The following case is a medical emergency call handled by a large metropolitan emergency medical service (EMS) agency. This agency handles over 12,000 emergency and non-emergency ambulance calls per month in an area over 270 square miles, with a population of around 500,000. The emergency medical dispatcher (EMD) used the Medical Priority Dispatch System (MPDS®) version 13.3 (NAE) to handle this call.
Call to 911 and Ambulance Arrival
A second party caller (one who is with the patient now) called for a 62-year-old male who gave several complaints initially. The caller stated chest pain, seizure, and trouble breathing. The EMD selected Protocol 12 (Convulsions/Seizures) following Protocol 12 rule 4. Below is a description of the emergency medical dispatcher (EMD) caller interaction, along with the field-provider scene findings upon arrival: Address and phone asked and verified.
Case Entry Questioning
CT: Tell me exactly what happened?
C: My husband woke up with some chest pain and some coughing, now it looks like he is having a seizure.
CT: are you with him right now?
C: and he is having trouble breathing.
CT: ok are you with him right now?
C: I am.
CT: How old is he?
C: 62.
Ct: Is he awake?
C: No, now it looks like a seizure.
CT: Is he breathing?
C: Yes, he is breathing.
Protocol 12 Chief Complaint (Convulsions/Seizures) selected by the EMD
KQ 1 has he had more than one seizure in a row?
C: No, he looks like he is having trouble breathing
KQ 2 Is he a diabetic?
C: No.
KQ 3 is he an epileptic?
C: No.
KQ 4 Does he have a history of stroke or brain tumor?
C: Will you quit asking me these questions!
CT: Ma’am the ambulance is already on the way, this isn’t slowing them down, these questions make sure we send him the right help.
KQ 4 Does he have a history of stroke or brain tumor?
C: No.
KQ 5 Has the jerking stopped yet?
C: to someone else, is he still breathing?
CT: is he still jerking?
C: no.
CT: is he breathing right now?
C: he is breathing now.
At this point, the EMD used the Breathing Detector and Diagnostic Tool (BVDxT) to determine the patient’s breathing status.
The patient could be heard breathing along with the caller stating “now” every time the patient breathed. The Breathing diagnostic tool indicated the patient was breathing effectively.
Case Exit Instructions
MPDS Panels X-1 (2nd party) and X-3 (stay on the line) instructions were given per dispatch protocol.
At this point—2 minutes and 35 seconds into the case-- the patient could be heard moaning and the caller(patient’s wife) talking to the patient.
The EMD remained on the line with the caller for 6 more minutes until responders arrived. During the 6 minutes the caller and EMD conversed about what hospital to go to, the patient’s history, as well as several checks of the patient’s breathing status. Throughout the remainder of the call the patient could be heard breathing effectively but did not ever regain consciousness enough to communicate with the caller.
Retrospective Review
The call-taker managed this call per protocol and correctly assigned the final code of 12-C-4 [not seizing now and effective breathing verified (>6, confirmed no seizure disorder)].
A retrospective review of this case determined that while this initially sounded like a routine seizure call as presented to the EMD, the patient went into cardiac arrest just as the responders were arriving at the patient’s side. Several experienced case reviewers evaluated the EMD’s performance and all of them agreed that the call was coded correctly and the correct DLS instructions were given.
Discussion
This case raises an important question regarding the 12-C-4 Determinant Code. Are there conditions within this code that suggest a DELTA-level code is warranted? And if so, is there a need to separate those conditions with a protocol change, assigning the high-risk patients to a new higher DELTA coding?
An initial look at a finite dataset suggested there might be an increased risk of poor outcomes for patients over 50 years of age who do not have a history of seizures. This data revealed that 24% of patients who were over 50 with a final code of 12-C-4 were transported “hot” (lights and siren), compared to a hot transport rate of 6.8% for ages 7-49. While this provides us a clue, it doesn’t conclusively point to a higher priority for those seizure patients in the 50+ age group who have no history of seizures. And hot transport is only one of several predictors of acutely ill patients. Without a hospital-confirmed diagnosis of a severe condition on individual patients, it is difficult to draw conclusions about the need for a high-priority (DELTA level) response.
The Centers for Disease Control reports that epilepsy is more likely to develop in older adults due to risk factors that are more common in this age group.1.2 This later-in-life-onset phenomenon could explain why some older patients do not have a history of seizures when they are reported to 911 as seizing—since it is their first epileptic episode that is occurring at the time of the emergency call for help. And while some risk factors associated with higher age can become life-threatening when combined with a seizure, the CHARLIE level priority appears sufficiently high to deal with most of these conditions. Recall that the standard CHARLIE response is an advanced life support crew to respond urgently, but without lights and siren.
A more complete review of the literature doesn’t reveal significantly higher risk for elderly first-time seizure patients. Also, the caller reported chest pain and difficulty breathing as patient symptoms, in addition to the seizure, in this case. These two symptoms could be an important factor in deteriorating patient status leading to cardiac arrest here. Indeed, this is the primary reason for using the BVDxT after the seizure has stopped—as existing MPDS protocol logic directs. And when the BVDxT determines ineffective breathing or absence of breathing, a higher DELTA level coding is assigned. Since the 12-C-4 code appears sufficient to handle most of these seizure cases in elderly patients, and with use of the BVDxT to identify the most critical deteriorating patients, there is not sufficient evidence to propose a protocol change at this time.
1. Epilepsy and Seizures in Older Adults.(2023. March 29th). Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. https://www.cdc.gov/epilepsy/communications/features/olderadults.htm#:~:text=As%20our%20population%20ages%2C%20there,Head%20injuries%20from%20falls. Accessed November 28, 2023.
2. Brodie MJ, Elder AT, Kwan P. Epilepsy in later life. Lancet Neurol. 2009;8(11):1019-1030. DOI: 10.1016/S1474-4422(09)70240-6.