Download - Protocols and Advanced Patient Assessment
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?