Editor’s Note: This CDE is based on previous articles by Brett Patterson, IAED™ Academics & Standards Associate and Chair of the Medical Council of Standards. This article involves Protocol 17: Falls and the Case Entry Rules. Brett’s full Chief Complaint selection article can be found at iaedjournal.org/art-and-science.
Scenario: A son hears a crashing noise coming from the kitchen and rushes in the room to find his mother collapsed on the floor. She is conscious but does not respond to her son’s questions of “What happened? Are you hurt?” The son calls the emergency line and states what he heard and observed.
Should the EMD use a trauma protocol or a medical protocol? Protocol 17: Falls makes sense since it is believed that the woman hit her head, but there is now a priority symptom, with the patient’s level of consciousness being altered.
So, what do you do?
Case Entry Rule 2 of the Medical Priority Dispatch System™ (MPDS®) instructs you to “choose the Chief Complaint Protocol that best addresses the mechanism of injury.” Case Entry Rule 6 states “If the complaint description appears to be MEDICAL in nature, choose the Chief Complaint Protocol that best fits the patient’s foremost symptom, with consideration given to priority symptoms.”
The patient may have potentially had a cerebrovascular accident (CVA) and fallen. Could the Stroke Diagnostic Tool better help evaluate the scenario?
Discussion
An EMD may initially think about the fall (Mechanism of Injury or MOI) when considering which Chief Complaint Protocol to select. However, because nothing is known about the circumstances of this fall, the prudent EMD asks again, “Tell me exactly what happened” to which the caller replies, “She was in the kitchen, and I heard her fall. Now she’s not responding to me!”
In this case, the complaint description contains mention of a fall. However, the complete scenario—the sudden, unexplained collapse of a previously normal patient—strongly suggests sudden cardiac arrest. The trained EMD understands that a ground-level fall is very unlikely to cause unconsciousness, but the sudden collapse and unresponsiveness is highly indicative of cardiac arrest, followed by stroke or seizure. So, while the complaint description made mention of possible TRAUMA, the Chief Complaint is most likely MEDICAL.
This dilemma is particularly important when dealing with a fall resulting in cardiac arrest because even a few moments delay in starting CPR may adversely affect the patient’s outcome.
If the Chief Complaint is fall, use Protocol 17 to address the MOI and any subsequent injuries; the Not alert DELTA driver adequately addresses the response. If stroke is suspected as the cause of the fall, it is quite prudent to use the Stroke Diagnostic Tool and report the results to the responders.
If the Chief Complaint description is highly suggestive of cardiac arrest, stroke, diabetic problem, etc., and the subsequent fall is known to be ground level, the EMD should go with the cause and then use the Target Tool to address any injuries. In most cases, injuries from a ground-level fall are not as serious as the underlying cause, especially when dealing with cardiac arrest.
There is a high incidence of cardiac arrest in the 17-D-3 “Unconscious” code, so it is prudent to take the cardiac arrest pathway when the scenario strongly suggests sudden collapse resulting in unconsciousness, even if the caller is only reporting the fall they have witnessed.
Chief Complaint review
A Chief Complaint may be described as the reason a caller is seeking help. The Chief Complaint may or may not be accurately expressed by the caller for various reasons including a tendency to self-diagnose, a lack of knowledge concerning clinical or situational priorities, multiple/concurrent problems, or emotional distress, among other factors. Case Entry Question 3, “Okay, tell me exactly what happened,” was designed to solicit a complete complaint description from the caller that can then be interpreted by the trained EMD to determine an accurate Chief Complaint and, ultimately, select an appropriate Chief Complaint Protocol.
The objectives associated with determining an accurate Chief Complaint include the discovery of any potential safety issues, any significant MOI, and the identification of priority symptoms and/ or conditions that can be used to select a Chief Complaint Protocol. The selection of an appropriate Chief Complaint Protocol then helps to meet the primary objectives of the MPDS: safety, response allocation, patient care, and information for responders.
Understanding exactly what is happening, or has happened, at a given scene is essential to accomplishing these objectives. For this reason, Case Entry Question 3 is perhaps the most important question in the MPDS. Because callers may not understand the EMD’s objectives or priorities, they may not initially provide a complete or accurate complaint description, making a second or clarifying attempt at asking this question mandatory. Most often, simply repeating the phrase “… tell me exactly what happened” is enough to obtain the information necessary to identify a Chief Complaint. However, if this does not work, rephrasing or otherwise attempting to find out exactly what triggered the call for help is compulsory. Cutting the caller off at Case Entry Question 3 is self-defeating as an inaccurate result is far worse than sacrificing a few seconds to get it right.
The Chief Complaint Selection Rules, found primarily on the Case Entry Protocol but also on various Chief Complaint Protocols, are designed to guide the EMD by setting some basic priorities. Once a Chief Complaint is identified, these Rules ensure that safety, MOI, and Priority Symptoms are always considered when selecting a Chief Complaint Protocol. In other cases, a Rule may ensure a specific condition or situation is addressed accordingly on a specific Chief Complaint Protocol, e.g., that hazardous materials are addressed on Protocol 8: Carbon Monoxide/Inhalation/HAZMAT/CBRN, or that the apparently non-breathing seizure patient is evaluated on Protocol 12: Convulsions/Seizures before response assignment and caller instruction.
The first Case Entry Rule is perhaps the most easily understood because safety is always the priority. If the caller’s complaint description identifies any safety issues, the EMD must choose the Chief Complaint Protocol that best manages those issues. This applies even to those cases where another Chief Complaint Protocol may seem more appropriate for the caller’s concern, or even the patient’s care. A basic premise is introduced here: More than one Chief Complaint Protocol may address a safety issue, an MOI, or a Priority Symptom. All EMDs should be familiar enough with the MPDS to know the basic functions of each protocol.
Our second Case Entry Rule is designed to identify specific MOIs addressed by the MPDS. This is because significant MOIs can cause undiscovered (occult) injuries that may not be noticed by the caller or patient but require a certain level of response to address the potential injury. The classic example is LONG or EXTREME falls. While a caller may be concerned about a particular injury, perhaps a broken leg that Protocol 30: Traumatic Injuries (Specific) would address, Protocol 17: Falls is most appropriate because it will prioritize the call based on the MOI alone, if necessary.
In MEDICAL cases, Case Entry Rule 6 was designed to establish priorities when multiple complaints are expressed in the caller’s complaint description. The EMD wants to know the primary reason the caller decided to call for emergency help. This is called the foremost symptom. In many cases, knowing why the caller is seeking help right now is enough to determine the Chief Complaint. Second, the EMD must make sure priority symptoms are not missed because lay callers may not understand their clinical significance.
However, to appropriately apply these Rules and ensure the selection of an appropriate Chief Complaint Protocol, the EMD must first obtain a complete complaint description and then formulate an accurate Chief Complaint that fits the rules. To do this, the EMD must consider the clinical and situational scenario presented to them and should also have a thorough knowledge of the content and capabilities of the Chief Complaint Protocols.
