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. 

I'm hoping to get clarification regarding ASA administration. I noticed since the MPDS adoption that CACC now recommends patients take 4 x 81mg ASA when they call 911 for chest pain, as opposed to the previous recommendation of 2.

With that new change, are we still expected to administer 2 more on our arrival? This would result in a dose of 486 mg which seems above the therapeutic index for this med.

In order to ensure appropriate treatment, paramedics should continue to administer ASA as per the ALS PCS regardless of what the patient has taken prior to paramedic arrival.  As per the Companion Document “ASA is a safe medication with a wide therapeutic index (the effective dose without side effects can be from 80 – 1500 mg). The additional dose provided by Paramedics will not exceed the therapeutic dose while ensuring the correct administration of correct dose of the medication. Therefore, apply the cardiac ischemia medical directive as if no care had been rendered prior to your arrival.”

While attending a stroke transfer recently, I noticed that no medical staff at the sending or receiving facility, including multiple ER doctors and an ICU stroke specialist, knew what a LAMS score is. As it is something that is mandatorily in our forms, on any call that we suspect to be CVA related, I had assumed it was a scale used by the hospitals. I am now writing to ask if there is a separate reason we use this score, or if there is perhaps a better categorization tool that EMS could follow so that hospitals understand the degree of symptoms with which the CVA patient is presenting.

In 2019 the LAMS score was selected as the standard prehospital severity screen to be built into the province-wide Acute Stroke Bypass Protocol.  It is a quick screen (20-30 seconds) that answers one key question, assessing stroke severity and risk for a large vessel occlusion (LVO) necessitating transfer to nearest Stroke Centre.   A patient with a LVO may benefit from Endovascular Thrombectomy (EVT).  Emergency departments use the NIHSS score, which is a 11-item, 42-point clinical scale evaluating cranial nerves, visual fields, cerebellar function, language. and sensory loss.  It takes considerably more time than the LAMS score. The NIHSS score is used in determining treatment decisions  (eg. tPA vs EVT thresholds). 

It is important hospitals educate their staff and physicians on the risk assessment tools used by EMS services.  Hospitals are made aware and provided with education materials on risk assessment tools used by EMS services.  

A quick explanation of the score to the providers on transfer may help to remind and familiarize the team to this score. Simply describe the onset and symptoms you observed on your assessment of the patient to the receiving hospital.

Do I need to patch to withhold lidocaine/amiodarone in the management of a cardiac arrest secondary to hyperkalemia? These patients are ventricularly driven and the administration of these drugs could suppress the ventricles and lead to worse outcomes, but the ALS and ACLS don't speak towards this and I would rather not disrupt care 3-5 minutes into an arrest just to patch for this.

Thank you for the question. 

Short answer is: you never have to patch to withhold a medication.

Patching is for authority to provide a treatment that is outside the medical directive (but within scope) ,  a "mandatory patch point" or clinical advice.

I would encourage you to document the reason for withholding the medication.

The bigger issue is that in the prehospital environment, you do not have the ability to determine if a cardiac arrest patient has hyperkalemia.  Amiodarone and lidocaine are problematic in the patient with known hyperkalemia not in cardiac arrest, where it can lead to BRASH syndrome.  In a cardiac arrest patient who is in recurrent V fib or V tach, the benefits of amiodarone and lidocaine would probably be reasonable since potassium levels are unknown.

Regarding the PCP Opioid Withdrawal Medical Directive, is the additional 8 mg of Suboxone intended to be administered routinely 10 minutes after the initial 16 mg dose, or only if the patient continues to exhibit withdrawal symptoms upon reassessment? Should a repeat COWS assessment be completed before administering the additional dose, given that the medication’s effects may not be fully apparent within 10 minutes?

The intent of the suboxone is to decrease the withdrawal symptoms.  If administration of the initial 16 mg relieves symptoms, no further suboxone is required.  A COWS score should be documented after each treatment dose and subsequent doses are only necessary if COWS score remains high.