We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Not Carrying Essential Drugs on an Ambulance

 

A paramedic responded to dispatch that he did not have any seizure medicines and that no other medics have seizure medicines.
 


 

How does this happen?

Is it a result of the drug shortage?[1]
 

Paramedic: “We don’t have any seizure medication?”
Dispatcher: “You don’t have any seizure medication?”
Paramedic: “That’s affirmative. No paramedic unit does.”
[2]

 

This was in January. A similar conversation occurred in December.

The article makes it seem as if the medics only carry lorazepam (Ativan) for seizures – when they carry seizure medication.

Why not any IM (IntraMuscular) seizure medication?[3],[4],[5],[6]

Unreasonable optimism?

Inability to keep up with research?

Inability to understand research?

There is a lot of that in EMS.

Do they carry a dose that will be effective?

4 mg IV lorazepam for an adult and 2 mg IV for a small child – if the goal is to actually stop the seizure, rather than just document the administration of sub-therapeutic doses of something.[7],[8]

If the dose is inadequate or if the dose cannot be given because of a failure to obtain an IV – then the drug is not a life saving drug.

Does Rural Metro/Clark County have these under-dosing problems with their seizure medications? I don’t know.

As it turns out, the reason the medics do not have lorazepam is that the DEA (Drug Enforcement Administration) is investigating.
 

It’s because of a DEA investigation into Rural Metro Ambulance when they worked out of Louisville. There was morphine and Valium missing from ambulances and the DEA was trying to figure out who took the drugs. Because of that investigation their paramedics were banned from carrying certain medications, medications used to stop seizures.[9]

 

Diazepam (Valium) is also a seizure medication. Diazepam can be given IM, but EMS usually gives it rectally.

Why?

Because giving a drug in a socially inappropriate way that is also less effective than other ways of giving the drug is what EMS does. Does Rural Metro/Clark County give rectal seizure medications? I don’t know.

Who should be notifying Clark County when required drugs are pulled from the ambulance?

The DEA apparently gave the order, so they should be notifying Clark County of the DEA’s change to the medications carried by medics.

Rural Metro appears to be required to carry the medications, so they should notify Clark County that they are not satisfying the drug requirements. The contract should be specific about what minimum standards any company must meet and what notification must be made when the minimum standards are not met. If the contract does not require notification, then Clark County is being willfully ignorant. Especially with the drug shortages, Clark County (and any EMS agency) should be keeping aware of any supply problems ambulance companies are having.

Maryland changed their protocols because of the drug shortages, so this is affecting EMS in other places.[10]

It looks as if all three (Clark County, Rural Metro, and the DEA) failed to act responsibly toward the citizens of Indiana.

Footnotes:

[1] Drug Shortages
FDA
Drug Safety and Availability
Current Drug Shortages Index

[2] Paramedics say area Ambulance service not carrying needed medicine
WHAS11.com
Posted on February 5, 2013 at 6:22 PM
Updated Tuesday, Feb 5 at 6:41 PM
Article

[3] Midazolam in treatment of epileptic seizures.
Lahat E, Aladjem M, Eshel G, Bistritzer T, Katz Y.
Pediatr Neurol. 1992 May-Jun;8(3):215-6.
PMID: 1622519 [PubMed – indexed for MEDLINE]
 

Midazolam (Versed), the first water-soluble benzodiazepine, has had widespread acceptance as a parenteral anxiolitic agent. Its antiepileptic properties were studied in adult patients with good results. Midazolam was administered intramuscularly to 48 children, ages 4 months to 14 years, with 69 epileptic episodes of various types. In all but 5 epileptic episodes, seizures stopped 1-10 min after injection. These results suggest that midazolam administered intramuscularly may be useful in a variety of epileptic seizures during childhood, specifically when attempts to introduce an intravenous line in convulsing children are unsuccessful.

That is from 1992 – over two decades ago.

[4] Midazolam in treatment of various types of seizures in children.
Yakinci C, Müngen B, Sahin S, Karabiber H, Durmaz Y.
Brain Dev. 1997 Dec;19(8):571-2.
PMID: 9440805 [PubMed – indexed for MEDLINE]
 

No side effects were observed. These results suggest that i.m. administration of midazolam may be useful in a variety of seizures during childhood, especially in case of intravenous (i.v.) line problem.

That is from 1997 over a decade and a half ago.

[5] A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children.
Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y.
Pediatr Emerg Care. 1997 Apr;13(2):92-4.
PMID: 9127414 [PubMed – indexed for MEDLINE]
 

CONCLUSIONS:
IM midazolam is an effective anticonvulsant for children with motor seizures. Compared to IV diazepam, IM midazolam results in more rapid cessation of seizures because of more rapid administration. The IM route of administration may be particularly useful in physicians’ offices, in the prehospital setting, and for children with difficult IV access.

That is also from 1997 over a decade and a half ago.

[6] Use of intramuscular midazolam for status epilepticus.
Towne AR, DeLorenzo RJ.
J Emerg Med. 1999 Mar-Apr;17(2):323-8. Review.
PMID: 10195494 [PubMed – indexed for MEDLINE]
 

The pharmacodynamic effects of midazolam can be seen within seconds of its administration, and seizure arrest is usually attained within 5 to 10 min. Case reports and a recent randomized trial that demonstrate the successful use of i.m. midazolam in the termination of epileptic seizures are reviewed.

That is from 1999 – still over a decade ago. There have been more studies of IM midazolam (Versed) in this century.

[7] Lorazepam (lorazepam) Injection, Solution
[Baxter Healthcare Corporation]

DailyMed
NLM
FDA label
 

For the treatment of status epilepticus, the usual recommended dose of Lorazepam Injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional Lorazepam Injection is required. If seizures continue or recur after a 10- to 15- minute observation period, an additional 4 mg intravenous dose may be slowly administered.

[8] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed – in process]

Free Full Text from N Engl J Med.
 

All adults and those children with an estimated body weight of more than 40 kg received either 10 mg of intramuscular midazolam followed by intravenous placebo or intramuscular placebo followed by 4 mg of intravenous lorazepam.

 

The relationships among benzodiazepine dose, respiratory depression, and subsequent need for endotracheal intubation are poorly characterized, but higher doses of benzodiazepines may actually reduce the number of airway interventions. Our data are consistent with the finding that endotracheal intubation is more commonly a sequela of continued seizures than it is an adverse effect of sedation from benzodiazepines.11

[9] Rural Metro Ambulance responds about carrying meds on their vehicles
by Renee Murphy
WHAS11.com
Posted on February 6, 2013 at 7:02 PM
Updated Wednesday, Feb 6 at 8:49 PM
Article

[10] Drug shortages leading to better EMS protocols
Fri, 19 Oct 2012
Rogue Medic
Article

.

Comments

  1. The Clark County operation was being managed through the Indianapolis office, not KY, thus the DEA excuse was not valid; this operation had a history of poor management of its controlled substances, and used the drug shortages, and other excuses, to justify why it couldn’t keep the required equipment on the trucks.

    But, you’re right–the contract-holders need to have oversight where they can.

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