States and EMT-B Morphine Administration

[Hal9000]

Having recently received an email on the matter, I began to wonder how many states in the US allow EMT-Bs to administer morphine. I imagine that the number is low—in the single digits—but I'm not really sure.

If your state does it, what are your thoughts on the practice?

 

[exodus]

No state allows EMT-B to push anything.

 

[Hal9000]

No state allows EMT-B to push anything.

Ok, not "push," then, but auto-inject.

Sorry for using such a broad term. Didn't mean to cause any confusion.

 

[JPINFV]

Even auto-inject I highly doubt it. In fact, I highly doubt that any states allow EMT-Bs to administer any schedule controlled drug, little less a schedule 2. Ignoring the psychomotor and assessment aspect of autoinjection, once you start involving narcotics, you start playing with legal fire.

 

[Hal9000]

Even auto-inject I highly doubt it. In fact, I highly doubt that any states allow EMT-Bs to administer any schedule controlled drug, little less a schedule 2

Yeah, that's why I went with just single digits. I thought that perhaps such rural areas as WY, AK, etc. might.

According to the Montanan Board of Medical Examiners, EMT-Bs can now utilize Morphine 2.5mg auto after contacting medical control and with BP systolic >100; further admin requires further medical control direction.

However, these "partial-ALS" units are mostly EMT-B (with endorsements) + EMT-B, or FR+ EMT-B, so there is not really much supervision. Currently, EMT-Bs can perform unsupervised IOs, administer Glucagon, etc.

I was curious to know if there were any other states like that, but perhaps MT is just rogue.


From the MT protocol book:

EMT-B (medication endorsement)

Administer 2.5 mg Morphine (auto-injector only) in cases of isolated injury to prevent pain induced during patient movement and transport ONLY if blood pressure is above 100 systolic, and with direct communication from medical control

Can be repeated only with direct communication from medical control

I am myself somewhat uncomfortable with EMT-Bs doing ET tubes, IOs, and morphine, but I do understand the theory behind it, and a board of people much more intelligent and well-versed than I made the decisions.

Regardless, it's above my pay grade, and not within my current degree. I'd have to defer to any comments made by ALS providers. What are your thoughts on the practice, keeping in mind that this is probably aimed at areas that are superrural?

 

[JPINFV]

There's a big difference between communities that can't afford and communities that won't afford the $20/person extra a month for paramedic service. In those (really rare on a per-capita basis) locations, I'm somewhat more comfortable with expanded scopes for EMTs. However, I'd rather see blind airways than ET tubes, IVs than IO, and something a little further down the schedule list than morphine. There's a big difference between someone screwing up or losing a tube or oral glucose and an auto injector of morphine, and I'd hate to be the medical director the first time an audit comes up with a missing auto injector of morphine.

 

[Hal9000]

Those are very valid concerns, not that you need me to confirm that. I have witnessed a certain naivety among rural providers. It's sometimes easy to forget that their are meth labs around, but out of sight, out of mind. What would you suggest instead of morphine, if you don't mind my inquisitiveness?

This will almost certainly become something of an ordeal for some medical directors in the future, especially the superrural types. I can't really see this being viable on the East Coast, but there are many places in MT that have >45 minutes until arrival of HEMS, even, and with less than 300 calls/year. In such cases, it seems somewhat cruel to deny pain management to a patient, but it's a catch-22.

Back to the original subject, I suppose that there may only be one state that does allow -B morphine. I was assuming that they were following a model from some other state. I may have been incorrect.

 

[rhan101277]

Well 2.5mg IM Morphine for isolated extremity trauma may be better than no pain management at all, certainly better than distraction procedures. Even 2.5mg IVP is not really that much pain management but better than IM.

Giving 2.5mg IM will absorb slow and take time to onset. Pain management will not be maximized but better than nothing.

IM dosages need to be higher to achieve effect, here medics can give up to 10mg IM if unable to establish IV. IV dosages are only allowed in 2mg increments q 3-5

 

[Hal9000]

Well 2.5mg IM Morphine for isolated extremity trauma may be better than no pain management at all, certainly better than distraction procedures. Even 2.5mg IVP is not really that much pain management but better than IM.

Giving 2.5mg IM will absorb slow and take time to onset. Pain management will not be maximized but better than nothing.

IM dosages need to be higher to achieve effect, here medics can give up to 10mg IM if unable to establish IV. IV dosages are only allowed in 2mg increments q 3-5

I suppose that will come down to whoever is on the other end of the radio/phone in consultation with the EMT-B in the field. Many of the physicians in the rural areas are of course familiar with the resources they (don't) have, so I imagine that they'll authorize higher doses, in this case done by utilizing more auto-injectors.

Keeping better inventory of items will become a necessity for those BLS units which begin using morphine.

 

[Shishkabob]

Severe pain + 2mg morphine = severe pain.

 

[MrBrown]

Brown is very worried about all of this :unsure:

 

[rhan101277]

Severe pain + 2mg morphine = severe pain.

Yeah I agree, here we can't give the whole 10mg at one time due to a bad reaction or maybe they just don't want us zonking people out.

I can give 2mg morphine q 3 min, so some on scene, some in ambulance, some upon arrival at ER. How are your protocols.

Well I say that but I am starting work for a new service maybe we can give up to 10mg, I think they are worried about blood pressure w/ high dosages in the emergency setting.

 

[Hal9000]

Brown is very worried about all of this :unsure:

I cannot express my apprehension as a function of my arms, Mr. Brown.

Severe pain + 2mg morphine = severe pain.

The number of auto-injectors is limited only to the number the physician online says may be used.

 

[MrBrown]

Yeah I agree, here we can't give the whole 10mg at one time due to a bad reaction or maybe they just don't want us zonking people out.

I can give 2mg morphine q 3 min, so some on scene, some in ambulance, some upon arrival at ER. How are your protocols.

Well I say that but I am starting work for a new service maybe we can give up to 10mg, I think they are worried about blood pressure w/ high dosages in the emergency setting.

Gah! Please tell your Medical Director that it is no longer 1990.

We have unlimited morphine plus midaz and ketamine.

 

[ERMedic]

What would you suggest instead of morphine, if you don't mind my inquisitiveness?
QUOTE]


Some sqauds here in PA allow their EMTs to adminster nitrous oxide depending on their medical director and protocols. It's been succesful and the patient's just need to inhale it with a mask.

 

[MrBrown]

Some sqauds here in PA allow their EMTs to adminster nitrous oxide depending on their medical director and protocols. It's been succesful and the patient's just need to inhale it with a mask.

Nitrous is great stuff, it's sometimes called Nitronox or entonox and we have used it here for by george .... well since the seventies at least with excellent effect.

Interestingly we are replacing it with methoxyflurane

 

[Melclin]

What would you suggest instead of morphine, if you don't mind my inquisitiveness?.

What about IN fentanyl. Faster onset, no sharps, probably cheaper than a couple of auto-injectors and less likely to cause BP problems.

 

[Hal9000]

Some sqauds here in PA allow their EMTs to adminster nitrous oxide depending on their medical director and protocols. It's been succesful and the patient's just need to inhale it with a mask.

What about IN fentanyl. Faster onset, no sharps, probably cheaper than a couple of auto-injectors and less likely to cause BP problems.

I'd personally like either of those options better. Nitrous would be nice because I believe is not on the Schedule, and fentanyl because I prefer its use. The medic system in which I work has moved to almost exclusive use of fentanyl. Your mention of no sharps is also very important, as many rural services have no Shuttles, instead carrying sharps to whatever bins they have in their ambulances.

Interestingly, medical directors can petition for their own expanded protocols, including drug administration, so it wouldn't be impossible for a director to submit his proposal and have it accepted, for his system.

 

[medicRob]

No state allows EMT-B to push anything.

Wrong. TN allows Subq Epi, is about to allow Narcan. Colorado already allows Narcan. TN also allows D5w, Glucagon, and is about to allow Nitrous since we train our lowest level (The EMT-IV not B with IV at I/85).


@OP

EMT-B and Morphine won't happen, as it shouldn't. They have nowhere near the training to carry out such actions.

 

[Hal9000]

Wrong. TN allows Subq Epi, is about to allow Narcan. Colorado already allows Narcan. TN also allows D5w, Glucagon, and is about to allow Nitrous since we train our lowest level (The EMT-IV not B with IV at I/85).


@OP

EMT-B and Morphine won't happen, as it shouldn't. They have nowhere near the training to carry out such actions.

MT also has glucagon and dextrose, but not Narcan. Of course, most of these are EMT-B plus a couple hours for an endorsement here and there. I'm not familiar with the levels in TN.

Regarding

EMT-B and Morphine won't happen, as it shouldn't. They have nowhere near the training to carry out such actions.

, would you elaborate?