A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedic Program who requires Vitamin B12 (Cyanocobalamin) intramuscular injection per Nurse Practitioner, or Physician prescription.

CONDITIONS

• Vitamin B12 (Cyanocobalamin)
• Age: > 18 years of age
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A
• Other: Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• Vitamin B12 (Cyanocobalamin)
• No consent from patient or substitute decision maker.
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• Prior anaphylaxis reaction to the injection.

TREATMENT

• Vitamin B12 (Cyanocobalamin)
• Route IM
• Dose 1000 mcg/1 mL or Specified on the prescription vial/box.
• Dosing Interval The injection is usually given once every 4 weeks

POST TREATMENT PLAN

• Schedule next dose based on prescribed regimen (e.g., monthly).
• Observe for 15-30 minutes post-injection.
• Record dose, site, and batch number.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedic Program who requires Prolia (Denosumab) intramuscular injection per Nurse Practitioner, or Physician prescription
• AND Men diagnosed with osteoporosis or postmenopausal women who have high risk of bone breakage (fracture) or women and men with a high risk of bone fracture due to treatments for certain types of cancer (breast cancer or prostate cancer).

CONDITIONS

• Jubbonti (Denosumab)
• Age: > 18
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A
• Other: Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• Jubbonti (Denosumab)
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• No consent received from patient or substitute decision maker.
• Known Allergy or hypersensitivity
• Low blood calcium (hypocalcemia)
• Pregnant or plan to become pregnant

TREATMENT

• Jubbonti (Denosumab)
• Route SC
• Dose 60 mg or Specified on the prescription vial/box.
• Dosing Interval The injection is usually given once every 6 months but frequency can vary depending on prescription.

CLINICAL CONSIDERATIONS

• Administer the injection in the upper arm, upper thigh, or abdomen, rotating injection sites with each administration.

POST TREATMENT PLAN

• Observe for 15-30 minutes post-injection
• Record dose, site, and batch number.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedic Program who requires Abilify Maintena intramuscular injection per Nurse Practitioner, or Physician prescription.
• AND Patient has been diagnosed with Schizophrenia or bipolar disorder or major depressive disorder or Autism Spectrum Disorders and has a history on non-compliance of medications.

CONDITIONS

• Aripiprazole (Abilify Maintena)
• Age: > 18
• LOA: Unaltered
• HR: N/A
• SBP: Normotension
• RR: N/A
• Other: Patient is followed by a physician or Canadian Mental Health & Addictions (CMHA).

CONTRAINDICATIONS

• Aripiprazole (Abilify Maintena)
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• No consent received from patient or substitute decision maker.
• Known Allergy or hypersensitivity
• > 65 years of age with Dementia or Alzheimer’s disease
• < 26 days since previous Abilify Maintena intramuscular injection
• Patient is receiving medication as part of a Community Treatment Order (CTO)

TREATMENT

• Aripiprazole (Abilify Maintena)
• Route IM
• Dose 300mg or 400mg or Specified on the prescription vial/box.
• Dosing Interval The injection is usually given once every 4 weeks but frequency can vary depending on prescription.

Mandatory physician/CMHA notification required when treatment is provided OR if the patient cannot be contacted OR patient misses a dose.

CLINICAL CONSIDERATIONS

• Monitor patient for orthostatic Hypotension, especially those with known cardiovascular or cerebrovascular disease, and risk of dehydration or syncope.

POST TREATMENT PLAN

• Observe for 15-30 minutes post-injection due to potential for sedation, orthostatic hypotension, or extrapyramidal symptoms (EPS)
• Record dose, site, and batch number.
• Notify mental health provider or PCP of administration to coordinate psychiatric monitoring.
• Coordinate next dose if ordered (typically every 4 weeks)

• NOTE: This service is intended to provide a clinical bridge when other options are unavailable.
• Community Paramedics will only administer up to a maximum of three concurrent medication doses.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient enrolled in the Parry Sound Disctrict Community Paramedicine Program who requires Clopixol Depot (zuclopenthixol) intramuscular injection per Nurse Practitioner, or Physician prescription
• AND Patient has been diagnosed with Schizophrenia or other psychotic illnesses and patient has history on non-compliance of medications.

CONDITIONS

• Clopixol Depot (zuclopenthixol)
• Age: > 18
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A
• Other: Patient is followed by a physician or Canadian Mental Health & Addictions (CMHA).

CONTRAINDICATIONS

• Clopixol Depot (zuclopenthixol)
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• No consent received from patient or substitute decision maker.
• Known Allergy or hypersensitivity
• Patient is receiving medication as part of a Community Treatment Order (CTO)

TREATMENT

• Clopixol Depot (zuclopenthixol)
• Route IM
• Dose 200 mg
• Dosing Interval The injection is usually given once every 2-4 weeks but frequency can vary depending on prescription.

Mandatory physician/CMHA notification required when treatment is provided OR if the patient cannot be contacted OR patient misses a dose.

CLINICAL CONSIDERATIONS

• The following types of medications may interact with Clopixol:
• Certain medications for allergies (e.g., lorazepam, zopiclone)
• Certain medications for pain (e.g., fentanyl)
• Anti-Parkinson agents

• The patient should avoid drinking alcohol or using illegal drugs while taking Clopixol.

POST TREATMENT PLAN

• Monitor for 15-30 minutes post-injection for sedation, EPS, or cardiovascular effects.
• Record dose, site, and batch number.
• Document full injection details and any side effects.
• Confirm and document next dose date (often every 2–4 weeks, per patient-specific regimen).

• NOTE: This service is intended to provide a clinical bridge when other options are unavailable.
• Community Paramedics will only administer up to a maximum of three concurrent medication doses.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient enrolled in the Parry Sound Disctrict Community Paramedicine Program who requires Paliperidone (Invega Sustenna) intramuscular injection per Nurse Practitioner, or Physician prescription.
• AND Patient has been diagnosed with Schizophrenia and has already had initial dose of Paliperidone (Invega Sustenna) administered, and patient has history on non-compliance of medications.

CONDITIONS

• Paliperidone (Invega Sustenna)
• Age: > 18
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A
• Other: Patient is followed by a physician or Canadian Mental Health & Addictions (CMHA).

CONTRAINDICATIONS

• Paliperidone (Invega Sustenna)
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• No consent received from patient or substitute decision maker.
• Known Allergy or hypersensitivity
• Has known medical condition or is taking other medications that may cause QT prolongation.
• ECG confirms QTc >480 ms.
• Patient is receiving medication as part of a Community Treatment Order (CTO)

TREATMENT

• Paliperidone (Invega Sustenna)
• Route IM
• Dose 50 mg or 75 mg or 100 mg
• Dosing Interval The injection is usually given once every 4 weeks but frequency can vary depending on prescription.

Mandatory physician/CMHA notification required when treatment is provided OR if the patient cannot be contacted OR patient misses a dose.

CLINICAL CONSIDERATIONS

• Monitor patient for signs of kidney problems (such as change in the amount of urine) or dark urine.

POST TREATMENT PLAN

• Monitor for 15-30 post-injection.
• Record dose, site, and batch number.
• Document full injection details and any side effects.
• Confirm and document next dose date (often every 4 weeks, per patient-specific regimen).

• NOTE: This service is intended to provide a clinical bridge when other options are unavailable.
• Community Paramedics will only administer up to a maximum of three concurrent medication doses.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• For individuals 9 years of age or older who are eligible to receive an influenza vaccine and given verbal consent or had a substitute decision maker give consent on their behalf.

CONDITIONS

• Standard-Dose Quadrivalent (QIV) & Trivalent Inactivated Influenza Vaccine (TIV) High-Dose Quadrivalent (QIV-HD) & High-Dose Trivalent Inactivated Influenza Vaccine (TIV-HD) Adjuvanted Trivalent (TIV-adj)
• Age: > 9 years of age > 65 years > 65 years
• LOA: Unaltered Unaltered Unaltered
• HR: N/A N/A N/A
• SBP: N/A N/A N/A
• RR: N/A N/A N/A
• Other: Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• QIV & TIV QIV-HD & TIV-HD Adjuvanted Trivalent (TIV-adj)
• No consent from patient or substitute decision maker.
• Patient has a fever or displaying signs of current illness.
• Prior anaphylaxis reaction to the vaccine.

TREATMENT

• QIV & TIV QIV-HD & TIV-HD Adjuvanted Trivalent (TIV-adj)
• Route IM IM IM
• Dose Current dose as per annual health unit guidelines
• Current dose as per annual health unit guidelines
• Current dose as per annual health unit guidelines

CLINICAL CONSIDERATIONS

• QIV-HD, TIV-HD, TIV-adj are all the preferred vaccine for those 65 years of age and older. There is no preferential recommendation for the use of QIV-HD, TIV-HD versus TIV-adj vaccine for this age group unless specifically requested by the patient.

POST TREATMENT PLAN

• Patient must be observed for at least 15 minutes for adverse reaction

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedic
Program, and paramedic student under the supervision of an authorized community paramedic, may
initiate a COVID-19 mRNA vaccination to prevent COVID-19 disease caused by SARS-CoV-2 virus.

INDICATIONS

• For individuals 18 years of age or older or individuals identified in “High Risk” groups who are eligible to receive a Bivalent COVID-19 vaccine as a booster dose for the prevention of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus

CONDITIONS

• Moderna Spikevax Bivalent COVID-19 Vaccine Pfizer-BioNTech Bivalent COVID-19 Vaccine Age > 18 years of age > 18 years of age LOA Unaltered Unaltered HR N/A N/A SBP N/A N/A RR N/A N/A Other Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• Moderna Spikevax Bivalent COVID-19 Vaccine Pfizer-BioNTech Bivalent COVID-19 Vaccine
• No consent from patient or substitute decision maker.
• Patients with a previous history of allergy or a prior anaphylaxis reaction to an mRNA vaccine or any component of a COVID-19 vaccine.
• Individuals who had an episode of myocarditis (with or without pericarditis) within 6 weeks following a previous administration of an mRNA vaccine
• Patient has a fever or displaying signs of current illness.

TREATMENT

• Moderna Spikevax Bivalent
• COVID-19 Vaccine
• Pfizer-BioNTech Bivalent
• COVID-19 Vaccine
• Route IM IM
• Dose 50 mcg (0.5 ml) 30 mcg (0.3 ml)
• Maximum single dose 50 mcg (0.5 ml) 30 mcg (0.3 ml)
• Dosing Interval after last dose of a COVID-19 vaccine or after symptom onset or positive test from a previous COVID-19 infection.
• Recommended: 6 months (182 days)
• Minimum 3 months (91 days)
• Recommended: 6 months (182 days)
• Minimum 3 months (91 days)

CLINICAL CONSIDERATIONS

• A previous infection with SARS-CoV-2 is defined as:
• Confirmed by a molecular (e.g., PCR or PCS) or rapid antigen test; or
• Symptomatic AND household contact of a confirmed COVID-19 case.
• Dosing interval:
• Recommended interval refers to the Ministry of Health’s recommendation that longer intervals between the first and second doses of COVID-19 vaccines result in more robust or durable immune response and higher vaccine effectiveness.
• Pregnancy and Breastfeeding:
• Pregnant and breastfeeding individuals should receive all recommended doses of a COVID-19 vaccine (including booster doses) as soon as they become eligible.
• The following high-risk groups are recommended to receive a COVID-19 bivalent booster dose, regardless of the number of booster doses previously received, as soon as they are eligible:
• Residents of long-term care homes, retirement homes, Elder Care Lodges, and individual’s living in other congregate settings.
• Individuals aged 70 years and older.
• Individuals who are 18 years and older with moderately to severely immunocompromising conditions.
• Adults 18 years and older who identify as First Nation, Inuit or Métis and their non-indigenous household members aged 18 years and older.
• Pregnant individuals aged 18 years and older.
• Health care workers aged 18 years and older.

POST TREATMENT PLAN

• Patient must be observed for at least 15 minutes for adverse reaction
• NOTES: Once opened, the entire vial of COVID vaccine must be used within the following timeframes:
• Moderna Spikevax—Royal blue cap vial: 24 hours (5 doses)
• Pfizer-BioNTech—Gray cap & blue cap vials: 12 hours (6 doses)

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patients enrolled in the Parry Sound District Community Paramedic Program who are 50 years of age or older and require Shingrix dose #1 or dose #2 intramuscular injection per Nurse Practitioner, or Physician prescription.

CONDITIONS

• Shingrix Vaccine Age > 50 years of age LOA Unaltered HR N/A SBP N/A RR N/A Other Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• Shingrix Vaccine
• No consent from patient or substitute decision maker.
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• Prior anaphylaxis reaction to the injection.
• Pregnancy.

TREATMENT

• Shingrix Vaccine
• Route IM
• Dose 0.5 ml
• Maximum single dose 0.5 ml
• Dosing Interval between 1st and 2nd dose 2 to 6 months

POST TREATMENT PLAN

• Patient must be observed for at least 15 minutes for adverse reaction
• NOTES: This vaccine is covered by Ontario Health Insurance Plan (OHIP) only for those aged 65-70 years old. For other age groups, there is a cost which may be covered by your insurance benefit plan.
• Prior to reconstitution: Store both the antigen and adjuvant vials between 2° and 8°C (36° and 46°F).
• Protect vials from light. Do not freeze; discard if frozen.

• How to prepare SHINGRIX:
• Withdraw the entire contents of the vial containing the suspension into a sterile syringe.
• Add the entire contents of the syringe into the vial containing the lyophilized powder.
• Shake gently until the lyophilized powder is completely dissolved.
• The reconstituted vaccine is an opalescent, colourless to brownish liquid.
• The reconstituted vaccine should be inspected visually for any foreign particulate matter
• and/or variation of appearance. If either is observed, do not administer the vaccine.
• After reconstitution, the vaccine should be used promptly. If this is not possible, the vaccine should be stored in a refrigerator (2C to 8C). If not used within 6 hours it should be discarded.
• Before administration:
• Withdraw the entire contents of the vial containing the reconstituted vaccine into a sterile syringe.
• Change the needle so that you are using a new needle to administer the vaccine.
• Any unused medicinal product or waste material should be disposed of.
• After reconstitution: Administer immediately or store refrigerated between 2° and 8°C (36° and 46°F).
• Discard reconstituted vaccine if not used within 6 hours. Do not freeze; discard if frozen.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patients enrolled in the Parry Sound District Community Paramedic Program who are greater than 65 years of age or greater than 19 years of age with an immunocompromising condition
• and require Prevnar 20 intramuscular injection per Nurse Practitioner, or Physician prescription.

CONDITIONS

• Prevnar 20 Vaccine Age > 65 years of age or > 19 years of age with an immunocompromising condition with prescription.
• LOA Unaltered HR N/A SBP N/A RR N/A Other Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• Prevnar 20 Vaccine
• No consent from patient or substitute decision maker.
• No order or prescription. All patients must have the dose specified on the prescription vial/box.
• History of an anaphylactic reaction to a previous dose of a pneumococcal vaccine or to any component of Prevnar 20 vaccine.

TREATMENT

• Prevnar 20 Vaccine
• Route IM
• Dose 0.5 ml
• Maximum single dose 0.5 ml

POST TREATMENT PLAN

• Patient must be observed for at least 15 minutes for adverse reaction
• NOTES: Single-dose, prefilled syringe:
• The package does not contain a needle. Attach a sterile needle to the prefilled syringe by twisting in a clockwise direction until the needle fits securely on the syringe.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event if authorized.

INDICATIONS

• History/diagnosis of congestive heart failure;
• AND Suspected increase in peripheral/pulmonary edema;
• OR Exacerbation of current heart failure

CONDITIONS

• Furosemide
• Age: > 18 years of age
• LOA: Unaltered
• HR: N/A
• SBP: Normotension
• RR: N/A
• Other: 12-LEAD ECG, ePOC Blood analysis & POCUS completed (if available)

CONTRAINDICATIONS

• Furosemide
• Allergy or sensitivity to Furosemide or Sulfa class drugs
• Nausea, vomiting, or abdominal pain
• NO prior use of Furosemide
• Potassium (K⁺) < 3.0 mmol/L
• Sodium (Na⁺) < 125 mmol/L eGFR < 30

TREATMENT

Mandatory Consultation Point: Request prescription for 2 days of Furosemide at doses determined within this directive

• Consider Furosemide
• Currently using Furosemide Not currently using Furosemide
• Route PO PO
• Max. single dose 2x current/prescribed dose, to
• maximum dose of 80 mg BID 40 mg
• Dosing Interval Repeat daily AM x3 days (PRN)
• Max. # of doses 1 (Initial dose at time of assessment) 1 (Initial dose at time of assessment)

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• Ascertain past medical history of chronic renal failure and prior history of use of furosemide.
• Consider transport to emergency department if patient appears to be in severe distress and has:
• Ongoing chest pain,
• Arrhythmias, i.e., new onset irregular heart rate.
• O2 sat <87% or new drop of 5% from normal,
• Acute onset of >5kg weight gain
• If any concerns regarding the clinical stability or suitability of the patient for treatment at home
• Consult with primary care provider or medical director.

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call within 24 hours & home visit within 2–3 days to recheck vitals, weight, and edema.

• Reassess for signs of fluid offload (e.g., decreased dyspnea, improved SpO₂) prior to departing visit.
• Consider Remote Patient Monitoring (RPM) for oxygen saturation, Blood Pressure, and daily weight tracking
• Encourage compliance with dietary/fluid restrictions and early escalation for worsening symptoms.
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Exacerbation of current COPD from their normal baseline condition
• AND Suspected Bronchoconstriction

• Patient specific COPD action plan on file overrides this directive and should be followed

CONDITIONS

• Home Oxygen Salbutamol Ipratropium Bromide
• Age: > 18 years of age > 18 years of age > 18 years of age
• LOA: Unaltered from normal Unaltered from normal Unaltered from normal
• HR: N/A 60-125 bpm 60-125 bpm
• SBP: N/A SBP: >100mmHg SBP: >100mmHg
• RR: N/A 12-40 12-40
• Other: O2 >88% or <5% from normal O2 >88% or <5% from normal O2 >88% or <5% from normal

• Prednisone
• Age: > 18 years of age
• LOA: Unaltered from normal
• HR: N/A
• SBP: N/A
• RR: N/A
• Other: Worsening COPD with ≥2 of the following:
• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence (Thick, yellow/green, opaque mucus)

CONTRAINDICATIONS

• Home Oxygen Salbutamol Ipratropium Bromide Prednisone
• O2 > 93% Allergy/sensitivity to
• Salbutamol
• Allergy/sensitivity to
• Ipratropium bromide
• Allergy/sensitivity to
• Prednisone
• Presence of fluid in base of lungs based on auscultation or POCUS
• Hypersensitivity to
• Atropine or it’s derivatives
• Recent use within past 3 months
• Presence of fluid in base of lungs based on auscultation or POCUS
• Presence of fluid in base of lungs based on auscultation or POCUS

TREATMENT

• Consider Home Oxygen Consider Salbutamol Consider Ipratropium
• Bromide
• Route Nasal Canula MDI MDI
• Max.
• single dose 1-6 L/min (FiO2 24%-44% to titrate to O2 saturation of 90% – 92% 100mcg 20mcg
• Dosing
• Interval 3 days 1-4 puffs Q1-4h PRN 2 puffs Q4h PRN
• Max. # of doses N/A 8 puffs in 4 hours or 48 puffs in 24 hours for 3 days 2 puffs in 4 hours or 12 puffs in 24 hours for 3 days

Mandatory Consultation Point: Request prescription for 4 doses (5 days) of Prednisone

• Consider Prednisone
• Route PO
• Max. single dose 50mg
• Dosing Interval Repeat daily x5 days
• Max. # of doses 1 (Initial dose at time of assessment)

• Consider antibiotic therapy for moderate COPD exacerbation if conditions for Prednisone met

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• If patient is in severe distress, initiate transport to emergency department
• If available and staff trained, please perform POCUS
• Escalate to 911 if patient is presenting with signs of infection such as:
• Cough, which produce greenish, yellow or bloody mucus.
• Fever, sweating and shaking chills.
• Rapid, shallow breathing.
• Sharp or stabbing chest pain that gets worse when patient breathes deeply.
• Loss of appetite, low energy, and fatigue.

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours & home visit within 2–3 days if symptoms persist or if additional vitals/lab reassessment is required.

• Ensure patient understands medication instructions and red flags.
• Consider oxygen saturation Remote Patient Monitoring (RPM) for 1-2 weeks
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient meets the criteria for Uncomplicated UTI (Acute dysuria OR 2 or more of the following: fever > 37.9°C (100°F) or a 1.5°C increase above baseline on at least two occasions of the last 12 hours, new or worsening urgency, frequency, suprapubic pain or pressure, gross hematuria, flank pain, urinary incontinence
• AND POSITIVE urinalysis results suggesting a urinary tract infection (UTI) as per the conditions and results outlined in the Urinalysis Point-Of-Care directive.

CONDITIONS

• Fosfomycin
• Age: > 18 years of age
• LOA: N/A
• HR: < 100 bpm
• SBP: Normotension
• RR: N/A

CONTRAINDICATIONS

• Fosfomycin
• Previous sensitivity or documented allergy to Fosfomycin
• Previous known resistance to Fosfomycin
• Fever ≥38.0°C
• New or worsening back or flank pain
• Recurrent UTI (>2 in 6 months or >3 in 12 months)
• Nausea/vomiting

TREATMENT

Consider Primary Care or Medical Oversight Consultation Point

• Consider Fosfomycin
• Route PO
• Max. single dose 3g
• Dose 3g Dissolved in ½ cup (125ml) of cold water.
• Max. # of doses 1

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• Uncomplicated UTI:
• Definition: A urinary tract infection that occurs in a healthy individual with a normal urinary tract.
• Typical patients: Most commonly seen in healthy, non-pregnant women.
• Causes: Often caused by typical uropathogens, like Escherichia coli (E. coli).
• Risk factors: Minimal predisposing factors, no significant abnormalities of the urinary system.
• Treatment: Generally easier to treat with standard antibiotics, and the patient is expected to respond well to treatment.
• Complicated UTI:
• Definition: A urinary tract infection that occurs in individuals who have underlying health conditions or abnormalities in their urinary system, making the infection harder to treat or more severe.
• Typical patients: Seen in people with conditions such as:
• Urinary tract obstructions (e.g., kidney stones, spinal cord injury)
• Catheter use
• Immune suppression
• Anatomical abnormalities in the urinary tract
• Pregnant women
• Men (since UTIs are less common in men and often associated with underlying issues)
• Risk factors: Complicated UTIs are associated with a higher risk of treatment failure, recurrent infections, or serious health complications (e.g., sepsis or kidney damage).
• Treatment: Requires more aggressive or prolonged antibiotic therapy, and sometimes intervention to address the underlying condition.
• If patient is in severe distress or displaying signs of sepsis ACTIVATE EMS as per SOP 004.
• Early treatment of UTI, particularly in elderly/frail patients can prevent progression of systemic illness.
• No dose adjustment for liver/renal impairment (if renal impairment there may be more
• GI upset/diarrhea due to exposure)
• Best absorbed on an empty stomach but can be given with food to help with GI symptoms.

• Diabetic patients who are on SGLT2 inhibitors class drugs common side effect, genital and urinary tract infections, increased urination, and Vulvovaginal Candidiasis.
• If available and staff trained, please perform POCUS to ensure no urinary retention

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 36 hours & home visit if symptoms persist or additional vitals/lab reassessment is required.

• Reassess symptoms and oxygen saturation prior to departing leaving visit.
• Consider referral for catheter change within 24 hours for positive cultures.
• If symptoms persist/worsen, contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event if authorized.

INDICATIONS

• Intended for patients experiencing suspected cellulitis on a limb with any of the following:
• Skin erythema
• Edema
• Warmth
• Pain
• AND Unilateral limb presentation

CONDITIONS

• Cephalexin Doxycycline
• Age: > 18 years of age > 18 years of age
• LOA: Unaltered Unaltered
• HR: 50-110 50-110
• SBP: >100 systolic >100 systolic
• RR: N/A N/A
• Other: Temperature <38 degree Temperature <38 degree

CONTRAINDICATIONS

Mandatory Consultation Point: Diabetic Patient, Recent Hospital Admission, IV Drug Use

• Cephalexin Doxycycline
• Allergy or sensitivity to Cephalexin or beta-lactam antibiotics (penicillin or amoxicillin) Allergy or sensitivity to Doxycycline
• Recent use of cephalexin in past 3 months. Recent use of Doxycycline in past 3 months.
• Suspected DVT Suspected DVT
• Facial cellulitis Facial cellulitis
• Compartment syndrome Compartment syndrome
• Necrotizing soft tissue infection Necrotizing soft tissue infection
• Systemic toxicity Systemic toxicity
• Purulent wound drainage Purulent wound drainage
• GFR < 30 within last 6 months Pregnant or breastfeeding

TREATMENT

Mandatory Consultation Point: Request prescription for either 27 doses (7 days) of Cephalexin QID or 13 doses (7 days) of Doxycycline BID

• Consider Cephalexin Consider Doxycycline
• Route PO PO
• Max. single dose 500 mg 100 mg
• Dosing Interval Repeat QID (4x/day) Repeat BID (morning/night)
• Max. # of doses 1 (Initial dose at time of assessment) 1 (Initial dose at time of assessment)

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• Consider capturing image of area of erythema with wound ruler to monitor spread.
• Consider ePOC blood analysis for Cephalexin if most recent eGFR > 6 months and patient does not qualify for Doxycycline.

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours & home visit in 48-72 hours and refer to primary care if symptoms persist/worsens.

• Reassess prior to releasing from care to mark border of erythema if applicable and photograph for tracking.
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Have a minimum of one clinical presentation of pneumonia:
• Cough (with or without sputum production)
• Fever
• Increased dyspnea
• Pleuritic chest pain
• Increased work of breathing Have both of the following on physical examination:
• Adventitious breath sounds – including rales/crackles and/or rhonchi
• POCUS demonstrates consolidation
• AND Medically stable for home management – see CURB-65 CURB-65 Criteria Points Confusion – new disorientation to person, place or time 1 Urea (blood urea nitrogen) > 7mmol (epoc blood test) 1 Respiratory Rate > 30 1 Systolic Blood Pressure <90 mmHg and/or Diastolic <60 mmHg 1 Age > 65 1

• Total Score Risk Level Management Recommendation 0-1 Low Outpatient Treatment 2 Moderate Consider transfer to hospital or close monitoring 3-5 High Transfer to hospital

CONDITIONS

• Amoxicillin (without comorbidity/modifying factors) Amoxicillin/Clavulanate + Z-Pack (Azithromycin) (with comorbidity/modifying factors)
• Age: > 18 years of age > 18 years of age
• LOA: Unaltered Unaltered
• HR: 50-110 bpm 50-110 bpm
• SBP: Normotension Normotension
• RR: < 30 < 30
• Other: N/A Any of the following risk factors for resistant bacteria:

• Recent antibiotic use (<3 months)
• ≥ 2 exacerbations/year or recent hospitalization
• Comorbidities (cardiac, diabetes, renal, Immunosuppression, age >65)

CONTRAINDICATIONS

• Amoxicillin Amoxicillin/Clavulanate + Z-Pack (Azithromycin)
• Allergy to penicillins or β-lactam antibiotics Allergy to penicillins or β-lactam antibiotics
• Use of same antibiotic class within past 3 months Use of same antibiotic class within past 3 months
• Most recent eGFR < 30 within last 6 months Most recent eGFR < 30 within last 6 months
• Multiple or Uncontrolled comorbidities QT prolongation
• No consolidation seen on POCUS No consolidation seen on POCUS

TREATMENT

Mandatory Consultation Point: Request prescription for either 20 doses (7 days) of Amoxicillin TID or 13 doses (7 days) of Amoxicillin/Clavulanate BID + Z-Pack (5 days)

• Consider Amoxicillin Consider Amoxicillin/Clavulanate + Z-Pack (Azithromycin)
• Route PO PO
• Max. single
• dose 1000 mg Amox/Clav: 875/125 mg
• Z-pack: 500mg Day 1 and 250mg Day 2-5
• Dose TID Z-pack: Daily
• Max. # of doses 1 (initial dose at time of assessment) 1 (initial dose at time of assessment)

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• If patient is in severe distress, initiate transport to emergency department.
• Consider setting up remote patient monitoring for SP02 for one week or duration of treatment plan in order to help gauge effectiveness.
• Consider ePOC blood analysis if most recent eGFR > 6 months

POST TREATMENT PLAN

• Ensure patient understands medication instructions and red flags.
• Consider Remote Patient Monitoring (RPM) for 1-2 weeks.
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours & home visit within 2–3 days if symptoms persist or if additional vitals/lab reassessment is required.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Clinical presentation of sore throat
• AND Medically stable for home management

SORE THROAT SCORE

• *This should NOT be used in epidemic situations, individuals who have a history of rheumatic fevers, valvular disease and/or immunosuppression **80-90% of the time, pharyngitis is not bacterial
• Criteria Points
• Temperature > 38°C 1
• Absence of cough 1
• Swollen, tender anterior cervical nodes 1
• Tonsillar swelling of exudate 1
• Ages 3-14 1
• Ages 15-44 0
• Ages > 45 -1

• Total Score Risk Level Management Recommendation
• < 0 2.5% risk of streptococcal infection No culture or antibiotics needed. 1 5-10% risk of streptococcal infection 2 11-17% risk of streptococcal infection Perform rapid antigen test or culture – only treat if positive. 3 28-35% risk of streptococcal infection
• > 4 51-53% risk of streptococcal infection Start antibiotic therapy on clinical grounds.

CONDITIONS

• Amoxicillin Z-Pack (Azithromycin)
• Age: > 18 years of age > 18 years of age
• LOA: Unaltered Unaltered
• HR: 50-110 bpm 50-110 bpm
• SBP: Normotension Normotension
• RR: < 30 < 30

CONTRAINDICATIONS

• Amoxicillin Z-Pack (Azithromycin)
• Allergy to penicillins or β-lactam antibiotics QT prolongation
• Use of same antibiotic class within past 3 months Use of same antibiotic class within past 3 months
• Most recent eGFR < 30 within last 6 months Most recent eGFR < 30 within last 6 months

TREATMENT

Mandatory Consultation Point: Request prescription for either 9 doses (10 days) of Amoxicillin BID or Z-Pack (5 days)

• Consider Amoxicillin Consider Z-Pack (Azithromycin)
• Route PO PO
• Max. single
• dose 500 mg Z-pack: 500mg Day 1 and 250mg Day 2-5
• Dose BID Z-pack: Daily
• Max. # of doses 1 (initial dose at time of assessment) 1 (initial dose at time of assessment)

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• Approximately 20 % of the population may carry Group A Strep asymptomatically.
• Those experiencing significant difficulties swallowing, drooling, presence of altered voice (‘hot potato’ voice), or airway obstruction should be sent to ER.
• If patient is in severe distress, initiate transport to emergency department.
• Consider ePOC blood analysis if most recent eGFR > 6 months

POST TREATMENT PLAN

• Ensure patient understands medication instructions and red flags.
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours & home visit within 2–3 days if symptoms persist or if additional vitals/lab reassessment is required.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Mild to Moderate COPD exacerbation directive has been initiated
• AND Worsening COPD likely bacterial in origin with ≥2 of the following:
• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence (Thick, yellow/green, opaque mucus)
• AND Medically stable for home management

• Patient specific COPD action plan on file overrides this directive and should be followed

CONDITIONS

• Doxycycline (Simple Exacerbation) Amoxicillin/Clavulanate (Complicated Exacerbation)
• Age: > 18 > 18 years
• LOA: Unaltered Unaltered
• HR: 50–120 bpm 50–120 bpm
• SBP: Normotension Normotension
• RR: ≤ 28 bpm ≤ 30 bpm
• Other: Any of the following risk factors for resistant bacteria:
• Recent antibiotic use (<3 months)
• ≥2 exacerbations/year or recent hospitalization
• Comorbidities (cardiac, diabetes, renal, immunosuppression)

CONTRAINDICATION

• Doxycycline (Simple Exacerbation)
• Amoxicillin/Clavulanate (Complicated Exacerbation)
• Allergy or sensitivity to Doxycycline Allergy to penicillins or β-lactam antibiotics
• Recent use of Doxycycline in past 3 months. Use of same antibiotic class within past 3 months
• Pregnant or breastfeeding Recent C. difficile infection
• > 1 COPD exacerbation within past 12 months Most recent eGFR < 30 within last 6 months
• Multiple or Uncontrolled comorbidities

TREATMENT

Mandatory Consultation Point: Request prescription for either 13 doses (7 days) of Doxycyline BID or 9 doses (5 days) of Amoxicillin/Clavulanate BID

• Consider Doxycycline (Simple Exacerbation)
• Amoxicillin/Clavulanate (Complicated Exacerbation)
• Route PO PO
• Max single Dose 100 mg 875/125 mg
• Dosing Interval Repeat BID (morning/night) Repeat BID (morning/night)
• Max. # of doses 1 (Initial dose at time of assessment) 1 (Initial dose at time of assessment)

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• If patient is in severe distress, initiate transport to emergency department
• Consider setting up remote patient monitoring for SP02 for one week or duration of treatment plan in order to help gauge effectiveness
• Consider ePOC blood analysis if most recent eGFR > 6 month

POST TREATMENT PLAN

• Ensure patient understands medication instructions and red flags.
• Consider oxygen saturation Remote Patient Monitoring (RPM) for 1-2 weeks
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours & home visit within 2–3 days if symptoms persist or if additional vitals/lab reassessment is required.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Mild to moderate musculoskeletal pain (e.g., sprain, strain, minor soft tissue injury)
• AND Patient-reported pain score ≥4/10
• AND Pain present for <72 hours

CONDITIONS

• Acetaminophen Ibuprofen Ketorolac
• Age: > 18 years of age > 18 years of age > 18 years of age
• LOA: Unaltered Unaltered Unaltered
• HR: N/A N/A N/A
• SBP: Normotension Normotension Normotension
• RR: N/A N/A N/A
• Other: Ketorolac is restricted to those who are unable to tolerate oral medication

CONTRAINDICATIONS

• Acetaminophen Ibuprofen Ketorolac
• Acetaminophen use within previous 4 hours
• NSAID use within previous 6 hours
• NSAID use within previous 6 hours
• Allergy/sensitivity to acetaminophen
• Allergy/sensitivity to ASA or
• NSAIDs
• Allergy/sensitivity to ASA or
• NSAIDs
• Signs or symptoms indicative of intoxication
• Patient on anticoagulation therapy
• Patient on anticoagulation therapy
• Major Burns Current active bleeding Current active bleeding
• History of liver disease Hx of peptic ulcer disease or GI bleed
• Hx of peptic ulcer disease or GI bleed
• Active vomiting

TREATMENT

Consider Primary Care or Medical Oversight Consultation Point

• Consider Acetaminophen Consider Ibuprofen Consider Ketorolac
• Route PO PO IM
• Max. single dose 1000 mg 400 mg 10 mg
• Dose 960-1000 mg 400 mg 10 mg
• Max. # of doses 1 1 1

CLINICAL CONSIDERATIONS

• If patient is in severe distress, initiate transport to emergency department
• Assess for the cause and primary source of pain
• Whenever possible, both acetaminophen and ibuprofen should be used together .
• Ibuprofen and Ketoralac is not to be administered concurrently.

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24-48 hours

• If symptoms persist/worsen > 48 hours, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Intended for patients experiencing an uncomplicated headache conforming to the patient’s usual pattern.

CONDITIONS

• Acetaminophen
• Age: > 18 years of age
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Acetaminophen
• Acetaminophen use within previous 4 hours
• Allergy/sensitivity to acetaminophen
• Signs or symptoms indicative of intoxication
• Head trauma within previous 24 hours
• Repeat headache inconsistent with patient’s normal headache pattern
• Any new neurological symptoms
• Fever
• History of cancer

TREATMENT

Consider Primary Care or Medical Oversight Consultation Point

• Consider Acetaminophen
• Route PO
• Max. single dose 650 mg
• Dose 325-650 mg
• Max. # of doses 1

CLINICAL CONSIDERATIONS

• If patient is in severe distress, initiate transport to emergency department

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24-48 hours

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Intended for patients experiencing Signs & symptoms consistent with a minor allergic reaction
• AND Possible exposure to an allergen

CONDITIONS

• Diphenhydramine
• Age: > 18 years of age
• LOA: Unaltered
• HR: N/A
• SBP: Normotension
• RR: N/A WEIGHT: > 25kg

CONTRAINDICATIONS

• Diphenhydramine
• Allergy or sensitivity to diphenhydramine
• Signs or symptoms indicative of a moderate to severe allergic reaction
• Signs or symptoms indicative of intoxication
• Sedative use in the previous 4 hours
• Wheezing

TREATMENT

Consider Primary Care or Medical Oversight Consultation Point

• Consider Diphenhydramine
• Weight > 25 kg to < 50 kg > 50 kg
• Route IM IM
• Dose 25 mg 50 mg
• Max. # of doses 1 1

CLINICAL CONSIDERATIONS

• Rule out suspected bacterial infections (mild cellulitis, impetigo, scarlet fever) or viral infections (chickenpox, shingles, measles).
• Any patient showing evidence of the following should be transferred to hospital for further investigation:
• Signs of airway obstruction
• Unstable vital signs:

• ▪ Respiratory rate <10 or >29 ▪ Oxygen saturation <92% on home air ▪ Pulse rate <50 or >120 ▪ Systolic BP < 90 ▪ Altered LOA
• Definite exposure to a trigger that has previously lead to an anaphylactic reaction
• Self administration of adrenaline (epinephrine) by a patient for a suspected anaphylactic reaction
• A suspected anaphylactic reaction that has not fully developed
• Suspected rash of meningococcal septicaemia
• Other features of concern —for example, Patient is in severe distress, considerable pain
• or swelling, adverse social circumstances (lives alone, family unable to cope, etc)

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24-48 hours

• Monitor for 30 minutes post-treatment to rule out delayed reaction.
• Educate on avoidance of trigger and when to escalate care.
• If symptoms persist/worsen > 48 hours, perform follow-up visit and advise patient to be seen in emergency department.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Nausea and/or vomiting

CONDITIONS

• Dimenhydrinate Ondansetron
• Age: > 18 years < 65 years of age > 18 years of age
• LOA: Unaltered Unaltered
• HR: N/A N/A
• SBP: Normotension Normotension
• RR: N/A N/A WEIGHT: > 25 kg > 25 kg

CONTRAINDICATIONS

• Dimenhydrinate Ondansetron
• Allergy/sensitivity to Dimenhydrinate or Antihistamines Allergy/sensitivity to Ondansetron
• Overdose on antihistamines or anticholinergics or tricyclic antidepressants
• Prolonged QT syndrome (known to patient)
• Co-administration of diphenhydramine Apomorphine use

TREATMENT

Consider Primary Care or Medical Oversight Consultation Point

• Consider Dimenhydrinate Consider Ondansetron
• Weight > 25 kg to < 50 kg > 50 kg > 25 kg
• Route IM IM PO
• Dose 25 mg 50 mg 4 mg
• Max. # of doses 1 1 1

CLINICAL CONSIDERATIONS

• Assess for the cause and primary source of nausea/vomiting
• If the likely diagnosis is a non-specific viral illness, the patient can be left at home (assuming there is someone to care for them or they are capable of looking after themselves).
• Any patient showing evidence of the following should be transferred to hospital for further investigation:
• Altered level of consciousness
• Dehydration
• Neurological symptoms/signs
• Unusual, or uncertain rash

• Significant pain or distress
• Abdominal distension
• Temperature >39°c
• Signs of jaundice
• Drug/alcohol ingestion
• Blood in vomit

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24-48 hours

• Monitor for symptom improvement within 30 minutes post-medication.
• Educate patient on hydration and dietary adjustment.
• If symptoms persist/worsen > 48 hours, perform follow-up visit and advise patient to be seen in emergency department.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Intended for patients who has suspected or confirmed influenza and is experiencing severe protracted diarrhea.

CONDITIONS

• Loperamide Hydrochloride (Imodium®)
• Age: > 65 years of age
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Loperamide Hydrochloride (Imodium®)
• Dehydration
• Allergy or sensitivity to Loperamide Hydrochloride (Imodium®)
• Abdominal pain in the absence of diarrhea
• Patient taking Gemfibrozil (treatment of hypercholesterolemia)
• Patient taking Quinidine (class I antiarrhythmic)
• Patient taking Quinine (anti-malarial)
• Patient taking Ritonavir (anti-retroviral)
• Patient taking stomach acid reducers—cimetidine, ranitidine
• Patient taking Antibiotics—clarithromycin & erythromycin
• Patient taking Antifungal medicine—itraconazole & ketoconazole
• Not be used as the primary therapy for:
• Acute ulcerative colitis,
• Acute dysentery, which is characterized by blood in stools and high fever,
• Bacterial enterocolitis caused by invasive organisms including Salmonella, Shigella, and
• Campylobacter.
• Patients with pseudomembranous colitis associated with the use of broad- spectrum antibiotics.

TREATMENT

Consider Primary Care or Medical Oversight Consultation Point

• Consider Loperamide Hydrochloride (Imodium®)
• Route PO
• Max. single dose 4 mg
• Dosing Interval 2 mg subsequent dose after each unformed stool
• Max. # of doses 1 (Initial dose at time of assessment)

CLINICAL CONSIDERATIONS

• If patient is in severe distress, initiate transport to emergency department
• Monitor for signs of abdominal distension or reduced bowel sounds, which could indicate potential paralytic ileus.
• Symptoms of overdose may include constipation, CNS depression, and respiratory depression.

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 48-72 hours

• Monitor hydration status and provide symptom education.
• If bloody stools, fever, or dehydration noted, advise patient to be seen in emergency department.
• If symptoms persist/worsen > 48 hours, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Handling Biomedical and Infectious Substances
certificate if transporting specimen to lab.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires an oropharyngeal specimen swab per Nurse Practitioner, or Physician requisition for Step A or other pathogens.
• OR Patient has a clinical presentation of sore throat with a score of 2-3 (see pharyngitis directive)
• AND A requisition for culture has been acquired from the primary care provider, or medical oversight has been contacted for unattached patients, or rapid strep test is available and required for medical directive.

CONDITIONS

• Oropharyngeal Specimen Collection or Rapid Antigen Test
• Age: > 18 years of age
• LOA: Unaltered from normal
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Oropharyngeal Specimen Collection or Rapid Antigen Test
• No consent from patient or substitute decision maker.
• Inflamed epiglottis
• Inability to transport the specimen to the lab within 24hrs if transporting specimen.

PROCEDURE

• Perform Oropharyngeal swab collection and either perform rapid antigen test or transport to laboratory as per procedural guidelines.

CLINICAL CONSIDERATIONS

• The patient should NOT eat, drink, chew gum, smoke, or vape for at least 30 minutes before collecting the specimen.
• NOTES: Label the test tube with full name, date of collection and one other unique identifier such as date of birth or Health Card Number if transporting to lab.
• Attempt to acquire requisition from the primary care provider if Community Paramedic feels there is a need for culture and patient does not meet criteria for POC.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Handling Biomedical and Infectious Substances
certificate if transporting specimen to lab.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedic Program who requires a nasopharyngeal PCR swab per Nurse Practitioner, or Physician requisition for COVID-19 and respiratory infections such as influenza A/B, RSV, ADV, MP.
• OR Patient is presenting with signs or symptoms of acute respiratory infection when rapid identification may assist in immediate clinical decision-making or outbreak recognition.

CONDITIONS

• Nasopharyngeal Specimen or Rapid Antigen Test
• Age: > 18 years of age
• LOA: Unaltered from normal
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Nasopharyngeal Specimen Collection or Rapid Antigen Test
• No consent from patient or substitute decision maker.
• Inability to transport the specimen to the lab within 24hrs if transporting specimen.

PROCEDURE

• swab collection and either perform rapid antigen test or transport to laboratory as per procedural guidelines.

CLINICAL CONSIDERATIONS

• The patient should NOT eat, drink, chew gum, smoke, or vape for at least 30 minutes before collecting the specimen.
• Caution and clinical judgment may be advised when swabbing individuals with recent facial trauma, severe epistaxis, aspiration risk, and/or abnormalities of the nasal and oral anatomy.
• To maintain optimum viability, the specimen should be stored at 2-8°C if delay in transporting.
• NOTES: Label the test tube with full name, date of collection and two unique identifier such as date of birth or Health Card Number.

• Attempt to acquire requisition from the primary care provider if Community Paramedic feels there is a need for culture.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Handling Biomedical and Infectious Substances
certificate and Wound Care and Ostomy certificate.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires a wound culture specimen swab for wounds per Nurse Practitioner, or Physician requisition.
• OR Infected wounds that do not respond to or are deteriorating despite antimicrobial and/or antibiotic treatment or require local surveillance for drug resistant organisms.

CONDITIONS

• Wound Culture Collection
• Age: > 18 years of age
• LOA: Unaltered from normal
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Wound Culture Collection
• No consent from patient or substitute decision maker.
• Wounds that have been cultured within the last 24 – 72 hours.
• Inability to transport the specimen to the lab within 24hrs.
• The absence of signs of infection or delayed healing unless screening for drug resistant organisms is required.
• Dry, non-exudative wounds or wounds covered with necrotic eschar or slough.

Consider MRP Consultation Point

PROCEDURE

• Perform wound swab collection and transport to laboratory as per procedural guidelines.
• Document what type of dressing was on the wound and note on the sample container if an antibacterial dressing was used.

CLINICAL CONSIDERATIONS

• Ensure that the wound site is not cleansed with antiseptics or other agents that might inhibit bacterial growth before sample collection.
• Care should be taken with patients who have poor wound healing capabilities or are on immunosuppressive therapy.
• Specimens may be stored at 2-8°C and delivered to the lab within 24 hours.
• NOTES: Label the culture container with the patient's full name, date of collection, and two unique identifier such as date of birth or Health Card Number.
• Attempt to acquire requisition from the primary care provider if Community Paramedic feels there is a need for culture. (Use Standing Medical Requisition for unattached patients or if the primary care provider is unavailable)

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Handling Biomedical and Infectious Substances
certificate.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires a sputum culture specimen per Nurse Practitioner, or Physician requisition.
• OR Suspected lung infection and patient is presenting with a cough that produces dark yellow or greenish brown sputum with/without pain when breathing.
• AND A requisition has been acquired from the primary care provider or medical oversight has been contacted for unattached patients.

CONDITIONS

• Sputum Culture Collection
• Age: > 18 years of age
• LOA: Unaltered from normal
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Sputum Culture Collection
• No consent from patient or substitute decision maker.
• Inability for patient to produce sputum by coughing.
• Inability to transport the culture within 24hrs of taking the culture.

PROCEDURE

• Perform sputum collection and transport to laboratory as per procedural guidelines.

CLINICAL CONSIDERATIONS

• There must be at least 5 ml (1 teaspoon) of sputum, replace the lid on the container and tighten it so it does not leak.
• Too much saliva will compromise the sputum specimen.
• Specimens may be stored at 2-8°C and delivered to the lab within 24 hours.
• NOTES: Label the culture container with the patient's full name, date of collection, and two unique identifier such as date of birth or Health Card Number.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Handling Biomedical and Infectious Substances
certificate and authorization from medical oversight to perform Phlebotomy.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires phlebotomy or POC blood analysis per Nurse Practitioner, or Physician requisition and requisition for bloodwork or verbal order for POC blood analysis has been provided.
• OR A blood sample is required to fulfill other authorized Community Paramedicine medical directives.

CONDITIONS

• Phlebotomy POC Blood Analysis
• Age: > 18 > 18
• LOA: Unaltered from normal Unaltered from normal
• HR: N/A N/A
• SBP: N/A N/A
• RR: N/A N/A
• Other: Patient is homebound or has significant mobility problems or seen at Clinic/Event.
• Required for a CP medical directive or ordered by primary care provider.

CONTRAINDICATIONS

• Phlebotomy POC Blood Analysis
• Sample CAN NOT be delivered to the laboratory/collection site in the timeframe required (during open hours).
• Blood analysis is not required to support a
• Community Paramedicine medical directive OR the ordering primary care provider is not available for consultation (phone or video) within 30 minutes of obtaining results.
• No consent from patient or substitute decision maker.
• No consent from patient or substitute decision maker.
• Allergy or sensitivity to equipment used. N/A

PROCEDURE

• Perform blood collection and transport to laboratory as per procedural guidelines.
• Escalate to 911 if POC Blood Analysis results are within critical range and unable to contact the patient’s healthcare provider or medical oversight for further direction.

POST TREATMENT PLAN

• Send Point-of-Care results to primary care provider or medical oversight if no primary care provider.
• Consult primary care provider or escalate to 911 if patient condition deteriorates during the procedure.

• If unable to collect a complete sample, indicate “incomplete sample collection” on the requisition when dropping it off at the lab, or note if the sample is an additional collection to complete a previous draw.

BLOOD DRAW ORDER

• TOP COLOUR ADDITIVE COMMON TESTS SPECIAL INSTRUCTIONS

• Blood culture Aerobic + anaerobic Aerobic first
• Sodium citrate Coagulation, d-dimer.
• Thrombophilia screen
• Invert 3-4 times.
• Fill to intended line.
• Clot activator/plain Serology: Viral, fungal, bacterial.
• Request of laboratory Invert 5-6 times.
• Clot activator,
• Separation gel
• Urea & electrolytes, bone profile, liver function tests, thyroid function tests, troponin, lipid profile, immunology, serology
• Invert 5-6 times.
• Lithium heparin (light)
• Sodium heparin (dark)
• Ammonia, homocysteine.
• Routine biochemistry Invert 8-10 times.
• EDTA Full blood count, HbA1c, ESR.
• Peripheral blood film Invert 8-10 times.
• EDTA for Crossmatch Group & save, Cross-match direct anti-globulin test (DAT) Invert 8-10 times.
• EDTA /Plain Trace elements Invert 8-10 times.
• Fluoride oxalate Serum glucose
• Serum lactate Invert 8-10 times.
• NOTES: Label the collection tubes with the patient's full name, date of collection, and two unique identifier such as date of birth or Health Card Number.
• Gases +
• Test Normal Range Critical Low Critical High pH 7.35 – 7.45 < 7.0 > 7.7
• Chem+
• Sodium (Na⁺) 135 – 145 mmol/L < 120 mmol/L > 160 mmol/L
• Potassium (K⁺) 3.5 – 5.0 mmol/L < 2.5 mmol/L > 6.5 mmol/L
• Ionized Calcium (Ca⁺⁺) 1.1 – 1.3 mmol/L < 0.6 mmol/L N/A
• Chloride (Cl⁻) (M) 99 – 108 mmol/L (F) 98 – 109 mmol/L < 80 mmol/L > 125 mmol/L
• Total CO₂ (TCO₂) 24 – 29 mmol/L < 15 mmol/L > 40 mmol/L
• Hematocrit (Hct) (M) 0.40 – 0.54 L/L (F) 0.35 – 0.47 L/L ≤ 0.25 L/L ≥ 0.60 L/L
• Calculated Hemoglobin (cHgb) 120-170 g/L < 100 g/L > 180 g/L
• Meta+
• Glucose 4.1 – 5.5 mmol/L < 2.5 mmol/L > 25 mmol/L
• Lactate 0.5 – 2.5 mmol/L N/A > 4.0 mmol/L
• Urea
• BUN 2.9 – 9.3 mmol/L 8 – 26 mg/dL
• < 0.7 mmol/L
• N/A
• > 43.2 mmol/L
• N/A
• Creatinine (Crea) 45 – 105 µmol/L > 126 µmol/L N/A

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Handling Biomedical and Infectious Substances
certificate.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires Urine Sample Collection per Nurse Practitioner, or Physician requisition and requisition has been provided.
• OR Patient enrolled in the Parry Sound District Community Paramedicine and meets criteria for uncomplicated UTI Medical Directive

• Non-Catheterized Patient Catheterized Patient Acute dysuria OR 2 or more of the following:
• Fever > 37.9°C (100°F) or a 1.5°C increase above baseline on at least two occasions of the last 12 hours
• New or worsening urgency
• Frequency
• Suprapubic pain or pressure
• Gross hematuria
• Flank pain
• Urinary incontinence Any one of the following after alternate explanations have been excluded:
• Fever > 37.9°C (100°F) or a 1.5°C increase above baseline on at least two occasions of the last 12 hours
• Flank pain
• Shaking chills
• New onset delirium 1- Note that these are clinical criteria validated for diagnosis for a UTI and differ from criteria that are used for surveillance.
• 2- Note that confusion alone is not a symptom of a UTI in non-catheterized patients.

Mandatory Consultation Point: Patients who have a fever and/or vomiting and/or tenderness on palpation over the flank or lower back could have pyelonephritis or nephrolithiasis.

CONDITIONS

• Urine Sample Culture Collection Urinalysis Point-of-Care Testing
• Age: > 18 years of age > 18 years of age
• LOA: N/A N/A
• HR: N/A N/A
• SBP: N/A N/A
• RR: N/A N/A Criteria: Considered for catheterized patients or those considered complicated UTI Uncomplicated UTI symptoms
• Other: Patient must be reasonably unable to access other community services, or it is unsafe/unreasonable for them to attend.
• Patient must be reasonably unable to access other community services, or it is unsafe/unreasonable for them to attend.

CONTRAINDICATIONS

• Urine Sample Culture Collection Urinalysis Point-of-Care Testing
• No consent from patient or substitute decision maker.
• No consent from patient or substitute decision maker.
• Specimens can not be delivered to the lab within 24 hours. (For sample collection to lab only)
• Patient is catheterized or is considered a complicated UTI
• Patient was treated for an uncomplicated UTI in the last 3 months

Consider MRP Consultation Point

PROCEDURE

• Perform urine collection using sterile container, analysis of urine using urinalysis point-of-care testing
• and transport of specimen to laboratory if required as per procedural guidelines.
• Urine sample MUST be collected and brought to a laboratory for cultures if:
• Male patient with UTI
• Any patient with previous UTI in the last 3 months that required antibiotic treatment.
• Any patient at risk of developing a complicated UTI: multiple comorbidities and/or frailty.

INTERPRETATION

• Leukocytes (LEU) more than a trace (>75 leu/UL) = POSITIVE for potential UTI
• Nitrites (NIT) (pos) + Blood (ERY) (> Trace (TR) = POSITIVE for potential UTI
• Nitrites (NIT) (pos) + Leukocytes (LEU) (>25 leu/UL) = POSITIVE for potential UTI

Mandatory MRP SOAP notification required that treatment was started

CLINICAL CONSIDERATIONS

• Specimens may be stored at 2-8°C and delivered to the lab within 24 hours.
• Specific Gravity (SG): Assesses the concentration of urine.
• Well Hydrated < 1.010
• Minimal Dehydration 1.010.-1.020
• Significant Dehydration 1.021-1.030
• Serious Dehydration >1.030
• Nitrites (NIT): in the absence of Leukocytes (LEU) or Blood (ERY) is NOT a positive for UTI
• Blood (ERY): ALONE is NOT a positive for UTI
• pH Level (PH): Evaluates the acid-base balance, important for kidney stone prevention.
• Protein (PRO): Could suggest kidney issues.
• Glucose (GLU): Elevated levels may indicate diabetes.
• Ketones (KET): Could be present in diabetes or starvation.
• Bilirubin and Urobilinogen (BIL & UBG): Elevated levels suggest liver or gallbladder issues.
• NOTES: Label the culture container with the patient's full name, date of collection, and two unique identifier such as date of birth or Health Card Number.

• Attempt to acquire requisition from the primary care provider for suspected complicated. (Use Standing
• Medical Requisition for unattached patients or if the primary care provider is unavailable)

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATION

• Order for INR POC test from Physician, NP, or Anti-coagulation Clinic
• AND Patient is under the care of a physician or nurse practitioner.
• AND The patient requires regular INR testing and is homebound or has severe mobility problems.

CONDITIONS

• INR Point-of-Care Testing
• Age: > 18 years of age
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• INR Point-of-Care Testing
• Patient not currently taking Warfarin.
• No consent from patient or substitute decision maker.

PROCEDURE

• Perform INR point-of-care test as per procedural guidelines.
• If INR is outside the patient’s target range, use the INR Standing Medical Requisition and draw a venous sample for lab confirmation and provider review.

• Escalate to 911 if INR results are dangerously low or high (<0.8 or >4.5) and unable to contact the patient’s healthcare provider or medical oversight for further direction.

CLINICAL CONSIDERATIONS

• For each out-of-range INR value, attempt to identify and document the cause:
• Current warfarin dose? Inquire about the possibility of taking a dosage other than the prescribed one? Any missed dosages within the last week?
• Any medications being stopped/started recently? Any new changes in dosages?
• Any variances in diet? Any changes in alcohol consumption?

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient has condition which requires regular blood glucose monitoring.
• OR Patient presents as hypoglycemic or hyperglycemic.
• AND The patient is enrolled in the Parry Sound District Community Paramedic program or seen at clinic/event.

CONDITIONS

• Glucometry Point-of-Care Testing
• Age: > 2 years of age
• LOA: N/A
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Glucometry Point-of-Care Testing
• No consent from patient or substitute decision maker.

PROCEDURE

• Perform glucometry point-of-care test as per procedural guidelines.

• Repeat glucose test if initial reading is extremely low (<2.5 mmol/L) or high (>25 mmol/L).

• Escalate to 911 if glucose results are dangerously low or high and unable to contact the patient’s healthcare provider or medical oversight for further direction.
• NOTES: The normal fasting blood glucose range for adults without diabetes is approximately 4.0-5.9 mmol/L. For most patients with diabetes, the target range before meals is 4.0-7.0 mmol/L.
• For each out-of-range glucose value, attempt to identify and document the cause:
• Current insulin or oral hypoglycemic dose? Possibility of taking a dosage other than the prescribed one? Any missed dosages within the last week?
• Any medications being stopped/started recently? Any new changes in dosages?
• Any variances in diet? Any changes in alcohol consumption? Any changes in general health?
• Any condition that may affect blood glucose levels?

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Minor abrasion, minor cuts, minor burns which would benefit from infection prevention or treatment.

CONDITIONS

• Minor Abrasion
• Age: > 2 years of age
• LOA: Unaltered
• HR: N/A
• SBP: N/A
• RR: N/A

CONTRAINDICATIONS

• Minor Abrasion
• Allergy/sensitivity to the ingredients in the topical antibiotic (Polymyxin B & Bacitracin)

PROCEDURE

• Apply topical antibiotic ointment (Polymyxin B & Bacitracin) 1-3 times daily for 7 days as per procedural guidelines.

CLINICAL CONSIDERATIONS

• Ideal for minor abrasions on the face where bandaging is not practical.
• Avoid getting the medicine in the eyes, nose, or mouth.

POST TREATMENT PLAN

• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Wound Care and Ostomy certificate.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires suture removal per Nurse Practitioner, or Physician order.
• AND Patient is homebound or has significant mobility problems or is seen at Clinic/Event.

CONDITIONS

• Staple and Suture Removal
• Age: > 18 years of age
• LOA: Unaltered
• Other: An order must be received from the primary care provider. Contact medical oversight for unattached patients.

CONTRAINDICATIONS

• Name
• No consent from patient or substitute decision maker.
• Signs of wound infection (e.g., increased redness, swelling, heat, pus discharge).

PROCEDURE

• Perform interrupted or uninterrupted suture removal or surgical staple removal as per procedural guidelines.
• If the wound begins to separate during staple or suture removal, stop the procedure immediately
• and send a report to the primary care provider for follow-up.

CLINICAL CONSIDERATIONS

• Ensure the wound has healed appropriately before suture removal, typically around 7-14 days depending on the location and type of wound.
• Document the number of sutures removed and the condition of the wound.
• NOTES: Always ensure patient comfort and provide reassurance throughout the procedure and properly dispose of all used materials in a biohazard container.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Wound Care and Ostomy certificate.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires wound closure for category 1 or 2 skin tears or simple, thoroughly cleansed small (≤ 3 – 5 cm) lacerations with easily approximated, skin edges using 2-octyl Cyanoacrylate Tissue Adhesive.

CONDITIONS

• Wound Closure Using Cyanoacrylate Tissue Adhesive
• Age: >18 years of age
• LOA: Unaltered

CONTRAINDICATIONS

• Wound Closure Using Cyanoacrylate Tissue Adhesive
• No consent from patient or substitute decision maker.
• More than 12 hours since injury occurred.
• Known allergy or sensitivity or allergy to cyanoacrylate.
• Wounds under high tension or over joints with significant movement.
• Signs of wound infection (e.g., increased redness, swelling, heat, pus discharge).

PROCEDURE

• Perform wound cleansing and confirm edges are well-approximated without tension, then apply a thin layer of cyanoacrylate tissue adhesive over the wound as per procedural guidelines.

Mandatory Primary Care Provider notification required when treatment is provided without direct orders

CLINICAL CONSIDERATIONS

• Ensure the wound remains dry and avoid applying ointments or creams over the glue.
• Advise the patient to avoid vigorous activities that may disrupt the wound closure.
• Wounds must be cleansed very well, and debris removed.
• Ensure tetanus vaccine status.

POST TREATMENT PLAN

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours & home visit in 48-72 hours

• NOTES: Document the procedure, including the condition of the wound before and after closure, and any patient instructions provided.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The Paramedic must also have a valid Wound Care and Ostomy certificate.

INDICATIONS

• Patient enrolled in the Parry Sound District Community Paramedicine Program who requires wound care with Povidone Iodine 10% or Chlorhexidine 0.5% in white paraffin for the following:
• Povidone Iodine 10% Chlorhexidine 0.5% in white paraffin (Bactigras)

• Dry eschar covering a wound where the goal of healing has been determined by a Wound Clinician/physician/NP as Non- Healable or Maintenance.

• Treatment of wounds with signs and symptoms (S&S) of local infection.
• In combination with systemic antibiotics, to treat wounds with S&S of spreading infection or systemic infection.
• Prophylactically to prevent infection in clients at high risk for developing a wound infection.

CONDITIONS

• Povidone Iodine 10% Chlorhexidine 0.5% in white paraffin (Bactigras)
• Age: >18 years of age >18 years of age
• LOA: Unaltered Unaltered

CONTRAINDICATIONS

• Povidone Iodine 10% Chlorhexidine 0.5% in white paraffin (Bactigras)
• No consent from patient or substitute decision maker.
• No consent from patient or substitute decision maker.
• Known allergy or sensitivity. Sensitivity or allergy to chlorhexidine or any other components of the dressing.
• Concurrent use of silver-based dressings. Do not use with oxidising solutions (e.g., hypochlorite and hydrogen peroxide solutions).
• Concurrent use of enzymatic debriders.
• Thyroid disease or concurrent lithium therapy.
• Renal impairment.
• Do not apply to extensive irritated or broken skin.
• Do not use under occlusive dressings.

PROCEDURE

• Perform application of a thin layer of Povidone-Iodine 10% and/or apply Chlorhexidine 0.5% (Bactigras) dressing directly to the wound bed with even coverage, followed by an appropriate secondary dressing, as per procedural guidelines.

Consider Medical Oversight Consultation Point If Any Complications Arise

CLINICAL CONSIDERATIONS

• Use iodine judiciously to avoid cytotoxic effects on healthy tissue and promote optimal wound healing.
• Advise the patient on the need for regular dressing changes and when to seek further medical advice.
• Ensure the wound has healed appropriately before reapplication if needed, typically assessing every 7-14 days depending on the type and location of the wound.
• Monitor the wound for any signs of adverse reactions or allergic responses.
• NOTES: Document the procedure, including the condition of the wound before and after Povidone
• Iodine 10%/Chlorhexidine 0.5% (Bactigras) application.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedic
Program may provide the following treatment during a community home visit if authorized stated in this
Medical Directive.

INDICATIONS

• Need for intravenous access for Home and Community Care Support Services (HCCSS).
• AND IV initiation or restart within the community with saline lock only.

CONDITIONS

• Initiation of Intravenous Access
• Age: > 18
• LOA: N/A
• HR: N/A
• SBP: N/A
• RR: N/A
• Other: Patient must have an active file with HCCSS and be able to be directed to them for follow- up IV care.
• HCCSS must be unable to provide IV care for that patient at that time using mainstream home care service agencies due to extenuating circumstances such as, the Service Provider nurse has made attempts to initiate the IV as per the Service Provider’s respective protocol and has been unsuccessful or HCCSS has been unable to secure access to trained staff.
• Prior to initiation of intravenous access, the CP must confirm with HCCSS that a nurse is available for treatment within 4-6 hours.
• Community Paramedic will only accept requests for intravenous access from (or confirmed by) HCCSS.

CONTRAINDICATIONS

• Initiation of Intravenous Access
• Cellulitis to intravenous site
• Suspected fracture proximal to the access site

PROCEDURE

• Initiate IV cannulation and saline lock as per procedural guidelines and notify HCCSS regarding IV status to support additional treatment or care planning.
• NOTES: CP will not perform any of the following:
• Operate an IV pump or connect an IV cannula to an IV pump.
• Initiate fluid therapy under this directive.
• Administer medications via the saline lock under this directive.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patients enrolled in the Parry Sound District Community Paramedicine Program
• AND Is homebound and requires Otoscopy Imaging per Nurse Practitioner, or Physician.
• OR Patient has any of the following symptoms related to ear complaints: Pain and/or discomfort inside the ear, discharge running from the ear, feeling of pressure or fullness inside the ear.

CONDITIONS

• Otoscopy
• Age: > 18 years of age
• LOA: Unaltered

CONTRAINDICATIONS

• Otoscopy
• Presence of severe trauma or burns involving the ear, which may require surgical evaluation instead.
• Patients who exhibit severe pain which may be exacerbated by the procedure.
• Known or suspected eardrum perforation where the introduction of the speculum could worsen the condition.
• Patients with a history of ear surgeries where manipulation of the ear canal could disrupt surgical outcomes.
• Presence of severe trauma or burns involving the ear, which may require surgical evaluation instead.
• No verbal consent from patient or substitute decision maker.

PROCEDURE

• Insertion of speculum of otoscope into the external ear canal and inspect the tympanic membrane (TM), assessing both Rt and Lt ear as per procedural guidelines.

CLINICAL CONSIDERATIONS

• Ensure proper insertion technique to avoid discomfort or injury to the ear canal. Visualization of the entire tympanic membrane is essential for accurate assessment.

POST TREATMENT PLAN

• Advise on further medical treatment based on findings and refer to primary care if abnormalities are detected that require advanced care.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient is homebound and requires ear wax removal per Nurse Practitioner, or Physician.
• OR Confirmation of earwax impaction via otoscope examination, showing visible earwax obstructing the ear canal.

CONDITIONS

• Ear Irrigation
• Age: > 18 years of age
• LOA: Unaltered

CONTRAINDICATIONS

• Ear Irrigation
• Presence of severe trauma or burns involving the ear, which may require surgical evaluation instead.
• Patients who exhibit severe pain which may be exacerbated by the procedure.
• Known or suspected eardrum perforation where the introduction of the speculum could worsen the condition.
• Patients with a history of ear surgeries where manipulation of the ear canal could disrupt surgical outcomes.
• Previous history of tympanic membrane rupture.
• Active ear infection or inflammation (otitis externa or otitis media).
• No consent from patient or substitute decision maker.

PROCEDURE

• Using a syringe, gently introduce warm water into the ear canal, avoiding forceful irrigation to prevent injury as per procedural guidelines, then reassess using otoscope.

CLINICAL CONSIDERATIONS

• Preferable if patient can self administer 4 drops of mineral oil daily before bed for 5 days to soften wax and schedule the flush procedure for the 6th day.

POST TREATMENT PLAN

• Record findings before and after the procedure, including the appearance of the tympanic membrane
• and the amount of wax removed
• Educate the patient on ear care and prevention of future wax build-up.
• If symptoms persist/worsen, perform follow-up visit and contact patient’s primary care provider for consultation with recommendation for scheduled appointment.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event. The paramedic must also have completed the relevant training module.

INDICATIONS

• Requirement for catheter maintenance as part of ongoing patient care
• AND Presence of occlusion or suspected occlusion in the catheter

CONDITIONS

• Catheter Flushing
• Age: > 18 years of age
• LOA: Unaltered

CONTRAINDICATIONS

• Catheter Flushing
• Evidence of infection at the catheter insertion site.
• Severe bleeding disorders or anticoagulation therapy not cleared by a medical professional.
• No consent from the patient or substitute decision maker

TREATMENT

• Catheter Flushing
• Route Intraluminal (catheter)
• Dose 15-30 ml Normal Saline Sodium Chloride 0.9%
• Max # of Dose 3
• Dosing Interval 2-5min

Mandatory patient follow-up required when treatment is provided: phone call in 24 hours

CLINICAL CONSIDERATIONS

• If more then moderate resistance is met during flushing, do not force the flush and reassess the catheter for possible occlusion or kinking, if no obvious kinks and blockage is not cleared with moderate pressure escalate to appropriate medical oversight / primary care
• If signs of infection (redness, swelling, warmth, discharge) are observed, contact the primary care provider for further instructions.
• Maintain aseptic technique throughout the procedure to prevent introducing infections.
• Document the procedure and patient response in the medical record and report any complications to the primary care provider or medical oversight.
• If available and staff trained, please perform POCUS to ensure no urinary retention

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program, and paramedic student under the supervision of an authorized community paramedic, may
provide the following treatment stated in this Medical Directive during a community home
visit/clinic/event.

INDICATIONS

• Patient requires a continuous glucose monitoring (CGM) device to manage their condition per Nurse Practitioner, diabetes educator, or Physician.

CONDITIONS

• Application Of Continuous Glucose Monitoring (CGM) Device
• Age: > 18 years of age
• LOA: Unaltered

CONTRAINDICATIONS

• Application Of Continuous Glucose Monitoring (CGM) Device
• No consent from patient or substitute decision maker.
• No order or prescription.
• Known allergy or hypersensitivity to the adhesive or materials of the sensor.
• Presence of severe trauma or burns involving the intended sensor placement site.
• Active skin infection or inflammation at the intended sensor placement site.

PROCEDURE

• Press the continuous glucose monitoring (CGM) device Sensor applicator firmly against the skin at the cleaned site and push down to apply the sensor as per procedural guidelines.

POST TREATMENT PLAN

• Record the application of the sensor, including the date and time.
• Advise on sensor care and monitoring, including avoiding excessive moisture and impact.
• Educate the patient on the use of the continuous glucose monitoring (CGM) device system, including setting up alerts and interpreting glucose data.
• Provide contact information for support if the patient experiences issues with the sensor or app.

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program may perform focused point-of-care ultrasound during a community or home visit when
certified, authorized, and operating under this directive.

INDICATIONS

• Point-of-Care Ultrasound (POCUS) may be used as an adjunct to clinical assessment in clinically stable patients:

• Bladder Cardiac (Subxiphoid) Lung
• Anuria
• Catheter pre- or post- flushing, poorly draining catheter
• Hematuria
• Abdominal pain
• Urinary retention
• UTI symptoms
• Dyspnea
• Hypotension
• Fever
• Cough
• Chest pain
• Dyspnea
• Hypotension
• Fevers
• Cough
• Hypoxia

• AND
• Support risk identification and clinical decision-making
• Guide care planning and referral pathways
• Monitor known or suspected chronic conditions
• Assist with symptom assessment in community, home-based, or palliative settings.

• POCUS does not replace primary care provider’s diagnostic imaging and must not be used to definitively diagnose or exclude serious pathology.

CONDITIONS

• Bladder Cardiac (Subxiphoid) Lung
• Age: > 18 years of age
• LOA: Unaltered and ability to cooperate
• Other: An appropriate follow-up or escalation pathway is available

CONTRAINDICATIONS

• Bladder Cardiac (Subxiphoid) Lung
• Patient instability or active deterioration
• Patient instability or active deterioration
• Patient instability or active deterioration
• Open abdominal wounds Significant abdominal pain Open chest wounds
• Severe abdominal pain of unknown origin
• Recent abdominal surgery Severe agitation or inability to cooperate
• Recent pelvic trauma without medical oversight
• Rib fractures or chest wall injury Inability to tolerate sitting or semi-upright position.

• Post-operative abdominal or pelvic restrictions
• Inability to tolerate positioning Immediate respiratory compromise requiring urgent transport
• Inability to lay Supine or semi- recumbent
• Respiratory distress

AUTHORISED ASSESSMENTS

• Bladder Cardiac (Subxiphoid) Lung
• Measurement of urinary bladder volume
• Gross estimation of cardiac activity
• Presence of pneumothorax
• Assessment for urinary retention
• Detection of a pericardial effusion
• Presence of pleural effusion
• Pleural interrogation

INTERPRETATION GUIDELINES

• Bladder Volume Interpretation
• < 200 mL Likely adequate emptying
• > 200 mL Probable urinary retention
• > 500 mL Significant urinary retention

• Paramedics may identify the following cardiac (Subxiphoid) scans:
• Gross estimation of cardiac activity (absent, poor, good or indeterminate)
• Detection of a pericardial effusion (negative, positive or indeterminate)
• Paramedics must NOT: Diagnose heart failure severity, estimate ejection fraction, or exclude cardiac pathology based on limited views.
• Lung Interpretations Interpretation
• Smooth pleura, good lung sliding and lung pulse,
• A line present, No B Line’s, No consolidation
• Normal findings
• Consolidation / Shred sign / Dynamic bronchograms
• Possible pneumonia
• Static Bronchograms Atelectasis
• Pleural effusion / Jellyfish sign Fluid accumulation
• Multiple B-lines with abnormal thick lung pleura Interstitial fluid / CHF

Clinical correlation is mandatory.

CLINICAL CONSIDERATIONS

• Diffuse, bilateral, symmetric B-lines: more consistent with fluid overload
• Focal or asymmetric B-lines: consider infection or localized pathology
• Pleural line: Irregular or thickened pleura increases suspicion for:
• Pneumonia
• Chronic interstitial or fibrotic disease
• Consolidation: May represent infection, atelectasis, ARDS, or scarring.

• Chronic disease: Persistent B-lines may reflect baseline chronic lung disease.
• Catheters: Retention with a catheter suggests obstruction, not bladder failure.
• Timing: Bladder volume must be interpreted relative to recent voiding.
• Motion ≠ perfusion: Visible cardiac activity does not guarantee adequate output.
• Baseline: Chronic conditions may produce persistent abnormal findings.
• Adjunct only: POCUS supports decisions but never replaces clinical judgment.

POST ASSESSMENT PLAN

• Minor / Reassuring Findings:
• Bladder volume <200 mL
• Normal cardiac activity, no effusion
• Lung sliding present, no B-lines, no effusion
• Routine CP follow-up as scheduled

• Mild Abnormality / Monitoring Required Findings:
• Bladder volume < 200 mL
• Mild unilateral B-lines without hypoxia
• Small pleural effusion, asymptomatic
• Qualitatively reduced cardiac contractility with stable vitals

Consider MRP or Medical Oversight Consultation Patch Point if findings are new or unclear

• Report to MRP within 48–72 hours if symptoms persist
• Telephone follow-up within 48–72 hours and home visit only if symptoms persist or worsen

• Clinically Significant / Active Management Findings:
• Bladder volume >200 mL with symptoms
• Multiple bilateral B-lines (CHF pattern) without severe hypoxia
• Focal lung consolidation without sepsis
• Recurrent bladder retention with catheter in situ
• Reduced cardiac activity consistent with known CHF

Mandatory MRP notification required and patch to Medical Oversight if findings are new, worsening, or atypical

• Consider initiating care with appropriate directive if criteria met:
• CHF & Edema
• Pneumonia
• COPD Exacerbation
• Lower UTI
• Catheter Flushing
• Telephone follow-up within 24 hours and home visit within 48-36 hours.
• Consider Remote Patient Monitoring (7–14 days) based on clinical assessment.
• Consider ED escalation if symptoms fail to improve or new instability develops

• High-Risk / Urgent Findings:
• Bladder volume >500 mL
• Suspected large pericardial effusion (stable)
• Pleural effusion with increasing dyspnea

• Consolidation with fever or rising oxygen needs
• Any sign of potential pneumothorax

Mandatory immediate Medical Oversight consultation or escalation to 911

DOCUMENTATION STANDARDS

• Bladder
• Bladder volume
• Any urinary retention
• Any Foley issues or hematuria

• Cardiac (Sub-Xiphoid)
• Pericardial Effusion (PCE)
• PCE positive – visible pericardial effusion
• PCE negative – no PCE is seen
• PCE indeterminate – unable to adequately assess

• Cardiac Activity
• Good – 30% or greater fractional shortening
• Poor – much less than 30% LV fractional shortening by the eyeball method
• Absent – no movement of the LV inner wall
• Indeterminate – unable to adequately visualize the LV inner walls at the mid-LV level

• Lung
• Normal findings
• smooth pleura, good lung sliding
• and lung pulse, A line present, No B line or consolidation.
• Pneumothorax
• Left/right/bilateral
• Positive (small, medium, large)
• Negative
• Indeterminate
• Pleural Effusions
• Left/right/bilateral
• Positive (trace, moderate, large)
• Negative
• Indeterminate
• B-Lines
• Positive (3 or more in one intercoastal space with thin/crisp pleura)
• Negative
• Indeterminate
• Interstitial Disease
• Positive (2 or more positive zones for B-lines in EACH lung with thick pleura)
• Negative
• Indeterminate
• Heart Failure
• Positive (interstitial syndrome, in the acutely dyspneic patient with thin/crisp pleura)
• Negative
• Indeterminate

A primary care paramedic fulfilling duties in the Parry Sound District EMS Community Paramedicine
Program may perform focused Spirometry testing during a community or home visit when certified,
authorized, and operating under this directive.

INDICATIONS

• Intended for patients with suspected COPD with any of the following:
• Dyspnea
• Cough
• Sputum production
• Wheezing and/or chest tightness
• Reduced exercise tolerance
• Frequent lung infections
• AND current or ex-smoker

CONDITIONS

• Spirometry
• Age: > 40 years of age
• LOA: Unaltered and ability to cooperate
• HR: 50-100
• SBP: Normotensive
• RR: < 30
• Other: Patient is homebound or has significant mobility problems or seen at Clinic/Event.

CONTRAINDICATIONS

• Spirometry
• No consent from patient
• Unable to follow directions for spirometry
• Cardiovascular Conditions: Recent myocardial infarction (heart attack) or acute coronary syndrome (within 1 month), unstable angina, uncontrolled hypertension (e.g., >200/120 mmHg), severe hypotension, pulmonary embolism, and history of syncope related to forced exhalation
• Recent Surgical Procedures: Recent eye surgery (risk of increased intraocular pressure, 1–3 months depending on type), thoracic or abdominal surgery (within 4 weeks), and neurosurgery (within 4 weeks).
• Respiratory/Thoracic Conditions: Active tuberculosis or other infectious diseases (e.g., COVID-19), pneumothorax, large thoracic or abdominal aneurysm, and hemoptysis of unknown origin.
• Pulmonary Embolism within 3 months
• Neurological/Physical Conditions: Cerebral aneurysm, recent concussion with continuing symptoms,
• and severe facial/oral pain.
• Other: recent middle ear infection and/or surgery, pregnancy.

PROCEDURE

• Authorized Community Paramedics will perform spirometry as per procedural guidelines.

POST TREATMENT PLAN

• Send spirometry results to medical director for interpretation.
• Notify MRP that spirometry has been completed and results will be sent to their office
• Book follow up in 1-2 weeks with patient and medical director.