Question: There is certainly a lot of confusion that remains in regards to DNR’s. From your replies, I get the impression that if someone is breathing, has a pulse and a valid DNR, but has respiratory or cardiac problems which may or may not be corrected with artificial ventilation, assisted ventilation without an artificial airway (conscious CHF)or chest compressions we are to provide NRB O2, symptom relief meds and comfort measures. That being said, if someone has a valid DNR becomes obstructed with a FB, we have been instructed by BH personnel to attempt to clear the FB and if death results in the process, validate the DNR and stop the efforts. If this is correct, are we not providing or at least attempting to provide A/R in one of the steps to alleviate the obstruction? This would be in contraindication to past answers which the committee has provided. Not trying to be a pain, just looking for clarity for viewers and myself. Great site €“ your time and effort is appreciated.

Question: I like to give O2 to patients for pain (when not contraindicated) even if their stats are good. I have done this for years and have found that it seems to help. A fellow paramedic felt that this was a very useless application. I disagreed. I have looked for scientific evidence for this working and have found little on it. I was wondering if you would comment.

Question: If you have a VSA patient with a previous history of methadone use, is it beneficial to patch for Narcan while the patient is VSA or until you get a ROSC?

Question: Recently I had a call for a 2 year old anaphylaxis that I ended up treating with epi and ventolin. The patient was very short of breath and had a decreased LOC and ended up having to be ventilated. Eventually the patient came around with the epi and the bagging. This patient’s heart rate was approx. 70/min. My questions is, are we still starting CPR on pediatrics with signs of poor perfusion with a heart rate of less than 60 or is this just for neonates?

Question: Patient is unconscious respirations of 8 but DNR is present. We can’t assist respirations using a BVM? Sorry if this question had already been asked / answered.

Question: I have a question regarding nitro use with lung cancer patients. I recently had a patient who was obviously in the end stages of lung CA. Patient was complaining of mild SOB due excessive amounts of fluid buildup in his lungs. He stated that he needed to go to the hospital to have the fluid drained. Patent had 5-6 word dyspnea, O2 sats at 92 %, radial pulse 90, NSR, respiratory rate 22 regular, audible crackles when patient took a deep breath, and B/P 124/86. Patient stated that within the last couple of days he had noticed swelling to his ankles and abdomen which were abnormal for him. Patient had a previous history of nitro use due to angina. Would this patient benefit at all with nitro use? He wasn’t in severe respiratory distress nor did he require assisted ventilations.

Question: This question is regarding advance airway. I really don’t like the basic airway first then if there is a problem, now go to the advance airway, ie: intubation, I have had saves due intubation right away. Once the vomit starts it’s very hard to control the airway or intubate, during CPR, the vomit can come out in excess amounts that the suction cannot keep up with, let alone if by chance you do get a save, the patient dies of aspiration pneumonia later! Yes it’s a paramedic’s discretion to intubate or not, if you have a good seal with a basic airway and an IV you can run a code, and it’s also said intubation stops CPR, well all the CPR in the world won’t help if the airway is uncontrolled. This ROC survey with basic airway for the first 6 minutes can really cause a negative patient outcome if he vomits in excess. Well at least my compression stats are good!!!! Maybe this should be discussed in the next recert. Signed an ALS Paramedic.

Question: I had a call today to a nursing home where the patient had a valid DNR. The patient was in agonal respirations. The staff stated the patient HAD to be transported to ER as per direct orders from the doctor on call for the nursing home. She kept saying the patient was a level 3 and he had to go to ER. My partner and I told the staff we cannot do anything for him and with a valid DNR the patient does not need to be transported. The staff argued with us more saying the patient had to go and that they already called ER. Instead of getting into it further with staff my partner and I loaded the patient and went to ER. We transported Code 3 as the patient expired as soon and we left for ER. Were we right in doing so? I pre alerted ER about the situation and they were accommodating when we got there.

Question: This question is regarding not giving Narcan to a DNR patient. Obviously, if there is not an underlining medical issue (e.g. terminal CA) and a patient ODs, even with a DNR, we attempt to reverse any issues. However, if the patient does have a medical issue with a DNR, has decided to OD to commit suicide and is in a pre-arrest / arrested state, is it reasonable to assume that since they are breaking the law, that the DNR can no longer be valid?

Question: In the ROSC protocol I do not notice an age range specified. If we have a patient 0-2 years old that has a ROSC, can we bolus? Thank you.

Question: If a patient meets the protocol for having CPAP treatment but they have a valid DNR Confirmation Form can a PCP still administer CPAP?

Question: We haven’t heard much discussion on this topic lately, so could you please detail which vagal maneuvers we are able to perform?

Question: In regards to the bronchoconstriction protocol I was recently in a discussion with a coworker disputing the 5-15 min dosing interval. The question was does this interval begin when treatment begins or once a treatment is completed. For example nebulized ventolin may take approximately 5 mins to fully nebulize could I administer a second treatment immediately or would I have to wait 5-15 mins post completion of a treatment. Clarification would be greatly appreciated.

Question: When dealing with a VSA FB obstruction, directives are to analyze once, load and go, revert to medical cardiac arrest if airway clears. Knowing the concern is no air to the patient due to the obstruction, would it not be advantageous to include airway blockage due to anaphylaxis as a one analysis directive and when or if the epi allows for the delivery of air, revert to a medical cardiac arrest? The airway is blocked either way.

Question: I was wondering if there was a reason that, according to the standing orders, if you want to give a patient under 25 kg Gravol you can call the BHP for an order but there is no stipulation for giving Benadryl to a patient under 25 kg’s. Is this on purpose? It suggests to me I should not consider calling the BHP for an order for Benadryl for an under 25 kg pt. Is this correct?

Question: We had a patient who presented with bi lateral crackles and patient was in obvious distress and fit all of CPAP criteria, however the patient had a temp of 38.5. I remember that during our training it was clearly demonstrated that a patient with pneumonia is contraindicated for use of CPAP. Upon looking over the protocols it is not mentioned as a contra indication. Would CPAP be an appropriate treatment? If so would it still be appropriate if this patient was suspected of having pneumonia a few days prior by nursing staff. Thank you.

Question: Does a patient that suffered from hanging, electrocution, and/or drowning fall under medical tor protocol? Also, if a patient is suffering from anaphylaxis and airway is completely obstructed and you had analyzed once and transported as per FB protocol if on route airway becomes relieved and you have good compliance do you pull over and start your medical cardiac arrest protocol? If first analyze on scene was no shock and you do pull over and have two more no shocks does it fall under a medical tor protocol?

Question: In the event of a VSA where Anaphylaxis is the suspected cause, when would be the most ideal time to administer Epinephrine IM? I’m assuming we would start with CPR, attach PADS, Analyze, then Epi. Would this be a safe assumption?

Question: If a patient has a valid DNR, can they still fall under the Stroke Protocol? I realize the protocol’s contraindications list a palliative patient or terminally ill but does not address DNR. DNR in my point of view only applies to a patient who is dead, and wishes to not be resuscitated. Treatment for stroke at a proper facility could restore the patient’s quality of life if such is affected by the stroke, and I feel they should still be included. I just wanted to verify.

Question: I have a question in regards to a specific situation with the Acute Stroke Protocol. We were called at 06:30 for an 85 year old female in a nursing home with slurred speech as witnessed by nursing staff. Upon our arrival she has a GCS of 15, blood glucose of 6.2 and obvious unilateral facial droop and pronounced associated slurred speech. The patient stated that she was up at 03:00 without concern which removed her from the Acute Stroke Protocol with all other criteria being met.

I understand that if the stoke symptoms resolve prior to our arrival the patient is not eligible for transport under the by-pass protocol. Additionally if their symptoms improve or resolve en route to a Stroke Centre transport should continue. However, en route her symptoms completely resolved and subsequently reoccurred €“ resolved again and while reporting to triage reoccurred in front of the staff at emerg.

After dialog with emerg staff I have the understanding that with completely resolved symptoms the “clock” would start (for them) with the onset of the recurrent (and witnessed) symptoms.

I would believe she would have the most appropriate care and best outcome being treated at a Stroke Centre. My question is twofold: first, is this a correct understanding of the possible in hospital treatment in way of assessing the initial onset of symptoms? Secondly, specifically for our transport decision could we use the recurrence onset of symptoms as the initial onset for meeting the Acute Stroke Protocol individually if it happened on scene or en route given we had equal distance to an ER or UH?

Question: I was wondering if in the instance of a patient cutting their wrists, becoming hypovolemic and then going VSA if this should be treated as a medical arrest or a traumatic. Thank you in advance.

Question: I was recently on a call with a patient presenting with a tachy rhythm of 157 and his blood pressure was 74/42. I proceeded to start a line and was going to bolus but subsequent pressures were above 90 systolic. Would it have been reasonable to not bolus due to the fact that this patient most likely had a decreased BP due to the Fast heart rate and not because of a fluid deficit?

Question: I’m an IV certified PCP. A question came up last week in regards to aortic aneurysms and different blood pressures bilaterally. If one BP is hypotensive, and the other is normo- or hyper- do we bolus? Ideas that have come up include: Adding fluid may increase the overall pressure, causing the dissection to enlarge; however, the patient is losing fluid and therefore is compensating and needs more.

Question: I am a recent grad from the PCP program and a new hire at my service. I have a question regarding packaging. We were called code 4 for a patient who had a fall. A call from a wrist alarm company.

Patient was found on floor by superintendent in the patient’s building after connect care instructed the super. Upon arrival patient was found still sitting on the floor. The carpet behind the patient had a small pool approx. 200mls. Patient cannot remember event but is LOA x 3, good long term memory. Patient does not know how long she has been on the ground.

Physical assessments – Trauma noted on back of head. Lac (bleeding stopped) + Hematoma approx. 1 inch diameter noted on occipital area. Chest is clear, abdomen soft and non tender, pelvis stable, no trauma otherwise noted.

Equal grip strengths. Pupils PERL. Vitals are all within normal limits. Patient upon assessment has no complaints. No dizziness, no lightheaded. NO c-spine, tenderness, no back pain.

It looked as though the patient fell from height, backwards, struck head on dresser and activated wrist alarm. I decided to package the patient as a precaution. I padded the backboard with a towel before laying patient head on the board.

My question is was it necessary to apply collar and backboard this patient? Patient had no c-spine tenderness, no back pain, LOA x 3, good long term memory only issue is patient cannot remember the fall. Patient had no complaint, except the pain from the hematoma against the board.

Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed.

Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation.

I thank you for your comments and insights.

Question: My question is regarding CTAS with symptoms relief administration. It was my understanding that years ago symptom relief pocket books had an adverb that read something to the effect of ” If a symptom relief medication is administered then you should return to the ED no less than CTAS 2″. It seems to me there are circumstances that would allow symptom relief to be administered and return CTAS 3 or less. (i.e. Nausea due to flu gravol administered, mild to moderate allergic reactions with benadryl administered…) I had a debate with a peer stating it was their belief that any time SR is administered we are still to return code 4 CTAS 2. I was under the impression as thinking medics we could use some discretion, is this the case or should we always return minimum CTAS 2 in that scenario.

Question: When it comes to chemical sedation for combative or procedural reasons I noticed that the IN route is not included. I have read the rational for this in a previous question asked of MAC (Jan 19 2012). In this question it is mentioned SWORBH was suggesting the IN route be added during my re-cert I forgot to ask if that had taken effect. Is IN acceptable in these circumstances?

Question: I was wondering recently while reviewing my re-cert material why it is that if asthma exacerbation is the reason for a pt. becoming VSA why 0.5mg of epi IM would not be administered while preparing for IV in a similar fashion that epi is used for anaphylaxis if it is the causative reason a patient becomes VSA. Thanks for the help.

Question: Can you administer diphenhydramine to a patient that is in moderated to severe allergic reaction? The old directive was clear on this, which was allowable. The current directive leaves medics guessing treatment intervention. Epinephrine is indicated as a first round drug for anaphylaxis, which is understandable.

Question: In recerts we were informed that if we are extricating a patient who suffered blunt trauma and they go VSA in front of us. We are to run it as a medical arrest since it was witnessed? Is this true?

I just read a previous MAC post and it stated: ANSWER: Great question! Assuming this is a first arrest, the correct sequence would be to pull over, confirm the patient is VSA, begin CPR, and follow the Trauma Cardiac Arrest Medical Directive which includes one rhythm analysis.

Could you please clarify this?

Question: After 3 treatments of Ventolin be it MDI or NB i was understanding that we could patch for another 3 treatments if needed. I have spoke with other medics and some say yes and some say no could you please verify.

Question: In the area in which I work, there exists a statistical cluster of clients with Myasthenia Gravis. One client that I have now transported at least three times has got the message to call at the first sign of increasing SOB. Most recently he woke up at about 0300 feeling a bit more SOB than normal and not quite right. When we arrived at his house at 0600 he met us outside ambulatory and he had a temp of 39.8C. He was tachypneic. He was in respiratory distress related (In my opinion) to both his MG as well as pneumonia. He adamantly refused the stretcher. He stated that as per his directions he had taken a dose Mestinon when he awoke and that it had not helped. He had a weak or pretty much absent cough. He was placed on placed on high flow O2 by ‘Flow Max’ and was given at least one Ventolin treatment again using the ‘Flow Max’. His condition improved slightly. He was transported with great haste. I have reviewed MG as well as the action of Mestinon. At this point in his disease process he is still requesting that all that can be done be done. Do you have any suggestions as to how we can better care for this client? Putting headers on the ambulance, installing ‘NOS’ or a spoiler is not an acceptable answer. Is CPAP a possibility? I am aware that pneumonia is a relative contraindication for CPAP use. The mechanism of the two disease is quite different but the inability to expand (active muscle use) the chest seems to make them similar. I have attempted to reseach an answer and the best I have gotten after talking with a couple of ED Docs is, ‘Good question. Might buy you some time. How fast can you drive?’ Thank you for your time in considering and answering this question

Question: My questions have to do with resolved suspected ischemic chest pain and if we should administer ASA even if the symptoms have resolved.

Question: I am a PCP student, Under the cardiac ischemia medical directive it states that indications for nitro and ASA are “suspected cardiac ischemia” my question is, a patient without chest pain but has other symptoms such as weakness SOB, N/V etc. and a positive 12 lead showing either ST elevation or depression, do they qualify for Nitro under this protocol?

Question: What are your thoughts on oxygen therapy in myocardial ischemia from a medical evidence standpoint? Even though high flow o2 is regularly administered to PTs with chest pain as per the oxygen therapy and chest pain standards in the BLS standards, there is an increasing body of evidence suggesting that in uncomplicated MI O2 is of no benefit and may cause more harm than good due to ROS and ischemia-reperfusion injury.

The recent ACLS guidelines state to only administer O2 in acute coronary syndromes if the spo2 is < 94% or the PT is in respiratory distress or obviously hypoxic and there are several recent papers and clinical guidelines that suggest a similar course of action in uncomplicated MI. Basically, the evidence is suggesting that titration to spo2 is favorable over high flow o2 due to the risk of oxidative stress injury.

Any thoughts? Obviously you still follow the protocols, but I’m just interested to see if there is any medical opinion on this. Could the standards/guidelines eventually change to reflect the newer evidence?

Question: My question had to do with attending to a call where a patient is VSA and then throughout our medical directive the patient receives a ROSC and then a re-arrest. I know that in the old medical directive we would at this time do one further analysis and then transport the patient but in our current medical directives this is not mentioned. I would like to know if I should be attempting any analysis on a patient who re-arrests after receiving an initial ROSC with our current medical directive.

Question: This question is to clarify a point in the FBAO cardiac arrest protocol. If the airway obstruction is resolved after a first analysis, it is stated that the patient can then be treated per the medical cardiac arrest directive (presumably receiving three more analyses for a total of four). My question is regarding what to do if transport is in progress when the obstruction is removed- is transport continued with CPR only (as it is not a new arrest or a re-arrest after ROSC) or can the vehicle be stopped until the protocol is complete?

Question: With regards to the administration of D50W. I was just curious if it has ever been to considered for us to titrate this drug for effect. By this I mean, if you are pushing the 10ml of D50 then flushing and repeating this until the entire 50ml is given it is assumed that you will likely notice positive effects of the drug before it is all given. So would we be better off to stop the infusion and re-check a blood sugar at this point to see if we have achieved a blood glucose above 4 or within normal range as opposed to giving the whole dose and pushing their blood sugars usually above 10.

Question: On a recent call, we transported a patient from a nursing home with a valid MOHLTC DNR. In the middle of all the paperwork was a nursing home DNR with level 1, level 2, and there was a check mark that the patient did not want to decide on a DNR status at this time. The MOHLTC DNR was dated in 2009 and the nursing home DNR was dated 2010. Do we respect the valid MOHLTC DNR or the nursing home DNR dated later?

Question: What is the rationale behind no longer doing a 45 second pulse check on a severely hypothermic patient? BLS patient care standards in section 4-11 assessments #3 states a 45 second pulse and breathing check.

I understand that ALS standards trump BLS standards. Other than a summary that came from RPPEO August 2011 on the new November Directives where it stated no more 45 second pulse checks, there is no mention in the new Directives of this change that I could find.

Question: If the patient requires ventolin and has a fever but cannot tolerate the mdi, would it then be appropriate to use the nebulizer.

Question: Two questions which seem simple but as an educator I get asked all the time. 1.) FBAO VSA patient, you are unable to clear the airway, should we follow the BLS that indicates an oral airway should be inserted? 2.) Unwitnessed VSA, do we need to do a full two minutes of CPR or just CPR until we get the pads on.

Question: I recently had my recerts and have a question concerning Medical TOR. The way it was explained to me was that a TOR was a pronouncement. It was explained to me, if we receive a TOR in the back of the unit before the vehicle is put into drive, we have stay on scene with a patient until the coroner comes. Likewise if we received the TOR while the vehicle was in motion we could continue to the hospital. I really don’t understand the difference as to whether the vehicle is in gear or not. I was under the impression that if we receive a TOR, it is simply that, terminate resuscitation and continue transport (no lights and sirens) with no resuscitation. The decision on route would then be, do we go to the morgue or to the ER. I understand the delicacy of appearances and you may have to leave scene with lights and sirens but once away from the scene, judgment on activation of emergency signals would be up to the driver/crew. Could you elaborate some more on this?

My question concerning TOR is this. Is a patient deemed dead at the time of TOR or are they deemed dead when assessed either at the hospital by an ER physician or at the scene by the coroner?

Question: Just would like clarification that we “must” attempt an IV on all seizure patients first before moving on to either IM, IN, Buccal. The chart is written in this order. I feel that attempting IV’s on a lot of our seizure patients could very easily pose a safety hazard on ourselves and others in the field. Thanks.

Question: I would like to go back to the DNR ventilation question from Sept 4th. The way I understand your answer is that there is no difference between Assisted ventilations and Artificial ventilations in regards to a DNR; Both are inappropriate if a DNR is present, even if the patient has spontaneous respirations. I am interpreting your answer correctly?

Question: I am a current PCP taking ACP. I was recently informed, during an ACP class, that on an unconscious CHF patient, nitro can still be administered if vitals are within normal range and the other conditions are met. When I checked the protocols, under conditions, it states that LOA: N/A (whereas for cardiac ischemia, the LOA must be unaltered). However, it seems to me that if the patient is unconscious, the patient is too unstable to receive nitro. I have never experienced a call like this, and it would seem that in most cases an unconscious patient would have vitals outside the perimeters of nitro administration. Can you please verify this? Thanks

Question: I have a question about a call. Male patient severe SOB. Crackles throughout with a GCS of 4, suspected acute pulmonary edema. Obviously patient of out nitro protocol. Patient’s spo2 31 and 42% with mottling noted. Patient’s initial pulse 42 with a respiration rate of 33. CPAP is contraindicated at this time so ventilations assisted via BVM. Enroute patient’s GCS improves to 15 and spo2 increases to 99% with ventilation assist. At this point could CPAP be applied or is it like the nitro protocol, once your out your out?

Question: I have noticed a number of paramedics do blood glucose testing based on the hx of an event and not how the patient is presenting at the time of assessment. For example – hx of fainting, period of unresponsiveness, diabetic with N/V, etc. If the patient is not presenting with any of the indicators outlined in the hypoglycemia protocol should we be testing the patients blood glucose levels?

Question: Recent call of a 40 years old woman with a past history of renal colic and experiencing intense low back pain that she likens to an exacerbation. She is a small woman at about 45 kg and a candidate for narcotics under the standing order for pain relief. Two questions: Firstly, we were unable to establish an IV after 2 attempts and the standing order specifies only the IV route of administration. Can morphine and/or fentanyl be given IM in this instance as a standing order? Secondly, her initial BP was 90/60. Given the patient’s size and her statement of usually having a low BP, can this reading of 90/60 be considered as normotensive? What if it was 85/60? Thanks in advance for your answer.

Question: Do we have an idea when the iPhone app for our medical directives will be released. The majority of paramedics I know use iPhones and are anxiously waiting for this new tool. Any idea when?