me. Do you know the answer?

Teri Best

Chief Communications Officer

CHRISTUS® EMS

Longview, Texas (USA)

Hi Teri:

Congratulations on your appointment as an IAEMD instructor!

When the MPDS® was first developed, “convulsions” was the common term in the United States used to describe what are now more commonly known as seizures. Because the Protocol cardset was arranged alphabetically, this Protocol was set in the 12th position, and has been ever since, now approaching 40 years.

As you know, the Protocols are quickly learned by numerical position, and referred to as such, i.e., when I think Chest Pain, I think 10. And there are tens of thousands of certified EMDs out there that know the Seizure Protocol as Protocol 12. To rename and reposition this Protocol into the 25th position, would not only lose the familiar 12 label for seizures, it would necessarily change the numerical value of Protocols 13–25, and it would certainly take many years to recover (I have known these Protocols by number for over 30 years now!). And if we simply lost the term “Convulsions” and left the Seizure Protocol where it is, we would lose the alphabetical value your new students rely on to navigate the Protocol.

So while the answer to your question is not based on an orderly rationale, I’m sure you can appreciate the consequences of such a dramatic change midstream.

Thanks for asking …

Brett

 

Hello Brett,

I hope you do not mind that I am emailing you directly with this question, but I wanted to find out exactly where the problem was so I would know how to address it. Thanks in advance!

Comp Desc: 2 patients with heat exposure, poss[ible] dehydration. One is in and out of consciousness, and the other is having a “pseudo seizure” that is possibly anxiety.

CT selects Protocol 20: Heat/Cold Exposure and is Fast-Tracked through Case Entry when she enters two patients.

So far so good.

One patient DOES have chest pain 20-D-2 “Multiple victims (with priority symptoms).”

They are NOT completely alert—reconfigures to D-1 “Not alert.”

This is the problem I am having. Should it do this? There are still multiple patients with priority symptoms. I tried (in a later test call) selecting D-2 at the dispatch screen after answering “No” to completely alert, but after every subsequent question (“no” heart rx, “normal” skin temp, “yes” color change), it directs me back to the dispatch screen where it has again reconfigured to D-1. So, I have to manually select D-2 several times in order to get that final dispatch code. I have a few questions:

  • Why does the call reconfigure to D-1 when D-2 addresses multiple victims as well as priority symptoms?
  • Once we have manually selected D-2, why does it keep going back to D-1? There is nothing in those last few questions that should cause that.
  • Is this a logic issue that can be addressed that way or should I maybe be submitting a PFC to add a “Multiple patient” suffix for this protocol?

Darleen C. Pannell, ENP

Administrative Associate

Department of Emergency Services

Lynchburg, Virginia, USA

Hi Darleen:

I tend to agree that multiple patients, when priority symptoms are present, should probably trump the Not Alert code. I had a look at some other protocols where multiple victims are an option and the coding priority varies. For instance, on Protocol 8: Carbon Monoxide/Inhalation/Hazmat/CBRN, the Not alert code takes priority over multiple patients whereas multiple patients trumps Not alert on Protocol 7. I will look into the logic concerning this.

However, in the meantime, did you know that you can set the cursor priority in the Admin.exe Utility of ProQA? I set the cursor priority to multiple patients for your Protocol 20 example. The result is a 20-D-2H code.

Just a note to follow up:

While we try to place the Determinant Descriptor codes in an acuity hierarchy, there is always some local variance concerning this order. And, as we add codes to the list, we tend to add to the bottom of the list to avoid shuffling the codes, which obviously creates a lot more work for agencies as response plans in CAD need to be changed. As a result, not all protocols have the same hierarchy among codes, and variance depends on the Chief Complaint and, also, the additions and deletions of various codes. It is therefore recommended that the cursor priorities in a given code set be re-evaluated when upgrading to ensure local assignments are as desired.

In looking at this example, however, most seem to agree that multiple patients with priority symptoms trumps a single not alert finding, so an order change is likely, although not before a major version upgrade as to avoid extra CAD work for agencies. In the meantime, cursor priority deals with the issue locally.

Thanks for the great question.

Brett

ABOUT THE AUTHOR:
Brett A. Patterson is an Academics & Standards Associate and Medical Council of Standards Chair for the IAED.

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