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

- Rogue Medic

Drug shortages leading to better EMS protocols

MIEMSS (Maryland Institute for Emergency Medical Services Systems) has posted some changes to their protocols that are in response to the drug shortages affecting EMS.

This is good news, even though two of the three drugs being used as replacements are also subject to drug shortages. That is one of the problems with the drug shortage – the replacements end up suffering from increased demand to replace the original drugs.

Some of the drugs do not need any replacement, such as IV (IntraVenous) furosemide (Lasix) for CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure) patients. The best thing we can do is to stop giving the drug and to stop giving any other diuretic for a medical condition that is not effectively treated with diuretics.[1]

Pain management drugs are important and availability is important.

The continuing medication shortage continues to affect Maryland EMS Operational Programs (EMSOPs). Morphine is among the medications that EMSOPs have had difficulty restocking.

Because of the importance of successfully managing pain in out-of-hospital medicine, the Protocol Review Committee has looked into alternatives to Morphine for Maryland EMS. MIEMSS has emergently included fentanyl in the 2012 Maryland Medical Protocols effective immediately. Please see the attached protocol pages.[2]


Unfortunately, the obvious substitutes are also in short supply – fentanyl (Sublimaze), hydromorphone (Dilaudid), and other opioids.[3]

One interesting part of the Maryland protocols is the addition of abdominal pain to their standing orders for morphine or fentanyl administration. The Maryland protocols have leapfrogged past Pennsylvania’s protocols with a couple of big changes.

Image credit.

Even a surgical journal has research showing that treating undifferentiated abdominal pain with opioids does not make diagnosis more difficult.

The literature addressing early pain relief for abdominal pain is characterized by weaknesses, but there is a common theme suggesting that analgesia is safe. Pending further research, which should address some of the shortcomings of extant studies, a practice of judicious provision of analgesia appears safe, reasonable and in the best interests of patients in pain.


A much more recent Cochrane Review comes to the same conclusion.

Eight studies fulfilled the inclusion criteria. Differences with use of opioid analgesia were verified in variables: Change in the intensity of the pain, change in the patients comfort level.

The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.


If we were to ask the patients what they prefer, I expect that a lot would choose to decrease their pain, even if there is the minimal possibility of alteration in physical assessment. That alteration may be for the better – if the patient is not in severe pain at the slightest touch, the patient may be able to localize the pain, which is a big part of the physical assessment of undifferentiated abdominal pain.


[1] Drug Shortages Affect Those Still in the Dark Ages – Furosemide
Rogue Medic
Thu, 26 Aug 2010

[2] NEW (June 2012) – Emergency Medication Addition Due to Medication Shortage: FENTANYL
Maryland Institute for Emergency Medical Services Systems
June 12, 2012
MIEMSS page with links to this and other updates and to current protocols

There is also information at that page about the following two changes because of the drug shortage –

NEW (April 2012) – Emergency Medication Addition Due to Medication Shortage: KETAMINE

NEW (May 2012) – Emergency Medication Addition Due to Medication Shortage: DIAZEPAM

[3] Current Drug Shortages Index
Current Drug Shortages Index

[4] Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain.
Thomas SH, Silen W.
Br J Surg. 2003 Jan;90(1):5-9. Review.
PMID: 12520567 [PubMed – indexed for MEDLINE]

[5] Analgesia in patients with acute abdominal pain.
Manterola C, Vial M, Moraga J, Astudillo P.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. Review.
PMID: 21249672 [PubMed – indexed for MEDLINE]



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