Question: CPAP for CHF and COPD is to maintain a constant pressure in the airways (splinting with COPD) and to help push the fluid out of the alveoli and into the circulation with CHF. Would paramedics who do not have CPAP available be wrong, if the patient is conscious and tolerates, assist each inhalation with a BVM to increase tidal volume and create more positive pressure during inhalation, although not maintained with exhalation, in an attempt to force the fluid out with CHF. Debate is that we assist the ventilation at one breath every 5 seconds or 12/minute unless hyperventilating due to head trauma and respiratory problems with coning of the pupil(s). Thanks for the assistance.

Question: Regarding Benadryl, in the auxiliary protocol it states that you cannot give Benadryl if the patient has taken a sedative or antihistamine in past 4 hours. This is not, however, indicated in the normal standing order protocol for Benadryl.

I am wondering if this is applicable as well if you arrive on scene with a patient who has taken Benadryl oral prior to your arrival. Do they still meet the protocol to give Benadryl even if they have already taken it? Should I still give it or withhold since they might have an overdose of Benadryl or have both the doses reacting at the same time? Would this also apply to a patient who has taken Gravol prior to EMS arrival as well?

Hope this can be clarified. I feel it’s a grey area that most of us don’t think about until put in the situation. Thanks.

Question: In a patient with an allergic reaction or anaphylaxis, who is experiencing nausea or vomiting, is it okay to treat them with Gravol after I have administered Benadryl?

Question: VSA trauma patients – chest compressions and defib is the priority for this patient. C-spine maintained manually. In this scenario, is it mandatory to apply a collar prior to a shock being delivered as the manual c-spine must be removed to deliver the shock?

CPAP- indication b/p 100 or above systolic. Contraindication is hypotension. If CPAP is applied while normotensive, can we leave the device on until they become hypotensive or we must remove when b/p drops below 100? Thanks.

Question: I have read the post Jan. 31 2012 in regards to R/A vs. 02 when resuscitating a neonate. It states that 100% 02 will be used after 90 sec with compressions if HR is below 60. It also states that 100% 02 will be continued until HR is normal. Does this refer to 100 bpm?

The reason I ask is if I read the flow chart to the letter at 90 sec with a HR below 60, 02 and compressions are begun. If I reassess 30 sec later and the HR has improved above 60 but below 100 (ex. 80 bpm), I continue ventilating, but do I discontinue the 02 and use R/A only? Also compressions are to be discontinued. What is stance on using a pedi-mate on a critical or VSA neonate or child (below 40 lbs)? Is it necessary as it can be cumbersome and time consuming when trying to get off scene quickly?

Question: I’ve heard the discussion among crews about allowing certain procedures to be performed on patients while still on EMS stretchers and on delay. I’ve received conflicting responses. I am perfectly fine with 12 lead, blood samples and going to x-ray while patient is with EMS. I’m not comfortable with any medications being given outside my scope of practice while under my care. Some crews say no “hospital” procedures are to be done until the patient is accepted by the ER. My personal opinion is that is possibly delaying patient care and causing more back up delays in the ER. I’ve received different opinions by our management. I know MAC cannot answer to service direction but what is the direction of MAC to what can or should be allowed to be performed by ER staff while under EMS care.

Question: We had our recert this week and I have a question about DNR patients. In the pocket book it says that a patient will get epi IM if they have a history of asthma and BVM ventilation is required. So I am wondering, if a DNR patient does not receive a BVM under any circumstance and an asthma patient with a valid DNR who started off just slightly SOB became severe and required a BVM would they still be eligible for epi? In other words does “required” mean that yes it is required due to the severity of SOB, but due to the fact they have a DNR they don’t actually get the BVM, can they still receive the epi, which is not contraindicated on the DNR validity form? Thanks in advance.

Question: My question is about pain management. Our directive states a maximum of 4 doses of 25-50mcg fentanyl (200mcg max) or 2-5mg morphine. (20mg max). Is there a reason we could not just have a max total dose of 200mcg/20mg and be able to give, say, 8x25mcg fentanyl q5? I feel that with the increasing frequency of offload delays it could be beneficial to the patient for us to have the ability to spread the maximum dosage out over a longer duration.

Question: With reference to the cardiac ischemia protocol. Would it be possible to update the protocol for the administration of nitro (without a BHP consult) for normotensive patient on beta blockers by either: a) lowering the heart rate parameters from 60bpm to 50bpm or b) to lower heart rate parameter from 60bpm to 50bpm when patient is currently taking antihypertensive medications within the beta blocker family with an IV established?

Question: Is the IV protocol like others in that once the patient falls out of a protocol, they cannot be put back in. For example, patient initial BP less than 90 systolic, decision made to load patient prior to IV attempt, on loading patient BP now above 90.

Question: I was looking at the PCP Medical Cardiac Arrest Medical Directive. I understand that we can give IM epinephrine in the setting of an anaphylaxis induced VSA. In the event of a ROSC from this type of VSA can Benadryl be administered IM/IV? Is there any benefit to doing this?

Question: Are MOOCs eligible for continuing education (CE) points?

Question: I have a question regarding a call done recently; dispatched to a 73 year old female patient, healthy, independently and living with husband; takes no medications and has no allergies. In recent past however, has had NYD syncopal episodes lasting up to 30 minutes, no residual deficits from events suffered.

At 08:10, patient had sudden onset of weakness, called husband who held her before she fell and gently lowered her down to floor while family member called 911. They thought patient was having yet another familiar syncope. No seizure activity witnessed.

Patient was found unconscious on floor. While on scene patient regained consciousness to a GCS of 14, she had left sided facial droop, left sided paralysis and slurred speech which has never been the case in past events. All other vital signs where within limits including BS.

Although patient had initial GCS of 3 (normal for patient’s events) Would it have been prudent to consider these two as different events and include her as a Stroke protocol candidate given the clear time of onset, her history and the marked CVA like symptoms. Thank you.

Question: If TCP with Zoll E series, what are the steps to be taken when transferring care to the receiving facility? Procedure to switch to their machine?

Question: Is a non-IV certified paramedic allowed to monitor an IV started TKVO by an IV certified paramedic on route to the hospital?

Question: There have been a few discussions flying around about a call where the patient had an internal defib whose activity was captured shocking the patient X 3 by the EMS defib. Of course, the whole discussion is treat vs. transport and shock once vs. follow the entire protocol. Can you provide some insight into these rare cases?

Question: Why don’t Base Hospital Doctors at either Hospital carry a cellphone so when paramedic’s call for a physician patch that call goes directly to them instead of being routed to triage and then to the red phone at either hospital? I have had a couple of calls recently where by the time I was speaking to the Doctor we were almost at the hospital when I got the order. I think this would be a tremendous asset for the medics if we could have this option.

Question: In the BLS Standards I found in Section 1, General Standard of Care, Directive H. Patient Transport, the following statement in subsection 1 “in the absence of direction, transport to the closest or most appropriate hospital emergency unit capable of providing the medical care apparently required by the patient.” So one question I have is the trauma patient, if they needed care above the capabilities of the closest hospital emergency unit, do we transport the patient to the closest hospital emergency unit that has these capabilities?

Question: My question is in regards when a crew has a positive STEMI result on a cardiac ischemia call. I noticed that on these types of calls there has been incidents where patients have been going in lethal dysrhythmias as crews are trying to deliver the patient to the cath lab. Most recently I was at a hospital and as a crew was entering the elevator the patient went into V-Tach and there was a delay to defibrillating because the crew had to attach the defib pads.

I noticed myself when entering the cath lab the first thing the staff does before even accepting the patient and allowing crews to disconnect the cardiac monitor is attach defib pads. Due to the high mortality rates (5%) of STEMI patients transported by EMS and the time it takes to attach the defib pads when the patient enters the lethal rhythm, would it be wise to attach the defib pads on positive STEMI patients during transport(even though they have not gone VSA) to decrease the time to defibrillated the patient if in fact the patient enters the letahal rhythm.

Question: Would SWORBHP ever consider putting a system in place for medics to learn the in hospital diagnosis of patients they transported. There are times when we transport patients and never learn what was causing them to present as they did. I think it would be beneficial to learn what the cause of the patient’s condition in those instances for our own improvement and growth. I understand it would be unreasonable to do this for every patient but it would not be difficult to set up a flagging system to tag specific interesting calls. A system similar to the follow up after a ROSC may be a model to base it on.

Question: I recently have had a couple of patients, on separate shifts, presenting with symptoms of an allergic reaction. The first patient confirmed he was stung by a bee and has reacted to them in the past. He presented with peri-orbital edema and diffuse wheezes with mild SOB. He was in no obvious distress despite the complaint of SOB. I treated him with Benadryl and ventolin, with a reduction in wheezes after the 3rd dose. I decided that it was appropriate to patch to continue with ventolin, given the patient’s improvement. The BHP’s order was to discontinue ventolin and administer subQ Epi for anaphylaxis.

My second patient presented with intense itching and generalized urticaria with edema to the suspected site of exposure. She also presented with diffuse pulmonary crackles and a non-productive cough, no angio-edema or stridor was noted. Again, this patient was not in any obvious distress despite the respiratory findings. Based on my assessment findings and the patient’s age, I decided it would be appropriate to patch for Benadryl and further consult. The BHP (different than the first) again ordered Epi for anaphylaxis (in addition to Benadryl).

Both of these patients presented with normal vital signs and perfusion status. I felt that both BHP’s orders were appropriate in these cases given that Epi is a wonder drug in the setting of anaphylaxis and allergic rxns. However, I’ve always been under the impression that it should be reserved for severe reactions, which would mean altered, mental/perfusion status, unstable vital signs, decreased/absent a/e, severe distress etc… I have no doubt that both of these patients would have arrived in the ER in stable condition without the Epi, but I also believe that epi played a big role in each of these patients’ improved condition.

My question is, at which point does our protocol allow for the administration of Epi? Or in other words, at what stage of an allergic/anaphylactic reaction do you feel it is appropriate to administer epi without an order?

Question: I have a question regarding the Gravol protocol. I had a 15 year old patient that had taken a combination of 50 pills of Advil, Tylenol and Midol at approximately 3 or 4 am. It is 7 am now when we arrive at the patient. Patient’s vitals are within normal range but patient c/o of dizziness and nausea. Patient has not eaten since dinner last night. Patient does vomit once with us while on offload delay. I opted not to give Gravol with reasoning that it is probably best for her to vomit and get it out. I understand that none of those meds are a contraindication for Gravol so in this case am better off giving the Gravol for nausea or withholding Gravol for the reason mentioned above?

Question: In regards to the bronchoconstriction protocol, in order to administer to Epi, the patient must require BVM ventilation and have a history of asthma. What if the patient is alone or they are so short of breath that a history of asthma cannot be obtained? Or possibly this could be their very first asthma attack without an actual diagnosis yet?

We were dispatched to an 8 year old with asthma experiencing SOB; on arrival no wheezing present, lungs clear, no obvious respiratory distress noted, sats at 95 RA; 100 on o2. Mom states he takes puffers but his doctor never actually told her that he has asthma. I found this odd since he is on ventolin and steroid rescue inhaler. If that scenario was different, and we did have to bag him, we absolutely can’t give this patient Epi due to the fact that the doctor never confirmed he has asthma even though he is prescribed inhalers? Is this correct?

Would a BHP patch be appropriate for an order, knowing that his air entry is diminished and the probable cause is severe bronchoconstriction, most likely due to asthma but not confirmed by diagnosis according to parent?

Question: While taking our manual defibrillation training on the new LP15 we were told “if the rhythm is fast and wide, shock it” obviously the PT is pulseless as well. We were told the “fast” value is greater than 120. We were never told the “wide” value. I have asked both ACP and PCP paramedics and have gotten responses of 0.12, 0.16, and 0.20. So, could you tell me what SWORBHP considers the correct value for “fast”? Thanks!

Question: I have a number of questions in regards to the management of obstetrical emergencies and the established standards outlined in the BLS. I know that out of hospital delivery in comparison to other call types is a rare occurrence for Paramedics. So it may be reasonable to deter pre-hospital management of certain situations for definitive care, just based on training, risk and benefit. However, I think it is important for Paramedics to know how to manage these situations when they arise.

For an example, In the BLS standards shoulder dystocia although rare is not specifically outlined. If one does some research or digs back to many college programs where the HELPER mnemonic is touched on we find that suprapubic pressure and the McRoberts maneuver can resolve many of these situations, preventing trauma and harm to the mother and newborn. Although not identified clearly in the BLS both of these interventions are touched on in other areas such as breech delivery and emergency delivery. I wondered the reason why these interventions are not applied specifically to the situation where the shoulders do not deliver and rather the Paramedic is to initiate transport immediately? Secondly, what would MAC’s direction be to the Paramedic managing a possible shoulder dystocia? With the potential for fetal hypoxia and stress it seems reasonable to apply these same interventions in this setting.

If we go along the same question of course we aren’t performing field episiotomy or controlled clavicle fractures but why can we not assist a shoulder or roll the pt on all fours in this setting? Sure we can and use our judgment but with the legalities of following the standards it may be deemed as a deviation. Can Paramedics really apply the appropriate measures from various parts of the standards to situations like dystocia and still remain legally within their scope?

The only other question this may bring up is how do we hold midwives, who have a higher level of training and knowledge to the BLS Standards?

Question: I have heard from our base hospital that MAC is considering removing KING-LT airways from the directives? Is this true, and if so, what supraglottic rescue airway option are they looking at going to, both for ACP’s and PCP’s. Not every patient can be ventilated using BVM alone.

I’ve also heard that they are looking at removing needle cric and intubation from ACP scope? If this is true, then why? Intubation does have major problems in the pre-hospital setting, but outside of cardiac arrest it is a very valuable method of controlling the airway (the gold standard) especially for long transport times or complex patient presentations.

Finally, I understand the theoretical rational behind not using CPAP in asthma PTS, but there are services in North America using it for end-stage asthma exacerbation as a option before intubating the patient. They combine low levels of CPAP (3-5 cmH2O) with a salbutamol nebulizer tied in line to the CPAP mask and are getting good results.

Is there any possibility of a clinical trial of CPAP in asthma exacerbation refractory to salbutamol/epi alone? Is there evidence against using it in asthma (besides theoretical problems).

Question: If we are treating a patient with acute cardiogenic pulmonary edema that is a nitro virgin that’s blood pressure is above 140 systolic and then their blood pressure drops below 140 systolic but not by one third then can we consider them now as not being a nitro virgin and therefore continue treating them with 0.4 nitro? Thank you for taking the time to answer all of these questions.

Question: You are called to a retirement home for an 85 y/o female for a possible CVA. On arrival you are met by a Nurse Practioner who stated patient is having a stroke. Nurse Practioner also states that patient (who is a retired RN) has talked to her family doctor who agrees with patient’s decision of not wanting to go to stroke centre or stroke protocol done. Patient has history of heart. Assessment reveals patient alert, orientated x 3 and meets stroke protocol. Patient wants to be transported to the local hospital for assessment. Does this patient or any patient have the right to refuse transport to a stroke centre?

Question: With respect to use of an OPA, I have had discussions with coworkers who always will insert one with an unconscious patient. Is this proper? My argument is, even the MOH literature seems to state that ‘less invasive’ airway management such as positioning, suctioning and constant monitoring of the airway is acceptable. Some common situations of this would be a post-itcal or alcohol intoxication persons. Thanks.

Question: I am asked to transport a patient to the cath lab. The new onset unstable angina patient (who is bradicardic with a lowest rate of 38 and multiple unifocal pvcs) and is only CP free because of the nitro during patch put on by the ER doctor.

Does leaving the patch on constitute me giving a medication that is out of my skill set? Since she/he is bradicardic (but has a good pressure) do I have to remove it? Do I have the ability/obligation to remove a treatment started by the attending ER physician? Escort required? Other suggestions?

Question: I have been hearing a lot lately of BHPs telling PCP crews to give a drug (such as Epi) on a VSA when they call for a TOR. Even after reiterating that they were a PCP/BLS crew there still seemed to be some confusion. In some cases complicating the situation to the point where the misunderstanding seemed to lead to an order to transport as opposed to granting a TOR. Is there a better way to disseminate the differences to the doctors who may be taking the TOR or BHP patch (such as a card distributed to the doctors or a chart posted at the patch phones outlining what PCP crews can do vs. ACP crews)? I am sure it is as frustrating for the doctor taking the patch as it is for the crew trying to explain why they can’t do what is being asked. Maybe something like this could help ease the whole process?

Question: I’m wondering if IN Midazolam should be administered by full dose or until effect if effect is reached prior to the administration of the full dose? Does the answer change if given IV?

For example, patient is in seizure so I administer 5mg Midazolam IN and seizure stops. Am I to continue and administer the remaining 5mg to a total dose of 10mg as per the directive, or do I stop?

Question: I understand there is no current contraindication for giving gravol to an actively vomiting patient with a suspected head injury, or to pregnant patients. Would I be wrong to withhold the drug from either patient?

Question: When a patient presents with Subcutaneous Emphysema? Can we give A.S.A.? Patient has taken it before and there are no other contraindications. SubQ is sometimes caused by perforations in the digestive and/or respiratory system, so I’m thinking ASA would be contraindicated – just looking for your thoughts or if there is a precaution.

Question: Could you clarify the Bronchoconstriction directive (epi for asthma exacerbation)? You have to be bagging the patient to give the epi. Our old directives said “any patient with severe SOB from suspected asthma exacerbation AND requires ventilatory support via BVM and OR severe agitation, confusion and cyanosis” but our new directive just says BVM required with history of asthma. I just want to be really clear, now we MUST be bagging them?

Question: A CHF patient who has a BP of over 140mmHg systolic who is getting 0.8mg of NTG for SOB, patient’s BP drops below 140mmHg so NTG dosage is changed to 0.4mg, patient’s systolic BP rebounds above 140mmHg. Does patient go back to getting 0.8mg of NTG or is it like the “once you are out, you are out” mentality that they stay at 0.4mg NTG?

General answers to this question from other paramedics I have asked usually say that the patient will continue to get 0.4mg of NTG regardless of systoloic BP, if it has dropped below 140mmHg at any time during the call. Thank you in advance for your time and help.

Question: I have a question regarding the order of cardiac ischemia SR medication in the protocol. I have been informed by a source that 0.4mg nitro should be the first SR medication given in a suspected cardiac ischemic event, followed by x2 80 mg ASA. I respectfully disagree with him due to the fact that although nitro is significantly more fast acting, its effects only last 3-5 minutes, hence the spray every 5 minutes stated in the protocol, and although the ASA is slower in its absorption rate, is effects will benefit the Pt. more (in my opinion) than the nitro. The short and sweet version, am I correct in saying that ASA should be administer first before the initial nitro dose is given, if the protocol for both is met.

Question: In the last year I have been presented with two different special occurrences regarding vital sign absent patients.

The first one involved a patient who was VSA on our arrival. We were presented with a legal living will as well as a note provided by a Doctor stating “DNR”. Unfortunately there was no ministry DNR validity form. We completed a full medical TOR as the patient met the requirements and after I was informed by co-workers that I could have called for a medical TOR after the first no shock indicated. They stated this was covered under special occurrence. I have looked and found no evidence of this existing although this could be very handy. Does such protocol or language exist?

The second incident involved a patient that we witnessed from a reasonable distance to be VSA. Due to safety reasons we could not access the patient for approximately 45 minutes. The patient did not meet obviously dead and didn’t have a DNR. We performed a medical TOR. Again informed that this falls under special occurrence and we could have called for medical tor after the first no shock indicated.

I’d really like to know if this is an option. It would come in handy for similar instances.

Question: I was just wondering if we have a patient with a valid DNR are we still allowed to Bolus if they fit our protocol or is this considered an advanced life saving technique?

Question: Are we allowed to give gravol to head injury patients that are suspected to have the nausea due to that? Also to pregnant women?

Question: Where can we find a copy of our Destination Protocol for Essex Windsor?

Question: I recently did a call in which the patient was found by nursing home staff to be agitated and non-verbal with left sided arm paralysis. On EMS arrival the patient was moving all limbs but was still non-verbal and agitated. I also noted LT side neglect and some LT side facial drooping. The patient was last seen in a normal state at 04:30 and the time of our arrival was 08:30. The patient also had a valid DNR and I confirmed again with the POA on scene that it was still the wishes. By the time we loaded and transported the patient was outside the 4 hour mark for any CVA treatment. I returned to patient CTAS 3 as they were outside the time line and for the valid DNR. I am wondering if the patient had been within the 4 hour mark for treatment should this patient be returned CTAS 2 or would they still be CTAS due to the DNR? Thanks.

Question: I have a quick question on the PCP supraglottic airway medical directive. What is the rationale for the “must be VSA” condition on the directive for PCP, yet ACP’s can use it as a back-up device for failed airway management. Would it not make more sense to make the conditions for PCP something like “Patient must have a GCS=3 and other airway management is inadequate or ineffective”?

The issue here could be two-fold. First, if BVM ventilation is ineffective as a PCP, there is nothing you can fall back on, whereas the ACP can use either ETI or a SGA as indicated. If this ineffective BVM situation occurs as a PCP and the patient is GCS=3, why can’t we insert a SGA as a rescue device for ineffective BVM ventilation?

Secondly, with some new evidence beginning to show that SGA’s may actually not be as great as we thought in VSA patients, is there a risk we could abandon them entirely from the PCP level, in essence “throwing the baby out with the bathwater” and abandoning a valuable device simply because the conditions for its use were restrictive.

Also, do you have any idea when the new revised BLS standards may be coming out from the MOHLTC? I’m hoping there are new evidence based oxygen therapy guidelines. Any thoughts? Thanks.

Question: I apologize in advance if this question is redundant, but I have searched and cannot find an answer. For a crew where both medics are IV certified (autonomous certification), are both medics allowed 2 starts (4 attempts in total) on a single patient? Or are attempts limited to 2 attempts per patient regardless of who makes the attempts? Thanks.

Question: I am a PCP and was wondering what constitutes a IV attempt. Does simply palpating and visually assessing the patient constitute an attempt if I do not find an accessible vein and do not blindly pic attempt insertion?

Question: If a hypothermic patient re-arrests is it considered a new protocol or just continue transport? Due to the 1 shock protocol.

Question: Is a police officer considered a qualified personnel to be able to witness a cardiac arrest? In regards to “witnessed arrest”.

Question: This question is regarding a cardiac arrest from anaphylaxis. If epi is given and the patient has no ROSC, arrest is unwitnessed, and by the 3rd analysis no shock is given, is it acceptable to patch for TOR, or is the TOR contraindicated due to the arrest being of non-cardiac origin?

Question: What is the Medical Director’s direction on doing repeated blood sugars after treatment for hypoglycemia? I recently had a patient who complained of chest pain after a fall. He was a diabetic with a GCS of 14 on initial assessment. His blood sugar was 3.8 and I treated him with oral glucose. He felt better and his GCS became 15. I got a comment back from an auditor who felt I should have done a follow up blood sugar after treating him. I was always taught that it was unnecessary to do a blood glucose if the patient had a GCS of 15. Has there been a change in thinking?

Question: This question is regarding cardiac arrest documentation expectations. Is it a requirement to document vital signs every 2 minutes or would it be sufficient to document one set with a comment: Patient remained pulseless throughout? As well, CPR charted once, with a similar comment: CPR performed throughout. In my opinion, this would be more efficient and concise.

As well, if in a position where we are transporting a VSA patient, as an ACP I have always performed a rhythm interpretation even while the vehicle is moving. I have never really noticed artifact as an issue, and cannot find any documentation relating to ACP practice stating I must pull over. I have not had any feedback from base hospital regarding this practice, but my supervisor has mentioned some serious concerns.

Thanks again for this forum that helps our practice.