Transcript Advanced Patient Assessment

Protocols and
Advanced Patient Assessment
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 !
Delegated Medical Acts and the
Paramedics Role
 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
 Some examples:
 12 lead
 SpO2 and ETCO2 monitoring
 Symptom Relief
 SQ/IM/IV medications
 Defibrillation- Cardioversion, “electrical therapy”
 IV maintenance
So what is required of You??
 Due diligence to perform only the DMAs you are training
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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
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
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!!
Examples of Rule In and Rule Out
Chest Pain Patient
 Ischemic Heart disease
 Yes I think so
 Why??....
Chest Pain Patient –Rule
Out
 AAA
 TAA
 Pericarditis
 Flu
 Pneumonia
 Myocarditis
 Cardiogenic shock
 Chest wall pain
 Pleurisy
 Endocarditis
& more
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
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!!
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
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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
History and Physical Should get more
focused as your call progresses!
Chest Pain?
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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!!
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
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 site
3. Read SO book on Cardiac
arrest algorithms
 For next week
 Defib !
Case of the Week
Differentiating
between CHF and
pneumonia-How
do we do it? Why
would we want to
be SURE?