Emergency Department Management
SALT LAKE CITY — Like EDs, emergency medical service (EMS) providers have also been struggling with drug shortages in recent years. In fact, some would argue that these pre-hospital providers are among the hardest hit by these shortages because they have fewer resources to rely on in emergency situations. “We carry one drug for each disease process,” explains Jeff Beeson, DO, medical director, MedStar Emergency Medical Services, Fort Worth, TX. “In the hospital, I may have two or three drugs for that disease process, so I have more options in the hospital than the pre-hospital environment.”
Furthermore, Beeson — who is also an ED physician at Huguley Memorial Hospital in Fort Worth, TX, and Parkland Memorial Hospital in Dallas, TX — points out that hospitals may have larger sway with pharmaceutical manufacturers than EMS providers because they purchase in such large quantities.
“It seems that specific distributors set back certain lots of medications and drug supplies for their big customers,” says Beeson. “Traditionally, EMS systems are not those big customers, so they may suffer from not having that control of distribution for what limited supplies are out there.”
In the last 18 months, such conditions have contributed to a “phenomenal” decrease in available supplies of medications that are critical to EMS medicine, explains Raymond Fowler, MD, FACEP, Chief of EMS Operations, BioTel EMS System, University of Texas Southwestern Medical Center in Dallas, TX. “We have, at times, seen shortages of medications for cardiac arrest, diabetic coma, seizures, for the management of excited delirium, and for such problems as eclampsia of pregnancy,” says Fowler.
As a result, there have been instances in which EMS providers have had to search for new pools of medication, or dip into supplies of other medicines to formulate solutions of critical medications to treat such conditions as diabetic coma, for example, says Fowler.
To deal with critical shortages for such drugs as epinephrine and atropine, EMS providers have had to, at times, resort to diluting medications used for anaphylaxis in order to treat patients experiencing cardiac arrest, explains Fowler. However, while such short-term fixes have been available, Fowler says EMS providers have to devote much more time to this issue than they have in the past. “The message is very clear that we have to be very diligent to make sure that we are always staying one step ahead of the manufacturers so that we can anticipate that there might be a shortage,” adds Fowler.
Maintain consistency
For example, while Beeson never used to have to devote any time to making sure that adequate supplies of critical drugs were available, he now meets with medical patrol teams and his supply officer on a weekly basis to discuss what critical medications are on the shortage list and how much of these drugs MedStar has in stock.
The crisis has also prompted Beeson to evaluate historical data to see if EMS providers are really carrying the optimal amounts of various drugs, or whether routine practices need to be modified. For example, he is looking more closely at such as questions as:Is this a drug of convenience or a drug of necessity? If we don’t have a drug, what are the clinical implications? What will happen to the patient if he or she doesn’t get a particular drug until reaching the hospital in 15 or 20 minutes?
In evaluating drug usage patterns, Beeson has found that while cardiac drugs get used frequently for cardiac arrest, some other medications may only get used once or twice a year.
“Also, we have come to the point with some of our medications where instead of leaving them on the ambulances, we actually check them out on a daily basis just like we do with narcotics because they are in such short supply,” says Beeson.
To minimize errors associated with different drug concentrations, Beeson has also endeavored to maintain as much consistency as possible. For example, when there was a shortage of the most-used concentration of epinephrine, Beeson worked with a local pharmacist to formulate and package the drug so that it was in its familiar concentration. “It was what [the EMS providers] were used to when they pull the drug out of the bag,” he says.
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