Author Archives: SWORBHP

Trach re-insertion still allowed during the pandemic

Proper Airway Positioning of the Morbidly Obese Patient

Posted on: September 16th, 2020

Trach re-insertion still allowed during the pandemic

Remember that tracheostomy tube re-insertion per the Emergency Tracheostomy Tube Reinsertion Medical Directive, is still to be performed (with appropriate PPE) during the COVID-19 pandemic.  Since the initial recommendations (Feb 6, 2020) paramedics are to consider withholding suction via an endotracheal or tracheostomy tube unless using a closed-system unit.  However, re-insertion is still a life-saving and allowable procedure during the pandemic.

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Proper Airway Positioning of the Morbidly Obese Patient

Proper Airway Positioning of the Morbidly Obese Patient

Posted on: September 11th, 2020
Intranasal Medication STILL Out When Another Route ExistsProper positioning is extremely important in morbidly obese patients, to alleviate obstruction and optimize ventilation.

During intubation, proper positioning will improve your chance for success and it will also help bring the trachea into view.

This picture illustrates the “ear-to-sternal notch” positioning ideal for morbidly obese patients.  Notice the amount of sheets and blankets used.

Remember, obese patients have the same internal anatomy as lean patients of the same height (ex. Similar lung volumes, the distance from the mouth to the lungs is similar).  However, excess tissue causes:

  • Impaired laryngoscopy visualization – which means you want to optimize your technique with the ear-to-sternal notch positioning
  • Increased oxygen demand and decreased reserve – these patients desaturate quickly!

THEREFORE, make sure to set yourself up for success with optimizing positioning and pre/peri-oxygenation as much as possible.

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Intranasal Medication STILL Out When Another Route Exists

Intranasal Medication STILL Out When Another Route Exists

Posted on: September 2nd, 2020
Intranasal Medication STILL Out When Another Route ExistsRemember that intranasal (IN) and buccal medications should be withheld when alternative routes exist (link to most recent OBHG Recommendations), including naloxone. There is a recent Ask MAC posted (here) that highlights the rationale for this.
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SALT Triage

SALT Triage

Posted on: August 26th, 2020

SALT Triage
You are dispatched Code 4 to an MVC. According to the SALT Triage method, which of the following patients should be assessed first?
A – 80 year old who is able to walk but has an obvious deformity to his right humerus.
B – 2 year old who is unable to walk but is screaming for her mother. There are no obvious injuries but the screaming is alarming and she ‘sounds’ injured.
C – 23 year old male who is unresponsive, is breathing regularly and has significant bruising and swelling to his left femur.
The ANSWER is C, however if you’re unsure, or are interested in learning more about SALT Triage, click here for a webinar (recorded April 2017) on the topic: http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/Paramedic_Rounds.htm
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AUSCULTATION AWARENESS: HELPFUL STETHOSCOPE TIPS

AUSCULTATION AWARENESS: HELPFUL STETHOSCOPE TIPS

Posted on: August 12th, 2020

AUSCULTATION AWARENESS: HELPFUL STETHOSCOPE TIPS

 

 

 

Sound loses quality when it travels through the patient’s clothing. You can buy the best stethoscope in the world, but if you use it over clothing, you are blocking sound from ever reaching it. Place the stethoscope directly on the patient’s skin, exposing the patient’s skin when necessary to auscultate a blood pressure, lung sounds or heart sounds.

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Hello! Question about using CPAP during this time. I've had a two instances where my patients could've potentially benefitted from the use of CPAP, however they had went into cardiac arrest during transport and ended up pronounced at the hospital. I was wondering what you're thoughts are now, in terms of applying CPAP to a patient who fits all the criteria as long as we wear the right PPE. In our service Level 1(Tyvek Suit, P100, safety goggles, and gloves) is indicated whenever we are to perform an AGMP. Cardiac arrests are one of these scenarios where we utilize the BVM with a HEPA Filter. I was just wondering, since CPAP is withheld do to it being an AGMP why can't we use it to our discretion with a HEPA filter and wearing Level 1 PPE. The concern is obviously depending on where the patient is located and having CPAP on a patient and then transporting across public space to get to the ambulance is a risk for transmission to others. How do you feel during that instance if we just get on High Flow o2 @15L/min and then once in the back of the ambulance with the exhaust on and having Level 1 PPE on to be okay to use CPAP? Also giving the hospital a pre-alert to have a negative pressure room ready. Sometimes 5cm of H2O(which is 8L/min or can be helpful to a patients breathing. Also just to confirm anything greater than 15L/min of oxygen is considered an AGMP, according to the new research?

In current pandemic situation, nebulized epinephrine is being withheld for those with croup. What management is recommended, should the patient (without hx of asthma) deteriorate (apnea/silent chest) ? Is epinephrine IM an acceptable route? If not, what is the rationale?

ACR Documentation

ACR Documentation

Posted on: August 5th, 2020

ACR Documentation

Remember when electing to start an IV on your patient, separate procedures call for separate codes!

 

 

IV Procedures    

340         IV Monitoring

341         IV Cannulation

342         Lock

345         Normal Saline

349         Other IV Solutions

350         IV Cannulation Unsuccessful

351         Fluid Bolus

353         Blood Sampling

355         IV Discontinued (Intentional)

356         IV Discontinued (Unintentional)

358         lntraosseous Cannulation Successful

359         lntraosseous Cannulation Unsuccessful

360         Blood / Blood Product Administration

361         CVAD Access

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Elements of a Highly Effective Paramedic Team:

Elements of a Highly Effective Paramedic Team:

Posted on: July 29th, 2020

Elements of a Highly Effective Paramedic Team:

Teamwork is as much a science as it is an art; some teams work extremely well together, while others fall apart. Here are some key elements to build your team for great patient care success…

 

Communication:  must be open and flow between all members of your high-performance team.  Team members must never be hesitant to communicate about issues, concerns, new ideas or personal observations during patient interactions.

Adaptability:  Team members must be flexible and adaptable to change.  Team members should be able to rally together and meet new challenges head-on.  The prehospital world is rarely static: scene and patient-conditions are ever-dynamic (and things happen quickly).  The most highly effective paramedic teams roll with the punches and adapt to change on-the-fly.

Respect:  Teams possess a wide range of professional competencies and capabilities to meet a wide range of challenges.  Each team member must trust in one and other to obtain the highest level of patient care; fully understanding what their contributions are to the team, while respecting one and other.

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The Art of the Refusal

The Art of the Refusal 

Posted on: July 23rd, 2020

The art of refusal

We’ve all heard, “We can’t force people to go to the hospital” and while that’s mostly true, it’s weak as a stand-alone statement.

Just as consent must be “informed” so, too, must a refusal be “informed,” and in this context “informed” entails education because the patient may not understand the seriousness of the situation.

As the medical professional on the scene, it’s imperative that our actions are reasonable: That means performing a mental status exam to make sure the patient possesses decisional capacity, explaining to the patient the risk of refusing care, ensuring that the patient can articulate that risk in his or her own words, and taking other steps to help mitigate the patient’s risk. For a full listing of the criteria that must be met for a Refusal, please see the Aid to Capacity Assessment of the Ambulance Call Report Completion manual.

These include encouraging the patient to go to the hospital, waiting on scene, making sure the patient is not left alone, encouraging the patient to contact 911 again if he changes his mind, and so on.

By doing something other than saying “sign here,” you can save lives.

The bottom line from both a patient care perspective, as well as risk management perspective, is that the patient needs to be well-informed of their situation and is able to make a clear and concise decision for their health and well-being. Documentation of these events on the ACR help provide crucial information, that validate the findings and the patient decision regardless of outcome.

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