BLS Patient Care Standards | SWORBHP Ask MAC

Category Archives: BLS Patient Care Standards

August 22, 2012 SWORBHP Category: Medical Cardiac Arrest, Do Not Resuscitate (DNR) | Date: 22-Aug-2012

Question: I have recently received an ACR audit, and have spoken to others, within my service, who have received audits as well, stating that a DNR patient who has not arrested should be ventilated via BVM. Everyone is under the impression that a DNR patient should not be bagged. I know that I have had previous conversations with SWORBHP educators in which the final word on this subject had been no BVM in the presence of a DNR irregardless of whether then patient was VSA or pre-arrest. A similar question on this issue was previously asked and answered on 1-March-2012 with the resulting answer being "therefore, to answer your question, if a valid DNR form is available, none of these "advanced cardiopulmonary resuscitation" procedures should be initiated, period. The SWORBHP medical directors would suggest that this is independent of whether or not the patient has completely arrested or not". The question now is what is the right thing to do? What we have previously been told is right or what the auditors are now saying we should be doing? Could you please shed some light on the situation because there's once again a lot of confusion surrounding the correct application of the DNR. Thanks.

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July 3, 2012 SWORBHP Category: Oxygen Therapy | Date: 03-Jul-2012

Question: I have some questions regarding supplemental oxygen. For a patient who requires oxygen, but is vomiting frequently is a nasal cannula an adequate oxygen delivery system, or should a Non Rebreather be continually removed an reapplied as necessary? Also I see a wide range of flow rates applied to the nasal cannula (anywhere from 2-8 lpm). What flow rate is most beneficial to a patient in a pre-hospital setting who requires supplemental oxygen via nasal cannula?

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Oxygen Therapy

June 12, 2012 SWORBHP Category: Stroke Bypass | Date: 12-Jun-2012

Question: We are transporting a patient from a small hospital without a CT scanner to a larger hospital with a CT scanner but not a Stroke Centre. Our patient is an obvious stroke patient...slurred speech for over 1 day, but is getting better and no other issues...stable, but still with slurred speech (does not meet Stroke Protocol as onset over 24hrs).

What should we do should this patient become worse enroute to the CT capable hospital? Say his slurred speech becomes worse or he shows other signs and symptoms? Is this considered a "new onset" or a continuation of his current CVA/TIA? If "new onset" I would think he now meets the Stroke Protocol and should be diverted to the Stroke Centre? Could you please clarify?

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Stroke Bypass

April 24, 2012 SWORBHP Category: STEMI Bypass | Date: 24-Apr-2012

Question: For STEMI Bypass, what is the delay in extending the bypass into all of the services that would meet the transport criteria? Originally I was told it was an issue of having an IV established, now with the increasing number of service providers with autonomous PCP IVs this would no longer seem to be an issue. I never understood the initial rationale since say Glencoe is 50km from UH and St Thomas is roughly 20km closer. Yet Glencoe could bypass and St. Thomas couldn't. Thanks in advance.

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Answer: Great question! The 2010 AHA Guidelines state that “it is reasonable to transport patients directly to the nearest PCI facility, bypassing closer EDs as necessary, in systems where time intervals between first medical contact and balloon times are < 90min and transport times are relatively short (ie, < 30min) (ClassIIa, LOE B).” (O’Connor et al, Part 10: Acute Coronary Syndromes)

Your point is very well taken. There are areas within each municipality from which a patient can be transported to the PCI capable centre and still meet the time guidelines. As you correctly point out, not all of these municipalities currently participate in a STEMI bypass agreement. That being said, the boundaries of municipalities and EMS services vary and are not (unfortunately) built around the PCI centre. That would certainly make a lot of our work so much easier!

In the example above, yes, there are areas of Elgin County from which a patient could be but also would not be able (most likely) to be transported to the PCI capable centre within the time lines set forth from the AHA Guidelines. Compounding this is the background work that is required with each hospital in the creation of repatriation agreements for admission beds, bypass agreements with government officials and MOHLTC-EHS branch, training of paramedic staff on varying bypass protocols, not to mention the ongoing evolution of the literature that surrounds STEMI Bypass as our experience with this grows.

Bottom line: Your point is well taken. We are in fact actively working behind the scenes aggressively both locally and provincially with multiple stakeholders (cardiac care network (CCN), cath lab leadership, interventional cardiologists, MOHLTC-EHS officials, multiple local hospitals –maybe even yours!) in attempting to expand our current STEMI bypass agreement to the maximal benefit for as many patients as safely as possible. Stay tuned. This is an area (similar to Stroke Bypass 10 years ago) of tremendous interest and growth.

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STEMI Bypass

March 13, 2012 SWORBHP Category: Stroke Bypass | Date: 13-Mar-2012

Question: I don't agree with the transport consideration in case study #1 of the Acute Stroke Protocol that states the patient is excluded from transport to a Designated Stroke Centre due to not being able to determine onset of symptoms: male, age 58, found unconscious on the floor at 0800 by a friend, when he came to pick him up for work.

Shouldn't we consider it likely the symptom onset was < 3.5hrs especially in this case where it would be safe to assume symptom onset probably occurred after patient got up to get ready for work and that he probably does not get up three and a half hours prior to getting picked up at 0800.

Further, it's more likely his GCS would be worse than 10 had he been down much longer. Bottom line, shouldn't we be erring on the side of caution for these patients and give them the benefit of the doubt that symptom onset might be < 3.5hrs given the evidence at hand? Or even with less evidence? As an aside, is the time going to be extended as i believe some doctors think it should?

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Answer: Thanks for the question. We are sorry that you don’t agree with the current Stroke Guidelines.

The stipulation that the patient must arrive to a Designated Stroke Centre within 3.5h of a clearly determined time of symptom onset or the time the patient was “last seen in a usual state of health” is one of the most common questions we receive from paramedics. Interestingly, this is also one of the most common protocol violations from the Paramedic Prompt Card for Acute Stroke Protocol and one of the most common complaints the Stroke Neurologists refer back to the Base Hospital for investigation.

The Prompt Card was created from a joint working group of neurologists and emergency physicians and is designed to reflect the latest in clinical practice.

As you know, recently the window was expanded to 3.5h. A good review of the literature for the rationale for this decision can be found here: http://stroke.ahajournals.org/content/40/7/2438.full.pdf+html

Dr. Lewell recently presented this information via Webinar and in live rounds. The specific “last seen well” criteria and rationale were discussed at that time. The audio from these presentations can be found on our website here: www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/Paramedic_Rounds.htm

Unfortunately, we know from experience that as soon as we vary from the very strict protocols for thrombolysis, the frequency of complications (and specifically intra-cerebral hemorrhage) increases. Evidence for this can be found here: http://stroke.ahajournals.org/content/32/1/12.full.pdf+html

And specifically related to the time interval you mention “from last seen well” from the Cleveland experience: http://jama.ama-assn.org/content/283/9/1151.full.pdf+html

In reference to your comments that the current evidence suggests that the time window should be increased again, while this may occur in the future as experience with thrombolysis for stroke grows, the latest update from the American Heart Association clearly suggests that the current practice in Ontario in consistent with best practice. The AHA guidelines for stroke can be found here: http://circ.ahajournals.org/content/122/18_suppl_3/S818.full.pdf+html

Bottom line: Your suggestion of erring on the side of caution and giving the patient in the case you describe the benefit of doubt may actually increase their risk of harm from TPA.

A couple of points about your case: You describe a patient suffering from a stroke as being unconscious. Remember, most often, patients need to have a bi-hemispheric insult to their brain in order to be unconscious. Given the duplicate bilateral vascular supply the brain receives, it is not common for a true ischemic stroke patient to be unconscious. The altered GCS (< 10) on the Prompt Card is designed to allow a patient to have completely lost speech (complete aphasia = 1 out of 5) and still be a candidate for “Stroke Bypass”. A further fall of 2 points to < 10 would suggest that another process is in place affecting the patients level of consciousness. It is not clear that the length of time lying on the floor can be directly or accurately linked to level of consciousness as you suggest.

Finally, from a patient safety point of view, it is also not clear that transporting unconscious patients for up to two hours to a designated stroke centre can be done safely without advanced airways and/or other interventions. This may also further increase the risk of harm to patients.

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Stroke Bypass

March 13, 2012 SWORBHP Category: Pediatrics | Date: 13-Mar-2012

Question: If we are on a call and suspect child abuse or neglect may be taking place what would be the best way to contact child services? Also could we run into confidentiality problems? An example would be if we are called to a residence for a woman with abdo pains. After assessing the scene we notice an infant sitting next to drug paraphernalia.

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Pediatrics

March 1, 2012 SWORBHP Category: Do Not Resuscitate (DNR) | Date: 1-Mar-2012

Question: The DNR confirmation form states the paramedic will not initiate basic or advanced CPR such as, TCP being one of them. From what I understand, until that person suffers cardiac or respiratory arrest, they are fair game for treatment. So, if a patient is in a 3rd degree block at 20bpm and they have a DNR, we are pacing this patient?

Also, what do they mean on the DNR confirmation form about palliative care? They say we are to provide care to alleviate pain/discomfort such as - NTG, ASA, benzodiazepine, epi for anaphylaxis, o2, Morphine etc. Is this merely an FYI on how to treat a pre-code patient? Clearly the patient would have to be alive to administer these drugs. Again it is said that the DNR does not come into play unless the patient codes. Why is this on the form?

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Answer: Thanks for the terrific question. The DNR standard has been a source of many frequently asked questions, and we are pleased that we may be able to clarify a few concerns through this forum.

It is essential that you review the DNR Confirmation Form. It can be found here:
http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/EHS_Training_Bulletins.htm

The actual DNR standard itself speaks of “a person who has suffered respiratory or cardiorespiratory arrest” on many occasions. The standard directs paramedic practice “with respect to the management of situations where a patient…..has expressed the wish not to be resuscitated in the event that they experience a respiratory or cardiorespiratory arrest” No doubt this is where the confusion comes in.

Ironically, on the actual DNR confirmation form itself, nowhere does it state that a cardiac arrest must have occurred. Careful review of Part 1 of the form will show that the definition of “do not resuscitate” includes “advanced cardiopulmonary resuscitation (CPR)” which is defined as: chest compression, defibrillation, artificial ventilation, insertion of a OPA or NPA, endotracheal intubation, transcutaneous pacing, and advanced resuscitation drugs such as vasopressors, antiarrythmic agents and opioid antagonists.

Clearly, some of these procedures (such as pacing as you describe) would not be used exclusively for a patient who has suffered a cardiac arrest. As you know, pacing most often is for profoundly bradycardic patients who have not yet suffered a complete “cardiorespiratory arrest”, yet are found to be tremendously unstable and hypotensive.

Therefore, to answer your question, if a valid DNR Confirmation Form is available, none of these “advanced cardiopulmonary resuscitation” procedures should be initiated period. The SWORBHP Medical Directors would suggest that this is independent of whether the patient has completely arrested or not.

Think of it this way: if a patient is in a pre-arrested state, is tremendously unstable, or has suffered a cardiorespiratory arrest, and one of these listed procedures would be indicated, they should not be performed by the paramedic as the patient has specifically requested this course of conservative action.

Consider the following situation….if a patient has a signed and valid DNR Confirmation form, and had a decreased LOC with oxygen saturations of 60% despite 100% FIO2, but had a perfusing rhythm and blood pressure, this patient should not be intubated.

To answer the second part of your question, those interventions or therapies listed in Part 2 are considered necessary to provide comfort or alleviate pain and therefore should be provided where indicated by your directives. THis section was included to specifically reinforce that depite a patient having a valid DNR confirmation form, certain medications and procedures are acceptable- specifically if the goal is to maintain patient comfort. You are correct in your assertion that clearly the patient would have to be alive to administer these drugs, and this lends further credibility to the SWORBHP Medical Directors interpretation that this form should be followed by the paramedic regardless of whether the patient has completely arrested or not.

Hope this clarifies things.

Bottom line, think of the DNR confirmation form as list of specific patient instructions of how they wish to be treated when they become extremely unwell or have arrested and they are unable to communicate for themselves.

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Do Not Resuscitate (DNR)

March 1, 2012 SWORBHP Category: Do Not Resuscitate (DNR) | Date: 1-Mar-2012

Question: If a DNR only comes into play once the patient has suffered respiratory or cardiac arrest, why do hospitals use DNR as an excuse to downgrade CTAS or justify putting certain patients as a code 7?

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Do Not Resuscitate (DNR)

February 15, 2012 SWORBHP Category: Stroke Bypass | Date: 15-Feb-2012

Question: Recently, after transporting a stroke bypass patient we were told they could not be treated for the stroke (with thrombolytic) due to the patient's history of warfarin use.

How does this fall under our protocol but outside theirs? If blood thinners (either in conjunction with a specific disease or as a certain dose) are a roadblock to thrombolytic therapy why isn't it listed as a contraindication to the bypass protocol? We did not have time to discuss the rationale behind the statement and have been wondering since if we misinterpreted the statement or if warfarin and similar drugs really do prevent thrombolytic use with CVA's? I know there have been studies linking problems with tPA in patients with warfarin history but didn't know that played an active role in the exclusion criteria at stroke centers now. If this is the case why not change the protocol to eliminate needless transport (especially when transporting from outside of the city/county where the center is located?

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Stroke Bypass

February 6, 2012 SWORBHP Category: Do Not Resuscitate (DNR) | Date: 6-Feb-2012

Question: Called to a nursing home for 90 year old male. On scene staff state patient has valid DNR but they are unable to produce it. The crew continues to resuscitate patient as per usual. Enroute to receiving facility, CACC advises the crew that family has phoned in and stated that they have the DNR and they do not want the patient resuscitated. The attendant phones the attending BHP and advises him of the situation. The BHP orders EMS to cease resuscitation efforts on patient. Is this right or wrong?

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Do Not Resuscitate (DNR)

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