Protocols andAdvanced Patient Assessment

Delegated Medical Acts and the Paramedics RoleLicensed vs certified (a review)Base Hospital –their roleDelegating Physician vs Medical directorMedical DirectivesStanding OrdersPCP vs ACP or CCPTransfer of CarePatching

Read your handouts well! Check out RPP Handouts !

DMA’s- what are they?From the college of Physicians and Surgeons

of OntarioUnder certain conditions and with specific

instructionWhich ones to use?

Usually only life threatening ones (e.g. ??)Sometime potentially life threatening ones

(e.g ??)Important to remember whose license you

are working under

Delegated Medical Acts and the Paramedics Role

Some examples:12 lead SpO2 and ETCO2 monitoringSymptom ReliefSQ/IM/IV medicationsDefibrillation- Cardioversion, “electrical

therapy”IV maintenance

Delegated Medical Acts and the Paramedics Role

So what is required of You??Due diligence to perform only the DMAs

you are training and being paid to do!!4 Steps of DMAs (or any other BLS skill for

that matter)Attention to Patient AssessmentRule In/Rule OutRisk Analysis

4 Steps of DMAs

1. Proper assessment and history taking of the patient

2. Assess the need for the skill/or intervention or drug

DECISION MAKING3.Perform the DMA4 Reassess the patient condition and need

for further treatment or other

Rule In/Rule Out

Don't only Rule In the indications and conditions of a DMA or skill

Don’t forget to Rule Out things that may harm the patient if your assessment or history are too superficial

First…..Do NO HARM!!

Chest Pain Patient

Chest Pain Patient –Rule Out

Ischemic Heart diseaseYes I think soWhy??....

AAATAAPericarditisFluPneumoniaMyocarditisCardiogenic shockChest wall painPleurisyEndocarditis &

more

Examples of Rule In and Rule Out

Risk Benefit AnalysisALL skills and procedures have a potentially negative

side effectE.g NTG (obviously), 12/15 lead in cardiac patient, post MI

Some are worse than others Just because a patient meets a particular protocol does

not mean they HAVE to get the drug or have the procedure

There is room for judgement (work outside the standard but make sure you document why you have done so)

Don’t just do it because you can!!You need to be a patient advocate and decide if the

risks outweigh the benefits

Detailed (System Specific Patient Assessment)Focused on system involved- remove all non essentialsREAL LIFEBoth history and physical are focused on the

problem at handE.g no neck palp in patient with CP

History needs to prioritize the questions (not SAMPLE necessarily first) – Focused History

“Follow” the questions until get to dead endE.g don’t go on to next question until sure of all the

information you need If looking for SR meds, start with these questions

first! To Rule In, then other questions to Rule OutNot beat the sheet any more

On ACR for pelvis – write “Not examined” in patient with CP!!

Get pertinent “top three” vitals first!!

What does that mean? System Specific?Look at primary and secondary systems ONLY!!When I think a patient is having a primarily

cardiac event, I don’t even think about MSK assessment

Look at associated systems (e.g resp etc)Look at pedal edema (why?)Focus on the system affected (heart)Focus on three vital signs first (which ones do

you want ____, _____ and _____)Focus on nature of pain, OPQRST to STARTPMEDHX (relevant), relevant meds, associated

familiar hx

History and Physical Should get more focused as your call progresses!

Chest Pain?OPQRSTAssociates S and S?Previous cardiac event?When?Similar?What happened in

hosp?Add monitoring?Add physical examAdd pertinent vitalsFormulate a

Differential Diagnosis!!

Differential diagnosis

Remember to come up initially with three things you think it may be- can do this on the way to calls- narrow it down through focuses exam and history

E.g chest pain

DD-1. angina2. MI3. flu

Patching

A paramedic should patch to the Base Hospital:

• When a medical directive contains a mandatory provincial patch point;

OR

• When a Regional BH introduces a mandatory BH patch point;

OR

• For situations that fall outside of these medical directives where the paramedic believes the patient may benefit from online medical direction that falls within the prescribed paramedic scope of practice;

OR

• When there is uncertainty about the appropriateness of a medical directive, either in whole or in part.

See ‘Patching’ in Introduction, ALS PCS V 3.1

For readings

1.Carolines, 27.68 2.Please review history taking and see history taking ppt on web site3. Read SO book on Cardiac arrest algorithms

Case of the Week

For next weekDefib !

Differentiating between CHF and pneumonia-How do we do it? Why would we want to be SURE?