Is it acceptable to give oral medications to a patient wearing a cervical Caller that meets the indications for the medication and none of the contraindications? 

Can you please clarify the CPR ratio for different ages with the new neonatal resuscitation changed from 30 days to 24 hours. At what age are we performing 3:1 CPR, 15:2. and 30:2?

If a patient is capable – why is there a section for “Emergency Treatment of a Capable Patient without Consent”?

can you insert an OPA in an old person

So we had a call to a burn victim that was grossly charred, but was breathing. He started to deteriorate in transport but we made it to the hospital. I was wondering if he were to arrest if that would be a traumatic VSA, I know it’s not a blunt or penetrating trauma but it doesn’t make much sense as a medical cardiac arrest either. Also could a patient meet the standards for an obvious death after patient contact?

This has been a question of mine recently that not many people have the answer for in my service. My question is; if we have given the pt any sort of medication or initiated an IV can the pt be offloaded to the waiting room or to a bed in the hallway? Thank you in advance!

Tension pneumothorax Could someone please clarify the BLS section on ventilating a suspected tension pneumothorax. Is it just slower and not as hard of a squeeze as usual

What is our responsibilities once a patient has been arrested under the mental health act? Is it considered implied consent? Are we responsible for vital taking, blood sugar and treatment if the BG is below four? Can the patient refused treatment with a decreased BG and a GCS of 14(confusion)?

Is external manual compression of the chest and appropriate prehospital consideration for peri-arrested or arrested asthma exacerbated patients who are showing obvious signs of chest hyperinflation and air trapping. I have read about its anecdotal use on website like EMDocs.net and in the Prehospital Care Journal (Harrison, R. Chest compression first aid for respiratory arrest due to acute asphyxic asthma. Emerg Med J 2010;27:59€“61. doi:10.1136/emj.2007.056119) as a few sources. I have also seen it performed in the emergency department by emergency physicians. I assume with good technique, it can assist with expiration and minimize the risk of barotrauma in these patients who require ventilation. Thank you!

Question: In regards to the BLS version 2.0 – extremity injury, bone/joint, there’s a guideline regarding elbow dislocations. It says that if we encounter an elbow dislocation with nerovascular compromise, that we can contact receiving hospital or Base Hospital Physician for advice regarding manipulation or in-line traction. In the new BLS 3.0, this guideline has been left out. Are we still expected to perform the guideline if we ever encounter this, or has this been purposely taken out? Thank you.

Question: CPR guidelines: I understand that we start CPR with a patient less than 16 years old, heart rate less than 60 and signs of poor perfusion, agonal respirations as per the CPR guidelines. My question is if we have the same situation with an adult patient, what would be beneficial for this type of patient (CPR)?

Question: How many liters to we run a BVM at?

Question: Although not employed by a service under the SWORBHP, I have been closely following this site and your LINKS newsletter. Thank you for both of these invaluable resources. After reading the most recent question regarding spinal immobilization, I had to share a resource with you that can located here https://m.youtube.com/watch?v=eM4hxuooNN0. This is a lecture by Dr. Ryan Jacobson, a former paramedic who is now medical director of Johnson County EMS in Kansas and Assistant Professor of Emergency Medicine at University of Missouri-Kansas City School of Medicine. If you have already seen it, you are familiar with its informative value. If not, I’m confident that you will find it of value. This link is unplublished and cannot be found via YouTube search.

Something that I have been wondering after viewing the lecture and statistical evidence is as follows. Hypothetically, if the current practice of securing patients to backboards increases morbidity and mortality (particularly penetrating trauma) and that there is greater spinal movement than if secured directly to the stretcher, and that no negative effects have been observed by not securing to a backboard, is it reasonable to consider foregoing the backboard as care superior to the minimum requirement as written in the BLS? Similarly to a “letter of the law” vs. “spirit of the law” question. LBBs have been contraindicated for transport in Queensland, Australia for the past five years among numerous other jurisdictions. I’ve inquired with my employer but was given the old “We have standards” response.

Thank you for your time and consideration on this topic. I look forward to your reply.

Question: I have heard the term “best practice” used quite often in the past little while. I was wondering if you could elaborate on the means of “best practice”, and if the SWORBHP guidelines can be considered “best practice”?

If not, where would one look to ensure they are using the “best practice”? For example, in recent studies, best practice may not be to administer oxygen to each and every patient, however the BLS states that we should administer oxygen to each patient.

Question: How often should you reassess the respiratory rate for apneic patients?

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 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: Are there contraindications for sager applications?

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

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.

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: 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: 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: 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.?

Question: This is in regard to the Medical TOR protocol. If we’ve reached the mandatory patch point at three consecutive non-shockable analyses (and made the call to the BHP) and there is any sort of delay (meaning we’ve reached the fourth analysis), do we then transport? People are getting confused because some heard that they were to keep analyzing while they waited for the BHP to come on the line. That’s not how I perceived it. Regardless of any delay at any time, the protocol states that we only analyze a total of four times (unless you are an ERU) followed by CPR for the duration of the call, correct? People hear different things, and I just want clarification so that we can all be on the same page. Thanks

Question: In performing your ABCs on unconscious patients, the BLS has never clarified whether, after checking the airway you should, insert an airway then go to breathing OR go to breathing, insert 2 breaths, then insert an airway. Can you finally put an end to this debate?

Question: Can you explain what this part in the consent section means? It seems to give more flexibility to not begin resuscitation based on family members who seem reliable saying that that is what the patient wanted. “If a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated).”

Question: I was just wondering in case Im asked by the Police Department… in a medical TOR, what physician signs the death certificate?

Question: The PCP Medical TOR says that I can “move the patient to the ambulance prior to initiating the TOR if family is not coping well or the arrest occurred in a public place”. What is an example of a public place? and if I move them to the ambulance and then get the TOR, is this now the place of death and I have to wait for the coroner to arrive?