Hi MAC, hope you folks are well. I was curious if you can provide clarification and potentially rational to the “Mandatory Patch Point” for Medical Cardiac Arrests. Although I understand calling for termination or potentially further direction, I am curious if we have to BHP patch if the attending Paramedic feels the Pt in cardiac arrest [that fits criteria for TOR] would benefit from transportation for any variety of situations (age, geo. location, ect.). It seems it would be counter-intuitive to spend the time calling an MD to tell them we feel transport would be beneficial for a Pt (especially if ready to transport) instead of initiating time critical transport + our active resuscitation efforts. Would a BHP ever say no, do not transport this Pt, regardless of potential ED Tx benefit? I recognize this is an odd question that is a rarity, but I’ve found myself in this position more than once and am wondering how to efficiently tackle these situations in the future without a potential protocol violation. Cheers MAC.

As a PCP I am trying to get a better understanding of what orders a BHP can give and when certain orders may be considered outside our scope of practice. My understanding has always been that deviations can be made to most areas of a protocol like age, RR, SBP, LOA, contraindications, dosing levels, # of doses etc., but what about treating conditions or diseases that are not written into the protocol? ex. Tylenol for fever, Glucagon for beta blocker toxicity, energy for SVT or Ventolin for hyperkalemia? Although we are trained in how to use these drugs are we expected to give them for conditions not listed in our protocol, if ordered by a BHP? Thanks

I had a call the other day, 40s female with 7/10 central chest pressure radiating to her left arm, under left breast. PT said that how she felt now is identical to how she felt a few years ago; she had SCAD as in sudden coronary arterial dissection then and had stents put in. How does ASA and nitro play a role in this case, because it sounds textbook ischemic but with such a rare and bizarre medical history. Please let me know what you think?

Question regarding procedural sedation. During a recent call we had a patient that was believed to be flash pulmonary oedema (audible crackles, blood tinged frothy sputum, confusion). The patient was quite agitated, wouldnt answer questions, resistive to any intervention or assessment, resistant to vitals and non-tolerable of O2 via any route and had difficulty remaining still. Is it reasonable to consider sedation for these patients? Would this be considered a special circumstance requiring BHP consultation? Would Ketamine be the drug of choice over Midazolam?

Due to known patching issues inhibited by the currently required PPE can the OBHG look at omitting mandatory patch points specifically surrounding Midazolam and Ketamine administration for combative and excited delirium patients. I have never been denied an order for either of these medications and the time required to call for an order increases the risk of injury to everyone involved with the extra time required to complete the call delaying treatment. Second question, can we also look at increasing the maximum dose of Midazolam to 10 mg for combative patients as I have found that often times 5mg is insufficient especially when used on patients with known drug abuse. Or, is it possible for the OBHG to considering opening up Ketamine to be used on combative patients, as its my understanding Ketamine is a safer drug with less side effects?