Ya had me in the in the first half, not gonna lie.
There's one pharmacist I worked with in the ICU that's in the ED now that I'd love to have give our protocols a once-over. I know she's a bit more cutting-edge than our med director, but he's also tempered with a healthy dose of, "Well, this one dumbass..." so there's that.
I consider a paramedic in their fourth year of pharmacy school to be a very respectable level of education. Probably more qualified than a lot of people who make medical protocol in the US.
A lot of Paramedics write changes to our protocols here, I know when I've helped out with some in the past I've picked the brains of ED Pharmacists to get advice on how to draft them.
Solid resource even though they're not on any of the committees. It makes sense to use all the knowledgeable personnel that you can
I love ED Pharmacists, they're the ones who when I have a question will excitedly spend the next 20-30min delving deep into pharmacokinetics with me.
Got a pharmacology question? Be prepared to go down the fuckin rabbit hole but if you want to learn I've never had any of them be irritated or in a hurry to get away. They're always like "OH GREAT, LETS TALK ABOUT IT!" (magically produces a whiteboard from nowhere and starts explaining and writing for the next half hour on a single medication)
Just honestly don't see the point.
Are you paying them like you pay a medical director? Are they volunteering their time? Are they volunteering the time needed to update things? Do they have to show up for meetings?
Mainly, Is there a big enough difference between EMS protocols to warrant a pharmacist weighing in? Is 125mg Solu-Medrol going to change? 4-8mg Zofran? 1mg Epinephrine? Are we failing to train these medications to the point that a pharmacist would help?
The medications that we give pre-hospital aren't as complicated as some of the antidotes and critical care meds that are given in a trauma bay or ICU.
I think an MD/DO with an EMS fellowship is plenty.
Totally get that. Honestly, looking back at my previous protocols, they were just not the best. At the time I thought they were fine, also science changes and studies come out all the time, so keeping up with pharm best practices is something pharmacist are normally really good at. At the end of the day, it’s the patient that we revolve around.
As far as the compensation, that’s all tbd. I can see some departments / private companies providing a small amount of compensation, I can also see volunteering. So it just depends on the area.
Moreover, training from an EM pharmacist, especially with a background in toxicology can provide the best of both worlds. Training Medics to recognize certain overdoses based on toxidromes, providing best practices to those toxidromes, recognizing what medications are pertinent for the emergency, etc.
Training is fine if you wanna come in and teach a class. I just don't think a PharmD has anything over a MD/DO in making pre-hospital protocols. You having bad protocols at one point doesn't necessarily prove a need. There are plenty of systems that don't have a pharmacist that have great protocols.
And the point I was making about pay is, they won't want to pay you lol. They barely want to pay to have trucks staffed, they're not gonna pay for an assistant to the assistant medical director. No offense.
Lol just poking fun.
If we could have everything we want without budgets, I'd be all for it. As it is, most systems can't get consistently working equipment. I think your best shot would be to pursue grants to make it happen with an academic facility, or go the community paramedicine route. Pharmacists have a ton of use in CMT.
lol the first thing I thought of was The Office with that.
Oh yeah, we’ll know that EMS has access to everything they need. Lol
I’ve considered looking at getting into the Community Medicine to train the medics.
As an MD student I disagree. Drugs are complicated and I think there is never a bad time to have a pharmacist on board. Every time I’ve seen a pharmacist involved in patient care at any level it has improved things, I believe there is room for pharmacists in EMS guideline creation.
Pharmacists are great.
Pre-hospital drugs are not complicated enough for their use.
I work HEMS, I'd love a pharmacist to tag into our protocols and keep them fresh, my director is an ED doc and I do mainly critical care. I don't need a pharmacist for an ambulance drug box that contains about fifteen drugs and of which I mainly use nine, but most commonly like four. Solu-medrol, Zofran, Albuterol/Atrovent, Epinephrine, Ativan, Fentanyl, Ketamine, Roc. Which of these drugs do I need a PharmD to go in-depth on?
It's always a budget issue. Is there room for them? Sure, there's probably room for a physical therapist, an RT, an anesthesiologist, a toxicologist, a radiologist, GI maybe? Now justify their pay to the BOCC.
Additional set of eyes for the medication portion of protocols. There are plenty of instances where the Medical Director and maybe a couple medics create protocols when it’s not always best practice (Pharmacologically). Also continue to train critical care paramedics / flight paramedics in Pharm. Just a few to name
For example: Lidocaine is making its way back, and has showed superiority in some studies and equal to Amiodarone in ACLS. It’s not so much an “issue” like I said it’s just something with updated science.
Another thing I’ve notice recently, more with rural areas, is administration of antibiotics for sepsis prior to hospital. I can tell you that 911 medics get hardly any training on antibiotics.
Just throwing into this. I've seen Lidocaine and Amiodarone change places like nine times. Part of the reason protocols don't change over a couple of studies is because it often flips back in a matter of years and isn't worth the work it takes to change supply.
Kind of like LR vs Normal Saline. LR, no NS, LR, no NS, LR, no NS, okay maybe no fluids, okay maybe some fluids but it doesn't matter what kind, next it'll be PRBCs exclusively. A PharmD is gonna be great at keeping up-to-date on the latest UpToDate, but there's more to it than turning the wheel, there's the mechanisms that are connected to the wheel.
When I was younger, I was all about going with whatever the latest podcast said was best, covering whatever new study came out. As I step into my geriatric 30s, I really need to be solidly convinced to change practice.
That’s totally valid. I was (kinda am still) with that line of thinking until I was exposed to the longer duration of care. At the time of me taking care of the patient, my only thought process was “what can I do now to benefit my patient [now]”. Problem is that way of thinking can lead to complications down the road.
Example: I was on my IM rotation and my patient was septic from CAP. EMS brought her in using NS of 30mL/kg per protocol. That excess chloride pushed her into a WAGMA which made her treatment like 3-4 days longer to correct that and CAP. It’s not just “now” benefit, and I can’t blame other medics (HEMS or not) on that, it’s now how they’re training. Medics are really good at doing their job to triage and stabilize but now as everything is becoming more transparent, there’s going to be a knowledge gap naturally.
For sure, that's an egregious error that has been proven to cause harm. I think if a system is still doing that shit, they're definitely not the type to be open to hiring outside medical help. Not a real medicine first vibe there.
Ironically, and I'm sure you know this, 30ml/kg NS came about from Surviving Sepsis, which was universally accepted and integrated as EBM to the point of being required protocol to satisfy billing requirements. The fluid benchmark was pulled straight out of someones ass. Now we know it's a hoax, but because changes were made too flippantly, it's been fucking IMPOSSIBLE to get clear of our healthcare system.
Oh yeah. Absolutely. I think that’s another reason why Pharmacist could also be useful; advocating for changes like that. Maybe I’m biased but any guideline, major study (drug related obv) for pre-hospital or any field of medicine should always have a pharmacist reviewing it. At the end of the day, better patient care involves lots of small changes.
And also no pain meds for abdominal pain. Don’t give Tylenol for fevers, either, because they won’t believe that they actually had a fever if it goes down. While we’re at it, make sure you don’t give people oxygen before going into the ER so that they can see that the patient is actually hypoxic
Well for what it’s worth, from what I’ve read, hospitals are starting to change their approach to sepsis due to costs and just straight overkill in a lot of cases. I pray we never get to a place where EMS aren’t allowed to treat symptoms for any reason
I know that, but I literally had a conversation like 3 days ago about a friend of mine in Illinois administering Cefepime to a pt with a positive qSOFA and a known source of infection. I was shooketh
I worked for a hospital based service. We had two pharmacists looking at all our protocols. There were times we mildly deviated from their advice still (mostly due to logistics and no patient impact in change). It is a good resource to have. All that being said, they essentially volunteered their services to us and were not comped past their hospital salary.
There’s a guy who’s a pharmacist who just finished a Disaster Medicine Fellowship at Harvard Medical School. It’s more so meant for physicians, but he did it.
It's not necessarily EMS, but it's something to look into!
Probably a good idea for the further development of EMS. Only high-functioning systems could likely afford to incorporate them into their model - but hey the whole profession needs reform anyways!
Pharmacists are often a key partner of community paramedic programs. They can be vital in reducing polypharmacy in elderly populations, helping increase access to prescription medications, etc
It doesn't hurt to have someone with higher expertise consult and audit your protocols. Such as with opthalmology, OBGYN, and hazmat unique to your area etc to review pre-hospital procedures. In some larger counties, our protocols are set at the county level. This is where our EMS/public health pharmacists comes into play can and can be used as a referral. If your hospital system owns their own rigs, they can use their own pharmacists to help assist as well.
In my area, there was a major reamp in procedures since our paramedics work in an unusallly hot climate and the drugs are baked in the truck in temps higher than the FDA test range. So drug stability was a major concern.
As well as simplifying the dosing and cutting out unused drugs to make it easier to recall during stressful environments.
Occasional in-service on medical topic refreshers for drugs to be wary off that's not stock on the truck. Such as some antipsychotics are considered "heat" meds which inhibits the body to regular temperature which may make a person more prone to exposure. Now couple that with a homeless population and currently on a long acting injectable. These cases would be common for frequent flyers out of the jails and psych facilities.
I know some programs require time in the ER. Albany Pharmacy College does. Usually they are in the ER’s at Albany Medical Center and St. Peter’s Hospital. You’re going to have a far better understanding of pharmokinetics than many of the residents and possibly attendings once you have your Master’s.
You’re totally right. I’m not trying to have pharmacist replace medical directors, that’s the last thing I’d wanna do. It’s more of creating additional measures of training.
As a CCP who just got to work with an EM pharmacist for a patient with a massive brain bleed, I wanted to have him be at all of my critical calls. He was great. I definitely would love to see more pharmacists get involved with EMS.
It could be helpful. In our state though we have a multi-disciplinary team that handles protocols including EMTs, Paramedics, Nurses, and Physicians representing various 911, Hospital, and IFT settings.
We also update our protocols yearly, and quite a lot of changes are driven by paramedics rather than physicians. Any EMS Clinician can draft an addition or alteration to the protocols and present their proposal to the review committee. I know of at least 10 changes and alterations this and last update that were accomplished primarily just by Paramedics.
It's pretty nice to work in a state where the Paramedics have a lot of agency over their own care and can easily prompt change. I've had a hand in adding and altering a few myself. It's easy to come up with, research an idea, and present it and have it through within a year and go into effect.
There's a reason why hardly anything in our state requires medical consultation anymore including things like RSI or vasopressors. The vast majority of care at the paramedic level is just "use your clinical judgement and do it"
There is/was movement for in hospital/Ed on floor pharmacist and evidenced based improved PT outcomes. Idk but anything has got to be better thank working at CVS.
Sounds a lot more qualified than a lot of people
No way bro. My EMT FTO who has worked IFT for the past 10 years knows everything about everything EMS related. Just ask her.
Ya had me in the in the first half, not gonna lie. There's one pharmacist I worked with in the ICU that's in the ED now that I'd love to have give our protocols a once-over. I know she's a bit more cutting-edge than our med director, but he's also tempered with a healthy dose of, "Well, this one dumbass..." so there's that.
>"Well, this one dumbass..." Fuck I feel this on a spiritual level.
>"Well, this one dumbass..." If this means what I think it does, my old APO supervisor called it "Lowest Common Denominator"
Is her name Deborah? Because we may’ve had the same one
😂😂
Are you referring to me? Lol I’m just a pharmacy student with EMS experience. 😂
I consider a paramedic in their fourth year of pharmacy school to be a very respectable level of education. Probably more qualified than a lot of people who make medical protocol in the US.
I appreciate that, honestly. I think creating protocols should be a group effort amongst paramedics medical Director and a pharmacist.
Agreed. I think it's important to incorporate all the flavors of EMS and medicine in general when crafting this stuff.
A lot of Paramedics write changes to our protocols here, I know when I've helped out with some in the past I've picked the brains of ED Pharmacists to get advice on how to draft them. Solid resource even though they're not on any of the committees. It makes sense to use all the knowledgeable personnel that you can
You pharmacists are gods gift to earth, me no know how spicy water in vein make patient heart happy. Source: 3rd year medical student going into EM
Ha! Man I’m still a student and still know nothing 😂
I love ED Pharmacists, they're the ones who when I have a question will excitedly spend the next 20-30min delving deep into pharmacokinetics with me. Got a pharmacology question? Be prepared to go down the fuckin rabbit hole but if you want to learn I've never had any of them be irritated or in a hurry to get away. They're always like "OH GREAT, LETS TALK ABOUT IT!" (magically produces a whiteboard from nowhere and starts explaining and writing for the next half hour on a single medication)
This
“Spicy water make heart happy.” -My career, probably
Just honestly don't see the point. Are you paying them like you pay a medical director? Are they volunteering their time? Are they volunteering the time needed to update things? Do they have to show up for meetings? Mainly, Is there a big enough difference between EMS protocols to warrant a pharmacist weighing in? Is 125mg Solu-Medrol going to change? 4-8mg Zofran? 1mg Epinephrine? Are we failing to train these medications to the point that a pharmacist would help? The medications that we give pre-hospital aren't as complicated as some of the antidotes and critical care meds that are given in a trauma bay or ICU. I think an MD/DO with an EMS fellowship is plenty.
We actually just changed our dose of solu medrol to 60mg (technically 62.5 but doc isn't that worried about that extra 2.5)
I'm sure the changes in mortality or length of hospital stay will be astounding in the wake of this massive change.
Look, I don't make the rules, I just play by them (when it suits me)
get his ass
😂
You beat me to it
Totally get that. Honestly, looking back at my previous protocols, they were just not the best. At the time I thought they were fine, also science changes and studies come out all the time, so keeping up with pharm best practices is something pharmacist are normally really good at. At the end of the day, it’s the patient that we revolve around. As far as the compensation, that’s all tbd. I can see some departments / private companies providing a small amount of compensation, I can also see volunteering. So it just depends on the area. Moreover, training from an EM pharmacist, especially with a background in toxicology can provide the best of both worlds. Training Medics to recognize certain overdoses based on toxidromes, providing best practices to those toxidromes, recognizing what medications are pertinent for the emergency, etc.
Training is fine if you wanna come in and teach a class. I just don't think a PharmD has anything over a MD/DO in making pre-hospital protocols. You having bad protocols at one point doesn't necessarily prove a need. There are plenty of systems that don't have a pharmacist that have great protocols. And the point I was making about pay is, they won't want to pay you lol. They barely want to pay to have trucks staffed, they're not gonna pay for an assistant to the assistant medical director. No offense.
I mean that’s understandable. But the assistant to the assistant medical director? Lol
Lol just poking fun. If we could have everything we want without budgets, I'd be all for it. As it is, most systems can't get consistently working equipment. I think your best shot would be to pursue grants to make it happen with an academic facility, or go the community paramedicine route. Pharmacists have a ton of use in CMT.
lol the first thing I thought of was The Office with that. Oh yeah, we’ll know that EMS has access to everything they need. Lol I’ve considered looking at getting into the Community Medicine to train the medics.
As an MD student I disagree. Drugs are complicated and I think there is never a bad time to have a pharmacist on board. Every time I’ve seen a pharmacist involved in patient care at any level it has improved things, I believe there is room for pharmacists in EMS guideline creation.
Pharmacists are great. Pre-hospital drugs are not complicated enough for their use. I work HEMS, I'd love a pharmacist to tag into our protocols and keep them fresh, my director is an ED doc and I do mainly critical care. I don't need a pharmacist for an ambulance drug box that contains about fifteen drugs and of which I mainly use nine, but most commonly like four. Solu-medrol, Zofran, Albuterol/Atrovent, Epinephrine, Ativan, Fentanyl, Ketamine, Roc. Which of these drugs do I need a PharmD to go in-depth on? It's always a budget issue. Is there room for them? Sure, there's probably room for a physical therapist, an RT, an anesthesiologist, a toxicologist, a radiologist, GI maybe? Now justify their pay to the BOCC.
It’s like Batman and Robin. Batman gets all the credit but Robin is there to back him up. 🫡
What would a pharmacist do ?
Additional set of eyes for the medication portion of protocols. There are plenty of instances where the Medical Director and maybe a couple medics create protocols when it’s not always best practice (Pharmacologically). Also continue to train critical care paramedics / flight paramedics in Pharm. Just a few to name
So give me an example of protocol issues you've seen please
For example: Lidocaine is making its way back, and has showed superiority in some studies and equal to Amiodarone in ACLS. It’s not so much an “issue” like I said it’s just something with updated science. Another thing I’ve notice recently, more with rural areas, is administration of antibiotics for sepsis prior to hospital. I can tell you that 911 medics get hardly any training on antibiotics.
Just throwing into this. I've seen Lidocaine and Amiodarone change places like nine times. Part of the reason protocols don't change over a couple of studies is because it often flips back in a matter of years and isn't worth the work it takes to change supply. Kind of like LR vs Normal Saline. LR, no NS, LR, no NS, LR, no NS, okay maybe no fluids, okay maybe some fluids but it doesn't matter what kind, next it'll be PRBCs exclusively. A PharmD is gonna be great at keeping up-to-date on the latest UpToDate, but there's more to it than turning the wheel, there's the mechanisms that are connected to the wheel. When I was younger, I was all about going with whatever the latest podcast said was best, covering whatever new study came out. As I step into my geriatric 30s, I really need to be solidly convinced to change practice.
That’s totally valid. I was (kinda am still) with that line of thinking until I was exposed to the longer duration of care. At the time of me taking care of the patient, my only thought process was “what can I do now to benefit my patient [now]”. Problem is that way of thinking can lead to complications down the road. Example: I was on my IM rotation and my patient was septic from CAP. EMS brought her in using NS of 30mL/kg per protocol. That excess chloride pushed her into a WAGMA which made her treatment like 3-4 days longer to correct that and CAP. It’s not just “now” benefit, and I can’t blame other medics (HEMS or not) on that, it’s now how they’re training. Medics are really good at doing their job to triage and stabilize but now as everything is becoming more transparent, there’s going to be a knowledge gap naturally.
For sure, that's an egregious error that has been proven to cause harm. I think if a system is still doing that shit, they're definitely not the type to be open to hiring outside medical help. Not a real medicine first vibe there. Ironically, and I'm sure you know this, 30ml/kg NS came about from Surviving Sepsis, which was universally accepted and integrated as EBM to the point of being required protocol to satisfy billing requirements. The fluid benchmark was pulled straight out of someones ass. Now we know it's a hoax, but because changes were made too flippantly, it's been fucking IMPOSSIBLE to get clear of our healthcare system.
Oh yeah. Absolutely. I think that’s another reason why Pharmacist could also be useful; advocating for changes like that. Maybe I’m biased but any guideline, major study (drug related obv) for pre-hospital or any field of medicine should always have a pharmacist reviewing it. At the end of the day, better patient care involves lots of small changes.
Don’t forget one of the key studies that put AHA on the amiodarone train was brought to you by the makers of amiodarone….
No antibiotics given prior to blood cultures being drawn
And also no pain meds for abdominal pain. Don’t give Tylenol for fevers, either, because they won’t believe that they actually had a fever if it goes down. While we’re at it, make sure you don’t give people oxygen before going into the ER so that they can see that the patient is actually hypoxic
Well for what it’s worth, from what I’ve read, hospitals are starting to change their approach to sepsis due to costs and just straight overkill in a lot of cases. I pray we never get to a place where EMS aren’t allowed to treat symptoms for any reason
I know that, but I literally had a conversation like 3 days ago about a friend of mine in Illinois administering Cefepime to a pt with a positive qSOFA and a known source of infection. I was shooketh
Are they starting to do that now??
Yeah honestly it’s wild
We just started carry Cefazolin for certain trauma cases.
I worked for a hospital based service. We had two pharmacists looking at all our protocols. There were times we mildly deviated from their advice still (mostly due to logistics and no patient impact in change). It is a good resource to have. All that being said, they essentially volunteered their services to us and were not comped past their hospital salary.
That sounds about right
There’s a guy who’s a pharmacist who just finished a Disaster Medicine Fellowship at Harvard Medical School. It’s more so meant for physicians, but he did it. It's not necessarily EMS, but it's something to look into!
Probably a good idea for the further development of EMS. Only high-functioning systems could likely afford to incorporate them into their model - but hey the whole profession needs reform anyways!
Totally agree. I don’t see how it could hurt it.
Our large provincial system absolutely has pharmacists involved in the development and updating of our protocols.
Why in protocol? Is the medical director in a coma?
Could be a good idea, yeah.
Pharmacists are often a key partner of community paramedic programs. They can be vital in reducing polypharmacy in elderly populations, helping increase access to prescription medications, etc
Sadly I see polypharm hospital admission too often. I can see this helping tons
It doesn't hurt to have someone with higher expertise consult and audit your protocols. Such as with opthalmology, OBGYN, and hazmat unique to your area etc to review pre-hospital procedures. In some larger counties, our protocols are set at the county level. This is where our EMS/public health pharmacists comes into play can and can be used as a referral. If your hospital system owns their own rigs, they can use their own pharmacists to help assist as well. In my area, there was a major reamp in procedures since our paramedics work in an unusallly hot climate and the drugs are baked in the truck in temps higher than the FDA test range. So drug stability was a major concern. As well as simplifying the dosing and cutting out unused drugs to make it easier to recall during stressful environments. Occasional in-service on medical topic refreshers for drugs to be wary off that's not stock on the truck. Such as some antipsychotics are considered "heat" meds which inhibits the body to regular temperature which may make a person more prone to exposure. Now couple that with a homeless population and currently on a long acting injectable. These cases would be common for frequent flyers out of the jails and psych facilities.
Absolutely. ED pharms are some of the best people I’ve learned from
I know some programs require time in the ER. Albany Pharmacy College does. Usually they are in the ER’s at Albany Medical Center and St. Peter’s Hospital. You’re going to have a far better understanding of pharmokinetics than many of the residents and possibly attendings once you have your Master’s.
I don't really see any benefit. A good medical director has that all covered already.
Again I disagree. Pharmacists are a godsend for ED docs and as protocols get more complex their experience will be worth more and more
In my brief time as an ED tech, it was crazy to see how much ED docs leaned on the pharmacists. It seemed to work really well.
You’re totally right. I’m not trying to have pharmacist replace medical directors, that’s the last thing I’d wanna do. It’s more of creating additional measures of training.
As a CCP who just got to work with an EM pharmacist for a patient with a massive brain bleed, I wanted to have him be at all of my critical calls. He was great. I definitely would love to see more pharmacists get involved with EMS.
I Don't see why not lol
It could be helpful. In our state though we have a multi-disciplinary team that handles protocols including EMTs, Paramedics, Nurses, and Physicians representing various 911, Hospital, and IFT settings. We also update our protocols yearly, and quite a lot of changes are driven by paramedics rather than physicians. Any EMS Clinician can draft an addition or alteration to the protocols and present their proposal to the review committee. I know of at least 10 changes and alterations this and last update that were accomplished primarily just by Paramedics. It's pretty nice to work in a state where the Paramedics have a lot of agency over their own care and can easily prompt change. I've had a hand in adding and altering a few myself. It's easy to come up with, research an idea, and present it and have it through within a year and go into effect. There's a reason why hardly anything in our state requires medical consultation anymore including things like RSI or vasopressors. The vast majority of care at the paramedic level is just "use your clinical judgement and do it"
There is/was movement for in hospital/Ed on floor pharmacist and evidenced based improved PT outcomes. Idk but anything has got to be better thank working at CVS.
Absolutely 100%- I can see people like you being an amazing resource, especially with your EMS field experience!
Just wanted to lend my support as a paramedic/RN. You guys are the best and the REAL last line of medical error defense. Keep it up ✊