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Reference and Educational Notes

Medicine is a discipline in which no two situations are the same. Every patient must be thoroughly assessed and decisions are to be made based on the caregiver’s interpretation. The goal of the provincial Advanced Life Support Patient Care Standards (ALS PCS) is to provide guidance for certain clinical
scenarios that fall within the scope of practice of Ontario Paramedics. That being said, no directive is all encompassing and cannot provide guidance for each and every situation encountered.

The Ontario Base Hospital Group (OBHG) has purposefully reformatted the ALS PCS in order to provide Paramedics with a succinct yet practical reference book that provides the ability to obtain information quickly. As such, many of the previously found detailed clinical notes and references have been omitted
from the ALS PCS and have been placed into this companion document to provide intent and clarification regarding the application of the directives. Much of the information contained herein was generated as a result of the many “Frequently Asked Questions” received following the implementation of the ALS PCS in 2011.

This companion document should be used as a reference tool to further appreciate the applicability of the Medical Directives within the ALS PCS. In an attempt to standardize Paramedic education and certification provincially, this document further provides guidance for scenarios that historically have had
differing treatments across Ontario Regional Base Hospital Programs. The provincial Medical Advisory Committee’s (MAC) consensus and best practice approach to these unique scenarios are highlighted within this document.


The Medical Directives apply to Paramedics who provide patient care under the license and/or authority of the Regional Base Hospital (RBH) Program Medical Director. Delegation of controlled acts or Medical Directives in the ALS PCS to paramedics falls under the exclusive oversight of the MOHLTC’s RBH

The Medical Directives are designed to guide a paramedic in the provision of timely and appropriate care to ill and/or injured patients in the prehospital setting, in accordance with the paramedic’s training and authorized skill set. While great care has been taken in developing these Medical Directives, they cannot account for every clinical situation. Thus, they are not a substitute for sound clinical judgment.
In the section titled “Home Medical Technology and Novel Medications” the sentence that reads, “Alternatively consider contacting the responsible member of a regulated health profession” is not for the purposes of obtaining medical delegation.

This document will be updated regularly and the most current version will always be the electronic version available on the Ontario Base Hospital Group’s website: http://www.ontariobasehospitalgroup.ca


A patch may be made to a BHP for critically ill or injured patients that may benefit from additional/further treatment beyond what is specified in the medical directives, but is within the Paramedic’s scope of practice.

Patch points or dosing end points within directives have been created to act as ‘safe margins’ or ‘check points’, where BHPs need to be involved in patient care.
Medication doses may be calculated based upon weight or other factors and result in a fraction that cannot be measured accurately. Depending on the delivery method used, medication doses may require rounding from the exact dose alculated. In these cases, the medication dose delivered will be rounded to the closest dose that can accurately be measured.

Medications listed in the following directives may be administered via 50mL 0.9% Normal Saline (NS) Medication bag, if available, intravenously at the discretion of the paramedic as an alternative to bolus/slow IV push administration:

MedicationMedical Directive
Dimenhydrinate (Gravol) Nausea/Vomiting Medical Directive
Diphenhydramine (Benadryl) Moderate to Severe Allergic Reaction Medical Directive
Amiodarone Tachydysrhythmia Medical Directive
Morphine Adult/Pediatric Analgesia Medical Directive
Fentanyl Adult/Pediatric Analgesia Medical Directive
Calcium Gluconate Hyperkalemia Medical Directive
  1. All medications given via 50mL 0.9% NS bag must be appropriately labelled with the following minimum information:
    1. Drug Name
    2. Drug Dosage
    3. Time initiated
    4. Attending Paramedic Name and initials
  2. Only one medication may be administered per 50mL 0.9% NS bag.
  3. Volume of 50mL 0.9 NS% bag and medication is not to be counted towards total fluid volume administered to the patient.
  4. Flush IV line with 10mL of 0.9%NS once the medication infusion is complete to ensure all medication has been administered.
  5. IV drug dosages remain the same, medication bag infusion allows for slow IV administration to be accomplished while providing ongoing patient care. Follow current directives for drug dosing. (ie. Hyperkalemia Medical Directive – Administer 1.0g of Calcium Gluconate over 3 minutes. Inject your medication into the medication bag and titrate drip rate accordingly for a 3 minute delivery).


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