Question: What are your thoughts on CPR with ventilations vs. continuous chest compression CPR? – Student PCP

Question: In regards to a traumatic VSA. The patient goes VSA during transport to the closest ER. The paramedic believes the arrest is of trauma origin. Do we pull over and perform one analysis and then resume transport? Or do we just do CPR until we arrive at the ER?

Question: With these new medical directives, I was under the impression that we as medics are able to use our judgment and discretion on calls. It is mine and many of my colleagues opinion that oxygen is not required on all calls, maybe even some calls when you provide sympatientom relief, depending on the circumstances. Does MAC agree? Or should oxygen be applied to most patients, and in all cases that sympatientom relief is provided?

Question: As a PCP, can you do an inter-facility transfer with a patient with IV running lactated ringers without an escort?

Question: In the case of a patient who is in obvious respiratory distress with wheezes audible once you make patient contact (i.e. without auscultation), is it necessary to administer o2 via NRB first? Obviously these patients are in need of salbuMtamol and can not tolerate an MDI and spacer. The time it takes to first put on a NRB and then set up a nebulized treatment seems counter productive. Can we start with a nebulized treatment and then apply o2 via NRB after the 1st treatment while we reassess the patient?

Question: I just have a quick question regarding IV Monitoring. Are PCP’s allowed to transport a patient without an escort who has an IV running lactated ringers? This question came up the other day at work and everyone seems to have a different answer. I just wanted to clear this up with you so I know the correct answer!

Question: On medical VSA’s, as an IV certified PCP, if you have time and enough hands to start an IV, are you giving a fluid bolus? I realize when you get a ROSC you are doing a fluid bolus of 10ml/kg (if chest is clear), but while the patient is VSA, are you giving a bolus? Or are you starting a line, just running TKVO in preparation of getting a ROSC and then bolusing?

Question: I am a recent graduate and have a question regarding the traumatic VSA protocol. We arrive on scene to find 5 patients. Two are VSA and three are CTAS 2. The next ambulance is 5 min away. We use triage but after the three CTAS 2 patients are gone what do we do with the 2 VSA patients? Are we to do a Trauma TOR? Or is it just left at that point?

Question: A patient requires assisted ventilations via BVM for shortness of breath for CHF or for exacerbated asthma, can we assisted ventilations for this patient. I understand that we cannot perform artificial respirations for a patient who is apneic, but can we assist ventilations with a patient who is conscious and breathing on their own, but needs assistance? Patient has a valid DNR.

Question: Just some clarification in regards to DNR’s. If a patient is having an episode of an exacerbated Asthma and has a valid DNR, do we administer Epi for the asthma? I understand that we cannot “bag” the Patient due to the DNR status.

Question: To what extent am I allowed to take orders from a physician who is riding out with me? Are there any set guidelines to direct us and the physicians in this aspect? A recent resident riding with me said they had no issue with providing the order if it seemed reasonable. Narcan administration was used as an example as something that seemed reasonable. However the resident felt (and I agreed) something like a TOR order warranted a call to a BHP. Discussion of this subject would be appreciated.

Question: I work out of a first response vehicle. If I start an IV to deliver a med such as gravol, and the patient will not require anymore treatment via IV and I am handing the patient over to a crew that is not IV certified what is my responsibility? Do I have to accompany the patient? Or can I lock the IV or can they monitor the IV TKVO?

Question: I’m an ACP in my primary service, but I am working as a PCP in a different service. Does my IV certification status automatically transfer directly to the service in which I am working as a PCP? If so, I have not been trained on the equipment being used in my PCP service and would prefer not to use my IV skills there. Am I obliged to?

Question: Example: A patient presents generally unwell, lightheaded and feels like their heart is beating fast, not an unusual call for any paramedic. On exam the patient has a pulse of 130-150 BPM, sinus tach to match on the monitor and BP is 100-110 systolic. Would it not be safe to assume that the BP is being maintained by the HR?

The question: Could this patient not benefit from a one time fluid bolus/challenge of 250ml to see if it decreases the HR decreasing cardiac demand and maintain the BP thus being beneficial for the patients overall condition? I realize that the IV and fluid therapy directive is for a BP less that 90 Systolic and is to ensure that a patient has an adequate perfusion or actual/potential need for medication, however would this not fall under the fluid therapy part of the IV and fluid therapy directive?

Question: I have recently heard several answers to the following question, so I would really appreciate hearing the answer. How many IV attempts are allowed/permitted/encouraged per paramedic/patient?

Question: I’m curious if it is recommended to take blood sugar readings on VSA patients? If a blood sugar is taken on a VSA patient, and the reading is < 4mmol/L (which may be quite common due to the sample being capillary and CPR not perfusing sugar to the extremities), do we treat with Glucagon or D50? What if we suspect the patient is VSA due to a diabetic event? Does the answer change whether I'm a PCP or an ACP? Thanks!

Question: I have recently received an ACR audit, and have spoken to others, within my service, who have received audits as well, stating that a DNR patient who has not arrested should be ventilated via BVM. Everyone is under the impression that a DNR patient should not be bagged. I know that I have had previous conversations with SWORBHP educators in which the final word on this subject had been no BVM in the presence of a DNR irregardless of whether then patient was VSA or pre-arrest. A similar question on this issue was previously asked and answered on 1-March-2012 with the resulting answer being “therefore, to answer your question, if a valid DNR form is available, none of these “advanced cardiopulmonary resuscitation” procedures should be initiated, period. The SWORBHP medical directors would suggest that this is independent of whether or not the patient has completely arrested or not”. The question now is what is the right thing to do? What we have previously been told is right or what the auditors are now saying we should be doing? Could you please shed some light on the situation because there’s once again a lot of confusion surrounding the correct application of the DNR. Thanks.

Question: Can an off duty medic who stops to assist an on duty crew the care (in the area for which he works and is certified) at an accident scene or medical event provide advanced care i.e. IV, med administration injections etc.?

Question: I have some questions regarding supplemental oxygen. For a patient who requires oxygen, but is vomiting frequently is a nasal cannula an adequate oxygen delivery system, or should a Non Rebreather be continually removed an reapplied as necessary? Also I see a wide range of flow rates applied to the nasal cannula (anywhere from 2-8 lpm). What flow rate is most beneficial to a patient in a pre-hospital setting who requires supplemental oxygen via nasal cannula?

Question: In the medical cardiac arrest directive it states, In unusual circumstances (e.g. pediatric), consider initiating transportation following the first rhythm analysis that does not result in a defibrillation being deliver.” My question is: What is the age range for a pediatric? Thanks in advance.

Question: Do all Phosphodiesterase Inhibitors generic names end in “fil”? Are all drugs that end “fil” Phosphodiesterase Inhibitors? Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

Question: I am wondering if it is acceptable to initiate a bolus for hypotension based on “estimated” blood pressures. I.e. you are unable to obtain a BP through auscultation and the patient has no palpable radial pulses. We have been taught that you can estimate a patient’s blood pressure to be 80 systolic or less with the absence of palpable radial pulses. So, can I treat a patient with a bolus, based on estimated BP’s and in conjunction with other symptoms, or do I need an actual and specific number. Thanks in advance.

Question: I was just wondering the reasoning as to why we don’t check for a pulse after we deliver a shock, and instead jump right into CPR? I have watched many VSA’s ran in the ER and always see the ER physicians check for a pulse after delivering a shock before resuming CPR. I have asked several co-workers and no one seems to have an answer for this.

Question: I know there have been a lot of questions regarding the new cardiogenic pulmonary edema protocol. I am a student and just had a call regarding this. After the call there has been discussion about the directive and I have heard three different views and they are…

1. The first treatment column <140 you can ONLY give NTG if a IV is established (no hx.) 2. The second column stating that =>140 with no hx or Iv you can give 0.4mg is to be completely disregarded as it contraindicate the directives conditions 3. The third column stating that =>140 give 0.8mg ONLY if an IV is established (no hx.)

So the question I am asking is can you please clarify the treatment chart of the acute pulmonary edema directive?

Question: We are transporting a patient from a small hospital without a CT scanner to a larger hospital with a CT scanner but not a Stroke Centre. Our patient is an obvious stroke patient…slurred speech for over 1 day, but is getting better and no other issues…stable, but still with slurred speech (does not meet Stroke Protocol as onset over 24hrs).

What should we do should this patient become worse enroute to the CT capable hospital? Say his slurred speech becomes worse or he shows other signs and symptoms? Is this considered a “new onset” or a continuation of his current CVA/TIA? If “new onset” I would think he now meets the Stroke Protocol and should be diverted to the Stroke Centre? Could you please clarify?

Question: Our medical cardiac arrest protocol states for pediatric patients consider initiating transportation following the first rhythm analysis that does not result in a defibrillation being delivered. My question is, “Until what age do we consider a patient a pediatric?. Thanks in advance.

Question: I was just wondering how CVAD access should be documented on the ACR? There is no specific code for CVAD. Is it ok to document using the Normal Saline code (345) and just specify that it was via CVAD in remarks? Should I always get blood when I aspirate? (I didnt but it seemed to flow well).

Question: I need some further clarification on the question “Seeking Clarification” from March 1 2012 regarding hypothermia. It has been my understanding that we DO NOT give medications to hypothermic VSA patients. I have clarified this before, unless this rule has changed since, so could you please readdress this part of the question for me?

Question: I am an A-EMCA certified paramedic (PCP) who opted to work in Ottawa full time for a full year after graduation in 2009. After returning to London to apply, I am now advised that my IV certification issued by RPPEO is not eligible for SWORBH. Are there IV certification courses I can take in London to become “IV Autonomous Certified” without going back to Fanshawe College to repeat my entire second year of school? Please let me know so that I may increase my eligibility to someday secure work here in my home town.

Question: I was just wondering when the smart phone app is going to be released with medical directives?

Question: When arriving at a scene that turns out to be a ROSC, say Fire applied two shocks and now patient is alert and oriented, and fire pads are not compatible. Do we apply monitor electrodes, defib pads or choose based on our gut of how unstable the patient looks and might re-arrest? Having chosen and justified on the remarks section, what would you like to read to feel we were justified?

Question: This question is similar to one already answered but slightly different. If you have a VSA patient as a result of a FBAO and the obstruction is relieved, should you analyze right away or continue with a 2 minute block of CPR. Also, after having done the medical defib protocol does this patient now qualify for a Medical TOR?

Question: I have heard paramedics inquiring amongst fellow paramedics about the use of epi without a cardiac monitor applied or a full set of vitals when dealing with a patient who is suffering from anaphylaxis. My stance is that all meds (except ASA) require a full set of vitals and the cardiac monitor applied. Please clarify.

Question: At a meeting with Dr. Lewell in the past, he stated that there is no time set for the administration of medication. Some medics are directed by their services to deliver the medication within 5 minutes and yet the Base Hospital directive asks to have the monitor on in 5 minutes. Medication cannot be delivered without the monitor being applied, so is it correct to say that the time limit is not 5 minutes, but ASAP after the monitor is applied?

Question: For STEMI Bypass, what is the delay in extending the bypass into all of the services that would meet the transport criteria? Originally I was told it was an issue of having an IV established, now with the increasing number of service providers with autonomous PCP IVs this would no longer seem to be an issue. I never understood the initial rationale since say Glencoe is 50km from UH and St Thomas is roughly 20km closer. Yet Glencoe could bypass and St. Thomas couldn’t. Thanks in advance.

Question: With regards to the CPAP protocol, one contraindication is a tracheostomy. If this was just temporary and the tube had recently been removed, would CPAP be able to be administered?

Question: In a PCP crew with one of those PCP IV certified, should the PCP IV attend on all VSA’s? All chest pains with nitro use? It’s just that the IV directive is very vague and leaves it very open to interpretation. Thanks in advance!

Question: ALS paramedics have directives as to when they must attend/start IV’s to give meds in various situations/bolus etc. The directive for starting an IV is for the “potential need” for an IV, administering meds or bolus. Are there specific times we should always attempt an IV if time permits? (pre arrest, post-ictal, chest pain with past nitro use etc?)

Question: In a hypothermia patient, what is the reason behind the possibility of them going into A Fib?

Question: When a hospital is on “consideration” and we are not accepted by this particular hospital due to their CTAS score or related clinical condition and they are to deteriorate while en-route to the next receiving hospital. What liability do we as paramedics wear in these situations?

Question: In the previous cardiac ischemia medical directive it said that if the patients symptoms resolved after the administration of nitro and then returned that you could administer another 6 sprays of nitro. I was wondering if this was still the case.

Question: I have a few questions about some of the omissions from these protocols that were in the old protocols. The first one is in the event chest pain resolves and re-occurs it is treated as a new episode and nitro protocol repeated. This isn’t stated in the new protocol so if this were to occur can we repeat although it isn’t stated? The other question is regarding the medical arrest protocol. No provision is made in regards to on scene ROSC and re-arresting patient in ambulance. The old protocol says we can pull over and analyze once then continue to receiving facility. With nothing in the new protocol do we follow the same format? Thank you.

Question: If a patient from, for example, a structure fire is VSA with severe 3rd degree burns to the majority of their body and asystolic upon arrival would this fall under a medical or trauma cardiac arrest protocol? I would assume there is a high likelihood that the cause of arrest is more asphyxial in nature from smoke and toxic fume inhalation so it would be a medical protocol. That being said would this patient also meet medical TOR protocol since the arrest is asphyxial in origin? In discussion there seems to be so many variables put forward that there is no general consensus on which protocol to follow. Assuming there is no associated blunt trauma (e.g. structural collapse or explosion) or any penetrating trauma (e.g. explosion or injury occurred prior to burns) and the only trauma is the burns themselves what’s the most advisable course of action to follow?

Question: As far as the TOR mandatory patch point goes: if we are able to relay to the BHP that we would like to transport as opposed to terminating (e.g. public place, family insists we do so etc.) then why not allow the discretion of the paramedic to dictate whether to spend the time actually doing the patch? Since the physician is relying on us to paint a picture of the scene and if the BHP will accept our interpretation of the events unfolding and most likely state to transport anyway, patching to get permission to initiate transport seems to be more of a delay than a benefit.

Question: This question is a follow-up to clarify between two questions previously asked- specifically, regarding advanced resuscitation in the setting of DNR, and treatment of FBAO in the setting of DNR. In the most recent question the DNR validity form is quoted as stating that chest compressions should not be initiated on patients with a valid DNR, while in the earlier question it was stated that DNR does not preclude treatment for choking. Should we come across this situation, would we then only administer ‘Heimlich’-like abdominal thrusts and not proceed to chest compressions when the patient goes unresponsive, or should chest compressions be initiated until the heart has arrested and then discontinued (i.e. not proceeding to true CPR)?

Question: I don’t agree with the transport consideration in case study #1 of the Acute Stroke Protocol that states the patient is excluded from transport to a Designated Stroke Centre due to not being able to determine onset of symptoms: male, age 58, found unconscious on the floor at 0800 by a friend, when he came to pick him up for work.

Shouldn’t we consider it likely the symptom onset was < 3.5hrs especially in this case where it would be safe to assume symptom onset probably occurred after patient got up to get ready for work and that he probably does not get up three and a half hours prior to getting picked up at 0800.

Further, it’s more likely his GCS would be worse than 10 had he been down much longer. Bottom line, shouldn’t we be erring on the side of caution for these patients and give them the benefit of the doubt that symptom onset might be < 3.5hrs given the evidence at hand? Or even with less evidence? As an aside, is the time going to be extended as i believe some doctors think it should?

Question: The old protocol for Gravol stated it may be given for severe nausea or vomiting. The new one also says we may give it for nausea or vomiting. It does not say severe anymore. My question is do we have to give it to everyone who says they have nausea even if it’s minor?

Question: In the ALS patient care standards it states that a Supraglottic Airway (King) is indicated when “Need for ventilatory assistance OR airway control AND Other airway management is inadequate or ineffective”

In the “un-controlled” world of EMS would it not be more effective to use a King over an oral airway after the first round of CPR is complete? The King allows for movement from the floor to stretcher with no worry about “losing” your airway. It also doesn’t fall out as an oral airway will in the difficult situations/extrications we face in the field. The fear of gastric distention is also completely alleviated, making the King more effective. It would also allow for constant compressions, which is the best treatment for cardiac arrest patients in pre-hospital settings according to the Heart & Stroke. I have had many discussions with other paramedics and they seem to think that you can’t use the King at all if you have an oral airway that is giving adequate control. So my question is, if you use the King on VSA patients, is it acceptable even if the oral airway will work (just not as adequately or effectively in my opinion)?

Question: If we are on a call and suspect child abuse or neglect may be taking place what would be the best way to contact child services? Also could we run into confidentiality problems? An example would be if we are called to a residence for a woman with abdo pains. After assessing the scene we notice an infant sitting next to drug paraphernalia.

Question: With respect to the Medical TOR, can we leave a deceased patient with family members after the TOR has been granted? It does not state in our medical directive who we can leave the body with (I always presumed it would Police, a family doctor, Coroner, Supervisor, Nurse at Nursing Home / patients home, etc.). In the Deceased Patient Standards it does state under responsible person / unexpected death chart… family members would be acceptable. I would imagine it would depend on the situation at the scene and family members state of mind. If you and your partner are at the scene of a medical TOR and another call comes in down the street for a code 4 – VSA for example, can both crew members leave the scene and have family take over care of the body? I know you could do a first response with one crew member, but again, two would be optimal. If you were a Supervisor on scene taking over care for your crew, could you leave the pt in the care of family and do a first response? You are on scene with a patient who has met the Obvious Death Criteria, can you leave the patient with family members or do we wait for Police, Supervisor etc. to attend the scene?

Just wanting clarification on who would be the ‘responsible person’. If a Paramedic felt that family would meet the criteria for ‘responsible person’, could we have family take over custody of the deceased person for Medical TOR or Obvious Death Criteria providing scene was safe, family coping well, no suspicious events at scene, etc.?