1. Protocols and Advanced Patient Assessment

2. Delegated Medical Acts and the Paramedics Role Licensed vs certified (a review) Base Hospital –their role Delegating Physician vs Medical director Medical Directives Standing Orders PCP vs ACP or CCP Transfer of Care Patching Read your handouts well! Check out RPP Handouts !

3. DMA’s- what are they? From the college of Physicians and Surgeons of Ontario Under certain conditions and with specific instruction Which 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

4. Some examples: 12 lead SpO2 and ETCO2 monitoring Symptom Relief SQ/IM/IV medications Defibrillation- Cardioversion, “electrical therapy” IV maintenance Delegated Medical Acts and the Paramedics Role

5. 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 Assessment Rule In/Rule Out Risk Analysis

6. 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 MAKING 3.Perform the DMA 4 Reassess the patient condition and need for further treatment or other

7. 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!!

8. Chest Pain Patient Chest Pain Patient –Rule Out Ischemic Heart disease Yes I think so Why??.... AAA TAA Pericarditis Flu Pneumonia Myocarditis Cardiogenic shock Chest wall pain Pleurisy Endocarditis & more Examples of Rule In and Rule Out

9. Risk Benefit Analysis ALL skills and procedures have a potentially negative side effect E.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

10. Detailed (System Specific Patient Assessment) Focused on system involved- remove all non essentials REAL LIFE Both history and physical are focused on the problem at hand E.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 end E.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 Out Not beat the sheet any more On ACR for pelvis – write “Not examined” in patient with CP!! Get pertinent “top three” vitals first!!

11. 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 START PMEDHX (relevant), relevant meds, associated familiar hx

12. History and Physical Should get more focused as your call progresses! Chest Pain? OPQRST Associates S and S? Previous cardiac event? When? Similar? What happened in hosp? Add monitoring? Add physical exam Add pertinent vitals Formulate a Differential Diagnosis!!

13. 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. angina 2. MI 3. flu

14. 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

15. For readings 1.Carolines, 27.68 2.Please review history taking and see history taking ppt on web site 3. Read SO book on Cardiac arrest algorithms Case of the Week For next week Defib ! Differentiating between CHF and pneumonia-How do we do it? Why would we want to be SURE?