Answer: In the patient that you describe: suspected cardiogenic shock with hypotension and crackles; yes you are correct that they cannot receive a bolus or CPAP per the Medical Directives. The concern being that if they already have fluid overload (crackles) that a bolus could worsen their respiratory status. Similarly, CPAP can worsen their hypotension via decreased venous return due to an increase in intra-thoracic pressure. Once you bring them to hospital, both interventions may immediately be performed. But, this is because the consequences of these actions (respiratory failure and hypotension) are much more easily managed with the personnel, equipment and drugs that are just not available pre-hospital. That being said, the one thing that you could do for this patient with suspected cardiac ischemia, that has not yet been mentioned, with proven mortality benefit is give ASA.