Limited supply: How drug shortages are impacting EMS

Rotating pharmaceutical stock, and exploring alternative pain management and expired drug options can mitigate EMS drug shortages

A recent report puts the death toll from Hurricane Maria and its aftermath at more than 4,500 people in Puerto Rico, where a lack of electricity and resources led to months of hardship for millions. Hurricane Maria’s effects spread far and wide, and can still be felt – even within the healthcare and pharmaceutical industries.

Drug shortages have had a unique impact within the EMS industry, from epinephrine, to fentanyl and ondansetron, to normal saline. Coupling with the national fight against the opioid epidemic, significant – albeit acute – changes have swept across our industry and have affected how we treat our patients.

These changes have caused us to not only look back to past practices, but they’ve also caused us to get a bit creative in how we stock our medications and how long we carry them.

Drug shortages have had a unique impact within the EMS industry, from epinephrine, to fentanyl and ondansetron, to normal saline.
Drug shortages have had a unique impact within the EMS industry, from epinephrine, to fentanyl and ondansetron, to normal saline. (Photo/Max Pixel)

Revisit pain management, comfort options

Many EMS agencies throughout our industry have transitioned away from medications like morphine sulfate and hydromorphone, and toward fentanyl for different etiologies requiring pain management. Drug shortages, however, caused a need for shifting back to past practices in order to provide many of the same patient treatment and comfort options that we currently practice.

A shortage of ondansetron created a resurgence of promethazine, and decreased supplies of normal saline liter bags resulted toward a shift to other quantity options ... or even limiting their use all together.

Consult with medical director about mixing EMS drugs

What happens with you run out of your brown-box Epi 1:10,000? You make it with a vial or ampule of epinephrine 1:1000 and a saline flush.

By no means are we in the pharmaceutical manufacturing business, but we can certainly get a little bit creative in order to create medication concentrations that we need to do our job.

A large shift within the EMS field is directed toward transitioning away from administering dextrose 50 percent to hypoglycemic patients and towards a 10 percent mixture instead. Inevitably, however, the 250 mL bag that holds the 25 grams of this 10 percent solution will (too) be in short supply. So, how do we create D10 percent?

Reach for your 250 mL bag of normal saline, remove 50 mL from the bag, then inject 25 grams of dextrose 50 percent (50 mL from an ampule or vial) into the bag to create your mixture.

While there’s no way that we can create lemonade using limes and tomatoes, we can, however, create a refreshing salsa, instead! As with any situation where creativity becomes warranted, it is recommended to consult with your medical director to make sure that everyone is on the same page and with the same level of understanding of the circumstances.

Rotating pharmaceutical stock

While there’s an arguable benefit for staffing urban fire engines with a mix of BLS and ALS providers, stocking them with a full array of ALS medications might not be the most feasible option during times of shortage.

Implementing aggressive rotation practices can also help to combat some of the effects of drug shortages. Rotating near-expiring stock on fire apparatus or reserve units to front-line units can help to extend the duration of your current medication stocks. If you order your medications from a local hospital’s pharmacy, working out an exchange program with their facility may also be an option to lessen some of the effects of drug shortages.

On the topic of expirations, while your local pharmacy may not be in favor of using expired drugs, your medical director may grant a temporary pass until a replenished stock becomes available. Keep in mind, moreover, that utilizing a medication that is 1 month past expiration is likely entirely different than 1 year past expiration.

In any event, working to find solutions to your shortage or stocking problems will likely be a need that we’ll face for the foreseeable near future. Anticipating what your plan B will be before the need to implement it arises will help you to keep better accountability over your agency’s medication needs. Implementing creative practices to acutely reduce stock, as well as developing a rotation relationship with other higher-volume entities or units can also work in your favor.

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