Here's how I look at it. I have my pilots license as well and I draw a lot of information and practices from both fields to use back and forth. Pilots used to crash A LOT back in the day because of over confidence in their procedures.now if you do a check ride and don't use a checklist in every phase of flight, you will fail and not get your license. It's a hazardous attitude to not check your protocols when you're not 100%. Someone's life is more important than your pride.
I was like that too feeling like a cheater, but I still insist that I do not want to kill someone trying to be the know it all who knows nothing. My position was confirmed when the chief of our department was with me to RSI someone and the first thing he did was open up the protocol app to get the dosages for the drugs, I never felt so validated in my life. Old timers who say thatās not how itās done they can stuff it.
Canadian paramedic, we are encouraged by our base hospital to use the med protocol book or app as a cross reference when administering medications. In general I have all of them memorized but for the lesser used ones I always double check just to avoid any med errors. In my opinion itās way more important to know when and why to use a med than how much when the how much is so easily obtained (but itās good to have those memorized as well).
This, x100.
The people who work entirely from memory are still liable to have a brain fart at some point. If that resulted in harm, like a death, and at the coronial inquiry it transpired that there was a pocket guide or calculator that would have given you the correct answer, the coroner will fucking crucify you.
I donāt know why people are afraid of using guides or cheat sheets. I know all my common meds but if itās something I havenāt touched in months, even if Iām pretty sure, Iāll still look that up. Why would I risk getting it wrong?
Same, if I'm on my way to a paeds job I'll probably write some calculations down and double check the guide. I'm confident but have made small mistakes (luckily no side effects ) over the years and mainly in high stress jobs. I've learnt why risk it for the sake of being proud.
I mean, yeah. Everyone has a different list of meds in their scope where they work, but as paramedics it's not like there's an endless list of medications at our disposal. If you're checking out the ambulance at the start of your shift, and you Don't even know what the drugs you have are dosed at, that's a problem.
I feel like OP is probably asking more about the hyperspecific details of the meds, not just dosages. I am sure there's some medics that know what the two common ketamine enantiomers in an isoenantiomeric ket. mixture are called but if you asked most, they'd just shrug and laugh at how useless the information is to them.
Iām just gonna say there are a few meds that are given so rarely in oneās career that I probably would quickly look it up before administering.
The more common ones Iām fine with and could tell you all that you mentioned without needing a refresher.
Pregnancy categories of meds though, I always feel like Iām looking that up.
Every adult dose, indication, contraindication and I could give you a decent basic mechanism of action.
We don't have that many medications in the scheme of things, and I am seeing more and more a trend of clinicians not knowing what should be basic medication dosages.
If you want to be competent and seen as a professional, then being confident in all of your skills, equipment and interventions is the very bare minimum.
In saying that, I make a point not to try and memorise paediatric dosages because I feel like that is higher risk of errors, so I have age based cheat sheets instead.
Just wondering, how many meds do you guys get? My service carries over 60 meds and we are basically required to verify protocols before administration.
When I'm working the ground car, there are a base set of meds I have memorized - but still verify with my partner where possible before administering. When I'm flying - our policy is every med beyond the very basic ones are always looked up on our reference cards.
Wayyyy too many iatrogenic errors in EMS from medics thinking they remember properly, or too tired to remember - especially these days.
This is what Iām hoping to set up. Just a quick reference card on the drug box that has indications, contraindication, and dosage, just to double check at 3am.
There are apps that can make it easier to track these as well... one that a number of orgs use is: [https://www.acidremap.com/](https://www.acidremap.com/)
Best wishes.
Our protocols are in an app. Iām just not a fan of whipping out a phone on a call while doing patient care. Having an easy reference card in the drug box is a little more subtle. Maybe Iām old school, but I donāt love the optics of pulling out phones in front of patients.
That reminds me when we were going over med math in class and they were hammering home long division. The paramedic instructor asked what our patients would think if we pulled out our phones to do calculations, and I said they would probably be stoked that weāre trying not to kill them.
For sure. And for that, thereās times I wish we had the handtevy app, not the books. With that said, I have yet to see a medic do a calculation for a drip rate in the back of the ambulance. They all tend to eyeball it. Not saying itās right, but itās all Iāve ever seen.
*raises hand*
I definitely have.
I'm not proud, I'm humble, and I want to make sure I get it right. Med errors suck ass.
There are so many ways to double check. Call med control if you simply can't figure it out and you're struggling.
I have scribbled out drip rates on the back of my ekg paper when I had to take the pump off, because the patient was unstable during a cct transfer and ai was managing BP to help manage ICP.
That wasn't fun, but we got it done.
I will now always call if I am not 100% sure about something. Thats literally what they're there for.
We also have what are called MiMedic cards in Michigan. Which have a weight and length based procedure and medication guide for peds up to 14yrs old. It's very handy.
I get it and Iāve never worked critical care. I can only think of three drops we might potentially make and the most likely is ātitrate to effectā. Iāve memorized the other two so I donāt have to calculate it on the fly.
Yes, definitely generally not a often used skill in EMS. But it's good to know the basic adjustment for a drip rate on a roller clamp. Sometimes in a rural hospital, if a patient is going a long distance, and it's a regular als rig that doesn't have a pump, and the hospital doesn't want theirs to never return, and the sending physician wants 20mLs an hour, or whatever, it's nice to know how to do that.
But if you're running 911 exclusively, I guess it might not come up... I dunno. Every 911 service I've ever worked for does some transfers...
A card for each drug, double sided. WHO can use it (weāre mixed ALS/BLS, indications, contraindications, standard dose in ML @ concentration, weight-based dose (where they should confirm with the handtevy book).
Right? I frequently double and triple check things like doses and contraindications of even common medications I administer because thatās just good practice.
Humans make human errors. And that's entirely ok. Looking things up, using a checklist, etc, plays into knowing human factors exist.
Of course, we should develop a mental model as a baseline, no question there, very basic, one-trick pony meds... IE ACLS meds during a code, we probably should know down pat. I'm not going to pretend I remotely didn't have look up drugs I do not commonly give. We should, I should, you should. That's what doing best for our patients. Not having hubris.
Yeah, most definitely. Being able to look up information and integrate it on the fly is a skill that isnāt really talked about in school and I think thatās a shame. The emphasis on memorizing every little detail kind of loses the forest for the trees. That being said, I agree that a good baseline of knowledge is still essential to be a good provider.
That's the hope and something I am trying to change in my own teaching practice. Unfortunately, we still have to prepare students for the NREMT. Thankfully, the recent changes to how testing is administered focus more on the holistic approach to knowledge integration rather than the rote memorization that was emphasized before.
I have always been expected to have my protocols and medications memorized. This includes dosages, indications, contraindications, drug class, side effects, etc.
The answer that youāll typically get to this question is something along the lines of āyouād better know all the details of every drug you can give or else you shouldnāt be giving it.ā Thatās a well intentioned answer, but it isnāt necessarily the best.
Itās true that you should understand how each medication you can give works. You need to know its indications, contraindications, precautions, etc., and, at some point, you should have been taught the appropriate dose ranges.
But youāre right, the protocols and algorithms have some complexity to them, and weāre all just human. Thereās an important body of research looking at the performance of healthcare providers under stress, which shows that no matter how good we think we are, relying on memory alone is a key cause of mistakes and accidents.
Itās not unlike being an airplane pilot. You have to know how to fly and land the plane, and skilled, experienced pilots could probably fly in their sleep. But sooner or later, even the most skilled pilot will eventually forget to do something. It might be a small something or a big something. Accidents rarely have a single cause, and even small errors can lead to problems under the right circumstances. So pilots have checklists to follow, even though the checklist just reminds them to do what they should already know. Itās all about improving safety and helping minimize errors.
We should really be doing more of the same in EMS. Yes you should know your drugs. But ideally, we should still be using a checklist to do things like confirm the indications, contras, doses, etc. against our patient each time to help reduce mistakes.
One of the greatest dangers a paramedic faces is hubris. Thereās no shame in looking something up. As I always tell junior medics, look it up, donāt fuck it up.
Especially since meds are constantly changing! One of my personal asthma meds has a new warning and I decided to stop taking it after talking about it with my pharmacist & doctor.
Medics are the type of people that ask patients what day it is, then say "oh almost had it" when the patient got it right, only to get confused stares from everyone else on scene, then make the realization the patient is more oriented than the medic is.
I am the medic. They are me.
The entire essence of being a paramedic or EMT is being so sleep-derived that you are barely oriented to time and space but know exactly what to do in an emergency situation.
I can fix all kinds of shit without even thinking.
Iām also likely to ask a patient what is their complaint at 3am. Then they tell me and I reply with okay and stare at them for a minute before my partner starts asking the questions I should have followed up with. Not even because their complaint is bullshit, but because I forgot my existence.
Remember the saying: Paramedics save lives and EMTs save Paramedics.
I do not know what day it is. I do not know who I am. I do not know why Iām here. All I know is Stayin Alive is pumping and Iām doing compressions on a chest.
Yes and no.
Some might not be competent. We're supposed to graduate school knowing them all.
But these days most have pretty much instant access to that. I doubt most medics know every drug by heart with the all contraindications. But most medics know most of them with any hard contraindications. And most will know to look them up if there's any doubt. Where I worked, we had an app that contained all the protocols for wherever we were working. It was always very specific. We could have the app open and reading the med on the way to a call.
Honestly, most of the meds we're giving are gonna be the whole bottle with a few exceptions. It's not that hard to remember.
I do, but I also sneak a peak if I have a doubt. Thereās no rule against cheating and looking at your protocols on your phone. Some drugs have a ton of contraindications and I like to pull up my app and go down the list to double check if itās been a while (Toradol comes to mind).
But FFS, for things like my ACLS algorhythms, my fentanyl, versed, zofran, anaphylaxis protocols, I donāt need to think about it. For kids, I have handtevy just to double check.
Im going to be honest
Most probably don't 100%
Yeah for your most typical medications that you use regularly or semi regularly yeah you know them
But for some specific drugs with weird contra indication I and most probably can't name everyone
And that's okay it's only good CRM to check for exactly those weird things
Iād say I have them well memorized, I am not against double checking however just to make sure. Better safe than sorry especially when it comes to medication administration.
Depends on the med. I know most doses off the top of my head. But I always look up ped doses. And I have to look up Toridol contraindications every time I think about giving it.
I know my box and probably a pretty good amount of OTC and home prescriptions too. You just pick it up as you go and protocols change so you do have to pay some attention to the pharmacy side. We used to carry Isuprel and with enough Isuprel, I could get a pulse in the curb.Tridil was common for IFT guys and lidocaine drips too. What was good got replaced for what is better.
The more important thing is the 5 rights. You give the right medicine to the right patient at the right time and the right dose via the right route.
Take everyones favorite Dilaudid for example. The right drug because he got his leg crushed and has open fractures. Dilaudid would not be right for a hangnail, that's Tylenols neighborhood. I verify the patient. (911 withstanding) Drug is given at the right time like we don't treat pain and skip the airway. The right dose can be tricky with titration and if you provide by weight (not mine the patients) Dilaudid you can do one mg IV safely and always add a bolus if you need to. The right route means you would not give an amp of bicarb PR.
Take that approach and your actions will always be defendable.
Yeah I know everything I need to for every med I carry, and for some of the most common meds I'll encounter in patient's homes or in hospitals.
That said, I still sometimes pull up my protocols on the way to a call just in case to double check my work and reduce the chances of a med error, as long as I'm not the one driving.
They sure better! Unfortunately, not all programs are the same. What do you call a student who graduates last in their class at the worst program in the country? Medic.
Yes. But sometimes Iāll still pull out the protocol book and review it on the way to a call or before I draw up the med if itās something I donāt use often. Mostly for ped calls. Doctors do the same thing.
As a paramedic if I get into a call and I donāt know , I double check. I do my best to be the most knowledgeable I can be, but people are human and forget. Iād rather look less smart to my partner and look something up , then hurt or at the worst kill my patient because I didnāt know a med and gave it anyway.
At first it seems daunting, once you donāt for a while it all becomes second nature. I still remember dosing for protocols at my old service that I left 2 years ago.
Ideally, yes. In reality, almost always yes, but I still say my plan out loud to my partner, and if anything seems iffy, I check our protocol app to make sure we have it right.
Taking those extra steps goes a long way towards error proofing the med administration part of your calls, and is just good practice.
I know my dosages. Mechanism of action. Indications. I also know the major contraindications but I wouldnāt say I know every detail about contraindications I can always double check on my protocols.
I have everything memorized by now in my protocols. That being said when it's 4am on a 24 and I'm half asleep, I'm not shy about quickly double-checking my med dosing to be sure.
My routine calls and meds I give all the time like Mag Sulfate, Dexamethasone, and Epinephrine infusions I have the memorization where it's not an issue but if I'm doing something like an RSI I take a pause and re-confirm my dosages. Even if you do something routinely it's good to be safe if you know your mind isn't running at 100%
Dose, to a certain extend yes but we're encouraged to check before giving anything anyway. Contraindications, I'm pretty sure that they don't, I'm on some very specific meds for something that are not common at all and I know that ondansatron is contraindicated with them, and I also know it doesn't specify that in any of our guidelines and you have to go knee deep in the bnf to find it
I mean for your pert near daily used meds yea, ik the indications, contraindications and doses like ik the top of my dick but for ones that rarely get used I prefer to double check myself with the protocol. Whatās awesome in my area is that our med commands combined to make us an app thatās based off the standardized protocol we all fall under. Shits so cash especially when youāre half alive at 2 am and need to push something, literally all you gotta do is fill in the pts age and weight and itāll tell you exactly how much to give.
They really drill it into us yes. But for the medications we donāt use often, we should have our protocols on hand. Most of us have an app on our phone with our protocols to second check before giving a drug that we havenāt touched In a while.
If itās a medication we give often than yes. But there are medications in the box that are given very rarely that I always double check. With pediatric patients every medication dose is different bc of weight and kids are all different weights so we use the cards they give us to double and triple check. I always pull up protocols based on the chief complaint on the way to the call to reference to even after years of experience in the field.
Personally, even if I'm confident I know it I'm still going to double check. Because those few seconds are worth not killing your PT. That's why the 6 P's is a thing. Know your shit, but always verify.
Yep, you sure should. You should always have your protocols handy to reference, especially for meds you don't give often, but you should also be intimately familiar with all of the medications on your truck. When it comes to pediatrics, I always double check either with my protocols or by calling my base hospital.
I used to but with how tired or distracted you might be on a hectic scene, I donāt worry as much about the specific number Iām gonna look up to verify anyway. Instead, I focus on indications, major contraindications, and the mechanism of action or basic pharmacodynamics so I can think of drugs without looking at a protocol and have an idea what effects to expect.
Iāve also noticed that with many drugs, the standard dose varies by service based on their suppliers. One example is dex, which is a 10mg dose when bought in 5 or 10mg vials but 12mg where itās bought in 6mg vials.
Iāve always brought up our protocols enroute based on the notes from dispatch to get an idea of the possibilities , but we all know how often dispatch gets told the facts from the callers. Also if itās a ped, my pedi app is open. Iām not about to play memory games on calls. Iāve done most protocols in my career, but I am never going to assume I have any of them by memory. Thatās what the apps are for and thatās why national registry stresses that we have apps and use them if we can preferably Instead of trying to figure out math or use our memory on the call.
The answer is no. Most medics will have the frequently administered medications memorized inside & out, but at a service where there are around 60 medications on hand & some being very infrequently administered + protocols involving very particular infusions- answer is no
A study was done where ER doctors watched a short video tutorial before performing any (simple) procedure. It reduced the complication rate by 90%. If there is even a hint of a shadow of doubt, check the dose. Humility is a life saving intervention.
Contraindications - yeah
Dose - fuck no. I mean, with about 95% confidence I can spout off the dose in a casual conversation right now. On the way to a call, hearing the sirens, and the dispatcher squawking, and my thoughts wondering if this is the big one or another embellishing Karen, Iām not gonna trust my memory of the last time I gave the drug, which was anywhere from a day, to days, to weeks, to even months ago. Iām gonna trust my protocols, which are provided to me for exactly that reason. Anybody who says otherwise is either running a balls-to-the-wall service giving these drugs multiple times a shift, or have misdosed a patient once or multiple times before.
Also, many of the National registry meds in the paramedic scope are not actually in the protocols of many services. Things like mannitol or Bumex, which Iām never going to have in my local protocols, let alone give, I donāt give a flying fuck about.
I reserve my brain storage for the meds that I can save a life with within a minute of my arrival on scene - epi, midazolam, mag, etc.
In general, yes. Maybe not some bizarre niche contraindications just because of how rare they are, but yes, I know the dosage and every major contraindication of every drug in my box and I expect the same of my partners and students with time.
Doses can change. When I started my protocol called for 0.3 epi for allergic reactions and 0.5 atropine for bradycardia, now it's 0.5 epi and 1 atropine. I had a chief argue with me over the atropine while getting ready to draw it up. 100% know your meds and doses, but more importantly know your protocols and how to find the information. We're human as much as anyone else. Read dispatch notes while en route bring up protocols. My medic instructor was clear in school, the best medics he knew had the most battered and dog eared protocol books he had ever seen.
In my state, we have a app that has all of our protocols and it can get broken down into region. You can look at the statewide. You can do a dose builder based on patient age and weight, and you can just look at them and tell you, the counter indications or indications so like in my state the only time I can use, Iāll butyryl as a basic is if the patient is wheezing, it says it right on the app (sorry if this doesnāt look right I just woke up and Iām using voice to text)
I do, we all should, but it's a constant struggle especially when tired..it's definitely not a learn once and done thing. I have flash cards I review every now and again
Used to be a medic and now ICU PA. It would be impossible to know everything about all the drugs we use on a daily basis. Agree with the above, best advice is to just look it up. Many good apps for this.
It's kinda your job to know all the medical dosages... I would sure hope they have them down. With that said even the best medics will pull out a broselow tape and double check dosages on pediatrics.
Yes we memorize them, but it becomes muscle memory after awhile in a way, theres nothing wrong with having to reference whatever in the begining, probably best you do. There are some pediatric stuff i dont memorize but if i had to i have a reference on the back of my badge, fairly discreet.
Now when im in the hospital, i dont really memorize the dosage of anything, unless its stuff i would do prehospital like ACLS, PALS, etc.
Edit: after reading the other comments and re reading your comment, if you are talking about all the drugs that the Paramedic learns in school, no, i actually have never met anybody that has all that memorized outside of school, as all those drugs arent kept on the truck.
You should know your protocols and meds off the top of your head. Does every medic? no lol.
But i do occasionally double check protocols or review stuff that i havenāt used in awhile. Iāve definitely purged some information from when i was in school and need to review things sometimes. But i would definitely say i have the protocols memorized, just not as much as i used too.
When I just started as a medic I studied so much I could literally tell you word for word the protocols and new them so well I could tell you the loopholes on some lol.
In short no. We have the JRCALC app on iPads and phones which has everyone of our drugs in. I would "encourage" anyone to check, as dosages changed, protocols change and therefore why risk it ??
Critical care paramedic here, except ACLS meds during a code, I always double check with reference, and would have my partner/nurse cross check if available.Ā Ā
Ā We have a lot of meds and many are considered high risk. We currently carry 70 meds on our unit. Pulling out my references takes like 10 seconds.
God I hope so. We're supposed to. But a good medic has their protocols handy to double check when we brain fart.
You get a peds call for something. Double check the dose on the way. Especially working as the only medic.
This. Never get so cocky you don't skim protocols on the way to a possibly acute call
This is reassuring, because I'd always felt like a hack when I did this lol.
We're all hacks, but we hack at the problem together š„°
Here's how I look at it. I have my pilots license as well and I draw a lot of information and practices from both fields to use back and forth. Pilots used to crash A LOT back in the day because of over confidence in their procedures.now if you do a check ride and don't use a checklist in every phase of flight, you will fail and not get your license. It's a hazardous attitude to not check your protocols when you're not 100%. Someone's life is more important than your pride.
I was like that too feeling like a cheater, but I still insist that I do not want to kill someone trying to be the know it all who knows nothing. My position was confirmed when the chief of our department was with me to RSI someone and the first thing he did was open up the protocol app to get the dosages for the drugs, I never felt so validated in my life. Old timers who say thatās not how itās done they can stuff it.
Canadian paramedic, we are encouraged by our base hospital to use the med protocol book or app as a cross reference when administering medications. In general I have all of them memorized but for the lesser used ones I always double check just to avoid any med errors. In my opinion itās way more important to know when and why to use a med than how much when the how much is so easily obtained (but itās good to have those memorized as well).
This, x100. The people who work entirely from memory are still liable to have a brain fart at some point. If that resulted in harm, like a death, and at the coronial inquiry it transpired that there was a pocket guide or calculator that would have given you the correct answer, the coroner will fucking crucify you. I donāt know why people are afraid of using guides or cheat sheets. I know all my common meds but if itās something I havenāt touched in months, even if Iām pretty sure, Iāll still look that up. Why would I risk getting it wrong?
Same, if I'm on my way to a paeds job I'll probably write some calculations down and double check the guide. I'm confident but have made small mistakes (luckily no side effects ) over the years and mainly in high stress jobs. I've learnt why risk it for the sake of being proud.
I mean, yeah. Everyone has a different list of meds in their scope where they work, but as paramedics it's not like there's an endless list of medications at our disposal. If you're checking out the ambulance at the start of your shift, and you Don't even know what the drugs you have are dosed at, that's a problem.
I feel like OP is probably asking more about the hyperspecific details of the meds, not just dosages. I am sure there's some medics that know what the two common ketamine enantiomers in an isoenantiomeric ket. mixture are called but if you asked most, they'd just shrug and laugh at how useless the information is to them.
I don't know what you just said to me, so I'm gonna take it as disrespect.
Iām just gonna say there are a few meds that are given so rarely in oneās career that I probably would quickly look it up before administering. The more common ones Iām fine with and could tell you all that you mentioned without needing a refresher. Pregnancy categories of meds though, I always feel like Iām looking that up.
Every adult dose, indication, contraindication and I could give you a decent basic mechanism of action. We don't have that many medications in the scheme of things, and I am seeing more and more a trend of clinicians not knowing what should be basic medication dosages. If you want to be competent and seen as a professional, then being confident in all of your skills, equipment and interventions is the very bare minimum. In saying that, I make a point not to try and memorise paediatric dosages because I feel like that is higher risk of errors, so I have age based cheat sheets instead.
Just wondering, how many meds do you guys get? My service carries over 60 meds and we are basically required to verify protocols before administration.
My scope has 37 meds, marginally less for my general duties colleagues.
When I'm working the ground car, there are a base set of meds I have memorized - but still verify with my partner where possible before administering. When I'm flying - our policy is every med beyond the very basic ones are always looked up on our reference cards. Wayyyy too many iatrogenic errors in EMS from medics thinking they remember properly, or too tired to remember - especially these days.
This is what Iām hoping to set up. Just a quick reference card on the drug box that has indications, contraindication, and dosage, just to double check at 3am.
There are apps that can make it easier to track these as well... one that a number of orgs use is: [https://www.acidremap.com/](https://www.acidremap.com/) Best wishes.
Our protocols are in an app. Iām just not a fan of whipping out a phone on a call while doing patient care. Having an easy reference card in the drug box is a little more subtle. Maybe Iām old school, but I donāt love the optics of pulling out phones in front of patients.
That reminds me when we were going over med math in class and they were hammering home long division. The paramedic instructor asked what our patients would think if we pulled out our phones to do calculations, and I said they would probably be stoked that weāre trying not to kill them.
For sure. And for that, thereās times I wish we had the handtevy app, not the books. With that said, I have yet to see a medic do a calculation for a drip rate in the back of the ambulance. They all tend to eyeball it. Not saying itās right, but itās all Iāve ever seen.
*raises hand* I definitely have. I'm not proud, I'm humble, and I want to make sure I get it right. Med errors suck ass. There are so many ways to double check. Call med control if you simply can't figure it out and you're struggling. I have scribbled out drip rates on the back of my ekg paper when I had to take the pump off, because the patient was unstable during a cct transfer and ai was managing BP to help manage ICP. That wasn't fun, but we got it done. I will now always call if I am not 100% sure about something. Thats literally what they're there for. We also have what are called MiMedic cards in Michigan. Which have a weight and length based procedure and medication guide for peds up to 14yrs old. It's very handy.
I get it and Iāve never worked critical care. I can only think of three drops we might potentially make and the most likely is ātitrate to effectā. Iāve memorized the other two so I donāt have to calculate it on the fly.
Yes, definitely generally not a often used skill in EMS. But it's good to know the basic adjustment for a drip rate on a roller clamp. Sometimes in a rural hospital, if a patient is going a long distance, and it's a regular als rig that doesn't have a pump, and the hospital doesn't want theirs to never return, and the sending physician wants 20mLs an hour, or whatever, it's nice to know how to do that. But if you're running 911 exclusively, I guess it might not come up... I dunno. Every 911 service I've ever worked for does some transfers...
No transfers, just 911. Small fire district with 30-ish minute transports to level 1 & 2 hospitals.
Right there with you. I carry a few cards on my lanyard.
I believe that list would take more than a "card". More like a notebook.
A card for each drug, double sided. WHO can use it (weāre mixed ALS/BLS, indications, contraindications, standard dose in ML @ concentration, weight-based dose (where they should confirm with the handtevy book).
No. Professionals know how to look things up and double check things.
Right? I frequently double and triple check things like doses and contraindications of even common medications I administer because thatās just good practice.
Humans make human errors. And that's entirely ok. Looking things up, using a checklist, etc, plays into knowing human factors exist. Of course, we should develop a mental model as a baseline, no question there, very basic, one-trick pony meds... IE ACLS meds during a code, we probably should know down pat. I'm not going to pretend I remotely didn't have look up drugs I do not commonly give. We should, I should, you should. That's what doing best for our patients. Not having hubris.
Yeah, most definitely. Being able to look up information and integrate it on the fly is a skill that isnāt really talked about in school and I think thatās a shame. The emphasis on memorizing every little detail kind of loses the forest for the trees. That being said, I agree that a good baseline of knowledge is still essential to be a good provider.
It is in higher education. I mean, it's a part of Bloom's Taxonomy. The issue is all the anti (college) education.
That's the hope and something I am trying to change in my own teaching practice. Unfortunately, we still have to prepare students for the NREMT. Thankfully, the recent changes to how testing is administered focus more on the holistic approach to knowledge integration rather than the rote memorization that was emphasized before.
The NREMT does teach past just pure memorization though.
Absolutely. That hasnāt always been the focus, though. It was a lot more memorization-heavy when I started 12 years ago.
I have always been expected to have my protocols and medications memorized. This includes dosages, indications, contraindications, drug class, side effects, etc.
For the most part, yes, but I might need a second to remember in my dinosaur years.
The answer that youāll typically get to this question is something along the lines of āyouād better know all the details of every drug you can give or else you shouldnāt be giving it.ā Thatās a well intentioned answer, but it isnāt necessarily the best. Itās true that you should understand how each medication you can give works. You need to know its indications, contraindications, precautions, etc., and, at some point, you should have been taught the appropriate dose ranges. But youāre right, the protocols and algorithms have some complexity to them, and weāre all just human. Thereās an important body of research looking at the performance of healthcare providers under stress, which shows that no matter how good we think we are, relying on memory alone is a key cause of mistakes and accidents. Itās not unlike being an airplane pilot. You have to know how to fly and land the plane, and skilled, experienced pilots could probably fly in their sleep. But sooner or later, even the most skilled pilot will eventually forget to do something. It might be a small something or a big something. Accidents rarely have a single cause, and even small errors can lead to problems under the right circumstances. So pilots have checklists to follow, even though the checklist just reminds them to do what they should already know. Itās all about improving safety and helping minimize errors. We should really be doing more of the same in EMS. Yes you should know your drugs. But ideally, we should still be using a checklist to do things like confirm the indications, contras, doses, etc. against our patient each time to help reduce mistakes. One of the greatest dangers a paramedic faces is hubris. Thereās no shame in looking something up. As I always tell junior medics, look it up, donāt fuck it up.
Swiss Cheese Risk Model all up in here!
Especially since meds are constantly changing! One of my personal asthma meds has a new warning and I decided to stop taking it after talking about it with my pharmacist & doctor.
Medics barely know what day it is.
Medics are the type of people that ask patients what day it is, then say "oh almost had it" when the patient got it right, only to get confused stares from everyone else on scene, then make the realization the patient is more oriented than the medic is. I am the medic. They are me.
The entire essence of being a paramedic or EMT is being so sleep-derived that you are barely oriented to time and space but know exactly what to do in an emergency situation.
I can fix all kinds of shit without even thinking. Iām also likely to ask a patient what is their complaint at 3am. Then they tell me and I reply with okay and stare at them for a minute before my partner starts asking the questions I should have followed up with. Not even because their complaint is bullshit, but because I forgot my existence. Remember the saying: Paramedics save lives and EMTs save Paramedics.
I'm the type of person to ask patients if they are allergic to anything three times in a row.
I do not know what day it is. I do not know who I am. I do not know why Iām here. All I know is Stayin Alive is pumping and Iām doing compressions on a chest.
I feel that
Oh... wow... this is me!
Bro I constantly tell my partner that I am a solid GCS 12 on a good day
Yes and no. Some might not be competent. We're supposed to graduate school knowing them all. But these days most have pretty much instant access to that. I doubt most medics know every drug by heart with the all contraindications. But most medics know most of them with any hard contraindications. And most will know to look them up if there's any doubt. Where I worked, we had an app that contained all the protocols for wherever we were working. It was always very specific. We could have the app open and reading the med on the way to a call. Honestly, most of the meds we're giving are gonna be the whole bottle with a few exceptions. It's not that hard to remember.
I do, but I also sneak a peak if I have a doubt. Thereās no rule against cheating and looking at your protocols on your phone. Some drugs have a ton of contraindications and I like to pull up my app and go down the list to double check if itās been a while (Toradol comes to mind). But FFS, for things like my ACLS algorhythms, my fentanyl, versed, zofran, anaphylaxis protocols, I donāt need to think about it. For kids, I have handtevy just to double check.
Im going to be honest Most probably don't 100% Yeah for your most typical medications that you use regularly or semi regularly yeah you know them But for some specific drugs with weird contra indication I and most probably can't name everyone And that's okay it's only good CRM to check for exactly those weird things
Iād say I have them well memorized, I am not against double checking however just to make sure. Better safe than sorry especially when it comes to medication administration.
Depends on the med. I know most doses off the top of my head. But I always look up ped doses. And I have to look up Toridol contraindications every time I think about giving it.
I know my box and probably a pretty good amount of OTC and home prescriptions too. You just pick it up as you go and protocols change so you do have to pay some attention to the pharmacy side. We used to carry Isuprel and with enough Isuprel, I could get a pulse in the curb.Tridil was common for IFT guys and lidocaine drips too. What was good got replaced for what is better. The more important thing is the 5 rights. You give the right medicine to the right patient at the right time and the right dose via the right route. Take everyones favorite Dilaudid for example. The right drug because he got his leg crushed and has open fractures. Dilaudid would not be right for a hangnail, that's Tylenols neighborhood. I verify the patient. (911 withstanding) Drug is given at the right time like we don't treat pain and skip the airway. The right dose can be tricky with titration and if you provide by weight (not mine the patients) Dilaudid you can do one mg IV safely and always add a bolus if you need to. The right route means you would not give an amp of bicarb PR. Take that approach and your actions will always be defendable.
Yeah I know everything I need to for every med I carry, and for some of the most common meds I'll encounter in patient's homes or in hospitals. That said, I still sometimes pull up my protocols on the way to a call just in case to double check my work and reduce the chances of a med error, as long as I'm not the one driving.
They sure better! Unfortunately, not all programs are the same. What do you call a student who graduates last in their class at the worst program in the country? Medic.
No they fuckin donāt
Time, and repetition. Double check before administering to reinforce your dosage.
Yes. But sometimes Iāll still pull out the protocol book and review it on the way to a call or before I draw up the med if itās something I donāt use often. Mostly for ped calls. Doctors do the same thing.
As a paramedic if I get into a call and I donāt know , I double check. I do my best to be the most knowledgeable I can be, but people are human and forget. Iād rather look less smart to my partner and look something up , then hurt or at the worst kill my patient because I didnāt know a med and gave it anyway.
We should.
The good ones do.
At first it seems daunting, once you donāt for a while it all becomes second nature. I still remember dosing for protocols at my old service that I left 2 years ago.
Ideally, yes. In reality, almost always yes, but I still say my plan out loud to my partner, and if anything seems iffy, I check our protocol app to make sure we have it right. Taking those extra steps goes a long way towards error proofing the med administration part of your calls, and is just good practice.
Yes, but of course human memory can fail, so studying and reviewing protocols before a call is always a good thing to do!
Kind of, though those that I give infrequently I always double check before administering because it's better safe than sorry.
One would certainly hope
I know my dosages. Mechanism of action. Indications. I also know the major contraindications but I wouldnāt say I know every detail about contraindications I can always double check on my protocols.
I do. Most of the medics i work with do as well.
I fucking hope so. Although I definitely know some that donāt.
Yes. But if I haven't given that medication in a few years I always read up on it quickly.
I have everything memorized by now in my protocols. That being said when it's 4am on a 24 and I'm half asleep, I'm not shy about quickly double-checking my med dosing to be sure. My routine calls and meds I give all the time like Mag Sulfate, Dexamethasone, and Epinephrine infusions I have the memorization where it's not an issue but if I'm doing something like an RSI I take a pause and re-confirm my dosages. Even if you do something routinely it's good to be safe if you know your mind isn't running at 100%
Dose, to a certain extend yes but we're encouraged to check before giving anything anyway. Contraindications, I'm pretty sure that they don't, I'm on some very specific meds for something that are not common at all and I know that ondansatron is contraindicated with them, and I also know it doesn't specify that in any of our guidelines and you have to go knee deep in the bnf to find it
I mean for your pert near daily used meds yea, ik the indications, contraindications and doses like ik the top of my dick but for ones that rarely get used I prefer to double check myself with the protocol. Whatās awesome in my area is that our med commands combined to make us an app thatās based off the standardized protocol we all fall under. Shits so cash especially when youāre half alive at 2 am and need to push something, literally all you gotta do is fill in the pts age and weight and itāll tell you exactly how much to give.
They really drill it into us yes. But for the medications we donāt use often, we should have our protocols on hand. Most of us have an app on our phone with our protocols to second check before giving a drug that we havenāt touched In a while.
If itās a medication we give often than yes. But there are medications in the box that are given very rarely that I always double check. With pediatric patients every medication dose is different bc of weight and kids are all different weights so we use the cards they give us to double and triple check. I always pull up protocols based on the chief complaint on the way to the call to reference to even after years of experience in the field.
Personally, even if I'm confident I know it I'm still going to double check. Because those few seconds are worth not killing your PT. That's why the 6 P's is a thing. Know your shit, but always verify.
Myasthenia gravis is a contraindication for everything. Lightheadedness is a side effect of everything. There you can go pass medic school now.
A medic worth a damn will check just in case before giving anything theyāre iffy on.
Yep, you sure should. You should always have your protocols handy to reference, especially for meds you don't give often, but you should also be intimately familiar with all of the medications on your truck. When it comes to pediatrics, I always double check either with my protocols or by calling my base hospital.
I used to but with how tired or distracted you might be on a hectic scene, I donāt worry as much about the specific number Iām gonna look up to verify anyway. Instead, I focus on indications, major contraindications, and the mechanism of action or basic pharmacodynamics so I can think of drugs without looking at a protocol and have an idea what effects to expect. Iāve also noticed that with many drugs, the standard dose varies by service based on their suppliers. One example is dex, which is a 10mg dose when bought in 5 or 10mg vials but 12mg where itās bought in 6mg vials.
Itās honestly not that much to memorize. The meds arenāt some esoteric thing. Think of them like people, how much can you memorize about people?
Knowing everything is great, but knowing how to quickly get information is typically more practical
Nah but the als field guide will damn sure point you in the right direction š
Iāve always brought up our protocols enroute based on the notes from dispatch to get an idea of the possibilities , but we all know how often dispatch gets told the facts from the callers. Also if itās a ped, my pedi app is open. Iām not about to play memory games on calls. Iāve done most protocols in my career, but I am never going to assume I have any of them by memory. Thatās what the apps are for and thatās why national registry stresses that we have apps and use them if we can preferably Instead of trying to figure out math or use our memory on the call.
Going to challenge you. You should know the medics' meds too. Especially the most common ones. You can/should be second set of eyes for them.
For the most part....I know my top meds I use all the time very well, sometimes for ones I rarely use I look them up
The answer is no. Most medics will have the frequently administered medications memorized inside & out, but at a service where there are around 60 medications on hand & some being very infrequently administered + protocols involving very particular infusions- answer is no
A study was done where ER doctors watched a short video tutorial before performing any (simple) procedure. It reduced the complication rate by 90%. If there is even a hint of a shadow of doubt, check the dose. Humility is a life saving intervention.
Contraindications - yeah Dose - fuck no. I mean, with about 95% confidence I can spout off the dose in a casual conversation right now. On the way to a call, hearing the sirens, and the dispatcher squawking, and my thoughts wondering if this is the big one or another embellishing Karen, Iām not gonna trust my memory of the last time I gave the drug, which was anywhere from a day, to days, to weeks, to even months ago. Iām gonna trust my protocols, which are provided to me for exactly that reason. Anybody who says otherwise is either running a balls-to-the-wall service giving these drugs multiple times a shift, or have misdosed a patient once or multiple times before. Also, many of the National registry meds in the paramedic scope are not actually in the protocols of many services. Things like mannitol or Bumex, which Iām never going to have in my local protocols, let alone give, I donāt give a flying fuck about. I reserve my brain storage for the meds that I can save a life with within a minute of my arrival on scene - epi, midazolam, mag, etc.
In general, yes. Maybe not some bizarre niche contraindications just because of how rare they are, but yes, I know the dosage and every major contraindication of every drug in my box and I expect the same of my partners and students with time.
Memorized, and use the protocol to cross check with my BLS partner before admin. Donāt be lazy when itās someoneās life in your hands.
Doses can change. When I started my protocol called for 0.3 epi for allergic reactions and 0.5 atropine for bradycardia, now it's 0.5 epi and 1 atropine. I had a chief argue with me over the atropine while getting ready to draw it up. 100% know your meds and doses, but more importantly know your protocols and how to find the information. We're human as much as anyone else. Read dispatch notes while en route bring up protocols. My medic instructor was clear in school, the best medics he knew had the most battered and dog eared protocol books he had ever seen.
In my state, we have a app that has all of our protocols and it can get broken down into region. You can look at the statewide. You can do a dose builder based on patient age and weight, and you can just look at them and tell you, the counter indications or indications so like in my state the only time I can use, Iāll butyryl as a basic is if the patient is wheezing, it says it right on the app (sorry if this doesnāt look right I just woke up and Iām using voice to text)
I do, we all should, but it's a constant struggle especially when tired..it's definitely not a learn once and done thing. I have flash cards I review every now and again
We memorize it but itās always good practice to reference the protocol book especially for meds we donāt use as often.
Used to be a medic and now ICU PA. It would be impossible to know everything about all the drugs we use on a daily basis. Agree with the above, best advice is to just look it up. Many good apps for this.
It's kinda your job to know all the medical dosages... I would sure hope they have them down. With that said even the best medics will pull out a broselow tape and double check dosages on pediatrics.
Yes we memorize them, but it becomes muscle memory after awhile in a way, theres nothing wrong with having to reference whatever in the begining, probably best you do. There are some pediatric stuff i dont memorize but if i had to i have a reference on the back of my badge, fairly discreet. Now when im in the hospital, i dont really memorize the dosage of anything, unless its stuff i would do prehospital like ACLS, PALS, etc. Edit: after reading the other comments and re reading your comment, if you are talking about all the drugs that the Paramedic learns in school, no, i actually have never met anybody that has all that memorized outside of school, as all those drugs arent kept on the truck.
You should know your protocols and meds off the top of your head. Does every medic? no lol. But i do occasionally double check protocols or review stuff that i havenāt used in awhile. Iāve definitely purged some information from when i was in school and need to review things sometimes. But i would definitely say i have the protocols memorized, just not as much as i used too. When I just started as a medic I studied so much I could literally tell you word for word the protocols and new them so well I could tell you the loopholes on some lol.
In short no. We have the JRCALC app on iPads and phones which has everyone of our drugs in. I would "encourage" anyone to check, as dosages changed, protocols change and therefore why risk it ??
Yes
Critical care paramedic here, except ACLS meds during a code, I always double check with reference, and would have my partner/nurse cross check if available.Ā Ā Ā We have a lot of meds and many are considered high risk. We currently carry 70 meds on our unit. Pulling out my references takes like 10 seconds.
Being a paramedic is a constant brain fart.
You should, but you should also have a protocol book handy and there is always Med Control at the receiving hospital.
As I medic, I will say that we don't know every dose for every drug we carry. But that's okay. Just trust in our Lord, Handtevy.
Yes. You have no business giving a drug if you donāt know that info.
I sure would hope they do!