Continuing from Part I (right time). It is also important to give the right dose.
What is the dose?
The amount of medication in the concentration used over the amount of time the drug is given.
Don’t be silly. We don’t need that kind of information. All we need to know is the amount of drug.
Even the most basic drug administration should include this information.
Do doctors give orders that leave out some of this information?
Of course they do, but bad handwriting is given much more likely to be given as the cause of confusion. We have been told to avoid using certain abbreviations, because they are easy to mistake for other abbreviations. This is only a part of the problem. The problem is that the orders that are given are often incomplete, not just abbreviated, but incomplete. Whatever doctors do badly, we tend to make even worse.
Give an amp of _________.
Is it ever appropriate to give a dose of anything as X cc of drug Z or as X ml of drug Z or as 1 amp of drug Z? (cc = Cubic Centimeters; ml or mL = MilliLiters)
Suppose the drug is morphine.
Give 1 cc of morphine.
What dose is being ordered?
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A bad excuse for knowing what dose is being ordered is to pretend that normally only carrying one concentration is important.
Does the doctor only deal with one concentration?
Does the doctor only deal with one EMS agency?
Has the doctor worked with other EMS agencies that might use different concentrations?
Are you sure? Does that apply to all of the doctors? Should this information be necessary to understand the doctor’s order?
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2 mg morphine in 1 ml saline.
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4 mg morphine in 1 ml saline.
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8 mg morphine in 1 ml saline.
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10 mg morphine in 1 ml saline.
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15 mg morphine in 1 ml saline.
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Give 1 cc of morphine.
What dose is being ordered?
Few patients are going to have negative responses to 15 mg of morphine. The side effects are exaggerated, especially in the presence of competent medical personnel. Of course, the requirement for medical command orders for doses of morphine only encourage medical directors to authorize incompetent paramedics, using the excuse that they have to call for anything dangerous. Too many medical directors do not understand that everything in the drug bag is dangerous. Morphine is actually one of the safest drugs we carry. Fentanyl is even more safe than morphine.
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We need to understand all of the components of the dose being given, including the rate. The rate is also not given in the order above.
Can we give morphine too quickly?
The problem with giving drugs quickly, that are supposed to be given slowly, is that the rate of administration has a big effect on the rate of occurrence of side effects. The faster we push morphine, the more likely we are to produce side effects.
Pushing a drug slowly into the IV line, or hep lock, then flushing it in is idiotic, but it is not rare.
We have been taught to give certain drugs slowly. We slowly give the drug to the tubing, then we quickly flush it into the patient, about as fast as if we were giving adenosine. We have convinced ourselves that what we are doing is smart patient care. Our intent is good, but so what?
We need to have a better understanding what we are doing when we are giving medications.
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I recently took a pair of classes focused on neonatal resuscitation (NRP and STABLE) and both of those classes insisted on giving drug doses in the form of milliliters. I was the only paramedic in the class, surrounded by nurses and respiratory therapists, and no one could seem to wrap their brain around why I asked for clarification on EVERY SINGLE DRUG REFERENCE that was expressed in volume as opposed to DOSE. These varied from “point three milliliters of epinepherine” to “four milliliters of dextrose” to your aforementioned “one milliliter of morphine” or “half milliliter of fentanyl.”
I found the use of volume to determine dosage to be frighteningly vague, particularly within the context of neonatal and pediatric resuscitation. I’ve recently begun working in a hospital and found that this use of volume as opposed to dose is prevalent in the emergency department. It concerns me that some of our practitioners in the hospital may be making assumptions about the concentration of the drugs they routinely administer and may be passing those assumptions on to us during telemetry calls.
I was taught in paramedic school that drug administration in terms of volume to be administered was appropriate in ONE instance and ONE instance ONLY: the administration of fluid boluses. All other drug dosages should be expressed in mg, mcg, or meq.