Question: There is some confusion about patients that have a valid DNR, and are very sick requiring transport. It makes sense that many of the ACP skills might not be utilized on these patients, and CPAP would be a PCP skill. There are cases where the family changes their mind on a DNR, and cases where the status is not clear. There are also other cases where a patient may be a trauma and have a valid DNR where they may need a needle decompression, but not necessarily cardiac arrest needing CPR or intubation. Is it OK for ACPs not to attend valid DNR patients?

Question: Is narcotic analgesia recommended for patients currently on methadone? Would there be any synergistic effect? Would it cause the patient to relapse?

Question: I have a few questions regarding the new analgesia and moderate to severe pain medical directives.

1. Could you be more specific on what you mean with “current active bleed”? Would this include the possible bleeding attributed with fractures? Blood in urine from damage caused by known kidney stones? Menstrual bleeding?

2. Could you elaborate on the condition of “patient must remain NPO or is unable to take oral medications” for Ketorolac? Does this mean it is only to be given if Tylenol/Ibuprofen cannot be given orally, or they should remain NPO after medication administration?

3. Should we avoid giving Tylenol/Ibuprofen/Ketorolac if patient has already self-medicated with other pain medications? i.e. Percocet, Demerol, etc.

Thank you in advance for your clarification.

Question: I am a PCP-IV medic who recently transferred a patient between facilities – from county hospital to trauma centre. On arrival I was told by the attending physician that the patient was to be spinal immobilized as a precaution as instructed by the trauma centre. The physician also informed me that the trauma centre requested that the patient receive 1000ml NaCl prior to arrival at the LTC. I inquired about the patient’s vitals and assessed the patient as normotensive with no indications of poor perfusion. I told the physician that my protocols did not permit me to fluid bolus the patient with up to 1000ml enroute unless the patient was hypotensive and remained hypotensive. Moreover the sending facility was not sending an escort on this long CODE 4 STAT transfer. I called my Duty Manager for advice and was told to abide by my directives and follow the BLS standard for IV monitoring – 200ml/hr max pending patient presentation enroute. This is the direction I proceeded with.

My question is – was I correct in my course of action and was it advisable to press the physician for an escort based on the requirements of the LTC?

Question: If a doctor is someone who can assume care of a VSA patient and decide to have resuscitative efforts ceased, then why is a doctor not someone who counts as a witness in the ‘unwitnessed arrest’ condition of a TOR, along with paramedics and firefighters? Thanks in advance.

Question: I have a question about postictal patients and cardiac monitoring. I have been told two things by several other partners in past few weeks. Assume you are a regular seizure patient whom you have seen many times and he/she is in their normal postictal state and you are not suspecting brain trauma. Is there any clinical reason/need to put cardiac monitor (e.g. limb leads) on? Also assuming you have a 1 min transport time. I was told as per BLS standard you “must” but in the postictal section it mentions that the paramedic may consider enroute. Thanks.

Question: I have recently came across a situation where an ACP/PCP crew decided to have the non-IV cert PCP attend a Stroke Protocol call, and the ACP replied that he/she did not think it was necessary. Because the protocol requests a IV be established whenever possible, should the ACP have attempted an IV and attended?

Question: Is there any chance we will start giving acetaminophen to children with fevers (a temperature above 38 degrees) in the future? If not, what are the reasons why we can’t add this to our protocols?

Question: Trauma and BGL. Is it imperative, at a traumatic event, when no signs of hypoglycemia where evident (e.g. guy on a bike hit by a car) to do a blood glucose reading even when a decreased LOA is present. Generally, does stressful events such as this not trigger a sympathetic response which would elevate the reading anyway? I understand if someone was acting different prior to such events. If BGL reading is to be done, when would the MAC feel it most appropriate to obtain, immediately or after package and in the truck? Thanks.

Question: On February 21, of this year the London Free Press had an article stating that the Middlesex London Health Unit plans to roll out naloxone kits to the public in hopes of preventing deaths from unintentional overdoses. Toronto Health Unit has already been distributing these kits. Why are Primary Care Paramedics still without this drug when Naloxone now in the hand of the public?

Question: My question is regarding our chest pain protocol. There is a 48 year old male complaining of chest pain. It is substernal, 7/10, onset 1 hour, provoked at rest, radiates to left arm sitting steady.

O/E patient’s history is hypertension; vitals H/R 78 regular and full; breathing 20x / minute; B/P 138/99; conscious and alert x 3. Patient is not allergic to ASA, so he receives ASA.

History of nitro is in question. The patient states he was in hospital once with similar chest pain and doctor “gave me a spray of something for my chest pain”. When asked if it was nitro, the patient did not know name of medication.

Could this patient receive NTG or should we patch?

Question: I have a question regarding an MCI scenario. There is a total of 10 patients; 3 patients are dead from trauma and 7 patients are cleared off scene from other ambulances. You now have the 3 black tag patients left. Do we need to re-assess these patients and get trauma TOR for each one?

Question: I am just curious as to why SWORBHP or MAC has opted to pull the android/iPhone medical directives app? This was a great tool if a quick refresh was needed while en route to a call. I realize we should all know our protocols inside out, but sometimes a quick reference for reassurance is needed. I was under the impression when the app was pulled it was perhaps for a further refinement/usability and we would be seeing it again soon. It makes no sense that a tool like this was given to us then pulled back. Also, it’s a great tool for SWORBHP to update any protocol changes from year to year as you are no longer supplying us with books.

Question: Are there contraindications for sager applications?

Question: Couple of questions regarding the Musculoskeletal pain protocols:

To be clear, we are to give Acetaminophen and Ibuprofen OR Ketorolac. There is no case where we can give all 3 medications, as Ketorolac requires NPO?

Also Cardiovascular Disease means anyone with any hint of HTN, Athersclerosis, Dysrrhthmias, Heart Failure, and Peripheral Vascular issues, anything of the sort are not to get Ibuprophen?

And lastly for Ketorolac, is a daily ASA considered anticoagulation therapy?

Question: With the new PCP pain medical directives, I realize there has been a lot of debate over the age range. That being said, if we end up with a patient outside the age range (within reason), in severe pain, who does not meet any other contraindications, if a BH patch would be advisable for the possible administration of ketoralac? I realize that the patch orders are generally doctor specific but I was just unsure if these ages are set in stone or given special circumstances and orders if the rules can be bent. Thanks for the help!

Question: I have a question regarding the Analgesia and Moderate to Severe Pain medical directives for torodol and narcotics. Can a narcotic analgesia and torodol be administered to the same patient on the same call if the ACP determines the patient’s pain is severe enough and the properties of both analgesics would be beneficial given the situation? Or are we best to pick the most appropriate analgesia and possible consult with a BHP? Thanks for your time and input!

Question: With the Middlesex-London Health Unit distributing Narcan to the public for high risk users, I can’t help but picture getting sent code 4 for an overdose and on arrival a bystander hands us this kit because they didn’t want to be the Good Samaritan drug user. Will there be any changes to the Narcan Medical Directives to somehow include PCP’s in the near future?

Thanks in advance.
http://www.lfpress.com/2014/02/21/a-life-saving-role-for-users

Question: For Traumatic Cardiac arrest protocol in regards to age, is it = or > 16 or => 18?

Question: On a recent ischemic chest pain call with an approximately 60 year old female patient, conscious and alert, 2 nitro sprays prior to arrival. The 12 lead was normal and I gave ASA, but decided to withhold nitro as I had difficulty obtaining a BP on scene. The patient had no palpable radial or brachial pulses bilaterally. My partner and I made 4 NiBP attempts on scene with no reading on either arm and manual BP attempts bilat with no sound on auscultation or deflection of the needle. I was unable to also confirm the HR that showed on the monitor as she was uncooperative while attempting a carotid (although present). After extricating the patient on a stair chair, I decided to continue my care with an IV TKVO in the truck. I did not want to delay scene time any further. While in the truck I continued to attempt NiBPs which was now displaying a reading of hypertension, yet no pulses other than carotid were palpable. Although the monitor was always showing vitals within my parameters to administer nitro, I withheld it, as I was treating the findings with the patient, not the monitor. She had stated her pulses were usually weak. She remained conscious and alert with no signs of hypotension other than weak/absent pulses. My question is€¦ was I ever justified to administer a bolus to this patient?

Question: I have overheard a couple of crews recently discussing the ACP cardiac arrest protocol for when you arrive on-scene and a PCP has already initiated their protocol.

I’ve overheard that some crews use what the PCP crew has done (say two no shocks) and then just do two more and either call for pronouncement or transport. I also know other crews that will show up and do their entire three rounds of epi, etc. and then call/leave regardless of how many or what the first arriving PCP crew has done.

I know what I do but which one is actually correct because now I’m wondering if I’m doing the right method.

Question: You respond to a call for a 57 year old male patient who collapsed while cutting the lawn. On arrival, his neighbour who witnessed the arrest, reports that she saw him fall and when she checked on him, she realized that he was in cardiac arrest and started CPR. You confirm that the patient is VSA and quickly apply the defib pads. You deliver one shock and start CPR again but the patient begins to moan and tries to raise his arms. Your next action would be to…?

Question: Penetrating without neurological deficits. Delay on scene to spinal immobilize?

Question: Here is a question that has been up for debate from a few paramedics I work with. If you have a penetrating trauma, either in the chest or back, the BLS states to immobilize the object and transport to the best of your ability.

If the patient were to go VSA and the object was impeding CPR, either from the chest or back (not being able to do proper compressions), it was my understanding that we as paramedics are supposed to remove the object if we cannot do proper CPR instead of working around the object, which is the counter argument. What is the direction regarding this?

Question: I am seeking direction in the management of a patient(s) who have sustained exposure to Hydrogen Sulfide (H2S) in suicide; taking into account the presenting HAZ-Mat situation and the associated dangers to 911 allied agency personnel. Specifically, assessments, resuscitation, TOR, field pronouncement, transport guidelines and recommendations.

My major concern is the potential harm to transporting crews due to external ventilation of the lethal gases notably if the Fire Dep’t “4 Gas Monitor” monitors indicate a presence of H2S.

Question: In the thermal burns webinar very near the end, mention was made of London Fire carrying an ointment for treating burns. If Fire had not applied this prior to a paramedic taking over care for the patient, could the medic allow the ointment to be applied or apply it themselves? Or would this fall out of our scope of practice because such treatment isn’t mentioned in the BLS or Medical Directives?

Question: In the case of a post-ictal combative patient, is time considered a “reversible” cause? I’m hesitant to jump to sedation for somebody who could resolve on their own in a few minutes. However, today we had a case where we held off, but the patient was not improving and beginning to pose a danger to himself so we went ahead with the standing order. Should we have initiated it immediately? Or if safe for the patient wait to see if they do resolve on their own, and what would be an acceptable time frame?

Question: According to the PCP Dimenhydrinate Learner’s Certification Package on the SWORBHP website under training materials, it says “It is also very important to note that Dimenhydrinate should not be administered to anyone with a recent history of closed head injury or medical history of a seizure disorder” (due to the decrease of seizure threshold)

However, history of seizure disorders is not a contraindication in our medical directives. Does this mean we are able to treat patients presenting under the nausea and vomiting protocol with a history of seizure disorders with Dimenhydrinate?

Question: Once I’ve started my bolus, do I stop once just above 90 say 92 or do I stop once normal tensive at 100? This has been tossed around so many times and I get both answers.

Question: What is the reason why IV certified PCPs cannot bolus PEA patients?

Question: In studying for this year’s recert, I started to wonder why the administration of intramuscular epinephrine was being advocated for a first line drug in the management of an arrest where the patient was suspected to be suffering from anaphylaxis. The impression from the protocol is that this procedure should be given priority over starting an IV or an IO. Given that as a routine course in all arrests, an ACP will usually manage to initiate an IV / IO and administer epinephrine (1.0 mg €“ twice the dose that would be given IM) early in the call, it doesn’t seem to make sense to delay the initiation of the line.

With few hands on scene, and the PCP partner performing CPR, the ACP will only likely be able to perform one procedure during the two minutes between rhythm analyses €“ draw up and deliver epi IM or initiate an IV and deliver epi IV €“ but probably not both. Since the patient was likely suffering profound vasodilation prior to the arrest, there is low likelihood that there would be much effectiveness in circulating the half millilitre of fluid that is administered IM into a deltoid using CPR alone (which, at best, is only 25% as effective as the heart pumping on it’s own). The introduction of epinephrine directly into the bloodstream would likely have a much higher probability of achieving systemic circulation and effect as compared to the IM injection.

The recommendation seems to stem from an interpretation of Part 12 of the 2010 AHA ECC guidelines (Cardiac Arrest in Special Circumstances) where the use of IM epinephrine in arrests of suspected anaphylactic etiology is advised as a modification in the management of a BLS arrest. The recommendation is not present in the modifications in the management of an ALS arrest where, conversely, it is advised that epinephrine is administered by IV where a line is present. In fact, the one recommendation for ALS modification in the management of anaphylactic arrests in the AHA ECC guidelines is absent from our protocols. Currently, a fluid bolus is only indicated where the patient presents in PEA, however, the AHA ECC guidelines make the recommendation that “Vasogenic shock from anaphylaxis may require aggressive fluid resuscitation (Class IIa, LOE C).”

I understand that OBHG MAC might have apprehensions in delaying the administration of epinephrine in circumstances where an IV or IO could not be initiated in short order, however, would it not be more effective to use IM epinephrine as a backup where the line could not be initiated quickly (as in the case with Glucagon vs. IV Dextrose)? The IM administration would also have a higher likelihood of success if given once optimal circulation due to CPR was achieved (which would not occur until a couple minutes into the call).

Thanks for your consideration!

Question: What position should patients be in when we are doing do a 12-lead?

Question: A hospital wants to send a hip fracture patient for transfer. They claim blood pressure is normally high 80’s and doesn’t require an escort. Should they not still be sending one?

Question: If a crew shows up on scene to VSA patient and fire has already analyzed/shocked, can we include those in our protocols or do we start from the beginning?

Question: My question is regarding Traumatic TOR caused by penetrating injury. I have been informed that penetrating trauma TOR is only allowed if it involves the head or torso. Is this correct or is it anywhere on the body? Thanks.

For pediatric VSAs, at what heart rate do we initiate compressions?

Question: If an IV certified paramedic with a non-IV certified partner initiates a saline lock but does not give fluid or medication; can the partner without IV certification attend the call?

Question: The medical directives state that in order to call for a medical TOR one of the conditions is for the arrest to not be witnessed by EMS.

Does this just refer to EMS or does it include other emergency services, such as Nurses, Fire, Police or PSW? For example if PSW or Fire witnessed the arrest before EMS arrival and EMS arrived on scene and completed 4 analyzes and no shocks delivered, can EMS still call for a TOR because it was not witnessed by EMS?

Question: Can ALS take a pronouncement from the on-scene doctor at a retirement home? I ran the code, since the patient was full code, and got a pronouncement on the phone with the BHP. Once we stopped care, the guy who had been watching us, said that he was her doctor and didn’t think we would get her back.

I was wondering if that the on-scene doctor had said something at the beginning of the call, could I just ask him for the pronouncement instead of waiting for the BHP to come to the telephone? We cleared it with management to leave care with that doctor since police didn’t come to the scene to call the coroner and take over. Otherwise we would wait for police until we left scene.

Question: Whilst completing my pre-course recertification material, we were asked a question with regards to blood glucose testing. Following administration of med for hypoglycemia, the question asked when next should you do a blood glucose test. I had guessed after 5 min although re-dosing would not be for 10 or 20 min depending on drug used. I guessed wrong apparently.

The other choices would have been:
a) With EVERY vitals post treatment (what about a long off load, we might do 3 or 4 more sets of vitals!)
b) After no improvement (no time noted and they might not show no improvement for a few minutes and sticking them after just two would be unnecessary)
c) Once at the hospital (that would disallow the re-administration of a second dose of treatment.)

Question: I was taught that if there is some clinical improvement, when using CPAP, we are not to titrate the pressure any higher. I understand the rationale for this, however my question is, are there clinical guidelines that quantify a patient having sufficient “clinical improvement”?

Example being a patient breathing at a rate of 34 bpm with accessory muscle use, sp02 of 85%, audible crackles through all 4 lobes. With CPAP applied at 5 cmH20 vitals improve to RR of 28 bpm, sp02 of 91% and crackles remain. This patient has had a degree of improvement but would it not be advisable to titrate the pressure 2.5 cmH20 higher (after 5 mins) to attempt to further normalize the patient’s VS and clinical condition? Or is the goal to increase the sp02 above 90 % with no accessory muscle use and decrease RR below 28 bpm as the directive lists these as conditions needed for application.

Question: Multi-part question on croup. I’ve heard that croup is becoming more prevalent in older children (8 years & up). What is the incidence of croup in older children, and how would their treatment differ in the ER from the < 8 year old group?

Question: A nitro virgin patient presenting with chest pain attends a doctor’s office. Doctor administers 1 spray of nitro prior to EMS arrival. Upon assessment by EMS, patient still presents with chest pain. Is the patient still considered a virgin nitro patient as this is the first incident he/she has had with nitro? Or since the doctor administered a spray, does that count as a previous use of nitro?

Question: We are instructed to get the nitro in, if applicable, apply the CPAP and if there is improvement, do not remove the mask for additional nitro sprays. Is the improvement slight or significant? If slight improvement, do we leave the pressure at the slight improvement pressure or titrate 2.5cmH2O?

Question: If respirations are at or above 28, historically paramedics are taught to assist via BVM. What is the rationale with pulmonary edema to apply NRB with tachypnea instead of assisting with a BVM until CPAP and or nitro is prepared?

Question: If you come to a scenario being a PCP paramedic uncertified in IV, where when finding and assessing the patient you come to terms that he/she is VSA due to anaphylaxis.

Do you have to administer epi, because in the protocol for administering epi on a VSA, it says “in the event anaphylaxis is suspected as the causative event of the cardiac arrest, a single dose of 0.01mg/kg 1:1000 solution, to a maximum of 0.5mg IM, may be give prior to obtaining the IV/IO”. Since it is saying you “may” give it, do you know if you have a choice?

Question: There is some debate in regards to chest compression’s, monitor applied, analyze and then airway. What happens when the compression count is at thirty and the pads are still not applied? Does the paramedic at the chest check the oral cavity, get the airway, insert it, open the BVM bag, prepare the BVM and attempt 2 breaths or continue compression’s until the other medic applies the pads and the analysis is complete?

Question: I recently did a transfer with a physician going to LHSC University Hospital with a confirmed subarachnoid bleed. The patient was conscious, conversed and was oriented x 3. They were mildly lethargic, c/o an occipital headache with no neuro deficits. The physician accompanied the patient to give a medication to keep the BP on or around 140 systolic.

During transport, the patients BP began to rise to 160-180 because of nausea and vomiting. Gravol was administered and a drug (sorry, I can’t recall the name).

He asked me if we carried anything that could drop the BP. He suggested Nitro. I know this is not listed as a contraindication but would it be wise to give a vaso dilator to a patient with a cerebral bleed. We did not administer nitro, but the question still remains. Thanks in advance.

Question: I was told by a physician that a DNR becomes void with a suicide attempt. I was wondering how we should approach this situation.

Question: I think a lot of paramedics have trouble telling the difference between pulmonary edema (CHF) and bronchoconstriction now. If we had capnography nasal sensors, you could see that the wave form is still flat on top for the CHF while the bronchoconstriction has the shark tooth pattern. This could be a good tool for all paramedics to learn pulse ox without capnography. It is like looking at the heart rate with out and EKG. This should be taught to all paramedics, what do you think? As of now we do not have the nasal sensors, only the ET hook ups.