Question: Just would like clarification that we “must” attempt an IV on all seizure patients first before moving on to either IM, IN, Buccal. The chart is written in this order. I feel that attempting IV’s on a lot of our seizure patients could very easily pose a safety hazard on ourselves and others in the field. Thanks.

Question: I would like to go back to the DNR ventilation question from Sept 4th. The way I understand your answer is that there is no difference between Assisted ventilations and Artificial ventilations in regards to a DNR; Both are inappropriate if a DNR is present, even if the patient has spontaneous respirations. I am interpreting your answer correctly?

Question: Do we have an idea when the iPhone app for our medical directives will be released. The majority of paramedics I know use iPhones and are anxiously waiting for this new tool. Any idea when?

Question: What are your thoughts on CPR with ventilations vs. continuous chest compression CPR? – Student PCP

Question: In regards to a traumatic VSA. The patient goes VSA during transport to the closest ER. The paramedic believes the arrest is of trauma origin. Do we pull over and perform one analysis and then resume transport? Or do we just do CPR until we arrive at the ER?

Question: With these new medical directives, I was under the impression that we as medics are able to use our judgment and discretion on calls. It is mine and many of my colleagues opinion that oxygen is not required on all calls, maybe even some calls when you provide sympatientom relief, depending on the circumstances. Does MAC agree? Or should oxygen be applied to most patients, and in all cases that sympatientom relief is provided?

Question: As a PCP, can you do an inter-facility transfer with a patient with IV running lactated ringers without an escort?

Question: I’m an ACP in my primary service, but I am working as a PCP in a different service. Does my IV certification status automatically transfer directly to the service in which I am working as a PCP? If so, I have not been trained on the equipment being used in my PCP service and would prefer not to use my IV skills there. Am I obliged to?

Question: I have some questions regarding supplemental oxygen. For a patient who requires oxygen, but is vomiting frequently is a nasal cannula an adequate oxygen delivery system, or should a Non Rebreather be continually removed an reapplied as necessary? Also I see a wide range of flow rates applied to the nasal cannula (anywhere from 2-8 lpm). What flow rate is most beneficial to a patient in a pre-hospital setting who requires supplemental oxygen via nasal cannula?

Question: In the medical cardiac arrest directive it states, In unusual circumstances (e.g. pediatric), consider initiating transportation following the first rhythm analysis that does not result in a defibrillation being deliver.” My question is: What is the age range for a pediatric? Thanks in advance.

Question: I was just wondering the reasoning as to why we don’t check for a pulse after we deliver a shock, and instead jump right into CPR? I have watched many VSA’s ran in the ER and always see the ER physicians check for a pulse after delivering a shock before resuming CPR. I have asked several co-workers and no one seems to have an answer for this.

Question: I know there have been a lot of questions regarding the new cardiogenic pulmonary edema protocol. I am a student and just had a call regarding this. After the call there has been discussion about the directive and I have heard three different views and they are…

1. The first treatment column <140 you can ONLY give NTG if a IV is established (no hx.) 2. The second column stating that =>140 with no hx or Iv you can give 0.4mg is to be completely disregarded as it contraindicate the directives conditions 3. The third column stating that =>140 give 0.8mg ONLY if an IV is established (no hx.)

So the question I am asking is can you please clarify the treatment chart of the acute pulmonary edema directive?

Question: We are transporting a patient from a small hospital without a CT scanner to a larger hospital with a CT scanner but not a Stroke Centre. Our patient is an obvious stroke patient…slurred speech for over 1 day, but is getting better and no other issues…stable, but still with slurred speech (does not meet Stroke Protocol as onset over 24hrs).

What should we do should this patient become worse enroute to the CT capable hospital? Say his slurred speech becomes worse or he shows other signs and symptoms? Is this considered a “new onset” or a continuation of his current CVA/TIA? If “new onset” I would think he now meets the Stroke Protocol and should be diverted to the Stroke Centre? Could you please clarify?

Question: I need some further clarification on the question “Seeking Clarification” from March 1 2012 regarding hypothermia. It has been my understanding that we DO NOT give medications to hypothermic VSA patients. I have clarified this before, unless this rule has changed since, so could you please readdress this part of the question for me?

Question: I am an A-EMCA certified paramedic (PCP) who opted to work in Ottawa full time for a full year after graduation in 2009. After returning to London to apply, I am now advised that my IV certification issued by RPPEO is not eligible for SWORBH. Are there IV certification courses I can take in London to become “IV Autonomous Certified” without going back to Fanshawe College to repeat my entire second year of school? Please let me know so that I may increase my eligibility to someday secure work here in my home town.

Question: I was just wondering when the smart phone app is going to be released with medical directives?

Question: When arriving at a scene that turns out to be a ROSC, say Fire applied two shocks and now patient is alert and oriented, and fire pads are not compatible. Do we apply monitor electrodes, defib pads or choose based on our gut of how unstable the patient looks and might re-arrest? Having chosen and justified on the remarks section, what would you like to read to feel we were justified?

Question: This question is similar to one already answered but slightly different. If you have a VSA patient as a result of a FBAO and the obstruction is relieved, should you analyze right away or continue with a 2 minute block of CPR. Also, after having done the medical defib protocol does this patient now qualify for a Medical TOR?

Question: For STEMI Bypass, what is the delay in extending the bypass into all of the services that would meet the transport criteria? Originally I was told it was an issue of having an IV established, now with the increasing number of service providers with autonomous PCP IVs this would no longer seem to be an issue. I never understood the initial rationale since say Glencoe is 50km from UH and St Thomas is roughly 20km closer. Yet Glencoe could bypass and St. Thomas couldn’t. Thanks in advance.

Question: In the previous cardiac ischemia medical directive it said that if the patients symptoms resolved after the administration of nitro and then returned that you could administer another 6 sprays of nitro. I was wondering if this was still the case.

Question: I don’t agree with the transport consideration in case study #1 of the Acute Stroke Protocol that states the patient is excluded from transport to a Designated Stroke Centre due to not being able to determine onset of symptoms: male, age 58, found unconscious on the floor at 0800 by a friend, when he came to pick him up for work.

Shouldn’t we consider it likely the symptom onset was < 3.5hrs especially in this case where it would be safe to assume symptom onset probably occurred after patient got up to get ready for work and that he probably does not get up three and a half hours prior to getting picked up at 0800.

Further, it’s more likely his GCS would be worse than 10 had he been down much longer. Bottom line, shouldn’t we be erring on the side of caution for these patients and give them the benefit of the doubt that symptom onset might be < 3.5hrs given the evidence at hand? Or even with less evidence? As an aside, is the time going to be extended as i believe some doctors think it should?

Question: The old protocol for Gravol stated it may be given for severe nausea or vomiting. The new one also says we may give it for nausea or vomiting. It does not say severe anymore. My question is do we have to give it to everyone who says they have nausea even if it’s minor?

Question: In the ALS patient care standards it states that a Supraglottic Airway (King) is indicated when “Need for ventilatory assistance OR airway control AND Other airway management is inadequate or ineffective”

In the “un-controlled” world of EMS would it not be more effective to use a King over an oral airway after the first round of CPR is complete? The King allows for movement from the floor to stretcher with no worry about “losing” your airway. It also doesn’t fall out as an oral airway will in the difficult situations/extrications we face in the field. The fear of gastric distention is also completely alleviated, making the King more effective. It would also allow for constant compressions, which is the best treatment for cardiac arrest patients in pre-hospital settings according to the Heart & Stroke. I have had many discussions with other paramedics and they seem to think that you can’t use the King at all if you have an oral airway that is giving adequate control. So my question is, if you use the King on VSA patients, is it acceptable even if the oral airway will work (just not as adequately or effectively in my opinion)?

Question: If we are on a call and suspect child abuse or neglect may be taking place what would be the best way to contact child services? Also could we run into confidentiality problems? An example would be if we are called to a residence for a woman with abdo pains. After assessing the scene we notice an infant sitting next to drug paraphernalia.

Question: Seeking clarification: Traumatic Cardiac Arrest where TOR does not apply and we are transporting to nearest ER. While en-route, the medical directives currently state we are to transport with CPR and no further treatment. Is it acceptable to intubate if required, IV and epi q 4 min, consideration of bilateral chest needles? Would I require an order to proceed with the chest needles if patient is in PEA.

Same question for hypothermic arrest, is it permissible to intubate, IV access, patch for further orders, i.e. epi?

Question: Is the stipulation that the patient must be VSA upon arrival to qualify for a Trauma TOR is a SWORBHP deviation from the provincial directives? The protocol does not specifically state witnessed or unwitnessed arrest (as does the Medical TOR protocol). After talking to a couple paramedics under another Base Hospital they have informed me that they can Trauma TOR a witnessed traumatic VSA (for example, the patient goes VSA during extrication and meets all other criteria).

Question: When is the “new” treatment algorithm ALS/BLS for Medical Cardiac Arrest being posted?

Question: In regard to the new Acute Pulmonary Edema protocol and the confusion surrounding it. Are we really giving 0.6 to 0.8 mg of Nitroglycerin SL to a patient with no IV and an Hx of use and a SBP of >140 mmHg?

Question: With the assumption that the Cardiac Arrest Medical Directive applies to patients > 30 days, and the Neonate Resuscitate Medical Directive applies to patients < 30 days, can we administer Epi to Anaphylaxis VSA patients under the age of 30 days? (We realize this is a VERY rare what-if).

Question: Recently, after transporting a stroke bypass patient we were told they could not be treated for the stroke (with thrombolytic) due to the patient’s history of warfarin use.

How does this fall under our protocol but outside theirs? If blood thinners (either in conjunction with a specific disease or as a certain dose) are a roadblock to thrombolytic therapy why isn’t it listed as a contraindication to the bypass protocol? We did not have time to discuss the rationale behind the statement and have been wondering since if we misinterpreted the statement or if warfarin and similar drugs really do prevent thrombolytic use with CVA’s? I know there have been studies linking problems with tPA in patients with warfarin history but didn’t know that played an active role in the exclusion criteria at stroke centers now. If this is the case why not change the protocol to eliminate needless transport (especially when transporting from outside of the city/county where the center is located?

Question: Would bolusing a hypothermic ROSC be considered active rewarming?

Question: During my recent last autumn, my instructor mentioned that our base hospital medical protocols might be available as an App for a smart phone. Are there been any updates on that process?

Question: Can there be some consideration to an inclusion of a (1mg-2mg) Naloxone standing order for VSA patients from a suspected opioid overdose as per current literature and practice?

Question: With regards to neonatal resuscitation, are we to provide room air PPV for 30sec (as per ALS PCS), or provide room air PPV for 90sec (as per AHA guidelines)? Also, why is room air the preferable choice for initial PPV over 100% O2? (Updated)

Question: Can we please have our standing order pocket booklets? I know I speak for dozens of medics in this regard. We really need them with so many changes in place.

Question: What was the rational for all the little tweaks to this years symptom relief protocols? For example, removing 100mcg from the Ventolin protocol?

Question: On page 2-29 it says “A single dose of atropine should be considered for second degree type II or third degree AV blocks with fluid bolus. Does that mean fluid bolus for both or just third degree?

Question: For combative patient, preference for route choice from left to right is IV then IM. Shouldn’t it be IM first? It is kind of hard to get an IV on a combative patient. Why no IN anymore?

Question: Why did the dosing of salbutamol change by 100 mcg per administration? I am all for evidence-based changes to our protocols, but why such a small change? Surely the extra 100 mcg wasn’t hurting anyone.

Question: Nitro Protocol for CHF the new protocol diagram says… Consider nitroglycerin: ‰¥140 mmHg, IV or Hx 0.6 or 0.8 mg. I have been told the diagram is wrong and I cannot double dose unless I have an IV regardless of history. If this true can you fix the diagram and issue a clear concise overview of this protocol?

Question: This morning at 3am I did a call that involved a 4 year old in seizure. The mother had given the child 1mg Ativan SL prior to our arrival. The seizure had stopped during our assessment and drawing up of Midazolam, so no further drugs were given by me. The mother had stated that the last time the patient went to ER in seizure, the doctor gave her Ativan and then Diazepam when the seizure did not stop. The Diazepam worked, but the mother said that the child took about 1 week to totally recover/wake up. She wasn’t sure if the ER gave too much drug or simply the combination of the two affecting her.

So my question is, with the Ativan already on board, would there be a significant synergetic response with this patient once Midazolam is given? Priority of course is to stop the seizure and close observation regarding respirations is a must, but are we okay to give the proper dosage or should it be reduced?

Question: Dr. Bradford still ok with us not having to patch for naloxone?