Tip of the Week

.
Welcome to the Tip of the Week section!

EMS is filled with tricks of the trade and our hope is to share these tips in order to improve patient care, save time and at the very least, provide some interesting information! Have a tip you want to share? Email us at paramedicportalontario@lhsc.on.ca.
D10W: Methods of Administration
Posted on: December 6, 2017
QUESTION: What is the best and most appropriate way to administer D10W?

Answer: Great question! There are actually a couple ways of doing so. Keep in mind that administering D10W to hypoglycemic patients is new to the majority of Paramedics in SWORBHP region; and that the appropriate dose is 0.2 g/kg (2 ml/kg) to a maximum of 10 g (100 ml).

It’s likely that the D10W on your trucks is supplied in a 250ml bag (or similar), which means that you have far too much medication available in that one bag and are required to measure out the appropriate volume in order to administer the appropriate dose.

So, how do you measure out the appropriate volume?


CASE: Your hypoglycemic pediatric patient weighs 40 kg – the required dose is 8g and required volume is 80 ml.

Option 1: Set up an Inline Volumetric Cylinder (ie. Buretrol) to the bag of D10W and fill the chamber with 80 ml of fluid. Once filled with 80 ml, clamp above the chamber and run the line below. The inline Volumetric Cylinder prevents larger volumes of fluid inadvertently being infused.

Option 2: Use a large syringe to draw up 80 ml of D10W directly from the bag and administer via IV push (much like you would push D50W).

Note: SWORBHP does not support simply attaching the bag of D10W to an IV line and measuring volume administration via bag markers. One of the above two options must be used.

When selecting your option for administration, use clinical judgment and decide based on ease of use, safety, available equipment and timely medication delivery. Ensure you go through the RIGHTS of medication administration and perform an independent double check with your partner. The most important step is safety – safety of the appropriate dose, route, method, etc.

Inspecting the Placenta
Posted on: October 24, 2017
As you will have noticed during your Fall Mandatory CME, we are deemphasizing the need to inspect the placenta post-delivery. We have done this because we are far from experienced placenta inspectors – it just not something we see very often. For those of you who are interested, this video provides a great overview of what the pros are looking for. Please remember to bring the placenta to the hospital!

Pediatric Cardiac Arrest – When Do I Leave?
Posted on: September 1, 2017
Does the ALS PCS 4.3 (with in-force date of July 17, 2017) have you confused as to when you’re to initiate transport with a pediatric cardiac arrest?

We understand the potential for confusion! The excerpt below is found in the ALS PCS v4.3 within the Medical Cardiac Arrest Medical Directive.

“Consider very early transport after the 1st analysis (and defibrillation if indicated) in the following settings: pregnancy presumed to be ≥20 weeks gestation (fundus above umbilicus, ensure manualdisplacement of uterus to left), hypothermia, airway obstruction, suspected pulmonary embolus, medication overdose/toxicology, or other known reversible cause of arrest not addressed. Similarly, plan for extrication and transport for patients with refractory ventricular fibrillation and pediatric cardiac arrest (after 3 analyses), ensure quality CPR can be continued.”

  • The 1st paragraph speaks to initiating transport after the 1st analysis in cases of known reversible cause.
  • The 2nd paragraph speaks to initiating transport after 3 analyses for patients with refractory VF, in addition to pediatric patients in cardiac arrest.

So what does this actually mean? What are the intentions of these Clinical Considerations?

  • The majority of pediatric cardiac arrests are a result of a reversible cause
    • In most cases, transport following the first analysis since the majority of pediatric cardiac arrests are related to reversible causes
  • If you do stay on scene for 3 analyses, be prepared to transport the pediatric cardiac arrest patient
    • ACPs – You’re extremely unlikely to receive a field pronouncement
    • PCPs – Pediatric patients don’t meet TOR criteria
  • Rarely, a pediatric patient requires defibrillation
    • In these cases, remain on scene for a maximum of 3 analyses to provide defibrillation

Ultimately, the medical directive allows for clinical judgment: It allows the paramedic to transport pediatric cardiac arrest patients after one analysis if presumed reversible causes of cardiac arrest exist (ex. sepsis, hypoxia) or otherwise stay on scene for 3 analyses (e.g. VF arrest).

Naloxone and Cardiac Arrest
Posted on: August 11, 2017
Did you know… patients in cardiac arrest should NOT routinely be considered for naloxone administration.

Naloxone can reverse respiratory depression and apnea in opioid toxicity but it does NOT reverse cardiac arrest. Focus during cardiac arrest should be on effective CPR and ventilation in addition to defibrillation and epinephrine (ACPs). In rare circumstances such as with a high ETCO2 or narrow-complex PEA, naloxone could be considered after consultation with a BHP.

Travel and Illness
Posted on: July 26, 2017
Patients who present with mild symptoms after recent travel may be afflicted with a travel-related disease. A thorough history, including countries that the patient recently traveled to can help identify this possibility. While many of these diseases are vector-borne (e.g. Malaria, Zika virus), some are communicable between humans (Ebola, MERS). Never take a chance, always opt for the appropriate level of PPE available.
.
Pediatric Respiratory Distress – Case #3
Posted on: June 28, 2017
Case: A 2 month old has had a cold for 2 days. The baby’s father called 911 when he thought the baby stopped breathing and turned blue. The father performed CPR for approximately 30 seconds and the apparent apnea lasted less than 1 minute.

Click on the link below to hear the audible respiratory sounds. What sound are you hearing?


.
Pediatric Respiratory Distress – Case #2
Posted on: May 18, 2017
Case: A 3 year old male has had rhinorrhea since yesterday and woke his parents with noisy breathing around 3am.

Click on the link below to hear the audible respiratory sounds. What sound are you hearing?


.
Prior and Subsequent ASA Administration
Posted on: May 8, 2017
Case: A 68 year old male is complaining of ischemic-type chest discomfort. During your assessment, he states that the 911 operator told him to chew some of his Aspirin, which he says he did. Assuming he meets the indications and has no contraindications, do you administer more ASA?

Answer: 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.

Pediatric Respiratory Distress – Case #1
Posted on: Apr 18, 2017
Case: The mother of an 8 month old female called 911 when her daughter’s breathing sounded fast and noisy. She had been coughing for a few hours this morning, but the breathing issues are new.

Click on the link below to hear the audible respiratory sounds. What sound are you hearing?


.
Documentation for BHP Patch Forms
Posted on: Mar 27, 2017

You may not be aware, but all calls that involve a Base Hospital Physician (BHP) patch are audited by the Local Medical Directors. Based on these audits, feedback may be given to a variety of individuals including paramedics, the BHPs and even physicians from admitting services regarding patients who may have recently been under their care. This feedback is given in attempts to improve patient care both at the level of the individual, but also at the level of the entire prehospital and hospital system.

BHPs are instructed to record your Run Number on each patch sheet in order to link it to the ACR. If unavailable at the time of the patch, please provide it as soon as feasible. Also, the patch sheet acts as a permanent record of medical orders. As a result, the BHP must be the only individual who records information on it.

Base Hospital Physician Patch Form
Posted on: Mar 15, 2017

A new version of the Base Hospital Physician patch form was released November 1, 2016. Here are a few key points to note about the new form:

  • It’s now simplified and no longer has a patch form number; meaning you don’t need to ask for it anymore!
  • The patch form is a Physician’s order and is to be completed by the Physician ONLY; meaning, please DO NOT add, attach or write any additional information on these forms.

.

Diluting Gravol
Posted on: Mar 2, 2017
Remember to dilute Gravol 1:9 with normal saline when administering it IV.
.
.
.
.
When to Check Blood Sugar
Posted on: Feb 24, 2017

Obtain blood glucose readings on patients presenting with an altered LOA, agitation, seizure or signs and symptoms of a stroke.

The Hypoglycemia Medical Directive should be utilized in patients meeting the following readings:

Age > 2 years: glucometry < 4.0 mmol/L
Age < 2 years: glucometry < 3.0 mmol/L

Sometimes trying to catch a STEMI is like going fishing…
Posted on: Jan 24, 2017

Cast as wide a net as you can… STEMI care starts with recognition, which requires capturing a 12-lead ECG as early as possible on any patient with possible ACS.

Perform a 12-lead ECG with the first set of vital signs on patients with any of these symptoms: chest discomfort (often described as a heaviness or pressure that may radiate into the left arm, jaw or shoulder), shortness of breath, nausea, vomiting, weakness, or syncope. STEMIs can sometimes present with atypical symptoms; especially in elderly, female, and diabetic patients. STEMIs also evolve and may not be evident on an initial ECG, so keep the leads connected and perform additional 12-leads during transport.

Also, keep in mind that prehospital ECG abnormalities may resolve by the time the patient receives a 12-lead in the Emergency Department. As a result, prehospital ECGs also have the potential to change the ED management of patients who are not experiencing a STEMI.

Also, remember to repeat an 12-lead when pain increases and mark on the 12-lead the patient’s pain scale, for example: “with x/10 pain). This helps interpret the 12-leads in hospital, even if there is no **ACUTE MI** or **STEMI**.

Going beyond your Medical Directives
Posted on: Jan 10, 2017

Case: A 39 year old male is found unresponsive. A bystander states they were going to try a new drug; his buddy went first. He presents with the classic signs and symptoms of opioid toxicity and his ventilation hasn’t improved following 3 doses of naloxone and ongoing assisted ventilation with a BVM. You’re still 20 minutes from the ED. You patch to the Base Hospital Physician (BHP), who orders 2mg of naloxone IN (provided you have it in stock).

What do you do?
Consider this: Written medical directives are considered offline medical control, and BHP patch orders are considered online medical control. BHPs can give orders that fall outside of the medical directives (online trumps offline) provided the intervention is within the paramedic’s scope of practice.

Now what do you do?
Yes, administer the 2mg of naloxone IN. Consider this a similar example to requesting additional nitroglycerin from a BHP for a patient who has ongoing ischemic chest discomfort following the administration of 6 doses. A higher dose in this case, is still within the paramedic’s scope of practice.

Keep in mind, however, that if a BHP directs a paramedic to perform an assessment or intervention that exceeds the paramedic’s scope of practice (for example, asking a PCP to administer epinephrine to a VSA patient), the paramedic must advise the BHP of such and notify the physician that he or she cannot comply with the direction as it exceeds his or her scope of practice.

Changes in Airway Resistance
Posted on: Oct 18, 2016

Airway resistance is not constant but varies according to the relation:

where η is the dynamic viscosity of air; l and r are the length and radius of the airway respectively. Airway resistance depends greatly upon the size of the airway opening – inversely proportional to the fourth power of the radius.

Any disease affecting the respiratory tract has the potential of increasing airway resistance. Changes in airway resistance can occur suddenly and be sustained as in the case of an asthma attack or anaphylaxis. However, airway resistance can also vary between inspiration and expiration.

Patients with emphysema experience a destruction of the elastic tissue of the lungs which holds the small airways open. During expiration, particularly forced expiration, these airways may collapse causing increased airway resistance. Vigilance in monitoring patients’ breathing at all times is prudent.

Rhab-Doh!
Posted on: Oct 13, 2016

When muscle tissue breaks down and cellular contents are released into the circulation, complications can ensue: compartment syndrome, peripheral neuropathy, acute renal failure, metabolic derangements, disseminating intravascular coagulopathy (DIC) and death.“Rhabdomyolysis is a clinical and biochemical syndrome that results from acute necrosis of skeletal muscle fibers and the leakage of cellular contents into the circulation” (Counselman, 2011).

When should we be considering rhabdomyolysis as part of our patient’s clinical picture? There are lots of causes and precipitating factors, including:

Trauma: crush injury, electrical or lightning injury, compartment syndrome, compression injury including prolonged pressure from own body weight (fall and can’t get up, coma of any origin, etc)

Exertional: heavy training or contact sports, delirium tremens, psychosis, excited delirium, seizure

Other: hyperthermia, heat stroke, drugs or toxins, infections, electrolyte disorders, sepsis

If your patient is potentially suffering from rhabdomyolysis, then establishing IV access would be an appropriate procedure.

Identifying patients who are at risk for rhanbdomyolysis and by initiating IV access can help prepare for potential complications that can be addressed in the prehospital setting (hypotension, arrhythmias, hyperk
alemia).


References:
Counselman F.L., Lo B.M. (2011). Chapter 92. Rhabdomyolysis. In Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Retrieved December 01, 2015 from http://accessmedicine.mhmedical.com/content. aspx? bookid=348& Sectionid=40381560.

Miller, M.L. (2015). Causes of rhabdomyolysis. Up To Date. Retrieved from http://www.uptodate.com/contents/causes-of-rhabdomyolysis?source=search_result&search=rhabdomyolysis&selected Title= 1%7E150#H31738599

Obtaining an Early 12 Lead
Posted on: Oct 4, 2016

Try obtaining a 12 lead early in the call.

A few extra seconds to attach the 12 lead cables along with the monitoring electrodes could benefit the patients overall outcome.

 

EtCO2 Monitoring
Posted on: Sep 23, 2016

The 2010 AHA Guidelines for ACLS recommend using quantitative waveform capnography in intubated patients during CPR. Waveform capnography allows providers to monitor CPR quality by optimizing chest compressions and can be used as a tool to help detect ROSC (return of spontaneous circulation) during CPR.

Two very practical applications of waveform capnography in CPR are:

1. Evaluating the effectiveness of chest compressions
Measurement of a low EtCO2 value (<10 mmHg) during CPR in an intubated patient may indicate that the quality of chest compressions needs improvement.  High quality chest compressions are achieved when the EtCO2 value is at least 10-12 mmHg.  If EtCO2 is less than 10 mmHg, determine if provider fatigue is occurring.

2. Assistance with the identification of ROSC
When ROSC occurs, there will be a significant increase in EtCO2 (~35-45 mmHg) which indicates a dramatic increase in cardiac output resulting in increased perfusion. The CO2 that accumulated during the cardiac arrest is now being transported to the lungs, is exhaled, and is measured by the EtCO2 detector.

WTS?
Posted on: Aug 25, 2016

SpO2 is one of many useful measurements used to build an understanding of patient status but like every other vital sign SpO2 must be critically evaluated each time you take it.Mechem (2015) cautions, “Interpretation of pulse oximetry readings mist account for a variety of factors that may artifactually influence the results. The best defense agaisnt these potential sources of error is a high index of suspicion”

In other words, it’s not an accurate SpO2 until you decide it is.

How SpO2 works: The probe emits two wavelengths of light from one side of the probe and measures the amount of each of those wavelengths that reaches the other side. As the light travels through blood in a finger the oxyhemoglobin absorbs one wavelength and deoxyglobin absorbs the other. The results are microprocessed into a percentage of bound Hb and presto: SpO2.

Remember, SpO2 is not a measure of overall patient oxygenation or wellbeing—you also need to consider if oxygen is being extracted at the cellular level. For example, in cyanide toxicity, the SpO2 is often normal, but cells are unable to extract oxygen from hemoglobin and cellular respiration is inhibited (cells are unable to utilize the oxygen that is present in the blood)

You should consider the following factors that render an SpO2 a potentially unreliable measure of patient oxygenation:

Color- other absorbent colors in the probe’s environment

  • Nail polish and/or fake nails, particularyly dark colors, can alter SpO2 results
  • Dark pigmentation of skin has affected readings in the past but newer technology has improved reliability in this regard
  • Ambient lighting like fluorescent, infrared, incandescent can be picked up by the probe’s sensor

Reduce perfusion – other absorbent colors in the probe’s environment

  • Inflation of BP cuff on same limb
  • Elevation of limb
  • Peripheral vasoconstriction due to hypothermia, medications, shock, injury

Abnormal hemoglobin situation

  • Anemia—if there is less Hb overall in patient’s system then a 100% SpO2 isn’t reassuring
  • Sickle hemoglobin—patients at particular risk of hypoxemia despite “normal” SpO2 reading
  • Hypovolemia due to blood loss
  • Poisoning—Hb carries stuff other than O2, and the SpO2 only measures if the Hb is bound, not whether it’s bound to actual O2. If something else has displaced oxygen on the Hb, the SpO2 can’t tell the difference. Carbon monoxide poisoning is an example (smoke inhalation or smokers). A life-threatening arterial desaturation can be masked by a falsely reassuring SpO2.
  • Acidosis—when patient is acidotic there is an increased affinity between Hb and oxygen, meaning that although there may be a normal SpO2, cellular respiration may be altered as oxygen will not dissociate from hemoglobin. As a result, the hemoglobin retains oxygen, the SpO2 is normal, but cells are unable to extract oxygen and revert to anaerobic metabolism

Probe limitations

  • SpO2 is averaged over several seconds, therefore you may have a newly hypoxemic patient and the SpO2 has not yet caught up to the true reading. Think: hypoxia during intubation.
  • Fit/displacement of probe—incomplete capture of both wavelengths of light can result from ill-fitting or slightly displaced probe resulting in falsely inflated or deflated readings.

If your defib isn’t configured to automatically display the SpO2 waveform you can dial it up easily on each call. A curvaceous waveform at least tells you the SpO2 reflects movement of blood through the patient’s finger.

So to recap: when you are measuring SpO2 you must always consider whether the result is actually a reliable measure of patient oxygenation or if it is CRAP!


References:
Mechem, C.C. (2015). Pulse Oximetry. Up To Date.
Retrieved from http://www.uptodate.com/contents/pulse-oximetry?source=machineLearning&search=oxygen+saturation &selectedTitle=1%7E150&sectionRank=1&anchor=H16#H16

Fluid Bolus
Posted on: Jun 20, 2016

Start a fluid bolus on an adult patient that has a SBP > 89 and continue the bolus until the SBP reaches 100.
.
.
.
.
.
.
.

Pediatric Vital Signs
Posted on: May 5, 2016
Normotension – SBP > 90 mmHg + (2 x age in years)
Hypotension – SBP < 70 mmHg + (2 x age in years)
Weight (kg) = (age x 2) + 10
.
Refer to page 110 in your Medical Directive Handbook for review:

.
.
.
.
.
.
.
.
A Scenario – SVT vs. Atrial Flutter with Rapid Ventricular Response
Posted on: Mar 16, 2016

View this link for a scenario and answers on SVT vs. Atrial Flutter with Rapid Ventricular Response

Link: www.lhsc.on.ca/About_Us/Base_Hospital_Program/TipoftheWeek-AtrialFlutter.pdf
.
.

A Quick Case – Cardiac Ischemia
Posted on: Mar 1, 2016

View this link for a Quick Case on Cardiac Ischemia

Link: www.cper.ca/images/CPER/Digest/CPERDigest20January2015.pdf
.
.
.
.

Taking Experienced Providers to the Next Level
Posted on: Feb 11, 2016

Remember those “Four Stages of Learning”?

  1. Unconscious Incompetence: when you don’t know how little you know
  2. Conscious Incompetence: when you realize how little you know
  3. Conscious Competence: when you are mindful of every aspect of skill application
  4. Unconscious Competence: when you are so practiced that you can perform a skill without thinking about it

Well, no longer is Unconscious Competence the top of the food chain. It has been argued that stalling out in this fourth stage allows development of bad habits, complacency, loss of theory mastery and failure to keep up with emerging research and innovation.

A fifth stage of learning is being debated that embraces creativity, problem solving in novel situations and the pursuit of ongoing learning. This fifth stage has been called “Reflective Competence”, “Enlightened Competence” and “Conscious Competence of Unconscious Competence”. Essentially it means a skilled provider is aware of and nimbly avoids the traps of stage four complacency.

In which of your many skills do you practice this fifth stage of Reflective Competence?


References:
Chapman, A. (2015). Conscious competence learning model. Businessballs.com.
Retrieved from: www.businessballs.com/consciouscompetencelearningmodel.htm#standard-copyright

Remember to attach your ECG STRIPS
Posted on: Jan 29, 2016
Please remember to attach a copy of the ECG before completing your ACR. This enables us to complete ACR audits faster and more effectively.
.
.
.
Update Your Account Settings
Posted on: Jan 6, 2016

This New Year make sure your Ontario Paramedic Portal account information is up to date and accurate! Whether you’ve switched services, changed your last name or have new contact information.Help us keep you up to date and in the loop about all things relating to your certification and education.

To modify your account settings login to the Paramedic Registry via:
www.paramedicportalontario.ca and select “ACCOUNT SETTINGS”.

Croup Season is Here!
Posted on: Dec 29, 2015

Consider utilizing the Croup Medical Directive when presented with a patient < 8 years old experiencing ALL of the following symptoms:

  • Severe Respiratory Distress
  • Stridor at rest
  • Current history of URTI
  • Barking cough OR recent history of a barking cough
  • Heart Rate < 200 / min
IV Initiation
Posted on: Dec 8, 2015
IV’s should be initiated on patients that have an actual or potential need for fluid or drug administration. SWORBHP does not have a maximum number of attempts allowed. If the patient needs it then attempt within reason!
.
.
.
38 Degrees Celsius
Posted on: Nov 25, 2015

The Bronchoconstriction Medical Directive states that, “nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health”.**a known fever is described by the BLS PCS as greater than 38 degrees Celcius (>38C)**

Patients with a temperature of >38 should NOT be treated with nebulized Salbutamol.

3 Tips Why Writing on your Gloves isn’t the Best Idea
Posted on: Nov 9, 2015

1. Gloves are PROTECTION. Gloves should only be used for what they do best – protecting you from the patient and protecting the patient from you.

2. Damage. Writing on your glove may compromise its structure and make it permeable to microscopic particles, like bacteria and viruses.

3. Cross contamination. In an ideal world, one person touches the patient and one member touches everything else to avoid cross contamination. Writing on your gloves compromises this if you’re the one caring for the patient.

How Frequent is Infrequent?
Posted on: Aug 17, 2015

When completing an ACR, paramedics encounter certain problem codes more frequently than others – some only occur several times per year across all of SWORBHP region.

Did you know that a problem/procedure occurring 125 times per year distributed randomly across SWORBHP region will only be encountered by a paramedic once every 5 years on average? Also, those problems/procedures occurring

Perhaps use this information as a reminder to double check infrequent problem codes when you enter them into your ACR. Accurate documentation is crucial to professional standards process, but also to your practice as a paramedic.

IT for Online Modules
Posted on: Aug 8, 2015

As you may remember from your recent 2014-2015 Recert Precourse, we have introduced a series of new interactive eLearning modules. One of the key factors to viewing these modules is ensuring that you are using a compatible web browser. We have done some in depth testing and have determined that the best web browser is Google Chrome 14 or later. By using Google Chrome in conjunction with Flash 10 or later, you should easily be able to access, view and navigate through any of our interactive modules.

To download the Google Chrome web browser, click the link below:

https://support.google.com/chrome/answer/95346?hl=en&ref_topic=14660

If you require assistance or have any questions, feel free to contact our IT Support Team at: paramedicportalontario@lhsc.on.ca or 519-685-8500, ext. 76521.

Staying Up-to-Date with SWORBHP
Posted on: Jul 28, 2015

Want to stay up-to-date with what is happening at the Southwest Ontario Regional Base Hospital Program (SWORBHP)?

If so, please email michelle.priebe@lhsc.on.ca to subscribe to our email notifications for when new information and updates are posted on our website!
.

Get the PAINFUL Truth!
Posted on: Jul 16, 2015

OPQRST is the beginning of a conversation about a patient’s pain. Don’t limit yourself to the six common questions. Use your patient assessment skills to learn more about the patient’s pain. This may help guide your treatments or give you a better understanding of what pathophysiological process is occurring.

Some additional questions might include:

  • What were you doing when the pain started?
  • Is your pain constant or intermittent?
  • Has the pain been constant or has it gradually worsened?
  • As your pain travels from the point of origin, how does it change?
  • Have you experienced pain like this before? If yes, what was it?
  • Have you done anything for your pain like pain medications, ice, or elevation?
  • Are there positions or activities that make the pain better or worse?
  • What else can you tell me about your pain?
Texting 911
Posted on: May 21, 2015

Did you know? Text with 9-1-1 is available in 340 communities across Ontario! In the SWORBHP region text to 9-1-1 is available in the Counties of Essex, Lambton, Oneida and the Cities of Sarnia and Windsor.

This service is available to residents who are deaf, deafened, hard of hearing or speech impaired and offers registered persons an alternative method of communicating with 9-1-1 call takers in the event of an emergency.

This is great opportunity for paramedics to assist at risk community members by directing them to register for text to 9-1-1 with their cell phone provider!*

*For more information and a complete list of the communities involved visit www.textwith911.ca.

Forgot Your Book and Having Trouble Remembering Ketorolac Contraindications?
Posted on: May 7, 2015

Looking for an easier way to remember or identify the contraindications for Ketorolac? Remember to use your books – it’s easier than remembering a mnemonic, or try adding BIRP to the ASA Contraindications!

ASA Contraindications PLUS…

  • Blood thinners (patient on anticoagulation therapy)
  • Ingestion of NSAIDS in the last 6h
  • Renal impairment
  • Pregnancy
Calculating a Heart Rate from an ECG
Posted on: Apr 10, 2015

Calculation of heart rate is important because a deviation from normal may affect the patient’s ability to maintain adequate blood pressure and cardiac output. There are several methods for calculating heart rate:

Six-Second Method: Count the number of QRS complexes within a 6 second strip (30 large boxes) and multiply by 10 to find the number of complexes in a minute.

 

 

 

 

 

For the following methods, the rhythm must be regular.

Large Boxes: Count the number of large boxes between one R-R interval and divide into 300.

Small Boxes: Count the number of small boxes between one R-R interval and divide into 1500.

Sequence Method: Select an R wave that falls on a dark vertical line. Number the next 6 consecutive dark vertical lines as follows: 300, 150, 100, 75, 60, 50. Note where the next R wave falls in relation to the 6 dark vertical lines = this is the heart rate.


.
.
.
.
.

Gravol and Benadryl
Posted on: Mar 23, 2015
Scenario: You have responded for to call for a 43 year old who is experiencing an allergic reaction after being exposed to peanuts. Your assessment reveals diffuse hives, facial swelling, tachycardia and reported SOB. The patient states that prior to your arrival he experienced severe abdominal cramping and multiple episodes of vomiting. He is currently nauseated.You proceed to treat the patient according to the Moderate to Severe Allergic Reaction Medical Directive and the patient receives 0.5 mg of epinephrine and 50 mg of diphenhydramine.The patient remains nauseated and has an episode of vomiting prior to departure.

Should this patient receive dimenhydrinate according to the Nausea/Vomiting Medical Directive?
Answer: The correct answer is no. Diphenhydramine (Benadryl) has both antihistamine and anticholinergic properties. Diphenhydramine prevents the physiological effects of histamine by blocking H1 receptor sites. This provides symptomatic relief of allergic symptoms caused by the release of histamine.Dimenhydrinate (Gravol) also has both antihistamine and anticholinergic properties. In fact, its molecular structure is a combination of diphenhydramine and 8-clorotheophylline. Dimenhydrinate is used to diminish vestibular stimulation and depress labyrinthine function through its central anticholinergic activity (decreases vomiting secondary to motion sickness). It also depresses the chemoreceptor trigger zone in the hypothalamus to prevent vomiting. Gravol competes with H1 receptor sites due to antihistamine properties.

How does this information apply to YOU as a paramedic?
Both medications have antihistamine and anticholinergic properties. As a result, a synergistic effect can occur if Gravol and Benadryl are administered together.Synergism occurs when two medications that have similar pharmacological properties are taken together (ie. two anticholinergic medications). The combined effect of these two medications is greater than the effect of the two medications administered alone (similarly to: 1+1=5). Neither drug by itself is necessarily harmful but together they have the potential to cause undesired side effects (sedation, hallucinations, agitation, tachycardia). This differs from potentiation which occurs when two drugs are taken together and the effect of one drug intensifies the other (a+b=B).
STEMI Mimickers
Posted on: Mar 2, 2015

Myocardial infarction affects ventricular repolarization and/or depolarization, often producing ST elevation. Similarly, any condition that affects ventricular repolarization and/or depolarization may also produce ST elevation. Some of these conditions include:

  • Left Ventricular Hypertrophy
  • Left Bundle Branch Block
  • Ventricular Rhythms
  • Benign Early Repolarization
  • Pericarditis
  • Hemmorhagic Stroke
  • Pulmonary Embolism
  • Aortic Dissection
  • Brugada Syndrome
  • Hypothermia
  • Hyperkalemia
  • Coronary Vasospasm
  • Ventricular Aneurysm
  • Paced rhythm

References:
Phalen, T., & Aehlert, B. (2012). The 12-Lead ECG in Acute Coronary Syndromes (Third Ed.). Maryland Heights, Missouri: Elsevier.

How to acquire a quality 12-lead EKG
Posted on: Feb 13, 2015
Arteriosclerosis vs. Atherosclerosis
Posted on: Jan 24, 2015
Arteriosclerosis
Arteriosclerosis is a chronic disease of the arterial system characterized by abnormal thickening and hardening and loss of elasticity of the vessel walls causing a decrease in blood flow. It is a term often used interchangeably with atherosclerosis.VS.Atherosclerosis
Atherosclerosis is a form of arteriosclerosis (and the most common), characterized by thickening and hardening of the arterial vessels through build-up of fat-like deposits (plaque). It is characterized by endothelial dysfunction, inflammation, and the build-up of lipids, cholesterol, calcium, and cellular debris within the intima of the vessel wall. This build-up results in plaque formation, vascular remodeling, acute and chronic luminal obstruction, abnormalities of blood flow, and diminished oxygen supply to target organs. When plaque within a lumen ruptures, acute ischemic events can take place (i.e. myocardial infarction, stroke)
Self-Reports
Posted on: Jan 16, 2015

The self-report line hotline and email are available for paramedics to use 24 hours a day to report deviations from medically designated acts.Here are some fast facts related to self-reports:

  • Self-reporting is up 9% since 2013 (235 in 2014 versus 215 in 2013).
  • The time required to close a self-report has decreased 3% since 2013 (25.7 days in 2014 versus 26.6 days in 2013).
  • 19% of paramedics self-reported in 2014; an increase of 17% from 2013
  • On a per call basis, self-reports have increased 7% from 2013 to 2014
  • How to self-report: Call 1-888-997-6718 or email selfreport@lhsc.on.ca
  • What to include in your self-report (click here)
Keeping them Warm
Posted on: Jan 9, 2015

Cold weather has crept into the region! Here are 7 simple tips to help keep your patients warm this winter:

1. Cover the patient with an insulating layer (thermal/regular blanket)

2. Insulate your patient from the ground. Remember cold floors (tiling, concrete and linoleum) are a quick way to lose body heat

3. Minimize the time that your backboard sits outside in the cold

4. Turn the heat on in the back of the truck BEFORE patient contact

5. For extended outdoor extrications, package IV & O2 tubing close to the body so that fluid/O2 are warm when entering the body

6. Maintain adequate temperatures in the back of the truck so medications don’t become cold or freeze

7. Ensure your patient is dry. Wet skin conducts heat faster and results in greater heat loss.

CPAP and Nitro
Posted on: Nov 29, 2014

If your patient’s condition is improving on CPAP alone, there is no need to break the seal to administer Nitro. If, however, you feel your patient may benefit from Nitro use in addition to CPAP, go ahead, break the seal, administer the Nitro and reapply CPAP.

Nitro should NEVER be administered via MDI port on the CPAP device. This would cause inhalation of the medication, which is not recommended.

Nitro should ONLY be administered sublingually by spraying it under the patient’s tongue.
.

Managing the Elements
Posted on: Apr 17, 2014

As a paramedic, there are many sources of stress: information overload, emotions, nervousness and that’s before you even clock into work! So, how do you manage all of those elements and still successfully treat your patient?The key is to remember these simple guidelines:

BLS before ALS: Remember, the basics are the foundation for everything else. What do we call a perfectly packaged trauma patient? A patient with multiple IVs, bandaging, splinting, and C-spine precautions; who ultimately died from mismanagement of the BLS airway? The answer: a mismanaged patient.

Try answering these questions when treating a patient:

  • Is the airway secure?
  • Is breathing adequate and oxygenation effective?
  • How is their circulatory system?

Patient assessment: The cornerstone of a great paramedic is not about the “cool” things we do; it’s about the ability to provide a consistent, solid patient exam. After all, we can all do the same skills, the importance lies in the basics every time. So, when you’re feeling frustrated, just remember to start with the ABCs and a thorough exam.

Get the right answer to your question!
Posted on: Mar 21, 2014

A good question will usually get a good answer. A bad question almost always gets a bad answer. Surprised? Try the following patient assessment activity with your fellow co-workers:

Try to think of an ailment or injury that you are suffering from. Each person can ask one question. Start at one side of the room and work your way around the room answering each person’s questions.

If you are asked a yes or no question (i.e. “Do you have any allergies?”), then answer, “Yes” or “No”. If you are asked the better question (“What are your allergies?”), then list your allergies.

A sharp class will then ask the logical follow-up questions about your allergies:

Have you been exposed to any of those allergens?

  • What happens when you are exposed?
  • What treatment have you needed in the past for your allergic reaction?
  • Real patients answer yes or no questions with yes or no answers.

In real life, good questions get good answers!

That Darn Blood Pressure
Posted on: Mar 6, 2014

One of the most annoying things is trying to get a blood pressure in the back of one of our rigs: how are you supposed to hear it?

You can use the cardiac monitor with NIBP that gives you readings of 160/140, but is that accurate? Old, young, heavy, thin, pink or pale, everybody has a suspiciously normal blood pressure that always ends with a zero. What is just as bad is the medic who hesitantly stammers, “Uhhhh… 135/79?” Now let’s face reality…these simply are not true readings.

So, how do you get an accurate reading?

  1. Isolate the patient from everything else. Simply isolate the patient’s arm from touching anything else that it might come in contact with besides your cupped non –dominant hand under their elbow.
  2. Use the bell of your stethoscope, not the diaphragm.
  3. Use a good stethoscope.
  4. Turn your cuff upside down. This will prevent any annoying bumps against the head of your stethoscope. Upside down does not affect the accuracy of your findings.
  5. Learn to palpate. Sometimes you need to settle only for a rough systolic blood pressure.
  6. Turn everything off in the back of the truck. Get it as quiet as you can.
Analgesia & Moderate to Severe Pain Documentation
Posted on: Feb 12, 2014

Having trouble finding your ACR codes for the new medication for the Analgesia & Moderate to Severe Pain Medical Directives? Here they are!

Acetaminophen – 702
Ibuprofen – 703
Ketorolac – 704

Cardiogenic Shock Patients
Posted on: Feb 7, 2014
Remember, if you have a patient in cardiogenic shock (STEMI positive on 12 lead and hypotensive) the 0.9% NaCl fluid bolus is 10ml/kg.
.
.
.
Base Hospital Patching
Posted on: Jan 21, 2014

What should a paramedic do if a BHP patch is indicated but the BHP cannot be reached?

Answer: If a BHP patch is indicated and the BHP cannot be reached despite reasonable attempts by the paramedic to establish contact, a paramedic may initiate the required treatment without the requisite online authorization if the patient is in severe distress and, in the paramedic’s opinion, the medical directive would otherwise apply.

Link to Patching in the Medical Directives Handbook:
www.lhsc.on.ca/About_Us/Base_Hospital_Program/PCPMAR28.pdf#page=19

Sizing a King LT
Posted on:

Remember, when sizing a King LT its 3, 4 and 5:

3 – (4 to 5 feet)
4 – (5 to 6 feet)
5 – (6 feet and greater)
.

Head Injury + Pregnancy
Posted on: Dec 20, 2013
Remember that head injury and pregnancy are not contraindications to administer Dimenhydrinate. As long as there are no other contraindications, a paramedic may provide this treatment.
.
.
.
Air Ambulance for Medical VSA?
Posted on: Dec 10, 2013

You are dispatched to a Medical VSA. Should the air ambulance be triaged to respond as well if available?Successful resuscitation of a patient from a Medical Cardiac Arrest is listed as an indication, however responding to patients who are currently VSA from a medical arrest is not listed as a current indication. Many barriers exist to having air ambulances respond as a general rule to VSA patients (time on scene of land crews vs time for air ambulance to respond to scene, landing zones etc.).

For further information please see the BLS Patient Care Standards Air Ambulance Utilization Standard.
http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/bls_patient.pdf#page=45

Do Not Resuscitate (DNR)
Posted on: Dec 2, 2013

When assessing a patient with a DNR, it is essential to remember which procedures are not to be initiated (and others that still should!).

Not sure? Check out the Do Not Resuscitate (DNR) Standard Training Bulletin.
http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/No.108V.1.0DNRStandard.pdf

Assessing Patients with Pain (OPQRST)
Posted on: Nov 22, 2013

Remember, when assessing a patient who is experiencing pain use OPQRST:

O – Onset
P – Provoking factors
Q – Quality
R – Region/Radiation
S – Severity
T – Time

Causes of ST “ELEVATION”
Posted on: Nov 13, 2013

Here is a tip regarding possible causes of ST Elevation. Remember the Mnemonic – “ELEVATION”

Causes of ST Elevation:

E – Electrolytes
L – LBBB
E – Early Repolarization
V – Ventricular hypertrophy
A – Aneurysm
T – Treatment – Pericardiocentesis
I – Injury (AMI, contusion)
O – Osborne waves (hypothermia)
N – Non-occlusive vasospasm

Get to the “heart” of the matter!
Posted on: Nov 6, 2013
Certain classes of medications (i.e. beta blockers, calcium channel blockers, etc) often blunt the normal physiologic response to stressors such as sepsis, hypovolemia and hemorrhage. As a result, the heart rate may not be appropriately elevated or in keeping with the severity of the disease process in patients who are taking these medications.
.
.
Got Ribs?
Posted on: Oct 30, 2013
Part 1:
Now that we have your attention… when trying to remember how many ribs there are, you have to know how many vertebrae there are. Think of the common meal times, 7am, 12noon, and 5pm, which corresponds with breakfast, lunch and supper respectively. Of course you can enjoy ribs at any meal of the day. This also corresponds to the divisions between the vertebrae: cervical (7), thoracic (12), and lumbar (5). Each rib is associated with its own thoracic vertebrae, hence there are 12 pairs of ribs.Part 2: Land marking to decompress…Rib 1 is not palpable because it is buried under the clavicle and subclavian vessels. Therefore, when counting intercostal spaces, you always begin by land marking the second rib. This can be accomplished by locating the sternal angle (Angle of Louis). Think of the sternum as being a sword, it can be divided into three parts, the manubrium (the handle), the body, or gladiolus (the blade), and the xyphoid (the tip of the blade). The sternal angle is the palpable “step” that divides the handle and the blade. It marks the location of the second rib. Insertion of a needle for decompression should be performed at the lower part of the second intercostal space, to avoid damaging the vessel bundle that runs along the lower edge of each rib.Now you can “Take a Stab” at it!


References:
Drake R., Vogl A., & Mitchell A. (2010) Grey’s Anatomy for Students. Philidelphia, PA: Churchill Livingstone, p.14

Paramedic Stress, PTSD and Supports
Posted on: Oct 11, 2013

Have you had a call that has shaken you? Use your peers as a support network; they have likely been there and can help you through it.

You can also watch on webinar on Paramedic Stress, PTSD and Supports (http://bit.ly/15tfWhW).
.

AV Blocks (Third Degree)
Posted on: Oct 3, 2013

Here is a tip and story to help you remember AV blocks (continuation).

Third Degree: The ventricles have no access to the atria and are left to their own devices to contract at 20 to 40 beats per minute. The atria, however, march along to their usual drummer at the normal sinus rate. (Don’t be fooled by P waves hiding inside the QRS complexes).

You have a few kids but end up divorced and go about your lives doing your own thing, HE IS ALWAYS THERE BUT YOU WANT NOTHING TO DO WITH HIM.

.
.
.
.
.
.
.
.
You will never look at blocks the same.

AV Blocks (Second Degree Type 2)
Posted on: Sep 16, 2013

Here is a tip and story to help you remember AV blocks (continuation).

Second Degree Type 2: The P-R interval is consistent; it’s just not always followed by a QRS complex.

So you decide to have a talk with your husband. He says he is going to try to not be late. The next few times he goes out he’s back on time (PR 0.12-.20) then BAM HE DOESNT SHOW UP (missed QRS).

HE IS CONSTANT BUT THEN FOR NO REASON DOESNT SHOW UP.

.
.
.
.
.

AV Blocks (Second Degree Type 1)
Posted on: Sep 9, 2013

Here is a tip and story to help you remember AV blocks (continuation).The P-R interval gets progressively longer until a QRS is dropped. You decided to marry the guy who is always late so he decides he’s going to test his boundaries when he goes out with his buddies. He says he will be back at 1200 and the first night he is, the next night he goes out he comes back later – 1 am, the next night is later – 2 am, then the next night he’s so late you lock him out of the house! HE IS PROGRESSIVELY LATE and GETS LOCKED OUT.

But there is something about him you like and you forgive him and the cycle continues…late…late…late… locked out for the night!

Remember Wencke always comes bach!

.
.
.
.
.

AV Blocks (First Degree)
Posted on: Sep 4, 2013

Here is a tip and story to help you remember AV blocks.

First Degree: Look at the P-R interval, if it is longer than 0.20 seconds, it’s a first-degree AV block.

You are dating a guy and you tell him to pick you up at 8. Instead he picks you up at 8:30. This happens consistently every time you go out. HE ALWAYS SHOWS UP BUT IS CHRONICALLY LATE.

.
.
.
.
.

Assessing Patients (SAMPLE)
Posted on: Aug 26, 2013

Remember, when assessing your patient use SAMPLE.

S – Symptoms
A – Allergies
M – Medications
P – Past medical history
L – Last meal eaten
E – Events leading up to the incident

Inserting IVs
Posted on: Aug 19, 2013
When starting an IV, remember to go low and slow. Also when you feel the pop, drop. This is in reference to when you first insert the IV catheter as you do not want to go through the vein.
.
.
.