Question: When is a patient no longer considered nitro naive? Issue: you have a patient that is suffering chest pain and qualifies for ischemic protocol. You establish a patient IV and give them nitro. The patient accepts the nitro without any adverse reactions and pressure does not fall out of protocol at any time. After your second dose of nitro you check the IV and discover its no longer patent and you have to discontinue it. You attempt your second IV and are unsuccessful. Nitro has been decreasing patient’s pain but they still have active chest pain. Can we still continue with nitro without an IV as the patient has already been given nitro and not had any reaction?

Question: I was having a debate with another paramedic about the proper order of procedure in the following situation: You are en-route to the hospital, in the back of the ambulance alone with your patient, and they go VSA. You check for pulse and respirations and confirm VSA, update your partner, and ask them to pull over and help. While they are pulling over and moving to the back of the ambulance should you: a) begin chest compressions; or b) immediately apply defib pads and analyze?

Question: I have checked with a SWORBHP Educator and they did confirm that you cannot Medical TOR an OD but you can do Medical TOR on Drowning Hanging and Electrocution. There still seems to be doubt out in the field so I thought I would post so all could see answer

Question: With respect to the Medical Arrest Protocol, are we still to alternate giving Epi and Amio/Lido on the 2 minute mark since each are to be given Q4 minute? Or can we give them at the same time? What is preferred?

Question: This question is in regards to the TOR’s and calling BHP. Some paramedic services lack having a spare cell phone while the primary cell phone for a truck is “out for service”, missing etc. I have heard of some paramedics using their personal cell phones to call for the mandatory BHP patch for a pronouncement. I have spoken to Police and Crown Officials, and they have both stated that our personal phone can be submitted into evidence at an inquest or other matters, as this was the tool used to make that pronouncement (upon further investigation a paramedics credibility can be challenged as the court can see text messages, pictures, and phone calls placed on the personal phone). If our service fails to provide us with a cell phone for that shift for whatever reason, are we obligated to use our personal phone knowing it could be taking from us in an investigation for an unknown length of time? Would we document “no cell phone available” on the ACR?

Question: This question was addressed at the end of January but I’m still unclear on the answer. In our protocol is discusses DKA and the patch point for pts from 2 to 12 for obvious reasons to me. It does not discuss any patient greater than 12. In the past if pt was DKA and showing signs of dehydration we could do a 10ml/kg bolus, then it was changed so that we had to patch for this bolus.

The previous question was weather or not we were doing boluses for adults and it was not addressed. There is no talk of it in our latest protocols. Can we go ahead and bolus an adult in DKA who is showing signs of dehydration without a patch or even with a patch?

Question: In regards to cardiac arrest secondary to drug overdose. A VSA in an instance where Cocaine and or Meth have been used in excess causing death. Would this fall under unusual circumstances and therefore be transported or would it follow a medical TOR and require a patch to base hospital?

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: Why do we have a mandatory patch point for pediatric patients (> 2 but less than 12) with a blood sugar over 25 mmol/l and suspected to be in DKA for a fluid bolus but there is no patch point for adult patients.

Question: For a patient with fluid building up in the lungs (recently having the same issue and having to have fluid drained via chest tube) due to a complication of CA, what is the best course of action? It wouldn’t seem that a bronchodilator wouldn’t be effective and since the fluid is of non-cardiogenic nature would nitro work?

Question: On our ROSC protocol, the ONLY route that we are allowed to give a fluid bolus/dopamine is via an IV. Please confirm that we are NOT allowed to do so via IO or CVAD? This does vary from the IV and Fluid Therapy protocol which allows us to do so.

Question: If a patient is between ages 8-12 and is VSA, are we still using the lowest Joule setting?

Question: If you get a ROSC on scene, after one analyze, patient rearrests enroute, can we pull over and finish the protocol? One analyze or three?

Question: Since we’re now able to administer Epi for VSA Anaphylaxis, why are we not able to do so for Severe Asthma VSA?

Question: If a patient presents with both chest pain and sudden onset stroke symptoms, can we still give all medications for cardiac ischemia protocol while doing stroke bypass?

Question: In the December 11, 2011 powerpoint on Termination of Resuscitation. The slide on page 37 states the Medical TOR applies to all medical VSA that are cardiac in nature and asphyxial in origin including hanging, drowning electrocution. The webinar from our recerts states Arrest thought to be non cardiac in origin, i.e. OD, Trauma, Hanging, Drowning are a contraindication to the TOR. Could you please clarify?

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

Question: Can you clarify a condition in the contraindications for nitro use protocols? Current contraindications listed under the protocol are self explanatory, where as one to me seems to be very vague. The one Im referring to is the use of a “Phosphodiesterase Inhibitors” within the previous 48 hours. They are many examples of this type of inhibitor (including caffeine) and it might reduce confusion if the specific and relevant ones were listed under the protocol specific to cardiac. For example, a patient who has had a cup of coffee prior to your arrival or 48 hours prior to for that matter has ingested a Phosphodiesterase Inhibitor. Under the current directive and the way it is written, could be argued that this patient is contraindicated to receive Nitro.

Question: When treating a patient with suspected cardiac ischemia, should I acquire a 12-Lead ECG before giving nitro or ASA? If the patient is hypotensive, should I bolus at 20 ml/kg, or 10 ml/kg as per the cardiogenic shock directive? And how do I know if the patient has a right ventricular infarct? (Updated)

Question: If I have a patient that appears to be in cardiogenic shock with a STEMI ECG should I be calling for a BH patch to have an order for aspirin after initiating an IV bolus?

Question: ROSC Protocol states bolus 10ml/kg if under 12 check at 100ml and over 12 check at 250. Cardiogenic Shock Protocol (includes ROSC) -states bolus 10ml/kg -if 2 to 18 check at 100ml and over 18 check at 250ml. One states the 12 to 18 range at 250ml but the other 2 to 18 at 100ml. Can you clear this up for me please?

Question: In our recert course, we were told that ACPs must patch to the BHP after the third analysis (during a medical arrest). Why do we have to patch so early? Shouldn’t we patch after three rounds of epi?

Question: In regards to the new medical VSA directive: Would CO poisoning leading to VSA be considered an unusual circumstance? Thus performing one analysis and transporting would be acceptable?

Question: I see that it says consider NaCl bolus in the cardiac arrest standing order. In the past we gave a bolus for PEA as well as Rosc’s. Can you confirm the exact circumstances we are to give the bolus as I find there to be a lot of gray areas in our orders.

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?

Question: My question is regarding fluid bolus for DKA. Past practice has been to initiate a BHP patch for direction to administer a fluid bolus. The most recent Provincial Protocol states that a patch is only necessary for DKA in patients under 12. Are we still required to patch for a fluid bolus for adults in DKA?

Question: Why was Lasix removed from the pre-hospital CHF/Pulmonary Edema protocol, when the first thing an ER Physician orders on arrival at the ER is Lasix?