Why do we UNDERTREAT our patients ?

[Just Plain Ruff]

GAMEDIC Step away from the Kool aid get off your high horse and re-read the articles that I posted. Before you cast stones you had better be able to prove that for every overdose patient you have responded to that you have given charcoal to them. I bet you cannot say that.

I for one can count on my right and left hand the number of times in the past 20 years that I have heard of Activated Charcoal given in the field.

First off there are many many many if not every overdose that you run(some fit a single drug) overdose but a vast majority of overdoses fit the criteria of multiple med overdoses and many of those drugs that the patient has taken either are not affected by activated charcoal or the patient has called later than 3 hours.

I have given AC maybe 5 times in my career in the ambulance and that was because we were greater than 20 minutes from the hospital. If the window is less than 3 hours than gastric lavage is indicated before charcoal.

Even the poison control system in our area is advocating that if the overdose is greater than 3 hours hence then Activate will not do anything. Your stomach has emptied out anything you have taken within the last 3 hours and it has probably already gone thru the intestines too.

If you can prove that you have given activated charcoal for every overdose you have taken care of in the ambulance then you can cast stones but until you can prove that you give charcoal to all your patients who fit the criteria then you have NO Place to criticize treatment.

[tinman694]

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?

Where I work, we are at most 15 minutes from the farthest facility (5 ED's) going emergent--if it is a stay and play--we will, but the question is WHY? It would take between 10-15 minutes to get poison control on the phone and definitive instructions for care---I will be doing it en route to the nearest facility if warranted.

Where I used to run, in a large western states county...we had 45 minute to 1 hour transport times...then you could be doing more for the patient---

Even if you are in the remotest part of Georgia, you can still be at a decent sized ED in maybe 20min.... (as we are in neighboring states)

So I guess what I would like to know is why you would take additional time to 'follow protocol' and delay more definitive care (while practicing cookbook medicine) rather than just transporting in and treating what you can en route......

Also, does poison control over rule medical control? If we pulled such a stunt...`I know for a fact everyone involved license would be pulled---they make the call not you.

[GAmedic1506]

I never got on a high-horse, and i never said that I was better than anyone else. Yes, I was just as guilty as everyone else, until I began to work in the emergency room. I realized that I was wrong, and that our system was failing these patients. I educated my coworkers to the issue, and they agreed that we needed to change. We now administer it quite frequently. I felt that this would be a good topic to discuss, despite how defensive it might make people feel, because I know that this issue occurs in every community. How many over-dose patients die or suffer long-term consequences because we fail to treat them appropriately in the first few minutes of an overdose ? How many ICU-stays could be avoided if we treated these patients as aggressively as we treat stroke or heart disease ? None of us can say that we have done all that we could do when it comes to AC and overdose patients. But that doesnt mean we can't fix it moving forward. I am not suggesting that we treat every medication OD patient with AC --- I am just asking everyone to start treating the apporpriate ones.

If I were a medic that refused to give Morphine to symptomatic Chest Pain patients that fit the protocol for its use, because I was afraid they might puke on me, you would want my license pulled. Every day there are overdose patients who need and should receive Activated Charcoal, but are not getting it, because we might have to clean up a mess. The vast majority of chest pain patients are not diagnosed with a cardiac event, yet EMS treats them because it could be life-threatening, and the treatment is rarely life threatening. When you have a patient who has just taken a toxic dose of medicine, and you continue to let the drugs be absorbed, even though you have the mechanism to stop it, I think that is just wrong. Maybe the rest of the EMS world sees it differently.

[kevkei]

GAmedic1506, so are you telling me that if yo have a patient that states they took 10 tablets of extra strenght Tylenol, you are going to administer AC?

I'll tell you why it is being given less and less, because people are better understanding pharmacodynamics and pharmacokinetics. To be specific, our local ER's are now only giving it in few and very specific cases. One needs to understand the LD 50 (lethal dose) and toxic levels of a drug, then they need to understand what those effects will be. For example, if you have someone that has an isolated intentional overdose of 100 tabs of Paxil, they may have toxicity but there is no chance of it being fatal or even causing any harm to the body.

AC administration is looked at by evidence based medicine based on a risk vs benefit analysis. The FACT is, the risk typically is a lot higher than the benefit. And don't tell me that aspiration is crap. It is a given fact that charcol is bad and does nasty things to alveolar tissue.

So if you want to practice cook book medicine, go ahead. But don't try to tell a bunch of these very intelligent and well respected posters here they are out to lunch. Maybe it is you that needs to look in the mirror?

[Ridryder 911]

I highly suggest you talk to a a poison center, just like any medication Activated Charcoal has its' indications and also side effects as well. It is not a carte blanche' medication.

There is a lot of difference between treating accordingly and appropriately. I work part time in a large metro area as well, with an attached state poison control unit about 10 feet, with 3 full time pharmacist and 1 toxicologist personal, manning the center. I can assure I can count the number of times when we give activated charcoal, (hint maybe your ER is giving it in inappropriate or prophylactic, or simply following the standard guidelines.)

I highly suggest before announcing to the world of under usage of activated charcoal, one would have a full understanding of toxicology and full understanding of the a) drug that was ingested breakdown and metabolism & absorption of such drug 3) if adsorption will be truly beneficial to such patient, not just an indication to treat with AC.

Yes, it might be one of the lacking treatment modalities, but yet again, scientific studies need to be performed to justify such statements, and if there really is a difference, outcome when & if AC was used.

Again, without Sorbital, the meds sit in the GI tract, and still is absorbed from the adsorbed AC. As well, one should know Sorbital causes diarrhea, within about 30 minutes, to remove such contents.

Again, one has to justify each and every medication, not just because one has seen differential treatment in ER, than the field. If that was the case, working ICU/CCU verily ever cardioverts V-tach, PVC's etc.. because of the difference in setting, and patient presentation, history, as well differential in treatment modalities.

R/r 911

[redwolfef6]

Here in Denver we don't even carry AC. Our tx of OD's depends on what is ingested. Quite honestly everything is a call in at that point. It is almost better to maintain airway, IV with blood draws, monitor and drive fast.

[Ridryder 911]

Here in Denver we don't even carry AC. Our tx of OD's depends on what is ingested. Quite honestly everything is a call in at that point. It is almost better to maintain airway, IV with blood draws, monitor and drive fast.

Okay.. I know different in Denver!.. Load and go, is not highly recommended. As well driving fast went out with Mother, Jugs, and Speed. Diesel medicine KILLS!

Hint: http://www.emsnetwork.org/ambulance_crashes_2000.htm

R/r 911

[Just Plain Ruff]

Drive fast, he he he that did go away with Mother Jugs and Speed. Maybe the more appropriate term would be emergent with all due caution.

Do you drive fast with all patients or was that just a Homer Simpson Statement - DOH!

[Nate]

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.

That is the truth, we don't carry it anymore at all. Then again, most of our OD's aren't able to sit up and drink the stuff either. :?

[flight-lp]

I am sorry if I made you look in the mirror to see something you didn't 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.

Well, I thought I said my piece earlier, until I read this crap. Wasn't going to respond, but something about the presumptuous nature of this individual inclines me to step up on my soapbox for a moment...................

First off, I think there is more to this story than you "started working in the ER and now see the light of how little we care for our patients". Did something bad happen to you or someone you are close to?

Next, you are wrong in your estimates. Since January 2006, I have run the following calls:

OD's - 12

Cardioversions - 4 in flight

Pedi Arrests - Typically don't fly arrests, but have worked 4

OB's - 3, we do not fly active labor patients

Burns - 17

Seems your x10 estimate is slightly incorrect, go back and learn some basic math.

You do not know my protocols for OD patients and I doubt seriously that you have anything close to available interventions pre-hospital.

I don't think anyone cares about convincing you about anything as you seem to already be the all mighty knowledgeable about everything OD, except having the ability to read current literature and speak to people who are actually experts and get there recommendations.

Plus you can spare me the whole "cleaning up a mess" crap. After the condition my helicopter is in after most calls, I would welcome an OD patient....................

Like I said before, there are reasons why EMS agencies do not carry the drug anymore and it has nothing to do with failing our patients. If all of these medical directors agree, who are you to change their minds. Let it go, or produce a PROFESSIONAL method of research and statistics to show validation of why our medical directors should change their mind. Coming in here saying that we are not "advocates for our patients" and that we "fail our patients", isn't going to get you far in this family! Go take some Xanax................