If I am in a first response truck and have no shocks, do I have to wait until the transporting unit gets there to call for a TOR or can I call when I meet all the criteria?

The ALS PCS 4.5 STEMI directive follows the BLS V3.0.1 criteria and no longer has a pulse rate of <50 as a contraindication for bypass. Does this mean a bradycardic patient with a pulse in the 40s can now be transported on a STEMI bypass? In the past medics where taught differing regions would have slightly different STEMI receiving acceptance criteria. Are there any considerations we as medics should consider for STEMI receiving hospitals in our governing region?

Are there any tools that we can use to differentiate Bells palsy from a CVA to prevent us from an unnecessary stroke bypass?

When considering Gravol, if the pt has taken any antihistamines, anticholinergics, or tricyclic anti depressants should we withhold Gravol or only if they already appear to have overdosed? For example, would it be o.k. to give the patient Gravol if they take a daily antihistamine for allergies?

If the modified valsalva works & then they revert back into an SVT, can I perform the modified valsalva again? Is it only 2 attempts or 2 per episode if safe and feasible to do so; being sure not to perform more than 2 on scene delaying transport?

Is it acceptable to cannulate an umbilical cord, if required, during resuscitation of the newborn?

Can Ketamine be used on a combative post-ictal patient or would Midazolam be the drug of choice in this case?

Do we really need to get a blood glucose on an overdose patient prior to administering Naloxone?

Is there really a priority with the delivery of Ketorolac over Tylenol/Ibuprofen in the new pain protocol?

Question: In regards to the new BLS 3.0.1 under the paramedic prompt card for acute stroke protocol contraindications, it clearly states CTAS 2 and/or uncorrected airway, breathing or circulatory problem. My question in regards to this contraindication is does this automatically make a patient a CTAS level 1 when they are presenting with all signs and symptoms of a stroke and meet stroke protocol or does this mean that any other issues (i.e. chest pain making them a CTAS 2) puts them out of stroke protocol?

Question: As per the ALS PCS, why is there a deliberate gap between normotension and hypotension?

Question: The Opioid Medical Directive allows for Naloxone to be administered 0.8mg SC/IM/IN and 0.4mg IV. The IV route allows the paramedic to titrate to restore the patient’s respiratory status. Can this titration also be applied to the SC/IM/IN?

Question: My question is in regards to the moderate to severe allergic reaction and medical cardiac arrest. With the new changes, the moderate to severe allergic reaction directive allows us to administer 2 doses of epinephrine q 5 minutes to a max of 2. If a patient were to go into cardiac arrest due to anaphylaxis (after already administering 2 doses of epinephrine), are we still able to administer another dose under the medical cardiac arrest directive? (Leading to a total of 3 doses).

Question: There was a discussion among crews surrounding DNRs and our permitted treatment such as epi can be given for anaphylaxis or silent chest, but not as a pressor as listed on the DNR. That being said, I found a previous Ask MAC question where you addressed isolated epi administration as not very effective (where the BVM is contraindicated due to a valid DNR) in the situation of severe bronchoconstriction. Wondering if the same logic applies to the setting of anaphylactic VSA patients? If we cannot begin CPR or utilize a BVM, should we give isolated epi to that patient, as it is not being given as a pressor? (I’m of the opinion that a VSA patient gets no treatment in the presence of a DNR).

Question: With the introduction of commercial tourniquets and hemostatic dressings for Soft Tissue Injuries/Uncontrolled bleeds in the BLSPCS 3.0, where does the OBHG and MOH stand on wound packing for hemorrhage control? It is generally accepted among TCCC guidelines as a part of basic hemorrhage control, and even taught as a part of First Aid with some organizations. Unfortunately the BLS 3.0 (or 2.xx as well) do not explicitly mention it as an option, as well it is technically prohibited under the Registered Health Professions Act which lists “Putting an instrument, hand or finger, into an artificial opening in the body” as a delegated act. Is this something that we will see added to our scope in the future? Why or why not?

Question: Our current stroke directive reads that 3.5 hours is the timeline from time of onset to stroke center. The new BLS reads that the time from onset to stroke center is 4.5 hours. Which timeline are we expected to follow as of Dec 11th?

Question: My question relates to narcan. Do you feel it is necessary in all cases to check BGL prior to administering narcan? The Medical Directive reads uncorrected hypoglycemia as contraindication but in the presence of no diabetic history and an incident history which is clearly indicating opioid overdose combined with critically low oxygen saturation and no ability to ventilate are we to invariably to take a BGL prior to treating obvious signs and symptoms of opioid overdose or can we use clinical judgement based on findings? It goes without saying that a BGL should eventually be taken on such a patient at some point but my question is with a critical patient, no history or finding consistent with low BGL and multiple indicators for OD are we not safe to presume OD, treat accordingly and follow up with BGL afterwards to rule out hypoglycemia?

Question: I have a question regarding the administration of narcan. Narcan seems to be given more often now that there is no patch point. The wording of the medical directive hasn’t changed though so just to confirm, are we still just to be giving it when we cannot adequately ventilate the patient? Example, if they are GCS of 3 and breathing inadequately but we are getting good compliance on the BVM and the patients vitals are otherwise stable, are we ok to not give it? If we do go ahead and give narcan to a patient who is NOT breathing and they start breathing on their own but are still GCS of 3 are we to stop there since we can now manage their airway or do we continue up to our maximum of 3 doses or until they become GCS of 15?

Question: If the Valsalva Maneuver is not a medically controlled act why would a PCP not be able to carry out this procedure for a symptomatic narrow complex, regular rhythm tachycardia that is symptomatic? PCP’s are supposed to be able to identify sinus tachycardia, atrial fibrillation or atrial flutter which would be contraindicated and especially if no other immediate care is available. Why such be restricted to only ACP’s, again especially if no other immediate care is available?

Question: In a setting where you arrive on scene and you are presented with a patient who is unconscious and is hypotensive, the patient has a valid DNR. Can you still administer fluids to this patient or does that fall under the same category as inserting an OPA/NPA and BVM to a patient with a DNR?

Question: In a setting where you arrive on scene and you are presented with a patient who is unconscious and is hypotensive, the patient has a valid DNR. Can you still administer fluids to this patient or does that fall under the same category as inserting an OPA/NPA and BVM to a patient with a DNR?

Question: For teaching purposes. While assessing a patient, how important is it to determine any and all treatments or interventions provided to the patient by allied agencies, bystanders, self-administration or other medical professionals prior to the arrival of the Paramedics? How important is it to determine an accurate time line of those treatments or interventions? Is oxygen a treatment and/or intervention?

Question: What is the rationale for the 18 years old and greater age for naloxone administration? (i.e. legal, risk factors?)

Question: Reviewing the STEMI bypass protocol I noticed that it requires 2mm of elevation in V1-V3 in two contiguous leads and 1mm of elevation in any other contiguous leads.

My question is then twofold:
1. What’s different about V1-V3 that we require 2mm of elevation?
2. Why is V3 included in this since it is not anatomically contiguous with V1 or V2? Should then V4 not be included to give a “partner” to V3?

Thanks for your help!

Question: In Elgin county we have been having trouble with our defibs spitting out ‘noisy data’ warnings on our 12 lead ECG’s lately which has prompted conversation with crews about the STEMI protocol. Though the protocol clearly states that LP15 ECG software interpretation meets ***MEETS ST ELEVATION… some crews are saying that due to this issue with noisy data, we are able to interpret the ECG on our own and determine if it meets our criteria based on the >1 mm/or the >2mm ST elevation criteria. Your thoughts? Should we patch the cardiologist? Should we transport to nearest ED due to software not recognizing due to noisy data?

Question: Can you go stroke bypass with the only complaint being a defined onset of confusion?

Question: In reference to LOA and gravol administration: a patient who has had a fall and struck their head, has a GCS of 14 (4,4,6) and is alert to person but not place and time, confused about previous events, but can follow commands and is answering some questions appropriately (ie… Birthday, wifes name). Does this rule them out for gravol? My concern is if they are nauseated and we dont treat it early, vomiting and being supine on a spinal board can be very difficult to manage by yourself. I appreciate the definition of LOA is a GCS less than normal for the patient. Can you explain the reasoning for this condition?

Question: I had a scenario where my patient stated he had a few drinks and was slightly drowsy, he answered all my questions fine and was alert to person place and time, once in the ambulance he became nauseous and began vomiting two emesis bags full, I gave gravol in this situation after listing off the contraindications and patient confirming there were none. My question is, would this have been acceptable?

Question: Any news or updates regarding the progress of a new BLS version?

Question: I know that the standard practice for Epinephrine administration in the case of anaphylaxis is in the patient’s deltoid. I have heard and read that the time to maximal serum concentration of epinephrine is 7 times faster with IM administration to the anterolateral thigh.

My question therefore is: Would it be acceptable to administer epinephrine in the anterolateral thigh as opposed to the deltoid? Or, is SWORBHPs preferred administration site the deltoid and if so why?

References:
http://emergencymedicinecases.com/anaphylaxis-anaphylactic-shock/

Simmons, F.E., Kelso J.M., Feldweg A.M. (2015). Anaphylaxis: Rapid recognition and treatment. In T. W. Post (Ed.), UpToDate. Retrieved from http://www.uptodate.com/contents/anaphylaxis-rapid-recognition-and-treatment/

Question: You have a patient who you obtain ROSC and return of spontaneous respiration on scene who was in a VF (post rosc 12lead shows STEMI). They arrest on route into a VF, we pull over, defibrillate. You resume transport and reassess after each cycle of CPR. If you obtain ROSC again during transport, and the patient rearrests for a second time, is it prudent to pause transport quickly again for defibrillation. The treatment for VF is defibrillation. If there is still prolonged transport the pt will likely deteriorate to asystole if not defibrillated, correct? I appreciate we do not want to delay definitive care, would it be helpful or harmful to continue defibrillation in this setting.

Question: In reviewing literature addressing treatment and management of tachyarrhythmias, I’ve encountered several articles stating that lidocaine and amiodarone are contraindicated for treatment of Torsades de Pointes as they could prolong the QT interval and worsen the situation. However, our medical directives for ventricular tachycardia make no mention of this contraindication and make no distinction in the management of VT vs TdP. Recognizing that lidocaine as a Class I antiarrythmic would be worse for the patient than amiodarone (Class III) and that amiodarone is the preferred drug in our protocols for VTach, should we nonetheless be concerned with the use of either of these in managing TdP? Thanks for providing the forum in which to ask and share with colleagues.

Question: A recent study, published in the Lancet showed an alternative way of performing a Valsalva maneuver, that is much more effective.

It is described and shown in a video here:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61485-4/abstract

Is it acceptable for us to perform this when a Valsalva is called for in our directives?

Question: In regards to gravol. Pregnancy is not a contradiction but after doing research most medical journals state the following: because the studies in humans cannot rule out the possibility of harm, Dimenhydrinate should be used during pregnancy only if clearly needed. What are your thoughts?

Question: Can a PCP insert a King LT in a non-VSA patient with a GCS of 3 under the direction of an ACP?

Question: If an 18 year old male hockey player was tackled and hit his face off the ice, has otorrhagea and and is VSA. First analysis shows asystole. Should he be treated under the trauma cardiac arrest directive or medical?

Question: I have a question in regards to right sided MI’s. We had a patient that had slight elevation in his 12 lead inferior leads, but not enough to call for a STEMI. I once worked for a service that I could do a right sided 12 lead ECG. Are we allowed to perform right sided 12 leads here at SWORBHP if we do suspect an inferior MI?

Question: Recently we were on scene with an unresponsive 65 year old female. This was a witnessed event by a friend. While on route to the nearest ED patients condition improved. The patient started to answer questions. At this time the patient found to have left sided deficits. Should we continue to the local ED (5 min transport) or turn around for stroke bypass (50 min transport) After assessment in ED we ended up transporting to Stroke Unit.

Question: Referring to the STEMI by-pass medical directive, is it 60 minutes from patient contact or 60 minutes transport time?

Question: At our recent recertification, I posed a question that was answered by a doctor. This was regarding the ability to call a cardiologist if we had a patient with a STEMI who did not have chest pain. Her answer was: not at this time. However, in conversation with medics from other classes, this seems to contradict what they have been told. Can you please clarify?
br>Also, are we to continue to understand that once a patient is out of the STEMI protocol (e.g. with vitals) that they continue to be so even if the vitals improve to within proper range?

Question: Upon review of the new Field Trauma Triage Guidelines, colleagues and I noticed that those patients who have sustained penetrating trauma to the head/neck or torso (with or without vital signs) should be transported to the lead trauma hospital providing it’s within 30 minutes transport. Our question is why is this not the case for blunt trauma patients (in particular, those patients VSA from blunt trauma)?

Question: An ACP is doing an inter-facility transfer of a 16 year old patient with a fracture. During the journey the patient’s pain becomes severe in nature. The sending facility had been administering 1mg doses of Morphine with good effect however the medical directives would indicate that the paramedic should administer a 3mg dose of Morphine.

Can the paramedic elect to give a lower (1mg) dose since it has been already proven to be “the right dose” for this patient, or does this require consultation with a BHP

Question: We have been trained on the Opioid Toxicity Medical Directive and the educators reiterated to use it as a last resort because of the potential for violence. I understand their concerns. I also appreciate these kits are out in the public for use and our skill set should continue to exceed that of the layperson(s). However, I wonder why not consider expanding the king LT insertion medical directive to include GCS = 3 for PCPs? This would allow safe and effective airway management of suspected overdose patients (or other GCS = 3 patients), even in situations of long transport times. We already preform this task in situations where a ROSC is obtained. We are familiar and proficient with the equipment and there is no additional cost to the services.

Question: I had a question about the ACP Pain Management Medical Directive. I can give 4 doses of 5mg max of morphine (a total of 20mg).  If I give a loading dose of let’s say 4mg to achieve the desired effect then I could give maintenance doses of 2mg every 5 min to keep the patient’s pain controlled. So instead of giving 20mg over 15 min I could give it over 40 min. This way I am giving a smaller dose, hopefully meaning I have less side effects (nausea, vasodilation) and if I have a longer transport time can better manage my patient’s pain for longer. I understand that Base Hospitals are very strict about giving only 4 doses. Thank you. PS: I think this is a great tool!

Question: At what gestation would it be deemed appropriate for neonatal resuscitation?

Question: My question is in regards to abdominal pain and analgesia. I was always under the understanding that as ACP’s we should not be patching to a BHP for analgesia when a patient is experiencing severe abdominal pain. I have come into discussion with other ACP’s where some have and some have not patched for analgesia in severe abdominal pain. I am a bit confused about this particular situation. Should I be patching a BHP for analgesia orders for a patient experiencing severe abdominal pain?

Question: I would like to know the actual medical directive and/or guidelines regarding PCP’s transporting trach patients with no nurse, doctor or RT escort.

Additionally, what the medical directive is if staff is sending the patient to the ER without their vent, therefore, the paramedic is required to bag the patient via BVM for the duration of transport and until there is transfer of care at the ER?

Is this in the BLS scope of practice?

Question: In the Symptomatic Bradycardia Medical Directive, both atropine administration and TCP have hypothermia listed in the contraindications. However, this contraindication is not present for dopamine administration.

This seems to contradict the practice of not giving drugs to the severely hypothermic patient and focusing prehospital care on rapid transport and passive rewarming. Was this omission voluntary and if so, what is the rationale or the studies that support the use of dopamine in such a case? Thank you!

PS: Hypothermia is not listed as a contraindication for dopamine in the ROSC protocol either.

Question: With regards to Moderate to Severe medical directive. The directives states one dose of EPI only. Does this include if the patient has given themselves their own EPI injector before our arrival? Or does it mean only our ability to give only one dose?

Question: Recently on a call, a patient presented with the following: sudden onset of fever (approx. 1 hour prior to EMS arrival as per those on scene) @ 38.2°, angio-edema (specifically, swollen tongue only), difficulty breathing (6-7 word dyspnea) and tremors.

Upon arrival, patient was tachycardic, presented with stridor and a plural rub upon auscultation, mild hypertension and room air saturation of 87% (patient had removed home oxygen prior to EMS arrival).

Patient had a history of CHF, COPD, IDDM, MI and several others, but no history of the same and no known allergies. Patient also had been sitting on their couch all day prior to sudden onset with no precipitating event and no known causative agent (including any recent changes to their medications or the dosing levels).

On route, patient became confused, pale, diaphoretic and extremely combative (preventing any other attempts to assist).

Upon arrival, the receiving physician inquired as to what interventions, if any, were administered beyond oxygen administration and supportive care. Based on the incident history, the patient did not appear to fit with any of the directives, as there was no indication of a potential exposure.

My question is whether it would be a stretch to reason that a potential change (perhaps unknown to the patient) to the medication could have caused the reaction as a “probable allergen” and administer epinephrine as per the “Moderate to Severe Allergic Reaction” directive, or whether it is simply a matter of providing high flow oxygen and rapid transport.

It seemed unclear if this particular case was an adverse reaction to the ACE inhibitor the patient had been taking for some time, some sort of infection or an unknown allergen (deemed unlikely from sitting in a controlled home environment).