Why do we UNDERTREAT our patients ?

[GAmedic1506]

It is time for the EMS community to improve in an area where we are substandard, nation-wide. Ask a Paramedic how many overdose calls he/she ran last year -- then ask how many times they administered activated charcoal ? To continue to let the body absorb toxins, when the medication for treating this disorder is sitting less than 3 feet from the patient in inexcusable. And dont give me that crap about "airway concerns", we know why we don'd do it, and it has nothing to do with the airway. Today's charcoal is easier to swallow from a cup, it is not as gritty or chunky as it once was. Most patients will drink it once they know an NG tube is coming if they don't.

***** PLEASE READ FOLLOW-UP COMMENT BELOW -- MAKES THE ISSUE MORE CLEAR !!!

** Thank you to the person who noted that I typed "antidote", that was an error that i corrected.

[medic001918]

Using your example of an overdose, charcoal is not the universal antidote for all overdoses. And secondly, while it's in my protocol I have to contact medical control for it for some reason. Being that I work in a city, most of the overdoses I do that would warrant it are too close to the hosptial and I can have them in the ED before I can get a doc on the phone. These patients are usually ambulatory and scene times are pretty short (<5min on avg). It's not always as easy as just reaching for the medication on the shelf. Make sure you're doing the most appropriate thing for your patient.

Local protocols will dictate many treatments...both minimums and maximums.

Shane

NREMT-P

[thbarnes]

It's all about protocols, but it's also up to the medic to take the initiative in carrying out those protocols. I know many medics who would just assume get the patient to the ER quicker than actually call for orders and begin definitive treatment in the field. How many medics actually contact poison control while still on-scene of a poisoning or haz mat incident? While en route? How many leave it up to the ED?

I remember one instance in which a patient arrived in the ED slathered in mayonnaise after a haz mat exposure. The ED physicians were furious, however the Paramedics had been instructed to do so by Poison Control when they called from the scene. And it saved the patients life.

Just yesterday I began a thread in the main EMS Discussion forum on administering 30 - 60 ml of ethanol for a methanol or ethylene glycol poisoning. Are you up to the challenge of giving a patient report to the ED MD and then requesting orders to administer a shot of vodka or whiskey en route?

[flight-lp]

It is time for the EMS community to improve in an area where we are substandard, nation-wide. Ask a Paramedic how many overdose calls he/she ran last year -- then ask how many times they administered activated charcoal ? To continue to let the body absorb toxins, when the antidote is sitting less than 3 feet from the patient in inexcusable. And dont give me that crap about "airway concerns", we know why we don'd do it, and it has nothing to do with the airway. Today's charcoal is easier to swallow from a cup, it is not as gritty or chunky as it once was. Most patients will drink it once they know an NG tube is coming if they don't.

I have not given charcoal in the field in years. Many no longer carry it. There is a reason why and it has nothing to do with airway maintenence or the cleanup required afterwards. Many OD calls received allow a patient contact within 1-3 hours of ingestion. That time frame necessitates a gastric lavage prior to charcoal, you can't do it the other way around. Also if you exceed this time frame, more than likely, the substance has already been absorbed and reveals systemic effects. Now, its just too late, time for other interventions. Its not substandard, its common sense. If the drug is not indicated due to a better option being available or having knowledge that the drug just flat out will not work are pretty good reasons not to give it. Not to mention the fact that I have seen many dumbass medics trying to force charcoal down someone, on occasion even forcing an NG tube into them, when a patient took 5 APAP's because her boyfriend dumped her. Instead of griping about a medication not needed in the field, perhaps you could focus on a much bigger issue, COMMON SENSE!

[Just Plain Ruff]

Here are some articles on this. these give the full spectrum of activated charcoal administration

One argues that activated charcoal should not be given routinely. http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Citation

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Citation

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Citation

http://www.chestjournal.org/cgi/content/abstract/96/3/672

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Citation

http://www.springerlink.com/(20jidc3tb4ndf...ults,1:100413,1

[GAmedic1506]

I am sorry if I made you look in the mirror to see something you didnt like. I see a bunch of excuses and reasons for dancing around the issue, but you know that we (as an industry) are failing our patients. Yes there are cases where charcoal should not be administered, or administered first, but it isnt 100% of the cases. And since we are not administering it to anyone, either 100 % of the patients meet exclusion criteria, or we have a bunch of lazy medics in our workforce. When you go back to work, look at your monthly report and see how many overdoses your service ran last month, and then check to see how many times charcoal was administered -- ZERO -- you will have a hard time convincing me that 100% of your patients met exclusion criteria. You know, as well as I, that the majority of those patients received charcoal in the ER ! As far as it being an issue of protocols --- Good medics are patient advocates first, and your protocols shoud be reflective of those values (Currently your protocols are reflective: since you do not value treating an OD patient as highly as you do a chest pain patient, you do not have a protocol). If you didnt have a protocol for cardioversion you would be jumping up and down on your medical director's desk. I imagine that you run ten times the number of overdose patients, than you do cardioversion, pediatric arrests, OB, or burns (whether your service is urban or rural). The fact is that we do not administer it because we are scared of a mess, and it is time for us to wake up and right a wrong.

PS to the city medic who is 5 minutes from the hospital --- i would buy that arguement if you didnt treat any other patients as well -- but my guess is you are providing the required treatment for all of the asthmatics and chest pain patients that are also only 5 minutes away. And its not 5 minutes: Lets say it takes you 8 minutes to get on scene, you spend 10 minutes on scene, 5 minutes to the hospital, 10 minutes to transfer triage and give report -- the drugs have now been on-board 33 minutes and the Physician hasn't even seen the patient, called poison control, or wrote an order. You know it will be atleast another 10-30 minutes before charcoal is in that patient's system.

[AZCEP]

First, activated charcoal is NOT an antidote. It does not reverse the effects of the toxin you are trying to treat. It is an ADSORBENT. It's entire reason for being used is to prevent the toxin from being ABSORBED by binding to it, then allowing it to move through the small intestine for excretion. Once the toxin has reached the small intestine, usually a 45-60 minute trip, the effectiveness of charcoal is greatly reduced.

More than 30-45 minutes gastric lavage will be ineffective, and most poison centers discourage it's use routinely. 45-60 minutes, charcoal can work. If the contact is made with an inexact time of ingestion, charcoal use is reasonable. If the patient is symptomatic, with the threat of airway compromise, then charcoal has to wait until the airway is secured to be administered.

Second, and maybe more important, more overdose patients are saved through a thorough assessment and appropriate supportive care than will ever be by using charcoal. Once there are symptoms present, charcoal is not going to help, and could very well make the situation worse.

When you go on a call for an overdose contact your local poison center, and ask their advice. That is what they are there for.

1-800-222-1222 is there number, and it doesn't matter where you are. Dial the number and you will get the closest one that is open for business. Canada may have a different number, but they can use this one as well.

[Ridryder 911]

Good points, you are right it only acts like " saw dust" and adsorbs (not absorb) the poison, and then excreted. Far as NG with irrigation, we no longer even perform those unless it is a tricyclic or something similar. As well you better have activated charcoal with sorbital.. and then I would expediting to the ER.. (non-sorbital for ped.'s and O.B.'s) ...

As most have described, if ingestion of the poison occured > 30 minutes to an hour pta, then the treatment should be supportive and monitoring, the posion has hit the G.I. tract...

R/r 911

[Scaramedic]

We need to look into the etiology of an overdose before we pass judgments on Medics in the field. When an adult overdoses on a medication for the most part it is intentional. It is rare for an adult patient to accidentally ingest toxic levels of a medication or toxin, not impossible but unlikely. The intentional overdose patient then tends to wait until they are getting very sick before they call 911. Many times an hour has passed before we hit the doors and begin treatment.

Yes I know that there are the patients that take a 100 acetaminophen, or drink some funky tea and immediately call 911, and yes they would benefit from AC if they agree to drink it or will accept an NG. Good luck trying to get them to accept either, keep in mind they are patients and have right of refusal.

So back to the patient who waited an hour, you now have a patient with AMS and who has absorbed a large amount of the toxin into their system. Studies show that AC at this point is a toss up at best, so do we take the time on scene to drop an NG tube, draw up AC into a big syringe and take the ten minutes it takes to ram the charcoal thru an NG tube or do we just transport providing treatment to the effects of the toxicity? In my personal opinion it is best to transport and treat then waste my time on something that will probably not be effective.

The pts that we will get called for who have just ingested meds/toxins are children. Once again this is a situation that AC would indicated, and yes I would place an NG tube and give AC in this case if the levels were potentially toxic. I do not consider three Flinstones chewable vitamins to be toxic. The problem with kids is that many systems do not have NG tubes in their protocols yet, so the only route available would be PO. On a side note, I used to have an old uniform shirt I would wear when working in the yard or working on my car. It was peppered with AC from a little one who weighed the benefits-risks of AC and found that it tasted "yucky" and spit it all over me. Getting a ped to accept AC is a tough proposition, trust me cherry flavored AC still tastes (and feels) nasty.

My point is that yes AC will work in certain situations, but those situations are not as common as you believe they are. I do not believe AC is underutilized anymore than other interventions we carry on the units.

Peace,

Marty

:joker:

[GAmedic1506]

I am sorry, I just can not agree with the statement that it is no more underused than any other drug. I tell you what, I will make you a deal. I will pay you $5.00 for every AC administration that occured at your service in 2005, if you will pay me $1.00 for every case where it was indicated, needed, but not done. . DEAL OR NO DEAL ?