TWO CASES: WHICH PROTOCOL?

By Brett Patterson

Brett: 

Need your advice on these two cases.

Case 1: When this call was answered, the caller was heard saying “sit down before you fall down.” The caller then repeated this phrase several times while the address and phone number were being obtained and verified. It sounded as though the patient was either unable or unwilling to listen to the caller’s instructions. When the EMD asked “OK, tell me exactly what happened,” the caller said, “I don’t know; she said she’s feeling pretty bad and has been sick for a long time. She’s crying.” The EMD attempted to clarify this answer by asking “What kind of symptoms is she having right now?” The caller answered “anxiety right now, but I don’t know exactly what is wrong.” Our EMD chose Protocol 26: Sick Person. We are wondering if Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt may have been an acceptable, or even more appropriate choice in this case. Thoughts? 

Case 2: Caller states, “I have recently been diagnosed with Deep Vein Thrombosis, and I’m having pain with deep breaths.” Our EMD chose Protocol 6: Breathing Problems. When she got to the prescribed inhaler question, the caller answered “yes.” When the EMD asked her if she had used it yet, the caller said, “No, I’m not having shortness of breath; I am having pain with breaths.” First Law of Chest Pain: “Hurts to breathe” is not considered difficulty or abnormal breathing. Because of this rule, we are wondering if Protocol 10: Chest Pain may have been an acceptable, or even more appropriate choice in this case. Thoughts? 

I look forward to hearing from you. Thank you for answering our past questions so quickly and clearly.

Paul Hacker

Supervisor

Manitowoc County Joint Dispatch Center

Wisconsin, USA

Paul: 

You are correct regarding Case 2, even though the problem may actually be in the lungs. The caller should clarify where it “hurts to breathe.” Most likely, this will come out as chest pain. Please remind your calltakers that the protocol does not attempt to diagnose but rather determine what sort of evaluation and instructions the patient needs. In this case, ALS is appropriate.

Regarding Case 1, I think the EMD did the right thing. “Anxiety” is really a caller diagnosis, and “sick” was the predominant Chief Complaint. The attempt to obtain a better Chief Complaint was good, but I would encourage simply asking “Tell  me exactly what happened” a second time, which normally works best as it focuses the caller on the more recent events. If that doesn’t work, “What prompted you to call right now?” often does.

Hope that helps.

Brett A. Patterson

Academics & Standards Associate

Medical Council of Standards Chair

Brett: 

A calltaker is using cardiac/heart problems for blood pressure issues and, according to MPDS, I am under the assumption that sick person with the priority complaint of blood pressure abnormalities would be the right choice over heart problems.

Ashley Partridge, TC08 ED-Q

Macoupin County Sheriff Department

Carlinville, Illinois, USA

Hi Ashley: 

Your question is rather common, as there is some confusion regarding what sort of complaints are appropriate for Protocol 19: Heart Problems/A.I.C.D, and there is also a tendency to relate or “diagnose” some complaints, like blood pressure abnormalities or “heart attack” to this protocol. Let’s address the latter issue first.

If a caller provides a diagnosis in response to “Tell me exactly what happened?”, i.e., “He has high blood pressure” or “He’s having a heart attack,” it is most appropriate to simply ask the question again in order to solicit a sign, symptom, or circumstance relating to the Chief Complaint, i.e., the reason for the call. This is because the MPDS Chief Complaint Protocols are sign, symptom, or event based, not diagnostically based. There are two important exceptions, however. Without reading the next sentence, can you name the two Chief Complaint Protocols that are actually named after a diagnosis? [short pause here …] I will assume you thought of Protocol 13: Diabetic Problems and Protocol 28: Stroke (CVA)/Transient Ischemic Attack (TIA). Nice job! These “exceptions” are quite purposeful because data shows us that laypersons generally get these right. Friends and family members of diabetic patients know the signs and symptoms of diabetic problems, and laypersons, in general, know the signs and symptoms of stroke, although they often don’t call us soon enough.

Anyway, back to your question. If the caller provides a specific diagnosis such as high blood pressure, or even gives you a numeric blood pressure reading, but offers no accompanying symptoms, you are right to use Protocol 26: Sick Person (Specific Diagnosis), rather than assuming the problem is related to a heart problem. Note the definition of Sick Person in the Additional Information section of Protocol 26, which reads: “A patient with a non-categorizable Chief Complaint who does not have an identifiable priority symptom.” And, in your case, and as you correctly mentioned, there is a specific code on this protocol for such cases, 26-A-2 Blood pressure abnormality (asymptomatic). I would add, however, that it is always appropriate to clarify that the numeric abnormality is the only reason for the call, i.e., “I understand that her blood pressure is high. Is she having any symptoms?”

Let me briefly clarify the first point I made above. When should the EMD use Protocol 19: Heart Problems/A.I.C.D? When you think about it, “Heart Problems” is actually a caller diagnosis, much like “Heart attack.” So, if the caller simply states “heart problem” or “heart attack,” the EMD needs to clarify by repeating “Tell me exactly what happened?” in an attempt to obtain a sign or symptom that can be categorized. This protocol was developed for signs or symptoms clearly related to the heart, namely heart rhythm complaints such as fast or slow heart rates, fluttering or skipping of heartbeats, or similar issues that can be felt or sensed and that often alarm patients. It is also used, as mentioned in the protocol’s title, when there is an issue with an Automatic Implanted Cardiac Defibrillator, i.e., single or multiple firings.

Please do not hesitate to contact me directly with any additional MPDS inquiries, and I’ll try to be brief next time.

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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