Date Published

April 17, 2013

Updated For

ALS PCS Version ALS PCS Version 5.2


Question: In the last year I have been presented with two different special occurrences regarding vital sign absent patients.

The first one involved a patient who was VSA on our arrival. We were presented with a legal living will as well as a note provided by a Doctor stating "DNR". Unfortunately there was no ministry DNR validity form. We completed a full medical TOR as the patient met the requirements and after I was informed by co-workers that I could have called for a medical TOR after the first no shock indicated. They stated this was covered under special occurrence. I have looked and found no evidence of this existing although this could be very handy. Does such protocol or language exist?

The second incident involved a patient that we witnessed from a reasonable distance to be VSA. Due to safety reasons we could not access the patient for approximately 45 minutes. The patient did not meet obviously dead and didn't have a DNR. We performed a medical TOR. Again informed that this falls under special occurrence and we could have called for medical tor after the first no shock indicated.

I'd really like to know if this is an option. It would come in handy for similar instances.


 Great questions. Your excellent case examples highlight situations which are not necessarily specifically outlined in your medical directives.

The difficult scenario you note with the non-standard DNR form is not addressed by the DNR standard either.

To answer your question, there is not a specific Unusual Circumstance Medical Directive however the Base Hospital Physicians (BHP) are available for consultation when you are unsure of how best to proceed.

In your first case example (non-standard DNR form), initiating CPR and following your medical directives would be the first step. As soon as possible, a patch to the BHP for direction as to how best to proceed is entirely reasonable. Your action in completing the Medical Cardiac Arrest Medical Directive was also an acceptable approach.

In terms of your second scenario, we assume you did wait on scene until you actually were able to establish patient contact. In this case, your actions were entirely appropriate: follow your Medical Cardiac Arrest Medical Directive.



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