Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What should be the rules for safe drug administration – Part I

There are the 5 Rights of drug administration, they are often cited as the defenders of the patients, but I do not think they are adequate. They can even cause harm.

The 5 Rights –

The Right Time.

This one is actually sometimes used to hurt patients. If we do interfacility transports and we have a patient who is in pain, or anxious, and we ask the doctor/nurse to give the patient some of the medication that they obviously have not received enough of – too often the response is, She’s not due for that yet.

Image credit.

Keeping to a schedule that requires harming the patient by refusing to treat the patient’s pain/anxiety is not good patient care. Pain and anxiety are both considered appropriate indications for medication. Undertreatment should result in malpractice law suits.

A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines. – Ralph Waldo Emerson.

Is this consistency foolish? When it harms the patient, it certainly is.

If a patient is hyperventilating due to severe pain, should we be worried about respiratory depression?

But the order says to give the pain medicine every 6 hours. We can’t give it too early.

Then call the doctor. If you are a doctor, call your attending. If you have to wake them up, then maybe they will learn to write appropriate orders for when they want to sleep. If the medication wears off before the next dose is due, then that is an important assessment finding that the doctor should be informed about.

Why is the medication not working?

Has the patient’s medical condition changed? We get excited when the patient’s oxygen saturation drops, but is a change in the patient’s level of pain (or anxiety) any less important? Maybe the patient has never been given enough pain medicine.

If you think pain is less important than SpO2 (Saturation of peripheral Oxygen – pulse oximetry reading), ask the patient what is more important. The patient’s priorities are not the same as our priorities, but we should be trying to come to some sort of agreement about priorities. The truth is that both pain and SpO2 are important. So is anxiety.

The Right Time does not mean when it is convenient to document giving the medication in order to go along to get along. That isn’t patient care.

Some of you are thinking that I should just shut up and give the medication. As if patient care is not a responsibility of the hospital.

1. The patient is still the doctor’s patient until we leave.

2. Do the hospital staff really need to have EMS come in and do their work for them? The patient is supposed to be prepared for transport. Unless this is a sudden change, this is not prepared.

3. There is supposed to be a continuity of care, not abandonment of care. Would it be appropriate to transfer a patient within the hospital without treating the patient? I realize that this is done, but that does not make it right.

4. I may not have protocols that permit me to give the medication, but I will call medical command and ask for permission to give medication, if I need to. Also, I do not carry the doses that may be needed in treating patients with a tolerance to opioids. I do not have a pharmacy available to restock me. If I have other patients with severe pain, I may run out of opioids. I have before. I don’t even carry enough to treat a patient with severe burns.[1]

What makes me thing that I know enough to question a doctor’s orders?

I am there, assessing the patient. Where is this omniscient doctor?

I am familiar with giving large doses of opioids, benzodiazepines, and combinations of opioids and benzodiazepines.

I am capable of assessing respiratory drive.

Oh, there is one other thing. I can ask the patient to talk to me, if there is any respiratory depression. Not that there is much chance of that with patients who have been deprived of care due to a foolish consistency to a schedule (Right Time is a schedule). This is not quantum physics.


[1] Who Carries Enough to Manage Severe Pain from Burns?
Rogue Medic
Sat, 15 Jan 2011



  1. I see this all the time (as I’m sure most medics and even most Basics do, and how much worse for the Basic who has NO options whatsoever). When I was a Basic, my handling of it usually involved asking the nurse to administer more pain meds, explaining that moving the patient from bed, to stretcher, to ambulance, taking a bumpy ride in the back of a truck, then moving from ambulance, off of stretcher, and into another bed, would require more analgesia than is typically required from a patient who would be lying motionless… I have, on at least one occasion, called Medical Control for guidance when these requests were repeatedly denied, and on that occasion, Medical Control told me not to assume care for the patient because they believed that the risks of transporting the patient without appropriate pain control outweighed the benefit of taking the patient for their CT scan. The facility complained to my employer, who called me on the carpet for “refusing to transport the patient,” conveniently ignoring the fact that I had been given an order by Medical Control. Thankfully, I no longer work there.

    The area of analgesia is one where we REALLY need to hound our PMD’s for a longer leash and more options.

  2. Fortunately in our area we are now able to take orders from the sending physician on an interfacility transfer. On more than one occasion I have spoken to the physician directly expressing my concerns and come up with a reasonable plan of action. Failing that (say the primary physician is unavailable), I have the secondary option of speaking with my base hospital physican on the phone. If the issue is still not resolved to my (and ultimately what will be my patient’s) satisfaction, I would advise the sending facility that I can not accept responsibility for being the primary caregiver on a patient whom will not receive adequate patient care and that they must send an escort who will take that responsibility.

    Having said that, all situations are different and it is hard to apply one “catch all” this is what I would do in every possible situation….

  3. Pain management does not have a nice, easy, one-size-fits-all solution, because there are a lot of factors that have be taken into consideration when deciding how to best medicate for pain … not just the patient’s size and when the last dose was given. Does the patient have a history of chronic narcotic use? Is the patient’s respiratory status stable? Is the patient hemodynamically stable? Is the patient taking other medications which may potentiate or antagonize the effects of the analgesic? And so on …

    Most pain management protocols, and many physician orders, seem to be written to the lowest common denomiator … that is, pain medications are ordered in the doses and frequencies that are the least likely to cause harm if given inappropriately, rather than requiring the providers to continually reassess the patient and determine whether or not pain is adequately controlled, and expecting them to have the knowledge and training to make an appropriate decision as to whether additional medication should be given.

    If we are allowed to be resonsible for patients’ lives, we should be held to a higher standard.

  4. I treat the patient under standing orders at all times. If I feel they need pain management they belong to me and are the responsibility of me and my Medical Director, not the facility I pick them up from or the recieving facility. I have an obligation to treat them appropiately and will do so until someone tells me to stop doing it.

    EMS is not a taxi on interfacility transports, we have a duty to treat and continue care. Until there is a Standing Order for IFTs that says the rest of my SOs are invalid and I have to call for orders I will do what is best for my patient just as I do for 911 responses.

  5. We are taught 10 rights at my college:
    Just thought you’d be interested. 🙂