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

- Rogue Medic

Community and International All in One – EMS Garage Episode 150 and Fentanyl

This week’s EMS Garage covered several topics. Community and International All in One: EMS Garage Episode 150. Chris Montera, Gary Wingrove, Pat Songer, Russell Stine, and I discuss these topics –

International Roundtable of Community Paramedics and Community Paramedic – Community Paramedic is something that is inevitable. Many people do not like the idea, but there is no practical alternative. The main question is how to best set up a Community Paramedic program.

International Paramedic – We need to stop using the infantile excuse of That’s not the way we do it here. This attitude kills patients. Imagine if everyone decided that they would freeze their thinking at some point in time and never make any progress beyond that point unless it came from their own people. That is the opposition to International Paramedic. We need to recognize that we have a lot to learn from the way the rest of the world implements EMS. We need to stop ignoring what others are doing and start learning from others. Go sign up at International Paramedic.

Image credit.

Ultrasound in EMS“Machines made by Sono-Site Inc. will be put on 12 ambulances. The company provided the devices, which cost $60,000 to $70,000 each, and about $52,000 in training, Knapp said.” According to Pat Songer, his service is using different devices that only cost $6,000 to $6,700 each – less than 10% of the cost listed in the article. They have a lot of support from the hospital, which is very important. This has a lot of potential to improve care. We need to pay attention to the research and see what the advantages and disadvantages are. I am hesitant to suggest that this be used to encourage refusals, but triaging patients to community hospitals seems to be an area where this cuts costs and improves care.

Legal Medicine – We assume that we know how not to be sued or how not to lose a law suit, but this is just another EMS myth.

And fentanyl

A little bit on fentanyl. I mentioned that the most important advantage in using fentanyl is that it wears off quickly. This means that a patient who receives enough fentanyl to tolerate an ambulance ride (a bouncy truck ride lying on top of the rear axle as it hits pot holes) should already have the fentanyl wearing off when we arrive at the ED (Emergency Department). Time from administration and total dose will affect how quickly it wears off.

Why is fentanyl wearing off quickly important?

If the patient has enough fentanyl on board to tolerate the ambulance ride, then lying in a much better padded hospital bed that does not bounce around may result in oversedation and the main complication we wish to avoid – respiratory depression. In the ED they can assign one nurse to take care of this patient until the patient is breathing more deeply or they can give naloxone (Narcan).

Unfortunately, in some EDs they will quickly whip out the naloxone and will not titrate it to the desired effect – adequate respirations. A standard dose of naloxone can result in complete reversal of the pain management and increase the pain to much more than it was when we began treating the pain. Not titrating naloxone results in reversal of all of the endorphin effects – all the things that a person is able to do on their own to manage their pain.

Not titrating naloxone is torture.

Image credit. Ouch! Don’t be stingy with the fentanyl.

We want to avoid putting the patient in the situation of having their pain relief reversed. In the ED, one on one observation of patients is not common. The patient is being transferred from EMS, which has several people observing the patient, to the ED, which has several patients per nurse. The ED is just not staffed to provide one on one observation without detracting from the care of other patients. Sometimes staff will over-react to respiratory depression and hurt the patient.

We should not be causing problems for the ED or for the patient by transferring a patient that the ED is not as prepared to treat than we are in EMS.

Not noticing dangerous respiratory depression in EMS is incompetence.

Not noticing dangerous respiratory depression in the ED may be just due to having divide attention among many patients at a time when things change.

Go listen to all of these at EMS Garage.



  1. I would really like to get US on the “official” Paramedic scope at some point (quote fingers when I say official). Perhaps if the Advanced Practice Paramedic/Community Paramedic can adopt it as a standard of care skill.

    Evidence based trauma notifications here we come!