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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Using the form via the link below, ask us your question and our Medical Advisory Committee will review it and provide you with an answer.

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You can also search for questions by the date they were posted with the following format: yyyy-mm-dd

  • Question: When administering a fluid bolus, are we to give the full bolus amount (i.e. 1000ml for a 50kg patient) reassessing for fluid overload or return to TKVO when the BP reaches 100mmHg or greater? Given so much fluid shifts, administering the full bolus when no fluid overload is present (either 10 or 20ml/kg), particularly with the septic or preload dependent patient would be beneficial.

    Published On: September 29, 2016

  • Question: In the setting of an adult who has extremity trauma with severe pain and has vomited along with nausea, could this patient receive dimenhydrinate with ketorolac?

    Published On: September 29, 2016

  • Question: Is daily, low dose ASA considered towards ‘NSAID use in the past 6 hours,’ as per the Adult Analgesia Medical Directive?

    Published On: September 29, 2016

  • Question: Under the Analgesia & Moderate to Severe Pain Protocol. What is the definition of cancer pain? And if they fall under the guidelines of cancer pain, what kind of relief would a half dose of Ketorolac provide seeing as they are probably on much stronger medications?

    Published On: September 29, 2016

  • Question: In regards to the adult analgesia medical directive, it states “in patients with isolated hip or extremity trauma, ibuprofen and acetaminophen are preferred to ketorolac except where the patient is unable to tolerate oral medications.” It is my understanding that together, they provide similar pain relief to ketorolac. If the patient is in severe pain, but is unable to take acetaminophen due to a contraindication (ex. due to having taken some in the past 4 hours), is it appropriate to administer ketorolac instead? Or is it still preferred to administer just the Ibuprofen at this point.

    Published On: September 29, 2016

  • Question: I was going over the CPAP standing order today and would like clarification on whether the contraindication “Major trauma or burns to the head or torso” only means for a new occurrence or does it also include persons with prior existing major trauma or burns to head and torso?

    Published On: June 20, 2016

  • Question: In regards to the CPAP medical directive, it states in the ALS PCS Companion document that CPAP is the treatment for Acute Pulmonary Edema (REGARDLESS of origin). Does this mean that the cause does not need to be cardiogenic in nature? Could you please elaborate on this?

    Published On: June 20, 2016

  • Question: If a person have a near fresh water (lake water) drowning and Spo2 <90 % severe SOB, and by auscultating lungs I hear Crackles all over the places mainly on lower lobes tachypnea and normotensive. As per CPAP protocol: indication severe respiratory distress and signs and/ or symptoms of Acute pulmonary edema or COPD is the indication, and patient is above 18years and no contraindication met, can I apply CPAP on this patient ? If not please tell me why and I know Nitro is not applicable in this case because this is not a cariogenic pulmonary edema.

    Published On: June 20, 2016

  • Question: As per the question posted Feb 5th, 2014, if the FD shocks a patient prior to our arrival, we may count that shock into our protocol assuming we deem their care to adhere to AHA guidelines. In that setting, do we dial up to our second shock dose, or start at our first shock dose and dial up appropriately after that?

    Published On: June 20, 2016

  • Question: After the recent introduction of Narcan for PCPs, I’m still a little confused about the role of Narcan in an arrest. The 2010 AHA Guidelines state there is no role for Naloxone in cardiac arrest but the 2015 Guidelines are less prohibitive, leaving some room for interpretation. I understand that where there is question whether the patient is pulseless or not, there is a role for naloxone in the setting of presumed opioid overdose but what is the direction of base hospital for the use of naloxone where there is definite absence of vital signs in the setting of a PCP-only arrest. Is it the expectation of the base hospital that PCPs attempt to administer naloxone at some point during that call? If so, when during the cardiac arrest protocol? On scene or en route to hospital?

    Published On: June 20, 2016

  • Question: I am a ACP student and was discussing among my colleagues the proper time frame for vitals and drug administration for morphine and NTG in the cardiac ischemia medical directive. I understand that each drug has a 5 minute intervals but someone had mentioned that you could stagger both drugs in 5 minute intervals, for example after administering a third NTG wait 5 minutes then morphine then wait 5 minutes then NTG etc. I was wondering what the preferred interval for vital signs and drug administration would be with two drugs staggered at 5 minute intervals.

    Published On: June 20, 2016

  • Question: My question is regarding fluid bolus for DKA. There seems to be varying belief on whether or not a DKA patient must be hypotensive to administer a bolus. There is no specific language that I can find addressing bolus protocol for DKA other than the mandatory BHP patch point if the suspected DKA pt is 2-12yrs old, but this is listed under the NaCl fluid bolus protocol where hypotension is a condition for treatment. Just looking for a little clarification on the entire DKA bolus protocol.

    Published On: June 20, 2016

  • Question: The PCP adult analgesia directive is for “isolated extremity injuries”, if there’s more than one injury is it a contraindication? For example, burns to more than one location (shoulder and a portion of the ant chest) or an ankle and a knee injury.

    Published On: June 20, 2016

  • Question: In Ask MAC it states : “As for Ketorolac, daily ASA is not considered anticoagulation therapy as it affect platelet function and does not result in a true anticoagulated state.” So PLAVIX (clopidogrel) is also affect platelet function, even though ASA affects the cyclooxygenase 1 (COX-1) pathway, and PLAVIX affect the adenosine diphosphate (ADP) pathway, still I think both PLAVIX and ASA affect platelet function . And I think daily dose of PLAVIX also not a true anti-coagulated state and Ketorolac is not contra-indicated. Please let me know if I am right or wrong by those explanations.

    Published On: June 20, 2016

  • Question: If a pediatric patient is significantly larger than expected (for example, a 6 year old female who weighs 120lbs), do we still use the pediatric dosing chart OR calculation OR adult settings? Personally, if I’d done this call today, I probably would have chosen to use the pediatric calculations of 2J/kg then 4J/kg etc.

    i.e.: If using peds dosing chart, this 6 year old would only get a shock of 50J 100J 100J 100J

    i.e.: If using peds calculation, she would receive 110J 220J 220J 220J

    i.e.: If using adult settings, she would receive 200J 300J 360J 360J

    Published On: December 17, 2015

  • Question: If you have a ROSC and the patient re-arrests and is now in a shockable rhythm do you shock at the next highest setting or do you revert back to 200 joules?For example, if one shock delivered on scene for an adult at 200J, then ROSC, then rearrest – next shock (as I suggest) would be 300J.

    Published On: December 17, 2015

  • Question: Under the Adult Analgesia Medical Directive, it indicates that for Mild-Moderate Pain, Acetaminophen and Ibuprofen should be considered. If the pain is mild-severe pain than ketorolac should be considered. If a patient is reporting severe pain as a result of isolated hip or extremity trauma, and the MOI is consistent with severe pain, does this mean that only ketorolac should be considered, regardless of the patients ability to tolerate oral medications?
    The way that I read this is that Acetaminophen and Ibuprofen would not be indicated if the pain is severe.

    Published On: December 17, 2015

  • Question: Just to clarify about Ketorolac. The indications states localized hip OR extremity trauma. Are we to interpret this as isolated (single) hip AND isolated (single) extremity trauma? For example, if an old lady has fallen and broken both wrists, can we administer Toradol?

    Published On: December 17, 2015

  • Question: Would it be a waste of a paramedics time to deliver Salbutamol through a BVM to an unconscious patient while setting up for Epi in the case of an Asthma or anaphylaxis? Would the OPA if used, not block the mist and prevent inhalation? To me, Epi administration (scenario dependent) would be the priority. Thanks

    Published On: October 23, 2015

  • Question: A patient meets the Croup Medical Directive but has a fever, do you give Epi via nebulizer or not? I thought in the past this was dealt with but I am not able to source this through the Ask MAC website.

    Published On: October 23, 2015

  • Question: In the situation of being an ACP making a rendezvous with a PCP crew to assist on a medical cardiac arrest patient that they already initiated transport with and did not arrest on route, would you suggest once we make patient contact to administer 3 EPI q4/lidocaine or amio/saline bolus (depending on rhythms), BHP patch and then continue transport or continue transport and administer epi q4 until transfer of core or ROSC? There seems to be different opinions about this in my service. I appreciate you taking the time to answer.

    Published On: October 23, 2015

  • Question: With the expansion of Analgesia/pain relief being delivered to all paramedics. Is there going to be an addition to the standing order for the expansion of Ketorolac to the pediatric population either for ACP or PCP?

    Published On: October 23, 2015

  • Question: A patient is presenting with pulmonary edema. Patient became more symptomatic before calling and dyspnea worsened. Upon gathering history and taking vitals, they meet the criteria for Nitro and CPAP. The patient is currently prescribed Lasix for fluid in the lungs from doctor visit one week ago.

    With the history of pulmonary edema and being prescribed Lasix for fluid in the lungs, would this now be considered Non-Acute Pulmonary Edema?

    I need a better understanding of Acute Pulmonary Edema vs. Non-Acute Pulmonary Edema. The CPAP protocol indication lists: Suspected Acute Pulmonary Edema.

    Since the pulmonary edema is non-acute would CPAP and Nitro be withheld? Or, since the symptoms have worsened, provided I can recognize a patient that is truly in need of CPAP and Nitro, would I administer them? I want to clarify – thanks.

    Published On: July 23, 2015

  • Question: Is it advised that when a patient is not adequately perfusing but still technically with a pulse, that CPR be commenced? In discussing this with my colleagues, we are speaking in regards to a patient who may technically still have an idioventricular or agonal pulse and is circling the drain. Instead of waiting the 30 sec-1 min for the patient to be completely VSA, would it not be better to get on the chest and begin compressions in an attempt at increasing perfusion?

    Published On: June 4, 2015

  • Question: My question is in regards to the Cardiac Ischemia protocol. I am currently a PCP student and we had a chest pain call. The patient was complaining of chest discomfort and described it as a pressure starting sub-sternal and going to patients left shoulder. The patient was also experiencing SOB. This pain was a 6/10 when it first came on and went down to a 5/10 with relaxation. The patient did not have a history of angina but had received NTG in the hospital a couple years before and did not know the why. The patient did not have NTG on their own list of meds. We gave 2 81mg ASA and did a 12-lead which was negative for a right ventricular infarct. My preceptor did establish an IV and got a line started set at TKVO before we gave the NTG.

    The question is even though the patient did not have NTG on their own med list at the time of the call; does the time the patient was in hospital and was given NTG count as prior history for the Cardiac Ischemia protocol?

    I did see a related question on the site but it was related to a doctor giving the NTG before EMS arrival and it was stated that it should be prescribed. So does that mean it has to be a current prescription or can a patient have it in the hospital and it count? I know it does not matter after you get an IV establish but if we weren’t able to get an IV established then would we have been able to give it?

    Published On: April 10, 2015

  • Question: I have been talking with my paramedic colleagues and I am wondering about the role of CPAP and aspiration. My understanding of the Medical Directive is that CPAP is not indicated for pneumonia or aspiration but rather severe SOB from either COPD or pulmonary edema. Can you please clarify the role of CPAP for respiratory distress patients with either pneumonia or aspiration as the underlying precipitating factor for their SOB?

    Published On: February 18, 2015

  • Question: When managing a cardiac arrest as a PCP and following the Medical Cardiac Arrest Medical Directive, if the patient does not qualify for a TOR (shock delivered, ROSC obtained at some point etc.), why is it required to patch to the BHP (Mandatory Provincial Patch Point) for authorization to transport when it is clear that transport is the only option?

    Published On: February 18, 2015

  • Question: My question relates to analgesia that I can provide patients as an ACP. If I have a patient that meets the indications and conditions for Morphine or Fentanyl under the ACP Core Pain Medical Directive, and if the patients discomfort is improving with the administration of the above narcotic analgesic, is it a requirement that I must proceed to administer Ketorolac?

    Published On: February 18, 2015

  • Question: There was a question posted in January 2012 that asked if CO poisoning leading from VSA would be considered an unusual circumstance and whether performing one analysis and transporting would be acceptable. Medical Councils answer was that this would be analogous to an asphyxial cardiac arrest such as a drowning and hanging. In these cases, the SWORBHP Medical Directors have preferred that the Medical Cardiac Arrest Medical Directive be followed.

    This question was asked a long time ago, however, during one of my Base Hospital training sessions, I was told by an Educator that CO (it specifically said) does fall under an “unusual circumstance” and therefore you would transport after the first analysis leading to a NO SHOCK ADVISED.

    Can you clarify what should be done?

    Published On: January 12, 2015

  • Question: Your partner is preparing O2, obtaining vitals and attaching the monitor for a chest pain patient. You are performing a primary survey, gathering your SAMPLE Hx, ruling the patient in protocol for ASA, giving the ASA and doing the same for Nitro. Vitals are obtained 3-4 minutes earlier than the Nitro administration.

    From past experience and following the protocol which states vitals q5 min, nitro q5 min and vitals must be obtained within 5 minutes of medication delivery, is this improper as 3 minutes has lapsed prior to the nitro administration? I have been informed that past deactivation has resulted from this?

    Published On: January 12, 2015

  • Question: A question arose today after a call where a patient clearly did not meet the protocol for Ketorolac. Upon reviewing the contraindications for this protocol, what exactly are being considered to be NSAIDs? The MEDList on the website included Ibuprofen, Naproxen, Celebrex, etc. but what about ASA? Tylenol? Excedrin? I was under the impression that both ASA and Tylenol were considered NSAIDs? My partner and I could not come to a conclusion and wanted further clarification.

    Published On: January 12, 2015

  • Question: My question is in regards to pneumonia and continuous positive airway pressure (CPAP). Bacterial infections are a common trigger for chronic obstructive pulmonary disease (COPD) exacerbations.

    If we have a patient who has possibly developed a pneumonia (isolated crackles mid lobe in one lung, low grade fever, purulent sputum) but is in respiratory distress with a history of COPD and is showing signs of a COPD exacerbation (decreased breath sounds in bases, showing signs of hypoxia, accessory muscle use, tachypnea, mild diffuse exp wheezes), are we not to treat with CPAP and just use bronchodilators and high flow O2? Thank you!

    Published On: December 3, 2014

  • Question: How often should you reassess the respiratory rate for apneic patients?

    Published On: December 3, 2014

  • Question: I have a question regarding congestive heart failure (CHF) and ASA. If a patient is having acute CHF and is coughing up blood but is also having chest pain are they still a candidate to receive ASA given the active “bleeding”. I would think the blood from back up into your lungs is different than the blood from an ulcer or something. Thanks for your help.

    Published On: December 3, 2014

  • Question: I’m a PCP with autonomous IV. It states that a contraindication for a fluid bolus is “signs of fluid overload”. I realize the obvious one is pulmonary edema as that is the example that is always brought up in this scenario. What about a pt that has a clear chest with no fluid accumulation in the lungs, but has peripheral edema in the legs or abdomen? I’ve also had pt’s with hypotension that are on dialysis and have stated that they cannot receive large amounts of fluid due to kidney failure. Do we just document their condition? I’ve heard different answers from everyone and would appreciate some clarification.

    Published On: December 3, 2014

  • Question: There was a question posted on Sep 23, 2014 in regards to a fluid bolus on a transfer between facilities. As I agree that there should have been an RN escort for this patient, the paramedic was certified in IV fluid therapy including boluses. Your answer has me perplexed however. If a physician gave the paramedic a fluid bolus order how would that differ from getting a similar order from a BHP through phone patch. It is in the scope of practice for the paramedic to administer NaCl 0.9% as a bolus, the volume was prescribed by the physician(s) in charge of this patient’s care. Would any paramedic be wrong in following the order given by the physician?

    Published On: December 3, 2014

  • Question: Last night I had a 75 year old patient calling because he was SOB x 2 days with it worsening this evening. Patient could not sleep (could not breathe very well laying down) and was more SOB on exertion. I could hear fine crackles in the bases of his lungs.

    There was no ischemic chest pain or NTG history. His vitals on contact were HR 90, BP 188/70 (ish), SPO2 95% on Room air, 100% on NRB, RR 24 verified with an with ETCO2 of 40mmHg, No ST changes in 12 lead.

    He had some slight increased work of breathing on scene with mild increased diaphragmatic use but was speaking full sentences and in good spirits with us. Patient had a history of COPD and CHF. He also stated he had taken some of his Ventolin puffers prior to our arrival with no relief (probably made things worse). I wanted to treat him with NTG but he did not seem to be in enough distress initially, so I kept him on the NRB which he stated help initially. We got to the truck and started an IV enroute, then administered 0.8mg NTG. Literally… within about 2 minutes of the NTG admin, while I was patching, the patient had a sudden onset of severe SOB. We were right outside the hospital, so I grabbed my BVM, assisted his respirations distress until my partner could get us out of the truck and help me put CPAP on. CPAP helped and he was back to normal shortly after our transfer of care.

    My question is, should I have used the CPAP right away with the NTG, even though the patient was not showing signs of severe respiratory distress at the time, and on numerous auscultations of the lung, did not have any increase in crackles… until of course, he developed that sudden severe respiratory distress? My gut was to CPAP him early, but I felt he did not fit the protocol yet given his level of dyspnea, SPO2 sats, RR and minimal accessory muscle use.

    Published On: November 5, 2014

  • Question: This question is in regards to timing during a medical VSA. Would your 2 minutes in between analysis restart when you stop to analyse or after you have analysed or shocked? For example, you stop to analyse at 1500:00 and you start your CPR at 1500:10 after shock or no shock, would your next analyze be at 1502:00 or 1502:10?

    Published On: November 5, 2014

  • Question: In which instance should a transdermal patch be removed in the pre-hospital setting? Example 1: Hypotensive patient with a Nitro patch on. Example 2: VSA with a narcotic patch on. Example 3: Suspected OD with a narcotic patch on (or several).

    Published On: November 5, 2014

  • Question: Is narcotic analgesia recommended for patients currently on methadone? Would there be any synergistic effect? Would it cause the patient to relapse?

    Published On: November 5, 2014

  • Question: I have a few questions regarding the new analgesia and moderate to severe pain medical directives.

    1. Could you be more specific on what you mean with “current active bleed”? Would this include the possible bleeding attributed with fractures? Blood in urine from damage caused by known kidney stones? Menstrual bleeding?

    2. Could you elaborate on the condition of “patient must remain NPO or is unable to take oral medications” for Ketorolac? Does this mean it is only to be given if Tylenol/Ibuprofen cannot be given orally, or they should remain NPO after medication administration?

    3. Should we avoid giving Tylenol/Ibuprofen/Ketorolac if patient has already self-medicated with other pain medications? i.e. Percocet, Demerol, etc.

    Thank you in advance for your clarification.

    Published On: November 5, 2014

  • Question: If a doctor is someone who can assume care of a VSA patient and decide to have resuscitative efforts ceased, then why is a doctor not someone who counts as a witness in the ‘unwitnessed arrest’ condition of a TOR, along with paramedics and firefighters? Thanks in advance.

    Published On: September 23, 2014

  • Question: I am a PCP-IV medic who recently transferred a patient between facilities – from county hospital to trauma centre. On arrival I was told by the attending physician that the patient was to be spinal immobilized as a precaution as instructed by the trauma centre. The physician also informed me that the trauma centre requested that the patient receive 1000ml NaCl prior to arrival at the LTC. I inquired about the patient’s vitals and assessed the patient as normotensive with no indications of poor perfusion. I told the physician that my protocols did not permit me to fluid bolus the patient with up to 1000ml enroute unless the patient was hypotensive and remained hypotensive. Moreover the sending facility was not sending an escort on this long CODE 4 STAT transfer. I called my Duty Manager for advice and was told to abide by my directives and follow the BLS standard for IV monitoring – 200ml/hr max pending patient presentation enroute. This is the direction I proceeded with.

    My question is – was I correct in my course of action and was it advisable to press the physician for an escort based on the requirements of the LTC?

    Published On: September 23, 2014

  • Question: I have a question about postictal patients and cardiac monitoring. I have been told two things by several other partners in past few weeks. Assume you are a regular seizure patient whom you have seen many times and he/she is in their normal postictal state and you are not suspecting brain trauma. Is there any clinical reason/need to put cardiac monitor (e.g. limb leads) on? Also assuming you have a 1 min transport time. I was told as per BLS standard you “must” but in the postictal section it mentions that the paramedic may consider enroute. Thanks.

    Published On: September 23, 2014

  • Question: I have a question regarding an MCI scenario. There is a total of 10 patients; 3 patients are dead from trauma and 7 patients are cleared off scene from other ambulances. You now have the 3 black tag patients left. Do we need to re-assess these patients and get trauma TOR for each one?

    Published On: May 13, 2014

  • Question: My question is regarding our chest pain protocol. There is a 48 year old male complaining of chest pain. It is substernal, 7/10, onset 1 hour, provoked at rest, radiates to left arm sitting steady.

    O/E patient’s history is hypertension; vitals H/R 78 regular and full; breathing 20x / minute; B/P 138/99; conscious and alert x 3. Patient is not allergic to ASA, so he receives ASA.

    History of nitro is in question. The patient states he was in hospital once with similar chest pain and doctor “gave me a spray of something for my chest pain”. When asked if it was nitro, the patient did not know name of medication.

    Could this patient receive NTG or should we patch?

    Published On: May 13, 2014

  • Question: Couple of questions regarding the Musculoskeletal pain protocols:

    To be clear, we are to give Acetaminophen and Ibuprofen OR Ketorolac. There is no case where we can give all 3 medications, as Ketorolac requires NPO?

    Also Cardiovascular Disease means anyone with any hint of HTN, Athersclerosis, Dysrrhthmias, Heart Failure, and Peripheral Vascular issues, anything of the sort are not to get Ibuprophen?

    And lastly for Ketorolac, is a daily ASA considered anticoagulation therapy?

    Published On: May 13, 2014

  • Question: With the new PCP pain medical directives, I realize there has been a lot of debate over the age range. That being said, if we end up with a patient outside the age range (within reason), in severe pain, who does not meet any other contraindications, if a BH patch would be advisable for the possible administration of ketoralac? I realize that the patch orders are generally doctor specific but I was just unsure if these ages are set in stone or given special circumstances and orders if the rules can be bent. Thanks for the help!

    Published On: May 13, 2014

  • Question: I have a question regarding the Analgesia and Moderate to Severe Pain medical directives for torodol and narcotics. Can a narcotic analgesia and torodol be administered to the same patient on the same call if the ACP determines the patient’s pain is severe enough and the properties of both analgesics would be beneficial given the situation? Or are we best to pick the most appropriate analgesia and possible consult with a BHP? Thanks for your time and input!

    Published On: May 13, 2014

  • Question: I have overheard a couple of crews recently discussing the ACP cardiac arrest protocol for when you arrive on-scene and a PCP has already initiated their protocol.

    I’ve overheard that some crews use what the PCP crew has done (say two no shocks) and then just do two more and either call for pronouncement or transport. I also know other crews that will show up and do their entire three rounds of epi, etc. and then call/leave regardless of how many or what the first arriving PCP crew has done.

    I know what I do but which one is actually correct because now I’m wondering if I’m doing the right method.

    Published On: April 8, 2014