Editor’s note: The right medication can change a patient’s outcome — but only if it is available, secure and properly managed. Follow EMS1’s Medication Matters Week, Oct. 12-16, for practical guidance on medication safety and management in EMS, sponsored by NarcBox.
ORLANDO, Fla. — EMS providers rely on medications every day to treat pain, nausea, respiratory emergencies, dysrhythmias and other conditions. Over the last 15 years, medication shortages have made that more difficult, causing agencies to adjust medications, concentrations and even the way medications are packaged in the drug box.
During his 2026 EMS World Expo presentation, “Gaining creds with meds: Critical elements of medication delivery by EMS providers,” James Augustine, MD, medical director for Lee County EMS and Collier County EMS, and chief medical officer for the North Collier Fire Control and Rescue District in Southwest Florida, reviewed medications commonly used in EMS, and discussed how shortages, new medications, different routes of administration and quality improvement data are changing medication use in the field.
| MORE: Medication management: Pre-shift checklist. Use this checklist to identify medication inventory, storage and security issues before they become operational problems
Memorable quotes on EMS medications
Here are some memorable quotes from Augustine on EMS medications:
- “The first three drugs for anaphylaxis are epi, epi and epi, in that order.”
- “Remember the ones and the twos.”
- “If they don’t refuse electricity, they need it.”
- “Shortages are unfortunately going to stay, and we have to be able to plan around them and deliver around them.”
Top takeaways on EMS medications
1. Plan for medication shortages
Augustine discussed how much the EMS drug box has changed because of medication shortages. He recalled working in systems where medications remained in the same location for years. Providers knew exactly where to reach for a medication, even in the middle of the night. Today, a shortage may mean a different medication, vial size, concentration or location in the drug box.
Augustine encouraged agencies to have a secondary medication list in the event there is a shortage. For example, if ondansetron is not available, other medications, such as droperidol or promethazine may be options. Similar alternatives can be identified for medications used for pain, bronchospasm, dysrhythmias and other conditions.
There are also medications without a good substitute. Augustine identified magnesium sulfate for preeclampsia and eclampsia as one example. Knowing which medications can be substituted, and which cannot, allows agencies to prepare before the next national backorder occurs.
2. Use QI to take another look at the most popular medications given
Augustine presented results from a quality improvement review of 109 patients who received adenosine. Documented success occurred in 70 encounters (64.2%). Cardioversion was ultimately used in 12 encounters (11%).
The review found several cases where rapid atrial fibrillation or another rhythm that would not respond to adenosine was initially identified as SVT. Other patients who presented with fever, hypovolemia, overdose or substance-related illness and patients 80 years or older were also not responsive to the treatment.
ugustine used the results to show how QI can change education. Before reaching for adenosine, providers should take another look at the rhythm. Slowing the monitor or printing the rhythm strip and checking the patient’s pulse for irregularity may help identify rapid atrial fibrillation before adenosine is given.
The review found no cases where a patient deteriorated because of adenosine administration. The medication itself was not necessarily the problem. The findings showed the importance of making sure the medication matches the rhythm and the patient’s condition.
3. “Epi, epi and epi”
Augustine described epinephrine as one of the most important lifesaving medications carried by EMS. For anaphylaxis, his message was simple: “The first three drugs for anaphylaxis are epi, epi and epi, in that order.”
What is changing is how epinephrine may be given. Augustine discussed intranasal epinephrine and the move toward more medications being administered through the nose. EMS providers are already familiar with intranasal naloxone, and intranasal epinephrine provides another example of how familiar medications may eventually be delivered differently.
Augustine discussed its use in children with food allergies and the advantage of administering epinephrine without an injection. He noted that more information will be needed as its use expands and its role in EMS develops.
4. Remember the “ones and twos” in pediatrics
Pediatric medication dosing can be difficult to remember, especially when critically ill pediatric patients are not something providers encounter every day.
Augustine encouraged providers to “remember the ones and the twos” for several important pediatric doses. He used the phrase as a simple way to remember critical information while still using pediatric reference tools when needed.
The point was not to memorize every pediatric medication dose. Having a few important numbers readily available gives providers a place to start while treating a pediatric patient and using their reference tools and local protocols to confirm dosing.
5. Know when it is time for electricity
Augustine divided treatment of cardiac problems into three options: supportive care, chemicals and electricity. The difficult part is determining when the patient needs medication and when it is time to move to electricity.
His rule was simple: “If they don’t refuse electricity, they need it.”
Augustine used examples of patients with very slow or very fast heart rates who were still awake, talking and perfusing. A number on the monitor does not always mean the patient needs immediate treatment. The patient’s condition should help determine what comes next.
The same approach applies to medication administration. Before reaching for a drug, providers should understand what problem they are trying to correct and whether medication is the best treatment for the patient in front of them.
