General Standard of Care Flashcards
GCS (Glasgow Coma Scale)
Eye Opening
What are the possible results?
1 - Does not open eyes in response to anything.
2 - Opens eyes in response to painful stimuli.
3 - Opens eyes in response to voice.
4 - Opens eyes spontaneously.
Goes from 1-4
GCS (Glasgow Coma Scale)
Verbal Response
What are the possible results?
1 - Makes no sounds.
2 - Incomprehensible sounds.
3 - Utters incoherent words.
4 - Confused, disoriented.
5 - Oriented, converses normally.
Goes from 1-5
GCS (Glasgow Coma Scale)
Motor Activity
What are the possible results?
1 - Makes no movements.
2 - Decerebrate (extensor) posture (an abnormal posture that can include arms and legs held straight out, toes pointed downward, head and neck arched backward).
3 - Decorticate (flexor) posture (an abnormal posture that can include clenched fists, legs held straight out - “to the core”).
4 - Withdrawal from painful stimuli.
5- Localizes to painful stimuli.
6 - Obeys commands.
Goes from 1-6
GCS (Glasgow Coma Scale)
8 or lower
What’s the significance?
any patient with an 8 or lower is strongly considered for intubation
GCS (Glasgow Coma Scale)
3
What’s the significance?
The lowest possible GCS; this indicates a patient is wholly unresponsive.
GCS (Glasgow Coma Scale)
15
What’s the significance?
The highest GCS score
Baseline Vital Signs
What are the 8
AND what else might you ask you partner to check or “do”?
1 - HR
2 - RR
3 - BP
4 - SPO2
5 - GCS
6 - Temp
7 - Pupils
8 - Skin
Put the BP on 3-5min repeat
End tital C02
4-lead/12-lead
BGL
Patient Assessment Standard
When would you use a cardiac monitor?
4-lead/12-lead
Any Neuro, Cardio, or Resp Call
Patient Management Standard
What are the 6 reasons for positioning or re-positioning the patient?
1 - C-spine alignment
2 - Airway patency
3 - Breathing
4 - Venous return and perfusion
5 - Extremity Injury
6 - Patient Comfort
Patient Transport Standard
What of the patient’s do you need to take with you?
Relvent Patient Medications
Record of Medications
Relevent identification
Patient Refusal/Emergency Treatment Standard
What are the 5 things you NEED to do before leaving scene?
Patient with capacity refusal
Inform the patient that treatment/transport are recommended
Explain the consequences of the refusal
Confirm the patient has capacity
Advise patient to call 911 if further concerns arise
Obtain needed signatures for your ACR
Patient Refusal/Emergency Treatment Standard
When do you emergency transport regardless?
Incapable patient without consent
Patient doesn’nt have capacity
Patient is experiencing severe suffering/at risk of sustaining harm (wihtout treatment)
The delay (amount of time) it takes to obtain consent/refusal is prolonging the suffering or putting them at risk
Document everything on ACR
Patient Refusal/Emergency Treatment Standard
When do you emergency transport regardless?
Capable patient without consent
Patient is experiencing severe suffering/at risk of sustaining harm (wihtout treatment)
When a disability or language barrier impeeds the ability to obtain consent/refusal
When efforts have been made to help with the communication issues but nothing’s been found
When the delay (amount of time) it takes to find a practical means to help with communication to obtain consent/refusal is prolonging the suffering or putting them at risk
When there’s no reason to believe the patient does not want the treatment.
Document everything in ACR
Reporting of Patient Care to Receiving Facility Standard
What CTAS would you transmit a report while on route for?
All CTAS 1 and 2
Reporting of Patient Care to Receiving Facility Standard
What do you report to receiving facility for CTAS 1 and 2 patients?
10 things and 2 things to remember to do
Unit #
Patient age
Patient sex
CTAS Level
Cheif Complaint
Pertinent history
Pertinant assessment findings
Pertinent management and response to management
Abnormal vital signs
Estimated time of arrival
Remember to confirm that the facility has ackknowleged the report
provide any changes if the CTAS increases
Patch to Base Hospital Physician Standard
When do you initiate a patch?
When required by the standard or ALS PCS
When there is uncertainty or further direction desired
Patch to Base Hospital Physician Standard
What do you report?
2 things to remember to do
Your level of certification
Provide the pt’s condition, situation, or circumstance
Provided any rquested information
Confirm direction, authorization, and orders given AND document in ACR
Oxygen Therapy Standard
What % do you attempt to maintain oxygen saturation of a patient?
92%-96%
Oxygen Therapy Standard
For what patients do you administer high concentration of oxygen?
6 things
Confirmed/suspected CO, cyanide toxicity, or noxious gas exposure
Upper airway burn
Scuba-diving related disorders
Ongoing cardiopulmonary arrest
Complete airway obstruction
Sickle cell anemia with suspected vaso-occlusive crisis
Oxygen Therapy Standard
What patients do you proceed to give high concentration of oxygen to if SPO2 isn’t working?
5 types + the normal 6
Age-specific hypotension
Respiratory distress
Cyanosis, ashen colour, pallor
Altered level of consciousness
Abnormal pregnancy or labour
Oxygen Therapy Standard (COPD)
What are the indications to begin treatment in a pt with COPD?
Increased Dyspnea
Decreased level of consciousness
An altered mental status
Suffered major traum
Oxygen Therapy Standard (COPD)
What % do you keep the pt’s oxygen concentration at?
What do yu do if SPO2 isn’t working
88%-92%
Administer O2 by nasal cannula with O2 at 2lpm above their home O2
or at 2lpm if they don’t have home O2
Oxygen Therapy Standard (COPD)
What should you be prepared for and checking on after setting up their O2
Re-assess vitals every 10min
Be prepared to ventilate
If status improves then maintain the flow rate
If the status declines (or they feel worse) then increase oxygen every 2-3min by increments of 2lpm
In what order do you Don AND Doff PPE?
DON - - Gown, Mask, Eyewear, and Gloves
DOF - - Gloves, Eyewear, Mask, and Gown
Field Trauma Triage Standard
What are the PHYSIOLOGICAL criteria?
What’s the breaths per minute for infant aged less than a year?
Patient does not follow commands
Systolic BP less than 90mmHg
Respriratory rate less than 10 to greater or equal to 30 breaths per minute or need for ventilitory support
less than 20
Field Trauma Triage Standard
After assessing PHYSIOLOGICAL criteria when can you go to the LTH?
When the the patient meets any of the PHYSIOLOGICAL criteria AND the land transport time is less than 30min
Field Trauma Triage Standard
What are the ANATOMICAL criteria?
8
After assessing ANATOMICAL criteria when can you go to the LTH?
Any penetrating injuries to head, neck, torso and extremities proximal to
elbow or knee
Chest wall instability or deformity (e.g. flail chest),
Two or more proximal long-bone fractures,
Crushed, de-gloved, mangled or pulseless extremity,
Amputation proximal to wrist or ankle,
Pelvic fractures,
Open or depressed skull fracture, or
Paralysis
if the patient meets the anatomical criteria listed
AND the land transport time is less than 30min
Field Trauma Triage
Even if a patient meets either PHYSIOLOGICAL or ANATOMCAL criteria, would you ever transport to the closest emergency department instead of the LTH?
Yes, you would do so if you’re unable to secure the pt’s airway OR survival to the LTH is unlikely
Field Trauma Triage
What criteria does a pt have to meet if a pt has a penetrating chest trauma to the torso or head/neck, for you to transport to LTH not the emerg?
despite it beging dire or terrible airway
Vital signs absent yet not subject to TOR described in the General Directive above
AND
Land transport to the LTH or regionally designated equivalent hospital is
estimated to be <30 minutes
Field Trauma Triage
What are all of the traumatic mechanisms of injury?
8
When would the pt that meets any of the MOI criteria be transported to the LTH?
Falls
i. Adults: falls greater or equal to 6 metres (one story is equal to 3 metres)
ii. Children (age <15): falls ≥3 metres or two to three times the height of the child
High Risk Auto Crash
i. Intrusion ≥0.3 metres occupant site; ≥0.5 metres any site, including the roof
ii. Ejection (partial or complete) from automobile
iii. Death in the same passenger compartment
iv. Vehicle telemetry data consistent with high risk injury
Pedestrian or bicyclist thrown, run over or struck with significant impact (≥30 km/hr) by an automobile
Motorcycle crash ≥30 km/h
When land transport time is less than 30min
Field Trauma Triage
What SPECIALCRITERIA should you consider?
this is in conjuction with the other 3 catagories
When would you transport the pt to the LTH if they did meet any SPECIAL CRITERIA?
Age
i. Risk of injury/death increases after age 55
ii. SBP <110 may represent shock after age 65
Anticoagulation and bleeding disorders
Burns
i. With trauma mechanism: triage to LTH
Pregnancy ≥20 weeks
When the land transport time is less than 30min
Air Ambulance Utilization Standard
What are the indications?
Meeting at least 1 of the bulleted operational criteria AND 1 of the clinical criteria (in FTT)
Air Ambulance Utilization Standard
What are the OPERATIONAL criteria?
4
The land ambulance is estimated to require more than 30 minutes to
reach the scene and the air ambulance can reach the scene quicker.
The land ambulance is estimated to require more than 30 minutes to
travel from the scene to the closest appropriate hospital and the air ambulance helicopter can reach the scene and transport the patient to the
closest appropriate hospital quicker than the land ambulance.
The estimated response for both land and air is estimated to be greater
than 30 minutes, but approximately equal, and the patient needs care
which cannot be provided by the responding land ambulance.
There are multiple patients who meet the clinical criteria and the local
land ambulance resources are already being fully utilized
Air Ambulance Utilization Standard
After assessing the OPERATIONAL criteria what are the CLINICAL criteria you look for?
The medical and obstetircal
keeping in mind that the FTT is inculded as well
Medical:
1. Shock, especially hypotension with altered mentation (e.g.
suspected aortic aneurysm rupture, massive gastrointestinal
bleed, severe sepsis, anaphylaxis, cardiogenic shock
- Acute stroke with a clearly determined time of onset or last
known to be normal <6.0 hours - Altered level of consciousness (GCS <10)
- Acute respiratory failure or distress
- Suspected STEMI or potentially lethal dysrhythmia
- Resuscitation from respiratory or cardiac arrest
- Status epilepticus
- Unstable airway or partial airway obstruction
Obstetrical:
1. Active labour with abnormal presentation (i.e. shoulder,
breech or limb)
- Multiple gestation and active labour
- Umbilical cord prolapse
- Significant vaginal bleeding (suspected placental abruption or placenta previa or ectopic pregnancy)
Air Ambulance Utilization Standard
When Requesting air ambulance, what do you report?
2
You must provide the criteria that the pt meets and all estimated times related to transporting.
stretcher to air-ambulance, air ambulance ride, stretcher to hospital
Air Ambulance Utilization Standard
When do you go to the hospital even though you’ve called the air-ambulance?
If the air ambulance helicopter is en route but not on final approach to the scene, and the land paramedics have the patient in his/her ambulance, then the land ambulance will
proceed to the closest local hospital with an emergency department
Air Ambulance Utilization Standard
When can the land paramedics rendezvous with the air-ambulance?
If the air ambulance helicopter is able to land along the direct route of the land ambulance
AND
It would result in a significant reduction in transport time to the most appropriate hospital.
Remember if they don’t meet criteria or things change then call CACC/ACS to report it’s no longer required
Air Ambulance Utilization Standard
What are the “other” considerations of air-ambulance?
They’re not permitted at night
They’re not permitted to perform search and rescure calls
Land Ambulance trumps air-amublance if both are able to make it to the scene
If land ambulance reaches the scene before on-scene ai-ambulance does they will inform CACC/ACS
Spinal Motion Restriction (SMR) Standard
(SMR) Standard
What are the MOI criteria?
9
Any trauma associated with complaints of neck or back pain,
Sports accidents (impaction, falls)
Diving incidents and submersion injuries
Explosions, other types of forceful acceleration/deceleration injuries
Falls (e.g. stairs)
Pedestrians struck
Electrocution
Lightning strikes
OR
Penetrating trauma to the head, neck or torso
Spinal Motion Restriction (SMR) Standard
(SMR) Standard
After assessing MOI criteria what RISK criteria do you assess?
15
And do they have to meet a certain set or #?
1 - Neck or back pain
2 - Spine tenderness
3 - neurologic signs or symptoms
4 - altered level of consciousness
5 - suspected drug or alcohol intoxication
6 - a distracting painful injury (any painful injury that may distract the patient from the pain of a spinal injury)
7 - anatomic deformity of the spine
8 - high-energy mechanism of injury, such as:
i. fall from elevation greater than 3 feet/5 stairs
ii. axial load to the head (e.g. diving accidents),
iii. high speed motor vehicle collisions (≥100 km/hr), rollover, ejection,
iv. hit by bus or large truck,
v. motorized/ATV recreational vehicles collision, or
vi. bicyclist struck, collision
15 - Age ≥65 years old including falls from standing height
No the pt only needs to meet 1
Spinal Motion Restriction (SMR) Standard
When do you NOT apply SMR (C-colar)?
If the pt meets the MOI criteria but meets none of the RISK criteria
OR
The pt exhibits ALL of the 6 “NO GO” criteria
Spinal Motion Restriction (SMR) Standard
After assessing the MOI, RISK, and “NO GO” criteria…the pt meets an MOI, RISK, and none of the “NO GO” criteria…Do you c-colar/apply SMR?
YES
Spinal Motion Restriction (SMR) Standard
What are the “NO GO” criteria that inhibits you from applying SMR?
6
No spine tenderness
No neurologic signs or symptoms
No altered level of consciousness
No evidence of drug or alcohol intoxication
No distracting painful injury
AND
No anatomic deformity of the spine
The pt MUST meet all the the previouoslt menttioned criteria
Spinal Motion Restriction (SMR) Standard
Does this standard allow the paramedic to “clear the spine”?
NO
It identifies pt’s where the MOI in combo with the absence of RISK criteris mean SMR no longer needs to be considered
Spinal Motion Restriction (SMR) Standard
In terms of SMR and c-colar, what should you document on the ACR?
There’s a before and after
The pt’s neurological status
Spinal Motion Restriction (SMR) Standard
Tell me about the use of Spinal Boards
3 main things
They should be consiered as extrication devices - the ot should be removed from the device onto the stretcher if safe to do so
They can remain in place if you deem if morre comfortable and it’s less than 30min of trsnport
Pt’s with suspected PEVLIC FRACTURES should be secured on a spinal board as per the ‘Blunt/Penetrating Injury Standard’
Spinal Motion Restriction (SMR) Standard
In what situation would you document on your ACR the inablity or difficulty of applying SMR?
When the pt becomes increasingly confused, agitated, or combative the more you try to apply SMR
Spinal Motion Restriction (SMR) Standard
What position can these pt’s be in?
What do you do if they’re on responsive?
Is it standard to place the c-colar before moving?
semi-sitting or supine position
apply manual c-spineuntil you can apply appropriate SMR
Yes, place the colar befoer moving the pt
Spinal Motion Restriction (SMR) Standard
What pt’s may use the ‘stand, turn, and pivot onto stretcher’ method?
You arrive on scene and SMR has already been applied, what do you do?
Can inter-facility tranfers have SMR modifications?
Pt’s that have been in a MVC AND remian with isolated neck/back pain WITH no neurolgoical signs or symptoms
You still do a full SMR assessment
Yes they can - could be removal of spinal board
Do Not Resuscitate (DNR)
Standard
What is CPR? What are the 7 life-saving measures?
CPR means cardiopulmonary resusitation, it’s an immediate appliaction of life-saving measures
Chest Compressions
Defibrillation
Artificial ventilation
Insertion of an oropharyngeal, nasopharyngeal or supraglottic airway
Endotracheal intubation
Transcutaneous pacing
Advanced resuscitation drugs such as, but not limited to, vasopressors,
antiarrhythmic agents and opioid antagonists
Do Not Resuscitate (DNR)
Standard
What does DNR mean?
What do we need to be able to go forward with this standard?
It means Do Not Resuscitate
Valid MOH DNR Confirmation Form
Do Not Resuscitate (DNR)
Standard
Can you have a copy or does it HAVE to be the OG copy?
It can be the OG or a copy of the OG
Do Not Resuscitate (DNR)
Standard
When would you initiate CPR?
What is deemed cardiorespiratory arrest?
the patient with a Valid MOH DNR Confirmation Form appears to the paramedic to be capable and expresses clearly a wish to be resuscitated in the event that he/she experiences a respiratory or cardiac arrest; or
the patient with a Valid MOH DNR Confirmation Form appears to the paramedic to be capable and expresses a wish to be resuscitated in the event that he/she experiences respiratory or cardiorespiratory arrest, but the request is vague, incomplete or ambiguous such that it is no longer clear what the wishes of the patient are
Respirations and pulse are absent for at least three minutes from the time you 1st noted.
Do Not Resuscitate (DNR) Standard
What should YOU provide?
Once death has been determined what SHALL you do?
What do you make sure to do following the above question?
Patient management necessary to provide comfort or alleviate pain
Adivse the CACC/ACS
AND
Follow the DeceasedPatient Standard
Note the TOD (time of death)
Do Not Resuscitate (DNR)
Standard
What Does a Valid MOH DNR Confirmation Form Look Like?
Deceased Patient Standard
What Does a Deceased Patient Mean?
5
What’s expected death mean?
Obviously dead
The subject of a medical certificate of death, presented to the paramedic crew, in the form that is prescribed by the Vital Statistics Act (Ontario) and that appears on its face to be completed and signed in accordance with that Act
Without vital signs and the subject of an MOH Do Not Resuscitate (DNR) Confirmation Form
Without vital signs and the subject of a Termination of Resuscitation (TOR) Order
given by a Base Hospital Physician
OR
Without vital signs and the subject of a Withhold Resuscitation Order given by a
Base Hospital Physician.
A death that was imminently anticipated (terminal illness)
Deceased Patient Standard
How can you tell if someone is obviously dead?
DTVP and 4 wihtout something
Decapitation, transection, visible decomposition, putrefaction
OR
Absence of vital signs AND
A grossly charred body
An open head or torso wound with gross outpouring of cranial or visceral contents
Gross rigor mortis
OR
Depdendent lividity (fixed, non-blanching purple or black discolouration
of skin in dependent area of body)
Deceased Patient Standard
What is a Palliative Care Team?
What’s a TOR?
What is a ‘Responsible Person’?
A team of health care professionals that provide palliative care to termially ill patients
AN order given by BHP to a parmedic to stop resuscitation measures.
An adult (who YOU believe) is able to remain with and assume respoonsiblity for the deceased patient.
Deceased Patient Standard
What’s an unexpected Death?
What’s a Hold Resuscitation Order?
A death that was not imminently anticipated (sudden)
An order given by BHP to YOU to not initiate resuscitation measures
Deceased Patient Standard
What SHALL you do in ALL cases of death?
7 things
Confirm the patient is deceased as per the definitions in the standard
Ensure that the Deceased Patient is treated with respect and dignity
Consider the needs of family members of the decedent and provide compassion-informed decision-making
In cases of suspected foul play, follow the directions set out in the Police Notification Standard
If applicable follow all directions issued by a coroner or to whom a coroner has delegated any powers or authority pursuant to the Coroners Act (Ontario)
If termination of resuscitation occurs in the ambulance en route to a health care facility, advise CACC/ACS to contact the coroner, and continue to the
destination unless otherwise directed by CACC/ACS
AND
For cases of obvious death, note and document the time at which the paramedic confirms the patient was deceased as per the Standards
Deceased Patient Standard
What SHALL you do in cases of unexpected death?
4 things
What does an ‘unexpected’ death NOT necessarily imply?
In the absence of police or a coroner on-scene, the paramedic shall advise CACC/ACS of the death, in which case CACC/ACS shall notify the police or coroner
If a coroner indicates that he/she will attend at the scene, the paramedic shall remain at the scene until the coroner arrives and assumes custody of the Deceased Patient. If the coroner indicates that he/she will not attend at the scene, the paramedic shall remain on the scene until the arrival of a person appointed by a coroner or to whom a coroner has delegated any powers or
authority pursuant to the Coroners Act (Ontario)
Notwithstanding what I just said, if police are present and have secured the scene, the paramedic may depart as soon as documentation has been
completed or he/she is assigned to another call
AND
Where at any time the paramedic has not received any further direction from
CACC/ACS, the paramedic shall request that CACC/ACS seek direction from the coroner concerning his/her responsibilities, including whether he/she may leave the scene.
That the death requires investigation by a coroner under the Coroners Act
Deceased Patient Standard
What SHALL you do in cases of expected deaths?
7 things
The paramedic shall advise CACC/ACS of the death
The paramedic shall make a request of a “Responsible Person” to notify the primary care practitioner or a member of the Palliative Care Team (if any) of the patient and request his/her attendance at the scene
If the Responsible Person is unable to provide the notice above, the paramedic shall advise CACC/ACS of the death, in which case CACC/ACS shall attempt to notify the primary care practitioner or member of
the Palliative Care Team (if any) of the Deceased Patient, and request his/her
attendance at the scene
If the Deceased Patient’s primary care practitioner or Palliative Care Team
member is contacted and indicates that he/she will attend at the scene, then the paramedic shall remain at the scene until his/her arrival
If there is a Responsible Person present, and the paramedics reasonably believe that the Responsible Person will remain until the primary care practitioner or Palliative Care Team arrives, then the paramedic may depart as soon as all required documentation has been completed or he/she are assigned to another call. The police can take over watch as well
If the primary care practitioner or Palliative Care Team member cannot be contacted or if he/she is unable to attend, or there is no Responsible Person on-scene, the paramedic crew shall advise CACC/ACS, in which case
CACC/ACS shall notify the police or coroner of the death and that there is no one else at the scene who can take responsibility for the Deceased Patient
AND
If requested by the coroner, the paramedic will provide the coroner with the circumstances of the death; the paramedic will either be released from the scene or instructed to remain with the Deceased Patient until the coroner or a person appointed by a coroner or to whom a coroner has delegated any powers or authority pursuant to the Coroners Act (Ontario) or a Responsible Person CAN attend the scene and assume responsibility for the Deceased Patient
General Pediatric Standard
What are the 7 SHALLs you must do when being involved with pediatrics?
Determine CTAS level by the Prehospital CTAS Paramedic Guide
What should you always do when assessing pediatric patients (2)?
Be aware of problems due to A+P during the primary survey
Be aware the primary cause of cardiac arrest is respiratory arrest
Remeber Pediatric Vital Signs
Consider Assessments for 8 - change in appetite - - change in behaviour/personality - - excessive drooling - - decrease in # of wet diapers - - inconsolable crying or screaming - - lethargy - - tripoding/odd postioning - - work of breathing
Conduct a full secondary survey from ‘head-to-toe’
Have care giers present if possible
AND
If they’re an infant then asses fontanelles
Maintain a high index of suspicion when assessing pediatric patients AND
Provide support for the head and neck
Child in Need of Protection
Standard
What are the GUIDELINES?
(not including the noteworthy pediatric problems)
The duty to report overrides any other provincial statute, including any provisions that would otherwise prohibit someone from making a disclosure (it’s an offence under the Act to fail to report)
The duty to report under the Child and Family Services Act extends to any child you meet during professional duties NOT just 911 calls
Child in Need of Protection Standard
What are the NOTEWORTHY pediatric problems?
4
Submersion injury
All burns
Accidental ingestions/poisoning
Other types of in-home injuries, e.g. falls
Child in Need of Protection Standard
What are the SCENE OBSERVATIONS which may trigger this standard?
5
Household/siblings dirty, unkempt, and/or in disarray
Evidence of violence, e.g. overturned or broken furniture
Animal/pet abuse
Evidence of substance abuse, e.g. empty liquor bottles, drug paraphernalia
Child in Need of Protection Standard
What are the PHYSICAL signs which may trigger this standard?
8
Gross or multiple deformities which are incompatible with the incident history, especially in a child under 2 years of age who is developmentally
incapable of sustaining this type of injury
Multiple new and/or old bruises which have not been reported, or which have been reported as all being new
Distinctive marks or burns, e.g. belt, hand imprint, cigarette burns
Bruises in unusual areas: chest, abdomen, genitals, buttocks
Burns in unusual areas: buttocks, genitals, soles of feet
Signs of long-standing physical neglect, e.g. dirty, malodourous skin, hair and clothing, severe diaper rash, uncut/dirty fingernails
Signs of malnutrition - slack skin folds, extreme pallor, dull/thin hair, dehydration
Signs of “shaking” syndrome - hemorrhages over the whites of the eyes; hand or fingerprints on the neck, upper arms or shoulders; signs of head
injury unrelated to the incident history.
Child in Need of Protection Standard
What’s a child in need of protection and the concerns?
What does reasonable Grounds mean?
What’s a Duty To Report?
A child who is or who appears to be suffering from abuse and/or neglect. Concerning Circumstances (i.e. physical, sexual, or emotional abuse, neglect, or risk of harm)
The inforamtion that a person needs in order to decide to report
The requirement to promptly report that a child is or may be in need of protection directly to a Children’s Aid Society (CAS)
Child in Need of Protection
Standard
What does the general directive say you SHALL do if a pediatric patient is believed to be in need of protection?
1- Ensure the pt is not left alone
2- Request police if you belive the pt is at risk of imminent harm
3- Obtain a clear hx attempting to determine validity of the hx by
-if the story changes frequently
-the parents are vague or blame each other
-the NOI is inconsistent with the explanation provided
-the mechanism of injury is obviuosly beyond the developmental capabilities of the child
-there is unexplained prolonged delay in seeking treatment
-there is a hx of recurrent injuries
3.b) interaction beteen parents-child-cargivers (children may paradoxically protect the abusive party)
3.c) appropriateness of child’s behaviour relevant to the situation/injury
3.d) appropriateness of the parental response to the child’s injury and/or emotional distress
4 - make no accusations or comments about your thoughts infront of the parents or bystanders
5 - transport the child in all cases
AND
6 - report suspicions tothe RH and complete the duty to report to the CAS
General Geriatric Standard
What SHALL you do?
What are the guidelines assoiciated with what you SHALL do?
4 things
Assume that all geriatric pts are capable of normal hearing, sight, speech, mobility, and mental function unless otherwise told
Assess living conditions and consider the pts ability to perform ADL (Activities of Daily Living)
Be aware of pt presentations associated with elder abuse
AND
If elder abuse is suspected then offer to contact police if they’re not already on scene AND alert receiving facility staff.
1 - Geriatric pts can present atypically and may have no co-morbidities
- they mey have diminished responses to pain, infection, heat/cold
2 - consider refering them to local agency resources (living conditions) eg. CACC
-ADL include: bathing, dressing, transferring, toileting, and eating
- relatives, friends, or neighbors my be able to provide allateral information (normal level of function and available support)
3 - Forms of elder abuse include (5):
- Financial abuse
- Psychological abuse
- Physical abuse
- Sexual abuse
- Neglect (emotional abuse)
Violent/Aggressive Patient Standard
What SHALL you do?
10 thigns
Consider underlying organic disorders
Give particular attention to personal safety as per the general measures standard
request police assistance on scene
wait for police assistance if there is an active shooter OR there is direct evidence of ongoing violence
If electing to delay service do immediately notify CACC/ACS
If the pt is uncooperative then attempt to determine
- if illness an/or alcohol/drug intoxication has triggered the present behaviour AND
- whether there is a past hx of violence
Be alert for behavioural signs of impending violence
If confronted then seek egress and attempt to withdraw safely
Attempt to speek and calm the pt if you cannot withdraw safely
Consider the need for restraints (see mental health cards)
Violent/Aggressive Patient Standard
In situations involving a pt with an ECD (embedded electronic control device) probe you SHALL?
What shoudl you remember?
Remove the ECD probe(s)
You might decide to leave the probes in during transport if the ECD is above the clavicle, in th nipple, in the genital area or other un usual circumstances
AND
Police may require preservation of the probes for evidentiary purposes
Load and Go Patient Standard
What pts may require interventions prior to initation of rapid transport?
3
Vital signs absent pts in which a TOR is not indicated as per the ALS PCS
Pts with conditions which require immediate, life-saving interventions which YOU can perfoms.
Obstetrical pts in which delivery appears imminent
Load and Go Patient Standard
When SHALL you initiate rapid transport?
3 (3rd has 5)
For CTAS 1 pts
For pts who meet bypass criteria protocols as per the standards
For obstetrical pts with
- eclampsia/pre-eclampsia
- limb presentation
- ultiple births expected
- premature labour expected
- umbilical cord prolapse
Sexual Assualt (Reported) Standard
What SHALL you do if the pt has reported to have been sexually asssualted?
4 things
Ensure the pt is not left alone
If the pt is a child - follow the Child in Need of Protection Standard
Offer to contact the police if they’re not already on scene
UPON police request—-bag the stretcher linen, dressings, and other materials in contact with the pt then leave with the attending police officer
Research Trial Standard
If properly enrolled in a trial you SHALL?
3 things (sub categories)
Where do the guidelines tell you to go to recall information?
1- Determine whether a pt may be treated in accordance with a research trial ONLY if the following conditions have been met
- MOH has approved the pt care practices set out in the Standards
- The research trial has been approved by a Research Ethics Board (REB) that: Abides by and is consistent with the version of the Tri-council Policy Statement on Ethical Conduct for Research involving Humans current at the time of submission AND
Meets the requirements for an REB set out in section 15 of O. Reg, 329/04 made under PHIPA AND
The research trial has been reviewed and supported in writing by the Ontario Base Hospital Group Medical Advisory Committee
2 - Obtain the appropriate pt consent for participation in the research trial
AND
3 - Provide care in accordance with the approved research trial
Section 44 of PHIPA - personal health information and researchers
AND
Paragraph 11 of General Measures Standard - consent
Mental Health Standard
In situations involving a pt with an emotional disturbance you SHALL?
Consider Underlying Organic Disorders
Give particular atttention to personal safety as per the genreal measures standard
Mental Health Standard
What do you do in cases of pt with known or suspected suicide attempts or self-harm?
Assume hat all attempts are of serious intent
AND
Ask the pt directly whether they have ideation or intent of suicide/self-harm
Mental Health Standard
What do you do in cases in which a patient is being transported without consent.
What are signs a pt may need an escort?
Do NOT proceed without appropriate documentation and/or escort
If a patient is violent or potentially vioolent - refer to the Violent/Aggressive Patient Standard
If a patient is in custudy under
-Court
-Ontario Review Board Disposition
a Justive of Peace or hospital’s officer in charge or delegate will designate the escort
Mental Health Standard
ONLY restrain a person if?
How much force should uou be using?
What do I need to know about transporting while restrained?
- directed by a physician or police officer
- an unescorted aptient becomes violent en route
- the use of restraints is required to provideemergency treatment as per the Patient/Emergency Treatment Stantdard
Only the reasonable and minimum force will be used to restrain the pt
When applied prior to departing the scene, whomever ordered the restraint (police officer or physcician) must accompany the pt in the ambulance
If the pt meets the Patient Refusal/Emergency Standard AND a police officer has handcuffed the pt, you can’t proceed with transport until the police officer takes the pt into custody and it present in the patient compartment.
Do NOT transport the pt in prone position
Mental Health Standard
How do restraints work for inter-facility transfers?
In cases where the patient is restrianed when can you proceed with transport?
All restraints must be provided and applied by hospital staff or police prior to transport (when sending facility requests them)
When the sending facility or physician has made a decision that the pt can be transferred safely (with or wihtout a hospital escort)
When the patient does not appear to be a safety risk or have the potential to become violent en route
AND
If the paramedic feels comfortable with the decision that the patient does not appear to be a safety risk or potential to become one en route
Mental Health Standard
Who may not be transported without consent based off of the Mental Health Act?
Who CAN be transported wihtout consent?
A person who is recommended by a physician for admission to a psychiatric facility as an informal or voluntary patient.
The subject of an application for assessment signed by a physician
under subsection 15(1) or 15(1.1) of the Mental Health Act (Ontario) (Form
The subject of an order for examination signed by a Justice of the
Peace under subsection 16(1) of the Mental Health Act (Form 2)
AND
A person taken into custody by a police officer under subsection 17 of
the Mental Health Act (Ontario)
AND
A patient detained in a psychiatric facility under a certificate of involuntary admission under subsection 20(4) of the Mental Health Act (Ontario) (Form 3) or a certificate of renewal (Form 4).
Mental Health Standard
What should you maintain when restraining a pt?
What do you do when initiating a full body restraint?
A high index of suspicion in terms of rapid deterioration
Attempt to organize the team before attempting restraint.
Prepare all equipment in advance.
Inform the patient of the need to restrain them and explain the procedure.
Immobilize the patient’s limbs and head in one coordinated effort. Grasp
each limb at the main joint and between the main joint and the distal joint,
e.g. one hand on the elbow, the other on the forearm.
Place the patient in a supine “spread eagle” position or in the left lateral
position.
If the patient is spitting consider the use of a surgical mask on the pt.
Restrain the extremities as follows:
- Secure 1 aarm above the head and the other at waist level (or secure BOTH hands to 1 side of the stretcher)
- Elevate the head of the stretcher to protect the airway and allow yourself greater visability
- Secure the feet
- Esnure all limbs are secured to the MAIN FRAME of the stratcher
Mental Health Standard
If the patient is restrained what should you document on your ACR?
That the patient was restrained
A description of the patient’s behaviour that required that he/she be restrained or continue to be restrained
A description of the means of restraint, including the method of restraint
the person ordering restraints
The position of the patient during restraint
The clinical response to restraint
Intravenous Line Maintenance Standard
What do you monitor the flow rate at for any isotonic crystalloid solution IV for an OPEN VEIN patient LESS than 12 years of age?
What do you monitor for patients GREATER or EQUAL to 12 years of age?
To maintain IV patency is 15mL/hr
To maintain IV patency is 30-60mL/hr
Intravenous Line Maintenance Standard
What do you monitor in patients with an IV for fluid replacement?
That it never go over the max flow rate of up to 2mL/kg/hr (200mL/hr)
Monitor thiamine, multivitamin preperations
Monitor drugs within your level of certification
Monitor pts with potassium chloride (KCL) for patients GREATER or EQUAL to 18 years of age to a MAX of 10mEq in a 250mL bag.
Intravenous Line Maintenance Standard
When do you request a medically responsible escort in the event a patient requires an IV?
When the IV is being used for blood (or blood product) administration
When the IV is being used to administer potassium chloride to a patient who is <18
years of age
When the IV is being used to administer medication
When the IV requires electronic monitoring or uses a pressurized intravenous fluid
infuser, pump or central venous line
OR
For a neonate or pediatric patient <2 years of age.
Intravenous Line Maintenance
Standard
What is the PRE-TRANSPORT procedure?
When should the IV bag be changed ?
What is the DURING TRANSPORT procedure?
Confirm physician’s written IV order with sending facility staff
Determine IV solution, IV flow rate, catheter gauge, catheter length, and cannulation site
Note condition of IV site prior to transport
Confirm amount of fluid remaining in bag
Determine amount of fluid required for complete transport time and obtain more fluid if applicable
AND
Document all pre-transport IV information on the Ambulance Call Report.
When there is approx. 150mL of solution remaining
Monitor and maintain IV at the prescribed rate, this may include changing the IV bag as required
If the IV becomes dislodged or interstitial, discontinue the IV flow and remove the catheter with particular attention to aseptic technique
AND
Confirm condition of catheter if removed.
Police Notification Standard
When should you notify the police?
How do you notify the police?
What are the steps in contacting the police? (6 things)
Any cases involving unusual or suspicious situations i.e
- sudden death
- foul play
- violence
- accidents involving emergency vehicles
Code 10-200, Code 10-2000, and Emergency button on radio
Contact his/her CACC/ACS via radio or telephone
State the nature of the request
Indicate the urgency of response and request the estimated time of arrival
Advise of possible hazards
Indicate access routes (where applicable)
Provide police with an update of the situation when they arrive at the
scene
Police Notification Standard
What do you NOTE when there’s suspected Foul Play?
What is discouraged during transport?
What should you be doing during a suspected foul play call?
Once a body is moved it can never be put back in its original position
Careful attention is required whenever something is moved
Whenever possible use the shortest, most direct path to the patient and the same path when leaving the scene
Attempt to preserve the chain of evidence; do not discard linen/clothes after call completion without checking with the receiving facility or
investigating officer
The receiving facility staff should also be cautioned regarding the
suspected foul play
The use of a police escort to control traffic as it presents more danger
Every effort should be made to leave the scene undisturbed and to preserve as much evidence as possible for the police.
Police Notification Standard
What are the Special Precautions you should take when arriving to a HANGING call?
2
Make careful observation of the position of the rope around the pts neck
The rope should only be cut IF it cannot be readily slipped off in a way where the knot stays preserved
