Another blow to Massachusetts ALS...

T

the magic of 3 am

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Due to the state rubber stamping ANY fire department wanting an ALS license, we will now be loosing 1:1000 Epi vials. Why? Too many IV PUSHES of Epi 1:1000 during asthma's and allergic reactions. Instead of SQ epi, these folks were pushing 1:1000 IV. No repeat assessments, no 'second' doses of Benadryl- just right to IV EPI!!! I guess if OEMS keeps diluting the field we'll revert back to the 'scoop and screw' days of yore.
 
Just to point out that accidental administration of 1:1000 epi IV instead of subcut is not unique to Massachusetts. In our area we had 10+ cases. This is more of a human factors issue than EMS providers realize. We're just not used to giving Epi 1:1000 and so it goes straight to the Y port.

Strategies to prevent this from occurring is to do things like:
- Use Epi-Pens (which is what our area did for a year)
- Storing 1:1000 epi vials in a bag that is clearly marked "FOR SUB-CUT USE ONLY"
- Require a second medic verify the drug before giving it (nurses are quite familiar with doing this for high risk drugs like insulin or alteplase)
- Make IV Epi for anaphylaxis a base hospital order
- Don't allow IV drip sets with needle-accessible Y-Ports (use only needle-less systems) and have a fixed needle on the syringe to draw up the IM Epi 1:1000.

"To Err is Human" is really a truth in the medical profession. Particularly at 3am.
 
You were being sarcastic about the 3 short years right? I know most places have their ETCo2 built into their monitors, and monitors are expensive, but still. It's not like the concept of ETCo2 pre-hospital is brand new, they've had a few years to know this was coming.


As for the IV Epi thing, I'm confused. Do you guys only carry it in one concentration? To me, since the different concentrations come packaged differently it's very easy to remember that the 1:1000 Epi isn't primarily used IV.
 
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Is it just me because I didn't seem to have any difficulty grasping that IV adrenaline as a first-line treatment was for cardiac arrest only. Maybe I was taught differently? I dno ....

Here in Kiwi we have the option of IV adrenaline for bradycardia that does not respond to atropine and pacing, asthma and anaphylaxis (all 1mg in 1 litre NaCl infused at two drops per second initially then titrated) however for the latter two we start with IM adrenaline 0.3-0.5mg.

I think having to call and ask for an order to give adrenaline IM is pretty piss poor myself but hey, it's understandable!
 
They are not eliminating the 1:1,000 vials, they are still available for use, they just want the epi-pen for initial tx. Its kind of stupid, but given the mistakes made, not terribly suprising. Maybe someone at OEMS owns stock in the company that makes auto-injectors? :P
 
If multiple people are making the same mistakes with th same drugs in the same situation, that says to me that there is a significant issue with the systems in place and more importantly, with the education and training being provided to the medics.

I personally would look at fixing the root cause of the problem by improving education rather than just trying to engineer it out with protocol and equipment changes. I would suggest that this is just a manifestation of a deeper problem and "fixing" this in such a manner will not prevent further issues in the future.
 
Our allergic reaction protocols used to state that after benadryl & albuterol we would give 1:1,000 epi sub-q. That was followed up with more albuterol, and then 1:100,000 epi IV. We rarely get deep enough into the protocol around here to get to the IV epi, so in the handful of times it was given last year there were dosing errors made - medics weren't diluting the epi properly. We can no longer give 1:100,000 epi IV without calling the ER and getting orders first. We are still allowed to give the 1:1,000 epi sub-q without orders.
 
Smash said:
If multiple people are making the same mistakes with th same drugs in the same situation, that says to me that there is a significant issue with the systems in place and more importantly, with the education and training being provided to the medics.

I personally would look at fixing the root cause of the problem by improving education rather than just trying to engineer it out with protocol and equipment changes. I would suggest that this is just a manifestation of a deeper problem and "fixing" this in such a manner will not prevent further issues in the future.
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What, you mean we should actually fix the entire problem instead of slapping a band-aid on it an calling it good? You mean we should actually do something proactive (reactive in this case unfortunately) that would really prevent this from happening again instead of a quickie fix that won't stop this from happening? Gosh...where do you come up with these crazy ideas...:D On a serious note, it'd be nice if more people (in a position to make this type of decision) thought along the same lines you do...but...:censored::censored::censored::censored:.

Moving along, I don't remember ever seeing this; did anyone ever determine if the actual DOSE of epi given was wrong, or was it soley the wrong CONCENTRATION? 1:1000 given IV without any dilution can definitely cause damage to the vein and surrounding tissue, so I'm curious more than anything.
 
Smash said:
I personally would look at fixing the root cause of the problem by improving education rather than just trying to engineer it out with protocol and equipment changes. I would suggest that this is just a manifestation of a deeper problem and "fixing" this in such a manner will not prevent further issues in the future.
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You know, I will never understand why those involved in medical oversight view this method of just axing procedures from the local scope as an adequate "fix" to a problem in their system. I had come to think of it as something unique to California and its political climate of tension between paramedics and others in healthcare, but I guess it's more widespread than I thought. This practice honestly just augments the ruminations I've recently been having of leaving EMS. That the so-called experts who are in charge of us feel that the solution to any problem with paramedics performing intervention XYZ is to just no longer have paramedics do XYZ is incredibly disheartening and makes me sick. Heaven forbid we do something proactive instead - like going to the root of the problem and actually educating paramedics, and providing remediation when there are problems (if a physician makes a mistake [perish the thought!] is he/she just no longer allowed to do whatever it is he/she messed up doing? Of course not). It's just maddening.
 
thegreypilgrim said:
You know, I will never understand why those involved in medical oversight view this method of just axing procedures from the local scope as an adequate "fix" to a problem in their system ... it's just maddening.
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Because that is the easiest way to fix the problem, if you're having a high failure rate or rate of errors, well it's easier to just stop the ambo's doing it.

I am honestly dumbfounded that there is such a lack of proficiency at what must be considered basic patient assessment, trending and technical skill that such a simple procedure is being withdrawn.

Adrenaline comes as 1mg/1ml so to say these guys are giving 1:1000 IV then they must simply not be diluting and just pushing the whole ampoule in a 1cc syringe! Are you telling me some Paramedics are so stupid they forgot the basic rules of drug administration, since when do ambo's give ANY drug without diluting it?

I am really, really just blown away, really, this is something so simple and it's just beyond comprehension as to how they screwed it up this bad.
 
MrBrown said:
Because that is the easiest way to fix the problem, if you're having a high failure rate or rate of errors, well it's easier to just stop the ambo's doing it.
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Naturally, unfortunately the easy way out is typically the road everyone takes.

I am honestly dumbfounded that there is such a lack of proficiency at what must be considered basic patient assessment, trending and technical skill that such a simple procedure is being withdrawn.
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It is shocking. But, what could this possibly reflect on other than the sort of education & training they received? Like, seriously - if it was just a handful of isolated incidents over a given period of time that would be one thing, but if it's a consistent problem, then it should make one wonder what is being missed. This actually would be an easy fix should this problem be mitigated through remediation (as you said, it's so utterly basic). Why people are so quick to just further and further restrict what happens in the prehospital system rather than advancing prehospital medicine is just beyond me. It seems like doing the latter would be more beneficial and cost-efficient in the long-run.
 
thegreypilgrim said:
...what could this possibly reflect on other than the sort of education & training they received?...
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I agree, it's obvious they aren't being taught something or aren't using it enough to remember.

Now it's not hard, I haven't dished out any meds in ages but yet I still remember any IV drug is generally diluted up to 10ml however there are exceptions like ketamine and amiodarone which are diluted in D5.

This is very, very disturbing
 
MrBrown said:
I agree, it's obvious they aren't being taught something or aren't using it enough to remember.

Now it's not hard, I haven't dished out any meds in ages but yet I still remember any IV drug is generally diluted up to 10ml however there are exceptions like ketamine and amiodarone which are diluted in D5.

This is very, very disturbing
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You would think it wouldn't be too difficult to remember. Apparently it happens quite commonly though. During our internship one of my classmates in medic school had a call to an urgent care doc-in-the-box for a patient approaching anaphylaxis. The physician on-duty there pushed 0.5 mg of 1:1000 epi by IV turning the anaphylaxis case into an SVT one for my classmate.
 
thegreypilgrim said:
You would think it wouldn't be too difficult to remember. Apparently it happens quite commonly though. During our internship one of my classmates in medic school had a call to an urgent care doc-in-the-box for a patient approaching anaphylaxis. The physician on-duty there pushed 0.5 mg of 1:1000 epi by IV turning the anaphylaxis case into an SVT one for my classmate.
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Oh dear, our IV adrenaline for anything except cardiac arrest is 1mg in 1 litre of NS infused at 2gtt/sec or titrated.

We also have the option of 0.01mg IV bolus but again, it's 10ml of a 1:1,000,000 solution
 
For severe allergic reaction we use .3-.5 mg 1:1000 epi DEEP IM instead of SubQ... our medical director feels it gets better circulation that way because of the difference in vasculature between the subcutaneous tissue and the muscle tissue.

As far as IV epi... we can do an epi drip titrated to effect. 1mg in a 250cc bag... ive used it once, and it worked.. quite well.. saved us from having to intubate this poor lady.
 
FLEMTP said:
For severe allergic reaction we use .3-.5 mg 1:1000 epi DEEP IM instead of SubQ... our medical director feels it gets better circulation that way because of the difference in vasculature between the subcutaneous tissue and the muscle tissue.

As far as IV epi... we can do an epi drip titrated to effect. 1mg in a 250cc bag... ive used it once, and it worked.. quite well.. saved us from having to intubate this poor lady.
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Our January protocol update changed it from subcutaneous to deep intramuscular injection as well. Same dosing as above. We also have the protocol suggestion (requiring med control) of a similar IV dose 1:10,000, or hanging a drip.
 
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