Originally distributed in November 2008 (updated December 2015):
For a cardiac arrest patient, can I give D50 on standing orders?
- You may not give D50 simply because the patient is unconscious. Administering D50 to a cardiac arrest patient who is not hypoglycemic has been associated with poor neurologic outcome if the patient is resuscitated. However, if the patient has documented hypoglycemia, confirmed by glucometry, D50 is appropriate. D50 can only be administered on standing orders with documented hypoglycemia. For other cases, contact Medical Control.
For a cardiac arrest patient, can I give Narcan on standing orders?
- If you have reason to suspect an opiate overdose – for example, you find needles/syringes at the scene, a family member/friend/bystander reports a history of drug abuse or you find empty containers of opiate medications, Narcan is appropriate. You may not give Narcan simply because the patient is unconscious.
If I have a cardiac arrest patient and I call for “full ACLS orders,” can I give any drug under standing orders?
- Yes and No. “Full ACLS orders” means that as the patient’s condition changes, you can implement the appropriate cardiac arrest/post-resuscitation protocol without calling the online physician back. You can implement the treatments and medications listed on those protocols. “Full ACLS orders” also allows you to implement “rule out” protocols where you have standing orders (i.e. administer a fluid bolus for hypovolemia (see vascular access protocol); secure the airway (see Airway/Oxygenation/Ventilation protocol), D50 only in cases of documented hypoglycemia (see above). You must call medical control and get specific orders to administer sodium bicarbonate or calcium chloride or other drugs (except as noted in the protocol).
If I think my patient will need treatment in a hyperbaric chamber (i.e. for diving emergencies or carbon monoxide poisoning), can I bypass other hospitals and transport directly to Sentara Leigh Hospital?
- No. The closest hospital should be contacted to request permission to bypass that facility. Time is of the essence in treating these conditions. An approved bypass could avoid the delay of going to a facility without a chamber first.
If I am transporting a patient from a military base and I’m told to transport the patient to the hyperbaric chamber at Little Creek, can I do that?
- No. Patients being transported on a Virginia Beach ambulance or in the care of a Virginia Beach ALS provider onboard a Navy ambulance will be transported to a hospital ER. The hyperbaric chamber at Little Creek is NOT a medical hyperbaric facility.
If I am transporting a patient from a military base and told to transport the patient to Portsmouth Naval Hospital, can I do that?
- No. Virginia Beach EMS does not transport patients to PNH.
The TEMS protocols say Enhanced/Advanced EMT providers can use CPAP with physician orders – can I do that?
- Previously, Enhanced providers were not able to use CPAP. As of December 2015, initial CPAP training is being developed. Once Enhanced providers complete the department’s initial CPAP training (this is not the same class/presentation as the ALS release training), they will be able to use CPAP in Virginia Beach.
- Providers who were initially certified as an “Advanced EMT” will not need to take the initial CPAP training and will only need to complete the ALS release training presentation/quiz as part of the internship process.
If I’m resuscitating a newborn baby, can I use the umbilical vein for IV access?
- No. You do not have the correct equipment in the IV box for umbilical vein catheterization. Most newborn babies can be resuscitated without IV access but if you cannot obtain peripheral IV access, place an IO.
My patient is complaining of chest pain and breathing difficulty, with rales and a heart rate of 200 with VT on the monitor. Do I follow the Chest Pain protocol, the Breathing Difficulty protocol or the Tachycardia protocol?
- You need to control the rate first. This patient should be treated with amiodarone if he/she is stable (ie. good mental status with no signs of hypoperfusion) or with cardioversion if he/she is hemodynamically unstable (altered mental status and signs of hypoperfusion). If the patient is still symptomatic after the tachycardia is resolved, consult medical control.
My patient is showing sinus tachycardia on the monitor at a rate of 170 with hypotension. He/she needs to be cardioverted, right?
- NO. Cardioversion “resets” a dysrhythmia with an abnormal pathway to a sinus pathway. Since the patient already has a sinus pathway, cardioversion will not help and may cause serious harm the patient. Look for the underlying reason that the heart rate is elevated (hypoxia, hypovolemia, fever, pain, anxiety, etc.) and implement the appropriate protocol.
Can we use the AED on pediatric patients?
- Yes. If an Intermediate or Paramedic is immediately available, manual defibrillation should be used. However, if manual defibrillation is not immediately available, an AED must be applied. The American Heart Association and TEMS protocols are both very clear that while a pediatric AED is preferred for children 1-8 years old, an adult AED should be used if a pediatric AED is not available. For children over 8 years old, an adult AED must be used.
When do I use the pediatric defibrillation pads?
- Pediatric defibrillation pads may be used on children between 1 and 8 years old if the adult pads are too big. Defibrillation pads should not touch each other – if the pads touch, either use the pediatric pads or use a anterior-posterior placement. Adult pads must be used on all patients 8 years old or older. The pediatric defibrillation pads are not attenuating, meaning they do not change the amount of energy that is delivered.
Why do I have to stop the ambulance to do an RSI?
- RSI is implemented for patients where traditional airway management will not work. In many cases the patient will have a difficult airway. To maximize the ability of the RSI paramedic to secure the patient’s airway, the TEMS OMD committee decided that RSI will not be done in a moving ambulance. When the online physician gives the OK to RSI a patient, the additional on scene time is considered. (That is why RSI is often denied if the patient is close to the hospital). It is OK to begin transport while you are calling medical control for RSI orders. However, once you start implementing RSI (including pushing the medications), the ambulance must be stopped.
I have a patient with a submersion injury who is vomiting. Can I insert a nasogastric or orogastric tube to evacuate the patient’s stomach and protect his/her airway?
- No. You may only insert a nasogastric tube on patients who are intubated. If the patient has an unstable airway, intubation may be warranted and then post-intubation, an NG/OG tube would be appropriate. If the submersion incident patient is vomiting but does not require intubation, maintain the airway by rolling the patient onto his/her side and/or use suction.
If I have a patient with a submersion injury who has fluid in his/her lungs, can I administer Lasix?
- No. Lasix is not appropriate for patients with external causes of pulmonary edema. The fluid in the lungs in a submersion injury is not from the same mechanism as CHF, so lasix is not indicated. To a great extent the problem is alveolar collapse, which C-PAP would improve.
If I have a patient with a submersion injury who has fluid in his/her lungs, can I use CPAP?
- Yes, CPAP is an appropriate treatment for these patients.
If I have a patient with a submersion injury who has no complaints and normal vital signs, can I get a refusal?
- You should strongly encourage this patient to accept transport to the hospital. Any submersion incident can wash away surfactant in the lungs (remember surfactant keeps the alveoli open when the patient exhales). A submersion victim can develop life-threatening pulmonary edema up to 72 hours after the incident.
Is an isolated hip fracture considered an isolated extremity fracture allowing paramedics to administer morphine under standing orders?
- Yes. However, be sure the patient is hemodynamically stable prior to administering morphine.
Once I put CPAP on a patient, can I defer giving the patient nitroglycerin so I don’t break the mask seal?
- No. Studies are showing that nitrates provide the maximum benefit to patients with pulmonary edema from CHF. You should administer nitroglycerin to your patients every 5 minutes (as long as there are no contraindications) – breaking the mask seal on the CPAP for a few seconds is not detrimental to the patient.
Do I need permission from EMS5 to transport to Chesapeake General Hospital?
- Yes. We do not perform routine transports to CGH. When a patient asks for that hospital, check with EMS5 for guidance. With the exception of locations in the southwest portion of the City, we will seldom allow those trips.
Can I transport to DePaul?
- No. Virginia Beach EMS does not transport to DePaul hospital during routine operations.
When is it appropriate to transport to Norfolk General Hospital?
- Routine patients are not taken to SNGH. The only patients appropriate for Va. Beach transports to SNGH are traumas or special care patients (i.e. post-transplant related emergencies). As always, follow the directions of medical control when diversions are ordered.
When is it OK to transport to Children’s Hospital of the King’s Daughters?
- We do not transport to CHKD on a routine basis. Only specialty pediatric cases (trauma) or patients diverted by medical control should be taken to CHKD. Contact medical control for guidance, especially for specialty cases that are routinely cared for at CHKD.
Is it true that putting someone on the monitor requires and ALS provider accompany the patient to the hospital?
- If an Intermediate or Paramedic places a patient on the monitor based on presenting signs and symptoms (i.e., chest pain that appears to be cardiac in origin), the patient must be monitored throughout the transport. If the medic applied the monitor because it is a tool he/she can use, but it was not required by protocol to assess or treat the patient’s complaint (i.e uncomplicated asthma, altered mental status, trauma, etc), the monitor can be discontinued.