Professional Development for Base Hospital Staff

Welcome to OBHG24: 15 Years in the Making, the essential Ontario Base Hospital Group professional development event for base hospital staff and collaborators happening from Tuesday evening, September 24 until noon on Thursday, September 26, 2024, at Andaz in Ottawa's historic Byward Market.

OBHG24 is presented as part of OBHG's AGM Week programming from Monday, September 23 until noon on Thursday, September 26, 2024.

The Annual Meeting is on September 23 & 24 and includes meetings for G8, G16, MAC, and sub-committees.

On this site, you'll find more information about both the Annual Meeting and OBHG24 events. If you plan to attend both events, please register for both OBHG24 and the Annual Meeting: you will need to complete two separate registrations.

About OBHG24

OBHG24 is a milestone event for invited participants to mark 15 years since the inception of the regional base hospital system in Ontario. A celebratory event, OBHG24 is a time to reflect on our journeys and achievements in shaping emergency healthcare in the province. With a curated array of experts and voices uniting Base Hospitals, healthcare professionals, and specialists from various disciplines, OBHG24 serves as a crossroads in our continued journey, bringing base hospital staff together for collaborative discussions amidst a healthcare landscape facing unprecedented challenges.

Emphasizing collaboration, this platform provides many opportunities to meet colleagues and potential collaborators, and to learn about the work we all do across this province. We've chosen a wonderful venue to support getting to know one another, and the OBHG24 Program focuses on working together.

OBHG24 invites experts in adult learning, quality management, risk assessment, emergency healthcare, research, technology, and partner engagement to animate discussions that can help our work. Acknowledging the ever-evolving nature of Ontario's emergency healthcare system, OBHG24 provides a space for dialogue and exploration of innovative strategies.

OBHG24 applauds the invaluable contributions of Base Hospitals in shaping emergency paramedic practice over the past 15 years. As we reflect on this journey, we recognize the uncertainty and anticipation surrounding the future of healthcare. Attendees will engage in dialogues that underscore the vital role of varied fields in recalibrating emergency responses for today and tomorrow while steadfastly maintaining person-centered care. It's an environment where diverse perspectives converge, fostering insightful exchanges and collective exploration.

Join us at OBHG24 as we celebrate the progress made in the last 15 years and chart the course for the future of emergency healthcare in Ontario. This is an opportunity to be part of a dynamic gathering where experts, professionals, and visionaries come together to shape the trajectory of paramedic care for the years to come.

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2024 Fall CME Case Studies

Patellar Dislocation

• 

  Patellar Dislocation Case Study 1

  Call Information
  
  You are dispatched to a sports field for a 17-year-old male complaining of left knee pain following a fall.

  Patient Presentation
  
  Male patient sitting in the middle of a sports field, clutching his left knee.

  Incident History
  
  The patient was participating in a game of ultimate frisbee at a local sports field. The patient reports he suddenly stopped and turned to catch a frisbee. Immediately afterward, he experienced severe pain 8/10 in his left knee and lowered himself to the ground with assistance. He is unable to bear weight at the moment. No other visible injuries were noted.

  Health History
  
  Medical History:
  ● Exercise induced asthma
  ● No previous knee injuries
  
  Medications:
  ● None
  
  Allergies: 
  ● Hornets & Bees

  Vital Signs
  
  Initial
  GCS: 15 (E=4, V=5, M=6)
  Pulse: Radials: strong/regular
  HR: 90bpm; regular
  Cardiac Monitor: NSR
  BP: 132/84 mmHg
  RR: 18 per minute, regular/deep
  SpO2: 98% (room air)
  Temperature: 37.5 C
  Pupils: 4 mm PERL
  Skin: Warm, normal, clammy
  
  

  Physical Exam
  
  Initial
  H/N: Patient denies striking his head and has no complaints of head or neck pain.
  Chest: Unremarkable
  Abdomen: Unremarkable
  Pelvis: Unremarkable
  Extremities: Symmetrical bilateral pedal pulses, sensation and temperature noted in feet.

  Treatment
  
  Consider:
  ● Patellar Reduction

  Review the call information and case study with your group and discuss the following:
  
  1. What assessments or patient information is necessary to make an accurate differential diagnosis and treatment plan?
  2. What are some differential diagnoses for this patient?
  3. What treatment plan would you initiate?
  4. How would you approach pain management for this patient?
  5. What patient care should be provided during transport?
  6. What could be the cause of the patella dislocation?
  7. What are the risks and benefits of the procedure?

• 

  Patellar Dislocation Case Study 2

  Call Information
  
  You have been called code 4 for a 14-year-old female patient with left knee pain.

  Patient Presentation
  
  14-year-old female patient lying left lateral position, clutching her right knee and crying in pain. Patient appears to weigh about 40 kg.

  Incident History
  
  The patient was doing gymnastics moves on a trampoline when she recalls she came down awkwardly on one of her moves. She stopped immediately and called for her coach. She complains of 7/10 pain.

  Health History
  
  Past Medical History:
  ● Generalized joint laxity
  
  Medications:
  ● Birth Control
  
  Allergies:
  ● None

  Vital Signs
  
  Initial
  GCS: 15
  HR: 110 Strong & Regular
  Cardiac Monitor: Sinus Tachycardia
  BP: 112/62 mmHg
  RR: 20 Regular & Full
  ETCO2: 42 mmHg
  SpO2: 99% RA
  Temp: 36.2 C
  Pupils: 4 mm PERL
  Skin: Warm & Clammy
  
  

  Physical Exam
  
  Head: No trauma noted and no complains of pain
  Chest: Breath sounds clear
  Abdomen: soft
  Back/Pelvis: unremarkable
  Extremities: Symmetrical bilateral pedal pulses, sensation and temperature noted in feet.

  Treatment
  
  Consider:
  ● Patellar Reduction

  Review the call information and case study with your group and discuss the following:
  
  1. What assessments or patient information is necessary to make an accurate differential diagnosis and treatment plan?
  2. What are some differential diagnoses for this patient?
  3. What treatment plan would you initiate?
  4. How would you approach pain management for this patient?
  5. What are some risk factors for patella dislocation, and does the patient have any?
  6. Does the patient’s fall constitute high-velocity or direct knee trauma? How do you know?
  7. What patient care should be provided during transport?

Tachydysrhythmia Management

• Tachydysrhythmia Case Study 1

  Call Information
  
  You are called for a 48-year-old female complaining of dyspnea.

  Patient Presentation
  
  Female patient sitting on a bench, rubbing her sternum. She is alert and tracking paramedics.

  Incident History
  
  You arrive at an amusement park and find a 48-year-old female, Hess Vittie, sitting on a bench beside the line to a rollercoaster. Hess tells you that she has been experiencing shortness of breath and palpitations for the past 10 minutes with some dizziness. No complaints of nausea or chest pain. She has spent the past few hours walking around this amusement park with her grandson and her husband.

  Health History
  
  Past Medical History:
  ● NIDDM
  ● hyperlipidemia
  ● SVT
  ● HTN
  
  Medications:
  ● metformin
  ● atorvastatin
  ● bisoprolol
  
  Allergies:
  ● bees

  Vital Signs
  
  Initial:
  GCS: 15 (E=4, V=5, M=6)
  HR: 240 bpm, regular, weak radial pulses
  Cardiac Monitor: as seen in attached ECG
  BP: 104/66 mmHg
  RR: 28 regular, shallow
  SpO2: 97% RA
  Temp. 36.4 C
  Pupils: 3 mm equal and reactive
  Skin: Pink, warm and dry
  BGL: 8.4 mmol/L
  

  Physical Exam
  
  H/N: No headache.
  Chest: Clear air entry, bilaterally
  Abdomen: Soft, non-tender
  Pelvis: Unremarkable
  Extremities: Good skin turgor

  Post Treatment
  
  Second vitals:
  GCS: 15 (E=4, V=5, M=6)
  HR:74 bpm regular, strong radial pulse
  Cardiac Monitor: Sinus rhythm, 12 lead: STEMI negative
  BP: 122/74 mmHg
  RR: 18 per minute
  SpO2: 98%
  Temp.: 36.2 C
  Pupils: 3 mm equal and reactive
  Skin: Pink, warm and dry
  
  

  Treatment
  
  Consider:
  ● Modified Valsalva Maneuver
  ● Treat and Discharge

  Review the call information and case discussion with your group and answer the following:
  
  1. What are some differential diagnoses for this patient?
  2. What assessments or patient information is necessary to make an accurate differential diagnosis and treatment plan?
  3. What treatment(s) would you perform on this patient?
  4. Based on the information you receive, would this patient qualify for the Treat and Discharge directive? Why or why not? Please explain your findings.
  5. Determine an appropriate care plan for this patient.
  6. While forming your Discharge plan, your partner notices that the patient’s ECG has changed from NSR to SVT again. What are your actions

• Tachydysrhythmia Case Study 2

  Call Information
  
  You are called for a 24-year-old male complaining of anxiety.

  Patient Presentation
  
  Male patient appears anxious, walking around and very jittery.

  Incident History
  
  You arrive on the scene and find a 24-year-old male, Yang Schuss, walking around in his apartment. He is very anxious and appears to be very jumpy and jittery. He tells you that he was partying with friends, had some cocaine (which he hasn’t done in a while) and came home to go to bed. His anxiousness started about 25 minutes after the cocaine, and he thought he should go home and sleep it off. He woke up about 35 minutes later feeling very anxious and had some dizziness. No N/V, CP or SOB. Yang states that he suffers from anxiety. However, this feels different than his typical anxiety attacks, as the feeling won’t go away.

  Health History
  
  Past Medical History:
  ● Anxiety
  ● ADHD
  ● Occasional Recreational Drug User
  
  Medications:
  ● lorazepam
  ● concerta
  
  Allergies:
  ● penicillin

  Vital Signs
  
  Initial:
  GCS: 15 (E=4, V=5, M=6)
  HR: 180 bpm, regular, strong radial pulses
  Cardiac Monitor: as seen in attached ECG
  BP: 142/86 mmHg
  RR: 26 regular, shallow
  SpO2: 97% RA
  Temp. 37.1 C
  Pupils: 6 mm equal and reactive
  Skin: Flushed, warm and dry
  BGL: 4.6 mmol/L
  
  QRS is wide at 138ms, with a prolonged QTc at 596ms.

  Physical Exam
  
  H/N: Pupils dilated.
  Chest: Clear air entry, bilaterally
  Abdomen: Soft, non-tender
  Pelvis: Unremarkable
  Extremities: Unremarkable

  Post Treatment
  
  Second vitals:
  GCS: 15 (E=4, V=5, M=6)
  HR:140 bpm regular, strong radial pulse
  Cardiac Monitor: Sinus Tachycardia, 12 lead: STEMI negative
  BP: 128/76 mmHg
  RR: 18 per minute
  SpO2: 98%
  Temp.: 37.1 C
  Pupils: 6 mm equal and reactive
  Skin: Flushed, warm and dry
  
  
  QRS is now 130ms, and the QTc is 587ms.

  Treatment
  
  Consider:
  ● Modified Valsalva Maneuver
  ● Treat and Discharge

  Review the call information and case study with your group and discuss the following:
  
  1. What are some differential diagnoses for this patient?
  2. What assessments or patient information is necessary to make an accurate differential diagnosis and treatment plan?
  3. What is the patient’s initial ECG? What was the cause of the ECG rhythm? Write out the 7 steps to ECG identification.
  4. What treatment(s) would you perform on this patient?
  5. Based on the information you receive, would this patient qualify for the Treat and Discharge directive? Why or why not? Please explain your findings.

Substance Use Healthcare

• Suboxone Case Study 1

  Call Information
  
  Dispatched to a local homeless shelter for a male patient in his 30’s unconscious. Fire is on scene.

  Patient Presentation
  
  Patient was found supine on the floor of the restroom, patient was diaphoretic. A: patent and self-maintained, B: spontaneous and regular, C: regular and present @radial. Pt fully alert and oriented x 3.

  Incident History
  
  Patient consumed an unspecified amount of fentanyl in the bathroom at the living space homeless shelter, patient was found unconscious by staff and administered one dose of naloxone. Fire arrived on scene next and administered two doses of naloxone as well. Patient gained consciousness after the third dose. Patient received 12 mg of naloxone in total.

  Treatment Prior to Arrival
  
  Shelter Staff administered 4mg Naloxone IN
  Fire administered 4mg Naloxone x 2
  A total of 12mg Naloxone given.

  Health History
  
  Past Medical History: Opioid Use Disorder
  Medications: None
  Allergies: NKA

  Vital Signs
  
  GCS: 15
  HR: 120 bpm, regular, full
  RR: 12 per minute, full, normal
  ETCO2: 48 mmHg
  BP: 170/121 mmHg
  SpO2: 99% on NRB Oxygen
  Temp.: 36.6 C
  BGL: 6.7 mmol/L

  Review the call information and case discussion with your group and answer the following:
  
  1. Based off the information thus far, do you believe the patient could potentially qualify for Suboxone administration? What other assessment would be required?
  2. Based on the COWS information below, calculated the patient’s COW score. Guideline: <5 – no active withdrawal, 5-12 – mild withdrawal, 13-24 – moderate withdrawal, 25- 36 – moderately severe withdrawal, >36 – severe withdrawal.
  Note: A score of greater or equal to 8 is an indication for Buprenorphine/Naloxone (Suboxone) administration.

  ASSESSMENT	OBSERVATION	COW SCALE
  Resting pulse (BPM)	120
  Sweating	Flushed or observable moistness on face
  Restlessness	Frequent shifting or extraneous movements of legs/arms
  Pupil Size	Larger than normal
  Bone/joint aches	No
  Runny nose/tearing	Nose constantly running or tears streaming down cheeks
  GI upset	No
  Tremors with outstretched hands	Slight tremor observable
  Yawning	Yawning several times/minute
  Anxiety/irritability	Patient obviously irritable/anxious
  Gooseflesh skin	Piloerection can be felt or hairs standing up on arms
  TOTAL SCORE

  3. You determine your patient meets the criteria for Suboxone administration. What is the initial dose and route of Suboxone to administer? What else do you need to do?
  4. Your patient is reassessed 10 minutes after the initial dose of Suboxone and it is determined the COWS Score is 6. Can your patient receive an additional dose of Suboxone, if so what dose would you administer?
  5. When should we consider/advocate for transport to ED?

• Suboxone Case Study 2

  Call Information
  
  Sent to a residential home for a patient in their late 20’s unconscious. CACC advises the patient has been administered Naloxone and is waking up. Fire has been tiered.

  Patient Presentation
  
  Patient is alert, responsive, GCS 15, female patient found on the couch, strong radial pulse, breathing spontaneously, airway patent, very lethargic, eyes closed, answering questions with delay, drug paraphernalia on scene. Pt has tremors noted to both hands.

  Incident History
  
  Patient’s friend arrived at the pts house to find her unresponsive, unable to be roused, patient is known opioid user, so the friend administered all the Narcan available which was 5 canisters for a total of 20mg IN. Patient was GCS 15 on arrival, very lethargic and admitted to taking an unknown amount of an unknown pain killer. Pt was also known to police on scene as an opioid user.

  Treatment Prior to Arrival
  
  Bystander administered 4mg Naloxone IN x 5
  A total of 20mg Naloxone given.

  Health History
  
  Past Medical History: Opioid Use Disorder
  Medications: None
  Allergies: NKA

  Vital Signs
  
  GCS: 15
  HR: 125 bpm, regular, full
  RR: 8 per minute, shallow
  ETCO2: 45 mmHg
  BP: 128/90 mmHg
  SpO2: 92%
  Temp.: 36.6 C
  BGL: 6.7 mmol/L

  Review the call information and case discussion with your group and answer the following:
  
  1. Does this patient require more naloxone?
  2. What term describes the rapid onset of withdrawal symptoms, exacerbated by the administration of naloxone to individuals dependent on opioids, leading to intensified physical and psychological distress?
  3. Based on the COWS information below, calculated the patient’s COW score.
  Guideline: <5 – no active withdrawal, 5-12 – mild withdrawal, 13-24 – moderate withdrawal, 25- 36 – moderately severe withdrawal, >36 – severe withdrawal.
  Note: A score of greater or equal to 8 is an indication for Buprenorphine/Naloxone (Suboxone) administration.

  ASSESSMENT	OBSERVATION	COW SCALE
  Resting pulse (BPM)	125
  Sweating	Flushed or observable moistness on face
  Restlessness	Frequent shifting or extraneous movements of legs/arms
  Pupil Size	Pupils possibly larger than normal for room light
  Bone/joint aches	Mild diffuse discomfort
  Runny nose/tearing	Not present
  GI upset	No
  Tremors with outstretched hands	Slight tremor observable
  Yawning	Yawning once or twice during assessment
  Anxiety/irritability	None
  Gooseflesh skin	Piloerection can be felt or hairs standing up on arms
  TOTAL SCORE

  4. What concerns should we have for this patient?
  5. You determine your patient meets the criteria for Suboxone administration. You administer 16mg of Suboxone (SL/Buccal) and reassess your patient after 10 minutes and calculate another COWS score in which you determine to be 10. The patient consents and accepts an 8mg.
  6. Hypothetically, this is a long transport to the hospital. As a group, discuss some potential harm reduction strategies and community resources that could support your patient.

• Suboxone Case Study 3

  Call Information
  
  Sent to an apartment complex for a 25-year-old patient; generally unwell.

  Patient Presentation
  
  Patient was found in bed, covered in vomiting/diarrhea. Scabs and fresh sores on their body. Drowsy but alert/oriented. A: patent and self-maintained, B: spontaneous and regular, C: regular and present radial. Pt fully alert and oriented x 3.

  Incident History
  
  Patient found by roommates covered in vomit/diarrhea. Patient states they recreationally use fentanyl, but haven’t been able to score a dose for a few days (pt unclear on exact timeline, but states approx. 3-5 days). Patient appears unwell and frail. Is interested in “detoxing”, but not sure how.

  Treatment Prior to Arrival
  
  None

  Health History
  
  Past Medical History: Opioid Use Disorder
  Medications: None
  Allergies: NKA

  Vital Signs
  
  GCS: 15
  HR: 105 bpm, regular, full
  RR: 12 per minute, normal
  BP: 110/70 mmHg
  SpO2: 99%
  Temp.: 37.5 C
  BGL: 5.4 mmol/L

  Review the call information and case discussion with your group and answer the following:
  
  1. Based off the information thus far, do you believe the patient could potentially qualify for Suboxone administration? What other assessment would be required?
  2. Based on the COWS information below, calculated the patient’s COW score.
  Guideline: <5 – no active withdrawal, 5-12 – mild withdrawal, 13-24 – moderate withdrawal, 25- 36 – moderately severe withdrawal, >36 – severe withdrawal.
  Note: A score of greater or equal to 8 is an indication for Buprenorphine/Naloxone (Suboxone) administration.

  ASSESSMENT	OBSERVATION	COW SCALE
  Resting pulse (BPM)	105
  Sweating	Pt says they have some chills
  Restlessness	Feels shifty but is able to sit still
  Pupil Size	5mm
  Bone/joint aches	None mentioned
  Runny nose/tearing	Watery, caked mucus on them
  GI upset	Covered in vomit
  Tremors with outstretched hands	Patient says they feel tremulous, but you can’t see it
  Yawning	None
  Anxiety/irritability	Getting annoyed with your questioning but managing
  Gooseflesh skin	Significant piloerection
  TOTAL SCORE

  3. Does this patient meet the criteria for Suboxone administration?
  4. Despite this, in the interest of patient-centered-care, you have elected to patch for orders. What is the initial dose and route of Suboxone to administer? What else should we ensure?
  5. What dosing strategies can we consider?

• Suboxone Case Study 4

  Call Information
  
  Dispatched light and sirens to a college dorm party for a 22-year-old female patient who had a brief LOC after consuming an unknown substance and has received one dose of Narcan by bystanders.

  Patient Presentation
  
  Patient is found sitting on the floor of the bathroom; patient is slow to respond and slightly confused. A: patent and self-maintained, B: normal and regular, C: regular and fast @ radial.

  Incident History
  
  Patient consumed an unknown substance (pill) at a college party. Shortly after she had a loss of consciousness, was sweaty and barely breathing so her friend administered 4mg of Narcan IN. She immediately woke up and was altered. Friends were worried so they called 911 as she still seems “out of it.”

  Treatment Prior to Arrival
  
  Friend administered 4mg Naloxone IN.

  Health History
  
  Past Medical History: None
  Medications: None
  Allergies: NKA

  Vital Signs
  
  GCS: 14 (E-4, V-4, M-6)
  HR: 110 bpm, regular, full
  RR: 10 per minute, shallow
  BP: 140/90 mmHg
  SpO2: 94%
  Temp.: 37.0 C
  BGL: 5.1 mmol/L

  Review the call information and case discussion with your group and answer the following:
  
  1. Based off the information thus far, do you believe the patient could potentially qualify for Suboxone administration? What other assessment would be required?
  2. Based on the COWS information below, calculated the patient’s COW score.
  Guideline: <5 – no active withdrawal, 5-12 – mild withdrawal, 13-24 – moderate withdrawal, 25- 36 – moderately severe withdrawal, >36 – severe withdrawal.
  Note: A score of greater or equal to 8 is an indication for Buprenorphine/Naloxone (Suboxone) administration.

  ASSESSMENT	OBSERVATION	COW SCALE
  Resting pulse (BPM)	110
  Sweating	Moist on face
  Restlessness	No
  Pupil Size	Pinpoint
  Bone/joint aches	No
  Runny nose/tearing	No
  GI upset	No
  Tremors with outstretched hands	No
  Yawning	No
  Anxiety/irritability	No
  Gooseflesh skin	Smooth
  TOTAL SCORE

  3. Based on the total COWS, does your patient quality for Suboxone administration?
  4. Your patient is reassessed after 10 minutes, and the COWS is now 5. Can your patient receive a dose of Suboxone now? If so, what dose would you administer? What must you do prior to administration?

Ketamine for Analgesia

• Ketamine Case Study 1

  Call Information
  
  You respond to a 6-year old child who was struck by a car.

  Patient Presentation
  
  You find your patient lying beside a crosswalk outside a busy school parking lot. Witnesses state that he was hit by a midsize car at approximately 60 km/hr and thrown to the side of the road.  Bilateral femurs deformity with external rotation to both legs. Pelvis unstable with urinary incontinence.

  Health History
  
  Past Medical History: None
  Medications: Epi-pen
  Allergies: PEanuts

  Vital Signs
  
  GCS: 15
  Pupils: 3 PERL
  HR: 160 bpm, regular, strong
  RR: 28 per minute, shallow, normal
  BP: 90/50 mmHg
  Skin: Pale, cool and sweaty with delayed capillary refill
  Monitor: Sinus Tachycardia
  SpO2: 96%
  ETCO2: 35 mmHg
  Temp.: 36.2 C
  Weight: 50 lbs

  Review the call information and case discussion with your group and answer the following:
  
  1. What are your treatment priorities?
  2. What are your analgesia options for this child?
  3. Why is a patch required for pediatric analgesia, even with the detailed dosing chart that is provided for ketamine?

• Ketamine Case Study 2

  Call Information
  
  You receive a call for a high-velocity collision on the highway involving a motorcyclist.

  Patient Presentation
  
  Upon arrival, you find a 180 lb male patient lying on the road with a complete leg amputation at the right knee. Police applied a tourniquet approximately 2 minutes prior to your arrival and bleeding is now controlled.  Right leg missing at the knee. Road rash on both arms, torso and remaining legs. You are unable to find a site for an IV.

  Health History
  
  Past Medical History: CNO - patient is screaming
  Medications: CNO - patient is screaming
  Allergies: CNO - patient is screaming

  Vital Signs
  
  GCS: 13 (E-4, V-4, M-5)
  Pupils: 4 PERL
  HR: 134 bpm, regular, weak
  RR: 28 per minute, shallow, normal
  BP: 88/64 mmHg
  Skin: Pale, cool and sweaty
  Monitor: Sinus Tachycardia
  SpO2: 96%
  ETCO2: 33 mmHg
  Temp.: 36.0 C

  Review the call information and case discussion with your group and answer the following:
  
  1. What are your treatment priorities for this patient?
  2. What medications are appropriate for this patient? Why?
  3. Which analgesia would you choose for this hypotensive patient? Why?

• Ketamine Case Study 3

  Call Information
  
  You receive a call for a female patient that has fallen outside during an ice storm.

  Patient Presentation
  
  A 35 year old female patient has slipped on the ice and has an obvious left tib/fib fracture. She states she heard her leg crack when she fell and that her pain is 8/10.  Patient has an obvious deformity, with weak pedal pulses.

  Health History
  
  Past Medical History: Hypothyroid, Opioid Use Disorder
  Medications: Synthroid, Epi-pen
  Allergies: Peanuts

  Vital Signs
  
  GCS: 15
  Pupils: 3 PERL
  HR: 120 bpm, regular, strong
  RR: 26 per minute, shallow, normal
  BP: 122/82 mmHg
  Skin: Pale, cold and sweaty
  Monitor: Sinus Tachycardia
  SpO2: 99%
  ETCO2: 35 mmHg
  Temp.: 36.4 C
  Weight: 140 lbs

  Review the call information and case discussion with your group and answer the following:
  
  1. What analgesia would you consider for this patient? Why?
  2. Is ketamine appropriate for this patient? Why or why not?

• Ketamine Case Study 4

  Call Information
  
  You are called to a congregate living facility for a patient who had a fall.

  Patient Presentation
  
  Upon arrival, you find a 42-year-old female patient lying in bed with a shortened and rotated left leg. She reports that she has Osteogenesis Imperfecta Type IV (connective tissue disorder that causes fragile bones) and felt a sudden, severe pain in her left hip and pelvis when she transferred herself from wheelchair to bed.  Bruising and tenderness on the right side of chest from recent rib fractures. Left leg is shortened and rotated externally. 

  Health History
  
  Past Medical History: Osteogenesis Imperfecta Type IV. Fractured 3 ribs on right side 5 days prior. Severe scoliosis.
  Medications: Fentanyl patch, Fosamax (alendronate), vitamin D
  Allergies: Penicillin

  Vital Signs
  
  GCS: 15
  Pupils: 4 PERL
  HR: 144 bpm, regular, strong
  RR: 32 per minute, very shallow, normal
  BP: 134/92 mmHg
  Skin: Pale, warm and sweaty
  Monitor: Sinus Tachycardia
  SpO2: 96%
  ETCO2: 35 mmHg
  Temp.: 36.6 C
  Weight: 50 kg

  Review the call information and case discussion with your group and answer the following:
  
  1. Treatment of chronic pain is a contraindication for many of your analgesics. Is this chronic pain?
  2. What are your treatment priorities?
  3. What are your analgesia options for this patient?

The CEC Team

Continuing Education and Certifications staff are available Monday - Friday from 8:00AM - 5:00PM.

To reach a coordinator you may call our MedicLINE 1-877-587-7736 Option 1

Certification is the means by which the Medical Director may authorize a paramedic to perform specific delegated controlled medical acts.

Certification to Practice

• Certification for Ontario Candidates to work as Paramedics

  Once you’ve graduated from a recognized paramedic program in Ontario, you may apply to the Ministry of Health for your AEMCA or ACP certificate. With one of these certificates, you may apply for work as a paramedic at Ontario paramedic services.

  In Ontario, every person who wishes to practice as a paramedic must be employed by a paramedic service. Once you have secured an employment offer, the paramedic service will request certification.

  To practice as a paramedic in Eastern Ontario, Primary Care or Advanced Care Paramedics must be certified by the RPPEO.

  If you change your level of competency, you will need to be certified in the new level before you begin using that scope of practice. A PCP who has trained as an ACP needs ACP certification before using the ACP scope of practice.

  The RPPEO’s certification process for both PCP and ACP scopes of practice uses scenarios to test a paramedic’s knowledge and skills.

  Once you successfully complete the RPPEO’s certification process, you will receive a Letter of Certification. This letter details the delegated controlled medical acts that the medical director authorizes you to use.

  CERTIFICATION REQUEST FORM FOR PARAMEDIC SERVICES

• Certification of Paramedics in training

  Paramedics in training who wish to undertake Delegated Medical Acts during preceptorship may be able to do so if their academic institution sponsors them in the Academic Certification process. Upon receipt of the college's request and with the agreement of the host paramedic service, the RPPEO may certify paramedics in training. Paramedics who receive this academic certification are supervised by a qualitied RPPEO certified paramedic. This is a special Academic Certification for training purposes for both PCP and ACP scopes of practice.

  A college may request Academic Certification on behalf of a paramedic using the form below.

  Certification Request Form for Colleges

• Cross certification within Ontario

  Paramedics currently certified by another Base Hospital in Ontario may apply for certification in Eastern Ontario through the Cross-Certification process. The RPPEO understands that training, skills and continuing education are quite similar across the province. The Provincial Patient Care Standards apply throughout Ontario. Paramedics already practicing elsewhere in Ontario may benefit from an expedited cross-certification if they wish to work for a paramedic service in the RPPEO’s coverage area. 

  Cross Certification Referral Form

• Certifying in Eastern Ontario from elsewhere in Canada or from abroad (Labour mobility)

  Paramedics who are licensed outside of Ontario must use the Ministry of Health’s Paramedic Equivalency Process in order to apply for an Ontario AEMCA or ACP certificate. Once you have obtained the certificate, if an employer in Eastern Ontario offers you employment you will enter the same certification process with the RPPEO as other paramedics at the PCP or ACP level.

  Labour Mobility and Equivalency in Ontario

Editing page content

• 

  Edit the Classroom Links page

  When you are logged in there will be an Edit button available at the bottom of the page. If the edit button is not displayed, the editor is already open by someone else.

• 

  Open the Yootheme Builder

  The Joomla atricle editor will open, however there will be a button where the article would normally be that says Yootheme Builder. Click this button.

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  Select the Module to Edit

  The grid module is used to create the list of content. The layout is very flexable and can be adjusted as needed.

  To edit the grid, click on the grid from the left hand side, or by hovering over the module and clicking the edit icon.

• 

  Edit the Grid

  When the grid element has been seleced you will see the Content options for the grid. You can adjust the ordering by draging items up/down, add new items, edit, duplicate or delete existing items.

  On main grid page you can also decide with itmes to display or hide. By default all are displayed.

• 

  Editing Grid Content

  Each panel in a grid has a Title, Meta, Content, Image, Link, Link Text. It is best to maintain a consist ant style within a grid layout. If a second grid, or another type of content is required additional elements can be added to the page.

• 

  Adjusting the Grid Settings

  The setting tab allows you to adjust the grid layout. You can adjust the number of columns, the panel style, and how all of the various element of the grid module are displayed.

• 

  Finish Editing

  When you have completed your changes to the page, the Save Layout button, saves the Yootheme Pro changes to the page.

  When  you click CLOSE you are returned to the Joomla articel editing layout. DO NOT navigate away from this page without clicking SAVE or CANCEL. When you forget to SVE or CANCEL before leaving this page, the content will be LOCKED and only you will be able to reopen the article. 

• 

  Grid Elements (Modules)

  There are many useful element/modules that can be added to a page. The Grid, List, and Panel modules are the most useful to quickly setup and display content. 

  Please do not add new sections or edit the existing section, column, etc. If additional layout changes are required please contact Niall Sheehan as these steps are beyond the scope of this How-to. 

Uploading and managing files

Creating QR Codes

Use your phone to scan and test this link.

QR Codes are scannable images that link to a specific URL.

To generate a QR Code, you will need the URL to a page, file, or other resource. Go to QRbot.net and paste the link into the URL filed and save the QR Code image. If the QR Code is going to be used for printing save a large version of the code.

If a file that has been saved to the Classroom Files folder needs to be updated, the existing file must be deleted and the new file must have EXACTLY the same filename for the QR Code to continue to work as needed.

The QR Code above represents the link:
https://www.rppeo.ca/manage-files-long/download-file.html?path=QRCODE-TEST-Station%2B1%2BCVAD.docx

• 

  Add an Element (Module)

• 

  Add a row

• 

  Add a Section

2024 Fall CME In-Person Activities

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  Patellar Reduction

  OBHG Skill Video: Patellar Reduction

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  Patellar Reduction is a brand new skill for all Paramedics in Ontario.  Following a successful trial in the Health Sciences North region, Patellar Reduction was found to be a safe and easy skill to learn and apply in the pre-hospital environment.

  What are the potential complications of patellar dislocation?
  Complications include ligament or cartilage damage, fractures, nerve compression, and vascular compromise.
  What are some key findings that are indicative of a knee dislocation?
  Mechanism of Injury: Knee dislocations often result from direct injury or blow to the knee, weak quadricep muscles, excessive Q angle, excessive foot pronation.
  Clinical Presentation: Gross deformity: A knee dislocation typically presents with a grossly deformed and visibly misaligned knee joint.
  Limited range of motion: The patient may have a severely restricted range of motion, with the inability to bend or straighten the knee.
  Severe pain and swelling: Pain is usually severe, accompanied by significant swelling and bruising around the knee.
  Neurovascular Compromise: Knee dislocations can potentially cause neurovascular injuries due to the high-energy nature of the trauma.

  What are the risks and benefits of the procedure?
  Risks: Temporary pain exacerbation if reduction attempts fail.
  Benefits: 85% success rate in the Health Sciences North pilot study
  reduces pain by ~5 points on a 10-point scale.

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  Ketamine for Analgesia

  Ketamine Continuum Graphic

  Larson Notch Maneuver (NEJM)

  ---

  It is important to realize that ketamine has never been considered first-line for severe pain, but the proposed new ACP Analgesia Medical Directive certainly makes it appear so for paramedics.

  Hospitals will not be familiar with this practice - ie: potentially a lot of people receiving ketamine for pain, where the hospitals traditionally would not have provided ketamine.

  It will be important for paramedics to understand that they are out in front, leading the way, and other healthcare providers may find it unusual as it first gets unrolled.

  ---

  

  Multimodal Analgesia generally refers to the use of medications that work through different mechanisms in the body to achieve better pain control while potentially minimizing side effects (NSAIDs and/or Acetaminophen).
  When considering fentanyl, morphine, or ketamine, these drugs act in distinct ways but are typically used based on the specific needs of the patient or the desired outcome:
  Fentanyl is short-acting and potent, making it useful for acute pain or rapid pain relief.
  Morphine is longer-acting, often used for more sustained pain control.
  Ketamine works differently, often employed for severe pain that doesn’t respond well to opioids, or in situations where dissociation or avoiding respiratory depression is desirable.
  In most cases, we stick with one of these 3 primary medication for pain management. However, we might transition from one to another, like starting with fentanyl for quick relief and then switching to morphine for longer-lasting control. However, we must make sure we don't stack and contribute to adverse events, ensuring the interval is safe when changing. Combining medications like fentanyl, morphine, and ketamine simultaneously doesn’t usually make sense due to overlap in their effects and potential complications.
  However, using something like Advil and Tylenol as a multimodal approach is a more familiar concept since they work differently without the risks of opioid stacking. The combination of morphine/fentanyl and ketamine might not be necessary or advisable without a specific reason.
  Swapping or using combination 'strong medications (fentanyl, morphine, ketamine) needs to have a reason, and there needs to be a healthy respect for the risk-benefit, and the patient should be aware of these risks.  Pain doesn't go away in seconds, it takes time, and that is part of the role of a clinician, to maintain communication with the patient on the treatments and time it might take to support the presenting complaint.
  

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  PCP Tachydysrhythmia

  OBHG Skill Video: Modified Valsalva Maneuver

  How does the Valsalva work?

  ---

  While ACPs have been treating Tachydysrhythmias with pharmacology and electricity for years, they have always relied on the Valsalva Maneuver for SVTs first.  Now, PCPs have the ability to treat these patients as well!

  Primary tachycardia is caused and originates from within the heart. Secondary tachycardia is caused by external forces that act on the heart indirectly to cause a change in its rate or rhythm. It is important to differentiate between the two. VM should only be attempted on primary tachycardias.
  Sinus tachycardia (although technically “SVT”) is usually caused by other underlying factors such as exercise, illness, pain, dehydration, emotional response, etc. A thorough medical history of the patient along with incident history will help you further determine if the tachycardia is of primary nature or secondary nature.
  Best practice to have the pads ready in case the patient goes into a more serious arrythmia. The potential is always there. Evidence and research show that the VM/mVM are very safe and the risks of adverse events are very low.
  If the patient is presenting with signs and symptoms of cardiac ischemia, ASA should be administered as per the Cardiac Ischemia Medical Directive. These patients should be transported to hospital for further evaluation and tests.
  “Rate related pain and/or signs of ischemia” are considered cardiac ischemia as per the directives and should be treated as per the directives.

  Sinus Tach vs SVT:
  • Obtaining a good medical history and history of the event will help in determining the reason for onset of the tachycardia.
  • Was the patient exercising?
  • Did the patient recently go through an emotional event?
  • Has the patient been ill for the past few days? 2024 Fall CME- PCP Tachydysrhythmia Medical Directive 2
  • Sinus tachycardia often has a gradual onset. SVT will often present itself “out of nowhere” or “paroxysmal”.
  • Observing the patient and monitor will also help in determining the difference. Sinus tach is often variable and will change with patient movement, deep breathing, stimuli and/or distractions.
  • Are there p waves? If you can see p waves the rhythm is most likely sinus tach
  • To note: ~1% of the general population have “Inappropriate Sinus Tachycardia” which is considered a generally benign condition that presents with an average sinus HR>90bpm or HR>100bpm at rest, can be symptomatic with palpitations, dyspnea, dizziness, etc., and other causes of sinus tachycardia have been ruled out.

  ECG Practice 1

  ECG Practice 2

  ECG Practice 3

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  Traumatic Hemorrhage

  OBHG Skill Video: Pelvic Binding by SAM Medical

  OBHG Skill Video: Pelvic Binding by T-POD

  OBHG Skill Video: Pelvic Binding with a Circumferential Sheet

  OBHG Skill Video: Administering Medication with a Minibag

  ---

  Field Trauma Triage Prompt Card

  Tachydysrhythmia Treat and Discharge Prompt Card

  TXA:
  • Antifibrinolytic – inhibits activation of plasminogen at several sites which involve fibrin.
  Stabilizes the clot and prevents further hemorrhage.
  • Most effective given early while the body is still forming clots. After 3 hours increases risks
  of adverse effects (severe = DVT/PE) with no real benefit

  Do not delay transport in these trauma patients to obtain and IV and administer TXA. This should be done enroute. Priority is still given to controlling hemorrhage and managing other reversible causes such as tension pneumo and dealing with the trauma. TXA is NOT a lifesaving medication. While it certainly has its benefits, these pt’s require trauma management and rapid transport to a trauma centre BEFORE TXA which is why it can be done enroute.

  TXA can be given for internal bleeding, not just external obvious bleeding (i.e. pt. in MVC who is tachycardic/hypotensive). It should not be given to pt’s with isolated extremity fractures or even amputations where the hemorrhage can be controlled with a tourniquet/direct pressure. It should also not be given to pt’s with rectal bleeds, epistaxis, severe menstrual periods,or post-partum hemorrhage as it is currently only for trauma pt’s. We are working on allowing for additional considerations for TXA but are not there yet.

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  Substance Use Healthcare

  COWS Score Guide

  ---

  The addition of Suboxone to the Opioid Toxicity and Withdrawal Medical Directive was unexpected, but not unwelcome.  We can finally deliver the education on the fascinating new medication, and discover new patient pathways as well!

• 

  Gastric Port Suctioning

  OBHG Skill Video: Gastric Port Suctioning

  OBHG Skill Video: Stomach Suctioning

  ---

  Inserting an iGel for advanced airway control is a great way for all Paramedics to gain an advantage during stressful airway management calls.  When you are also dealing with gastric distention or regurgitation, the ability to utilize the Gastric Suction Port cannot be under appreciated!

  What needs to be documented on your paperwork following IGEL usage and Gastric port suctioning?
  - Catheter size
  - Number of suction times
  - Result of suctioning
  - Suction pressure used
  What are some situations where we should be considering Gastric port suctioning instead of removing the IGEL?
  - Small drop in ETCO2
  - Evidence of fluids in the airway
  - Gastric distention
  What are the correct suction pressures that should be utilized?
  - Infant 60-100
  - Child 100-120
  - Adult 100-150
  How long, how often, how many times can we gastric port suction?
  - 15 sec each time
  - Reassess regularly, suctioning can occur as needed for unlimited times

• 

  Intranasal Glucagon

  Video: How to Use Baqsimi

  ---

  Key points regarding Intranasal Glucagon:

  • Ages 4 years and up only!
  • If you have both IM and IN Glucagon available, your Medical Directors would prefer you save the IM Glucagon for patients under 4 years of age.
  • Formulation invented in Canada.
  • Dry powder form of glucagon.
  • Nasal congestion does not impact the absorption of intranasal glucagon.
  • Single use, pre-filled nasal device with a 3mg dose.
  • Ready to use with no reconstitution or priming required.
  • Does not need to be refrigerated.
  • Can be stored up to 30 degrees Celcius in the shrink wrapped tube provided.
  • Do not remove shrink wrap or open the tube until ready to use.
  • Absorbed passively via the intranasal route - no inhalation required.
  • Intranasal glucagon has not been studied in pediatric patients less than 4 years old.
  • Limited clinical trial experience has not identified difference in responses between elderly (65 and older) and younger patients.

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