BLS Patient Care Standards | SWORBHP Ask MAC

Category Archives: BLS Patient Care Standards

November 28, 2017 SWORBHP Category: Stroke Bypass | Date: 28-Nov-2017

Question: Our current stroke directive reads that 3.5 hours is the timeline from time of onset to stroke center. The new BLS reads that the time from onset to stroke center is 4.5 hours. Which timeline are we expected to follow as of Dec 11th?

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Stroke Bypass

September 11, 2017 SWORBHP Category: Immobilization | Date: 11-Sep-2017

Question: In regards to the BLS version 2.0 - extremity injury, bone/joint, there's a guideline regarding elbow dislocations. It says that if we encounter an elbow dislocation with nerovascular compromise, that we can contact receiving hospital or Base Hospital Physician for advice regarding manipulation or in-line traction. In the new BLS 3.0, this guideline has been left out. Are we still expected to perform the guideline if we ever encounter this, or has this been purposely taken out? Thank you.

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Immobilization

August 11, 2017 SWORBHP Category: Do Not Resuscitate (DNR) | Date: 11-Aug-2017

Question: When the Ministry of Health's DNR forms are filled out, can the section where the patient's name goes have a sticker from the hospital with the patients name/health card #/DOB, etc. instead of having the name printed or does that make the form invalid. The form specifically states the patient’s name should be printed clearly. I wasn't sure if the ID sticker was something we could accept instead or if that section can only be filled out by hand.

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Do Not Resuscitate (DNR)

July 7, 2017 SWORBHP Category: Intravenous and Fluid Therapy, Do Not Resuscitate (DNR) | Date: 7-Jul-2017

Question: In a setting where you arrive on scene and you are presented with a patient who is unconscious and is hypotensive, the patient has a valid DNR. Can you still administer fluids to this patient or does that fall under the same category as inserting an OPA/NPA and BVM to a patient with a DNR?

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July 7, 2017 SWORBHP Category: Miscellaneous, Oxygen Therapy | Date: 7-Jul-2017

Question: For teaching purposes. While assessing a patient, how important is it to determine any and all treatments or interventions provided to the patient by allied agencies, bystanders, self-administration or other medical professionals prior to the arrival of the Paramedics? How important is it to determine an accurate time line of those treatments or interventions? Is oxygen a treatment and/or intervention?

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July 7, 2017 SWORBHP Category: CPAP, Oxygen Therapy | Date: 7-Jul-2017

Question: Is PEEP being considered for inclusion into the paramedic scope of practice? I recently had a patient who was in CHF to the point of unconsciousness whom we would have absolutely given CPAP had he been conscious. Although PEEP isn't exactly the same as CPAP, would it not have potentially provided some benefit?

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Answer: You are correct, Positive End Expiratory Pressure (PEEP) is not exactly the same as CPAP. PEEP can be administered by application of a PEEP valve to a BVM. PEEP works by limiting exhalation by way of maintaining a small amount of positive pressure. This helps to splint alveoli open, and increases functional residual capacity, which is the volume of gas that remains in lungs after a normal breath. CPAP, on the other hand, provides continuous positive pressure throughout the respiratory cycle, thereby improving oxygenation and tidal volumes.

The issue of CPAP vs BVM has been brought up with Ask MAC previously, so some of the following is taken from that (from Nov. 2013)

Both interventions may lead to improved lung compliance and reduced work of breathing. This effect will be much more prominent in the case of CPAP compared to PEEP. Nonetheless, the decision to use a BVM is a decision that must be made on paramedic judgment as to the patient’s level of consciousness and respiratory effectiveness/distress as well as where indicated by the BLS Patient Care Standards.
If a patient is in respiratory distress and has an oxygen saturation of less than 90% or accessory muscle use such that CPAP would be considered (and CPAP is not available or contraindicated) then it would be reasonable to consider using a BVM to assist with ventilations. In this case, using a PEEP valve on the BVM would be of benefit. As PEEP valves are not controlled medical acts, these equipment components fall under the oversight of paramedic services.

Strictly speaking however, providing ventilations through the BVM does not provide a continuous level of airway pressure (although with the use of a PEEP valve on a BVM we may be able to approach some level of continuous airway pressure) therefore the physiology (and potentially the benefit) may not be the same. Bottom line: the use of the BVM is a skill that paramedics must be familiar with and used as per their own judgment and the BLS Patient Care Standards but not as a substitute for CPAP.

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February 13, 2017 SWORBHP Category: Medical Cardiac Arrest, Oxygen Therapy | Date: 13-Feb-2017

Question: How many liters to we run a BVM at?

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February 13, 2017 SWORBHP Category: Miscellaneous, Cardiac Ischemia, Stroke Bypass | Date: 13-Feb-2017

Question: In Elgin county we have been having trouble with our defibs spitting out 'noisy data' warnings on our 12 lead ECG's lately which has prompted conversation with crews about the STEMI protocol. Though the protocol clearly states that LP15 ECG software interpretation meets ***MEETS ST ELEVATION... some crews are saying that due to this issue with noisy data, we are able to interpret the ECG on our own and determine if it meets our criteria based on the >1 mm/or the >2mm ST elevation criteria. Your thoughts? Should we patch the cardiologist? Should we transport to nearest ED due to software not recognizing due to noisy data?

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Answer: This is an interesting question. I direct you to the LP15 Operating Manual pages 4-17, 4-18, 4-22, and 4-23. I will quote the relevant pages 4-17 and 4-18 from the manual:

“ECG Override:

If the monitor detects signal noise while acquiring data (such as patient motion or a disconnected electrode), the screen displays the message: NOISY DATA! PRESS 12-LEAD TO ACCEPT. The message remains and 12-lead ECG acquisition is interrupted until noise is eliminated. Take appropriate action to eliminate the signal noise. This message remains as long as signal noise is detected. When signal noise is eliminated, the monitor resumes acquiring data. To override the message and acquire the 12-lead ECG in spite of the signal noise, press 12-LEAD again. The 12-lead ECG will be acquired and printed with no interpretive statements. Any 12-lead ECG report acquired in this way is annotated with the following statement: ECG OVERRIDE: DATA QUALITY PROHIBITS INTERPRETATION. If the signal noise persists for longer than 30 seconds, 12-lead ECG acquisition stops. The screen displays EXCESSIVE NOISE–12-LEAD CANCELLED. You must then press 12-LEAD to restart 12-lead ECG acquisition.

Note: If 12-LEAD is pressed immediately after ECG electrodes are applied, the message NOISY DATA may occur. This message is due to the temporary instability between the electrode gel and the patient’s skin that is not viewable on the ECG monitor screen, but is detected as noisy data. In general, it is best to wait at least 30 seconds after applying the last electrode before pressing the 12-LEAD button, to allow for electrode/skin stabilization. Also, good skin preparation shortens the stabilization time.”

Pages 4-22 and 4-23 gives a list of possible causes for the noisy data warning and what to do about trying to fix them.

If you are still unable to obtain a “clean” 12 lead ECG that does not contain the warnings as listed above, then it is reasonable to go to the closest ED and have the emergency physician sort out the diagnosis before undertaking a STEMI bypass.

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September 29, 2016 SWORBHP Category: Stroke Bypass | Date: 29-Sep-2016

Question: Can you go stroke bypass with the only complaint being a defined onset of confusion?

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Stroke Bypass

September 29, 2016 SWORBHP Category: Do Not Resuscitate (DNR) | Date: 29-Sep-2016

Question: How is the DNR standard in the BLS PCS reconciled with this statement in the ALS PCS: "if a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated)."

Obviously the ideal situation is that the patient has the DNR confirmation form and there are no issues. The issue comes up with regards to verbal DNRs issued by a capable patient or SDM (that are reasonable), or in such cases where the patient has a DNR, living will or other advanced directive that specifies the patients wishes, but no prehospital DNR form. Is this form not redundant provided there is a reasonable indication that the patient does not wish to be resuscitated or have aggressive life sustaining therapies delivered?

How can the BLS PCS DNR standard be reconciled with the ALS PCS regarding honouring a prior capable wish when the provider is made aware of such wish (provided its reasonable)? Especially given that in nearly ever other case, a directive in the ALS PCS over-rides the BLS-PCS. Given that this issue is not nearly as cut and dry in reality, or in any other healthcare setting, as it seems to be made out to be in EMS in this province what is the situation with regards to this? Especially given that end-of-life issues are increasingly common, the issue is not going to disappear. There are many other provinces that use a similar wording or philosophy to that mentioned in the ALS-PCS under consent and capacity.

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Answer: Thank you for your question. It is a confusing area of practice. The short, straight forward, policy answer is that paramedics provide resuscitation procedures to everyone who requires them UNLESS the patient has a signed Ministry of Health / Fire Marshall approved DNR form indicating there is a DNR plan in place or there is a signed inter-facility DNR order. If the form is not available to be checked then resuscitative measures should be started until the form is produced.

While we wish to follow a person’s wishes regarding their end of life, the dilemma is that resuscitation in cardiac arrest is a time sensitive situation. The default expectation is to begin resuscitation if someone calls 911 and requests assistance. A paramedic does not have the luxury of spending time to sort out what the person’s wishes are, who is the designated alternate decision maker is if the person is not capable of indicating their own wishes etc.

As you correctly point out, the real world is not so clear. People frequently don’t discuss their end of life wishes. When they do, they often don’t write down their wishes. They seldom do so on an “approved” form. Likely the person or their family doesn’t know such a form exists. The form requires substantial effort to obtain.

The problem is what to do; when the form does not exist, when it can’t be readily produced, or when a family member is clearly stating the person does not want resuscitation. It is tempting to follow the direction of the family member but this action does not comply with the standard.

We suggest the following compromise. If an approved form is not readily produced to examine and bystanders indicate the patient does not wish resuscitation then CPR or other resuscitative measures should begin. One of the paramedics should obtain the details and explain that they are obliged to begin until the situation is clarified. This information should be relayed in a patch to the Base Hospital physician and discussed. In most cases the paramedic will be given a cease resuscitation order and the resuscitation can be stopped.

While this is not an ideal solution, this course of action balances the legal obligations and moral claims to respect the autonomy and wishes of the patient. Everyone should be encouraged to discuss their end of life wishes with their family and to document their wishes appropriately.

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Do Not Resuscitate (DNR)

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