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 III

I mentioned and the right time in Part I and the right dose in Part II.

Karen Sugarpants commented that there are at least ten rights. This isn’t about a number, but about what is right for the patient. As long as we understand the pharmacology of what we are giving and we are reassessing our patients, we should do what is right for each of our patients.

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

What about the right frequency?

In How to Torture Patients, that is the problem. The long-lasting paralytic is being given with a sedative that is not even close to long-lasting.

And nothing is being given for pain.

CombatDoc commented –

Of 3% of patients given fentanyl that became hypertensive, could it be possible that they were under medicated?

Changes in vital signs should always encourage reassessment, especially when we are giving a variety of medications. An improvement in vital signs does not necessarily mean that the patient is getting better, or that we are doing a good job medicating the patient. We need to reassess to try to figure out what we are doing right, or what we are doing wrong that is coincidentally producing better looking numbers on the monitor.

If the patient is experiencing extreme stress, we should find out what is going on.

I have said for years, since Vec and Roc have been added to ambulances with the RSI protocols, EMS needs a long acting sedative or dissociative that is safe to use with hypotension. Versed is good when hypotension is not an issue and Ativan with Fentanyl is adequate with hypotension but, Ketamine or Propofol is better.

Vec is vecuronium (Norcuron), Roc is rocuronium (Zemuron), Succs is succinylcholine (suxamethonium in Commonwealth countries, brand name Anectine) and RSI is Rapid Sequence Induction/Intubation.

There are many possible medication combinations that will work for the chemically paralyzed patient. If we have used RSI to intubate, we will assess (and continually reassess) placement of the tube. Why do so many of us not reassess what we are doing with medications?

Why should we give a drug that lasts a long time with a drug that wears off quickly?

Part of the right frequency should be the right combination.

Another right. I think I took it to eleven. 😳

It is easy to remember the different duration of different drugs in an environment that is not stressful. When treating a patient who has just been emergently paralyzed and intubated as just the preparation for everything else, the environment can be stressful. Reassessing can remind us of things we have forgotten, but maybe we should avoid these reminders by being better prepared with combinations that go together. Similar onset. Similar duration of effect.

That is not even considering the very real problem of the patient’s pain. What are we giving for pain?

We have Succs for the intubation and in all reality if we had the proper meds for long term sedation we would not need to use our Vec but, medical directors would rather give us half the tools for patient care than allow us to properly treat the patient. Makes no sense to me that I can use a long acting paralytic but, not a short or long acting sedative that is appropriate for patient condition.

Protocols have some big problems. One is that the people who write them often do not have to follow them. Often, the paramedics involved in writing protocols are members of the QA/QI/CYA committee and may have agenda that do not place patient care anywhere near the top of the list.

There are dramatic differences among protocols in different systems. Some use the protocol as a ceiling, above which no medic may rise, regardless of whether there is a dominus vobiscum from the online medical command permission physician. Protocols that discourage recognizing and treating this patient’s condition, rather than treating this patient as if all patients should be made to fit the protocol.

Kelly Grayson writes about this in his excellent Meditations on Being an EMS Cowboy, which is not just relevant to EMS.

At least, that’s the theory. All too often, the protocols are written in such a way that the strongest medic is forced to lower his level of care to that of the weakest paramedic. The protocols provide a ceiling of care, rather than a floor. So it occasionally becomes necessary to decide, in the best interests of the patient, when to deviate from said protocol.

Highlighting is mine. Unfortunately, we cannot use tools we do not have. We are always going to be limited to what is practical to put into a drug bag/box, but we should have drugs that play well together. Just because drugs are compatible in the same IV line, does not mean that they work well for the patient.