HSNCPC

In regard to the position of a base hospital physician, would there be any problem with a Land Ambulance PCP reaching a patient by a third-party helicopter service, and providing appropriate care on scene? Secondly could a PCP in this position transport with the patient while rendering appropriate care on the helicopter ride back?

This question is primarily operational + medical-legal and depends on:

• service policy,
• aircraft operator policy, and
• whether the paramedic is acting under their land service medical delegation while in a third-party air environment.

In general, providing care on scene is not inherently an issue, but transporting as a clinician on an aircraft is not automatically permitted and requires confirmation through the air operator and service leadership. Paramedics should follow their service policy on remote responses and utilizing allied agencies to access patients.

For reversible causes we transport after the 1st analysis. What if that first analysis reveals a shockable rhythm that we shock and then becomes refractory? Would it still be best to focus on transport to ED following that 1st analysis, or would it be best to remain on scene for a max of 6 shocks utilizing VC or DSED and transport following that?

Thank you for your question. Refractory by definition is after three shocks so it would require at least three analyses before we can make that statement. With respect to transport after one analysis that only applies if we have a pregnant patient >20 weeks or if there is a reversible cause that we cannot address or manage on scene. Everyone else, after 3 shocks, VC or DSED can be considered. This does not mean it must be initiated but it can be considered prior to transport. This involves a discussion between the paramedics whether to stay and play versus to scoop and run.

Understanding that this isn't ALS related, but the BLS doesn't speak to it.  Should paramedics avoid splinting a flail chest? It appears that pain management, oxygenation and ventilation are more appropriate treatments.

A flail chest by definition would mean multiple levels of ribs are fractured in two or more locations. This would be very difficult to determine in the prehospital setting. The focus for paramedics should include pain management and respiratory support. 

Would you give NTG in a cardiac Ischemia call but there is no presence of pain? I am seeking clarification regarding the administration of Nitro during a cardiac ischemia call. Specifically, if the patient does not exhibit pain, should Nitro still be administered? My understanding from training is that Nitro should not be given in the absence of pain, with pain defined as discomfort, heaviness, or tightness.

Nitroglycerin is a symptom management treatment and has never shown any decrease in mortality for ischemic chest pain.  For this reason, I would withhold nitroglycerin if the patient has no chest pain or chest pain equivalent (SOB, neck pain, jaw pain, arm pain, etc..).

Hi, under the 'Traumatic Cardiac Arrest" section of the Companion Document it states "An intravenous fluid bolus may be considered to assist with reversible causes if transport to the ED will not be delayed."  Say we have a long transport time, LUCAS is running, we obtain IV access, would we be following the ROSC directive's guidelines for max infusion, volumes, ages etc?  Would BH want a BP attempted/documented prior to the bolus even though it wouldn't be reliable with the LUCAS running?

Unfortunately traumatic cardiac arrest, especially blunt trauma, has dismal survival rate.  IV fluid is not the answer. The main reversible cause that can be addressed in the prehospital setting (and may lead to survival) is tension pneumothorax.  IV fluids have lost favour in trauma as they tend to dilute clotting factors and do not carry oxygen to tissue. Therefore, I would concentrate on rapid transport, needle decompression if indicated and good CPR.   Also, there is never a reason to check a BP in a patient who is requiring mechanical CPR.