Opinion of Medications being pulled

[THFD332]

I am curious, what are your opinions with Medical Control wanting to pull meds from your protocols. There hasn't been an pt bad outcome to call for this but just that it is not really being used that much. Though on this hand, the drug is not being used according to ACLS standards. (oddly enough the exact reason that protocols are being updated!) Currently Cardizem is looking at being pulled, and the only use for it in our protocol is A-FIB c RVR. It is also used in symptomatic pt with SVT but only after cardioversion c conscious sedation and after Medical control permission. Current ACLS states that it can be used p the second 12 mg dose of adenosine if there is no conversion, or if a recurrence of SVT occurs.

Any help with this would be appreciated, Also we just had a call yesterday where Adenosine didn't do the trick, and the pt was left to run at 180bpm until delivery at the ED.

Any opinions about any medication being pulled, Would you rather keep them and have them available if needed even though it would be rare to use just to have the freedom to use it, or the feeling of being limited in a rather lenient system.

Thanks

Robert

[Mateo_1387]

I do not know if your agency does this, but my agency looks at patient outcome along with medications that are administered. With these statistics they are looking at if the medications we give really make an difference on patient outcome. One drug they are looking at taking off in my area is lasix. It is not the "favorite" drug of choice for PE anymore in my system, yet for the moment we still carry the drug. It has to do with evidence based patient care. This of course can vary from area to area.

Lasix here may not be a big benefit because of short transport times, and blah blah blah, but for someone who has 3 hr transport times, this may be a different story.

Did they give you a replacement drug to give for a-fib with RVR such as amiodarone?

[AZCEP]

Are you not using it because it is not indicated, or because you are not being allowed to do so by medical control?

If you have to call for the okay to use something, your system sucks. If you are not being allowed to use it after calling for approval, your medics suck.

If you aren't allowed to use something because it isn't indicated, and can't justify the expense of having it, what is the problem exactly?

[CBEMT]

Don't have that option here- most medications are mandated by the state. For example, an ALS ambulance can't be licensed without Lasix- 240mg minimum.

We do have optional meds though, and Cardizem is one of them since it's a paramedic-level drug.

[Doczilla]

Whether or not a drug or protocol is maintained depends largely on the success with it. If the drug is never getting used, there may be an issue of concern over potential errors in use. The less frequently we use something, the more likely we'll screw it up. If a large number of adverse events, errors, or bad outcomes are identified in chart review, then it may be appropriate to retrain the providers or pull it entirely. While there may not be any bad outcomes, there may be some "near misses" where a bad outcome was possible but didn't occur, or a provider reports that they "almost" screwed it up but caught it before harm was done.

Cardizem is kind of a special case. The single dose carpuject that we've used in the past has been discontinued. Available single dose formulations used now have to be refrigerated. The only non-refrigerated kind is the AddVantage bag, which has 100mg in a 100cc bag. In our system, with 540 drug bags to be filled, we looked at how often it's used, transport times, relative cost of stocking, and the possibility of a dosing error, (particularly because the AddVantage has 4 doses of the cardizem in it) so we were afraid that some idiot would just run the whole thing in as a single dose. This kind of dosing error is likely to be irreversible and fatal. We looked into having a compounding pharmacy make single dose vials of powder for us to reconstitute in the field at time of use, but it was cost-prohibitive and labor intensive.

If the patient doesn't respond to the adenosine and is otherwise stable, they can probably last the 20-40 minute transport time from our most outlying squads to the ED. Unstable narrow complex tachycardias need to be cardioverted, and should be diverted to the nearest ED.

For us, the cost in stocking, training, testing, etc. was just not worthwhile when we looked at the "what if I don't have it" scenarios. Add in the burden of either a) requiring squads to refrigerate the drug bag, which most can't do without significant burdensome expense, or having a dosage form that is not a single dose like most other EMS drugs and therefore prone to error, we decided to wait until someone decides to make the single dose form in a reconstitutible powder like Solu-medrol or vecuronium.

'zilla

[tinman694]

Thanks for the excellent details. We just got a "were not gonna let you carry it anymore" and that was that.

(I have only administered it twice in 5 years from looking back at records)

Oh, well---not like we really see that much Narrow Complex Tach's either....mostly diabetics and drunks here in Dixie.