I’m seeking clarification regarding a call we attended today. We were dispatched for a shortness of breath patient who was in acute CHF and also presented with slurred speech. At the time, we were not aware that his slurred speech was baseline due to tongue CA. Out of caution, we checked his blood glucose, which returned at 3.6 mmol/L. We initiated CPAP in conjunction with nitroglycerin for the CHF, which the patient tolerated well. However, due to the CPAP, we were unable to administer oral glucose paste. The directives for glucagon and dextrose specify that the patient must have an “altered LOA” to administer these agents. In this case, the patient had no signs of hypoglycemia and no altered mental status. My question is: in situations like this, when a patient cannot receive oral glucose but does not meet the conditions for glucagon or dextrose, should we attempt to administer either of those treatments, or is withholding them appropriate?

We have a young (15) female patient in that has been diagnosed with Hereditary Angioedema. This Pt has had some severe episodes in the past and has required intubation and admittance into the ICU multiple times. I have completed interfacility transports with this patient from one hospital to another. Upon acquiring information from the sending Physician and his treatment in the ER was Epinephrine and Benadryl which he admitted does little to no help for the condition. He then told me that he was also treating with TXA because it inhibits bradykinin formation. My question is since we carry TXA and this is a known condition (HAE) for this Patient could the crew patch and ask for an order for TXA in the pre-hospital environment since the Patient does not fit into our moderate or severe allergic reaction protocol ? Since this is not an allergen based reaction and yet is still a life threatening.

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?