Question: When administering Ketorolac, is it required that the medication is diluted prior to administration?

Question: As an Advanced Care Paramedic, can I administer dopamine IO?

Question: There has been a great deal written lately about the use of the long spine board (LSB) and its use in prehospital care. Many jurisdictions have eliminated or curtailed the use of the LSB due to the lack of clinical evidence supporting its benefit and the growing evidence that it actually increases morbidity and mortality in many types of patients. When is MAC going to examine this issue and hopefully revise the Standards to reflect the current knowledge base?

Question: In regards to the base hospital recertification for 2014-2015, in the video for medical cardiac arrest the paramedic received a ROSC and was re-evaluating vitals q1 minutes, however, in the quiz it was noted that you are to re-evaluated vitals q3-5 minutes. Can you please clarify?

Question: My question falls under the category of Trauma Cardiac Arrests. Are we expected to check the pulse of a PEA patient, secondary to trauma, every two minutes? I believe we do as this follows heart and stroke and also verifies a PEA is in fact pulseless.

The BLS states to reassess pulse every 2 minutes under medical section 2-18, but trauma section 3-6, referring to trauma VSA, states to follow ALS patient care standards and protocols.

Our protocol does not state or outline the desired pulse assessment treatment during transport after the one analysis is performed. Thank you in advance.

Question: This question is based around a call that has had some interesting discussion and I am curious to get your input on. The call was initially for an allergic reaction, updated while en route to say that the patient was seizing.

Upon arrival, you find a 28 year old male lying on the ground. A family member states that the patient was stung by a wasp on the back of the neck approximately 15 minutes ago. They immediately gave him Benadryl orally and he self-administered his EpiPen (the family seems reliable and as far as you can ascertain both of these medications were administered appropriately and were not expired).

They continue on to tell you that about five minutes ago, the patient had a seizure that just ended as you arrived. The patient has never had a seizure before. There was no trauma suffered from the seizure. The patient has a history of anaphylaxis to wasp stings but no other past medical history.

On examination, there are no signs of trauma and the patient denies any pain. The patient is conscious, but agitated and confused to place and time (GCS 14). He has slight swelling of the lip but no urticaria anywhere on his body and no other facial swelling. His breath sounds are clear on auscultation. He appears to have been incontinent of urine. There has been no vomiting or diarrhea.

Initial vitals are a heart rate of 102 regular and full, respirations 24 regular and full, pupils PEARL 4mm. Blood sugar is 6.7 mmol/L. BP is unobtainable as the patient continues to become more agitated and will not remain still. Oxygen saturation is also unobtainable as the probe keeps coming off his finger while he moves around.

Specific points that came up in our discussion that we would love to hear your thoughts on are:

1. Based on the information available here, should this patient receive epinephrine (epi)? It is easy for us to second guess the inability to obtain a blood pressure (BP) on this patient, but for the purposes of discussion, I think we should accept that none of us were on the call and it was not possible for this medic to obtain a BP even by palp.

2. Are we held strictly to the traditional “two systems involvement” view of the diagnosis of anaphylaxis or are we permitted to consider a broader definition such as that published by Sampson et al. in the summary report of the Symposium on the Definition and Management of Anaphylaxis?

Question: I recently had a patient with ischemic like she’s pain (no ECG changes). When going through questions to administer ASA, the patient stated she could not have ASA as per her physician because she was recently placed on Clopidogrel after a stroke about 3 weeks ago. I ask the patient if she meant she should not have daily aspirin, or if a one-time aspirin was okay. She could not answer the question, and stated she did not want to be treated with the aspirin. Is the patient correct, or should I have pushed harder to administer it?

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: 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: 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: 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.

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.

Question: We had our recert this week and I have a question about DNR patients. In the pocket book it says that a patient will get epi IM if they have a history of asthma and BVM ventilation is required. So I am wondering, if a DNR patient does not receive a BVM under any circumstance and an asthma patient with a valid DNR who started off just slightly SOB became severe and required a BVM would they still be eligible for epi? In other words does “required” mean that yes it is required due to the severity of SOB, but due to the fact they have a DNR they don’t actually get the BVM, can they still receive the epi, which is not contraindicated on the DNR validity form? Thanks in advance.

Question: My question is about pain management. Our directive states a maximum of 4 doses of 25-50mcg fentanyl (200mcg max) or 2-5mg morphine. (20mg max). Is there a reason we could not just have a max total dose of 200mcg/20mg and be able to give, say, 8x25mcg fentanyl q5? I feel that with the increasing frequency of offload delays it could be beneficial to the patient for us to have the ability to spread the maximum dosage out over a longer duration.

Question: Are MOOCs eligible for continuing education (CE) points?

Question: I have a question regarding a call done recently; dispatched to a 73 year old female patient, healthy, independently and living with husband; takes no medications and has no allergies. In recent past however, has had NYD syncopal episodes lasting up to 30 minutes, no residual deficits from events suffered.

At 08:10, patient had sudden onset of weakness, called husband who held her before she fell and gently lowered her down to floor while family member called 911. They thought patient was having yet another familiar syncope. No seizure activity witnessed.

Patient was found unconscious on floor. While on scene patient regained consciousness to a GCS of 14, she had left sided facial droop, left sided paralysis and slurred speech which has never been the case in past events. All other vital signs where within limits including BS.

Although patient had initial GCS of 3 (normal for patient’s events) Would it have been prudent to consider these two as different events and include her as a Stroke protocol candidate given the clear time of onset, her history and the marked CVA like symptoms. Thank you.

Question: If TCP with Zoll E series, what are the steps to be taken when transferring care to the receiving facility? Procedure to switch to their machine?

Question: In the BLS Standards I found in Section 1, General Standard of Care, Directive H. Patient Transport, the following statement in subsection 1 “in the absence of direction, transport to the closest or most appropriate hospital emergency unit capable of providing the medical care apparently required by the patient.” So one question I have is the trauma patient, if they needed care above the capabilities of the closest hospital emergency unit, do we transport the patient to the closest hospital emergency unit that has these capabilities?

Question: My question is in regards when a crew has a positive STEMI result on a cardiac ischemia call. I noticed that on these types of calls there has been incidents where patients have been going in lethal dysrhythmias as crews are trying to deliver the patient to the cath lab. Most recently I was at a hospital and as a crew was entering the elevator the patient went into V-Tach and there was a delay to defibrillating because the crew had to attach the defib pads.

I noticed myself when entering the cath lab the first thing the staff does before even accepting the patient and allowing crews to disconnect the cardiac monitor is attach defib pads. Due to the high mortality rates (5%) of STEMI patients transported by EMS and the time it takes to attach the defib pads when the patient enters the lethal rhythm, would it be wise to attach the defib pads on positive STEMI patients during transport(even though they have not gone VSA) to decrease the time to defibrillated the patient if in fact the patient enters the letahal rhythm.

Question: I recently have had a couple of patients, on separate shifts, presenting with symptoms of an allergic reaction. The first patient confirmed he was stung by a bee and has reacted to them in the past. He presented with peri-orbital edema and diffuse wheezes with mild SOB. He was in no obvious distress despite the complaint of SOB. I treated him with Benadryl and ventolin, with a reduction in wheezes after the 3rd dose. I decided that it was appropriate to patch to continue with ventolin, given the patient’s improvement. The BHP’s order was to discontinue ventolin and administer subQ Epi for anaphylaxis.

My second patient presented with intense itching and generalized urticaria with edema to the suspected site of exposure. She also presented with diffuse pulmonary crackles and a non-productive cough, no angio-edema or stridor was noted. Again, this patient was not in any obvious distress despite the respiratory findings. Based on my assessment findings and the patient’s age, I decided it would be appropriate to patch for Benadryl and further consult. The BHP (different than the first) again ordered Epi for anaphylaxis (in addition to Benadryl).

Both of these patients presented with normal vital signs and perfusion status. I felt that both BHP’s orders were appropriate in these cases given that Epi is a wonder drug in the setting of anaphylaxis and allergic rxns. However, I’ve always been under the impression that it should be reserved for severe reactions, which would mean altered, mental/perfusion status, unstable vital signs, decreased/absent a/e, severe distress etc… I have no doubt that both of these patients would have arrived in the ER in stable condition without the Epi, but I also believe that epi played a big role in each of these patients’ improved condition.

My question is, at which point does our protocol allow for the administration of Epi? Or in other words, at what stage of an allergic/anaphylactic reaction do you feel it is appropriate to administer epi without an order?

Question: I have a question regarding the Gravol protocol. I had a 15 year old patient that had taken a combination of 50 pills of Advil, Tylenol and Midol at approximately 3 or 4 am. It is 7 am now when we arrive at the patient. Patient’s vitals are within normal range but patient c/o of dizziness and nausea. Patient has not eaten since dinner last night. Patient does vomit once with us while on offload delay. I opted not to give Gravol with reasoning that it is probably best for her to vomit and get it out. I understand that none of those meds are a contraindication for Gravol so in this case am better off giving the Gravol for nausea or withholding Gravol for the reason mentioned above?

Question: I have a number of questions in regards to the management of obstetrical emergencies and the established standards outlined in the BLS. I know that out of hospital delivery in comparison to other call types is a rare occurrence for Paramedics. So it may be reasonable to deter pre-hospital management of certain situations for definitive care, just based on training, risk and benefit. However, I think it is important for Paramedics to know how to manage these situations when they arise.

For an example, In the BLS standards shoulder dystocia although rare is not specifically outlined. If one does some research or digs back to many college programs where the HELPER mnemonic is touched on we find that suprapubic pressure and the McRoberts maneuver can resolve many of these situations, preventing trauma and harm to the mother and newborn. Although not identified clearly in the BLS both of these interventions are touched on in other areas such as breech delivery and emergency delivery. I wondered the reason why these interventions are not applied specifically to the situation where the shoulders do not deliver and rather the Paramedic is to initiate transport immediately? Secondly, what would MAC’s direction be to the Paramedic managing a possible shoulder dystocia? With the potential for fetal hypoxia and stress it seems reasonable to apply these same interventions in this setting.

If we go along the same question of course we aren’t performing field episiotomy or controlled clavicle fractures but why can we not assist a shoulder or roll the pt on all fours in this setting? Sure we can and use our judgment but with the legalities of following the standards it may be deemed as a deviation. Can Paramedics really apply the appropriate measures from various parts of the standards to situations like dystocia and still remain legally within their scope?

The only other question this may bring up is how do we hold midwives, who have a higher level of training and knowledge to the BLS Standards?

Question: You are called to a retirement home for an 85 y/o female for a possible CVA. On arrival you are met by a Nurse Practioner who stated patient is having a stroke. Nurse Practioner also states that patient (who is a retired RN) has talked to her family doctor who agrees with patient’s decision of not wanting to go to stroke centre or stroke protocol done. Patient has history of heart. Assessment reveals patient alert, orientated x 3 and meets stroke protocol. Patient wants to be transported to the local hospital for assessment. Does this patient or any patient have the right to refuse transport to a stroke centre?

Question: With respect to use of an OPA, I have had discussions with coworkers who always will insert one with an unconscious patient. Is this proper? My argument is, even the MOH literature seems to state that ‘less invasive’ airway management such as positioning, suctioning and constant monitoring of the airway is acceptable. Some common situations of this would be a post-itcal or alcohol intoxication persons. Thanks.

Question: I’m wondering if IN Midazolam should be administered by full dose or until effect if effect is reached prior to the administration of the full dose? Does the answer change if given IV?

For example, patient is in seizure so I administer 5mg Midazolam IN and seizure stops. Am I to continue and administer the remaining 5mg to a total dose of 10mg as per the directive, or do I stop?

Question: I understand there is no current contraindication for giving gravol to an actively vomiting patient with a suspected head injury, or to pregnant patients. Would I be wrong to withhold the drug from either patient?

Question: When a patient presents with Subcutaneous Emphysema? Can we give A.S.A.? Patient has taken it before and there are no other contraindications. SubQ is sometimes caused by perforations in the digestive and/or respiratory system, so I’m thinking ASA would be contraindicated – just looking for your thoughts or if there is a precaution.

Question: Are we allowed to give gravol to head injury patients that are suspected to have the nausea due to that? Also to pregnant women?

Question: Where can we find a copy of our Destination Protocol for Essex Windsor?

Question: I recently did a call in which the patient was found by nursing home staff to be agitated and non-verbal with left sided arm paralysis. On EMS arrival the patient was moving all limbs but was still non-verbal and agitated. I also noted LT side neglect and some LT side facial drooping. The patient was last seen in a normal state at 04:30 and the time of our arrival was 08:30. The patient also had a valid DNR and I confirmed again with the POA on scene that it was still the wishes. By the time we loaded and transported the patient was outside the 4 hour mark for any CVA treatment. I returned to patient CTAS 3 as they were outside the time line and for the valid DNR. I am wondering if the patient had been within the 4 hour mark for treatment should this patient be returned CTAS 2 or would they still be CTAS due to the DNR? Thanks.

Question: I have a quick question on the PCP supraglottic airway medical directive. What is the rationale for the “must be VSA” condition on the directive for PCP, yet ACP’s can use it as a back-up device for failed airway management. Would it not make more sense to make the conditions for PCP something like “Patient must have a GCS=3 and other airway management is inadequate or ineffective”?

The issue here could be two-fold. First, if BVM ventilation is ineffective as a PCP, there is nothing you can fall back on, whereas the ACP can use either ETI or a SGA as indicated. If this ineffective BVM situation occurs as a PCP and the patient is GCS=3, why can’t we insert a SGA as a rescue device for ineffective BVM ventilation?

Secondly, with some new evidence beginning to show that SGA’s may actually not be as great as we thought in VSA patients, is there a risk we could abandon them entirely from the PCP level, in essence “throwing the baby out with the bathwater” and abandoning a valuable device simply because the conditions for its use were restrictive.

Also, do you have any idea when the new revised BLS standards may be coming out from the MOHLTC? I’m hoping there are new evidence based oxygen therapy guidelines. Any thoughts? Thanks.

Question: There is certainly a lot of confusion that remains in regards to DNR’s. From your replies, I get the impression that if someone is breathing, has a pulse and a valid DNR, but has respiratory or cardiac problems which may or may not be corrected with artificial ventilation, assisted ventilation without an artificial airway (conscious CHF)or chest compressions we are to provide NRB O2, symptom relief meds and comfort measures. That being said, if someone has a valid DNR becomes obstructed with a FB, we have been instructed by BH personnel to attempt to clear the FB and if death results in the process, validate the DNR and stop the efforts. If this is correct, are we not providing or at least attempting to provide A/R in one of the steps to alleviate the obstruction? This would be in contraindication to past answers which the committee has provided. Not trying to be a pain, just looking for clarity for viewers and myself. Great site €“ your time and effort is appreciated.

Question: I like to give O2 to patients for pain (when not contraindicated) even if their stats are good. I have done this for years and have found that it seems to help. A fellow paramedic felt that this was a very useless application. I disagreed. I have looked for scientific evidence for this working and have found little on it. I was wondering if you would comment.

Question: If you have a VSA patient with a previous history of methadone use, is it beneficial to patch for Narcan while the patient is VSA or until you get a ROSC?

Question: Recently I had a call for a 2 year old anaphylaxis that I ended up treating with epi and ventolin. The patient was very short of breath and had a decreased LOC and ended up having to be ventilated. Eventually the patient came around with the epi and the bagging. This patient’s heart rate was approx. 70/min. My questions is, are we still starting CPR on pediatrics with signs of poor perfusion with a heart rate of less than 60 or is this just for neonates?

Question: Patient is unconscious respirations of 8 but DNR is present. We can’t assist respirations using a BVM? Sorry if this question had already been asked / answered.

Question: In the ROSC protocol I do not notice an age range specified. If we have a patient 0-2 years old that has a ROSC, can we bolus? Thank you.

Question: We haven’t heard much discussion on this topic lately, so could you please detail which vagal maneuvers we are able to perform?

Question: I was wondering if there was a reason that, according to the standing orders, if you want to give a patient under 25 kg Gravol you can call the BHP for an order but there is no stipulation for giving Benadryl to a patient under 25 kg’s. Is this on purpose? It suggests to me I should not consider calling the BHP for an order for Benadryl for an under 25 kg pt. Is this correct?

Question: I have a question in regards to a specific situation with the Acute Stroke Protocol. We were called at 06:30 for an 85 year old female in a nursing home with slurred speech as witnessed by nursing staff. Upon our arrival she has a GCS of 15, blood glucose of 6.2 and obvious unilateral facial droop and pronounced associated slurred speech. The patient stated that she was up at 03:00 without concern which removed her from the Acute Stroke Protocol with all other criteria being met.

I understand that if the stoke symptoms resolve prior to our arrival the patient is not eligible for transport under the by-pass protocol. Additionally if their symptoms improve or resolve en route to a Stroke Centre transport should continue. However, en route her symptoms completely resolved and subsequently reoccurred €“ resolved again and while reporting to triage reoccurred in front of the staff at emerg.

After dialog with emerg staff I have the understanding that with completely resolved symptoms the “clock” would start (for them) with the onset of the recurrent (and witnessed) symptoms.

I would believe she would have the most appropriate care and best outcome being treated at a Stroke Centre. My question is twofold: first, is this a correct understanding of the possible in hospital treatment in way of assessing the initial onset of symptoms? Secondly, specifically for our transport decision could we use the recurrence onset of symptoms as the initial onset for meeting the Acute Stroke Protocol individually if it happened on scene or en route given we had equal distance to an ER or UH?

Question: I was wondering if in the instance of a patient cutting their wrists, becoming hypovolemic and then going VSA if this should be treated as a medical arrest or a traumatic. Thank you in advance.

Question: When it comes to chemical sedation for combative or procedural reasons I noticed that the IN route is not included. I have read the rational for this in a previous question asked of MAC (Jan 19 2012). In this question it is mentioned SWORBH was suggesting the IN route be added during my re-cert I forgot to ask if that had taken effect. Is IN acceptable in these circumstances?

Question: I was wondering recently while reviewing my re-cert material why it is that if asthma exacerbation is the reason for a pt. becoming VSA why 0.5mg of epi IM would not be administered while preparing for IV in a similar fashion that epi is used for anaphylaxis if it is the causative reason a patient becomes VSA. Thanks for the help.

Question: Can you administer diphenhydramine to a patient that is in moderated to severe allergic reaction? The old directive was clear on this, which was allowable. The current directive leaves medics guessing treatment intervention. Epinephrine is indicated as a first round drug for anaphylaxis, which is understandable.

Question: In recerts we were informed that if we are extricating a patient who suffered blunt trauma and they go VSA in front of us. We are to run it as a medical arrest since it was witnessed? Is this true?

I just read a previous MAC post and it stated: ANSWER: Great question! Assuming this is a first arrest, the correct sequence would be to pull over, confirm the patient is VSA, begin CPR, and follow the Trauma Cardiac Arrest Medical Directive which includes one rhythm analysis.

Could you please clarify this?

Question: What is the rationale behind no longer doing a 45 second pulse check on a severely hypothermic patient? BLS patient care standards in section 4-11 assessments #3 states a 45 second pulse and breathing check.

I understand that ALS standards trump BLS standards. Other than a summary that came from RPPEO August 2011 on the new November Directives where it stated no more 45 second pulse checks, there is no mention in the new Directives of this change that I could find.