Welcome to Ask MAC
Ask MAC is a tool aimed at providing paramedics with an opportunity to find question and answers related to the medical directives, challenging or unique calls, or other relevant topics for discussion.
All answers provided on Ask MAC have been reviewed by and reflect the opinions of the Medical Directors within the Southwest Ontario Regional Base Hospital Program (SWORBHP).
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- Acute Cardiogenic Pulmonary Edema
- Adult Intraosseous
- Analgesia
- Bronchoconstriction
- Cardiac Ischemia
- Cardiogenic Shock
- Central Venous Access Device
- Combative Patient
- Continuous Positive Airway Pressure (CPAP)
- Croup
- Cyanide Exposure
- Emergency Childbirth
- Endotracheal and Tracheostomy Suctioning and Reinsertion
- Hyperkalemia
- Hypoglycemia
- Intravenous and Fluid Therapy
- Medical Cardiac Arrest
- Moderate to Severe Allergic Reaction
- Nausea Vomiting
- Newborn Resuscitation
- Opioid Toxicity
- Orotracheal Intubation
- Pediatric Intraosseous
- Procedural Sedation
- Return of Spontaneous Circulation (ROSC)
- Seizure
- Supraglottic Airway
- Symptomatic Bradycardia
- Tachydysrhythmia
- Trauma Cardiac Arrest
What should I do when the defibrillator advises a shock, however the rhythm I see (and confirm with my partner) is PEA? Am I allowed to disarm a shock that I belive the monitor is mistakenly picking up artifact and suggesting a shock when it is unwarranted?
Published On: June 19, 2026We treated a patient c/o dyspnea, febrile, cough, generally unwell. I wanted to treat patient’s chronic pain, new body aches, and sore throat with Tylenol and Advil, so I went through the contraindications and treated. Prior to giving Advil, I knew the pt had an ulcer 15 years ago and has no issues since. From my memory, I recalled the contraindications stated “current peptic ulcer”. On review of the directive, I later saw it stated “history of peptic ulcer disease”. In the future I will make sure I have the directive in front of me if I’m unsure. I think it would be a good idea to bring out my directives on calls if I haven’t given medications in a while, so I refresh my memory on the wording. The patient had stated she had a duodenum ulcer and she has not for 15 years.” Can we get some clarification on “history peptic ulcer disease”, I have traditionally always viewed this a recent history, or something that is currently active, not a history of ever having ulcers.
Published On: June 19, 2026If a ROSC patient is bradycardic and hypotensive, can we proceed with TCP under the Symptomatic Bradycardia MD or must we stick with Dopamine under the ROSC MD?
Published On: June 19, 2026I’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?
Published On: June 19, 2026Regarding Gravol for patients over 65 years. The age condition was removed, but the treatment section states that gravol may be considered for patients over the age of 65 if ondansetron is “unavailable.” My question: would it still be a patch to BHP if ondansetron is available, but Gravol would be the more appropriate antiemetic? Example being vertigo symptoms where the pt can’t even consume the PO ondansetron, but technically it is “available.”
Published On: June 19, 2026Would you treat a patient with COPD who is in severe respiratory distress, using accessory muscle use, cyanotic around the lips, no wheezes, but mild crackles in the bases with 1. Salbutamol, dexamethasone, and then CPAP? 2. Or just Dexamethasone and then CPAP? 3. Or just Salbutamol and CPAP? According to the companion Doc for CPAP it states that “CPAP should be considered as an additive therapy to the bronchoconstriction (specifically COPD exacerbation) or acute cardiogenic pulmonary edema medical directive, not a replacement.” Please clarify for me. Thanks!
Published On: June 19, 2026Back to basics – there is a debate about the volume in the nebulizer cup to achieve appropriate aerosol. When administering 2.5mg of epi for croup or 2.5mgs of salbutamol for bronchoconstriction is it not best practice to add 2.5mls of saline to achieve appropriate aerosol? My co-workers and I are split on this debate.
Published On: June 19, 2026With PCPs having the ability to shock a rhythm en route now, is it expected and best practice to stop compressions every two minutes during transport to analyze the rhythm. Or should we discontinue doing 2 minute analysis of the rhythm once transport is initiated.
Published On: June 19, 2026I am curious to know why some of our medical directives are systolic driven rather than mean arterial pressure driven? Current research suggests MAP is more accurate than SBP in non-invasive monitoring and better reflects perfusion pressure in shock, is a better indicator of organ perfusion and is a better predictor of post-cardiac arrest outcomes. Even ACLS recommends a target MAP of 65mmHg for post-cardiac arrest care as opposed to a certain SBP. Is this a change that OBHG would consider in future iterations of the medical directives?
Published On: June 19, 2026Scenario: 91 yo M pt VSA, last seen 7 hours ago, extensive medical hx, rigid in his jaw, mouth shut, no lividity, incontinent of urine, coffee ground emesis to his upper shirt, pale, cold to touch and hx of pacemaker. In and out of hospital multiple times recently. General decline recently. Would you be at fault to fit this pt in the deceased pt standard since there is only rigidity to his jaw? Does rigidity have to be gross for a pt to fit the deceased standard? Does hx and last seen baseline alter the deceased pt standard?
Published On: June 19, 2026In ALS version 5.4, the medical cardiac arrest directive talks about DSD or VCD for refractory VF or pulseless VT. It defines refractory as persistent VF or pulseless VT after 3 consecutive shocks. Does each of those 3 shockable rhythms have to be only VF or only pulseless VT or could those 3 consecutive shocks have been from a mixture of VF and pulseless VT? Essentially is any sequence of 3 consecutive shockable rhythms grounds to perform DSD or VCD?
Published On: June 19, 2026After reviewing the Vector change defib video on the paramedic portal, the video shows when switching to AP position (after the initial 3 AL shocks), “3 more remaining shocks in AP”. However, in the protocol it states there are no max number of doses. My question is, do we only do 3 analyze/shocks in AP position, OR , continue analyze/shocks in AP position , every 2 minutes, until the 20 minute scene time is complete?
Published On: June 19, 2026Would a traumatic VSA patient meet the indications for TXA (hypotension)? I appreciate that it would not be a priority but rather if you had the extra time and resources after any other interventions and after transport.
Published On: June 19, 2026I had a question about the fluid overload contraindication for the IV and fluid therapy directive. I had a patient who was hypotensive with a history of CHF. They were hypotensive at 84/66, however had a mild increase in peripheral edema from their chronic swelling. Their chest sounded clear and they denied having any shortness of breath. Their work of breathing was laboured and they were satting between 90-93 on room air. They do have home o2 that they use intermittently when needed. Would this patient benefit from fluid bolus, or would they be contraindicated?
Published On: June 19, 2026During a medical code, after the first three shocks we are now doing a vector change. The directive states to then do 3 more shocks with the new pad placement. My question is if we only get one or two shocks following that pad placement change, are we now remaining on scene for the full 20 minutes since they’re no longer in refractory VF/VT or still leaving early since they were in that state and have shocked 4-5 times.
Published On: June 19, 2026What constitutes as tbi? Does every fall were the person struck their head mean that they can not have any pain management or is there a symptom we can look for to narrow down the risk of increasing bleeding?
Published On: April 1, 2026I was hoping to get clarification on the appropriate fluid bolus amounts for a patient suspected to be in cardiogenic shock but not having an identified STEMI. The patient I attended to in this call was found to be in rapid atrial fibrillation and hypotensive, along with appearing pale and having complaints of dizziness. From the 12-lead ECG we did not identify any STEMI. The patient did complain of nausea/vomiting earlier in the day, and also did have a fall approx 1 week earlier where pt fell on his left side. There were multiple factors at play here which may have contributed to this patient’s complaints of dizziness and hypotension. In hindsight, I am now suspicious that this patient was in cardiogenic shock. In the cardiogenic shock auxiliary directive, it states that the patient needs to have a STEMI positive 12-lead ECG and be in cardiogenic shock to be administered a halved saline fluid bolus (10mL/kg). However, in the IV fluid auxiliary directive, it only requires the patient to be in cardiogenic shock to have the halved saline fluid bolus administered. In hindsight, I believe I should have administered approx 500ml of saline instead of the 1000ml I did administer.
Published On: April 1, 2026Can I give a pediatric patient some juice, with their dexamethasone, to make it more palatable? I see this done in-hospital.
Published On: April 1, 2026If I’m doing a STEMI bypass and patient goes VSA, do I transport to nearest ED or continue to go to PCI centre? And could you explain as well If I obtain a ROSC during said transfer, closest ED or continue to PCI centre?
Published On: November 21, 2025If I am certified in manual defibrillation, however in a cardiac arrest call am not confident in my rhythm analysis, can I switch to SAED to help interpret/treat the patient?
Published On: November 21, 2025If patient is experiencing chest pain and all signs/symptoms lead to suspected cardiac Ischemia, and considering ASA. Patient has a history of sensitivity to ibuprofen however takes ASA daily as well as patient took own ASA prior to EMS arrival Am I still alright to administer my own ASA even though patient has hx if sensitivity to Ibuprofen but takes ASA daily?
Published On: November 21, 2025is there any consideration(s) to move away from the ” double syringe method” to a single syringe method for adenosine ?? – using 20 ml or larger syringe meaning adenosine mixed with ns and then pushed as 1 dose – medication and flush ?? various studies have shown that is effective, less operational stressors , and easier to manage then attempting use a stop cock valve, ns line wide open with flushes, etc
Published On: November 21, 2025Revisiting this question from 2020…For a VSA patient who is in refractory vfib after 3 analyses, can we call BHP for double sequential defibrillation (or vector change pad placement) if we have a second PCP unit? This question is asked in the updated context of Dr Cheskis’ DSED study and other Ontario Base Hospitals having already implemented this practice.
Published On: November 21, 2025For Oxytocin administration, can you please clarify if the placenta has to be out prior to. Or can the patient have Placenta in and us administer Oxytocin as long as baby is out?
Published On: November 21, 2025Crew responded code 4 to possible allergic reaction. PT was a bad historian, who states he has a chest pain post being stung by a wasp. Pt had swelling on the left side of his lower lip where he got stung. PT complains of dizziness/lightheaded. PT had no adventitious sounds in the lungs. PT complained of mild nausea with no vomiting. No incontinence. PT complained of weakness as well. During the assessment, pt complains of chest tightness post the wasp sting, all the answers to CP questions were leading the crew to believe that patient was experiencing ischemic chest pain. Pt states he has hx of allergic reaction to bee sting. Vitals: 58, sinus bradycardia with LBBB in 12 leads noted. BP: 86/42, RR 22, Sat of 90%. In this case, pt is showing signs of anaphylaxis with multiple symptoms being affected and known allergen exposure, but complaining of ischemic sounding chest pain. Is the crew to be treating with Epi, or should the crew withhold the epi as patient may have ischemic chest pain and it can worsen the cardiac symptoms?
Published On: November 21, 2025If a PCP crew has a RN onboard from a previous transfer and is assigned a VSA call what is the base hospitals position on said nurse providing ACLS care such as Epinephrine administration if their transfer bag has the medications. What about if a RT is in a similar position when it comes to airway management?
Published On: November 21, 2025The directive now states that we are to initiate transcutaneous pacing immediately if the pt is severely symptomatic/pre-arrest and not delay for IV access or atropine, etc. If they are in a spot that requires a lifting chair to extricate, should we wait until they are on the stretcher to initiate it or initiate then discontinue for extrication, reinitiate, etc. Then how would you like us to move the pt to the stretcher?
Published On: November 21, 2025In regards to endotracheal suctionning protocol, how far can we insert the French catheter? I can’t find the answer anywhere in the protocol book, companion document or BLS standards.
Published On: November 21, 2025Nitroglycerin – SBP drop by one third. Is this a 1/3 drop directly after a dose of nitroglycerin or a cumulative drop after multiple doses/sprays? My understanding was that this 1/3 drop in SBP was being used to determine the pts sensitivity to nitroglycerin. If the pt had mild/moderate SBP drops after each dose it indicated that the pt tolerated nitro well and it was safe to give higher amounts and more doses. However, a large 1/3 drop immediately after a dose of nitro meant that the pt had a high sensitivity to nitro and further tx should be discontinued for pt safety and impending hypotension. Scenario: Ischemic chest pain (Non-STEMI) with an initial SBP of 180mmHg. 1/3 dictates a drop of 60mmHg. After 4 sprays of nitro (with mild SBP drops between each dose) the pts SBP is now 115mmHg. Is this pt exempt from further nitroglycerin because cumulatively their SBP dropped by more than 1/3 OR can I continue to treat because a large 1/3 drop was not seen following an isolated spray of nitro.
Published On: November 21, 2025Is there a reason why epinephrine dosing intervals in cardiac arrest patients is set to q4min instead of q3-5 minutes as per AHA guidelines? By having them set at q4min, it puts the provider in stressful situation trying to sequence the doses at a speicific time rather than a range as suggested by AHA.
Published On: November 21, 2025Hello, I was hoping you can put my overthinking mind at ease. I responded to a traumatic vsa. Single stab wound to the chest with the knife still impaled. Single stab wound to the lower left side of his chest(left of his nipple). He was asystole, very rigored at the jaw but no other obvious signs of “ Obivously Dead Criteria” My question is technically can we deem that enough to not continue resuscitative efforts? Or do they need gross rigor mortis at the extremities or lividity to call it? We decided to run the call as we did not feel comfortable calling it with just rigor at the jaw. Removed the knife as it was impending CPR, applied an asherman seal, rhythm analysis revealing asystole, double NPA with two handed seal and adequate ventilations with equal chest rise and fall with good air entry(did not needle decompress), end tidal of 20-22, IO access and transported. Arrival at the ER, got odd looks from ER team and got questioned why we transported someone who was rigored at the jaw and explained to them that we did not have enough to pronounce them on scene. Hoping you can give some clarification on this challenging scenario and whether I could’ve done that call differently. Thank you!
Published On: November 21, 2025How long after someone took an oral steroid (example prednisone) would be contraindicated for giving dexamethasone within the Bronchoconstriction Medical Directive? The Croup Medical Directive is clear that steroids must not have been taken within the past 48 hours. But, the Bronchoconstriction Medical Directive only says, “Currently on PO or parenteral steroids”. What is considered Currently on – taken within the last 24 hours?
Published On: November 18, 2025When giving Epinephrine for anaphylaxis is it expectable to delay administration of diphenhydramine following the first dose of Epinephrine if it is getting close to the 5 minute dose interval for the second dose of Epinephrine and the patient is requiring the second dose of Epinephrine? My understanding is that Epinephrine in anaphylaxis is the priority medication and I could use clarification as to whether or not it is okay to delay administration of diphenhydramine until after the second dose of Epinephrine if the patient requires a second dose and we were not able to administer diphenhydramine in between the required 5 minute dose interval for the second dose of Epinephrine.
Published On: November 18, 2025Hello, some further clarity/confirmations on the trauma cardiac arrest algorithm is still needed for a rather large group of paramedic students. Note, some of the “greater/less than” symbols in your previous replies show up as papyrus-esque and cannot be deciphered. Please reply with words only in case that issue repeats itself. -A patient with penetrating trauma to head/neck/torso in asystole (and no signs of life): if nearest LTH is greater than 30 min away, but nearest regular ED is 15 min away, we still patch for trauma TOR, right? Or do we transport to that nearest regular ED? -A patient with penetrating trauma to head/neck/torso in PEA: if nearest LTH is greater than 30 min away, but nearest regular ED is 15 min away, do we patch for trauma TOR (due to over 30 min transport time to LTH) or do we transport to that nearest regular ED that’s 15 min away? -A patient with a blunt trauma and asystole (and no signs of life) automatically gets a patch for TOR, right? -A patient with blunt trauma in PEA would only get a patch for TOR if there was no hospital (regular ED or LTH) that was less than 30 minutes away? Ie. Only patch for TOR if either ED or LTH were both over 30 minutes away. Thanks!
Published On: November 18, 2025I have an question regarding the symptomatic tachy/brady directive. A patient with a hx of atrial fibrillation, currently in a rapid afib at 180 BPM. But they have periods of chest pain and pre-syncope every minute or so due to a sinus arrest lasting approximately 8-9 seconds before they flip back into rapid afib. My understanding is that sick sinus syndrome is often the culprit, which can cause alternating rhythms on an ECG and needs to be treated in hospital. In terms of ACLS and pre-hospital care, which would be most appropriate? cardioversion or pacing? providing indications are met and the pt is unstable. Hypothetically, in different scenario, a patient with an underlying regular/brady rhythm and prolonged symptomatic runs of Vtach. What would be most appropriate in that scenario? Any input you could provide is greatly appreciated! Thanks
Published On: November 18, 2025We recently had a call with a 3 year old being exposed to pepper/bear spray. Although our Pt. was not experiencing any respiratory Sx. During and after the call my partner and I were discussing Epinephrine under anaphalaxis as a possible Tx. If the Pt. airway became a serious concern. What are some thoughts from SWORB.
Published On: November 18, 2025Q: pt has been dx by a doctor with pneumonia and the pt is now septic from not taking anti-biotics. Pt is hypotensive from sepsis and has the crackles in lungs from the pneumonia- not fluid overload from CHF. Is it okay to bolus this pt?
Published On: November 18, 2025Should Midazolam be considered in the management of a trauma patient with trismus? In the absence of tonic/clonic seizure.
Published On: November 18, 2025Question is regarding dexamethasone in anaphylaxis. Scenario of a 50s M stung by a bee, known anaphylaxis reactions in past, no epi pen called EMS. Pt had angioedema, hives, and signs of bronchoconstriction. Pt treated with epi, followed by benadryl and some salbutamol for his bronchoconstriction. Pt has a history of asthma. Causative factor of bronchoconstriction likely being from anaphylaxic reaction to the bee sting, which the bronchoconstriction quickly resolved with epi, benadryl and salbutamol. Could this pt benefit from dexamethasone? Is this part of the expectation if you have anaphylaxis and the pt also has bronchostriction, with indications as described in protocol, that we should follow the protocol including dexamethasone? And while I’m on the topic, thoughts on dexamethasone in anaphylaxis in general, often steroids are given in hospital, could dexamethasone be beneficial?
Published On: April 15, 2025This is a 2 part question: 1) Can we effectively administer the newly Provincially Mandated IntraNasal Glucagon 3mg (we carry 2 of them at our service + 1 I/M 1mg Glucagon) to treat either a BetaBlocker or a Calcium Channel Blocker OD? 2) Can it be used in conjunction with IV Glucagon to be within the therapeutic range of efficacy.
Published On: April 15, 2025Hi 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.
Published On: April 15, 2025As 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
Published On: April 15, 2025how does ” take home narcan kits” that are left with pt and family of opioid use pts fall under the ” dispensing of medication” under the ambulance act. is this considered dispensing of medication by paramedics , of any designation, pcp , acp or community paramedic as SWORBHP social media post(S) about dispensing medications was recently released across multiple social media platforms
Published On: April 15, 2025In the case of a workable drowning VSA, that is not in a shockable rhythm, would it be in the best interest to call for a TOR, preform 20 minutes or resuscitation or transport early? Would this fall under extenuating circumstances?
Published On: April 14, 2025If a combined crew configuration of PCP and PCP expanded scope (IV) attend a VSA that will be transported and it is the PCP’s turn to attend, can the PCP attend it en route to hospital or should the PCP expanded scope have to take over in case of a ROSC with need of bolus?
Published On: April 14, 2025From my understanding, the narcan in suboxone is in there in order to abstain individuals from using the drug incorrectly, ie. Crushing and inhaling or injecting, but administered correctly, the narcan gets eliminated via the liver. My question is how does inhaling and sublingual administration differ in terms of first pass? I always thought sublingual administration circumvented the first pass effect. I understand the protocol states oral administration and may not be sublingual but I am just curious about the mechanism of action since suboxone is often administered sublingually. Thank you
Published On: April 14, 2025For a pt who has sustained a head injury and is combative, as an ACP are we able to give low dose midaz or ketamine if required for everyone’s safety? Obviously you don’t want to alter them more but if we are unable to safely transport them is there anything we can do? Or just get police to help restrain them. Thanks.
Published On: April 14, 2025With regard to the croup protocol, I am looking for clarification on the indication of “history of URTI.” Does this need to be diagnosed in hospital, or can recent symptoms of an URTI be enough? If the symptoms are enough, how long should the patient present with them for it to qualify as an URTI?
Published On: April 14, 2025The question I have is about organ donation/transplant. Just had a young person traumatic VSA in which his core body was still intact I just got thinking afterwards that I should I have called base hospital to see if the family would like to donate his organs. Just thought that pt had been young and healthy. Was wondering the proper way to go about it? How long the organs can be without blood flow. How far from London or where do we take the body? Who do you contact. I know the scene is overwhelming and was one of the last things thinking about.
Published On: April 14, 2025What is considered suspected cardiac ischemia? Is it just the presence of chest pain/ discomfort (heaviness or tightness). Are chest palpitations considered a chest discomfort as well?
Published On: April 14, 2025
