Of the 6 R’s EMS personnel may think the Right Patient doesn’t apply to us. After all, it is not like we are charged with giving medication to a ward full of patients. We are dispatched usually only for one patient at a time. When we arrive on scene, we are pointed to our patient. We assess the patient and treat according to our findings and take the patient to the hospital. Our patient is rarely if ever out of our sight.

Let me tell you about a hypothetical call. You are dispatched for altered mental status at an assisted living facility. A staff member directs you to the first room on the right where you find an elderly woman laying unresponsive on the carpet, cool and clammy with snoring respirations. Her blood pressure is 138/70 and her heart rate is 80. The lighting in the room is not very good and on quick glance the woman has poor IV access. After repositioning her airway and applying oxygen you make the decision to put her on the stretcher and get her out to the ambulance where you can work on her. You are thinking she is may be a diabetic or possibly having a stroke. You make the decision to load the patient and get her out. The staff member has gone to get the paperwork so there is no one to ask about medical history. On your way out the door, you ask again for the paperwork, and the staff member says she will bring it out to you.

In the ambulance, you check the woman’s sugar. The glucometer reads LO, which means less than 20. You manage to get a IV in the woman’s hand and are able to push in an amp of D50. She rouses somewhat and stops snoring. Her skin is warmer. You recheck her sugar and find it to be 54. By now the aide has brought out the paperwork, which you look through. The woman has a history of MI, but does not appear to be a diabetic. She was last seen at three the previous afternoon, almost seven hours ago. You give her a second amp of sugar and she is again more alert, but her speech is somewhat slurred and she is not certain of her whereabouts. She are uncertain if this is normal confusion for her or she has some degree of dementia. Again, the W10 lists alert and oriented as her norm.

At the hospital, you give your report and turn over care.

The next day, you follow up. Here is what the nurse tells you.

“We couldn’t figure out what was going on with your lady. We did a CAT scan, ran every battery of tests, admitted her for observation. The CAT scan was clean – no CVA, but her confusion continued. She wouldn’t answer to her name, and her sugar was all over the place. Then this morning, the assisted living facility calls to see how Mrs. W, one of their residents was doing. I looked through the system. We had no one by that name here. They were certain we did. I told them to call the other hospitals. I looked through our records and the only person from that facility was the lady you brought in – Mrs. K. When they called back insisting we had Mrs. W, I told them we didn’t but we had a Mrs. K from their facility. No, you don’t the woman from the facility said, Mrs. K is sitting right next to me now in her wheelchair eating her cornflakes.”

So what happened? You guessed it. The facility gave you the wrong paperwork. No wonder Mrs. W wasn’t answering to Mrs. K’s name.

While this particular call did not happen to me, I have had similar situations. I have sat in the ambulance outside a SNF, working on a patient waiting for the staff to bring out the paperwork and once they did, glanced at it to see the paperwork was for a woman when I had a man on my stretcher. I have been handed paperwork for one patient and told to take the patient by the door in the last room on the left and done so, only to have the staff chase after me to say I had taken the patient from the wrong room. They had meant I should take the patient from the last room on the right.

Think this only happens at nursing homes. You are on scene at a fall, unresponsive man fell out of a tree. While you quickly backboard the patient and protect his airway, you ask the police officer to get demographics for you. He hands you a page he tears out of his notepad. You stuff it in your pocket. At the hospital, you give them the name and date of birth on the note pad. Only later do you learn that the name you gave the hospital was for the asthmatic the police officer had treated earlier in the day. In his haste, he tore the wrong page out of his notepad, not the fresh information he had gathered from a bystander who knew the patient

What to do? While there are some times, you will not know the identity of your patient, (you will have John or Jane Doe), there are some steps you can take to protect yourself and your patient. If you are given papers for a patient, ask someone to verify that the papers and the patient are a match. “This is Hazel Jones?” If you are on scene in a house or street, try to get a bystander or family member to verify the patient’s name. “This is Robert Jones?”

While we can work in a chaotic environment, it is our job to bring order to that chaos. Sure the assisted living facility bears a large amount of fault for giving the crew the wrong paperwork, but the crew needs a mechanism to help protect the patient from what by all means is not a completely unforeseeable medical error. Now when the staff brings the paperwork out, I have them provide me with a positive ID of the patient. I read the name on the paperwork and say, “This lady is Mrs. G, right? Right?”

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More Thoughts on the 6 R’s

There are numerous routes of drug administration prehospitally:

Inhaled (Nebulized)
Intranasal
Oral (PO)
Lingual or Sub Lingual
IV (Intravenous – rapid, slow, drip)
IO (Intraosseus)
IM (Intramuscular)
SQ (Subcutaneous)
ET (Down the tube)
Rectal

Some would say rectal is the only wrong route. I have never given a drug this way, but I can see how in a dire situation and depending what drugs you carry, rectal would be the right route. Say you carried Diastat (rectal valium) and had a seizing baby. In basic EMT class, my teacher talked about squirting a tube of glucose in an unconcious patient’s rectum. I am glad I am no longer a basic. Like I said, I have never had to go this route.

The most serious wrong route which I have written about in Medication Errors – Epinephrine– is epi 1:1000 IV. It can be and often is fatal. We are guarding against this by requiring our services to carry epi-pens as their front line drug. Epi should only be given IV in the 1:10,000 concentration, and even then, unless the patient is already in cardiac arrest, it must be given very slowly. (0.1 mg Epi 1:10,000 over 2-3 minutes).

Years ago, when we gave epi 1:1000 we gave it SQ. Since the 2005 AHA guidelines came out we have been giving it IM on the theory that a person possibly undergoing peripheral shutdown will get the drug quicker and more effectively IM.

Also, years ago, I also almost always gave Narcan to unresponsive heroin addicts IV. You wanted an IV in case they didn’t wake up with the narcan, or even if they did, it was easier to get the IV when they were unresponsive than if they were awake and battling you. (The other side would say, why put in an IV when they are just going to wake up and rip it out before they stalk away.) There was the long running joke about getting an IV in the heroin addict, putting the narcan syringe in the IV and then waiting to slam it as you came through the ED doors so the junkie would puke on the mean triage nurse.

That was wrong then and it is wrong today.

I don’t know how it is where you practice, but I don’t see as much cowboy stuff as I used to. I once “hotwired” a patient. I had heard of this technique and wanted to be cool, so I drew up my narcan and instead of bothering to get an IV or even do the standard IM or SQ, I shot it right into the apneic patient’s EJ (external jugular) vein with predictable results. The patient woke up puked, oh, and they were now bleeding from the neck. Stupid. My argument was — this guy is not breathing, he needs the drug right now and the fastest way is to hotwire him. But what would have been the harm in taking out the ambu bag, giving him some breaths and then giving him a nice easy IM dose?

I like the IM or SQ route for the narcan. Let them wake up slower and easier. If I do do it IV, I always push very slowly, just a little at a time.

Many of our drugs we give IV, but — at least prehospitally — I find many medics push the drugs way too fast. The thinking may be we are out in the wild and have to get the work done so time applies to us differently. I have seen medics demonstrate their sixty second push. They say “One, two, three, sixty,” as they push the plunger in.

A rapid IV push is the wrong route when the drug is supposed to be given over 1-2 minutes. Most of the drugs we carry with the exception of adenosine and drugs for cardiac arrest should be pushed over 1-2 minutes and not slammed in.

When I QA run forms, one of the most frequent mistakes I see is medics giving Amiodarone rapid IV push to a patient in VT (with pulses). Medics think wow — this patient is in VT — I have to do something quick and slam it in, forgetting or not knowing perhaps that this can cause a sudden and critical drop in blood pressure. (I confess I did this myself the first time I gave it). Mix it and drip it in over 10 minutes. In the meantime if you need to shock the patient if they are deteriorating, shock them.

Just because we are prehospital doesn’t mean we can create our own rules for drug administration.

Zofran needs to pushed over 2-5 minutes. The medics questioned this and I asked our medical director, how about letting medics do it over a minute. His response was, “What does the manufacturer say? And what would you want for yourself, what the manufacturer says or what is convenient for a medic? It is not that hard to push a drug over two minutes. A little bit at a time or slow and steady while you chat with your patient.

When I gave morphine years ago, nearly all my patients felt sick and nauseous. I was pushing it too fast. Now I always push it slow, real slooooowwww. And while I like to give it IV, sometimes IM is the right route. For instance, my patient has a broken leg is lying in the middle of a football field. I can give IM morphine more quickly and get some pain relief started until I can move the patient to the ambulance where I can then do the IV. If the patient with the broken leg is lying on her living room floor, then it is easier to do the IV right there, unless the lighting is poor and the apartment roach invested. In that case I would say IM is the best initial route.

We also have permission now to mix our morphine in a small IV bag and drip it in. I tried that for the first time the other day. 5 milligrams in 100 cc. It was a great. The patient slowly became more and more pleasant and animated until she suddenly realized hey I feel pretty good. I forgot my leg was broken.

D50 is an IV push, but pushing it too fast can cause severe headache for patients, not to mention the thick drug can cause severe damage to their veins. We are also able to dilute our D50 to make it D25 or D10 and drip it in. Works great, much better for some patients.

Ativan. We carry it in the 2 mg/2 ml concentration. It needs to be diluted 1-1 with saline before you give it IV. Many don’t do this. I didn’t until someone showed me where it said right on the vial. IV use requires dilution. It was in black and white. Now that we have the EZ-IO, I never have to go ET (Down the Tube) with drugs in a cardiac arrest. I still hear of some medics using this route routinely. The thinking may be get the drug in as soon as possible. The problem is the drugs are very unreliable by that route and likely do not even work.

What does this all mean? If you are going to give a patient a drug — there is a right route for it. Your job as a medic is to decide what that best and safest route is and provide your patient with the best care possible.

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The 6Rs – The Right Dose

The 6Rs – The Right Drug

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