Dispatch treating CVA with ASA

[Richard B the EMT]

I spent 11 years in the NYC EMS Communications Bureau/FDNY EMS EMD. I think this might have some weight in this discussion.

Someone called 9-1-1 for an ambulance, and the call went to an Automatic Call Distribution Operator, a civilian NYPD communications specialist. On their initial interview of the caller, determining EMS was requested, would push a button, and the call became a 3 way between the "ACD", the EMS Call Receiving Operator (ACD, an outdated term, by the way, but that is what we were called back then), and the caller.

What information the ACD had, was sent by the ACD to the CRO via the compu-link from NYPD's "SPRINT" to EMS' "MedStar" computer systems (all terminology might not be the current names for specific equipment, I am using the terminology from 1997), and the CRO would confirm with the caller such information as the address of the call, was the patient awake, was the patient breathing, and what was going on that an ambulance was needed.

This system might have seemed to be taking a lot of time, but with an address and call type, the CRO might still be talking with the caller, have the call entered into the Computer Assisted Dispatch system within the MedStar computer system, and the dispatcher in the next room might already have sent the information to the nearest available BLS, ALS (or both) ambulance(s) via the radio/computer link, with the ambulance(s) already on the way, while the ACD was still on the phone with the caller, giving first aid instructions.

If needed, MedStar, at certain priority or call types, would notify the FDNY "FireStar" computer that a medical "First Responder" Engine company should also respond.

Throughout all of this, the PD ACD would still be online, adding whatever information they felt would be needed for the "Sprint" "assignment history, for an NYPD Dispatcher to advise the LEOs who might be assigned the call.

Now, a head count. We are talking 2 separate call-taker and dispatcher systems for the EMS and the PD, and 5 separate borough Fire Dispatch centers, where the call-taker also dispatches the fire apparatus. Clunky? Yes, but it works surprisingly well, with room for improvement always there.

All CROs and Dispatchers for the NYC EMS Communications Bureau/FDNY EMS EMD were then, and are now, a minimum of NYS DoH EMTs, and a few Paramedics, and use a "flip-book" similar to Dr. Jeff Clawson's dispatching algorithms (those interested in this algorithm can use, and are encouraged to use, the search engine of their choice for information).

FDNY EMS EMD is under the authority of a committee of Medical Control Physicians, so if they decided to have the instructions for aspirin administering to be told to a caller, under specific, and admittedly "cookie cutter" situations, the CRO would be covered under that Medical Advisory Committee's licences.

[katbemeEMT-B]

Well buff, I still disagree that this dispatcher was in the right. A dispatcher is not trained to be advising patients to take any medication regardless of what you may consider it's harmlessness. During an assessment EMTs and Medics ask certain questions that assist them in treating the patient. Dispatchers are not trained to ask these questions and do not have the time to assess a patient. I have spent time with our dispatch center and just today in four hours they had over ten calls for chest pain. Not one dispatcher ever suggested taking ASA. I asked the manager about this and he said that it is out of their scope of practice to suggest any patient take a medication. They are able, however; to instruct a caller on how to use an Epi-pen if the patient has one and the caller asks how to use it. They can not ask if the patient has one though.

So, while giving the patient ASA may not have harmed him, does that make it okay? No. If we allow dispatchers to work outside their scope of practice then do we allow EMTs to do the same, or medics? Where is the line drawn? Aside from that point, why would a dispatcher want that responsibility and liability? If for whatever reason that patient should have an adverse reaction the dispatcher becomes liable. Why take the risk? So you see, it comes down to common sense and self preservation. Working outside your scope of practice puts yourself and your service at risk for a major lawsuit and it isn't worth it. We have to remember that we live in a sue happy world. It's better to be safe then sorry.

[Richard B the EMT]

Now I am working totally on memory, as I stated that I used to work with those flip cards. If I remember correctly, they did have us ask if the patient had any allergy to aspirin, if yes or unknown, we didn't advise anyone to take it.

[Copperhead24]

This thread, in my opinion, has taken an unfortunate turn from the original topic to the maligning of one another's chosen professions. I do not have direct/reliable information or involvement in the original incident, or the "examples" that have been cited since then & therefore don't feel that it is professionally appropriate to comment on them.

As to the original discussion - the administration of ASA prior to the arrival of EMS & more specifically for a possible brain [CVA] attack or heart [ACS/MI] attack.

At the national level, AHA/ACLS guidelines recommend the administration of ASA prior to EMS arrival per the direction of appropriately trained Dispatch for a heart attack, as long as there are no contraindications. So it is an "accepted" standard based upon American Heart Association guidelines. During the AHA/Acute Coronary Syndrome video this procedure [dispatch asking the appropriate questions - e.g. indications; contraindications; etc. & directing the administration of ASA] is demonstrated.

In fact, one nationally known aspirin manufacturer has advertisements touting that there product might help save your life in this very situation.

As to the administration of ASA for possible brain attack patients. The majority of CVA's are ischemic in nature. The outcome of hemorrhagic CVA's are poor in prognosis. Several years ago our medical director consulted our local neurology/neurosurgery dept. & was advised to put ASA in our TX protocols for possible CVA patients. There opinion [the neurologists & neurosurgeons] was that it would have little to no effect in the final outcome of a patient with a hemorrhagic stroke & that it could possibly benefit an ischemic one.

As to dispatch. Locally our 911 dispatchers are certified "EMD" [Emergency Medical Dispatch] dispatchers. They are required to have a medical director [their's is a board-certified emergency room physician] that reviews & certifies their protocols [e.g. what pre-arrival instructions, including treatment or the administration of medication, prior to EMS contact]. I do not know what their specific protocols allow for them to do or not to do. That is not my job; it is their's. I know that locally I have witnessed dispatch save lives prior to EMS contact through the direction of various skills including CPR & the clearing of airway obstructions. I have been told by another medic of the successful direction of an infant's birth by certified dispatchers.

EMD "flip-card" or "flash-card" systems have been in place for many years & have been proven in numerous studies to be more reliable [when used correctly] than untrained [e.g. not trained in EMD dispatch] EMS personnel attempting pre-arrival instructions. And, I have been told by both dispatch trainers & lawyers knowledgeable on the subject that pre-arrival instructions are the accepted standard. Those that choose not to provide uniform pre-arrival instructions are considered to be sub-standard in the dispatch industry.

[Dustdevil]

EMD "flip-card" or "flash-card" systems have been in place for many years & have been proven in numerous studies to be more reliable [when used correctly] than untrained [e.g. not trained in EMD dispatch] EMS personnel attempting pre-arrival instructions.

Problems. First, those studies are all done by people with a vested interest in the perpetuation of EMD.

Second, they establish no objective criteria for defining "reliable."

Third, there are no studies at all showing any correlation between EMD and a reduction in mortality or morbidity.

EMD is a "standard" simply because Rescue 911 embedded it into the popular culture on television. Ever notice who the medical advisor to Rescue 911 was? Yep... the man who invented and profits most from EMD.

Sorry, Bro. You're going to have to give me more than scientifically unsubstantiated hype before you can float that turd. My belief is that EMD belongs in the same scrap heap as MAST, bretylium, and CISD.

[Copperhead24]

Just located the AHA link for ASA in Heart Attack & Stroke. It is http://www.americanheart.org/presenter.jhtml?identifier=4456

The heart attack scenario is presented with the patient potentially receivng ASA from the dispatcher. You will note that the AHA advises against the administration of ASA in stroke victims because it could potentially cause more bleeding with a hemorrhagic stroke, even though ischemic strokes are more common.

I guess that's why medicine is considered a healing "Art" & not a science to quote many a physician.

[Copperhead24]

Dust;

I totally agree that you can make a "study" say just about anything you want. And when it comes to the "money" talking we need look no further than the anti-arrhythmic changes in recent years for a prime example of that [& I teach the stuff]!

While I don't know if there have been any impartial studies in regards to EMD dispatching I do know that in recent years there have been law-suits brought for agencies not providing pre-arrival instructions.

[ERDoc]

While I can see why the immediate reaction of the EMS community is that medication advice shouldn't be given over the phone, in this case there was no real potential for harm. Aspirin's anti-coagulative properties are most potent in the coronary system and least potent in the brain. This is why aspirin is never used to treat CVA patients, even after a CT shows no bleed; it simply wouldn't be effective. So even if the patient did have a bleed, it wouldn't have made the situation worse. The other thing to keep in mind is the abysmal morbidity rate for hemorrhagic CVA, so even if the aspirin were to promote bleeding, it wouldn't really change the final outcome. I suppose the bottom line for me is that there is a clearly demonstrated benefit for getting an MI patient aspirin as soon as possible, and it won't really change the outcome for a patient with a CVA, so instructing the patient to take a safe, readily available medication over the phone seems the right thing to do.

As a newbie, I will not deduct any points (others may not be so kind). When you make a statement like that you need evidence to back up your claim. Sorry to jump on you right from the start. Welcome to the city.

Dust, what do you mean Rescue 911 is not a source of information. I thought it was THE source. Shatner is like a god. I even have a shrine to him in my basement. My life feels so empty and meaningless now.

[Just Plain Ruff]

Bill's the man but my shrine is for his days on Star Trek and TJ HOoker not Rescue 911(where no-one ever dies)

[AnthonyM83]

Bill's the man but my shrine is for his days on Star Trek and TJ HOoker not Rescue 911(where no-one ever dies)

Here here