We have reached the Essential Eight — eights drugs that I am not going on the road without.
I am in no way advocating that my 33 drugs be cut down to 8. I could cut my list down to 24 without much concern, but after that my effectiveness starts to diminish, more so with each drug as we move up the ladder. Some drugs such as Phenergan or Lidocaine could be taken out rather easily earlier on due to the ability of other drugs (Zofran and Amiodarone) to cover some of the indications. Another drug such as Aspirin (a very important drug) could be taken out because it is readily available in homes, businesses, doctor’s offices, and on entry to the ED. Still I wouldn’t want to be without it.
I suppose I could have had an Essential Ten or an Essential Sixteen, or even more daring, an Essential Six, but in the end, I came down with an Essential Eight that I could see absolutely no way around not carrying.
So here are the Essential Eight in alphabetical order
Ativan
Dextrose (D50)
DuoNeb(Albuterol/Atrovent)
Epinephrine
Morphine
Nitroglycerine
Normal Saline
Oxygen
In the coming days I will discusss these drugs, and, as an exercise only, I will force myself to remove one drug from this essential drug list every day until I am down to my most essential drug.
Stay tuned.
***
And here are 9-33.
9. Narcan
10. Aspirin
11. Amiodarone
12. Atropine
13. Dopamine
14. Zofran
15. Cardizem
16. Adenosine
17. Glucagon
18. Magnesium
19. Benadryl
20. Versed
21. Solu-Medrol
22. Sodium Bicarbonate
23. Calcium
24. Haldol
25. Metoprolol
26. Lidocaine
27. Toradol
28. Activated Charcoal
29. Tylenol
30. Tetracaine
31. Phenergan
32. Vasopressin
33. Lasix
Also on Street Watch …
- 2010: A Year in Paramedicine – January 18, 2011
- The 6Rs – The Right Route – December 7, 2010
- The 6 R’s – Right Dose – November 22, 2010
- Death in the ICU – January 15, 2011
How can you even consider carrying MS and not Naloxone?
Ian-
You need to read the series to understand what I am saying. I am not advocating getting rid of all the drugs. I am merely saying there are eight drugs I cannot due without. In a jam, I could do without narcan (please read the narcan entry). If I happened to give so much morphine that I knocked out a patient’s respiratory drive (an occurance that I have never come close too nor have I heard any medic in this area doing — it is hard to do if you dose properly and start low and slow as you work your way up the ladder), I could bag the patient.
thanks for commenting,
Peter C
I think that Morphine is far too infrequently given due to the “hassle” involved. Medics have to exchange their narcotics in a way that is usually significantly more involved than it would take to, for example, replace nitroglycerin.
At my most visited facility (depending on the agency of origin), drugs can be exchanged 1-for-1 or the entire drug box can be exchanged at a locked system right at the entrance of the ED. However, to replace a narcotics bag, the medic would have to make the long trek downstairs to the basement pharmacy and wait for a pharmacist to exchange the used narcotics bag for a new one. The system leads many medics to think “Well, we only have a 10 minute transport time…they can get some pain relief in the ED.”
After reading your posts on how long it truly takes to get pain relief in the ED – sometimes up to a couple of hours, depending on the situation – I will be far more inclined to advocate for appropriate pain relief in the field. I am not surprised that it made your Essential 8 after reading your posts on doing as much as you can to provide significant, but appropriate, pain relief in the field. I would certainly want a provider to give me or my family good pain relief if we were hurt.
As a side note, I don’t even believe my system carries enough Morphine in our bags to collapse an adult’s respiratory drive.
After watching my dad carry on a conversation while on a 40 mg/hr morphine drip in hospice(he was only 150lbs), I’m not nearly as concerned with giving 5mg increments for a broken leg.
And of the drugs you carry, my county does not carry:
Zofran
Cardizem
Glucagon
Versed
Solu-Medrol
Haldol
Metoprolol
Toradol
Tetracaine
Phenergan
Vasopressin
I’m certainly not the first one to bring this up, but I feel so strongly about aggressive pain control that I felt compelled to weigh in.
Morphine (and other opioids) depress respirations in two ways. First, recall that in healthy patients, the drive to take a breath is triggered by an increased PaCO2, perhaps around 45mmHg. Morphine increases this threshold in a dose-dependent manner–the more you push, the higher the PaCO2 has to get to trigger a breath. This is the way that morphine can cause genuine respiratory depression.
The other way that morphine can cause a decrease in a respiratory rate is through analgesia: folks breath fast when they are in pain, and when they get relief from that pain and maybe a little bit of a buzz, they quit breathing so fast. This is not respiratory depression–it is pain relief!
So unless you can make the case that your patient has a good story to be tachypneic from shock or hypoxia or something, the person breathing at 28 times a minute is not in any danger of depression from your morphine and would probably benefit. (The need to get an accurate rate count and our near-universal resistance to doing so is another rant.)
Finally, although I don’t think this was Peter’s point (he’s just doing an exercise on his blog), I would feel absolutely comfortable riding around without narcan. Narcan frees me from bagging or possibly intubating someone, and it keeps me free from back injuries from third-story carry-downs, but it is not a life-saving drug. Dramatic and fast-acting? Yes, and I think we paramedics like that. I sure do. But if you have a BVM in your kit, I would have a hard time buying a case where you needed narcan.
I wonder if anyone in EMS history has had to give a patient Narcan to reverse the effects of Morphine that they gave to that patient? I’ve never heard of it and I’ve been in EMS for more than 30 years.
Considering it’s potency versus on the street Heroin, Morphine is very unlikely to cause someone to go into respiratory arrest. Fentanyl is far more potent than Morphine, but at therapeutic doses still shouldn’t cause respiratory arrest.
totwtytr says
I wonder if anyone in EMS history has had to give a patient Narcan to reverse the effects of Morphine that they gave to that patient? I’ve never heard of it and I’ve been in EMS for more than 30 years
agreed i’ve been in ems 20 years and have given itn plenty of times and never had to reverse it with narcan.
speaking of morphine i’m looking for an article that concerns the reason that morphine drops your blood pressure is not as much related to it’s vasodilation properties but because it’s a natural drug that it caused a mast cell degranulation/immune system cascade/histamine/basofil dump and this is what mediates
most the hypotension of morphine. this article spoke about given benadryl with morphine. i can find the article. i just can’t find it for free.